Favorable Response of Pembrolizumab as Second-Line Therapy for Advanced Urothelial Carcinoma with Only Small Lesions to not be Considered Measurable by RECIST

PURPOSE

Pembrolizumab is currently considered the standard second-line treatment for advanced urothelial carcinoma (UC). This study aimed to investigate the efficacy and safety of pembrolizumab in patients with advanced UC in real-world data, which is not well-reported.

MATERIALS AND METHODS

The study included 97 patients with advanced UC whose lesions were classified according to the Response Evaluation Criteria in Solid Tumors (RECIST). The median age was 73 years. Nineteen patients (20%) with performance status (PS) 2-4 were included. The percentages of liver, lung, bone, and lymph node metastasis were 18%, 27%, 19%, and 76%, respectively. The efficacy, safety, and risk factors for prognosis were evaluated for patients with and without measurable lesions.

RESULTS

The best response was complete response in nine patients (9%) and partial response in 16 patients (17%). The median progression-free survival and overall survival were 3.7 months (95% confidence interval [CI]: 2.8-4.7) and 11.8 months (95% CI: 6.7-17.0), respectively. Twenty-one (22%) patients had no measurable lesions per RECIST. In univariate and multivariate analysis, PS 2-4 and lesions by RECIST were identified as factors associated with short overall survival (OS). The median OS of 18.3 months in patients without lesions by RECIST was significantly longer than the median OS of 6.7 months in patients with lesions by RECIST (p = .012).

CONCLUSION

We demonstrated that good PS 0-1 and no measurable lesions, especially small lesions, by RECIST were favorable prognostic factors in patients with advanced UC treated by pembrolizumab.

Test clamp procedure in robot-assisted partial nephrectomy: is it a safe procedure?

We performed test clamp procedure in robot-assisted partial nephrectomy (RAPN) to prevent massive bleeding during tumor resection and to omit dissection of non-feeding arteries around the tumor. We subsequently analyzed the safety and usefulness of the procedure. The Test clamp procedure was performed for 1 to 3 min during renal artery test ischemia prior to the actual ischemia and tumor resection. We confirmed the disappearance of blood flow around the renal tumor using color Doppler ultrasonography. If arterial blood flow around the tumor remained, we surveyed the site for other arteries that needed to be clamped and repeated the test clamp procedure until renal blood flow around the tumor disappeared. We retrospectively analyzed consecutive RAPN cases performed from July 2016 to March 2020 at our institutions and reviewed medical records. The clinical data of the RAPN cases were statistically analyzed. Sixty-four RAPN cases underwent the test clamp procedure, which was categorized as the TEST group. Test clamping was performed safely without any clamping-related complications in all cases. Eleven cases (17%) underwent partial ischemia, which was a significantly higher number than that in the control group. Massive bleeding during tumor resection was more frequent in the control group. Postoperative deterioration of estimated glomerular filtration rate did not differ significantly between both groups. Although further investigation was still necessary, our findings indicate that the test clamp procedure may be a safe and secure procedure to perform in RAPN for both patients and surgeons.

Blood Cell Count Biomarkers Predicting Efficacy of Pembrolizumab as Second-line Therapy for Advanced Urothelial Carcinoma

BACKGROUND/AIM

To investigate the blood markers for predicting pembrolizumab efficacy in advanced urothelial carcinoma (UC).

PATIENTS AND METHODS

This study included 91 advanced UC patients. The relationship between prognosis and markers from peripheral blood cell counts, including the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), and systemic inflammation response index (SIRI=monocytes × neutrophils/lymphocytes), was evaluated.

RESULTS

Multivariate analysis indicated that pretreatment NLR and the 1-month-change NLR were both significantly associated with overall survival (OS) after pembrolizumab initiation. When the patients were divided into four groups according to calculated cutoffs using Cox proportional hazard model, the pretreatment NLR <2.9 and 1-month change NLR <+43% groups had a significantly better OS than the pretreatment NLR ≥2.9 and 1-month-change NLR ≥+43% groups.

