Characterization of Staphylococcus aureus cardiolipin synthases 1 and 2 and their contribution to accumulation of cardiolipin in stationary phase and within phagocytes.

In many bacteria, including Staphylococcus aureus, progression from the logarithmic to the stationary phase is accompanied by conversion of most of bacterial membrane phosphatidylglycerol (PG) to cardiolipin (CL). Phagocytosis of S. aureus by human neutrophils also induces the conversion of most bacterial PG to CL. The genome of all sequenced strains of S. aureus contains two open reading frames (ORFs) predicting proteins encoded with ∼30% identity to the principal CL synthase (cls) of Escherichia coli. To test whether these ORFs (cls1 and cls2) encode cardiolipin synthases and contribute to CL accumulation in S. aureus, we expressed these proteins in a cls strain of E. coli and created isogenic single and double mutants in S. aureus. The expression of either Cls1 or Cls2 in CL-deficient E. coli resulted in CL accumulation in the stationary phase. S. aureus with deletion of both cls1 and cls2 showed no detectable CL accumulation in the stationary phase or after phagocytosis by neutrophils. CL accumulation in the stationary phase was due almost solely to Cls2, whereas both Cls1 and Cls2 contributed to CL accumulation following phagocytosis by neutrophils. Differences in the relative contributions of Cls1 and Cls2 to CL accumulation under different triggering conditions suggest differences in the role and regulation of these two enzymes.

Nocturia in men.

Nocturia is a common source of sleep disturbance in men and can result from many different causes. A patient-generated frequency/volume chart, along with several simple mathematical formulas, is used to classify nocturia according to its principal aetiology. The categories are nocturnal polyuria (NP), reduced voided volumes, 24-h polyuria and a combination of the aforementioned factors. Identification of the precise type of nocturia can help direct treatment in the cause-specific manner. In particular, use of the antidiuretic desmopressin can be of benefit in those with NP and may also be useful as part of a combination treatment approach in nocturia of mixed aetiology.

Monomeric endotoxin:protein complexes are essential for TLR4-dependent cell activation.

Potent TLR4-dependent cell activation by Gram-negative bacterial endotoxin depends on sequential endotoxin?protein and protein?protein interactions with LBP, CD14, MD-2 and TLR4. LBP and CD14 combine, in an albumin-dependent fashion, to extract single endotoxin molecules from purified endotoxin aggregates (E(agg)) or the bacterial outer membrane and form monomeric endotoxin:CD14 complexes that are the preferred presentation of endotoxin for transfer to MD-2. Endotoxin in endotoxin:CD14is readily transferred to MD-2, again in an albumin-dependent manner, to form monomeric endotoxin:MD-2 complex. This monomeric endotoxin:protein complex (endotoxin:MD-2) activates TLR4 at picomolar concentrations, independently of albumin, and is, therefore, the apparent ligand in endotoxin-dependent TLR4 activation. Tetra-, penta-, and hexa-acylated forms of meningococcal endotoxin (LOS) react similarly with LBP, CD14, and MD-2 to form endotoxin:MD-2 complexes. However, tetra- and penta-acylated LOS:MD-2 complexes are less potent TLR4 agonists than hexa-acylated LOS:MD-2. This is mirrored in the reduced activity of tetra-, penta- versus hexa-acylated LOS aggregates (LOS(agg)) + LBP toward cells containing mCD14, MD-2, and TLR4. Therefore, changes in agonist potency of under-acylated meninigococcal LOS are determined by differences in properties of monomeric endotoxin:MD-2.

Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices.

PURPOSE: We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms. MATERIALS AND METHODS: We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers. RESULTS: Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively. CONCLUSIONS: The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.

Outcome results of transurethral collagen injection for female stress incontinence: assessment by urinary incontinence score.

