Secreted proteins and genes in fetal and neonatal pig adipose tissue and stromal-vascular cells.

Although microarray and proteomic studies have indicated the expression of unique and unexpected genes and their products in human and rodent adipose tissue, similar studies of meat animal adipose tissue have not been reported. Thus, total RNA was isolated from stromal-vascular (S-V) cell cultures (n = 4; 2 arrays; 2 cultures/array) from 90-d (79% of gestation) fetuses and adipose tissue from 105-d (92% of gestation) fetuses (n = 2) and neonatal (5-d-old) pigs (n = 2). Duplicate adipose tissue microarrays (n = 4) represented RNA samples from a pig and a fetus. Dye-labeled cDNA probes were hybridized to custom microarrays (70-mer oligonucleotides) representing more than 600 pig genes involved in growth and reproduction. Microarray studies showed significant expression of 40 genes encoding for known adipose tissue secreted proteins in fetal S-V cell cultures and adipose tissue. Expression of 10 genes encoding secreted proteins not known to be expressed by adipose tissue was also observed in neonatal adipose tissue and fetal S-V cell cultures. Additionally, the agouti gene was detected by reverse transcription-PCR in pig S-V cultures and adipose tissue. Proteomic analysis of adipose tissue and fetal and young pig S-V cell culture-conditioned media identified multiple secreted proteins including heparin-like epidermal growth factor-like growth factor and several apolipoproteins. Another adipose tissue secreted protein, plasminogen activator inhibitor-1, was identified by ELISA in S-V cell culture media. A group of 20 adipose tissue secreted proteins were detected or identified using the gene microarray and the proteomic and protein assay approaches including apolipoprotein-A1, apolipoprotein-E, relaxin, brain-derived neurotrophic factor, and IGF binding protein-5. These studies demonstrate, for the first time, the expression of several major secreted proteins in pig adipose tissue that may influence local and central metabolism and growth.

Chronic intracerebroventricular infusion of lipopolysaccharide: effects of ibuprofen treatment and behavioural and histopathological correlates.

Twenty male Wistar rats were trained under an alternating-lever cyclic-ratio (ALCR) schedule of food reinforcement. When responding showed no trends, each subject was subcutaneously implanted with an Alzet osmotic mini-pump, connected to a chronic indwelling cannula extending into the lateral ventricle of the brain. The mini-pumps were primed to infuse 0.25 microl lipopolysaccharide (LPS) (1.0 microg/0.25 ml) or 0.25 microl artificial cerebrospinal fluid (aCSF) per hour and were implanted for 28 days. LPS infusion produced behavioural deficits which chronic ibuprofen treatment (40 mg/kg every 12 h) alleviated. Infusion of LPS induced R 1282-positive amyloid deposits, and activation of microglia and astrocytes. Ibuprofen treatment reduced the numbers of activated microglia, and withdrawal of ibuprofen resulted in an increase in activated microglia; however, ibuprofen treatment had no effect on numbers of activated astrocytes in the LPS-infused subjects.

Adipose tissue angiogenesis.

A review of adipose tissue angiogenesis includes the morphological and cytochemical development of adipose tissue vasculature and the concept of primitive fat organs. Spatial and temporal relationships between fetal vascular and fat cell development are discussed, including depot- and genetic-dependent arteriolar differentiation. The relationship between connective tissue deposition and elaboration of adipose tissue vasculature is discussed with respect to regulating adipocyte development in a depot-dependent manner. In vitro studies indicated that depot-dependent vascular traits may be attributable to intrinsic growth characteristics of adipose tissue endothelial cells. These studies indicate that adipogenesis may be regulated by factors that drive angiogenesis. Fundamental aspects of angiogenesis, including basement membrane breakdown, vasculogenesis, angiogenic remodeling, vessel stabilization, and vascular permeability were reviewed. Critical angiogenic factors include vascular endothelial growth factor (VEGF), VEGF receptors, angiopoietins (Ang), ephrins, matrix metalloproteinases, and the plasminogen enzymatic system. Vascular endothelial growth factor is the most critical factor because it initiates the formation of immature vessels and disruption of a single VEGF allele leads to embryonic lethality in mice. Expression of VEGF is influenced by hypoxia, insulin, growth factors, and several cytokines. Angiogenic factors secreted and/or produced by adipocytes or preadipocytes are discussed. Vascular endothelial growth factor expression and secretion by adipocytes is regulated by insulin and hypoxia, and is associated with adipose tissue accretion. Vascular endothelial growth factor accounts for most of the angiogenic activity of adipose tissue. The proposed role of leptin as an adipogenic factor is reviewed with respect to efficacy on various aspects of angiogenesis relative to other angiogenic factors. The VEGF and leptin genes are both hypoxia inducible, but potential links between VEGF and leptin gene expression have not been examined. Finally, several studies including a study of mice treated with antiangiogenic factors indicate that adipose tissue accretion can be controlled through the vasculature per se.

