Supine and upright urodynamic evaluation of incontinent ileovesicostomy in wheelchair-bound adults with neurogenic bladder.

STUDY DESIGN: Prospective. OBJECTIVES: To evaluate detrusor leak point pressure (DLPP) of the incontinent ileovesicostomy in the supine and upright position. SETTING: California, USA. METHODS: Urodynamic assessment of patients, 6-36 months after ileovesicostomy, was performed in the supine position and then immediately repeated in the upright position in the patient's wheelchair. RESULTS: Upright and supine urodynamic evaluation was performed following the Good Urodynamic Practice Guidelines. Ten patients (seven male and three female) were evaluated. Etiology of neurogenic bladder (NGB) included seven patients with spinal cord injury and one patient each with multiple sclerosis, myelomeningocele and cerebral palsy. Mean DLLP in the supine position was 8.6 cm H2O (range 2-20); mean DLLP in the sitting position was 11.6 cm H2O (range 5-25). Mean change in DLPP from supine to sitting was 3.1 cm H2O (range 1-12). The difference in DLPP between supine and sitting is statistically significant (P=0.0429); however, this does not appear to be a clinically significant difference. CONCLUSION: Ileovesicostomy is a safe option for management of the NGB in a selected patient population. A small and clinically insignificant or no change in DLPP was documented in all ten patients. We demonstrated that DLPP remains low within an ileovesicostomy while in the sitting position.

E2F1 regulates autophagy and the transcription of autophagy genes.

The retinoblastoma pathway is often inactivated in human tumors resulting in deregulated E2F activity that can induce both proliferation and cell death. Although the role of E2F in apoptosis is well characterized, little is known regarding its putative participation in other cell death pathways. We show here that activation of E2F1 upregulates the expression of four autophagy genes-microtubule-associated protein-1 light chain-3 (LC3), autophagy-related gene-1 (ATG1), ATG5 and damage-regulated autophagy modulator (DRAM). E2F1-mediated induction of LC3, ATG1 and DRAM is direct and indeed, endogenous E2F1 can be found bound to regions encompassing the promoters of these genes. Regulation of ATG5 by E2F1 is indirect. Importantly, we demonstrate that E2F1 activation enhances autophagy and conversely, reducing endogenous E2F1 expression inhibits DNA damage-induced autophagy. These studies identify E2F1 as a transcriptional regulator of autophagy, and for the first time establish a role for E2F1 in DNA damage-induced autophagy.

Novel link between E2F and p53: proapoptotic cofactors of p53 are transcriptionally upregulated by E2F.

The E2F1 transcription factor is a critical downstream target of the tumor suppressor RB. When activated, E2F1 induces cell proliferation. In addition, E2F1 can induce apoptosis via both p53-dependent and p53-independent pathways. A number of E2F-regulated genes, including ARF, ATM and Chk2, contribute to E2F-induced p53 stabilization. However, it is not known how E2F directs p53 activity towards apoptosis rather than growth arrest. We show that E2F1 upregulates the expression of four proapoptotic cofactors of p53--ASPP1, ASPP2, JMY and TP53INP1--through a direct transcriptional mechanism. Adenovirus E1A protein also induces upregulation of these genes, implicating endogenous E2F in this effect. TP53INP1 was shown to mediate phosphorylation of p53 on serine 46. We demonstrate that activation of E2F1 leads to phosphorylation of p53 on serine 46 and this modification is important for E2F1-p53 cooperation in apoptosis. Overall, these data provide novel functional links between RB/E2F pathway and p53-induced apoptosis.

Nuclear membrane protein LAP2beta mediates transcriptional repression alone and together with its binding partner GCL (germ-cell-less).

