Results of laparoscopic fundoplication where atypical symptoms coexist with oesophageal reflux

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has been increasingly performed for gastro-oesophageal reflux disease. The outcomes of LNF for patients with concurrent symptoms other than heartburn are unclear. The purpose of the present paper was to review the outcomes of LNF performed by one surgeon over 4 years and compare the outcomes of patients with reflux symptoms with those of patients having reflux symptoms plus atypical symptoms.

METHODS

The records of a consecutive series of 90 patients were reviewed. Preoperative symptoms were defined as typical (heartburn and reflux) or atypical (other symptoms, e.g. cough, atypical chest pain, choking). At the time of follow up an independent observer interviewed patients, and collected data on current symptoms and patient satisfaction. A questionnaire of current symptoms and patient satisfaction was completed. A satisfaction score from 1 to 10 was given by patients, with 1 being very unsatisfied and 10 being very satisfied.

RESULTS

Of the 90 patients, 97% had typical symptoms and 56% had concurrent atypical symptoms. Eighty-three of 90 patients were contacted; typical reflux symptoms improved in 95% of patients whereas atypical symptoms improved in only 54%. Overall, the mean satisfaction score was 8.7. Patients with atypical symptoms had a lower satisfaction score of 8.0 versus a satisfaction score of 9.0 for patients with only typical symptoms (P < 0.05). Patients with a satisfaction score < 8.0 had a higher rate of atypical symptoms (75%) than patients with a satisfaction score > or = 8 (50%).

CONCLUSION

Laparoscopic Nissen fundoplication controlled typical reflux symptoms very well but atypical symptoms were improved in only approximately 50%. A lower satisfaction score was associated with preoperative atypical symptoms.

The CardioVision 2020 baseline community report card

OBJECTIVE

To establish baseline data for the CardioVision 2020 program, a collaborative project in Olmsted County, Minnesota, organized to reduce cardiovascular disease rates by altering 5 health-related items: (1) eliminating tobacco use and exposure, (2) improving nutrition, (3) increasing physical activity, (4) lowering serum cholesterol level, and (5) controlling blood pressure.

SUBJECTS AND METHODS

Data about tobacco use, diet, and physical activity were collected by random digit dial interview and follow-up questionnaire from a sample of the population. Blood pressure data were collected from medical records at Mayo Clinic, and serum cholesterol data were derived from the Mayo Clinic laboratory database. Data were stratified into 6 age groups.

RESULTS

A total of 624 women and 608 men responded to the questionnaire. Population blood pressure data were available for 1,956 women and 1,084 men. Population serum cholesterol data were available for 17,042 women and 12,511 men. Except for women in the 30- to 39-year-old age group, less than 10% of the population sampled met 4 or 5 goals. Conversely, about 90% of the population met at least 1 goal, and about 80% met 1, 2, or 3 of the goals.

CONCLUSION

The data from the Olmsted County population indicate considerable opportunity to reduce this population's burden of cardiovascular disease.

A pilot study on the effects of exercise in patients with systemic lupus erythematosus

OBJECTIVE

A pilot study was designed to assess the efficacy and safety of different exercise therapies on patient-reported fatigue and functional status.

METHODS

Ten patients with systemic lupus erythematosus (SLE) were randomly placed in either an aerobic exercise group (group 1: n = 5) or a range of motion/muscle strengthening (ROM/MS) exercise group (group 2: n = 5). Outcome measures assessed at baseline and the end of the study were fatigue, functional status, disease activity, cardiovascular fitness, isometric strength, bone mineral density (BMD) of the lumbar spine and femoral neck, and parathyroid hormone and osteocalcin as representative bone biochemical markers for bone resorption and bone formation, respectively.

RESULTS

Both aerobic and ROM/MS types of exercise were safe and did not worsen SLE disease activity. Patients in both exercise groups showed some improvement in fatigue, functional status, cardiovascular fitness, and muscle strength. Both groups showed increased bone turnover, but BMD was unchanged. Eighty percent of the patients met the compliance standard for the study.

