Cell-free culture supernatant of Lactobacillus curvatus Wikim38 inhibits RANKL-induced osteoclast differentiation and ameliorates bone loss in ovariectomized mice.

This study was conducted to investigate the inhibitory effects of the cell-free culture supernatant of Lactobacillus curvatus Wikim 38 (LC38-CS) on RANKL-induced osteoclast differentiation and bone loss in a mice model of ovariectomy-induced post-menopausal osteoporosis. LC38-CS inhibited the RANKL-induced differentiation of bone marrow-derived macrophages (BMDMs) into osteoclasts in a dose-dependent manner. F-actin ring formation and bone resorption were also reduced by LC38-CS treatment of RANKL-treated BMDMs. In addition, LC38-CS decreased the RANKL-induced activation of the TRAF6/NF-κB/MAPKs axis at the early stage and the expression of osteoclastogenesis-related genes in BMDMs treated with RANKL. PRMT1 and ADMA levels, new biomarkers for osteoclastogenesis, were decreased by LC38-CS treatment. The administration of LC38-CS increased bone volume and bone mineral density in ovariectomized mice in µ-CT analysis. These findings suggest that LC38-CS inhibited RANKL-induced osteoclast differentiation by the downregulation of molecular mechanisms and exerted anti-osteoporotic effects.

Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial.

OBJECTIVES: Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia. METHODS: This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture. RESULTS: The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr). DISCUSSION: ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Copper toxicosis in New Zealand White rabbits (Oryctolagus cuniculus).

Six 12- to 14-month-old New Zealand White rabbits were diagnosed with copper toxicosis. These rabbits were part of a group of 110 purchased and shipped overnight for research purposes. On arrival, the group experienced an abrupt diet change. Eight died over 3 weeks and 6 were submitted for postmortem examination. Microscopic findings included severe centrilobular to midzonal hepatocellular necrosis with rhodanine stain-positive copper granules in the remaining hepatocytes. Mild periportal fibrosis and biliary hyperplasia, hemoglobinuric nephrosis, and splenic erythrophagocytosis were also observed. Hepatic copper concentrations were elevated, ranging from 319 to 997 ppm. Clinical disease was not previously observed in younger rabbits gradually transitioned from the supplier's copper-supplemented diet. Copper toxicosis likely occurred in these rabbits from a combination of (1) increased duration of copper supplementation leading to increased hepatocellular stores and (2) stress leading to anorexia and release of hepatocellular copper stores similar to chronic copper toxicosis as described in sheep.

Radiological response predicts survival following transarterial chemoembolisation in patients with unresectable hepatocellular carcinoma.

BACKGROUND: It remains unclear whether initial compact lipiodol uptake after transarterial chemoembolisation (TACE) is associated with improved survival in patients with hepatocellular carcinoma (HCC). AIM: To reveal the clinical relevance of compact lipiodolisation after TACE. METHODS: We studied 490 patients with unresectable HCC who had first been treated with TACE. Compact lipiodolisation was defined as the absence of an arterial enhancing lesion, reflecting complete lipiodol uptake, as assessed by dynamic computed tomography (CT) 1 month after treatment. The rate of initial compact lipiodolisation was analysed according to multiplicity and size of tumour, and survival of patients who achieved compact lipiodolisation was compared to that of patients who did not. RESULTS: Of the 490 patients, 409 (83.5%) were in Child-Pugh class A and 81 (16.5%) in class B. The rate of initial compact lipiodolisation in single HCCs was higher than that in multinodular HCCs (33.7% vs. 14.6%, P < 0.001). Among single HCCs, the rate of compact lipiodolisation in tumours ≤5, 5-10 and >10 cm was 46.6%, 13.6%, and 0% respectively. The 1-, 3- and 5-year survival rates of patients with compact uptake were 92.7%, 70.7% and 52.4% compared to 60.8%, 28.0% and 16.9% in patients with noncompact lipiodolisation. Multivariate analysis revealed that Child-Pugh class, alpha-fetoprotein level, tumour node metastasis stage, portal vein thrombosis and initial compact lipiodolisation were independent predictors of survival. CONCLUSIONS: Initial compact lipiodol uptake after transarterial chemoembolisation is associated with improved survival in patients with unresectable hepatocellular carcinoma. Accordingly, initial complete lipiodolisation should be considered a relevant therapeutic target.

