Limited sampling strategy for the estimation of the area under the concentration-time curve for ganciclovir in Chinese adult renal allograft recipients.

OBJECTIVES: Valganciclovir (VGCV) treatment is recommended for the prevention of cytomegalovirus (CMV) infection in renal allograft recipients. The aim of the present study is to investigate the pharmacokinetic characteristics of ganciclovir (GCV) after administration of VGCV in Chinese adult renal allograft recipients and estimate the exposure to GCV using limited sampling strategy (LSS). METHODS: Forty Chinese renal allograft recipients were given 450 mg or 900 mg VGCV daily. Blood samples were drawn before treatment and 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, and 24 h after 5 days of VGCV therapy, and the plasma concentrations of VGCV and GCV were determined using a liquid chromatography-mass spectrometry assay. The major pharmacokinetic parameters for GCV and VGCV were determined using a noncompartmental assay. Multiple stepwise linear regression analysis was conducted to establish a model equation for the estimation of the GCV AUC0-24 h in Chinese patients using LSS. RESULTS: In the 450 and 900 mg groups, the Cmax for VGCV was 0.2 ± 0.10 and 0.4 ± 0.16 mg/L, respectively; the Cmax for GCV was 4.2 ± 1.1 and 8.6 ± 1.6 mg/L, respectively; and the AUC0-24 h for GCV was 28.4 ± 8.4 and 60.7 ± 17.5 mg·h/L, respectively. For the establishment of LSS models, 40 patients were divided into the training group (n = 24) and validation group (n = 16). The model equations used for the calculation of AUC0-24 h for GCV were established in the training group by using multiple linear regression assay. Equations including AUC = 8.1 + 29.7 × C0 + 5.7 × C4 (r2 = 0.91) and AUC = - 0.4 + 11.0 × C0 + 2.1 × C2 + 13.7 × C8 (r2 = 0.98) were acceptable. The %MPE and %MAPE values obtained from the validation group for the two model equations were 5.89 ± 14.5% and 12.1 ± 9.53%, and - 1.30 ± 4.40% and 3.28 ± 3.11%, respectively. CONCLUSIONS: The LSS models that included C0 and C4 or C0, C2, and C8 in the estimation of AUC0-24 h for GCV had favorable performance and can be used for therapeutic drug monitoring in the prevention of CMV infection using VGCV in Chinese renal allograft recipients.

Retroperitoneal adrenal-sparing surgery for the treatment of Cushing's syndrome caused by adrenocortical adenoma: 8-year experience with 87 patients.

BACKGROUND: The objective of this study was to present our 8-year experience with partial adrenalectomy via the retroperitoneal approach for the treatment of Cushing's adenoma. METHODS: A total of 93 patients who underwent adrenal surgery for Cushing's adenoma from March 2003 to December 2010 were enrolled in this study. Preoperative, intraoperative, and postoperative variables were reviewed from the database. Student's t test was used to analyze the continuous data, and the χ(2) test was used to analyze the categoric data. A value of p < 0.05 was considered statistically significant. RESULTS: Adrenal-sparing surgery was performed in 87 cases (31 by open surgery, 56 by retroperitoneal laparoscopy). Six patients underwent open/laparoscopic total adrenalectomy because of recurrent disease or a large size. The cure rate in our series was 97.8%. Hypertension resolved in 34 of 64 patients (53.1%), diabetes in 7 of 27 patients (25.9%) and obesity in 28 of 48 patients (58.3%). One patient died during the postoperative period. The intraoperative complication rate for the open surgery group was significantly higher than that for the retroperitoneal laparoscopy group (9.1 vs. 1.7%). CONCLUSIONS: The retroperitoneal approach is reliable and safe for treating Cushing's syndrome. The laparoscopic technique can decrease the prevalence of intraoperative complications. Retroperitoneal laparoscopic partial adrenalectomy can be performed with extremely low morbidity and achieves an excellent outcome, although death may occur during the postoperative period in high-risk patients. Postoperative management plays an important role in the surgical treatment of Cushing's syndrome.

