Refractory and massive lymphocele in a transplant patient with encapsulating peritoneal sclerosis treated with a single infusion of bleomycin: a case report.

A 26-year-old Caucasian man developed a large lymphocele after living-related kidney transplantation necessitating repeated drainage of large volumes every other day owing to ureteral compression. An open laparotomy for internal drainage was unsuccessful because of severe encapsulating peritoneal sclerosis. Prolonged external drainage with a catheter was inefficient. Repeated fine-needle aspirations of large volumes were needed to maintain ureteral patency over a period of 4 months. Finally, a single instillation of bleomycin immediately and effectively treated the lympocele with no relapse over the following 5 years. The presence of encapsulating peritoneal sclerosis seemed to be an obstacle to surgical treatment.

Defining the surgical management of suspected early-stage ovarian cancer by estimating patient numbers through alternative management strategies.

OBJECTIVE: To establish the optimal management strategy for women with suspected stage 1 ovarian cancer. DESIGN: We created a flowchart to illustrate each of six hypothetical management strategies. These considered two surgical approaches (systematic lymphadenectomy versus no lymph node dissection at all) in combination with three different policies for giving adjuvant chemotherapy. SETTING: Gynaecological cancer centre, London, UK. DATA SOURCES: Patient data and published papers. METHODS: We developed a deterministic model that uses information from multiple sources to estimate patient flow through each level of a hypothesised decision tree. RESULTS: We estimated that for every 100 cases of suspected early-stage ovarian cancer, there would be 37 cases with 'apparent' stage 1 disease and that of these, two (6%) would be denied potentially life-saving adjuvant treatment if systematic lymphadenectomy was not performed. The number of women given chemotherapy would not, according to our estimates, differ greatly between the two surgical approaches, the 7% increase with systematic lymphadenectomy being because of cases identified as having nodal metastases. CONCLUSIONS: We present a model of the intraoperative decision-making process that determines the extent of the staging procedure to be performed within our department when early-stage ovarian cancer is suspected. Unless adjuvant chemotherapy is prescribed for all, systematic pelvic and para-aortic node dissection is required to optimise survival. However, in our department, this would result in 32% of women with suspected early-stage ovarian cancer undergoing systematic node dissection. This flexible focused model may facilitate multidisciplinary team discussion when this part of the surgical staging procedure is considered within the context of the population presenting to the team, the morbidity of the procedure within the department and the predictive values of frozen section within that department. As the model is not disease-specific, it may be useful for decision making in other medical disciplines.

A randomized comparison between intravaginal misoprostol and prostaglandin E2 for labor induction.

OBJECTIVE: The aim of this randomized study was to compare the effectiveness, safety, and side effects of 6 h vaginal misoprostol versus vaginal prostaglandin E(2) (PGE(2)) for labor induction. STUDY DESIGN: Fifty microgram of misoprostol was given intravaginally in the misoprostol group (204 women), and 3 mg PGE(2) was given intravaginally in the PGE(2) group (211 women). In both groups, the dose was repeated every 6 h for a maximum of three doses, until active labor was achieved. Artificial rupture of membranes and oxytocin infusion was used during labor in both groups where it was indicated. RESULTS: The mean interval from the institution of labor induction to delivery was 11.3 +/- 8.6 h for the misoprostol group, and 15.7 +/- 9.3 h for PGE(2 )group (P < 0.05). In the misoprostol group, oxytocin was used less frequently, but there was a higher prevalence of tachysystole. No statistically significant differences were observed between the two groups as regard abnormal patterns of fetal heart rate, the mode of delivery, and the need for neonatal intervention. CONCLUSION: In conclusion, the intravaginal administration of 50 mug misoprostol at 6 h interval (maximum three doses) is comparable in safety, but more effective for induction of labor than 3 mg intravaginal PGE(2).

Erythropoietin in the treatment of iron deficiency anemia during pregnancy.

