Aggregation of freshly precipitated calcium oxalate crystals in urine of calcium stone patients and controls.

Aggregation (AGN) of freshly precipitated calcium oxalate crystals was photometrically studied in urine of 30 calcium stone patients and 30 controls, in solutions containing urinary macromolecules (UMS) and in an inhibitor free control solution (CS). Crystals were produced by oxalate titration and crystallization was monitored measuring optical density (OD). Tests were repeated adding hydroxyapatite (HAP) to urine and UMS and adding citrate and pyrophosphate (PPi) to UMS of the controls. AGN was recognized as a rapid OD decrease being at least three times faster than sedimentation of single crystals (p < 0.001) and used to calculate an extent of AGN (EA%). The time between the end of titration and the beginning of AGN was determined as suspension stability (SS). The main effect of urinary inhibitors was retardation of AGN without changing EA, SS being higher in urine than UMS (p < 0.001) and in UMS than CS (p < 0.001). In urine of 63% of controls but only in 33% of patients, no AGN was recorded (p < 0.05). The high inhibitory activity of urine could not be reproduced in UMS even in combination with 3.5 mM citrate or 0.05 mM PPi. 0.05 mg/mL HAP reduced SS in all urine samples to low values and increased the rate of rapid OD decrease, being a measure for the size of aggregates. Retarding AGN of crystals during their passage through the kidney seems to be an important mechanism to prevent stone formation during crystalluria. The promotion of AGN by HAP reveals a new role of Randall's plaques in nephrolithiasis.

Ki67 labeling index in core needle biopsies independently predicts tumor-specific survival in prostate cancer.

A better knowledge of the biological aggressiveness of individual tumors could facilitate the selection of treatment in prostate cancer patients. This study assesses the influence of histological and molecular features in core needle biopsy specimens of prostate cancer on tumor-specific survival. Formalin-fixed core needle biopsy specimens from 111 consecutive patients (mean follow-up, 5.0 years) were immunohistochemically examined for their proliferative activity (Ki67 labeling index [LI]) and expression of p53 and Bcl-2. Overexpression of p53 was found in 16% of the biopsy specimens and was mainly restricted to poorly differentiated tumors. Bcl-2 positivity was found in 20% of tumors. The median Ki67 LI was 7.5%. There was a strong relationship between Ki67 LI and Gleason grade, with a continuous increase in the proliferative activity from low-grade to high-grade tumors (P = .0006). Univariate tumor-specific survival analysis showed that high Gleason score (P = .0018), high percentage of biopsy tumor involvement (P = .0227), high Ki67 LI (P = .0007), and p53 positivity (P = .0024) were predictors of tumor-related death. A high Ki67 LI emerged as the only independent predictor of tumor-specific survival in multiparametric analysis. These results indicate that core needle biopsy specimens of the prostate not only are useful for diagnosis of malignancy but also can provide valuable prognostic information. Immunohistochemical examinations of molecular features may be a helpful adjunct for a better pretherapeutic assessment of prostate cancer aggressiveness and therefore contribute to an improved initial patient management.

Reasons for discontinuing intracavernous injection therapy with prostaglandin E1 (alprostadil).

OBJECTIVES: To clarify the reasons why experience with self-injection therapy for erectile dysfunction shows high dropout rates. METHODS: We studied 86 patients 36 to 76 years old who had been on home treatment for at least 3 months. Sixty-nine patients (80%) were continuing to use injections, and 17 (20%) had discontinued the treatment. Patients were evaluated by interview and clinical examination. RESULTS: Patients still in the program used one injection every 2 weeks, and those who had given up treatment had used one injection in 3 weeks (P = 0.31). They were in the program for 39+/-27 and 16+/-22 months (P = 0.002), respectively, and had used 50 (95% confidence interval [CI] 21 to 91) versus 12 (95% CI 4 to 20) injections, respectively (P<0.0001). Injections producing unsatisfactory penile rigidity, prolonged erections, hematoma at injection site, corporal fibrosis, secondary penile deviation, and mean estimated duration of a pharmacoinduced erection showed no significant differences. Patient satisfaction (P = 0.02), estimated partner satisfaction (P = 0.02), increase in self-esteem (P = 0.01), and negligible effort in performing injections (P = 0.001) all showed significantly better results for those still in the program. CONCLUSIONS: Reasons for dropout from self-injection therapy are not based on objective side effects and discomfort. Patients leaving the program are less motivated, less satisfied with the quality of pharmacoinduced sexuality, consider the effort to perform injections to be substantial, and have not achieved improved self-esteem.

