Implications for sequencing of biologic therapy and choice of second anti-TNF in patients with inflammatory bowel disease: results from the IMmunogenicity to Second Anti-TNF therapy (IMSAT) therapeutic drug monitoring study

BACKGROUND

Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD).

AIM

To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence METHODS: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab.

RESULTS

In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure.

CONCLUSION

Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the second, which was mitigated by the introduction of an immunomodulator in patients with immunogenic, but not pharmacodynamic treatment failure.

P-064 Application of an artificial intelligence model for morphologic prediction of fertilization-competent human spermatozoa

Study question

What is the role of artificial intelligence in selecting fertilization-competent human spermatozoa according to their morphological characteristics? 

Summary answer

The established AI model in this study can be potentially used to select semen samples with superior fertilization potential in clinical settings.

What is known already

Defective spermatozoa-zona pellucida (ZP) interaction causes subfertility and is a major cause of low IVF fertilization rates. While ICSI benefits patients with defective spermatozoa-ZP binding, a standard method to identify such patients prior to conventional IVF is lacking. The application of artificial intelligence to sperm morphology analysis has become a topic of growing interest owing to the fact that the conventional assessment is highly subjective and time-consuming. Deep-learning, a core element of artificial intelligence (AI), incorporates the convolutional neural networks (CNN) to process all the data composing a digital image through successive layers to identify the underlying pattern.

Study design, size, duration

The fertilization-competent spermatozoa were isolated according to their binding ability to the ZP. The ZP-bound and -unbound spermatozoa were collected for functional assays and to establish an AI model for morphologic prediction of sperm fertilization potential. Human spermatozoa (n = 289) were isolated from normozoospermic samples. Human oocytes (n = 562) were collected from an assisted reproduction program in Hong Kong. Sample collection has been ongoing and will continue until the end of this study in November 2021.

Participants/materials, setting, methods

Sperm-ZP binding assay was employed to collect ZP-bound and -unbound spermatozoa. The fertilization potential and genetic quality of the collected spermatozoa were evaluated by our established protocols. Diff-Quik- stained images of ZP-bound and -unbound spermatozoa were collected respectively for the establishment of an AI model. A novel algorithm for sperm image transformation and segmentation was developed to pre-process the images. CNN architecture was then applied on these pre-processed images for feature extraction and model training.

Main results and the role of chance

Our result showed that the sperm-ZP binding assay had no detrimental effect on sperm viability when compared with the raw samples and unbound-sperm subpopulations. ZP-bound spermatozoa were found with statistically higher acrosome reaction rates, improved DNA integrity, better morphology, lower protamine deficiency and higher methylation level when compared with the unbound spermatozoa. A deep-learning model was trained and validated by analyzing a total of 1,334 and 885 of ZP-bound/unbound spermatozoa to evaluate the predictive power of sperm morphology for ZP binding ability. Our newly trained AI-based model showed initial success in classifying the ZP-bound/ unbound spermatozoa according to their morphological characteristics with high accuracy of 85% and low computational complexity.

Limitations, reasons for caution

This sperm selection method requires micromanipulation and relatively long processing time to recover ZP-bound spermatozoa. In addition to limited availability, the use of human materials may result in interassay variations affecting the reproducibility of this method among laboratories.

Wider implications of the findings

In light of current findings, AI-based sperm selection method may provide high predictive values of sperm fertilization potential for clinical purposes. This method is particularly applicable to patients who had poor fertilization outcomes after conventional IVF treatments or those with high degree of defective sperm-ZP binding ability. 

Trial registration number

not applicable

P–064 Application of an artificial intelligence model for morphologic prediction of fertilization-competent human spermatozoa

Study question

What is the role of artificial intelligence in selecting fertilization-competent human spermatozoa according to their morphological characteristics? Summary answer: The established AI model in this study can be potentially used to select semen samples with superior fertilization potential in clinical settings.

What is known already

Defective spermatozoa-zona pellucida (ZP) interaction causes subfertility and is a major cause of low IVF fertilization rates. While ICSI benefits patients with defective spermatozoa-ZP binding, a standard method to identify such patients prior to conventional IVF is lacking. The application of artificial intelligence to sperm morphology analysis has become a topic of growing interest owing to the fact that the conventional assessment is highly subjective and time-consuming. Deep-learning, a core element of artificial intelligence (AI), incorporates the convolutional neural networks (CNN) to process all the data composing a digital image through successive layers to identify the underlying pattern.

Study design, size, duration

The fertilization-competent spermatozoa were isolated according to their binding ability to the ZP. The ZP-bound and -unbound spermatozoa were collected for functional assays and to establish an AI model for morphologic prediction of sperm fertilization potential. Human spermatozoa (n = 289) were isolated from normozoospermic samples. Human oocytes (n = 562) were collected from an assisted reproduction program in Hong Kong. Sample collection has been ongoing and will continue until the end of this study in November 2021.

Participants/materials, setting, methods

Sperm-ZP binding assay was employed to collect ZP-bound and -unbound spermatozoa. The fertilization potential and genetic quality of the collected spermatozoa were evaluated by our established protocols. Diff-Quik- stained images of ZP-bound and -unbound spermatozoa were collected respectively for the establishment of an AI model. A novel algorithm for sperm image transformation and segmentation was developed to pre-process the images. CNN architecture was then applied on these pre-processed images for feature extraction and model training.

Main results and the role of chance

Our result showed that the sperm-ZP binding assay had no detrimental effect on sperm viability when compared with the raw samples and unbound-sperm subpopulations. ZP-bound spermatozoa were found with statistically higher acrosome reaction rates, improved DNA integrity, better morphology, lower protamine deficiency and higher methylation level when compared with the unbound spermatozoa. A deep-learning model was trained and validated by analyzing a total of 1,334 and 885 of ZP-bound/unbound spermatozoa to evaluate the predictive power of sperm morphology for ZP binding ability. Our newly trained AI-based model showed initial success in classifying the ZP-bound/ unbound spermatozoa according to their morphological characteristics with high accuracy of 85% and low computational complexity.

Limitations, reasons for caution

This sperm selection method requires micromanipulation and relatively long processing time to recover ZP-bound spermatozoa. In addition to limited availability, the use of human materials may result in interassay variations affecting the reproducibility of this method among laboratories.

Wider implications of the findings: In light of current findings, AI-based sperm selection method may provide high predictive values of sperm fertilization potential for clinical purposes. This method is particularly applicable to patients who had poor fertilization outcomes after conventional IVF treatments or those with high degree of defective sperm-ZP binding ability.

