Changes in hypothalamic-pituitary-adrenal axis function, immunity, and glucose during acute Plasmodium relictum infection in house sparrows (Passer domesticus)

Hosts of the same species vary in physiological responses to the same parasite, and some groups of individuals can disproportionately affect disease dynamics; however, the underlying pathophysiology of host-parasite interactions is poorly understood in wildlife. We tested the hypothesis that the hypothalamic-pituitary-adrenal (HPA) axis mediates host resistance and tolerance to avian malaria during the acute phase of infection by evaluating whether individual variation in circulating glucocorticoids predicted resistance to avian malaria in a songbird. We experimentally inoculated wild-caught house sparrows (Passer domesticus) with naturally sourced Plasmodium relictum and quantified baseline and restraint-induced circulating corticosterone, negative feedback ability, cellular and humoral immune function, and baseline and restraint-induced glycemia, prior to and during acute malaria infection. During peak parasitemia, we also evaluated the expression of several liver cytokines that are established pathological hallmarks of malaria in mammals: two pro-inflammatory (IFN-γ and TNF-α) and two anti-inflammatory (IL-10 and TGF-β). Although most of the host metrics we evaluated were not correlated with host resistance or tolerance to avian malaria, this experiment revealed novel relationships between malarial parasites and the avian immune system that further our understanding of the pathology of malaria infection in birds. Specifically, we found that: (1) TNF-α liver expression was positively correlated with parasitemia; (2) sparrows exhibited an anti-inflammatory profile during malaria infection; and (3) IFN-γ and circulating glucose were associated with several immune parameters, but only in infected sparrows. We also found that, during the acute phase of infection, sparrows increased the strength of corticosterone negative feedback at the level of the pituitary. In the context of our results, we discuss future methodological considerations and aspects of host physiology that may confer resistance to avian malaria, which can help inform conservation and rehabilitation strategies for avifauna at risk.

Rising to the Challenge: Mounting an Acute Phase Immune Response Has No Long-Term Negative Effects on Captive Sparrow Migratory Body Composition or Migratory Restlessness

Migratory animals may trade-off between investing energy in immune defense versus investing in energy reserves needed for seasonal migration. However, these trade-offs are often masked by other sources of variation and may not be detected through observational field studies of free-living animals. Moreover, observational studies can rarely distinguish the costs of pathogenic infection from those of mounting an immune response. To disentangle such effects, we conducted an immune challenge experiment. We captured song sparrows (Melospiza melodia) and white-throated sparrows (Zonotrichia albicollis) in autumn migratory condition, challenged the sparrows with non-infectious antigens that induce an acute-phase immune response, then monitored body composition and migratory restlessness behavior. For both species, body mass was higher the day after exposure to keyhole limpet hemocyanin (KLH) compared to controls. White-throated sparrows, but not song sparrows, increased lean mass 1 week after exposure to lipopolysaccharide (LPS), suggesting that effects of immune upregulation on body composition may be long-lasting and specific to certain combinations of hosts and antigens. White-throated sparrows exposed to KLH increased nocturnal migratory restlessness (Zugunruhe) for the week following exposure. These findings suggest that short-term activation of the acute immune response does not constrain migratory physiology in these songbirds.

Characterizing Wellness Leadership in Academic Radiation Oncology Departments in the United States

PURPOSE/OBJECTIVE(S)

Burnout is prevalent in radiation oncology (RO), with 56% of respondents in a 2020 survey reporting symptoms of burnout. This has led to an increased effort to promote physician wellness via formal wellness-directed initiatives in recent years. However, little is known about the specifics of wellness activities and their impact. We aim to characterize current wellness leadership positions and efforts within academic RO departments.

MATERIALS/METHODS

A total of 120 US academic RO department chairs were contacted to inquire whether they had a departmental wellness leader, with a request for leader contact information, if applicable. Wellness leaders were invited to complete an anonymous survey in January and February 2023 via a survey platform. Questions assessed leader demographics, role structure, resources, current initiatives, and impacts to date. Descriptive statistics and summaries of free text responses are reported.

RESULTS

Seventy-one chairs (59%) responded, among which 43 (61%) reported having departmental wellness leaders. On interim analysis, 11 (26%) responded to the survey. 82% were female and 73% were physician faculty. Leaders spanned career stages, and respondent ages ranged from 32-66. Wellness leaders were commonly in formal departmental committees (n = 4) or implemented hospital initiatives without independent departmental programming (n = 5). Committees had all been started since 2020. 5 respondents stated departmental wellness leadership was required by their institution. Some leaders were provided with administrative support (n = 4) and/or departmental program funding (n = 4), however only 1 had protected time for wellness work. Challenges included limited bandwidth (n = 7), lack of departmental interest (n = 4), and limited funding (n = 4). The most commonly completed initiatives include programming and education (n = 4) and improved support for caregivers (n = 3). No departments had hired physician coaches or created a peer support network. Of 14 initiatives, departments had, on average, implemented 2. 36% and 27% of respondents agree that because of wellness initiatives the department is more aware of the importance of wellness and wellness-promoting strategies, respectively. Only 9% and 18% felt initiatives changed a culture of constant availability and encouraged use of full PTO and limiting work off hours, respectively. Leaders highlight the importance of a dedicated individual to tangibly implement changes and the unique opportunity of someone within RO to understand the specific challenges faced by those in our field.

CONCLUSION

Wellness leadership roles exist in many RO departments. However, these roles are new and evolving, with a limited number of fully implemented initiatives to date. Longitudinal data collection and follow-up will help establish the impact of these roles on bringing positive change to departments. Full results will be presented at ASTRO 23.

Pre-Operative Radiotherapy in STS: Does Downsizing Matter?

PURPOSE/OBJECTIVE(S)

Soft tissue sarcomas (STS) are a rare but insidious tumor that arises from mesenchymal tissue. Preoperative RT, followed by resection, is routinely used in extremity and truncal STS. The impact of RT on tumor volume and implications for prognosis is a great concern for patients, as changes in volume is often perceived as a reflection of treatment response. To date, data between tumor volume changes after RT and overall survival (OS) and distant metastasis-free survival (DMFS) in STS is sparse. In this study, we investigate changes in tumor volume after preoperative RT and its impact on OS and DMFS.

MATERIALS/METHODS

Between 2000 and 2022, patients with stage I-III primary sarcoma of the extremity or trunk treated with pre-operative RT and wide resection were retrospectively reviewed from a prospective repository. Tumors were contoured using T2 sequences on MRIs within 2 weeks of initiation of RT and within 4 weeks post-RT. Tumor volume was determined using the medical image merge software. Univariate analysis (UVA) was performed using the log-rank test. Multivariate analysis (MVA) was performed using the Cox proportional hazards model.