CONCLUSIONS

This pilot study shows the feasibility of exercise for SLE patients. The potential value of this approach shows promise in the routine management of these patients.

Nuclear and nucleolar localization of parathyroid hormone-related protein

Parathyroid hormone-related protein (PTHrP) was first discovered as the factor causing hypercalcaemia produced by solid tumours frequently associated with the head and neck, breast, lung and kidney. The homology of its amino-terminus to parathyroid hormone (PTH; eight of the first 13 residues are identical), enables it to share the same receptor and perform similar biological functions to PTH. The sequences of PTHrP C-terminal to its PTH-like region confer functions such as transplacental calcium transport, renal bicarbonate excretion and in vitro osteoclast inhibition. Recent findings have shown that PTHrP is a nuclear/nucleolar protein in certain tissues and that this localization is cell cycle-regulated, mediated by the middle portion of the molecule, and involves the nuclear import receptor importin beta1. The present review discusses what is known about the pathway by which PTHrP localizes to the nucleus/nucleolus and the putative roles it may have there.

Comparison of macular versus paramacular retinal sensitivity to femtosecond laser pulses

Single 130 fs laser pulses in the near-IR (800 nm) were used to create ophthalmoscopically viewed minimum visible lesions (MVLs) within the macular and paramacular regions in rhesus monkey eyes. MVL thresholds at 1 and 24 h are reported as the 50% probability for damage (ED50) together with their fiducial limits at the 95% confidence level. These measured thresholds are compared with previously reported thresholds for near-IR and visible wavelengths for both macular and paramacular areas. Threshold doses were lower at the 24 h reading than at the 1 h reading for both retinal regions and the ED50s for the macula were slightly lower than for the paramacula. We measured the 24 h MVL ED50 thresholds to be 0.35 and 0.55 microJ for the macular and paramacular areas, respectively. The combined data for both areas yielded a threshold of 0.45 microJ.

The Absolute Abundance of Iron in the Solar Corona

We present a measurement of the abundance of Fe relative to H in the solar corona using a technique that differs from previous spectroscopic and solar wind measurements. Our method combines EUV line data from the Coronal Diagnostic Spectrometer (CDS) on the Solar and Heliospheric Observatory with thermal bremsstrahlung radio data from the VLA. The coronal Fe abundance is derived by equating the thermal bremsstrahlung radio emission calculated from the EUV Fe line data to that observed with the VLA, treating the Fe/H abundance as the sole unknown. We apply this technique to a compact cool active region and find Fe&solm0;H=1.56x10-4, or about 4 times its value in the solar photosphere. Uncertainties in the CDS radiometric calibration, the VLA intensity measurements, the atomic parameters, and the assumptions made in the spectral analysis yield net uncertainties of approximately 20%. This result implies that low first ionization potential elements such as Fe are enhanced in the solar corona relative to photospheric values.

Strategic diel regulation of body mass in European robins

Stochastic dynamic programming (SDP) is a computational technique that has been used to model daily routines of foraging in small birds. A diurnal bird must build up its fat reserves towards dusk in order to avoid starvation during the night, when it cannot feed. However, as well as the benefits of avoiding starvation, storing fat imposes costs such as an increased predation risk and higher flight and metabolic costs. There is therefore an optimal level of fat reserves for a bird to reach at dusk in order to survive overnight without being left with excessive fat reserves at dawn. I tested a prediction common to all SDP models of daily foraging routines, that a bird will attempt to reach this level at dusk, regardless of its fat reserves the previous dawn. I provided supplementary food to manipulate the fat reserves at dawn of free-living European robins, Erithacus rubecula. Diurnal changes in body mass (a reliable estimate of fat reserves) were then monitored remotely. Robins provided with an ad libitum food supply reached almost exactly the same body mass at dusk, regardless of their body mass at dawn, supporting the prediction that birds attempt to reach a target level of reserves at dusk. Copyright 2000 The Association for the Study of Animal Behaviour.

