Global kelp forest restoration: past lessons, present status, and future directions

Kelp forest ecosystems and their associated ecosystem services are declining around the world. In response, marine managers are working to restore and counteract these declines. Kelp restoration first started in the 1700s in Japan and since then has spread across the globe. Restoration efforts, however, have been largely disconnected, with varying methodologies trialled by different actors in different countries. Moreover, a small subset of these efforts are 'afforestation', which focuses on creating new kelp habitat, as opposed to restoring kelp where it previously existed. To distil lessons learned over the last 300 years of kelp restoration, we review the history of kelp restoration (including afforestation) around the world and synthesise the results of 259 documented restoration attempts spanning from 1957 to 2020, across 16 countries, five languages, and multiple user groups. Our results show that kelp restoration projects have increased in frequency, have employed 10 different methodologies and targeted 17 different kelp genera. Of these projects, the majority have been led by academics (62%), have been conducted at sizes of less than 1 ha (80%) and took place over time spans of less than 2 years. We show that projects are most successful when they are located near existing kelp forests. Further, disturbance events such as sea-urchin grazing are identified as regular causes of project failure. Costs for restoration are historically high, averaging hundreds of thousands of dollars per hectare, therefore we explore avenues to reduce these costs and suggest financial and legal pathways for scaling up future restoration efforts. One key suggestion is the creation of a living database which serves as a platform for recording restoration projects, showcasing and/or re-analysing existing data, and providing updated information. Our work establishes the groundwork to provide adaptive and relevant recommendations on best practices for kelp restoration projects today and into the future.

Brentuximab vedotin and ESHAP is highly effective as second-line therapy for Hodgkin lymphoma patients (long-term results of a trial by the Spanish GELTAMO Group)

BACKGROUND

In this work, we assessed the efficacy and safety of brentuximab vedotin (BV) plus ESHAP (BRESHAP) as second-line therapy for Relapsed/Refractory Hodgkin lymphoma (RRHL) to improve the results before autologous stem-cell transplantation (ASCT).

PATIENTS AND METHODS

This was a multicenter, open-label, phase I-II trial of patients with RRHL after first-line chemotherapy. Treatment had three 21-day cycles of etoposide, solumedrol, high-dose AraC, and cisplatin. BV was administered at three dose levels (0.9, 1.2, and 1.8 mg/kg) intravenous on day ‒1 to 3 + 3 cohorts of patients. Final BV dose was 1.8 mg/kg. Responding patients proceeded to ASCT, followed by three BV courses (1.8 mg/kg, every 21 days). Main end points for evaluation were maximum tolerable dose and overall and complete response (CR) before ASCT.

RESULTS

A total of 66 patients were recruited (median age 36 years; range 18-66): 40 were primary refractory, 16 early relapse and 10 late relapse. There were 39 severe adverse events were reported in 22 patients, most frequently fever (n = 25, 35% neutropenic), including 3 deaths. Grade 3-4 hematological toxicity presented in 28 cases: neutropenia (n = 21), thrombocytopenia (n = 14), and anemia (n = 7). Grade ≥3-4 extrahematological adverse events (≥5%) were non-neutropenic fever (n = 13) and hypomagnesaemia (n = 3). Sixty-four patients underwent stem-cell mobilization; all collected >2×10e6/kg CD34+ cells (median 5.75; range 2.12-33.4). Overall response before transplant was 91% (CI 84% to 98%), including 70% (CRs 95% CI 59% to 81%). 60 patients were transplanted with no failure engraftments. Post-transplant response was CR in 49 patients (82% CI 73% to 91%) and partial responses in six (10% CI 5% to 15%). After a mean follow-up of 27 months, the 30-month time to treatment to failure was 74% (95% CI 68% to 80%), progression-free survival 71% (95% CI 65% to 77%), and overall survival 91% (CI 84% to 98%).

CONCLUSION

BRESHAP looks a safe and effective pre-transplant induction regimen, does not jeopardize transplant and allows long-term remissions and survival.

