Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram

OBJECTIVES

The reported success rate of pneumatic dilation in patients with achalasia varies from 50% to 93%. This wide variability may be due to using symptom relief post-dilation as the only assessment of success. There are no studies comparing subjective symptom improvements to objective improvement in esophageal emptying after pneumatic dilation.

METHODS

Patients with achalasia undergoing pneumatic dilation from 1995 to 1997 were evaluated. Pre- and post-dilation symptoms were recorded using a standardized scoring system. Barium column height was measured 1 min and 5 min after upright ingestion to assess esophageal emptying. Based on percentage of total symptom and barium height improvement post-dilation, patients were grouped according to one of nine outcomes; the association between subjective and objective parameters of improvement was tested.

RESULTS

A total of 37 patients underwent 53 pneumatic dilations. There was a significant association (p < 0.001) between improvement in patient symptoms and barium height. In 38 of 53 (72%) pneumatic dilations, the degree of symptom and barium height improvement was similar. Near complete symptom resolution was reported after 26 dilations. In eight of 26 (31%) patients however, there was < 50% improvement in barium height (group A). Compared with the 16 patients with 91-100% improvement in both symptoms and barium height (group B), forward stepwise regression identified age as the only difference between the two groups, with group A patients being significantly (p = 0.04) older.

CONCLUSIONS

Objective assessment of esophageal emptying pre- and post-dilation identifies an important subset of patients with poor esophageal emptying who report near complete symptom resolution. This group may benefit from any early repeat pneumatic dilation.

Esophagectomy with gastric reconstruction for achalasia

PURPOSE

Achalasia is a degenerative esophageal disorder that may result in esophageal failure necessitating resection for restoration of gastrointestinal function. This study evaluates a protocol of esophageal resection and gastric reconstruction for end-stage achalasia.

METHODS

Hospital records, radiographic studies, and resection specimens of patients undergoing esophagectomy and gastric reconstruction were reviewed. Patient outcome was defined by an evaluation of symptoms (early satiety, dysphagia, regurgitation, and reflux), dietary restrictions, and ability to maintain or gain weight. Preoperative, operative, and postoperative variables and pathologic features in the resection specimens were analyzed to determine predictors of outcome.

RESULTS

In a 10-year period, 32 patients underwent esophagectomy with gastric reconstruction for achalasia; 30 (94%) underwent elective surgery and 2 (6%), emergency surgery. No postoperative deaths occurred. Of 29 patients completing telephone interviews, 24 (83%) had no or mild dysphagia; 21 (72%), no or mild regurgitation; 20 (69%), no or mild reflux; and 19 (66%), no or mild early satiety. Twenty-four (83%) patients had no or minimal dietary restrictions; 26 (90%) had no or minimal social dietary restrictions. Postoperative weight was not different from preoperative weight. Of 30 patients, 26 (87%) felt better after esophagectomy and 25 (83%) would have the operation again. There were few predictors of outcome. Younger patients were more likely to have dysphagia ( P =.03).

CONCLUSIONS

Esophagectomy with gastric reconstruction relieves preoperative dysphasia and regurgitation in the majority of patients. Dietary function and weight maintenance are excellent, attesting to the durability of the procedure in patients with end-stage achalasia.

A common ancestor for a subunit in the mitochondrial proton-translocating NADH:ubiquinone oxidoreductase (complex I) and short-chain dehydrogenases/reductases

The proton-translocating NADH:ubiquinone oxidoreductase or complex I is located in the inner membranes of mitochondria, where it catalyzes the transfer of electrons from NADH to ubiquinone. Here we report that one of the subunits in complex I is homologous to short-chain dehydrogenases and reductases, a family of enzymes with diverse activities that include metabolizing steroids, prostaglandins and nucleotide sugars. We discovered that a subunit of complex I in human, cow, Neurospora crassa and Aquifex aeolius is homologous to nucleotide-sugar epimerases and hydroxysteroid dehydrogenases while seeking distant homologs of these enzymes with a hidden Markov model-based search of Genpept. This homology allows us to use information from the solved three-dimensional structures of nucleotide-sugar epimerases and hydroxysteroid dehydrogenases and our motif analysis of these enzymes to predict functional domains on their homologs in complex I.

