Application of machine-learning methods to milk mid-infrared spectra for discrimination of cow milk from pasture or total mixed ration diets.

The prevalence of "grass-fed" labeled food products on the market has increased in recent years, often commanding a premium price. To date, the majority of methods used for the authentication of grass-fed source products are driven by auditing and inspection of farm records. As such, the ability to verify grass-fed source claims to ensure consumer confidence will be important in the future. Mid-infrared (MIR) spectroscopy is widely used in the dairy industry as a rapid method for the routine monitoring of individual herd milk composition and quality. Further harnessing the data from individual spectra offers a promising and readily implementable strategy to authenticate the milk source at both farm and processor levels. Herein, a comprehensive comparison of the robustness, specificity, and accuracy of 11 machine-learning statistical analysis methods were tested for the discrimination of grass-fed versus non-grass-fed milks based on the MIR spectra of 4,320 milk samples collected from cows on pasture or indoor total mixed ration-based feeding systems over a 3-yr period. Linear discriminant analysis and partial least squares discriminant analysis (PLS-DA) were demonstrated to offer the greatest level of accuracy for the prediction of cow diet from MIR spectra. Parsimonious strategies for the selection of the most discriminating wavelengths within the spectra are also highlighted.

Predicting cow milk quality traits from routinely available milk spectra using statistical machine learning methods.

Numerous statistical machine learning methods suitable for application to highly correlated features, as those that exist for spectral data, could potentially improve prediction performance over the commonly used partial least squares approach. Milk samples from 622 individual cows with known detailed protein composition and technological trait data accompanied by mid-infrared spectra were available to assess the predictive ability of different regression and classification algorithms. The regression-based approaches were partial least squares regression (PLSR), ridge regression (RR), least absolute shrinkage and selection operator (LASSO), elastic net, principal component regression, projection pursuit regression, spike and slab regression, random forests, boosting decision trees, neural networks (NN), and a post-hoc approach of model averaging (MA). Several classification methods (i.e., partial least squares discriminant analysis (PLSDA), random forests, boosting decision trees, and support vector machines (SVM)) were also used after stratifying the traits of interest into categories. In the regression analyses, MA was the best prediction method for 6 of the 14 traits investigated [curd firmness at 60 min, αS1-casein (CN), αS2-CN, κ-CN, α-lactalbumin, and ß-lactoglobulin B], whereas NN and RR were the best algorithms for 3 traits each (rennet coagulation time, curd-firming time, and heat stability, and curd firmness at 30 min, ß-CN, and ß-lactoglobulin A, respectively), PLSR was best for pH, and LASSO was best for CN micelle size. When traits were divided into 2 classes, SVM had the greatest accuracy for the majority of the traits investigated. Although the well-established PLSR-based method performed competitively, the application of statistical machine learning methods for regression analyses reduced the root mean square error compared with PLSR from between 0.18% (κ-CN) to 3.67% (heat stability). The use of modern statistical machine learning methods for trait prediction from mid-infrared spectroscopy may improve the prediction accuracy for some traits.

Beclomethasone dipropionate versus mesalazine in distal ulcerative colitis: a multicenter, randomized, double-blind study.

