Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial

Importance

The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy.

Objective

To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors.

Design, Setting, and Participants

This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022.

Exposure

Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals.

Main Outcomes and Measures

Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year.

Results

A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25).

Conclusions and Relevance

In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

Efficacy of Prophylactic Hemoclips in Prevention of Delayed Post-Polypectomy Bleeding in Patients With Large Colonic Polyps

BACKGROUND & AIMS

The efficacy of prophylactic placement of hemoclips to prevent delayed bleeding after removal of large colonic polyps has not been established. We conducted a randomized equivalence study to determine whether prophylactic placement of hemoclips affects incidence of delayed post-polypectomy bleeding (PPB).

METHODS

During elective colonoscopy performed at 4 Veterans Affairs Medical Centers, 1098 patients who had polyps ≥1 cm removed were randomly assigned to groups that received prophylactic hemoclips (n = 547) or no hemoclips (n = 551), from September 2011 through September 2018. Data on PPB (rectal bleeding resulting in hemoglobin decreases ≥2 g/dL, hemodynamic instability, colonoscopy, angiography, or surgery) within 30 days of colonoscopy (called delayed PPB) were collected during telephone interviews or hospital visits 7 and 30 days after colonoscopy. The primary outcome was the incidence of important post-polypectomy bleeding.

RESULTS

Twelve patients in the hemoclip group (2.3%) and 15 patients in the no hemoclip group (2.9%) had important delayed PPB. There were no deaths, and no patients in either group required angiography or surgery. In intention-to-treat analysis, two 1-sided test's lower and upper confidence interval limits were -2.07 and 1.01, indicating that the data approached but did not meet equivalence criteria. On multiple logistic regression analysis, significant predictors of PPB included use of warfarin with bridging, thienopyridines, polyp size, and polyp location, but hemoclip placement did not associate with important delayed PPB.

CONCLUSIONS

In a randomized trial, we found that prophylactic placement of hemoclips after removal of large colon polyps does not affect the proportion of important delayed PPB events, compared with no hemoclip placement. These findings call into question the widespread, expensive practice of routinely placing prophylactic hemoclips after polypectomy. ClinicalTrials.gov ID: NCT01647581.

What Can We Do to Optimize Colonoscopy and How Effective Can We Be?

In the USA, colorectal cancer is the third most common cancer and third leading cause of cancer death among both men and women. Declining rates of colon cancer in the past decade have been attributed in part to screening and removal of precancerous polyps via colonoscopy. Recent emphasis has been placed on measures to increase the quality and effectiveness of colonoscopy. These have been divided into pre-procedure quality metrics (bowel preparation), procedural quality metrics (cecal intubation, withdrawal time, and adenoma detection rate), post-procedure metrics (surveillance interval), and other quality metrics (patient satisfaction and willingness to repeat the procedure). The purpose of this article is to review the data and controversies surrounding each of these and identify ways to optimize the performance of colonoscopy.

Laser guided automated calibrating system for accurate bracket placement

BACKGROUND

The basic premise of preadjusted bracket system is accurate bracket positioning. It is widely recognized that accurate bracket placement is of critical importance in the efficient application of biomechanics and in realizing the full potential of a preadjusted edgewise appliance.

AIM

The purpose of this study was to design a calibrating system to accurately detect a point on a plane as well as to determine the accuracy of the Laser Guided Automated Calibrating (LGAC) System.

MATERIALS AND METHODS

To the lowest order of approximation a plane having two parallel lines is used to verify the accuracy of the system. On prescribing the distance of a point from the line, images of the plane are analyzed from controlled angles, calibrated and the point is identified with a laser marker.

RESULTS

The image was captured and analyzed using MATLAB ver. 7 software (The MathWorks Inc.). Each pixel in the image corresponded to a distance of 1cm/413 (10 mm/413) = 0.0242 mm (L/P). This implies any variations in distance above 0.024 mm can be measured and acted upon, and sets the highest possible accuracy for this system.

CONCLUSION

A new automated system is introduced having an accuracy of 0.024 mm for accurate bracket placement.

