Analysis of Anxiety, Depression and Fear of Progression at 12 Months Post-Cytoreductive Surgery in the SOCQER-2 (Surgery in Ovarian Cancer-Quality of Life Evaluation Research) Prospective, International, Multicentre Study

Patients with ovarian cancer (OC) often experience anxiety, depression and fear of progression (FOP); however, it is unclear whether surgical complexity has a role to play. We investigated the prevalence of anxiety, depression and FOP at 12 months post-cytoreductive surgery and investigated associations with surgical complexity, patient (age, ethnicity, performance status, BMI) and tumour (stage, disease load) factors. One hundred and forty-one patients with FIGO Stage III-IV OC, who did not have disease progression at 12 months post-surgery, completed the Hospital Anxiety and Depression Scale and FOP short-form questionnaire. Patients underwent surgery with low (40.4%), intermediate (31.2%) and high (28.4%) surgical complexity scores. At 12 months post-surgery, 99 of 141 (70%) patients with advanced OC undergoing surgery experienced clinically significant anxiety, 21 of 141 (14.9%) patients experienced moderate to severe depression and 37 of 140 (26.4%) experienced dysfunctional FOP. No associations were identified between the three different surgical complexity groups with regards to anxiety, depression or FOP scores. Unsurprisingly, given the natural history of the disease, most patients with OC suffer from anxiety, depression and fear of progression after completion of first-line cancer treatment. Surgical complexity at the time of surgery is not associated with a deleterious impact on anxiety, depression or FOP for patients with OC. Patients with OC experience a profound mental health impact and should be offered mental health support throughout their cancer journey.

A Retrospective Application of the Arbon and Hartman Models to the Union Cycliste International Mountain Bike World Cup

INTRODUCTION

Outdoor activities have accelerated in the past several years. The authors were tasked with providing medical care for the Union Cycliste International (UCI) mountain biking World Cup in Snowshoe, West Virginia (USA) in September 2021. The Hartman and Arbon models were designed to predict patient presentation and hospital transport rates as well as needed medical resources at urban mass-gathering events. However, there is a lack of standardized methods to predict injury, illness, and insult severity at rural mass gatherings.

STUDY OBJECTIVE

This study aimed to determine whether the Arbon model would predict, within 10%, the number of patient presentations to be expected and to determine if the event classification provided by the Hartman model would adequately predict resources needed during the event.

METHODS

Race data were collected from UCI event officials and injury data were collected from participants at time of presentation for medical care. Predicted presentation and transport rates were calculated using the Arbon model, which was then compared to the actual observed presentation rates. Furthermore, the event classification provided by the Hartman model was compared to the resources utilized during the event.

RESULTS

During the event, 34 patients presented for medical care and eight patients required some level of transport to a medical facility. The Arbon predictive model for the 2021 event yielded 30.3 expected patient presentations. There were 34 total patient presentations during the 2021 race, approximately 11% more than predicted. The Hartman model yielded a score of four. Based on this score, this race would be classified as an "intermediate" event, requiring multiple Advanced Life Support (ALS) and Basic Life Support (BLS) personnel and transport units.

CONCLUSION

The Arbon model provided a predicted patient presentation rate within reasonable error to allow for effective pre-event planning and resource allocation with only a four patient presentation difference from the actual data. While the Arbon model under-predicted patient presentations, the Hartman model under-estimated resources needed due to the high-risk nature of downhill cycling. The events staffed required physician skills and air medical services to safely care for patients. Further evaluation of rural events will be needed to determine if there is a generalized need for physician presence at smaller events with inherently risky activities, or if this recurring cycling event is an outlier.

Interval Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy for Ovarian Cancer: Report of a Single-center Experience

BACKGROUND/AIM

Emerging data suggest that addition of hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of interval cytoreduction for patients with metastatic ovarian cancer is associated with a survival benefit. However, the implementation of this treatment is affected by concerns related to its potential morbidity. We present data from the first centre in the UK implementing HIPEC as part of treatment for patients with advanced ovarian cancer undergoing interval cytoreductive surgery.

PATIENTS AND METHODS

This is a prospective study of patients planned to undergo cytoreductive surgery and HIPEC for advanced ovarian cancer over a 30-month period. All patients had undergone neoadjuvant chemotherapy prior to surgery. Patients with stage III/IV ovarian cancer who underwent complete or near complete cytoreduction (<2.5 mm residual disease) received HIPEC using a closed technique.

RESULTS

A total of 31 patients were included in the study, of which 30 had complete cytoreduction and 1 patient had residual disease <2.5 mm. The mean age of the patients was 63.7±2.8 years. Median peritoneal cancer index score was 9 (range=3-31). The mean operating time was 515.4±55.1 min. The mean length of hospital stay was 7.6±0.8 days. In total, 24 complications were observed in 18 patients (58.1%), while 6.5% of the patients experienced grade 3/4 complications. There were no deaths within 30-days from the surgery. Age was found to be an independent predictor of both postoperative complications of any grade and prolonged hospital stay.

CONCLUSION

Interval cytoreductive surgery and HIPEC for patients with advanced ovarian cancer is associated with low perioperative morbidity.

Understanding Online Registry Facilitators and Barriers Experienced by Black Brain Health Registry Participants: The Community Engaged Digital Alzheimer's Research (CEDAR) Study

BACKGROUND

Failure of Alzheimer's disease and related diseases (ADRD) research studies to include and engage Black participants is a major issue, which limits the impact and generalizability of research findings. Little is known about participation of Black adults in online ADRD-related research registries.

OBJECTIVES

As part of the Community Engaged Digital Alzheimer's Research (CEDAR) Study, this study aims to increase our understanding of facilitators and barriers of Black adults to participating in ADRD-related online registries, as well as to understand their preferences for communication channels.

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

We invited all Black participants enrolled in the Brain Health Registry (BHR) to complete a cross-sectional online survey. The survey consisted of rating scales and open-text questions asking about their attitudes towards brain health research, reasons for joining and continuing to participate in BHR, difficulties with participating, and preferences for modes of contact and website usage.

