Unplanned Extubations in Pediatric Critical Care: A Case–Control Study

The aim of this study was to quantify associations between the risk of unplanned extubation and patient-, environment-, and care-related factors in pediatric critical care and to compare outcomes between children who did and did not experience an unplanned extubation. This is a retrospective case–control analysis including patients <18 years who experienced an unplanned extubation during intensive care unit (ICU) admission (2004–2014). Cases were matched by age, duration of mechanical ventilation, and date to control patients (4:1) who were intubated but did not experience an unplanned extubation. Conditional logistic regression was used to evaluate associations between unplanned extubations and the abstracted characteristics. We identified 1,601 eligible controls matched to 458 case patients. When adjusted for confounders, eight variables were associated with unplanned extubation: three patient-related factors (previous ICU admission, previous intubation, and the volume of secretions); one environment-related factor (patient room setup); and four care-related factors (intubation route, and the use of sedation, muscle relaxation, and restraints). Patients who had an unplanned extubation had longer length of stay, but lower rate of mortality. This is the largest case–control study identifying variables associated with unplanned extubation in pediatric critical care. Several are potentially modifiable and may provide opportunities to improve quality of care in controlled ICU environments.

Variation in cloud immersion, not precipitation, drives leaf trait plasticity and water relations in vascular epiphytes during an extreme drought

PREMISE

Epiphytes are abundant in ecosystems such as tropical montane cloud forests where low-lying clouds are often in contact with vegetation. Climate projections for these regions include more variability in rainfall and an increase in cloud base heights, which would lead to drier conditions in the soil and atmosphere. While recent studies have examined the effects of drought on epiphytic water relations, the influence that atmospheric moisture has, either alone or in combination with drought, on the health and performance of epiphyte communities remains unclear.

METHODS

We conducted a 10-week drought experiment on seven vascular epiphyte species in two shadehouses, one with warmer and drier conditions and another that was cooler and more humid. We measured water relations across control and drought-treatment groups and assessed functional traits of leaves produced during drought conditions to evaluate trait plasticity.

RESULTS

Epiphytes exposed to drought and drier atmospheric conditions had a significant reduction in stomatal conductance and leaf water potential and an increase in leaf dry matter. Nonsucculent epiphytes from the drier shadehouse had the greatest shifts in functional traits, whereas succulent epiphytes released stored leaf water to maintain water status.

CONCLUSIONS

Individuals in the drier shadehouse had a substantial reduction in performance, whereas drought-treated individuals that experienced cloud immersion displayed minimal changes in water status. Our results indicate that projected increases in the cloud base height will reduce growth and performance of epiphytic communities and that nonsucculent epiphytes may be particularly vulnerable.

Trade-offs between succulent and non-succulent epiphytes underlie variation in drought tolerance and avoidance

Epiphyte communities comprise important components of many forest ecosystems in terms of biomass and diversity, but little is known regarding trade-offs that underlie diversity and structure in these communities or the impact that microclimate has on epiphyte trait allocation. We measured 22 functional traits in vascular epiphyte communities across six sites that span a microclimatic gradient in a tropical montane cloud forest region in Costa Rica. We quantified traits that relate to carbon and nitrogen allocation, gas exchange, water storage, and drought tolerance. Functional diversity was high in all but the lowest elevation site where drought likely limits the success of certain species with particular trait combinations. For most traits, variation was explained by relationships with other traits, rather than differences in microclimate across sites. Although there were significant differences in microclimate, epiphyte abundance, and diversity, we found substantial overlap in multivariate trait space across five of the sites. We found significant correlations between functional traits, many of which related to water storage (leaf water content, leaf thickness, hydrenchymal thickness), drought tolerance (turgor loss point), and carbon allocation (specific leaf area, leaf dry matter content). This suite of trait correlations suggests that the epiphyte community has evolved functional strategies along with a drought avoidance versus drought tolerance continuum where leaf succulence emerged as a pivotal overall trait.

The dynamics of stem water storage in the tops of Earth's largest trees-Sequoiadendron giganteum

Water stored in tree stems (i.e., trunks and branches) is an important contributor to transpiration that can improve photosynthetic carbon gain and reduce the probability of cavitation. However, in tall trees, the capacity to store water may decline with height because of chronically low water potentials associated with the gravitational potential gradient. We quantified the importance of elastic stem water storage in the top 5-6 m of large (4.2-5.0 m diameter at breast height, 82.1-86.3 m tall) Sequoiadendron giganteum (Lindley) J. Buchholz (giant sequoia) trees using a combination of architectural measurements and automated sensors that monitored summertime diel rhythms in sap flow, stem diameter and water potential. Stem water storage contributed 1.5-1.8% of water transpired at the tree tops, and hydraulic capacitance ranged from 2.6 to 4.1 l MPa-1 m-3. These values, which are considerably smaller than reported for shorter trees, may be associated with persistently low water potentials imposed by gravity and could indicate a trend of decreasing water storage dynamics with height in tree. Branch diameter contraction and expansion consistently and substantially lagged behind fluxes in water potential and sap flow, which occurred in sync. This lag suggests that the inner bark, which consists mostly of live secondary phloem tissue, was an important hydraulic capacitor, and that hydraulic resistance between xylem and phloem retards water transfer between these tissues. We also measured tree-base sap flux, which lagged behind that measured in trunks near the tree tops, indicating additional storage in the large trunks between these measurement positions. Whole-tree sap flow ranged from 2227 to 3752 l day-1, corroborating previous records for similar-sized giant sequoia and representing the largest yet reported for any individual tree. Despite such extraordinarily high daily water use, we estimate that water stored in tree-top stems contributes minimally to transpiration on typical summer days.

Tree genotypes affect rock lichens and understory plants: examples of trophic-independent interactions

Genetic variation in foundation tree species can strongly influence communities of trophic‐dependent organisms, such as herbivorous insects, pollinators, and mycorrhizal fungi. However, the extent and manner in which this variation results in unexpected interactions that reach trophic‐independent organisms remains poorly understood, even though these interactions are essential to understanding complex ecosystems. In pinyon–juniper woodland at Sunset Crater (Arizona, USA), we studied pinyon (Pinus edulis) that were either resistant or susceptible to stem‐boring moths (Dioryctria albovittella). Moth herbivory alters the architecture of susceptible trees, thereby modifying the microhabitat beneath their crowns. We tested the hypothesis that this interaction between herbivore and tree genotype extends to affect trophic‐independent communities of saxicolous (i.e., growing on rocks) lichens and bryophytes and vascular plants beneath their crowns. Under 30 pairs of moth‐resistant and moth‐susceptible trees, we estimated percent cover of lichens, bryophytes, and vascular plants. We also quantified the cover of leaf litter and rocks as well as light availability. Four major findings emerged. (1) Compared to moth‐resistant trees, which exhibited monopodial architecture, the microhabitat under the shrub‐like susceptible trees was 60% darker and had 21% more litter resulting in 68% less rock exposure. (2) Susceptible trees had 56% and 87% less cover, 42% and 80% less richness, and 38% and 92% less diversity of saxicolous and plant communities, respectively, compared to resistant trees. (3) Both saxicolous and plant species accumulated at a slower rate beneath susceptible trees, suggesting an environment that might inhibit colonization and/or growth. (4) Both saxicolous and plant communities were negatively affected by the habitat provided by susceptible trees. The results suggest that herbivory of moth‐susceptible trees generated litter at high enough rates to reduce rock substrate availability, thereby suppressing the saxicolous communities. However, our results did not provide a causal pathway explaining the suppression of vascular plants. Nonetheless, the cascading effects of genetic variation in pinyon appear to extend beyond trophic‐dependent moths to include trophic‐independent saxicolous and vascular plant communities that are affected by specific tree–herbivore interactions that modify the local environment. We suggest that such genetically based interactions are common in nature and contribute to the evolution of complex communities.

Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience

PURPOSE

Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation.

MATERIALS AND METHODS

Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days.

RESULTS

The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses.

CONCLUSION

Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.

Coping with gravity: the foliar water relations of giant sequoia

In tall trees, the mechanisms by which foliage maintains sufficient turgor pressure and water content against height-related constraints remain poorly understood. Pressure-volume curves generated from leafy shoots collected crown-wide from 12 large Sequoiadendron giganteum (Lindley) J. Buchholz (giant sequoia) trees provided mechanistic insights into how the components of water potential vary with height in tree and over time. The turgor loss point (TLP) decreased with height at a rate indistinguishable from the gravitational potential gradient and was controlled by changes in tissue osmotica. For all measured shoots, total relative water content at the TLP remained above 75%. This high value has been suggested to help leaves avoid precipitous declines in leaf-level physiological function, and in giant sequoia was controlled by both tissue elasticity and the balance of water between apoplasm and symplasm. Hydraulic capacitance decreased only slightly with height, but importantly this parameter was nearly double in value to that reported for other tree species. Total water storage capacity also decreased with height, but this trend essentially disappeared when considering only water available within the typical range of water potentials experienced by giant sequoia. From summer to fall measurement periods we did not observe osmotic adjustment that would depress the TLP. Instead we observed a proportional shift of water into less mobile apoplastic compartments leading to a reduction in hydraulic capacitance. This collection of foliar traits allows giant sequoia to routinely, but safely, operate close to its TLP, and suggests that gravity plays a major role in the water relations of Earth's largest tree species.

Abstract P3-07-02: Are we missing actionable targets in breast cancer? Novel insights into recurrent Ret alterations

Background: Recurrent gene fusions in breast cancer have been rarely reported suggesting that they either are not present or are not easily detected by standard sequencing methods. Comprehensive genomic profiling (CGP) by hybrid capture-based, high depth next-generation sequencing approaches, can be used to detect recurrent rearrangements and other genomic alterations involving target genes. We found that CGP can identify recurrent alterations involving RET, a known oncogenic tyrosine receptor kinase, in a subset of breast cancer.

Methods: CGP using FoundationOne platform was performed interrogating the entire coding region for up to 315 cancer-related genes and introns of up to 28 genes involved in rearrangements at a depth of 500-1000X in formalin-fixed, paraffin embedded tumor tissue (Foundation Medicine, MA). Engineered representative RET fusion vectors were synthesized and expressed in non-tumorigenic cell lines (breast MCF10A and mouse 3T3 fibroblasts), and cells were evaluated for RET kinase signaling, drug response, and tumorigenicity. Patient-derived xenografts (PDX) generated from two triple negative breast cancers (TNBCs) were used in an ex vivo assay (Response3DXTM, Molecular Response LLC, San Diego, CA).

Results: Twenty-two RET rearrangements were identified in 8119 (0.27%) breast cancer cases. Of these, 5 rearrangements were activating RET fusions including CCDC6-RET (n=4) and NCOA4-RET (n=1), that have been described in other cancer types. Five other cases had clear evidence of genomic rearrangement involving RET, but the 5' partners could not be definitively identified. The remaining twelve cases had complex rearrangements of RET including internal duplications. RET amplification was also observed, both in TNBC and in a HER2+ breast cancer at onset of resistance to HER2-targeted therapy.

Both NCOA4-RET and a novel RASGEF1A-RET fusion were characterized in vitro. Non-tumorigenic cells engineered to stably overexpress either RET fusions demonstrated transformed phenotypes. The fusions were constitutively active, as shown by endogenous phosphorylation of the kinase domain, and drove activation of downstream signaling as shown by increased phosphorylation of ERK and AKT. Cells transformed by RET-fusions were exquisitely sensitive to treatment with RET inhibitors. Interestingly, a PDX model of RET-amplified TNBC was sensitive to treatment with a PIK3CA inhibitor. An index case of ER+/PR-/HER2+, metastatic breast cancer that had radiographic evidence of disease progression while on trastuzumab, pertuzumab, and anastrazole was found to have a NCOA4-RET fusion by CGP. Subsequent treatment with with cabozantinib plus anastrazole led a rapid clinical and radiographic response.

Conclusions: CGP can identify recurrent RET rearrangements in breast cancer that act as primary oncogenic drivers and can be therapeutically targeted. RET alterations may also play a role in acquired resistance to HER2-targeted therapies, suggesting a role for combined RET and HER2-targeted therapy in this setting. Our data demonstrate that RET alterations can be identified by clinical-grade CGP and are promising candidates as therapeutic targets in selected breast cancer patients.

Citation Format: Hirshfield KM, Paratala BS, Hindoyan A, Dolfi SC, Yilmazel B, Schrock A, Gay L, Ali SM, Ross JS, Williams CB, Nair P, Ganesan S, Leyland-Jones B. Are we missing actionable targets in breast cancer? Novel insights into recurrent Ret alterations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-07-02.

Abstract P5-16-01: Implementation of routine genomic and proteomic profiling of metastatic breast cancer patients in a community cancer center

Background: The optimal treatment strategy for patients with metastatic breast cancer (MBC) is currently unknown. Resistance to standard therapies, including anthracyclines and taxanes, limit the number of treatment options in many patients to a small number of non-cross resistant regimens. Rational combination approaches that are selected based upon genomic and proteomic analysis represents a possible advance that warrants extensive exploration.

Methods: Single center analysis of 77 consecutive metastatic breast cancer patients seen over a 12 month period (June 2014 through May 2015). All patients were referred for sequencing and the metastatic disease was rebiopsied. All samples were sent for standard pathologic, genomic (FoundationOne), and proteomic (TheraLink) analysis.

Results: Genomic and proteomic analysis yielded actionable targets in a majority of cases (89%). The most common pathways involved were the following: PI3K/Akt/mTOR (73%), MAPK (46%), ErbB (36%), FGFR (25%), and Jak/STAT (11%). Over 100 unique molecular aberrations were identified in 40 evaluable patients. Current outcomes are summarized in Table 1. The overall response rate was 45%, with another 43% of patients with stable disease. Average number of prior therapies was over 4, with a range of 1-11.

Table 1ER+/HER2-CR = 3PR = 8SD = 15PD = 2NE = 20ER+/HER2+CR = 2PR = 2SD = 1PD = 0NE = 9ER-/HER2+CR = 0PR = 1SD = 1PD = 1NE = 2Triple NegativeCR = 0PR = 2SD = 0PD = 2NE = 6Total evaluable patients = 40Overall CR = 13%Overall PR = 33%Overall SD = 43%Overall PD = 13%Total Not Evaluable = 37 pts (48%)Overall Response Rate (ORR) = 45%     CR = complete response PR = partial response SD = stable disease PD = progressive disease NE = not evaluable

Conclusion: Since current literature suggests that an overall response rate of approximately 10% or less is expected for patients that have received greater than 4 previous lines of therapy, the ORR seen in this analysis is quite remarkable. Most patients in this analysis were treated with FDA approved drugs off label, which provided additional challenges and was the primary reason that many patients were not evaluable. Patients were only evaluable if they received the recommended therapy and were measured for outcome. Our initial data provides growing evidence that it is critical to incorporate genomic and proteomic analysis (preferably as early as possible in the disease course) to allow for the best chance of disease response.

Citation Format: Williams CB, Krie A, De P, Dey N, Klein J, Williams KA, Hoogeveen M, Solomon B, Leyland-Jones B. Implementation of routine genomic and proteomic profiling of metastatic breast cancer patients in a community cancer center. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-16-01.