Patterns and inferred processes associated with sea turtle strandings in Paraíba State, Northeast Brazil

This study analysed sea turtle strandings on the coast of Paraíba State, Northeastern Brazil, from August 2009 to July 2010. A total of 124 strandings were recorded in this period: green turtle Chelonia mydas (n = 106), hawksbill Eretmochelys imbricata (n = 15), olive ridley Lepidochelys olivacea (n = 2) and loggerhead Caretta caretta (n = 1). Of all turtles for which the Curved Carapace Length (CCL) was measured (n = 122), only 12 individuals (9.7%) were adults. Twenty individuals had synthetic anthropogenic debris in the gastrointestinal tract. Other traces of human interactions were observed in 43 individuals, such as injuries caused by entanglement in fishing lines or nets, collisions with vessels, direct contact with oil spills and lesions caused by sharp or spiked objects. Moreover, in 28.5% of the stranded turtles, the presence of external tumors was noticed, suggestive of fibropapillomatosis and in 9.7%, shark bite marks were observed. Of the 107 individuals that were sexed, 76 were females and 31 were males. Most turtles (72.6%) became stranded during the spring/summer (between October and March). We found evidence of human interactions (injuries) in half of the strandings, but in most cases it was not possible to determine if such interactions were the cause of death. A logistic regression found a significant relationship between CCL, ingestion of debris and lesions caused by sharks or spiked objects. Systematic data collection from stranded sea turtles can provide useful biological information, such as seasonal and spatial patterns in their occurrence and mortality, age structure, sex ratio and diet, as well as possible mortality causes.

Fertilidade de carneiros de raça Saloia com sémen refrigerado ou congelado

Avaliaram-se as fertilidades e coeficientes de variação (CV) de carneiros Saloios após inseminação artificial (IA) por via cervical com sémen refrigerado (SR) ou congelado (SC). Na 1ª experiência avaliou-se o efeito de duas épocas de IA (primavera vs. outono) sobre a fertilidade, utilizando SR (n=5 carneiros) e de duas épocas de congelação de sémen (outono vs. inverno) sobre a fertilidade de ovelhas inseminadas na primavera utilizando SC (n=3 carneiros). Nas outras experiências avaliaram-se as variações da fertilidade de carneiros, independentemente das épocas de IA ou congelação, utilizando SR e SC (2ª experiência: 4 carneiros comuns; 3ª experiência: 16 e 5 carneiros, respectivamente). Não foram observadas diferenças na fertilidade entre épocas de IA ou congelação de sémen. As fertilidades obtidas com SR foram superiores às do SC (2ª experiência: 51,28 vs. 13,65 %; 3ª experiência: 48,51 vs. 13,04 %). Os CV da fertilidade utilizando SC foram superiores aos do SR (2ª experiência: 41,3 % vs. 13,1 %; 3ª experiência: 38,9 vs. 19,5 %). Os carneiros de raça Saloia podem ser utilizados em programas de IA com SR e SC nas épocas do ano estudadas sem diminuição da fertilidade. O SC originou CV para a fertilidade superior sugerindo diferentes susceptibilidades dos carneiros à congelação.

Survival of patients with hepatocellular carcinoma in the San Joaquin Valley: a comparison with California Cancer Registry data

BACKGROUND

Variation in the survival of patients with hepatocellular carcinoma (HCC) is related to racial differences, socioeconomic disparities and treatment options among different populations.

METHODS

A retrospective review of the data from medical records of patients diagnosed with HCC were analyzed at an urban tertiary referral teaching hospital and compared to patients in the California Cancer Registry (CCR) - a participant in the Survival Epidemiology and End Results (SEER)program of the National Cancer Institute (NCI). The main outcome measure was overall survival rates.

RESULTS

160 patients with the diagnosis of HCC (M/F=127/33), mean age 59.7±10 years, 32% white, 49% Hispanic, 12% Asian and 6% African American. Multivariate analysis identified tumor size, model for end-stage liver disease (MELD) score, portal vein invasion and treatment offered as the independent predictors of survival (p <0.05). Survival rates across racial groups were not statistically significant. 5.6% received curative treatments (orthotopic liver transplantation, resection, rediofrequency ablation) (median survival 69 months), 34.4% received nonsurgical treatments (trans-arterial chemoembolization, systemic chemotherapy) (median survival 9 months), while 60% received palliative or no treatment (median survival 3 months) (p <0.001).

