Laparoscopic distal pancreatectomy for metastatic renal cell carcinoma.

A 64-year-old man with a remote history of left radical nephrectomy presented with a recurrent mass in the renal bed. Computed tomography findings suggested a mass in the bed of the psoas. On laparoscopic exploration, he had metastasis to the tail of the pancreas. We describe our surgical management and the patient's postoperative course.

Measurement of bio-impedance with a smart needle to confirm percutaneous kidney access.

PURPOSE: The traditional method of percutaneous renal access requires freehand needle placement guided by C-arm fluoroscopy, ultrasonography, or computerized tomography. This approach provides limited objective means for verifying successful access. We developed an impedance based percutaneous Smart Needle system and successfully used it to confirm collecting system access in ex vivo porcine kidneys. MATERIALS AND METHODS: The Smart Needle consists of a modified 18 gauge percutaneous access needle with the inner stylet electrically insulated from the outer sheath. Impedance is measured between the exposed stylet tip and sheath using Model 4275 LCR meter (Hewlett-Packard, Sunnyvale, California). An ex vivo porcine kidney was distended by continuous gravity infusion of 100 cm. water saline from a catheter passed through the parenchyma into the collecting system. The Smart Needle was gradually inserted into the kidney to measure depth precisely using a robotic needle placement system, while impedance was measured continuously. RESULTS: The Smart Needle was inserted 4 times in each of 4 kidneys. When the needle penetrated the distended collecting system in 11 of 16 attempts, a characteristic sharp drop in resistivity was noted from 1.9 to 1.1 ohm m. Entry into the collecting system was confirmed by removing the stylet and observing fluid flow from the sheath. This characteristic impedance change was observed only at successful entry into the collecting system. CONCLUSIONS: A characteristic sharp drop in impedance signifies successful entry into the collecting system. The Smart Needle system may prove useful for percutaneous kidney access.

Biocompatibility of NDGA-polymerized collagen fibers. I. Evaluation of cytotoxicity with tendon fibroblasts in vitro.

The material properties of tendon type I collagen fibers polymerized with nordihydroguaiaretic acid (NDGA) are equivalent to native tendon, suggesting that NDGA crosslinking may provide a viable approach to stabilizing collagenous materials for repairing ruptured, lacerated, or surgically transected fibrous tissues, such as tendon and ligament (Koob & Hernandez, Biomaterials, in press). Using standard cytotoxicity tests, the present study evaluated the biocompatibility of these fibers with cultured bovine tendon fibroblasts. Primary fibroblasts obtained from calf digital extensor tendons were exposed to NDGA, reaction products generated from the polymerization protocol, and the crosslinked fibers. NDGA was cytotoxic to these cells at concentrations above 100 microM. NDGA oxidation products were similarly cytotoxic. At concentrations below 100 microM, fibroblast viability was not affected by NDGA or its oxidation products. At these lower concentrations, fibroblast proliferation was unaffected compared to controls not exposed to NDGA. Fibers crosslinked with NDGA contained no unreacted NDGA, but they did contain soluble reaction products that were cytotoxic to tendon fibroblasts in both the elution and the direct contact tests. Washing the fibers in 70% ethanol and phosphate-buffered saline eliminated cytotoxicity of the fibers. Ethanol simultaneously sterilized the fibers. Tensile tests established that the ethanol/phosphate buffer wash did not adversely affect the material properties of the fibers. The results of these experiments indicate that NDGA-crosslinked fibers can be rendered nontoxic to tendon fibroblasts and may provide a novel approach for producing biologically based, biocompatible, tendon bioprostheses.

Biocompatibility of NDGA-polymerized collagen fibers. II. Attachment, proliferation, and migration of tendon fibroblasts in vitro.

