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We present a patient who was found to have a cholecystocolonic fistula during robotic cholecystectomy. The patient initially presented with Non-ST-elevation myocardial infarction (NSTEMI) and biliary obstruction. A delayed cholecystectomy was performed robotically after managing his Coronary Artery Disease (CAD) and relief of his biliary obstruction with endoscopic retrograde cholangiopancreatography (ERCP). Intraoperatively, a cholecystocolonic fistula, was found. This case report aims to highlight intraoperative management of the fistula and review the existing literature.

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Exoplanet detections have revolutionized astronomy, offering new insights into solar system architecture and planet demographics. While nearly 1,900 exoplanets have now been discovered and confirmed, none are still in the process of formation. Transition disks, protoplanetary disks with inner clearings best explained by the influence of accreting planets, are natural laboratories for the study of planet formation. Some transition disks show evidence for the presence of young planets in the form of disk asymmetries or infrared sources detected within their clearings, as in the case of LkCa 15 (refs 8, 9). Attempts to observe directly signatures of accretion onto protoplanets have hitherto proven unsuccessful. Here we report adaptive optics observations of LkCa 15 that probe within the disk clearing. With accurate source positions over multiple epochs spanning 2009-2015, we infer the presence of multiple companions on Keplerian orbits. We directly detect Hα emission from the innermost companion, LkCa 15 b, evincing hot (about 10,000 kelvin) gas falling deep into the potential well of an accreting protoplanet.

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It has been known for long time that asexual organisms may affect the distribution of sexual taxa. In fact, such phenomenon is inherent in the concept of geographical parthenogenesis. On the other hand, it was generally hypothesized that sperm-dependent asexuals may not exercise the same effect on related sexual population, due to their dependence upon them as sperm-donors. Recently, however, it became clear that sperm-dependent asexuals may directly or indirectly affect the distribution of their sperm-hosts, but rather in a small scale. No study addressed the large-scale biogeographic effect of the coexistence of such asexuals with the sexual species. In our study we were interested in the effect of sexual-asexual coexistence on the speed of spatial expansion of the whole complex. We expand previously published Lotka-Volterra model of the coexistence of sexual and gynogenetic forms of spined loach (Cobitis; Teleostei) hybrid complex by diffusion. We show that presence of sperm-dependent parthenogens is likely to negatively affect the spatial expansion of sexuals, and hence the whole complex, compared to pure sexual population. Given that most of the known sperm-dependent asexual complexes are distributed in areas prone to climate-induced colonization/extinction events, we conclude that such mechanism may be an important agent in determining the biogeography of sexual taxa and therefore requires further attention including empirical tests.

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Planetary systems (ours included) formed in disks of dust and gas around young stars. Disks are an integral part of the star and planet formation process, and knowledge of the distribution and temperature of inner-disk material is crucial for understanding terrestrial planet formation, giant planet migration, and accretion onto the central star. Although the inner regions of protoplanetary disks in nearby star-forming regions subtend only a few nano-radians, near-infrared interferometry has recently enabled the spatial resolution of these terrestrial zones. Most observations have probed only dust, which typically dominates the near-infrared emission. Here I report spectrally dispersed near-infrared interferometric observations that probe the gas (which dominates the mass and dynamics of the inner disk), in addition to the dust, within one astronomical unit (1 au, the Sun-Earth distance) of the young star MWC 480. I resolve gas, including water vapour and atomic hydrogen, interior to the edge of the dust disk; this contrasts with results of previous spectrally dispersed interferometry observations. Interactions of this accreting gas with migrating planets may lead to short-period exoplanets like those detected around main-sequence stars. The observed water vapour is probably produced by the sublimation of migrating icy bodies, and provides a potential reservoir of water for terrestrial planets.

