Impact of disclosure of radiographic test results on quality of life among patients with hernias: a randomized controlled trial

PURPOSE

Hernias noted on radiographic imaging are common. We aimed to determine if informing patients of the presence of a clinically apparent or occult hernia on imaging would change their abdominal wall quality of life (AW-QOL).

METHODS

This study was registered on clinicaltrials.gov (NCT04355819) in April 2020. Patients with a ventral hernia on elective CT abdomen/pelvis were enrolled. Patients underwent standardized abdominal examination by surgeons, and completed the modified Activities Assessment Scale, a validated, hernia-specific AW-QOL survey. On this scale, 1 is poor AW-QOL, 100 is perfect, and the minimally clinically important difference is five for a minor change. Patients were randomized to complete the one-year follow-up survey before or after being informed of the presence of a hernia on their imaging results. Primary outcome was follow-up AW-QOL adjusted for baseline AW-QOL.

RESULTS

Of 169 patients randomized, 126 (75%) completed follow up at one-year. Among patients with occult hernias, those who completed the follow-up survey after being informed of having a hernia had a lower follow-up AW-QOL (mean difference - 7.6, 95% CI =  - 20.8 to 5.7, p = 0.261) compared to those who completed the survey before being informed. Conversely, for patients with clinical hernias, those who completed the survey after being informed had higher adjusted follow-up AW-QOL (mean difference 10.3, 95% CI =  - 3.0 to 23.6, p = 0.126) than those that completed it after.

CONCLUSION

Conveying findings of hernias found on CT imaging can influence patients' AW-QOL. Future research should focus on identifying and addressing patients' concerns after disclosure of CT results.

Review article: the intersection of mucosal pathophysiology in HIV and inflammatory bowel disease, and its implications for therapy

BACKGROUND

The immunopathology of inflammatory bowel diseases (IBD) and HIV in the gastrointestinal (GI) tract can be viewed as ends of a spectrum with IBD being associated with 'immune excess' and HIV with 'immune paucity' within the GI tract.

AIM

To review the pathophysiology of IBD and HIV as they intersect in the gut immune system.

METHODS

A search was conducted in PubMed using defined keywords 'IBD, inflammatory bowel disease, Crohn's disease, ulcerative colitis, HIV, innate immunity, mucosal layer, macrophage, cytokine, dendritic cells, adaptive immunity, CD4, T cells, Th1, Th2, natural killer T cells (NKT)'.

RESULTS

Both the mucosal innate defence and adaptive immunity are profoundly affected by IBD and HIV. The pathophysiology of IBD and HIV with regard to mucosal barrier, macrophages, dendritic cells, NK cells, NKT cells and T-cell subsets is distinct yet closely interwoven. There is limited information on the clinical manifestations of patients who have both IBD and HIV. However, recent studies suggest that the clinical course of IBD may be attenuated by concurrent HIV infection - a premise that is reasonably supported by what is known of their pathophysiology.

CONCLUSIONS

It is apparent that through specific pathophysiological mechanisms, HIV is capable of attenuating inflammation in IBD. In the absence of experimental models, further clinical studies are necessary to better understand patients with concurrent disease and decipher the clinical and mechanistic relationship between HIV and IBD at mucosal surfaces. Such studies are critical to guide therapeutic decisions in the management of patients with IBD infected with HIV.

Fatigue is highly associated with poor health-related quality of life, disability and depression in newly-diagnosed patients with inflammatory bowel disease, independent of disease activity

BACKGROUND

Fatigue is common in Crohn's disease (CD) and ulcerative colitis (UC). Data on fatigue in newly diagnosed patients are unavailable.

AIM

To report prevalence of fatigue in newly diagnosed CD and UC patients and examine its association with health-related quality of life (HRQOL), depression and disability.

METHODS

The Ocean State Crohn's and Colitis Area Registry (OSCCAR) is a statewide cohort of newly diagnosed inflammatory bowel disease patients in Rhode Island. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue Scale. Patients were administered instruments measuring HRQOL, overall disability and work impairment, and depression.