Comparison of two barium suspensions for dedicated small-bowel series

OBJECTIVE

The in vivo radiographic features of two commercially available formulations of barium used as contrast media in dedicated small-bowel series were compared.

SUBJECTS AND METHODS

Fifty-six consecutive outpatients referred for a dedicated small-bowel series were randomly administered either E-Z-Paque or Entrobar. Representative survey radiographs from each examination were randomized and reviewed by six gastrointestinal radiologists from three institutions. Each observer assigned a numeric score (1 = poor, 2 = fair, 3 = good, and 4 = excellent) that rated the quality of the radiograph with respect to these characteristics: definition of fold pattern, translucency, distention, and integrity of the barium column. Statistical analysis was performed for each characteristic using Wilcoxon's two-sample rank sum test.

RESULTS

All six observers found a statistically significant difference between the two barium formulations for mean scores for definition of fold pattern and translucency. Mean scores for fold pattern were 3.3, 3.0, 3.2, 3.6, 3.3, and 3.4 for Entrobar and 2.1, 2.3, 2.4, 3.2, 2.6, and 2.7 for E-Z-Paque. Mean scores for translucency were 2.5, 2.7, 2.8, 3.1, 2.7, and 3.3 for Entrobar and 1.6, 1.7, 2.1, 2.3, 1.9, and 2.7 for E-Z-Paque. No statistically significant difference was found for mean score for distention or integrity of the barium column.

CONCLUSION

On radiographs, Entrobar was found to have superior characteristics for visualization of fold pattern and translucency but offered no advantages for distention or integrity of the barium column. Improved translucency and definition of fold pattern may translate into improved sensitivity and confidence in diagnosing small-bowel abnormality.

Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial

BACKGROUND

Intrasphincteric injection of botulinum toxin is a new treatment option for achalasia.

AIMS

To compare the immediate and long term efficacy of botulinum toxin with that of pneumatic dilatation.

METHODS

Symptomatic patients with achalasia were randomised to botulinum toxin (22 patients, median age 57 years) or pneumatic dilatation (20 patients, median age 56 years). Symptom scores were assessed initially, and at one, three, six, nine, and 12 months after treatment. Objective assessment included oesophageal manometry initially and at one month, and barium oesophagram initially and at one, six, and 12 months post-treatment.

RESULTS

Pneumatic dilatation resulted in a significantly (p=0.02) higher cumulative remission rate. At 12 months, 14/20 (70%) pneumatic dilatation and 7/22 (32%) botulinum toxin treated patients were in symptomatic remission (p=0.017). Failure rates were similar initially, but failure over time was significantly (p=0.01) higher after botulinum toxin (50%) than pneumatic dilatation (7%). Pneumatic dilatation resulted in significant (p<0.001) reduction in symptom scores, and lower oesophageal sphincter pressure, oesophageal barium column height, and oesophageal diameter. Botulinum toxin produced significant reduction in symptom scores (p<0.001), but no reduction in objective parameters.

CONCLUSIONS

At one year pneumatic dilatation is more effective than botulinum toxin. Symptom improvement parallels objective oesophageal measurements after pneumatic dilatation but not after botulinum toxin treatment for achalasia.

An NADPH-dependent reductase in neonatal pig testes that metabolizes androgens and xenobiotics

We have isolated an NADPH-dependent reductase from neonatal pig testes that metabolizes androgens and a variety of xenobiotics. This enzyme is distinct from 3alpha/beta,20beta-hydroxysteroid dehydrogenase or its homologue, carbonyl reductase, as judged by its immunological and molecular properties and its much narrower specificity for steroids. This reductase and 3alpha/beta,20beta-hydroxysteroid dehydrogenase may be part of a mechanism for regulating androgen levels the neonatal pig testes. Interestingly, we could not find multiple isoforms of 3alpha/beta,20beta-hydroxysteroid dehydrogenase/carbonyl reductase in pig testes unlike human and rat testes and other organs in which multiple isoforms are expressed.

Albumin's role in steroid hormone action and the origins of vertebrates: is albumin an essential protein?

