The Tailored Opioid Reduction Strategy (TORS): A Quality Improvement Initiative to Reduce Opioid Prescription Following Hysterectomy.

OBJECTIVE: To evaluate a tailored opioid reduction strategy (TORS) in minimizing opioid prescriptions for patients undergoing hysterectomy. METHODS: This quality improvement initiative was developed by multiple stakeholders at an academic hospital in a Canadian urban centre. The intervention consisted of a three-pronged approach: (1) patient and provider education, (2) perioperative multimodal analgesia, and (3) a targeted opioid reduction strategy. All eligible patients were asked to fill pre- and postoperative questionnaires. Analysis of outcomes pre- and post-TORS implementation as well as intervention compliance was performed. RESULTS: From September 2020 to April 2021, 133 patients who underwent hysterectomy were included in the study, 69 in the pre-intervention group and 64 in the post-intervention group. Of 133 hysterectomies, 78 (58.6%) were performed laparoscopically, 16 (12%) open, 14 (10.5%) vaginally, and 25 (18.8%) robotically. The rate of discharge opioid prescriptions was significantly reduced in the post-intervention group compared with the pre-intervention group (37/64, 58% versus 62/69, 90%, respectively, P < 0.001), as well as the amount of opioid prescribed in oral morphine equivalents (OME) (mean 47 mg pre-intervention, 28 mg post-intervention, P < 0.001). There was no significant difference in patient satisfaction or postoperative pain scores between groups. Overall, compliance with 2 or more components of TORS intervention was seen in 64/64 (100%) cases. CONCLUSION: TORS implementation was successful in reducing the rate of discharge opioid prescriptions and the total amount of opiates prescribed in patients undergoing hysterectomy with no decrease in patient satisfaction or change in postoperative pain scores. We believe it can be applied more broadly across different surgical patient populations to prevent opioid abuse.

Guideline No. 423: Female Genital Cosmetic Surgery and Procedures.

OBJECTIVE: To provide Canadian surgeons and other providers who offer female genital cosmetic surgery (FGCS) and procedures, and their referring practitioners, with evidence-based direction in response to increasing requests for, and availability of, vaginal and vulvar surgeries and procedures that fall outside the traditional realm of medically indicated reconstructions. TARGET POPULATION: Women of all ages seeking FGCS or procedures. BENEFITS, HARMS, AND COSTS: Health care providers play an important role in educating women about their anatomy and helping them appreciate individual variations. Most women requesting FGCS and procedures have normal genitalia, and up to 87% are reassured by counselling. At this time, due to lack of rigorous clinical or scientific evidence of short- and long-term efficacy and safety, FGCS and procedures for non-medical indications cannot be supported. FGCS and procedures are typically provided in the private sector, where costs are borne by the patient. EVIDENCE: Literature was retrieved through searches of MEDLINE, Scopus, and The Cochrane Library using appropriate controlled vocabulary and keywords. The selected search terms represented keywords for FGCS (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combined with female genital counselling, consent, satisfaction, follow-up, adolescent, and body dysmorphic or body dysmorphia. The search was restricted to publications after 2012 in order to update the literature since the previous guideline on this topic. Results were restricted to systematic reviews, randomized controlled trials, and observational studies. Studies were restricted to those involving humans, and no language restrictions were applied. The search was completed on May 20, 2020, and updated on November 10, 2020. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Gynaecologists, primary care providers, surgeons performing FGCS and/or procedures.

Directive clinique no 423 : Interventions chirurgicales et thérapeutiques esthétiques génitales féminines.

