Deep Learning-Based Software Improves Clinicians' Detection Sensitivity of Aneurysms on Brain TOF-MRA

BACKGROUND AND PURPOSE

The detection of cerebral aneurysms on MRA is a challenging task. Recent studies have used deep learning-based software for automated detection of aneurysms on MRA and have reported high performance. The purpose of this study was to evaluate the incremental value of using deep learning-based software for the detection of aneurysms on MRA by 2 radiologists, a neurosurgeon, and a neurologist.

MATERIALS AND METHODS

TOF-MRA examinations of intracranial aneurysms were retrospectively extracted. Four physicians interpreted the MRA blindly. After a washout period, they interpreted MRA again using the software. Sensitivity and specificity per patient, sensitivity per lesion, and the number of false-positives per case were measured. Diagnostic performances, including subgroup analysis of lesions, were compared. Logistic regression with a generalized estimating equation was used.

RESULTS

A total of 332 patients were evaluated; 135 patients had positive findings with 169 lesions. With software assistance, patient-based sensitivity was statistically improved after the washout period (73.5% versus 86.5%, P < .001). The neurosurgeon and neurologist showed a significant increase in patient-based sensitivity with software assistance (74.8% versus 85.2%, P = .03, and 56.3% versus 84.4%, P < .001, respectively), while the number of false-positive cases did not increase significantly (23 versus 30, P = .20, and 22 versus 24, P = .75, respectively).

CONCLUSIONS

Software-aided reading showed significant incremental value in the sensitivity of clinicians in the detection of aneurysms on MRA without a significant increase in false-positive findings, especially for the neurosurgeon and neurologist. Software-aided reading showed equivocal value for the radiologist.

Disrupted Functional and Structural Connectivity in Angelman Syndrome

BACKGROUND AND PURPOSE

This work investigated alterations in functional connectivity (FC) and associated structures in patients with Angelman syndrome (AS) by using integrated quantitative imaging analysis and connectivity measures.

MATERIALS AND METHODS

We obtained 3T brain MR imaging, including resting-state functional MR imaging, diffusion tensor imaging, and 3D T1-weighted imaging from children with AS (n = 14) and age- and sex-matched controls (n = 28). The brains of patients with AS were analyzed by measuring FC, white matter microstructural analysis, cortical thickness, and brain volumes; these were compared with brains of controls.

RESULTS

Interregional FC analysis revealed significantly reduced intra- and interhemispheric FC, especially in the basal ganglia and thalamus, in patients with AS. Significant reductions in fractional anisotropy were found in the corpus callosum, cingulum, posterior limb of the internal capsules, and arcuate fasciculus in patients with AS. Quantitative structural analysis also showed gray matter volume loss of the basal ganglia and diffuse WM volume reduction in AS compared with the control group.

CONCLUSIONS

This integrated quantitative MR imaging analysis demonstrated poor functional and structural connectivity, as well as brain volume reduction, in children with AS, which may explain the motor and language dysfunction observed in this well-characterized neurobehavioral phenotype.

miR-125b transcriptionally increased by Nrf2 inhibits AhR repressor, which protects kidney from cisplatin-induced injury

MicroRNAs (miRNAs) have a role in the cellular defense mechanism. Nuclear factor erythroid-2-related factor 2 (Nrf2) increases antioxidant enzyme capacity. However, miRNA transcriptionally controlled by Nrf2 had been uncharacterized. Here we report that miR-125b is transactivated by Nrf2 and inhibits aryl hydrocarbon receptor (AhR) repressor (AhRR). Bioinformatic approaches enabled us to extract six candidate miRNAs. Of them, only miR-125b was increased in the kidney of mice treated with oltipraz. Nrf2 overexpression enhanced primary, precursor and mature miR-125b levels. Functional assays revealed MIR125B1 is a bona fide target gene of Nrf2. Oltipraz treatment protected the kidney from cisplatin toxicity with increase of miR-125b. Consistently, Nrf2 knockout abrogated an adaptive increase of miR-125b elicited by cisplatin, augmenting kidney injury. An integrative network of miRNA and messenger RNA changes enabled us to predict miR-125b as an inhibitor of AhRR for the control of AhR activity and cell survival. In our molecular study, miR-125b inhibited AhRR and thereby activated AhR, leading to the induction of mdm2. Consistently, p53 activation by cisplatin was diminished by either miR-125b or oltipraz treatment. The results of experiments using miR-125b mimic or small interfering RNA of AhRR verified the role of miR-125b in AhRR regulation for kidney protection. In conclusion, miR-125b is transcriptionally activated by Nrf2 and serves as an inhibitor of AhRR, which contributes to protecting kidney from acute injury.