Albumin, the major serum protein, binds a wide variety of lipophilic compounds including steroids, other lipophilic hormones and phytochemicals that bind to hormone receptors. Albumin has a low affinity for these lipophilic compounds. However, due to albumin's high concentration in serum, albumin is a major carrier of steroids and lipophilic hormones and regulator of their access to their receptors. Moreover, albumin functions as a sink for phytochemicals, which prevents their binding to hormone receptors and other cellular proteins, protecting animals from disruptive phytochemical-mediated endocrine effects. We propose that these properties of albumin were important in protochordates and vertebrates about 550 to 520 million years ago, just before and during the Cambrian. At that time, animal body sizes and exposure to phytochemicals in food were increasing, and animals in which albumin expression was high had a selective advantage in surviving and reproducing in the presence of toxic phytochemicals. This hypothesis that albumin has essential function(s) in mammalian endocrine physiology can be tested by comparing the effects of phytochemicals in Nagase rats that have 1/1000 the normal albumin concentration or in mice in which the albumin gene is knocked out with those in normal rats and mice.

Flavonoids as hormones. A perspective from an analysis of molecular fossils

Although for centuries plants have been known to have hormone-like actions in humans, the mechanism(s) by which plant-derived compounds act in humans is still being elucidated, a goal that has assumed more importance due to interest in the protective actions of fruits and vegetables in diseases such as cancer. Here I use the "molecular fossil record" of amino acid sequences of proteins involved in regulating the actions steroids, retinoids, thyroid hormone and prostaglandins to propose some mechanisms by which flavonoids in fruits and vegetables can have hormone-like actions in humans. I focus on: i) hormone receptors that bind to DNA and regulate gene transcription and ii) the enzymes that regulate the concentrations of these hormones. Comparative analyses of amino acid sequences show that nuclear receptors for steroids, retinoids, thyroid hormone and prostaglandins in humans and insects are descended from a common ancestor. Similar analyses of dehydrogenases that regulate the concentrations of steroids, retinoids and prostaglandins reveal strong sequence similarity to enzymes in plants, insects, fungi, and bacteria. The similarity is sufficient to suggest that some compounds that bind receptors or enzymes in invertebrates, plants or unicellular organisms may also bind to mammalian homologs that are involved in endocrine physiology. Among the phytochemicals that are candidates for such activity are flavonoids because they are involved in plant-insect and plant-bacteria interactions and have some structural and chemical similarities to steroids, retinoids, thyroid hormone, prostaglandins and fatty acids. These similarities and the kinship of human, plant, insect and bacterial proteins involved in signal transduction provide a conceptual framework for investigating flavonoids for hormone-like actions in humans. Understanding these modes of action may be useful in developing protocols for preventing hormone-dependent diseases such as breast and prostate cancer.

Mutation of tyrosine-194 and lysine-198 in the catalytic site of pig 3alpha/beta,20beta-hydroxysteroid dehydrogenase

Pig 3alpha/beta,20beta-hydroxysteroid dehydrogenase is an NADPH-dependent enzyme that catalyses the reduction of ketones on steroids and aldehydes and ketones on various xenobiotics, like its homologue carbonyl reductase. 3alpha/beta,20beta-Hydroxysteroid dehydrogenase and carbonyl reductase are members of the short-chain dehydrogenases/reductase family, in which a tyrosine residue and a lysine residue have been identified as catalytically important. In pig 20beta-hydroxysteroid dehydrogenase these residues are tyrosine-194 and lysine-198. Here we report the effect on the reduction of two ketone and two aldehyde substrates by pig 3alpha/beta,20beta-hydroxysteroid dehydrogenase in which tyrosine-194 has been mutated to phenylalanine and cysteine, and lysine-198 has been mutated to isoleucine and arginine. Mutants with phenylalanine-194 or isoleucine-198 are inactive. Depending on the substrate, the mutant with cysteine-194 has a catalytic efficiency of 0.4-1% and the mutant with arginine-198 has a catalytic efficiency of 4-23% of the wild-type enzyme. We also mutated tyrosine-81 and tyrosine-253 to phenylalanine. Although both tyrosines are conserved in 3alpha/beta,20beta-hydroxysteroid dehydrogenase and carbonyl reductase, depending on the substrate, the mutant enzymes are as active as, or more active than, wild-type enzyme.