Population Pharmacokinetics and Bayesian Estimation of the Area Under the Concentration-Time Curve for Ganciclovir in Adult Chinese Renal Allograft Recipients After Valganciclovir Administration.

Valganciclovir (VGCV) is the prodrug of ganciclovir (GCV). The objective of this study was to establish a population pharmacokinetic model (PPK) of GCV to investigate the PK characteristics of GCV after administration of VGCV in adult Chinese renal allograft recipients. Seventy Chinese renal allograft recipients were given 450 mg (n = 41) or 900 mg (n = 29) VGCV daily. Blood samples were drawn 0-24 hours after 5 days' therapy, and GCV plasma levels were determined. The PPK model was constructed using nonlinear mixed-effects modeling, and the Bayesian estimation of AUC0-24h was constructed for an individual patient based on limited plasma samples. The PK of GCV was best described by a 2-compartment model with a first-order absorption process. The CL/F, V2 /F, Q/F, V3 /F, Ka , and lag time of GCV were 15.8 ± 0.71 L/h, 10.9 ± 2.38 L, 3.98 ± 0.40 L/h, 167 ± 44.0 L, 0.23 ± 0.0078 1/h, and 0.93 ± 0.017 hours, respectively. Clearance of creatinine was found to have a significant impact on the CL/F of GCV (P < .01). Sampling strategies consisted of plasma concentrations 0 and 2 and 0, 2, and 4 hours after VGCV administration were shown to be suitable for the estimation of the GCV AUC0-24h . The PPK model was acceptable and can describe the PK of GCV in Chinese renal transplant patients administered VGCV. The AUC0-24h of GCV in Chinese renal transplant patients can be calculated by a limited sampling strategy method.

Retroperitoneoscopic partial adrenalectomy for small adrenal tumours (< or =1 cm): the Ruijin clinical experience in 88 patients.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To present our experience of retroperitoneoscopic partial adrenalectomy (RPA) for small adrenal tumours, as with modern imaging methods small adrenal lesions are being diagnosed more commonly, and retroperitoneoscopic adrenal surgery for small adrenal tumours (< or =1 cm) can be challenging. PATIENTS AND METHODS: We retrospectively reviewed the records of 389 consecutive retroperitoneoscopic adrenalectomies from September 2005 to December 2008, 88 of which were small adrenal tumours and treated by RPA. Ultrasonography and computed tomography (CT) were used in all patients before RPA, and magnetic resonance imaging or positron emission tomography/CT in some patients. We used RPA for adrenal tumours and total adrenalectomy for adrenal cancer. During the surgery, the internal part of the adrenal gland close to the retroperitoneum was freed first, and the whole adrenal tissue was dissected completely. The preoperative imaging was important in these procedures. RESULTS: There were no deaths; conversions to open surgery were necessary in four patients (4.5%), the reasons being a missing target in two, massive haemorrhage caused by central adrenal vein injury in one, and severe adhesion in one. The mean (range) size of the adrenal tumours was 0.7 (0.5-1.0) cm, including 69 aldosterone-producing adenomas, 11 nonfunctional adrenal adenomas, three Cushing syndrome, two phaeochromocytomas, two myelolipomas and one melanoma. The operative duration in the initial 38 cases was significantly longer than that in the subsequent 50 (P < 0.01). However, there was no significant correlation between estimated blood loss and the number of procedures. Tumour size did not correlate with estimated blood loss and operative duration. There was no significant correlation between body mass index and operative duration. CONCLUSION: RPA is a safe, effective and minimally invasive therapeutic option for patients with small adrenal tumours. With improved operative technique the RPA has been completed in more quickly. Freeing the internal part of the adrenal gland close to the retroperitoneum first, and exploring the whole adrenal tissue during surgery are the key points of RPA. The location of the small adrenal tumour can be different from that shown on imaging before surgery, and the abnormality of the adrenal gland should be considered.