LAP2beta is an integral membrane protein of the nuclear envelope involved in chromatin and nuclear architecture. Using the yeast two-hybrid system, we have cloned a novel LAP2beta-binding protein, mGCL, which contains a BTB/POZ domain and is the mouse homologue of the Drosophila germ-cell-less (GCL) protein. In Drosophila embryos, GCL was shown to be essential for germ cell formation and was localized to the nuclear envelope. Here, we show that, in mammalian cells, GCL is co-localized with LAP2beta to the nuclear envelope. Nuclear fractionation studies reveal that mGCL acts as a nuclear matrix component and not as an integral protein of the nuclear envelope. Recently, mGCL was found to interact with the DP3alpha component of the E2F transcription factor. This interaction reduced the transcriptional activity of the E2F-DP heterodimer, probably by anchoring the complex to the nuclear envelope. We demonstrate here that LAP2beta is also capable of reducing the transcriptional activity of the E2F-DP complex and that it is more potent than mGCL in doing so. Co-expression of both LAP2beta and mGCL with the E2F-DP complex resulted in a reduced transcriptional activity equal to that exerted by the pRb protein.

Ras induces elevation of E2F-1 mRNA levels.

Both E2F-1 and Ras play pivotal roles in the regulation of cell proliferation, and in some biological settings, they collaborate in cell transformation. We show here that activated Ras induces an increase in E2F-1 mRNA and protein levels. This Ras-induced increase in E2F-1 levels is dependent on both MEK and PKB, and it is retinoblastoma-independent. The effect of Ras on the up-regulation of E2F-1 mRNA is at the level of mRNA stability. Our data describe a novel functional link between Ras and the retinoblastoma/E2F pathway. Furthermore, we suggest that one of the molecular mechanisms underlying the collaboration between Ras and E2F-1 involves a Ras-induced elevation of transcriptionally active E2F-1 levels.

Once-daily treatment of patients with hypertension: a placebo-controlled study of amlodipine and benazepril vs amlodipine or benazepril alone.

OBJECTIVE: To compare the efficacy, tolerability, and safety of once-daily therapy with amlodipine 5 mg/benazepril 10 mg vs amlodipine 5 mg, benazepril 10 mg, and placebo. DESIGN: Randomised, double-blind, placebo-controlled, parallel-group, multicentre trial. SETTING: Twenty-two clinical centres, including private practice groups and academic research clinics. PATIENTS: A total of 530 patients between 21 and 80 years of age with essential hypertension were screened for the study, and 454 were randomised to treatment with amlodipine 5 mg/benazepril 10 mg, amlodipine 5 mg, benazepril 10 mg, or placebo for 8 weeks. RESULTS: Amlodipine 5 mg/benazepril 10 mg produced greater reductions from baseline in sitting diastolic blood pressure than amlodipine 5 mg (P < 0.03), benazepril 10 mg (P < 0.001), and placebo (P < 0.001). The response rate in the amlodipine 5-mg/benazepril 10-mg treatment group (66.4%) was better than that observed in the amlodipine 5-mg (50.0% P < 0.02), benazepril 10-mg (38.3% P < 0.001), and placebo (24.4% P < 0.001) groups. There was no significant difference in heart rate among the four groups. The incidence of oedema in the amlodipine 5-mg/benazepril 10-mg (1.7%) group was somewhat less than that in the amlodipine 5-mg (4.5%) group. CONCLUSIONS: Therapy with amlodipine 5 mg/benazepril 10 mg was well tolerated and was superior to amlodipine 5 mg, benazepril 10 mg, and placebo in reducing sitting diastolic blood pressure in patients with essential hypertension.

Posterior vaginal wall prolapse: transvaginal repair of pelvic floor relaxation, rectocele, and perineal laxity.

