Effect of temperature manipulation during incubation on body weight, plasma parameters, muscle histology, and expression of myogenic genes in breast muscle of embryos and broiler chickens from two commercial strains.

1. This study evaluated the effect of a higher incubation temperature on body weight, plasma profile, histology and expression of myogenin (MYOG), insulin-like growth factor-I (IGF-I) and vascular endothelial growth factor A (VEGFA) genes in breast muscle of embryos and broilers from two commercial strains.2. A total of 784 eggs from Ross 308 and Cobb 500 broiler breeder flocks were used. Half of the eggs per strain were incubated at control temperature (37.8°C), whereas the other half were exposed to heat treatment (HT) of 38.8°C between embryonic day (ED) 10 and 14, for 6 h/day. Embryos and chicks were sampled on ED 19 and at hatch. A total of 480, one-day-old chicks per strain and incubation temperature were reared up to 42 d post-hatch.3. The HT increased hatch weight of Ross chicks and 42-d body weight of broilers from both strains. Lower plasma triacylglycerol levels were measured for HT embryos and broilers on ED 19 and 42 d post-hatch, respectively. HT reduced plasma T3 levels in Ross embryos and broilers for the same periods. Hepatic TBARS concentrations were elevated by HT compared to the control incubation.4. The HT reduced breast muscle VEGFA gene expression of Cobb embryos on ED 19, whereas expression was stimulated in day-old chicks. At 42 d post-hatch, fibre area was increased by HT regardless of strain. Compared to the control incubation, HT increased the breast yield of Ross broilers and leg yield of Cobb. Ross-HT broilers had a higher pH at 24 h after slaughter and better water holding capacity than Cobb-HT broilers.5. These results suggested that HT increased body weight, fibre area, IGF-I gene expression and lowered plasma triacylglycerol levels of broiler chickens from both strains at 42 d. However, HT influenced the expression of VEGF-A and MYOG genes and meat quality differently between the broiler strains.

Decreased mRNA and protein stability of W1282X limits response to modulator therapy.

BACKGROUND: Cell-based studies have shown that W1282X generates a truncated protein that can be functionally augmented by modulators. However, modulator treatment of primary cells from individuals who carry two copies of W1282X generates no functional CFTR. To understand the lack of response to modulators, we investigated the effect of W1282X on CFTR RNA transcript levels. METHODS: qRT-PCR and RNA-seq were performed on primary nasal epithelial (NE) cells of a previously studied individual who is homozygous for W1282X, her carrier parents and control individuals without nonsense variants in CFTR. RESULTS: CFTR RNA bearing W1282X in NE cells shows a steady-state level of 4.2 ±â€¯0.9% of wild-type (WT) CFTR RNA in the mother and 12.4 ±â€¯1.3% in the father. NMDI14, an inhibitor of nonsense-mediated mRNA decay (NMD), restored W1282X mRNA to almost 50% of WT levels in the parental NE cells. RNA-seq of the NE cells homozygous for W1282X showed that CFTR transcript level was reduced to 1.7% of WT (p-value: 4.6e-3). Negligible truncated CFTR protein was generated by Flp-In 293 cells stably expressing the W1282X EMG even though CFTR transcript was well above levels observed in the parents and proband. Finally, we demonstrated that NMD inhibition improved the stability and response to correctors of W1282X-CFTR protein expressed in the Flp-In-293 cells. CONCLUSION: These results show that W1282X can cause substantial degradation of CFTR mRNA that has to be addressed before efforts aimed at augmenting CFTR protein function can be effective.

Acromegaly is associated with high fibroblast growth factor-21 levels.

