Effect of rumen-protected choline on dairy cow metabolism, immunity, lactation performance, and vaginal discharge microbiome

Rumen-protected choline (RPC) promotes benefits in milk production, immunity, and health in dairy cows by optimizing lipid metabolism during transition period management and early lactation. However, the RPC success in dairy cows depends on choline bioavailability, which is affected by the type of protection used in rumen-protected choline. Therefore, our objectives were to determine the effects of a novel RPC on dry matter intake (DMI), identify markers of metabolism and immunity, and evaluate lactation performance. Dry Holstein (n = 48) cows at 245 ± 3 d of gestation were blocked by parity and assigned to control or RPC treatment within each block. Cows enrolled in the RPC treatment received 15 g/d of CholiGEM (Kemin Industries, Cavriago RE, Italy) from 21 d prepartum and 30 g/d of CholiGEM from calving to 21 d postpartum. During the transition period, DMI was measured daily, and blood was sampled weekly for energy-related metabolites such as β-hydroxybutyrate (BHB), glucose, and nonesterified fatty acids (NEFA), as well as immune function markers such as haptoglobin (Hp) and lipopolysaccharide-binding protein (LPB). Vaginal discharge samples were collected at the calving and 7 d postpartum and stored in microcentrifuge tubes at -80°C until 16S rRNA sequencing. The main responses of body condition score, body weight, DMI, milk yield, milk components, and immune function markers were analyzed using the GLIMMIX procedure of SAS with the effects of treatment, time, parity, and relevant covariates added to the models. The relative abundance of microbiome α-diversity was evaluated by 3 indexes (Chao1, Shannon, and Simpson) and β-diversity by principal coordinate analysis and permutational multivariate ANOVA. We found no differences in DMI in the pre- and postpartum periods. Cows fed RPC increased the yields of energy- and 3.5% fat-corrected milk and fat yield in primiparous and multiparous cows, with an interaction between treatment and parity for these lactation variables. However, we found no differences in milk protein and lactose up to 150 DIM between treatments. Glucose, NEFA, and BHB had no differences between the treatments. However, RPC decreased BHB numerically (control = 1.07 ± 0.13 vs. RPC = 0.63 ± 0.13) in multiparous on the third week postpartum and tended to reduce the incidence of subclinical ketosis (12.7% vs. 4.2%). No effects for Hp and LPB were found in cows fed RPC. Chao1, Shannon, and Simpson indexes were lower at calving in the RPC treatment than in the Control. However, no differences were found 7 d later for Chao1, Shannon, and Simpson indexes. The vaginal discharge microbiome was altered in cows fed RPC at 7 d postpartum. Fusobacterium, a common pathogen associated with metritis, was reduced in cows fed RPC. Rumen-protected choline enhanced lactation performance and health and altered the vaginal discharge microbiome which is a potential proxy for uterine healthy in dairy cows. The current study's findings corroborate that RPC is a tool to support adaptation to lactation and shed light on opportunities for further research in reproductive health.

Novel use of levodopa in human immunodeficiency virus encephalopathy-mediated parkinsonism in an adult

We report a case of a 36-year-old man with a medical history of human immunodeficiency virus (HIV) infection who presented with hypomimia, hypophonia, bradykinesia, rigidity, and freezing of gait. His clinical presentation and magnetic resonance imaging were consistent with HIV encephalopathy with involvement of the bilateral basal ganglia and diffuse leukoencephalopathy. We initiated a trial of carbidopa-levodopa. The dose was escalated to 1050 mg levodopa daily. Amantadine was also started. The patient was closely monitored for behavioral, neurological, or systemic side effects. He tolerated therapy well without adverse effects. The patient's neurological status significantly improved with levodopa, including hypomimia, hypophonia, bradykinesia, and fluidity of gait. This case demonstrates that carbidopa-levodopa can be safely utilized to manage parkinsonism in an adult patient with HIV encephalopathy.

Spectrum of hyperosmolar hyperglycaemic state in neurology practice

Background & objectives:

Hyperosmolar hyperglycaemic state (HHS) is a medical emergency, but there is a paucity of studies reporting the spectrum of neurological manifestations of HHS. We, therefore, report the neurological spectrum, triggering factors and outcome of HHS in general neurology practice.

Methods:

The records of the patients with HHS were extracted from computerized hospital information system and those managed currently were prospectively included. The demographic, clinical manifestations, duration of diabetes and precipitating events such as infection, stress and stroke were noted. Patients with HHS were categorized into seizure, movement disorder and encephalopathy groups. Their electroencephalography, magnetic resonance imaging (MRI) findings and outcome were noted.