Trial registration number

Not applicable

Using lactic acid bacteria and packaging with grapefruit seed extract for controlling Listeria monocytogenes growth in fresh soft cheese

Various cheese products are involved in outbreaks of listeriosis worldwide due to high consumption and prolonged refrigerated storage. The objective of this study was to determine the efficacy of using lactic acid bacteria and packaging with grapefruit seed extract (GSE) for controlling Listeria monocytogenes growth in soft cheese. Leuconostoc mesenteroides and Lactobacillus curvatus isolated from kimchi were used as a starter culture to make a soft cheese, which was inoculated with a cocktail strain of L. monocytogenes. The soft cheese was packed with low-density polyethylene, biodegradable polybutylene adipate-co-terephthalate (PBAT), low-density polyethylene with GSE, or PBAT with GSE and stored at 10°C and 15°C. Leuconostoc mesenteroides (LcM) better inhibited the growth of L. monocytogenes than Lb. curvatus. The PBAT with GSE film showed the best control for the growth of L. monocytogenes. When both LcM and PBAT with GSE were applied to the soft cheese, the growth of L. monocytogenes was inhibited significantly more than the use of LcM or PBAT with GSE alone. In all test groups, water activity, pH, and moisture on a fat-free basis decreased, and titratable acidity increased compared with the control group. These results suggest that LcM isolated from kimchi and PBAT with GSE packaging film can be used as a hurdle technology to lower the risk of L. monocytogenes in soft cheese at the retail market.

Accuracy of MRI in the diagnosis of meniscal tears in patients with chronic ACL tears

PURPOSE

This study was conducted to evaluate the accuracy of magnetic resonance imaging (MRI) in diagnosing meniscal tears in patients with anterior cruciate ligament (ACL) tears and to determine the frequency of missed meniscal tears on MRI.

METHODS

This prospective comparative study was conducted from 2009 to 2012. Patients with ACL injuries who underwent knee arthroscopy and MRI were included in the study. Two radiologists who were blinded to the clinical history and arthroscopic findings reviewed the pre-arthroscopic MR images. The presence and type of meniscal tears on MRI and arthroscopy were recorded. Arthroscopic findings were used as the reference standard. The accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of MRI in the evaluation of meniscal tears were calculated.

RESULTS

A total of 65 patients (66 knees) were included. The sensitivity, specificity, accuracy, PPV, and NPV for the MRI diagnosis of lateral meniscal tears in our patients were 83, 97, 92, 96, and 90 %, respectively, whereas those for medial meniscus tears were 82, 92, 88, 82, and 88 %, respectively. There were five false-negative diagnoses of medial meniscus tears and four false-negative diagnoses of lateral meniscus tears. The majority of missed meniscus tears on MRI affected the peripheral posterior horns.

CONCLUSION

The sensitivity for diagnosing a meniscal tear was significantly higher when the tear involved more than one-third of the meniscus or the anterior horn. The sensitivity was significantly lower for tears located in the posterior horn and for vertically oriented tears. Therefore, special attention should be given to the peripheral posterior horns of the meniscus, which are common sites of injury that could be easily missed on MRI. The high NPVs obtained in this study suggest that MRI is a valuable tool prior to arthroscopy.

Successful treatment of isolated fibular bone metastasis in a uterine endometrial cancer of clear cell carcinoma

Clear cell carcinoma of the endometrium is an uncommon histological subtype and isolated metastasis to bone is rare. The authors present a case of a 61-year-old woman who underwent laparoscopic staging surgery for clear cell carcinoma of uterine endometrium (FIGO Stage IB) and early recurrence with isolated fibular bone metastasis three months later. With salvage radiotherapy (RT), she remains disease-free after 46 months. Curative-intended treatment with RT is possible as in this case.

Imaging of Osteo-odontokeratoprosthesis(OOKP) Using Multidetector Computed Tomography: A UKMMC Experience

Osteo-odontokeratoprosthesis (OOKP) surgery is a technique used to replace damaged cornea in blind patients for whom cadaveric transplantation is not feasible. OOKP surgery is a complex procedure requiring lifetime follow-up. The preservation of the osteo-odontolamina is the vital feature in maintaining the stability of the OOKP. Early detection of lamina resorption enables early prophylactic measures to be taken and prevent resorption-related complications. This case illustrates the radiological findings of the first OOKP surgery in Malaysia and the role of multidetector computed tomography (MDCT) in postoperative management of OOKP surgery.

Observation of time-reversal violation in the B0 meson system

Although CP violation in the B meson system has been well established by the B factories, there has been no direct observation of time-reversal violation. The decays of entangled neutral B mesons into definite flavor states (B(0) or B(0)), and J/ψK(L)(0) or ccK(S)(0) final states (referred to as B(+) or B(-)), allow comparisons between the probabilities of four pairs of T-conjugated transitions, for example, B(0) → B(-) and B(-) → B(0), as a function of the time difference between the two B decays. Using 468 × 10(6) BB pairs produced in Υ(4S) decays collected by the BABAR detector at SLAC, we measure T-violating parameters in the time evolution of neutral B mesons, yielding ΔS(T)(+) = -1.37 ± 0.14(stat) ± 0.06(syst) and ΔS(T)(-) = 1.17 ± 0.18(stat) ± 0.11(syst). These nonzero results represent the first direct observation of T violation through the exchange of initial and final states in transitions that can only be connected by a T-symmetry transformation.

Precision measurement of the B → Xs γ photon energy spectrum, branching fraction, and direct CP asymmetry A(CP)((B → X(s+d)γ)

The photon spectrum in the inclusive electromagnetic radiative decays of the B meson, B → X(s)γ plus B → X(d)γ, is studied using a data sample of (382.8 ± 4.2) × 10(6)Υ(4S) → BB decays collected by the BABAR experiment at SLAC. The spectrum is used to extract the branching fraction B(B → X(s)γ) = (3.21 ± 0.33) × 10(-4) for E(γ) >1.8 GeV and the direct CP asymmetry A(CP) (B → X(s+d)γ) = 0.057 ± 0.063. The effects of detector resolution and Doppler smearing are unfolded to measure the photon energy spectrum in the B meson rest frame.

Evidence for an excess of B→D*τ(-)ν(τ) decays

Based on the full BABAR data sample, we report improved measurements of the ratios R(D(*))=B(B[over ¯]→D(*)τ(-)ν[over ¯](τ))/B(B[over ¯]→D(*)ℓ(ℓ)(-)ν[over ¯](ℓ)), where ℓ is either e or μ. These ratios are sensitive to new physics contributions in the form of a charged Higgs boson. We measure R(D)=0.440±0.058±0.042 and R(D(*))=0.332±0.024±0.018, which exceed the standard model expectations by 2.0σ and 2.7σ, respectively. Taken together, our results disagree with these expectations at the 3.4σ level. This excess cannot be explained by a charged Higgs boson in the type II two-Higgs-doublet model.

