Valor de la biopsia prostática contemporánea durante prostatectomía radical / Contemporary prostatic biopsy value during radical prostatectomy

La presencia de márgenes positivos en la pieza quirúrgica es un factor pronóstico adverso. La realización de biopsia rápida prostática y resección de los márgenes comprometidos durante prostatectomía radical (PR) podría mejorar el pronóstico de los pacientes. El objetivo de este trabajo es estudiar la relevancia de la biopsia contemporánea y la resección de los márgenes comprometidos durante PR. Material y Métodos: De una serie de 442 pacientes pT2, operados entre abril de 1997 y septiembre de 2004, se seleccionaron al azar 53 pacientes con márgenes (-) y 56 pacientes con márgenes (+). De este último grupo, a 31 pacientes se les realizó biopsia prostática rápida y resección de los márgenes comprometidos, y a los 25 restantes no. Todos los pacientes cuentan con un seguimiento de al menos 12 meses. Se comparó sobrevida libre de enfermedad por medio de curvas de Kaplan-Meier. Resultados: De los 53 pacientes con márgenes (-), 5 (9,4 por ciento) presentaron recurrencia bioquímica a los 18,8 meses promedio; de los 31 pacientes a quienes se les realizó biopsia rápida y re-resección, 7 (22,5 por ciento) presentaron recurrencia bioquímica a los 23,2 meses promedio, en cambio, en el grupo con márgenes (+) y sin biopsia rápida, 11 (44 por ciento) presentaron recurrencia bioquímica en un tiempo promedio de 6,9 meses. Al comparar las curvas de sobrevida libre de enfermedad se observa una diferencia estadísticamente significativa (P=0,017) entre el grupo con re-resección de márgenes v/s el que no la tenía. Conclusión: La resección de los márgenes comprometidos en pacientes con biopsia rápida positiva, se asocia a una sobrevida libre de enfermedad mayor que cuando no se realiza.

Introduction: Positive margin in surgical piece is an adverse prognosis factor. A soon prostate biopsy andinvolved margins resection during radical prostatectomy (RP) could improve prognosis. The purpose of thiswork is to study the contemporary biopsy relevance and the resection of the involved margins during RP.Material and methods: 53(-) margins patients and 56 (+) margins patients were selected at random, from atotal of 442 pT2 patients operated between April 1997 and September 2004. 31 patients from the last group,were made frozen prostate biopsy and resection of the involved margins. All of them were followed-up during12 months, at least. Healthy survival was compared, by Kaplan-Meier curves. Results: 5 of the total of 53patients with (-) margins (9.4%) shown biochemical recurrence at 18.8 months average; 7 of the 31 (22.5%)patients who were made fast and re-resection, shown biochemical recurrence at 23.2 months average. 11(44%) of the group with margin (+) and without a frozen biopsy, shown biochemical recurrence at 6.9months average. Comparing healthy survival curves, there is a significative difference (P = 0.017) in groupsof margins re-resection v/s groups without them. Conclusion: Margins resection involved in patients withpositive frozen biopsy is associated to a more healthy survival than if it is not made.

Transcriptional regulation of galectin-10 (eosinophil Charcot-Leyden crystal protein): a GC box (-44 to -50) controls butyric acid induction of gene expression.

Galectin-10 (gal-10, also known as Charcot-Leyden crystal protein) is a member of the galectin family of beta-galactoside binding proteins that is expressed uniquely in eosinophilic and basophilic leukocytes. To gain a better understanding of galectin gene expression, we present an analysis of the transcriptional regulation of the gene encoding gal-10. Analysis of the minimal promoter revealed nine consensus-binding sites for transcription factors, including several that are also found in the minimal promoters of galectins -1, -2, and -3. The decrease in gal-10 promoter activity after disruption of either the GC box (-44 to -50) or the Oct site (-255 to -261) suggests that these sites, along with the previously characterized GATA and EoTF sites, are necessary for full promoter activity. By supershift analysis, we demonstrate binding of the transcription factors Sp1 and Oct1 to the consensus GC box and the Oct site, respectively. Similar to gal-1, gal-10 expression is induced by butyric acid, an effect that is lost upon ablation of the GC box. Additionally, we demonstrate AML3 binding to the consensus AML site and YY1 binding to the Inr sequence, both elements functioning as silencers in the gal-10 promoter.