Results:

There were 17 patients with HHS (age range 40 and 75 yr) and seven were females. Seven patients were diabetic for five years, one for four years, one for one year and four were diagnosed after the occurrence of HHS. Four patients had epilepsia partialis continua persisting for 72-360 h, one patient had focal seizures and his MRI revealed T2 hyperintensity in frontal region in one patient and cerebellar vermian hyperintensity in another. All the five patients improved, but two had neurological deficits on discharge. Nine patients had encephalopathy which was precipitated by stroke in six patients, urinary infections in two and meningitis in one. Three females had hemichorea-hemiballismus syndrome, which was triggered by infections. Abnormal movements lasted 5-10 days and responded to correction of hyperosmolarity. Nine out of 17 patients improved completely whereas the remaining eight had partial recovery, these patients had stroke, ventilator-related complications or meningoencephalitis.

Interpretation & conclusions:

The most common presentation of HHS was encephalopathy (9) followed by seizure (5) and hemichorea-hemiballismus syndrome (3) which responded to the correction of hyperosmolar state.

Metabolomics approach discriminates toxicity index of pyrazinamide and its metabolic products, pyrazinoic acid and 5-hydroxy pyrazinoic acid

Pyrazinamide (PYZ)-an essential component of primary drug regimen used for the treatment and management of multidrug resistant or latent tuberculosis-is well known for its hepatoxicity. However, the mechanism of PYZ-induced hepatotoxicity is still unknown to researchers. Studies have shown that the drug is metabolized in the liver to pyrazinoic acid (PA) and 5-hydroxy pyrazinoic acid (5-OHPA) which individually may cause different degrees of hepatotoxicity. To evaluate this hypothesis, PYZ, PA, and 5-OHPA were administered to albino Wistar rats orally (respectively, at 250, 125, and 125 mg kg^-1 for 28 days). Compared to normal rats, PYZ and its metabolic products decreased the weights of dosed rats and induced liver injury and a status of oxidative stress as assessed by combined histopathological and biochemical analysis. Compared to normal controls, the biochemical and morphological changes were more aberrant in PA- and 5-OHPA-dosed rats with respect to those dosed with PYZ. Finally, the serum metabolic profiles of rats dosed with PYZ, PA, and 5-OHPA were measured and compared with those of normal control rats. With respect to normal control rats, the rats dosed with PYZ and 5-OHPA showed most aberrant metabolic perturbations in their sera as compared to those dosed with PA. Altogether, the study suggests that PYZ-induced hepatotoxicity might be associated with its metabolized products, where 5-OHPA contributes to a higher degree in its overall toxicity than PA.

CRTC1 nuclear localization in the hippocampus of the pilocarpine-induced status epilepticus model of temporal lobe epilepsy

cAMP response-element binding protein (CREB)-dependent genes are differentially expressed in brains of temporal lobe epilepsy (TLE) patients and also in animal models of TLE. Previous studies have demonstrated the importance of CREB regulated transcription in TLE. However, the role of the key regulator of CREB activity, CREB-regulated transcription coactivator 1 (CRTC1), has not been explored in epilepsy. In the present study the pilocarpine-induced status epilepticus (SE) model of TLE was used to study the regulation of CRTC1 during and following SE. Nuclear translocation of CRTC1 is critical for its transcriptional activity, and dephosphorylation at serine 151 residue via calcineurin phosphatase regulates cytoplasmic to nuclear transit of CRTC1. Here, we examined the localization and phosphorylation (Ser151) of CRTC1 in SE-induced rat hippocampus at two different time points after SE onset. One hour after SE onset, we found that CRTC1 translocates to the nucleus of CA1 neurons but not CA3 or dentate granule neurons. We further found that this CRTC1 nuclear localization is independent of Ser151 dephosphorylation since we did not detect any difference in dephosphorylation of Ser151 between control and SE animals at this time point. In contrast, 48 h after SE CRTC1 shows increased nuclear localization in the dentate gyrus (DG) of the SE-induced rats. At 48 h after SE, FK506 treatment blocked CRTC1 nuclear localization and dephosphorylation of Ser151. Our results provide evidence that CREB cofactor CRTC1 translocates into the nucleus of a distinct subset of hippocampal neurons during and following SE and this translocalization is regulated by calcineurin at a later time point following SE. Nuclear CRTC1 can bind to CREB possibly altering transcription during epileptogenesis.

Congenital posterior urethral diverticula causing bladder outlet obstruction in a young male

We present a case of 26-year-old male presenting with mild renal failure. Ultrasound findings were suggestive of posterior urethral valve, but micturating cystourethrogram and endoscopic evaluation confirmed the diagnosis of posterior urethral diverticulae. Transurethral resection of diverticulae was performed. Patient is voiding well and his renal function has stabilized.

Status of birth preparedness & complication readiness in Rewa District of Madhya Pradesh

OBJECTIVE

To assess status of birth preparedness & complication readiness among recently delivered and pregnant mothers in Rewa district of Madhya Pradesh.

METHODS

A cross-sectional descriptive study was conducted during September-November 2008 among a sample of 2022 study subjects (pregnant women in second/third trimester and/or mothers who have delivered within one year) selected through 30 cluster sampling technique. Investigators collected data using pre-designed schedule by house to house visit. 7 indicators were derived from elements of birth preparedness (BP)/complication readiness (CR). Mean of 7 indicators was taken as BP/CR Index.