CONCLUSION

There was decreased survival in our patient population with HCC beyond 2 years. 60% of our study population received only palliative or no treatment suggesting a possible lack of awareness of chronic liver disease as well as access to appropriate surveillance modalities. Ethnic disparities such as Hispanic predominance in this study in contrast to the CCR/SEER database may have been a contributing factor for poorer outcome.

Increased annexin-V and decreased TNF-α serum levels in chronic-medicated patients with schizophrenia

Schizophrenia (SZ) is a chronic severe mental disorder. Increased inflammatory processes have been shown in acute and chronic SZ. Apoptotic processes may alter the neuronal network and are involved in the pathogenesis of several neurodegenerative diseases, such as SZ. Annexin-V seems to have a role on inhibition of pro-inflammatory activities during apoptosis. Tumor necrosis factor (TNF-alpha) is a cytokine involved in systemic inflammation and is a member of a group of cytokines which stimulate acute phase reactions. A chronic immune activation in SZ has been shown. The aim of this study was to compare annexin-V and TNF-alpha serum levels in chronic medicated patients with SZ and healthy controls. Thirty-eight outpatients from the HCPA Schizophrenia Program and 38 healthy controls were enrolled to this study protocol. Annexin-V and TNF-alpha serum levels were measured with ELISA. Serum annexin-V levels were significantly higher in patients with SZ than in controls (p<0.001) and TNF-alpha significantly lower (p<0.001). The present result of increased annexin-V and decreased serum levels of TNF-alpha compared to controls may be a result of the stabilization phase of psychosis and a reduction in metabolic brain aggression. In this complex picture, increased levels of annexin-V and decreased levels of TNF-alpha in our sample would be explained by illness stability and chronic treatment. Our findings support the hypothesis of a state dependant process of inflammation in SZ. Further prospective studies to clarify the findings described in this paper are needed.

Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts

OBJECTIVES

The objective of this study was to evaluate and validate cyst fluid carcinoembyronic antigen (CEA) and amylase in differentiating (1) nonmucinous from mucinous pancreatic cystic lesions (PCLs), (2) benign mucinous from malignant mucinous PCLs, and (3) pseudocysts from nonpseudocysts (amylase only).

METHODS

A retrospective analysis of patients with histologically confirmed PCLs from February 1996 to April 2007 was performed. Cyst fluid CEA (n=124) and/or amylase (n=91) were measured and correlated to cyst type.

RESULTS

Carcinoembyronic antigen levels (P=0.0001), but not amylase, were higher in mucinous versus nonmucinous cysts. The sensitivity, specificity, and diagnostic accuracy of CEA 200 ng/mL or greater for the diagnosis of mucinous PCLs were 60%, 93%, and 72%, respectively. Carcinoembyronic antigen levels did not differentiate benign from malignant mucinous cysts. Whereas amylase levels were higher in pseudocysts than nonpseudocysts (P=0.009), 54% of noninflammatory PCLs had a level greater than 250 IU/L, including mucinous cystic neoplasms (median, 6800 IU/L; interquartile range, 70-25,295 IU/L). Malignant mucinous cysts had lower amylase levels than benign mucinous cysts (P=0.0008).

CONCLUSIONS

Cyst fluid CEA and amylase levels are suggestive but not diagnostic in differentiating PCLs. Unlike CEA, amylase may help differentiate benign from malignant mucinous cysts. Novel biomarkers are needed.

The relationship of various arch forms and cortical bone thickness

OBJECTIVE

Implants are being used in orthodontics as a reliable mode of anchorage. Among other factors, the cortical bone thickness plays a major role in determining the stability of these implants. The objective of this study was to study the relationship of various arch forms and the cortical bone thickness and to determine if the cortical bone thickness varies between various arch forms. This would help to determine the ideal length of an implant for a particular arch form.

MATERIALS AND METHODS

A cross sectional tomograph was obtained from 30 patients. Based on arch forms the patients' tomographs were equally divided into three basic square, tapered and ovoid categories, each consisting of 10 patients. Consequently, their buccal and lingual cortical plate thicknesses were measured.

RESULTS

The results showed that there was a statistically significant difference between the three arch forms, in which the square arch form had the greatest cortical bone thickness among the three arch forms.

CONCLUSION

Patients having a tapered arch form may require implants with greater length than patients having a square or an ovoid arch form. Since the availability of the cortical bone in square arch patients is greater, there is more stability for the implants in these cases; therefore, implants with a shorter length may be used in these cases.