US approach to jaundice in infants and children.

High-resolution real-time ultrasonography (US) serves as an important tool for differentiation of obstructive and nonobstructive causes of jaundice in infants and children, independent of liver function. Unconjugated hyperbilirubinemia occurs in approximately 60% of normal term infants and in 80% of preterm infants. Persistence of neonatal jaundice beyond 2 weeks of age demands US evaluation to differentiate between the three most common causes: hepatitis, biliary atresia, and choledochal cyst. In all three conditions, the hepatic echotexture is diffusely coarse and hyperechoic, but this appearance may be seen in a variety of hepatic inflammatory, obstructive, and metabolic processes. Thus, hepatic scintigraphy and at times percutaneous liver biopsy are necessary to narrow the differential diagnosis and to identify patients who require more invasive techniques (eg, intraoperative cholangiography). US is useful for demonstrating inspissated bile and biliary duct stones. In infants, stones are usually secondary to obstructive congenital anomalies of the biliary tract, total parenteral nutrition, furosemide treatment, phototherapy, dehydration, infection, hemolytic anemia, and short-gut syndrome, whereas in older children, stones are usually associated with sickle cell disease, bowel resection, hemolytic anemia, and choledochal cyst. Jaundice in infants and children may also be due to cirrhosis, benign strictures, and neoplastic processes.

The assessment of young children's expectancies of alcohol versus a control substance.

AIMS: The chief purpose of the current study was to assess whether young children endorse expectancies specific to alcohol. DESIGN: In order to accomplish this aim, a 2 (gender of child) by 2 (gender of adult drinker) by 2 (grade level) by 2 (beverage type) repeated measure design was employed with beverage type as the repeated measure. SETTING: Data were collected within elementary schools located in two Midwestern states. PARTICIPANTS: One hundred and twenty-four second and third graders (42% male) participated in individually structured interviews. MEASUREMENTS: The expectancy interview was based on the Children's Alcohol-Related Expectancy Questionnaire and assessed each child's beliefs about the desirable and undesirable consequences which adult men and women might experience after drinking alcohol (beer) and a control beverage (iced tea). FINDINGS: The results indicated that children endorsed significantly more undesirable expectancies for beer than for iced tea, and more desirable expectancies for iced tea than for beer. In addition, children's expectancies varied as a function of the gender of the drinker. Specifically, both second- and third-graders expected more undesirable outcomes for women than for men, and second graders expected fewer desirable outcomes for women than for men, regardless of beverage. CONCLUSIONS: Prior to substantial experience with alcohol consumption, children have already developed expectancies for alcohol. Specifically, young elementary children endorse predominantly undesirable expectancies for beer.

Kenneth K. Keown, MD: pioneer of cardiac anesthesiology.

In 1948, just 2 years out of his anesthesiology residency at Hahnemann Medical College and Hospital, Kenneth K. Keown, MD, was chosen as the anesthesiologist for the procedure that launched the era of intracardiac surgery--a mitral valves commissurotomy. Although surgery on stenotic mitral valves had met with some success as early as the 1920s, its application had lain dormant for some 25 years. In effect, Keown and Hahnemann's Chief of Thoracic Surgery, Charles P. Bailey, MD, who performed the daring operation, launched the acceptance of intracardiac procedures, showing that the heart could be invaded with a successful outcome. Keown and Bailey continued as a team through many innovative cardiac procedures, during which Keown wrote the first monograph on cardiac anesthesia in 1956. Keown was also an early innovator in perfecting methods of inducing hypothermia in cardiac surgery and is also renowned for his pioneering work in cardiac arrhythmias, using lidocaine to counteract fibrillation during cardiac surgery. In 1957, Keown returned to his home state of Missouri to build a department of anesthesiology at the University of Missouri School of Medicine. He advocated allowing only physicians trained in the specialty to administer anesthesia, and he believed firmly that anesthesiology should be a freestanding specialty separate from surgery. He also maintained a vigorous resident recruitment service. Keown held leadership positions in many medical organizations and, during a sabbatical from Missouri, served on the hospital ship Hope in Tunisia. He was Professor and Chief, and later Chairman, Section of Anesthesiology, at the University of Missouri Medical Center, and from 1969 until his death in 1985, he also served as the Center's Medical Director.

