Operative time and accrual of postoperative complications in minimally invasive versus open myomectomy

STUDY OBJECTIVE

To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM).

DESIGN

Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021.

PATIENTS

Female patients aged ≥ 18 years undergoing OM or MIM.

INTERVENTIONS

Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance.

MEASUREMENTS AND MAIN RESULTS

Of 27,728 patients, 11,071 underwent MIM and 16,657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM.

CONCLUSION

OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Safety of Same-Day Discharge Versus Hospital Admission in Minimally Invasive Myomectomy

STUDY OBJECTIVE

To compare postoperative complication rates between same-day discharge patients and patients admitted to hospital after minimally invasive myomectomy, stratified by patient demographics and perioperative variables including myoma burden.

DESIGN

Retrospective cohort study. Setting Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2019.

PATIENTS

Female patients aged ≥18 years undergoing minimally invasive myomectomy.

INTERVENTIONS

Patients were categorized into either the same-day discharge or admitted patient cohort. Univariate comparisons of demographics, perioperative variables, and 30-day postoperative complications were performed. Multivariate logistic regression was used to 1) identify demographic and perioperative factors associated with admission, and 2) compare postoperative complication rates of same-day discharge patients with those of admitted patients while adjusting for demographic and perioperative factors.

MEASUREMENTS AND MAIN RESULTS

Eight thousand one hundred patients were recruited during the study period. The overall rate of same-day discharge was 57.2% in 2015 and 65.0% in 2019. The same-day discharge rate was 64.6% for patients with a smaller myoma burden (1-4 fibroids and ≤250 grams, Current Procedural Terminology 58545) and 56.8% for larger myoma burden (≥5 fibroids or >250 grams, Current Procedural Terminology 58546). Age, race, American Society of Anesthesiologists classification III or IV, preoperative hematocrit <36%, hypertension, diabetes, bleeding disorder, and increasing operative time were associated with admission to hospital. After adjusting for these variables, composite postoperative complication rates were similar between admitted patients and patients who were discharged the same day regardless of myoma burden (adjusted OR [aOR], 0.66; 95% confidence interval [CI] 0.18-2.47 for low myoma burden and aOR, 0.91; 95% CI 0.18-4.63 for high myoma burden). Admitted patients with both low (aOR, 9.1; 95% CI 2.27-37.04) and high (aOR, 8.24; 95% CI 1.59-42.49) myoma burdens were significantly more likely to receive a blood transfusion compared to same-day discharge patients.

CONCLUSION

Same-day discharge after minimally invasive myomectomy, regardless of myoma burden, is associated with low complication rates. Our findings may aid in shared decision making on discharge planning.

Massive Subcutaneous Emphysema and Pneumothorax in a Case of Attacked by a Domesticated Bull - An Autopsy Based Diagnosis

Subcutaneous emphysema is a condition when air or gas gets trapped within the subcutaneous layer. It is characterised by crackling feeling on palpation of the skin known as subcutaneous crepitation which is described as touching rice krispies. A 70 years male from hilly region of Nepal with agricultural background suffered multiple injuries sustained due to an attack by domesticated bull in his house. Upon the incident the injured male was taken to hospital, where he was declared "Brought Dead" by the Emergency Department of Dhulikhel Hospital, Kathmandu University Hospital. His body was brought for autopsy in Department of Forensic Medicine and Toxicology of Kathmandu University School of Medical Sciences. On complete autopsy, massive subcutaneous emphysema and pneumothorax was demonstrated. The details of finding are discussed in detail as follows.

Laparoscopically Confirmed Endometriosis and Risk of Incident Stroke: A Prospective Cohort Study

BACKGROUND

Prior research suggests that women with endometriosis are at greater risk of coronary heart disease. Therefore, our objective was to prospectively investigate the association between laparoscopically confirmed endometriosis and risk of incident stroke during 28 years of follow-up.

METHODS

Participants in the NHSII cohort study (Nurses' Health Study II) were followed from 1989 when they were between the ages of 25 to 42 until 2017 for development of incident stroke (ischemic and hemorrhagic). Cox proportional hazard models were used to calculate hazard ratios and 95% CI, with adjustment for potential confounding variables (alcohol intake, body mass index at age 18, current body mass index, age at menarche, menstrual cycle pattern in adolescence, current menstrual cycle pattern, parity, oral contraceptive use history, smoking history, diet quality, physical activity, NSAID use, aspirin use, race/ethnicity, and income). We estimated the proportion of the total association mediated by history of hypertension, hypercholesterolemia, hysterectomy/oophorectomy, and hormone therapy. We also tested for effect modification by age (<50, ≥50 years), infertility history, body mass index (<25, ≥25 kg/m2), and menopausal status.

RESULTS

We documented 893 incident cases of stroke during 2 770 152 person-years of follow-up. Women with laparoscopically confirmed endometriosis had a 34% greater risk of stroke in multivariable-adjusted models (hazard ratio, 1.34 [95% CI, 1.10-1.62]), compared to those without a history of endometriosis. Of the total association of endometriosis with risk of stroke, the largest proportion was attributed to hysterectomy/oophorectomy (39% mediated [95% CI, 14%-71%]) and hormone therapy (16% mediated [95% CI, 5%-40%]). We observed no differences in the relationship between endometriosis and stroke by age, infertility history, body mass index, or menopausal status.

CONCLUSIONS

We observed that women with endometriosis were at elevated risk of stroke. Women and their health care providers should be aware of endometriosis history, maximize primary cardiovascular prevention, and discuss signs and symptoms of cardiovascular disease.