RESULTS

Fatigue was prevalent in 26.4% of 220 subjects. Cohen's d effect sizes for fatigue were large: Short-Form 36 Health Survey mental health component (CD 1.5, UC 1.4) and physical health component (CD 1.4, UC 1.4), EuroQol-5D valuation of current health state (CD 1.2, UC 1.0), Inflammatory Bowel Disease Questionnaire (CD 1.9, UC 1.6) and Patient Health Questionnaire depression scale (CD 1.8, UC 1.7). Fatigued patients reported more work impairment (Score difference: CD 29.5%, UC 23.8%) and activity impairment (score difference: CD 32.3%, UC 25.7%) on the Work Productivity and Activity Impairment Questionnaire. Fatigue's association with all scores remained highly significant despite controlling for disease activity.

CONCLUSIONS

Fatigue is strongly associated with poor HRQOL, disability and depression similarly in CD and UC even when controlling for disease activity. Fatigue's association with a wide range of patient-reported outcome measures suggests that monitoring fatigue is a simple way to screen for overall disruption in patient life.

Subversion of the T/B lineage decision in the thymus by lunatic fringe-mediated inhibition of Notch-1

Notch-1 signaling is essential for lymphoid progenitors to undergo T cell commitment, but the mechanism has not been defined. Here we show that thymocytes ectopically expressing Lunatic Fringe, a modifier of Notch-1 signaling, induce lymphoid progenitors to develop into B cells in the thymus. This cell fate switch resulted from Lunatic Fringe-mediated inhibition of Notch-1 function, as revealed by experiments utilizing lymphoid progenitors in which Notch-1 activity was genetically manipulated. These data identify Lunatic Fringe as a potent regulator of Notch-1 during the T/B lineage decision and show that an important function of Notch-1 in T cell commitment is to suppress B cell development in the thymus.

Testing a BEIR-VI suggestion for explaining the lung cancer vs. radon relationship for U.S. counties

The BEIR-VI Report suggests that the large discrepancy between the observed lung cancer rate vs. radon exposure relationship for U.S. counties, and the predictions of linear no-threshold theory, may be explained by a strong negative correlation between smoking intensity and radon exposure. It proposes a model for testing that suggestion. We apply that model to the detailed data for U.S. counties; analysis shows that even a perfect negative correlation explains little more than half of the discrepancy, and the largest not-implausible correlation can explain less than a quarter of the discrepancy. We then extend the BEIR-VI suggestion to include a strong negative correlation between both the prevalence of smoking and the intensity of smoking. The largest not-implausible correlations can explain no more than 30% of the discrepancy. It is concluded that the previous interpretation of these data, that linear no-threshold theory fails this test, is sustained.

Monophyly of brachiopods and phoronids: reconciliation of molecular evidence with Linnaean classification (the subphylum Phoroniformea nov.)

Molecular phylogenetic analyses of aligned 18S rDNA gene sequences from articulate and inarticulate brachiopods representing all major extant lineages, an enhanced set of phoronids and several unrelated protostome taxa, confirm previous indications that in such data, brachiopod and phoronids form a well-supported clade that (on previous evidence) is unambiguously affiliated with protostomes rather than deuterostomes. Within the brachiopod-phoronid clade, an association between phoronids and inarticulate brachiopods is moderately well supported, whilst a close relationship between phoronids and craniid inarticulates is weakly indicated. Brachiopod-phoronid monophyly is reconciled with the most recent Linnaean classification of brachiopods by abolition of the phylum Phoronida and rediagnosis of the phylum Brachiopoda to include tubiculous, shell-less forms. Recognition that brachiopods and phoronids are close genealogical allies of protostome phyla such as molluscs and annelids, but are much more distantly related to deuterostome phyla such as echinoderms and chordates, implies either (or both) that the morphology and ontogeny of blastopore, mesoderm and coelom formation have been widely misreported or misinterpreted, or that these characters have been subject to extensive homoplasy. This inference, if true, undermines virtually all morphology-based reconstructions of phylogeny made during the past century or more.