RESULTS

One hundred thirty-two patients had both pre- and post-RT MRIs available for contours. Median follow-up was 6 years. Median age at diagnosis was 56 years (range = 19-92). Most patients had stage III (73%) disease in the lower extremity (75%). The most common histology was undifferentiated sarcoma (30%). Median dose was 50 Gy in 25 fractions. Chemotherapy was administered in 44 (33%) patients. Median tumor volume prior to and after RT was 198 cc (range = 7.49 - 3899.87) and 225.21 cc (range = 0-9879.2), respectively. A decrease in tumor volume was seen in 90 patients (68%) from pre- to post-RT. In these patients, the mean percent change was -35%. Forty-two patients had an increase in tumor volume post-RT with a mean percent change of 56%. Overall local control was 98%. The 2- and 5-year OS were 89% and 76%, respectively. The 2- and 5-year DMFS was 76% and 70%, respectively. On UVA, increased age (p < 0.001), KPS ≤80 (p = 0.002), and smokers (p = 0.009) were associated with decreased OS. No variables were associated with DMFS. On MVA, age (p = 0.01) was associated with decreased OS and female gender (p = 0.03) and high-grade disease was associated with decreased DMFS (p = 0.04) Change in tumor volume did not impact OS (p = 0.15) or DMFS (p = 0.75). The 2- and 5-year DMFS for patients with a decrease in tumor volume was 79% and 71%, respectively. The 2 and 5-year DMFS for patients with an increase in tumor volume was 77% and 70%, respectively. The 2- and 5-year OS for patients with a decrease in tumor volume was 92% and 80%, respectively. The 2 and 5-year OS for patients with an increase in tumor volume was 83% and 69%, respectively.

CONCLUSION

Change in tumor volume did not significantly impact OS and DMFS. Further studies with an increased sample size are warranted to corroborate these findings, however these results may assuage patient anxieties about the perceived tumor response to RT.

Effect of estradiol and predator cues on behavior and brain responses of captive female house sparrows (Passer domesticus)

The presence of predators can cause major changes in animal behavior, but how this interacts with hormonal state and brain activity is poorly understood. We gave female house sparrows (Passer domesticus) in post-molt condition an estradiol (n = 17) or empty implant (n = 16) for 1 week. Four weeks after implant removal, a time when female sparrows show large differences in neuronal activity to conspecific vs. heterospecific song, we exposed birds to either 30 min of conspecific song or predator calls, and video recorded their behavior. Females were then euthanized, and we examined neuronal activity using the expression of the immediate early gene (IEG) ZENK to identify how the acoustic stimuli affected neuronal activation. We predicted that if female sparrows with estradiol implants reduce neuronal activity in response to predator calls as they do to neutral tones and non-predatory heterospecifics, they would show less fear behavior and a decreased ZENK response in brain regions involved in auditory (e.g., caudomedial mesopallium) and threat perception functions (e.g., medial ventral arcopallium) compared to controls. Conversely, we predicted that if females maintain auditory and/or brain sensitivity towards predator calls, then female sparrows exposed to estradiol would not show any differences in ZENK response regardless of playback type. We found that female sparrows were less active during predator playbacks independent of hormone treatment and spent more time feeding during conspecific playback if they had previously been exposed to estradiol. We observed no effect of hormone or sound treatment on ZENK response in any region of interest. Our results suggest that female songbirds maintain vigilance towards predators even when in breeding condition.

Constitutive gene expression differs in three brain regions important for cognition in neophobic and non-neophobic house sparrows (Passer domesticus)

Neophobia (aversion to new objects, food, and environments) is a personality trait that affects the ability of wildlife to adapt to new challenges and opportunities. Despite the ubiquity and importance of this trait, the molecular mechanisms underlying repeatable individual differences in neophobia in wild animals are poorly understood. We evaluated wild-caught house sparrows (Passer domesticus) for neophobia in the lab using novel object tests. We then selected a subset of neophobic and non-neophobic individuals (n = 3 of each, all females) and extracted RNA from four brain regions involved in learning, memory, threat perception, and executive function: striatum, caudal dorsomedial hippocampus, medial ventral arcopallium, and caudolateral nidopallium (NCL). Our analysis of differentially expressed genes (DEGs) used 11,889 gene regions annotated in the house sparrow reference genome for which we had an average of 25.7 million mapped reads/sample. PERMANOVA identified significant effects of brain region, phenotype (neophobic vs. non-neophobic), and a brain region by phenotype interaction. Comparing neophobic and non-neophobic birds revealed constitutive differences in DEGs in three of the four brain regions examined: hippocampus (12% of the transcriptome significantly differentially expressed), striatum (4%) and NCL (3%). DEGs included important known neuroendocrine mediators of learning, memory, executive function, and anxiety behavior, including serotonin receptor 5A, dopamine receptors 1, 2 and 5 (downregulated in neophobic birds), and estrogen receptor beta (upregulated in neophobic birds). These results suggest that some of the behavioral differences between phenotypes may be due to underlying gene expression differences in the brain. The large number of DEGs in neophobic and non-neophobic birds also implies that there are major differences in neural function between the two phenotypes that could affect a wide variety of behavioral traits beyond neophobia.

No guts about it: captivity, but not neophobia phenotype, influences the cloacal microbiome of house sparrows (Passer domesticus)

Behavioral traits such as anxiety and depression have been linked to diversity of the gut microbiome in humans, domesticated animals, and lab-bred model species, but the extent to which this link exists in wild animals, and thus its ecological relevance, is poorly understood. We examined the relationship between a behavioral trait (neophobia) and the cloacal microbiome in wild house sparrows (Passer domesticus,n = 22) to determine whether gut microbial diversity is related to personality in a wild animal. We swabbed the cloaca immediately upon capture, assessed neophobia phenotypes in the lab, and then swabbed the cloaca again after several weeks in captivity to additionally test whether the microbiome of different personality types is affected disparately by captivity, and characterized gut microbiomes using 16S rRNA gene amplicon sequencing. We did not detect differences in cloacal alpha or beta microbial diversity between neophobic and non-neophobic house sparrows, and diversity for both phenotypes was negatively impacted by captivity. Although our results suggest that the adult cloacal microbiome and neophobia are not strongly linked in wild sparrows, we did detect specific OTUs that appeared more frequently and at higher abundances in neophobic sparrows, suggesting that links between the gut microbiome and behavior may occur at the level of specific taxa. Further investigations of personality and the gut microbiome are needed in more wild species to reveal how the microbiome-gut-brain axis and behavior interact in an ecological context.