CONCLUSION

NLR, MLR, PLR and SIRI before pembrolizumab and 1-month-change NLR in advanced UC correlated with OS after pembrolizumab treatment.

Effectiveness of Synthetic Polymer-coated Peripherally Inserted Central Catheter in Patients With Advanced Cancer

BACKGROUND/AIM

A peripherally inserted central catheter (PICC) is recommended for the safe administration of anticancer agents. The effectiveness of synthetic polymer-coated and non-coated PICCs was compared.

PATIENTS AND METHODS

Patients with advanced cancers who had indwelling PICCs were reviewed using their medical records. Three types of PICCs were compared in terms of complications and catheter failure.

RESULTS

A total of 90 patients were retrospectively analyzed, including 31 with Groshong PICCs, 30 with Argyle PICC kit, and 29 with Argyle PICC kit II. The incidence of catheter failure for Groshong PICC, Argyle PICC kit, and Argyle PICC kit II per 1,000 PICC days was 4.4614, 5.6617, and 0.8658, respectively. Catheter failure-free survival in the Argyle PICC kit II group was significantly better than that in the Argyle PICC kit group (p=0.0339).

CONCLUSION

Argyle PICC kit II, a synthetic polymer-coated PICC, may render longer patency and prevention of catheter failure than non-coated PICCs.

Evaluation of Factors Affecting Metastasis for Renal Cell Carcinoma Based on Current Guidelines in Japan

BACKGROUND/AIM

To analyze the suitability for metastasis evaluation of each pathologic item on the Fourth Edition of the General Rule for Clinical and Pathologic Studies on Renal Cell Carcinoma in Japan.

PATIENTS AND METHODS

We retrospectively examined 457 cases of renal operation after 2011 using the current edition of the guidelines.

RESULTS

The mean postoperative follow-up period was 25.3 months. Radical nephrectomy was performed in 264 cases, whereas partial nephrectomy was performed in 193 cases. Including the 33 cases discovered after operation, the overall number of metastatic cases was 68 (14.9%). Using the current edition of the guidelines, the items of histologic grade, morphology of tumor invasion, tumor pseudocapsule, and intrarenal metastasis were all correlated with distant metastasis.

CONCLUSION

This is the first report showing that each item on the current Japanese guidelines for renal cell cancer was useful for predicting metastasis.

Usefulness of selective renal artery embolization for urinary fistula following partial nephrectomy: Two case reports

The present study reported two cases in which selective artery embolization were identified to assist in resolving urinary fistulae following partial nephrectomies. The first case involved a 51-year-old male who received a mini-incision partial nephrectomy with renorrhaphy. Following the operation, urine continued to discharge from the retroperitoneal drain. Selective renal artery embolization of the upper calyx at post-operation day 20 was highly effective and urine output from the drain stopped immediately. Case 2 involved a 66-year-old male, who also suffered from a urinary fistula following a partial nephrectomy. Selective renal artery embolization performed at post-operation day 21 was again effective. In each case, the upper calyx was separated from the renal pelvis. These cases demonstrated that suturing of the collecting system and renal parenchyma may result in the separation of the urine pathway, and that selective renal artery embolization appears to be a highly effective treatment in such cases.

Holmium Laser Enucleation of the Prostate With Percutaneous Nephrostomy Into the Transplanted Kidney in Patient With Severe Benign Prostatic Hyperplasia With Vesicoureteral Reflux - A Case Report

A 66-year-old male, who had received renal transplantation 10 years before, was admitted to our hospital with urinary retention. The prostate volume was 169.2 ml. Furthermore, grade 5 vesicoureteral reflux (VUR) was shown in the cystography. Holmium laser enucleation of prostate (HoLEP) was performed, and percutaneous nephrostomy to the transplanted kidney was performed simultaneously to prevent from severe perioperative infection. After that, renal graft function improved and no urinary retention reoccurred, although surgical repair against VUR was necessary 10 months after HoLEP. We conclude that surgical treatment for BPH after kidney transplantation should be strongly considered with care for infections.