Evolution of mammalian 11beta- and 17beta-hydroxysteroid dehydrogenases-type 2 and retinol dehydrogenases from ancestors in Caenorhabditis elegans and evidence for horizontal transfer of a eukaryote dehydrogenase to E. coli

Physiological responses due to steroid hormones and retinoids are regulated by their cognate receptors and dehydrogenases. The origins of either regulatory mechanism are not fully understood. Here we examine the origins of the human 11beta-hydroxysteroid dehydrogenase-type 2, which regulates access of glucocorticoids to cells, and 17beta-hydroxysteroid dehydrogenase-type 2, which regulates access of androgens and estrogens to cells. Sequence comparisons trace their ancestry to homologs in Caenorhabditis elegans. These C. elegans proteins most closely resemble mammalian all-trans and 11-cis-retinol dehydrogenases. The similarity is sufficient -37% to 43% identity to suggest that one or more of the C. elegans homologs metabolizes a retinoid. Receptors for retinoids, but not for androgens, estrogens or glucocorticoids have been identified in C. elegans, suggesting that retinoid-mediated gene transcription is more ancient than that for adrenal and sex steroids. We propose that the hydroxysteroid dehydrogenase-type 2 mechanism for regulating the androgen, estrogen and glucocorticoid concentrations in mammals descended from that for regulating retinoid concentrations. Interestingly, E. coli contains a protein with strong sequence similarity to mammalian retinol dehydrogenases. Sequence comparisons and phylogenetic analysis indicate that the E. coli protein may be an example of horizontal transfer from a eukaryote ancestor.

Characterization of Ke 6, a new 17beta-hydroxysteroid dehydrogenase, and its expression in gonadal tissues

The abnormal regulation of the Ke 6 gene has been linked to the development of recessive polycystic kidney disease in the mouse. In this report, we have shown that Ke 6 is a 17beta-hydroxysteroid dehydrogenase and can regulate the concentration of biologically active estrogens and androgens. The Ke 6 enzyme is preferentially an oxidative enzyme and inactivates estradiol, testosterone, and dihydrotestosterone. However, the enzyme has some reductive activity and can synthesize estradiol from estrone. We find that the Ke 6 gene is expressed within the ovaries and testes. The presence of Ke 6 protein within the cumulus cells surrounding the oocyte places it in a strategic location to control the level of steroids to which the egg is exposed. Previously, it had been shown that glucocorticoids can induce renal cysts in the neonatal rodent, only when given at a narrow time window of postnatal kidney development. We propose that the reduction in the level of Ke 6 enzyme, which occurs in the cpk, jck, and pcy mice, may lead to abnormal elevations in local level of sex steroids, which either directly or indirectly via abnormal glucocorticoid metabolism result in recessive renal cystic disease, a developmental disorder of the kidney.

Spinach CSP41, an mRNA-binding protein and ribonuclease, is homologous to nucleotide-sugar epimerases and hydroxysteroid dehydrogenases

Spinach CSP41 is part of a protein complex that binds to the 3' untranslated region (UTR) of petD precursor-mRNA, a chloroplast gene encoding subunit IV of the cytochrome b6/f complex. CSP41 cleaves the 3'-UTR of petD mRNA within the stem-loop structure, suggesting a key role in the control of chloroplast mRNA stability. We discovered that CSP41 is homologous to nucleotide-sugar epimerases and hydroxysteroid dehydrogenases while seeking distant homologs of these enzymes with a hidden Markov model-based search of Genpept. This analysis identified Synechocystis ORF, Accession 1652543 as a homolog. Subsequent analyses show that spinach CSP41 and Arabidopsis thaliana 2765081 are homologous to the Synechocystis ORF. Information from the solved 3D structures of epimerases and dehydrogenases and our motif analysis of these enzymes is used to predict domains on CSP41 that are important in binding and metabolism of mRNA. Cyanobacteria are among the earliest life forms, indicating that the divergence from a common ancestor of nucleotide-sugar epimerases and an mRNA binding protein with ribonuclease activity was ancient.