Renal dysgenesis in a monozygotic twin: association with in utero exposure to indomethacin.

We report oligohydramnios and renal dysgenesis in one of identical twins, which might have resulted from in utero exposure to early, prolonged high-dose indomethacin. The proposita was the second of twin girls born at 36 weeks of gestation. Pregnancy was complicated initially by polyhydramnios in both amniotic sacs and premature uterine contractions. After administration of indomethacin and terbutaline from 16 to 30 weeks' gestation, serial prenatal ultrasound examinations ultimately showed oligohydramnios in twin B and resolution of polyhydramnios in twin A. On day 5 twin B developed hematuria, hypertension, renal failure, hyponatremia, hyperkalemia, metabolic acidosis, sodium wasting and severe, transient inability to excrete potassium. Renal sonography showed enlarged, hyperechoic kidneys with almost no corticomedullary differentiation. Renal biopsy revealed immature glomeruli, dilated Bowman's spaces, dilated tubules, and interstitial fibrosis. The liver was histologically normal. Indomethacin may induce oligohydramnios and transient renal insufficiency in humans and renal dysgenesis in fetal monkeys; it might have induced the abnormalities in this patient.

Relationships between block-of-twitch and train-of-four fade in the mouse phrenic nerve-diaphragm preparation.

The relationships between the block-of-twitch and train-of-four fade in the presence of nondepolarizing neuromuscular blocking drugs (d-tubocurarine, vecuronium and pancuronium) were examined in vitro by measuring the contractile tension from mouse phrenic nerve-diaphragm preparations. The slope of the block/fade relationship differed between onset of and recovery from neuromuscular block following single doses of d-tubocurarine, vecuronium or pancuronium. Decreasing the dose of d-tubocurarine or using a divided dose technique to accelerate onset (i.e., priming) increased the amount of fade for a given amount of block. In addition, the block/fade relationships for cumulative dosing and sequential dilution were the same when measurements were made at steady-state for several doses. It is concluded that the block/fade relationship in the mouse phrenic nerve-diaphragm preparation is variable, and is related to the time course of the neuromuscular block. In addition, the block/fade relationships for d-tubocurarine, vecuronium and pancuronium did not differ when determined at steady-state.

Anticonvulsant actions and interaction of GABA agonists and a benzodiazepine in pars reticulata of substantia nigra.

In a previous study, infusion of flurazepam and midazolam, but not GABA or muscimol into the pars reticulata of substantia nigra (SNpr), blocked the tonus induced by a high dose of pentylenetetrazol (PTZ). It was hypothesized that the divergence of GABAA agonist and benzodiazepine (BZ) actions might be due to a complex action of the GABAA agonists in SNpr that is not shared by the BZs, and which is specific for certain experimental seizures. This was tested in the present study in which GABA, muscimol, midazolam, and combinations of midazolam with GABA and with muscimol were tested against seizures induced by PTZ (40 or 100 mg/kg, i.p.), bicuculline (0.5 mg/kg, i.v.) and maximal electroshock (MES). Intranigral midazolam was effective against PTZ, bicuculline and MES seizures. Intranigral GABA or muscimol, infused together with midazolam, prevented midazolam from blocking tonus induced by the high dose of PTZ. For bicuculline seizures, midazolam alone had a better overall anticonvulsant effect than did the combination of midazolam plus muscimol. Intranigral muscimol, midazolam and a combination of two were equally effective against the low dose PTZ (40 mg/kg, i.p.) and MES seizures. Since the effect of intranigral drugs was model-specific, it was suggested that different populations of nigral output neurons were involved in regulating the generalization of these seizures.

The role of nonphysician consultants as health-care educators in postgraduate programs of anesthesiology.

Many physicians believe that the tasks of postgraduate medical education and faculty development are best carried out by senior physicians trained in the appropriate specialty. However, many also will admit that, as physicians, they have received too little training for such an educational role, and that the practical demands of medical practice, scientific research, and administration make it difficult if not impossible to allocate time to continuing medical education program development, curriculum design for residency training, teacher training, and other key aspects of postgraduate medical education. Many medical disciplines have attempted to alleviate this problem by using nonphysician health-care educational consultants in their training programs. However, little attention has been paid to the possibilities of using such consultants in anesthesiology residency education and faculty development. Such consultants in postgraduate medical education and training programs in anesthesiology could perform a wide variety of functions and roles because they possess skills and technical expertise in teaching, training, curriculum design, evaluation, program planning, and interpersonal communications that faculty members often lack. The successful use of a nonphysician consultant in the Department of Anesthesiology at Hahnemann University in Philadelphia, Pennsylvania, is described.

