Evaluation of serum MMP-9 as predictive biomarker for antisense therapy in Duchenne.

Duchenne Muscular Dystrophy (DMD) is a severe muscle disorder caused by lack of dystrophin. Predictive biomarkers able to anticipate response to the therapeutic treatments aiming at dystrophin re-expression are lacking. The objective of this study is to investigate Matrix Metalloproteinase-9 (MMP-9) as predictive biomarker for Duchenne. Two natural history cohorts were studied including 168 longitudinal samples belonging to 66 patients. We further studied 1536 samples obtained from 3 independent clinical trials with drisapersen, an antisense oligonucleotide targeting exon 51: an open label study including 12 patients; a phase 3 randomized, double blind, placebo controlled study involving 186 patients; an open label extension study performed after the phase 3. Analysis of natural history cohorts showed elevated MMP-9 levels in patients and a significant increase over time in longitudinal samples. MMP-9 decreased in parallel to clinical stabilization in the 12 patients involved in the open label study. The phase 3 study and subsequent extension study clarified that the decrease in MMP-9 levels was not predictive of treatment response. These data do not support the inclusion of serum MMP-9 as predictive biomarker for DMD patients.

Effect of Extending the Original Eligibility Criteria for the CROSS Neoadjuvant Chemoradiotherapy on Toxicity and Survival in Esophageal Cancer.

BACKGROUND: Patients with curable esophageal cancer (EC) who proceed beyond the original Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) eligibility criteria are also treated with neoadjuvant chemoradiotherapy (nCRT). This study assessed the effect that extending the CROSS eligibility criteria for nCRT has on treatment-related toxicity and overall survival (OS) in EC. METHODS: The study enrolled 161 patients with locally advanced EC (T1N1-3/T2-4aN0-3/M0) treated with the CROSS schedule followed by esophagectomy. Group 1 consisted of 89 patients who met the CROSS criteria, and group 2 consisted of 72 patients who met the extended eligibility criteria, i.e. a tumor length greater than 8 cm (n = 24), more than 10% weight loss (n = 35), more than 2-4 cm extension in the stomach (n = 21), celiac lymph node metastasis (n = 13), and/or age over 75 years (n = 2). The study assessed the differences in nCRT-associated toxicity [National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3] and 90-day postoperative mortality. Moreover, the prognostic value for OS was assessed with multivariate Cox regression analysis. RESULTS: No difference was found in nCRT-associated toxicity (P = 0.117), postoperative complications (P = 0.783), and 90-day mortality (P = 0.492). The OS differed significantly (P = 0.004), with a median of 37.3 months [95% confidence interval (CI), 10.4-64.2 months] for group 1 and 17.2 months (95% CI 13.8-20.7 months) for group 2. Pathologic N stage (P = 0.023), pathologic T stage (P = 0.043), and group 2 (P = 0.008) were independent prognostic factors for OS. CONCLUSIONS: Extension of the CROSS study eligibility criteria for nCRT did not affect nCRT-associated toxicity, postoperative complications, and postoperative mortality, but was prognostic for OS.

Co-transmission of the non-transmissible South African Babesia bovis S24 vaccine strain during mixed infection with a field isolate.

The South African Babesia bovis live blood vaccine, originating from a field isolate attenuated by 23 serial syringe passages in splenectomized calves, has lost the ability to infect the natural vector Rhipicephalus (Boophilus) microplus. In this study, infection with mixed parasites from the vaccine strain and a field isolate, resulted in transmission of both genotype populations. Comparing the field isolate and transmitted combination indicated no significant difference in their virulence, while challenge of vaccinated cattle with these isolates showed the ability of the vaccine to protect against both. Limiting dilution of the transmitted combination, followed by infection of splenectomized cattle (n=34) yielded no single infections for the vaccine strain genotype, seven clonal lines of the field isolate and one mixture of vaccine strain and field isolate. Only one of two field isolate clonal lines selected for vector transmission study was transmitted. Showing that B. bovis isolates can contain both tick transmissible and non-transmissible subpopulations. The findings of this study also indicate the probability of vaccine co-infection transmission occurring in the field, which may result in new genotype populations of B. bovis. However, the impact of this recombination with field isolates is considered negligible since a genotypically diverse population of B. bovis is already present in South Africa.

