Needs of caregivers of the patients with dementia.

This study was conducted to isolate the needs families express both for medical and psychological care, and for educational and social support in 112 caregivers of patients affected by moderate to severe dementia (mini mental state examination=MMSE score: 9+/-7) consecutively recruited at our Memory Clinic, to develop approaches as individualized as possible. The medical needs caregivers express are mainly relative to a better knowledge of the disease (78%) and the exact diagnosis (65%); the education-related needs are mainly relative to the acquisition of communicational skills (83%) and the optimal handling of cognitive (77%) and behavioral disorders (81%); the psychological ones mainly concern the area of assistance induced emotional stress management (37%) and the elaboration of feelings such as anxiety, rage and guilt (49%). Variance analysis shows a correlation between emotional caregivers' needs and the subjective and objective burdens they carry. Despite the attention to the role families play in caring for patients with a diagnoses of moderate to severe dementia, caregivers still express low levels of illness-consciousness and high levels of psychological discomfort. A lot more ought to be done in order to provide better information about the disease, about appropriate cognitive and behavioral disorder management skills, and about viable psychological support.

Normalización de la medición de la actividad de la Na+/K+-ATPasa en glóbulos rojos humanos / Normalization of the measurement activity of the Na+/K+-ATPase in human erythrocytes

Los fantasmas de glóbulos rojos (FGR) humanos obtenidos de sujetos sanos muestran actividad de la Na+/K+-ATpasa de 1,68 ñ 0,08 nmoles Pi/mg proteína x min (n=65; edad: 30 a 60 años). No hubo diferencias entre sexos, tampoco entre muestras obtenidas en ayuno o postprandiales. Comprobamos que la sangre debe mantenerse en frío (0ºC) si no es procesada de inmediato. Obtenidos los FGR a 0ºC, la actividad enzimática no varía entre el momento de la toma y las 4 h; pero si varía significativamente a las 24 y 48 h. Los FGR conservados a -40ºC, mantienen la actividad por 48 h. En dos voluntarios sanos tratados con digoxina por una semana observamos una disminución en la actividad enzimática el primer día (17 por ciento y 22 por ciento de control, respectivamente). Los niveles de digoxina en suero no mostraron paralelismo con la actividad enzimática y fueron siempre menores de 0,7 ng/ml. Conclusión: Se dan las pautas metodológicas para obtener muestras útiles en clínica

Double-J ureteral stents: an alternative to external urinary stents in orthotopic bladder substitution.

OBJECTIVE: The aim of this study was to compare advantages and disadvantages of using double-J or external stents to preserve the uretero-ileal anastomosis in patients receiving an orthotopic neobladder. METHODS: 77 consecutive patients with bladder cancer who underwent radical cystoprostatectomy and Studer neobladder were evaluated. All patients received a direct spatulated end-to-side uretero-ileal anastomosis in the afferent loop (Nesbit technique). In 45 patients (group A), the stents (Bracci ureteral splint) were brought our through the reservoir and anchored to the skin; in 32 patients (group B), an internal double-J stent was used. Median follow-up was 30 months. RESULTS: 9 (11.5%) uretero-ileal anastomosis strictures in group A and 7 (11.6%) in group B were observed. There was a significant difference in the side of stricture with a greater prevalence on the left side (p<0.004). Stricture formation and side were not related to the type of stent used. 14 (20%) neobladder-ureteral refluxes occurred, with a non-significant difference between the two groups (p = 0.37). 12 patients (86%) were asymptomatic; two patients developed pyelonephritis and needed antibiotic treatment. Neobladder catheter was removed after 17 days (range: 15-18 days) and 14 days (range: 12-15 days), respectively, in group A and group B with an earlier discharge of the patients in group B. There was a significant difference in mean hospital stay between the two groups (Mann-Whitney test p<0.0001). Discomfort related to the stent was mild for most of the patients of group B (84%). CONCLUSIONS: Internal stenting is an equally effective alternative to external stent in patients undergoing bladder replacement. The use of double-j stents appears to be associated with minimal discomfort, earlier mobilization and a shorter hospital stay.

Renal oncocytoma: image diagnostics and therapeutic aspects.

The renal oncocytoma is a solid epithelial neoplasm with a generally benign course. The improved image diagnostics with the computerized tomography (CT) and magnetic resonance imaging (MRI) should today permit the identification of these lesions preoperatively so that conservative rather than radical surgery can be employed, especially in the presence of an early or incidental diagnosis, this latter being always more frequent today. Eighteen patients (9 women and 9 men) with renal oncocytoma are presented. The sizes of the lesions ranged from 1.5 to 12 cm and all were studied by means of ultrasonography, CT and MRI. The MRI was found to be superior to both the ultrasonography and the CT in identifying smaller than 5 cm lesions, presenting typical, homogeneous low-density images in the T1-weighted image sequences which appeared hyperintense in the T2-weighted ones. The presence of a central scar or stellate architecture, the absence of hemorrhage and necrosis and the presence of a pseudocapsule are other elements to differentiate an oncocytoma from a renal carcinoma. These aspects are less characteristic in greater than 5 cm lesions, making the differential diagnosis more difficult. Twelve patients were submitted to a radical nephrectomy and 6 underwent enucleation. The follow-up of the patients (6-74 months) showed a disease-free survival in 17, while one patient died of distant metastases. No local recurrences were observed after conservative surgery which should be considered the treatment of choice in cases of renal oncocytoma with lesions of less than 5 cm.