Search for low-mass dark-sector Higgs bosons

Recent astrophysical and terrestrial experiments have motivated the proposal of a dark sector with GeV-scale gauge boson force carriers and new Higgs bosons. We present a search for a dark Higgs boson using 516 fb(-1) of data collected with the BABAR detector. We do not observe a significant signal and we set 90% confidence level upper limits on the product of the standard model-dark-sector mixing angle and the dark-sector coupling constant.

Search for hadronic decays of a light Higgs boson in the radiative decay Υ→γA0

We search for hadronic decays of a light Higgs boson (A(0)) produced in radiative decays of an Υ(2S) or Υ(3S) meson, Υ→γA(0). The data have been recorded by the BABAR experiment at the Υ(3S) and Υ(2S) center-of-mass energies and include (121.3±1.2)×10(6) Υ(3S) and (98.3±0.9)×10(6) Υ(2S) mesons. No significant signal is observed. We set 90% confidence level upper limits on the product branching fractions B(Υ(nS)→γA(0))B(A(0)→hadrons) (n=2 or 3) that range from 1×10(-6) for an A(0) mass of 0.3 GeV/c(2) to 8×10(-5) at 7 GeV/c(2).

Observation of the decay B- → D(s)((*)+) K- ℓ- ν(ℓ)

We report the observation of the decay B- → D(s)((*)+) K- ℓ- ν(ℓ) based on 342  fb(-1) of data collected at the Υ(4S) resonance with the BABAR detector at the PEP-II e+ e- storage rings at SLAC. A simultaneous fit to three D(s)(+) decay chains is performed to extract the signal yield from measurements of the squared missing mass in the B meson decay. We observe the decay B- → D(s)((*)+) K- ℓ- ν(ℓ) with a significance greater than 5 standard deviations (including systematic uncertainties) and measure its branching fraction to be B(B- → D(s)((*)+) K- ℓ- ν(ℓ)) = [6.13(-1.03)(+1.04)(stat)±0.43(syst)±0.51(B(D(s)))]×10(-4), where the last error reflects the limited knowledge of the D(s) branching fractions.

Search for production of invisible final states in single-photon decays of Υ(1S)

We search for single-photon decays of the Υ(1S) resonance, Υ → γ + invisible, where the invisible state is either a particle of definite mass, such as a light Higgs boson A⁰, or a pair of dark matter particles, χχ. Both A⁰ and χ are assumed to have zero spin. We tag Υ(1S) decays with a dipion transition Υ(2S) → π⁺π⁻Υ(1S) and look for events with a single energetic photon and significant missing energy. We find no evidence for such processes in the mass range m(A⁰) ≤ 9.2 GeV and m(χ) ≤ 4.5 GeV in the sample of 98 × 10⁶ Υ(2S) decays collected with the BABAR detector and set stringent limits on new physics models that contain light dark matter states.

Effects of the different frequencies of whole-body vibration during the recovery phase after exhaustive exercise

AIM

This study was to investigate the effects of vibration exercise on the oxygen consumption (VO2) and heart rate variability (HRV) during the recovery phase after exhaustive exercise.

METHODS

Twenty male college students volunteered as subjects to participate in the study. The subjects were randomly crossover assigned to perform three 10 min vibration exercises, namely non-vibration (CON, 0 Hz, 0 mm), low-frequency (LFT, 20 Hz, 0.4 mm) and high-frequency (HFT, 36 Hz, 0.4 mm) treatments immediately after an incremental exhaustive cycling exercise in separated days. The beat-to-beat HRV, blood lactate concentration and VO2 were measured during the 1-hour recovery phase. The time- and frequency-domain indices of HRV were analyzed to confirm the effects of vibration exercises on the cardiac autonomic modulation.

RESULTS

There were no significant differences on the VO2, HRV and blood lactate concentrations at 30th minute (post-30 min) or 60th minute (post-60 min) during the recovery phase among the three treatments. There were also no significant differences on the excess post-exercise oxygen consumption (EPOC) during the recovery phase among the treatments. However, the VO2 at post-30 min in CON and LFT were significantly higher than the baseline values, whereas the VO2 in HFT returned to resting condition at the post-30 min.

CONCLUSIONS

The results indicate that both low and high frequency vibration exercises could not improve the physiological recovery after exhaustive cycling exercise. However, the high frequency vibration exercise probably has a potential to facilitate the VO2 to return to the resting level during the recovery phase.

Search for f(J)(2220) in radiative J/ψ decays

We present a search for f(J)(2220) production in radiative J/ψ→γf(J)(2220) decays using 460  fb⁻¹ of data collected with the BABAR detector at the SLAC PEP-II e(+)e⁻ collider. The f(J)(2220) is searched for in the decays to K(+)K⁻ and K(S)⁰K(S)⁰. No evidence of this resonance is observed, and 90% confidence level upper limits on the product of the branching fractions for J/ψ→γf(J)(2220) and f(J)(2220)→K(+)K⁻(K(S)⁰K(S)⁰) as a function of spin and helicity are set at the level of 10⁻⁵, below the central values reported by the Mark III experiment.

Measurement of D0-D0 mixing parameters using D0 → K(S)(0)π+ π- and D0 → K(S)(0)K+ K- decays

We report a direct measurement of D0-D0 mixing parameters through a time-dependent amplitude analysis of the Dalitz plots of D(0) → K(S)(0) π+ π- and, for the first time, D0 → K(S)(0)K+ K- decays. The low-momentum pion π(s)(+) in the decay D*+ → D0 π(s)(+) identifies the flavor of the neutral D meson at its production. Using 468.5 fb(-1) of e+ e- colliding-beam data recorded near square root(s)=10.6 GeV by the BABAR detector at the PEP-II asymmetric-energy collider at SLAC, we measure the mixing parameters x = [1.6 ± 2.3(stat) ± 1.2(syst) ± 0.8(model)] × 10(-3), and y = [5.7 ± 2.0(stat) ± 1.3(syst) ± 0.7(model)] × 10(-3). These results provide the best measurement to date of x and y. The knowledge of the value of x, in particular, is crucial for understanding the origin of mixing.