RESULTS

Among 2022 women, 632 were pregnant and 1390 were recently delivered. BP/CR index was found to be 47.5. BP/CR index was significantly high in above poverty line families (50.9), higher educational level (63.6) and in service and business group (59.3). BP/CR were significantly higher in primi-para (50.9) as compared to multipara (40.1). Some indicators for example knowledge of danger sign (18.6%), about transportation facilities (18.6%) and 1st trimester ANC (24.1%) was very low.

Nephron sparing surgery: A single institution experience

Objective:

To report our experience in managing various benign and malignant renal tumors with nephron-sparing surgery.

Materials and Methods:

Records of patients who underwent nephron-sparing surgery (NSS) either through open or laparoscopic approach between May 1997 and June 2006 at our institution were reviewed. Patient and tumor-related characteristics, treatment modality and complications were noted.

Results:

There were 26 patients (29 renal units), including three with bilateral lesions who underwent nephron-sparing surgery. Mean age at surgery was 47.0 years (range 16-67 years). Mean tumor size was 4.7 cm (range 2-7.5 cm). Mean warm ischemia time was 41 min and 32.5 min, operative time 158 min and 186 min and blood loss 200ml and 85 ml in open (n=24) and laparoscopic approach (n=2) respectively. Complications were seen in five (19.2%) patients of whom two had postoperative bleeding requiring nephrectomy in one and angioembolization in another. One patient with persistent urinary leak required intervention. Local wound infection in one patient and incisional hernia in another were surgically managed. Histopathological profile revealed 13 (44.8%) benign lesions which included angiomyolipoma (eight), simple cyst (two), cortical adenoma (one), metanephric adenoma (one) and myelolipoma (one). The remaining 16 (55.2%) malignant lesions included renal cell carcinoma (15) and metastatic adenocarcinoma (one). At a mean follow-up of 38.6 months (range 1-91) no patient had local recurrence or distant metastasis. Cancer-specific survival was 100% and overall survival was 92.3%.

Conclusions:

Nephron-sparing surgery is a safe and effective alternative to nephrectomy in both benign and malignant lesions of the kidney.

Is Laparoscopic Approach Safe for Ectopic Pelvic Kidneys?

OBJECTIVE

To assess the feasibility and safety of a laparoscopic approach to pelvic kidneys for ablative and reconstructive surgery.

METHODS

Between January 2002 and February 2005, 6 patients with a left pelvic kidney; 2 with ureteropelvic junction obstruction, 2 with nonfunctioning kidney and 2 with pelvic stones were selected. These patients underwent dismembered pyeloplasty, simple nephrectomy and pyelolithotomy by laparoscopic approach. For pyeloplasty, omitting the prior retrograde stent facilitated dissection around the pelvis, which was identified first and then the ureter was traced downwards. Dismembered pyeloplasty was done by continuous sutures using 4-0 vicryl over a double-J stent placed antegradely. During nephrectomy, the ureter was identified over the iliac vessels and divided first. Subsequent dissection was carried out after lifting the kidney to identify ectopic renal vessels. Pyelolithotomy was performed for a large single pelvic stone after placing the ureteric catheter and confirming the stone's position by fluoroscopy.

RESULTS

One patient with pyelolithotomy was converted to open surgery while the others were completed laparoscopically. Mean hospital stay was 4.16 (range 3-5) days, blood loss 115 (range 30-300) ml and mean operative time was 170 (range 140-220) min. There were no post-operative complications. After pyeloplasty there was significant improvement in renal function and drainage pattern on diuretic scan at 11 and 12 months.

CONCLUSION

The laparoscopic approach provides all the benefits of a minimally invasive procedure to the patients. Due to the different locations of renal vessels, it is safe to approach the ureter first when performing nephrectomy. When performing pyeloplasty, omitting the prior stent placement helps in the identification and dissection of the renal pelvis.

Enterococcal resistance--an overview

Nosocomial acquisition of microorganisms resistant to multiple antibiotics represents a threat to patient safety. Here, we review the antimicrobial resistance in Enterococcus, which makes it important nosocomial pathogen. The emergence of enterococci with acquired resistance to vancomycin has been particularly problematic as it often occurs in enterococci that are also highly resistant to ampicillin and aminoglycoside thereby associated with devastating therapeutic consequences. Multiple factors contribute to colonization and infection with vancomycin resistant enterococci ultimately leading to environmental contamination and cross infection. Decreasing the prevalence of these resistant strains by multiple control efforts therefore, is of paramount importance.

Prognosticfactors in patients with renal cell carcinoma: is TNM (1997) staging relevant in Indian subpopulation?

BACKGROUND

RCC (Renal Cell Carcinoma) is a common genitourinary malignancy, but its behavior has not been studied in the Indian Subpopulation.

AIMS

The aim of this study was to assess the validity of 1997 AJCC TNM staging in Indian subpopulation and also to identify independent predictors for survival in patients having RCC.