The pharmacokinetics and disposition of MK-0524, a Prostaglandin D2receptor 1 antagonist, in rats, dogs and monkeys

MK-0524 is a potent, selective and orally active Prosglandin D(2) Receptor 1 (DP(1)) antagonist currently under clinical development for the treatment of niacin-induced flushing. Experiments to study the pharmacokinetics, metabolism and excretion of MK-0524 were conducted in rats, dogs and monkeys. MK-0524 displayed linear kinetics and rapid absorption following an oral dose. Following intravenous (i.v.) administration of MK-0524 to rats and dogs (1 and 5 mg/kg), the mean Cl(p) was approximately 2 and approximately 6 ml/min/kg, the T(1/2) was approximately 7 and approximately 13 h and the Vd(ss) was approximately 1 and approximately 5 L/kg, respectively. In monkeys dosed i.v. at 3 mg/kg, the corresponding values were 8 ml/min/kg, 3 h and 1 L/kg, respectively. Following oral dosing of MK-0524 to rats (5, 25 and 100 mg/kg), dogs (5 mg/kg) and monkeys (3 mg/kg), the absorption was rapid with the mean C(max) occurring between 1 and 4 h. Absolute oral bioavailability values in rats, dogs and monkeys were 50, 70 and 8%, respectively. The major circulating metabolite was the acyl glucuronide of MK-0524 (M2), with ratios of glucuronide to the parent aglycone being highest in the monkey followed by dog and rat. In bile duct-cannulated rats and dogs, MK-0524 was eliminated primarily via acyl glucuronidation followed by biliary excretion of the acyl glucuronide, M2, the major drug-related entity in bile.

Preclinical Cushing's syndrome resulting from adrenal black adenoma diagnosed with diabetic ketoacidosis

A right adrenal tumor was incidentally discovered on abdominal computed tomography performed on a 53-year-old Japanese man, who had been hospitalized with diabetic ketoacidosis. Normal values were obtained for adrenal hormones in the morning after an overnight fast and urinary cortisol excretion after treatment of diabetic ketoacidosis with insulin. However, overnight dexamethasone administration with 1 mg or 8 mg did not completely suppress serum cortisol levels. There were no remarkable physical findings related to Cushing's syndrome. The patient was diagnosed as having preclinical Cushing's syndrome (PCS). Histological examination of the adrenalectomy specimen demonstrated adrenal black adenoma. Blood glucose levels subsequently improved after adrenalectomy, and the patient never developed adrenal insufficiency after hydrocortisone withdrawal. The patient was treated with diet therapy alone, and maintained good glycemic control. However, the patient still showed a diabetic pattern in an oral glucose tolerance test. It seems that the existence of PCS in addition to the underlying type 2 diabetes mellitus contributed to aggravation of blood glucose levels. Although there are many aspects of the natural course of PCS that have not been thoroughly elucidated, it is necessary to remain aware that a PCS patient with abnormal glucose metabolism may develop diabetic ketoacidosis by environmental agents.

The pathology of jaundice-related renal insufficiency: cholemic nephrosis revisited

The spectrum of jaundice-related nephropathy can range from limited proximal tubulopathy to renal failure. The latter condition was known as cholemic nephrosis in the early literature on this subject. Elevated plasma concentrations of bile salts and bilirubin conjugated or not, putatively mediate the nephrotoxicity. A functional derangement of renal tubule cells is considered to underlie the nephropathy, but published data on renal histology are scarce. In this report, we describe the renal biopsies of two jaundiced patients with reduced creatinine clearance, and we critically review the literature on the pathogenesis of jaundice-related nephropathy. Normal renal architecture, indicating functional renal impairment, and extensive renal tubule necrosis were both observed in jaundice-related renal failure. The findings fit the original description of cholemic nephrosis. Both bilirubin and bile salts are potential nephrotoxins in animal models, but their precise role in the pathogenesis of jaundice-related nephropathy is not known. Patients with bilirubin plasma concentrations >20 mg/dL, a low serum albumin concentration or endo-toxemia, could be more prone to develop renal failure due to jaundice-related tubulopathy. In conclusion, jaundice-related nephropathy is essentially a tubulopathy, but the exact nature of the Pathogenesis is still uncertain.