Short-term teriparatide therapy as an adjunctive modality for bisphosphonate-related osteonecrosis of the jaws.

UNLABELLED: To review the effect of teriparatide as an adjunctive modality for bisphosphonate-related osteonecrosis of the jaws (BRONJ), we describe a series of cases of teriparatide therapy for the treatment of BRONJ and serial changes of serum osteoclacin (s-OC) and serum C-terminal telopeptide cross-link of type I collagen (s-CTX). INTRODUCTION: Management of BRONJ is quite challenging and the currently recommended modalities for BRONJ are still suboptimal. For the improvement of bony remodeling, some clinicians advocated bisphosphonate holiday although validity of this drug holiday has been debated so far. Recently, the use of teriparatide was introduced in several cases, but the number of the publication is limited and mostly anecdotal so far. METHOD: Bisphosphonate was suspended and teriparatide was given to six patients diagnosed with BRONJ by single bone specialist. Medical record review and interviews were carried out. S-CTX and s-OC were measured at the baseline, 2 months and 3 months later teriparatide therapy. The outcome of the treatment and the change of biochemical markers were compared. RESULT: In all six patients, s-OC values were significantly elevated within 2 months after teriparatide treatment and the BRONJ lesions were healed. S-CTX values were also elevated in four patients, whereas those of the rest two patients stayed within minimal change. The change was marginally significant at 3 months. CONCLUSION: In terms of the multifactorial etiology of BRONJ, bone formation suppression was noticed in the patients. Based upon this finding, the short-term use of teriparatide might be beneficial to the resolution of BRONJ lesions by improving suppressed bone remodeling.

Assessing cancer treatment related information online: unintended retrieval of complementary and alternative medicine web sites.

The aims of this study were to determine the number of Complementary and Alternative Medicine (CAM) web sites retrieved form Korean search engines, and to evaluate the quality of online CAM content. We evaluated results retrieved by the use of the key word 'anticancer treatment' on six common search engines in Korea. Among a total of 651 web sites, 226 web sites (35%) related to CAM were identified. The quality and risk of these sites were assessed for 97 web sites after removing duplicate and dysfunctional web sites. We evaluated the quality of the sites using Sandvik score. Scores in this study varied between 5 and 12 points, with a maximum of 14 points. We categorized the risk score for each web site based on the following criteria: (1) the site discourages the use of conventional medicine (23%: 22/97); (2) the site discourages adherence to the advice of a clinician (15%:15/97); (3) the site either provides opinions and experiences, or factual details (26%: 25/97); and (4) the site provides commercial details (46%: 45/97). The most popular web sites in Korea that relate to CAM for cancer offer information of extremely variable quality. Clinicians should be aware of the risks of inaccurate online information and attempt to protect their patients from those.

Pre-operative chemo-radiotherapy improves the sphincter preservation rate in patients with rectal cancer located within 3 cm of the anal verge.

AIMS: To evaluate whether pre-operative chemo-radiotherapy (CRT) improves the sphincter preservation rate for distal rectal cancers within 3 cm of the anal verge. METHODS: Between January 2001 and December 2004, 49 patients underwent surgery with or without pre-operative CRT for primary rectal adenocarcinoma within 3 cm of the anal verge. Clinical data were retrospectively reviewed, including stage workups, surgical records and pathology records to determine sphincter preservation rate and the factors influencing sphincter preservation. RESULTS: Of 49 patients with rectal tumours within 3 cm of the anal verge, 31 underwent pre-operative CRT followed by surgery (CRT group), and 18 underwent surgery alone (non-CRT group). Sphincter preservation was possible in 11 of 31 CRT patients, and only one of 18 non-CRT patients (p=0.036). The factors most influencing sphincter preservation were reduction in tumour size (p=0.005) and downstaging (p=0.001) following pre-operative CRT. CONCLUSION: We could observe that sphincter preservation was improved in CRT group with statistical significance when compared to non-CRT group in our study patients with rectal cancer within 3 cm of the anal verge.