Gait assessment in Parkinson's disease patients through a network of wearable accelerometers in unsupervised environments

Parkinson's disease (PD) predominantly alters the motor performance of the affected individuals. In particular, the loss of dopaminergic neurons compromises the speed, the automaticity and fluidity of movements. As the disease evolves, PD patient's motion becomes slower and tremoric and the response to medication fluctuates along the day. In addition, the presence of involuntary movements deteriorates voluntary movement in advanced state of the disease. These changes in the motion can be detected by studying the variation of the signals recorded by accelerometers attached in the limbs and belt of the patients. The analysis of the most significant changes in these signals make possible to build an individualized motor profile of the disease, allowing doctors to personalize the medication intakes and consequently improving the response of the patient to the treatment. Several works have been done in a laboratory and supervised environments providing solid results; this work focused on the design of unsupervised method for the assessment of gait in PD patients. The development of a reliable quantitative tool for long-term monitoring of PD symptoms would allow the accurate detection of the clinical status during the different PD stages and the evaluation of motor complications. Besides, it would be very useful both for routine clinical care as well as for novel therapies testing.

Curvature elasticity of mixed amphiphilic bilayers

Elastic bending constants of mixed amphiphilic bilayers are calculated using a molecular approach. The free energy is expanded up to quadratic order in curvatures and compositions, choosing a flat symmetrical bilayer as the reference state. Bending constants are then calculated from the derivatives of the free energy evaluated at this reference state. Two-component bilayers are considered. As a novelty, the local compositions are allowed to fully relax upon bending so that the 2 monolayers are at chemical equilibrium with each other at every curvature. The compositional degree of freedom is shown to affect the bending constant k, but not the saddle-splay constant k. The influence on the membrane elastic properties of various chain structural features, such as length, volume, and stiffness, is investigated. This may prove useful to model mixed bilayers composed of hydrocarbon/hydrocarbon and hydrocarbon/fluorocarbon chains.

Effects of warm Carolina rinse on microvascular reperfusion injury in rat liver transplantation

Recently, it has been demonstrated that the use of both cold Carolina rinse (CR, 4 degrees C) as well as warm Ringer's lactate (RL, 37 degrees C) attenuates microvascular perfusion failure and leukocyte (WBC) accumulation in liver grafts. The aim of this study was to analyse in vivo whether warming of CR can also lead to a reduction in microvascular reperfusion injury in rat liver transplantation. Syngeneic orthotopic liver transplantation, including arterial reconstruction, was performed in male Lewis rats (180-300 g). Livers were stored in University of Wisconsin (UW) solution for 24 h and rinsed with 15 ml CR which was either cold 4 degrees C (n = 7) or warm 37 degrees C (n = 8) prior to reperfusion. Hepatic microcirculation and WBC accumulation were assessed by intravital fluorescence microscopy, and graft function was determined by analysis of bile flow during the 90-min reperfusion period. Warm CR yielded significantly (P < 0.01) improved sinusoidal perfusion when compared with cold CR; however, the extent of WBC adherence in both sinusoids and postsinusoidal venules did not vary between the groups. In addition, bile flow was slightly increased after warm CR. We conclude that after 24 h of cold storage in UW solution, warming of CR may offer additional benefit in the prevention of microcirculatory reperfusion injury without affecting WBC accumulation.

Carolina rinse attenuates postischemic microvascular injury in rat small bowel isografts

BACKGROUND

Apart from rejection-related events, the manifestation of ischemia/reperfusion (I/R) injury remains a major problem, hampering success in human small bowel transplantation (SBTx). Therefore the aim of this study was to determine the potential of Carolina rinse (CR) to attenuate microvascular reperfusion injury in rat intestinal isografts.

METHODS

After 18 hours of cold preservation in 4 degrees C University of Wisconsin solution (UW), rat SBTx was performed. Immediately before reperfusion the intestine was flushed with 4 degrees C or 37 degrees C Ringer's lactate (RL, groups 1 and 2) or CR (groups 3 and 4), respectively. In vivo fluorescence microscopy was used to analyze the grafts' microcirculation.

RESULTS

In group 1 severe microvascular I/R injury was observed in mucosa and muscle layers. Microcirculatory deterioration was paralleled by enhanced leukocyte accumulation in submucosal venules and by impaired subserosal lymphatic capillary drainage (FCLD). Rinsing the grafts with 37 degrees C RL attenuated leukocyte-endothelial cell interaction and improved subserosal FCLD; however, it did not affect mucosal microvascular reperfusion damage. In contrast, 4 degrees C CR dramatically improved nutritive perfusion within muscle and mucosa (p < 0.05) and attenuated leukocyte adherence within submucosal venules (p < 0.05). Additional prewarming of CR almost completely prevented mucosal I/R injury (p < 0.05 versus group 3) and caused a fourfold increase of FCLD. CONCLUSIONS. With this study we demonstrate that CR in combination with rewarming of the graft before reperfusion is an effective regimen to prevent leukocyte accumulation and to counteract microvascular injury after SBTx.

