A novel dual balloon rectal catheter for use in the postoperative assessment of low rectal anastomoses following low anterior resection

Following low anterior resection (LAR) of the colon, an image-guided assessment of the anastomosis for leak is typically performed using an enema via a rectal catheter, whether by CT or fluoroscopy. However, there is potential for poor assessment due to inappropriate catheter positioning as well as potential risk that the anastomosis becomes compromised by the balloon inflation. This article discusses the adaptation of a novel double-balloon catheter (originally designed by a member of our institution for use in pediatric intussusception reduction) for assessment of low rectal anastomoses. The goal of this technical note is to demonstrate our experience with this catheter, primarily through example cases, and explain its potential for optimizing colon distension, minimizing improper catheter placement, and potentially reducing the risk of iatrogenic anastomosis disruption.

Added value of iodine-specific imaging and virtual non-contrast imaging for gastrointestinal assessment using dual-energy computed tomography

Dual-energy computed tomography (DECT) has become increasingly available and can be readily incorporated into clinical practice. Although DECT can provide a wide variety of spectral imaging reconstructions, most clinically valuable information is available from a limited number of standard image reconstructions including virtual non-contrast and iodine overlay. The combination of these standard reconstructions can be used for specific diagnostic tasks that provide added value over traditional CT protocols. In this pictorial essay, the added value of these standard reconstructed images will be demonstrated by case examples for diseases specifically related to the gastrointestinal system.

Multi-Center Follow-up Study to Develop a Classification System Which Differentiates Mucinous Cystic Neoplasm of the Liver and Benign Hepatic Cyst Using Machine Learning

RATIONALE AND OBJECTIVES

To date, no clinically useful classification system has been developed for reliably differentiating mucinous cystic neoplasm (MCN) from a benign hepatic cyst (BHC) in the liver. The objective was to use machine learning and a multi-center study design to develop and assess the performance of a novel classification system for predicting whether a hepatic cystic lesion represents MCN or BHC.

MATERIALS AND METHODS

A multi-center cohort study identified 154 surgically resected hepatic cystic lesions in 154 subjects which were pathologic confirmed as MCN (43) or BHC (111). Readers at each institution recorded seven pre-determined imaging features previously identified as potential differentiating features from prior publications. The contribution of each of these features to differentiating MCN from BHC was assessed by machine learning to develop an optimal classification system.

RESULTS

Although several of the assessed imaging features demonstrated statistical significance, only 3 imaging features were found by machine learning to significantly contribute to a potential classification system: (1) solid enhancing nodule (2) all septations arising from an external macro-lobulation (3) whether the lesion was solitary or one of multiple cystic liver lesions. The optimal classification system had only four categories and correctly identified 144/154 lesion (93.5%).

CONCLUSION

This multi-center follow-up study was able to use machine learning to develop a highly accurate classification system for differentiation of hepatic MCN from BHC, which could be readily applied to clinical practice.

Genetic and functional assessment of the role of the rs13431652-A and rs573225-A alleles in the G6PC2 promoter that are strongly associated with elevated fasting glucose levels

OBJECTIVE

Genome-wide association studies have identified a single nucleotide polymorphism (SNP), rs560887, located in a G6PC2 intron that is highly correlated with variations in fasting plasma glucose (FPG). G6PC2 encodes an islet-specific glucose-6-phosphatase catalytic subunit. This study examines the contribution of two G6PC2 promoter SNPs, rs13431652 and rs573225, to the association signal.

RESEARCH DESIGN AND METHODS

We genotyped 9,532 normal FPG participants (FPG <6.1 mmol/l) for three G6PC2 SNPs, rs13431652 (distal promoter), rs573225 (proximal promoter), rs560887 (3rd intron). We used regression analyses adjusted for age, sex, and BMI to assess the association with FPG and haplotype analyses to assess comparative SNP contributions. Fusion gene and gel retardation analyses characterized the effect of rs13431652 and rs573225 on G6PC2 promoter activity and transcription factor binding.

RESULTS

Genetic analyses provide evidence for a strong contribution of the promoter SNPs to FPG variability at the G6PC2 locus (rs13431652: β = 0.075, P = 3.6 × 10(-35); rs573225 β = 0.073 P = 3.6 × 10(-34)), in addition to rs560887 (β = 0.071, P = 1.2 × 10(-31)). The rs13431652-A and rs573225-A alleles promote increased NF-Y and Foxa2 binding, respectively. The rs13431652-A allele is associated with increased FPG and elevated promoter activity, consistent with the function of G6PC2 in pancreatic islets. In contrast, the rs573225-A allele is associated with elevated FPG but reduced promoter activity.

CONCLUSIONS

Genetic and in situ functional data support a potential role for rs13431652, but not rs573225, as a causative SNP linking G6PC2 to variations in FPG, though a causative role for rs573225 in vivo cannot be ruled out.