A transient reduction in circulating corticosterone reduces object neophobia in male house sparrows

Aversive reactions to novelty (or "neophobia") have been described in a wide variety of different animal species and can affect an individual's ability to exploit new resources and avoid potential dangers. However, despite its ecological importance, the proximate causes of neophobia are poorly understood. In this study, we tested the role of glucocorticoid hormones in neophobia in wild-caught house sparrows (Passer domesticus, n = 11 males) by giving an injection of the drug mitotane that reduced endogenous corticosterone for several days or a vehicle control, and then examined the latency to feed when the food dish was presented with or without a novel object in, on, or near the dish. Each sparrow was exposed to multiple novel object and control trials and received both vehicle control and mitotane treatments, with a week between treatments to allow the drug to wash out. As found previously, all novel objects significantly increased sparrows' latency to feed compared to no object present. Reducing corticosterone using mitotane significantly reduced the latency to feed in the presence of novel objects. In control trials without objects, mitotane had no significant effects on feeding time. Although we have shown that corticosterone affects neophobia, further studies using specific receptor agonists and antagonists will help clarify the neurobiological mechanisms involved and determine whether baseline or stress-induced corticosterone is driving this effect. These results suggest that increased glucocorticoids (e.g., due to human-induced stressors) could increase neophobia, affecting the ability of individuals to exploit novel resources, and, ultimately, to persist in human-altered environments.

Preen gland microbiota of songbirds differ across populations but not sexes

Metabolites produced by symbiotic microbes can affect the odour of their hosts, providing olfactory cues of identity, sex or other salient features. In birds, preen oil is a major source of body odour that differs between populations and sexes. We hypothesized that population and sex differences in preen oil chemistry reflect underlying differences in preen gland microbiota, predicting that these microbes also differ among populations and between the sexes. We further predicted that pairwise similarity in the community composition of preen gland microbiota would covary with that of preen oil chemical composition, consistent with the fermentation hypothesis for chemical recognition. We analysed preen oil chemistry and preen gland bacterial communities of song sparrows Melospiza melodia. Birds were sampled at sites for which population and sex differences in preen oil have been reported, and at a third site that has been less studied. Consistent with prior work in this system, we found population and sex differences in preen oil chemistry. By contrast, we found population differences but not sex differences in the community composition of preen gland microbes. Overall similarity in the community composition of preen gland microbiota did not significantly covary with that of preen oil chemistry. However, we identified a subset of six microbial genera that maximally correlated with preen oil composition. Although both preen gland microbiota and preen oil composition differ across populations, we did not observe an overall association between them that would implicate symbiotic microbes in mediating variation in olfactory cues associated with preen oil. Instead, certain subsets of microbes may be involved in mediating olfactory cues in birds, but experiments are required to test this.

No, you go first: phenotype and social context affect house sparrow neophobia

Novel object trials are commonly used to assess aversion to novelty (neophobia), and previous work has shown neophobia can be influenced by the social environment, but whether the altered behaviour persists afterwards (social learning) is largely unknown in wild animals. We assessed house sparrow (Passer domesticus) novel object responses before, during and after being paired with a conspecific of either similar or different behavioural phenotype. During paired trials, animals housed with a similar or more neophobic partner demonstrated an increased aversion to novel objects. This change did not persist a week after unpairing, but neophobia decreased after unpairing in birds previously housed with a less neophobic partner. We also compared novel object responses to non-object control trials to validate our experimental procedure. Our results provide evidence of social learning in a highly successful invasive species, and an interesting asymmetry in the effects of social environment on neophobia behaviour depending on the animal's initial behavioural phenotype.

Experimental Malaria Infection Affects Songbirds' Nocturnal Migratory Activity

Migratory animals encounter multiple parasite communities, raising concerns that migration may aid transport of infectious disease. How migration affects disease spread depends fundamentally on how disease affects migration, specifically whether infection alters individuals' migratory physiology and behavior. We inoculated white-throated sparrows (Zonotrichia albicollis) with avian malaria parasites (Plasmodium sp.), monitored parasite loads for 5 wk as the birds reached spring migratory condition, and compared nocturnal migratory restlessness (Zugunruhe), body composition (fat, lean, and whole-body mass), and hematocrit among experimentally infected birds, sham-inoculated birds, and birds that were exposed to parasites but resisted infection. Migratory restlessness increased over time in the study, but the rate of change varied between sham (control) birds, infected birds, and birds that resisted infection. We were unable to detect any effects of malaria exposure on body condition. Our findings suggest that encountering parasites affects migratory activity, regardless of whether infection occurs or is resisted.

Glucocorticoid negative feedback as a potential mediator of trade-offs between reproduction and survival

A large increase in glucocorticoid hormones can inhibit or completely shut down breeding in wild animals. Because of its critical role in reducing glucocorticoids after exposure to stressors, hypothalamic-pituitary-adrenal (HPA) negative feedback could be an important mediator of the ecological trade-off between investing limited resources into survival/self vs. reproduction/offspring. Although assessing negative feedback in a standardized way using injections of the synthetic glucocorticoid dexamethasone is a straightforward procedure, we show that several different approaches are used to report negative feedback in the literature, and then demonstrate that this can in turn affect the statistical results and conclusions of a study. We then review six specific predictions about adaptive within- and across-species patterns in glucocorticoids based on the relative costs and benefits of maintaining or abandoning breeding attempts when animals are faced with prolonged strong stressors, and examine evidence for these predictions in the context of HPA negative feedback. Thus far, evidence supporting these predictions for negative feedback is mixed, with the strongest evidence supporting a link between poor body condition and weak negative feedback in breeding animals. However, more research is necessary to assess the importance of changes in HPA negative feedback, especially in reptile, fish, and amphibian species. Furthermore, future research would benefit from reporting negative feedback ability in a standardized way, or at least making raw data available for the computation of alternate measures, to more easily compare studies in this growing area of research.

Alternative reproductive strategies in white-throated sparrows are associated with differences in parasite load following experimental infection

Immune defences often trade off with other life-history components. Within species, optimal allocation to immunity may differ between the sexes or between alternative life-history strategies. White-throated sparrows (Zonotrichia albicollis) are unusual in having two discrete plumage morphs, white-striped and tan-striped. Within each sex, white-striped individuals are more aggressive and provide less parental care than tan-striped individuals. We extended immunocompetence handicap models, which predict sex differences in immunity and parasitism, to hypothesize that infection susceptibility should be greater in white-striped than tan-striped birds. We inoculated birds of both morphs with malarial parasites. Contrary to our prediction, among birds that became infected, parasite loads were higher in tan-striped than white-striped individuals and did not differ between the sexes. Circulating androgen levels did not differ between morphs but were higher in males than females. Our findings are not consistent with androgen-mediated immunosuppression. Instead, morph differences in immunity could reflect social interactions or life-history-related differences in risk of injury, and/or genetic factors. Although plumage and behavioural morphs of white-throated sparrow may differ in disease resistance, these differences do not parallel sex differences that have been reported in animals, and do not appear to be mediated by differences in androgen levels.