Defining occupational and consumer exposure limits for enzyme protein respiratory allergens under REACH

A wide range of substances have been recognized as sensitizing, either to the skin and/or to the respiratory tract. Many of these are useful materials, so to ensure that they can be used safely it is necessary to characterize the hazards and establish appropriate exposure limits. Under new EU legislation (REACH), there is a requirement to define a derived no effect level (DNEL). Where a DNEL cannot be established, e.g. for sensitizing substances, then a derived minimal effect level (DMEL) is recommended. For the bacterial and fungal enzymes which are well recognized respiratory sensitizers and have widespread use industrially as well as in a range of consumer products, a DMEL can be established by thorough retrospective review of occupational and consumer experience. In particular, setting the validated employee medical surveillance data against exposure records generated over an extended period of time is vital in informing the occupational DMEL. This experience shows that a long established limit of 60 ng/m(3) for pure enzyme protein has been a successful starting point for the definition of occupational health limits for sensitization in the detergent industry. Application to this of adjustment factors has limited sensitization induction, avoided any meaningful risk of the elicitation of symptoms with known enzymes and provided an appropriate level of security for new enzymes whose potency has not been fully characterized. For example, in the detergent industry, this has led to general use of occupational exposure limits 3-10 times lower than the 60 ng/m(3) starting point. In contrast, consumer exposure limits vary because the types of exposure themselves cover a wide range. The highest levels shown to be safe in use, 15 ng/m(3), are associated with laundry trigger sprays, but very much lower levels (e.g. 0.01 ng/m(3)) are commonly associated with other types of safe exposure. Consumer limits typically will lie between these values and depend on the actual exposure associated with product use.

Recent advances in liver transplantation for the practicing gastroenterologist

Liver transplantation is the definitive therapy for end-stage liver disease of various etiologies as well as acute liver failure and early-stage hepatocellular carcinoma. The Model for End-Stage Liver Disease (MELD) score is essential for organ allocation in the United States. Addition of the serum sodium level to the MELD score is a recent development that helps prognosticate cirrhotic patients with hyponatremia, a commonly seen manifestation of end-stage liver disease. The currently used Milan criteria for hepatocellular carcinoma have been expanded with some success at certain transplant centers, and tumor downstaging prior to transplant is being used more frequently. The tremendous shortage of donor organs continues to be the major limitation of this life-saving therapy. This has led to the use of extended-criteria donors, donation after cardiac death, split liver grafts, and live donor liver transplants. Renal dysfunction following liver transplant requires close monitoring and dose adjustments of immunosuppressive medications. Although most liver transplants in the United States are for chronic hepatitis C infection and its sequelae, hepatitis C virus recurrence is a common problem that is challenging to treat in the post-transplant population.

Origin and characterisation of preovulatory follicles of hyperstimulated oestrous cycles in goats

The origin and evolution of preovulatory follicles (POF) in 9 hyperstimulated (polyovulatory) Serrana goats were characterised. After oestrus synchronisation and detection, transrectal ovarian ultrasonography was performed daily during two complete oestrous cycles. Blood samples were taken every 4 h during 24 h after oestrus detection for preovulatory LH peak and twice a week for plasma progesterone determinations. The interovulatory interval of 14 oestrous cycles with double ovulations was 21.1 +/- 0.3 days. The onset of ovulatory follicular wave occurred 4 days (-3.9 +/- 0.3 days, n = 14) prior to the ovulation day (day 0) with a POF size of 6.9 +/- 0.2 mm (n = 28). In goats with ovulations in both ovaries (78.6%), the emergence of the first POF occurred earlier (-4.1 +/- 0.3 days) than the second POF (-3.3 +/- 0.2 days, n = 11, P < 0.05). No differences in the total number of follicles > or = 2 mm were found between the day of POF emergence (4.3 +/- 0.4) and the day before ovulation (3.5 +/- 0.3, P > 0.05). These results showed the existence of a delay between the emergence of first and second POF and suggest a weak dominance effect in goats with double ovulations.