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INTRODUCTION: Prenatally androgenized (PA) female rhesus monkeys share metabolic abnormalities in common with polycystic ovary syndrome (PCOS) women. Early gestation exposure (E) results in insulin resistance, impaired pancreatic beta-cell function and type 2 diabetes, while late gestation exposure (L) results in supranormal insulin sensitivity that declines with increasing body mass index (BMI). OBJECTIVE: To determine whether PA females have altered body fat distribution. DESIGN: Five early-treated PA (EPA), five late-treated PA (LPA) and five control adult female monkeys underwent somatometrics, dual-X-ray absorptiometry (DXA) and abdominal computed tomography (CT). Five control and five EPA females underwent an intravenous glucose tolerance test to assess the relationship between body composition and glucoregulation. RESULTS: There were no differences in age, weight, BMI or somatometrics. LPA females had approximately 20% greater DXA-determined total fat and percent body fat, as well as total and percent abdominal fat than EPA or control females (P< or =0.05). LPA females also had approximately 40% more CT-determined non-visceral abdominal fat than EPA or control females (P< or =0.05). The volume of visceral fat was similar among the three groups. EPA (R (2)=0.94, P< or =0.01) and LPA (R (2)=0.53, P=0.16) females had a positive relationship between visceral fat and BMI, although not significant for LPA females. Conversely, control females had a positive relationship between non-visceral fat and BMI (R (2)=0.98, P< or =0.001). There was a positive relationship between basal insulin and total body (R (2)=0.95, P< or =0.007), total abdominal (R (2)=0.81, P< or =0.04) and visceral (R (2)=0.82, P< or =0.03) fat quantities in EPA, but not control females. CONCLUSIONS: Prenatal androgenization in female rhesus monkeys induces adiposity-dependent visceral fat accumulation, and late gestation androgenization causes increased total body and non-visceral fat mass. Early gestation androgenization induces visceral fat-dependent hyperinsulinemia. The relationship between the timing of prenatal androgen exposure and body composition phenotypes in this nonhuman primate model for PCOS may provide insight into the heterogeneity of metabolic defects found in PCOS women.

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Species-specific polymorphisms in the noncoding internal transcribed spacer 2 (ITS2) region of the rRNA operon provide accurate identification of clinically significant yeasts. In this study, we tested the hypothesis that ITS1 noncoding regions contain diagnostically useful alleles. The length of ITS1 region PCR products amplified from 40 species (106 clinical strains, 5 reference strains, and 30 type strains) was rapidly determined with single-base precision by automated capillary electrophoresis. Polymorphisms in the PCR product length permitted 19 species to be distinguished by ITS1 alone, compared with 16 species distinguished by using only ITS2. However, combination of both ITS alleles permitted identification of 30 species (98% of clinical isolates). The remaining 10 species with PCR products of similar sizes contained unique ITS alleles distinguishable by restriction enzyme analysis. DNA sequence analysis of amplified ITS1 region DNA from 79 isolates revealed species-specific ITS1 alleles for each of the 40 pathogenic species examined. This provided identification of unusual clinical isolates, and 53 diagnostic ITS1 sequences were deposited in GenBank. Phylogenetic analyses based on ITS sequences showed a similar overall topology to 26S rRNA gene-based trees. However, different species with identical 26S sequences contained distinct ITS alleles that provided species identification with strong statistical support. Together, these data indicate that the analysis of ITS polymorphisms can reliably identify 40 species of clinically significant yeasts and that the capacity for identifying potentially new pathogenic species by using this database holds significant promise.

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BACKGROUND: Former studies on sternal wound infections indicate predisposing factors like diabetes, obesity, use of bilateral internal mammary grafts, impaired renal function and reoperation. We wanted to evaluate whether the time of resternotomy for postoperative bleeding has any influence on the development of a sternal wound infection and other complications. METHODS: In our department, 12,315 patients underwent median sternotomy for cardiac surgery between 1987 and 1998. We analyzed the clinical data of all patients which were reoperated on for postoperative bleeding, especially patients with subsequent operations caused by sternal wound infections. All data were compared by T-test respectively chi2-test, and p<0.05 was regarded as significant. RESULTS: 406 of the 12,315 patients were re-explored because of postoperative bleeding (3.3%). 57 (14%) of these patients died in the postoperative period of non-infectious complications. The remaining patients were divided into two groups: Group A (286 patients) (70.4%) did not suffer from any sternal wound complications, where as group B patients (n = 63) (15.6%) needed subsequent surgery due to sternal infection. There were no significant differences in either concerning age, clinical data and first operation. All patients had an average blood loss of 223 ml/hr. The time before re-operation for bleeding was 5.3+/-1.7 hours in group A compared to 11.1+/-4.2 hours in group B (p<0.05). A significant delay of reoperation for bleeding could also be found for patients with postoperative septic complications (ø: 5.2+/-1.9 hours, +: 12.9+/-5.2 hours), renal failure, mechanical ventilation >48 hours and a stay in hospital >20 days. CONCLUSIONS: Early reoperation for postoperative bleeding decreases the number of subsequent complications, e.g. sternal wound infections, septic complications and prolonged mechanical ventilation.