SETTING AND DESIGN

Retrospective uncontrolled analysis of patients with RCC was performed at our centre.

MATERIAL AND METHODS

Medical records of patients of undergoing radical nephrectomy at our center between 1994 to August 2003 were identified retrospectively. Medical records of 178 patients were available for analysis. Patient characteristics, preoperative imaging and surgical details were reviewed. Each tumor was staged according to the 1997 AJCC TNM classification. Nuclear grade was assigned according to the Fuhrman's grading system.

STATISTICAL METHODS

Statistical analysis was performed using statistical software and descriptive statistics and survival functions were obtained. Univariate and multivariate analysis of factors affecting outcome of the patient were performed.

RESULTS

Mean follow up period was 42.3 months (range 3 to 108 months). Stage wise 5-year Cancer specific survival was 87.2% in stage 1 disease, 74.3% in stage 2, 36.4% in stage 3 and 3.1% in stage 4. Univariate analysis revealed that stage, grade and lymph node status were statistically significant (P=0.009, 0.007 and 0.003 respectively). Sub-classifying stage 1 tumors between tumor of less than 4 cm. and more than 4 cm. did not reveal any statistically significant difference in survival (P=0.32). Multivariate analysis model revealed that Fuhrman's grade and lymph node status were statistically significant (P=0.007 and 0.002 respectively).

CONCLUSION

This study validates the TNM (1997) staging for RCC as having significant survival impact in the Indian subpopulation. Sub-classifying stage 1 tumors between tumor of less than 4 cm. and more than 4 cm is not of much importance. Nuclear grade and lymph node involvement are important independent predictors of survival. Organ confined tumors with high nuclear grades need to be followed up more rigorously.

Correlation of radiological and clinical features of metanephric neoplasms in adults

The main objective was to determine the clinical and radiological features of metanephric neoplasms. The tumors were diagnosed on histopathological examination. The clinical data and imaging features were retrospectively analyzed. Between 1998 and 2003, 3 patients underwent radical nephrectomy for renal masses turning out as metanephric neoplasms on histopathology. Two of these tumors were metanephric adenoma (MA) and one was metanephric adenofibroma (MAF). Clinical and radiological features were reviewed. All patients were adult females who presented with flank pain. Tumor was detected on screening ultrasound as a hyperechoic lesion. In all cases CT showed a hyper-attenuating exophytic lesion with cystic areas that enhanced with IV contrast. Based on combination of clinical and imaging features it may be possible to prospectively identify metanephric neoplasms and thus avoid unnecessary radical nephrectomy in favor of conservative surgery.

Stones associated renal pelvic malignancies

BACKGROUND

The clinico-pathological characteristics of renal pelvic malignancies associated with stones were retrospectively analyzed.

AIMS

The main objective was to define the biological behavior and prognostic factors for these malignancies.

SETTINGS & DESIGN

The tumors were classified according to the pathological types. The clinical data, imaging features and pathological features were analyzed with relation to prognosis.

MATERIAL AND METHODS

Eighteen cases of malignancies associated with stone disease were retrospectively studied. The institute review board permitted the study.

RESULTS

High incidence (15/18) of squamous cell carcinoma (SCC) was noted. The prognosis in this group of patients was uniformly poor. The median survival time was 3.6 months in the SCC group, 7.5 months in the Transitional Cell Carcinoma (TCC) group and 24 months in the Adenocarcinoma (AC) group. Infectious and systemic symptoms were noted in the majority of the patients. Preoperative Imaging techniques revealed tumor in only 2 cases. Both underwent radical extirpation and the median survival is 18 months till date. In the other 16 patients, where the initial diagnosis was made only on histological analysis of incomplete nephrectomy specimens, the survival was 3.56 months. All patients had prolonged history of staghorn stone disease with associated non-functioning kidney. We found that the main prognostic factor was the stage of the disease.

CONCLUSIONS

Malignancies associated with stone disease have insidious onset of clinical symptoms and need a high degree of suspicion to identify them pre-operatively. The grave prognosis associated with incomplete excision makes it imperative to diagnose them earlier.

Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques

OBJECTIVE

To retrospectively compare the outcome of various techniques of substitution urethroplasty.

PATIENTS AND METHODS

Between 1989 and 2000, 109 patients (mean age 39.5 years) underwent substitution urethroplasty for recurrent anterior urethral strictures. Between 1989 and 1995 the procedure was by ventral placement of free grafts (bladder mucosa, buccal mucosa, penile skin) or penile skin flaps. From 1995 onwards the flaps and grafts (buccal mucosa) were applied either ventrally or dorsally. Stricture recurrence and the complications associated with each technique were compared.

RESULTS

Ventral onlay repairs were associated with a higher incidence of complications than dorsal repairs, e.g. postvoid dribbling (39% vs 23%, P = 0.01), ejaculatory dysfunction (20% vs 5%, P = 0.03) and flap/graft pseudo-diverticulum or out-pouching (26% vs 2.6%, P = 0.01). Superficial penile skin necrosis was significantly more common with the use of penile skin flaps than with free grafts. There was no significant difference in stricture recurrence, erectile dysfunction and residual penile deformity among the various techniques.