Carolina rinse attenuates postischemic microvascular injury in rat small bowel isografts

BACKGROUND

Apart from rejection-related events, the manifestation of ischemia/reperfusion (I/R) injury remains a major problem, hampering success in human small bowel transplantation (SBTx). Therefore the aim of this study was to determine the potential of Carolina rinse (CR) to attenuate microvascular reperfusion injury in rat intestinal isografts.

METHODS

After 18 hours of cold preservation in 4 degrees C University of Wisconsin solution (UW), rat SBTx was performed. Immediately before reperfusion the intestine was flushed with 4 degrees C or 37 degrees C Ringer's lactate (RL, groups 1 and 2) or CR (groups 3 and 4), respectively. In vivo fluorescence microscopy was used to analyze the grafts' microcirculation.

RESULTS

In group 1 severe microvascular I/R injury was observed in mucosa and muscle layers. Microcirculatory deterioration was paralleled by enhanced leukocyte accumulation in submucosal venules and by impaired subserosal lymphatic capillary drainage (FCLD). Rinsing the grafts with 37 degrees C RL attenuated leukocyte-endothelial cell interaction and improved subserosal FCLD; however, it did not affect mucosal microvascular reperfusion damage. In contrast, 4 degrees C CR dramatically improved nutritive perfusion within muscle and mucosa (p < 0.05) and attenuated leukocyte adherence within submucosal venules (p < 0.05). Additional prewarming of CR almost completely prevented mucosal I/R injury (p < 0.05 versus group 3) and caused a fourfold increase of FCLD. CONCLUSIONS. With this study we demonstrate that CR in combination with rewarming of the graft before reperfusion is an effective regimen to prevent leukocyte accumulation and to counteract microvascular injury after SBTx.

In vivo assessment of the influence of cold preservation time on microvascular reperfusion injury after experimental small bowel transplantation

BACKGROUND

This study describes the impact of prolonged cold storage on microvascular reperfusion injury of transplanted rat small bowel isografts.

METHODS

In vivo fluorescence microscopy was used to assess intestinal microcirculation after 6, 12, 18 and 24 h of cold (4 degrees C) ischaemia in University of Wisconsin solution and 20-90 min of reperfusion. Sham-operated animals served as controls.

RESULTS

Whereas 6 and 12 h of ischaemia did not affect functional capillary density of the intestinal graft mucosa, villous perfusion was significantly impaired after 18 and 24 h of cold preservation. Similarly, microvascular perfusion of circular and longitudinal muscle was not affected after 6 h, but deteriorated following prolonged cold ischaemia. Leucocyte-endothelial cell interaction in submucosal venules was significantly enhanced after 6 h of ischaemia with peak values after 12 and 18 h. A progressive reduction of lymphatic capillary drainage indicated an ischaemia time-related deterioration in graft function.

CONCLUSION

The results provide evidence that leucocyte-endothelial cell interaction in submucosal venules of the transplanted intestine is a primary step in the manifestation of reperfusion injury following short periods of cold ischaemia.

Intravital studies on beneficial effects of warm Ringer's lactate rinse in liver transplantation