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OBJECTIVE: To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization. DESIGN: Secondary analysis of a prospective cohort study. PARTICIPANTS: Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed. MEASUREMENTS: One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization. RESULTS: One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P =.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7. 6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11. 9) times more likely to be admitted to a nursing home in the month after hospitalization. CONCLUSION: Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence.

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OBJECTIVE: The purpose of this study was to describe the relationship between command hallucinations and violent behavior. METHODS: One hundred and three psychiatric inpatients completed measures of command hallucinations, other psychotic symptoms, violent behavior, and social desirability response biases. RESULTS: Thirty percent of the patients reported having had command hallucinations to harm others during the last year, and 22 percent of the patients reported they complied with such commands. Logistic regression analyses suggested that patients who experienced command hallucinations to harm others were more than twice as likely to be violent, even when the analysis controlled for demographic variables, history of substance abuse, and social desirability response biases. CONCLUSIONS: The results support the clinical utility of asking about command hallucinations when assessing the risk of violence in patients with major mental disorders.

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Identification of medically relevant yeasts can be time-consuming and inaccurate with current methods. We evaluated PCR-based detection of sequence polymorphisms in the internal transcribed spacer 2 (ITS2) region of the rRNA genes as a means of fungal identification. Clinical isolates (401), reference strains (6), and type strains (27), representing 34 species of yeasts were examined. The length of PCR-amplified ITS2 region DNA was determined with single-base precision in less than 30 min by using automated capillary electrophoresis. Unique, species-specific PCR products ranging from 237 to 429 bp were obtained from 92% of the clinical isolates. The remaining 8%, divided into groups with ITS2 regions which differed by /=99%. Seven clinical isolates contained ITS2 sequences that did not agree with their phenotypic identification, and ITS2-based phylogenetic analyses indicate the possibility of new or clinically unusual species in the Rhodotorula and Candida genera. This work establishes an initial database, validated with over 400 clinical isolates, of ITS2 length and sequence polymorphisms for 34 species of yeasts. We conclude that size and restriction analysis of PCR-amplified ITS2 region DNA is a rapid and reliable method to identify clinically significant yeasts, including potentially new or emerging pathogenic species.

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This study determined whether timing of prenatal androgen excess resulted in differential impairment of insulin-glucose homeostasis in adult female rhesus monkeys. Ten female rhesus monkeys exposed to testosterone propionate starting on gestational day 40 (early treated), 9 females exposed to testosterone propionate starting between gestational days 100-115 (late treated), and 15 control females were studied. The modified minimal model was used to examine various measures derived from an i.v. glucose tolerance test, with regression analysis performed between these variables and body mass index. In addition, the disposition index (DI) and the hyperbolic relationship between insulin sensitivity (S(I)) and acute insulin response to glucose were examined. Early treated females demonstrated impaired pancreatic beta-cell function, as shown by diminished DI and decreased percentile ranking for the hyperbolic relationship between S(I) and acute insulin response to glucose. In contrast, late treated females exhibited both an increase in DI and a negative relationship between body mass index and S(I). These results suggest that prenatal androgen excess in female rhesus monkeys, regardless of gestational timing, perturbs insulin-glucose homeodynamics, with androgen excess in early and late gestation impairing pancreatic beta-cell function and altering insulin sensitivity, respectively.

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OBJECTIVE: To determine whether 3-month GnRH analogue (GnRH-a) administration to hyperandrogenic anovulatory patients and healthy women affects glucose utilization or endogenous glucose production (EGP) in the postabsorptive state and during variable hyperglycemic-hyperinsulinemic infusions. DESIGN: Prospective, nonrandomized study. SETTING: Academic research environment. PATIENT(S): Twelve hyperandrogenic anovulatory patients and 11 healthy women matched by body mass index and waist to hip circumference ratio. INTERVENTION(S): Variable hyperglycemic-hyperinsulinemic infusions replicated physiological increases in circulating glucose and insulin levels before and after 3-month GnRH-a administration. MAIN OUTCOME MEASURE(S): Glucose utilization and EGP. RESULT(S): In the postabsorptive state, plasma glucose and insulin levels, glucose utilization, and EGP were similar in hyperandrogenic patients and healthy women. During variable hyperglycemic-hyperinsulinemic infusions, glucose use increased and EGP decreased to similar degrees in both groups of women. Three-month GnRH-a administration to hyperandrogenic patients and healthy women did not affect plasma glucose and insulin levels, glucose utilization and EGP in the postabsorptive state, or glucose utilization and EGP during variable hyperglycemic-hyperinsulinemic infusions. CONCLUSION(S): Glucose use and EGP in the postabsorptive state and during variable hyperglycemic-hyperinsulinemic infusions are similar in hyperandrogenic anovulatory patients and healthy women of similar body fat distribution and are unaffected by 3-month GnRH-a administration.