BACKGROUND: Topical beclomethasone diproprionate has shown efficacy in ulcerative colitis. AIM: To assess, in a multicenter, randomized, double-blind study, the tolerability and safety of topical beclomethasone diproprionate (3mg) enema and foam versus mesalazine (2g) enema and foam in mild-moderate distal ulcerative colitis. PATIENTS: In 15 referral gastrointestinal units, 99 patients with distal ulcerative colitis were enrolled. This number was lower than planned according to the statistical analysis, due to a low recruitment rate. METHODS: Patients were randomly assigned to random preparations (beclomethasone diproprionate enema, beclomethasone diproprionate foam, mesalazine enema, mesalazine foam) once nightly for 8 weeks, with clinical and endoscopical assessment (Disease Activity Index score) at baseline (T0), 4 (T4) and 8 weeks (T8). Results were expressed as median and range (95% confidence interval). The efficacy was assessed by comparing the Disease Activity Index value at T4 and T8 by using the Student's t-test or the Wilcoxon-Mann-Whitney test. RESULTS: Efficacy was comparable in the beclomethasone diproprionate or mesalazine groups at both T4 and T8 (response at T4: beclomethasone diproprionate 78% [95% confidence interval 0.6-0.8] versus mesalazine 79% [95% confidence interval 0.6-0.8]; T8: beclomethasone diproprionate 84% [95% confidence interval 0.7-0.9] versus mesalazine 90% [95% confidence interval 0.7-1.0]; p=n.s.; remission at T4: beclomethasone diproprionate 24% [95% confidence interval 0.1-0.3] versus mesalazine 28% [95% confidence interval 0.1-0.3]; remission at T8: beclomethasone diproprionate 36% [95% confidence interval 0.2-0.5] versus mesalazine 52% [95% confidence interval 0.3-0.6]; p=n.s.). The Disease Activity Index lowered at T4 and T8 versus T0 in the four groups (T4 versus T0: beclomethasone diproprionate foam Disease Activity Index 2 versus 6 p<0.0001; beclomethasone diproprionate enema 4 versus 6, mesalazine enema 3 versus 6, mesalazine foam 3.5 versus 7, p<0.001 for all three groups; T8 versus T0: p<0.01). The Disease Activity Index lowered at T8 versus T4 in the beclomethasone diproprionate enema and foam (Disease Activity Index: 2 versus 4 and 1 versus 4, respectively; p<0.05) and in the mesalazine enema (Disease Activity Index: 1.5, range 0-4 versus 3, range 0-12; p<0.01), but not in the mesalazine foam group (Disease Activity Index: 1, range 0-9 versus 3.5, range 0-8; p=n.s.). The safety profile was favourable for all groups. CONCLUSIONS: Beclomethasone diproprionate and mesalazine enema and foam show a comparable tolerability and efficacy in mild active distal ulcerative colitis.

Sperm head ellipticity as a heat stress indicator in Australian Merino rams (Ovis aries) in Northern Patagonia, Argentina.

In Northern Patagonia, Argentina, the ovine mating season starts on March 15, which is the time when rams are submitted to summer temperatures. This study assessed the adaptability of 12 Australian Merino rams, six unshorn and six shorn, half of which were treated in a heat chamber for five days (09.00 hours to 17.00 hours) that gradually reached 40 °C. In an attempt to quantify the effects of heat stress on sperm head morphology, ellipticity was analyzed to establish the relationship between the distributions of subpopulations, light hours, temperature and humidity. Ellipticity was measured on 9224 sperm heads that were obtained over 12 weeks starting in the summer time. Four sperm head subpopulations (S) were identified by comparison with a sperm head population of ejaculates obtained in the late breeding season without the effect of heat stress (S1 = heads with ellipticity ≥ 2.00; S2 = sperm head with range of ellipticity between 1.80 and 1.99; S3 = sperm head with range of ellipticity from 1.60 to 1.79; and S4 = sperm head with range of ellipticity from 1.30 to 1.59). The variable sperm head ellipticity for each ejaculate was expressed as the means and frequencies of subpopulation. The results demonstrate changes in ram sperm head ellipticity in different conditions (control/treated, unshorn/shorn) throughout the experiment (P < 0.05). Treated shorn rams had a higher mean ellipticity and frequency of elliptical heads (mean ellipticity value = 2.06 and S1 frequency = 76.35%), peaking in the seventh week posttreatment (on the basis of the action of heat stress on seminiferous tubules). According to this study, unshorn rams were better adapted to heat stress than the shorn ones.

Genomic typing of Escherichia coli O157:H7 by semi-automated fluorescent AFLP analysis.

Escherichia coli serotype O157:H7 isolates were analyzed using a relatively new DNA fingerprinting method, amplified fragment length polymorphism (AFLP). Total genomic DNA was digested with two restriction endonucleases (EcoRI and MseI), and compatible oligonucleotide adapters were ligated to the ends of the resulting DNA fragments. Subsets of fragments from the total pool of cleaved DNA were then amplified by the polymerase chain reaction (PCR) using selective primers that extended beyond the adapter and restriction site sequences. One of the primers from each set was labeled with a fluorescent dye, which enabled amplified fragments to be detected and sized automatically on an automated DNA sequencer. Three AFLP primer sets generated a total of thirty-seven unique genotypes among the 48 E. coli O157:H7 isolates tested. Prior fingerprinting analysis of large restriction fragments from these same isolates by pulsed-field gel electrophoresis (PFGE) resulted in only 21 unique DNA profiles. Also, AFLP fingerprinting was successful for one DNA sample that was not typable by PFGE, presumably because of template degradation. AFLP analysis, therefore, provided greater genetic resolution and was less sensitive to DNA quality than PFGE. Consequently, this DNA typing technology should be very useful for genetic subtyping of bacterial pathogens in epidemiologic studies.

