Long-term followup and selection criteria for penile revascularization in erectile failure

PURPOSE: We report the long-term results of penile revascularization surgery for erectile failure and suggest possible selection criteria for this controversial surgical procedure. MATERIALS AND METHODS: In 7 years 62 impotent men who did not respond to pharmacotherapy underwent microsurgical penile revascularization and completed long-term followup evaluation in 41 months (range 18 to greater than 62) consisting of a detailed questionnaire, duplex sonography and optional pharmacotherapy or angiography. The Virag procedure was chosen for the first 7 patients, the original Hauri technique for the next 13 and the modified Mannheim triple anastomosis for 42. RESULTS: Of all patients 34% achieved spontaneous and another 20% pharmacologically induced erections. Success in diabetics and older patients was lower (43% for diabetics, 39% for those older than 50 years at surgery), while it was high in men with less than 2 risk factors (58%) as well as in younger patients (69% for those up to 50 years old). Shunt patency was 92%. Complications such as glans hyperemia developed in 13% of patients, shunt thrombosis in 8% and inguinal hernias in 6.5%. CONCLUSIONS: Patient selection is vital for the successful outcome of penile revascularization surgery. We adhere to strict selection criteria, such as patient age maximum of 50 years, less than 2 risk factors, no recent diabetes and termination of nicotine abuse. Penile revascularization surgery is highly indicated in this group of patients, especially since it is the only causal therapy for erectile failure.     

bcl-2 expression in the spectrum of preinvasive breast lesions

This study was designed to define more precisely the relationship between specific angiotensin receptors and the growth of vascular smooth muscle cells in response to angiotensin II. These experiments employed quiescent A10 cells which were characterized as smooth muscle by the expression of specific contractlle proteins. Cell growth was monitored by measuring the incorporation of metabolic precursors into RNA or DNA. The treatment of A10 cells with angiotensin II (1 microM) stimulated a hypertrophic response as indicated by an increase in RNA synthesis and protooncogene expression in the absence of DNA synthesis. This increase in RNA synthesis could be blocked by PD123319, an AT2 antagonist, but not by losartan, an AT1 antagonist. RT-PCR analysis demonstrated that quiescent A10 cells express only the AT2 receptor while proliferating A10 cells express the AT1a and AT1b receptors in addition to the AT2 receptor. In addition, induction of AT2 receptor-mediated RNA synthesis was prevented by indomethacin, a cyclooxygenase inhibitor. These studies therefore support a direct connection between the AT2 receptor and smooth muscle growth that is mediated, in part, by prostaglandin synthesis.     

Bioactive and nuclease-resistant L-DNA ligand of vasopressin

In vitro selection experiments have produced nucleic acid ligands (aptamers) that bind tightly and specifically to a great variety of target biomolecules. The utility of aptamers is often limited by their vulnerability to nucleases present in biological materials. One way to circumvent this problem is to select an aptamer that binds the enantiomer of the target, then synthesize the enantiomer of the aptamer as a nuclease-insensitive ligand of the normal target. We have so identified a mirror-image single-stranded DNA that binds the peptide hormone vasopressin and have demonstrated its stability to nucleases and its bioactivity as a vasopressin antagonist in cell culture.     

Assessment of accuracy of the Doppler pressure half-time method in the estimation of the mitral valve area immediately after balloon mitral valvuloplasty

AIM: The reliability of Doppler echocardiography in determining the mitral valve area after balloon mitral valvuloplasty has been questioned, as discrepancies were noted between measurements obtained by the pressure half-time method and those derived haemodynamically, immediately following completion of the procedure. Recent investigations, however, have indicated that these discrepancies may be attributable to the over-estimation of the mitral valve area by haemodynamic measurements, caused by the presence of the iatrogenic atrial septal defect complicating transseptal catheterization. The aim of the present study was to further test this hypothesis. METHODS AND RESULTS: Measurements of the mitral valve area by the Doppler pressure half-time method and the Gorlin formula were obtained and compared in 238 consecutive patients before and immediately after retrograde non-transseptal balloon mitral valvuloplasty, which does not involve puncture and/or dilatation of the inter-atrial septum. No significant difference was found between Doppler- and Gorlin-derived measurements, neither before (1.04 +/- 0.23 vs 1.03 +/- 0.23 cm2, P = ns) nor immediately after (2.14 +/- 0.47 vs 2.12 +/- 0.49 cm2, P = ns) valvuloplasty. Linear regression analysis demonstrated a high degree of correlation between Doppler and Gorlin measurements before (r = 0.778) and after (r = 0.886) the procedure. Good agreement was confirmed by the Bland-Altman method. CONCLUSION: Doppler echocardiography yields accurate measurements of the mitral valve area immediately after retrograde non-transseptal balloon mitral valvuloplasty. This finding supports the hypothesis that the creation of an iatrogenic atrial septal defect during transseptal catheterization may contribute to the poor agreement between Doppler and Gorlin data after balloon mitral valvuloplasty.     

