Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis

BACKGROUND

Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase.

RESULTS

Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients).

CONCLUSION

Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.

Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy

STUDY PURPOSE

The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases.

METHODS

The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection.

RESULTS

Not applicable.

CONCLUSION

DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Mobility and transformation of CdSe/ZnS quantum dots in soil: Role of the capping ligands and ageing effect

The increasing application of Quantum Dots (QDs) is cause of concern for the potential negative effects for the ecosystem, especially in soils that may act as a sink. In this study, soil leaching experiments were performed in quartz sand packed columns to investigate the behavior of core-shell CdSe/ZnS QDs coated with either small ligands (TGA-QDs) or more complex polymers (POAMA-QDs). Fluorescence emission was compared to mass spectrometric measurements to assess the nanoparticles (NPs) state in both the leachate (transported species) and porous media (deposited amounts). Although both QDs were strongly retained in the column, large differences were observed depending on their capping ligand stability. Specifically, for TGA-QDs elution was negligible and the retained fraction accumulated in the top-columns. Furthermore, 74% of the NPs were degraded and 38% of the Se was found in the leachate in non-NPs state. Conversely, POAMA-QDs were recovered to a larger extent (78.1%), and displayed a higher transport along the soil profile. Further experiments with altered NPs showed that homo-aggregation of the QDs prior injection determined a reduced mobility but no significant changes in their stability. Eventually, ageing of the NPs in the column (15 days) caused the disruption of up to 92% of the original QDs and the immobilization of NPs and metals. These results indicate that QDs will accumulate in top-soils, where transformations phenomena will determine the overall transport, persistency and degradation of these chemicals. Once accumulated, they may act as a source for potentially toxic Cd and Se metal species displaying enhanced mobility.

Behavior and fate of industrial zinc oxide nanoparticles in a carbonate-rich river water

The present study precisely describes the solubility patterns of commercial uncoated and organic coated ZnO NPs (nc-NPs and c-NPs, respectively) in a natural carbonate-rich water and the physicochemical processes involved. NPs transformation rates were determined with the Donnan Membrane approach (DMT, to obtain Zn(2+) concentration) and ultrafiltration (i.e. Zn(2+) and Zn bound to small organic ligands) and modeled with VMinteQ. XPS measurements evidenced the presence on native nc-NPs of a Zn(OH)2 layer which accounts for almost 22% of total Zn. This Zn(OH)2 phase is more soluble than ZnO, and could control the early dissolution steps of the nc-NPs in our system. Indeed, nc-NPs display a fast (<1 h) dissolution step reaching 19 μM Zn in solution (<1% of the total initial zinc concentration). Comparatively, c-NPs progressively release zinc during the first 48 h, to finally reach a maximum of 197 μM (10% of total Zn), which is 10 times the maximum value measured for nc-NPs. Over the long term, dissolved Zn concentrations decrease in both systems, corresponding to the neoformation of carbonate phases observed by TEM imaging. The kinetic modeling allows highlighting two different ranges of time, corresponding to (i) first 10h with a fast precipitation (kp(')=-182.10(-4)) related to a highly oversaturated solution with respect to carbonate zinc mineral and (ii) a second slower precipitation step (kp(')=-8.10(-4)), related to the embedding of NPs in the precipitated carbonate matrix. The steady state is reached after 3 months of interaction.

Status epilepticus with visual seizures in ketotic hyperglycemia

Metabolic disturbances are often associated with epileptic seizures, but the pathogenesis of this relationship is poorly understood. We describe the case of a 48-year-old man who presented with complex partial status epilepticus with visual seizures in the context of ketotic hyperglycemia. The EEG revealed a temporal epileptogenic focus and alterations were apparent on MRI in the acute phase and 4 months later. Very few cases of seizures in ketotic patients have been reported because ketone bodies have a protective effect against epilepsy. Seizures in hyperglycemia tend to be partial, and the only reports of visual seizures were due to occipital foci. Neuroradiological alterations have been reported in epileptic seizures, although usually in generalized seizures. The clinical, electrical, and imaging characteristics of this case are interesting and suggest that partial seizures can also cause long-term neuronal damage.