Realization of the T Lineage Program Involves GATA-3 Induction of Bcl11b and Repression of Cdkn2b Expression

The zinc-finger transcription factor GATA-3 plays a crucial role during early T cell development and also dictates later T cell differentiation outcomes. However, its role and collaboration with the Notch signaling pathway in the induction of T lineage specification and commitment have not been fully elucidated. We show that GATA-3 deficiency in mouse hematopoietic progenitors results in an early block in T cell development despite the presence of Notch signals, with a failure to upregulate Bcl11b expression, leading to a diversion along a myeloid, but not a B cell, lineage fate. GATA-3 deficiency in the presence of Notch signaling results in the apoptosis of early T lineage cells, as seen with inhibition of CDK4/6 (cyclin-dependent kinases 4 and 6) function, and dysregulated cyclin-dependent kinase inhibitor 2b (Cdkn2b) expression. We also show that GATA-3 induces Bcl11b, and together with Bcl11b represses Cdkn2b expression; however, loss of Cdkn2b failed to rescue the developmental block of GATA-3-deficient T cell progenitor. Our findings provide a signaling and transcriptional network by which the T lineage program in response to Notch signals is realized.

Research priorities for neuroimmunology: identifying the key research questions to be addressed by 2030

Neuroimmunology in the broadest sense is the study of interactions between the nervous and the immune systems. These interactions play important roles in health from supporting neural development, homeostasis and plasticity to modifying behaviour. Neuroimmunology is increasingly recognised as a field with the potential to deliver a significant positive impact on human health and treatment for neurological and psychiatric disorders. Yet, translation to the clinic is hindered by fundamental knowledge gaps on the underlying mechanisms of action or the optimal timing of an intervention, and a lack of appropriate tools to visualise and modulate both systems. Here we propose ten key disease-agnostic research questions that, if addressed, could lead to significant progress within neuroimmunology in the short to medium term. We also discuss four cross-cutting themes to be considered when addressing each question: i) bi-directionality of neuroimmune interactions; ii) the biological context in which the questions are addressed (e.g. health vs disease vs across the lifespan); iii) tools and technologies required to fully answer the questions; and iv) translation into the clinic. We acknowledge that these ten questions cannot represent the full breadth of gaps in our understanding; rather they focus on areas which, if addressed, may have the most broad and immediate impacts. By defining these neuroimmunology priorities, we hope to unite existing and future research teams, who can make meaningful progress through a collaborative and cross-disciplinary effort.

Sexual Dimorphism of Greater Sciatic Notch among Nepalese Population by Three Dimensional CT Images of Pelvis

Background Sex identification from the skeletal remains, is the first and the foremost step encountered by forensic experts. Hip bone being comparatively robust is resistant to damage and scores even in improperly preserved skeletons. It is also widely agreed that the greater sciatic notch (GSN) holds the greatest degree of sexual dimorphism. Objective To study the role of greater Sciatic Notch parameters in sex determination among Nepalese population by means of reconstructed Multi Slice Three-Dimensional Computed Tomography (MDCT) images. Method The CT images of individuals who underwent pelvic CT in the Department of Radiology, Dhulikhel Hospital were included in the study. Measurements of width, depth, angles and indices of greater sciatic notch were measured and calculated. Data were entered and analyzed using SPSS (Statistical Package for Social Sciences) version 25.0. Result There was a significant difference between means of all greater sciatic notch parameters (p > 0.001) between sex showing sexual dimorphism except depth (p=0.65). By using limiting point, 78.18% male and 83.64% female were correctly classified by using total width. Total angle, Posterior segment and Total width had sensitivity and specificity exceeding 80% and overall accuracy of 87% to 92% in all parameters except depth by receiver-operator characteristic curve analysis. Conclusion Application of 3D-CT virtual images in the present study helped us to easily quantify greater sciatic notch parameters. The important greater sciatic notch predictors for sex determination in Nepalese population were determined which would help forensic experts in ascertaining the sex of an unknown individual.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training

Objective

To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency.

Design

Prospective evaluation.

Setting

Simulation Center.

Patients

Forty REI fellows.

Interventions

Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice.

Main Outcome Measures

Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency.

Results

Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03).

Conclusions

An intensive surgical boot camp enhances surgical skill among REI fellows.

Maximising the potential of neuroimmunology

Technological developments in recent years have led to a surge in advances in neuroimmunology, making real progress towards improving human health. With the scale of the challenges ahead, realising this potential requires a collaborative effort. The neuroscience, immunology and wider scientific community, both academia and industry, must come together to pool together ideas, experiences and resources.

Age-related changes in amplitude, latency and specialization of ERP responses to faces and watches

Healthy aging is associated with impairments in face recognition. While earlier research suggests that these impairments arise during memory retrieval, more recent findings suggest that earlier mechanisms, at the perceptual stage, may also be at play. However, results are often inconsistent and very few studies have included a non-face control stimulus to facilitate interpretation of results with respect to the implication of specialized face mechanisms vs. general cognitive factors. To address these issues, P100, N170 and P200 event-related potentials (ERPs) were measured during processing of faces and watches. For faces, age-related differences were found for P100, N170 and P200 ERPs. For watches, age-related differences were found for N170 and P200 ERPs. Older adults showed less selective and less lateralized N170 responses to faces, suggesting that ERPs can detect age-related de-differentiation of specialized face networks. We conclude that age-related impairments in face recognition arise in part from difficulties in the earliest perceptual stages of visual information processing. A working model is presented based on coarse-to-fine analysis of visually similar exemplars.

Risk for and consequences of endometriosis: A critical epidemiologic review

Endometriosis affects approximately 10% of women of reproductive age. Characteristics robustly associated with a greater risk for endometriosis include early age at menarche, short menstrual cycle length, and lean body size, whereas greater parity has been associated with a lower risk. Relationships with other potential characteristics including physical activity, dietary factors, and lactation have been less consistent, partially because of the need for rigorous data collection and a longitudinal study design. Critical methodologic complexities include the need for a clear case definition; valid selection of comparison/control groups; and consideration of diagnostic bias and reverse causation when exploring demographic characteristics, medical history, and lifestyle factors. Reviewers and editors must demand a detailed description of rigorous methods to facilitate comparison and replication to advance our understanding of endometriosis.

Difference between mean gestational sac diameter and crown-rump length as a marker of first-trimester pregnancy loss after in vitro fertilization

OBJECTIVE

To investigate whether the difference between mean gestational sac diameter and crown-rump length (mGSD - CRL) is associated with first-trimester pregnancy loss or adverse pregnancy outcomes after in vitro fertilization (IVF) and to determine if mGSD - CRL is a better predictor of pregnancy loss than either measurement alone.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

A total of 1,243 IVF cycles with fresh or cryopreserved autologous embryo transfers resulting in singleton gestations performed at the University of Iowa Hospitals and Clinics from January 2005 through December 2014. Cycles included ultrasound measurements of mGSD and CRL at 45-56 days' gestation.