Behavioural and histopathological analyses of ibuprofen treatment on the effect of aggregated Abeta(1-42) injections in the rat.

It has been suggested that inflammatory processes may play a role in the development of Alzheimer's disease (AD), and that nonsteroidal anti-inflammatory drug treatments may provide protection against the onset of AD. In the current study male Wistar rats were trained in two-lever operant chambers under an alternating lever cyclic-ratio ratio (ALCR) schedule. When responding showed no trends, subjects were divided into groups. One group was bilaterally injected into the CA3 area of the hippocampus with 5 microl of aggregated beta-amyloid (Abeta) suspension, and one group was bilaterally injected into the CA3 area of the hippocampus with 5 microl of sterile saline. Subgroups were treated twice daily with 0.1 ml (40 mg/kg) ibuprofen administered orally. The results indicated that chronic administration of ibuprofen protected against detrimental behavioural effects following aggregated Abeta injections. Withdrawal of ibuprofen treatment from aggregated Abeta-injected subjects produced a decline in behavioural performance to the level of the non-treated aggregated Abeta-injected group. Ibuprofen treatment reduced the numbers of reactive astrocytes following aggregated Abeta injection, and withdrawal of ibuprofen resulted in an increase of reactive astrocytes. These results suggest that induced inflammatory processes may play a role in AD, and that ibuprofen treatment may protect against some of the symptoms seen in AD.

Secretion of insulin-like growth factor (IGF)-I and -II and IGF binding proteins (IGFBPs) in fetal stromal-vascular (S-V) cell cultures obtained before and after the onset of adipogenesis in vivo.

The present study examined the influence of dexamethasone (DEX) treatment on preadipocyte differentiation and insulin-like growth factor binding protein (IGFBP) secretion in stromal-vascular (S-V) cell cultures established from subcutaneous adipose tissue obtained from nine 75 day and four 50 day pig fetuses. Cultures of S-V cells from four young pigs (5-7 days old) were also studied. Each fetal S-V cell culture represented 1 pool of S-V cells/dam. Cultures were seeded and plated in 10% FBS from day 0-3 and treated with insulin (ITS) + 10 nM DEX from day 3-6 (late DEX treatment). Alternatively, cultures were seeded and plated in 10% FBS + 80 nM DEX from day 0-3 and treated with insulin alone from day 3-6 (early DEX treatment). Conditioned media was collected on day 6 of culture after 3 days of conditioning, and prepared for subsequent 125I-IGF-I ligand blot analysis for IGFBPs and RIA for IGF-I and IGF-II. Early and late DEX increased (P<0.05) preadipocyte (AD-3+) recruitment but only early DEX increased preadipocyte differentiation (lipid + and C/EBP alpha+) by day 6 in S-V cultures from 75 day fetuses. Levels of IGFBP-2, IGFBP-4, IGF-I and IGF-II in media conditioned by 75 day fetal S-V cultures were not influenced by late DEX. However, late DEX reduced levels of 29 kDa IGFBPs and markedly increased (P<0.05) IGFBP-3 levels in 75 day S-V media. Late DEX also markedly increased (P<0.05) IGFBP-3 levels in 50 day S-V media but had little influence on other IGFBPs. Early DEX treatment increased (P<0.05) IGFBP-4 levels in 75 day S-V media but had little to no influence on levels of IGF-I, IGF-II and other IGFBPs. These studies indicate that IGFBP-4 may regulate local metabolism during preadipocyte differentiation, whereas IGFBP-3 may antagonize preadipocyte differentiation by targeting IGF-I away from differentiating cells and towards growing cells.

Long-term results of a phase I/II study of high-dose thoracic radiotherapy with concomitant cisplatin and etoposide in limited stage small-cell lung cancer.