Blood perfusion of the contralateral testis evaluated with contrast-enhanced ultrasound in rabbits with unilateral testicular torsion.

The changes of blood perfusion of contralateral testis after unilateral testicular torsion remain controversial. In this study, 28 New Zealand white male rabbits were randomly divided into five groups. Group A (n = 8), the control group, underwent a sham operation on the unilateral testis without inducing testicular torsion. In groups B, C, and D (n = 5 each), unilateral testicular torsion was induced, and, after 3, 6 or 24 h, respectively, detorsion was performed. In group E (n = 5), permanent unilateral testicular torsion was applied. Contrast-enhanced ultrasound was used to observe the blood perfusion of the contralateral testis at the following stages: pre-torsion (preopration), immediately post-torsion (postopration), pre-detorsion, immediately post-detorsion, and late-stage post-detorsion (6-12 h post-detorsion in groups B-D) or at a similar time point (15-21 h post-torsion in group E). Time-intensity curves were generated, and the following parameters were derived and analyzed: arrival time, time to peak intensity, peak intensity, and half-time of the descending peak intensity. The analysis revealed that blood perfusion of the contralateral testis increased immediately after testicular torsion on the opposite side (P < 0.05), which increased with prolonged testicular torsion of the other testis. This research demonstrated that contrast-enhanced ultrasound was valuable in evaluating blood perfusion of the contralateral testis after unilateral testicular torsion.

[Efficacy and safety of tadalafil for erectile dysfunction: an updated review].

As a long-acting phosphodiesterase type 5 (PDE5) inhibitor, tadalafil is administered orally as the first line therapy for erectile dysfunction (ED). Its efficacy and safety have been confirmed by many clinical studies in the treatment of ED in general patients, elderly patients and those with diabetes mellitus or spinal cord injury or after prostate cancer surgery. With its prolonged action of 36 hours, tadalafil can not only increase the self-esteem of ED men but also improve the quality of life of both the patients and their partners.

[Surgical treatment of 486 cases of adrenal gland diseases: a retrospective study].

OBJECTIVE: To evaluate the roles of laparoscopic adrenalectomy (LA) and open adrenalectomy (GA) for treatment of adrenal gland diseases. METHODS: The data of 486 patients with adrenal gland diseases was analyzed retrospectively during 5 years. A total of 478 patients received surgical treatments including 318 GAs and 160 LAs. The operation time, bleeding volume during operation, intestine function recovery time, pain postoperatively, hospital stay time postoperatively and postoperative complications in group GA and group LA respectively were compared. RESULTS: All cases in group GA were successful. A total of 154 cases in group LA were successful, and 6 cases were converted to open surgery. In group LA, there were 9 cases whose tumor diameter exceeded 6 cm. There were 3 malignant cases in group LA, and no recurrence and metastasis were observed during 3-20 months follow-up. The average operation time was (112 +/- 16) mmn and (69 +/- 10) min in group GA and LA respectively. The average bleeding volume during operation was (286 +/- 23) ml, (56 +/- 10) ml in group GA and LA respectively. The average intestine function recovery time was (66 +/- 7) h, (24 +/- 7) h in group GA and LA respectively. The average frequency of treatment of pain was 1.9 +/- 0.4 and 0.5 +/- 0.1 in group GA and LA respectively. The average hospital stay time postoperatively was (10.3 +/- 1.1) d and (7.2 +/- 0.7) d in group GA and LA respectively. The rate of postoperative complications was 40.3% and 7.5% in group GA and LA respectively. All differences were significant (P = 0.023, 0.007, 0.039, 0.003, 0.029 and 0.001). CONCLUSIONS: LA has the added benefit of shorter convalescent times, improving patients satisfaction and less associated complications, as it has proved to be as effective as OA.

