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OBJECTIVES: Minimally invasive gynecologic surgery (MIGS) is the standard of care in performing hysterectomy for benign conditions. However, the choice of laparoscopic modality is largely dependent on surgeon's discretion, experience, and equipment availability. The objective of this study is: To compare outcomes between different minimally invasive approaches available for benign hysterectomies and to evaluate patient factors that influence the use of one approach over another. With this study, we sought to provide some objective criteria while deciding the appropriate MIGS technique. MATERIALS AND METHODS: This is a retrospective study comparing perioperative outcomes between three techniques of minimally invasive hysterectomy: laparoscopy (LSC), multiport daVinci (MP-Rob) and single-site daVinci (SS-Rob). Patients undergoing benign hysterectomy (daVinci or conventional LSC) from January 2015 to July 2016 were included. 129 patients were identified and divided into: LSC (n = 44), MP-Rob (n = 36) and SS-Rob (n = 49). RESULTS: There were statistically significant differences in age (MP-Rob46 ≠ LSC39), body mass index (BMI) (MP-Rob33 ≠ LSC27 or SS-Rob26.8), uterus weight (MP-Rob144 ≠ LSC102 or SS-Rob105) and operative time (LSC192 ≠ SS-Rob162.3 or MP-Rob163). Chi-square analyses revealed history of endometriosis and clinical endometriosis was statistically less common while leiomyomas were more common indications of MP-Rob. There was no statistically significant difference noted between length of stay, estimated blood loss, intraoperative, and post-operative complications between different surgical types. CONCLUSION: Patients with higher age, BMI, uterus weight and abnormal uterine bleeding were noted to undergo MP-Rob surgery. Patients with history of endometriosis were more likely to undergo LSC or SS-Rob surgery. Operative time was significantly less for daVinci hysterectomies (SS-Rob and MP-Rob) as compared to conventional LSC.

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Variations involving the cervical portion of the vagus nerve are seemingly very rare. We report an adult male found to harbour a right cervical vagus nerve that crossed anterior to the right common carotid artery to terminate in the lateral aspect of the thyroid gland. A very small continuation of this nerve was found to continue distally into the thorax. Histologically, this part of the vagus nerve did not contain ganglion or other cell bodies. There were no heterologous inclusions (thyroid, parathyroid, thymus, salivary gland or branchial cleft remnants) present. Although grossly there was a connection into the thyroid gland, this was not observed histologically. No signs of trauma were found to the ipsilateral neck region. We hypothesise that this variation is due to entanglement between the thyroid gland and cervical vagus nerve during development. This rare variation might be considered by the clinician who operates in the cervical region or interprets imaging of the neck. To our knowledge, a vagus nerve with the above described morphology has not been described.

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Abdominal compartment syndrome is a well-described condition in which increased intra-abdominal pressure causes various physiologic derangements with adverse effects on cardiac, pulmonary, and renal function. A patient presented with radiation-induced distal colonic obstruction, abdominal distention, and severe bilateral leg edema. We performed a diverting transverse loop colostomy as treatment for her obstruction. This resulted in massive, spontaneous diuresis with complete resolution of her lower-limb edema. Abdominal compartment syndrome due to colonic obstruction can contribute to the development of lower-extremity edema. Colon decompression with reduction of intra-abdominal pressure can lead to resolution of edema in this situation.

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Giant colonic diverticulum is a rare manifestation of a common disease primarily affecting patients over the age of 50 years. We reviewed all 81 cases of giant colonic diverticulum reported in the medical literature and present herein an additional case in a younger patient. Published reports were summarized with regard to current epidemiology, clinical aspects, diagnosis, pathogenesis, treatment, and complications. Giant colonic diverticulum can present as an acute, chronic, or incidental condition, or with complications. There are several suggested theories for the pathogenesis of giant colonic diverticulum, but none is universally satisfactory. A diagnosis can be made with plain films, barium enema, and CT scans. A combination of sigmoid resection and primary anastomosis was successful in 75% of the cases reported after the mid-1970s. More than 90% of giant colonic diverticula are found in the sigmoid colon. Sigmoid resection with primary anastomosis is the preferred treatment, although patients presenting with complications typically should be treated with Hartmann's procedure for free perforation or percutaneous drainage for a localized abscess. Because of the high risk of complications, we recommend segmental resection of the involved colon for those found incidentally.