Abortion may sensitize the mother to HLA antigens

The incidence of cytotoxic antibodies in relation to histories of abortions was analyzed in sera from 474 nulliparous pregnant women. In patients with previous spontaneous abortions, there is a higher incidence of positive sera than in primigravidae. Furthermore, patients with two or more prior abortions show a greater incidence of cytotoxic activity in their sera than women who have had only one abortion.

Secular trends in survival in prostate cancer (PC) (1992–2005) in a public hospital in Barcelona: Impact of PSA implementation and hormone-radiotherapy (HT+RT) treatment introduction—An observational study

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Background: There are reports of declines in mortality in several series and countries following introduction of PSA test. With routinely collected data we explore changes over time in PC survival, its correlation with PSA implementation and with the introduction of HT+RT. Methods: From the Hospital del Mar Cancer Registry we selected patients with histological confirmation of PC diagnosed between 1992 and 2005. Clinical and pathological stage, grade, PSA at diagnosis, type of treatment and follow-up until 2005 were available, and patients were grouped in three-years periods. Results: Out of 1,185 registered, 897 patients were evaluable. Median age at diagnosis decreased from 72 in 1992–96 to 70 in 2003–05 (p<.001). Median PSA at diagnosis decreased from 35 μg/ml to 14 μg/ml after 1996. Patients being diagnosed as metastatic changed from 67% before 1997 to 29% in 1997–99. A trend towards lower pathological stage has been observed, although in stage II and III no significant changes in risk group distribution were observed throughout the study period (χ2 =.318). Since 1999 there is a progressive increase in HT+RT indication in stages II and III with a significant decrease in the indication of surgery. There is an improvement in overall relative survival at 5 years before and after 1999, from 67,3% (CI: 60,2–75,2) to 92,9% (CI: 87,3–98,9).The same tendency was found in patients with localized tumour with intermediate and high risk coincidentally with the implementation of HT+RT. Conclusions: An increase in survival of patients with PC has been observed, coinciding with a shift towards lower stages and PSA levels at presentation, suggesting an influence of early detection by PSA. The increase in survival among localized tumors since 1999 could be explained by secular variations in the treatment of PC, as the implementation of HT+RT in patients with intermediate and high risk localized PC.

No significant financial relationships to disclose.

Neonatal-onset multisystem inflammatory disease responsive to interleukin-1beta inhibition

BACKGROUND

Neonatal-onset multisystem inflammatory disease is characterized by fever, urticarial rash, aseptic meningitis, deforming arthropathy, hearing loss, and mental retardation. Many patients have mutations in the cold-induced autoinflammatory syndrome 1 (CIAS1) gene, encoding cryopyrin, a protein that regulates inflammation.

METHODS

We selected 18 patients with neonatal-onset multisystem inflammatory disease (12 with identifiable CIAS1 mutations) to receive anakinra, an interleukin-1-receptor antagonist (1 to 2 mg per kilogram of body weight per day subcutaneously). In 11 patients, anakinra was withdrawn at three months until a flare occurred. The primary end points included changes in scores in a daily diary of symptoms, serum levels of amyloid A and C-reactive protein, and the erythrocyte sedimentation rate from baseline to month 3 and from month 3 until a disease flare.

RESULTS

All 18 patients had a rapid response to anakinra, with disappearance of rash. Diary scores improved (P<0.001) and serum amyloid A (from a median of 174 mg to 8 mg per liter), C-reactive protein (from a median of 5.29 mg to 0.34 mg per deciliter), and the erythrocyte sedimentation rate decreased at month 3 (all P<0.001), and remained low at month 6. Magnetic resonance imaging showed improvement in cochlear and leptomeningeal lesions as compared with baseline. Withdrawal of anakinra uniformly resulted in relapse within days; retreatment led to rapid improvement. There were no drug-related serious adverse events.

CONCLUSIONS

Daily injections of anakinra markedly improved clinical and laboratory manifestations in patients with neonatal-onset multisystem inflammatory disease, with or without CIAS1 mutations. (ClinicalTrials.gov number, NCT00069329 [ClinicalTrials.gov].).

Bladder Blood Flow and De-Obstructive Open Prostatectomy: Correlation with Clinical and Urodynamic Parameters

PURPOSE

To assess the relation between tissue blood flow changes during surgery with clinical and urodynamic parameters in obstructed patients.