Abstract P6-12-10: The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards

Background: Froedtert Hospital and the Medical College of Wisconsin's Breast Care Center (F&MCWBCC), is a Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) accredited facility providing care to over 500 patients a year. The F&MCWBCC recognized the importance of following the IOM survivorship recommendations and in 2014 began providing a survivorship care plan (SCP) to patients completing radiation therapy. In 2015, SCP standards for both CoC and NAPBC were established. A redesign of the process was necessary to meet these new requirements.

Methods: A review of accreditation standards was conducted along with an examination of staff availability. A collaborative team of content experts was gathered who worked with an informatics nurse to design content and a template in the EHR that met the elements outlined by the accreditation standards. Initially, treating physicians and advanced practice nurses were responsible for creating the SCP. However, these providers found it to be increasingly difficult to manage on top of their other responsibilities.

In May 2015, an experienced breast cancer technician was identified for the survivorship data coordinator role. The coordinator used available sources, patient lists and clinic schedules, to case find. She developed spreadsheets to assist in tracking patients and measuring compliance. The coordinator communicated with providers to alert them to populate and review the SCP and coordinated the survivorship appointment with the nurse.

Once the SCP is completed, a dedicated RN position is utilized for a survivorship visit with patients. During this visit, the RN reviews the care plan and provides education on follow up care guidelines and overall health and wellness concepts. Assessments for further supportive services are performed, and appropriate referrals made. The RN shares the SCP with the primary care provider. Results are tracked and reported to Cancer Service Line Leadership and the Breast Steering and Cancer Committees.

Results: During the implementation phase, completion of SCPs by physicians and advance practice nurses was inconsistent. Once the survivorship coordinator role was created and implemented, compliance with NAPBC standards improved as SCP delivery numbers increased 141%.

The survivorship coordinator improved delivery of SCPs. In 2014, 130 plans were delivered, and 185 in 2015. In 2016, 314 were delivered, achieving 100% compliance to the NAPBC survivorship standard.

Conclusion:Compliance with NAPBC and CoC standards to deliver SCPs to patients and primary care providers is labor intensive and requires a large number of resources. Use of a survivorship data coordinator has proven successful in determining and tracking eligible patients and ensuring timely delivery of SCPs to patients. The monitoring of new patients through this process has enabled this center to go from estimates of analytic cases, to a current real-time numbers. This is necessary to provide a comprehensive review of care and survivorship guidelines to cancer survivors and meeting accreditation standards. Further work is needed to assess the impact of the SCPs on patient outcomes and satisfaction.

Citation Format: Blissitt J, Scalio R, Myers KB, Sweeney K, Kelly TR, Kong A, Chitambar C, Currey AD. The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-10.

Immune profiles vary seasonally, but are not significantly related to migration distance or natal dispersal, in a migratory songbird

A central tenet of ecoimmunology is that an organism's environment shapes its optimal investment in immunity. For example, the benefits of acquired (relatively pathogen specific) versus innate (nonspecific) immune defenses are thought to vary with the risk of encountering familiar versus unfamiliar pathogens. Because pathogen communities vary geographically, individuals that travel farther during seasonal migration or natal dispersal are predicted to have higher exposure to novel pathogens, and lower exposure to familiar pathogens, potentially favoring investment in innate immunity. During the breeding season, migratory animals' exposure to familiar pathogens should increase, potentially favoring investment in acquired immunity. We hypothesized that song sparrows Melospiza melodia adjust their constitutive immune profiles in response to risk of encountering novel versus familiar pathogens. We predicted that individuals migrating longer distances (inferred from stable hydrogen isotope analysis of claws) and less philopatric individuals (inferred from microsatellite assignment testing) would rely more heavily on acquired than innate defenses. We also predicted that reliance on acquired defenses would increase throughout the early breeding season. Consistent with trade-offs between acquired and innate defenses, levels of immunoglobulin Y (acquired) varied negatively with macrophage phagocytosis activity (innate). Levels of acquired relative to innate immunity did not vary significantly with migration distance or philopatry, but increased throughout the early breeding season. Macrophage phagocytosis was not significantly repeatable between years. Song sparrows appear to shift from innate defenses immediately after migration to acquired defenses with increasing time at the breeding grounds. These patterns highlight the plasticity of constitutive immune defenses in migratory animals.

Chemical composition of preen wax reflects major histocompatibility complex similarity in songbirds

In jawed vertebrates, genes of the major histocompatibility complex (MHC) play a key role in immunity by encoding cell-surface proteins that recognize and bind non-self antigens. High variability at MHC suggests that these loci may also function in social signalling such as mate choice and kin recognition. This requires that MHC genotype covaries with some perceptible phenotypic trait. In mammals and fish, MHC is signalled chemically through volatile and non-volatile peptide odour cues, facilitating MHC-dependent mate choice and other behaviours. In birds, despite evidence for MHC-dependent mating, candidate mechanisms for MHC signalling remain largely unexplored. However, feather preen wax has recently been implicated as a potential source of odour cues. We examined whether the chemical composition of preen wax correlates with MHC class IIβ genotypes of wild song sparrows (Melospiza melodia). Pairwise chemical distance reflected amino acid distance at MHC for male-female dyads, although not for same-sex dyads. Chemical diversity did not reflect MHC diversity. We used gas chromatography-mass spectrometry (GC-MS) to characterize preen wax compounds, and identified four wax esters that best reflect MHC similarity. Provided songbirds can detect variation in preen wax composition, this cue may allow individuals to assess MHC compatibility of potential mates.