PURPOSE: Fibroblast growth factor-21 (FGF-21) is a member of fibroblast growth factor family. Both growth hormone (GH) and FGF-21 take place in the regulation of glucose and lipid metabolism. We aimed to investigate FGF-21 levels in acromegaly which is characterized by excess GH levels and is associated with comorbidities and altered body composition. METHODS: We studied 43 subjects (21 females and 22 males, mean age of 50.0 ± 12.8) with acromegaly. The control group consisted of 40 gender- and age-matched subjects (25 females and 15 males, mean age of 48.8 ± 8.8). Acromegaly patients were classified into two groups; active acromegaly (AA; n = 26) and controlled acromegaly (CA; n = 17). Metabolic, anthropometric and laboratory values of subjects were recorded. FGF-21 level was measured by ELISA assay. RESULTS: Median FGF-21 levels were significantly higher in acromegaly group compared to control group (85.5 vs. 59.0 pg/mL, p = 0.02, respectively). In the multiple regression model, FPG, A1c, HOMA-IR, glucose intolerance, BMI, visceral fat, hs-CRP, presence of hypertension, dyslipidemia and acromegaly were included as independent variables to explain variability of plasma FGF-21 levels in whole study group. The presence of acromegaly was the only determinant of increased FGF-21 levels in the whole study group (ß coefficient = 0.253, p = 0.006). CONCLUSION: FGF-21 levels were increased significantly in acromegaly group. Increased FGF-21 levels were significantly and independently associated with the state of acromegaly. Acromegaly may also be a FGF-21 resistance state independent from insulin resistance, glucose intolerance, obesity, hypertension and dyslipidemia.

Circulating insulin-like peptide 5 levels and its association with metabolic and hormonal parameters in women with polycystic ovary syndrome.

PURPOSE: Insulin-like peptide 5 (INSL5) is a gut peptide hormone that is a member of relaxin/insulin superfamily. Growing evidence implicates the crucial role of the peptide in some metabolisms including food intake, glucose homeostasis and reproductive system. Polycystic ovary syndrome (PCOS) is involved in both reproductive and metabolic issues. The aim of the study was determination of circulating levels of INSL5 alteration in women with PCOS and evaluation of the relationship between INSL5 and hormonal-metabolic parameters as well as carotid intima media thickness (cIMT). METHODS: A total of 164 subjects were recruited in this cross-sectional study (82 women with PCOS and 82 age- and BMI-matched controls). Circulating INSL5 levels were assessed via ELISA method. High-resolution B-mode ultrasound was used to measure cIMT. The hormonal and metabolic parameters of the recruited subjects were determined. RESULTS: Circulating INSL5 levels were significantly elevated in women with PCOS compared to controls (27.63 ± 7.74 vs. 19.90 ± 5.85 ng/ml, P < 0.001). The mean values of INSL5 were significantly higher in overweight subjects compared to lean weight subjects in both groups. The women with PCOS having insulin resistance have increased INSL5 compared to those of PCOS subjects without insulin resistance. INSL5 is associated with insulin resistance, BMI, luteinizing hormone and free androgen index. Multivariate logistic regression analyses revealed that the odds ratio for having PCOS in the highest tertile of INSL5 was higher than in the lowest tertile. CONCLUSIONS: PCOS subjects exhibited an elevation in circulating INSL5 levels along with a link between INSL5 level induction and metabolic-hormonal parameters.

Exposure of embryos to cyclically cold incubation temperatures durably affects energy metabolism and antioxidant pathways in broiler chickens.

Cyclically cold incubation temperatures have been suggested as a means to improve resistance of broiler chickens to ascites; however, the underlying mechanisms are not known. Nine hundred eggs obtained from 48 wk Ross broiler breeders were randomly assigned to 2 incubation treatments: control I eggs were incubated at 37.6°C throughout, whereas for cold I eggs the incubation temperature was reduced by 1°C for 6 h daily from 10 to 18 d of incubation. Thereafter, chickens were reared at standard temperatures or under cold exposure that was associated or not with a postnatal cold acclimation at d 5 posthatch. At hatch, hepatic catalase activity and malondialdehyde content were measured. Serum thyroid hormone and triglyceride concentrations, and muscle expression of several genes involved in the regulation of energy metabolism and oxidative stress were also measured at hatch and 5 and 25 d posthatch. Cold incubation induced modifications in antioxidant pathways with higher catalase activity, but lower expression of avian uncoupling protein 3 at hatch. However, long-term enhancement in the expression of avian uncoupling protein 3 was observed, probably caused by an increase in the expression of the transcription factor peroxisome proliferator activated receptor-γ coactivator-1α. These effects were not systematically associated with an increase in serum triiodothyronine concentrations that were observed only in chickens exposed to both cold incubation and later acclimation at 5 d with cold rearing. Our results suggest that these conditions of cyclically cold incubation resulted in the long-term in changes in antioxidant pathways and energy metabolism, which could enhance the health of chickens reared under cold conditions.

