Metabolic regulation of calcium pumps in pancreatic cancer: role of phosphofructokinase-fructose-bisphosphatase-3 (PFKFB3).

BACKGROUND: High glycolytic rate is a hallmark of cancer (Warburg effect). Glycolytic ATP is required for fuelling plasma membrane calcium ATPases (PMCAs), responsible for extrusion of cytosolic calcium, in pancreatic ductal adenocarcinoma (PDAC). Phosphofructokinase-fructose-bisphosphatase-3 (PFKFB3) is a glycolytic driver that activates key rate-limiting enzyme Phosphofructokinase-1; we investigated whether PFKFB3 is required for PMCA function in PDAC cells. METHODS: PDAC cell-lines, MIA PaCa-2, BxPC-3, PANC1 and non-cancerous human pancreatic stellate cells (HPSCs) were used. Cell growth, death and metabolism were assessed using sulforhodamine-B/tetrazolium-based assays, poly-ADP-ribose-polymerase (PARP1) cleavage and seahorse XF analysis, respectively. ATP was measured using a luciferase-based assay, membrane proteins were isolated using a kit and intracellular calcium concentration and PMCA activity were measured using Fura-2 fluorescence imaging. RESULTS: PFKFB3 was highly expressed in PDAC cells but not HPSCs. In MIA PaCa-2, a pool of PFKFB3 was identified at the plasma membrane. PFKFB3 inhibitor, PFK15, caused reduced cell growth and PMCA activity, leading to calcium overload and apoptosis in PDAC cells. PFK15 reduced glycolysis but had no effect on steady-state ATP concentration in MIA PaCa-2. CONCLUSIONS: PFKFB3 is important for maintaining PMCA function in PDAC, independently of cytosolic ATP levels and may be involved in providing a localised ATP supply at the plasma membrane.

Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE).

OBJECTIVES: The aim of the study was to determine whether cardiac pacing reduces falls in older adults with cardioinhibitory carotid sinus hypersensitivity (CSH). BACKGROUND: Cardioinhibitory carotid sinus syndrome causes syncope, and symptoms respond to cardiac pacing. There is circumstantial evidence for an association between falls and the syndrome. METHODS: A randomized controlled trial was done of consecutive older patients (>50 years) attending an accident and emergency facility because of a non-accidental fall. Patients were randomized to dual-chamber pacemaker implant (paced patients) or standard treatment (controls). The primary outcome was the number of falls during one year of follow-up. RESULTS: One hundred seventy-five eligible patients (mean age 73 +/- 10 years; 60% women) were randomized to the trial: pacemaker 87; controls 88. Falls (without loss of consciousness) were reduced by two-thirds: controls reported 669 falls (mean 9.3; range 0 to 89), and paced patients 216 falls (mean 4.1; range 0 to 29). Thus, paced patients were significantly less likely to fall (odds ratio 0.42; 95% confidence interval: 0.23, 0.75) than were controls. Syncopal events were also reduced during the follow-up period, but there were much fewer syncopal events than falls-28 episodes in paced patients and 47 in controls. Injurious events were reduced by 70% (202 in controls compared to 61 in paced patients). CONCLUSIONS: There is a strong association between non-accidental falls and cardioinhibitory CSH. These patients would not usually be referred for cardiovascular assessment. Carotid sinus hypersensitivity should be considered in all older adults who have non-accidental falls.

ATR/ATM-mediated phosphorylation of human Rad17 is required for genotoxic stress responses.

Genotoxic stress triggers the activation of checkpoints that delay cell-cycle progression to allow for DNA repair. Studies in fission yeast implicate members of the Rad family of checkpoint proteins, which includes Rad17, Rad1, Rad9 and Hus1, as key early-response elements during the activation of both the DNA damage and replication checkpoints. Here we demonstrate a direct regulatory linkage between the human Rad17 homologue (hRad17) and the checkpoint kinases, ATM and ATR. Treatment of human cells with genotoxic agents induced ATM/ATR-dependent phosphorylation of hRad17 at Ser 635 and Ser 645. Overexpression of a hRad17 mutant (hRad17AA) bearing Ala substitutions at both phosphorylation sites abrogated the DNA-damage-induced G2 checkpoint, and sensitized human fibroblasts to genotoxic stress. In contrast to wild-type hRad17, the hRad17AA mutant showed no ionizing-radiation-inducible association with hRad1, a component of the hRad1-hRad9-hHus1 checkpoint complex. These findings demonstrate that ATR/ATM-dependent phosphorylation of hRad17 is a critical early event during checkpoint signalling in DNA-damaged cells.

Complications of carotid sinus massage--a prospective series of older patients.

