Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement - a discrete choice experiment.

OBJECTIVE: To study the preferences of women with deep endometriosis (DE) with bowel involvement when they have to choose between conservative (medication) or surgical treatment. DESIGN: Labelled discrete choice experiment (DCE). SETTING: Dutch academic and non-academic hospitals and online recruitment. POPULATION OR SAMPLE: A total of 169 women diagnosed with DE of the bowel. METHODS: Baseline characteristics and the fear of surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression. MAIN OUTCOME MEASURES: The following attributes - effect on/risk of pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms - were used in this DCE. RESULTS: In the ranking, osteoporosis was ranked with low importance, whereas in the DCE, a lower chance of osteoporosis was one of the most important drivers when choosing a conservative treatment. Women with previous surgery showed less fear of surgery compared with women without surgery. Low anterior resection syndrome was almost equally important for patients as the chance of pain reduction. Pain reduction had higher importance than improving fertility chances, even in women with desire for a future child. CONCLUSIONS: The risk of developing low anterior resection syndrome as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear of surgery compared with women without a surgical history. TWEETABLE ABSTRACT: First discrete choice experiment in patients with deep endometriosis.

Improving the Digestibility of Plant Defensins to Meet Regulatory Requirements for Transgene Products in Crop Protection.

Despite the use of chemical fungicides, fungal diseases have a major impact on the yield and quality of plant produce globally and hence there is a need for new approaches for disease control. Several groups have examined the potential use of antifungal plant defensins for plant protection and have produced transgenic plants expressing plant defensins with enhanced resistance to fungal disease. However, before they can be developed commercially, transgenic plants must pass a series of strict regulations to ensure that they are safe for human and animal consumption as well as the environment. One of the requirements is rapid digestion of the transgene protein in the gastrointestinal tract to minimize the risk of any potential allergic response. Here, we examine the digestibility of two plant defensins, NaD1 from Nicotiana alata and SBI6 from soybean, which have potent antifungal activity against major cereal pathogens. The native defensins were not digestible in simulated gastrointestinal fluid assays. Several modifications to the sequences enhanced the digestibility of the two small proteins without severely impacting their antifungal activity. However, these modified proteins did not accumulate as well as the native proteins when transiently expressed in planta, suggesting that the protease-resistant structure of plant defensins facilitates their stability in planta.

Ocular trauma associated with falls in older people: A 10-year review from a state trauma service.

BACKGROUND: Falls are the leading cause of injury-related emergency presentations, hospital admissions and deaths in Victorians over the age of 65. While there is extensive literature analysing traumatic injuries resulting from falls in older patients, there is little data on ocular injuries in this patient group. METHODOLOGY: A retrospective audit of all patients over 65 years referred to the Ophthalmology Department of a tertiary hospital following fall from standing height between January 2009 and December 2018 to determine the demographics, injury setting, ophthalmic injuries, interventions and outcomes of ocular trauma secondary to falls. RESULTS: Two hundred and seventy patients (F = 155, M = 115) were included, with a mean age of 81 years. 180 falls (66.7%) occurred in a residential environment. The most common reason for referral was orbital fracture (n = 155). Severe ocular injuries included globe rupture (n = 23), retro-bulbar haematoma (n = 22), retinal detachment (n = 6) and traumatic optic neuropathy (n = 6). Forty patients (14.8%) presented with a visual acuity (VA) below 6/60 while 34 patients (12.5%) had a non-assessable VA secondary to delirium or intubation. Of these 34, 9 had a significant ocular injury. A total of 28 patients (10.4%) were permanently blinded by their injuries. Twenty-three patients (8.5%) required admission to ICU and 16 patients (5.93%) died during their in-hospital stay. Thirty-six injuries were referred beyond the 24-hour mark, including a globe rupture and a case of traumatic optic neuropathy. With the exception of the missed globe rupture, all other injuries requiring emergency surgery were operated on within 24 h. CONCLUSION: Falls in older people may be associated with sight-threatening ocular injuries which are common and easy to miss in this population demographic. The presence of ocular injuries in this patient group is associated with significant rates of in-hospital mortality and poor functional outcomes. It is therefore essential for trauma practitioners to perform a detailed and systematic assessment in order to identify sight-threatening ocular injuries and allow for expedient sight-saving intervention to be performed.

Paediatric orbital conjunctival epithelial cyst with positive asialotransferrin.