Anti-protozoal efficacy of high performance liquid chromatography fractions of Torilis japonica and Sophora flavescens extracts on Neospora caninum and Toxoplasma gondii.

We previously reported that alcoholic extracts of Sophora flavescens and Torilis japonica from South Korea demonstrated good efficacy in reducing replication of Toxoplasma gondii and Neospora caninum. To characterize the chemical component associated with anti-protozoal activity, specific fractions were isolated by high performance liquid chromatography (HPLC) and used for in vitro testing. These fractions were evaluated in vitro against T. gondii and N. caninum. Fractions of the herb extracts were serially diluted to final concentrations of 2.850 to 0.356 ng/ml in medium and added to wells containing replicating T. gondii and N. caninum. To determine the ability of each fraction to inhibit parasite proliferation, 3H-uracil incorporation was used to determine parasite replication. In cultures infected with T. gondii, a fraction of T. japonica (TJ2) inhibited T. gondii proliferation by 99.2, 94.4, 88.6 and 27.0% in the range from 2.850 to 0.356 ng/ml. Four fractions of S. flavescens (SF1-SF4) inhibited T. gondii proliferation by 99.6-60.6, 96.9-48.1, 92.3-68.2 and 95.4-52.9% in the range from 2.850 to 0.356 ng/ml. In cultures infected with N. caninum, a fraction of T. japonica (TJ2) inhibited N. caninum proliferation by 98.3, 95.5, 79.7 and 30.6% in the range from 2.850 to 0.356 ng/ml. Four fractions of S. flavescens (SF1-SF4) inhibited N. caninum proliferation by 97.1-25.9, 94.8-35.5, 95.9-33.7 and 95.4-49.4% in the range from 2.850 to 0.356 ng/ml. These fractions of T. japonica and S. flavescens extracts are currently undergoing in vivo evaluation in experimentally infected mice.

Patterns of failure in gastric carcinoma after D2 gastrectomy and chemoradiotherapy: a radiation oncologist's view.

The risk of locoregional recurrence in resected gastric adenocarcinoma is high, but the benefit of adjuvant treatment remains controversial. In particular, after extended lymph node dissection, the role of radiotherapy is questionable. Since 1995, we started a clinical protocol of adjuvant chemoradiotherapy after D2 gastrectomy and analysed the patterns of failure for 291 patients. Adjuvant chemotherapy consisted of five cycles of fluorouracil and leucovorin, and concurrent radiotherapy was given with 4500 cGy from the second cycle of chemotherapy. With a median follow-up of 48 months, 114 patients (39%) showed any type of failure, and the local and regional failures were seen in 7% (20 out of 291) and 12% (35 out of 291), respectively. When the recurrent site was analysed with respect to the radiation field, in-field recurrence was 16% and represented 35% of all recurrences. Our results suggest that adjuvant chemoradiotherapy has a potential effect on reducing locoregional recurrence. Moreover, low locoregional recurrence rates could give a clue as to which subset of patients could be helped by radiotherapy after D2 gastrectomy. However, in order to draw a conclusion on the role of adjuvant radiotherapy, a randomised study is needed.

Anti-protozoal efficacy of medicinal herb extracts against Toxoplasma gondii and Neospora caninum.