BACKGROUND: there is a causal association between carotid sinus hypersensitivity, falls and syncope in elderly subjects. Neurological complications during carotid sinus massage have been reported in case studies and two retrospective series. Our aim was prospectively to ascertain the incidence of complications occurring after carotid sinus massage performed for diagnostic purposes in a consecutive series of patients. METHODS: 1000 consecutive subjects aged 50 years or over who attended the accident and emergency department with syncope or 'unexplained' falls had carotid sinus massage. Carotid sinus massage was performed for 5 s on the right and then left sides both supine and upright (70 degrees head-up tilt) with continuous heart rate and phasic blood pressure recording. Contraindications to carotid sinus massage were the presence of a carotid bruit, recent history of stroke or myocardial infarction or previous ventricular tachyarrhythmia. RESULTS: complications occurred in nine patients immediately after cessation of carotid sinus massage. Eight had transient neurological complications possibly attributable to carotid sinus massage: visual disturbance, 'pins and needles' and sensation of finger numbness in two cases each, leg weakness in one and sensation of 'being drunk' in one. All transient complications resolved within 24 h. In one patient mild weakness of the right hand persisted. CONCLUSIONS: no subjects had cardiac complications and 1% had possible neurological symptoms, which resolved in most cases. Persistent neurological complications are uncommon, occurring in 1:1000 patients (0.1%) or 1: 3805 episodes of carotid sinus massage (0.03%).

Assessing medical students' perceptions of mistreatment in their second and third years.

PURPOSE: To study medical students' perceptions of mistreatment in their second and third years of training. METHOD: A questionnaire was distributed at Wayne State University School of Medicine to the class of 1993 at the end of its third year and to the class of 1994 at the end of its second and third years. The students were asked if they had been subjected to various forms of mistreatment; the third-year students were asked to rate their perceptions of each clinical department's response to them on the basis of gender and race-ethnicity, as well as their overall treatment. The students also completed demographic information about age, gender, and marital status, number of children, and race-ethnicity. Results were analyzed using chi-square statistics, multivariate statistical analyses, analyses of variance, and Duncan's post-hoc comparisons. RESULTS: The response rate for the class of 1993 was 71.5%; response for the class of 1994 were 66.9% in their second year and 75.2% in their third year; 41.7% were women, and the racial-ethnic breakdown was 71.2% white/Caucasian, 11.7% black/African American and 16.8% other. There was a significant difference between the percentages of second-year and third-year students reporting any experience of mistreatment (37.2% vs 75.8%, p < .001). Canonical correlation analysis revealed bias in the third year based on gender (p < .0001) and race-ethnicity (p < .0002); both variates were related to sexual humor. The students' perceptions of mistreatment were lowest for family medicine and highest for obstetrics-gynecology and surgery. Perceptions of mistreatment in departments varied significantly by gender and race-ethnicity. The nonwhite males reported the least favorable treatment in most departments. CONCLUSION: Marked variability in the students' perceptions of mistreatment within departments suggest that a variety of approaches will be required to improve the medical training environment.

Prevalence of cardioinhibitory carotid sinus hypersensitivity in patients 50 years or over presenting to the accident and emergency department with "unexplained" or "recurrent" falls.

To study the prevalence of Cardioinhibitory Carotid Sinus Hypersensitivity (CICSH) in patients 50 years or over presenting to casualty with "unexplained" or "recurrent" falls. The prospective study was from October 1, 1995 to April 30, 1996 in the Inner City Accident and Emergency Departments, Newcastle Upon Tyne, U.K. Ten thousand four hundred forty-three patients 50 years and over presented, of which 4,051 (39%) were fallers. Fallers were excluded if they lived over 15 miles from the hospital (81), were registered blind (17), were unable to speak English (22), were unable to previously walk (27), if there was a history of only one accidental fall (1,659) or were cognitively impaired (776: Mini Mental State Examination < 24 [30]) or if there was a clear attributable medical diagnosis for the fall (871). Five hundred ninety-eight "unexplained" or "recurrent" fallers (defined as three or more falls in the previous 12 months) were assessed for carotid sinus massage (CSM). One hundred forty-five patients declined CSM (24%), 70 (12%) had relative contraindications to CSM and 13 already had pacemakers in situ (2%). Two hundred seventy-nine underwent CSM, of whom 65 had CICSH (23%), which might be amenable to treatment with pacemakers. The prevalence of CICSH (a potentially treatable condition) in "unexplained" or "recurrent" fallers who present to the accident and emergency department is 23%. A randomized control study to assess benefit from pacemaker intervention in these patients is underway.

Stability of orthognathic surgery: a review of rigid fixation.

