Utility of screening for other causes of infertility in women with "known" polycystic ovary syndrome

We investigated the prevalence of abnormal screening results (questionnaire and testing for other causes of oligo-ovulation, male or tubal factor infertility) in a group of 1,313 oligo-ovulatory women (included and excluded subjects) whose condition was screened for inclusion in the Pregnancy in Polycystic Ovary Syndrome trial, a multicenter clinical trial that was conducted at 13 sites in the United States. Other than failure to demonstrate laboratory evidence of hyperandrogenemia, the most common reasons for subject exclusion were persistent oligospermia and tubal factor infertility.     

Responsive robotic prey reveal how predators adapt to predictability in escape tactics

To increase their chances of survival, prey often behave unpredictably when escaping from predators. However, the response of predators to, and hence the effectiveness of, such tactics is unknown. We programmed interactive prey to flee from an approaching fish predator (the blue acara, Andinoacara pulcher) using real-time computer vision and two-wheeled robots that controlled the prey’s movements via magnets. This allowed us to manipulate the prey’s initial escape direction and how predictable it was between successive trials with the same individual predator. When repeatedly exposed to predictable prey, the predators adjusted their behavior before the prey even began to escape: prey programmed to escape directly away were approached more rapidly than prey escaping at an acute angle. These faster approach speeds compensated for a longer time needed to capture such prey during the subsequent pursuit phase. By contrast, when attacking unpredictable prey, the predators adopted intermediate approach speeds and were not sensitive to the prey’s escape angle but instead showed greater acceleration during the pursuit. Collectively, these behavioral responses resulted in the prey’s predictability having no net effect on the time taken to capture prey, suggesting that unpredictable escape behavior may be advantageous to prey in fewer circumstances than originally thought. Rather than minimizing capture times, the predators in our study appear to instead adjust their behavior to maintain an adequate level of performance during prey capture.

Rapid evasive responses are a vital tool prey use to minimize capture by predators (1, 2). Despite their ubiquity, it can be challenging to demonstrate the benefit of escape strategies, due to the difficulties involved in designing studies which integrate realistic predation with manipulation of prey behavior that experimentally controls for confounding effects. Studying the behavior of real predators is crucial when attempting to demonstrate the adaptive value of prey adaptations, especially when these are dependent on features of predator cognition (3–5). This applies particularly to unpredictable escape behavior by prey, which is thought to enhance prey survival by compromising the ability of predators to anticipate the movement of their target (6). Although unpredictable escape tactics are widespread taxonomically (7, 8), we know little about how real predators respond to unpredictability in prey escape strategies and whether this prevents predators from adjusting their behavior over multiple interactions with prey (9, 10).Controlled experiments in which human predators target continuously moving virtual prey have demonstrated that abrupt and unpredictable changes in direction reduce the accuracy of prey targeting (11, 12). However, it is unknown whether the survival advantage conferred by unpredictable motion also applies against nonhuman predators. Additionally, the escape responses of prey which are initially stationary are common in nature, as numerous prey taxa freeze once they have detected a potential threat or remain motionless to avoid detection by predators, before eventually fleeing only once a predator gets too close (1, 13–15). One way for stationary prey to be unpredictable is to vary the initial escape angle from one encounter to the next (16). This is a distinct tactic to the unpredictable movements made by prey which move continuously regardless of the presence of a predatory threat (6) or the abrupt turns made by some prey in anticipation of a predator’s attack (17). Although theoretical models predict that for a predator of a given speed, prey should select a single optimal escape trajectory which maximizes the distance from an approaching predator (18, 19), predators might anticipate the movements of prey which repeatedly escape at a fixed angle relative to their approach (20). Contrary to expectations based on a single optimal escape path, a wide range of prey species show a substantial degree of variability in their initial escape angles (16), including amphibians (21), crustaceans (22, 23), fish (24–27), insects (28, 29), mammals (30), and reptiles (31). Given that this variability is so widespread taxonomically, investigating whether it represents an antipredator strategy aimed at generating unpredictability could have major implications for our understanding of prey escape behavior (32, 33).Many predator-prey interactions are typified by feedback between the attacker and the target (34), making it difficult to disentangle the effects of prey defenses on predators from the impact of predator behavior on prey using a purely observational approach. One way to determine the importance of prey defensive tactics is to present real predators with standardized virtual prey, whose movements and behavior can be precisely controlled and experimentally manipulated (35–39). However, previous experiments with virtual prey have used unresponsive prey items which do not react to predators, and do not allow the predator to capture prey and be rewarded, making it extremely challenging to study repeated interactions between predators and prey. These limitations can be overcome by using interactive robotic prey (40).To study the effect of unpredictability in prey escape on predators, we developed an experimental system [Fig. 1A; see also Swain et al. (41)], in which artificial robot-controlled prey were programmed to flee from blue acara cichlid (Andinoacara pulcher) predatory fish. Blue acaras are opportunistic predators with a broad diet but actively pursue highly evasive prey such as Trinidadian guppies (Poecilia reticulata) (42, 43). Prey initiated their escape response once the predator had approached within a threshold distance (Fig. 1B), mimicking the tendency of many prey to flee from a distant predator at submaximal speeds (14, 44). After an initial period in which groups of blue acaras were trained to attack the prey (the training period, SI Appendix, SI Methods), individual predators were repeatedly presented with prey which escaped either in predictable or unpredictable directions over 20 successive experimental trials (the test period). For individuals assigned to the predictable treatment (which acted as the control), prey escaped at the same angle relative to the predator’s approach from one trial to the next, whereas in the unpredictable treatment, prey were programmed to flee in random directions over successive trials (Fig. 1C). To successfully capture prey, pursuit predators must respond to changes in prey direction, which occur at the start of a chase (45–47). Across trials with predictable prey, the predators had the opportunity to gain reliable information about the prey’s likely escape direction, in contrast to the unpredictable treatment where the prey’s escape angle in previous trials was not a reliable indicator of its escape direction in future encounters. If unpredictable escape behavior is adaptive, increased uncertainty about the prey’s likely escape direction in the unpredictable treatment should reduce the performance of the predator in these trials, with slower speeds of approach (i.e., before the prey respond), longer times taken to capture prey, and/or greater kinematic costs resulting from higher speeds, increased acceleration, and more turning during the pursuit.Open in a separate windowFig. 1.The robotic prey system. (A) Diagram (not to scale) showing a side view of the experimental system, with the Bluetooth-controlled robot situated on a platform underneath the experimental tank and the webcam used to monitor the predator’s movements suspended overhead. The prey’s movements are controlled by the robot via magnets, enabling the prey to escape from an attacking predator once the predator approaches within 27 cm of the prey’s starting position. See ref. 41 for a similar system designed for robotic predators attacking prey fish shoals. (B) Prey escape angles were defined relative to the predator’s approach direction. (C) In the predictable treatment, prey escaped at the same initial angle over successive trials (the escape angle varied between individual predators). In the unpredictable treatment, the prey’s initial escape angle varied randomly from trial to trial. While the experiment manipulated the prey’s initial escape angle, the prey’s subsequent escape trajectory was fixed as a straight-line path in both treatments.     