Conjunctival orbital cysts are rare; they are typically either conjunctival dermoid or conjunctival epithelial cysts - congenital or acquired (inclusion). We describe the case of a 15-month-old girl presenting with strabismus and proptosis who had a retrobulbar intraconal cystic lesion displacing the optic nerve, with an adjacent middle cranial fossa anomaly. Aspiration of the orbital cyst tested positive for asialotransferrin, raising the suspicion of a direct communication with cerebrospinal fluid (CSF). Subsequent fine cut CT scanning disproved any connection with the intracranial space, and the cyst was excised complete and intact. Histopathology showed a conjunctival epithelial cyst. To our knowledge, this is the first case report in the literature of an asialotransferrin positive pediatric orbital conjunctival epithelial cyst. It is of clinical relevance as it explores the possibility of either a false positive asialotransferrin or potentially a prior developmental communication with the subarachnoid space. These two diagnostic possibilities are discussed.

Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation.

There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a total endovascular arch repair by means of a novel technique for graft fenestration using a trans-septal needle with extracorporeal membrane oxygenation support. Although the use of trans-septal needle fenestration use has been described, the use in arch fenestrations has not. We present this case as an example of techniques that may be useful in the expanding landscape of endovascular ascending and arch repair.

Limited Added Value of Magnetic Resonance Imaging After Dynamic Transvaginal Ultrasound for Preoperative Staging of Endometriosis in Daily Practice: A Prospective Cohort Study.

OBJECTIVES: To assess the added value of magnetic resonance imaging (MRI) after dynamic transvaginal ultrasound (TVUS) in the diagnostic pathway for preoperative staging of pelvic endometriosis. METHODS: A prospective observational study was conducted between April 22, 2014, and May 1, 2015. During that period, 363 patients with a clinical suspicion of endometriosis were included. All patients underwent a history, clinical examination, and dynamic TVUS examination. Most of the patients (n = 274) underwent conservative treatment according to the European Society of Human Reproduction and Embryology guidelines. Eighty-nine patients were selected for surgery, of whom 72 patients underwent the complete diagnostic pathway: ie, history, clinical examination, dynamic TVUS, and MRI. All data were analyzed by the nonparametric McNemar test for comparing each step in the diagnostic algorithm. RESULTS: The sensitivity and specificity for the history, pelvic examination, and dynamic TVUS were 93.7% and 55.6% (P < .001), respectively; when MRI findings were included, the sensitivity and specificity were 85.9% and 62.5%. Adding MRI routinely to the diagnostic procedure of endometriosis did not significantly improve the sensitivity or specificity. CONCLUSIONS: There is no significant added value of routine MRI after dynamic TVUS for the preoperative staging of endometriosis.

The Role of FDG-PET in the Diagnosis and Staging of Ocular Adnexal Lymphoproliferative Disease.

PURPOSE: To further evaluate fluorine 18 fluoro-deoxyglucose positron emission tomography (FDG PET) in the staging of ocular adnexal lymphoproliferative disease (OALD). METHODS: Retrospective and prospective case series with review of clinical and imaging records including computed tomography (CT), FDG PET (± PET/CT) and/or magnetic resonance imaging (MRI). RESULTS: Thirty-four patients had FDG PET and CT scans at initial staging. Eleven were retrospectively reviewed and 23 were prospectively enrolled. Of 34 patients, 17 (50%) had primary disease, 17 (50%) had secondary and of these, 13 patients (38%) had OALD as their initial manifestation. Sixteen patients had active systemic disease in conjunction with their orbital disease. Systemic disease was demonstrated by FDG PET (± CT) in 15 of 16 (94%) patients and 11 of 16 (69%) patients with CT. FDG PET found orbital disease in 27 of 34 patients (79%) versus 33 of 34 patients with orbital CT (97%). Four of 16 patients in which FDG-PET detected systemic disease where CT did not were upstaged and their management changed significantly in 5 cases. CONCLUSIONS: This study reaffirms FDG PET as an important part of initial staging. Our study suggests FDG PET detects systemic disease more reliably than CT alone and results in significant changes in management. Our findings suggest FDG PET detection for local OALD is less sensitive than CT. MRI is helpful in augmenting other imaging modalities in further identifying disease. Given the prevalence of simultaneous systemic presentations of OALD, FDG PET in this regard is especially important and highlights the need for coordinated multidisciplinary care.

Limited segmental rectal resection in the treatment of deeply infiltrating rectal endometriosis: 10 years' experience from a tertiary referral unit.