The aim of this study was to investigate the efficacy of recombinant human erythropoietin (rHuEPO) combined with parenteral iron, in the treatment of moderate and severe iron deficiency anemia during pregnancy. Twenty-six pregnant women, who had been ineffectively treated with iron supplementation alone for at least 8 weeks, were enrolled. They met the following criteria for inclusion in the study: hemoglobin (Hb) concentration <8.5 g/dl, evidence of iron deficiency anemia, and absence of other pregnancy complications, or severe systemic diseases. The treatment protocol comprised of a combination therapy with 150 IU/kg rHuEPO subcutaneously three times per week and 100 mg parenteral iron daily, for a total period of 4 weeks. Nineteen out of 26 women (73%) showed a quick response, with Hb reaching normal levels within the first 2 weeks of treatment. They displayed an average of 3.17 g/dl increase in Hb concentration during the total period of therapy, with 3.0 g/dl increase within the first 2 weeks. In 5 women (19.2%) there was no significant increase in Hb levels, while in 2 women (7.6%) a further decline in Hb concentration was observed, that necessitated a blood transfusion. In conclusion, rHuEPO combined with parenteral iron is an effective treatment for moderate and severe iron deficiency anemia during pregnancy, with minimal adverse or side effects. It may serve as an alternative to blood transfusion, or in cases of resistant anemia that are not effectively treated by iron supplementation alone. However, further studies are needed to investigate the poor response observed in about 25% of treated patients.

Actin cytoskeleton: a signaling sensor in cell volume regulation.

The actin microfilaments are well known dynamic structures that support and organize the cell membrane and functions associated with the membrane such as ion channels and transporters. In addition, many aspects of cellular physiology seem to be actively modulated by changes in actin cytoskeleton dynamics, which involve reorganization and restructuring of the filaments. For both of these reasons, the actin cytoskeleton has attracted special attention since the early days of cell volume regulation research. Mechanisms controlling the actin equilibrium in response to external stimuli were studied and the signaling cascades leading to the regulation of actin cytoskeleton dynamics have been partially elucidated. They include: a) activation of specific actin binding proteins that regulate actin polymerization dynamics, b) activation of protein kinases or phosphatases regulating phosphorylation of specific cytoskeletal proteins and c) activation of signal transduction pathways leading from membrane receptor activation to actin reorganization involving small GTPases of the Rho and Rac families. These intracellular signal transducers are activated by extracellular stimuli that include hormones, growth factors, cytokines, or ions, many of them in turn are partially known to participate in cell volume regulation. These findings provide strong evidence that the actin cytoskeleton is involved in cell volume regulation by sensing and mediating extracellular signals.

TNF-alpha induces actin cytoskeleton reorganization in glomerular epithelial cells involving tyrosine phosphorylation of paxillin and focal adhesion kinase.

Glomerular permeability for macromolecules depends partially on proper attachment of the glomerular epithelial cells (GEC) to the glomerular basement membrane (GBM). The latter requires integrity of the actin cytoskeleton, which in turn is regulated by specific actin-associated proteins. Since several glomerulopathies characterized by heavy proteinuria are associated with increased glomerular tumor necrosis factor alpha (TNF-alpha) expression, we studied the interaction of TNF-alpha with the actin cytoskeleton of cultured rat GEC. Incubation of GEC with 10 ng/ml TNF-alpha for variable time periods ranging from 15 min to 24 hr demonstrated a marked accentuation and redistribution of actin microfilaments, as shown by direct fluorescence analysis and confocal laser scanning microscopy. Quantitative biochemical determination of the G/total-actin ratio confirmed the above observations. Indeed, this ratio was significantly reduced, indicating substantial polymerization of G-actin and formation of F-actin. Concurrently, TNF-alpha rapidly induced tyrosine phosphorylation of both paxillin and focal adhesion kinase, without affecting the expression levels of these two proteins. In addition, tyrosine phosphorylation of vinculin became evident, indicating involvement of this focal adhesion marker in the observed actin reorganization. Inhibition of tyrosine phosphorylation by genistein prevented the reorganization of the actin cytoskeleton by TNF-alpha. We conclude that TNF-alpha induces substantial reorganization of actin cytoskeleton and focal adhesions. These effects occur simultaneously, with a prompt TNF-alpha-induced tyrosine phosphorylation of paxillin and focal adhesion kinase, indicating that these proteins, known to regulate actin polymerization and formation of focal adhesions, may be directly involved in the mechanism controlling the observed actin redistribution. These findings suggest that the observed TNF-alpha-actin cytoskeleton interactions may relate to the pathogenesis of glomerulopathies with heavy proteinuria, in which increased glomerular expression of TNF-alpha is associated with disturbances in the attachment of podocytes to the GBM.