Assessment of luteal function by ultrasonographic appearance and measurement of corpora lutea in goats

In order to characterize the evolution pattern of the corpora lutea (CL) and to compare luteal function with their ultrasonographic appearance, 37 estrous cycles of Serrana goats (n=22) were studied during breeding season. A daily transrectal ultrasound scanning was performed through two successive estrous cycles. Both solid and fluid-filled CL were observed and measured in both ovaries of each goat. Additionally, each CL was classified as CL(ICHE) (CL with irregular contours and heterogeneous echotexture) or CL(RCGE) (CL with regular contours and granular echotexture). Ovarian cyclic activity and luteal function were evaluated by biweekly plasma progesterone (P4) determination. The CL (n=60) were first visualized on day 2.9+/-1.0 after the day of ovulation (day 0), showing 7.1+/-1.8mm of diameter and reach their maximum size (12.5+/-1.6mm) on day 10.7+/-3.2 (P<0.001). Two days before the following ovulation (day -2), the CL regressed to 8.4+/-1.3mm (P<0.001). The central cavity was found in 78.3% of CL, and had a persistence of over 50% until the last days of estrous cycle. The ratio CL length/cavity length was low during the first-third and high during the remaining two-thirds of estrous cycle. On day 2, the percentage of CL(ICHE) was 33.3%, and began to decrease to 16.7% on day 6, reaching the minimum of 3.3% on day 10 (P<0.001). This proportion increased on day -3 to 48.3% and reached 90% on day -1 (P<0.001). The correlation between CL size and plasma P4 levels was r=0.63 (n=87; P<0.001). A negative correlation between the daily proportion of CL(ICHE) and plasma P4 levels was found (r=-0.95; n=18; P<0.001). These results suggest that the ultrasonographic appearance of CL is a reliable parameter for the assessment of luteal function in goats. Both the characterization of echotexture and size of central cavity could be valuable tools to differentiate between phases of normal estrous cycles.

Follicular dynamics in Serrana goats

Twenty-two Serrana goats were studied through two successive estrous cycles in order to characterize their follicular dynamics during the breeding season. The ovaries of the goats were scanned daily by real-time ultrasonography and all follicles >or=3mm were measured and classified. The data were classified by the number of follicular waves per goat to test the hypothesis that temporal and morphological differences between the last follicular wave of an ovary, irrespective of ovulation, will affect the selection of the next ovulatory wave. The mean interovulatory interval was 20.7+/-1.0 days (mean+/-S.D.). Three to five waves per estrous cycle were observed and 61.3% (19/31) of cycles had four waves. In estrous cycles with four waves, the day of onset of the first, second, third and fourth wave was 1.4+/-1.0, 6.9+/-1.4, 11.6+/-1.8 and 16.8+/-1.6, respectively. No differences (P>0.05) were found between the day of onset of the first and second waves for estrous cycles with three, four or five waves. However, the day of onset of the third and fourth waves occurred later when the number of waves per estrous cycle increased (P<0.001). The duration of the interwave interval (time between the day of onset of two consecutive waves) was longer when the second wave was ovulatory. The length of the growth phase (2.4+/-0.9 days) and size (5.9+/-0.7 mm) of the dominant follicle in the second wave were lower (P<0.01) than for the first wave (3.3+/-1.2 days and 6.6+/-0.9 mm, respectively) and the fifth wave (4.1+/-1.2 days and 7.5+/-1.0mm, respectively). Within pairs of ovaries, the onset of the last wave occurred later (P<0.05) and was less variable in ovulatory ovaries (day 16.8+/-1.4, n=20) than in anovulatory ovaries (day 15.1+/-3.7, n=20). The length of the growing phase was longer (P<0.001) in the last waves of ovulatory ovaries (3.1+/-0.9 days) than in the last waves of anovulatory ovaries (1.7+/-0.8 days). These results support the hypothesis that the day of onset of the ovulatory wave is related to or, at least, conditioned by the luteolysis and the decrease in plasma progesterone. In summary, the estrous cycle of Serrana goats is characterized by sequential follicular wave growth with a great variability in their onset and duration, with the exception of the ovulatory wave. The temporal and morphological differences observed in the last wave of estrous cycle provide strong evidence for the role of progesterone in their regulation.