OBJECTIF: Fournir aux chirurgiens et autres fournisseurs de soins canadiens qui réalisent des interventions chirurgicales ou thérapeutiques esthétiques génitales féminines, et tout praticien demandeur, des directives fondées sur des données probantes en réponse à l'augmentation des demandes et de la disponibilité des interventions chirurgicales et thérapeutiques vaginales et vulvaires sortant du cadre traditionnel de la reconstruction avec indication médicale. POPULATION CIBLE: Les femmes de tous âges qui consultent pour subir une intervention chirurgicale ou thérapeutique esthétique génitale. BéNéFICES, RISQUES ET COûTS: Les professionnels de la santé qui prodiguent des soins aux femmes jouent un rôle important en renseignant les femmes sur leur anatomie et en les aidant à prendre conscience des variations individuelles. La plupart des femmes qui demandent une intervention chirurgicale ou thérapeutique esthétique génitale féminine ont des organes génitaux normaux, et jusqu'à 87 % d'entre elles sont rassurées par des conseils. À l'heure actuelle, étant donné le manque de données probantes cliniques et scientifiques rigoureuses sur l'efficacité et l'innocuité à court et à long terme, il n'y a aucune base pour se prononcer en faveur des interventions chirurgicales ou thérapeutiques esthétiques génitales féminines sans indication médicale. Les interventions chirurgicales ou thérapeutiques esthétiques génitales féminines sont généralement réalisées dans le secteur privé, où les coûts sont assumés par la patiente. DONNéES PROBANTES: La littérature publiée a été rassemblée par des recherches dans les bases de données Medline, Scopus et Cochrane Library au moyen de termes et mots clés pertinents et validés. Les termes de recherche sélectionnés se composaient de mots clés sur les interventions chirurgicales ou thérapeutiques esthétiques génitales féminines (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combinés à female genital counselling, consent, satisfaction, follow-up, adolescent et body dysmorphic or body dysmorphia. La recherche a été limitée aux articles publiés après 2012 afin de mettre à jour la documentation depuis la dernière directive à ce sujet. Les résultats ont été restreints aux revues systématiques, aux essais cliniques randomisés et aux études observationnelles. Les études ont été limitées à celles menées chez l'humain seulement, et aucune restriction linguistique n'a été appliquée. La recherche a été effectuée le 20 mai 2020 et mise à jour le 10 novembre 2020. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Gynécologues, fournisseurs de soins primaires, chirurgiens réalisant des interventions chirurgicales et/ou thérapeutiques esthétiques génitales féminines. RECOMMANDATIONS.

Impact of a Blood Conservation Bundle Checklist on Perioperative Transfusion Rates during Myomectomy.

STUDY OBJECTIVE: The primary objective was to introduce an intraoperative blood conservation bundle (BCB) checklist into clinical practice and assess its impact on perioperative blood transfusion rates during myomectomy. DESIGN: Prospective cohort study with retrospective control group. SETTING: A Canadian tertiary-care teaching hospital. PATIENTS: One hundred and eighty-six women who underwent myomectomy. INTERVENTIONS: The BCB is a physical checklist attached to the patient chart and consists of evidence-based medical and surgical interventions to reduce intraoperative blood loss. It was introduced in October 2018, and data were collected prospectively during a 12-month period for all open, robotic, and laparoscopic myomectomies at our institution. The primary outcome was the perioperative transfusion rate, and the secondary outcomes included estimated intraoperative blood loss, perioperative complications, readmissions, and BCB usage rates. Data were compared with those of a historic control group for a 24-month period before the BCB introduction. MEASUREMENTS AND MAIN RESULTS: In the pre-BCB period, 134 myomectomies (90 open, 31 robotic, and 13 laparoscopic) were performed, and during our study period, 52 myomectomies (33 open, 10 robotic, and 9 laparoscopic) were performed. There was a decrease in transfusion rate from 15.7% (21/134) to 7.7% (4/52) after introduction of the BCB; however, this was not significant (p = .152). The mean estimated blood loss was lower postintervention (491 mL ± 440 mL vs 350 mL ± 255 mL; p <.05) as was the mean delta hemoglobin (-28 g/L ± 13.0 g/L vs -23 g/L ± 11.4g/L; p <.05]. The checklist was used in 92.3% of cases (48/52). There were no differences in intraoperative or postoperative complications or readmission rates. CONCLUSION: Best practice care bundles can improve knowledge translation of guidelines into care delivery. The introduction of the BCB was successful in reducing intraoperative blood loss during myomectomy at our institution. The BCB is a simple, effective tool that can be easily adopted by gynecologic surgeons to guide intraoperative decision-making during myomectomy.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies.

STUDY OBJECTIVE: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING: Canada. PATIENTS: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Robotic-Assisted Laparoscopic Hysterectomy for Endometrial Hyperplasia or Grade 1 Endometrial Adenocarcinoma: A 10-year, Single-Centre Experience.