Association of energy intake and macronutrient composition with overweight and obesity in malay women from klang valley

This cross-sectional study investigates the association between energy intake and macronutrient composition of the diet with overweight and obesity among Malaysian women. One hundred and fifteen adult Malay women aged 20 to 59 years (mean age 37.2±7.6 years) were interviewed. Dietary intake was assessed using the food history method. Body weight status was assessed using weight, height, waist circumference and fat percentage measurements. When energy intake was assessed for accuracy, only 41% of the subjects (n=47) were normal energy reporters. Among the normal energy reporters, 55% were of normal weight whereas 32% and 13% were overweight and obese. Mean energy intake for normal weight, overweight and obese subjects was 1685±199 kcal/day, 1810±166 kcal/day and 2119±222 kcal/day, respectively. Energy intake increased with body mass index (BMI) category. Among the overweight and obese, energy intake was respectively higher by 125 kcal/day and 434 kcal/day as compared to their normal weight counterparts (p< 0.001). There was also a significant, moderate and positive correlation between energy intake and BMI (r=0.635), waist circumference (r=0.545), and body fat percentage (r=0.534). When macronutrient composition of diet was analysed (% energy and g/1000 kcal), there was no significant difference in carbohydrate, protein or fat intake between the obese, overweight and normal weight subjects. There was also no significant correlation between macronutrient composition of the diet and body weight status. Based on these findings, we conclude that the subjects' body weight status is likely to be influenced by energy intake rather than the macronutrient composition of the diet.

Prolonged time to pregnancy in residents exposed to ionising radiation in cobalt-60-contaminated buildings

OBJECTIVES

Radiation-induced cytogenetic damage in somatic cells has raised concern that low-dose ionising radiation can also damage germ cells and influence gamete production and/or function, resulting in decreased fertility. Time to pregnancy (TTP) was used to investigate whether exposure to gamma-radiation affected fertility among the residents of cobalt-60-contaminated buildings in Taiwan.

METHODS

This was a retrospective pregnancy-based study of 357 pregnancies born to 124 exposed couples. Both the cumulative dose and the dose rate for each pregnancy was estimated based on a physical dose reconstruction programme. The comparison population consisted of 612 pregnancies born to 225 couples randomly sampled from the Taiwan general population. Information on TTP was collected by personal interviews. Fecundability ratios (FRs) were calculated with a discrete proportional hazards model.

RESULTS

For exposed mothers, fertility decreased significantly when unprotected intercourse began during the period of living in the radiation-contaminated buildings (FR 0.75, 95% CI 0.61 to 0.92). The effect was borderline significant for fathers (FR 0.83, 95% CI 0.68 to 1.02). There was evidence that prolonged TTP was associated with the rate of exposure for both mothers and fathers (tests for trend: female, p=0.0006; male, p=0.03), especially evident for dose rates > or =10 mSv/year (female, FR 0.60, 95% CI 0.43 to 0.84; male, FR 0.68, 95% CI 0.49 to 0.96).

CONCLUSIONS

Our findings suggest that exposure to low-dose ionising radiation of cobalt-60-contaminated buildings may decrease fertility, especially in females. Fertility declined with increasing concurrent dose but not with cumulative dose.

Native human zona pellucida glycoproteins: purification and binding properties

BACKGROUND

Fertilization starts with the binding of the spermatozoa to the zona pellucida (ZP) of the oocyte. Such binding is a carbohydrate-mediated event and consists of a series of tightly regulated events. Molecular interactions between spermatozoon and ZP in human are not well characterized due to limited availability of oocytes for research. Our current technology cannot generate recombinant human ZP (hZP) glycoproteins with native glycosylation.

METHODS AND RESULTS

In this study, hZP glycoproteins, hZP2 (approximately 120 kDa), hZP3 (approximately 58 kDa) and hZP4 (approximately 65 kDa) were purified from ZP (purity >88%) by immunoaffinity columns. The binding sites of the purified native hZP3 and hZP4 were localized to the acrosome region of the capacitated human spermatozoa, and were lost after acrosome reaction. Purified human hZP2 bound to this region only in acrosome-reacted spermatozoa. Differential binding of the three glycoproteins to the post-acrosomal region and the midpiece of the spermatozoa was observed. In addition, hZP3, but not hZP2 and hZP4, induced hyperactivation. The stimulatory activity was dependent partly on N-linked glycosylation of hZP3.

CONCLUSIONS

This manuscript describes the biological activities of purified hZP glycoproteins from the native source for the first time.

Exclusive branching-fraction measurements of semileptonic tau decays into three charged hadrons, into phipi(-)nu tau, and into phi K(-)nu tau

Using a data sample corresponding to an integrated luminosity of 342 fb(-1) collected with the BABAR detector at the SLAC PEP-II electron-positron storage ring operating at a center-of-mass energy near 10.58 GeV, we measure B(tau(-)--> pi(-)pi(-)pi+nu(tau)(ex.K(S0))=(8.83+/-0.01+/-0.13)%, B(tau(-) -->K(-)pi(-)pi+nu tau(ex.K(S0))=(0.273+/-0.002+/-0.009)%, B(tau(-) -->K(-)pi(-)K+nu tau)=(0.1346+/-0.0010+/-0.0036)%, and B(tau(-) -->K(-)K(-)K+nu tau)=(1.58+/-0.13+/-0.12)x10;{-5}, where the uncertainties are statistical and systematic, respectively. These include significant improvements over previous measurements and a first measurement of B(tau(-) -->K(-)K(-)K+nu tau) in which no resonance structure is assumed. We also report a first measurement of B(tau(-) -->var phi(-)nu tau)=(3.42+/-0.55+/-0.25)x10(-5), a new measurement of B(tau(-) -->var phi K(-)nu tau)=(3.39+/-0.20+/-0.28)x10(-5) and a first upper limit on B(tau(-) -->K(-)K(-)K+nu tau(ex.var phi)).

Nocturia in men

Nocturia is a common source of sleep disturbance in men and can result from many different causes. A patient-generated frequency/volume chart, along with several simple mathematical formulas, is used to classify nocturia according to its principal aetiology. The categories are nocturnal polyuria (NP), reduced voided volumes, 24-h polyuria and a combination of the aforementioned factors. Identification of the precise type of nocturia can help direct treatment in the cause-specific manner. In particular, use of the antidiuretic desmopressin can be of benefit in those with NP and may also be useful as part of a combination treatment approach in nocturia of mixed aetiology.

Microlensed microchip VECSEL

We report a 1.055-mum microchip VECSEL array which uses a microlens-patterned diamond both as a heatspreader and as an array of concave output mirrors. This configuration, which is suitable for laser array operation, is here exploited to perform a systematic study of a set of microchip lasers with the same semiconductor structure but different cavity properties. The transverse mode selection of individual VECSELs is found to depend on the mode-matching conditions and on the microlens aperture size. Mode-matched single-device emission in the fundamental mode (M2~1.1) with pump-limited output power of 70 mW is demonstrated.