RESULTS

Of all invited Black BHR participants (N=3,636), 198 (5.5%) completed the survey. The mean age was 58.4 (SD=11.3), mean years of education were 16.3 (SD=2.4), and 85.5% identified as female. Reported facilitators for joining and continuing to participate in BHR were personal interest (e.g., learning more about own brain health) and altruism (e.g., helping research). Among additional registry features which could encourage return, receiving feedback or scores about BHR tasks was rated the highest. Of those who found BHR participation difficult (21%), the most frequent reason was time burden. The most preferred way of receiving study information was via email. Participants reported that the websites that they used the most were YouTube and Facebook.

DISCUSSION

The results of our study can inform the development of culturally-responsive registry features and engagement efforts to improve inclusion and participation of Black adults in online ADRD research. Providing participants with feedback about their registry performance and reducing the number of registry tasks are among the recommended strategies.

Different clinocopathological presentations of steroid cell tumour - Report of three rare cases

INTRODUCTION AND IMPORTANCE

We present three cases of steroid cell tumour due to their rarity, their differing clinical presentations and the distinct pathology.

CASE PRESENTATION

Case 1: A 50-year-old female presented with heavy menstrual bleeding. Adenomyosis and multiple leiomyomata were found along with an incidental 2.5mm, paratubal steroid cell tumour. Given the size of the tumour and the histopathological features this was considered benign. Case 2: A 69-year-old female patient presented with virilization, found to have a left ovarian steroid cell tumour. Since there was capsular infiltration, close follow up was advised. Case 3: A 35-year-old female patient presenting with an acute abdomen due to torsion of a 15 cm right ovarian mass. The mass showed immunomorphological features of a steroid cell tumour. Since this tumour was large and had features of necrosis, high mitotic activity and nuclear pleomorphism, it was regarded as malignant.

CLINICAL DISCUSSION

Steroid cell tumours of the ovary are rare (<0.1 % of all ovarian neoplasms) with uncertain malignant behaviour and are difficult to diagnose especially if classical virilising symptoms are absent.

CONCLUSION

Thorough histopathological analysis and immunohistochemistry are essential in arriving at a definite diagnosis when the classical presentation is absent.

Autologous skin-derived neural precursor cell therapy reverses canine Alzheimer dementia-like syndrome in a proof of concept veterinary trial

BACKGROUND

Older companion dogs naturally develop a dementia-like syndrome with biological, clinical and therapeutic similarities to Alzheimer disease (AD). Given there has been no new safe, clinically effective and widely accessible treatment for AD for almost 20 years, an all-new cell therapeutic approach was trialled in canine veterinary patients, and further modelled in aged rats for more detailed neurobiological analysis.

METHODS

A Phase 1/2A veterinary trial was conducted in N = 6 older companion dogs with definitive diagnosis of Canine Cognitive Dysfunction (CCD). Treatment comprised direct microinjection of 250,000 autologous skin-derived neuroprecursors (SKNs) into the bilateral hippocampus using MRI-guided stereotaxis. Safety was assessed clinically and efficacy using the validated Canine Cognitive Dysfunction Rating Scale (CCDR) at baseline and 3-month post treatment. Intention to treat analysis imputed a single patient that had a surgical adverse event requiring euthanasia. Three dog brains were donated following natural death and histology carried out to quantify Alzheimer pathology as well as immature neurons and synapses; these were compared to a brain bank (N = 12) of untreated aged dogs with and without CCD. Further, an age-related memory dysfunction rat model (N = 16) was used to more closely evaluate intrahippocampal engraftment of canine SKN cells, focusing on mnemonic and synaptic effects as well as donor cell survival, neurodifferentation and electrophysiologic circuit integration in a live hippocampal slice preparation.

RESULTS

Four out-of-five dogs improved on the primary clinical CCDR endpoint, three fell below diagnostic threshold, and remarkably, two underwent full syndromal reversal lasting up to 2 years. At post mortem, synaptic density in the hippocampus specifically was nine standard deviations above non-treated dogs, and intensity of new neurons also several fold higher. There was no impact on AD pathology or long-term safety signals. Modelling in aged rats replicated the main canine trial findings: hippocampally-dependent place memory deficits were reversed and synaptic depletion rescued. In addition, this model confirmed donor cell survival and migration throughout the hippocampus, neuronal differentiation in situ, and physiologically-correct integration into pyramidal layer circuits.

CONCLUSIONS

With further development, SKN cell therapy may have potential for treating carefully chosen AD patients based on neurosynaptic restoration in the hippocampus.

Advanced brain age in deployment-related traumatic brain injury: A LIMBIC-CENC neuroimaging study

OBJECTIVE

To determine if history of mild traumatic brain injury (mTBI) is associated with advanced or accelerated brain aging among the United States (US) military Service Members and Veterans.

METHODS

Eight hundred and twenty-two participants (mean age = 40.4 years, 714 male/108 female) underwent MRI sessions at eight sites across the US. Two hundred and one participants completed a follow-up scan between five months and four years later. Predicted brain ages were calculated using T1-weighted MRIs and then compared with chronological ages to generate an Age Deviation Score for cross-sectional analyses and an Interval Deviation Score for longitudinal analyses. Participants also completed a neuropsychological battery, including measures of both cognitive functioning and psychological health.

RESULT

In cross-sectional analyses, males with a history of deployment-related mTBI showed advanced brain age compared to those without (t(884) = 2.1, p = .038), while this association was not significant in females. In follow-up analyses of the male participants, severity of posttraumatic stress disorder (PTSD), depression symptoms, and alcohol misuse were also associated with advanced brain age.

CONCLUSION

History of deployment-related mTBI, severity of PTSD and depression symptoms, and alcohol misuse are associated with advanced brain aging in male US military Service Members and Veterans.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

Asymptomatic COVID-19: What the Neuroradiologist Needs to Know about Pulmonary Manifestations

Coronavirus disease 2019 (COVID-19) is an infectious disease with a high asymptomatic incidence. Asymptomatic infections within a population will inevitably lead to diagnosis via unrelated medical imaging. We report the case of an asymptomatic patient undergoing a spine CT examination for trauma who was incidentally found to have lung abnormalities later confirmed to be COVID-19. We aim to familiarize neuroradiologists with the spectrum of COVID-19 pulmonary manifestations that are likely to be observed on neck and spine CT imaging.