A case of bilateral testicular calcifications in a bicycle motocross rider accompanied by bulbar urethral injury

A 21-year-old Japanese man who was a professional bicycle motocross rider injured his perineum during a competition. Chief complaints were gross hematuria, perineal pain, and subcutaneous ecchymosis of the scrotum. Urethrocystography revealed a torn bulbar urethra and extravasation in the same region. Scrotal ultrasonography revealed small calcifications in the bilateral testes. Here, we report a case of bilateral testicular calcifications caused by the continuous shock and vibration of the saddle in an off-road bicycle rider.

Percutaneous pneumatic and laser lithotripsy as a possible therapeutic strategy for bilateral large calculi in a horseshoe kidney

This report concerns a case of bilateral large calculi in a horseshoe kidney. Three sessions of percutaneous nephrolithotripsy for the calculi successfully disintegrated and removed the fragments without any complications. For complete stone removal we used pneumatic and laser lithotriptors which were passed, respectively, through a rigid nephroscope and a flexible pyeloscope. It is emphasized that the selection of the most suitable lithotriptor by taking their various features into account is important in endoscopic surgery for calculi which are likely to recur such as stones accompanied by infection or for anatomically anomalous kidneys such as horseshoe kidneys.

High-dose chemotherapy with peripheral blood stem cell transplantation for advanced testicular cancer

BACKGROUND

The aim of this study was to investigate the efficacy and safety of high-dose chemotherapy (HDCT) for the treatment of patients with advanced testicular cancer.

METHODS

Fourteen patients were treated with high-dose carboplatin, etoposide and cyclophosphamide (with or without THP-adriamycin) followed by peripheral blood stem cell transplantation. The treatment was used for two refractory cases, a second relapse, and for consolidation after the first relapse in one case each. It was also used for nine cases as part of the first-line treatment following primary conventional-dose chemotherapy, and for one case as the first salvage for a late recurrent tumor of teratoma with malignant transformation.

RESULTS

The first two patients who received intensive pretreatment with cisplatin-based chemotherapy did not respond to HDCT. The two patients who were treated with HDCT as the first or second salvage therapy achieved successful outcomes. The results for the subsequent nine patients (consisting of two with stage IIIC, five with IIIB2, one with IIB, and one extragonadal seminoma) were two progressive disease, three no change and four partial remission. Only three are alive with NED following salvage surgery. Finally, a case of teratoma with malignant transformation did not respond well to two cycles of HDCT. There were no marked adverse reactions except one episode of severe neutropenic colitis.

CONCLUSIONS

The results demonstrated the limited efficacy of HDCT even in cases with a good to intermediate risk rating according to classification by the International Germ Cell Cancer Collaborative Group. Because treatment for relapse after HDCT is extremely difficult, new HDCT regimens consisting of drugs that are not used in induction chemotherapy need to be established.

Effects of ionization mode on charge-site-remote and related fragmentation reactions of long-chain quaternary ammonium ions

Comparison of collisionally activated fragment spectra of long-chain quaternary ammonium ions, formed by liquid-assisted secondary ion mass spectrometry (LSIMS) and electrospray ionization (ESI), shows the latter are dominated by radical cations while the former yield mainly even-electron charge-site-remote (CSR) fragments, similar to the report for different precursors by Cheng et al., J. Am. Soc. Mass Spectrom. 1998, 9, 840. Here, mixed-site fragmentation products (formal loss of a radical directly bonded to the nitrogen plus a radical derived from the long chain) are of comparable importance for both ionization techniques. These observations are difficult to understand if the CSR ions are formed by a concerted rearrangement-elimination reaction, since precollision internal energies of the ESI ions are much lower than those of the ions from LSIMS. Alternatively, if one discards the concerted mechanism for high-energy CA, and assumes that the even-electron fragments are predominantly formed via homolytic bond cleavage, the colder radical cations from ESI survive to the detector while the more energized counterparts from LSIMS preferentially lose a hydrogen atom to yield the CSR ions, as proposed by Wysocki and Ross (Int. J. Mass Spectrom. Ion Processes 1991, 104, 179). The present work also attempts to reconcile discrepancies involving critical energies and known structures for neutral fragments.