Search for lepton flavor violating decays tau(+/-) --> l(+/-)pi0, l(+/-)eta, l(+/-)eta'

A search for lepton flavor violating decays of the tau lepton to a lighter mass lepton and a pseudoscalar meson has been performed using 339 fb;{-1} of e;{+}e;{-} annihilation data collected at a center-of-mass energy near 10.58 GeV by the BABAR detector at the SLAC PEP-II storage ring. No evidence of a signal has been found, and upper limits on the branching fractions are set at the 10;{-7} level.

Vector-tensor and vector-vector decay amplitude analysis of B0-->phiK*0

We perform an amplitude analysis of the decays B(0)-->phiK*(2)(1430)(0), phiK*(892)(0), and phi(Kpi)(0)(S-wave) with a sample of about 384x10(6) BB[over ] pairs recorded with the BABAR detector. The fractions of longitudinal polarization f(L) of the vector-tensor and vector-vector decay modes are measured to be 0.853(-0.069+0.061)+/-0.036 and 0.506+/-0.040+/-0.015, respectively. Overall, twelve parameters are measured for the vector-vector decay and seven parameters for the vector-tensor decay, including the branching fractions and parameters sensitive to CP violation.

Observation of CP violation in B --> eta'K0 decays

We present measurements of the time-dependent CP-violation parameters S and C in B(0) --> eta(')K(0) decays. The data sample corresponds to 384 x 10(6) BB pairs produced by e(+)e(-) annihilation at the Upsilon(4S). The results are S=0.58+/-0.10+/-0.03 and C=-0.16+/-0.07+/-0.03. We observe mixing-induced CP violation with a significance of 5.5 standard deviations in this b --> s penguin dominated mode.

Laparoscopic myomectomy for large uterine fibroids. A comparative study

BACKGROUND

The goal of this study was to examine the safety and feasibility of laparoscopic myomectomy (LM) for the management of symptomatic intramural uterine fibroids with weight greater than 80 g as compared to those less than 80 g.

METHODS

In a prospective comparative study, 176 women with symptomatic uterine fibroids were scheduled for LM. They were divided into two groups, one with main uterine fibroid (intramural type) weight greater than 80 g and the other with fibroid weight less than 80 g. Outcome measures for the two groups were studied in terms of operation time, amount of blood loss, requirement of blood transfusion, and length of hospital stay.

RESULT

Operation time and amount of blood loss were significantly greater in the group with fibroid > or = 80 g than in the group < 80 g (121.5 +/- 58.9 min versus 79.1 +/- 28.6 min, p < 0.001; and 346.3 +/- 299.6 ml versus 123.0 +/- 89.7 ml, p < 0.001, respectively). However, there was no difference in the length of hospital stay and overall incidence of operative complications between these two groups. None of the women had any major complications. Nevertheless, 11 minor complications were noted, including two pelvic abscesses requiring a second laparoscopic treatment. There was no incidence of switching to laparatomy during the operation. Extreme intraoperative hemorrhage of more than 1000 ml occurred in 8 patients; however, all progressed to full recovery after blood transfusion. Rate of blood transfusion was significantly lower in the group with fibroid < 80 g (3.2% versus 22.1%, p < 0.001).

CONCLUSIONS

Despite the increased operation time and blood loss, LM can be safely performed in the treatment of large uterine fibroid. However, high risk of blood transfusion in these patients has to be kept in mind.

Observation of B0-->omega K0, B+-->eta pi+, and B+-->eta K+ and study of related decays

We present measurements of branching fractions and charge asymmetries for seven B-meson decays with an eta, eta', or omega meson in the final state. The data sample corresponds to 89x10(6) BB pairs produced from e(+)e(-) annihilation at the Upsilon(4S) resonance. We measure the following branching fractions in units of 10(-6): B(B+-->eta pi(+))=5.3+/-1.0+/-0.3, B(B+-->eta K+)=3.4+/-0.8+/-0.2, B(B0-->eta K0)=2.9+/-1.0+/-0.2 (<5.2, 90% C.L.), B(B+-->eta(')pi(+))=2.7+/-1.2+/-0.3 (<4.5, 90% C.L.), B(B+-->omega pi(+))=5.5+/-0.9+/-0.5, B(B+-->omega K+)=4.8+/-0.8+/-0.4, and B(B0-->omega K0)=5.9(+1.6)(-1.3)+/-0.5. The charge asymmetries are A(ch)(B+-->eta pi(+))=-0.44+/-0.18+/-0.01, A(ch)(B+-->eta K+)=-0.52+/-0.24+/-0.01, A(ch)(B+-->omega pi(+))=0.03+/-0.16+/-0.01, and A(ch)(B+-->omega K+)=-0.09+/-0.17+/-0.01.

The differential effects of tamoxifen and ICI 182,780 on the reduction of Na+/K+ ATPase activity and spontaneous oscillations by 17beta-estradiol

A prolonged treatment with 17beta-estradiol reduces the frequency of spontaneous oscillations and the Na+/K+ ATPase activity in rat uteri. Acute inhibition of Na+/K+ ATPase activity by a Na+/K+ ATPase inhibitor, ouabain, decreases the frequency of oxytocin-induced oscillations in uteri. Therefore, the purpose of this study was to examine whether the prolonged inhibition of Na+/K+ ATPase activity by 17beta-estradiol was estrogen receptor (ER)-dependent. The uterine explants from ovariectomized rats were cultured in vitro as our experimental model to compare the effect of two antiestrogenic compounds (ICI 182,780 and tamoxifen) on the Na+/K+ ATPase activity and the frequency of spontaneous oscillations. ATPase assay and a standard muscle bath apparatus were to measure the activity and the contraction. When compared with the control, a 2-day treatment with 17beta-estradiol in vivo or in vitro decreased the activity and the frequency. ICI 182,780 lowered the activity but tamoxifen did not. ICI 182,780 did not decrease the frequency but tamoxifen did. Even the reversal effects of these antiestrogenic compounds on the reduced activity and the frequency by 17beta-estradiol were different. Tamoxifen elicited a greater reversal effect on the reduced activity but ICI 182,780 did not. In contrast, ICI 182,780 elicited a greater reversal effect on the reduced frequency but tamoxifen did not. Prolonged inhibition of Na+/K+ ATPase activity by K+-free solution suppressed the frequency with the elevation of basal tension. Addition of KCl at lower concentrations (0.3-1.2 mM) induced oscillatory contraction after reducing the basal tension. As our data suggest, the prolonged effect of 17beta-estradiol may decrease uterine the activity through ER dependent and independent pathways. The reduction of uterine Na+/K+ ATPase activity by estrogens may increase the basal tension after each oscillatory cycle, which, in part, contributes to the reduced frequency of spontaneous oscillations.