Review article: prevention of postsurgical relapse and recurrence in Crohn's disease.

After first resection in Crohn's disease at 1 year 60-80% of patients have endoscopic recurrence, 10-20% have clinical relapse, and 5% have surgical recurrence.1, 2 This review focuses on the actual evidence on the prevention of recurrence and relapse dealing with risk factors and with drugs. Smoking is the only risk factor for Crohn's disease, that has been shown to be related to both endoscopic and surgical recurrence and relapse. Among the different drugs evaluated, some (Mesalamine and Metronidazole) have been shown to be effective, whereas others (immunosuppressive) need to be evaluated in further, new trials.

Evaluation of Hbr (MITE) markers for assessment of genetic relationships among maize ( Zea mays L.) inbred lines.

Recently, a new type of molecular marker has been developed that is based on the presence or absence of the miniature inverted repeat transposable element (MITE) family Heartbreaker ( Hbr) in the maize genome. These so-called Hbr markers have been shown to be stable, highly polymorphic, easily mapped, and evenly distributed throughout the maize genome. In this work, we used Hbr-derived markers for genetic characterization of a set of maize inbred lines belonging to Stiff Stalk (SS) and Non-Stiff Stalk (NSS) heterotic groups. In total, 111 markers were evaluated across 62 SS and NSS lines. Seventy six markers (68%) were shared between the two groups, and 25 of the common markers occurred at fairly low frequency (

Severe acute colitis associated with CMV: a prevalence study.

BACKGROUND: Cytomegalovirus has been identified as a pathogen that contributes to flares of colitis when detected in colonic specimens of patients with inflammatory bowel disease. AIM: To determine the overall prevalence and the role of cytomegalovirus infection in a consecutive series of patients with acute severe colitis admitted to our department from 2000 to 2003. METHODS: Among 42 patients (38 with ulcerative colitis and 4 with Crohn's disease) admitted to our hospital for acute severe colitis, we performed proctoscopy and biopsy together with blood sample for cytomegalovirus determination at the time of admission, regardless of their steroid resistance. RESULTS: In the 42 patients, we discovered an overall cytomegalovirus infection prevalence of 21.4% (9/42) in our geographical area. In seven patients (16.6%), cytomegalovirus was detected through biopsy. The presence of cytomegalovirus in biopsies was not always predictive of steroid resistance. Three patients with cytomegalovirus in biopsies responded to conventional treatment without needing any antiviral treatment, which suggests that the virus plays only an incidental role. CONCLUSIONS: Cytomegalovirus is frequently associated with colitis but it is not always pathogenic. Studies on the genotyping of the virus might explain the diversity of its biological behaviour.

[Determination of endotoxemia by means of the Limulus test in patients with septicemia (author's transl)]. / Determinación de endotoxemia por el test del Limulus en enfermos septicémicos.

The Limulus test was applied to determine bacterial endotoxemia in 42 patients suspected of having septicemia. Hemocultures were practiced simultaneously. A comparative study is made of the two presently most commonly recommended tests for neutralizing the factors inhibiting the endotoxin-amebocyte reaction. According to our results the dilution of plasma in isotonic saline solution is preferable; we obtained a sensitivity of determination of 0.0001 micrograms of E. coli endotoxin per ml of plasm. Seventeen cases of bacteriemia were diagnosed, only one of which with sepsis due to Serratia marcescens responded positively to the limulus test. The test was positive in three of the remaining 25 patients. Two of them had liver failure. The basic role that liver failure plays in the high level of endotoxin in the blood is discussed. The prognostic value of this test and the low correlation between bacteremia and endotoxemia are also commented on

[Antibiotic sensitivity, serology and typing by pyocine in 154 cultures of Pseudomonas aeruginosa (author's transl)]. / Sensibilidad antibiótica, serología y piocinotipia de 154 aislamientos clínicos de Pseudomonas aeruginosa.