Comprehensive genomic meta-analysis identifies intra-tumoural stroma as a predictor of survival in patients with gastric cancer

OBJECTIVE

Gastric adenocarcinoma (gastric cancer, GC) is a major cause of global cancer mortality. Identifying molecular programmes contributing to GC patient survival may improve our understanding of GC pathogenesis, highlight new prognostic factors and reveal novel therapeutic targets. The authors aimed to produce a comprehensive inventory of gene expression programmes expressed in primary GCs, and to identify those expression programmes significantly associated with patient survival.

DESIGN

Using a network-modelling approach, the authors performed a large-scale meta-analysis of GC transcriptome data integrating 940 gastric transcriptomes from multiple independent patient cohorts. The authors analysed a training set of 428 GCs and 163 non-malignant gastric samples, and a validation set of 288 GCs and 61 non-malignant gastric samples.

RESULTS

The authors identified 178 gene expression programmes ('modules') expressed in primary GCs, which were associated with distinct biological processes, chromosomal location patterns, cis-regulatory motifs and clinicopathological parameters. Expression of a transforming growth factor β (TGF-β) signalling associated 'super-module' of stroma-related genes consistently predicted patient survival in multiple GC validation cohorts. The proportion of intra-tumoural stroma, quantified by morphometry in tissue sections from gastrectomy specimens, was also significantly associated with stromal super-module expression and GC patient survival.

CONCLUSION

Stromal gene expression predicts GC patient survival in multiple independent cohorts, and may be closely related to the intra-tumoural stroma proportion, a specific morphological GC phenotype. These findings suggest that therapeutic approaches targeting the GC stroma may merit evaluation.

Thermal characterization of polyamide 11/nanographene platelet nanocomposites

The objective of this study is to evaluate thermal properties of polyamide 11 (PA11)/nanographene platelet (NGP) nanocomposites. Samples were prepared using 1 wt%, 3 wt%, and 5 wt% of NGPs. Isopropyl alcohol (IPA) was used as a solvent to assist in dispersion of the NGPs within the PA11 powder. The NGPs were hand mixed evenly into the PA11 powder using a wooden dowel. Morphological characterization of the PA11/NGP nanocomposite was conducted using scanning electron microscopy. Thermal characterization of nanocomposites includes thermogravimetric analysis, differential scanning calorimetry and thermomechanical analysis. Results indicate that the addition of NGPs shows an initial increase in thermal stability and crystallization temperature (T(c)) along with a decrease in glass transition temperature (T(g)) and no improvement in coefficient of thermal expansion (alpha). These results are attributed to improved interfacial adhesion between NGPs and PA11, restricting polymer chain mobility.

Suppressing harmonic vibrations of a miniature cryogenic cooler using an adaptive tunable vibration absorber based on magneto-rheological elastomers

This paper presents dynamic performances of an adaptive tunable vibration absorber (TVA) designed to suppress the main harmonic disturbance of a miniature linear cryogenic cooler, which is being used in space applications such as an observation satellite. The adaptive TVA employs a magneto-rheological elastomer (MRE) for a variable stiffness element. This study first investigates the shear modulus change of MRE samples with respect to the magnetic flux density, which varies through the alignment of particle chains. The MRE with the maximal shear modulus change is mounted for the TVA on a prototype cooler, which emulates the characteristics of a miniature cryogenic cooler. Using the test setup, a series of vibration tests are performed to evaluate the performance and efficacy of the MRE TVA and its re-tuning ability. The experimental results show that the MRE TVA is able to robustly suppress the vibration of the cooler even when the frequency of resonant vibration is changed up to 87% from its initial frequency.

A dual-design expandable colorectal stent for malignant colorectal obstruction: results of a multicenter study

BACKGROUND AND STUDY AIMS

It is known that metal stent placement is safe, easy, and effective for the treatment of malignant colorectal obstruction, but these stents are associated with delayed complications of tumor ingrowth and stent migration. The aim of this study was to prospectively investigate the technical feasibility, clinical effectiveness, and safety of a dual-design colorectal stent (consisting of an outer stent and an inner bare nitinol stent) in patients with malignant colorectal obstruction.