New paradigms for BRCA1/BRCA2 testing in women with ovarian cancer: results of the Genetic Testing in Epithelial Ovarian Cancer (GTEOC) study

BACKGROUND

Over recent years genetic testing for germline mutations in BRCA1/BRCA2 has become more readily available because of technological advances and reducing costs.

OBJECTIVE

To explore the feasibility and acceptability of offering genetic testing to all women recently diagnosed with epithelial ovarian cancer (EOC).

METHODS

Between 1 July 2013 and 30 June 2015 women newly diagnosed with EOC were recruited through six sites in East Anglia, UK into the Genetic Testing in Epithelial Ovarian Cancer (GTEOC) study. Eligibility was irrespective of patient age and family history of cancer. The psychosocial arm of the study used self-report, psychometrically validated questionnaires (Depression Anxiety and Stress Scale (DASS-21); Impact of Event Scale (IES)) and cost analysis was performed.

RESULTS

232 women were recruited and 18 mutations were detected (12 in BRCA1, 6 in BRCA2), giving a mutation yield of 8%, which increased to 12% in unselected women aged <70 years (17/146) but was only 1% in unselected women aged ≥70 years (1/86). IES and DASS-21 scores in response to genetic testing were significantly lower than equivalent scores in response to cancer diagnosis (p<0.001). Correlation tests indicated that although older age is a protective factor against any traumatic impacts of genetic testing, no significant correlation exists between age and distress outcomes.

CONCLUSIONS

The mutation yield in unselected women diagnosed with EOC from a heterogeneous population with no founder mutations was 8% in all ages and 12% in women under 70. Unselected genetic testing in women with EOC was acceptable to patients and is potentially less resource-intensive than current standard practice.

Retrospective review of Pneumocystis jirovecii pneumonia over two decades

The aim of the study was to compare a retrospective case note review of all cases of Pneumocystis carinii (now Pneumocystis jirovecii) pneumonia (PJP) over the period 1997-2004 at North Manchester General Hospital with a previous audit covering the years 1986-1995. During 1986-1995, 777 patients were diagnosed with HIV. One hundred and eighty-one were also diagnosed with PJP. Of these, 11 patients required ventilation with a mortality rate of 100%. For the current review during 1997-2004, 210 patients were diagnosed with PJP, and 64 with severe PJP. Median age was 39 years (interquartile range [IQR] 22-61). Twenty-four patients had a prior diagnosis of HIV (median 43 months, IQR 6-72 months), and for 38 patients this was the presenting diagnosis of HIV. Median CD4 was 34 cells/L (IQR of 12-80 cells/L). Median viral load was 3.5 x 10(5) copies/mL (IQR 1-5.8 x 10(5) copies/mL). Eighteen patients required intubation during this period. Nine (50%) were alive at 30 days postextubation. We believe that the 50% reduction in mortality seen between 1997-2004 in intubated patients with severe PJP is due to the improvement in intensive care management of severe respiratory failure rather than changes in the specific management of PJP. The necessity of ventilation in HIV patients is no longer a mandatory death sentence.

Laparoscopic palliative surgery for complicated colorectal cancer

BACKGROUND

The aim of this study was to evaluate the feasibility and outcomes of the laparoscopic approach for the palliation of advanced complicated colorectal cancer (CRC).

METHODS

We reviewed 21 laparoscopic palliative procedures for emergent complications of advanced CRC between 1994 and 2002. Intraoperative complications, estimated blood loss, transfusions, operative times, time to first bowel movement, length of hospital stay, and postoperative complications were assessed.

RESULTS

Indications for surgery included perforation (n = 10), bleeding (n = 7), and obstruction (n = 4). A proximal diverting procedure was performed in all patients, and a concomitant colon resection was performed in 18 patients (86%). The mean operative time was 181 +/- 22 min. Estimated blood loss was 283 +/- 48 cc, with three patients (14%) requiring transfusions. The average length of hospital stay was 8.6 +/- 2 days, and time to first bowel movement was 61 +/- 9 h. The complication rate and the 30-day mortality rate were 33% and 0%, respectively.

CONCLUSION

A laparoscopic approach to address advanced CRC is safe and effective and should be considered part of the surgeon's armamentarium for the palliation of advanced complicated CRC.

Laparoscopic vs open resection for the treatment of diverticular disease

INTRODUCTION

The aim of this study was to evaluate whether laparoscopic colon resection (LCR) offers any advantages over open colon resection (OCR) in the treatment of diverticular disease.

METHODS

Between 1992 and 2002, 95 patients underwent LCR and 80 patients underwent OCR for the treatment of diverticular disease. Demographics, details of operative procedure, outcome, and pathology were compared.

RESULTS

Patients in both groups were matched for age, sex, body mass index, history of previous abdominal operations, comorbidities, location of the disease, and presence of complications. LCR resulted in significantly less estimated blood loss and postoperative complications, shorter time to first bowel movement, and shorter length of stay than the OCR. There was no difference in operative time, intraoperative complications, mortality rates between groups.

CONCLUSIONS

LCR is a safe and effective approach for the treatment of patients with diverticular disease. It results in less estimated blood loss, shorter time to first bowel movement, less postoperative complications, and shorter length of hospital stay.

New B-type cyclin synthesis is required between meiosis I and II duringXenopusoocyte maturation

Progression through meiosis requires two waves of maturation promoting factor (MPF) activity corresponding to meiosis I and meiosis II. Frog oocytes contain a pool of inactive ‘pre-MPF’ consisting of cyclin-dependent kinase 1 bound to B-type cyclins, of which we now find three previously unsuspected members, cyclins B3, B4 and B5. Protein synthesis is required to activate pre-MPF, and we show here that this does not require new B-type cyclin synthesis, probably because of a large maternal stockpile of cyclins B2 and B5. This stockpile is degraded after meiosis I and consequently, the activation of MPF for meiosis II requires new cyclin synthesis, principally of cyclins B1 and B4, whose translation is strongly activated after meiosis I. If this wave of new cyclin synthesis is ablated by antisense oligonucleotides, the oocytes degenerate and fail to form a second meiotic spindle. The effects on meiotic progression are even more severe when all new protein synthesis is blocked by cycloheximide added after meiosis I, but can be rescued by injection of indestructible B-type cyclins. B-type cyclins and MPF activity are required to maintain c-mos and MAP kinase activity during meiosis II, and to establish the metaphase arrest at the end of meiotic maturation. We discuss the interdependence of c-mos and MPF, and reveal an important role for translational control of cyclin synthesis between the two meiotic divisions.