MATERIAL AND METHODS

A prospective study was conducted in 18 symptomatic patients with bladder outlet obstruction undergoing retropubic prostatectomy. A symptom assessment and a preoperative urodynamic study were performed. To measure bladder blood flow a BLF-10 laser Doppler flowmeter and a blunt-tipped probe were used intraoperatively. Tissue flow was measured in TPU units (1 TPU unit=1 ml per minute per 100 mg of tissue). Six measurements were taken: two control in the rectus abdominis muscle and four in the detrusor, two before the incision of the prostatic capsule and two after closure. For the statistical analysis, Wilcoxon test and a regression analysis were performed.

RESULTS

Mean age was 70 years (range: 56-84). Six patients had an episode of acute urinary retention (AUR). No differences were found in the initial and final values of bladder blood flow of the rectus muscle and the bladder dome. A decrease of bladder blood flow in the anterior bladder wall was observed after prostate enucleation. AUR patients showed no differences in bladder blood flow values. Bladder blood flow (BBF) changes showed no correlation with any urodynamic or clinical parameter.

CONCLUSIONS

Laser Doppler flowmetry is useful to study BBF with low morbidity, ease of use and reproducibility. Following de-obstructive surgery, a decrease in BBF occurs, probably associated with surgery. These changes are similar in patients with and without AUR and show no correlation with other parameters studied.

Chromosomal High-Polysomies Predict Tumour Progression in T1 Transitional Cell Carcinoma of the Bladder

The main prognostic factor generally accepted for tumour progression in T1 transitional cell carcinoma (TCC) of the bladder is histological grade. Despite this fact it is considered inaccurate to make clinical decisions on individuals. It appears that progression from minimally invasive to deeply invasive cancer is concurrent with the acquisition of genomic alterations that increase the malignant potential of cancer cells. The aim of this study is to determine if changes in chromosomes 7, 8, 9 and 17 copy number can be used to predict recurrence and progression in patients with T1 TCC of the urinary bladder.

METHODS

Thirty-one T1 TCC samples were analyzed for chromosomal alterations by fluorescence in situ hybridization using centromeric probes for chromosomes 7, 8, 9 and 17. Clinical data were collected from the patients' clinical records and correlated with chromosomal studies.

RESULTS

Histological grade was confirmed as a prognostic factor of tumour progression (p=0.01). None of the cytogenetic alterations demonstrated in the studied group could be related to tumour recurrence. The high-polysomies (five or more copies) of chromosomes 8, 9 and 17 showed predictive value (p=0.05, 0.05, 0.03 respectively) for tumour progression since it was observed that patients with high-polysomy of these chromosomes showed more risk of tumour progression towards muscle-invasive disease than those without high-polysomy alteration.

CONCLUSION

Our findings suggest a possible prognostic significance of highly aneuploid cells (high-polysomies of chromosomes 8, 9 and 17) in tumour progression of T1 TCC bladder tumours. FISH analysis is a reproducible technique for evaluating cytogenetic alterations and could contribute to the assessment of the individual prognosis of T1 transitional cell carcinoma of the bladder.

Renal cell carcinoma with syncytial giant cell component

We report a case of clear cell renal cell carcinoma in which a prominent multinucleated giant cell component was intermingled with clear, granular, and spindle cells. Histological, ultrastructural, cytometric, and cytogenetic features of giant cells were similar to those of mononucleated cells in the tumor, and therefore they were not from stromal or osteoclast derivation. These giant cells had homogeneous, finely granular, abundant cytoplasm, often with scalloped cell borders, and contained from 5 to more than 50 nuclei, all of them very similar in size and shape, with prominent central nucleoli. Occasionally, surrounding inflammatory cells were also engulfed in the cytoplasm. This syncytial appearance was more similar to that of some giant cell carcinomas from the lung than to the pleomorphic giant cells often encountered in high grade renal cell tumors. Although the patient is alive and free of disease 6 years after diagnosis, a longer follow-up will be required to assess the potential prognostic influence of this peculiar histological appearance.

Detection of chromosomal imbalances in papillary bladder tumors by comparative genomic hybridization

OBJECTIVES

To identify those genetic alterations that are associated with bladder cancer invasion and progression.