The complementary roles of ultrasound and plain film radiography in differentiating pediatric chest abnormalities.

Sonography, as a complement to plain film radiography, is reliable for limiting the differential diagnosis and obviating the need for more invasive studies.

Malignant hyperthermia in a halothane-anesthetized horse.

Malignant hyperthermia developed in a 4-year-old Thoroughbred horse following 3 hours and 15 minutes of halothane anesthesia, with supplementary succinylcholine. Clinical signs included fever, sweating, hyperventilation, tachycardia, and decreased blood pressure followed by a rapid increase in blood pressure. Biochemical aberrations included hypocalcemia, hyperkalemia, hyperphosphatemia, myoglobinuria, and high creatine phosphokinase and ornithine carbamyl transferase activities. Treatment consisted initially of surface cooling with cold water, alcohol and ice, IV administration of cooled balanced electrolyte solutions and sodium bicarbonate, and removal from the anesthetic and rebreathing circuit. Oxygen was given by endotracheal insufflation. The rectum was then packed with ice, the horse was moved to a recovery raft and pool, and his body was packed in ice. Xylazine and dantrolene were given during recovery from anesthesia. Following recovery, treatment consisted of administration of balanced electrolyte solutions, calcium borogluconate, potassium penicillin, meperidine, and additional dantrolene. Muscle biopsy demonstrated exaggerated contracture responses to halothane and caffeine, confirming a diagnosis of malignant hyperthermia. The horse was returned to training following a routine postsurgical convalescent period.

Radiographic features of gastrointestinal graft-vs.-host disease.

Five patients underwent bone-marrow transplantation, and graft-vs.-host disease (GVHD) developed. Radiographic features are described. Three patients showed an abrupt transition at the jejuno-ileal junction from normal small bowel to ileal loops which were narrowed, tubular, separated, edematous, and, generally, without mucosal markings. The transit time for the contrast material to reach the anus from the mouth was 20 to 25 minutes. A fourth patient showed mucosal ulcerations of the transverse and descending colon. The fifth patient with acute, ultimately fatal GVHD had an edematous duodenum and colon, in addition to an edematous, tubular jejunum and ileum without mucosal markings. Transit time through the intestines for the contrast material was rapid.

The Dominican Republic conjoined twins: ischiopagus, tetrapus, omphalophagus.

Alta and Clara, the Dominican Republic conjoined twins (ischiopagus, omphalopagus, tetrapus) were evaluated prior to separation with plain films, vaginograms, arteriograms, intravenous pyelogram, barium enema, and upper gastrointestinal series with small bowel follow-through. The clear demonstration of their internal anatomy allowed the surgeons to plan the operative approach and to make a reasonable judgment regarding viability of each baby. Each twin had a semicircular pelvis which joined the other to form a complete ring. There were a few hepatic arterial twigs from Alta which crossed the midline, proving at surgery to be a small bridge of tissue connecting the two livers. Clara's superior mesenteric arteries supplied the majority of the small bowel. Portal venous drainage was separate for each twin. Each baby had two kidneys in normal position with the bladders laterally placed. Each bladder received one ureter from each twin. Two separate small bowels joined proximal to the single colon which terminated in an anus related to Clara's pelvic structures. Following separation, each baby did well. Their postoperative anatomy is described.

Heart rate and physical activity of children during dental treatment.

Children with grossly observable physical activity during intraoral injection have significant heart rate accelerations. Children in whom movement is absent or confined to the muscles of facial expression experience heart rate deceleration. Both groups of children show anxiety, hence heart rate cannot be used to index anxiety. Moreover, anxiety cannot be described along a single dimension of arousal.

Steroids and steroid metabolism in plant tissue cultures.

The steroids which have been isolated from plant callus and suspension cultures are reviewed. In addition, the research involving the use of plant tissue cultures to investigate steroid biosynthesis and metabolism is summarized.