Stable Transmission of Borrelia burgdorferi Sensu Stricto on the Outer Banks of North Carolina

The spirochaete (Borrelia burgdorferi) associated with Lyme disease was detected in questing ticks and rodents during a period of 18 years, 1991-2009, at five locations on the Outer Banks of North Carolina. The black-legged tick (Ixodes scapularis) was collected at varied intervals between 1991 and 2009 and examined for B. burgdorferi. The white-footed mouse (Peromyscus leucopus), house mouse (Mus musculus) marsh rice rat (Oryzomys palustris), marsh rabbit (Sylvilagus palustris), eastern cottontail (Sylvilagus floridanus) and six-lined racerunner (Cnemidophorus sexlineatus) were live-trapped, and their tissues cultured to isolate spirochaetes. Borrelia burgdorferi isolates were obtained from questing adult I. scapularis and engorged I. scapularis removed from P. leucopus, O. palustris and S. floridanus. The prevalence of B. burgdorferi infection was variable at different times and sites ranging from 7 to 14% of examined questing I. scapularis. Mitochondrial (16S) rRNA gene phylogenetic analysis from 65 adult I. scapularis identified 12 haplotypes in two major clades. Nine haplotypes were associated with northern/Midwestern I. scapularis populations and three with southern I. scapularis populations. Sixteen isolates obtained from tick hosts in 2005 were confirmed to be B. burgdorferi by amplifying and sequencing of 16S rRNA and 5S-23S intergenic spacer fragments. The sequences had 98-99% identity to B. burgdorferi sensu stricto strains B31, JD1 and M11p. Taken together, these studies indicate that B. burgdorferi sensu stricto is endemic in questing I. scapularis and mammalian tick hosts on the Outer Banks of North Carolina.

Testosterone, migration distance, and migratory timing in song sparrows Melospiza melodia

In seasonally migratory animals, migration distance often varies substantially within populations such that individuals breeding at the same site may overwinter different distances from the breeding grounds. Shorter migration may allow earlier return to the breeding grounds, which may be particularly advantageous to males competing to acquire a breeding territory. However, little is known about potential mechanisms that may mediate migration distance. We investigated naturally-occurring variation in androgen levels at the time of arrival to the breeding site and its relationship to overwintering latitude in male and female song sparrows (Melospiza melodia). We used stable isotope analysis of hydrogen (δ(2)H) in winter-grown claw tissue to infer relative overwintering latitude (migration distance), combined with 14years of capture records from a long-term study population to infer the arrival timing of males versus females. Relative to females, males had higher circulating androgen levels, migrated shorter distances, and were more likely to be caught early in the breeding season. Males that migrate short distances may benefit from early arrival at the breeding grounds, allowing them to establish a breeding territory. Even after controlling for sex and date, androgen levels were highest in individuals that migrated shorter distances. Our findings indicate that androgens and migration distance are correlated traits within and between sexes that may reflect individual variation within an integrated phenotype in which testosterone has correlated effects on behavioral traits such as migration.

Lead in ammunition: a persistent threat to health and conservation

Many scavenging bird populations have experienced abrupt declines across the globe, and intensive recovery activities have been necessary to sustain several species, including the critically endangered California condor (Gymnogyps californianus). Exposure to lead from lead-based ammunition is widespread in condors and lead toxicosis presents an immediate threat to condor recovery, accounting for the highest proportion of adult mortality. Lead contamination of carcasses across the landscape remains a serious threat to the health and sustainability of scavenging birds, and here we summarize recent evidence for exposure to lead-based ammunition and health implications across many species. California condors and other scavenging species are sensitive indicators of the occurrence of lead contaminated carcasses in the environment. Transdisciplinary science-based approaches have been critical to managing lead exposure in California condors and paving the way for use of non-lead ammunition in California. Similar transdisciplinary approaches are now needed to translate the science informing on this issue and establish education and outreach efforts that focus on concerns brought forth by key stakeholders.

Phacoemulsification of bilateral cataracts in a loggerhead sea turtle (Caretta caretta )

An immature free-living loggerhead sea turtle (Caretta caretta) of unknown sex was found moribund off the coast of Wise Point, Virginia. It was suffering from cachexia and had bilateral hypermature cataracts which were treated by phacoemulsification under general anaesthesia. The surgery restored the turtle's vision and it was returned to the wild.

Facile metal-assisted hydrolysis of a urethane

Kinetic studies demonstrate that it is possible to achieve large rate enhancements (2 x 10(4)) for the hydrolysis of a urethane group by using metal-bound water or hydroxide as the nucleophile. [reaction: see text]

Progress toward a rationally designed molecular motor

A retrospective overview of the work in the author's laboratory leading to a prototype (43a) of a chemically powered molecular motor is provided. Beginning with a molecular brake (23) and then proceeding through a molecular "ratchet" (31), the development of a rationally designed molecular motor is described. The thermodynamic underpinnings of the concept are outlined, the synthetic routes to 23, 31, and 43a, are summarized, and the data documenting the function of 23, 31, and 43a are presented.

Synthesis of the potent antimalarials calothrixin A and B

A concise synthesis of calothrixins A (1) and B (2) that confirms their assigned structures and affords straightforward synthetic access to them is reported.

Synthesis of an orange anthrathiophene pigment isolated from a Japanese bryozoan

A short, regiospecific synthesis of the naturally occurring anthrathiophene 1 from naphthazarin (7) is described.

Unidirectional rotary motion in a molecular system

The conversion of energy into controlled motion plays an important role in both man-made devices and biological systems. The principles of operation of conventional motors are well established, but the molecular processes used by 'biological motors' such as muscle fibres, flagella and cilia to convert chemical energy into co-ordinated movement remain poorly understood. Although 'brownian ratchets' are known to permit thermally activated motion in one direction only, the concept of channelling random thermal energy into controlled motion has not yet been extended to the molecular level. Here we describe a molecule that uses chemical energy to activate and bias a thermally induced isomerization reaction, and thereby achieve unidirectional intramolecular rotary motion. The motion consists of a 120 degrees rotation around a single bond connecting a three-bladed subunit to the bulky remainder of the molecule, and unidirectional motion is achieved by reversibly introducing a tether between the two units to energetically favour one of the two possible rotation directions. Although our system does not achieve continuous and fast rotation, the design principles that we have used may prove relevant for a better understanding of biological and synthetic molecular motors producing unidirectional rotary motion.

Ultrastructural aspects of human cystic duct epithelium as a result of cholelithiasis and cholesterolosis

Although there is a large body of data on the gallbladder and the importance of the cystic duct in surgical procedures, there is insufficient data regarding the morphology of the human cystic duct. In the present study, transmission electron microscopic (TEM) and scanning electron microscopic (SEM) survey of several surgical and autopsy cystic ducts in cholelithiasis and cholesterolosis is reported. In cholelithiasis, similar to gallbladder epithelium, the cystic duct epithelial cells display minor-to-severe alterations of the epithelial surface accompanied by variable erosion of the epithelium. Areas of intact surface epithelium demonstrate microvilli-covered cells coated by a rich glycocalyx and mucous production. In other areas, apical excrescences are associated with mucus hyperproduction and secretory events. Lipoid bodies are also present in many cells and especially in many of the cells' subliminal apical areas. In cholesterolosis, mucous secretory granules appear dilated, fatty deposits are infrequent, and peculiar intracellular cholesterol deposits can be detected in the apical and subapical region of cells and around condensed mitochondria. Following elective cholecystectomies, predominantly in association with cholelithiasis, eroded areas were detected; therefore, it appears that the action of intraluminal calculi may be a principal causative factor in discrete epithelial erosions of the cystic duct. Intraluminal calculi/ debris, along with the alteration of mucus, cell sloughing, and a decreased pool of bile acids and motility may participate in the gallstone nucleation process. The peculiar cholesterol inclusions may also play a role in that nucleating process.