An in vitro and in vivo study of toothbrush bristle splaying.

The extent to which a toothbrush is worn out, as evidenced by bristle splaying, is an important determinant of cleaning efficacy. In order for this aspect of oral hygiene to be studied, an accelerated means of producing a life-like pattern of bristle splaying was investigated and compared with splaying induced by a human test-panel. Porcelain denture teeth were brushed under a static applied load in a slurry of dentifrice, by means of a revolving "figure 8" motion, for up to 12,000 revolutions. This was found to induce an increase in the degree of splaying (as measured by "wear index") that was well-fitted (R2 = 0.96) by a second-order expression of the form: WI = WIi + Ritj - Ctj2 where WI = wear index, WIi = initial wear index, Ri = initial rate of increase in WI, tj = brushing time measured in either machine revolutions (tr) or weeks of human use (tw), and C = a separate constant for each brushing mode (machine or human panel). The rate of splaying was found to be strongly influenced by the quality of the bristle filament, but not by small differences in toothbrush design. The splaying pattern induced by the machine could not be distinguished visually from that in a set of brushes used at home by human volunteers. A strong correlation was found between the splaying produced by machine-brushing and by a panel who brushed free-style at home for 13 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

The measurement of toothbrush wear.

Toothbrushes wear out and progressively lose their ability to clean as the bristles abrade and become curled and matted. To study the factors that influence this process, we developed a quantitative measure of bristle splaying (wear index) and a method for judging and ranking the overall state of brush deterioration (wear rating) and used these to determine the effects of the individual user, brush design, time in use, and bristle material. Wear index is the average increase in brush-head dimensions normalized for maximum bristle length, and is dimensionless. Wear rating is a subjective means of classifying the increasing severity of deterioration on a scale of 0 to 3. The wear characteristics of a variety of commercial and experimental brushes with different design features were determined. Test variables were time in use, brush design (e.g., geometry and size of the brush head), and bristle composition. Time of use, the individual user, and bristle composition were found to have the strongest influences on splaying, and brush design was found to have the least influence. The wear index offers a quantitative means of comparing brushes of different dimensions at various stages of splaying. The wear rating, although qualitative, is a quick means of ranking brushes in various stages of deterioration. The two methods correlate (R2 = 0.87), and both are sensitive to several factors that affect brush durability. Therefore, these methods appear to be suitable not only for research, but also for quality control, the setting of standards, and for substantiation of advertising claims.

Hyperoxaluria and urinary tract calculi after jejunoileal bypass.

Five patients with jejunoileal shunt for morbid obesity in whom postshunt hyperoxaluria and recurrent urinary tract calculi developed are presented. All the stones were composed of calcium oxalate. The twenty-four hour urinary oxalic acid levels were also elevated in twenty of twenty-six patients who had had jejunoileal shunt for six months or longer. No correlation was present between urolithiasis and the degree of hyperoxaluria.

Retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction.

BACKGROUND AND PURPOSE: Retroperitoneoscopy is an established procedure for renal surgery. We evaluated our results with retroperitoneoscopic pyeloplasty for ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS: In 14 female and 10 male patients, a retroperitoneoscopic pyeloplasty was performed (13 right/11 left). Four patients had previously had an endopyelotomy. The operation was performed using standard retroperitoneoscopic technique with the patient in a flank position. After preparation of the ureter and renal pelvis, the UPJ was resected in 22 patients in an Anderson-Hynes pyeloplasty. Twenty of these patients had a crossing vessel. The other two patients, who had small renal pelves, were operated on with a Fenger pyeloplasty. In all patients a 7F double-J stent was placed. RESULTS: The mean operative time was 189 minutes (range 70-360 minutes), and the average blood loss was 110 mL (range 50-400 mL). There were no intraoperative complications, although one patient with adhesions and scarring after previous endopyelotomy had to be converted to open surgery. The transurethral catheter was left for 7 days in the first 10 cases and for 4 days in the 14 subsequent patients. The hospitalization time was 9.7 and 7.5 days, respectively. The only postoperative complication was a urinoma, which was punctured. The double-J catheter was removed after an average of 4.6 weeks (range 4-8 weeks). Intravenous urography 6 weeks later showed no obstruction. The mean follow-up time was 11.5 months (range 1-24 months) with no signs of obstruction on ultrasonography. CONCLUSIONS: Retroperitoneoscopic pyeloplasty for UPJ obstruction is a safe and effective procedure. Our short-term results are similar to those of open pyeloplasty with the advantage of a minimally invasive approach.