PURPOSE: Posterior vaginal wall laxity is one manifestation of pelvic organ prolapse in the female. Recognition and repair of the inherent anatomical defects present in this condition are essential in order to ensure a satisfactory surgical result. METHODS AND MATERIALS: A successful operation for posterior vaginal wall prolapse will often involve repair of three discreet abnormalities in support of the posterior vaginal wall, including the pelvic floor, posterior vaginal wall fascia, and perineal musculature. An overaggressive repair is to be assiduously avoided as this can lead to excessive narrowing of the vaginal canal and considerable postoperative symptoms including dyspareunia. RESULTS: Durable restoration of anatomical support can be achieved in >80% of cases. Functional results in symptomatic patients undergoing posterior vaginal wall prolapse repair do not appear to be as successful in some areas. CONCLUSIONS: Successful surgical repair of posterior vaginal wall prolapse requires a thorough understanding of the anatomy and pathophysiology involved in this condition. A careful anatomical dissection and reconstruction will result in successful anatomical repair in the majority of patients with minimal morbidity.

Effects of nefazodone on body weight: a pooled analysis of selective serotonin reuptake inhibitor- and imipramine-controlled trials.

BACKGROUND: Evidence suggests that the newer antidepressant drugs may differ with respect to their effects on body weight, especially during long-term treatment. However, the published data about treatment-emergent weight change with the newer antidepressants are limited. Most reports of unexpected selective serotonin reuptake inhibitor (SSRI)-associated weight gain are anecdotal or from small controlled trials. To determine if differences exist among the newer antidepressants, the authors retrospectively analyzed data from clinical trials comparing nefazodone with SSRIs and with imipramine. METHOD: Weight change data supplied by Bristol-Myers Squibb from 6 completed clinical trials comparing the antidepressant nefazodone (N = 523) with 3 SSRIs, fluoxetine, sertraline, and paroxetine (N = 513), as well as 3 trials comparing nefazodone (N = 225) with the tricyclic antidepressant imipramine (N = 224) were analyzed. In all studies, nefazodone was found to be equal in efficacy to the comparator antidepressants. Studies that included both acute and long-term treatment phases were included in the analysis. Acute phases of the trials lasted either 6 or 8 weeks, and long-term phases varied in duration from 16 to 46 weeks. The analysis included summarizing the number and percentage of patients in each group with a > or = 7% change in body weight from baseline at any point in the long-term and acute phases, at endpoint, and at week 16 of the long-term phases. RESULTS: Using 7% or greater weight change as the measure of clinical significance, 4.3% of SSRI-treated patients had lost weight at any point in the acute phase versus 1.7% of those treated with nefazodone (p = .017). However, at any point during the long-term phase, significantly more SSRI-treated patients than nefazodone-treated patients showed a significant increase in body weight (17.9% vs. 8.3%; p = .003). At any point in the acute phase, significantly more imipramine-treated patients than nefazodone-treated patients had a 7% or greater increase in body weight (4.9% vs. 0.9%; p = .027), and for the long-term phase the comparison yielded 24.5% versus 9.5%. The difference during the long-term phase was statistically significant in women (p = .017), but not in men (p = .078) due to the small numbers of men in each group. CONCLUSION: SSRIs caused more weight loss during short-term treatment but more weight gain during long-term treatment. These results lend support to the observation that some antidepressants have a greater expected risk of weight gain than others during long-term therapy.

Expression analysis using DNA microarrays demonstrates that E2F-1 up-regulates expression of DNA replication genes including replication protein A2.

The transcription factor E2F-1 plays a pivotal role in the regulation of G1/S transition in higher eukaryotes cell cycle. We used a cell line containing an inducible E2F-1 and oligonucleotide microarray analysis to identify novel E2F target genes. We show that E2F-1 up-regulates the expression of a number of genes coding for components of the DNA replication machinery. Among them is the gene coding for the 32 Kd subunit of replication protein A (RPA2). Replication protein A is the most abundant single strand DNA binding complex and it is essential for DNA replication. We demonstrate that RPA2 is a novel E2F target gene whose expression can be directly regulated by E2F-1 via E2F binding sites in its promoter. In addition, expression of Topoisomerase IIalpha and subunit IV of DNA polymerase alpha is also up-regulated upon E2F-1 induction. Taken together, these results provide novel links between components of the DNA replication machinery and the cell growth regulatory pathway involving the Rb tumor suppressor and E2F.