Pseudomonas infections continue to be an important problem in the hospital environment. Serious infections are always invariably associated with severe underlying conditions or with diminished host resistance. The increasingly resistance of strains and hospital epidemics favour the organism prevalence. During 1978, Pseudomonas aeruginosa was isolated in 154 cultures from a variety of biological samples in the hospital. Tests of biochemical identification, serological typing, and typing by pyocine production were carried out. Susceptibility to aminoglycosides and beta-lactamic antibiotics was also tested. Serological study demonstrated a higher incidence of 4 and 11 serotypes; 69.4 percent corresponded to type I when typing by pyocine production was carried out. No relationship between serotypes and pyocine-types has been found. Ticarcillin showed a greater activity than carbenicillin (minimal inhibitory concentration less than or equal to 16 micrograms/ml). Amikacin, tobramicin, sisomicin and gentamicin inhibited 83.7 percent, 73.6 percent, 70.7 percent and 69.4 percent of the isolated strains, respectively.

[Prevalence of mental subnormality recorded in the province of Jaen]. / Prevalencia de la subnormalidad mental censada en la provincia de Jaén.

It is done a cross-sectional study of the prevalence of mental retardation in the province of Jaén (Spain), based on the cumulated cases reported to the Institute of Social Services of the Social Security (INSERSO) until January 1, 1984. The main objective of this research is to know the prevalence of mental retardation in our province, and to analize its relationship with some sociodemographic variables. The prevalence obtained has been 4.09%, being a 59.27% of the prevalence due to endogenous/unexplained etiology. Mild subnormality constitutes a 8.4% of cases, being closely related with the size of the locality (municipio). Prevalence of mental subnormality showed a significative linear association with the size of the locality (r = -0.904, p less than 0.05), and with the population growth (r = -0.929, p less than 0.01). This relationship was not observed neither with the level of per capita income nor the altitude of the locality. A multiple regression analysis is made for every etiology of mental retardation and several social and geographic variables. We conclude that the figures for mental retardation in our province show a direct relationship with local development parameters.

[Treatment of acute a steroid-resistant ulcerative colitis with continuous venous infusion of cyclosporine]. / Trattamento dell'attacco acuto di colite ulcerosa steroido-resistente con ciclosporina in infusione venosa continua.

UNLABELLED: Aim of this open study is to evaluate the efficacy and safety of a low-dose treatment of continuous intravenous infusion of cyclosporine. We treated twelve patients with severe active ulcerative colitis, that did not respond to high doses of intravenous steroid for at least ten days. We used a dose of 2 mg/kg/day for 15 days. After this period, if patients improved, cyclosporine was administered orally at the dose of 6 mg/kg/day for six months. The response rate to acute phase therapy was 92.8%. The mean response time was 5.8 days. Sixty-nine percent of patients responded within the first week. No adverse reaction was observed. The first five patients responding to acute phase therapy relapsed during or at the end of maintenance phase. Because of that, azathioprine was associated in the successive patients. Only 4 out of 12 patients (33%) were operated on. CONCLUSIONS: continuous intravenous infusion of cyclosporine at dosage of 2 mg/kg/day is a highly effective and safe therapy that may avoid or defer colectomy to eligible conditions.

[Treatment with chimeric monoclonal antitumor necrosis factor (infliximab) of patients with active steroid-dependent/resistant Crohn's disease and fistulas]. / Il trattamento con anticorpi chimerici monoclonali antitumor necrosis factor (infliximab) in pazienti con malattia di Crohn attiva steroido-dipendente/resistente e con fistole.

30 patients--13 with active steroid-dependent/resistant Crohn's disease (CD), 8 with active steroid-dependent/resistant disease complicated by fistulas and 9 with fistulas only (perianal or abdominal)--were treated with infliximab. "Clinical response or remission" were defined as the reduction by 70 or more points or below 150 points of the CDAI score, respectively. As regards fistulas, "response" was defined as the reduction of 50 percent or more from baseline in the number of draining fistulas or of the quantity of drainage, "remission" as their closure. At 8 weeks 13/21 (61.9%) patients treated for active disease went on remission and 6/21 (28.5%) had a clinical response; 6/17 (35.2%) patients treated for fistulas went on remission and 8/17 (47%) had a response, while 3/17 (17.6%) didn't have any response. At 24 weeks, 9/12 (75%) patients treated for active disease and 13/16 (81.25%) treated for fistulas had a recurrence in a median time of 18.3 weeks (range, 1-36 weeks) after the first infusion.