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Although cessation of growth is the most apparent symptom of boron deficiency, the biochemical function of boron in growth processes is not well understood. We propose that the action of boron in root meristems is associated with ascorbate metabolism. Total inhibition of root growth in squash (Cucurbita pepo L.) plants transferred to boron-free medium coincided with a major decrease (up to 98%) in the ascorbate concentration of root apices. Under low-boron conditions, in which root growth was partially inhibited, ascorbate concentration declined in proportion to growth rate. The decline in ascorbate concentration in boron-deficient root tips was not related to ascorbate oxidation. Ascorbate added to the medium improved root growth in plants supplied with insufficient boron. Increasing concentrations of aluminum in the nutrient medium caused progressive inhibition of root growth and a parallel reduction in ascorbate concentration of root apices. Elevated boron levels improved root growth under toxic aluminum conditions and produced root apices with higher ascorbate concentrations. To our knowledge, this is the first report of a correlation between boron nutrition, ascorbate concentration in root apices, and growth. These findings show that root growth inhibition resulting from either boron deficiency or aluminum toxicity may be a consequence of disrupted ascorbate metabolism.

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Resistance patterns of Streptococcus pneumoniae in southwest Virginia were determined for 100 consecutive, hospital-based isolates, mostly from adults. Oxacillin disk screening identified all resistant isolates. Sixteen percent of the isolates were penicillin resistant (10% were highly resistant). E-strip testing revealed the following MICs (in micrograms per milliliter, with percentages of isolates in parentheses): cefotaxime, < or = 0.5 (92%); ceftriaxone, < or = 0.5 (95%); ceftizoxime, < or = 0.5 (85%); erythromycin, < or = 1 (87%); ofloxacin, < or = 2 (80%); vancomycin, < or = 1 (98%).

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Boron has been recognized since 1923 as an essential micronutrient element for higher plants. Over the years, many roles for boron in plants have been proposed, including functions in sugar transport, cell wall synthesis and lignification, cell wall structure, carbohydrate metabolism, RNA metabolism, respiration, indole acetic acid metabolism, phenol metabolism and membrane transport. However, the mechanism of boron involvement in each case remains unclear. Recent work has focused on two major plant-cell components: cell walls and membranes. In both, boron could play a structural role by bridging hydroxyl groups. In membranes, it could also be involved in ion transport and redox reactions by stimulating enzymes like nicotinamide adenine dinucleotide and reduced (NADH) oxidase. There is a very narrow window between the levels of boron required by and toxic to plants. The mechanisms of boron toxicity are also unknown. In nitrogen-fixing leguminous plants, foliarly applied boron causes up to a 1000% increase in the concentration of allantoic acid in leaves. In vitro studies show that boron inhibits the manganese-dependent allantoate amidohydrolase, and foliar application of manganese prior to application of boron eliminates allantoic acid accumulation in leaves. Interaction between borate and divalent cations like manganese may alter metabolic pathways, which could explain why higher concentrations of boron can be toxic to plants.

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Lima bean (Phaseolus lunatus L.) plants inoculated with Bradyrhizobium sp. strain 127E14 displayed a period of marked internode elongation that was not observed in plants inoculated with other compatible bradyrhizobia, including strain 127E15. When strain 127E14 nodulated an alternate host, cowpea (Vigna unguiculata L. Walp), a similar, although less dramatic growth response induced by the bacteria was observed. It has been speculated that the elongative growth promotion brought about by inoculation with strain 127E14 is mediated by gibberellins (GAs). Using deuterated internal standards and gas chromatography-mass spectroscopy analysis, we have quantified the levels of GA(1), GA(20), GA(19), and GA(44) in nodules and stems of two varieties of lima bean (bush and pole) and one variety of cowpea that were inoculated with either strain 127E14 or 127E15. In nodules formed by strain 127E14 on lima bean, endogenous levels of GA(20) and GA(19) were 10 to 40 times higher (35-88 ng/g dry weight) than amounts found in nodules formed by strain 127E15 (2.2-3.9 ng/g dry weight). Relative amounts of GA(44) were also higher (4- to 11-fold) in 127E14 nodules, but this increase was less pronounced. The rhizobial-induced increase of these GAs in the nodule occurred in both pole and bush varieties and seemed to be independent of host morphology. Regardless of rhizobial inoculum, levels of the "bioactive" GA(1) in the nodule (0.3-1.1 ng/g dry weight) were similar. In cowpea nodules, a similar, although smaller, difference in GA content due to rhizobial strain was observed. The concentration of GA(1) in lima bean stems was generally higher than that observed in the nodule, whereas concentrations of the other GAs measured were lower. In contrast with the nodule, GA concentrations in lima bean stems were not greater in plants inoculated with strain 127E14, and in some cases the slower growing plants inoculated with strain 127E15 actually had higher levels of GA(20), GA(19), and GA(44). Thus, there were major differences in concentrations of the precursors to GA(1) in nodules formed by the two bacterial strains, which were positively correlated with the observed elongation growth. These results support the hypothesis that the rhizobial strain modifies the endogenous GA status of the symbiotic system. This alteration in GA balance within the plant, presumably, underlies the observed growth response.