Response to criticisms of Smith et al

The various criticisms of our test of the linear no-threshold theory of radiation carcinogenesis in the paper by Smith et al. are considered and shown to be invalid. It is shown that there is no significant difference between the BEIR IV formula and the formula we use, that the uncertainties in effective average radon exposures in U.S. counties due to the issues they raise are not very large and that even if they were implausibly large, the results of our study would not be much affected. I review the seven essentially independent methods we used to estimate smoking prevalence, all of which give the same results but most of which, including the most important, were ignored by Smith et al.; explaining our results by uncertainties in smoking data would require correlations between radon and smoking that are grossly implausible. Our use of measurements of radon, smoking, and lung cancer rates from different time periods is justified, and it is shown that if more recent lung cancer rates are used, the results are not changed. Problems in comparing Iowa data with our study are discussed. It is shown that many of their criticisms of our study are more applicable to the case-control and cohort studies that they endorse. Many of their conclusions are presented without valid supporting evidence. A simple procedure is suggested that can easily settle any questions about the validity of our study; with this procedure, I offer to show that any other published ecological study might give invalid results. The point here is that our study is very different from all other published ecological studies.

Response to Lubin's proposed explanations of our discrepancy

Lubin's proposal that a correlation between radon and smoking among individuals might explain the very large discrepancy between our data on U.S. counties and the prediction of linear no-threshold theory of radiation induced cancer is tested. It is shown that even correlations far beyond the limits of plausibility cannot explain an appreciable part of our discrepancy. On the other hand, Lubin is commended for proposing a definite potential explanation for our discrepancy that can be quantitatively tested for applicability to our analysis, and further such proposals are strongly invited. All other explanations of our discrepancy and all other reasons for not accepting our conclusions that are proposed in the Lubin paper are shown not to be applicable. The role of plausibility in epidemiological studies is discussed and shown to be all-important.

Comparison of articulate brachiopod nuclear and mitochondrial gene trees leads to a clade-based redefinition of protostomes (Protostomozoa) and deuterostomes (Deuterostomozoa)

Nuclear and mtDNA sequences from selected short-looped terebratuloid (terebratulacean) articulate brachiopods yield congruent and genetically independent phylogenetic reconstructions by parsimony, neighbour-joining and maximum likelihood methods, suggesting that both sources of data are reliable guides to brachiopod species phylogeny. The present-day genealogical relationships and geographical distributions of the tested terebratuloid brachiopods are consistent with a tethyan dispersal and subsequent radiation. Concordance of nuclear and mitochondrial gene phylogenies reinforces previous indications that articulate brachiopods, inarticulate brachiopods, phoronids and ectoprocts cluster with other organisms generally regarded as protostomes. Since ontogeny and morphology in brachiopods, ectoprocts and phoronids depart in important respects from those features supposedly diagnostic of protostomes, this demonstrates that the operational definition of protostomy by the usual ontological characters must be misleading or unreliable. New, molecular, operational definitions are proposed to replace the traditional criteria for the recognition of protostomes and deuterostomes, and the clade-based terms 'Protostomoza' and 'Deuterostomozoa' are proposed to replace the existing term 'Protostomia' and 'Deuterostomia'.

Prevention of thrombocytopenia by thrombopoietin in myelosuppressed rhesus monkeys accompanied by prominent erythropoietic stimulation and iron depletion

The effectiveness of thrombopoietin (TPO) in alleviating thrombocytopenia was evaluated in a placebo-controlled study involving rhesus monkeys exposed to 5 Gy total-body irradiation (TBI) (300-kV x-rays) to result in 3 weeks of pancytopenia. Supraoptimal treatment with human recombinant TPO (10 microg/kg/d subcutaneously, days 1 to 21 after TBI) was highly effective in preventing thrombocytopenia, with nadirs for thrombocytes, on average, far higher than 100 x 10(9)/L, a greatly accelerated recovery to normal values, and no need for thrombocyte transfusions. TPO appeared to act selectively in that neutrophil regeneration was not influenced but red blood cell lineage recovery was prominently stimulated, with reticulocyte regeneration being initiated 10 days earlier than in placebo-treated animals. The reticulocytosis was followed by a normoblastosis that occurred earlier and was more pronounced than in placebo-treated monkeys. The effect of TPO on the red blood cell lineage was also reflected in a less profound nadir for hemoglobin (Hb) and hematocrit values than in placebo controls. However, this effect was not followed by a rapid recovery to normal values, due to development of a microcytic hypochromic anemia. Iron depletion was demonstrated by measurements of total serum iron and total iron-binding capacity (TIBC) and could be prevented by prophylactic intramuscular (IM) iron before TBI or corrected by IM iron after TPO treatment. Rechallenging with TPO in week 8 after TBI demonstrated a homogenous thrombocyte response similar in magnitude to the initial response, but a greatly diminished reticulocyte response. This demonstrated that the erythropoietic response to TPO administration depends on the hemopoietic state of the animal and may reflect multiple TPO target cells. It is postulated that the extremely rapid erythropoiesis due to TPO treatment in the initial regeneration phase following myelosuppression results in iron depletion by a mechanism similar to that seen following erythropoietin treatment in patients with end-stage renal failure. It is concluded that protracted TPO therapy to counteract thrombocytopenic states may result in iron depletion and that the iron status should be monitored before, during, and after TPO treatment.