PATIENTS AND METHODS

Placement of the dual stent using a 4.5-mm stent delivery system was attempted in 151 patients with malignant colorectal obstruction, either before surgery (n = 50) or for palliation (n = 101). Multivariate logistic regression analysis was used to identify risk factors associated with complications.

RESULTS

Stent placement was technically successful in 145/151 patients (96%). Of the patients who had a technically successful placement, bowel obstruction resolved within 2 days after stent placement in 48/50 (96%) of the patients in the bridge-to-surgery group and in 87/95 (92%) of the patients in the palliative group. Perforation occurred in 16 patients, incomplete stent expansion in eight patients, stent migration in four patients, tumor overgrowth in five patients, severe rectal pain in five patients, and bleeding in eight patients. Complete obstruction was the only significant risk factor for perforation (odds ratio 6.88, 95% CI 2.04-23.17, P = 0.002). In the palliative group, the median survival was 152.0 days and the mean survival was 263.8 days.

CONCLUSIONS

The dual stent with a 4.5-mm stent delivery system is easy to insert, safe, and reasonably effective for the palliative treatment of malignant colorectal obstruction. However, a great deal of care is needed in its deployment because of the high rate of perforation.

Quantifying the dispersion of mixture microstructures

A general method to quantify the inclusion dispersion of mixture microstructures has been developed. The dispersion quantity, D, is defined as the probability of inclusion particle free-path spacing falling into a certain range of the mean spacing mu, according to the particle spacing data frequency distribution. Two quantities, D(0.1) and D(0.2), are proposed, which are the probabilities of the particle free-path spacing falling into the ranges of mu+/- 0.1 mu and mu+/- 0.2 mu, respectively. Both normal and lognormal distributions are discussed, and in both cases, the quantities D(0.1) and D(0.2) are specified as monotonous increasing functions of mu/sigma, where mu and sigma; are the mean particle free-path spacing and standard deviation, respectively. Examples of composite are presented to quantify the dispersion of foreign reinforcements based on the proposed method.

Effect of AP-1 decoy using hemagglutinating virus of Japan-liposome on the intimal hyperplasia of the autogenous vein graft in mongrel dogs

Intimal hyperplasia is the leading cause of late vein graft failure. Smooth muscle cell proliferation and migration is the underlying mechanism. Pharmacological approaches to prolong vein graft patency have produced limited results. AP-1 proteins play a role in the expression of many genes involved in cellular proliferation and cell cycle progression. Previously we reported inhibition of vascular smooth muscle cell migration, proliferation, and intimal hyperplasia in the balloon-injured rat carotid artery using an AP-1 decoy with HVJ-liposomes. In this report, we evaluated the effect of the AP-1 decoy on intimal hyperplasia in a large animal model. The jugular vein was transfected with hemagglutinating virus of Japan-liposomes containing the AP-1 decoy or scrambled oligonucleotides. An interposition graft was performed with the pretreated jugular vein between the transected femoral arteries. The graft was harvested at 16 weeks after the procedure. The intimal area was compared: the intimal area of the AP-1 decoy-treated versus control group was 47.3 +/- 15.2 versus 102.3 +/- 15.9 (P < .05), respectively. In conclusion, AP-1 decoy using HVJ-liposomes effectively prevented intimal hyperplasia of an autogenous vein graft in mongrel dogs.

Relationship between sonographic and pathologic findings in epidermal inclusion cysts

PURPOSE

We evaluated the sonographic findings in epidermal inclusion cysts and related them to the pathologic findings.

METHODS

We retrospectively reviewed the sonograms and pathology specimens of 24 patients with pathologically proven epidermal inclusion cysts. We evaluated the lesions for shape, size, internal echogenicity, posterior sound enhancement, and presence of color Doppler signals. We classified the masses into 5 sonographic types according to their internal echogenicity. The relationship between the sonographic types and the pathologic findings was examined.