This report presents the results from a Mayo Clinic initiated phase I/II study exploring a potentially more aggressive local and systemic approach for treatment of limited-stage small-cell lung cancer (LSSCLC). Five patients with LSSCLC received three cycles of induction cyclophosphamide, etoposide, and infusion cisplatin chemotherapy. This was followed by accelerated hyperfractionated thoracic radiotherapy (AHFTRT) consisting of 30 Gy given as 1.5-Gy fractions twice daily with a 2-week break and then the AHFTRT was repeated. The AHFTRT was given concomitantly with daily oral etoposide and daily intravenous cisplatin. Prophylactic cranial radiation was delivered with the AHFTRT. After completion of the AHFTRT, patients received 4 cycles of oral etoposide maintenance chemotherapy. Follow-up of patients was continued until death or a minimum of 42 months. Three patients had severe toxic responses. No patients completed the entire protocol because of toxicity or progression during treatment. Three patients completed the majority of the protocol except for the four cycles of maintenance etoposide. Four of five patients achieved a complete response. There were two recurrences within the irradiated field, and distant metastases developed in four patients. Acute nonlymphocytic leukemia developed in one patient, who died 2 months later. No patient completed the entire protocol, because of toxicity or progression; therefore, this protocol cannot be recommended for the treatment of LSSCLC.

Where there is hope, there is life: toward a biology of hope.

Argues the thesis that where there is hope there is life. Grounds this thesis philosophically and theologically, then reviews it from the medical and nursing literature, and illustrates it in a vignette of hospital ministry. Argues that hope can enhance the quality and even the quantity of life. Proposes that hope helps people to deal with their feelings and to cope with their illness. Hope affects immunity and survival. Challenges chaplains, pastoral counselors, and parish clergy to become more effective "agents of hope."

Phase II study of paclitaxel and cisplatin for advanced urothelial cancer.

PURPOSE: We examined the role of paclitaxel and cisplatin as first line therapy for metastatic urothelial cancer. MATERIALS AND METHODS: A total of 34 patients were enrolled in this study, and all were eligible for treatment and assessable for response. Patients received 135 mg./m.2 paclitaxel intravenously for 3 hours followed by 70 mg./m.2 cisplatin for 2 hours every 3 weeks to a maximum of 6 cycles. RESULTS: Of the patients 70% experienced a major response to treatment, which was partial/regression in 38% and complete in 32%. Toxicity was manageable with no episodes of grade 4 leukopenia or thrombocytopenia. Nonhematological toxicities included primarily nausea, anorexia and neuropathy, which rarely were severe. CONCLUSIONS: This regimen of paclitaxel and cisplatin is effective, safe and convenient to administer in an outpatient setting for advanced urothelial cancer.

Expression of insulin-like growth factor binding proteins (IGFBPs) before and during the hormone sensitive period of adipose tissue development in the fetal pig.

The present study examined the influence of fetal age and thyroxine (T4) and growth hormone (GH) treatment, on the expression of insulin-like growth factor binding proteins (IGFBPs) in fetal pigs. On day 70 of gestation fetuses were either hypophysectomized (hypox), hypox and implanted with T4 pellets, or left intact, and were recovered 5, 10, 15 and 20 days following hypox and T4 pellet placement. Intact fetuses were also recovered from several dams at 50 days of gestation. In additional dams, hypox fetuses (day 70) were implanted with GH loaded Alzet mini-pumps on day 90, and control, untreated, and GH-treated hypox fetuses were recovered on day 105 of development. Subcutaneous adipose tissue, serum and other fetal tissues were collected at the time of recovery and prepared for subsequent ligand blot analysis with 125I -IGF-1 and immunoblot analysis with IGFBP antibodies. The main effect of IGFBP was significant (P <0.01) for age associated changes in serum IGFBP percentages. Between 50 and 75 days of fetal development the levels of 29 kDa IGFBPs in adipose tissue and serum markedly increased. In contrast, IGFBP-2 levels decreased and IGFBP-4 levels increased in adipose tissue while IGFBP-2 levels increased and levels of IGFBP-4 and -3 decreased in serum. Fetal hypox decreased adipose tissue IGFBP levels in a time and IGFBP-dependent manner. For instance, IGFBP-2 and 29 kDa IGFBP levels decreased much faster after fetal hypox than did IGFBP-3 levels whereas IGFBP-4 levels did not decrease. The main effect of IGFBP was significant (P<0.01) for T4-induced changes in adipose tissue IGFBP levels. T4 treatment increased adipose tissue levels of 29 kDa IGFBPs but did not influence IGFBP-2,-3 and -4 levels. GH treatment had no influence on adipose tissue or serum IGFBP levels. These studies indicate that IGFBP-1 (one of the 29 kDa IGFBPs) may be the major IGFBP mediator of the influence of T4 on fetal development.