Contrasting drought-response strategies in California redwoods

We compared the physiology and growth of seedlings originating from different Sequoia sempervirens (D. Don.) Endl. (coast redwood) and Sequoiadendron giganteum (Lindl.) Buchh. (giant sequoia) populations subjected to progressive drought followed by a recovery period in a controlled greenhouse experiment. Our objective was to examine how multiple plant traits interact to influence the response of seedlings of each species and seed population to a single drought and recovery cycle. We measured soil and plant water status, leaf gas exchange, stem embolism and growth of control (well-watered) and drought-stressed (water withheld) seedlings from each population at the beginning, middle and end of a 6-week drought period and again 2 weeks after re-watering. The drought had a significant effect on many aspects of seedling performance, but water-stressed seedlings regained most physiological functioning by the end of the recovery period. Sequoiadendron seedlings exhibited a greater degree of isohydry (water status regulation), lower levels of stem embolism, higher biomass allocation to roots and lower sensitivity of growth to drought compared with Sequoia. Only minor intra-specific differences were observed among populations. Our results show that seedlings of the two redwood species exhibit contrasting drought-response strategies that align with the environmental conditions these trees experience in their native habitats, and demonstrate trade-offs and coordination among traits affecting plant water use, carbon gain and growth under drought.

An examination of resveratrol's mechanisms of action in human tissue: impact of a single dose in vivo and dose responses in skeletal muscle ex vivo

The current study tested the hypothesis that a single, moderate dose of RSV would activate the AMPK/SIRT1 axis in human skeletal muscle and adipose tissue. Additionally, the effects of RSV on mitochondrial respiration in PmFBs were examined. Eight sedentary men (23.8±2.4 yrs; BMI: 32.7±7.1) reported to the lab on two occasions where they were provided a meal supplemented with 300 mg of RSV or a placebo. Blood samples, and a muscle biopsy were obtained in the fasted state and again, with the addition of an adipose tissue biopsy, two hours post-prandial. The effect of RSV on mitochondrial respiration was examined in PmFBs taken from muscle biopsies from an additional eight men (23.4±5.4 yrs; BMI: 24.4±2.8). No effect of RSV was observed on nuclear SIRT1 activity, acetylation of p53, or phosphorylation of AMPK, ACC or PKA in either skeletal muscle or adipose tissue. A decrease in post absorptive insulin levels was accompanied by elevated skeletal muscle phosphorylation of p38 MAPK, but no change in either skeletal muscle or adipose tissue insulin signalling. Mitochondrial respiration in PmFBs was rapidly inhibited by RSV at 100–300 uM depending on the substrate examined. These results question the efficacy of a single dose of RSV at altering skeletal muscle and adipose tissue AMPK/SIRT1 activity in humans and suggest that RSV mechanisms of action in humans may be associated with altered cellular energetics resulting from impaired mitochondrial ATP production.

Changes in mechanisms proposed to mediate fat loss following an acute bout of high-intensity interval and endurance exercise

The purpose of this study was to investigate the acute effects of endurance exercise (END; 65% V̇O2peak for 60 min) and high-intensity interval exercise (HIE; four 30 s Wingates separated by 4.5 min of active rest) on cardiorespiratory, hormonal, and subjective appetite measures that may account for the previously reported superior fat loss with low volume HIE compared with END. Recreationally active males (n = 18) completed END, HIE, and control (CON) protocols. On each test day, cardiorespiratory measures including oxygen uptake (V̇O2), respiratory exchange ratio (RER), and heart rate were recorded and blood samples were obtained at baseline (BSL), 60 min after exercise, and 180 min after exercise (equivalent times for CON). Subjective measures of appetite (hunger, fullness, nausea, and prospective consumption) were assessed using visual analogue scales, administered at BSL, 0, 60, 120, and 180 min after exercise. No significant differences in excess postexercise oxygen consumption (EPOC) were observed between conditions. RER was significantly (P < 0.05) depressed in HIE compared with CON at 60 min after exercise, yet estimates of total fat oxidation over CON were not different between HIE and END. No differences in plasma adiponectin concentrations between protocols or time points were present. Epinephrine and norepinephrine were significantly (P < 0.05) elevated immediately after exercise in HIE compared with CON. Several subjective measures of appetite were significantly (P < 0.05) depressed immediately following HIE. Our data indicate that increases in EPOC or fat oxidation following HIE appear unlikely to contribute to the reported superior fat loss compared with END.

Skeletal muscle SIRT1 and the genetics of metabolic health: therapeutic activation by pharmaceuticals and exercise

Silent mating type information regulation 2 homolog 1 (SIRT1) is implicated in the control of skeletal muscle mitochondrial content and function through deacetylation of peroxisome proliferator-activated receptor γ coactivator-1α (PGC-1α) and participation in the SIRT1/PGC-1α axis. The SIRT1/PGC-1α axis control of skeletal muscle mitochondrial biogenesis is an important therapeutic target for obesity and obesity-related metabolic dysfunction, as skeletal muscle mitochondrial dysfunction is implicated in the pathogenesis of multiple metabolic diseases. This review will establish the importance of the SIRT1/PGC-1α axis in the control of skeletal muscle mitochondrial biogenesis, and explore possible pharmacological and physiological interventions designed to activate SIRT1 and the SIRT1/PGC-1α axis in order to prevent and/or treat obesity and obesity-related metabolic disease. The current evidence supports a role for therapeutic activation of SIRT1 and the SIRT1/PGC-1α axis by both pharmaceuticals and exercise in the treatment and prevention of metabolic disease. Future research should be directed toward the feasibility of pharmaceutical activation of SIRT1 in humans and refining exercise prescriptions for optimal SIRT1 activation.

Application of biological simulation models in estimating feed efficiency of finishing steers

Data on individual daily feed intake, BW at 28-d intervals, and carcass composition were obtained on 1,212 crossbred steers. Within-animal regressions of cumulative feed intake and BW on linear and quadratic days on feed were used to quantify initial and ending BW, average daily observed feed intake (OFI), and ADG over a 120-d finishing period. Feed intake was predicted (PFI) with 3 biological simulation models (BSM): a) Decision Evaluator for the Cattle Industry, b) Cornell Value Discovery System, and c) NRC update 2000, using observed growth and carcass data as input. Residual feed intake (RFI) was estimated using OFI (RFI(EL)) in a linear statistical model (LSM), and feed conversion ratio (FCR) was estimated as OFI/ADG (FCR(E)). Output from the BSM was used to estimate RFI by using PFI in place of OFI with the same LSM, and FCR was estimated as PFI/ADG. These estimates were evaluated against RFI(EL) and FCR(E). In a second analysis, estimates of RFI were obtained for the 3 BSM as the difference between OFI and PFI, and these estimates were evaluated against RFI(EL). The residual variation was extremely small when PFI was used in the LSM to estimate RFI, and this was mainly due to the fact that the same input variables (initial BW, days on feed, and ADG) were used in the BSM and LSM. Hence, the use of PFI obtained with BSM as a replacement for OFI in a LSM to characterize individual animals for RFI was not feasible. This conclusion was also supported by weak correlations (<0.4) between RFI(EL) and RFI obtained with PFI in the LSM, and very weak correlations (<0.13) between RFI(EL) and FCR obtained with PFI. In the second analysis, correlations (>0.89) for RFI(EL) with the other RFI estimates suggest little difference between RFI(EL) and any of these RFI estimates. In addition, results suggest that the RFI estimates calculated with PFI would be better able to identify animals with low OFI and small ADG as inefficient compared with RFI(EL). These results may be due to the fact that computer models predict performance on an individual-animal basis in contrast to a LSM, which estimates a fixed relationship for all animals; hence, the BSM may provide RFI estimates that are closer to the true biological efficiency of animals. In addition, BSM may facilitate comparisons across different data sets and provide more accurate estimates of efficiency in small data sets where errors would be greater with a LSM.