5-Alkyltryptamine derivatives as highly selective and potent 5-HT1D receptor agonists

A series of 5-alkyltryptamines (6) and the corresponding conformationally constrained analogues (8) have been synthesized. The structure activity relationships (SAR) at the 5-position of the indole skeleton and the ethylamine side chain have been studied. Functional activities were assessed using isolated rabbit saphenous vein. Potent, selective ligands were found (6e, Ki 2.5 nM, 5-HT1B/5-HT1D 125-fold) that have potential for treating acute migraine.

Biotinylation of substituted cysteines in the nicotinic acetylcholine receptor reveals distinct binding modes for alpha-bungarotoxin and erabutoxin a

Although previous results indicate that alpha-subunit residues Trp(187), Val(188), Phe(189), Tyr(190), and Pro(194) of the mouse nicotinic acetylcholine receptor are solvent-accessible and are in a position to contribute to the alpha-bungarotoxin (alpha-Bgtx) binding site (Spura, A., Russin, T. S., Freedman, N. D., Grant, M., McLaughlin, J. T., and Hawrot, E. (1999) Biochemistry 38, 4912-4921), little is known about the accessibility of other residues within this region. By determining second-order rate constants for the reaction of cysteine mutants at alpha184-alpha197 with the thiol-specific biotin derivative (+)-biotinyl-3-maleimidopropionamidyl-3,6-dioxaoctanediamine , we now show that only very subtle differences in reactivity (approximately 10-fold) are detectable, arguing that the entire region is solvent-exposed. Importantly, biotinylation in the presence of saturating concentrations of the long neurotoxin alpha-Bgtx is significantly retarded for positions alphaW187C, alphaF189C, and reduced wild-type receptors (alphaCys(192) and alphaCys(193)), further emphasizing their major contribution to the alpha-Bgtx binding site. Interestingly, although biotinylation of position alphaV188C is not affected by the presence of alpha-Bgtx, erabutoxin a, which is a member of the short neurotoxin family, inhibits biotinylation at position alphaV188C, but not at alphaW187C or alphaF189C. Taken together, these results indicate that short and long neurotoxins establish interactions with distinct amino acids on the nicotinic acetylcholine receptor.

Charge-remote fragmentation characteristics of functionalized alkanes in high-energy collision-induced dissociation

In this study we report on high-energy, collision-induced dissociation processes leading to charge-remote fragmentations, using three alkyl cations, namely n-hexadecylpyridinium, n-hexadecyltriphenylphosphonium and n-hexadecyltriethylammonium, each with and without (2)H(2)-labelling at the C(9) position of the hexadecyl chain. The characteristic patterns corresponding to the formal elimination of alkane elements were observed, and the (2)H(2)-labelling at C(9) clearly affected only one charge-remote fragment ion of the homologous series. However, in addition to the expected fragment ion containing only one deuterium atom, a significant ion retaining two deuterium atoms was observed. MS/MS/MS experiments demonstrated clearly that the latter ion showed partial deuteration around the charge site, the level of deuteration depending on the structure of the original precursor cation. These results can be interpreted in terms of two novel, distinct mechanisms, one of which involves an excited state in an aromatic ring. Mixed-site fragmentation (MSF) ions were also observed from the phosphonium and ammonium ion precursors. We believe that the observation of the MSF process occurring at an sp(2)-hybridized center in the phosphonium series has not been reported previously. It thus becomes apparent that high-energy collisions leading to charge-remote reactions in fact lead to a broad range of pathways. Copyright 2000 John Wiley & Sons, Ltd.