Prostate carcinoma--the value of T stage and grade in predicting metastases and prognosis. A cost-effective approach to clinical staging.

In order to evaluate the initial T stage and tumour grade as predictors of metastatic disease and prognosis in adenocarcinoma of the prostate, 963 patients were reviewed. Of the patients, 41% presented with metastatic disease. Stage T4 tumours were associated with a consistently poor prognosis, and 70% of such patients had demonstrable distant metastases. No patient with TOf local disease had metastases or died of prostate cancer during follow-up. The incidence of metastases was also low in stages T1 and T2. High tumour grade correlated strongly with more advanced disease. Using this information a more cost-effective approach to the staging of prostate carcinoma is proposed.

[Intravesical BCG as a treatment for superficial and in situ transitional cell carcinoma of the bladder]. / Intravesikale BCG as behandeling van herhalende oppervlakkige en in situ oorgangselkarsinoom van die blaas.

Intravesical BCG is already established as effective therapy in the management of superficial bladder cancer. However, varying results have been obtained with different BCG strains; these are ascribed to variations in their immunogenicity. The locally available BCG strain which contains approximately 1.2 x 10(9) colony-forming units per 120 mg was used for intravesical instillation in 27 patients with recurrent superficial transitional cancer of the bladder. Ten of the 13 patients who received BCG prophylactically to reduce or stop recurrencies completed therapy and 7 (70%) were in remission after 1 or 2 courses with a mean follow-up of 2 years. Fourteen patients received BCG therapeutically for in situ carcinoma. Thirteen of these patients completed therapy and 9 (69%) responded favourably after 1 or 2 courses of BCG for a mean follow-up period of 23 months. Adverse effects of the treatment were mild and well tolerated except in a patient who received radiotherapy. Although 21 patients experienced irritable bladder symptoms only 1 discontinued treatment as a direct result. The only other patient in whom treatment had to be stopped, developed severe polyarthritis after 3 instillations. A statistically significant reduction in the number of recurrences (P less than 0.001) was experienced by the patients who received BCG prophylactically. Although this is a very limited study, the locally available BCG strain exhibited therapeutic activity. It is cost-effective and warrants further study.

The glycosaminoglycans of the gubernaculum during testicular descent in the fetus.

Tissues were obtained from 387 male pig fetuses ranging from 60 to 120 days of gestation. The relative wet mass and water content of the gubernaculum increased during and decreased after the period of testicular descent. The extracellular glycosaminoglycans (GAG) were assayed to determine whether these polyanionic macromolecules are responsible for the increased water content of the gubernaculum. The total GAG/wet tissue mass in the gubernaculum decreased during and increased after descent, while the total GAG/dry mass decreased during and after descent, indicating an accumulation of water during descent, with a loss of water and an increase in less hydrated tissue components after descent. The major GAG fraction in the gubernaculum was dermatan sulfate, but the percentage hyaluronate in the gubernaculum was two times higher than in striated muscle or umbilical cord, indicating that this GAG fraction may be responsible for the increased water content of the gubernaculum, which probably serves to dilate the inguinal canal and scrotum, thus facilitating descent.

Resistance of Nguni, Bonsmara and Hereford cattle to ticks in a Bushveld region of South Africa.

Counts of engorged female ticks on naturally infested cattle over a 2 year period, showed that indigenous Nguni cattle harboured significantly fewer Amblyomma hebraeum, Boophilus decoloratus and Hyalomma spp. during periods of peak abundance than either Bonsmara or Hereford cattle. Fewer abscesses, associated with tick bite, were also present in the Nguni cattle. Individual tick resistance indices, determined after artificial tick infestation in the field, could not be correlated with hair length, skin thickness or conglutinin titres. The consistently large percentage of Nguni cattle showing high tick resistance according to index determinations, indicates a superior level of natural immunity in this breed. The relative incidence of individuals in high, medium and low resistance classes reflected an increase in resistance with exposure to ticks and the potential for the selection for tick resistance within all 3 breeds.