Identification, expression, and substrate specificity of a mammalian beta-carotene 15,15'-dioxygenase

We have identified from mouse the first mammalian beta-carotene 15,15'-dioxygenase (beta-CD), a crucial enzyme in development and metabolism that governs the de novo entry of vitamin A from plant-derived precursors. beta-CD is related to the retinal pigment epithelium-expressed protein RPE65 and belongs to a diverse family that includes the plant 9-cis-epoxycarotenoid dioxygenase and bacterial lignostilbene dioxygenases. beta-CD expression in Escherichia coli cells engineered to produce beta-carotene led to the accumulation of all-trans-retinal at the expense of beta-carotene, confirming that beta-CD catalyzed the central cleavage of this vitamin A precursor. Purified recombinant beta-CD protein cleaves beta-carotene in vitro with a V(max) of 36 pmol of retinal/mg of enzyme/min and a K(m) of 6 microm. Non-provitamin A carotenoids were also cleaved, although with much lower activity. By Northern analysis, a 2.4-kilobase (kb) message was observed in liver, kidney, small intestine, and testis, tissues important in retinoid/carotenoid metabolism. This message encoded a 63-kDa cytosolic protein expressed in these tissues. A shorter transcript of 1.8 kb was found in testis and skin. Developmentally, the 2.4-kb mRNA was abundant at embryonic day 7, with lower expression at embryonic days 11, 13, and 15, suggesting a critical role for this enzyme in gastrulation. Identification of beta-CD in an accessible model organism will create new opportunities to study vitamin A metabolism.

African Americans' views on research and the Tuskegee Syphilis Study

The participation of African Americans in clinical and public health research is essential. However, for a multitude of reasons, participation is low in many research studies. This article reviews the literature that substantiates barriers to participation and the legacy of past abuses of human subjects through research. The article then reports the results of seven focus groups with 60 African Americans in Los Angeles, Chicago, Washington, DC, and Atlanta during the winter of 1997. In order to improve recruitment and retention in research, the focus group study examined knowledge of and attitudes toward medical research, knowledge of the Tuskegee Syphilis Study, and reactions to the Home Box Office production, Miss Evers' Boys, a fictionalized version of the Tuskegee Study, that premiered in February, 1997. The study found that accurate knowledge about research was limited; lack of understanding and trust of informed consent procedures was problematic; and distrust of researchers posed a substantial barrier to recruitment. Additionally, the study found that, in general, participants believed that research was important, but they clearly distinguished between types of research they would be willing to consider participating in and their motivations for doing so.

Molecular characterization and developmental expression of NORPEG, a novel gene induced by retinoic acid

We have characterized NORPEG, a novel gene from human retinal pigment epithelial cells (ARPE-19), in which its expression is induced by all-trans-retinoic acid. Two transcripts ( approximately 3 and approximately 5 kilobases in size) have been detected for this gene, which is localized to chromosome band 5p13.2-13.3. Placenta and testis showed the highest level of expression among various human tissues tested. Six ankyrin repeats and a long coiled-coil domain are present in the predicted sequence of the NORPEG protein, which contains 980 amino acid residues. This approximately 110-kDa protein was transiently expressed in COS-7 cells as a FLAG fusion protein and immunolocalized to the cytoplasm. Confocal microscopic analysis of the NORPEG protein in ARPE-19 cells showed threadlike projections in the cytoplasm reminiscent of the cytoskeleton. Consistent with this localization, the expressed NORPEG protein showed resistance to solubilization by Triton X-100 and KCl. An ortholog of NORPEG characterized from mouse encoded a protein that showed 91% sequence similarity to the human NORPEG protein. The expression of Norpeg mRNA was detected in mouse embryo at embryonic day 9.5 by in situ hybridization, and the expression appears to be developmentally regulated. In adult mouse, the highest level of expression was detected in the seminiferous tubules of testis.

The role of multimedia interactive programs in training for laparoscopic procedures

BACKGROUND

The application of minimally invasive techniques to the performance of abdominal surgery by general surgeons has been perhaps the greatest advance in the history of general surgery. The safe adoption of many of these procedures, however, has been hampered by significant obstacles, mainly due to the problem of providing adequate training for surgeons. Outside of animal and cadaver labs, most training has been didactic in nature, and adoption rates after completion of these courses are discouraging. Multimedia interactive training has been used in a number of high-tech industries with great success. A >60% improvement in the learning curve after multimedia interactive training, as compared to traditional didactic training, has been reported. Multimedia interactive training programs for surgeons that use content and input from multiple experts in laparoscopic procedures have now been developed.

METHODS

Residents from a general surgery residency program who used these programs were asked to rate their effectiveness in increasing their knowledge and comfort level prior to their participation in a real procedure as the primary surgeon or first assistant. A comparison to other traditional training techniques was also made. Eleven residents completed 41 programs designed to teach one of five different laparoscopic procedures-cholecystectomy, fundoplication, appendectomy, colon resection, or hernia repair.

RESULTS

On a scale of 1 to 10, with 10 being the highest, the residents reported that the multimedia interactive training programs raised their knowledge level of the procedure from 6.0 to 8.7 (+2.7 point value increase after using the multimedia interactive program). The programs increased their comfort level when actually called on to perform or assist with the procedure from 5.3 to 8.1 (+2.8 point value increase after using the multimedia interactive program). In comparing the value of training methods for learning laparoscopic procedures, the residents rated text, lectures, videos, and animal labs at 4.7, 5.1, 6.0 and 7.3, respectively. By comparison, the residents rated the multimedia interactive training program at 8.8.