BACKGROUND: The management of symptomatic rectal endometriosis is a challenging condition that may necessitate limited stripping or limited segmental anterior rectal resection (LSARR) depending upon the extent and severity of the disease. OBJECTIVE: To report the efficacy of LSARR in terms of pain, quality of life and short- and long-term complications-in particular, those pertaining to bowel function. METHODS: The case notes of all patients undergoing LSARR were reviewed. The analysed variables included surgical complications, overall symptomatic improvement rate, dysmenorrhoea, dyspareunia, and dyschezia. Chronic pain was measured using a visual analogue scale. Quality of life was measured using the EQ-5D questionnaire. Bowel symptoms were assessed using the Memorial Sloan Kettering Cancer Centre (MSKCC) questionnaire. RESULTS: Seventy-four women who underwent LSARR by both open and laparoscopic approaches were included in this study. Sixty-nine (93.2%) women reported improvement in pain and the same percentage would recommend the similar procedure to a friend with the same problem. Approximately 42% of women who wished to conceive had at least one baby. The higher frequency of defecation was a problem in the early post-operative period but this settled in later stages without influencing the quality of life score. Post-operative complications were recorded in 14.9% of cases. CONCLUSIONS: LSARR for rectal endometriosis is associated with a high degree of symptomatic relief. Pain relief achieved following LSARR does not appear to degrade with time. As anticipated, some rectal symptoms persist in few patients after long-term follow-up but LSARR is nonetheless still associated with a very high degree of patient satisfaction.

Subcellular localization and biochemical comparison of cytosolic and secreted cytokinin dehydrogenase enzymes from maize.

Cytokinin dehydrogenase (CKX; EC 1.5.99.12) degrades cytokinin hormones in plants. There are several differently targeted isoforms of CKX in plant cells. While most CKX enzymes appear to be localized in the apoplast or vacuoles, there is generally only one CKX per plant genome that lacks a translocation signal and presumably functions in the cytosol. The only extensively characterized maize CKX is the apoplastic ZmCKX1; a maize gene encoding a non-secreted CKX has not previously been cloned or characterized. Thus, the aim of this work was to characterize the maize non-secreted CKX gene (ZmCKX10), elucidate the subcellular localization of ZmCKX10, and compare its biochemical properties with those of ZmCKX1. Expression profiling of ZmCKX1 and ZmCKX10 was performed in maize tissues to determine their transcript abundance and organ-specific expression. For determination of the subcellular localization, the CKX genes were fused with green fluorescent protein (GFP) and overexpressed in tomato hairy roots. Using confocal microscopy, the ZmCKX1-GFP signal was confirmed to be present in the apoplast, whereas ZmCKX10-GFP was detected in the cytosol. No interactions of ZmCKX1 with the plasma membrane were observed. While roots overexpressing ZmCKX1-GFP formed significantly more mass in comparison with the control, non-secreted CKX overexpression resulted in a small reduction in root mass accumulation. Biochemical characterization of ZmCKX10 was performed using recombinant protein produced in Pichia pastoris. In contrast to the preference for 2,6-dichlorophenolindophenol (DCPIP) as an electron acceptor and trans-zeatin, N(6)-(Delta(2)-isopentenyl)adenine (iP) and N(6)-(Delta(2)-isopentenyl)adenosine (iPR) as substrates for ZmCKX1, the non-secreted ZmCKX10 had a range of suitable electron acceptors, and the enzyme had a higher preference for cis-zeatin and cytokinin N-glucosides as substrates.

Combinatorially selected defense peptides protect plant roots from pathogen infection.

Agricultural productivity and sustainability are continually challenged by emerging and indigenous pathogens. Currently, many pathogens can be combatted only with biocides or environmentally dangerous fumigants. Here, we report a rapid and pathogen-specific strategy to reduce infection by organisms that target plant roots. Combinatorially selected defense peptides, previously shown to effect premature encystment of Phytophthora capsici zoospores, were fused to maize cytokinin oxidase/dehydrogenase as a display scaffold. When expressed in tomato roots, the peptide-scaffold constructs were secreted and accumulated to sufficient concentrations in the rhizosphere to induce zoospore encystment and thereby deter taxis to the root surface. Pathogen infection was significantly inhibited in roots expressing bioactive peptides fused to the maize cytokinin oxidase/dehydrogenase scaffold. This peptide-delivery technology is broadly applicable for rapid development of plant defense attributes against plant pathogens.

The Surgical Simulation and Training Markup Language (SSTML): an XML-based language for medical simulation.

Under contract with the Telemedicine & Advanced Technology Research Center (TATRC), Energid Technologies is developing a new XML-based language for describing surgical training exercises, the Surgical Simulation and Training Markup Language (SSTML). SSTML must represent everything from organ models (including tissue properties) to surgical procedures. SSTML is an open language (i.e., freely downloadable) that defines surgical training data through an XML schema. This article focuses on the data representation of the surgical procedures and organ modeling, as they highlight the need for a standard language and illustrate the features of SSTML. Integration of SSTML with software is also discussed.