Effect of manipulation of incubation temperature on fatty acid profiles and antioxidant enzyme activities in meat-type chicken embryos.

Eggs (n = 1,800) obtained from Ross broiler breeders at 32 and 48 wk of age were incubated at either a constant temperature of 37.6°C throughout (T1), or the temperature was reduced for 6 h to 36.6°C each day during embryonic age (EA) 10 to 18 (T2). Yolk sac, liver, and brain fatty acid profiles and oxidant and antioxidant status of liver and brain were measured at EA 14, 19, and day of hatch (DOH). Fatty acid profiles of yolk sac, liver, and brain were influenced by age of breeder with significant breeder hen age × incubation temperature interactions. At EA 14, higher levels of 20:4n-6 and 22:6n-3 had been transferred from the yolk sac to T2 embryos from younger than older breeders, whereas for T1 and T2 embryos, yolk sac 20:4n-6 and 22.6n-3 values were similar for older breeders. Accumulation of 20:4n-6 and 22:6n-3 fatty acids in the liver of T1 and T2 embryos from younger breeders was similar; however, T2 embryos from older breeders had higher liver levels of 20:4n-6 and 22:6n-3 than T1 embryos. At EA 19, liver nitric oxide levels were higher for T2 embryos from younger breeders than those from breeders incubated at T1. Brain catalase levels of T2 embryos from younger breeders were higher than those from older breeders at DOH. Thus, changes in fatty acid profiles and catalase and nitric oxide production of brain and liver tissues resulting from 1°C lower incubation temperature from EA 10 to 18 reflect adaptive changes.

Brooding temperatures for chicks acclimated to heat during incubation: effects on post-hatch intestinal development and body weight under heat stress.

1. The objective was to evaluate the effects of brooding temperature on intestinal development, oxidative organ damage, and performance of chicks acclimated to high temperature during incubation. The effects of acclimation and brooding temperatures on slaughter weights of broilers under heat stress were also investigated. 2. Eggs were incubated at either 378 degrees C (INC(Cont)) or heat-acclimated at 395 degrees C for 6 h daily from d 10 to d 18 of incubation (INC(H)). Brooding temperatures at floor level were set at 32, 335 and 35 degrees C (Bt(32), Bt(335), Bt(35), respectively) for the first 5 d. The temperature was reduced gradually to 30 degrees C from d 6 to d 10. From 21 to 42 d, broilers from INC(Cont) Bt(32) and INC(H) Bt(32) and Bt(35) were divided into two groups; half from each group was exposed to daily cyclic higher ambient temperatures, while the other half was reared at control temperature. 3. INC(H) chicks had lower jejunum, but greater liver and residual yolk sac weights than INC(Cont) chicks on the day of hatching. Although INC(H) chicks from Bt(335) and Bt(35) had lighter body weights than Bt(32) on d 5, no significant differences were observed in the body weight of broilers among treatments at 10 and 21 d. 4. Similar jejunum protein, alkaline phosphatase, maltase, glutathione, and malondialdehyde contents of chicks from INC(Cont) and INC(H) suggested that heat acclimation during incubation has no effect on jejunum enzyme activity or oxidative status of chicks. 5. Taking into account INC(H) Bt(35) chicks having lower T(3) levels on d 5, lower heterophil/lymphocyte (H/L) ratios and similar weights at 42 d under heat stress compared with control broilers, the results suggested that although higher brooding temperatures had no effect on body weights of INC(H) chicks during the brooding period, those broilers may able to cope better with heat stress.

Low-mannose-binding lectin levels in susceptibility to neonatal sepsis in preterm neonates with fetal inflammatory response syndrome.

AIM: In this study, we aimed to evaluate cord blood mannose binding levels (MBL), to evaluate possible relationship between cord blood MBL levels with neonatal sepsis and culture confirmed neonatal sepsis in preterm newborn with gestational age below 34 weeks with fetal inflammatory response syndrome (FIRS). METHODS: Forty-four randomly selected < or =34 weeks gestational age newborns with FIRS were evaluated. MBL deficiency was described as cord blood levels were below 400 ng/ml. RESULTS: Mean value of umbilical cord MBL was significantly lower in newborns with culture confirmed sepsis (p < 0.01) and also all cases with sepsis (including culture negative or positive) (p < 0.05) than newborns without sepsis. Culture-confirmed sepsis was statistically common in MBL deficient premature newborns with FIRS. Univariate analysis showed that gestational age, birth weight, low serum MBL level and poor obstetric history were all significantly associated with the risk of neonatal sepsis. A subsequent multivariate analysis showed that the association between serum MBL level and the risk of suspected sepsis and culture confirmed sepsis independently from gestational age and birth weight. CONCLUSION: Here in, we report firstly lower MBL levels were found related with sepsis in neonates, especially in newborns with culture proven sepsis. Low MBL levels may help to identify neonates with FIRS at high risk of developing sepsis.