CONCLUSION

The use of multimedia interactive training programs in addition to current laparoscopic training courses may help to increase the safe adoption of laparoscopic procedures. These programs may be a beneficial adjunct to residency training programs.

Plasma vascular endothelial growth factor in acute mountain sickness

STUDY OBJECTIVES

To investigate the hypothesis that an increase in circulating vascular endothelial growth factor (VEGF) occurs in mountaineers at high altitude, particularly in association with acute mountain sickness (AMS) and/or low hemoglobin oxygen saturation.

DESIGN

: Collection of medical histories, AMS scores, plasma samples, and arterial oxygen saturation (SaO(2)) measurements from mountaineers at 1,500 feet (sea level) and at 14,200 feet.

SETTING

Mount McKinley ("Denali"), AK.

PARTICIPANTS

Sixty-six mountaineers.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Plasma VEGF at 14,200 feet was not increased in any group. In fact, plasma VEGF was significantly lower in subjects who did not develop AMS (53 +/- 7.9 pg/mL; mean +/- SEM; n = 47) compared to control subjects at sea level (98.4 +/- 14.3 pg/mL; n = 7; p = 0.005). Plasma VEGF at 14, 200 feet for subjects with AMS (62 +/- 12 pg/mL; n = 15) did not differ significantly from subjects at 14,200 feet without AMS, or from control subjects at sea level. Of a small number of subjects with paired specimens at sea level and at base camp (n = 5), subjects who exhibited a decrease in plasma VEGF at 14,200 feet were those who did not develop AMS. Neither SaO(2), prior AMS, AMS symptom scores, or acetazolamide use were correlated with plasma VEGF.

CONCLUSIONS

Subjects at high altitude who do not develop AMS have lower plasma VEGF levels compared to control subjects at sea level. Plasma VEGF at high altitude is not elevated in association with AMS or hypoxia. Sustained plasma VEGF at altitude may reflect a phenotype more susceptible to AMS.

The use of water-soluble contrast in evaluating clinically equivocal small bowel obstruction

This study seeks to determine whether a 6-hour abdominal radiograph after oral Gastrografin is a reliable indicator for nonoperative treatment in patients with a clinically equivocal small bowel obstruction. We collected retrospective data from medical records. Patients who received a Gastrografin transit time (GGTT) study between January 1995 and September 1998 were included in the study. Patients who did not appear to be obvious operative candidates, but had signs of intestinal obstruction, underwent a GGTT study. Serial plain abdominal radiographs were taken. If the contrast was in the colon within 6 hours, then the result was negative. A total of 418 GGTT studies were reviewed. Contrast reached the colon within 6 hours in 283 (68%) patients, and 247 (88%) of these patients were managed nonoperatively. The positive predictive value, negative predictive value, sensitivity, and specificity of Gastrografin reaching the colon within 6 hours were 48, 87, 64, and 78, respectively. False negatives included high-grade partial obstructions that ultimately required surgery. Recent operation preceded the GGTT in 128 (31%) cases. Of these 128 patients, only 17 (14%) received an operation. Although the decision to operate or not should never be based on a GGTT study alone, GGTT studies are of significant help in the clinical management of patients suspected to have a small bowel obstruction. GGTT allows for the judicious selection of the appropriate patient for nonoperative management. GGTT studies are cost effective, safe, and clinically useful when attempting to treat patients conservatively.

A randomised controlled trial of a community intervention to prevent adolescent tobacco use

OBJECTIVE

Experimental evaluation of comprehensive community wide programme to prevent adolescent tobacco use.

DESIGN

Eight pairs of small Oregon communities (population 1700 to 13 500) were randomly assigned to receive a school based prevention programme or the school based programme plus a community programme. Effects were assessed through five annual surveys (time 1-5) of seventh and ninth grade (ages 12-15 years) students.

INTERVENTION

The community programme included: (a) media advocacy, (b) youth anti-tobacco activities, (c) family communications about tobacco use, and (d) reduction of youth access to tobacco.

MAIN OUTCOME MEASURE

The prevalence of self reported smoking and smokeless tobacco use in the week before assessment.

RESULTS

The community programme had significant effects on the prevalence of weekly cigarette use at times 2 and 5 and the effect approached significance at time 4. An effect on the slope of prevalence across time points was evident only when time 2 data points were eliminated from the analysis. The intervention affected the prevalence of smokeless tobacco among grade 9 boys at time 2. There were also significant effects on the slope of alcohol use among ninth graders and the quadratic slope of marijuana for all students.

CONCLUSION

The results suggest that comprehensive community wide interventions can improve on the preventive effect of school based tobacco prevention programmes and that effective tobacco prevention may prevent other substance use.

The bill drops here. Concurrent coding reduces billing delays, improves accuracy and saves time and money

PROBLEM

Salinas Valley wanted to improve its reporting procedures to payors for reimbursement. Delays in reporting referred outpatients and inpatients can significantly impact receipt of reimbursements from payors.

SOLUTION

Salinas Valley developed a program of concurrent coding in which every procedure is assigned a reimbursement code that is automatically registered in the patient's B/AR record when the procedure is logged into any of the clinical applications in the healthcare information system.

RESULTS

Quicker turnaround on receiving payments from payors, as well as an increased return on investment as the ratio of reimbursement to cost-of-time-spent increases.

KEYS TO SUCCESS

Integral to the success of the concurrent coding review program was the openness of the operating system at Salinas Valley.

Managed care enrollee utilization of 911 medical services

OBJECTIVE

To determine the mechanism by which managed care organization (MCO) enrollees enter the emergency medical services (EMS) system.

METHODS

All enrollees belonging to the region's largest MCO and transported to emergency departments by a paramedic-level municipal EMS system were identified from billing records. Dispatch logs were examined to determine the time and origin of the call to the 911 communication center. Patient care records were used to obtain age, the level of care delivered (advanced or basic life support), and whether the patient received any medications while out of hospital. Hospital admission was also determined.