INTERVENTION(S)

Mean gestational sac diameter to crown-rump length difference.

MAIN OUTCOME MEASURE(S)

Primary outcomes were first-trimester pregnancy loss and gestational age at delivery. Secondary outcomes were infant birth weight and pregnancy complications.

RESULT(S)

First-trimester pregnancy loss rates were significantly higher in pregnancies with mGSD - CRL <5 mm (43.7%) compared with 5-9.99 mm (15.8%), 10-14.99 mm (9.9%), and ≥15 mm (7.1%). No correlations were found with infant birth weight, gestational age at delivery, or other pregnancy complications. mGSD - CRL was not a better predictor of pregnancy loss than mGSD or CRL alone.

CONCLUSION(S)

There is a strong inverse relationship between mGSD - CRL and first-trimester pregnancy loss in IVF patients, although the incidence of pregnancy loss with a mGSD - CRL <5 mm was significantly lower than previously reported. Small mGSD - CRL was not associated with an increased risk of complications in pregnancies that continued beyond 20 weeks. The association between mGSD, CRL, and miscarriage is complex.

Meckel's Diverticulum: a Systematic Review

Meckel's diverticulum is the most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration, haemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae and tumours. These complications, especially bleeding, are more common in the paediatric age group than in adults; however it is not uncommon to miss the diagnosis of Meckel's diverticulum in adults. Here, we reviewed the literature regarding the complications of this forgotten clinical entity in adults with potential diagnostic difficulties and management strategies.

A study of Eagle’s syndrome in CMS-TH Bharatpur

Objective To study the common symptoms and outcome of surgical treatment of Eagle’s syndromeMethods A total of 22 cases were studied prospectively in both sexes from January 2008 to December 2010, in Department of ENT-HNS College Of Medical Sciences-Teaching Hospital, Bharatpur, Nepal. Patients with symptomatic styloid process were clinically palpated at tonsillar fossa and finally sent for X-ray styloid process. Patients underwent intra-oral tonsillectomy with styloidectomy. Post-operative improvement was analysed by follow up at one three and six months interval.Results Most common age group was 30-40 years (63.63%) with female dominance (M:F=1:4.5). The most frequent symptoms were pain in throat (29.62%), referred pain in ear (20.37%), pain in anterior triangle in neck (24.07%), foreign body sensation in throat (14.81%) and difficulty in swallowing (11.11%). Fifty nine percent of patients were having symptoms for last two to four years and 50% were on medication for last one to two years. All the patients underwent styloidectomy through intra-oral route. (63.63%) patients became symptom free and 13.63% didn’t show improvement even after operation.Conclusion Eagle’s syndrome is common in young females with various atypical presentations. Dull/throbbing or radiationg throat pain and pain in anterior triangle of the neck are common presentations. Diagnosis is done simply by palpating the tonsillar fossa.Journal of College of Medical Sciences-Nepal, 2014, Vol.10(1); 5-10

An overview of the intrathymic intricacies of T cell development

The generation of a functional and diverse repertoire of T cells occurs in the thymus from precursors arriving from the bone marrow. In this article, we introduce the various stages of mouse thymocyte development and highlight recent work using various in vivo, and, where appropriate, in vitro models of T cell development that led to discoveries in the regulation afforded by transcription factors and receptor-ligand signaling pathways in specifying, maintaining, and promoting the T cell lineage and the production of T cells. This review also discusses the role of the thymic microenvironment in providing a niche for the successful development of T cells. In particular, we focus on advances in Notch signaling and developments in Notch ligand interactions in this process.

Pharmacokinetics of human chorionic gonadotropin injection in obese and normal-weight women

CONTEXT

Obese women have poorer in vitro fertilization outcomes, but underlying mechanisms remain unclear.

OBJECTIVE

The objectives of the study were to compare the pharmacokinetics of human chorionic gonadotropin (hCG) and ovarian steroid hormone production, after subcutaneous (s.c.) and intramuscular (i.m.) injection of hCG in obese and normal-weight women.

DESIGN AND SETTING

This was a randomized, experimental study.

PATIENTS OR OTHER PARTICIPANTS

Twenty-two women aged 18-42 years with body mass index of 18.5-24.9 (normal) or 30-40 kg/m(2) (obese).

INTERVENTIONS

Participants received im urinary hCG or s.c. recombinant hCG and returned for a second injection type after a 4-week washout. Intramuscular injections were performed under ultrasound guidance. Blood was taken 0, 0.5, 1, 2, 4, 6, 8, 12, 24, and 36 hours after injection.

MAIN OUTCOME MEASURES

hCG was measured at each time point; estradiol, progesterone, 17-hydroxyprogesterone (17-OHP), testosterone (T), dehydroepiandrosterone, and SHBG were measured at 0 and 36 hours.

RESULTS

Twenty-two women completed the study. In both normal-weight and obese women, peak serum concentration (Cmax), area under the curve (AUC), and average hCG concentration were higher after i.m. injection as compared with s.c. injection (all P < .003). Obese women had markedly lower Cmax, AUC, and average hCG concentration after s.c. injection as compared with normal-weight women (P = .02, P = .009, and P = .008, respectively). After i.m. injection, Cmax, AUC, and average concentration were similar for normal-weight and obese women (P = .31, P = .25, and P = .18, respectively). Thirty-six percent of obese women had muscular layers beyond the reach of a standard 1.5 inch needle. hCG caused a significant rise in 17-OHP in both obese and normal-weight women and an increase in T in obese but not normal-weight women (all P < .04).

CONCLUSIONS

Subcutaneous injection yields lower hCG levels in obese women. Standard-length needles are insufficient to administer i.m. injections in many obese women.