Problems in the radon vs lung cancer test of the linear no-threshold theory and a procedure for resolving them

It has been shown that lung cancer rates in U.S. Counties, with or without correction for smoking, decrease with increasing radon exposure, in sharp contrast to the increase predicted by the linear no-threshold theory. The discrepancy is by 20 standard deviations, and very extensive efforts to explain it were not successful. It is pointed out that, unless a plausible explanation for this discrepancy (or conflicting evidence) can be found, continued use of the linear no-threshold theory is a violation of "The Scientific Method." Various explanations that have been offered for ignoring these results are examined and shown not to be valid. A simple procedure for clearly settling the issue is proposed.

Questionnaire study of the lung cancer risk from radon in homes

First time measurements of radon levels in homes, self-selected by occupants, were accompanied by questionnaires asking about people who had lived in the house and died of cancer. Responses were received before measurement results were available. The ratio of lung cancer deaths to deaths from other cancers was plotted as a function of radon level in the house. The results seem to indicate essentially no dependence of this ratio on radon exposure, in sharp contrast to the strong increase with increasing radon exposure predicted by the theory which should have been easily observable. Possible explanations of the discrepancy are discussed. Use of two alternative control groups increases the discrepancy with theory. This work has no connection with the recent test of the linear nonthreshold theory in the low dose region by the same author.

Enigmatic phylogeny of skuas (Aves:Stercorariidae)

Multiple sources of evidence show that the skuas (Aves:Stercorariidae) are a monophyletic group, closely related to gulls (Laridae. On morphological and behavioural evidence the Stercorariidae are divided into two widely divergent genera, Catharacta and Stercorarius, consistent with observed levels of nuclear and mitochondrial gene divergence. Catharacta skuas are large-bodied and with one exception breed in the Southern Hemisphere. Stercorarius skuas otherwise known as jaegers) are smaller bodied and breed exclusively in the Northern Hemisphere. Evidence from both mitochondrial and nuclear genomes and from ectoparasitic lice (Insecta:Phthiraptera) shows that the Pomarine skua, S. pomarinus, which has been recognized as being somewhat intermediate in certain morphological and behavioural characteristics, is much more closely related to species in the genus Catharacta, especially to the Northern Hemisphere-breeding Great skua, C. skua, than it is to the other two Stercorarius skuas, the Arctic skua, S. parasiticus and the Longtailed skua, S. longicaudus. Three possible explanations that might account for this discordant aspect of skua phylogeny are explored. These involve (i) the segregation of ancestral polymorphism, (ii) convergent evolution of morphology and behaviour or (iii) inter-generic hybridization. The available evidence from both nuclear and mitochondrial genomes does not exclude any of these hypotheses. Thus, resolution of this enigma of skua phylogeny awaits further work.

Lung cancer rate vs. mean radon level in U.S. counties of various characteristics

Plots of lung cancer rates corrected for smoking prevalence vs. average home radon levels are presented for U.S. counties with a wide variety of socioeconomic characteristics. The data are generally well described by the same negative slope linear, plus positive slope quadratic, "standard" curve. Plots are presented for geographic regions and these are also reasonably well fit by the standard curve. The findings are not consistent with predictions based on a linear no-threshold model.

How dangerous is low level radiation?