CONCLUSIONS

Dorsal free graft/flap onlay urethroplasty gives better results than ventrally placed free grafts/flaps. Dorsal onlay buccal mucosal urethroplasty is a versatile procedure and associated with fewer complications than other substitution methods.

Dorsal placement of the pedicled preputial/penile onlay flap for anterior urethral stricture: is it more logical?

OBJECTIVES

We present our preliminary experience in the management of inflammatory anterior urethral strictures with a dorsally/dorsolaterally placed penile/preputial vascularized flap and discuss the distinct advantages of this procedure over a traditional ventrally placed flap.

METHODS

Twelve patients (age, 20-66 years; mean age, 40.5 years) with recurrent inflammatory strictures of the penile and/or bulbar urethra (penile, 2; bulbar, 5 and bulbopenile, 5) were treated with dorsally/dorsolaterally placed penile/preputial (penile skin, 5; prepuce, 7) vascularized flap substitution urethroplasty. Prior to surgery, 7 patients had suprapubic cystostomy for acute urinary retention and 5 had a mean peak flow rate of 6.2 ml/sec. Inferior pubectomy was performed as an adjunct in two patients to facilitate proximal placement of the flap. Follow-up (5 to 24 months; mean, 15.5) included uroflowmetry and retrograde urethrograms at 6, 12 and 18 months, and thereafter as required.

RESULTS

The mean stricture length was 5.8 cm (range, 3 to 12 cm) and all strictures were associated with dense spongifibrosis. Temporary urethral fistulae, which healed spontaneously, occurred in 4 patients. The clinical and radiological outcome during the mean follow up of 15.5 months was gratifying. The mean peak flow rate improved to 24.2 ml/sec. No stricture recurrence has been noted to date. Sacculation of the flap, diverticulum formation and post-void dribble have not been encountered. None of the patients developed chordee or erectile dysfunction.

CONCLUSIONS

Dorsal onlay preputial/penile flap urethroplasty is a versatile procedure in the treatment of inflammatory anterior urethral strictures. The dorsal pedicle flap may be anatomically and functionally more logical as compared to the traditional ventrally placed flap.

Acute urinary retention: defining the need and timing for pressure-flow studies

OBJECTIVE

To investigate the utility of "late" pressure-flow studies in predicting the outcome of prostatectomy for acute urinary retention.

PATIENTS AND METHODS

Fifty-eight patients with acute urinary retention were prospectively assessed using the International Prostate Symptom Score and pressure-flow studies at a median (range) of 24 (13-60) days after the episode of retention, and before transurethral resection of the prostate. Bladder outlet obstruction and bladder contractility were graded using a modified adaptation of Schäfer's passive urethral linear resistance relation.

RESULTS

Fifty-six (97%) patients generated a voluntary detrusor contraction, with a mean (range) detrusor pressure at maximum flow of 72.7 (5-144) cmH2O, and 43 (75%) patients were deemed to be obstructed. Eight (16%) patients failed to void after prostatectomy and required clean intermittent catheterization. There were statistically significant differences between successful and unsuccessful patients in mean (SD) age, at 66.30 (6.9) vs 78.8 (2.6) years (P = 0.001), detrusor instability (49% vs 0%, P = 0.01), inability to void during pressure study (8% vs 75%, P = 0.001), and maximal detrusor pressure in the voiding phase, at 80 (36.0) vs 19 (11.2) cmH2O (P = 0.001).

CONCLUSIONS

In patients with acute urinary retention, pressure-flow studies undertaken after a period of adequate bladder rest (> 3 weeks) are useful in predicting the surgical outcome. Old age, absence of bladder instability, inability to void during the pressure-flow study and a maximal detrusor pressure of < 20 cmH2O are associated with a poor outcome after prostatectomy.

Dorsal or ventral placement of the preputial/penile skin onlay flap for anterior urethral strictures:does it make a difference?

OBJECTIVE

To report our experience in managing complex anterior urethral strictures with a dorsally/dorsolaterally placed penile/preputial vascularized flap, and to discuss the advantages of this procedure over a traditional ventrally placed flap.

PATIENTS AND METHODS

Between 1995 and 1999, 40 patients (mean age 40.5 years) with recurrent strictures of the pendulous and/or bulbar urethra were treated with longitudinal penile/circumpenile flap substitution urethroplasty. Nineteen patients underwent dorsal placement of the flap as an onlay (DO), whereas 21 patients had a ventral onlay (VO). Five patients needed inferior pubectomy to facilitate high proximal placement of the flap.