The material properties of collagen fibers polymerized with nordihydroguaiaretic acid (NDGA) are equivalent to native tendon, suggesting that NDGA crosslinking may provide a viable approach to stabilizing collagenous materials for use in repairing ruptured, lacerated, or surgically transected fibrous tissues, such as tendons and ligaments (Koob & Hernandez, Biomaterials, in press). The present study evaluated the biocompatibility of these fibers with cultured bovine tendon fibroblasts. Fibroblast attachment, migration, and proliferation on NDGA-crosslinked materials were compared to those on prepolymerized type I tendon collagen constructs as well as on tissue-culture-treated plastic. Fibroblast attachment on NDGA-crosslinked collagen fibrils was equivalent to attachment on plates coated with collagen alone. Over a period of 8 days in culture, attached fibroblasts proliferated on NDGA-crosslinked collagen at a rate identical to that of fibroblasts attached to native collagen. In order for the biomaterial effectively to bridge gaps in fibrous tissues, fibroblasts must be able to migrate and replicate on the bridging fiber. Control and crosslinked fibers were inserted in calf tendon explants, with a portion of the fiber extending out of the sectioned end of the tendon. Explants were cultured for 9 weeks, and the number of cells was measured at weekly intervals. Cells appeared on the fibers after 1 week of culture. By 2 weeks, cells had colonized the entire fiber. The number of cells continued to increase throughout the 9 weeks in culture, forming a layer several cells thick. Histologic analysis indicated that the fibroblasts populating the fibers appeared to originate in the epitenon. There was no difference in the rate of fibroblast migration and replication, nor in the ultimate number of colonizing cells, between control collagen fibers and NDGA-crosslinked fibers. NDGA-crosslinked fibers may provide a means of bridging gaps in ruptured, lacerated, or surgically transected tendons by providing a mechanically competent scaffold on which tendon fibroblasts can migrate, attach, and proliferate.

Pleiotrophin inhibits chondrocyte proliferation and stimulates proteoglycan synthesis in mature bovine cartilage.

Pleiotrophin (PTN) is a secreted heparin-binding, developmentally regulated protein that is found in abundance in fetal, but not mature, cartilage. SDS-page and glycosaminoglycan (GAG) analysis of sulfate-radiolabeled proteoglycans isolated from the medium of mature cultured chondrocytes treated with PTN showed a threefold increase in the levels of proteoglycan synthesis. In contrast, in cultures of fetal chondrocytes, no changes in proteoglycan synthesis were observed. Thymidine incorporation experiments showed a dose-dependent decrease in proliferation of treated cells compared with control cultures, suggesting that pleiotrophin had an inhibitory effect on growth of chondrocytes. Neither FGF or heparin reversed the inhibitory effect of PTN. Capillary electrophoresis of chondroitinase ABC-digested proteoglycans isolated from mature chondrocytes showed 2-4-fold increases in the amounts of the 4S- and 6S-substituted GAG chains for the PTN-treated chondrocytes. Northern analysis showed a twofold upregulation in the mRNA levels of biglycan and collagen type II, but no difference in the message levels for decorin and aggrecan. These results establish that PTN inhibits cell proliferation, while stimulating the synthesis of proteoglycans in mature chondrocytes in vitro, suggesting that PTN may act directly or indirectly to regulate growth and proteoglycan synthesis in the developing matrix of fetal cartilage.

Giant hamartoma of the oropharynx.

Giant polypoidal hamartomas of the pharynx and oesophagus are rare benign tumours of unknown origin, exceptionally arising from the oropharynx. We report the case of a 74-year-old man who developed sudden nausea and a foreign body sensation. Shortly afterwards he regurgitated a 25 x 3 x 1.5 cm pedunculated fleshy mass, still attached to the inside of his thorat. The patient was anaesthetised, the mass traced to the right tonsillar fossa and adjacent oropharyngeal wall. The pedicle was clamped and the lesion excised. Histology was consistent with a giant oropharyngeal hamartoma. We discuss the pathogenesis and potential complications of this condition. The literature is reviewed.

Changing demographics: past and future demands for early childhood programs.

This article provides a historical analysis of how demographic changes in the organization of American family life from the mid-1800s to the present have shaped the demand for programs to complement the efforts of families to educate and care for their children. The author asserts that the United States is in the midst of a second child care revolution. The first occurred in the late 1800s, when families left farming to enable fathers to take jobs in urban areas and when compulsory free public schooling was established for children age six and above. The second has developed over the past 55 years as the proportion of children under six living in families with two wage earners or a single working parent has escalated and propelled more and more young children into the early childhood care and education programs discussed throughout this journal issue. Looking to the future, the author sees indications that the demand for early childhood care and education programs will continue to grow while the needs of the children to be served will become increasingly diverse. To meet these dual pressures, the author argues that public funding for early childhood programs--like funding for public schools--is justified by the value such programs have for the broader society.