Ultrastructural aspects of human gallbladder epithelial cells in cholelithiasis: production of anionic mucus

The surface epithelium of 28 gallbladders removed during elective cholecystectomies and pathology collection was studied ultrastructurally. Focusing on 10 of the 28 cases that were diagnosed as cholecystitis, we found that the epithelium displayed numerous apical mucous granules and bulging apical apices. Mucous granule changes included 1) hyperproduction of secretory granules of neutral type containing an electron-dense proteinaceous spherule, similar to that described in other mucus-producing glands of the digestive system, and 2) production of anionic, osmiophilic secretory mucus. Other alterations of the surface epithelial cells included the production of bizarre surface appendages resembling primitive cilia without axoneme and epithelial excrescences.

Ultrastructural changes of female Syrian hamster cystic duct epithelium as a result of sex steroid treatment

In view of the lack of sufficient data regarding the morphology of the cystic duct and the extensive focus on the gallbladder, a preliminary examination of the cystic duct response to female sex steroid treatment was conducted to follow up a detailed ultrastructural study of the gallbladder epithelial response to a similar treatment. As observed in the gallbladder epithelium, the cystic duct epithelial cells of nulliparous Syrian hamsters demonstrate morphologic changes in response to female sex steroid treatment. Control (C) cystic duct epithelial cells are covered by short microvilli and each cell appears to exhibit a single vestigial cilium. Estrogen (E)- and estrogen + medroxyprogesterone (E + MP)-treatments induce differential duct cell morphologic changes. These changes are the result of steroid treatments in the significant decreasing sequence E > E + MP > C for nuclear volume, indentations and perinuclear lysosomal/lipofuscin bodies. Moreover E + MP-treatment results in larger cytoplasmic volume and more sloughing of apical cell excrescences than following E treatment. It is suggested that, similar to that in the gallbladder, the action of progestin is paramount in favoring cytoplasmic morphological changes in the cystic duct which, along with the alteration of mucus, cell sloughing, decreased bile acids and motility could also participate in the gallstone nucleation process as they are brought into the gallbladder with the incoming bile flow.

Morphological aspects of female Syrian hamster gallbladder induced by one-month sex steroid treatment

Light (LM), transmission (TEM), and scanning (SEM) electron microscopy were used to characterize morphological changes induced in the gallbladder epithelium of female Syrian hamsters in response to one-month estradiol alone (E) and estradiol with medroxyprogesterone (E + MP) treatments. TEM data were correlated with the SEM observations. Compared with control (C), E- and E + MP-treated hamsters showed significant decreases in body weight, while the liver and gallbladder, and uterus weights increased. Moreover, E treatment induced some subcellular changes (microvilli, nucleus, mitochondria, RER, glycogen, abundant apical granules). The E + MP treatment appeared to exacerbate these similar changes and, in addition, induced apical excrescences and cell shedding. Both E and E + MP gallbladders showed luminal micelles, cellular debris and crystalliths associated with mucus. Simultaneously, an increased acidification of the mucoid content of the apical granules was noticed.

Epithelial surface changes and induction of gallstones in the male Syrian hamster gallbladder as a result of a two-month sex steroid treatment

Transmission (TEM) and scanning (SEM) electron microscopic observations were correlated to characterize morphologic changes induced in the gallbladder of male Syrian hamsters following a two-month estradiol (E) and estradiol + medroxyprogesterone (E + MP) treatment. Compared to control (C), E-treated surface epithelial cells show pleomorphism, cytoplasmic vacuolizations, apical granules, excrescences and decapitations, and small gallstone-like deposits. Following both E + MP treatment, a large accumulation of apical granules containing acidic mucoid products, abundant intraluminal deposits and numerous fields of observation suggest that cell debris and mucous condensation could participate in the formation of the large intraluminal gallstone-like deposits detected as a result of this treatment. In control gallbladders these events were never observed. MP added to E also increases liver and gallbladder weight as well as blood lipid levels. These findings complement and confirm other previous data obtained following short steroid treatment in male, ovariectomized and intact female hamsters. In addition, these results support our hypothesis that gallstone nucleation and growth originate from multiple factors, hormonal disturbance, modulation of liver lipid metabolism, production of cell debris and mucus, can be responsible for the initial gallstone nucleation.

Cytometric study of the female Syrian hamster gallbladder epithelium following sex steroid administration

This report is a cytometric study of the female Syrian hamster gallbladder epithelium following 1-, 2-, and 3-month administration of female sex steroids. Nulliparous, multiparous, young, old and pregnant hamsters were used in this study. A 1 month treatment with estrogen alone significantly increases the nuclear volume of the gallbladder epithelial cells, while E + P treatment significantly affects the nuclear volume only after a 2 month treatment. On the other hand, E + P and P treatments significantly increase the cell volumes as compared to the E-treated groups, this effect is most striking following the 1 month period. Prolonged sex steroid treatment (2 and 3 month) does not appear to influence the gallbladder epithelial cell and nuclear volumes as dramatically as that observed following the 1 month treatment. The nulliparous, progesterone-treated hamsters appear to have a greater cytoplasmic volume than the multiparous group and this is substantiated by the bulging apices and the luminal cellular excrescences observed with scanning and transmission electron microscopy. These observations are similar to those reported in ovariectomized hamsters (Gilloteaux et al., 1992). Further, the gallbladder epithelial cells and nuclei of the older female hamsters demonstrate an accentuated response to a 1 month sex steroid treatment as compared to the younger hamsters for the same treatment duration. These results enable us to hypothesize that changes induced by a short term sex steroid treatment participate in the gallstone nucleation process, while longer duration of the treatments contribute to progressive enlargement and accumulation of gallbladder calculi.