Abnormal cell morphology and cytotoxic effect are induced by 6-0-palmitol-ascorbate-2-0-phosphate, but not by ascorbic acid or hyperthermia alone

A new derivative of ascorbic acid (AsA), 6-0-palmitoyl-ascorbate 2-0-phosphate (Asc2P6Pal) was developed to enhance the antitumor activity of AsA. When Ehrlich ascites tumor cells were treated with 50 microM Asc2P6Pal at 37 degrees C or 42 degrees C for 1 h and then cultured for 20 h, most of cells exhibited some morphological abnormalities, including exudation of intracellular granules together with other contents on the cell membrane surface, resulting in cell fragmentation. The abnormal features were further enhanced by a long term culture for 96 h and heat treatment at 42 degrees C. In contrast, no abnormality was detected for untreated cells or cells treated with AsA (free acid) at 37 degrees C or 42 degrees C. Cells cultured for 96 h after the treatment suffered from inhibition of DNA synthesis and proliferation. This inhibition was markedly enhanced by combination with the hyperthermic treatment at 42 degrees C, but not for a short-term culture of 20 h after the treatment. No effects were seen upon similar treatment with AsA. The abnormal cells produced during culture for 20 h after the treatment were evaluated to be viable, because they failed to be stained with trypan blue and retained most of the DNA synthesizing ability of Asc2P6Pal-untreated cells. However, they appeared and died after a continuous 76 h of culture (96 h).

[A case report of urinary tract infection and meningitis caused by methicillin-resistant Staphylococcus aureus (MRSA) after transurethral resection of the prostate]

We present a case of meningitis that developed following a urinary tract infection caused by methicillin-resistant Staphylococcus aureus (MRSA) after transurethral resection of the prostate. The patient, a 69-year-old man with diabetes mellitis, underwent transurethral resection of the prostate following a diagnosis of benign prostatic hypertrophy. On the 4 th day after surgery, high fever occurred immediately after the removal of the indwelling urethral catheter. Cultures of urine and blood revealed MRSA. On the 6 th day after surgery, severe lumbago was evident and MRSA was isolated from cerebrospinal fluid. Separate administration of arbekacin or vancomycin, to which the isolated MRSA was sensitive, was not effective. Combined therapy with fosfomycin, vancomycin and human immunoglobulin effectively relieved the inflammation. Although it is generally reported that the pathogenicity of MRSA is low in the urinary tract, this case suggests that a urinary tract infection caused by MRSA can advance to sepsis and meningitis.

The leuO gene product has a latent ability to relieve bgl silencing in Escherichia coli

The Escherichia coli bgl operon is of interest, since its expression is silent (phenotypically Bgl-), at least under standard laboratory conditions. Here we attempted to identify a trans-acting factor(s) that is presumably relevant to the regulation of bgl by a random insertion mutagenesis with mini-Tn10. These collected mutations, conferring the phenotype of Bgl+, were localized in three loci on the genetic map, two of which appeared to be hns and bglJ, which were previously implicated as the factors affecting the Bgl phenotype. The other locus at 1 to 2 min on the genetic map appeared to be a new one. In this case, the insertion mutation was found to be just in front of the leuO gene encoding a putative LysR-like DNA-binding protein. Genetic analyses revealed that overproduction of LeuO in the wild-type cells causes the phenotype of Bgl+. A leuO deletion mutant was also characterized in terms of expression of bgl. From these results, the possible function of LeuO in bgl expression will be discussed from an evolutionary and/or ecological point of view.

Clarification of the dimerization domain and its functional significance for the Escherichia coli nucleoid protein H-NS