The purpose of this study was to determine whether alcohol extracts of herbs (Sophora flavescens Aiton, Sinomenium acutum (Thunb.) Rehder and E.H. Wilson, Pulsatilla koreana (Yabe ex Nakai) Nakai ex T. Mori, Ulmus macrocarpa Hance and Torilis japonica (Houtt.) DC.) from South Korea, possess in vitro anti-protozoal activity against cultures of Toxoplasma gondii and Neospora caninum. These herbs have been used as human anti-parasitics in Asian countries for many years. Alcohol extracts of these herbs were serially diluted to final concentrations ranging from 625 to 19.5 ng/ml in media and added to wells containing either T. gondii or N. caninum tachyzoites in equine dermal (ED) cells. Parasite growth inhibition was measured using 3H-uracil incorporation as compared to untreated controls. T. japonica inhibited T. gondii proliferation by 99.3, 95.5, 73.0 and 54.0% in the range from 156 to 19.5 ng/ml, and S. flavescens inhibited T. gondii proliferation by 98.7, 83.0 and 27.2% in the range from 156 to 39 ng/ml. T. japonica inhibited N. caninum proliferation by 97.8, 97.9, 85.3 and 46.4% in the range from 156 to 19.5 ng/ml. S. flavescens inhibited N. caninum proliferation by 98.6, 97.0, 69.5 and 14.0% in the range from 156 to 19.5 ng/ml. Toxicity to host cells was noted when concentrations of T. japonica and S. flavescens exceeded 625 ng/ml. The herb extracts from S. acutum, Pulsatilla koreana, and U. macrocarpa also showed toxicity at higher levels but did not achieve the same inhibition effects at the lower concentrations against T. gondii and N. caninum as T. japonica and S. flavescens.

Postoperative chemoradiotherapy for gastric cancer.

BACKGROUND: We report the results of postoperative chemoradiotherapy after curative resection in gastric cancer patients. PATIENTS AND METHODS: Patients with gastric cancer staged IB to IV(M0) were treated with chemoradiotherapy after curative resection with extensive (D2) lymph node dissection. Nodal metastases were observed in 261 (90%) patients. The chemotherapy consisted of fluorouracil 400 mg/m(2) plus leucovorin 20 mg/m(2) for 5 days, followed by 4500 cGy of radiotherapy for 5 weeks with fluorouracil and leucovorin on the first 4 days and the last 3 days of radiotherapy. Two 5-day cycles of chemotherapy were given 4 weeks after the completion of radiotherapy. RESULTS: Of 290 patients accrued, 229 (79%) patients completed chemoradiotherapy as planned. With a median follow-up of 49 months, 114 (34%) patients have relapsed: 33 (29%) locoregional relapses, 76 (67%) peritoneal relapses and 41 (36%) distant metastases. The 5-year overall and relapse-free survivals were 60% and 57%, respectively. Tolerance was acceptable, the main toxicity being neutropenia. CONCLUSIONS: This postoperative chemoradiotherapy after curative resection of gastric cancer was feasible, with acceptable toxicities. Whether this adjuvant therapy in gastric cancer patients that have undergone a D2 lymph node dissection impacts on survival or reduces the incidence of relapses remains to be studied.

The cerebrovascular response to traditional acupuncture after stroke.

Acupuncture is useful in treating the nausea and vomiting related to chemotherapy, adult postoperative surgery pain and postoperative dental pain. We obtained single-photon emission computed tomography (SPECT) brain perfusion images of six patients with middle cerebral artery occlusion obtained before and after acupuncture and compared the changes in regional cerebral blood flow (rCBF) to those in normal control. Images were obtained before and after acupuncture at six traditional acupoints (LI 4, 10, 11, 15 and 16 and TE5) in the affected arm. The baseline image was subtracted from the postacupuncture image, to produce a subtraction image displaying only voxels with values >2 SD from the mean and those voxels were coregistered to the baseline SPECT or T2-weighted MRI. Similar images were obtained before and after acupuncture of eight normal volunteers. Statistical parametric mapping with a threshold of P =0.001 and a corrected P of 0.05 was performed for group comparison between postacupuncture and baseline SPECT. Focally increased CBF was seen in all patients especially in the hypoperfused zone surrounding the ischaemic lesion, the ipsilateral or contralateral sensorimotor area, or both. Normal subjects showed increased rCBF mainly in the parahippocampal gyrus, premotor area, frontal and temporal areas bilaterally and ipsilateral globus pallidus. Acupuncture stimulation after stroke patients appears to activate perilesional or use-dependent reorganised sites and might be a way of looking at brain reorganisation.