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OBJECTIVE: To determine whether hyperandrogenism in anovulatory women affects body fat distribution. DESIGN: Prospective nonrandomized study. SETTING: An academic research environment. PATIENT(S): Ten hyperandrogenic anovulatory patients and 10 healthy women matched by body mass index. INTERVENTION(S): Regional body fat analysis was performed before and after 3 months of GnRH analogue (GnRH-a) therapy. MAIN OUTCOME MEASURE(S): Body fat distribution was measured by waist-to-hip circumference ratio, single-slice computed tomography imaging (L2-3 interspace), and total body dual-energy x-ray absorptiometry. RESULT(S): Weight, body mass index, waist-to-hip circumference ratio, total body and leg fat mass, and subcutaneous adipose area were unaffected by the presence of hyperandrogenism or the use of GnRH-a therapy. Basal abdominal fat mass, abdomen-to-leg fat mass ratio, visceral adipose area, and total visceral adipose volume were comparable in both study groups. The abdominal fat mass increased in both groups during GnRH-a therapy, whereas the abdomen-to-leg fat mass ratio rose significantly only in the hyperandrogenic patients. During GnRH-a therapy, the hyperandrogenic patients demonstrated a significant increase in visceral adipose area compared with the healthy women so that total visceral adipose volume increased significantly in the former but not the latter. CONCLUSION(S): Three months of GnRH-a administration preferentially increased abdominal fat, as measured by single-slice computed tomography imaging and total body dual-energy x-ray absorptiometry, in hyperandrogenic anovulatory women.

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The developmental pathophysiology of polycystic ovary syndrome (PCOS) is unknown. However, prenatally androgenized female rhesus monkeys exhibit ovarian and endocrinological features that mimic those found in women with PCOS. Thus, prenatal androgen excess may provide an etiology for hyperandrogenism and anovulation in adulthood.

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Dominant gain-of-function mutations can give unique insights into the study of gene function. In addition, gain-of-function mutations, unlike loss-of-function alleles, are not biased against the identification of genetically redundant loci. To identify novel genetic functions active during Caenorhabditis elegans embryogenesis, we have collected a set of dominant temperature-sensitive maternal-effect embryonic lethal mutations. In a previous screen, we isolated eight such mutations, distributed among six genes. In the present study, we describe eight new dominant mutations that identify only three additional genes, yielding a total of 16 dominant mutations found in nine genes. Therefore, it appears that a limited number of C. elegans genes mutate to this phenotype at appreciable frequencies. Five of the genes that we identified by dominant mutations have loss-of-function alleles. Two of these genes may lack loss-of-function phenotypes, indicating that they are nonessential and so may represent redundant loci. Loss-of-function mutations of three other genes are associated with recessive lethality, indicating nonredundancy.

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OBJECTIVE: To determine whether prenatal androgenization of the developing primate hypothalamohypophyseal unit induces irreversible changes in LH secretion. DESIGN: Prospective nonrandomized study. SETTING: An academic research environment. ANIMALS: Forty-one adult ovulatory female rhesus monkeys. INTERVENTION(S): Seventeen female rhesus monkeys exposed prenatally to testosterone propionate (female pseudohermaphrodites) and 24 normal females underwent blood sampling over two ovulatory menstrual cycles. MAIN OUTCOME MEASURE(S): Serum FSH, LH, E2, and T were determined by RIA; P was determined by enzyme immunoassay. Serum bioactive LH was measured by mouse Leydig cell bioassay. RESULT(S): Tonic immunoactive LH hypersecretion and normal FSH release occurred in female pseudohermaphrodites compared with normal females. Periovulatory immunoactive LH and FSH secretion was similar in both female types, whereas a relative increase in the amount of circulating bioactive LH to immunoactive LH was found at midcycle in female pseudohermaphrodites versus normal females. The length of the follicular phase was unaffected by prenatal androgen exposure, but the slopes of serum T and E2 concentrations versus follicular phase cycle day were significantly lower in female pseudohermaphrodites than normal females. Luteal phase length and P secretion were comparable in both types of females. CONCLUSION(S): Androgen exposure during primate neural differentiation may alter permanently the pattern of LH secretion in the presence of cyclic gonadotropin release.

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