METHODS

A total of 30 specimens of transitional cell carcinoma of the bladder were analyzed by comparative genomic hybridization. The results were compared and summarized with previously reported studies.

RESULTS

The most frequent chromosome changes detected in our series of tumors were losses in 9q, 9p, 8p, and 11p and gains in 8q, 1q, 20q, and 11q. Three regions of deletion on chromosome 9 were delineated, at 9p21-p22, 9q13-q22, and 9q31-q34. Gains in 1q and losses on 11p were significantly more frequent in pT1G2 tumors than in superficial (pTa) ones. In our study, the most striking differences were seen between pT1G3 and pT1G2 tumors. Gains on 10p and 6p and losses at 5q, 6q, and 18q were significantly more frequent in the former.

CONCLUSIONS

A summary of our results and those available from published reports suggest that several groups of chromosomal imbalances may be associated with specific steps along bladder cancer progression. These genetic changes assume two different patterns: those that are shared, but are more intensive in one stage than in the other, and those such as a gain on 3p that are unique to invasive tumors.

Comparative genomic hybridization analysis of transitional cell carcinomas of the renal pelvis

We used comparative genomic hybridization to analyze 10 primary tumor samples from patients with transitional cell carcinoma of the renal pelvis. The most frequent loss was located at 9q, that is, in 50% of the tumors. Gains of DNA sequences were most frequently observed in chromosome regions 1q21 approximately q23, 2p23 approximately p25, 8q21.1 approximately q22 and in the whole chromosome 20. High level amplifications at 1q21 approximately q25, 6p22 approximately p23, 8q21 approximately q22, 8q22 approximately q24.1, 11q13, and 12q14 approximately q21 were detected. Most of these regions have previously been reported to be involved in transitional cell carcinoma of the bladder, thus confirming the importance of an increasing number of chromosome imbalances in the development and progression of this type of tumors.

Ultrastructural morphometry of nucleoli: potential usefulness for objective grading of clear cell renal cell carcinoma

The authors attempted to determine the potential prognostic value of several ultrastructural morphometric parameters, including nuclear, nucleolar, and cytoplasmic features, that could be used in the objective and reproducible histological grading of clear cell renal cell carcinoma. Several nuclear and cytoplasmic parameters were assessed by ultrastructural morphometry in 26 consecutive cases of clear cell renal cell carcinoma. The nuclear and nucleolar sizes, the number of nucleoli per nuclear section and the number of marginated nucleoli, Fuhrman's nuclear grade, and Robson's stage were recorded. In addition, the proportion of cytoplasmic components was semiquantitatively estimated and compared to light microscopic appearance. Follow-up ranged from 5 to 15 years (mean = 10 years). Statistical evaluations were performed by means of the Pearson or Spearman correlation coefficient tests, and differences in survival were estimated, using the Mantel-Cox proportional risk method. Differences in survival among patients with a mean nuclear area over and under 160 microm2, and among those with a mean nucleolar area over and under 10 microm2, were statistically significant. (Cutoff points were selected at the median value for both parameters; Mantel-Cox test: chi2 = 7.102, p < .01; and chi2 = 11.096, p < .001, respectively). Fuhrman's nuclear grade (p < .01) and tumor stage at diagnosis (p < .001) were also related to survival. These data suggest that, out of all the ultrastructural morphometric features, nucleolar area is the most useful in the reproducible and accurate grading of clear cell renal cell carcinoma.

Study of allelic losses on 3p, 6q, and 17p in human urothelial cancer

Forty-eight transitional cell carcinomas of the bladder and three transitional cell carcinomas of the renal pelvis were examined for loss of heterozygosity (LOH) on chromosomes 3p, 6q, and 17p. The most frequent allelic loss was seen on 17p (18/36, 50%) followed by 6q (6/22, 27%), and 3p (5/22, 23%). In cases with LOH at more than one locus, the same DNA sample often varied in degree of signal reduction for missing alleles. This observation indicates that LOH studies can serve to detect intratumor heterogeneity. No correlation was found between allelic losses at these chromosome arms and tumor grade and stage. Allelic losses on 6q were associated with tumors having a solid growth pattern; in this kind of tumors, allelic losses on 3p were associated with invasion.