Apical excrescences in the gallbladder epithelium of the female Syrian hamster in response to medroxyprogesterone

All the intact female Syrian hamsters treated with medroxyprogesterone (MP) for a one-month period, without dietary manipulation, display gallbladder surface epithelial changes, and intraluminal deposits. These changes include excrescences in various stages, bulging, and extrusion of material from the epithelial cells. The most striking scanning electron microscopic observations are the dramatic events, comparable to apocrine-like secretory events observed in another related study using oophorectomized hamsters. Since the hamster gallbladder does not possess mucous goblet cells, it appears that this phenomenon could be a response to the MP treatment, thus providing a larger amount of mucous product than usual with cellular material, in addition to the possible alteration in the quality of the bile following this treatment. As a result of MP treatment, intraluminal deposits were also confirmed by using light and transmission electron microscopy. In control hamsters these events were not observed, however, small blebs outlining surface epithelial cells are seen. The results in this report complement the previous studies using the male and oophorectomized Syrian hamster model subjected to similar experimental conditions.

Sex steroid induction of gallstones in the male Syrian hamster

Light (LM), transmission (TEM) and scanning (SEM) electron microscopic techniques were used to characterize morphologic changes induced in the gallbladder of Syrian hamsters following a one-month estradiol (E) and estradiol + medroxyprogesterone (E+MP) treatment. The TEM results were correlated with the SEM findings. Compared to control (C), E-treated surface epithelial cells contain abundant RER, enlarged Golgi, multivesicular (foamy-heterophagosomes) bodies or lipofuscin inclusions. A 10-day E treatment showed large vesicles develop and, after longer E treatment, they could coalesce and create some of the large multivesicular bodies. Interestingly, E+MP epithelia are characterized by distinct bulging apices where a large number of apical granules accumulate, and contain an anionic mucous core. After a 4-week E+MP treatment, even though all the hamsters were fed a diet with trace cholesterol, significant increase in hamster liver weight, serum level of cholesterol and HDL were measured and, correspondingly, gallstones were found exclusively in E+MP-treated hamsters. Our results showed that not only does the Syrian hamster provide an appropriate model to study experimental lithogenesis without manipulating the diet. In addition, MP appears to induce morphologic changes associated with the formation of gallstones.

Female sex steroid induced epithelial changes in the gallbladder of the ovariectomized Syrian hamster

Ovariectomized Syrian hamsters treated by female sex steroids during a 1-month period show gallbladder surface epithelial changes in the fundic area consistent with apical bulging and decapitations of the epithelial cells. These events were detected in the infundibulum and the fundic or body regions of estrogen- and estrogen+progesterone-treated hamsters. In control hamsters, these events were restricted to the region in the vicinity of the bile duct. Following steroid treatment, intraluminal deposits detected resembled Ca-bilirubinate deposits described in previous studies while decapitations are similar to endometrial epithelium changes associated with hormonal physiological changes or treatments. Moreover some small electron-dense deposits are comparable to those found in human cholesterol gallstones. This report indicates that, besides an alteration in bile composition, cell fragments originating from the surface epithelium of the bile duct and/or of the gallbladder mucosal epithelium could participate in gallstone nucleation.

Primary hyperparathyroidism during pregnancy

Historically, primary hyperparathyroidism during pregnancy was associated with significant risk of maternal morbidity and fetal death. Maternal hypercalcemia results in fetal hypercalcemia, leading to suppression of fetal parathyroid gland function. Neonatal hypocalcemia with tetany is a common occurrence after birth when maternal calcium flow is interrupted. From 1930 to 1990, 109 cases of women with primary hyperparathyroidism associated with pregnancy have been reported, 39 of whom were treated surgically before delivery. Although fetal mortality rates for medically treated women have improved, fetal morbidity continues to remain higher than in women who undergo surgical treatment of parathyroid disease during pregnancy. Of 850 patients treated surgically for primary hyperparathyroidism since 1960, 12 were pregnant. Four of the patients were treated medically during pregnancy and underwent surgery after delivery; all four infants had neonatal hypocalcemia and tetany. The remaining eight patients were treated surgically during pregnancy: six in the second trimester and two (one with associated pancreatitis and one with hypercalcemic crisis) during the first trimester. There was no fetal or maternal morbidity or death in the surgical group. Parathyroid adenomas were present in 10 of the patients, hyperplasia in one, and parathyroid carcinoma in one. The management of maternal primary hyperparathyroidism diagnosed during pregnancy should be based on the patient's symptoms and severity of disease. Hyperparathyroidism characterized by progressive symptoms should be treated surgically, preferably during the second trimester. Symptom-free patients and those with mild hypercalcemia diagnosed in the third trimester may be managed medically, postponing operation until after delivery.

Osteitis fibrosa cystica (brown tumor) of the spine with cord compression: report of a case with needle aspiration biopsy findings

A case of osteitis fibrosa cystica or brown tumor of bone in a patient presenting with acute spinal cord compression that was suggested initially by needle aspiration biopsy of the spine is described. Following the aspiration biopsy, excision of vertebral lesions, cord decompression, and spinal fusion were successfully performed. A parathyroid adenoma was subsequently identified and also resected. Along with the diagnosis of malignancy, the presence of hyperparathyroidism with osteitis fibrosa cystica should be considered in a patient presenting with lytic lesions in bone, especially if they are associated with hypercalcemia. Serum parathormone level determination is usually diagnostic of hyperparathyroidism, but this test has a 7-10-day turnaround time. Preoperative needle aspiration biopsy is a safe and rapid method of diagnosing osteitis fibrosa cystica and may be of critical importance in a patient with acute and progressive symptoms such as cord compression.

Pseudogout as a clue and complication in primary hyperparathyroidism

The pseudogout syndrome has been suggested to be a diagnostic clue of hyperparathyroidism or a complication after parathyroidectomy that abruptly relieves hypercalcemia. In this report of 20 patients who had pseudogout, eight had intermittent attacks of arthritis associated with chondrocalcinosis that led through the pseudogout syndrome to a confirmed diagnosis of primary hyperparathyroidism. In an additional 12 patients, the diagnosis of pseudogout was made in patients who suffered from acute arthritis after parathyroidectomy that relieved the primary hyperparathyroidism. The postoperative attacks were seen most commonly on or after the second day after surgery and were associated with the lowest point in serum calcium levels. Pseudogout occurred in one or more joints, often involving the knee. The diagnosis was proved by aspiration of joint synovial fluid in many of the patients and identification of calcium pyrophosphate dihydrate crystals. To estimate the incidence of pseudogout in the population of patients with primary hyperparathyroidism, these 20 patients were distinguished in 531 patients undergoing parathyroidectomy, for a 3.8% incidence of the pseudogout feature. No other markers of higher risk for this complication were apparent, including age, sex, biochemistry, or prior history. This collected experience suggests that (1) pseudogout is a biochemical entity associated with primary hyperparathyroidism and may offer a useful clue to the recognition of the disease in screening; (2) acute arthritis after parathyroidectomy is most likely pseudogout, and this complication occurs more frequently than has been recognized previously; (3) patients with hypercalcemia have a high incidence of calcium pyrophosphate dihydrate crystal deposition in articular cartilage (chondrocalcinosis); and (4) relative hypocalcemia after parathyroidectomy is a stimulus for crystal shedding into synovial fluid, which may precipitate acute attacks of pseudogout.