RESULTS

Over a six-month period, 195 enrollees were transported. Three modes of 911 EMS system entry were identified: group I-enrollees who called 911 directly; group II-enrollees who called the MCO triage center, who then called 911 on behalf of the patient; and group III--enrollees who were sent to the MCO health center for evaluation, and subsequently the MCO called 911 to transfer the patient to the hospital. Of the 195 patients transported to the emergency department, the dispositions of 108 (55%) patients were obtained. Group I (n = 109) patients were more likely to be transported in the evening (3 PM to 11 PM), less likely to require advanced life support therapies, and less likely to be admitted to the hospital when compared with groups II (n = 32) and III (n = 54) patients. Group III patients were the most likely to receive advanced life support care and require admission to the hospital.

CONCLUSION

The majority of MCO enrollees called 911 directly, and were most likely to do so during evening hours. Enrollees who called 911 directly (group I) had a trend toward lower acuity, based on the lowest ALS utilization of any group. Those enrollees who most frequently required advanced life support were those who received initial treatment at the MCO center prior to EMS transport. Though EMS system-specific, this type of descriptive analysis is helpful in assisting both EMS systems and MCOs to better assess utilization of 911 EMS resources by MCO enrollees. This study also challenges the prudent layperson paradigm.

Heme-binding by Drosophila retinoid- and fatty acid-binding glycoprotein (RFABG), a member of the proapolipophorin gene family

We previously have cloned and characterized a retinoid- and fatty acid-binding glycoprotein (RFABG) isolated from the heads of Drosophila melanogaster. The protein is composed of two glycosylated subunits (Mr = >200,000 and 70,000) and is a member of the proapolipophorin gene family. Spectral analysis of purified RFABG revealed an absolute absorbance peak at 405 nm, which is typical for a heme-containing protein. The aim of the present study was to characterize the heme-binding properties of RFABG. Upon saturation of the protein solution with carbon monoxide followed by dithionite reduction, a red shift of the Soret peak to 424 nm and the characteristic alpha- and beta- bands at 567 and 539 nm were observed. Native RFABG contains approximately 0.175 moles of heme (mol/mol) indicating that purified RFABG is primarily the apoprotein. Hemin-agarose affinity chromatography of the native RFABG followed by Western blot analysis showed a single immunoreactive band at 70 kDa, indicating that the heme-binding domain resides in the 70 kDa subunit. Although retinoid and fatty acid also bind to the 70 kDa subunit, no competition was observed when an excess of heme was added to a solution of retinoid or fatty acid bound to RFABG. Heme added to a solution of purified RFABG bound in a saturable manner with an affinity of 3.8 x 10(-7) m.Thus, the current study clearly demonstrates that retinoid- and fatty acid-binding glycoprotein is a novel heme-binding protein, which may be involved in the transport and/or metabolism of heme in Drosophila.

Levels of retinoic acid and retinaldehyde dehydrogenase expression in eyes of the Mitf-vit mouse model of retinal degeneration

PURPOSE

Several reports have characterized the retinal degeneration observed in the Mitf(vit) mutant mouse. Despite these reports, the factor(s) that may cause or modulate the degeneration still are not well defined; however, it is known that the photoreceptors of Mitf(vit) mice die through an apoptotic mechanism. We reported previously that retinoid metabolism in the RPE of Mitf(vit)++ mice is perturbed. Retinoids regulate genes via the RAR and RXR nuclear receptor pathway that are involved in numerous cellular responses including apoptosis. It is possible that retinoic acid (RA) modulates the retinal degeneration observed in the Mitf(vit) mice. The purpose of this study was to evaluate the levels of RA in whole eyes, as well as its distribution between neural retina and RPE, of the Mitf(vit) mutant mouse model. An additional purpose was to examine the expression of the RA generating enzyme, retinaldehyde dehydrogenase (AHD2), in the eyes of mutant and control mice.

METHODS

The distribution of AHD2 in eyes of pre- and postnatal Mitf(vit) and C57BL/6 wild-type mice was determined immunohistochemically. Quantitative and qualitative analyses of RA were performed using reversed-phase high performance liquid chromatography (HPLC).

RESULTS

The distribution of AHD2 in ocular tissues was similar between pre- and postnatal Mitf(vit) and C57BL/6 control mice. At postnatal week 10, however, a marked increase in AHD2 immunoreactivity was noted in the central dorsal neural retina of Mitf(vit) mice. No differences in the level of total RA in whole eyes were noted between Mitf(vit) and control mice at early postnatal ages. By 10 weeks of age there was a significant elevation of RA that was localized to the neural retina.

CONCLUSIONS

In this study, we show a high level of AHD2 and RA in the neural retina of Mitf(vit) mice relative to control mice. It is possible that this elevation of RAs contributes to the retinal degeneration observed in Mitf(vit) mice either by inducing apoptosis or by enhancing the effect of some other factor(s) involved in the apoptotic pathway.

Laparoscopy for diagnosis and staging of malignancy

The use of minimally invasive surgery for abdominal pathology, including malignancy, has increased significantly within the past decade. Despite the advances in radiographic imaging, the use of laparoscopy for diagnosing and staging abdominal malignancy has become an important tool in the overall care of these patients. A review of published series for a variety of abdominal malignancies is presented. With the growing experience in this technique, some preliminary conclusions and ongoing issues are discussed.

Expeditious diagnosis of primary prosthetic valve failure

Primary prosthetic valve failure is a catastrophic complication of prosthetic valves. Expeditious diagnosis of this complication is crucial because survival time is minutes to hours after valvular dysfunction. The only life-saving therapy for primary prosthetic valve failure is immediate surgical intervention for valve replacement. Because primary prosthetic valve failure rarely occurs, most physicians do not have experience with such patients and appropriate diagnosis and management may be delayed. A case is presented of a patient with primary prosthetic valve failure. This case illustrates how rapidly such a patient can deteriorate. This report discusses how recognition of key findings on history, physical examination, and plain chest radiography can lead to a rapid diagnosis.