Flavonoids inhibit estrogen binding to rat alpha-fetoprotein

There is considerable interest in the role(s) of plant-derived compounds such as bioflavonoids in regulating steroid hormone action in mammals, and in particular, the possible effects of the bioflavonoids on the growth of steroid-dependent breast and prostate tumors and on possible abnormal development of steroid-sensitive tissues. Studies of the hormone-like actions of bioflavonoids often use fetal or neonatal rats, which contain high levels of serum alpha-fetoprotein (AFP), a protein that binds estradiol with a Kd approximately 5 x 10(-9) M. Interaction of bioflavonoids with AFP could affect the availability of estrogens to estrogen-responsive cells, as well as the actions of bioflavonoids. These considerations motivated us to study the effect of several flavonoids (quercetin, rutin, naringenin, chrysin, apigenin, kaempferol, myricetin, morin, fisetin) and isoflavonoids (daidzein, genistein) on estrogen binding to rat AFP. We found that naringenin, a flavanone, and quercetin and kaempferol, flavonols, inhibit estrogen binding to AFP with apparent Kds of about 5 x 10(-7) M. To our surprise, the two isoflavonoids, daidzein and genistein, have Kds of about 5 x 10(-6) M for AFP. This 10-fold [correction of 1Q-fold] difference in affinity for AFP between flavonoids and isoflavonoids suggests that AFP has a specificity for the flavonoid structure. Moreover, the affinities of bioflavonoids for rat AFP are sufficiently high to suggest that flavonoids and isoflavonoids could modulate estradiol and estrone binding to rat AFP in vivo, when present at dietary levels. Additionally, the potency of the plant estrogens may be altered by binding to AFP. The flavonoids that we tested have different hydroxyl and glucoside substituents on the A, B, and C rings, which allows us to define some of the spatial requirements for binding to AFP. We find that 5,7-hydroxyl groups in ring A and a 4'-hydroxyl group in ring B are important for binding to AFP. This information, combined with molecular modeling studies, may elucidate the molecular basis for recognition of flavonoids and estrogens by AFP. Also, these findings indicate that the flavonoid levels in the diet need to be considered in studies of the effects of various xenobiotics and endocrine manipulations on experimental animals, particularly during development when serum estrogen binding protein concentrations are often elevated. Finally, bioflavonoids should be useful tools for understanding the variety of estrogen actions initiated by different structural classes of estrogens.

Comparison of examination times between CT scanners: are the newer scanners faster?

OBJECTIVE

The purpose of this study was to determine if a newer technology helical CT scanner can reduce CT examination times.

MATERIALS AND METHODS

Data from 1049 CT examinations were recorded prospectively during a 5-week period. "Room time" was defined as the time each patient spent in the CT room (time patient exited minus time patient entered) and "scanner time" was defined as the time a scanner was dedicated to a specific patient (longer of either time that image processing was complete minus time patient entered room, or total time that patient spent in the scanner room). Data to calculate the room and scanner times were recorded along with the scanner type, examination protocol, and five other covariates. Both times were calculated for the 10 most common examination protocols (n = 769 patients) and compared between the older and newer model CT scanner using analysis of covariance models. The most common protocols were abdomen and pelvis (n = 211); head (n = 146); chest (n = 99); simple sinus (n = 99); and chest, abdomen, and pelvis (n = 68).

RESULTS

The mean room and scanner times, adjusted for covariates, were both significantly shorter for the newer scanner (p = .0001). The results for room time were statistically significant for six of the 10 examination protocols (84% of examinations). Likewise, the results for scanner time were statistically significant for four examination protocols (68% of examinations). Examination times were longer for inpatients (p = .0001) and when problems occurred during the examination (p = .0001). Sex and age did not significantly affect examination times (p > .08).

CONCLUSION

The newer helical CT scanner we studied significantly reduced the time for many types of examinations.

Steroid receptor phylogeny and vertebrate origins

Vertebrates appear about 500 million years ago in the fossil record. This is only 25-50 million years after the great explosion of multicellular invertebrate body plans in the early Cambrian. On a geological time scale, this interval is a 'blink of an eye', suggesting that the evolution of regulatory genes is likely to be important in the origins of vertebrates. Here we present evidence for a role of steroid receptors in this process based on a phylogenetic analysis suggesting that receptors for androgens, glucocorticoids, mineralocorticoids, and progesterone evolved from an ancestral steroid receptor gene by two successive duplications over a brief time that could have coincided with the origins of vertebrates. Moreover, the duplications of these steroid receptors may be additional evidence for the two duplications on a genome-scale that have been proposed to be important in the evolution of vertebrates. The two successive duplications of steroid receptor genes and their subsequent sequence divergence leading to steroid-specific receptors that regulate growth, development, reproduction and homeostasis in vertebrates may have been one of the events important in vertebrate survival after the Cambrian during global extinctions that occurred about 440 and 370 million years ago.