Complications of epidural infusions for analgesia in postoperative and trauma patients.

Few studies compare complications of continuous and bolus epidural analgesia. Ninety-eight postoperative and trauma patients receiving epidural infusions over 15 months were retrospectively studied. Continuous epidural analgesia was used for pain management in 60 patients (61%). Bolus epidural analgesia was administered to 38 patients (39%). Sixty patients reported 98 complications. Sixty-eight per cent of complications occurred in patients receiving continuous infusions. For the continuous infusions, motor blockade (18%), nausea/vomiting, (18%), and catheter leaks (12%) were the most common complications. For bolus infusions, nausea/vomiting (25%), mental status changes (21%), and erythema at placement site (13%) were encountered. Continuous infusions were associated with an increased incidence of complications compared with bolus infusions (P < 0.05). Patients undergoing abdominal surgery had an increased incidence of complications compared with other patients (P < 0.05). Epidural catheters are safe and effective for pain management, but they are not without risk. Hemodynamic stability and pulmonary status should be considered when evaluating patients.

The physicochemical characteristics and bioavailability of indomethacin from beta-cyclodextrin, hydroxyethyl-beta-cyclodextrin, and hydroxypropyl-beta-cyclodextrin complexes.

In an effort to improve the bioavailability of the insoluble drug indomethacin, three complexes were prepared with indomethacin and the soluble complexing agents beta-, hydroxyethyl-beta-, and hydroxypropyl-beta-cyclodextrin. The indomethacin content was similar among the complexes (P

[Sexually and drug-stimulated erections are proportional]. / Sexuell- und pharmakostimulierte Erektionen sind proportional.

Even complex diagnostic tests may not establish aetiology and degree of erectile dysfunction (ED) in many patients. Therefore, we evaluated a self-report method with a restrictive focus to quality of erections which may yield information sufficient to make an aetiologic diagnosis. We studied 74 patients 25 to 75 years of age with untreated ED. Sexually stimulated erections were quantified and compared to duplexsonographically and clinically evaluated data from pharmacostimulated erections. Patients reported that there was a marked decrease in ability to penetrate the partner, to sustain an erection and of penile rigidity (p < 0.001). Parameters from duplexsonography and clinically assessed response to pharmacostimulation correlated (r = 0.72). Direct comparison of these data with quantified history showed no relation (r = 0.05). Using change in penile volume due to erection as a basis to compare with, showed significant correlation with quantified data from history (r = 0.26-0.34; p < 0.03) and measured parameters from pharmacostimulated erections (r = 0.44-0.55; p < 0.0001). Sexually- and pharmacostimulated erections are proportional to change in penile volume. Although there is a relation between erections emerging from both stimulations, quantifying history on sexually stimulated erections does not qualify to make an aetiologic diagnosis without using complex tests.

[The 80 W potassium-titanium-phosphate (KTP) laser vaporization of the prostate. Technique and 6 month follow-up after 70 procedures]. / Die 80-Watt-Kalium-Titanyl-Phosphat- (KTP-)Laservaporisation der Prostata. Technik und 6-Monatsergebnisse nach 70 Eingriffen.

BACKGROUND: Despite good efficacy, even in our days, TURP remains a potentially difficult procedure to perform and is associated with significant risks for the patient. Several alternatives have been tried to reduce the known perioperative morbidity. We report our first experiences with 80 W potassium titanyl phosphate (KTP) laser vaporization of the prostate in patients with symptomatic BPH. PATIENTS AND METHODS: In 70 patients 80 W KTP laser vaporization was performed successfully. Mean age was 70.5 years (46-93 years) and mean transrectal prostate volume was 48.1 ml (10-250 ml). RESULTS: Mean operating time was 41 min ( n=22), 64 min ( n=33), and 80 min ( n=15) for a 26 ml, 46 ml, and a 91 ml prostate, respectively. At time of discharge, after 1 month, and 6 months the urinary peak flow increased by 75.4%, 166.8%, and 168.6%, respectively. CONCLUSION: The 80 W KTP laser vaporization of the prostate combines the tissue-debulking properties of transurethral resection of the prostate with the known good hemostatic properties of other laser procedures. It is a safe procedure for the patient and provides a virtually bloodless operation and immediate improvement of voiding.

[Gallstone ileus--still a current disease]. / Gallensteinileus--ein immer noch aktuelles Krankheitsbild.