The Escherichia coli nucleoid protein, H-NS, functions as a global regulator for expression of a wide variety of genes. We recently analyzed the structure-function relationship of H-NS with special reference to the domains responsible for transcriptional repression and DNA-binding, respectively. However, identification of the presumed dimerization domain of H-NS and its functional significance was elusive. To address this particular issue, we first examined a set of N-terminally or C-terminally truncated forms of H-NS, in terms of their so-called dominant-negative effect on the in vivo function of the wild-type H-NS. The results showed that certain truncated forms exhibit such a dominant-negative effect, but others did not. As judged by the results of the dominant-negative effect, it was assumed that a relatively central portion of H-NS extending from residues 21 to 63 is involved in dimerization. This was confirmed by an in vitro chemical cross-linking analysis and a gel filtration analysis with these truncated forms of H-NS. Furthermore, the use of the dominant-negative phenotype, caused by a truncated form of H-NS (named N91), allowed us to isolate a missense mutant, which was expected to be specifically defective in dimerization. This mutant had an amino acid substitution at position 30 (Leu30 to Pro) in N91 consisting of the N-terminal 91 amino acids of H-NS. This mutant was indeed defective in the in vitro ability to form a heterodimer with the wild-type H-NS. When this particular single amino acid substitution was introduced into the full-length H-NS, the resultant H-NS mutant had lost the ability to form dimers in vitro and to function as a transcriptional repressor. These findings collectively provided us with evidence that the ability of H-NS to form a dimer is crucial for H-NS to function as a transcriptional repressor.

Endoscopic treatment of vesicoureteral reflux in patients with myelodysplasia

PURPOSE

We assessed the usefulness of and indications for endoscopic treatment of vesicoureteral reflux in myelodysplasia patients.

MATERIALS AND METHODS

A total of 26 patients treated with intermittent catheterization was divided into 11 (16 ureters) with and 15 without vesicoureteral reflux. In 9 patients (13 ureters) endoscopic correction was performed with 3% atelo-collagen and without anesthesia at the outpatient clinic. In each ureter we obtained the sum of scores for 4 risk factors for upper urinary tract deterioration: bladder compliance less than 10 ml./cm. water, grade 2 to 3 bladder deformity, detrusor-sphincter dyssynergia and urethral closure pressure 50 cm. water or greater.

RESULTS

No reflux was demonstrated immediately after the initial collagen injection but cystography 3 to 6 months later showed recurrent reflux in 5 ureters (38%). Repeat injection cured the reflux, with results persisting for an average of 17 months. Mean risk factor score for patients without vesicoureteral reflux was significantly lower than that for patients with reflux. In patients treated with intermittent catheterization and anticholinergic agents the mean score for ureters with an increased or unchanged reflux grade was significantly greater than for those with a decreased grade.

CONCLUSIONS

Endoscopic treatment of reflux appears to be safe and useful in patients with myelodysplasia. The treatment is preferable in those with high risk factor scores due to the possibility of increased reflux grade in such patients.

D-arabinitol versus mannan antigen and candidal protein antigen as a serum marker for Candida pyelonephritis

To evaluate serum markers for the diagnosis of Candida pyelonephritis, levels of D-arabinitol, candidal mannan antigen and candidal protein antigen were measured using an enzymatic fluorometric assay, an enzyme immunoassay and a latex agglutination assay, respectively. The study group comprised 36 patients with candiduria (11 disseminated candidiasis, 9 Candida pyelonephritis and 16 colonization) and 27 without candiduria. The D-arabinitol/creatinine ratio was the only marker that differentiated between Candida pyelonephritis and colonization (p < 0.01). Using the cut-off values (1.4 mumol/mg of D-arabinitol/creatinine ratio, 0.28 of mannan/creatinine ratio (x 10(4)) and 1:4 of protein antigen titer) D-arabinitol/creatinine ratio showed the highest sensitivity in Candida pyelonephritis (77.8%) as compared to mannan/creatinine ratio (55.6%) and protein antigen titer (11.1%) although there were no differences in specificity, positive predictive value or negative predictive value. These results suggest that D-arabinitol/creatinine ratio is the most useful marker of Candida pyelonephritis.