Physiological "constants" for PBPK models for pregnancy

Physiologically based pharmacokinetic (PBPK) models for pregnancy are inherently more complex than conventional PBPK models due to the growth of the maternal and embryo/fetal tissues. Physiological parameters such as compartmental volumes or flow rates are relatively constant at any particular time during gestation when an acute experiment might be conducted, but vary greatly throughout the course of gestation (e.g., contrast relative fetal weight during the first month of gestation with the ninth month). Maternal physiological parameters change during gestation, depending upon the particular system; for example, cardiac output increases by approximately 50% during human gestation; plasma protein concentration decreases during pregnancy; overall metabolism remains fairly constant. Maternal compartmental volumes may change by 10-30%; embryo/fetal volume increases over a billionfold from conception to birth. Data describing these physiological changes in the human are available from the literature. Human embryo/fetal growth can be well described using the Gompertz equation. By contrast, very little of these same types of data is available for the laboratory animal. In the rodent there is a dearth of information during organogenesis as to embryo weights, and even less organ or tissue weight or volume data during embryonic or fetal periods. Allometric modeling offers a reasonable choice to extrapolate (approximately) from humans to animals; validation, however, is confined to comparisons with limited data during the late embryonic and fetal periods of development (after gestation d 11 in the rat and mouse). Embryonic weight measurements are limited by the small size of the embryo and the current state of technology. However, the application of the laser scanning confocal microscope (LSCM) to optically section intact embryos offers the capability of precise structural measurements and computer-generated three-dimensional reconstruction of early embryos. Application of these PBPK models of pregnancy in laboratory animal models at teratogenically sensitive periods of development provides exposure values at specific target tissues. These exposures provide fundamentally important data to help design and interpret molecular probe investigations into mechanisms of teratogenesis.

MLN64 contains a domain with homology to the steroidogenic acute regulatory protein (StAR) that stimulates steroidogenesis

MLN64 is a protein that is highly expressed in certain breast carcinomas. The C terminus of MLN64 shares significant homology with the steroidogenic acute regulatory protein (StAR), which plays a key role in steroid hormone biosynthesis by enhancing the intramitochondrial translocation of cholesterol to the cholesterol side-chain cleavage enzyme. We tested the ability of MLN64 to stimulate steroidogenesis by using COS-1 cells cotransfected with plasmids expressing the human cholesterol side-chain cleavage enzyme system and wild-type and mutant MLN64 proteins. Wild-type MLN64 increased pregnenolone secretion in this system 2-fold. The steroidogenic activity of MLN64 was found to reside in the C terminus of the protein, because constructs from which the C-terminal StAR homology domain was deleted had no steroidogenic activity. In contrast, removal of N-terminal sequences increased MLN64's steroidogenesis-enhancing activity. MLN64 mRNA was found in many human tissues, including the placenta and brain, which synthesize steroid hormones but do not express StAR. Western blot analysis revealed the presence of lower molecular weight immunoreactive MLN64 species that contain the C-terminal sequences in human tissues. Homologs of both MLN64 and StAR were identified in Caenorhabditis elegans, indicating that the two proteins are ancient. Mutations that inactivate StAR were correlated with amino acid residues that are identical or similar among StAR and MLN64, indicating that conserved motifs are important for steroidogenic activity. We conclude that MLN64 stimulates steroidogenesis by virtue of its homology to StAR.

Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia

OBJECTIVE

Our purpose was to define a simple technique for timing a barium swallow by which radiologists can assess esophageal emptying in patients with achalasia before and after minimally invasive therapy. Our purpose was also to determine the best method of quantifying the degree of emptying using this timed technique.