Intensive training over 5 days improves colonoscopy skills long-term

BACKGROUND AND AIMS

Poor standards in colonoscopy services and the introduction of a colorectal cancer screening program in the United Kingdom have highlighted the need to establish high-quality training and competency assessments in colonoscopy. The aims of this study were to evaluate the effectiveness of a 1-week hands-on colonoscopy course utilizing novel assessment tools.

METHODS

Twenty-one doctors with varying colonoscopy experience who attended an accelerated colonoscopy training week (ACTW) were prospectively studied. They were trained and assessed in key aspects of colonoscopy. Knowledge was assessed with a multiple choice question (MCQ) paper. Practical hand skills were taught and evaluated using a computer simulator and live case teaching. Actual colonoscopy performance was assessed using Direct Observation of Procedural Skills scores (DOPS) and an objective tri-split video score of insertion technique. Two independent trainers taught and assessed the trainees at the start and end of the ACTW and at a median of 9 months' follow-up.

RESULTS

Following training there were significant improvements in the MCQ score (P < 0.001), the simulator test case times (P = 0.02, P = 0.003), and the global DOPS score (P < or = 0.02). All improvements following the accelerated training were sustained at a median follow-up of 9 months.

CONCLUSIONS

This study is the first in the literature to describe the positive, sustained impact of an intensive hands-on colonoscopy training course. Measurements of performance in key areas of skill acquisition improved following training.

Using simulation models to predict feed intake: phenotypic and genetic relationships between observed and predicted values in cattle

The objectives of this study were to evaluate the accuracy of the Decision Evaluator for the Cattle Industry (DECI) and the Cornell Value Discovery System (CVDS) in predicting individual DMI and to assess the feasibility of using predicted DMI data in genetic evaluations of cattle. Observed individual animal data on the average daily DMI (OFI), ADG, and carcass measurements were obtained from postweaning records of 504 steers from 52 sires (502 with complete data). The experimental data and daily temperature and wind speed data were used as inputs to predict average daily feed DMI (kg) required (feed required; FR) for maintenance, cold stress, and ADG; maintenance and cold stress; ADG; maintenance and ADG; and maintenance alone, with CVDS (CFRmcg, CFRmc, CFRg, CFRmg, and CFRm, respectively) and DECI (DFRmcg, DFRmc, DFRg, DFRmg, and DFRm, respectively). Genetic parameters were estimated by REML using an animal model with age on test as a covariate and with genotype, age of dam, and year as fixed effects. Regression equations for observed on predicted DMI were OFI = 1.27 (SE = 0.27) + 0.83 (SE = 0.04) x CFRmcg [R2 = 0.44, residual SD (s(y.x)) = 0.669 kg/d] and OFI = 1.32 (SE = 0.22) + 0.8 (SE = 0.03) x DFRmcg (R2 = 0.53, s(y.x) = 0.612 kg/d). Heritability of OFI was 0.27 +/- 0.12, and heritabilities ranged from 0.33 +/- 0.12 to 0.41 +/- 0.13 for predicted measures of DMI. Phenotypic and genetic correlations between OFI and CFRmcg, CFRmc, CFRg, CFRmg, CFRm, DFRmcg, DFRmc, DFRg, DFRmg, and DFRm were 0.67, 0.73, 0.41, 0.63, 0.78, 0.73, 0.82, 0.45, 0.77, and 0.86 (P < 0.001 for all phenotypic correlations); and 0.95 +/- 0.07, 0.82 +/- 0.13, 0.89 +/- 0.09, 0.95 +/- 0.07, 0.91 +/- 0.09, 0.96 +/- 0.07, 0.89 +/- 0.09, 0.88 +/- 0.09, 0.96 +/- 0.06, and 0.96 +/- 0.07, respectively. Phenotypic and genetic correlations between CFRmcg and DFRmcg, CFRmc and DFRmc, CFRg and DFRg, CFRmg and DFRmg, and CFRm and DFRm were 0.98, 0.94, 0.99, 0.98, and 0.95 (P < 0.001 for all phenotypic correlations), and 0.99 +/- 0.004, 0.98 +/- 0.017, 0.99 +/- 0.004, 0.99 +/- 0.005, and 0.97 +/- 0.021, respectively. The strong genetic relationships between OFI and CFRmcg, CFRmg, DFRmcg, and DFRmg indicate that these predicted measures of DMI may be used in genetic evaluations and that DM requirements for cold stress may not be needed, thus reducing model complexity. However, high genetic correlations for final weight with OFI, CFRmcg, and DFRmcg suggest that the technology needs to be further evaluated in populations with genetic variance in feed efficiency.

Review article: Population screening for colorectal cancer

Colorectal cancer is a common cancer and common cause of death. The mortality rate from colorectal cancer can be reduced by identification and removal of cancer precursors, adenomas, or by detection of cancer at an earlier stage. Pilot screening programmes have demonstrated decreased colorectal cancer mortality; as a result many countries are developing colorectal cancer screening programmes. The most common modalities being evaluated are faecal occult blood testing, flexible sigmoidoscopy and colonoscopy. Implementation of screening tests has been hampered by cost, invasiveness, availability of resources and patient acceptance. New technologies such at computed tomographic colonography and stool screening for molecular markers of neoplasia are in development as potential minimally invasive tools. This review considers who should be screened, which test to use and how often to screen.

Technical Note: A dynamic model to predict the composition of fat-free matter gains in cattle

Composition of empty BW (EBW) was described in terms of ether-extractable lipid (FAT) and fat-free matter (FFM), and the terms dEBW, dFAT, and dFFM were used to represent daily gains in these components. The dFFM comprised protein, water, and ash, and a model was developed to predict the composition of dFFM. The conceptual approach used in model development was based on experimental data that showed as cattle grew from birth to maturity: 1) the water content of FFM decreased and the protein and ash content increased; 2) the protein content of FFM increased at a decreasing rate; and 3) the protein-to-ash ratio in the fat-free DM was approximately constant. These results suggest that the protein content of dFFM would be high at birth and decrease at a decreasing rate as the animal grows. The protein content of dFFM was predicted as a function of the fraction of dEBW that was dFFM, FAT content of EBW, and dFFM. A fixed protein-to-ash ratio of 4.1:1 was used to calculate the quantity of ash, and water was obtained as a residual. Growth and body composition of Hereford x Angus steers from birth to 500 kg BW were simulated with a previously published model using the experimental growth data as input, and the model under discussion was used to predict the composition of dFFM. Predicted response curves of the EBW components over the growth period were similar in shape to observed data. Predicted curvilinearity in response of protein weight against FFM weight for Hereford x Angus steers was similar to observed data. The standard error about the regression of predicted on observed protein weight was 1.87 kg, and the average bias of the model was to underpredict protein weight by 0.64%. Compared with using a constant value for the protein fraction of dFFM, the model provided more accurate predictions of dEBW in an independent evaluation data set.

Cancer surveillance in longstanding ulcerative colitis: endoscopic appearances help predict cancer risk

BACKGROUND AND AIMS

The risk of colorectal cancer is increased in ulcerative colitis (UC). Patients with UC have diverse colonoscopic appearances. Determining colonoscopic markers for cancer risk could allow patient risk stratification.

PATIENTS AND METHODS

Following on from an earlier study which demonstrated a correlation between inflammation severity and neoplasia risk, a case control study was performed to look for colonoscopic markers of colorectal neoplasia risk in UC. Each patient with neoplasia detected between 1988 and 2002 was matched with two non-dysplastic colitic controls. Data were collected on post-inflammatory polyps, scarring, strictures, backwash ileitis, a shortened, tubular, or featureless colon, severe inflammation, and normal looking surveillance colonoscopies.