Comparison of azelastine nasal spray and oral ebastine in treating seasonal allergic rhinitis.

The efficacy and safety of the nasally administered histamine H1 receptor blocking drug azelastine was investigated in a randomized comparative trial with ebastine. Patients were treated for 14 days and efficacy was assessed by the physician using a rating scale measuring 10 nasal and ocular symptoms of seasonal rhinitis (0 = absent, 1 = mild, 2 = moderate, 3 = severe). Tolerability was measured on the basis of reported adverse events. Data from a total of 59 patients were included in the efficacy analysis. Both treatment groups had dramatic reductions in the physician's total symptom score following treatment. Mean scores in the azelastine group decreased from 12.4 pretreatment to 5.6, while the mean ebastine scores decreased from 13.6 to 6.6. There was no significant difference between the two groups (p = 0.86). Changes in individual rhinitis symptoms showed no differences between the two groups. The majority of patients in both treatment groups reported an initial relief of symptoms within 1 h of dosing. For seven patients treated with azelastine, the initial effect was already seen after 10 min (ebastine: two patients). Eight adverse events were reported in each treatment group; all were mild except one report of sedation in an ebastine patient, which was of moderate severity. Three patients reported somnolence during treatment with ebastine. A bitter taste was mentioned by four patients in the azelastine group, but neither somnolence nor sedation was reported with azelastine. In conclusion, the results of the study suggest that both azelastine and ebastine are effective treatments of the symptoms of seasonal allergic rhinitis. Both drugs were well tolerated.

The in vitro interaction of proteoglycans with type I collagen is modulated by phosphate.

Binding of proteoglycans to type I collagen in vitro was assessed using radiolabeled decorin, biglycan, and large proteoglycans and acid-extracted bovine tendon collagen. Decorin, biglycan, and large proteoglycans were all bound to collagen fibrils in phosphate-buffered saline (PBS) containing 3 mM sodium phosphate. Only decorin was bound when the phosphate concentration in PBS was increased to 30 mM. These distinct binding characteristics were not altered by the presence of 10% serum, by purification of the proteoglycans in 7 M urea and 4 M guanidine HCl, or by digestion of the collagen with pepsin. In addition to being affected by phosphate, both glycosaminoglycan and proteoglycan binding to collagen was inhibited by sulfate, an anion with similar structure, and by molecules that contain sulfate or sulfonate groups, such as chondroitin sulfate and N-tris[hydroxymethyl]methyl-2-aminoethanesulfonic acid (Tes). The rate of in vitro collagen fibrillogenesis was retarded by increasing concentrations of phosphate. Decorin decreased the rate of collagen fibrillogenesis in all buffers and virtually abolished fibril formation when added in buffer containing both 30 mM phosphate and 30 mM Tes. It is concluded that decorin binds to collagen through interaction between collagen and the decorin core protein, whereas biglycan and large proteoglycans bind to collagen fibrils through their glycosaminoglycan chains. This glycosaminoglycan-collagen interaction is inhibited by phosphate, sulfate, and sulfonate. These observations may clarify contradictory results among previous in vitro studies of proteoglycan-collagen interaction. Since the phosphate concentration of blood and interstitial fluid is estimated to be approximately 1 mM, collagen-glycosaminoglycan interactions could occur in tissue.

The effects of transforming growth factor-beta and serum on proteoglycan synthesis by tendon fibrocartilage.

The effects of transforming growth factor-beta (TGF-beta) and serum on proteoglycan synthesis by tissue explants from the fibrocartilaginous region of adult bovine tendon and by cells in culture from this region were assessed. The most characteristic effect of added TGF-beta on both explant tissue and cells in culture was enhanced synthesis of one small proteoglycan-biglycan. Lowered serum concentration diminished incorporation of Na2 35SO4 into proteoglycans. Added TGF-beta (1 ng/ml) stimulated cell proliferation, increased overall proteoglycan synthesis, and increased the length of glycosaminoglycan chains on all secreted proteoglycans. The effect of TGF-beta on cells in culture was highly consistent whereas explants from different animals showed greater variability in the response. It was concluded that TGF-beta did not specifically promote or maintain the cartilaginous nature of this tissue because supplementing medium with TGF-beta did not significantly alter the ratio of large/small proteoglycans synthesized by tissue explants. However, the observation of enhanced biglycan synthesis by TGF-beta suggests that TGF-beta could be involved in differentiation of regions of tendon subjected to compression, because compressed tendon contains both decorin and biglycan small proteoglycans whereas tensional tendon contains primarily decorin. Excess decorin added to cell culture medium did not affect the ability of TGF-beta to enhance synthesis of biglycan.