OBJECTIVE: To describe the outcomes of patients undergoing robotic-assisted laparoscopic hysterectomy for grade-1 endometroid endometrial cancer or endometrial hyperplasia at our centre. METHODS: Retrospective chart review was completed for 160 patients who underwent robotic-assisted laparoscopic hysterectomy by 5 general gynaecologists in a tertiary care setting between September 2008 and September 2018. Outcomes collected included operative time, estimated blood loss, length of stay, perioperative complications, readmissions, and recurrences. Subgroup analysis was completed after stratifying by body mass index (BMI; 3 groups: A, <40 kg/m2; B, 40-50 kg/m2; and C, >50 kg/m2). Subgroups were compared with ANOVA or Fisher exact test. RESULTS: The intraoperative complication rate was 3%. The rate of conversion to laparotomy was 2%, and the rate of bowel injury, 1%. The postoperative complication rate was 8%. The rate of major postoperative complications was 4%, and 3% of patients required readmission postoperatively. The mean BMI was 43 (range 21-71) kg/m2. There were no differences in perioperative complication, readmission, or recurrence rates between subgroups. Groups B and C were more likely to have had an ASA of 3-4, suggesting a higher burden of comorbidity. Operating room time, procedure time, and estimated blood loss were higher in group C. CONCLUSION: Despite this cohort's mean BMI falling within the category of class III obesity, complication and conversion rates were similar to those reported in the literature and did not increase with BMI, despite an increased comorbidity burden. These results suggest that robotic surgery is a safe and effective method for providing minimally invasive surgery to a technically challenging population.

Measures to Reduce Perioperative and Intraoperative Blood Loss at Myomectomy: A Survey of Obstetrician-Gynaecologists.

OBJECTIVE: This study sought to determine current techniques used by Canadian obstetrician-gynaecologists (OB/GYNs) to medically optimize patients undergoing myomectomy during the perioperative and intraoperative periods and to identify gaps in knowledge or barriers to access of blood conservation methods. METHODS: From September to December 2016, a self-administered electronic questionnaire was distributed to 120 Canadian OB/GYNs who perform myomectomies and who practise in either academic, community, or community academic-affiliated hospitals. RESULTS: A total of 68 of 120 (57%) completed responses were analyzed. Most respondents were general OB/GYNs (72.1%; n = 49) who worked in the community (70.6%; n = 48) and had practised >10 years (67.7%; n = 46); 79.4% (n = 54) delayed surgery to correct anemia. The most common preoperative medical agents used included tranexamic acid (94.1%), ulipristal acetate (92.6%), gonadotropin-releasing hormone agonist (79.4%), and combined hormonal contraception (58.8%). The majority had access to hematology (83.8%; n = 57) and intravenous iron (82.4%; n = 56). However, respondents had variable knowledge of oral and intravenous iron dosing and administration. The most common intraoperative agents used included vasopressin (94.1%; n = 64 [subserosal, 59.4% vs. intramyometrial, 40.6%]), vasopressin with epinephrine (26.6%; n = 17 [subserosal, 58.8% vs. intramyometrial, 41.2%]), intravenous tranexamic acid (73.5%; n = 50), mechanical tourniquet (66.2%; n = 45), misoprostol (33.8%; n = 23), uterine artery ligation (22.1%; n = 15), topical sealant (17.6%; n = 12), and intraoperative blood salvage (11.8%; n = 8). CONCLUSION: Most OB/GYNs delay surgery to correct anemia, but they are uncertain of personal and institutional transfusion rates, iron dosing and administration, and optimal multimodal approaches to minimize intraoperative blood loss during myomectomy. Education and creation of a clinical pathway to address blood conservation may decrease perioperative morbidity for patients undergoing myomectomy.

Delphi Approach for the Design of an Intraoperative Blood Conservation Pathway for Open Myomectomy.

OBJECTIVE: Myomectomy is offered for treatment of symptomatic uterine fibroids in women who desire to maintain fertility. An open approach, sometimes necessitated by the size or number of fibroids, is associated with a high rate of perioperative blood transfusion. Our goal was to obtain expert consensus on interventions aimed at reducing blood loss and subsequent transfusion in open myomectomy for inclusion in an intraoperative care pathway. METHODS: A two-round modified Delphi approach was used to generate consensus on a pathway of interventions to reduce blood loss in open myomectomy. A multidisciplinary expert panel consisting of anaesthesiologists, hematologists, and gynaecologic surgeons rated interventions for inclusion in or exclusion from the pathway (Canadian Task Force Classification III). RESULTS: Twenty-three expert panel members participated in the Delphi. Consensus was achieved in both the Delphi's first (Cronbach α = 0.92) and second (Cronbach α = 0.94) rounds. Of 11 proposed interventions, five (dilute vasopressin, tranexamic acid, pericervical tourniquet, cell saver, and restrictive transfusion practice) reached consensus for inclusion in the pathway. CONCLUSION: A modified Delphi consensus approach was used to inform the development of an intraoperative pathway to reduce blood loss and subsequent transfusion in women undergoing open myomectomy. Future studies will investigate the effect of this intraoperative blood conservation pathway on reducing intraoperative blood loss and blood transfusion rates among women undergoing open myomectomy.