Identification of a new member of transforming growth factor-beta superfamily in Drosophila: the first invertebrate activin gene

Activins, a subgroup of the transforming growth factor-beta (TGF-beta) superfamily, have been extensively studied in vertebrates for their roles in growth and development. However, activins are not thought to be expressed in invertebrates. The identification of the first invertebrate activin gene is reported here. A genomic clone representing 102 F region of the Drosophila chromosome 4 is found to encode a putative activin beta. The predicted protein sequence has a multibasic protease site that would generate a mature C-terminal peptide containing 113 amino acids showing > 60% similarity to the vertebrate activin beta B (inhibin beta B) sequences. A TGF-beta family signature as well as all 9 cysteine residues conserved in the vertebrate activins are also present in this mature peptide sequence. Northern blot and RT-PCR analyses indicated that the activin beta gene is expressed in embryo, larva and adult stages of Drosophila.

Breaking the cycle of violence among youth living in metropolitan Atlanta: a case history of kids alive and loved

More teenagers in the United States die from gunshot wounds than from all natural causes of disease combined. Firearm-related mortality accounts for almost half of all deaths among African American teens. Residents of central cities have the highest probability of experiencing violent crimes. This article describes an innovative community-based intervention designed to break the cycle of violence among youth in metropolitan Atlanta. The intervention, Kids Alive and Loved (KAL), emerged from the African American community as one mother's response to the violent death of her 17-year-old son. The authors describe how her response to tragedy gave birth to a culturally appropriate intervention for youth exposed to violence. This article delineates the evolution of KAL, the role of community partners in the design of the intervention, and how diffusion of innovation theory has implications for understanding the KAL approach to breaking the cycle of violence.

Using geographic information systems to assess spatial patterns of drug use, selection bias and attrition among a sample of injection drug users

This study sought to assess whether frequency and type of drug use are geographically located within the city of Baltimore independent of neighborhood characteristics. The second goal was to assess geographic factors associated with sample selection and attrition. The sample consisted of 597 inner-city injection drug users who were enrolled in a HIV prevention study. The residential locations were plotted using Geographic Information Systems (GIS) software. Three patterns of drug use in the prior 6 months were examined: daily use of injection heroin, daily use of injection cocaine and any use of crack cocaine. Daily use of cocaine and any use of crack were found to be statistically associated with residing in the western portion of the city and distance from the western district sexually transmitted disease clinic. After adjusting for individual level characteristics and neighborhood level variables, as measured by 1990 census tract data, daily use of cocaine was found to be associated with residing in a more southern area of the city and distance from the western district sexually transmitted disease clinic, and any crack use was found to be associated with residing in a more western area of the city and distance from the western district sexually transmitted disease clinic. Men and younger participants were more likely to reside further away from the study clinic as were individuals who dropped out of the intervention condition. The results of this study suggest that type and frequency of drug use is associated with specific geographic areas, independent of neighborhood characteristics. These results have implications for the location of drug prevention, needle exchange and other HIV prevention activities.

Causes of recurrence after laparoscopic hernioplasty. A multicenter study

BACKGROUND

To determine if there are common factors beyond the learning curve that lead to recurrence after laparoscopic hernioplasty, we analyzed failures seen in seven centers specializing in laparoscopic hernia repair.

METHOD

We performed a retrospective review of patients who had a laparoscopic hernioplasty (Tapp or Tep) between 1990 and 1996 at centers specializing in laparoscopic repairs (>500 repairs at each center).

RESULTS

In all, 7661 patients had 10,053 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach; they were followed for 1 month to 6 years. In patients followed for >/=6 months with a median follow-up of 36 months, 35 repairs failed (0.4%), and all but one of these patients underwent a remedial operation. Twenty-nine had a laparoscopic repair, four had a combined laparoscopic and anterior repair, and one had an anterior repair alone. The cause of failure was determined in all 34 patients. The mechanism of recurrence was inadequate lateral fixation of the mesh in 11 cases, inadequate lateral fixation compounded by too small a mesh in three cases, missed lipoma of the cord in four cases, inadequate fixation of the mesh medially to Cooper's ligament in eight cases (seven of which were associated with too small a mesh), a missed hernia in four cases, and a hernia through a keyhole in the mesh in five cases. As surgeons gained experience, the incidence of recurrence due to missed hernias or too small a mesh decreased.

CONCLUSIONS

This large multicenter study demonstrated that the incidence of recurrence after laparoscopic hernioplasty performed by experienced surgeons was extremely low and that some causes could be corrected by experience, whereas others will require changes in technique or equipment.

Laparoscopy in the evaluation and treatment of patients with AIDS and acute abdominal complaints

BACKGROUND

The evaluation of AIDS patients with acute abdominal complaints (AAC) is quite difficult, and surgical intervention is associated with a high complication rate. The intent of this study is to evaluate the application of laparoscopy in the diagnosis and treatment of AIDS patients with AAC.

METHODS

This is a retrospective analysis of 10 consecutive AIDS patients who presented with AAC. Each had evaluation by a surgical team with subsequent laparoscopic intervention. The charts were reviewed for age, sex, time with AIDS, AIDS comorbidities, evaluation modalities, findings, treatment modalities, and outcome.

RESULTS

Laparoscopy resulted in the successful surgical treatment of four patients, diagnosis of medically treatable conditions in four patients, and alteration of the incision site in the remaining two patients. Each patient thus received direct benefit from laparoscopy. Two complications, in the converted patients, and no mortalities were encountered.

CONCLUSIONS

Laparoscopy is a safe and effective interventional modality in the diagnosis and treatment of AAC in the AIDS patient.

Pheochromocytoma, chronic renal insufficiency, and hemodialysis: a combination leading to a diagnostic and therapeutic dilemma

Pheochromocytomas are functioning paragangliomas often presenting with paroxysmal hypertension due to catecholamine secretion. The preferential diagnostic workup includes urine and serum catecholamine measurements. Therapeutic management consists of pharmacologic cardiovascular manipulation and volume expansion with subsequent surgical resection. We have encountered a symptomatic pheochromocytoma in a chronic renal insufficiency patient on hemodialysis. The diagnostic dilemma arose due to the patient's anuric status and the inherent increase in serum catecholamine levels noted in anuric patients. The therapeutic dilemma arose in the proper pharmacologic management and volume expansion in this patient on hemodialysis. The patient underwent successful resection of the pheochromocytoma and has done well. An analysis of our diagnostic and therapeutic processes as well as a review of the literature are presented to assist in the management of this difficult clinical situation.