[Primary pigmented nodular adrenocortical disease report of 5 cases].

OBJECTIVE: To study the pathology, diagnostic and therapeutic method of primary pigmented nodular adrenocortical disease (PPNAD). METHODS: The data of 5 cases of PPNAD were analyzed retrospectively. Among the 5 cases, 2 were male and 3 were female. The range of age was from 12 to 53 years. All the 5 cases had symptoms of Cushing syndrome. The diagnose depended on the results of endocrine exams, ultrasound, CT, MR and pathological reports. All patients received operation of unilateral adrenalectomy. The therapeutic effects were determined by post-operative results, which concluded clinical symptoms and endocrine exams. RESULTS: The follow-up time was from 4 months to 3 years. All patients' symptoms of Cushing syndrome were relieved in 6 months after operation. The endocrine exam was normal in one case and obvious improved in the other four cases. Up to now, one patient drop out of the follow-up, the other 4 cases had no evidence of recurrence. CONCLUSION: PPNAD is a rare type of Cushing syndrome. Diagnose depends on endocrine exams and pathological results. Operation is the effective method for the disease.

Expression of kallikrein-related peptidase 7 is decreased in prostate cancer.

Recent evidence suggests that the human kallikrein 7 (KLK7) is differentially regulated in a variety of tumors. The aim of this study was to determine the expression of kallikrein-related peptidase 7 and KLK7 in our large collection of prostate samples. Between August 2000 and December 2012, 116 patients with histologically confirmed prostate cancer (PCa) and 92 with benign prostate hyperplasia (BPH) were recruited into the study. Using immunohistochemistry, quantitative reverse transcription polymerase chain reaction (RT-PCR) and western blot, kallikrein-related peptidase 7 expression in BPH and PCa tissues was determined at the mRNA and protein levels. The relationships between kallikrein-related peptidase 7 mRNA expression and clinicopathological features were analyzed. A total of 64 of 92 (69.57%) benign cases showed positive staining for KLK7 and 23 of 116 (19.83%) malignant cases showed positive, the difference of KLK7 expression between PCa and BPH was statistically significant (P < 0.001). The expression level of kallikrein-related peptidase 7 mRNA was significantly decreased in PCa tissues compared with that in BPH tissues and normal prostate tissue. Kallikrein-related peptidase 7 mRNA exhibited different expression patterns in terms of localization depending on pathological category of PCa. Similarly, our western immunoblot analyses demonstrated that the protein expression levels of KLK7 was lower in PCa than in BPH tissues and normal prostate tissue. Kallikrein-related peptidase 7 and KLK7 expression are down-regulated in PCa and lower expression of kallikrein-related peptidase 7 closely correlates with higher Gleason score and higher prostate-specific antigen level.

[The analysis of the factors for postoperative blood pressure recovery of aldosterone producing adenoma patients].

OBJECTIVE: To investigate the factors regarding the recovery of postoperative blood pressure of aldosterone producing adenoma (APA) patients. METHODS: Sixty-eight patients with APA were recruited and their data including retinal blood vessel by Doppler sonography, urinary trace albumin, pathological changes of renal biopsy and the adrenal tissues around the adenoma were analyzed in order to determine the correlation between these data and postoperative durative hypertension. RESULTS: Postoperative durative hypertension occurred in 14 cases (41.2%) with increased resistance of unilateral or bilateral central artery of retina, in 16 cases (66.7%) with increased level of urinary trace albumin. Fifteen cases underwent renal biopsy and all of them showed different pathological alterations, 11 cases (73.3%) of which presented with postoperative durative hypertension. The pathological changes of the adrenal tissues around the adenoma is either atrophy or non-atrophy (normal or hyperplasia), 8 cases (40%) and 10 cases (22.2%) of which showed postoperative durative hypertension, respectively. CONCLUSION: The renal pathological changes and increased resistance of retinal blood vessel are the main reasons leading to postoperative hypertension in patients with APA.