Problems in the theoretical basis for the linear-no threshold theory of radiation carcinogenesis are reviewed, and it is shown that they very strongly suggest that the theory greatly overestimates the risk of low level radiation. A direct test of the theory, based on the radon-lung cancer relationship is described; it strongly reinforces that conclusion. However, it is shown that even if the linear-no threshold theory is valid, the public's fear of low level radiation, at least in some contexts, is grossly exaggerated.

Antigen-presenting cells for naive transgenic gamma delta T cells. Potent activation by activated alpha beta T cells

The function of gamma delta T cells, particularly the minor population of circulating gamma delta T cells, remains unclear. To study these lymphoid gamma delta T cells, a transgenic SCID mouse containing the KN6 gamma delta TCR whose ligand is the TL gene product, T22b, was created. KN6-SCID mice contain a monoclonal population of naive KN6+ gamma delta T cells. Using these mice, we have studied the APC required for activation of KN6+ gamma delta T cells in vitro and in vivo. Analysis of an in vitro mixed lymphocyte response identified a hierarchy of potency for stimulation: dendritic cells = T cell blasts > B cell blasts > B cells > resting T cells. In contrast, in vivo, only alpha beta T cells fully activated KN6+ gamma delta T cells as measured by an increase in the number of splenic KN6+ cells, the development of blast morphology, and the development of proliferative anergy in the responding KN6+ cells. The strong stimulatory properties of C57BL/6J T cells appeared to depend on their having been activated by KN6-SCID alloantigens. T cells from (C57BL/6J x BALB/c)F1 mice, which are tolerant of KN6-SCID alloantigens, could not fully activate KN6+ cells. However, the F1 T cells could activate KN6+ cells if they were activated in vivo by the mitogen, staphylococcal enterotoxin B. A mixture of third party activated T cells plus T22b+ non-T cells only partially activated KN6+ cells, implying that activated T22b+ T cells are acting directly as stimulatory cells. Although the Ags recognized by gamma delta T cells are generally unknown, Ag presentation by activated alpha beta T cells may be an important method of activation.

Antigen-presenting cells for naive transgenic gamma delta T cells. Potent activation by activated alpha beta T cells

The function of gamma delta T cells, particularly the minor population of circulating gamma delta T cells, remains unclear. To study these lymphoid gamma delta T cells, a transgenic SCID mouse containing the KN6 gamma delta TCR whose ligand is the TL gene product, T22b, was created. KN6-SCID mice contain a monoclonal population of naive KN6+ gamma delta T cells. Using these mice, we have studied the APC required for activation of KN6+ gamma delta T cells in vitro and in vivo. Analysis of an in vitro mixed lymphocyte response identified a hierarchy of potency for stimulation: dendritic cells = T cell blasts > B cell blasts > B cells > resting T cells. In contrast, in vivo, only alpha beta T cells fully activated KN6+ gamma delta T cells as measured by an increase in the number of splenic KN6+ cells, the development of blast morphology, and the development of proliferative anergy in the responding KN6+ cells. The strong stimulatory properties of C57BL/6J T cells appeared to depend on their having been activated by KN6-SCID alloantigens. T cells from (C57BL/6J x BALB/c)F1 mice, which are tolerant of KN6-SCID alloantigens, could not fully activate KN6+ cells. However, the F1 T cells could activate KN6+ cells if they were activated in vivo by the mitogen, staphylococcal enterotoxin B. A mixture of third party activated T cells plus T22b+ non-T cells only partially activated KN6+ cells, implying that activated T22b+ T cells are acting directly as stimulatory cells. Although the Ags recognized by gamma delta T cells are generally unknown, Ag presentation by activated alpha beta T cells may be an important method of activation.

Direct transcriptional repression by pRB and its reversal by specific cyclins

It was recently shown that the E2F-pRB complex is a negative transcriptional regulator. However, it was not determined whether the whole complex or pRB alone is required for repression. Here we show that pRB and the related protein p107 are capable of direct transcriptional repression independent of E2F. When fused to the DNA binding domain of GAL4, pRB or p107 represses transcription of promoters with GAL4 binding sites. Thus, E2F acts as a tether for pRB or p107 but is not actively involved in repression of other enhancers. This function of pRB maps to the pocket and is abrogated by mutation of this domain. This result suggests an intriguing model in which the pocket has a dual function, first to bind E2F and second to repress transcription directly, possibly through interaction with other proteins. We also show that direct transcriptional repression by pRB is regulated by phosphorylation. Mutations which render pRB constitutively hypophosphorylated potentiate repression, while phosphorylation induced by cyclin A or E reduces repression ninefold.