PURPOSE: We assessed the results of collagen injection for female sphincteric incontinence using strict subjective and objective criteria. MATERIALS AND METHODS: We evaluated 63 consecutive women with sphincteric incontinence who underwent a total of 131 transurethral collagen injections. Sphincteric incontinence was confirmed by urodynamics. All patients were treated with 1 to 5 transurethral collagen injections and treatment outcome was classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence documented by a 24-hour diary and pad test, and patient assessment that cure was achieved. Failure was defined as poor objective results and patient assessment that treatment failed. Cases that did not fulfill these cure and failure criteria were considered improved and further classified as a good, fair or poor response. RESULTS: Mean patient age plus or minus standard deviation was 67.7 +/- 12.8 years. All women had a long history of severe stress urinary incontinence, 18 (29%) underwent previous anti-incontinence surgery, and 41% had combined stress and urge incontinence. Preoperatively diary and pad tests revealed a mean of 7.5 +/- 4.6 incontinence episodes and 152 +/- 172 gm. of urine lost per 24 hours. Overall 1 to 5 injections were given in 26, 17, 13, 3 and 4 patients, respectively. Mean interval between injections was 4.4 +/- 5.7 months, mean followup was 12 +/- 9.6 months, and mean interval between the final injection and outcome assessment was 6.4 +/- 4.9 months. There was a statistically significant decrease in the total number of incontinence episodes per 24-hour voiding diary after each injection session. Although there was a clear trend toward decreased urinary loss per 24-hour pad test, statistical significance was not established. Using the strict criteria of our outcome score overall 13% of procedures were classified as cure, 10%, 17% and 42% as good, fair and poor, respectively, and 18% as failure. CONCLUSIONS: As defined by strict subjective and objective criteria, we noted a low short-term cure rate after collagen injection in women with severe sphincteric incontinence. It remains to be determined how patients with less severe incontinence would fare using our outcome assessment instruments.

The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study.

PURPOSE: We examine various mechanisms of post-radical prostatectomy incontinence. MATERIALS AND METHODS: A total of 83 consecutive men (mean age 68 +/- 6.6 years) referred for evaluation of persistent post-radical prostatectomy incontinence were enrolled in the study. All patients underwent clinical and urodynamic evaluation. Final diagnosis was based on clinical judgment considering patient history, pad test, voiding diary, free (unintubated) uroflow measurements, video urodynamics and linear passive urethral resistance relation curves. We compared free uroflow and pressure flow obtained with a 7Fr urethral catheter in place, and empirically defined low urethral compliance as at least 10 ml. per second difference between these measurements. RESULTS: Sphincteric incontinence was the most common urodynamic finding, occurring in 73 patients (88%). Detrusor instability was identified in 28 patients (33.7%) and in 6 (7.2%) was the main cause of incontinence. In 2 other patients bladder outlet obstruction (1.2%) or impaired detrusor contractility (1.2%) was the only urodynamic finding. Impaired detrusor contractility was diagnosed by linear passive urethral resistance relation in 82% of cases but considered to be clinically relevant in only a third. In 25 cases (30.1%) low urethral compliance was noted, which we consider nearly synonymous with urethral scarring. CONCLUSIONS: Sphincteric incontinence is the most common urodynamic finding in patients with post-radical prostatectomy incontinence, although other findings may coexist. The most accurate diagnosis is attained when all objective measures are put in perspective with the clinical setting.

Ordering an echocardiogram for evaluation of left ventricular function: level of expertise necessary for efficient use.

This prospective study was performed to test the hypothesis that the yield of 2-dimensional echocardiography (2DE) would be higher when it is ordered by a cardiologist than by a noncardiologist. Patients referred for transthoracic 2DE for the evaluation of left ventricular systolic function for the 11-month period between July 10, 1995, and June 10, 1996, were included in the study. Demographic, historical, and clinical findings were recorded. Whether the patient was referred by a cardiologist versus a noncardiologist was used as the predictor variable in a binary logistic regression analysis. To address the possibility that the yield of 2DE may be higher for cardiologists because the prevalence of disease in patients referred to them may be higher (selection bias), the analysis was subjected to a propensity score adjustment. Of 2176 patients referred for 2DE during the study, 1033 were referred for the evaluation of left ventricular function. The test had a positive yield in 52% of patients for cardiologists versus 31% for noncardiologists (chi(2) = 45.5, P <.0001, odds ratio 2.4 [CI = 1. 9-3.1]). This difference remained highly significant even when propensity score risk adjustment was made (chi(2) = 54.2, P <.0001, odds ratio 2.0 [CI = 1.5-2.8]). We conclude that the yield of 2DE is higher for cardiologists compared with noncardiologists and that this result was not related to differences in patient populations examined by the two groups. Thus, more efficient use of 2DE may be achieved if patients are referred to cardiologists rather than directly sent for 2DE.

Nocturia.