RESULTS

Cases (n = 68) and controls (n = 136) were well matched. On univariate analysis, cases were significantly more likely to have post-inflammatory polyps (odds ratio (OR) 2.14 (95% confidence interval 1.24-3.70)), strictures (OR 4.22; 1.08-15.54), shortened colons (OR 10.0; 1.17-85.6), tubular colons (OR 2.03; 1.00-4.08), or segments of severe inflammation (OR 3.38; 1.41-10.13), and less likely to have had a macroscopically normal looking colonoscopy (OR 0.40; 0.21-0.74). After multivariate analysis, a macroscopically normal looking colonoscopy (OR 0.38; 0.19-0.73), post-inflammatory polyps (2.29; 1.28-4.11), and strictures (4.62; 1.03-20.8) remained significant. The five year risk of colorectal cancer following a normal looking colonoscopy was no different from that of matched general population controls.

CONCLUSIONS

Macroscopic colonoscopic features help predict neoplasia risk in UC. Features of previous/ongoing inflammation signify an increased risk. A macroscopically normal looking colonoscopy returns the cancer risk to that of the general population: it should be possible to reduce surveillance frequency to five years in this cohort.

A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?

AIM

To study the availability and quality of adult and paediatric colonoscopy in three National Health Service (NHS) regions.

METHOD

A prospective four month study of colonoscopies in North East Thames, West Midlands, and East Anglia.

PATIENTS

Subjects undergoing colonoscopy in 68 endoscopy units.

RESULTS

A total of 9223 colonoscopies were studied. The mean number of colonoscopies performed over the four month period was 142 in district general hospitals and 213 in teaching hospitals. Intravenous sedation was administered in 94.6% of procedures, but 2.2% and 11.4% of "at risk" patients did not have continuous venous access or did not receive supplemental oxygen, respectively. Caecal intubation was recorded in 76.9% of procedures but the adjusted caecal intubation rate was only 56.9%. Reasons for failing to reach the caecum included patient discomfort (34.7%), looping (29.7%), and poor bowel preparation (19.6%). A normal colonoscopy was reported in 42.1%. The most common diagnosis was polyps (22.5%) followed by diverticular disease (14.9%). Inflammatory bowel disease was recorded in 13.9% and carcinoma in 3.8%. Only half of the patients remembered being told of possible adverse events prior to the procedure. Rectal bleeding requiring admission following colonoscopy was reported in six patients. The overall perforation rate was 1:769 and colonoscopy was considered a possible factor in six deaths occurring within 30 days of the procedure. Only 17.0% of colonoscopists had received supervised training for their first 100 colonoscopies and only 39.3% had attended a training course.

CONCLUSION

There is serious under provision of colonoscopy service in most NHS hospitals. Endoscopy sedation guidelines are not always adhered to and there is a wide variation in practice between units. Colonoscopy is often incomplete and does not achieve the target 90% caecal intubation rate. Serious complications of colonoscopy were comparable with previous studies. Training in colonoscopy is often inadequate and improved practice should result from better training.

A dynamic model of metabolizable energy utilization in growing and mature cattle. III. Model evaluation

Component models of heat production identified in a proposed system of partitioning ME intake and a dynamic systems model that predicts gain in empty BW in cattle resulting from a known intake of ME were evaluated. Evaluations were done in four main areas: 1) net efficiency of ME utilization for gain, 2) relationship between recovered energy and ME intake, 3) predicting gain in empty BW from recovered energy, and 4) predicting gain in empty BW from ME intake. An analysis of published data showed that the net partial efficiencies of ME utilization for protein and fat gain were approximately 0.2 and 0.75, respectively, and that the net efficiency of ME utilization for gain could be estimated using these net partial efficiencies and the fraction of recovered energy that is contained in protein. Analyses of published sheep and cattle experimental data showed a significant linear relationship between recovered energy and ME intake, with no evidence for a nonlinear relationship. Growth and body composition of Hereford x Angus steers simulated from weaning to slaughter showed that over the finishing period, 20.8% of ME intake was recovered in gain. These results were similar to observed data and comparable to feedlot data of 26.5% for a shorter finishing period with a higher-quality diet. The component model to predict gain in empty BW from recovered energy was evaluated with growth and body composition data of five steer genotypes on two levels of nutrition. Linear regression of observed on predicted values for empty BW resulted in an intercept and slope that were not different (P < 0.05) from 0 and 1, respectively. Evaluations of the dynamic systems model to predict gain in empty BW using ME intake as the input showed close agreement between predicted and observed final empty BW for steers that were finished on high-energy diets, and the model accurately predicted growth patterns for Angus, Charolais, and Simmental reproducing females from 10 mo to 7 yr of age.

A dynamic model of metabolizable energy utilization in growing and mature cattle. II. Metabolizable energy utilization for gain

Component models were developed to predict the net efficiency of ME utilization for gain in cattle and to predict daily gain using recovered energy as the input. These models were integrated into a single model to predict daily gain from ME available for gain. One component model predicts the net efficiency of ME utilization for gain using constant partial net efficiencies of 0.2 and 0.75 for ME retention as protein and fat, respectively. This model predicts net efficiency of ME utilization for gain as a function of the ratio of the energy recovered in protein to the total energy recovered. The other component model predicts daily gain as a function of recovered energy and is represented by a system of ordinary differential equations that are numerically integrated on a daily basis. This model was developed by reformulating the equations in a published body composition model that uses daily gain to predict composition of gain since recovered energy is a function of gain and composition of gain. The equations in the two component models interact in that net efficiency is used to predict recovered energy from ME for gain, and in turn, recovered energy is used to predict gain in empty BW, which determines net efficiency through composition of gain. The numeric integration procedure provides an iterative solution for net efficiency. Simulated response of net efficiency for Hereford x Angus steers at 400 kg of empty BW decreased from 0.57 to 0.52 on diets with ME densities of 3.1 and 2.6 Mcal/kg of DM, and restricting the lower-quality diet to 75% of ad libitum intake resulted in a simulated net efficiency of 0.47. These responses in net efficiency were shown to be a result of composition of gain, with leaner gains resulting in lower net efficiencies.

A dynamic model of metabolizable energy utilization in growing and mature cattle. I. Metabolizable energy utilization for maintenance and support metabolism

Models to predict heat production attributable to maintenance and support metabolism in growing and mature cattle were developed on the basis of three concepts. The first concept is that animals fed fixed amounts of the same diet achieve weight equilibrium over an extended feeding period, and that the ME consumed at weight equilibrium is the maintenance requirement. The second concept is that a part of the heat production resulting from ME consumed above the maintenance requirement is associated with an elevation of vital functions (support metabolism), and this heat production can be modeled as a function of the level of feeding. The third concept is that previous levels of nutrition affect current estimates of heat production, and that this impact can be modeled as a delayed response in heat production associated with support metabolism. Experimental data on feed consumption showed that maintenance requirements varied in simple proportion to BW, not only for different breeds of mature cattle at BW equilibrium, but also for calves and growing steers held at BW stasis. Experimental data in which different breeds of cattle achieved weight equilibrium when fed fixed amounts of a specific diet were used to estimate breed parameters associated with maintenance for 21 breeds of cattle and 15 biological types of crossbred cattle. Level of feeding was estimated as a multiple of the maintenance intake and used to model heat production associated with support metabolism. Other experimental data on growing cattle were used to estimate breed parameters for predicting heat production associated with support metabolism for 21 breeds of cattle and 15 biological types of crossbred cattle. A distributed lag function was used to model the delayed response in heat production associated with support metabolism with changes in plane of nutrition. The models were tested by simulating experimental data for three breeds of weaned steers finished on high-energy diets. Results for the total heat production associated with maintenance and support metabolism expressed on a unit BW basis showed a similar response with stage of maturity when compared with other experimental data.