Serum bone alkaline phosphatase levels enhance the clinical utility of prostate specific antigen in the staging of newly diagnosed prostate cancer patients

The aim of this study was to analyse the clinical utility of serum bone alkaline phosphatase (BAP) in addition to prostate-specific antigen (PSA) in the staging of newly diagnosed untreated prostate cancer patients. A prospective study was conducted, analysing serum BAP and PSA concentrations in 295 consecutive newly diagnosed untreated prostate cancer patients (T1-4, N0-1, M0-1b), 93 of whom had bone metastases on bone scan. The relationship of each marker with extent of bone disease, the influence of several clinical variables on both serum marker levels, the efficiency in predicting bone metastasis through receiver operating characteristic curves and, finally, the clinical utility in avoiding unnecessary bone scans were determined. Significant differences were found in the serum levels of both BAP and PSA between patients with and patients without bone metastases. Multiple regression analysis showed the extent of bone disease to be the only variable that influenced both serum levels. However, while serum BAP levels showed a statistical relationship with extent of bone disease, serum PSA levels did not. The best prediction of bone scan findings was obtained with the combination of both markers using a cut-off of 20 ng/ml, with positive and negative predictive values of 46.5% and 100%, respectively. This greater efficiency could permit 32.2% of initial bone scans to be avoided. False-positive and false-negative rates of BAP were 7.5% and 14%, respectively. This study suggests that serum BAP levels could play a complementary role in the diagnosis of bone metastasis in prostate cancer patients. This marker could provide useful clinical information on the degree of skeletal metastasis and constitute an easy way of enhancing the clinical utility of PSA. The addition of this marker to PSA in the initial evaluation could permit staging bone scan to be avoided at a PSA range of 10-20 ng/ml, with significant implications for cost saving.

Chromosome instability in lymphocytes from two patients affected by three sequential primary cancers: the role of fragile sites

The chromosomal aberration rate and the expression of fragile sites induced by aphidicolin were evaluated in metaphase chromosomes obtained from peripheral blood lymphocytes of two untreated patients with multiple primary cancers. Spontaneous aberrations of chromosome number and structure and chromosome fragility were compared with controls with the use of the same methods. Chromosomal aberration rates and expression frequencies of fragile sites were significantly higher in the patients than in normal control subjects. In the patients, all but one structural chromosome aberration involved at least one fragile site. Our results suggest that fragile sites may be unstable regions of the human genome, which might play an important role in the genetic instability associated with cancer predisposition.

Complete resolution of post-traumatic high-flow priapism with conservative treatment

The most frequent cause of high-flow priapism is penile or perineal closed trauma with laceration of the cavernous artery and the formation of an arterial-lacunar fistula. We present the case of a high-flow priapism due to closed perineal trauma and damage to the left cavernous artery which completely resolved following conservative treatment. The case was documented by duplex Doppler ultrasound and selective pudendal arteriogram before and after resolution.

Analysis of 3p allelic losses in renal cell carcinomas: comparison with cytogenetic results

We performed a study of loss of heterozygosity (LOH) at 3p by restriction fragment length polymorphism analysis in a series of 22 renal tumors. In 11 cases, molecular results could be compared with those of cytogenetic studies. The highest frequency of allelic losses at 3p was seen in clear cell non-papillary renal tumors, whereas none of the papillary renal cell carcinomas showed LOH at 3p. Allelic losses on 3p were found to be independent of tumor grade or stage or both. One case analyzed showed a discrepancy between cytogenetic and LOH studies. This tumor displayed rearrangements of chromosome 3 and no LOH at the c-RAF-1 (close to the Von Hippel Lindau gene) locus.

Piroxicam fast-dissolving dosage form vs diclofenac sodium in the treatment of acute renal colic: a double-blind controlled trial

OBJECTIVE

To assess the possible therapeutic effect of 40 mg sublingual piroxicam (fast-dissolving dosage form, FDDF) compared with intramuscular 75 mg diclofenac, as a reference drug, on acute renal colic in a randomized, double-blind controlled clinical trial.