Nasal septum perforation as the presenting sign of lupus erythematosus

Nasal septum perforation is an uncommon and not well known feature of lupus erythematosus (LE). In general, it occurs during exacerbations and in a context of systemic vasculitis. Very rarely it can be a presenting sign, accompanying more usual manifestations of LE. We report the case of a 30-year-old woman who presented with a 2-year history of painful, slowly progressive nasal septum perforation. Laboratory study disclosed positive antinuclear antibodies, circulating immune complexes, hypocomplementemia, nuclear epidermal deposition of IgG in normal skin and transitory positive antiphospholipid antibodies. Symmetric peripheral joint arthritis, photosensitivity and diffuse alopecia subsequently developed. This case seems unique in that the nasal septum perforation occurred as an isolated presenting sign; it emphasizes the value of this feature in the diagnosis of LE.

Morphometry of ovarian structures by transrectal ultrasonography in Serrana goats

The accuracy of transrectal real-time ultrasonography (RTU) scanning technique to detect ovarian structures (follicles and corpus luteum) of Serrana goats was compared to the data obtained by observation of ovarian sequential slices. This slicing technique (SLI) was considered as reference method. The laparoscopy and laparotomy techniques were also used for corpora lutea identification. For this purpose the ovaries of 14 females were observed, 7-8 days after ovulation, by transrectal ultrasonography followed by laparoscopic examination. Then ovaries were removed and studied by slicing. In the sliced sections of each ovary (n=28), follicles and corpus luteum (CL) were identified and counted. CL and follicular diameters were measured using a millimetre scale. The total number of follicles, counted by RTU, was significantly lower than that observed by SLI (P <0.01). This difference was mainly due to the under estimation of <2 mm follicles category. The correlation coefficient between category data obtained by RTU and SLI methods for the number of follicles > or =3 mm was high (r2=0.95, P <0.001), which highlights the use of UTR as a potential methodology to study the follicular dynamic of goats. There were no significant differences (P >0.05) between the average number (mean +/- S.D.) of corpus luteum identified per ovary by RTU (0.71 +/- 0.75), laparoscopy (0.58 +/- 0.71), laparotomy (0.67 +/- 0.76) or SLI (0.83 +/- 0.76) methods. The accuracy for the identification of ovulation, validated by CL detection on D7-D8 by SLI (100%), was 91.7%, 87.5% and 83.3% by RTU, laparotomy and laparoscopy, respectively. The negative predictive value of RTU, laparotomy and laparoscopy to verify the absence of a CL in the ovary was 81.8%, 75.0% and 69.2%, respectively. The specificity of all three methods for the CL identification was 100%. No significant differences (P >0.05) were found in the probability to detect the exact number of CL (0, 1 or 2) counted in each ovary between the RTU (87.5%), laparotomy (83.3%) and laparoscopy (75.0%) methods when compared with the reference method. The diameter of spherical CL could be estimated with reliability (r2=0.86; P <0.001). The real-time ultrasonographic scanning proved to be a highly accurate method for detection and measurement of several categories of follicles and CL size in Serrana goats. The results of the present study show that laparoscopy and RTU are similarly reliable techniques for CL detection. However, the RTU represents a non-traumatic technique with advantages to animal welfare both in experimental and reproductive evaluation of the size of ovarian structures.

Hypovitaminosis D-induced pain

Vitamin D deficiency is a problem of considerable magnitude that has reemerged as a major public health issue in the United States and several other developed countries. Vitamin D plays a crucial role in calcium homeostasis in the body. Hypovitaminosis D leads to osteomalacia and increased risk of fractures, especially in the elderly. Preliminary research suggests that vitamin D can prevent certain types of cancer and autoimmune diseases. A recent large study has shown the association between severe hypovitaminosis D and persistent, non-specific musculoskeletal pain, further suggesting that patients with no apparent cause of pain should be assessed and possibly treated for vitamin D deficiency.

Tamm-Horsfall protein knockout mice are more prone to urinary tract infection: rapid communication

BACKGROUND

Human colon contains many bacteria that commonly colonize the perineum and frequently enter the urinary tract. Uropathogenic Escherichia coli are the most common cause of urinary tract infection. Type 1 fimbriated E. coli have been associated with cystitis, and P fimbriated E. coli with pyelonephritis. Factors involved in clearing bacteria from the urinary tract are poorly understood. Tamm-Horsfall protein (THP), the most abundant protein in mammalian urine, has been postulated to play a role in defense against urinary tract infection but definitive proof for this idea has been lacking.