This quantitative in vivo fluorescence microscopy study investigated the impact of warm versus cold Ringer's lactate (RL) graft rinse on various microvascular manifestations of ischemia-reperfusion injury after liver transplantation in the rat. Syngeneic orthotopic liver transplantation, including arterial revascularization, was performed in male Lewis rats following 24 h of cold storage in University of Wisconsin (UW) solution. In one group (n = 8) liver grafts were rinsed with 4 degrees C (cold) RL, whereas in the other group (n = 8) grafts were rinsed with 37 degrees C (warm) RL immediately prior to revascularization. Hepatic microvascular perfusion, leukocyteendothelium interaction, and Kupffer cell activation were quantified 30-90 min after graft reperfusion by direct visualization with intravital fluorescence microscopy. Moreover, biliary excretory graft function was analyzed by determination of bile flow and bile salt excretion during the first 90 min after reperfusion. Compared to grafts rinsed with cold RL, acinar and sinusoidal perfusion were found to be significantly increased after rinsing the grafts with warm RL. The amount of nonperfused acini declined from 18.1% +/- 4.0% to 7.4% +/- 1.6% (P < 0.05), and the total percentage of perfused sinusoids increased from 80.1 +/- 1.4 to 88.4 +/- 1.2 (P < 0.001) after cold and warm rinse, respectively. After rinsing the graft with warm RL, WBC adherence in sinusoids and especially in postsinusoidal venules decreased significantly by 28% (P < 0.001) and 33% (P < 0.001), respectively. Kupffer cell activation was markedly reduced after rinsing with RL at 37 degrees C, as indicated by a decelerated adherence of latex particles injected 80 min after reperfusion. Excretory graft function was dramatically increased following warm RL rinse during the 90-min observation period. Bile flow was enhanced from 1.04 +/- 0.5 to 3.9 +/- 0.8 ml/100 g liver per 90 min (P < 0.01), with a parallel rise in bile salt excretion from 24.3 +/- 5.8 to 128.0 +/- 19.8 mmol/ 100 g liver per 90 min (P < 0.05) when compared to cold RL. These data strongly suggest that rinsing liver grafts with warm RL prior to reperfusion represents a simple and inexpensive way to reduce the incidence of primary graft failure secondary to ischemia and reperfusion injury in liver transplantation.

Timing of arterialization in liver transplantation

OBJECTIVE

This study analyzed the pathophysiologic sequela of different modes of graft reperfusion in liver transplantation.

SUMMARY BACKGROUND DATA

The grafted liver may be reperfused either immediately after completion of portal anastomosis followed by delayed arterial reconstruction or simultaneously by portal and arterial blood if all vascular anastomoses are completed during the anhepatic period.

METHODS

Delayed arterialization, that is, arterial reperfusion 8 minutes after portal revascularization (n = 12), was compared with simultaneous arterialization (n = 8) using the model of syngeneic orthotopic liver transplantation in male Lewis rats. After cold storage for 24 hours in University of Wisconsin (UW) solution, intravital fluorescence microscopy was employed 30 to 90 minutes after reperfusion to assess hepatic microvascular perfusion, leukocyte accumulation, and phagocytic activity of Kupffer cells.

RESULTS

Compared with delayed arterialization, the number of both nonperfused acini and nonperfused sinusoids was reduced after simultaneous reperfusion by 71% (p = 0.008) and 78% (p < 0.001), respectively. Leukocyte accumulation in sinusoids and postsinusoidal venules after simultaneous arterialization decreased by 17% (p = 0.01) and 64% (P < 0.001), respectively. In addition, simultaneous revascularization was able to attenuate Kupffer cell activation, indicated by significantly slower adherence of latex beads injected 80 minutes after reperfusion. Improved hepatocellular excretory function after simultaneous arterialization was demonstrated by increased bile flow during the observation period of 90 minutes after reperfusion (2.24 +/- 0.7 vs. 0.95 +/- 0.4 mL/100 g liver [mean +/- SEM], p < 0.05).

CONCLUSIONS

Timing of arterial reperfusion in liver transplantation may be of critical importance in the prevention of various manifestations of reperfusion injury.

In vivo fluorescence microscopy for the assessment of microvascular reperfusion injury in small bowel transplants in rats

With the use of in vivo fluorescence microscopy we have analyzed microvascular reperfusion injury of small bowel isograft transplants in rats. Following 1 hr cold storage in University of Wisconsin solution, the small bowel was transplanted heterotopically, and the intestinal microcirculation was quantitatively analyzed 20-60 min after onset of reperfusion. The intestinal grafts' capillary perfusion of both the mucosa and the circular and longitudinal muscles was not found altered when compared with the intestinal capillary perfusion of sham-operated controls. In contrast, leukocyte-endothelial cell interaction, including leukocyte rolling (40 +/- 5%) and sticking (280 +/- 100 mm-2) in submucosal postcapillary venules, was significantly increased when compared with nontransplanted controls (12 +/- 8% and 20 +/- 10 mm-2, P < 0.01 and P < 0.05, respectively). Leukocyte-endothelial cell interaction was associated with a marked alteration of lymphatic capillary drainage, as indicated by the low functional density of lymphatic microvessels of 10.2 +/- 6.1 cm-1 (P < 0.01 vs. sham-operated controls (39.2 +/- 6.1 cm-1)). From these results we propose that leukocyte-endothelial cell interaction, not capillary "no-reflow," is the primary step in the manifestation of microvascular reperfusion injury following a short period of cold ischemia in small bowel grafts.