Development of maternal and neonatal composite outcomes for trials evaluating management of late-onset pre-eclampsia

OBJECTIVE

Pre-eclampsia is associated with significant maternal and neonatal complications, and delivery is often expedited to minimise complications. For randomised trials evaluating interventions in women with late-onset (>34 weeks) mild to moderate pre-eclampsia, no single outcome has been identified to be the most clinically important. Existing composite outcomes with more than one clinically relevant endpoint to evaluate interventions in pre-eclampsia provide limited justification for selection of the components. Our objective was to develop robust, valid composite maternal and neonatal outcome measures for clinical trials evaluating interventions in women with late-onset mild and moderate pre-eclampsia.

STUDY DESIGN

A two-generational Delphi method was used to identify these clinically important maternal and neonatal outcomes. Composite outcomes were developed based on biological plausibility, independence from each other, frequency of occurrence and level of importance.

RESULTS

The final maternal composite outcome included maternal death, eclampsia, stroke or reversible ischaemic neurological deficit, pulmonary oedema, major obstetric haemorrhage, need for positive inotropic support, haemolysis, elevated liver enzymes and low platelets syndrome and placental abruption; and the neonatal composite outcome included neonatal death, respiratory distress syndrome needing ventilator support and neurological outcomes as cystic periventricular leukomalacia and grade III/IV intraventricular haemorrhage.

CONCLUSION

The composite outcomes developed will enable clinical trials to provide robust estimates on the effectiveness of the interventions in women with mild to moderate late onset pre-eclampsia to inform clinical practice. Caution is needed in the interpretation of composite outcomes due to variation in the importance of individual components.

Induction of T-cell development by Delta-like 4-expressing fibroblasts

The thymus provides a unique environment for the induction of T-cell lineage commitment and differentiation, which is predicted by specific Notch ligand-receptor interactions on epithelial cells and lymphoid progenitors, respectively. Accordingly, a bone marrow-derived stromal cell line (OP9) ectopically expressing the Notch ligand Delta-like 1 (Dll1) or Dll4 (OP9-DL1 and OP9-DL4, respectively) gains the ability to recapitulate thymus-like function, supporting T-cell differentiation of both mouse and human progenitors. In this study, we extend these findings by demonstrating that, unlike the NIH3T3 cell line, mouse primary fibroblasts made to express Dll4 (mFibro-DL4) acquire the capacity to promote and support T-cell development from hematopoietic stem cells (HSCs) into TCRαβ(+), CD4(+) and CD8(+) T-lineage cells. However, mFibro-DL4 cells showed a lower efficiency of T-cell generation than OP9-DL4 cells did. Nevertheless, progenitor T-cells (CD117(+) CD44(+) CD25(+)) generated in HSC/mFibro-DL4 co-cultures, when intravenously transferred into immunodeficient (Rag2(-/-) γc(-/-)) mice, home to the thymus, undergo differentiation, and give rise to mature T-cells that go on to populate the periphery. Surprisingly, primary human fibroblast cells expressing Dll4 showed very low efficiency in supporting human T-lineage differentiation, which could not be improved by blocking myelopoiesis. Nevertheless, mFibro-DL4 cells could support human T-cell lineage differentiation. Our results provide a functional framework for the induction of T-cell development using easily accessible fibroblasts made to express Dll4. These cells, which are amenable for in vitro applications, can be further utilized in the design of individualized systems for T-cell production, with implications for the treatment of immunodeficiencies.

Body size and endometriosis: results from 20 years of follow-up within the Nurses' Health Study II prospective cohort

STUDY QUESTION

Is there a relationship between body mass index (BMI), body shape and endometriosis?

SUMMARY ANSWER

Endometriosis is inversely associated with early adult BMI and may correlate with a peripheral body fat distribution.

WHAT IS KNOWN ALREADY

The literature suggests an inverse relation between endometriosis and BMI, although few studies have specifically explored this association in depth.

STUDY DESIGN, SIZE, DURATION

Prospective cohort study using data collected from 116 430 female nurses from September 1989 to June 2011 as part of the Nurses' Health Study II cohort. PARTICIPANTS/MATERIALS, METHODS AND SETTING: Cases were restricted to laparoscopically confirmed endometriosis. Weight at age 18 and height were reported at baseline, and current weight was updated every 2 years. Waist and hip measurements were first taken in 1993 and updated in 2005. Rate ratios (RR) and 95% confidence intervals (CI) were calculated using Cox proportional hazards models with time-varying covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 5504 incident cases of endometriosis were reported during 1 299 349 woman-years (incidence rate = 385 per 100 000 woman-years). BMI at age 18 and current BMI were each significantly inversely associated with endometriosis (P-value, test for linear trend <0.0001). Both associations were stronger among infertile women. Obese infertile women with current BMIs of 35-39.9 kg/m(2) and ≥ 40 kg/m(2) had a 55% (95% CI 0.30-0.67) and a 62% (95% CI 0.23-0.62) lower risk of endometriosis, respectively, compared with the low-normal BMI referent (18.5-22.4 kg/m(2)). Rates of endometriosis were nearly 3-fold higher in women with waist-to-hip ratios <0.60 (RR = 2.78, 95% CI 1.38-5.60) compared with those with waist-to-hip ratios between 0.70 and 0.79, although the sample size for this category was very small.

LIMITATIONS AND REASONS FOR CAUTION

Although women with undiagnosed endometriosis certainly remain in the comparison population even in this prospective cohort study, the community prevalence of endometriosis in an asymptomatic population is very low. Moreover, the characteristics of this small proportion of undiagnosed cases are diluted among the >90 000 women accurately defined as being endometriosis-free and are, therefore, unlikely to impact on effect estimation. Although geographically diverse, the NHS II cohort is overwhelmingly Caucasian, which may limit generalizability to more ethnically diverse populations. WIDER IMPLICATIONS OF THE STUDY: The results of this study suggest that endometriosis is inversely associated with early adult BMI and may correlate with a peripheral body fat distribution.