Preoperative alpha blockade for normotensive pheochromocytoma: is it necessary?

OBJECTIVE: To compare the intraoperative hemodynamics in normotensive pheochromocytoma patients undergoing tumor resection between those with α-blockade preparation, preoperatively, and those without it. METHODS: From January 2003 to July 2011, patients with adrenal incidentaloma, which was highly suspected as normotensive pheochromocytoma, were divided into two groups. Group 1 recieved α1-blockade doxazosin before adrenalectomy. Group 2 received no α-adrenoceptor, preoperatively. Data regarding the intraoperative hemodynamics was collected. These include peak/nadir blood pressure (BP) and heart rate, vasoactive medication and fluid infusion. RESULTS: Fifty-nine cases of pheochromocytoma were confirmed by histopathology examination: 38 in group 1 and 21 in group 2. No differences were found in the preoperative demographics, comorbidities, BP and anesthesia. Intraoperative BP and heart rate showed no difference between these two groups. Intraoperative use of nitroglycerin (P < 0.001), norepinephrine (P < 0.001), phentolamine (P < 0.001) and colloid fluid (P = 0.008) was significantly greater in group 1 with doxazosin. CONCLUSION: Preoperative α1-adrenoceptor antagonist has no benefit in maintaining intraoperative hemodynamic stability in patients with normotensive pheochromocytoma. It may increase the use of vasoactive drugs and colloid infusion.

Significance of heparanase-1 and vascular endothelial growth factor in adrenocortical carcinoma angiogenesis: potential for therapy.

The purpose of this study was to determine the correlation between human adrenocortical carcinoma (ACC) and the proteins involved in tumor angiogenesis, and to evaluate the angiogenic status of ACC. The expression of heparanase-1 (HPA-1), vascular endothelial growth factor (VEGF), and vascular endothelial growth factor receptor-2 (VEGFR-2) as well as microvessel density (MVD) were measured in a series of tissue samples from 44 human sporadic adrenocortical tumors by immunohistochemistry. These specimens were classified as adenomas (n = 20) and carcinomas (n = 24) according to the histological criteria defined by Weiss. A total of 22 of 24 (91.67%) malignant cases showed positive staining for HPA-1 and 3 of 20 (15%) benign cases showed positive, the difference of HPA-1 expression between ACA and ACC was statistically significant (P < 0.001). Similarly, VEGF staining was seen in 70.83% (17/24) of the malignant cases versus 25% (5/20) of the benign, the difference of VEGF expression among two groups was statistically significant (P = 0.002). VEGFR-2 expressed highly in the ACC group (79.17%, 19/24) and lowly in the benign group (25%, 5/20), the two groups had extremely significant difference (P < 0.001). Malignant cases showed higher MVD compared to benign tumors (84.70 ± 12.44 vs. 21.05 ± 8.07, P < 0.001). HPA-1 and VEGF expression were positively correlated with MVD in all specimens (r_s = 0.812, P = 0.001; r_s = 0.834, P < 0.001). In conclusion, these results suggest that angiogenesis of human ACC maybe mediated by these proteins and they could represent selective targets for the molecularly targeted treatments of ACC.

Intravesical instillation of hyaluronic acid prolonged the effect of bladder hydrodistention in patients with severe interstitial cystitis.