Lower urinary tract reconstruction following cystectomy: experience and results in 96 patients using the orthotopic ileal bladder substitution of Studer et al.

Between 1989 and 1993 96 patients (89 males and 7 females) affected with invasive neoplasms of the bladder underwent surgery consisting of the creation of an orthotopic ileal neobladder according to Studer et al., after radical cystectomy. Patient selection and details of the surgical procedure are described. An accurate follow-up of 3-60 months (mean: 28 months) is presented. There have been 6 perioperative deaths (6.2%) and 11 early complications, all directly related to the neobladder and requiring reoperation in 6 cases (6.2%). Late complications required rehospitalization in 23 cases (23.9%) and a second reoperation was necessary in 10 (10.4%). The urodynamic tests show that the neobladder assumes an average capacity at about 330 cm3 after 1 year. Pressure at maximum capacity decreases in time and ranges from 10 to 20 cm H2O at 2 years. After 1 year, the complete urinary continence rate by day is 97% and the stress incontinence rate is 22%. Night-time continence, instead, increases to 74% after 1 year and to 83% after 2 years. In female patients, the functional results were satisfactory thanks to careful patient selection and to the surgical procedure adopted. Twenty-four patients had disease progression; 17 of these patients with locally advanced neoplasms died. The authors believe that the orthotopic ileal continent reservoir can be a satisfactory solution after cystectomy for bladder cancer, offering the patients a better quality of life compared to other urinary diversions both in male and female patients.

Varying heparin requirements in hemodialysis patients receiving erythropoietin.

A two-phase study was undertaken to investigate the incidence, extent, and management of increased heparin needs occurring during erythropoietin (EPO) therapy in the hemodialysis patient. Individual heparin doses and activated clotting time (ACT) test values were the parameters used to indicate changes in heparin requirements. It appears that increased heparin requirements are frequently associated with EPO therapy, and awareness of this finding, coupled with close ACT monitoring, may possibly prevent complications associated with undetected increases in heparin requirement.

Signal transduction of gamma/delta T cell antigen receptor with a novel mitogenic anti-delta antibody.

Human T lymphocytes express either alpha/beta- or gamma/delta-TCR in association with the CD3 complex. We have isolated a mAb, delta TCS1, that immunoprecipitated the gamma/delta-TCR heterodimer from cell lysates of Peer and Molt-13 leukemia cell lines. After dissociation of the gamma- and delta-chains of TCR by treatment with SDS, delta TCS1 specifically immunoprecipitated the delta-chain. This antibody bound to the surface of other gamma/delta-positive T cell lines and clones and was able to stimulate the proliferation of a minor cell population (0.9 to 4.0%) of resting human PBL. Upon binding to gamma/delta-TCR-bearing Molt-13 cells and PBL, delta TCS1 elicited a fura-2 Caa+ signal indicating that the gamma/delta-receptor is functionally similar to the alpha/beta-heterodimer. These data indicate that the delta TCS1 antibody recognizes an epitope on TCR delta-chain and its mitogenic activity should be useful in characterizing the functional properties of human gamma/delta-positive T lymphocytes.

Disulfide spacer between methotrexate and poly(D-lysine). A probe for exploring the reductive process in endocytosis.

Poly(D-lysine) is taken up avidly by cultured cells through adsorptive endocytosis and can serve as a carrier to increase cellular uptake of other molecules. While direct conjugation of methotrexate to poly(D-lysine) yields a conjugate devoid of cytotoxic effects because poly(D-lysine) is not digested in lysosomes, the indirect conjugation using a triglycine spacer or a disulfide spacer strongly inhibits the growth of both the wild type and the methotrexate transport-defective Chinese hamster ovary cells. Cell treatment with 3 mM NH4Cl or 50 micrograms/ml leupeptin prevents the effect of conjugate with the triglycine spacer, but not of conjugate with the disulfide spacer. On the other hand, preincubation with 2-mercaptoethanol abolishes the effect of the drug-disulfide conjugate in the methotrexate transport-defective mutant, but not the effect of the drug-triglycine conjugate. The disulfide conjugate shows an identical cytotoxic effect in alpha-minimal essential medium and RPMI 1640 media, even though cells grown in the latter have only half the glutathione content as cells grown in the former medium. We conclude that the reductive process through which methotrexate is released from the disulfide spacer (a) occurs inside cells and not at the cell surface, (b) requires neither acid pH nor lysosomal enzymes, and (c) is not mediated by a glutathione-disulfide exchange reaction requiring high glutathione concentrations. Although the cellular compartment in which this reductive process occurs is not yet identified, there are reasons to assume that it is prelysosomal.