MATERIALS AND METHODS

In the barium swallow technique, upright frontal spot films of the esophagus are obtained at 1, 2, and 5 min after ingestion of 100-200 ml of low-density (45% weight in volume) barium sulfate (volume of barium determined by patient tolerance). Forty-two of these barium swallows done by 23 patients with achalasia were retrospectively reviewed. The examination served either as a baseline study or as a 1-month follow-up study after patients had undergone pneumatic dilatation or Clostridium botulinum toxin injection. The spot films were digitized, and a region of interest was drawn around the column of barium by two observers. The change in area seen in the region of interest on the 1- and 5-min films served as the gold standard for percentage of emptying. The spot films were then analyzed by four other observers, each of whom independently, subjectively, and qualitatively estimated the percentage of emptying between the 1- and 5-min spot films. Percentages were divided into quintiles. On a separate occasion, each of these four observers also independently measured the height and width of the barium column on the 1- and 5-min spot films. The product of height times width seen on the 1- and 5-min films became the quantitative estimate for percentage of emptying.

RESULTS

We found no statistically significant difference between the percentage of emptying as measured on the digitized images by the two observers and the height-times-width calculations or qualitative emptying percentage as estimated by the four observers. Interobserver agreement for the area evaluated on the digitized films as well as the height-times-width measurements and qualitative estimates of emptying was almost perfect (the correlation coefficients being 0.99, 0.87, and 0.93, respectively).

CONCLUSION

The timed barium swallow is a simple and reproducible technique. Both qualitative assessment and estimated change in area based on height-times-width measurements of the barium column are accurate methods of estimating esophageal emptying.

Meta-MEME: motif-based hidden Markov models of protein families

MOTIVATION

Modeling families of related biological sequences using Hidden Markov models (HMMs), although increasingly widespread, faces at least one major problem: because of the complexity of these mathematical models, they require a relatively large training set in order to accurately recognize a given family. For families in which there are few known sequences, a standard linear HMM contains too many parameters to be trained adequately.

RESULTS

This work attempts to solve that problem by generating smaller HMMs which precisely model only the conserved regions of the family. These HMMs are constructed from motif models generated by the EM algorithm using the MEME software. Because motif-based HMMs have relatively few parameters, they can be trained using smaller data sets. Studies of short chain alcohol dehydrogenases and 4Fe-4S ferredoxins support the claim that motif-based HMMs exhibit increased sensitivity and selectivity in database searches, especially when training sets contain few sequences.

Spiral noncontrast CT versus combined plain radiography and renal US after extracorporeal shock wave lithotripsy: cost-identification analysis

PURPOSE

To investigate the costs of spiral computed tomography (CT) versus those of combined plain radiography and renal ultrasound (US) in screening for postprocedural complications after extracorporeal shock wave lithotripsy (ESWL).

MATERIALS AND METHODS

Twenty-five adult patients who had undergone ESWL were prospectively examined with spiral CT, renal US, and plain abdominal radiography. Each examination was timed, and direct technical costs were calculated by using a procedural-based cost-accounting system. The combined cost of US and plain radiography was compared with the cost of spiral CT.

RESULTS

The average time for spiral CT was 15.3 minutes compared with 37.2 minutes for combined US and plain radiography. The direct technical cost of spiral CT was $36.86 compared with $57.60 for combined US and plain radiography. Average examination times were varied to assess the effect on overall costs. Within reasonable time ranges, combined US and plain radiography cannot be cost equivalent to spiral CT.

CONCLUSION

Spiral CT is faster and is associated with less direct technical cost than combined US and plain radiography when used to examine patients after ESWL, given the dependence of this model on time of examination. Further studies are needed to assess the relative accuracy of these alternative approaches.

Local recurrence of rectal cancer: evaluation with F-18 fluorodeoxyglucose PET imaging

BACKGROUND

Positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) is a useful technique for detection of malignancy. The purpose of this study was to determine if FDG-PET scanning using visual and quantitative analyses can identify patients with recurrent colorectal tumor following abdominoperineal resection.

METHODS

Eighteen patients were evaluated for possible local recurrence of rectal carcinoma following abdominoperineal resection. The clinical presentation included rising carcinoembryonic antigen levels (n = 5), increasing size of a presacral mass on computed tomography or magnetic resonance (n = 13), or local symptoms (n = 3). Axial PET images of the pelvis were obtained following an injection of 10 mCi of FDG prior to biopsy. Quantitative analysis was performed by calculation of a standardized uptake ratio (SUR), and the images were interpreted by two radiologists in consensus. FDG-PET findings were correlated with histological or cytological findings and with the clinical outcome.