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Our previous work demonstrated substantial accumulation of allantoate in leaf tissue of nodulated soybeans (Glycine max L. Merr., cv Williams) in response to nitrogen fertilization. Research was continued to determine the effect of nitrate and asparagine on ureide assimilation in soybean leaves. Stem infusion of asparagine into ureide-transporting soybeans resulted in a significant increase in allantoate concentration in leaf tissue. Accumulation of allantoate was also observed when asparagine was supplied in the presence of allopurinol, an inhibitor of xanthine dehydrogenase in the pathway of ureide biosynthesis. In vitro, asparagine was found to have an inhibitory effect on the activity of allantoate amidohydrolase, a Mn(2+)-dependent enzyme catalyzing allantoate breakdown in soybean leaves. The inhibition was partially overcome by supplemental Mn(2+) in enzyme assays. Another inhibitor of allantoate amidohydrolase, boric acid, applied foliarly on field-grown nodulated soybeans, caused up to a 10-fold increase in allantoate content of leaf tissue. Accumulation of allantoate in response to boric acid was either eliminated or greatly reduced in plants presprayed with Mn(2+). We conclude that elevated levels of allantoate in leaves of ureide-transporting soybeans fertilized with ammonium nitrate result from inhibition of allantoate degradation by asparagine and that Mn(2+) is a critical factor in this inhibition. Furthermore, our studies with asparagine and boric acid indicate that availability of Mn(2+) has a direct effect on ureide catabolism in soybean.

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AIDS Clinical Trial Group Randomized Trial 002 compared the effect of high-dose with low-dose 3-azido-3-deoxythymidine (AZT) on the survival of AIDS patients. Embedded within the trial was an essentially uncontrolled observational study of the effect of prophylaxis therapy for pneumocystis carinii pneumonia on survival. In this paper, we estimate the causal effect of prophylaxis therapy on survival by using the method of G-estimation to estimate the parameters of a structural nested failure time model (SNFTM). Our SNFTM relates a subject's observed time of death and observed prophylaxis history to the time the subject would have died if, possibly contrary to fact, prophylaxis therapy had been withheld. We find that, under our assumptions, the data are consistent with prophylaxis therapy increasing survival by 16% or decreasing survival by 18% at the alpha = 0.05 level. The analytic approach proposed in this paper will be necessary to control bias in any epidemiologic study in which there exists a time-dependent risk factor for death, such as pneumocystis carinii pneumonia history, that (A1) influences subsequent exposure to the agent under study, for example, prophylaxis therapy, and (A2) is itself influenced by past exposure to the study agent. Conditions A1 and A2 will be true whenever there exists a time-dependent risk factor that is simultaneously a confounder and an intermediate variable.

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The content of gibberellin-like substances in nodules formed by Bradyrhizobium species strain 127E14 on roots of lima bean (Phaseolus lunatus L.) has been previously found to be relatively high. The objectives of the present study were to purify and identify the endogenous gibberellins from the stems and nodules of lima bean. By sequential silica gel partition column chromatography, C(18) reverse-phase high performance liquid chromatography, and combined gas chromatography-mass spectrometry, the gibberellins A(1), A(3), A(19), A(20), A(29), and A(44) were identified from root nodules. Gibberellins A(1), A(3), A(19), A(20), and A(44) were also identified from lima bean stem tissue. These data provide the first mass spectral-based evidence that gibberellins are present in leguminous root nodules. The presence of the gibberellins identified indicates that the early 13-hydroxylation gibberellin biosynthetic pathway predominates in stem and nodule tissue. However, it is not known if the gibberellins within the nodules are produced in situ, or if they are imported from some remote host plant tissue.

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Toxic shock syndrome is a multisystem illness frequently complicated by hypocalcemia. The etiology of the hypocalcemia, which may be severe, is not well understood. We report two cases of fatal toxic shock syndrome accompanied by severe hypocalcemia; each patient also had an inappropriately elevated serum calcitonin level, which in one case was as high as 179,000 pg/mL. Hypercalcitoninemia may be a cause of the low serum calcium levels as well as of certain clinical manifestations of toxic shock syndrome.