Effects of SKI 306X, a new herbal agent, on proteoglycan degradation in cartilage explant culture and collagenase-induced rabbit osteoarthritis model.

OBJECTIVE: Protective effects of SKI 306X, a natural herbal product extracted from three herbs Clematis mandshurica, Trichosanthes kirilowii, and Prunella vulgaris, on articular cartilage was examined and compared with other osteoarthritis (OA) drugs using in vitro and in vivo models. METHODS: In vitro culture of rabbit articular cartilage explants was used as a model to measure the effects of drugs on the matrix degradation. The recombinant human interleukin-1alpha (rhIL-1alpha, 5 ng/ml) was added to induce proteoglycan (PG) degradation and the degree of PG degradation was assessed by measuring the amount of glycosaminoglycan (GAG) released into the culture medium. In in vivo experiment, collagenase was intraarticularly injected twice into the right knee joint of rabbits to induce OA-like change, and test agents were orally administered once a day for 28 days. The degrees of OA-like changes were evaluated through a histological examination. RESULTS: In vitro study revealed SKI 306X inhibited the degradation of PG in a concentration-dependent manner. Trichosanthes kirilowii, which is one of the major components of SKI 306X, also significantly inhibited the GAG release in cartilage explant culture at 0.3 and 0.1 mg/ml. Dexamethasone and NSAIDs, such as diclofenac and rofecoxib, had no significant effects on the suppression of PG degradation. In in vivo studies, OA-like degeneration of the articular cartilage and synovial tissue was induced by injecting collagenase into the right knee joint of mature rabbits. At a dose of 200 mg/kg, SKI 306X reduced the OA-like histological changes, whereas diclofenac had no effect at 10 mg/kg. CONCLUSION: These results indicate that SKI 306X inhibited PG degradation in cartilage explant culture, and its prophylactic administration significantly protected the knee joint of rabbit from OA-like change in collagenase-induced experimental OA model. This strongly suggests that SKI 306X can be a good OA agent with some cartilage protection activity.

Dietary hematein ameliorates fatty streak lesions in the rabbit by the possible mechanism of reducing VCAM-1 and MCP-1 expression.

Hematein is a compound isolated from Caesalpinia sappan that has been used in oriental medicine as both an analgesic and an anti-inflammatory agent. In this study, we examined the anti-atherogenic potential of hematein using cholesterol-fed New Zealand White (NZW) rabbits. NZW rabbits were divided into a hematein-supplemented (0.05% in diet) group (n=6), a probucol-supplemented (0.25% in diet) group (n=6), and a control group (n=6). After 8 weeks of treatments, the extent of the atherosclerotic lesions was significantly reduced in the hematein-supplemented group and the probucol-supplemented group without changing plasma lipoprotein levels. Hematein and probucol prevented the up-regulation of the vascular cell adhesion molecule-1 (VCAM-1) expression on the descending aorta induced by cholesterol diet. In culture, hematein also significantly inhibited the secretion of soluble VCAM-1 and of monocyte chemotactic protein-1 (MCP-1) respectively induced by tumor necrotic factor alpha (TNF-alpha) and mildly oxidized low density lipoprotein in human umbilical vein endothelial cell (HUVEC) culture. Also, hematein inhibited monocyte adhesion to endothelial cell and the activation of NF-kappaB in HUVECs stimulated with TNF-alpha. The results of the present study suggest that the anti-atherogenic effect of hematein is not related to control of the plasma lipid profile but probably related to the inhibition of VCAM-1 and MCP-1 expression resulting in an amelioration of lesion development in the rabbit.

Substance p plays a critical role in photic resetting of the circadian pacemaker in the rat hypothalamus.