Spatial learning deficits without hippocampal neuronal loss in a model of early-onset epilepsy

Studies were undertaken to examine the effects recurrent early-life seizures have on the ability of rats to acquire spatial memories in adulthood. A minute quantity of tetanus toxin was injected unilaterally into the hippocampus on postnatal day 10. Within 48 h, rats developed recurrent seizures that persisted for 1 week. Between postnatal days 57 and 61, rats were trained in a Morris water maze. Toxin-injected rats were markedly deficient in learning this task. While these rats showed gradual improvement in escape latencies over 20 trials, their performance always lagged behind that of controls. Poor performance could not be explained by motor impairments or motivational difficulties since swimming speed was similar for the groups. Only eight of 16 toxin-injected animals showed focal interictal spikes in the hippocampus during electroencephalographic recordings. This suggests that learning deficiencies and chronic epilepsy may be independent products of recurrent early-life seizures. A quantitative analysis of hippocampus revealed a significant decrease in neuronal density in stratum pyramidale of experimental rats. However, the differences were largely explained by a concomitant increase in the area of stratum pyramidale. Studies of glial fibrillary acidic protein expression and spread of horseradish peroxidase-conjugated tetanus toxin in the hippocampus suggest that the dispersion of cell bodies in stratum pyramidale can neither be explained by a reactive gliosis nor the direct action of the toxin itself. Taken together, we suggest that recurrent seizures beginning in early life can lead to a significant deficiency in spatial learning without ongoing hippocampal synchronized network discharging or a substantial loss of hippocampal pyramidal cells.

Quantitative analysis of end-tidal carbon dioxide during mechanical and spontaneous ventilation in infants and young children

Capnography provides a substitute for monitoring of arterial carbon dioxide tension (PCO(2)). We performed a prospective study to evaluate a new application of capnography, using quantitative curve analysis in the pediatric ICU. Twenty-five infants and children admitted to the pediatric ICU after cardiovascular surgery for congenital heart diseases were included in the study. Capnographic curves were recorded during 3 phases of mechanical and spontaneous ventilation: phase 1, immediate postoperative period; phase 3, preextubation period; and phase 2, period between phases 1 and 3. Each recording included 17 sec of capnographic tracings from consecutive spontaneous and/or ventilator-driven breaths. Quantitative curve analysis was made to define parameters including peak value of exhaled PCO(2) (P), mean rate of rise of PCO(2) (R), and area under each capnographic curve (A). Qualitative inspection of the wave contour showed no obvious difference in phase 3 during spontaneous and mechanically assisted ventilator breaths. However, an obvious difference existed between spontaneous and mechanically assisted breaths in phase 2. For each parameter (P, R, and A), there was a significant difference in phases 2 and 3 from spontaneous breaths. However, there was no significant difference in phases 2 and 3 from ventilator-assisted breaths. We further calculated the ratio of parameters of spontaneous breaths (S) and ventilator-assisted breaths (V) in phase 2 and phase 3. The ratio of S/V for P, R, and A showed significant differences between phase 2 and phase 3. We conclude that quantitative analysis of exhaled end-tidal PCO(2) curves revealed significant changes of specific parameters during the transition from the ventilator-dependent state to the spontaneously breathing ventilator-independent state. This new approach provides a new way to estimate respiratory status in infants and children receiving ventilator therapy. Through quantitative capnographic curve analysis, if P, R, and A from spontaneous breaths approached those of ventilator-assisted breaths, patients have resumed reasonable pulmonary mechanics, and extubation may then be considered.

Geometric parameters of the in vivo tissues at the lumbosacral joint of young Asian adults

STUDY DESIGN

Magnetic resonance images (MRIs) were used to determine the geometry of the tissues studied.

OBJECTIVE

To investigate the geometric parameters of tissues around the lumbosacral joint.

SUMMARY OF BACKGROUND DATA

Cross-sectional area (CSA), moment arms, and line of action of the tissues located at lumbosacral joint (L5-S1), which are important in the study of spinal mechanics and models for the investigation of low back pain. It was insufficient information to describe the relative dimension of spinal tissues except muscles around the lumbar spine.

METHODS

MRIs from eight asymptomatic young Taiwanese male adults were collected to present CSA, moment arms, and line of action of the tissues located at lumbosacral joint (L5-S1). Four pairs of trunk muscles, erector spinae, rectus abdominis, abdominal oblique externus, and psoas muscles, ligamentum flavum, and facet joints at the bilateral sides were studied.

RESULTS

Spinal tissues at the level of lumbosacral joint were determined. The CSAs of the spinal elements at the L5-S1 normalized by the CSA of trunk ranged from 5.42% (the erector spinae) to 0.14% (the ligamentum flavum). The moment arm of the spinal elements relative to the trunk width and depth ranged from 40.91% (rectus abdominis at the y direction) to 0.38% (ligamentum flavum at the x direction). The profile of geometric elements of lumbosacral joint in the Asian male subjects was similar to the data collected from the white population. The data also showed that right-left symmetry in the aforementioned dimension.

CONCLUSION

Normalized data of the CSA, moment arm, and line of action of the spinal tissues at the L5-S1 joint were reported in vivo through the MRI techniques. The profile of geometric elements of lumbosacral joint in the Asian male subjects did not differ from the white population. In addition to muscles, the geometry of facet joint and ligament was determined, which would be important to the calculation of force distribution on the lumbosacral joint.

Endoscopic ultrasonography to study the causes of extragastric compression mimicking gastric submucosal tumor

BACKGROUND AND PURPOSE

Many reports have confirmed that endoscopic ultrasonography (EUS) can differentiate gastric submucosal tumor from extragastric compression, but only a few specifically concentrated on EUS in identifying the causes of external compression.

MATERIALS AND METHODS

From May 1993 to May 2001, we used EUS in 238 patients to diagnose gastric submucosal tumor or external compression. We excluded 183 patients who had submucosal tumors and analyzed the remaining 55 patients with extragastric compression. Malignant causes of external compression were proved by surgery or biopsy. Benign causes of external compression were proved by other imaging examinations (abdominal ultrasound, computerized tomography, angiography) or surgery. Patients with external compression caused by normal organs were followed up with repeated upper gastrointestinal endoscopy or EUS.