Low preoperative HSP70 atrial myocardial levels correlate significantly with high incidence of postoperative atrial fibrillation after cardiac surgery

PURPOSE OF THE STUDY: Atrial fibrillation after cardiac surgery is still a frequent encountered complication and has been associated with increased hospital length of stay and numerous postoperative complications. The pathogenesis of atrial fibrillation involves an overall sequence of perioperative events, collectively termed as ischemia-reperfusion injury. Heat-shock proteins have been found to provide increased protection during ischemia-reperfusion as well as increased postischemic cardiac functional recovery. We sought to determine whether preoperative atrial heat shock levels were correlated with the appearance of postoperative atrial fibrillation. BASIC METHODS: Preoperative atrial myocardial samples obtained just before cannulation from 101 patients were used to detect immunohistochemically the expression of heat-shock proteins. The derived results were compared statistically with the incidence of postoperative atrial fibrillation, its time of appearance, duration and resistance to administered antiarrhythmics. PRINCIPAL FINDINGS: The overall incidence of postoperative atrial fibrillation was 22.3%. Of these patients, 58.3% had no detectable heat shock proteins in their cytoplasm, in sharp contrast with 100% of the patients with no atrial fibrillation who were positive for heat shock proteins (p<0.01). Four percent of our patient group had prolonged atrial fibrillation (defined as duration >48 h). These patients had significantly less (p<0.01) nuclear heat shock protein expression compared with the non-atrial fibrillation group. However, the difference of the heat shock protein expression between the prolonged atrial fibrillation and the rest of the atrial fibrillation patients was not significant (p=0.891). CONCLUSIONS: Our results indicate that patients with low preoperative atrial heat shock protein expression have a significantly greater incidence of postoperative atrial fibrillation. Heat shock protein expression did not, however, correlate with the onset of atrial fibrillation and the resistance to administered medications. Heat shock protein preoperative induction as a measure of myocardial preconditioning may potentially decrease the incidence of postoperative atrial fibrillation.     

The influence of perioperative blood transfusion on survival after esophageal resection for carcinoma

Background. There is evidence that perioperative blood transfusion may lead to immunosuppression. Our aim was to determine whether blood transfusion influenced survival after esophagectomy for carcinoma.

Methods. The study group comprised 234 consecutive patients (175 men and 59 women) with a mean age of 66 years who underwent esophagectomy for carcinoma by one surgeon between 1988 and 1998. The impact of 41 variables on survival was determined by means of univariate and multivariate analysis. Follow-up was complete (mean follow-up, 19.2 months; standard deviation, 16 months; range, 0 to 129 months).

Results. The operative mortality rate was 5.6% (13 deaths). Median operative blood loss was 700 mL (range, 150 to 7,000 mL). One hundred sixty-one patients (68.8%) received a blood transfusion postoperatively (mean transfusion, 2.6 units; range, 0 to 12 units). Overall actuarial 1-year, 3-year, and 5-year survival rates inclusive of operative mortality were 58.1%, 28.5%, and 16.1%, respectively. On univariate analysis, positive lymph nodes, pathological TNM stage, transfusion of more than 3 units of blood, incomplete resection, poor tumor cell differentiation, longer tumor, greater weight loss, male sex, and adenocarcinoma were significant (p < 0.05) negative factors for survival. On Cox proportional hazards regression analysis, after excluding operative mortality, lymph node involvement (p = 0.001), incomplete resection (p = 0.0001), poor tumor cell differentiation (p = 0.04), and transfusion of more than 3 units of blood (p = 0.04) were independent adverse predictors of late survival.

Conclusions. In addition to reaffirming the importance of completeness of resection and nodal involvement, this study demonstrates that blood transfusion (more than 3 units) may have a significant adverse effect on late survival after esophageal resection for carcinoma. Every effort should be made to limit the amount of transfused blood to the absolutely essential requirements.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.