Class III Obesity and Other Factors Associated with Longer Wait Times for Endometrial Cancer Surgery: A Population-Based Study.

OBJECTIVE: To evaluate the impact of class III obesity (body mass index >40 kg/m2) on wait times for endometrial cancer surgery in Ontario, as well as other factors that influence wait time. METHODS: We performed a population-based cross-sectional study evaluating diagnosis-to-surgery time for women with endometrioid adenocarcinoma of the endometrium, during the period of 2006 to 2015, using linked administrative databases. Wait time differences between women with and without class III obesity were evaluated using a Wilcoxon rank-sum test. A multivariable generalized linear model under a generalized estimating equations approach was used to evaluate patient factors (i.e., obesity, age, comorbidities, marginalization, recent immigration, diagnosis year, geographic location), tumour characteristics (i.e., grade, stage), provider type (i.e., surgeon specialty), and institutional characteristics (i.e., rurality, hysterectomy volume, availability of minimally invasive surgery) that influence wait times. RESULTS: In total, 9797 women met the criteria for inclusion; 2171 (22%) had class III obesity. The overall median wait time was 55 days (interquartile range [IQR] 37-77 d) and the median wait time was significantly longer for women with class III obesity (62 [IQR 43-88] vs. 53 [IQR 36-74] d, standardized mean difference, 0.30). Age <40 or >70 years, comorbidities, lower-grade disease, surgery at an urban teaching hospital, and surgery at a high-volume hospital with greater availability of minimally invasive surgery were associated with longer wait times. After adjusting for these variables, women with class III obesity waited 12% longer. CONCLUSION: Class III obesity, comorbidities, and older age are associated with a longer diagnosis-to-surgery time. As the prevalence of obesity and endometrial cancer rise, processes are needed to promote equitable, timely access to care.

Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications.

OBJECTIVE DATA: Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2). STUDY: We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2) who underwent primary hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS: We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies. RESULTS: We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m2). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m2, and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m2. Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms. CONCLUSION: Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.

Spontaneous uterine rupture and surgical repair at 21 weeks gestation with progression to live birth: a case report.

BACKGROUND: Uterine rupture in the non-laboring uterus is a rare occurrence, which can lead to significant morbidity and mortality for the mother and fetus. Management of this presentation is complex at pre-viable gestations. CASE PRESENTATION: A 35 year old primigravid woman with multiple previous myomectomies presented with spontaneous complete thickness uterine rupture at 21 weeks gestation. A 10 cm myometrial defect and iatrogenic amniotomy were surgically corrected with fetal preservation. This led to pregnancy continuation to 32 weeks gestation when elective cesarean delivery resulted in excellent neonatal outcome. CONCLUSIONS: Early surgical diagnosis, multidisciplinary team approach, iatrogenic amniotomy and continuous two-layer myometrial closure were factors that contributed to pregnancy prolongation in this large myometrial rupture.

Molecular evolution of nitrogen assimilatory enzymes in marine prasinophytes.

Nitrogen assimilation is a highly regulated process requiring metabolic coordination of enzymes and pathways in the cytosol, chloroplast, and mitochondria. Previous studies of prasinophyte genomes revealed that genes encoding nitrate and ammonium transporters have a complex evolutionary history involving both vertical and horizontal transmission. Here we examine the evolutionary history of well-conserved nitrogen-assimilating enzymes to determine if a similar complex history is observed. Phylogenetic analyses suggest that genes encoding glutamine synthetase (GS) III in the prasinophytes evolved by horizontal gene transfer from a member of the heterokonts. In contrast, genes encoding GSIIE, a canonical vascular plant and green algal enzyme, were found in the Micromonas genomes but have been lost from Ostreococcus. Phylogenetic analyses placed the Micromonas GSIIs in a larger chlorophyte/vascular plant clade; a similar topology was observed for ferredoxin-dependent nitrite reductase (Fd-NiR), indicating the genes encoding GSII and Fd-NiR in these prasinophytes evolved via vertical transmission. Our results show that genes encoding the nitrogen-assimilating enzymes in Micromonas and Ostreococcus have been differentially lost and as well as recruited from different evolutionary lineages, suggesting that the regulation of nitrogen assimilation in prasinophytes will differ from other green algae.