Methylation of exon 2 of p16 is associated with late stage oesophageal cancer

Methylation of the p16 gene was studied in 16 oesophageal tumours. Five (31%) of the tumours were found to be methylated in exon 1 and eight (50%) were methylated in exon 2. The loss of p16 protein correlated with methylation of exon 1 (P = 0.005). However, methylation of exon 2, but not exon 1, was found to be associated with late stage tumours (P = 0.01). We conclude that the methylation of exon 2 of p16 may have effects on the progression of oesophageal tumours that are independent of the expression of the p16 protein.

Localization of RANKL (receptor activator of NF kappa B ligand) mRNA and protein in skeletal and extraskeletal tissues

RANKL (receptor activator of NFkappaB ligand) is a membrane-associated osteoblastic molecule, and along with macrophage-colony-stimulating factor, is crucial for osteoclast formation. RANKL is known to be strongly expressed in osteoblasts and lymphoid tissues. We have sought to determine the skeletal and extraskeletal sites of production of RANKL mRNA and protein using the techniques of in situ hybridization and immunohistochemistry. Expression of RANKL mRNA and protein were determined in the developmental progression of endochondral bone formation in mouse, intramembranous bone formation in a rabbit model (mRNA only), in human giant cell tumors of bone, and at extraskeletal sites in the mouse. RANKL mRNA was expressed in prehypertrophic and hypertrophic chondrocytes at day E15 embryonic mouse long bone, and its expression was maintained at these sites throughout development. In newborn and adult mice, high levels of RANKL mRNA were expressed in mesenchymal cells of the periosteum and in mature osteoblasts, while megakaryocytes within the marrow microenvironment expressed RANKL mRNA from 1 week of age. Immunohistochemical analysis revealed a similar localization pattern of RANKL protein at the sites described. In the intramembranous bone formation model, RANKL mRNA was expressed in mesenchymal cells and in actively synthesizing osteoblasts, but not in flattened lining osteoblasts or late osteocytes. Expression of RANKL mRNA and protein in osteoclasts was variable with those within resorption lacunae showing the strongest signal/staining. Likewise, expression varied in osteoclasts from giant cell tumor of bone with a minority of tartrate-resistant acid phosphatase-positive multinucleated cells having no detectable RANKL mRNA or protein. In extraskeletal tissues, RANKL mRNA and protein were detected in the brain, heart, kidney, skeletal muscle, and skin throughout mouse development, suggesting the possibility of several other functions of the molecule. RANKL was also developmentally regulated, as evidenced by its expression in the intestine, liver, and lung at E15 and newborn mouse but not in the adult.

Breast cancer cells interact with osteoblasts to support osteoclast formation

Breast cancers commonly cause osteolytic metastases in bone, a process that is dependent upon osteoclast-mediated bone resorption. Recently the osteoclast differentiation factor (ODF), better termed RANKL (receptor activator of NF-kappaB ligand), expressed by osteoblasts has been cloned as well as its cognate signaling receptor, receptor activator of NFkappaB (RANK), and a secreted decoy receptor osteoprotegerin (OPG) that limits RANKL's biological action. We determined that the breast cancer cell lines MDA-MB-231, MCF-7, and T47D as well as primary breast cancers do not express RANKL but express OPG and RANK. MCF-7, MDA-MB-231, and T47D cells did not act as surrogate osteoblasts to support osteoclast formation in coculture experiments, a result consistent with the fact that they do not express RANKL. When MCF-7 cells overexpressing PTH-related protein (PTHrP) were added to cocultures of murine osteoblasts and hematopoietic cells, osteoclast formation resulted without the addition of any osteotropic agents; cocultures with MCF-7 or MCF-7 cells transfected with pcDNAIneo required exogenous agents for osteoclast formation. When MCF-7 cells overexpressing PTHrP were cultured with murine osteoblasts, osteoblastic RANKL messenger RNA (mRNA) levels were enhanced and osteoblastic OPG mRNA levels diminished; MCF-7 parental cells had no effect on RANKL or OPG mRNA levels when cultured with osteoblastic cells. Using a murine model of breast cancer metastasis to bone, we established that MCF-7 cells that overexpress PTHrP caused significantly more bone metastases, which were associated with increased osteoclast formation, elevated plasma PTHrP concentrations and hypercalcaemia compared with parental or empty vector controls.