Neurokinin-1 receptor signalling impacts bone marrow repopulation efficiency

Tachykinins are a large group of neuropeptides with both central and peripheral activity. Despite the increasing number of studies reporting a growth supportive effect of tachykinin peptides in various in vitro stem cell systems, it remains unclear whether these findings are applicable in vivo. To determine how neurokinin-1 receptor (NK-1R) deficient hematopoietic stem cells would behave in a normal in vivo environment, we tested their reconstitution efficiency using competitive bone marrow repopulation assays. We show here that bone marrow taken from NK-1R deficient mice (Tacr1(-/-)) showed lineage specific B and T cell engraftment deficits compared to wild-type competitor bone marrow cells, providing evidence for an involvement of NK-1R signalling in adult hematopoiesis. Tachykinin knockout mice lacking the peptides SP and/or HK-1 (Tac1 (-/-), Tac4 (-/-) and Tac1 (-/-)/Tac4 (-/-) mice) repopulated a lethally irradiated wild-type host with similar efficiency as competing wild-type bone marrow. The difference between peptide and receptor deficient mice indicates a paracrine and/or endocrine mechanism of action rather than autocrine signalling, as tachykinin peptides are supplied by the host environment.

Plasma adipokines and endometriosis risk: a prospective nested case-control investigation from the Nurses' Health Study II

STUDY QUESTION

Do higher leptin levels and lower adiponectin levels predict subsequent development of endometriosis?

SUMMARY ANSWER

Plasma leptin and adiponectin levels were not associated with laparoscopically confirmed endometriosis when collected prior to disease diagnosis.

WHAT IS KNOWN ALREADY

Case-control studies have identified altered levels of the inflammatory adipokines leptin and adiponectin in women with endometriosis, but it remains unclear whether inflammation results in endometriosis or whether the presence of endometriosis creates an inflammatory state.

STUDY DESIGN, SIZE, DURATION

Nested, matched, case-control study within the prospective Nurses' Health Study II (NHS II) cohort. Blood samples were collected between 1996 and 1999 from 29 611 female nurses within the cohort. Women who reported endometriosis before blood collection were excluded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Plasma leptin and adiponectin levels were assayed by ELISA. Three hundred and fifty cases of laparoscopically confirmed endometriosis were matched 1:2 with 694 controls of comparable race, age, infertility history, menopausal status and time of blood draw. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated using unconditional logistic regression models adjusting for matching factors and BMI.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjusting for BMI, there were no statistically significant associations between endometriosis and leptin [RR = 1.2; 95% CI = 0.7-2.0; P-value, test for linear trend (P(trend)) = 0.72], adiponectin (RR = 0.8; 95% CI = 0.5-1.2; P(trend) = 0.48) or the leptin to adiponectin ratio (RR = 0.8; 95% CI = 0.4-1.4; P(trend) = 0.14) when comparing the upper with the lower quartile. Results were unaltered when analyses were stratified by BMI or restricted to cases diagnosed ≥ 4 years after blood draw. To evaluate statistical significance and limit the role of chance to the gold standard of 5%, we present 95% CIs about the RRs, and for P-values calculated for linear tests of trend and tests of heterogeneity, we have set the α-level to be 0.05 (i.e. <0.05 is considered to be statistically significant).

LIMITATIONS AND REASONS FOR CAUTION

A limitation of this study is the inability to differentiate the time of endometriosis 'diagnosis' from the time of disease 'onset' due to the impossibility in identifying a precise time point at which the disease process was first initiated at a molecular or cellular level. Additional limitations include lack of information regarding stage of endometriosis and the possibility of asymptomatic disease in the control population.

WIDER IMPLICATIONS OF THE FINDINGS

The mean age at diagnosis of endometriosis in the study population is 41.7, ≈ 10 years older than the mean age of diagnosis in the general population. While this may limit the generalizability of the results, there is no reason to suspect that the association between adipokines and endometriosis risk should differ at a younger age of diagnosis in an adult population.

Role of recycling, Mindbomb1 association, and exclusion from lipid rafts of δ-like 4 for effective Notch signaling to drive T cell development

Intrathymic T cell development is predicated on the Notch1 ligand Delta-like (Dll) 4. However, both Dll4 and Dll1 can support T cell development in vitro. Endocytosis of Dll1 is important for Notch activation, whereas currently there is no evidence for the role of Dll4 endocytosis in T cell development. To elucidate this, we generated Dll4 constructs that modify or inhibit endocytosis. Our results show that targeting the intracellular domain affects Dll4's ability to induce Notch target gene expression, support efficient T cell development, and inhibit B cell development. Dll4 function relies on a combination of factors, which include strong Mindbomb1 (Mib1) association, ubiquitination, and internalization and recycling back to the cell surface, to engage Notch1 effectively. Distinct membrane localization and the Delta/Serrate/Lag2 (DSL) domain were important for Dll4 function. These features are consistent with a "recycling" model, but not in opposition to a "mechano-transduction" model, whereby Dll4 is able to engage Notch and create a pulling force required to activate signaling, leading to the induction of T-lineage development. Taken together, in contrast to Dll1, Dll4 does not localize to lipid rafts and shows stronger association with Mib1 and increased Notch1 uptake, which likely account for its superior ability to induce T cell development.

Notch receptor-ligand interactions during T cell development, a ligand endocytosis-driven mechanism

Notch signaling plays an important role during the development of different cell types and tissues. The role of Notch signaling in lymphocyte development, in particular in the development and commitment to the T cell lineage, has been the focus of research for many years. Notch signaling is absolutely required during the commitment and early stages of T cell development. Activation of the Notch signaling pathway is initiated by ligand-receptor interactions and appears to require active endocytosis of Notch ligands. Studies addressing the mechanism underlying endocytosis of Notch ligands have helped to identify the main players important and necessary for this process. Here, we review the Notch ligands, and the proposed models of Notch activation by Notch ligand endocytosis, highlighting key molecules involved. In particular, we discuss recent studies on Notch ligands involved in T cell development, current studies aimed at elucidating the relevance of Notch ligand endocytosis during T cell development and the identification of key players necessary for ligand endocytosis in the thymus and during T cell development.