Compression loading in vitro regulates proteoglycan synthesis by tendon fibrocartilage.

The regulation of proteoglycan synthesis in a fibrocartilaginous tissue by mechanical loading was assessed in vitro. Discs of bovine tendon fibrocartilage were loaded daily with unconfined, cyclic, uniaxial compression (5 s/min, 20 min/day) and the synthesis of large and small proteoglycans was measured by incorporation of [35S]sulfate. All discs synthesized predominantly large proteoglycan when first placed in culture. After 2 weeks in culture nonloaded discs synthesized predominantly small proteoglycans whereas loaded discs continued to produce predominantly large proteoglycan. The turnover of 35S-labeled proteoglycan was not significantly altered by the compression regime. Increased synthesis of large proteoglycans was induced by a 4-day compression regime following 21 days of culture without compression. Inclusion of cytochalasin B during compression mimicked this induction. Autoradiography demonstrated that cell proliferation was minimal and confined to the disc edges whereas 35S-labeled proteoglycan synthesis occurred throughout the discs. These experiments demonstrate that mechanical compression can regulate synthesis of distinct proteoglycan types in fibrocartilage.

Married-couple families with step, adopted, and biological children.

National estimates of the numbers of families with step, adopted, and biological children have not previously been developed. In this work, parent types for children in married-couple families were indirectly identified by using marriage and birth dates. Families were then classified by the types of children present. A large majority (79 percent) had only biological children; however, a significant minority (16 percent) had at least one stepchild and 4 percent had at least one adopted child. This analysis provides national estimates of the numbers and characteristics of married-couple families with step, adopted, and biological children.

Childhood in sociodemographic perspective.

This article reviews the emerging sociodemographic literature on the relationships linking children and their families, by focusing on 4 topics: (1) the short-term implications for children of parents' family behavior, (2) the short-term implications for parents of the number and ages, or spacing, of their children, (3) the long-term implications of childhood family experiences for subsequent adult behavior, and (4) the probable family circumstances of children in the future. Studies of how parents influence children found that (1) increases in illegitimate fertility and divorce led to a large rise in the proportion of children living in 1-parent families, usually with the mother, and in stepfamilies; (2) children in families maintained by mothers, but not in stepfamilies, experience numberous social, economic, and psychological disadvantages; (3) contrary to the popular stereotype, white children in families maintained by mothers are more likely than black children in such families either to be living with or to receive financial assistance from extended family members; and (4) declining fertility and birth cohort size may have led to reductions in the welfare of children compared to the welfare of the elderly during the last 20 years. Studies of how children influence parents found that 1) the presence of at least 1 child probably reduced marital satisfaction; 2) the presence of a small number of children, especially preschool children, deters parental divorce; 3) children reduce remarriage probabilities for young mothers, but increase them for older mothers; and 4) at least the 1st and 2nd child probably reduce family income and savings. Studies of how childhood experiences affect individuals in adulthood find that 1) divorce of one's parents reduces one's own marriage probabilities and increases one's own divorce probabilities; 2) childhood stepfamilies have little effect on adult circumstances; 3) contrary to the popular stereotype children without siblings are not disadvantaged compared to other children; 4) an increasing number of siblings leads to reduced educational attainments; and 5) increasing educational mobility among men with small or medium numbers of siblings accounts for the increase observed for all men during this century. Recent projections suggest that 50-75% of the 1980 birth cohort may live in a 1-parent family during childhood, with a range of 40-70% for whites and a range of 85-95% for blacks.

Fertility reduction policies and poverty in Third World countries: ethical issues.