AgNOR area measurements differentiate benign and malignant melanocytic lesions more accurately than simple counting

Comparison of argyrophilic nucleolar organizer region (AgNOR) counts has been found to yield statistically significant differences between benign and malignant conditions albeit with considerable overlap. In this study we compared the size of AgNORs and the nuclear areas, as well as the AgNOR count in 23 benign melanocytic lesions and 9 melanomas. Of these parameters, the ratio AgNOR area/nuclear area was found to be the main discriminating factor between melanoma and all the other benign groups studied, with p values of < 0.01 and no overlap. Next to it was the nuclear area, which in our study gave significant differences between the groups evaluated. The total AgNOR area and the largest AgNOR gave results comparable to the simple AgNOR counting in all groups studied, except in Spitz nevus, in which the AgNOR counts were less significant than the other parameters (p = 0.0420). We conclude that the ratio AgNOR area/nuclear area discriminates benign from malignant melanocytic lesions better than AgNOR counts or other parameters studied.

Differential impact of Carolina rinse and University of Wisconsin solutions on microcirculation, leukocyte adhesion, Kupffer cell activity and biliary excretion after liver transplantation

This quantitative in vivo fluorescence microscopy study investigated the relative impact of an optimized rinse solution (warm Carolina rinse) and that of an established storage solution (University of Wisconsin solution) on various pathomechanisms of hepatic reperfusion injury after cold storage. Syngeneic orthotopic, arterialized liver transplantation was performed in male Lewis rats after 24 hr of cold ischemia (n = 24). The four experimental groups differed according to the type of preservation/rinse solution used: University of Wisconsin solution/albumin rinse (group 1), autologous blood (just external cooling)/albumin rinse (group 2), blood/Carolina rinse (group 3) and University of Wisconsin solution/Carolina rinse (group 4). Hepatic microvascular perfusion, leukocyte accumulation and phagocytic activity of Kupffer cells were assessed by means of intravital fluorescence microscopy 30 to 90 min after reperfusion. Disturbances of microvascular perfusion were most pronounced in group 2, markedly reduced by University of Wisconsin solution (group 1) and Carolina rinse (group 3) and minimized by combined use of University of Wisconsin solution and Carolina rinse in group 4. Intrahepatic leukocyte-endothelium interaction in sinusoids and postsinusoidal venules was found to depend on the application of Carolina rinse before reperfusion rather than the use of University of Wisconsin solution during cold storage. Activation of phagocytosis by Kupffer cells was most pronounced in group 1, intermediate in groups 2 and 3 and not noticeable in group 4. Hepatocellular excretory function as assessed on the basis of total bile flow and excretion of bile acids during the first 90 min after reperfusion was found to be improved by application of Carolina rinse, both after storage in blood or in University of Wisconsin solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of Carolina rinse and adenosine rinse on microvascular perfusion and intrahepatic leukocyte-endothelium interaction after liver transplantation in the rat

Flushing hepatic grafts immediately before revascularization with a specially designed rinse solution such as "Carolina rinse" has been reported to improve survival after liver transplantation in the rat. This study investigated the influence of Carolina rinse and adenosine rinse on early graft function, microcirculation, and leukocyte (WBC)-endothelial cell interaction of arterialized syngeneic orthotopic liver transplants in Lewis rats. Livers were preserved for 24 hr in University of Wisconsin solution and flushed immediately before reperfusion with either Ringer's lactate (group A: n = 7), Ringer's lactate + 0.2 mmol/liter adenosine (group B: n = 6), or Carolina rinse (group C: n = 7). Microvascular perfusion and WBC accumulation were assessed by intravital fluorescence microscopy. In group C, acinar perfusion was significantly improved, accompanied by a lower percentage of nonperfused sinusoids 1 hr after reperfusion (mean +/- SEM: 26 +/- 2% [group A], 21 +/- 2% [B], 11 +/- 1% [C], P < 0.01 for C vs. A or B). In addition, Carolina rinse and, to a lesser extent, adenosine rinse reduced the number of WBC sticking in sinusoids and postsinusoidal venules. Better graft function in group C was indicated by increased bile flow during the observation period of 90 min after reperfusion (0.5 +/- 0.3 ml/100 g liver [group A], 1.5 +/- 0.7 [B], 3.7 +/- 0.6 [C], P < 0.01 for C vs. A or B). We conclude that Carolina rinse is able to improve early excretory hepatocellular function, microvascular perfusion, and intrahepatic WBC accumulation after prolonged cold ischemia and reperfusion, but adenosine is unlikely to be the key component of this rinse solution.