Gene expression studies for the analysis of domoic acid production in the marine diatom Pseudo-nitzschia multiseries.

BACKGROUND: Pseudo-nitzschia multiseries Hasle (Hasle) (Ps-n) is distinctive among the ecologically important marine diatoms because it produces the neurotoxin domoic acid. Although the biology of Ps-n has been investigated intensely, the characterization of the genes and biochemical pathways leading to domoic acid biosynthesis has been limited. To identify transcripts whose levels correlate with domoic acid production, we analyzed Ps-n under conditions of high and low domoic acid production by cDNA microarray technology and reverse-transcription quantitative PCR (RT-qPCR) methods. Our goals included identifying and validating robust reference genes for Ps-n RNA expression analysis under these conditions. RESULTS: Through microarray analysis of exponential- and stationary-phase cultures with low and high domoic acid production, respectively, we identified candidate reference genes whose transcripts did not vary across conditions. We tested eleven potential reference genes for stability using RT-qPCR and GeNorm analyses. Our results indicated that transcripts encoding JmjC, dynein, and histone H3 proteins were the most suitable for normalization of expression data under conditions of silicon-limitation, in late-exponential through stationary phase. The microarray studies identified a number of genes that were up- and down-regulated under toxin-producing conditions. RT-qPCR analysis, using the validated controls, confirmed the up-regulation of transcripts predicted to encode a cycloisomerase, an SLC6 transporter, phosphoenolpyruvate carboxykinase, glutamate dehydrogenase, a small heat shock protein, and an aldo-keto reductase, as well as the down-regulation of a transcript encoding a fucoxanthin-chlorophyll a-c binding protein, under these conditions. CONCLUSION: Our results provide a strong basis for further studies of RNA expression levels in Ps-n, which will contribute to our understanding of genes involved in the production and release of domoic acid, an important neurotoxin that affects human health as well as ecosystem function.

Combination etanercept and methotrexate provides better disease control in very early (<=4 months) versus early rheumatoid arthritis (>4 months and <2 years): post hoc analyses from the COMET study.

OBJECTIVE: The objective of this post hoc analysis was to test the benefits of treating very early rheumatoid arthritis (VERA; ≤4 months) using COMET trial data. Treatment response in VERA and early rheumatoid arthritis (ERA; >4 months to 2 years) with combination etanercept+methotrexate (ETN+MTX) or MTX monotherapy was compared. METHODS: Data assessed at week 52 for baseline disease duration effect included remission (disease activity score (DAS)28 <2.6, SDAI ≤3.3, Boolean), low disease activity (LDA; DAS28 <3.2), Boolean components of remission and radiographic non-progression. Subjects who discontinued because of lack of efficacy were included as non-responders. RESULTS: Higher proportions of VERA subjects achieved LDA (79%) and DAS28 remission (70%) than ERA (62%, 48%, respectively, p<0.05) with ETN+MTX. Such high responses with MTX monotherapy were not observed (VERA, LDA=47%, DAS28 remission=35%; ERA, 47% and 32% respectively, p>0.70 for each). Regardless of disease duration, no radiographic progression was seen in 80% of subjects with ETN+MTX. In contrast, a higher proportion of VERA subjects showed no radiographic progression compared with ERA subjects treated with MTX (73.9% vs 50%, p=0.01). CONCLUSIONS: Treatment of VERA with ETN+MTX provides qualitatively improved clinical outcomes not seen with MTX monotherapy, supporting the pivotal role of TNF inhibition in early disease.

Two-year clinical and radiographic results with combination etanercept-methotrexate therapy versus monotherapy in early rheumatoid arthritis: a two-year, double-blind, randomized study.