Spectrally resolved white-light interferometry for measurement of ocular dispersion

Spectrally resolved white-light interferometry was used to measure the wavelength dependence of refractive index (i.e., dispersion) for various ocular components. Verification of the technique's efficacy was substantiated by accurate measurement of the dispersive properties of water and fused silica, which have both been well-characterized in the past by single-wavelength measurement of the refractive index. The dispersion of bovine and rabbit aqueous and vitreous humors was measured from 400 to 1100 nm. In addition, the dispersion was measured from 400 to 700 nm for aqueous and vitreous humors extracted from goat and rhesus monkey eyes. An unsuccessful attempt was also made to use the technique for dispersion measurement of bovine cornea and lens. The principles of white-light interferometry, including image analysis, measurement accuracy, and limitations of the technique, are discussed. In addition, alternate techniques and previous measurements of ocular dispersion are reviewed.

Comparative study of laser damage threshold energies in the artificial retina

Laser damage threshold energies produced from ultrashort (i.e., ⩽1 ns) laser pulses are investigated as a function of both pulse width and spot size for an artificial retina. A piece of film acts as the absorbing layer and is positioned at the focus of a variant on the Cain artificial eye [C. Cain, G. D. Noojin, D. X. Hammer, R. J. Thomas, and B. A. Rockwell, "Artificial eye for in vitro experiments of laser light interaction with aqueous media," J. Biomed. Opt.2, 88-94 (1997)]. Experiments were performed at the focal point and at two and ten Rayleigh ranges (RR) in front of the focus with the damage end point being the presence of a bubble imaged at the film plane. Pulse energy thresholds were determined for wavelengths of 1064, 580, and 532 nm with pulse durations ranging from the nanosecond (ns) to the femtosecond (fs) regime. For the at-focus data in the visible regime, the threshold dropped from 0.25 μJ for a 532 nm, 5 ns pulse to 0.11 μJ for a 580 nm, 100 fs pulse. The near-infrared (NIR) threshold changed from 5.5 μJ for a 5 ns pulse to 0.9 μJ for a 130 fs pulse at a distance two RR in front of the focus. The experiment was repeated using the same pulse widths and wavelengths, except the water path was removed to determine the impact of nonlinear self-focusing in water. A vertical microscope imaging system was employed in order to observe the threshold event. The NIR fluence threshold of 0.5 J/cm2 remained constant within an experimental uncertainty for all pulse widths, which corresponds to values in the literature [C. P. Lin and M. W. Kelly, "Ultrafast time-resolved imaging of stress transient and cavitation from short pulsed laser irradiated melanin particles," SPIE Laser-Tissue Interactions VI, Proc. SPIE2391, 294-299 (1995)]. The visible data also demonstrated a nearly constant fluence of 0.07 J/cm2. The disparity in thresholds between the two techniques arises from nonlinear optical phenomena related to propagation differences in the ocular fluid. © 1999 Society of Photo-Optical Instrumentation Engineers.