Glutamate is considered to be the primary neurotransmitter in the retinohypothalamic tract (RHT), which delivers photic information from the retina to the suprachiasmatic nucleus (SCN), the locus of the mammalian circadian pacemaker. However, substance P (SP) also has been suggested to play a role in retinohypothalamic transmission. In this study, we sought evidence that SP from the RHT contributes to photic resetting of the circadian pacemaker and further explored the possible interaction of SP with glutamate in this process. In rat hypothalamic slices cut parasagittally, electrical stimulation of the optic nerve in early and late subjective night produced a phase delay (2.4 +/- 0.5 hr; mean +/- SEM) and advance (2.6 +/- 0.3 hr) of the circadian rhythm of SCN neuronal firing activity, respectively. The SP antagonist L-703,606 (10 microm) applied to the slices during the nerve stimulation completely blocked the phase shifts. Likewise, a cocktail of NMDA (2-amino-5-phosphonopentanoic acid, 50 microm) and non-NMDA (6,7-dinitroquinoxaline-2,3-dione, 10 microm) antagonists completely blocked the shifts. Exogenous application of SP (1 microm) or glutamate (100 microm) to the slices in early subjective night produced a phase delay ( approximately 3 hr) of the circadian firing activity rhythm of SCN neurons. Coapplication of the NMDA and non-NMDA antagonist cocktail (as well as L-703,606) resulted in a complete blockade of the SP-induced phase delay, whereas L-703,606 (10 microm) had no effect on the glutamate-induced delay. These results suggest that SP, as well as glutamate, has a critical role in photic resetting. Furthermore, the results suggest that the two agonists act in series, SP working upstream of glutamate.

Effect of hyperbaric oxygen on survival of the composite ear graft in rats.

In this study the authors set out to determine whether postoperative hyperbaric oxygen (HBO) therapy increases the survival rate of the composite graft in the rat ear model. A composite graft (1 x 0.5 cm2) that included skin, subcutaneous tissue, and cartilage was created from the left ear, and was transferred onto the posterior auricular site of the right ear. The animals were divided into two groups: a control group (N = 10) and an experimental group receiving HBO (N = 10). The experimental group was given HBO immediately following reattachment for 4 hours, and then for 6 hours each day for 5 days (2 atm). The results showed the average ear flap survival area in the experimental group was 82%, and it was 26.5% in the control group (p < 0.01). Histology demonstrated the existence of neovascularization in the experimental group. We have concluded that postoperative HBO therapy increases the survival of the rat ear composite graft, and that the effect of this therapy is influenced by the magnitude (size and thickness) of the graft.

Stimulatory effects of high-fat diets on colon cell proliferation depend on the type of dietary fat and site of the colon.

To compare the effects of various types of dietary fat on colon cell proliferation used as an intermediate biomarker for colon carcinogenesis, groups of 10 male Sprague-Dawley rats were fed one of four high-fat diets (45% of total calories from corn oil, butter, beef tallow, and fish oil) for three weeks. As a control, a low-fat diet (15% of total calories from corn oil) was fed to a separate group. Cell proliferation was measured by in vivo incorporation of bromodeoxyuridine into DNA in the proximal and distal colon. Total lipids in feces were measured by a gravimetric method. There were significant differences in colon cell proliferation among the diet groups, where the high corn oil diet stimulated cell proliferation in proximal and distal colon compared with the high fish oil diet (p < 0.05). The protective effect of the high fish oil diet on cell proliferation was similar to that of the low corn oil diet. The effects of high beef tallow and butter diets on colon cell proliferation were highly dependent on sites of the colon, because the hyperproliferative effects by these diets were found only in the distal colon (p < 0.05). Fecal total lipids and fecal lipid concentrations were significantly affected by the dietary fat sources, in that the groups fed the saturated fats, such as butter and beef tallow, excreted more lipids into feces than did the groups fed the unsaturated fats, such as corn oil and fish oil. Fecal lipids were significantly correlated to colon cell proliferation in the way that distal colon cell proliferation increases as fecal lipids increase. Therefore, these data suggest that high levels of dietary fats may not always promote colon carcinogenesis, and the effects may be dependent on the types of dietary fat and sites of the colon.