RESULTS

The masses were ovoid or spherical in 17 cases (71%), lobulated in 5 (21%), and tubular in 2 (8%). The longest diameter ranged from 1 to 6 cm (mean, 3.1 cm). Twenty-three cases (96%) were associated with posterior sound enhancement. Color Doppler signals were absent in 20 cases, but some vascularity was noted in 4 ruptured epidermal cysts, in areas of granulation tissue. The most common sonographic type was a hypoechoic lesion with scattered echogenic reflectors (10 cases). Sonographic findings were related to the lamellation of keratin debris and the granulation tissue secondary to rupture. Most cases with a lobulated configuration (4 of 5) or color Doppler signals (4 of 4) were ruptured cysts.

CONCLUSIONS

Epidermal inclusion cysts most often appeared sonographically as a hypoechoic mass containing variable echogenic foci without color Doppler signals. Ruptured epidermal cysts, however, may have lobulated contours and show color Doppler signals, mimicking a solid mass.

Detection of circulating tumor cells in patients with gastrointestinal tract cancer using RT-PCR and its clinical implications

To investigate the relationship between the presence of circulating tumor cells in different stages of gastrointestinal tract cancer and the subsequent relapse or distant metastasis, circulating levels of CEA mRNA was serially examined at an interval of 10.6+/-4.5 or 13.7+/-3.0 months in gastric or colorectal cancer patients, respectively. CEA mRNA was measured by means of RT-PCR amplification as an indicator for micrometastatic malignant cells. Seven of twenty-nine respectable gastric cancer patients (24.1%) [EGC: 2/9 (22.2%), AGC IIIa: 1/5 (20.0%), AGC IIIb: 4/15 (26.6%)] were positive for CEA mRNA on the initial test and 10 of 29 patients (34.4%) [EGC: 2/ 9 (22.2%), AGC IIIa: 1/5 (20.0%), AGC IIIb: 7/15 (46.7%)] were positive on a follow-up test. Only in AGC IIIb, the positive rate for CEA mRNA increased about twice and 6 of 7 positive cases (85.7%) relapsed within 2.6+/-2.4 months after the follow-up test. In colorectal cancer, 4 of 19 patients (21.1%) [B2: 1/6 (16.7%), C2: 3/13 (23.0%)] were positive on the initial test and 10 of 19 patients (52.6%) [B2: 4/6 (66.7%), C2: 6/13 (46.2%)] were positive on a follow-up test showing an increase in positive rates during a follow-up, however, no significant correlation between CEA mRNA positivity and subsequent relapse was demonstrated. These results suggest that an early tumor cell dissemination may occur in gastrointestinal tract cancer without subsequent relapse, however, the serial regular examination of CEA mRNA level may contribute to predicting a subsequent relapse in AGC IIIb in gastric cancer.

Bacterial biofilm formation under microgravity conditions

Although biofilm formation is widely documented on Earth, it has not been demonstrated in the absence of gravity. To explore this possibility, Pseudomonas aeruginosa, suspended in sterile buffer, was flown in a commercial payload on space shuttle flight STS-95. During earth orbit, biofilm formation was induced by exposing the bacteria to sterile media through a 0.2-microm (pore size) polycarbonate membrane. Examination of these membranes by confocal microscopy revealed biofilms to be present and that these biofilms could persist in spite of vigorous agitation. These results represent the first report of biofilm formation under microgravity conditions.

The malonate decarboxylase operon of Acinetobacter calcoaceticus KCCM 40902 is regulated by malonate and the transcriptional repressor MdcY

A regulatory gene-like open reading frame oriented oppositely to mdcL, coined mdcY, was found upstream from the structural genes of the mdcLMACDEGBH operon in Acinetobacter calcoaceticus KCCM 40902. To elucidate the function of this gene, mdcY was expressed in Escherichia coli, and the MdcY protein was purified to homogeneity. Its DNA binding activity and binding site were examined by gel retardation and footprinting assays in vitro and by site-directed mutagenesis of the binding sites in vivo. The regulator bound target DNA regardless of the presence of malonate, and the binding site was found centered at -65 relative to the mdcL transcriptional start site and contains a 12-bp palindromic structure (5'-ATTGTA/TACAAT-3'). Using a promoter fusion to the reporter gene luc, we found that the promoter P(mdcY) is negatively regulated by MdcY independent of malonate. However, the promoter P(mdcL) recovered its activity in the presence of malonate. When mdcY was introduced into A. calcoaceticus KCCM 40902 in which the gene is inactivated by an IS3 family element, malonate decarboxylase was significantly repressed in cultures growing in acetate, succinate, or Luria-Bertani medium. However, in cells growing in malonate, malonate decarboxylase was induced, indicating that MdcY is a transcriptional repressor and that malonate or a product resulting from malonate metabolism should be the intracellular inducer of the mdc operon.