Serum amyloid A, procalcitonin, tumor necrosis factor-alpha, and interleukin-1beta levels in neonatal late-onset sepsis.

BACKGROUND: Sepsis is an important cause of mortality in newborns. However, a single reliable marker is not available for the diagnosis of neonatal late-onset sepsis (NLS). The aim of this study is to evaluate the value of serum amyloid A (SAA) and procalcitonin (PCT) in the diagnosis and follow-up of NLS. METHODS: 36 septic and healthy newborns were included in the study. However, SAA, PCT, TNF-alpha, IL-1beta, and CRP were serially measured on days 0, 4, and 8 in the patients and once in the controls. Töllner's sepsis score (TSS) was calculated for each patient. RESULTS: CRP, PCT, and TNF-alpha levels in septic neonates at each study day were significantly higher than in the controls (P = .001). SAA and IL-1beta levels did not differ from healthy neonates. The sensitivity and specificity were 86.8% and 97.2% for PCT, 83.3% and 80.6% for TNF-alpha, 75% and 44.4% for SAA on day 0. CONCLUSION: Present study suggests that CRP seems to be the most helpful indicator and PCT and TNF-alpha may be useful markers for the early diagnosis of NLS. However, SAA, IL-1beta, and TSS are not reliable markers for the diagnosis and follow-up of NLS.

Clinical and laboratory findings of two newborns with Wiedemann-Rautenstrauch syndrome: additional features, evaluation of bone turnover and review of the literature.

Wiedemann-Rautenstrauch syndrome (WRS) is a rare autosomal recessive condition which represents a complex of symptoms and laboratory findings with unknown cause and pathogenesis. Approximately 30 patients with WRS have been reported. We report here two newborns with WRS from Turkey with clinical and laboratory findings including bone marker evaluation. Our two patients had characteristic features of WRS, including intrauterine growth retardation, aged appearance, near absence of subcutaneous fat, gluteal fat pads, also labial pad in the first infant, wrinkled thin skin, sparse scalp hair, prominent scalp veins and facial dysmorphism. They also have severe osteopenia and elevated urinary deoxypyridinoline levels which have not been previously described in patients with WRS. Impaired lipid and hormone profiles including elevated prolactin and triglyceride level have been reported in patients with WRS. Our first patient also has excessive joint contractures, persisting thrombocytosis and rectal prolapse. We evaluated bone mineral findings in our two patients with WRS and recommend caution when handling children with WRS.

Severe fatal course of axial mesodermal dysplasia spectrum associated with complex cardiac defect in an infant of a mother with insulin dependent diabetes.

Axial mesodermal dysplasia spectrum (AMDS) includes the features of other malformation complexes or sequences, such as oculo-auriculo-vertebral spectrum (OAVS) and sacral dysgenesis. We describe a new patient, an infant born to a type 1 diabetic mother, with the phenotype of AMDS as well as severe congenital cardiac anomalies including transposition of the great arteries and an atrioventricular septal defect. Congenital heart defects had been reported with OAVS, sacral dysgenesis, and in an infant born to a diabetic mother and combinations of these findings have been reported in the same patient. To our knowledge, this is the first patient with AMDS with transposition of great arteries and an atrioventricular septal defect and the second patient with AMDS who had history of parental consanguinity. The mechanism through which maternal diabetes mellitus leads to malformations is not entirely clear, but the glycemic control is essential in the care of mothers.

Quantitative analysis of myelinated axons of corpus callosum in the human brain.

In this study, the myelinated axons of the rostrum, genu, truncus and splenium parts of the corpus callosum were counted in the human brain by using a camera lucida. The numerical densities of these axons were compared with each other by means of quantitative analytical statistical methods. The number of myelinated axons of genu and truncus of the corpus callosum were found to be highest in number and they were nearly the same with each other. However, number of the myelinated axons of splenium was found to be lower in number, when compared with the other parts of corpus callosum.