Proteasome inhibition represses ERalpha gene expression in ER+ cells: a new link between proteasome activity and estrogen signaling in breast cancer.

Estrogen receptor-alpha (ERalpha) is a major therapeutic target of hormonal therapies in breast cancer, and its expression in tumors is predictive of clinical response. Protein levels of ERalpha are tightly controlled by the 26S proteasome; yet, how the clinical proteasome inhibitor, bortezomib, affects ERalpha regulation has not been studied. Bortezomib selectively inhibits the chymotrypsin-like activity of the proteasome. Unlike other laboratory proteasome inhibitors, bortezomib failed to stabilize ERalpha protein at a dose exceeding 90% inhibition of the chymotrypsin-like activity. Unexpectedly, however, chronic bortezomib exposure caused a reduction of ERalpha levels in multiple ER+ breast cancer cell lines. This response can be explained by the fact that bortezomib induced a dramatic decrease in ERalpha mRNA because of direct transcriptional inhibition and loss of RNA polymerase II recruitment on the ERalpha gene promoter. Bortezomib treatment resulted in promoter-specific changes in estrogen-induced gene transcription that related with occupancy of ERalpha and RNA polymerase II (PolII) on endogenous promoters. In addition, bortezomib inhibited estrogen-dependent growth in soft agar. These results reveal a novel link between proteasome activity and expression of ERalpha in breast cancer and uncover distinct roles of the chymotrypsin-like activity of the proteasome in the regulation of the ERalpha pathway.

Alignment of genetic maps and QTLs between inter- and intra-specific sorghum populations.

To increase the value of associated molecular tools and also to begin to explore the degree to which interspecific and intraspecific genetic variation in Sorghum is attributable to corresponding genetic loci, we have aligned genetic maps derived from two sorghum populations that share one common parent (Sorghum bicolor L. Moench accession BTx623) but differ in morphological and evolutionarily distant alternate parents (S. propinquum or S. bicolor accession IS3620C). A total of 106 well-distributed DNA markers provide for map alignment, revealing only six nominal differences in marker order that are readily explained by sampling variation or mapping of paralogous loci. We also report a total of 61 new QTLs detected from 17 traits in these crosses. Among eight corresponding traits (some new, some previously published) that could be directly compared between the two maps, QTLs for two (tiller height and tiller number) were found to correspond in a non-random manner (P<0.05). For several other traits, correspondence of subsets of QTLs narrowly missed statistical significance. In particular, several QTLs for leaf senescence were near loci previously mapped for 'stay-green' that have been implicated by others in drought tolerance. These data provide strong validation for the value of molecular tools developed in the interspecific cross for utilization in cultivated sorghum, and begin to separate QTLs that distinguish among Sorghum species from those that are informative within the cultigen (S. bicolor).

Incidence of Crohn's disease and CARD15 mutation in a small township in Sicily.

BACKGROUND: The incidence of Crohn's disease (CD) has been shown to be lower in Southern than in Northern Europe. Data on the frequency of the NOD2/CARD15 mutations for Mediterranean area are very scant. AIM: To determine the incidence of CD from 1979 to 2002 in a township in Sicily together with the allele frequency of NOD2/CARD15 mutations in patients, family members and controls, and to determine the allele frequency of these mutations in sporadic CD from other areas of Sicily in comparison with a control population. METHODS: Casteltermini is a small town close to Agrigento (Sicily) with a population of 9,130 inhabitants. All the diagnoses of inflammatory bowel disease (IBD) made from 1979 to 2002 were obtained through the local health authority. NOD2/CARD15 mutations were studied in 23 out of the 29 patients with CD in Casteltermini, in 60 family members and in 64 controls. NOD2/CARD15 was also studied in 80 sporadic cases of CD disease among Sicilians outside Casteltermini and 118 healthy controls. RESULTS: From 1979 to 2002, 29 patients with CD and 13 patients with ulcerative colitis (UC) were registered. The 6-year mean incidence of CD ranged from 8.0 to 17 new cases for every 100,000 inhabitants, whereas the mean incidence of UC ranged from five new cases to 7.8 for every 100,000 inhabitants. The allele frequencies of NOD2/CARD15 mutations (L1007finsC, G908R, R702W) were 8.7, 4.3 and 8.7%, respectively, in CD cases; 5.0, 4.2 and 3.1% in family members; 1.6, 2.3 and 3.1% in controls. In sporadic Sicilian CD patients outside Casteltermini the allele frequency was 7.5, 8.1, 6.2% whereas in control population it was 3.3, 1.6, 1.6%. CONCLUSIONS: A high incidence of CD compared with UC was observed in this small town in Southern Italy. The frequency of NOD2/CARD15 mutations in CD is similar to other Caucasian population studied so far.