This article begins with a discussion of the motivation for fertility reduction and related population policies. Next, it identifies the two major approaches to evaluating these policies in the population ethics literature: the individualistic approach and the international approach. Each approach is then characterized according to the kinds of policies evaluated, the ethical principles that are most prominent, and the major conclusions drawn. Major empirical gaps in the population ethics literature are identified, and pertinent social science issues concerning the effectiveness of family planning programs, the socioeconomic determinants of fertility, and the interpersonal or community determinants of fertility are discussed. Finally, these issues are linked with the United Nations World Population Plan of Action to identify ethical questions that warrant detailed scrutiny.

PIP: This article discusses motivation for fertility reduction and related population policies. It identifies the 2 major approaches to evaluating these policies in the population ethics literature: the individualistic approach and the international approach. Each approach is then characterized according to the kinds of policies evaluated, the ethical principles that are most prominent, and the major conclusions drawn. Major empirical gaps in the population ethics literature are identified, and pertinent social science issues concerning the effectiveness of family planning programs, the socioeconomic determinants of fertility, and the interpersonal or community determinants of fertility are discussed. Finally, these issues are linked with the United Nations World Population Plan of Action to identify ethical questions that warrant detailed scrutiny. Estimates indicate that about 1/2 billion people around the world are malnourished and that more than 1 billion people lack access to clean water, sanitary sewage disposal, and trained health care. Additionally, perhaps 1/3 of the world's labor force is unemployed or earning too little to lift themselves and their families out of poverty. 4 general types of policies are discussed: voluntarist policies, incentive and welfare programs, shifts in social conditions, and involuntary governmental controls. Inquiries within the individualistic approach rely on freedom, justice, security and survival, but especially freedom. The international approach to population ethics consists of 2 opposing schools of thought: the lifeboat ethics school and the spaceship earth school. The 1st views each nation as a lifeboat with limited carrying capacity and emphasizes the need to ensure welfare of future generations rather than that of people in poor countries today. The 2nd school emphasizes global cooperation to reduce consumption, military spending and the waste of energy and other resources. The following broad types of fertility reduction policies could be implemented to deal with the serious threat to welfare, security and survival in the 3rd World: socioeconomic development policies, positive incentives, negative incentives, and sociopolitical pressures and coercion. Without major new policy initiatives in 3rd World countries, and without changes in international policies, the number of deprived 3rd World people will continually increase.

America's children and public policy in the 1980s.

PIP: This paper discusses several major information systems and presents knowledge obtained from them which is directly relevant to several policies of the federal government that are critical to the well-being of many children and families in the US. The systems discussed are: 1) the Panel Study of Income Dynamics, which can pinpoint the extent to which families and children become permanently dependent on welfare; 2) the Current Population Survey, which provides statistics on poverty, as well as official US employment statistics; 3) the Consumer Expenditure Survey, which is the best information source on the standard of living of American families; 4) the National Vital Statistics System, which provides information on marriages, divorces, births, and deaths; 5) the National Health Interview Survey; 6) the National Health and Nutrition Examination Survey; 7) the National Survey of Family Growth; and 8) the National Assessment of Educational Progress. Unfortunately these information sources have suffered in a variety of ways from federal budget changes during the last few years. The Survey of Income and Program Participation is a new data system being implemented by the US Bureau of the Census. Its 2 primary goals are 1) to collect detailed information on the various sources of money and nonmonetary income, and 2) to collect extremely detailed information on eligibility for and participation in a wide variety of government transfer programs. The proposed budget for 11 federal programs that support social and behavioral science research shows a decline of about 2% between 1981 and 1984, without adjusting for inflation. Because of these budgetary declines, the Advisory Group on Child and Family Indicators of the Social Science Research Council made the following recommendations: 1) assure the continuation of the discussed information systems, 2) establish an archive for data on children, and 3) repeat several surveys regularly. The implementation of these recommendations would provide a strong foundation for the continued collection of current information and the creation of new information needed to advance the scientific understanding of the development of children and its ability to conduct critically needed policy analyses.^ieng

A note on measuring the independent impact of family planning programs on fertility declines.

This note critically evaluates recent cross-national studies that estimate the independent effect of family planning programs on the fertility of the developing world. The evaluation demonstrates that past research is biased to produce overestimates of net program impact. A new estimate is derived to account more completely for the effects of the social context and socioeconomic development on fertility. This estimate indicates that 5 percent of the variation in crude birth rate decline for 89 developing countries is due to family planning programs. This is substantially less than past estimates.