Basal serum follicle stimulating hormone (FSH) and estradiol levels as predictors of pregnancy in unstimulated donor insemination cycles

PURPOSE

The purpose of this study was to evaluate the utility of basal serum follicle stimulating hormone and estradiol levels in predicting pregnancy in women undergoing artificial insemination with donor sperm for severe male factor infertility.

METHOD

A retrospective chart review of 48 women who had at least 2 cycles of artificial insemination with donor sperm and who had undergone testing for basal serum follicle stimulating hormone and estradiol levels prior to or during therapy.

RESULTS

There was no difference in age or mean basal serum follicle stimulating hormone between women who conceived (clinical pregnancy) and those who did not. Women who conceived had significantly lower mean serum basal estradiol levels (P = 0.02) and significantly fewer numbers of treatment cycles (P = 0.041). The highest pregnancy rate was among those women with normal basal serum follicle stimulating hormone and estradiol levels. Receiver operating characteristic curve analysis revealed basal serum estradiol to be a more reliable predictor of pregnancy than follicle stimulating hormone.

CONCLUSIONS

Basal serum follicle stimulating hormone and estradiol levels may be useful in predicting success with artificial insemination with donor sperm. It may be useful to obtain basal serum follicle stimulating hormone and estradiol prior to initiating artificial insemination with donor sperm.

Test of the linear-no threshold theory of radiation carcinogenesis for inhaled radon decay products

Data on lung cancer mortality rates vs. average radon concentration in homes for 1,601 U.S. counties are used to test the linear-no threshold theory. The widely recognized problems with ecological studies, as applied to this work, are addressed extensively. With or without corrections for variations in smoking prevalence, there is a strong tendency for lung cancer rates to decrease with increasing radon exposure, in sharp contrast to the increase expected from the theory. The discrepancy in slope is about 20 standard deviations. It is shown that uncertainties in lung cancer rates, radon exposures, and smoking prevalence are not important and that confounding by 54 socioeconomic factors, by geography, and by altitude and climate can explain only a small fraction of the discrepancy. Effects of known radon-smoking prevalence correlations--rural people have higher radon levels and smoke less than urban people, and smokers are exposed to less radon than non-smokers--are calculated and found to be trivial. In spite of extensive efforts, no potential explanation for the discrepancy other than failure of the linear-no threshold theory for carcinogenesis from inhaled radon decay products could be found.

Effects of smoking on the levels of antioxidant beta carotene, alpha tocopherol and retinol in human ovarian follicular fluid

The concentrations of beta-carotene, retinol and alpha-tocopherol were measured by high-pressure liquid chromatography in ovarian follicular fluid and plasma samples collected at the time of oocyte recovery from patients enrolled in our in vitro fertilization program. The mean beta-carotene levels in follicular fluid [0.182 +/- (SEM) 0.04 nmol/ml] and plasma (0.37 +/- 0.34 mmol/ml) of smokers (n = 5) were significantly (p < 0.025 and p < 0.001, respectively) lower compared with the mean levels in follicular fluid (0.58 +/- 0.10 nmol/ml) and plasma (1.11 +/- 0.09 mmol/ml) in nonsmokers (n = 11). The follicular fluid and plasma retinol and alpha-tocopherol levels were comparable among the nonsmokers and smokers. These findings direct attention to a possible role of the antioxidant beta-carotene, per se, as a biological marker in ovarian oocyte follicular maturation and function.

Dose-response relationship for radiation carcinogenesis in the low-dose region

Evidence that low-level radiation substantially enhances the effectiveness of repair mechanisms is summarized. This finding destroys the theoretical basis (there is no other basis) for use of a linear-no threshold dose-response relationship to estimate the cancer risk of exposure to low-level radiation. Such a methodology will exaggerate the risk. This conclusion is further supported by epidemiological evidence and by studies of the effects of radon exposure in the home, which are reviewed.