The use of rigid fixation with orthognathic surgery was greeted by both excitement and healthy concern when it began to find its way into the literature approximately 10 years ago. The purpose of this paper is to review the literature and make comments based on the experience of the senior author on whether one of the early premises was true. Has rigid fixation improved stability with orthognathic surgery? The authors chose to examine mandibular advancements treated with a bilateral sagittal split osteotomy and maxillary osteotomies treated with a Le Fort I osteotomy. When compared to wire osteosynthesis, rigid fixation has improved stability; however, the individual move associated with the osteotomy must be considered. In some cases, auxiliary techniques should be used to ensure stability. Condylar resorption with mandibular advancement continues to be an area of concern.

Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial.

OBJECTIVE: Our purpose was to determine the efficacy of transvaginal electrical stimulation in treating genuine stress incontinence. STUDY DESIGN: This was a multicenter, prospective, randomized, double-blind, placebo-controlled 15-week trial comparing the use of an active pelvic floor stimulator with a sham device. Thirty-five women used an active unit and 17 control subjects used sham devices. Weekly and daily voiding diaries were recorded throughout the trial. Urodynamic testing, including pad test and subtracted cystometry, was done before and at the end of device use. Pelvic muscle strength was measured at baseline and at the end of the trial. Patients scored their symptoms on visual analog scales and completed quality-of-life questionnaires before and after therapy. RESULTS: Significant improvements from baseline were found in patients using active devices but not in controls. Comparisons of changes from baseline between active-device and control patients showed that active-device patients had significantly greater improvement in weekly (p = 0.009) and daily (p = 0.04) leakage episodes, pad testing (p = 0.005), and vaginal muscle strength (p = 0.02) when compared with control subjects. Significantly greater improvement was also found for both visual analog scores of urinary incontinence (p = 0.007) and stress incontinence (p = 0.02), as well as for subjective reporting of frequency of urine loss (p = 0.002), and urine loss with sneezing, coughing, or laughing (p = 0.02), when compared with controls. Pad testing showed that stress incontinence was improved by at least 50% in 62% of patients using an active device compared with only 19% of patients using sham devices (p = 0.01). Voiding diaries showed at least 50% improvement in 48% of active-device patients compared with 13% of women using the sham device (p = 0.02). No irreversible adverse effects were noted in either group. CONCLUSIONS: Transvaginal pelvic floor electrical stimulation was found to be a safe and effective therapy for genuine stress incontinence.

30-minute evaluation of incontinence in the older woman.

The key to successful management of urinary incontinence in the older woman is accurate diagnosis of the underlying condition. A simple 30-minute in-office evaluation answers the important questions that increase the likelihood of reaching the correct diagnosis. This core evaluation includes a history and physical exam, urinalysis and other basic lab tests, assessment of urethral angulation, and a simple cystometrogram. A patient voiding diary may also help to pinpoint the severity of incontinence. Further testing is required if symptoms fail to resolve after empiric therapy.

Ethics in gynecologic surgical innovation.

J. Marion Sims' efforts in surgically curing vesicovaginal fistula are retold. The controversy surrounding his surgical innovation on black slaves is discussed in the context of the ethical principles of autonomy, beneficence, and justice. The relevance of his story to modern surgical innovation in incontinence surgery is emphasized in a discussion of the Pereyra, Gittes, and paravaginal procedures. A call is made to establish a gynecologic ethic to ensure that patients' rights are respected in all future surgical innovation.

Complications from permanent suture in surgery for stress urinary incontinence. A report of two cases.

Two cases reports are used to illustrate potential complications of permanent suture in vaginal and abdominal surgical procedures for urinary incontinence. The first case used permanent suture for an abdominal retropubic urethropexy. A portion of a glove finger remained attached to the suture and was not recognized until the patient developed a retropubic abscess two years later. In the second case, permanent suture used in a vaginal retropubic urethropexy eroded through the vagina. The patient presented with lower abdominal pain 18 months after the procedure; the pain was relieved with removal of the suture. Complications of using permanent suture in abdominal retropubic urethropexy have not been reported, but the attachment of a foreign body, such as a glove finger, can create an adverse outcome. The use of permanent suture in vaginal procedures should be used with the awareness that there are potential complications.

Urethral stones in women. A case report.

Urethral stones are encountered rarely in the urethra in women. We report the clinical and urodynamic findings and the management of 17 stones in a urethral diverticulum.

Investigative procedures in urogynecology.

History and physical examination do not always correlate with final urodynamic diagnoses in incontinent women. A large number of diagnostic procedures are available to help the clinician establish the correct diagnosis. The importance of urine culture, Q-tip test, ultrasound, pessary test for potential incontinence, neurophysiologic testing, endoscopy, urethral pressure profiles, stress/pad tests, uroflowmetry, and cystometry are discussed. The physician should understand the importance and limitations of each of the different investigative procedures.