Endoscopic resection of large sessile colonic polyps by specialist and non-specialist endoscopists

BACKGROUND

Patients with large sessile colonic polyps for which endoscopic resection might be feasible are often referred directly for operation. The aim of this study was to determine the outcome of patients with such polyps diagnosed by specialist and non-specialist colonoscopists.

METHODS

Patients with large (greater than 2 cm) sessile polyps detected at colonoscopy from January 1995 to July 2000 were identified. Resection technique and clinical and endoscopic outcomes were recorded. Two of the colonoscopists (B.P.S., C.B.W.) are recognized as specialists.

RESULTS

Some 130 polyps were identified, 100 detected by either of two specialist endoscopists (including 14 cancers) and 30 by 14 non-specialist endoscopists (including ten cancers). Endoscopic resection of benign polyps was attempted by experts in 80 (93 per cent) of 86 cases and by non-experts in 15 of 20 cases (P = 0.03), with successful management by endoscopy alone in 61 (76 per cent) of 80 and in six of 15 cases respectively (P = 0.01). Complications occurred following three polypectomies performed by an expert (bleeding, two; pain, one) and one by a non-expert (bleeding). The estimated end-cost of management by specialists was less than half of that by non-specialists.

CONCLUSION

Endoscopic resection of large sessile colonic polyps is feasible in the majority of patients and should be considered as first-line therapy. Prompt referral to a specialist endoscopist may improve outcomes by avoiding operation or enabling complete excision at a single endoscopy session.

Patient pain during colonoscopy: an analysis using real-time magnetic endoscope imaging

BACKGROUND AND STUDY AIMS

Colonoscopy is generally perceived as being a painful procedure. Contributory factors are: stretching of the colonic wall and mesenteric attachments from looping of the instrument shaft, overinsufflation, the degree of torque or force applied to the colonoscope shaft, and patient pain threshold. The aim of this study was to determine the frequency of pain episodes experienced during diagnostic colonoscopy and the corresponding colonoscope configuration, utilizing real-time magnetic endoscope imaging (MEI).

PATIENTS AND METHODS

Consecutive outpatients undergoing colonoscopy were studied. Patients with previous colonic resections were excluded. Procedures were commenced with antispasmodics only, and patient sedation was self-administered whenever significant discomfort was experienced, using a patient-controlled analgesia (PCA) syringe pump. All "demands" were correlated with the MEI record, which was subsequently analysed.

RESULTS

A total of 650 demands were recorded in 102 patients. Seventy-seven percent of all demands occurred with the colonoscope tip in the sigmoid colon, 7 % in the descending colon, 6 % at the splenic flexure, 5 % in the transverse colon, and 4 % in the proximal colon. Ninety percent of all pain episodes coincided with either looping (79 %) or straightening of the colonoscope shaft (11 %); presumed overinsufflation being an infrequent cause of pain (9 %). Of the loops encountered during colonoscopy, the N-sigmoid spiral loop was associated with the majority of pain episodes (56 %). Looping was both more frequent ( P = 0.0002) and less well tolerated in women than in men ( P = 0.0140).

CONCLUSIONS

This study is the first to document pain at colonoscopy accurately. Looping, particularly in the variable anatomy of the sigmoid colon, is the major cause of pain, especially in women. Use of MEI may improve pain control by facilitating the straightening of loops within the sigmoid colon, and by enabling the endoscopist to target patient analgesia.

Design of a multicentre randomised trial to evaluate flexible sigmoidoscopy in colorectal cancer screening

A randomised, controlled trial in progress in 14 United Kingdom and six Italian centres is evaluating screening for colorectal cancer using a single flexible sigmoidoscopy (FS) at around the age of 60 with removal during FS of all small adenomas, and colonoscopy for "high risk" polyps. The regimen aims to ensure that 95% of people (with either no polyps or only low risk polyps) complete the entire screening process in a single visit. This paper describes the rationale and design of the trial. Participants were patients aged between 55 and 64 on the lists of designated general practitioners (GPs) who were not excluded by their GP. A two stage recruitment procedure was employed to raise compliance rates in the intervention group. Potentially eligible persons were sent an "interest in screening" questionnaire; those who responded positively were randomised to the intervention or control groups. The trial is sufficiently large to estimate within narrow confidence intervals the magnitude of benefit and the duration of effect and optimum age for a single screen. It also examines the feasibility and acceptability of the screening regimen, and will identify training and quality assurance issues. Recruitment and screening are now complete and all baseline data have been collected. The first analysis of the effect on colorectal cancer incidence and mortality rates and suitability for a national screening programme can be expected in 2004.

Spatial coherence does not affect contrast discrimination for multiple Gabor stimuli

Gestalt grouping rules imply a process or mechanism for grouping together local features of an object into a perceptual whole. Several psychophysical experiments have been interpreted as evidence for constrained interactions between nearby spatial filter elements and this has led to the hypothesis that element linking might be mediated by these interactions. A common tacit assumption is that these interactions result in response modulation which disturbs a local contrast code. We addressed this possibility by performing contrast discrimination experiments using two-dimensional arrays of multiple Gabor patches arranged either (i) vertically, (ii) in circles (coherent conditions), or (iii) randomly (incoherent condition), as well as for a single Gabor patch. In each condition, contrast increments were applied to either the entire test stimulus (experiment 1) or a single patch whose position was cued (experiment 2). In experiment 3, the texture stimuli were reduced to a single contour by displaying only the central vertical strip. Performance was better for the multiple-patch conditions than for the single-patch condition, but whether the multiple-patch stimulus was coherent or not had no systematic effect on the results in any of the experiments. We conclude that constrained local interactions do not interfere with a local contrast code for our suprathreshold stimuli, suggesting that, in general, this is not the way in which element linking is achieved. The possibility that interactions are involved in enhancing the detectability of contour elements at threshold remains unchallenged by our experiments.

Requirement for Ca2+/calmodulin-dependent kinase type IV/Gr in setting the thymocyte selection threshold

The outcome of thymocyte selection is influenced by the nature of Ca2+ signals transduced by the TCR. Robust Ca2+ responses characterize high-affinity, negatively selecting peptide/TCR interactions, while modest responses typify lower-affinity, positively selecting interactions. To elucidate mechanisms by which thymocytes decode distinct Ca2+ signals, we examined selection events in mice lacking Ca2+/calmodulin-dependent protein kinase type IV/Gr (CaMKIV/Gr), which is enriched in thymocytes. CaMKIV/Gr-deficient thymocytes exhibited impaired positive selection and defective Ca2+-dependent gene transcription. Significantly, CaMKIV/Gr deficiency raised the selection threshold of peptide/TCR interactions such that a peptide that normally induced weak negative selection instead promoted positive selection. These results demonstrate an important role for CaMKIV/Gr in sensitizing thymocytes to selection by low-affinity peptides.

Contour interaction for an easily resolvable stimulus

It is well known that adjacent contours can reduce the visual acuity of single letters. Although this has traditionally been considered only in terms of a neural-based interaction, it has recently been suggested that the information content in the stimulus may account for the interaction. Here we ask the question, "Do similar interference effects occur for the discrimination of low-contrast letters whose size is larger than that corresponding to the resolution limit?" If so, previous acuity-based interaction results may be of more general importance. We show that while there are interference effects of nearby contours, they are of a form different from that observed at the resolution limit. In particular, the contrast polarity of the nearby contour is unimportant, which in turn suggests that a physical explanation is inappropriate. Also, the discrimination of an easily resolvable, unflanked Landolt C target requires information over a much wider spatial-frequency range than its counterpart at the resolution limit.

Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial

BACKGROUND

Colonoscopy can be technically challenging because of unpredictable colonoscope looping. Without imaging, straightening the colonoscope is sometimes difficult since the endoscopist has to guess where the tip is. Magnetic endoscope imaging (MEI), a new non-radiographical technique for picturing the colonoscope shaft in real time, could facilitate loop straightening and thus improve performance.

METHODS

We assessed trainees and endoscopists with much experience of routine outpatient colonoscopy. In group 1, trainees examined 113 consecutive patients. MEI views were recorded in all examinations, but procedures were randomised to be done by two trainees, either with the endoscopist and endoscopy assistants viewing the imager display (n=58), or without the imager view (n=55). In group 2, two skilled endoscopists were randomised (as with group 1) to undertake consecutive examinations (n=183) either with (n=92) or without (n=91) the MEI view. MEI views of all procedures were analysed retrospectively.

FINDINGS

In both groups, intubation times were shorter (median 11.8 min [4.3-31.5] vs 15.3 min [4-67] [group 1]; 8.0 min [2.6-40.8] vs 9.3 min [2.5-52.6] [group 2]) and number of attempts at straightening the colonoscope fewer (median 5 [0-20] vs 12 [0-57] [group 1]; 7 [0-55] vs 10 [0-80] [group 2]), when the endoscopist was able to see the imager view. In group 1, colonoscopy completion rates were also higher (100% [58] vs 89% [49]) and duration of looping was reduced (median 3 min [0-18.8] vs 5.4 min [0-44.5]) when the imager could be seen. Abdominal hand pressure was more effective when the endoscopist and endoscopy assistant could see the imager view.

INTERPRETATION

MEI significantly improves performance of colonoscopy, particularly when used by trainees, or by experts in technically difficult cases; loops were straightened or controlled effectively, resulting in quick intubation times and high completion rates.

Development of colonoscopy teaching simulation

After 17 years of prototyping, a first release version of the St Mark's Hospital teaching simulator is in final preparation. Advances in computer processing power and graphics cards make it possible to achieve real-time processing of colon and endoscope characteristics and a simulated endoscopic view at an acceptable cost. Realistic feel or "force feedback" for all instrument controls and shaft movements is incorporated. To make the simulator more than a "video game", a package of teaching and assessment features is to be incorporated, including interactive animated graphics to explain particular endoscope loops and situations and the variations of colonic anatomy that are typically encountered. Simulation should spare patients from being used for the early phases of training and should speed up and quantify the learning process. Simulators may introduce even experienced endoscopists to some of the advanced options available in current or future endoscopes or accessories, as well as the use of imminent new technology such as the magnetic imaging system.

Probability summation for multiple patches of luminance modulation

When components of a compound pattern stimulate different visual mechanisms, psychophysical performance typically improves by a small amount consistent with probability summation amongst independent detectors. Here we extend previous summation experiments by (i) plotting full psychometric functions; and (ii) using compound stimuli with components that varied in up to three stimulus dimensions: spatial frequency (1, 4, 5 or 11 c/deg), orientation (0 degrees, +/-45 degrees ), and position. Stimulus components were isolated circular sine-phase patches of grating centred on up to four corners of an imaginary square surrounding a fixation-point. Combinations of component patches produced compound stimuli made from up to 16 components that differed in various combinations of the three stimulus dimensions. Other than when the spatial frequency was 11 c/deg, results were well described using: (i) probabilistic summation of individual psychometric functions; (ii) the Quick pooling formula; and (iii) the signal detection analysis for 2IFC developed by Tyler and Chen (2000) [Signal detection theory in the 2AFC paradigm: attention, channel uncertainty and probability summation (under review)]. We conclude that in general, nonlinear spatial summation is consistent with probabilistic summation across independent detecting mechanisms that vary in spatial frequency (a range of at least 1-5 c/deg), orientation (a range of 90 degrees ) and position (a range of at least 24 cycles at 4 c/deg). In further experiments, results were found to be consistent with probability summation for pairs of orthogonally oriented step-edge stimuli and a matrix of randomly oriented 11 c/deg sine-wave patches. This casts doubt on the generality of a recent suggestion that local interactions between colinearly oriented detectors within a spatial neighbourhood of around four cycles may contribute to nonlinear spatial summation [Bonneh & Sagi, 1998; Vision Research, 38, 3541-3553].

Endoscopic management of polypoid early colon cancer

Endoscopic management of polypoid early colonic cancer (malignant polyps and polypoid carcinomas) is no longer controversial. When the endoscopist is satisfied that excision is complete and histology is "favorable" (a resection margin of 2 mm and well or moderately well differentiated tumor), surgery is unnecessary. When histology show "unfavorable" characteristics (which a few histologists still take to include invasion into lymphatics), surgical or laparoscopic resection may be indicated, providing the patient is considered at suitable risk. Surgery kills some patients without finding residual cancer and cannot save others with metastases, so it should be recommended only with due clinical consideration. Sessile or broad-based polyps, especially those in the rectum, are more likely to be "high risk" and merit specialist management if local removal is to be attempted and to allow proper histologic assessment. Endoscopic approaches such as saline injection polypectomy, india-ink tattooing, and use of the argon beam coagulator are applicable in some cases. New approaches that still require trials include ultrasonographic probes, which occasionally clarify the degree of invasion, and prototype stapling devices to allow full-thickness histologic specimens to be obtained.

Carcinoid tumour in a caecal duplication cyst

Intestinal duplication cysts are rare congenital anomalies that may occasionally undergo neoplastic change. We report the case of a 30-year-old woman who was diagnosed to have a caecal duplication cyst. The cyst was excised and histology revealed the presence of a 10 mm diameter carcinoid tumour within the cyst wall. There was no evidence of metastatic spread and the patient remains well after 2 years follow-up. The 3 previously reported cases of carcinoid tumour arising within duplication cysts are reviewed.

Magnetic imaging of colonoscopy: an audit of looping, accuracy and ancillary maneuvers

BACKGROUND

Colonoscopy is one of the most frequently performed outpatient examinations. However, the procedure is still technically challenging, largely due to unpredictable looping during insertion. The aims of this study were (1) to assess the frequency of loop formation and types of loop during colonoscopy, (2) to determine the accuracy of the endoscopist's assessment of the anatomic location of the endoscope tip and of the presence and type of endoscope loop formation, and (3) to determine the efficacy of abdominal compression and change in patient position in promoting colonoscope advancement.

METHODS

Consecutive patients undergoing routine, day-case colonoscopy were studied using real-time, three-dimensional magnetic endoscope imaging. All examinations were performed by expert colonoscopists, blinded to the imager view. The endoscopist estimated the position of the colonoscope tip, assessed when and what type of loop had formed, and the efficacy of ancillary maneuvers such as hand pressure or patient position change. The magnetic imager view of each procedure was recorded and retrospectively analyzed.

RESULTS

One hundred complete colonoscopies were performed. Looping occurred in 91% with N-sigmoid (79%) and deep transverse (34%) being most common. Most loops (69%) were incorrectly diagnosed by the endoscopist. Atypical loops were more common in women than men (p = 0.025). The endoscopist's assessment of tip location was correct 85% of the time overall, but 100% in the cecum. Abdominal pressure was less effective (54 of 145 times, 37%) than patient position change (95 of 144 times, 66%) in promoting endoscope tip advancement.

CONCLUSIONS

Looping occurs frequently during routine colonoscopy. Although the endoscopist's assessment of tip location is fairly accurate, the majority of colonoscope loops are incorrectly appreciated. Although used frequently, ancillary maneuvers (abdominal compression and patient position change) are effective in only 52% of attempts.