RESULTS

The stomach was compressed by normal extragastric organs in 32 patients (spleen 10, splenic vessel 6, gall bladder 9, liver 3, pancreas 3, and intestine 1), by benign pathologic lesions in 12 patients (liver cyst 7, liver hemagioma 2, splenic cyst 1, pancreatic cyst 1, pancreatic cystadenoma 1) and by malignant tumors in 5 patients (hepatoma 1, liver metastasis from colon cancer 2, pancreatic cystadenocarcinoma 1 and lymphoma of spleen 1). In the remaining six patients, neither submucosal tumor nor external compression was found during EUS examination and the external compression was considered transient.

CONCLUSION

When an extragastric compression mimicking submucosal tumor is detected by upper gastrointestinal endoscopy, EUS is indicated to identify the cause of extragastric compression.

Detection of a novel t(6;15)(q21;q21) in a pediatric Wilms tumor

We report a novel cytogenetic finding in a favorable histology Wilms tumor occurring in a 4-month-old boy. Karyotypic analysis demonstrated a t(6;15)(q21;q21) in all tumor cells examined. This was confirmed using fluorescence in situ hybridization analysis. Molecular analysis of this rearrangement may provide clues to understanding the pathobiology of Wilms tumor.

Three-dimensional ultrasonic images of normal fetus

BACKGROUND

The purpose of this study was to assess the usefulness and feasibility of 3-dimensional (3D) ultrasound for routine fetal observation.

METHODS

Eighty-five normal pregnancies with gestational ages of 20-36 weeks were studied. A conventional ultrasound scanner with a specially designed operation unit, frame memory, and 3D probe was the apparatus used in this study. The unit has a circuit board consisting of digital integrated circuit chips designed to make calculations of volume ray tracings for volume rendering in real time. For each fetus, scanning was performed with different levels of opacity in the equation for volume rendering. In areas where there was an inadequate amniotic fluid pocket to perform an adequate examination, the pregnant woman was asked to push the fetus to the opposite side by gently pressing on her abdomen.

RESULTS

Face, limbs, and fingers which are difficult to visualize on conventional ultrasonography could be seen clearly. Extremely satisfactory images were obtained at between 24 and 34 weeks of gestation that produced sonographic pictures easily recognized even by laypersons. Beyond 34 weeks of gestation due to the relative decrease in the size of amniotic fluid pockets, and before 24 weeks of gestation due to frequent fetal movement, the soft tissue of fetuses is thin and its acoustic impedance is virtually the same as that of water, so surface-rendered images are less satisfactory. In addition, the anterior wall placenta, multiple pregnancies, and oligohydramnios made viewing even more difficult.

CONCLUSION

Between 24 and 34 weeks of gestation, 3D ultrasound is a feasible and useful procedure for routine antenatal examination.

Classification for endoscopic treatment of mullerian anomalies with an obstructive cervix

STUDY OBJECTIVE

To describe our classification according to severity of developmental mullerian anomalies with obstructed cervix.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

Ten women with developmental mullerian anomalies with obstructed cervix.

INTERVENTION

Patients with didelphic uterus with a rudimentary nonfunctional horn and hypoplastic cervix (type 1) underwent hemihysterectomy or diagnostic endoscopy. Those with agenesis of cervix with normal uterus (type 2) had uterovaginal canalization or neocervix with full-thickness skin graft. Women with identical didelphic uteri and hypoplastic cervix (type 3) underwent uterovaginal canalization with or without endometrial ablation or hemihysterectomy. Patients with didelphic uterus with a rudimentary horn and hypoplastic cervix (type 4) had laparoscopic hemihysterectomy. Those with agenesis of the vagina and cervix but with functional endometrium (type 5) had laparoscopic-assisted full-thickness skin graft.

MEASUREMENTS AND MAIN RESULTS

Average duration of surgery was 60 to 210 minutes. There were no intraoperative complications. Patients with type 1 anomaly are continuing infertility treatment. All three patients in type 2 continue to have regular menses without dysmenorrhea. In those with type 3 conditions, hemihysterectomy was performed in one woman and uterovaginal canalization was performed on the hypoplastic cervix in another. After the neocervix was created, endometrial ablation was performed. No evidence of cervical obstruction or hematometra was found in either patient. The patient with type 4 anomaly continues to have regular menstrual periods without dysmenorrhea. Women with type 5 disorder had good healing of vaginal skin grafts.

CONCLUSION

This classification helps identify mullerian anomalies in relation to obstructive cervix. It is useful in categorizing the disorders and determines management strategies and prognosis.

Extraperitoneal approach to laparoscopic Burch colposuspension

STUDY OBJECTIVE

To evaluate 3-year outcomes of extraperitoneal laparoscopic colposuspension in treating genuine stress incontinence.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

One hundred sixty women with genuine stress incontinence with bladder neck hypermobility.

INTERVENTION

Extraperitoneal space was created with CO2 through a 10-mm midline port 2 cm above the pubic hairline. A pair of sutures was inserted at the level of midurethral and urethrovesical junction, fixing them to Cooper's ligament on each side with proper tension.

MEASUREMENTS AND MAIN RESULTS

Of 160 women, 10 were lost to follow-up. On follow-up questionnaire sent to 150 patients, 148 (98.7%) were pleased with the results of surgery. Stress incontinence was cured in 136 women (90.7%) after a minimum of 3 years' follow-up.

CONCLUSION

Cure rates for extraperitoneal colposuspension were similar to those reported for traditional laparoscopic or laparotomy Burch procedures; however, this is a more direct method to expose the space of Retzius, thus eliminating the need to open and close peritoneum.

Microlaparoscopically assisted vaginal hysterectomy. A preliminary report

OBJECTIVE

To evaluate the clinical possibility of using a microlaparoscope in laparoscopically assisted vaginal hysterectomy.

STUDY DESIGN

Twenty-five women with different indications for hysterectomy and a uterine size < 14 weeks' gestation underwent laparoscopically assisted vaginal hysterectomy using a microlaparoscope and 2-mm instruments.

RESULTS

Microlaparoscopic procedures included coagulation and separation of infundibulopelvic or uteroovarian round ligaments, vesico-uterine-visceral peritoneal fold dissection, and anterior and posterior colpotomy. The mean operative time, blood loss and length of hospital stay were 84.40 +/- 16.85 minutes, 262.00 +/- 112.99 mL and 3.08 +/- 0.64 days, respectively. No patients developed serious complications, but there were two minor ones.

CONCLUSION

Microlaparoscopy appears to be an efficacious alternative treatment option in well-selected patients undergoing laparoscopically assisted vaginal hysterectomy.