RESULTS

Recurrent malignancy was confirmed in 13 patients by surgery (n = 8) or percutaneous biopsy (n = 5). Benign lesions were confirmed in five patients by surgery (n = 1), biopsy (n = 3), or clinical follow up (n = 1). Visual analysis of the FDG-PET data had a sensitivity of 92.3% (12/13) for recurrent disease (95% confidence limits; 63.9%, 99.8%) and a specificity of 80% (4/5; 95% confidence limits; 28.3%, 99.4%). SUR values were significantly higher in malignant lesions (range = 2.92-19.74, mean = 6.89) than in benign ones (range = 1.40-3.47, mean = 1.96; p = 0.002).

CONCLUSION

FDG-PET is an accurate technique for detection of locally recurrent colorectal carcinoma. Visual analysis is equivalent to quantitative analysis for detection of disease.

An artificial intelligence approach to motif discovery in protein sequences: application to steriod dehydrogenases

MEME (Multiple Expectation-maximization for Motif Elicitation) is a unique new software tool that uses artificial intelligence techniques to discover motifs shared by a set of protein sequences in a fully automated manner. This paper is the first detailed study of the use of MEME to analyse a large, biologically relevant set of sequences, and to evaluate the sensitivity and accuracy of MEME in identifying structurally important motifs. For this purpose, we chose the short-chain alcohol dehydrogenase superfamily because it is large and phylogenetically diverse, providing a test of how well MEME can work on sequences with low amino acid similarity. Moreover, this dataset contains enzymes of biological importance, and because several enzymes have known X-ray crystallographic structures, we can test the usefulness of MEME for structural analysis. The first six motifs from MEME map onto structurally important alpha-helices and beta-strands on Streptomyces hydrogenans 20beta-hydroxysteroid dehydrogenase. We also describe MAST (Motif Alignment Search Tool), which conveniently uses output from MEME for searching databases such as SWISS-PROT and Genpept. MAST provides statistical measures that permit a rigorous evaluation of the significance of database searches with individual motifs or groups of motifs. A database search of Genpept90 by MAST with the log-odds matrix of the first six motifs obtained from MEME yields a bimodal output, demonstrating the selectivity of MAST. We show for the first time, using primary sequence analysis, that bacterial sugar epimerases are homologs of short-chain dehydrogenases. MEME and MAST will be increasingly useful as genome sequencing provides large datasets of phylogenetically divergent sequences of biomedical interest.

Hidden Markov model analysis of motifs in steroid dehydrogenases and their homologs

The increasing size of protein sequence databases is straining methods of sequence analysis, even as the increased information offers opportunities for sophisticated analyses of protein structure, function, and evolution. Here we describe a method that uses artificial intelligence-based algorithms to build models of families of protein sequences. These models can be used to search protein sequence databases for remote homologs. The MEME (Multiple Expectation-maximization for Motif Elicitation) software package identifies motif patterns in a protein family, and these motifs are combined into a hidden Markvov model (HMM) for use as a database searching tool. Meta-MEME is sensitive and accurate, as well as automated and unbiased, making it suitable for the analysis of large datasets. We demonstrate Meta-MEME on a family of dehydrogenases that includes mammalian 11 beta-hydroxysteroid and 17 beta-hydroxysteroid dehydrogenase and their homologs in the short chain alcohol dehydrogenase family. We chose this dataset because it is large and phylogenetically diverse, providing a good test of the sensitivity and selectivity of Meta-MEME on a protein family of biological interest. Indeed, Meta-MEME identifies at least 350 members of this family in Genpept96 and clearly separates these sequences from non-homologous proteins. We also show how the MEME motif output can be used for phylogenetic analysis.

Bacterial 3alpha-hydroxysteroid dehydrogenase is homologous to a fusion of bacterial ribosomal L10 and L7/12 genes

3alpha-Hydroxysteroid dehydrogenase catalyzes the reversible oxidation of 3alpha-hydroxyl groups of the steroid nucleus. Sequence analysis reveals that this enzyme is homologous to ribosomal proteins L10 and L7/12. The alignment suggests that 3alpha-hydroxysteroid dehydrogenase is formed by a fusion of the two ribosomal proteins.