Two separable T cell receptor signals reconstitute positive selection of CD4 lineage T cells in vivo

Positive selection is an obligatory step during intrathymic T cell differentiation. It is associated with rescue of short-lived, self major histocompatibility complex (MHC)-restricted thymocytes from programmed cell death, CD4/CD8 T cell lineage commitment, and induction of lineage-specific differentiation programs. T cell receptor (TCR) signaling during positive selection can be closely mimicked by targeting TCR on immature thymocytes to cortical epithelial cells in situ via hybrid antibodies. We show that selection of CD4 T cell lineage cells in mice deficient for MHC class I and MHC class II expression can be reconstituted in vivo by two separable T cell receptor signaling steps, whereas a single TCR signal leads only to induction of short-lived CD4+CD8lo intermediates. These intermediates remain susceptible to a second TCR signal for 12-48 h providing an estimate for the duration of positive selection in situ. While both TCR signals induce differentiation steps, only the second one confers long-term survival on immature thymocytes. In further support of the two-step model of positive selection we provide evidence that CD4 T cell lineage cells rescued by a single hybrid antibody pulse in MHC class II-deficient mice are pre-selected by MHC class I.     

Improving the processes of care and outcomes in obstetrics/gynecology

BACKGROUND: The obstetrics/gynecology department of York Hospital (York Health System, York, Pennsylvania) initiated a program to improve the processes of care and control costs for common women's and newborns' health care services. Twelve clinical policies were established between June 1993 and February 1995. CONDUCTING THE QUALITY IMPROVEMENT (QI) PROJECTS: Using the plan-do-check-act (PDCA) improvement cycle method, the QI group established clinical pathways for high-volume conditions or procedures known to have low rates of complications and clinical guidelines for those conditions or procedures not requiring coordinated efforts of a group of health care professionals. EXAMPLE--PYELONEPHRITIS IN PREGNANCY: The literature had indicated that the prevalence of pyelonephritis can be decreased by identifying and treating asymptomatic bacteriuria early in prenatal care. After the validity of the clinical policy was demonstrated in the resident service, the policy was extended to all private obstetric practices. Dissemination of the finding that most of the admissions for pyelonephritis were for referred patients (for whom we had no control over prenatal care) or for patients referred by private physicians who were not yet following the guidelines quickly led to complete compliance by our obstetricians and other health care providers referring patients to the York Health System. RESULTS: The 12 clinical policies resulted in the elimination of 113 admissions and 5,595 inpatient days and in the reduction of the cost of patient care by $1,306,214 for the years 1994-1995 and 1995-1996 combined, without apparent adverse effects on patient health. CONCLUSION: A voluntary clinical policies program can change the culture of a department and lead to cost-effectiveness and better quality of patient care.     

Immediate sexual rehabilitation by simultaneous placement of penile prosthesis in patients undergoing radical prostatectomy: initial results in 50 patients

Hypotonicity-induced anion permeability changes were investigated but not detected in immortalised (RBE4) rat brain endothelial cells using iodide efflux measurements. Large, rapid increases were however observed in primary cultured cells. Both cell types were reinvestigated following culture in a common growth factor-depleted medium. Responses were still undetectable in the immortalised RBE4 cells. Reduced responses were observed in the primary cultured cells that also showed altered morphology and decreased activity of another transporter, P-glycoprotein. Thus both immortalisation and different culture conditions may alter functional expression in these cells of transporters involved in hypotonicity-induced anion permeability changes.     

Infection prophylaxis in complex limb trauma through immediate definitive reconstruction via a free tissue transfer

Levels of specific IgE antibodies to three kinds of venom (honeybee, wasp and yellow jacket) were followed up for two years in five male pest control operators (age: 24 to 50 years) with Hymenoptera sting within the latest six months. At the first examination, all subjects had a positive reaction for venom-specific IgE but their levels were varied in the range from class 2 to 5 (0.70 approximately 99.9 UA/ml), and a positive reaction was observed in the case of unoffending Hymenoptera. A subject who was re-stung during the two-year follow-up period showed increase in all of the venom-specific IgE levels. Of four subjects without re-stung during the two years, three subjects had a logarithmic decrease in all the specific IgE levels time-dependently, but one subject with a high total serum IgE level showed an increase and decrease alternately in the specific IgE The total serum IgE level may be a factor which influences the change in the venom-specific IgE level. In the four subjects without a high total serum IgE level, the biological half-life of venom-specific IgE was estimated to be 6 to 12 months based on the decreased level during the follow-up period.     

Cutting seton for anal fistulas: high risk of minor control defects

PURPOSE: Long-term results of cutting seton in the treatment of anal fistulas were studied. METHODS: Of the 44 patients with anal fistulas, mainly of the high variety, managed with this method, 35 (25 men) attended a clinical and manometric follow-up examination on average 70 (range, 28-184) months after operation. Fistula distribution was high transsphincteric (25), low transsphincteric (5), extrasphincteric (3), and suprasphincteric (2). The seton was tightened at one-week to two-week intervals to achieve gradual sphincter division. RESULTS: Time required to achieve complete fistula healing ranged from 37 to 557 (mean, 151) days. Two (6 percent) of the 35 patients re-examined had recurrence of fistula and 22 (63 percent) reported symptoms of minor impairment in anal control, which in four patients had existed already before operation. Anal resting pressures were similar for defective and normal control, but other manometric variables were inferior in incontinence, although total squeeze pressure only showed statistically significant difference from normal continence (P = 0.0345). Incontinence was likely associated with hard and gutter-shaped operation scars in the anal canal, but the difference from normal continence was not statistically significant. CONCLUSION: Cutting seton yields fairly good results in regard to cure of fistula, but the risk of anal incontinence, despite its minor degree, seems to be too high to recommend its routine use for all high fistulas. The suprasphincteric fistulas and some extrasphincteric fistulas are difficult to treat otherwise, but especially for high transsphincteric fistulas, other methods of treatment (preferably those in which sphincter division can be avoided and the risk of anal canal deformity and incontinence are minimized) are advocated.