Effectiveness of haptic feedback in open surgery simulation and training systems.

This paper presents progress in the development of an untethered haptic feedback system for open surgery simulation and training being developed by Energid Technologies. A key innovation in our simulation is an untethered haptic feedback method. In this paper, we describe our approach to developing an effective untethered haptic feedback system, and our current progress. We also present the results of a haptic feedback effectiveness study which explores how haptic rendering accuracy behaves as a function of sampling rate for tool tracking.

A new technique for laparoscopic anterior resection for rectal endometriosis.

BACKGROUND: Anterior rectal resection is sometimes necessary to treat deeply infiltrating rectovaginal endometriosis. We describe a completely laparoscopic approach as a new way of excising rectal endometriosis that can be used without opening any part of the rectum. This avoids opening the abdomen or any risk of fecal spillage. METHODS: The patient received preoperative oral bowel preparation. Ureteric stents (6 F) were inserted cystoscopically. The peritoneum in the ovarian fossae was opened lateral to any disease and the rectum reflected off the back of the cervix, leaving any endometriosis on the front of the rectum. The pelvic peritoneum was reflected medially, below the level of the ureters. The mesorectum was then dissected off a 6-cm length of rectum by using a Harmonic scalpel. A circular end-to-end anastomosis instrument was passed anally until the outline of the anvil was visible, inside the colon, above the diseased rectum. The anvil was detached and held by a soft grasper before the rectum was then divided above and below the disease using a laparoscopic stapling device. The tip of the anvil was pushed through the proximal end of the colon allowing reanastomosis of the rectal stump. CONCLUSION: The patient was discharged after 5 days without complications.

A vision-based surgical tool tracking approach for untethered surgery simulation and training.

This paper presents progress in the development of an untethered surgery simulation and training system. A surgical trainee interacts with the simulation in the most natural way possible-using standard, untethered surgical tools and hands. This natural interface requires innovations in tracking, haptic feedback, and visualization. This article describes the approach used for tool tracking with color cameras. A novel tracking algorithm is used to identify the type of tool, its position, and its orientation. Integration of the vision system with the tissue deformation and visualization modules is also discussed.

Pain, quality of life and complications following the radical resection of rectovaginal endometriosis.

OBJECTIVE: To determine the long term response, quality of life and levels of pain following the radical excision of rectovaginal endometriosis. DESIGN: A cohort study. SETTING: A tertiary referral centre for the management of advanced endometriosis. SAMPLE: All patients who had undergone radical resection. METHODS: Case note review and patient questionnaire. MAIN OUTCOME MEASURES: Surgical complications. Overall improvement. Dysmenorrhoea, dyspareunia, dyschezia and chronic pain were measured using a visual analogue scale. Quality of life was measured using the EQ-5D questionnaire. RESULTS: Twelve radical resections were performed by laparotomy, 48 by laparoscopy. Ten patients had a hysterectomy. Forty-eight patients underwent shaving of the pre-rectal fascia, two had a disc resection of the rectum, 10 had an anterior rectal resection. Two patients required a colostomy and two needed subsequent dilation of a stenosed anastomosis. Forty-four of the first 46 patients replied. The median follow up period was 12 months (range 2 to 22 months) and 86% (38/44) reported an improvement or whom 27 (61%) had a good response (pain completely gone or greatly improved). Patients having a hysterectomy or a disc or segmental resection of the rectum reported a good response and had a normal quality of life. Quality of life scores in the study group overall were lower than the background population. CONCLUSIONS: Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.

Phage-displayed peptides as developmental agonists for Phytophthora capsici zoospores.

As part of its pathogenic life cycle, Phytophthora capsici disperses to plants through a motile zoospore stage. Molecules on the zoospore surface are involved in reception of environmental signals that direct preinfection behavior. We developed a phage display protocol to identify peptides that bind to the surface molecules of P. capsici zoospores in vitro. The selected phage-displayed peptides contained an abundance of polar amino acids and proline but were otherwise not conserved. About half of the selected phage that were tested concomitantly induced zoospore encystment in the absence of other signaling agents. A display phage was shown to bind to the zoospore but not to the cyst form of P. capsici. Two free peptides corresponding to active phage were similarly able to induce encystment of zoospores, indicating that their ability to serve as signaling ligands did not depend on their exact molecular context. Isolation and subsequent expression of peptides that act on pathogens could allow the identification of receptor molecules on the zoospore surface, in addition to forming the basis for a novel plant disease resistance strategy.