PATIENTS AND METHODS

Eighty patients were assigned to one of two treatment groups; one received an intramuscular injection with 0.2 mL distilled water and two sublingual tablets of 20 mg piroxicam FDDF, and the other received an intramuscular injection with 75 mg diclofenac sodium and two sublingual tablets of placebo. Pain intensity was evaluated by the patient using a visual analogue scale and by the observers. Vital signs at baseline and 30 min after the administration of the study drugs were also recorded.

RESULTS

The overall efficacy of the treatment was 81%; nine patients in the piroxicam and six in the diclofenac group (no significant difference) required rescue treatment. Compared with baseline levels, the pain relief was significant (P < 0.001) at 30 min in both groups. Twenty-two patients in the piroxicam and 25 in the diclofenac group attained complete pain relief at 30 min, as evaluated by the observer (no significant difference). Both treatments were similarly effective in decreasing vital signs, mainly systolic blood pressure, heart and respiratory rates. However, when the percentage change was compared between the groups, piroxicam significantly decreased the respiratory rate (P < 0.03).

CONCLUSION

Piroxicam FDDF is as effective as parenteral diclofenac in emergency renal colic treatment. Furthermore, its ease of self-administration increases patient compliance and potential use in general practice.

Low-grade spindle cell carcinoma of the kidney

The authors report a renal cell carcinoma composed largely of spindle cells of Fuhrman's nuclear grade II in which the bland appearance of the cells and low mitotic index were reminiscent of a benign or low-grade smooth muscle tumor. Keratin immunostaining was positive, but evidence of epithelial differentiation was obtained by electron microscopy. The tumor was an incidental finding and it did not invade the perirenal fat or the renal vein. Follow-up is only 24 months but the histological features suggest that the prognosis may be better than that of a classic sarcomatoid renal cell carcinoma.

Renal malakoplakia: report of a case with multifocal involvement

The authors report the light microscopic and ultrastructural features in one case of malakoplakia involving the kidney, the urinary bladder, and the skin. The kidney was excised. Lesions of the urinary bladder and the skin regressed after topical treatment with cholinergic agonists and antimicrobial drugs. This case illustrates the pathogenesis of malakoplakia and the possibility that early lesions can be cured with medical therapy before extensive tissue destruction has taken place.

A case of transitional cell carcinoma of the bladder with a del(9)(q11q21.2)

Monosomy for chromosome 9, as well as loss of heterozygosity for markers on this chromosome, has been detected in a high percentage of transitional cell carcinomas (TCC) of the bladder. We report a case of a TCC of the bladder with an interstitial del(9)(q11q21.2) that could be indicative of the presence of a putative tumor-suppressor gene related to bladder tumor progression. To elucidate the role of chromosome 9 in bladder tumors, it would be interesting to study a possible loss of heterozygosity in this chromosome region.

[The optimization of the data base of a voluntary health care cooperative for the study of postoperative morbidity in benign prostatic hypertrophy]

BACKGROUND

Investigation in health care services by data bases (DB) is undergoing an important increase in numerous countries. Several of the most relevant epidemiologic studies on the postsurgical morbidity and mortality of benign hypertrophy of the prostate (BHP) have used DB. The aim of this study was to prepare and optimize the DB of a health cooperative (Asistencia Sanitaria Colegial).

METHODS

Since 1981 the DB contains sociodemographic variables, data concerning visits to general practitioners and specialists, complementary examinations and hospitalizations. The coding system was specifically developed by the cooperative. The study base was made up of all the policies of the members between January 1981 and December 1988 (101,400 males). To identify the policies 14 codes potentially related with BHP were initially chosen and all the policies containing any of these codes were selected, with the manual analysis of 204 policies being thereby performed.

RESULTS

The total number of policies initially selected for the study was 3,157. Manual revision discarded the use of 9 of the 14 codes used in the first selection. In agreement with the 5 codes able to define diseases of prostatic gland and to the file in which they appeared the policies were classified as probable diseases of prostatic gland (n = 1,007, 31.9%), possible (n = 805, 25.5%) and improbable (n = 1,345, 42.5%). Likewise, the strategy to follow for the selection of a cohort of BHP cases was defined.