Continence mechanism based on a modified ileocecal valve.

PURPOSE: We describe the technique and results of a simply constructed continence mechanism for continent urinary diversion to the skin based on the ileocecal valve. MATERIALS AND METHODS: During a 3-year period 28 patients underwent construction of a continent stoma using the ileocecal valve; 23 patients were available for evaluation. The various indications for lower urinary tract reconstruction in this patient population included malignancy (4), neurogenic bladder (11), and urethral dysfunction (8). The continence mechanism is provided by the ileocecal valve, with tapering of the distal ileal segment with an absorable stapling device and then securing the catheterizable ileal segment to the serosa of the cecum along an opened taenia to provide an additional level of continence to the ileocecal valve. RESULTS: Continence was achieved in 83% (19 of 23) of patients. Two patients required revision and are now dry, and two patients have not undergone revision and remain wet. No patients have had problems with difficult or traumatic catheterization of the limb or peristomal hernia. One case of stomal stenosis was identified and treated with an outpatient revision. CONCLUSIONS: This technique for construction of a continence mechanism for a continent cutaneous urinary reservoir is simple to create, reliable, and without excess morbidity.

Right intrathoracic renal ectopia: a case report and review of the literature.

We report a case of right intrathoracic renal ectopia associated with a previously unreported congenital anomaly (trisomy 21) and review of the literature.

Mitotic separation of daughter cells in the human lymphoma B cell line Daudi involves L-selectin engagement and shedding.

BACKGROUND AND OBJECTIVE: A novel role for shedding of the surface molecule L-selectin has been proposed as an adjunctive phenomenon during cell detachment from marrow stroma or vessel endothelium. We wished to examine whether variations in expression of L-selectin on a lymphoma B cell line were linked to shedding. DESIGN AND METHODS: Mapping of L-selectin expression on the surface of Daudi lymphoma cells was performed by flow cytometry, fluorescence microscopy, and electron microscopy. Levels of shed L-selectin were evaluated by Western blotting of culture supernatants. Evaluation of cell cycle and proliferative activity was performed by flow cytometry. RESULTS: Large Daudi cells in S+G(2)/M phases were L-selectin positive, whereas small Daudi cells in G(0)/G(1) phase were L-selectin negative. During mitosis, L-selectin was distributed along the cleavage furrow, and gradually lost. Electron microscopy revealed that separating Daudi cells were negative for L-selectin on the entire surface, except minute aggregates of L-selectin within the cleavage furrow. Addition of agents known to interfere with the ligand-binding portion of L-selectin (sulfatides, MoAbs: Lam1.3 and TQ1) results in loss of L-selectin. Removal of L-selectin by digestion with chymotrypsin inhibits Daudi proliferation. The MoAb FMC46 did not interfere with proliferation. Proliferating Daudi cells produced large quantities of shed L-selectin. Inhibition of Daudi proliferation resulted in levels of shed L-selectin below the limit of detection. INTERPRETATION AND CONCLUSIONS: L-selectin is re-distributed on the cell surface of Daudi cells during the last phase of mitosis, in which plasma membrane invagination occurs between newly formed daughter cells. Shedding of L-selectin is involved in the cytokinesis of Daudi cells.

4-Defect repair of grade 4 cystocele.