Agenesis of the bladder and urethra: a case report.

Agenesis of the bladder is an extremely rare congenital anomaly. We describe a girl with complete agenesis of the bladder and urethra, who is alive 2 years after bilateral cutaneous ureterostomy.

Rectal examination in the detection of prostatic cancer.

Since the aetiology of prostatic cancer is unknown, and therapy for metastatic disease non-curative, a decrease in the mortality rate from this condition can only be achieved by early diagnosis and effective treatment of the primary tumour. For diagnosis of localised cancer no practical alternative exists to rectal palpation. Of 629 cases of prostatic cancer seen at Tygerberg Hospital, the disease had metastasised in 29% of white and 58% of coloured patients at initial diagnosis. Prostatism or urinary retention was the presenting complaint in 74.7% of patients. The letters of referral of 97 patients were examined to determine whether prostatic cancer had been diagnosed by the primary care physician before referral. Rectal examination by the referring physician was recorded or implied in 64.9% of patients, and in those patients who underwent rectal examination before referral prostatic cancer was diagnosed in 54%. These findings imply that the opportunity for early diagnosis of prostatic cancer may be missed in many patients in whom rectal examination by the primary physician is indicated.

Percutaneous nephrolithotomy. Experience with renal and proximal ureteral calculi at Tygerberg Hospital.

Percutaneous nephrolithotomy (PCN) enables the urologist to remove upper urinary tract stones through a percutaneous nephrostomy tract. The principal advantages of PCN are the low morbidity, shortened hospital stay and rapid recovery. Percutaneous puncture failed in 5 (11%) of the first 44 patients with upper tract urolithiasis treated by PCN at Tygerberg Hospital. In 35 patients (80%) PCN cleared the kidney of stones but in 4 patients (9%) all stone fragments were not removed during the procedure. If the puncture and dilatation was successful, then 90% of patients were stone-free after PCN. Complications were minimal except for a diabetic who died of septicaemia. PCN is an alternative to open renal surgery in the management of most upper urinary tract stones. The technique is readily mastered by any urologist experienced in endoscopic surgery.

Nephroblastoma in an ovotestis of a true hermaphrodite: a case report.

We describe a patient who presented with a painful mass in the left inguinoscrotal region, gynecomastia, perineal hypospadias with chordee and a bifid scrotum with a small gonad in the right hemiscrotum. At operation the left mass was found to be an ovotestis with hemorrhage in a corpus luteum cyst. A rudimentary uterus and fallopian tube were situated next to the ovotestis. The right gonad also was an ovotestis with a tiny focus of small cell malignancy that was suggestive of nephroblastoma.

Light-microscopic stereologic analysis of spontaneous and steroid-induced canine prostatic hyperplasia.

A combined light-microscopic and stereologic analysis of the canine prostate was performed under the following experimental conditions: intact and castrated dogs, spontaneous benign prostatic hyperplasia, intact and castrated dogs after treatment with testosterone, 5 alpha-dihydrotestosterone or 3 alpha-androstanediol in combination with estradiol. Regarding the absolute amounts of the glandular and stromal parts of the prostate as well as the glandular cells, no difference was found among the testosterone, 3 alpha-androstanediol and 5 alpha-dihydrotestosterone treated castrated dogs. Treatment with 5 alpha-dihydrotestosterone or 3 alpha-androstanediol in combination with 17 beta-estradiol induced a four-fold increase in glandular and a two-fold increase in stromal tissue. The glandular to stromal tissue ratio equals that found in spontaneous canine hyperplasia, which is indicative of the glandular type of spontaneous canine hyperplasia. Therefore, it can be stated that treatment with 5 alpha-dihydrotestosterone or 3 alpha-androstanediol combined with 17 beta-estradiol not only induces prostatic overgrowth but also leads to prostatic hyperplasia of the glandular type. However, the stereologic analysis of canine prostates following steroid administration shows that canine hyperplasia is primarily a glandular disease, while human benign prostatic hyperplasia shows more stromal activation.