METHODS

In this study, we generated THP gene knockout mice by the technique of homologous recombination, and examined if the THP-deficient (THP-/-) mice were more prone to urinary tract infection. Various strains of E. coli expressing type 1 or P fimbriae were introduced transurethrally into the bladders of the THP-/- and genetically similar wild-type (THP+/+) mice. Urine, bladder, and kidney tissues were obtained from the mice and cultured for bacterial growth.

RESULTS

THP-/- mice inoculated with type 1 fimbriated E. coli had a longer duration of bacteriuria, and more intense colonization of the urinary bladder in comparison with THP+/+ mice. When inoculated with a P fimbriated strain of E. coli, the THP-/- mice showed no difference in kidney bacterial load when compared with the THP+/+ mice.

CONCLUSION

These findings support the idea that THP serves as a soluble receptor for type 1 fimbriated E. coli and helps eliminate bacteria from the urinary tract.

New support for branched-chain amino acid supplementation in advanced hepatic failure

Nutritional supplementation with branched-chain amino acids (BCAA) has been a topic of considerable debate for more than two decades. Several studies have demonstrated that supplementation with BCAA is associated with improvement of the catabolic state commonly seen in people with cirrhosis, whereas other studies have showed an improvement in portosystemic encephalopathy in patients with liver disease. Some studies have also shown there to be no benefit in BCAA supplementation in advanced cirrhosis. A recent large clinical trial showed that long-term BCAA supplementation may be useful in preventing progressive hepatic failure and improving liver function in some patients.

New support for branched-chain amino acid supplementation in advanced hepatic failure

Nutritional supplementation with branched-chain amino acids (BCAA) has been a topic of considerable debate for more than two decades. Several studies have demonstrated that supplementation with BCAA is associated with improvement of the catabolic state commonly seen in people with cirrhosis, whereas other studies have showed an improvement in portosystemic encephalopathy in patients with liver disease. Some studies have also shown there to be no benefit in BCAA supplementation in advanced cirrhosis. A recent large clinical trial showed that long-term BCAA supplementation may be useful in preventing progressive hepatic failure and improving liver function in some patients.

Pemphigus vulgaris with nail involvement presenting with vegetating and verrucous lesions

We report the case of a 68-year-old female with longstanding insulin-treated diabetes mellitus, observed for the first time in our department in August 1999 with multiple painful erosive lesions of the oral cavity and many bullous or erosive lesions on the abdominal wall, back, and thigh. She also had vegetating and verrucous lesions, similar to common warts, involving the hands and feet, mainly on the palms, palmar surface of the fingers, and nail folds. Her lesions were present for 1 year. Skin and mucous biopsies showed the characteristic histopathologic findings of pemphigus vulgaris, with an epidermal intercellular IgG deposition on direct immunofluorescence. Histology of a warty lesion of the finger also showed suprabasal acantholysis. After partial improvement with low doses of oral steroids and azathioprine, her disease progressed to involve the oral cavity, trunk, hands, feet, and scalp. Control of her disease required successive treatments of mycophenolate mofetil and cyclophosphamide, as well as corticosteroids. A partial response was obtained with all these treatments. After being controlled by cyclophosphamide that was slowly tapered, she is now well controlled with azathioprine and oral steroids, showing only discrete lesions of the oral mucosa after 1 year of followup. We report this case of pemphigus vulgaris with unusual clinical aspects, namely vegetating and verrucous lesions as well as nail involvement, rarely described in this disease.

Spontaneous hepatic rupture: a report of five cases

BACKGROUND

Spontaneous hepatic rupture is a well recognised but rare condition. Because of the difficulty in diagnosis, it is often associated with a high mortality rate. Pregnant women with HELLP syndrome are more prone to hepatic rupture, but it can also occur with other liver pathology. Different modalities of treatment, including liver resection, packing, hepatic artery ligation and even liver transplantation have been described for this condition.

PATIENTS AND RESULTS

We report a series of five cases, three of which were associated with pregnancy and two with no identifiable pathology. Pre-operative diagnosis was not made in any of these cases.Two of the five patients had hepatic resection, two had peri-hepatic packing and one was treated with laparoscopic drainage.

DISCUSSION

From our experience we conclude that no single form of treatment is applicable to all cases of hepatic rupture.The treatment should be individualised,depending on the extent of hepatic rupture and the expertise available, to obtain best outcome.