Renal cell carcinoma metastatic to the pancreas: clinical and radiological features.

OBJECTIVE: To review the clinical features, computed tomographic (CT) appearance, and treatment outcomes in a case series of patients with renal cell carcinoma (RCC) metastatic to the pancreas. PATIENTS AND METHODS: We retrospectively reviewed the records of 23 patients (15 men and 8 women) with RCC metastatic to the pancreas, detected by CT examination between 1986 and 1996. All patients had undergone a previous nephrectomy for RCC. RESULTS: Isolated mild elevation in liver function test results (in 5 patients) or in serum amylase level (in 8 patients) was observed. New-onset diabetes was detected in 3 patients. The CT characteristics of the pancreatic metastases generally resembled those of primary RCC with well-defined margins and greater enhancement than normal pancreas with a central area of low attenuation. The mean interval between resection of the primary RCC and detection of the pancreatic metastases was 116 months (range, 1-295 months). In 18 patients (78%), the pancreatic metastases were diagnosed more than 5 years after nephrectomy. The pancreas was the initial metastatic site in 12 patients (52%). Survival was shortened with higher tumor grade (mean survival time of 41 months and 10 months in patients with grade 2 and 3, respectively). Surgical resection was carried out in 11 patients (7 distal and 3 total pancreatectomies and 1 distal pancreatectomy followed 4 years later by total pancreatectomy), with 8 patients alive at a mean follow-up of 4 years, 6 of whom remained free of recurrence. Overall, 12 patients (52%) were alive at a mean of 42 months after diagnosis of metastatic disease. CONCLUSIONS: The appearance of metastatic RCC lesions in the pancreas closely resembles the appearance of primary RCC on CT images. Pancreatic metastases from RCC are frequently detected many years after nephrectomy. Patient survival correlates with tumor grade. Histologic analysis of pancreatic masses in patients with a history of resected primary RCC is important since the prognosis for RCC metastatic to the pancreas is much better than that for primary pancreatic adenocarcinoma.

Priming tissue-specific cellular immunity in a phase I trial of autologous dendritic cells for prostate cancer.

We attempted to induce therapeutic immunity against prostate-derived tissues in patients suffering from progressive hormone-refractory metastatic prostate carcinoma. Thirteen patients were treated with two infusions, 1 month apart, of autologous dendritic cells (APC8015) preexposed ex vivo to PA2024, a fusion protein consisting of human granulocyte/macrophage-colony stimulating factor (GM-CSF) and human prostatic acid phosphatase (PAP). The infusions were followed by three s.c. monthly doses of PA2024 without cells. Three groups of patients each received PA2024 at 0.3, 0.6, or 1.0 mg/injection. All Ps were two-sided. Treatment was well tolerated. After infusions of APC8015, patients experienced only mild (grade 1-2) short-lived fever and/or chills, myalgia, pain, and fatigue. One patient developed grade 3 fatigue. Four patients developed mild local reactions to s.c. PA2024. Twelve patients were evaluable for response to treatment. Circulating prostate-specific antigen levels dropped in three patients. T cells, drawn from patients after infusions of APC8015, but not before, could be stimulated in vitro by GM-CSF (P = 0.0004) and PAP (P = 0.0001), demonstrating broken immune tolerance against these two normal proteins. Injections of PA2024 did not influence the reactivity of T cells against PAP and GM-CSF. However, antibodies to GM-CSF and, to a much lesser extent, to PAP reached maximum titers only after two or even three injections of PA2024, showing that directly injected PA2024 was involved in stimulation of humoral immunity. Dendritic cells exposed to antigen ex vivo can induce antigen-specific cellular immunity in prostate cancer patients, warranting further studies of this mode of immunotherapy.

Brain metastasis: an unusual complication from prostatic adenocarcinoma.