The impact of arterialization on hepatic microcirculation and leukocyte accumulation after liver transplantation in the rat

This study investigated the influence of hepatic arterialization on early graft function, microcirculation, and leukocyte-endothelial interaction after syngeneic orthotopic liver transplantation in Lewis rats. Livers were preserved for 17 hr in UW solution and transplanted without rearterialization (group 1: n = 10) or with immediate arterial reconstruction (group 2: n = 10). Graft function was analyzed by bile flow; microcirculation was assessed by laser Doppler flowmetry (LDF) and intravital microscopy (IVM). In addition, flow behavior of leukocytes was quantified by IVM after i.v. injection of the WBC marker acridine orange. Improved graft function in group 2 was indicated by increased bile production during the observation period of 90 min after reperfusion (7.18 +/- 0.62 vs. 3.63 +/- 0.63 ml/100 g liver [mean +/- SEM] P < 0.001). In arterialized grafts LDF values increased by 22.9 +/- 3.8% upon reperfusion of the hepatic artery (P = 0.004). Arterialization increased WBC velocities in sinusoids (group 1: 0.29 +/- 0.02 mm/sec, group 2: 0.34 +/- 0.01 mm/sec, P < 0.001) and postsinusoidal venules (0.43 +/- 0.05 vs. 0.64 +/- 0.05 mm/sec, P = 0.029). In addition, the number of nonperfused midzonal sinusoids decreased significantly (8.5 +/- 2.2% of all sinusoids analyzed vs. 4.2 +/- 1.3%, P = 0.048). However, the marked sinusoidal and venular WBC adherence observed 1 hr after reperfusion was not altered by arterialization. It is concluded that arterial reconstruction in rat liver transplantation improves microvascular perfusion and graft function but this improvement does not relate to WBC accumulation within the graft. We propose that studies on hepatic preservation and postischemic reperfusion in the rat should be based on the physiological model of dual vascularization.

Assessment of hepatic phagocytic activity by in vivo microscopy after liver transplantation in the rat

Phagocytic activity of sinusoidal lining cells was studied in 32 livers of male Lewis rats by in vivo fluorescence microscopy with epiillumination. Normal livers (group 1, n = 8) were compared with orthotopic syngeneic liver grafts 90 min after reperfusion after a period of cold storage in University of Wisconsin solution for 17 hr (group 2, n = 10) or 24 hr (group 3, n = 14). After bolus injection of fluorescence-labeled latex particles (3 x 10(8)/kg; diameter = 1.1 micron), zonal distribution and kinetics of adherence of latex beads were quantified by off-line video analysis. Hepatocellular function was estimated by the rate of bile production and biliary concentrations of bile acids. In normal livers 50%, 37% and 13% of injected latex beads adhered in zones 1, 2 and 3, respectively, whereas in transplanted livers a more homogeneous distribution was found (group 2: 37%, 41%, 22%; group 3: 37%, 39%, 24%; p less than 0.01 vs. controls by analysis of variance). Kinetic analysis of phagocytic activity showed no significant difference between group 1 (88% adherence of visible latex beads 3 min after injection) and group 2 (90% adherence). However, after long-term preservation in group 3, sinusoidal adherence was significantly faster (96.4% adherence; p less than 0.001). Bile secretion in group 2 was lower than in controls and severely depressed in group 3 (group 1: 1.1 +/- 0.07 microliter/min/gm liver [mean +/- S.E.M.]; group 2: 0.8 +/- 0.07; group 3: 0.1 +/- 0.04; p less than 0.001) without significant changes in bile acid concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)