RESULTS

Both groups had statistically similar ages, number of previous interventions, stricture site, length and follow-up. After a median follow-up of 27.5 months, the stricture recurred in three (24%) of the VO and two (11%) of the DO groups (P > 0.05). One patient in the VO group required surgical closure of the urethral fistula. Flap pseudo-diverticulum and/or sacculation with postvoid dribble occurred in six patients in the VO and none in the DO group (P = 0.01).

CONCLUSIONS

Dorsal placement of the pedicled flap is anatomically and functionally more appropriate than the traditional VO placement. DO preputial/penile flap urethroplasty is a versatile procedure and can be applied even for long anterior urethral strictures, including reconstruction of the meatus and high proximal bulbar strictures.

Modified bulbar urethral sling procedure for the treatment of male sphincteric incontinence

BACKGROUND AND PURPOSE

Urinary incontinence secondary to intrinsic sphincter deficiency is a debilitating condition for the patient and an ordeal for the urologist. Because of the complexity of reconstructive surgical techniques and the prohibitive cost of the prosthetic devices used, there is a need for a simple procedure. We herein report our experience in managing urinary incontinence secondary to sphincteric incompetence in nine consecutive patients using a modified bulbar urethral sling procedure over a period of 2 years.

PATIENTS AND METHODS

In eight patients, the incontinence followed open prostatectomy or transurethral resection for benign prostatic hyperplasia, and one patient had incontinence following fulguration of posterior urethral valves. Our procedure uses bolsters that are suspended from the rectus fascia, and a hammock made of a folded Dacron patch is placed beneath the bulbospongiosus muscle to form a sling.

RESULTS

All patients were continent postoperatively, with only mild stress leakage in the erect posture, during a mean follow-up of 12.2 months (range 6-22 months) and required one or two improvised pads per day to remain continent during the daytime. Persistent perineal infection necessitated removal of the sling in one patient. One patient required clean intermittent catheterization for a short period postoperatively.

CONCLUSION

This modified bulbar urethral sling procedure is a simple yet effective method to treat sphincteric deficiency of any cause.

Cyclosporin A withdrawal in live related renal transplantation: long-term results

Cyclosporin A (CsA) withdrawal after 1 yr of stable graft function has been shown to be beneficial in cadaveric renal transplantation. This strategy could be even more suitable for 'immunologically advantaged' grafts as in live related renal transplantation. We report the long-term outcome of patients in a live related transplantation programme undergoing early (between 1989 and 1992) and late (1993 onwards) CsA withdrawal as compared with those on long-term low dose CsA (1993 onwards). Two-hundred and fifty-two patients were divided into three groups based on the following immunosuppressive protocol: group ECyW (n=99), early CsA withdrawal (9 months after transplantation); group LCyW (n=44), late CsA withdrawal (median 16 months, range 13--22 months after transplantation); and group LDCy (n=109), long-term low dose CsA. The median period of follow-up was 66 months after transplantation (range 43--84 months). There was no difference in the actuarial 6-yr patient or graft survival among the three groups. Acute rejection episodes were more frequent in ECyW (54.4%) than in LDCy (31.8%) and LCyW (23.8%) (p=0.001). The risk of developing late (> or =9 months) acute rejection was highest in ECyW 32/99 (32.3%) as compared with LCyW 8/44 (18.4%; p=0.08) and LDCy 8/109 (7.3%; p=0.0001). Of the 32 ECyW patients who developed acute rejection episodes after CsA withdrawal, 13 (40.6%) lost their grafts either due to uncontrolled acute rejection or to chronic rejection. Chronic rejection was higher in ECyW (24%) than in LCyW (11%; p=0.04) and LDCy (17%; p=0.17). Antihypertensive requirement was highest in patients maintained on low dose CsA. Graft function, as measured by serum creatinine levels, was significantly better in LCyW (1.24+/-0.4 mg%) as compared with ECyW (1.49+/-0.5 mg%) and LDCy (1.48+/-0.6 mg%). Early CsA withdrawal after live related renal transplantation is associated with a significant risk of acute rejection and subsequent chronic rejection. Slow withdrawal after 1 yr is safe and more economical than the long-term administration of low dose CsA.

Localization and treatment of an oxidation-sensitive defect within the TCR-coupled signalling pathway that is associated with normal and premature immunologic aging

The age-dependent decline in the ability of T-cells to mount a proliferative response both to mitogens and to receptor ligation is due to an age-related defect in signal transduction, since functional expression of receptors displayed by aged T-cells is not reduced. We show here that, although turnover of phosphatidylinositol is not diminished, total inositol-trisphosphate generation decreases after T-cell receptor (TCR) ligation, resulting in reduced flux of calcium. Defective inositol-trisphosphate generation may result from impaired activation of phospholipase C due to decreased tyrosine phosphorylation of this enzyme after ligation of CD3 in aged cells. Proliferation of aged T-cells, which is normally 10-30% of the level of young controls, was enhanced almost tenfold by glutathione or its precursor N-acetyl L-cysteine (NAC), reached levels of young controls and was accompanied by restoration of normal inositol-trisphosphate generation and calcium flux. These findings suggest that the T-cell antigen receptor is associated with at least two types of signal transduction modules. The first depends on synthesis and phosphorylation of phosphatidylinositol that is independent of sulphydryl groups and is not affected by senescence. The second transduction module includes tyrosine phosphorylation and activation of phospholipase C. This module is regulated by glutathione levels and is diminished in aged T-cells, that are deficient in reducing equivalents which support the PLC gamma-dependent generation of inositol-trisphosphate from phosphatidylinositol derivatives. This underlying biochemical defect also occurs earlier in strains which display premature aging due to differences in the H-2 region of MHC I.