Diversity and selection in sorghum: simultaneous analyses using simple sequence repeats.

Although molecular markers and DNA sequence data are now available for many crop species, our ability to identify genetic variation associated with functional or adaptive diversity is still limited. In this study, our aim was to quantify and characterize diversity in a panel of cultivated and wild sorghums (Sorghum bicolor), establish genetic relationships, and, simultaneously, identify selection signals that might be associated with sorghum domestication. We assayed 98 simple sequence repeat (SSR) loci distributed throughout the genome in a panel of 104 accessions comprising 73 landraces (i.e., cultivated lines) and 31 wild sorghums. Evaluation of SSR polymorphisms indicated that landraces retained 86% of the diversity observed in the wild sorghums. The landraces and wilds were moderately differentiated (F st=0.13), but there was little evidence of population differentiation among racial groups of cultivated sorghums (F st=0.06). Neighbor-joining analysis showed that wild sorghums generally formed a distinct group, and about half the landraces tended to cluster by race. Overall, bootstrap support was low, indicating a history of gene flow among the various cultivated types or recent common ancestry. Statistical methods (Ewens-Watterson test for allele excess, lnRH, and F st) for identifying genomic regions with patterns of variation consistent with selection gave significant results for 11 loci (approx. 15% of the SSRs used in the final analysis). Interestingly, seven of these loci mapped in or near genomic regions associated with domestication-related QTLs (i.e., shattering, seed weight, and rhizomatousness). We anticipate that such population genetics-based statistical approaches will be useful for re-evaluating extant SSR data for mining interesting genomic regions from germplasm collections.

RAPD analysis reveals genetic variability among sexual and Apomictic Paspalum dilatatum poiret biotypes.

Paspalum dilatatum is a valuable forage grass in the subtropics. This species consists of several sexual (tetraploid) and apomict (penta- and hexaploid) biotypes. It has been proposed that the presence of a genome of unknown origin, the X genome, is responsible for apomixis in penta- and hexaploid biotypes. Here we evaluated the utility of random amplified polymorphic DNA (RAPD) markers for discriminating sexual and apomictic P. dilatatum biotypes. DNA samples from nine accessions, including P. intermedium, P. juergensii, and P. dilatatum (ssp. flavescens, and the common and Uruguayan biotypes) were analyzed with 86 RAPD primers. Three hundred sixty-two fragments were scored and genetic similarity estimates revealed that the penta- and hexaploid biotypes were highly similar (S(D) > or = 0.913). Forty RAPDs were unique to the penta- and hexaploid biotypes. Overall RAPD markers were useful for assessing genetic variation among closely related P. dilatatum genotypes as well as generating putative X genome markers.

Laparoscopic Lymphadenectomy and Vaginal Radical Hysterectomy for the Treatment of Cervical Cancer

The choice of treatment (surgery, radiotherapy) for cervical carcinoma depends on surgical staging. The noninvasive approach for node evaluation is not very accurate; therefore lymph node metastasis has to be determined surgically. Seventeen women with cervical cancer underwent bilateral laparoscopic lymphadenectomy with dissection of the common iliac, hypogastric, and external iliac vessels and the obturator nerve. The average number of lymph nodes sampled was 14 (range 12-24 nodes). The mean duration of lymphadenectomy was 60 minutes (range 50-90 min). Based on preoperative evaluation and on the pathology report, a radical vaginal hysterectomy (Schauta-Amreich) was performed in all women at the end of laparoscopy. All laparoscopies and radical hysterectomies were uneventful. Based on this preliminary experience, laparoscopic lymphadenectomy may play an important role in reviving radical vaginal hysterectomy in women with cervical cancer. Followed by vaginal radical hysterectomy, it may be the treatment of choice in early disease, avoiding an abdominal incision.