Scientific investigation of endometriosis among adolescents

The scientific literature on endometriosis specific to the adolescent population is limited, and the existing data are retrospective and descriptive in nature. It is possible that the disease has a different pathophysiology in adolescents, but little epidemiologic or molecular data exist to support or refute this speculation. In addition, the limited literature does not yet confirm that intervening in the adolescent population prevents long-term sequelae such as pain and infertility as adults. Case-control and cohort studies to identify risk factors, as well as prospective observational and intervention studies to assess treatment outcome, are required to further knowledge about endometriosis in the adolescent population. The scientific literature on endometriosis specific to the adolescent population is limited, and the existing data are retrospective and descriptive in nature. This review summarizes studies that have been done to date and suggests areas for future investigation.

Medical, ethical, and legal considerations in fertility preservation

The past 2 decades have seen a significant rise in cancer survival rates, and an increasing proportion of survivors at reproductive age are interested in childbearing. Although assisted reproduction provides physicians with an array of potential possibilities to help patients whose fertility is compromised by cancer treatment, there is still a dearth of regulation regarding the application of this technology. The present paper reviews the current options for fertility preservation, with a particular focus on the legal and ethical challenges that confront providers of this type of care.

Direct comparison of Dll1- and Dll4-mediated Notch activation levels shows differential lymphomyeloid lineage commitment outcomes

In the thymus, Notch signaling is essential for T lymphopoiesis, with Delta-like (Dll)4 uniquely involved in this process. However, using cocultures, either Dll4 or Dll1 were shown to support T lymphopoiesis. To address which Dll is more effective at inducing hematopoietic progenitor cells to give rise to T lineage cells in vitro, we generated OP9 cells expressing a series of incrementally discrete and equivalent levels of Dll1 or Dll4. In keeping with previous findings, OP9 cells expressing high levels of either Dll1 or Dll4 gave rise to T lineage cells with similar efficacy, and prevented the differentiation of B and myeloid-lineage cells. However, at limiting levels, Dll4 maintained its ability to inhibit B lineage choice and induce T lineage commitment and differentiation at lower levels than Dll1. This manifest property of Dll4 is evident despite lower levels of steady-state surface expression than Dll1 on OP9 cells. The heightened effectiveness of Dll4 over Dll1 also corresponded to the induction of Notch target genes, and inhibition of B and myeloid-specific transcription factors. Furthermore, we show that OP9 cells expressing levels of Dll4 equivalent to those present in thymic epithelial cells, as expected, gave rise to T lineage cells, but were also permissive for the differentiation of myeloid cells; whereas, still inhibiting B lymphopoiesis. Our findings show that Dll4 expressed at physiological levels on OP9 cells is functionally distinct from similarly expressed levels of Dll1, illustrating the unique properties of Dll4 in supporting the combined T lineage and specific myeloid-lineage outcomes that underpin its function within the thymus.

Public perceptions of endometriosis: perspectives from both genders

OBJECTIVE

Many women with endometriosis experience significant delay between the onset of symptoms and definitive diagnosis. Much is published on physician awareness of endometriosis and on the experiences of women with the condition. There is a paucity of data, however, surrounding perceptions of endometriosis in the general population. This study aims to assess knowledge of endometriosis among individuals of both genders.

DESIGN

Survey study.

SETTING

Family waiting room of a large university hospital.

POPULATION

A total of 543 men and women.

METHODS

Surveys were distributed to men and women over the age of 18 in the family waiting room of a large university hospital.

MAIN OUTCOME MEASURES

A series of questions regarding the etiology, symptoms, and treatments for endometriosis were combined into a composite knowledge score.

RESULTS

Knowledge of endometriosis was positively correlated with female gender, education level, regular health care, and exposure to individuals with the disease. Women diagnosed with endometriosis were more likely to have discussed symptoms of the condition with their physicians than women without the diagnosis.

CONCLUSIONS

Individuals of both genders have limited knowledge of the signs and symptoms of endometriosis, which may contribute to the delay in diagnosis of the condition.

Thiazolidinediones decrease vascular endothelial growth factor (VEGF) production by human luteinized granulosa cells in vitro

OBJECTIVE

To determine the effect of thiazolidenedione derivatives (TZDs) on vascular endothelial growth factor (VEGF) production by human luteinized granulosa cells and the morphologic development of murine embryos.

DESIGN

Prospective, experimental, in vitro and in vivo study.

SETTING

Research laboratory.

PATIENT(S)

Follicular aspirates from 10 women undergoing oocyte retrieval.

INTERVENTION(S)

Isolated human granulosa cells were treated with a dimethyl sulfoxide (DMSO) control or ciglitazone, in the presence and absence of an hCG stimulus. Embryos extracted from superovulated B6C3F1 female mice were cultured in the presence of DMSO or pioglitazone.

MAIN OUTCOME MEASURE(S)

Vascular endothelial growth factor concentrations at 24 and 48 hours. Morphologic development of murine embryos at 96 hours.

RESULT(S)

Following an hCG stimulus, treatment with 20 microM or 40 microM ciglitazone decreased VEGF production in a statistically significant manner at both time intervals. Blastocyst development at 96 hours did not significantly differ between untreated zygotes and those treated with pioglitazone.

CONCLUSION(S)

Ciglitazone significantly decreased VEGF production by human granulosa cells in an in vitro model. Pioglitazone did not adversely impact the development of cultured murine embryos. Although mechanistic evidence is not provided, the pivotal role of VEGF in ovarian hyperstimulation syndrome prompts investigation of TZDs as a novel treatment for this condition.

Activation of the Hedgehog signaling pathway in T-lineage cells inhibits TCR repertoire selection in the thymus and peripheral T-cell activation

TCR signal strength is involved in many cell fate decisions in the T-cell lineage. Here, we show that transcriptional events induced by Hedgehog (Hh) signaling reduced TCR signal strength in mice. Activation of Hh signaling in thymocytes in vivo by expression of a transgenic transcriptional-activator form of Gli2 (Gli2DeltaN(2)) changed the outcome of TCR ligation at many stages of thymocyte development, allowing self-reactive cells to escape clonal deletion; reducing transgenic TCR-mediated positive selection; reducing the ratio of CD4/CD8 single-positive (SP) cells; and reducing cell surface CD5 expression. In contrast, in the Shh(-/-) thymus the ratio of CD4/CD8 cells and both positive and negative selection of a transgenic TCR were increased, demonstrating that Shh does indeed influence TCR repertoire selection and the transition from double-positive (DP) to SP cell in a physiological situation. In peripheral T cells, Gli2DeltaN(2) expression attenuated T-cell activation and proliferation, by a mechanism upstream of ERK phosphorylation.