OBJECTIVE: To evaluate how continuation of and alterations to initial year 1 combination etanercept-methotrexate (MTX) therapy and MTX monotherapy regimens affect long-term remission and radiographic progression in early, active rheumatoid arthritis. METHODS: Subjects were randomized at baseline for the entire 2-year period; those who completed 1 year of treatment with combination or MTX monotherapy entered year 2. The original combination group either continued combination therapy (the EM/EM group; n = 111) or received etanercept monotherapy (the EM/E group; n = 111) in year 2; the original MTX monotherapy group either received combination therapy (the M/EM group; n = 90) or continued monotherapy (the M/M group; n = 99) in year 2. Efficacy end points included remission (a Disease Activity Score in 28 joints [DAS28] <2.6) and radiographic nonprogression (change in the modified Sharp/van der Heijde score < or = 0.5) at year 2. A last observation carried forward analysis from the modified intention-to-treat population (n = 398) and a post hoc nonresponder imputation (NRI) analysis (n = 528) were performed for remission. RESULTS: At year 2, DAS28 remission was achieved by 62/108, 54/108, 51/88, and 33/94 subjects in the EM/EM, EM/E, M/EM, and M/M groups, respectively (P < 0.01 for the EM/EM and M/EM groups versus the M/M group). This effect was corroborated by a more conservative post hoc 2-year NRI analysis, with remission observed in 59/131, 50/134, 48/133, and 29/130 of the same respective groups (P < 0.05 for each of the EM/EM, EM/E, and M/EM groups versus the M/M group). The proportions of subjects achieving radiographic nonprogression (n = 360) were 89/99, 74/99, 59/79, and 56/83 in the EM/EM (P < 0.01 versus each of the other groups), EM/E, M/EM, and M/M groups, respectively. No new safety signals or between-group differences in serious adverse events were seen. CONCLUSION: Early sustained combination etanercept-MTX therapy was consistently superior to MTX monotherapy. Combination therapy resulted in important clinical and radiographic benefits over 2 study years, without significant additional safety risk.

Molecular evolution of glutamine synthetase II: Phylogenetic evidence of a non-endosymbiotic gene transfer event early in plant evolution.

BACKGROUND: Glutamine synthetase (GS) is essential for ammonium assimilation and the biosynthesis of glutamine. The three GS gene families (GSI, GSII, and GSIII) are represented in both prokaryotic and eukaryotic organisms. In this study, we examined the evolutionary relationship of GSII from eubacterial and eukaryotic lineages and present robust phylogenetic evidence that GSII was transferred from gamma-Proteobacteria (Eubacteria) to the Chloroplastida. RESULTS: GSII sequences were isolated from four species of green algae (Trebouxiophyceae), and additional green algal (Chlorophyceae and Prasinophytae) and streptophyte (Charales, Desmidiales, Bryophyta, Marchantiophyta, Lycopodiophyta and Tracheophyta) sequences were obtained from public databases. In Bayesian and maximum likelihood analyses, eubacterial (GSIIB) and eukaryotic (GSIIE) GSII sequences formed distinct clades. Both GSIIB and GSIIE were found in chlorophytes and early-diverging streptophytes. The GSIIB enzymes from these groups formed a well-supported sister clade with the gamma-Proteobacteria, providing evidence that GSIIB in the Chloroplastida arose by horizontal gene transfer (HGT). Bayesian relaxed molecular clock analyses suggest that GSIIB and GSIIE coexisted for an extended period of time but it is unclear whether the proposed HGT happened prior to or after the divergence of the primary endosymbiotic lineages (the Archaeplastida). However, GSIIB genes have not been identified in glaucophytes or red algae, favoring the hypothesis that GSIIB was gained after the divergence of the primary endosymbiotic lineages. Duplicate copies of the GSIIB gene were present in Chlamydomonas reinhardtii, Volvox carteri f. nagariensis, and Physcomitrella patens. Both GSIIB proteins in C. reinhardtii and V. carteri f. nagariensis had N-terminal transit sequences, indicating they are targeted to the chloroplast or mitochondrion. In contrast, GSIIB proteins of P. patens lacked transit sequences, suggesting a cytosolic function. GSIIB sequences were absent in vascular plants where the duplication of GSIIE replaced the function of GSIIB. CONCLUSIONS: Phylogenetic evidence suggests GSIIB in Chloroplastida evolved by HGT, possibly after the divergence of the primary endosymbiotic lineages. Thus while multiple GS isoenzymes are common among members of the Chloroplastida, the isoenzymes may have evolved via different evolutionary processes. The acquisition of essential enzymes by HGT may provide rapid changes in biochemical capacity and therefore be favored by natural selection.