Functional evaluation of the genes involved in malonate decarboxylation by Acinetobacter calcoaceticus

The genomic locus containing the potential repressor gene mdcY (inactivated by a putative IS3 element) and the mdcLMACDEGBH genes from Acinetobacter calcoaceticus was cloned and sequenced. In order to evaluate the biochemical function of the protein components, the genes were expressed independently and their activities predicted by database analysis. The mdcA gene product, the alpha subunit, was found to be malonate/acetyl-CoA transferase and the mdcD gene product, the beta subunit, was found to be malonyl-CoA decarboxylase. The mdcE gene product, the gamma subunit, may play a role in subunit interaction to form a stable complex or as a codecarboxylase. The mdcC gene product, the delta subunit, was an acyl-carrier protein, which has a unique CoA-like prosthetic group. Various combinations of malonate decarboxylase subunits allowed us to estimate their contribution to malonyl-CoA decarboxylase activity. The prosthetic group was identified as carboxymethylated 2'-(5"-phosphoribosyl)-3'-dephospho-CoA by mass spectrometry. The mdcH gene product was determined to have malonyl-CoA/dephospho-CoA acyltransferase activity. Using database analysis mdcLM, mdcG, mdcB and mdcI were estimated to be the genes for a malonate transporter, a holo-acyl carrier synthase, protein for the formation of precursor of the prosthetic group and a regulatory protein, respectively. From the data shown above we propose a metabolic pathway for malonate in A. calcoaceticus.

Stereochemical course of biotin-independent malonate decarboxylase catalysis

Malonate decarboxylases, which catalyze the conversion of malonate to acetate, can be classified into biotin-dependent and biotin-independent enzymes. In order to reveal the stereochemical course of the reactions catalyzed by the biotin-independent enzymes from Acinetobacter calcoaceticus and Pseudomonas fluorescens, a chiral substrate, malonate carrying (13)C in one carboxyl group and (3)H at one of the methylene positions, was prepared and used in the reactions catalyzed by these two enzymes. The decarboxylation of (R)-[1-(13)C(1), 2-(3)H]malonate in (2)H(2)O gave a pseudo-racemate of chiral acetate which was converted via acetyl-CoA into malate with malate synthase. From the relative proportions of the isotopomers of malate present, determined by (3)H NMR analysis, it was concluded that in the decarboxylation of malonate by these two biotin-independent enzymes COOH is replaced by H with retention of configuration. The same stereochemical outcome had been previously observed for the reaction catalyzed by the biotin-dependent malonate decarboxylase from Malonomonas rubra (J. Micklefield et al. J. Am. Chem. Soc. 117, 1153-1154, 1995).

Recombinant human growth hormone and Gitelman's syndrome

Gitelman's syndrome is a primary renal tubular disorder with hypokalemic metabolic alkalosis, hypocalciuria, and magnesium deficiency. Short stature is one of clinical manifestations in children. The pathogenesis of short stature in Gitelman's syndrome is not known. To evaluate whether growth hormone (GH) is deficient and whether recombinant human GH (rhGH) improves growth rate, rhGH therapy was tried in a child with Gitelman's syndrome. Both height and body weight were less than the third percentile. Laboratory and radiologic findings suggested GH deficiency. During the first 6 months, rhGH therapy with potassium supplement markedly elevated growth rate from 3.8 cm/yr to 12.0 cm/yr. After cessation of rhGH, height increment markedly decreased to the pretreatment level of 3.6 cm/yr during the second 6 months. Additionally, hypomagnesemia was corrected after rhGH therapy. Accordingly, GH deficiency may contribute to short stature in children with Gitelman's syndrome, and rhGH therapy would be an excellent adjunctive treatment for short children with Gitelman's syndrome whose condition is resistant to conventional therapies in terms of growth.

Ileal obstruction caused by idiopathic sclerosing encapsulating peritonitis

A 26-year-old woman presented with epigastric pain, vomiting, and a palpable mass in the right lower abdomen. Ultrasonography showed a high echogenic mass associated with a small amount of ascites in the right lower abdomen. Computed tomography demonstrated entrapped ileal loops within a thin-walled fibrous capsule. A thin fibrous sac encasing the terminal ileum was detected on laparotomy and confirmed as idiopathic sclerosing encapsulating peritonitis.