Two cases of gall-stone ileus during the past months have encouraged us to discuss the epidemiology, pathogenesis, diagnosis and therapy. This pathology is not as rare as one thinks and represents 23% of cases of mechanical ileus of the small intestine in patients over 65 years of age, thus being the third cause after stenosis due to carcinoma and incarcerated hernia. The importance of this illness is due to two factors: the diagnostic difficulties because of a periodic symptomatology with often a lack of typical radiologic signs and the still important mortality of 5 to 10% today. We present the casuistic of seven cases which have occurred over the last 15 years in our hospital and compare our experience with those of the literature. We discuss the therapeutic problem of enterolithotomy or one-stage repair. The main point for a reduction in mortality is an early diagnosis with the consequent reduction of the time from the appearance of the ileus to the operation.

Surgical management of renal cell carcinoma during the second trimester of pregnancy.

Renal cell carcinoma is rarely diagnosed during pregnancy and its management represents a real challenge. Pregnancy demands special consideration in terms of diagnostic evaluation and management, particularly during the second trimester. We report a patient undergoing left radical nephrectomy using a thoracoretroperitoneal approach at 22 weeks' gestation. Histological analysis revealed a pT2R0G2 chromophobic renal cell carcinoma. Furthermore, we review the sparse literature available.

Curative surgery for solitary adrenal metastasis of pT1 G3 transitional cell carcinoma of the bladder.

A preoperative computed tomography scan in a patient undergoing radical cystectomy for pT1N0 grade 3 transitional cell carcinoma revealed a tumor in the adrenal gland. Biopsy was negative, but 2 years later computed tomography showed progression, and adrenalectomy was performed, revealing transitional cell carcinoma. Four years after cystectomy, the patient had no evidence of other metastases. We discuss surgery for solitary metastasis of transitional cell carcinoma as a curative treatment option.

Does the prostate really need androgens to grow? Transurethral resection of the prostate in a male-to-female transsexual 25 years after sex-changing operation.

We present the case of a male-to-female transsexual presenting with obstructive voiding symptoms due to benign prostatic hyperplasia 25 years after sex-changing operation and under continuous estrogen therapy.

Retroperitoneoscopic nephropexy for symptomatic nephroptosis using a modified three-point fixation technique.

INTRODUCTION: Laparoscopy has been reported as a minimally invasive approach for performing nephropexy in patients with nephroptosis. We evaluated our results after retroperitoneoscopic nephropexy using a modified three-point fixation technique. TECHNICAL CONSIDERATIONS: Twelve women presenting with flank pain and radiologically documented nephroptosis underwent retroperitoneoscopic nephropexy. After complete dissection of the perirenal fat from the kidney, three nonabsorbable (Ethibond-0) sutures were placed on the posterior renal capsule between the upper pole, middle part, and lower pole of the kidney and the psoas muscle. The average operative time was 91 minutes (range 50 to 180), and the mean estimated blood loss was less than 50 mL in all patients. Postoperative urography revealed complete resolution of nephroptosis in all cases. On a comparative pain analog score patients had 84% improvement (range 0% to 100%). Nine patients had complete resolution of their pain, and two had improvement of 70% to 80%. One patient did not have any improvement. The mean follow-up time was 3.4 years (range 0.5 to 5.5). CONCLUSIONS: Retroperitoneosopic nephropexy with a modified three-point fixation technique of the upper posterior pole, middle part, and lower pole of the kidney to the psoas muscle is a rapid and effective minimally invasive procedure for treating symptomatic nephroptosis with excellent intermediate-term results.

Primitive neuroectodermal tumor of the kidney with hyaline cells.

Primitive neuroectodermal tumor (PNET) of the kidney is a rare disease with high malignant potential. It affects young adults and has the tendency towards early metastasis. Relying on recently available immunohistochemistry and cytogenetic investigations, today most authors define PNET as part of the same nosologic entity as Ewing's sarcoma. We present the case of a 22-year-old man with a PNET arising from the kidney with, to our knowledge, a previously undescribed finding of hyaline cells within the tumor.

Direct compression tablets containing a series of four beta-cyclodextrin complexes formed by neutralizing an acidic drug.