Development and evaluation of a sexual decision-making and social skills program: "the choice is yours--preventing HIV/STDs"

A series of interactive videodisc programs designed to reduce HIV/STD risk behaviors was developed and evaluated. Separate programs were developed for each of three race/ethnicities (African American, Hispanic, and Caucasian) at each of two age levels (middle school and high school) using extensive formative procedures. Each program uses scenarios with extensive branching story lines to teach decision-making skills and socially appropriate responses to potentially risky sexual situations. In a randomized experiment with 827 students, significant changes were observed at posttest for the four constructs assessed: (1) belief that sex occurs as a result of decisions (vs. "it just happens"), (2) belief that even a single incident of unprotected sex can result in an STD or pregnancy, (3) intentions and attitudes toward use of condoms, and (4) self-efficacy in remaining abstinent (i.e., avoiding sex). At 30-day follow-up, three of the four measures remained significant.

Molecular characterization and developmental expression of a retinoid- and fatty acid-binding glycoprotein from Drosophila. A putative lipophorin

A detailed understanding of the mechanism of lipid transport in insects has been hampered by the inability to identify the proapolipophorin gene that encodes apolipophorins I and II, the principal protein components of lipophorin, the lipid transport vehicle. Here we provide the first molecular description of the Drosophila gene encoding a retinoid- and fatty acid-binding glycoprotein (RFABG) and present evidence that it is a member of the proapolipophorin gene family. The gene, localized to the chromosome 4 (102 F region), encodes a 3351-amino acid protein that could serve as the precursor for the approximately 70-kDa and >200-kDa polypeptides associated with RFABG. The N-terminal sequence of the approximately 70-kDa polypeptide and that predicted for the >200-kDa polypeptide showed high sequence similarity to blowfly apolipophorin II and apolipophorin I, respectively. The RFABG precursor contains a signal peptide and exhibits a multidomain mosaic protein structure, which is typical of extracellular proteins. It has structural domains similar to lipid-binding proteins, namely vitellogenins and apolipoprotein B. The protein also contains a domain similar to the D domain of von Willebrand factor and mucin. The gene is expressed in the Drosophila embryo during development in cells that make up the amnioserosa and fat bodies. Immunolocalizations using specific antibodies against RFABG reveal that the protein is initially dispersed through the embryonic amnioserosa sac and latter concentrated at skeletal muscle-epidermis apodemeal contact junctions during larval development. This novel gene may play an important role in the transport of lipids, including retinoids and fatty acids, in insects.

The effect of previous lower abdominal surgery on performing the total extraperitoneal approach to laparoscopic herniorrhaphy

At Georgia Baptist Medical Center in Atlanta, GA, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphies because of the concerns of potential early and late complications associated with entering the abdominal cavity. In our institution, the TEPA has compared favorably with the transabdominal approach, with lower complication and recurrence rates. There has been concern, however, in performing the TEPA in patients with previous lower abdominal surgery. The question has been raised that there is increased risk of complications in these patients. From June 1993 to May 1994, we performed 247 laparoscopic herniorrhaphies in 192 patients using the TEPA. Of these, 55 hernias were repaired in 45 patients with previous lower abdominal surgery. Overall retrospective results showed a slightly higher complication rate (23.1% vs 11.3%) and slightly higher recurrence rate (1.8% vs 0%) in the patients with previous surgery over those without. Although these differences are not statistically significant, it is important to keep these risks in mind when selecting the appropriate hernia repair for each patient.

A retrospective analysis of laparoscopically assisted ventriculoperitoneal shunts

BACKGROUND

During the last two years, laparoscopy has been utilized to facilitate the rapid, safe and direct placement of the abdominal component of ventriculoperitoneal shunts. This study was undertaken to review the feasibility, benefits, technique, and clinical application of laparoscopically assisted ventriculoperitoneal (LAVP) shunt placement.

METHODS

A retrospective analysis of the records of six patients who underwent LAVP shunt placement was undertaken. The sex, age, technique, indication for surgery, comorbid conditions, complications operative time, results, and mortality were noted.

RESULTS

All patients underwent successful shunt placement. This included placement in the face of previous abdominal surgery, including a percutaneous gastrostomy. The one major complication, hemothorax, was not associated with the laparoscopic portion of the procedure.

CONCLUSIONS

Using basic laparoscopic skills and nonspecialized equipment, laparoscopic assistance in ventriculoperitoneal shunt placement offers easy, direct placement of the intraabdominal portion of the catheter in most situations and provides definite patient benefits.

A glycoprotein binding retinoids and fatty acids is present in Drosophila

In the search for a possible Drosophila melanogaster homolog of interphotoreceptor retinoid-binding protein (IRBP), a approximately 140-kDa retinoid- and fatty acid-binding glycoprotein found in vertebrates, the 110,000 g supernatant fraction prepared from homogenates of fly heads was analyzed for the presence of proteins capable of binding radiolabeled retinol and palmitic acid. A soluble protein, which binds concanavalin A and has a retention time on size-exclusion high-performance liquid chromatography identical to that of purified bovine IRBP, was identified as binding both ligands. As assessed by fluorescence titration, the protein fraction obtained by concanavalin A-Sepharose affinity chromatography and size-exclusion chromatography of fly head supernatant had apparent dissociation constants of 2.9 x 10(-7) +/- 0.6 M for all-trans retinol, with the number (n) of independent ligand binding sites per protein molecule = 2, and 3.5 x 10(-7) +/- 0.1 M for 16-[9-anthroyloxy] palmitic acid with n = 7. High-performance liquid chromatography of hexane extracts of this protein fraction resolved several peaks with polarity and relative retention times similar, but not identical to all-trans retinol and retinal and their 9-, 11-, and 13-cis isomers. Gas chromatography/mass spectrometry analysis of fatty acid methyl esters prepared following lipid extraction of the protein identified lauric, myristic, palmitic, palmitoleic, and oleic acids as being covalently bound. Laurate, myristate, palmitate, and stearate were noncovalently bound. The apparent molecular mass of the Drosophila protein as assessed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and silver staining of the retinoid- and fatty acid-binding peak obtained by hydrophobic interaction chromatography of the size-exclusion fraction was approximately 70 kDa.