Cord blood IGF-1 and IGFBP-3 levels in asphyxiated term newborns.

OBJECTIVE: Determination and pathogenesis of perinatal asphyxia is still an important problem. During the asphyxial insult and recovery phase, alteration of the growth factors has been demonstrated and there is evidence that expression of insulin-like growth factors (IGF) and their insulin-like growth factor binding proteins (IGFBP) in injured sites in experimental studies. Aim of this study was to evaluate relationship between serum IGF-1, IGFBP-3 levels and perinatal asphyxia. PATIENTS AND METHODS: 18 term-newborn who defined as perinatal asphyxia and 12 term-healthy newborn were enrolled. Umbilical cord IGF-1 and IGFBP-3 levels were detected and searched correlation with apgar scores and umbilical artery gas analysis as pH, pC02, pO2, base excess, HCO3, ctO2, SO2 and lactate levels. RESULTS: Cord blood IGF-1 and IGFBP-3 levels for asphyxiated newborns were lower than normal group (27.8+/-2.6 ng/ml, 55.1+/-2.8 ng/ml respectively, p<0.01 for IGF-1; 1107.7+/-320.4, 1682.5+/-364.1, p<0.001 for IGFBP-3). Cord blood IGF-1 levels were positively correlated with birth weight; first and 5th minute Apgar score, cord blood arterial pH, ABE, HCO3, SO2 levels. Cord blood IGFBP-3 levels were positively correlated with first and 5th minutes Apgar scores, cord blood arterial pH, pCO2, ABE, HCO3, sO2, and also negatively correlated with cord CO2 and cord lactate levels. CONCLUSION: Our study demonstrates that exposure to hypoxia and acidosis at birth strongly correlated with a fall in IGF-1 and IGFBP-3 levels in cord blood.

Effects of temperature during rearing and crating on stress parameters and meat quality of broilers.

Two trials were conducted to study the effects of heat stress during rearing (trial 1) and crating (trial 2) on broiler stress parameters and fear, breast meat quality, and nutrient composition. The relationships between stress parameters and meat quality traits were also determined. Trial 1 consisted of 3 temperature treatments from 3 to 7 wk: control (temperature was 22 degrees C); diurnal cyclic temperature (temperature was 28 degrees C from 1000 to 1700 h and 22 degrees C from 1700 to 1000 h); and constant high temperature (34 degrees C; temperature was 34 degrees C). In trial 2, broilers from the control and 34 degrees C groups in trial 1 were used. Broilers in each group were placed in transport cages. The 9 cages from the control group were divided into 3 groups and placed into 3 rooms at 15, 22, or 34 degrees C for 2 h. The 3 cages from the 34 degrees C group were also held in the room at 34 degrees C (34-34 degrees C). Diurnal cyclic temperature had no effect on BW up to 5 wk of age. The effect of 34 degrees C constant temperature on BW of broilers increased with age. Plasma levels of glucose and albumin increased by 34 degrees C, but no dramatic change in levels occurred when those broilers were crated at 34 degrees C. The heterophil:lymphocyte (H:L) was higher for the 34-34 degrees C broilers and the control broilers in the 34 degrees C room than those from the 22 and 15 degrees C room. Breast muscle glycogen level decreased in broilers reared under diurnal cyclic or high temperatures. A lower pH and higher lightness (L*) and redness values and redness:yellowness were found in meat for broilers from both 34 degrees C and 34-34 degrees C groups. Higher H:L was associated with breast muscle pH according to first-order polynomial regression. The H:L had a significant effect on L* values, which were described by a second-order polynomial regression. Blood glucose level was positively correlated with L* and redness values. Duration of tonic immobility was neither influenced by rearing and crating temperatures nor associated with meat quality parameters.

Blood lead levels of maternal-cord pairs, children and adults who live in a central urban area in Turkey.