Foxa2 and MafA regulate islet-specific glucose-6-phosphatase catalytic subunit-related protein gene expression

Islet-specific glucose-6-phosphatase catalytic subunit-related protein (IGRP/G6PC2) is a major autoantigen in both mouse and human type 1 diabetes. IGRP is selectively expressed in islet beta cells and polymorphisms in the IGRP gene have recently been associated with variations in fasting blood glucose levels and cardiovascular-associated mortality in humans. Chromatin immunoprecipitation (ChIP) assays have shown that the IGRP promoter binds the islet-enriched transcription factors Pax-6 and BETA2. We show here, again using ChIP assays, that the IGRP promoter also binds the islet-enriched transcription factors MafA and Foxa2. Single binding sites for these factors were identified in the proximal IGRP promoter, mutation of which resulted in decreased IGRP fusion gene expression in betaTC-3, Hamster insulinoma tumor (HIT), and Min6 cells. ChiP assays have shown that the islet-enriched transcription factor Pdx-1 also binds the IGRP promoter, but mutational analysis of four Pdx-1 binding sites in the proximal IGRP promoter revealed surprisingly little effect of Pdx-1 binding on IGRP fusion gene expression in betaTC-3 cells. In contrast, in both HIT and Min6 cells mutation of these four Pdx-1 binding sites resulted in a approximately 50% reduction in fusion gene expression. These data suggest that the same group of islet-enriched transcription factors, namely Pdx-1, Pax-6, MafA, BETA2, and Foxa2, directly or indirectly regulate expression of the two major autoantigens in type 1 diabetes.

Sequence variation between the mouse and human glucose-6-phosphatase catalytic subunit gene promoters results in differential activation by peroxisome proliferator activated receptor gamma coactivator-1alpha

AIMS/HYPOTHESIS

The glucose-6-phosphatase catalytic subunit (G6PC) plays a key role in hepatic glucose production by catalysing the final step in gluconeogenesis and glycogenolysis. Peroxisome proliferator activated receptor gamma coactivator-1alpha (PGC-1alpha) stimulates mouse G6pc-luciferase fusion gene expression through hepatocyte nuclear factor-4alpha (HNF-4alpha), which binds an element located between -76 and -64 in the promoter. The aim of this study was to compare the regulation of mouse G6pc and human G6PC gene expression by PGC-1alpha.

METHODS

PGC-1alpha action was analysed by transient transfection and gel retardation assays.

RESULTS

In H4IIE cells, PGC-1alpha alone failed to stimulate human G6PC-luciferase fusion gene expression even though the sequence of the -76 to -64 HNF-4alpha binding site is perfectly conserved in the human promoter. This difference could be explained, in part, by a 3 bp sequence variation between the mouse and human promoters. Introducing the human sequence into the mouse G6pc promoter reduced PGC-1alpha-stimulated fusion gene expression, whereas the inverse experiment, in which the mouse sequence was introduced into the human G6PC promoter, resulted in the generation of a G6PC-luciferase fusion gene that was now induced by PGC-1alpha. This critical 3 bp region is located immediately adjacent to a consensus nuclear hormone receptor half-site that is perfectly conserved between the mouse G6pc and human G6PC promoters. Gel retardation experiments revealed that this 3 bp region influences the affinity of HNF-4alpha binding to the half-site.

CONCLUSIONS/INTERPRETATION

These observations suggest that PGC-1alpha may be more important in the control of mouse G6pc than human G6PC gene expression.

Long-range enhancers are required to maintain expression of the autoantigen islet-specific glucose-6-phosphatase catalytic subunit-related protein in adult mouse islets in vivo

OBJECTIVE

Islet-specific glucose-6-phosphatase catalytic subunit-related protein (IGRP) is selectively expressed in islet beta-cells and is a major autoantigen in both mouse and human type 1 diabetes. This study describes the use of a combination of transgenic and transfection approaches to characterize the gene regions that confer the islet-specific expression of IGRP.

RESEARCH DESIGN AND METHODS

Transgenic mice were generated containing the IGRP promoter sequence from -306, -911, or -3911 to +3 ligated to a LacZ reporter gene. Transgene expression was monitored by 5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside staining of pancreatic tissue.

RESULTS

In all the transgenic mice, robust LacZ expression was detected in newborn mouse islets, but expression became mosaic as animals aged, suggesting that additional elements are required for the maintenance of IGRP gene expression. VISTA analyses identified two conserved regions in the distal IGRP promoter and one in the third intron. Transfection experiments demonstrated that all three regions confer enhanced luciferase reporter gene expression in beta TC-3 cells when ligated to a minimal IGRP promoter. A transgene containing all three conserved regions was generated by using a bacterial recombination strategy to insert a LacZ cassette into exon 5 of the IGRP gene. Transgenic mice containing a 15-kbp fragment of the IGRP gene were then generated. This transgene conferred LacZ expression in newborn mouse islets; however, expression was still suppressed as animals aged.

CONCLUSIONS

The data suggest that long-range enhancers 5' or 3' of the IGRP gene are required for the maintenance of IGRP gene expression in adult mice.

Gluconeogenesis: re-evaluating the FOXO1-PGC-1alpha connection

Increased expression of the gene encoding the enzyme glucose-6-phosphatase (G6Pase) contributes to the increased production of glucose by the liver that occurs in individuals with diabetes. Puigserver et al. show that the transcription factor FOXO1 and the transcriptional co-activator PGC-1alpha act synergistically to stimulate the expression of genes in the gluconeogenesis pathway and propose that PGC-1alpha acts, in part, directly through FOXO1. Here we show that FOXO1 is neither required nor sufficient for the stimulation of G6Pase-luciferase fusion gene expression by PGC-1alpha. Our results indicate that the transcriptional interaction between FOXO1 and PGC-1alpha is indirect.