Mechanisms underlying degeneration of cryopreserved vascular homografts

OBJECTIVE

To analyze the mechanism(s) underlying homograft degeneration, we designed an experimental model in which the behavior of cryopreserved autografts and homografts, as well as fresh autografts, implanted in the same animal was compared.

METHODS

A cryopreserved homograft was implanted in the aorta of 14 sheep. The excised aortic autologous segment was then subjected to cryopreservation, and 1 to 8 weeks later it was implanted 1 to 2 cm below the cryopreserved homograft. The intermediate segment of the native aorta, the fresh autograft, was dissected at this point. Animals were put to death at different times and the implanted segments were harvested together with a portion of native aorta. Histologic and immunohistochemical analyses, as well as cell viability assessments, were then performed on the explanted segments. Similar studies were also conducted on fragments of cryopreserved autografts and homografts before implantation.

RESULTS

With the exception of a partial loss of the endothelium, cryopreserved specimens retained cell viability and morphologic integrity before implantation. Explanted cryopreserved homografts showed profound changes affecting all strata, as well as a decline in cell viability. Lymphocyte infiltrates were found up to 12 months after implantation. Endothelium was always absent in cryopreserved homografts. However, a reendothelialization of the cryopreserved autografts was observed. After an initial period of neuronal degeneration, reenervation of the cryopreserved autograft segment occurred 6 to 12 months after the operation. Findings regarding the fresh autografts were similar to those of the cryopreserved autografts.

CONCLUSION

Our results suggest that the immunologic reaction rather than the cryopreservation process is responsible for the degenerative process occurring in cryopreserved homografts.

Electron nuclear double resonance and electron paramagnetic resonance study on the structure of the NO-ligated heme alpha 3 in cytochrome c oxidase

The techniques of EPR and electron nuclear double resonance (ENDOR) were used to probe structure and electronic distribution at the nitric oxide (NO)-ligated heme alpha 3 in the nitrosylferrocytochrome alpha 3 moiety of fully reduced cytochrome c oxidase. Hyperfine and quadrupole couplings to NO (in both 15NO and 14NO forms), to histidine nitrogens, and to protons near the heme site were obtained. Parallel studies were also performed on NO-ligated myoglobin and model NO-heme-imidazole systems. The major findings and interpretations on nitrosylferrocytochrome alpha 3 were: 1) compared to other NO-heme-imidazole systems, the nitrosylferrocytochrome alpha3 gave better resolution of EPR and ENDOR signals; 2) at the maximal g value (gx = 2.09), particularly well resolved NO nitrogen hyperfine and quadrupole couplings and mesoproton hyperfine couplings were seen. These hyperfine and quadrupole couplings gave information on the electronic distribution on the NO, on the orientation of the g tensor with respect to the heme, and possibly on the orientation of the FeNO plane; 3) a combination of experimental EPR-ENDOR results and EPR spectral simulations evidenced a rotation of the NO hyperfine tensor with respect to the electronic g tensor; this implied a bent Fe-NO bond; 4) ENDOR showed a unique proton not seen in the other NO heme systems studied. The magnitude of this proton's hyperfine coupling was consistent with this proton being part of a nearby protein side chain that perturbs an axial ligand like NO or O2.

Interaction in cytochrome c oxidase between cytochrome a3 ligated with nitric oxide and cytochrome a

EPR spectra of nitric oxide complexes of cytochrome c oxidase were studied as a function of temperature in the fully reduced form and in a mixed valence form. In the 12-77 K range, temperature-dependent motion changed the EPR spectral line shape of the mixed valence form but not the fully reduced form. Two separate hypotheses which both indicate cytochrome a-cytochrome a3 interaction could account for this phenomenon: i.e. either, in response to redox changes at cytochrome a, a changed ligand binding environment occurs at cytochrome a3 which has conformations that down to 40 K can interconvert on a 10(8) s-1 time scale, or dipolar spin-spin interaction occurs between the NO-liganded a3 center and a paramagnetic metal center in cytochrome a. This interaction is then modulated by the temperature-dependent spin-lattice relaxation behavior of the center in cytochrome a. If this latter hypothesis is correct, the intercenter distance can be estimated at 15 A, and the more likely interacting center can be predicted to be the heme moiety of cytochrome a.