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Although many studies have alluded to a role for boron (B) in membrane function, there is little evidence for a direct effect of B on the plasmalemma of higher plant cells. These studies were conducted to demonstrate, by electrophysiological techniques, a direct effect of B on the membrane potential (E(m)) of sunflower (Helianthus annuus [L.], cv Mammoth Grey Stripe) root tip cells and to determine if the response to B occurs rapidly enough to account for the previously observed effects of B on ion uptake. By inserting a glass microelectrode into an individual cell in the root tip, the E(m) of the cell was determined in basal salt medium (BSM), pH 6.0. The perfusion solution surrounding the root tissue was then changed to BSM + 50 micromolar H(3)BO(3), pH 6.0. The exposure to B induced a significant plasmalemma hyperpolarization in sunflower root cells within 20 minutes. After just 3 minutes of exposure to B, the change in E(m) was already significantly different from the negligible change in E(m) observed over time in root cells never exposed to B. Membrane hyperpolarization could be caused by a stimulation of the proton pump or by a change in the conductance of one or more permeable ions. Since B has been shown to affect K(+) uptake by plants, the electrophysiological techniques described above were used to determine if B has an effect on membrane permeability to K(+), and could thereby lead to an increased diffusion potential. When sunflower root tips were pretreated in 50 micromolar B for 2 hours, cell membranes exhibited a significantly greater depolarization with each 10-fold increase in external [K(+)] than minus-B cells. Subsequent studies demonstrated that the depolarization due to increased external [K(+)] was also significantly greater when tissue was exposed to B at the same time as the 10-fold increase in [K(+)], indicating that the effect of B on K(+) permeability was immediate. Analysis of sunflower root tips demonstrated that treatment in 50 micromolar B caused a significantly greater accumulation of K(+) after 48 hours. The B-induced increase in K(+) uptake may cause a subsequent stimulation of the H(+)-ATPase (proton pump) and lead to the observed hyperpolarization of root cell membranes. Alternatively, B may stimulate the proton pump, with the subsequent hyperpolarization resulting in an increased driving force for K(+) influx.

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Our previous work demonstrated that boron (B) supplied to soybeans (Glycine max [L.] Merrill cv ;Williams 82') by a stem infusion technique increased the number of pods on branches and led to a significant yield increase. Therefore, research was continued to determine whether soil or foliar applications of B could be used to achieve the same results. Field experiments were completed with both soil and foliar applications of B. Only the foliar applications of B resulted in a significant increase in the number of pods/branch. When split foliar treatments were applied twice during flowering, the total application of 0.56 kilograms of B per hectare was the optimal treatment for increasing pods/branch. In a second field experiment in 1987, soybeans were treated weekly from flowering through podfill with six split foliar applications of aqueous H(3)BO(3) solutions so that total applications were either 0, 1.1, or 2.24 kilograms of B per hectare. Foliar applications increased the number of branches/plant at the end of the season and significantly stimulated the formation of pods on branches, with 1.12 kilograms of B per hectare being the optimal treatment for these variables. This rate also tended to increase the number of seeds/plant and seed yield/plant. A duplicate experiment with minor modifications was conducted during the summer of 1988, and again the 1.12 kilograms of B per hectare application rate resulted in significant increases in number of branches at harvest as well as number of pods on branches. The 2.24 kilograms of B per hectare application rate also significantly increased these parameters. Foliar B applications induced increases in leaf B concentration far above the 60 micrograms per gram level that was previously accepted as the upper level of tolerance for soybeans. Since optimal branching and per plant yield parameters were achieved by plants with B leaf concentrations greater than 160 micrograms per gram, the accepted range of soybean tolerance for B must be reconsidered when B is foliarly applied.

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Several designs are proposed for case-control studies within cohorts when the cohort is open to late entry. These and previously proposed designs are examined with respect to consistency and efficiency of relative risk parameter estimation, and a small simulation study is reported. If study costs increase in proportion to the total number of "at-risk" controls, the most efficient design, Design C, is as follows. For a case failing at time t, controls are selected at random (and without regard to "at-risk" status) from among cohort members who are (i) known not to have failed prior to t and (ii) have not been previously selected as controls. At each t, control sampling proceeds until a prespecified number of controls who are "at risk" at t have been obtained. The efficiency advantage of Design C over that of the standard case-control design proposed by Thomas (in Appendix to Liddell, McDonald, and Thomas, 1977, Journal of the Royal Statistical Society, Series B 140, 469-490) will often be small. If, on the other hand, the costs increase in proportion to the number of distinct "at-risk" controls, Design C is no longer the most efficient design. In this case, several alternative designs are proposed.