Influence of optical aberrations on laser-induced plasma formation in water and their consequences for intraocular photodisruption

The influence of spherical aberrations on laser-induced plasma formation in water by 6-ns Nd:YAG laser pulses was investigated for focusing angles that are used in intraocular microsurgery. Waveform distortions of 5.5lambda and 18.5lambda between the optical axis and the 1/e(2) irradiance values of the laser beam were introduced by replacement of laser achromats in the delivery system by planoconvex lenses. Aberrations of 18.5lambda increased the energy threshold for plasma formation by a factor of 8.5 compared with the optimized system. The actual irradiance threshold for optical breakdown was determined from the threshold energy in the optimized system and the spot size measured with a knife-edge technique. For aberrations of 18.5lambda the irradiance threshold was 48 times larger than the actual threshold when it was calculated by use of the diffraction-limited spot size but was 35 times smaller when it was calculated by use of the measured spot size. The latter discrepancy is probably due to hot spots in the focal region of the aberrated laser beam. Hence the determination of the optical-breakdown threshold in the presence of aberrations leads to highly erroneous results. In the presence of aberrations the plasmas are as much as 3 times longer and the transmitted energy is 17-20 times higher than without aberrations. Aberrations can thus strongly compromise the precision and the safety of intraocular microsurgery. They can further account for a major part of the differences in the breakdown-threshold and the plasma-transmission values reported in previous investigations.

Lipopolysaccharide-induced priming of the human neutrophil is not associated with a change in phosphotyrosine phosphatase activity

The activation of the neutrophil respiratory burst is a two-step process involving an initial 'priming' phase followed by a 'triggering' event. The biochemical mechanisms which underlie these events are yet to be fully elucidated, but the evidence suggests a crucial role for stimulus-induced tyrosine phosphorylation. The enhanced tyrosine phosphorylation observed upon triggering primed cells may reflect an increase in tyrosine kinase activity or a reduction in the levels of the opposing phosphotyrosine phosphatases (PTPases). We have investigated the latter by examining the possibility that lipopolysaccharide (LPS)-induced priming of the neutrophil respiratory burst involves the suppression of cellular PTPase activity. Purified human neutrophils were incubated for 60 min with and without LPS. Priming of the respiratory burst was confirmed by fMet-Leu-Phe-induced cytochrome c reduction. The level of PTPase activity was assessed by dephosphorylation of [32P]RR-src peptide as substrate. Pretreatment of human neutrophils with 200 ng/ml LPS induced a 2.9 +/- 0.3 (mean +/- SEM, n = 3, P = 0.022) fold increase in the fMet-Leu-Phe-triggered respiratory burst. In the same cells, LPS did not induce a significant change in the total cellular PTPase activity (1.02 +/- 0.02-fold, mean +/- SEM, n = 3, P = 0.63). Similarly, stimulation of neutrophils with fMet-Leu-Phe or phorbol myristate acetate did not significantly affect the cellular PTPase activity (P = 0.94 and 0.68, respectively). Our results suggest that suppression of PTPase activity is not the mechanism underlying the priming and/or triggering of the neutrophil respiratory burst.

The effect of variability in the food supply on the daily singing routines of European robins: a test of a stochastic dynamic programming model

A stochastic dynamic programming (SDP) model offers a general explanation of daily singing routines in birds, but remains almost untested empirically. I examined a central prediction of the SDP model, that a more variable food supply decreases the bird's song output at dawn, relative to its song output at dusk. I provided supplementary food to make the food supply more or less variable over 2-week periods in the territories of free-living European robins Erithacus rubecula. Robins sang relatively less at dawn than at dusk after weeks in which their supplementary food supply was variable, and more at dawn than at dusk after weeks in which their food supplementation was constant. These results provide strong support for the prediction of the SDP model. Copyright 1999 The Association for the Study of Animal Behaviour.

Two tests of a stochastic dynamic programming model of daily singing routines in birds

Many hypotheses have been put forward to account for the dawn chorus in birds. Few of these, however, are able to account for variation in song output over the whole day, or for differences in daily singing routines between species, individuals, seasons and environmental conditions. One hypothesis that does offer a more general explanation is based on a stochastic dynamic programming (SDP) model of daily singing routines. This model relates the relative costs and benefits of feeding and singing at different times of day to the size of a bird's fat reserves and calculates the optimal daily routines of singing and foraging that will maximize the amount that the bird can sing while avoiding starvation. The use of SDP models in behavioural ecology has become well established, but they remain largely untested empirically. I tested two predictions of the SDP model of daily routines of singing, using free-living European robins Erithacus rubecula. The results supported both predictions: (1) food supplementation causing unpredictable short-term increases in foraging success increased subsequent song output; and (2) changes in ambient temperature were positively associated with changes in subsequent song output. Copyright 1999 The Association for the Study of Animal Behaviour.