PURPOSE: The 4-defect repair of grade 4 cystocele corrects discrete and severe deficiencies of vesicourethral support. We describe this technique used during pelvic reconstruction in 130 women. MATERIALS AND METHODS: During a 3-year period 130 patients (age range 35 to 96 years) underwent repair of grade 4 cystocele using the 4-defect repair technique. Cystocele repair had been performed in 60 patients (46%) and hysterectomy had been performed in 85 (65%). A "goalpost incision" is used in the vaginal wall to facilitate separation of the wall from underlying perivesical fascia, entry into the retropubic space, and exposure of the urethropelvic ligament, cardinal ligament and perivesical fascia. The 4 polypropylene sutures are used to provide an anterior vaginal wall sling which is modified to incorporate perivesical fascia and cardinal ligaments. Central defect repair is achieved by approximation of the cardinal ligaments and midline plication of the perivesical fascia over absorbable mesh. RESULTS: A total of 112 patients were available for followup which ranged from 6 to 42 months (mean 21). Repair of grade 4 cystocele was accompanied by other transvaginal repairs in 94 patients (83%), including rectocele repair in 81, hysterectomy in 22 and enterocele repair in 31. Of the patients 92% had excellent objective and subjective results for anatomical cystocele repair. Of the patients with preoperative stress urinary incontinence 90% had excellent or good subjective results. De novo urge incontinence was seen in 7% of patients. CONCLUSIONS: The 4-defect repair technique relies on anatomical restoration of 4 distinct deficiencies of pelvic support and is highly effective for relief of symptoms of grade 4 cystocele.

Prognostic markers in bladder cancer: a contemporary review of the literature.

PURPOSE: We provide a contemporary review of bladder tumor markers and summarize their role as prognostic indicators. MATERIALS AND METHODS: A comprehensive review of the literature on prognostic markers for transitional cell carcinoma of the bladder was performed. RESULTS: Intense research efforts are being made to identify and characterize better various bladder cancers and their true biological potential. The need to predict which superficial tumors will recur or progress and which invasive tumors will metastasize has led to the identification of a variety of potential prognostic markers. Blood group antigens, tumor associated antigens, proliferating antigens, oncogenes, peptide growth factors and their receptors, cell adhesion molecules, tumor angiogenesis and angiogenesis inhibitors, and cell cycle regulatory proteins have recently been identified. The potential clinical applications of these tumor markers are under active investigation. Recent attention has focused on which tumor markers may predict the responsiveness of a particular bladder cancer to systemic chemotherapy. CONCLUSIONS: At present conventional histopathological evaluation of bladder cancer (tumor grade and stage) cannot predict accurately the behavior of most bladder tumors. With a better understanding of the cell cycle, and cell to cell and cell to extracellular matrix interactions as well as improved diagnostic techniques (immunohistochemistry), progress is being made to identify and characterize other potential prognostic markers for transitional cell carcinoma of the bladder. The ultimate goal is to develop reliable prognostic markers that will accurately predict not only the course but also the response of a tumor to therapy. This information may then be used to dictate more aggressive treatment for tumors that are likely to progress and less aggressive treatment for those that are unlikely to progress. In the future these biological markers may also be used in gene therapy for the treatment of bladder cancer.

Posthysterectomy vaginal cuff fistula: diagnosis and management of an unusual cause of "incontinence".

OBJECTIVES: Connection between the vaginal cuff and the peritoneal cavity after hysterectomy is a rare event that can mimic urinary incontinence. The appropriate evaluation and treatment of these patients is discussed. METHODS: Five patients underwent excision of the vaginal cuff during a 12-month period. All of these patients had a negative workup for urinary incontinence, except for 1 patient who also had stress incontinence and required a vaginal wall sling at the time of cuff excision. RESULTS: All 5 patients are presently free of excess vaginal drainage or significantly improved, with a mean follow-up of 6 months. One patient developed stress incontinence after cuff excision and later required a vaginal wall sling. There have been no perioperative complications and no evidence of recurrent fistula. CONCLUSIONS: Fistula of the vaginal cuff is a diagnosis of exclusion after urinary incontinence has been ruled out. A high index of suspicion is often required to make the diagnosis because these patients often present with symptoms highly suggestive of urinary leakage. Fistula of the vaginal cuff is successfully treated with excision of the vaginal cuff and the fistulous tract (if identified), with minimal morbidity.