A new variable stiffness colonoscope makes colonoscopy easier: a randomised controlled trial

BACKGROUND

Colonoscopy remains technically difficult in 10-20% of procedures due to variable colonic anatomy and fixation. The ability to vary endoscope shaft flexibility may help insertion to the caecum.

METHODS

Consecutive patients attending for day case colonoscopy were randomised to examination with either the conventional Olympus CF200HL (200HL) or a new variable stiffness (VS) colonoscope. Intubation time, use of stiffening function, and patient pain scores were compared.

RESULTS

Of 100 cases, 43 were performed with the 200HL and 57 with the VS. Four incomplete examinations occurred with the 200HL (two sigmoid fixations, two benign strictures) and two with the VS (one obstructing cancer, one fixed sigmoid). Changing to the paediatric scope was successful in all but one patient from each group (obstructive lesions). Stiff mode was applied 23 times in 18 patients and was effective in 15 of these. Intubation time was quicker with the VS (median 6 minutes 32 seconds) than with the 200HL (median 10 minutes 35 seconds) (p = 0.0005). Pain scores were less with the VS (median 7) than with the 200HL (median 24) (p = 0.0081).

CONCLUSIONS

The variable stiffness colonoscope combines paediatric shaft characteristics with the ability to stiffen when needed. This instrument significantly reduces intubation time and patient discomfort. Further comparisons should be made with the newest colonoscopes which are less stiff.

Ligand-specific selection of MHC class II-restricted thymocytes in fetal thymic organ culture

Positive and negative selection of thymocytes is determined by the specificity of the TCR and signaling through its associated molecules. We have studied selection of thymocytes bearing a MHC class II-restricted TCR using fetal thymic organ culture. This system allows the addition of peptides to the already diverse panoply of endogenous peptide ligands and is useful for analyzing ligand-specific negative selection of CD4 single positive (CD4SP) thymocytes. The data reveal that the ability of a given ligand to mediate negative selection is related to its dissociation rate from the TCR. We find that negative selection is very sensitive, and only the weakest ligand that we can identify fails to induce negative selection. None of the numerous peptides tested were able to induce an increase in CD4SP thymocytes. In addition, the ligands that induce negative selection of CD4SP thymocytes also cause an increase in numbers of CD8SP thymocytes bearing high levels of the class II-restricted TCR. Although these cells have a cell surface phenotype consistent with positive selection, they most likely represent cells in the process of negative selection. Further analysis reveals that these cells are not induced by these ligands in intact adult animals and that their induction is probably only revealed in the organ culture system.

Role of p53 tumor suppressor gene in the toxicity of TCDD, endrin, naphthalene, and chromium (VI) in liver and brain tissues of mice

It has been postulated that tumor suppressor genes are involved in the cascade of events leading to the toxicity of diverse xenobiotics. Therefore, we have assessed the comparative effects of 0.01, 0.10, and 0.50 median lethal doses (LD(50)) of 2,3,7, 8-tetrachlorodibenzo-p-dioxin (TCDD), endrin, naphthalene, and sodium dichromate (VI) [Cr(VI)] on lipid peroxidation, DNA fragmentation, and enhanced production of superoxide anion (cytochrome c reduction) in liver and brain tissues of p53-deficient and standard C57BL/6NTac mice to determine the role of p53 gene in the toxic manifestations produced by these diverse xenobiotics. In general, p53-deficient mice are more susceptible to all four xenobiotics than C57BL/6NTac mice, with dose-dependent effects being observed. Specifically, at a 0.50 LD(50) dose, naphthalene and Cr(VI) induced the greatest toxicity in the liver tissue of mice, and naphthalene and endrin exhibited the greatest effect in the brain tissue. At this dose, TCDD, endrin, naphthalene, and Cr(VI) induced 2.3- to 3.7-fold higher increases in hepatic lipid peroxidation and 1.8- to 3.0-fold higher increases in brain lipid peroxidation in p53-deficient mice than in C57BL/6NTac mice. At a 0. 10 LD(50) dose, TCDD, endrin, naphthalene, and Cr(VI) induced 1.3- to 1.8-fold higher increases in hepatic lipid peroxidation and 1.4- to 1.9-fold higher increases in brain lipid peroxidation in p53-deficient mice than in C57BL/6NTac mice. Similar results were observed with respect to DNA fragmentation and cytochrome c reduction (superoxide anion production). For example, at the 0.10 LD(50) dose, the four xenobiotics induced increases of 1.6- to 3. 0-fold and 1.5- to 2.1-fold in brain and liver DNA fragmentation, respectively, and increases of 1.5- to 2.3-fold and 1.4- to 2.5-fold in brain and liver cytochrome c reduction (superoxide anion production), respectively, in p53-deficient mice compared with control C57BL/6NTac mice. These results suggest that the p53 tumor suppressor gene may play a role in the toxicity of structurally diverse xenobiotics.

The orientation discrimination deficit in strabismic amblyopia depends upon stimulus bandwidth

We show that the previously reported orientation deficit in amblyopia (Skottun, B. C., Bradley, A., & Freeman, R. D. (1986). Orientation discrimination in amblyopia. Investigative Ophthalmology and Visual Science, 30, 532-537) also occurs for arrays of randomly positioned Gabor micropatterns for which explanations based on either neural disarray or local neural interactions would not hold. Furthermore, when using Gabors, we show that the deficit varies with the spatial frequency and orientational bandwidth of the stimuli used to measure it. We discuss two competing explanations for this, one based on a broader underlying detector bandwidth in amblyopia (both orientation and spatial frequency) and the other based on a selective deficit of first-order, as opposed to second-order orientation processing in strabismic amblyopia. Our results favour the latter interpretation.

Effects of sire growth potential, growing-finishing strategy, and time on feed on performance, composition, and efficiency of steers

Beef production systems that increase use of unharvested forages and use animals with greater potential for gain affect age and size of animals placed on a finishing regimen. This experiment was conducted to evaluate effects of genetic potential for gain, age at the start of a finishing period, and time on feed on composition, quantity, and quality of beef produced and efficiency of production during finishing. Crossbred cows were bred by AI to Charolais or Line 1 Hereford bulls that represented potentially high (HG) or moderate growth (MG) rates, respectively, to produce spring- or fall-born calves. Steer calves from these matings were placed on an individually fed finishing diet at three ages (A). Spring-born steers were started at 6 or 18 mo of age (A6 and A18), and fall-born steers were started at 12 mo of age (A12). Slaughter times (T) were at 0, 90, 180, and 270 d for A6; 68, 136, and 204 d for A12; and 0, 45, 90, and 135 d for A18. Data collected on each animal included feed intake, growth, chemical composition of the complete body and carcass, and quantitative and qualitative assessment of the meat produced. Four steers of each sire group were slaughtered in each of the 11 A-T treatment groups, and the experiment was repeated for 2 yr in the A12 groups and 3 yr in the A6 and A18 groups (n = 237). Steers sired by HG bulls were larger and produced larger carcasses and more carcass protein than MG-sired steers (S, P < .05 or .01). Steers sired by MG bulls were fatter, had higher quality grades, and accumulated fat at a faster rate than HG-sired steers, and this effect was greater in older steers (G and GA, P < .05 or .01). Sire growth potential did not affect gain, intake, live weight efficiency, tenderness, or taste panel scores (P > .2). Steers sired by HG bulls were more efficient at producing carcass weight and carcass protein at A12 and A18 than were MG-sired steers. At the end of the finishing period, older (A18), HG-sired steers were too large with insufficient fat by current industry standards, and younger (A6), MG-sired steers were too small. Our conclusions are that both HG- and MG-sired steers can produce acceptable carcasses for current market standards with comparable efficiencies of live-weight gain, but the growing and finishing strategy must be adapted to the genotype.