A 61-year-old man with known prostatic carcinoma presented with acute mental status changes. Radiographic evaluation revealed a large intraparenchymal brain mass. Surgical biopsy demonstrated metastatic adenocarcinoma of the prostate. Our review of the literature reveals that cerebral metastasis is a rare complication of prostate cancer.

The expression of insulin-like growth factor-1 during adipogenesis in vivo: effect of thyroxine.

The expression of insulin-like growth factor-1 (IGF-1) was examined in subcutaneous (SQ) adipose tissue from 105-day pig fetuses by ribonuclease protection assays and in situ hybridization using a porcine IGF-1 riboprobe. Fetuses were hypophysectomized (hypox) at 70 days of gestation and at 90 days thyroxine (T4) pellets were implanted into some of the hypox fetuses. Fetuses were removed and SQ tissues collected on day 105 of gestation. RNase protection assays followed by scanning laser densitometry revealed that IGF-1 mRNA in SQ adipose tissue in hypox fetuses was significantly decreased to 19.8 +/- 1.2% of control values. T4 treatment increased the expression of IGF-1 by 174 +/- 26.6% of values for hypox fetuses. Using in situ hybridization we showed that fetal hypophysectomy reduced and T4 treatment increased expression of IGF-1 mRNA in the outer SQ adipose tissue layer (P < 0.05). However, T4 treatment after hypox did not influence IGF-1 expression in the inner SQ layer (P > 0.05). IGF-1 was expressed around capillaries, in small fat cells, and in fibroblasts in loose and dense connective tissue. Large fat cells, however, did not express IGF-1. Collectively, we concluded that (1) IGF-1 mRNA was decreased after hypox and increased by T4 treatment in SQ tissue of 105-day fetuses; (2) The expression of the IGF-1 gene was more sensitive to T4 treatment after hypox in outer SQ tissue than in inner SQ tissue; (3) Most stromal cells produced IGF-1 mRNA, and as a result they may influence adipogenesis in the outer layer of SQ adipose tissue; and (4) Once fat cells enlarged, expression of IGF-1 was not detected. Therefore, these studies provide evidence that IGF-1 may mediate the influence of T4 on fetal adipogenesis.

Phase I study of the duocarmycin semisynthetic derivative KW-2189 given daily for five days every six weeks.

The duocarmycins represent a new group of antitumor antibiotics produced by Streptomyces that bind to the minor groove of DNA. KW-2189 is a water-soluble semisynthetic derivative of duocarmycin B2, with significant activity in murine and human tumor models. We conducted a Phase I trial of KW-2189 in patients who had solid tumors that were refractory to standard chemotherapy or for whom no more effective therapy existed. KW-2189 was administered as a rapid i.v. bolus daily for 5 days every 6 weeks. Twenty-two patients were enrolled and received a total of 31 cycles of KW-2189. Leukopenia, neutropenia, and thrombocytopenia were the dose-limiting toxicities, with nadirs occurring at medians of 36, 38, and 29 days, respectively, at the 0.04 mg/m2/day dose level. Nonhematological toxicities were mild, although one patient developed grade 3 fatigue. Four patients had stable disease over two to four cycles of treatment and showed no cumulative toxicity. The mean t1/2, plasma clearance, and steady-state volume of distribution were 13.5 min, 1,287 ml/min/m2, and 10,638 ml/m2, respectively. Pharmacokinetics were similar on days 1 and 5, with no drug accumulation in plasma. The active metabolite DU-86 was not consistently found in patient plasma. For Phase II trials, when the 5 days every 6 weeks schedule was used, 0.04 mg/m2/day KW-2189 appears to be the maximal tolerated dose, especially for patients who have received prior chemotherapy. At this dose level, the drug was well tolerated, and the toxicities were acceptable.

Sarcoidosis and testicular carcinoma.