CONCLUSIONS

The manual analysis of policies evidenced a remarkable coherence and exhaustiveness of the information registered. The principal difficulties found with the data base used were the lack of a sole diagnosis and the coding system used in addition to the impossibility of automatically controlling the assistance received by the patients outside the cooperative system. The availability of a data base such as that herein described with a well defined large population and with accessible sociodemographic and health care information justifies collaborative efforts among health care administrators, clinicians, computer scientists and epidemiologists.

Massive renal infarction due to mucormycosis in an AIDS patient

Isolated renal infection by Mucor spp. occurs very rarely, even in the immunocompromised host. The mortality of the different forms of mucormycosis reaches 75-100% in most series. Infection of the kidney is usually diagnosed post-mortem. Thus, when renal infection is recognized, aggressive treatment including surgery and amphotericin B is required. We present a case in which a massive left renal infarction was the unique manifestation of mucormycosis in an AIDS patient. Administration of amphotericin B and left nephrectomy were necessary to achieve satisfactory outcome.

The use of ultrasonography as the initial diagnostic exploration in blunt renal trauma

Fifty-four patients with blunt renal trauma underwent abdominal ultrasound as their initial diagnostic exploration if their hemodynamic status and associated injuries did not contraindicate unnecessary delays. Renal ultrasound allowed us to diagnose the injuries and to identify which patients required a more aggressive radiological exploration to obtain a diagnosis of certainty. At the same time we were able to certify that this technique is highly accurate in the diagnosis of lesions associated with gross hematuria. The noninvasiveness and low cost of this procedure makes it, in our experience, the technique of choice in the initial workup of blunt renal trauma.

Two-stage papain-indirect antiglobulin test and LISS direct agglutination are not appropriate for pretransfusion screening for unexpected antibodies

BACKGROUND

The screening for unexpected antibodies has proved to be a suitable pretransfusion compatibility method, but controversy still remains regarding the most appropriate serologic techniques to use in such a screening and, in particular, whether or not to use enzyme-based methods.

METHODS

Over a period of three years, 27,149 patient sera submitted to pretransfusion testing were screened for unexpected antibodies. Serologic techniques included LISS-direct agglutination (DAG) reading plus indirect antiglobulin test (IAT), and two-stage papain (2SP)-IAT.

RESULTS

In all, 592 (2.18%) serum samples yielded a positive result. Further studies of these specimens disclosed 466 alloantibodies in 371 cases, and 221 unwanted positive reactivities. 2SP-IAT and LISS-DAG allowed the detection of 124 alloantibodies missed by LISS-IAT (78 anti-Lewis, 33 anti-E, 7 anti-P1, 2 anti-K1, 2 anti-K3, 1 anti-M, 1 anti-Cw), but were responsible for 81% of the unwanted positive reactivities.

CONCLUSIONS

Since most alloantibodies detected only by 2SP-IAT or LISS-DAG were of doubtful clinical significance, and these techniques produced a high number of unwanted positive reactivities, we conclude that 2SP-IAT and LISS-DAG are not appropriate for the pretransfusion screening for unexpected antibodies.

Incidence of non-A, non-B hepatitis after screening blood donors for antibodies to hepatitis C virus and surrogate markers

OBJECTIVE

To compare the effect of screening blood donors for antibodies to hepatitis C virus (anti-HCV) on the incidence of non-A, non-B hepatitis in recipients with that of screening blood donors for antibodies to hepatitis B core antigen (anti-HBc) and elevated alanine aminotransferase levels.

DESIGN

Cohort analysis of serum samples from donors and recipients. Recipients were followed for 12 months to determine the occurrence of non-A, non-B hepatitis.

SETTING

The blood-transmitted viruses unit and the liver unit of a university teaching hospital.

SUBJECTS

A total of 250 patients who had open heart surgery and their 3142 blood donors.

MEASUREMENTS

Donor sera were tested for anti-HCV by enzyme-linked immunosorbent assay (ELISA) and, in the event of a positive result, by recombinant immunoblot assay (RIBA). Antibodies to anti-HBc and serum alanine aminotransferase (ALT) levels were also measured. Measurements of anti-HCV and ALT activity in recipients were done before transfusion and at regular intervals during follow-up.