PURPOSE: We review the current state of knowledge of nocturia and present algorithms for diagnosis, classification and treatment. MATERIALS AND METHODS: We reviewed the recent literature on nocturia, and state-of-the-art methods of diagnosis, classification and treatment. RESULTS: Nocturia, which is among the most bothersome of all urological symptoms, has heretofore been poorly classified and understood. Multiple factors may result in nocturia, including pathological conditions, such as cardiovascular disease, diabetes mellitus, lower urinary tract obstruction, anxiety or primary sleep disorders, and behavioral and environmental factors. Nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction) and/or diminished nocturnal bladder capacity. Distinction between these conditions is made by a simple arithmetic analysis of a 24-hour voiding diary. CONCLUSIONS: Nocturia has been poorly studied, and its etiology and pathogenesis have been classified only recently. We present a scheme for diagnosis and care of patients suffering from loss of sleep due to nocturnal voiding.

Results of pubovaginal sling for stress incontinence: a prospective comparison of 4 instruments for outcome analysis.

PURPOSE: Presently to our knowledge there are no standardized techniques to assess outcomes after surgery for stress incontinence. We performed a prospective blinded study to assess the correlation among physician and patient assessments, and a validated 24-hour pad test and voiding diary. MATERIALS AND METHODS: A total of 84 women were evaluated before and after pubovaginal sling for stress incontinence with a voiding diary, pad test and symptom questionnaire (patient assessment) administered by a blinded third party. The operating surgeon evaluated the patient using history, physical examination, pad test and voiding diary but was blinded to results of the outcome questionnaire. Preoperative focused neurourological examination and video urodynamics confirmed stress incontinence. Patients were assessed at least 1 year postoperatively. We compared patient assessment (cured, improved, failure) to the outcome of the pad test, voiding diary and physician assessment. The physician and questioner were blinded to each other. We considered patients with a pad test of 0 to 2 ml. as cured, 50% or more volume reduction as improved and less than 50% volume reduction as failure. Postoperative assessment did not differentiate between stress and urge incontinence. The kappa coefficient was used for statistical comparison. RESULTS: Average patient age was 58 years and average followup for the entire group was 4 years. Agreement among the 4 instruments to assess outcome was excellent (k >0.9) with respect to cured/improved versus failure but only good for cured versus improved versus failure (k >0.5). CONCLUSIONS: Outcomes following incontinence surgery may vary depending on how the analysis was performed, patient selection, definition of success and so forth. Our results indicate that a pad test and voiding diary are reliable and should be part of the normal followup after pubovaginal sling for sphincteric incontinence. When these tests are used in conjunction with defined parameters of success, there is excellent agreement with patient feelings in regard to success or failure of surgery. Nevertheless, these instruments and methods are imperfect at best.

Evaluation of the etiology of nocturia in men: the nocturia and nocturnal bladder capacity indices.

To determine and quantify the cause of nocturia in men, we describe and evaluate the relative contribution of two complementary indices of nocturia: the nocturia index (Ni), a measure of nocturnal urine overproduction, and the nocturnal bladder capacity index (NBCi), reflective of nocturnal bladder capacity. The records of 100 consecutive men with lower urinary tract symptoms (LUTS), having undergone video-urodynamic studies (VUDS), were prospectively studied. Evaluation included American Urological Association symptom score (AUASS), micturition diary (day, night, and 24-hr voided volume), and VUDS. Voiding diary analysis was carried out as previously described by us, determining the Ni, NBCi, and nocturnal polyuria index (NPi) (nocturnal urine volume/24-hr urine volume). In the case of AUASS question #7 (degree of nocturia), the odds of having a severe AUA question #7 response was found to be 4.09 times higher for patients with NBCi > 2.0 compared with patients whose NBCi was 2 as highly significant in defining diminished NBC as a factor in the etiology of nocturia. In addition, we propose Ni of 1.5 as a threshold greater than which nocturia may be attributed to nocturnal urine overproduction in excess of maximum bladder capacity. Together, these indices describe in quantitative fashion the relative contributions of nocturnal urine overproduction and diminished NBC in identifying the etiology of nocturia in male patients. Neurourol. Urodynam. 18:559-565, 1999.

Fine needle aspiration cytology of gastric solitary fibrous tumor: a case report.