Intercalating agents with covalent bond forming capability. A novel type of potential anticancer agents. 2. Derivatives of chrysophanol and emodin

Fifty-one new C-methyl-modified derivatives of the anthraquinones chrysophanol and emodin or their various methyl ethers were prepared for structure-activity relationship studies of anticancer activity against mouse leukemia L1210 and human leukemia HL-60 cells. Representative compounds were spectrophotometrically studied for their capacity to interact with natural and denatured DNA. In general, those anthraquinones bearing an amino function interact with DNA. 1,8-Dimethoxyanthraquinones are incapable of intercalating into DNA. 1- or 8-Monohydroxymono-methoxyanthraquinones, however, interact with DNA to some extent. No straightforward correlation is apparent between the DNA-affinity data of the compounds studied spectrophotometrically and their cytotoxic effects. Cytotoxic potencies of these compounds on cell growth inhibition during a 72-h period are inversely correlated to their potencies when inhibiting [3H]TdR incorporation into DNA during the initial 30 min of exposure. Surprisingly, some compounds that showed more cytotoxicity did not inhibit initial TdR incorporation (0-30 min), while some others that strongly inhibited TdR incorporation initially did not exhibit cytotoxicity in 72 h. The results suggest that the cytotoxicity produced by these compounds is time dependent and is not a direct result of initial inhibition of DNA replication.

Management of gallstone pancreatitis during pregnancy and the postpartum period

In a 22 year study, 21 women had acute pancreatitis develop during pregnancy (11 women) or within six weeks post partum (ten women). Gallstones were the cause of the pancreatitis in all. Operation during the acute attack of pancreatitis was required in only two. Acute pancreatitis subsided in the remaining 19 patients; they were operated upon during the second trimester or the early postpartum period. During pregnancy, surgical treatment for gallstone pancreatitis should consist of cholecystectomy and exploration of the common bile duct without operative cholangiography. During the postpartum period, operative cholangiography is used to determine whether or not exploration of the common bile duct is necessary. Acute pancreatitis associated with pregnancy is "gallstone" pancreatitis; there is no evidence that pregnancy is a specific etiologic factor in pancreatitis. As opposed to nonoperative treatment of symptomatic gallstone pancreatitis in pregnancy, which is accompanied by maternal morbidity or fetal mortality, surgical treatment during the optimal time of the second trimester or early postpartum period was associated with no maternal morbidity or fetal mortality and no recurrent pancreatitis.

Human gallbladder mucosa ultrastructure: evidence of intraepithelial nerve structures

The zinc iodide-osmium tetroxide (ZIO) fixative-staining method was used along with topographical ultrastructure to investigate cholecystectomized human gallbladders under light and electron microscopic techniques. This method delineated neuronal structures which may be involved in controlling the functions of the gallbladder epithelium. Three epithelial cell types were described in the surface epithelium: 1) Columnar clear cells; 2) dark, tuft osmiophilic cells; and 3) basal clear cells with electron-dense granules and showing intense ZIOphilic staining properties. While mucous granules were delineated in the first two cell types, the columnar epithelial clear cells are of uncertain function(s) and content but are probably absorptive cells. The small basal clear cells displaying intense ZIOphilia are associated with intraepithelial nerve endings. These nerve structures may have a sensory and/or motor function(s); they were detected throughout the gallbladder epithelial lining and mucosa.

Gallstone pancreatitis: a prospective randomized trial of the timing of surgery

The correct timing of surgery in cases of gallstone pancreatitis is debatable. To delineate more clearly the influence of the timing of surgery in the treatment of the disease, a prospective randomized clinical study of early surgery (less than 48 hours after admission) and delayed surgery (more than 48 hours after admission) was conducted in 165 patients. Ranson's prognostic signs of severity of disease were used to classify the patients into two risk groups: mild pancreatitis (three or fewer positive signs) and severe pancreatitis (more than three positive signs). In patients with three or fewer positive Ranson's signs, the time of surgery appeared to have little effect on the outcome, whereas in patients with more than three positive signs, early surgery resulted in a significant increase in rates of morbidity and mortality. Controlled randomization showed that in patients with gallstone pancreatitis, edematous or hemorrhagic necrotizing pancreatitis can develop, with or without impacted stones, early or late in the progression of the disease, during early or delayed surgery. These findings suggest that (1) although a gallstone initiates a bout of pancreatitis, it does not cause the progression of the disease; (2) the fate of the progression of pancreatitis is decided early by the amount of digestive enzymes being activated; (3) early removal of an impacted stone does not ameliorate the progression of pancreatitis; and (4) surgery should be performed during the initial hospital admission after the pancreatitis has subsided.

Thoracic outlet syndrome

The diagnosis and treatment of thoracic outlet syndrome based on a personal experience with 473 patients resulted in relief of symptoms in over 90 percent of patients treated operatively. The diagnosis centers on a thorough history and the exclusion of other causes of arm and shoulder pain, utilizing a strict flow pattern of differential diagnosis. Angiography and electromyography are of limited value and should only be performed in selected cases. Operation should be reserved for the thoroughly evaluated patient who continues to have pain despite adequate conservative therapy. Transaxillary removal of the first rib, fibromuscular bands, and cervical rib, when present, is the operation of choice.

Primary hyperparathyroidism

An experience with 316 patients operated upon with a presumptive diagnosis of primary hyperparathyroidism is presented. Of the 316 patients, 291 (92.1 per cent) were cured after the initial cervical exploration without using any technique for preoperative localization of parathyroid tissue. Persistent and recurrent hyperparathyroidism occurred in 4.0 and 3.7 per cent, respectively. The success rate for secondary operations (cervical and mediastinal) was 82 per cent. Permanent unilateral vocal cord paralysis occurred in three patients and persistent symptomatic hypercalcemia occurred in another two. Twelve (4 per cent) of the patients had hyperparathyroid crisis and five (1.8 per cent) had carcinoma of the parathyroid gland. The mean follow-up time was six years. Removal of a single macroscopically enlarged gland, if the other glands are normal, is all that needs to be done in most instances. Subtotal parathyroidectomy should be preserved for those patients who have diffuse glandular hyperplasia.