Cell-mediated cytotoxicity: a predictor of chronic rejection in pediatric HLA haploidentical renal transplants

BACKGROUND

Recipient antidonor cytotoxic T-cell activity has been associated with graft loss and acute rejection in renal allograft recipients. The role of immunologic mechanisms in the development of chronic graft rejection is controversial. We analyzed all living related renal transplants performed at Children's Hospital (Boston, MA) from 1983 to 1995 to assess whether cell-mediated cytotoxicity, determined in vitro and measured before transplantation, was predictive of chronic rejection.

METHODS

Eighty-three patients were studied retrospectively. Fifty-seven patients with one haplotype-matched renal transplants from living related donors were studied to determine the association between cell-mediated lympholysis (CML) level, acute rejection, chronic rejection, and graft failure. Acute rejection was defined by the decision to treat. Chronic rejection was defined by histology and/or the absolute serum creatinine value using an increasing serum creatinine level >1.0 mg/dl for children less than 3, a creatinine level >1.5 mg/dl for children between 3 and 10 years of age, and a creatinine level >2.0 mg/dl for children above 10 years of age. Return to dialysis or retransplantation was considered graft failure.

RESULTS

Of the 57 haploidentical patients, there were 33 males and 24 females. The mean age at transplant was 11.1 years (SD=6.7). Twelve patients developed chronic rejection, 24 patients developed acute rejection, and 7 patients had graft failure. Pretransplant cytotoxic T lymphocyte activity was associated with chronic rejection (P=0.001) and graft failure (P=0.013) but only marginally with acute rejection (P=0.058). Controlling for age and sex, Cox's proportional hazards model revealed that CML level was predictive of time to chronic rejection (P<0.01) but not acute rejection (P=0.11). It was estimated that every 1-unit increase in CML level raises the monthly risk of chronic rejection by 7%. Ten children received HLA-identical kidneys from their siblings. There were no episodes of chronic rejection after 5 years. Two patients with high CML levels had episodes of acute rejection; both patients responded to treatment.

CONCLUSION

Our data demonstrate an association between pretransplant cell-mediated cytotoxicity and the occurrence of chronic rejection in living related one-haploidentical renal transplants in pediatric patients.

Anti-interleukin-2 receptor monoclonal antibody therapy supports a role for Th1-like cells in HgCl2-induced autoimmunity in rats

Brown-Norway (BN) rats injected with HgCl2 develop an autoimmune disease characterized by a T-dependent polyclonal B-cell activation. Increase in major histocompatibility complex class II molecule expression on B cells concomitant with enhancement of serum IgE concentration supports the involvement of the T helper 2 (Th2)-like subset in the induction of the disease. The mercury disease is autoregulated and does not develop in Lewis (LEW) rats. Considering the reciprocal regulation, well defined in mice, between the Th1 and Th2 subsets, we addressed the role of the Th1-like subset in this disease. Brown-Norway and LEW rats injected with HgCl2 were treated with NDS61, a mouse anti-rat-IL-2R MoAb that blocks mainly Th1 cells. Data reported herein show that: (1) HgCl2 treatment does not modify either the percentage of IL-2R+ cells or IL-2R expression in both BN and LEW rats; (2) treatment of BN rats with NDS61 MoAb does not modify the induction phase of the mercury disease but delays in part the regulation phase; (3) such a treatment leads to some immune abnormalities in LEW rats; (4) HgCl2 markedly potentiates the anti-mouse Ig antibody response in BN rats which probably limits the effect of this treatment. This study supports a role for the Th1-like subset in HgCl2-induced autoimmunity in the rat.

Patients and communities

In 1992, Chicago's Mount Sinai Hospital Medical Center was awarded the Foster G. McGaw Prize for outstanding community service. This article describes Mount Sinai's commitment and some of the programs that led to its receiving the prize, which is funded by The Baxter Foundation and administered by The Hospital Research and Educational Trust of the American Hospital Association.