BACKGROUND: Solitary fibrous tumors (SFT) occur mainly in the pleura and other serosal sites. However, they have been found in extraserosal sites and should be considered in the differential diagnosis (DDx) of any spindle cell lesion, including those in the gastrointestinal tract. In this report, we describe fine needle aspiration (FNA) cytologic evaluation of a gastric SFT, emphasizing the role of immunocytochemistry in the DDx. CASE: Computerized tomography-guided FNA of a subserosal gastric mass in a 77-year-old female was performed. The moderately cellular smears showed neoplastic cells arranged in interlacing fascicles and in a "patternless" pattern. There was variable collagenous stroma. The cell block revealed a similar pattern, with a single mitotic figure. Nuclear atypia and necrosis were absent. The neoplastic cells were strongly reactive for vimentin and CD34, with weak focal reactivity for smooth muscle actin, suggestive of vessels in tangential section. They were nonreactive for muscle specific actin, desmin, S-100 and pancytokeratin. Other immunocytochemical markers were also studied. CONCLUSION: SFT should be considered in the DDx of spindle cell lesion of the stomach. Cell block and immunocytochemical markers, especially CD34, were extremely useful in the diagnosis of SFT on FNA.

Nocturia in adults: etiology and classification.

Nocturia is one of the most bothersome of all urologic symptoms, yet even a rudimentary classification does not exist. We herein propose a classification system of nocturia based on a retrospective study. The records of 200 consecutive patients with nocturia were reviewed. Evaluation included history, micturition diary (including day, night, and 24-hr voided volume), postvoid residual urine (PVR), and videourodynamic study (VUDS). Functional bladder capacity (FBC) was determined to be the largest voided volume in a 24-hr period. The etiology of nocturia was thus classified into one of three groups: nocturnal polyuria ([NP] in which voided urine volume during the hours of sleep exceeds 35% of the 24-hr output), nocturnal detrusor overactivity ([NDO] defined as nocturia attributable to diminished bladder capacity during the hours of sleep), and mixed (NP+NDO); polyuria (24-hr urine output >2,500 cc) was classified separately. There were 129 women and 65 men ranging in age from 17 to 94 years (x=59). Overall 13 (7%) had NP, 111 (57%) NDO, and 70 (36%) had a mixed etiology of their nocturia (both NP and NDO). Forty-five (23%) also had polyuria. These data confirm that the etiology of nocturia is multifactorial and in many instances unrelated to the underlying urologic condition. Nocturnal overproduction of urine is a significant component of nocturia in 43% of patients, most of whom will also have NDO. We believe that treatment should be directed at both conditions.

Neutrophils exposed to bacterial lipopolysaccharide upregulate NADPH oxidase assembly.

Bacterial LPS is a pluripotent agonist for PMNs. Although it does not activate the NADPH-dependent oxidase directly, LPS renders PMNs more responsive to other stimuli, a phenomenon known as "priming." Since the mechanism of LPS-dependent priming is incompletely understood, we investigated its effects on assembly and activation of the NADPH oxidase. LPS pretreatment increased superoxide (O2-) generation nearly 10-fold in response to N-formyl methionyl leucyl phenylalanine (fMLP). In a broken-cell O2--generating system, activity was increased in plasma membrane-rich fractions and concomitantly decreased in specific granule-rich fractions from LPS-treated cells. Oxidation-reduction spectroscopy and flow cytometry indicated LPS increased plasma membrane association of flavocytochrome b558. Immunoblots of plasma membrane vesicles from LPS-treated PMNs demonstrated translocation of p47-phox but not of p67-phox or Rac2. However, PMNs treated sequentially with LPS and fMLP showed a three- to sixfold increase (compared with either agent alone) in plasma membrane-associated p47-phox, p67-phox, and Rac2, and translocation paralleled augmented O2- generation by intact PMNs. LPS treatment caused limited phosphorylation of p47-phox, and plasma membrane-enriched fractions from LPS- and/or fMLP-treated cells contained fewer acidic species of p47-phox than did those from cells treated with PMA. Taken together, these studies suggest that redistribution of NADPH oxidase components may underlie LPS priming of the respiratory burst.

Percutaneous drainage of recurrent pneumothoraces and pneumatoceles.

Thoracic trauma victims commonly sustain visceral pleural injury with resultant pneumothorax. These injuries usually respond to standard tube thoracostomy decompression and drainage. However, a subset of these patients develop recurrent and/or loculated pneumothoraces or pneumatoceles that are not readily accessible by tube thoracostomy. Percutaneous catheter drainage of these collections provides a safe and reliable method of management in critically ill patients.

Percutaneous retrieval of a surgical laparotomy sponge from the peritoneal cavity.

Percutaneous retrieval of an extravascular foreign body is an uncommon procedure. This report describes the successful retrieval of a 46 x 46-cm laparotomy sponge from the peritoneal cavity using a Nitinol Gooseneck Snare system. This technique can eliminate the need for exploratory surgery and may be particularly useful in poor operative candidates.