Meckel's diverticulum: a systematic review

Meckel's diverticulum is the most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration, haemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae and tumours. These complications, especially bleeding, are more common in the paediatric age group than in adults; however it is not uncommon to miss the diagnosis of Meckel's diverticulum in adults. Here, we reviewed the literature regarding the complications of this forgotten clinical entity in adults with potential diagnostic difficulties and management strategies.

Idiopathic infected hydrocele in a toddler: a case report with review

Idiopathic infected hydrocele in infants is a rare, but well-documented, entity in English literature; however, occurrence of such a condition in a toddler is not yet documented. Here we report the case of an idiopathic infected hydrocele in a toddler for the first time in English literature. We also discuss a review of literature and demonstrate management of infected hydrocele by antibiotics without any surgical intervention, also for the first time in English literature.

Spontaneous penile (cavernosal) abscess: case report with discussion of aetiology, diagnosis, and management with review of literature

The rare presentation of spontaneous, corpus cavernosal abscess with evident pus discharge is reported. The 19-year-old English man was successfully treated with surgical drainage and antibiotics with long-term sequelae in form of mild, left-sided penile deviation, but normal erectile function. Though he did not require any further surgical intervention for correction of chordee at that time, there remains a possibility of it getting worse over time, which may ultimately need surgery for correction. The possible aetiology, diagnosis, and treatment of this rare condition are briefly discussed.

Reduced thymocyte development in sonic hedgehog knockout embryos

The Hedgehog family of secreted intercellular signaling molecules are regulators of patterning and organogenesis during animal development. In this study we provide genetic evidence that Sonic Hedgehog (Shh) has a role in the control of murine T cell development. Analysis of Shh(-/-) mouse embryos revealed that Shh regulates fetal thymus cellularity and thymocyte differentiation. Shh is necessary for expansion of CD4(-)CD8(-) double-negative (DN) thymocytes and for efficient transition from the earliest CD44(+)CD25(-) DN population to the subsequent CD44(+)CD25(+) DN population and from DN to CD4(+)CD8(+) double-positive cells.

Bone morphogenetic protein 2/4 signaling regulates early thymocyte differentiation

Bone morphogenetic protein (BMP)2 and BMP4 are involved in the development of many tissues. In this study, we show that BMP2/4 signaling is involved in thymocyte development. Our data suggest that termination of BMP2/4 signaling is necessary for differentiation of CD44(+)CD25(-)CD4(-)CD8(-) double negative (DN) cells along the T cell lineage. BMP2 and BMP4 are produced by the thymic stroma and the requisite BMP receptor molecules (BMPR-1A, BMPR-1B, BMPR-II), and signal transduction molecules (Smad-1, -5, -8, and -4) are expressed by DN thymocytes. BMP4 inhibits thymocyte proliferation, enhances thymocyte survival, and arrests thymocyte differentiation at the CD44(+)CD25(-) DN stage, before T cell lineage commitment. Neutralization of endogenous BMP2 and BMP4 by treatment with the antagonist Noggin promotes and accelerates thymocyte differentiation, increasing the expression of CD2 and the proportion of CD44(-)CD25(-) DN cells and CD4(+)CD8(+) double-positive cells. Our study suggests that the BMP2/4 pathway may function in thymic homeostasis by regulating T cell lineage commitment and differentiation.

Neuroendocrine factors affecting the steady-state levels of early trypsin mRNA in Aedes aegypti

Transcription of the early trypsin gene occurs in the midgut after adult emergence under control of juvenile hormone (JH). We tested the hypothesis that factors that affect the steady-state levels of early trypsin mRNA do so by influencing the levels of JH. We investigated the effect of ingesting different meals on early trypsin mRNA levels as well as on JH levels. We also studied how early trypsin mRNA levels changed when the midgut was isolated from different components of the neuroendocrine system by abdominal ligation and decapitation. Early trypsin transcripts levels are high in unfed females; feeding different meals had three distinct effects on the changes of steady-state levels of early trypsin mRNA: (1) blood and protein meals caused the level to decrease drastically and remained low for at least 24 h; (2) amino acid meals caused a transient decrease in the mRNA level, but it returned to high levels after 12-18 h; and (3) sugar, latex and saline meals had no effect on the early trypsin mRNA steady-state levels. The changes in JH levels after ingesting blood and amino acid meals show profiles resembling the changes in early trypsin mRNA levels for the corresponding meal. Decapitation at 1, 2 and 3 days after emergence does not affect the steady-state levels of early trypsin in unfed females. In contrast, 24 h after feeding, transcript levels were significantly higher in decapitated females when compared with non-decapitated fed females. We propose that the changes in the steady-state levels of early trypsin mRNA observed after the ingestion of different meals, ligations and decapitations are generated by changes in the levels of juvenile hormone.

Endolymphatic sac surgery in Meniere's disease

Despite the controversy that surrounds sac surgery for Meniere's disease, it remains in the forefront of surgical intervention for the refractory patient. This article reviews the literature for all types of sac surgery, with emphasis on wide sac-vein decompression as performed at the Michigan Ear Institute.

Juvenile hormone controls early trypsin gene transcription in the midgut of Aedes aegypti

Early trypsin is a female-specific protease present in the Aedes aegypti midgut during the first few hours after ingestion of a blood meal. The enzymatic activity of early trypsin plays an essential role in the transcriptional activation of the late trypsin gene, which encodes the major midgut endoprotease involved in blood meal protein digestion. Transcription of the early trypsin gene is part of the normal post-emergence maturation of the midgut in the adult female. Abdominal ligation within 1 h of emergence completely prevented the transcription of the early trypsin gene. Topically applied JH III or methoprene induced transcription of the early trypsin gene in ligated abdomens to levels similar to those observed in non-ligated females. The induction of early trypsin transcription by JH is dose-dependent and 'head-independent', suggesting that factors coming from the neuro-secretory axis are not required.