[The usefulness of the emergency hepatobiliary scintigraphy to rule out acute cholecystitis--43 patients report]

We studied emergency hepatobiliary scintigraphy in the 43 patients to rule out acute cholecystitis. After injection of 185-222 MBq (5-6 mCi) of 99mTc-EHIDA or 99mTc-HIDA, serial static scintigraphic images were obtained up to 7 hours in maximum. Of 43 patients in this study, 20 had a normal scan and finally in all of them cholecystitis was ruled out. Of the 43 patients, 14 had an abnormal scan (nonvisualized gall bladder). In 10 of them the diagnosis of acute cholecystitis was confirmed after emergency cholecystectomy. The other 9 patients of 43 had an incomplete scan mainly due to liver dysfunction. Four of them had acute cholecystitis in the cholecystectomy. These results indicate that acute cholecystitis can be excluded by the findings of gall bladder visualization in hepatobiliary scintigram. We concluded that emergency hepatobiliary scintigraphy is very useful to rule out acute cholecystitis.

Human corneal endothelial permeability to fluorescein and fluorescein glucuronide

The corneal endothelial permeability coefficient (Pac) for fluorescein and fluorescein glucuronide was determined in ten normal young volunteers. After oral administration of fluorescein, the apparent concentrations of both dyes in the corneal stroma and the anterior chamber were measured by differential fluorometry. The apparent dye levels calculated directly from the in vivo fluorometric measurements were converted to the true ones, based on the result of a normalization experiment performed in rabbit eyes. The value of Pac averaged 5.44 +/- 1.77 X 10(-4) cm/min for fluorescein and 3.77 +/- 1.10 X 10(-4) cm/min for fluorescein glucuronide (mean +/- SD, N = 20); the former was significantly greater than the latter (paired t-test, P less than 0.001). The aqueous-cornea distribution ratio was 0.50 +/- 0.14 for fluorescein and 0.66 +/- 0.16 for fluorescein glucuronide; the latter was significantly greater than the former (paired t-test, P less than 0.001). It was suggested that the previously reported values of Pac for fluorescein in the human eye were underestimates.

Effects of retinal detachment surgery on standing potential

We studied the effects of retinal detachment surgery on the standing potential of the human eye using the electrooculographic technique. Before and two weeks after surgery, we measured the relative base value (rBV) which is the base value of the affected eye divided by the base value of the fellow eye. The rBV distributed around 1.0 before surgery and decreased below 1.0 two weeks after surgery. The change in the rBV through surgery represented by the value R is defined as preoperative rBV minus postoperative rBV divided by preoperative rBV; this was closely correlated with the area of the scleral buckling. The decrease in the rBV was thought to represent the reduction in the standing potential of the operated eye, probably due to circulatory disturbance of the choroid.

Study of fluorescein glucuronide. I. Isolation from urine

A method for isolating fluorescein glucuronide from the urine using silica gel chromatography and preparative high-performance liquid chromatography is described. The product obtained was free from significant fluorescent impurity on thin-layer chromatography and analytical high-performance liquid chromatography.

Study of fluorescein glucuronide. II. A comparative ocular kinetic study of fluorescein and fluorescein glucuronide

Comparative studies of fluorescein and fluorescein glucuronide were carried out. Binding to human serum protein was studied using an Amicon MPS-3 ultrafiltration unit; it averaged 63% for fluorescein glucuronide and 85% for fluorescein. Intracameral penetration of both compounds was studied in the human eye, and the concentration changes of both compounds in the plasma ultrafiltrate and in the anterior chamber were analyzed, based on Davson's equation. The coefficient of entry into the anterior chamber (ki) was 0.018 +/- 0.007 h-1 (mean +/- SD, n = 10) for fluorescein glucuronide and 0.054 +/- 0.033 h-1 for fluorescein, and the former was significantly lower than the latter (P less than 0.005). The rate of loss from the vitreous (kv) was studied by injecting each compound into the vitreous of the pigmented rabbit and following the fluorescein intensity changes in it. It was 0.042 +/- 0.008 h-1 (mean +/- SD, n = 8) for fluorescein glucuronide and 0.17 +/- 0.01 h-1 for fluorescein, and the former was significantly smaller than the latter (P less than 0.001). Intraperitoneal injection of probenecid significantly decreased the kv of fluorescein but had little effection that of fluorescein glucuronide. It was suggested that fluorescein glucuronide is lost from the vitreous mainly by a passive mechanism.