DNATYPE--a personal computer program for HLA-DR typing based upon restriction fragment length polymorphisms.

The use of specific cDNA probes and selected combinations of restriction endonucleases makes it possible to characterize specific antigens by the molecular weights of the hybridized restriction enzyme digests of DNA. We have developed a simple program suitable for personal computers which utilizes such results to deduce HLA-DR phenotypes of any nucleated cell from which DNA may be extracted.

Hyperplasia and hypertrophy of the gubernaculum during testicular descent in the fetus.

The role of the gubernaculum during testicular descent was investigated in 115 male pig fetuses ranging from 68 to 109 days of gestation. Descent of the testis through the inguinal canal occurred between 77 and 94 days. There was a marked increase in the total and relative wet mass as well as the wet/dry mass ratio of the gubernaculum, denoting an increase in the water content of this structure during descent of the testis. Similar changes were not seen in other fetal tissues. Asymmetrical descent of the testes occurred in seven of the 40 fetuses between 81 and 92 days of gestation. Descended testes had gubernacula with a greater relative wet mass than the gubernacula of undescended testes. These findings indicate that the increase in mass of the gubernaculum plays an important part in testicular descent. An increase in both the DNA content (hyperplasia) and the RNA/DNA ratio (hypertrophy) was noted in the gubernaculum during descent of the testis. Hyperplasia in the gubernaculum occurred at a rapid rate initially and ceased after the completion of descent. Hyperplasia was also seen in the testis and epididymis, but occurred at a slower rate initially, with a rapid acceleration after the completion of descent. Cellular hypertrophy was not noted in the testis and epididymis, but did occur in umbilical cord tissue. If gonadotropins acting via androgen secretion by the testis provide the stimulus for these changes, the observed difference in response between the gubernaculum and testis could be due to a difference in end-organ sensitivity. However, it is also possible that some unidentified non-androgenic gubernaculotropin, possibly secreted by the fetal testis, provides the stimulus for gubernacular growth.

Stromal and epithelial growth of the prostate during puberty.

In 30 male Chacma baboons, prepubertal, pubertal, and adult animals have been identified by their testicular and prostatic weights. The volume of the stromal and epithelial components of caudal prostate were calculated from morphometric determination of the percentage volume of each component and the total caudal prostate volume. Both stromal and epithelial volumes increased at puberty and plateaued at maturity. These increases could be fitted to logistic curves that support the conclusion that stromal pubertal growth precedes epithelial pubertal growth. The stromal contribution to prostates of increasing size followed a model distinct to that of the epithelial contribution, thus suggesting that the factors (e.g., androgens) controlling stromal and epithelial growth are not identical. Stromal growth may be a prerequisite for pubertal epithelial development of the prostate.

Crystalluria and urolithiasis in a relatively stone-free population.

The occurrence of renal stone in South African blacks is extremely rare. Whites however are prone to calculi to the same extent as that reported in other Western communities. The nature of the particulate material and crystalluria in urine samples from the two population groups were investigated using a Coulter Counter and scanning electron microscope. In addition, 10 calculi obtained from black patients over a 5 year period were analysed. The particle size distribution curves obtained for normal black and white males were identical. The curves for normal black and white females were also identical but different from those for males. Black male stone formers had larger particles than their controls while the single black female stone former investigated had particles of the same size as female controls, but in greater numbers. Scanning electron microscopy revealed profuse amounts of crystalline NaCl, KCl and other salts in the urinary sediments of blacks. These were not observed in the specimens from whites nor in the black stone formers' urines. Analysis of the calculi identified chemical and ultrastructural features similar to those observed in stones from whites. The hypothesis that the lower incidence of stone disease in blacks may be due to a high Na/Ca ratio is supported by our findings. It is suggested that various salts play a role in lowering the stone forming potential of such urines by a competitive substitution mechanism in which lattice calcium is displaced by sodium. It is also suggested that when urinary stone formation does occur in blacks, it does so via the same physicochemical mechanisms as in any other race group.