Cellular basis of defective cell-mediated lympholysis in atopic dermatitis

Peripheral blood lymphocytes (PBL) from patients with atopic dermatitis (A.D.) were examined for their capacity to generate cytotoxic T lymphocytes (CTL) during mixed lymphocyte cultures (MLC). Cell-mediated lympholysis (CML) activity, but not proliferative response during MLC, was significantly decreased (p less than 0.01) in patients with A.D. (n = 19) compared with normal controls (n = 19) or patients with other skin diseases (n = 14). Regression analysis revealed a significant correlation (p less than 0.001) between CML activity and the percentage of circulating T8+ suppressor/cytotoxic T cells. Deficient CML activity in A.D. patients, however, was not corrected when isolated autologous T4+ and T8+ cells were recombined at a normal ratio (2:1) of T4+ to T8+ cells. Examination of CML activity in co-cultures of isolated T4+ and T8+ cells obtained from two A.D. patients and their respective HLA-identical healthy siblings indicated that the defect in CML resided in both the helper/inducer T4+ cells and the effector T8+ cells. The defective cytotoxic T cell function reported in the present study may account for the increased susceptibility of patients with A.D. to develop severe viral infections.

Cellular basis of defective cell-mediated lympholysis in atopic dermatitis

Peripheral blood lymphocytes (PBL) from patients with atopic dermatitis (A.D.) were examined for their capacity to generate cytotoxic T lymphocytes (CTL) during mixed lymphocyte cultures (MLC). Cell-mediated lympholysis (CML) activity, but not proliferative response during MLC, was significantly decreased (p less than 0.01) in patients with A.D. (n = 19) compared with normal controls (n = 19) or patients with other skin diseases (n = 14). Regression analysis revealed a significant correlation (p less than 0.001) between CML activity and the percentage of circulating T8+ suppressor/cytotoxic T cells. Deficient CML activity in A.D. patients, however, was not corrected when isolated autologous T4+ and T8+ cells were recombined at a normal ratio (2:1) of T4+ to T8+ cells. Examination of CML activity in co-cultures of isolated T4+ and T8+ cells obtained from two A.D. patients and their respective HLA-identical healthy siblings indicated that the defect in CML resided in both the helper/inducer T4+ cells and the effector T8+ cells. The defective cytotoxic T cell function reported in the present study may account for the increased susceptibility of patients with A.D. to develop severe viral infections.

Platelet HLA typing and cross-matching by a direct microcytotoxic assay. A new method employing carboxyfluoresceindiacetate-stained platelets

Carboxyfluoresceindiacetate-labelled platelets can be used in direct microcytotoxic assays for the purpose of typing platelets for a number of antigenic determinants, such as HLA and beta-2 microglobulin. The assay when used in direct platelet cross-matching, where thrombocytopenic patient sera were screened, resulted in the uncovering of many extrapositive and weakly positive cross-matches not identified by the lymphocyte cross-match. The simplicity and rapidity of this new method makes it an attractive alternative for future use in research and clinical studies.

Use of monocytes in HLA-A, B, C and DR typings

A simple method of improved serologic typing of monocytes for HLA-A, B, C and DR specificities is described. The method employs monocytes recovered from frozen samples of peripheral blood mononuclear cells; it chiefly involves pretreatment of monocytes with 0.01% iodoacetamide (IAA) prior to typing. The advantage of this method lies principally in the lowering of the background nonspecific cytotoxicities and false positive readings upon IAA addition to the monocyte preparations. Using this method monocytes can be typed for HLA-A, B, C determinants. Although the addition of IAA results in substantial typing improvements, we found the assignment of A, B, C specificities difficult due to the presence of extra positive reactions when monocytes were compared to T lymphocyte typings. probably due to the presence of DR or monocyte specific antibodies in the routinely used HLA antisera. This method proved to be most useful in DR typings where mono cytes in the presence of IAA were compared with autologous B cells in the absence of IAA. The differences in typings due to a decrease in false positive cytotoxic readings were significantly in favor of using IAA treated monocytes in DR typings (P < 0.0001). The use of IAA in the course of B cell or T cell typings bad no adverse consequences on either A, B, C or DR typings, respectively. Our results indicate a potential usefulness for the use of IAA in typing monocytes HLA determinants in general and for the DR determinants in particular.

B lymphocyte determinants in immunoglobulin A nephropathy

Because of our prior demonstration of a strong association betwen a specific B lymphocyte determinant and the occurrence of chronic membranoproliferative glomerulonephritis and the demonstration by others of the frequent concurrence of an IgA deposit disease, anaphylactoid purpura nephritis,with HLA-BW35, we conducted an investigation of the association among Minnesota Caucasians of the HLA markers BW35, DW1 and B lymphocyte determinants identified by three alloantisera with IgA nephropathy and the syndrome of recurrent macroscopic hematuria. The highly significant association between HLA-BW35, DW1, and B cell antigens identified by alloantisera L, B, and F, present in 50 normal Minnesota Caucasians, was not observed in 18 Minnesota patients with IgA nephropathy. The frequency of HLA-DW1 was the same among controls and patients, whereas the relative risk of developing IgA nephropathy was demonstrated to be increased 4- to 5-fold in the presence of the B cell antigens identified by alloantisera L and B. These sera appear to identify determinants on B lymphocytes associated with the disease state and possibly not intimately related to the HLA-D region. These findings emphasize the possible informativeness of defining B cell alloantisera on disease panels.