OBJECTIVES: To evaluate the efficacy of intravesical instillation of hyaluronic acid (HA) after hydrodistention for the treatment of patients with interstitial cystitis (IC) having small bladder capacity. METHODS: A total of 47 patients with IC (aged 27-76 years) whose functional bladder capacity was less than 200 mL received bladder hydrodistention. Thereafter, 20 patients received intravesical instillation of 40 mg HA weekly in the first month and then monthly in the following 2 months. Sixteen patients received intravesical heparin instead and 11 patients received hydrodistention alone as the control. Mean voids per day, visual analog scale for pain, and functional bladder capacity were measured before hydrodistention and 3 and 6 months after hydrodistention in all 3 groups and 9 months after hydrodistention in HA and heparin groups. RESULTS: Two patients in the HA group and 1 in the heparin group failed to complete the treatment. Three months after hydrodistention, there was no improvement in the control group. Six and 9 months after hydrodistention, rate of improvement was significantly higher in the HA group than in the heparin group (77.8% vs 33.3%, P < .05; 50% vs 20%, P < .05). At 9 months, heparin treatment did not show any improvement. Improvement in voids per day (-1.8 +/- 2.5, P < .01), visual analog scale (-0.9 +/- 1.1, P < .01), and bladder capacity (16 +/- 18 mL, P < .01) was still significant in the HA group. CONCLUSIONS: Intravesical instillation of HA may obviously prolong the effect of bladder hydrodistention in patients with severe IC. Its effect was better than heparin.

Heparanase-1 and Cyclooxygenase-2: prognostic indicators of malignancy in pheochromocytomas.

The objective of this article is to evaluate Heparanase-1 and Cyclooxygenase-2 as tissue-based markers of pheochromocytoma prognosis. Ninety-two sporadic pheochromocytoma patients with a minimum of 8-year follow-up post-diagnosis were enrolled. Slides of normal adrenal glands in nephrectomy specimens from 20 patients with benign renal tumors were as control. Heparanase-1 and Cyclooxygenase-2 expression as well as microvessel density were examined using immunohistochemistry in tissues from these patients. Positive staining for Heparanase-1 was observed in 23.68% of the benign and 77.78% of the malignant cases, whereas none of the normal adrenal controls showed positive staining. Similarly, Cyclooxygenase-2 staining was seen in 23.68% of the benign versus 83.33% of the malignant cases, and none of the normal controls appeared positive for Cyclooxygenase-2. Using both HPA-1 and Cox-2 combined, the positive predictive value of malignancy was significantly increased to 0.72, compared to about 0.45 by their own. Malignant cases showed higher microvessel density compared to benign tumors and normal controls (36.41, 21.43, and 13.36%, respectively). Heparanase-1 and Cyclooxygenase-2 may contribute to the invasive characteristics of malignant pheochromocytomas. Heparanase-1 and Cyclooxygenase-2 combined is better than their own to be used as a marker to distinguish malignant from benign pheochromocytoma.

Selective α1-adrenoceptor antagonist (controlled release tablets) in preoperative management of pheochromocytoma.

The objective of this article is to evaluate the efficacy of Doxazosin Mesylate Controlled Release Tablets for preoperative treatment of patients with pheochromocytoma. Between 2003 and 2008, 67 patients with confirmed diagnoses of pheochromocytoma were enrolled in this study. According to the drug used in preoperative management, patients were divided into two groups: Doxazosin Mesylate pretreatment group (n=36) and Phenoxybenzamine pretreatment group (n=31). Surgery was performed only in patients who met the optimal preoperative condition. The hematocrit decreased significantly (P<0.001) after antiadrenergic therapy in patients pretreated with phenoxybenzamine or doxazosin. There was no significant difference between the fluid intakes during operation in both groups. The systolic arterial pressures both before and after induction of anesthesia were all significantly higher in the doxazosin patients than in the phenoxybenzamine group (P<0.05). After tumor removed, the lowest systolic arterial pressure was significantly higher in doxazosin group than in phenoxybenzamine group (P<0.05). The fluctuation of systolic arterial pressure during operation was more stable in doxazosin group than in phenoxybenzamine group (P<0.05). Doxazosin mesylate controlled release tablet was as effective as phenoxybenzamine in preoperative volume expansion. Although phenoxybenzamine provided better arterial pressure control, patients pretreated with DOX experienced more stable perioperative hemodynamic changes, shorter preoperative management periods and more simple medication.