Lead levels were measured in blood samples of 99 adults, 180 children and 143 pregnant women living in Eskisehir, an urban area in Turkey. One hundred and twenty 120 cord blood and 93 breast-milk samples were also obtained. Mean lead level in blood of adults, children, pregnants, cord blood and in breast-milk samples were 3.13 +/- 1.4 microg/dl, 3.56 +/- 1.7 microg/dl, 2.8 +/- 1.5 microg/dl, 1.65 +/- 1.4 microg/dl and 2.34 +/- 1 microg/L, respectively. It was higher in men than in women in adults (p<0.05) and in iron-deficient children than in those not deficient (p<0.01), and was negatively correlated with body weight (BW) and hemoglobin (Hb) in children (p<0.05 for both). Maternal lead level was strongly related with cord blood and breast-milk lead contents (p<0.001, p<0.0001, respectively). The lead exposure in this region is much lower than the critical level defined for lead poisoning as >10 microg/dl by the Centers for Disease Control and Prevention iron deficiency poor nutrition are the risk factors to lead exposure in children.

Normative findings of electrically evoked compound action potential measurements using the neural response telemetry of the Nucleus CI24M cochlear implant system.

One hundred and forty-seven adult recipients of the Nucleus 24 cochlear implant system, from 13 different European countries, were tested using neural response telemetry to measure the electrically evoked compound action potential (ECAP), according to a standardised postoperative measurement procedure. Recordings were obtained in 96% of these subjects with this standardised procedure. The group results are presented in terms of peak amplitude and latency, slope of the amplitude growth function and ECAP threshold. The effects of aetiological factors and the duration of deafness on the ECAP were also studied. While large intersubject variability and intrasubject variability (across electrodes) were found, results fell within a consistent pattern and a normative range of peak amplitudes and latencies was established. The aetiological factors had little effect on the ECAP characteristics. However, age affected ECAP amplitude and slope of the amplitude growth function significantly; i.e., the amplitude is higher in the lowest age category (15-30 years). Principal component analysis of the ECAP thresholds shows that the thresholds across 5 electrodes can be described by two factors accounting for 92% of the total variance. The two factors represent the overall level of the threshold profiles ('shift') and their slopes across the electrode array ('tilt'). Correlation between these two factors and the same factors describing the T- and C-levels appeared to be moderate, in the range of 0.5-0.6.

Vascular pedicles of infrahyoid muscles: an anatomical study.

This study was designed to determine the entering sites of vascular pedicles of the infrahyoid muscles. The neck regions of 12 cadavers were investigated bilaterally. The vascular pedicles of the infrahyoid muscles (except the thyrohyoid and inferior belly of the omohyoid muscle) were dissected and measurements taken with a caliper in reference to the attachments of the muscles. For the sternothyroid muscle, two vascular pedicles were found bilaterally in all cadavers. Two vascular pedicles were found bilaterally for the sternohyoid muscle in 11 cadavers; in one cadaver the inferior vascular pedicle was absent bilaterally. One vascular pedicle was found bilaterally for the superior belly of the omohyoid muscle in all cadavers. These data regarding the vascular pedicles of the infrahyoid muscles might be useful for preserving the vascular supply of the infrahyoid muscles during flap preparation.

Quantitative analysis of myelinated axons of commissural fibers in the cat brain.

OBJECTIVE: There are limited data related to the number of commissural axons found in various species. Although the corpus callosum has been investigated in cat, there are no data on the number of its myelinated axons. Additionally, the number of myelinated axons of anterior, posterior and habenular commissures are not documented for the cat. Therefore, we aimed to examine the topographic distribution and regional numerical differences of myelinated axons in encephalic commissures of the cat. METHODS: This study was carried out at the Faculty of Medicine, Hacettepe University, Ankara, Turkey, from March 2003 to July 2003. The myelinated axons of the encephalic commissures of one cat were counted in this study. RESULTS: In parts of the corpus callosum, a statistically significant difference was found between rostrum and genu, rostrum and truncus, genu and truncus, genu and splenium and truncus and splenium. However, no statistically significant difference was found between rostrum and splenium. When comparing the number of myelinated axons of anterior, posterior and habenular commissures, statistically significant differences were found between anterior and habenular commissures, and between posterior and habenular commissures. No statistically significant difference was found between anterior and posterior commissures. CONCLUSION: These numerical data, evaluated by quantitative analytical statistical methods, might be useful in filling the lack of information on the mean numbers of myelinated axons of different commissures. Knowledge of the number of myelinated axons in different parts of the corpus callosum may also be very important when performing surgical procedures of the corpus callosum, such as commissurectomies.