A series of four beta-cyclodextrin complexes (called products) was formed by neutralizing an acidic drug to study the effect of drug solubility on complex formation and the dissolution performance from direct compression tablets. Four solid products were prepared by neutralizing the drug in 0.05, 0.10, 0.20, and 0.30 M tromethamine solutions with a constant 0.09 M beta-cyclodextrin concentration, filtering the solutions, and removing the water through evaporation with heat and vacuum. The four products contained drug and water in a distinct relationship, thus suggesting a complex formation that was dependent on the tromethamine concentration. Infrared, powder X-ray diffraction, differential scanning calorimetry (DSC), phase solubility, and scanning electron microscopy (SEM) techniques revealed distinct differences among the four products, suggesting three of the four products were complexes, and one product was either a weak complex or a physical mixture. Ultraviolet (UV) analysis showed no evidence of complex formation. Phase solubility results showed one product had a slight increase in drug solubility, and three products had no increase in drug solubility with increasing beta-cyclodextrin concentration. The lack of a solubility increase suggests insoluble complex formation. Drug dissolution in water was improved significantly in all tablets containing either a product or a physical mixture when compared to the pure drug. The products prepared with the two highest concentrations of tromethamine showed a dissolution performance that was superior to all other formulations. Enthalpy measurements by DSC were a good indicator of dissolution performance for tablets containing the four products. Drug dissolution through salt formation in the absence of beta-cyclodextrin showed the drug-salt dissolution varied from better to worse when compared to the dissolution profiles of the four products. The varying dissolution performance was attributed to the formation of distinct beta-cyclodextrin complexes with varing solubilities.

Mumps orchitis: report of a mini-epidemic.

PURPOSE: The incidence of mumps orchitis has declined dramatically since the introduction of vaccination. While in the past cases of mumps have only been seen occasionally at our institution, recently there has been a sharp increase in the number of confirmed cases. MATERIALS AND METHODS: Between June 1995 and April 1996, 11 patients with severe mumps orchitis were hospitalized at our clinic. Medical history, therapeutic measures and clinical outcome were recorded for each patient. RESULTS: All patients showed marked scrotal swelling with a temperature above 38.5 C. Serum C-reactive protein was significantly elevated (mean 140 mg./l.). The vaccination status of 1 of the 11 patients (9%) was unknown. Medical records from the remaining 10 patients indicated that they had not been vaccinated. Nine patients (82%) had a typical mumps parotitis preceding the orchitis. In 2 patients the clinical diagnosis of parotitis was uncertain but mumps serology was positive. None of the patients showed other manifestations of mumps. Antibodies to the mumps virus (IgG and IgM) were determined in 6 patients and positive in all cases. The average interval between parotitis and onset of orchitis was 10 days. All patients were hospitalized for an average of 6 days. Treatment included bed rest with local cooling, scrotal support and systemic treatment with nonsteroidal anti-inflammatory drugs. Ciprofloxacin or clavulanic acid/amoxicillin was administered as bacterial orchitis could not be excluded at initial presentation. The mean time to cessation of fever was 3.6 days (range 3 to 5). Antibiotics were administered for an average of 8.8 days (range 7 to 13) and anti-inflammatory drugs were given an average of 8.6 days (range 7 to 11). One patient required scrotal exploration. CONCLUSIONS: Since the introduction of a vaccine against the mumps virus there is a diminished risk for mumps and its complications. However, in case of scrotal swelling mumps orchitis should still be considered. Despite vaccination mumps has not been erradicated. Therefore, continued vaccination should be considered an important step in minimizing clinical outbreaks and working towards a possible eradication of this disease in the future.

["Burned out" testicular tumor: a rare form of germ cell neoplasias]. / Der "ausgebrannte" Hodentumor: eine seltene Erscheinungsform der Keimzellneoplasien.

Burned-out tumour of the testis is a rare form of a germ-cell malignancy of testicular localisation which can regress or disappear. This is a rare form of germ-cell neoplasm. We report on 2 patients with such a tumour. The histological findings, on clinical manifestations, on difficult differential diagnosis from primary retroperitoneal germ-cell tumour, therapy, and outcome of this malignancy are discussed. In the absence of palpable testicular tumour the symptomatology is due to metastasis. Burned-out tumour of the testis must be considered in a patient with retroperitoneal lymph node involvement and histology of "germ-cell tumour". In these patients sonography of scrotal contents may be useful to identify intratesticular abnormalities. These are often the site of the primary tumour. If burned-out tumour of the testis is suspected, the indication for surgery is given. If the frozen section is not "normal testicular tissue", orchiectomy should be performed. The metastasis is treated according to the histology and clinical stage of the tumour. It is important to distinguish burned-out tumour of the testis from true extragonadal germ-cell tumours. Primary removal of the testicular tumour is necessary because of the high rate of persistent testicular malignancy, which may be as much as 50% despite systemic chemotherapy.