Cloning and sequencing of genes encoding malonate decarboxylase in Acinetobacter calcoaceticus

Malonate decarboxylase from Acinetobacter calcoaceticus was isolated and characterized (Kim, Y.S., Byun, H.S., J. Biol. Chem. 269 (1994) 29636-29641), and its subunits were reanalyzed recently to be alpha, beta, gamma, and delta. The genes for the subunits, MdcA (548 a.a.), B (295 a.a.), C (238 a.a.), and D (102 a.a.), of the enzyme have been cloned by using oligonucleotide primers deduced from amino acid sequences of peptides isolated from the purified enzyme, and sequenced to be clustered in an operon in the order of A-D-B-C. The operon was found to encode more genes than mdcABCD. The Escherichia coli, transformed with the vector containing the insert mdcADBC and about 1.7 kb of an upstream region, expressed the four subunits of the enzyme but the proteins did not show enzyme activity. It indicates that, like the enzymes from Malonomonas rubra and Klebsiella pneumoniae, more genes are needed for the formation of the functional malonate decarboxylase.

Synthesis of integral transform solutions for the reconstruction of particle-size distributions from forward-scattered light

Five integral transform solutions to the Fredholm integral equation that describes the forward-scattering properties of the distributions of spherical particles in the Fraunhofer diffraction regime have been studied. We have systematically reformulated the family of solutions, including four derivations by three other research groups and one developed as part of this work, using a standardized notation. This synthesis elucidates the mathematical interrelationships and fosters an understanding of the inversion performance of the five solutions. Finally a series of numerical experiments was carried out to demonstrate the relative performance of the techniques when applied to identical sets of simulated forward-scattering signatures.

The role of adenylyltransferase and uridylyltransferase in the regulation of glutamine synthetase in Escherichia coli

The regulation of GS activity involves two nucleotidylation cycles, the uridylylation cycle of PII and the adenylylation cycle of GS, which are catalyzed by two converter enzymes, uridylyltransferase and adenylyltransferase, respectively. The converter enzymes sense the fluctuation in the availability of nitrogen and accordingly regulate the activity of GS. On the other hand, the posttranslational modification of GS is tightly coupled to the transcriptional regulation of the glnA gene by unmodified PII protein acting as a repressor in the GS synthesis. Therefore, metabolic signals perceived by uridylyltransferase are transmitted through PII to two different levels of the regulation, namely, the posttranslational level and transcriptional level. In order to study the converter enzymes which exist in extremely low concentration, the glnD and glnE genes were cloned into a plasmid vector carrying the strong, regulatable lambda phage promoter. In this way, uridylyltransferase and adenylyltransferase were overproduced to the levels approaching 800- and 500-fold, respectively. The recombinant DNA technology also enabled us to examine the transcriptional regulation of the glnD and glnE genes. The expression of these genes was slightly repressed under nitrogen-excess conditions and the repressions were more pronounced under excess nitrogen plus carbon-limiting conditions. It was found that variations of the concentration of uridylyltransferase and adenylyltransferase also affect the rate of GS synthesis. Studies with strains harboring a multicopy plasmid, pglnD or pglnE, indicate that the elevated synthesis of the converter enzymes causes the enhancement of GS synthesis. In addition, the absence of one of the converter enzymes reduces the expression of the glnA gene. The parallel relationship between the converter enzymes and GS seems to derive from the binding capacity of the converter enzymes for the unbound PII, which is a repressor for the glnA gene. Therefore, it is believed that the metabolic regulation of the glnD and glnE genes is ultimately linked to the expression of the glnA operon.

Hypertension and narrowing of the renal arteries in infancy

The clinical histories of two infants who had severe hypertension and stenoses of the renal arteries are reported. In both children blood pressure fell significantly after surgical correction of renal ischemia. However, both infants had persistent mild hypertension for several months after surgical treatment. Similar results were found in other infants with renovascular hypertension, reported previously (11 cases). The mortality rate in this total group of 13 infants reviewed was high if renal ischemia was not corrected surgically (4/4). The reason why some infants have persistent hypertension after apparently adequate surgical relief of renal ischemia is not known.