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Low phosphate nutrition results in increased chlorophyll fluorescence, reduced photosynthetic rate, accumulation of starch and sucrose in leaves, and low crop yields. This study investigated physiological responses of soybean (Glycine max [L.] Merr.) leaves to low inorganic phosphate (Pi) conditions. Responses of photosynthesis to light and CO(2) were examined for leaves of soybean grown at high (0.50 millimolar) or low (0.05 millimolar) Pi. Leaves of low Pi plants exhibited paraheliotropic orientation on bright sunny days rather than the normal diaheliotropic orientation exhibited by leaves of high Pi soybeans. Leaves of plants grown at high Pi had significantly higher light saturation points (1000 versus 630 micromole photons [400-700 nanometers] per square meter per second) and higher apparent quantum efficiency (0.062 versus 0.044 mole CO(2) per mole photons) at ambient (34 pascals) CO(2) than did low Pi leaves, yet stomatal conductances were similar. High Pi leaves also had significantly higher carboxylation efficiency (2.90 versus 0.49 micromole CO(2) per square meter per second per pascal), a lower CO(2) compensation point (6.9 versus 11.9 pascals), and a higher photosynthetic rate at 34 pascals CO(2) (19.5 versus 6.7 micromoles CO(2) per square meter per second) than did low Pi leaves. Soluble protein (0.94 versus 0.73 milligram per square centimeter), ribulose-1,5-bisphosphate carboxylase/oxygenase content (0.33 versus 0.25 milligram per square centimeter), and ribulose-1,5-bisphosphate carboxylase/oxygenase specific activity (25.0 versus 16.7 micromoles per square meter per second) were significantly greater in leaves of plants in the high Pi treatment. The data indicate that Pi stress alters the plant's CO(2) reduction characteristics, which may in turn affect the plant's capacity to accommodate normal radiation loads.

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Most leaf phosphorus is remobilized to the seed during reproductive development in soybean. We determined, using (31)P-NMR, the effect phosphorus remobilization has on vacuolar inorganic phosphate pool size in soybean (Glycine max [L.] Merr.) leaves with respect to phosphorus nutrition and plant development. Phosphate compartmentation between cytoplasmic and vacuolar pools was observed and followed in intact tissue grown hydroponically, at the R2, R4, and R6 growth stages. As phosphorus in the nutrient solution decreased from 0.45 to 0.05 millimolar, the vacuolar phosphate peak became less prominent relative to cytoplasmic phosphate and hexose monophosphate peaks. At a nutrient phosphate concentration of 0.05 millimolar, the vacuolar phosphate peak was not detectable. At higher levels of nutrient phosphate, as plants progressed from the R2 to the R6 growth stage, the vacuolar phosphate peak was the first to disappear, suggesting that storage phosphate was remobilized to a greater extent than metabolic phosphate. Under suboptimal phosphate nutrition (

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Nucleoside diphosphatase and 5'-nucleotidase activities were both found to be very high in extracts of soybean (Glycine max L.) root nodules. Both activities increased early in soybean nodule development, prior to the rise in leghemoglobin, and both were found at equivalent levels in nitrogenfixing and nonfixing nodules. Based on a survey of other tissues, these activities were both highest in soybean nodules (1300 nanomoles per milligram protein per minute, nucleoside diphosphatase and 500 nanomoles per milligram protein per minute, 5'-nucleotidase), but they were not always associated with each other; in some tissues one was high and the other low. Neither activity correlated well with ureide production; both seem, rather, to be primarily involved in some other metabolic function. Both the nucleoside diphosphatase and 5'-nucleotidase of soybean nodules were soluble proteins, and neither appeared to be associated with plastids, mitochondria, or bacteroids.

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A specific nucleoside diphosphatase was purified from the plant portion of soybean (Glycine max L.) root nodules. This enzyme is highly specific for nucleotide diphosphates; it is unable to hydrolyze nucleotide tri- and monophosphates or a variety of other phosphorylated compounds. It will, however, hydrolyze any nucleotide disphosphate tested. The pH optimum of the enzyme is about 7.5; it requires a divalent cation for activity; and it is neither inhibited nor activated by any of the metabolites tested. It appears that in vivo this enzyme would be very active, but its function is not clear.

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