The glycosaminoglycans of human bladder cancers of varying grade and stage.

The glycosaminoglycans of four normal human bladders and fourteen bladder cancers were characterized and quantitated (after proteolytic extraction) by specific enzyme digestion, cellulose acetate electrophoresis and densitometry. Hyaluronic acid, heparan sulfate, dermatan sulfate and chondroitin sulfate were identified in both normal and cancerous bladders. Hyaluronic acid and dermatan sulfate were the major glycosaminoglycans of the normal epithelium/submucosa while heparan sulfate and dermatan sulfate were predominant in normal bladder muscle. Bladder cancer glycosaminoglycan content was influenced by the stage and grade of the neoplasm. Hyaluronic acid and dermatan sulfate tended to decrease and chondroitin sulfate to increase in infiltrating cancers, whereas a decrease in the percentage of heparan sulfate correlated closely with higher grade tumors. The bladder cancer glycosaminoglycan profile may be indicative of the tumor's invasive potential.

Nonoperative management of renal stab wounds.

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3). The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and 0 per cent in group 3. Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3. Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively. Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.

The gubernaculum during testicular descent in the pig fetus.

The role of the gubernaculum during testicular descent was investigated in a study of 119 male pig fetuses obtained at gestational ages ranging from 53 to 116 days. Histologically the gubernaculum was shown to consist of primitive mesenchymal cells with an abundant intercellular material containing glycosaminoglycans (mucopolysaccharides). Rapid descent of the testis through the inguinal canal occurred between 77 and 88 days' gestation, while sustained but slower descent occurred up to 109 days. There was a dramatic increase in the total wet mass of the gubernaculum at the commencement of rapid testicular descent from 77 to 81 days, and a further increase in wet mass during sustained descent from 91 to 95 days. In the period just prior to rapid testicular descent (day 74-81) the percentage increase in the water content of the gubernaculum was larger than the percentage increase in the dry mass. After descent of the testis (day 95-109) there was a decrease in the water content, but also an increase in the dry mass of the gubernaculum. No comparable increase in the water content of umbilical cord or striated muscle tissue occurred during the period of testicular descent. Thus, the marked swelling of the gubernaculum, which dilates the inguinal canal and scrotum and may possibly exert traction on the testis by the force of its expansion, is due largely to an accumulation of water by the gubernaculum. This process may be mediated by the intercellular glycosaminoglycans, since these poly-anionic macromolecules are known to have a large hydrodynamic volume and can act as a "water trap."

The effect of 5 alpha-androstane-3 alpha, 17 beta-diol and 17 beta-estradiol on the adult and immature chacma baboon prostate.

We have studied the Chacma baboon prostate in an attempt to develop a primate model of benign prostatic hyperplasia. Anatomically, the baboon prostate can be divided into caudal, cranial, and prostatic urethral segments. A peri-urethral group of glands has been identified in the prostatic urethra. Following treatment with either 5 alpha-androstane-3 alpha, 17 beta-diol or 17 beta-estradiol, or the hormones in combination, the mature baboon prostate showed very little response by gravimetric or morphometric analysis. In contrast, the stimulatory effect of 5 alpha-androstane-3 alpha, 17 beta-diol on the caudal lobe of the immature baboon prostate and the prostatic urethral segment (a structure that is largely fibromuscular) was potentiated by the addition of 17 beta-estradiol. The weight of the immature baboon cranial prostate was increased by 5 alpha-androstane-3 alpha, 17 beta-diol treatment, but 17 beta estradiol did not potentiate androgen-induced growth. By morphometric analysis it could be shown that both the epithelial and stromal component of the immature baboon caudal prostate responded to 5 alpha-androstane-3 alpha, 17 beta-diol (androstanediol) treatment and that the addition of 17 beta-estradiol had a slight, but significant, potentiating effect on the androstanediol-induced increase of epithelial volume.