Dysuria and urinary tract infections.

It has been estimated that up to 25% of American women may experience acute dysuria yearly. Many physicians commonly equate dysuria with urinary tract infection and will treat empirically without adequate evaluation. This therapeutic trial of antibiotics represents undertreatment for many patients and inappropriate treatment for others. It is important that physicians understand that dysuria is only a symptom that can be produced by many different clinical entities.

Cystourethroscopy in urogynecology.

Cystourethroscopy has become a basic tool in the investigation of female genitourinary problems. It provides the gynecologist with essential information regarding the presence of bladder or urethral pathology and documents ureteral patency.

Potassium homeostasis in pregnancy.

We selectively reviewed potassium (K) metabolism during human gestation, focusing on the influence of progesterone on renal K excretion. Approximately 300 mEq of K is gained during pregnancy. Two-thirds of it are in the products of conception, but little is known about renal K handling during gestation. We have suggested that progesterone may play a role in preventing the kaliuresis that normally occurs when aldosterone levels are elevated and substantial quantities of sodium are presented to distal nephron sites. In addition, we hypothesize that subtle K secretory problems, such as those known to occur in sickle cell disease, may be aggravated during gestation, probably due to elevated circulating levels of progesterone.

Endometrial immunofluorescence associated with endometriosis and pelvic inflammatory disease.

Anti-immunoglobulin G (anti-IgG) staining in the endometrium by immunofluorescence has been associated with endometriosis. To investigate this phenomenon further, we took endometrial samples from 42 patients who underwent laparoscopy or laparotomy, which were tested for immunofluorescence. Fluorescein-labeled anti-IgG was incubated with tissue samples. Of 18 patients with documented endometriosis, 16 had positive immunofluorescence (89% sensitivity). Of 24 patients with no evidence of endometriosis, 9 had false-positive immunofluorescence and 15 had negative immunofluorescence. Of the 9 false-positive samples, 8 had evidence of old pelvic inflammatory disease. In the absence of this condition, there was only one false-positive study for immunofluorescence. The implications of these findings in terms of the pathophysiology of endometriosis-associated infertility is that it may be an immune-mediated process. With regard to diagnosis, the high predictive value of endometrial immunofluorescent IgG may be a useful tool in indicating early laparoscopic examination of the infertile period.

Labial adhesions secondary to postpartum vulvar edema. A report of two cases.

Labial adhesions have been found commonly in children. Two patients developed thick labial adhesions secondary to massive postpartum vulvar edema.

Cesarean section. Assessment of the convenience factor.

To assess the potential input of physician convenience on the performance of cesarean sections (C-sections), analysis of C-sections by time of day and day of the week was undertaken at four Chicago-area hospitals. The primary C-section rate at the University of Chicago Chicago Lying-In Hospital, with a relatively high-risk patient population and a full-time salaried resident and faculty staff, was lower than at three other hospitals staffed predominantly by private practitioners. Indications for primary C-sections were classified as "acute," "semiacute" or "nonacute." Acute and semiacute C-sections were performed without demonstrated time biases in regard to the time of day or the day of the week at all four hospitals. Nonacute C-sections (70% cephalopelvic disproportion) were not performed as frequently at night (12-8 A.M.) as at other times at three of the four hospitals, but there were no differences in the individual characteristics of the outcomes of such deliveries between day and night. There was also no Friday afternoon or Monday morning frequency increase. The data failed to reveal significant variations in the performance of acute C-sections but did show day-night variability in C-sections done for non-acute indications.

Diagnosis of lower urinary tract disorders in postmenopausal patients.

One hundred patients over age 60 who had lower urinary tract symptoms were evaluated in detail. The five primary diagnoses were urethral syndrome (29%), genuine stress incontinence (21%), unstable bladder (19%), hypoestrogenism (7%), and pelvic relaxation (6%). Among patients with genuine stress incontinence, 95.2% had the symptom of stress incontinence. Of 43 patients with the symptom of stress incontinence, 67.4% had the diagnosis of genuine stress incontinence confirmed on urodynamic testing. Of the patients with an unstable bladder, 88.9% had urgency and/or urge incontinence; but of 40 patients with both of these symptoms, only 40% had the diagnosis of unstable bladder. Sixty-two patients who complained of urinary incontinence had the following primary diagnoses: genuine stress incontinence (36%), unstable bladder (29%), urethral syndrome (21%), and pelvic relaxation (5%). Because of the impossibility of clinically correlating symptom with diagnosis in the individual patient, extensive evaluation of postmenopausal patients to determine the etiology of incontinence is advised prior to surgical intervention.