BACKGROUND: Case reports and small case series have described patients with sarcoidosis and testicular carcinoma. The goals of this study were to determine the incidence of sarcoidosis in patients with testicular carcinoma seen at the Mayo Clinic between 1950 and 1996 and to examine the relation between these two diseases, particularly in regard to the therapy and follow-up of patients with testicular carcinoma. METHODS: A computerized search of the patient data base at the Mayo Clinic was conducted to identify all patients seen between 1950 and 1996 who had a diagnosis of a malignant testicular tumor and sarcoidosis. RESULTS: A total of 14 patients were identified. The median age at diagnosis of testicular carcinoma was 31.5 years. Eleven patients presented with Stage I disease and 3 with Stage II disease. Twelve patients had carcinoma diagnosed before sarcoidosis. The median age at the time of diagnosis of sarcoidosis was 36.5 years. Nine patients presented with radiographic Stage I disease, four with radiographic Stage II disease, and one with extrapulmonary disease. The estimated cumulative incidence of sarcoidosis in patients with testicular carcinoma seen at the Mayo Clinic between 1976 and 1995 was 617.3 per 100,000. CONCLUSIONS: These data suggest that, compared with other solid tumors, testicular carcinoma has the strongest association with sarcoidosis. The observed incidence represents an approximate 100-fold increase compared with a general population of young white men. Although an etiologic relation is possible, the problems of access and surveillance bias should be addressed in prospective studies.

Growth factor regulation of insulin-like growth factor (IGF) binding proteins (IGFBP) and preadipocyte differentiation in porcine stromal-vascular cell cultures.

The influence of anti-IGF-1 and anti-transforming growth factor beta (TGF-beta) neutralizing antibodies on preadipocyte differentiation and secretion of IGFBPs was examined in serum free porcine stromal-vascular cultures. Cultures were stained for morphological analysis and conditioned media were collected for: TGF-beta determination by ELISA, IGF-1 by RIA, and IGFBP analysis by ligand blotting. After 6 d of treatment, anti-TGF-beta increased fat proportions by 2.7 fold compared to controls. Anti-IGF-1 decreased fat cell proportions by 14-fold. Anti-TGF-beta increased concentrations of IGF-1 5.8-fold and IGFBP-2 and IGFBP-3 by 8- and 7-fold in conditioned media whereas IGFBP-4 decreased 5-fold. Anti-IGF-1 increased concentrations of IGFBP-2 and 3 by 9- and 35-fold, respectively. TGF-beta increased concentrations of IGFBP-1, 2 and 3 by 3-fold, 18-fold and 3-fold, respectively, after 9 d in culture (6 d of treatment). There was no change in TGF-beta levels in anti-IGF-1 treated cultures compared to controls. Control antibodies and negative controls had no effect. These results provide evidence that endogenously produced IGF-1 and TGF-beta has a major influence on preadipocyte differentiation in serum free media by modulating IGFBP production/secretion.

Diagnostic value of albumin gene expression in liver tumors: case report and review of the literature.

Management of a solitary liver mass necessitates reliable distinction between primary hepatocellular carcinoma and metastatic lesions. The histologic differentiation can be difficult even with special stains such as alpha-fetoprotein, cytokeratin, and carcinoembryonic antigen. Albumin is a specific product of hepatocytes, and in situ hybridization to reveal albumin messenger RNA (mRNA) is highly specific and sensitive for the diagnosis of primary hepatocellular carcinoma. This technique can be used on histopathologic specimens and in cytologic diagnosis. Herein we describe a patient with synchronous renal and hepatic masses, in whom the distinction had to be made between metastatic renal cell carcinoma and two separate primary tumors--one in the liver and one in the kidney. In situ hybridization for albumin mRNA proved helpful in making this distinction. In addition, we review the literature on the diagnostic use of albumin gene expression in liver tumors.

Collis-Nissen gastroplasty for shortened esophagus: long-term evaluation.

OBJECTIVE: The authors studied the short- and long-term results of an esophageal lengthening procedure (Collis gastroplasty) combined with a Nissen fundoplication in the management of patients with shortened esophagus and stricture secondary to gastroesophageal reflux disease. Summary Background Data There are several options for managing a shortened esophagus. There have been few long-term series with analysis of results regarding a lengthening procedure combined with a total fundoplication. METHODS: A personal series of 52 patients was examined with complete follow-up available for an average of 7 years. RESULTS: There were no deaths, esophageal leaks, or esophageal complications in the early postoperative period. Control of reflux was excellent and all patients had their dysphagia improved. The majority of patients with preoperative strictures required at least one postoperative dilation, but in most the need for dilation was short term. CONCLUSIONS: The Collis-Nissen procedure is a safe and reasonable alternative in the small subset of patients with severe reflux disease causing a shortened esophagus and stricture.