Combination therapy for salvaging a failing, experimental skin flap

The failing free flap remains a major problem for the reconstructive surgeon. Many and varied pharmacologic agents have been utilized to reverse the effects of ischemia in these flaps. Treatments have been aimed at inhibiting presumed causative factors in the no-reflow phenomenon. Therapy has generally been single in nature and designed to affect only one of these presumed factors. In this study, several pharmacologic agents were utilized individually or in combination therapy as postischemic washouts, in an effort to attack the multiple causative factors in the no-reflow phenomenon and to improve flap survival in a rat abdominal skin flap model. The treatment agents included lactated Ringer's, superoxide dismutase, and urokinase, with each used independently as a postischemic perfusion washout. Combination therapy utilized an initial postischemic perfusion with urokinase, followed by a second perfusion washout with superoxide dismutase. After 18 hr of primary ischemia, there was increased flap survival in the animals undergoing perfusion washout with either superoxide dismutase alone or with combined urokinase and superoxide dismutase washouts, compared to all other treatments (p < 0.001). It was found that flaps undergoing combined urokinase and superoxide dismutase postischemic perfusion washouts demonstrated significantly improved survival after 20 hr of primary ischemia, compared to all other therapies (p < 0.05). By demonstrating improved survival when a thrombolytic agent is used in conjunction with an oxygen free radical scavenger, these findings may have implications in the treatment of clinically failing free flaps.

Sinonasal hemangiopericytomas: a clinicopathologic and immunohistochemical study of seven cases

BACKGROUND

Sinonasal hemangiopericytoma (SNHPC) is a rare lesion usually of low-grade malignant potential. Aggressive and metastatic cases are uncommon, and experience using adjuvant therapy on these cases has been limited. Tumor-induced osteomalacia has a very rare association with SNHPC. Further, the diagnosis of SNHPC remains one of histologic-pattern recognition. Traditionally, immunohistochemistry has aided in excluding other diagnoses; only vimentin has been consistently expressed by the tumor spindle cells of HPC. Recent studies have shown that Factor XIIIa is also expressed by HPC, (as well as tumors of fibrohistiocytic differentiation) and hence may be yet another helpful positive marker in establishing an immunohistochemical profile.

METHODS

We identified 7 patients at this institution with SNHPC from 1990 to 1994. Immunohistochemistry was performed on seven formalin-fixed paraffin-embedded tumors utilizing antibodies to factor XIIIa as well as antibodies to vimentin, factor VIII, muscle-specific antigen, cytokeratin, and S-100.

RESULTS

All 7 patients were initially seen with nasal obstruction or epistaxis and underwent surgical resection. The period of follow-up was from 3 months to 14 years (mean 54 months) for 7 patients. Three patients had recurrent disease after 3, 5, and 10 years. The first 2 were known to have been originally treated by polypectomy. One patient required adjuvant radiotherapy for metastatic disease and local extension. One patient was initially seen with tumor-induced osteomalacia which dramatically improved following resection of the lesion. The immunohistochemical profile revealed strong expression of vimentin in 7/7 cases, and of factor XIIIa in 4/7 cases; tumor cells did not express the other markers studied.

CONCLUSIONS

Adequate surgical resection with negative margins appears to be the appropriate therapy for SNHPC. Our 1 case associated with tumor-induced osteomalacia was reversible after surgical excision of the tumor. The immunohistochemical results suggest that the pattern of vimentin and factor XIIIa positivity, as well as lack of expression of other markers, is consistent with the diagnosis of HPC, which still remains in the domain of histopathology.

Evaluation of a continuous systemic infusion of iloprost, a stable PGI-2 analog, on the survival of experimental skin flaps

Numerous investigators have attempted to enhance the survival of ischemic experimental skin flaps using various pharmacologic manipulations. Recently, the authors' laboratory demonstrated the beneficial effect of iloprost, a stable PGI2 analogue, as a post-ischemic perfusion washout, in improving the survival of ischemic skin flaps. The rat unilateral abdominal skin flap, based on the superficial epigastric vessels, was utilized in this study involving 30 animals. The animals were divided into three different treatment groups, with ischemic periods of 16 and 18 hr. Perfusion washouts were performed at the completion of the various ischemic periods. Alzet osmotic pumps were used to deliver a continuous systemic infusion of iloprost for 7 days postoperatively. The groups consisted of the following: Group 1 (single ILO)--perfusion washout with iloprost only; Group 2 (continuous LD ILO)--low-dose systemic iloprost infusion (0.066 mcg/kg/min) and perfusion washout with iloprost; and Group 3 (continuous HD ILO)--high-dose systemic iloprost infusion (0.1 mcg/kg/min) and perfusion washout with iloprost. The percentage of flap survival was assessed on postoperative day 7. Skin flaps of the animals receiving the continuous systemic infusion of iloprost were noted to have varying percentages of survival, while skin flaps undergoing perfusion washout only were found to have either complete survival using a continuous systemic infusion of iloprost, compared to iloprost perfusion washout alone. In addition, the hypotensive side effects of systemic iloprost infusion limit its use in the rat skin-flap model.

Cerebrospinal fluid rhinorrhea with bilateral intradiploic epidermoid tumors: a case report

Bilateral large intradiploic epidermoid tumors of the occipital bone presented clinically with CSF rhinorrhea are presented.

The cardiac inotropic responses to insulin in the rat heart

Insulin (5 to 40 I.U.) produced dose-dependent positive inotropic effect in the isolated rat heart. The responses to insulin were markedly inhibited in the presence of propranolol (1 . 1X10(-6) M). Insulin responses were markedly reduced in reserpine pretreated (5 mg/kg, i.p.) rats. Theophylline (4.4 mM), the phosphodiesterase inhibitor, potentiated the responses to insulin, whereas imidazole (20 mM), the phosphodiesterase stimulator inhibited the responses to insulin. The data suggest that the positive inotropic effects of insulin in rat heart is mediated through the release of cardiac catecholamines which stimulates beta-adrenoceptors. The final mediator of cardiac action seems to be cyclic-AMP.