Molecular subtyping of Shigella flexneri 3a isolates by plasmid profile analysis and pulsed-field gel electrophoresis

Twenty-two clinical isolates of Shigella flexneri 3a that were obtained from stool specimens from seven outbreaks of infection in northern Taiwan were subtyped and compared using plasmid profile analysis and pulsed-field gel electrophoresis (PFGE). Among 32 isolates, three distinct patterns were found by plasmid profile analysis and six by PFGE, with three different restriction enzymes, XbaI, SfiI, or NotI. Seven PFGE patterns were observed in a comparative analysis using a combination of these three enzymes. Isolates collected from the same outbreaks had the same PFGE combination patterns and were distinguishable from those obtained during other outbreaks. These findings suggest that PFGE may be the most powerful method of genotyping S. flexneri 3a in epidemiological studies.

Laparoscopic diagnosis and management of Fitz-Hugh-Curtis syndrome: report of three cases

Perihepatic adhesions between the liver capsule and the diaphragm or the anterior peritoneal surface characterizes Fitz-Hugh-Curtis syndrome (FHCS). FHCS is an extrapelvic manifestation of pelvic inflammatory disease and usually refractory to medical treatment and surgical intervention. With the increased incidence of pelvic inflammatory disease, chronic pelvic pain and sequalae of the process are becoming more common. Herein, we report 3 patients with pelvic inflammatory disease in whom medical treatment failed initially and FHCS was diagnosed via laparoscopy. Laparoscopic lysis of pelvic and perihepatic adhesions, irrigation of the abdomino-pelvic cavity, and antibiotics treatment after surgery successfully relieved these patients' symptoms. FHCS is not a new syndrome but most gynecologists might neglect this condition. Laparoscopy is a less invasive procedure than exploratory laparotomy. We recommend laparoscopy in patients with lower abdominal and right upper quadrant discomfort when other organic disease has been ruled out and medical treatment has failed to relieve symptoms.

[The effectiveness of implementing an unit-based shared governance model]

The purpose of the nonequivalent control group study was to establish a regional unit-based shared governance model. Fifty-three subjects distributing to experimental (n = 29) and control (n = 24) groups-age, working years, and education were matched statistically-were selected by "purposeful sampling" of Index of Professional Nurse Governance pretest mean scores from six units at a nursing department. Based on Martin's "systematic" evaluation model for shared governance, the study collected: (1) manager's and staff's perception of existing governance using open-ended questions, (2) measure of organizational efficiency using the IPNG and the Index of Working Satisfaction, and (3) the research team's assessment of the unit's willingness to continue this model in the future. The reliability and validity of the questionnaires were established. Intervention of the model was approximately four months, including: preparatory and evaluating phase: data was collected; educative phase: empowering managers and staff were educated in the shared governance concepts; implementing phase: shared governance team was built up. Two-tailed t and chi 2 tests were used to detect differences between the two groups. Results showed, after establishing the unit-based model, (1) an increase in the nursing professional governance and work satisfaction among nurses; (2) an enhanced partnership between managers and nurses; (3) staff nurses perceived increased autonomy, authority, and more frequently expressed their opinions to managers; (4) managers perceived their staff to have more potential competence, then task pushed effectively. The findings suggest that managers and nurses need to refine their professional roles based on the organizational mission, as well as to expand nurses' representation and participation in current organization-wide committees by trust and full delegation from their managers.

Neuronal activity and the establishment of normal and epileptic circuits during brain development

The question we attempted to address in this chapter is: Do brief but recurrent seizures in early life alter the ontogeny of hippocampal networks in ways that produce epileptic circuits? Results from the tetanus toxin model suggest that this is likely the case. Following seizures in Postnatal Weeks 2 and 3, most adult rats have a focal epilepsy that arises from hippocampus. Recordings from hippocampal slices support this conclusion since they demonstrated the occurrence of spontaneous network discharges in normal artificial cerebrospinal fluid. Moreover, when GABA-A receptor-mediated synaptic transmission was suppressed, slices from adult epileptic rats produced prolonged electrographic seizures which are never observed in control rats. This suggests that hyperexcitable recurrent excitatory networks contribute to hippocampal seizures in this model. In light of this, anatomical results from biocytin-filled neurons were surprising. Results suggest that recurrent axon arbors neither sprout additional branches as a result of seizure activity nor maintain their exuberant branching patterns of early life. Thus, excessive connectivity cannot explain seizure generation. Axon arbors either remodel in normal ways or prune additional collaterals as a result of ongoing epileptiform discharging. At the same time that axon arbors remodel, the dendrites of these cells have decreased dendritic spine density, suggesting a partial deafferentation. While a complete understanding of the origins of spine loss requires further investigation, we hypothesize that this loss is a product of a partial deafferentation that occurs due to excessive and abnormal selection of synaptic connections. Network-induced heterosynaptic LTD of noncoincidentally active afferants may be one mechanism that leads to a loss of synapses. Moreover, competition among and selection between individual recurrent excitatory synapses may contribute to spine loss as well. The "winners" of this competition, the most potent and effective early-formed recurrent excitatory synapses, are likely key contributors to seizure generation in this model and possibly in humans with early-onset temporal lobe epilepsy.

Spine loss and other dendritic abnormalities in epilepsy

Studies of neurons from human epilepsy tissue and comparable animal models of focal epilepsy have consistently reported a marked decrease in dendritic spine density on hippocampal and neocortical pyramidal cells. Spine loss is often accompanied by focal varicose swellings or beading of dendritic segments. An ongoing excitotoxic injury of dendrites (dendrotoxicity), produced by excessive release of glutamate during seizures, is often assumed to produce these abnormalities. Indeed, application of glutamate receptor agonists to dendrites can produce both spine loss and beading. However, the cellular mechanisms underlying the two processes appear to be different. One recent study suggests NMDA-induced spine loss is produced by Ca2+-mediated alterations of the spine cytoskeleton. In contrast, dendritic beading is not dependent on extracellular Ca2+; instead, it appears to be produced by the movement of Na+ and Cl- intracellularly and an obligate movement of water to maintain osmolarity. A decrease in dendritic spine density was recently reported in a model of recurrent focal seizures in early life. Unlike results from other models, dendritic beading was not observed, and other signs of neuronal injury and death were absent. Thus, additional mechanisms to those of excitotoxicity may produce dendritic spine loss in epileptic tissue. A hypothesis is presented that spine loss can be a product of a partial deafferentation of pyramidal cells, resulting from an activity-dependent pruning of neuronal connectivity induced by recurring seizures. The dendritic abnormalities observed in epilepsy are commonly suggested to be a product and not a cause of epilepsy. However, anatomical remodeling may be accompanied by alterations in molecular expression and targeting of both voltage- and ligand-gated channels in dendrites. It is conceivable that such changes could contribute to the neuronal hyperexcitability of epilepsy.