MAIN RESULTS

Of the 250 transfusion recipients, 40 developed non-A, non-B hepatitis. Of the 3142 donors, 70 were positive for anti-HCV by ELISA, 440 were positive for anti-HBc, and 177 had alanine aminotransferase levels between 0.67 and 1.33 mukat/L. The sensitivity (87%), specificity (89%), positive predictive value (59%), and negative predictive value (97%) of blood-donor screening were higher for anti-HCV than for anti-HBc (82%, 36%, 21%, and 91%, respectively) and 70%, 29%, and 91%, respectively). The expected number of donors excluded because of the presence of anti-HCV was considerably smaller than that of donors with positive results for surrogate markers of hepatitis.

CONCLUSION

Screening blood donors for the presence of anti-HCV is more accurate than screening for surrogate markers (anti-HBc and ALT) and protects more effectively against post-transfusion non-A, non-B hepatitis.

Centromere splitting in bladder cancer

Cytogenetic studies on a bladder carcinoma, carried out using short time cultures, showed centromere splitting (CS) mainly affecting chromosomes 22, 13, 14, 21, 15, 20, 12, 7, 17, and 18. Clonal trisomies and monosomies were also detected. Our case is the first description of CS in bladder tumor cells. Our results suggest that CS is an early phenomenon in the karyotypic evolution of this case; it can be considered a primary, yet unspecific, chromosome change related to aneuploidy in bladder cancer.

[Growing teratoma syndrome in metastatic germinal non-seminomatous testicular tumors]

Presence of retroperitoneal or mediastinal mature teratomas secondary to metastatic testicle germinal tumours which have not responded to multiple chemotherapy constitute the so called Growing Teratoma. They can either represent the metastasis of a mature teratoma site in the original testicle tumour or the evolution from a non-differentiated lesion during therapy. The first two cases of Growing Teratoma Syndrome published in the national literature are presented here. Both cases had a retroperitoneal growth of the mature teratoma following successful achievement of normalization of serum tumoral markers through chemotherapy with CDDP, Bleomycin, and VP-16 in one case (Hospital Clínico) and with BOMP/EPI (Belomycin, Metrothexate, Vincristine, Cisplatin/Vo-16, Cisplatin, Iphosphamide) in the second one (Hospital del Mar) of a non-seminomatose testicle tumour. After a follow-up of 14 and 9 months respectively the good prognosis of these mature teratomas was verified in both cases, so as in the rest of the literature. We coincide with regard to performing a retroperitoneal lymphadenectomy with exeresis of tumoral masses as the most adequate attitude, both to prevent growth of the mature teratoma and to allow us to discard the presence of residual immature lesions.

[Use of FMC macromolecular medium for determination of the erythrocyte ABO group using microtiter plates]

Several blood group determination techniques have been developed in recent years which provide easy handling, fine reproducibility and similar or even higher sensitivity than the procedures commonly employed, aimed to be used in the automation of blood bank work. A microtitration plate technique for ABO determination on red cells is presented in this report. A macromolecular medium, comprised of a mixture of the polymers Ficoll 400 and carboxymethyl cellulose (FMC) is used ad coadjuvant for the reaction. This medium increases by 15- the score units and by 4-fold (or more) the intensity of haemagglutination (titration) in typing the ABO antigenicity of red cell A, B, O and AB groups.

Plateletpheresis: a comparative study of six different protocols

Six different protocols were employed in 710 plateletpheresis employing Haemonetics 30, Fenwal CS-3000, IBM 2997 dual stage channel, IBM 2997 single-stage channel, and Haemonetics V-50 "surge pump" method. When Haemonetics 30 and IBM 2997 single-stage channel procedures were used, 5.4 to 5.9 X 10(11) platelets were collected with significant leukocyte contamination (10.8 to 11.6 X 10(9)). With Fenwal CS-3000, dual-stage channel of IBM 2997 and Haemonetics V-50 "surge pump" there was less leukocyte contamination in concentrates (0.3 to 0.9 X 10(9)) as well as a lower platelet yield (3.4 to 4.3 X 10(11)). No difference in yield was observed when plateletpheresis was performed with ACD-A or ACD-B employing the single-stage channel of IBM 2997. Paresthesias was the most frequently seen side effect in donors, with a higher incidence when using ACD-A and IBM 2997.