Gene organization and alternative splicing of human prohormone convertase PC8

The mammalian Ca2+-dependent serine protease prohormone convertase PC8 is expressed ubiquitously, being transcribed as 3.5, 4.3 and 6.0 kb mRNA isoforms in various tissues. To determine the origin of these various mRNA isoforms we report the characterization of the human PC8 gene, which has been previously localized to chromosome 11q23-24. Consisting of 16 exons, the human PC8 gene spans approx. 27 kb. A comparison of the position of intron-exon junctions of the human PC8 gene with the gene structures of previously reported prohormone convertase genes demonstrated a divergence of the human PC8 from the highly conserved nature of the gene organization of this enzyme family. The nucleotide sequence of the 5'-flanking region of the human PC8 is reported and possesses putative promoter elements characteristic of a GC-rich promoter. Further supporting the potential role of a GC-rich promoter element, multiple transcriptional initiation sites within a 200 bp region were demonstrated. We propose that the various mRNA isoforms of PC8 result from the inclusion of intronic sequences within transcripts.

Varied presentations of unilateral lung hypoplasia and agenesis: a report of four cases

Unilateral lung hypoplasia or agenesis can be asymptomatic or present with recurrent respiratory symptoms. The latter may be amenable to surgical treatment in selected cases. Of four children in this report, two are being managed without surgery. A third was relieved of his symptoms by pneumonectomy. The fourth presented with acute foreign-body inhalation into the healthy right main bronchus, and coexistent left pulmonary agenesis was discovered at bronchoscopy. Bronchoscopy and computed tomography were found to be the most useful investigations in management.

Parathyroid hormone-related protein (PTHrP) mRNA splicing and parathyroid hormone/PTHrP receptor mRNA expression in human placenta and fetal membranes

During human pregnancy, parathyroid hormone-related protein (PTHrP) and parathyroid hormone (PTH)/PTHrP receptor are produced by the uterus, placenta, fetal membranes (amnion and chorion) and developing fetus. PTHrP alternative 3' mRNA splicing results in transcripts which encode three PTHrP isoforms and have been identified in amnion. Uteroplacental PTHrP expression is greatest in amnion and increases dramatically during late pregnancy. The aims of this study were to determine PTH/PTHrP receptor mRNA expression at preterm and term gestations and to determine 3' alternative splicing patterns in placenta, amnion and choriodecidua at preterm and term gestations. Using semiquantitative reverse transcription-polymerase chain reaction, PTHrP and PTH/PTHrP receptor transcripts were identified in preterm (n=5) and term (n=7) gestational tissues. PTH/PTHrP receptor mRNA expression did not differ between tissue types or change with advancing gestation. In contrast, PTHrP expression in the same tissues increased with advancing gestation and was significantly greater in amnion than in placenta and choriodecidua. Thus PTHrP, although produced predominantly in amnion, may act in amnion and other tissues including placenta, choriodecidua and myometrium. In amnion over placenta, transcripts encoding PTHrP 1-139 and 1-173 were detected in some preterm and all term samples and those encoding PTHrP 1-141 were detected in all samples. Similar results were obtained for reflected amnion. In placenta and choriodecidua, PTHrP 1-139 and 1-173 transcripts were undetectable or of low abundance. PTHrP 1-141 transcripts were detected in some placenta and choriodecidua samples. In summary, transcripts encoding PTHrP 1-141 appeared to be more abundantly expressed than those encoding PTHrP 1-139 or 1-173. However, the up-regulation of PTHrP expression in amnion at term may involve each of the alternative 3' mRNA splicing pathways since transcripts for each isoform appeared to be more consistently expressed at term.