Global but not gonadotrope-specific disruption of Bmal1 abolishes the luteinizing hormone surge without affecting ovulation.

Although there is evidence for a circadian regulation of the preovulatory LH surge, the contributions of individual tissue clocks to this process remain unclear. We studied female mice deficient in the Bmal1 gene (Bmal1(-/-)), which is essential for circadian clock function, and found that they lack the proestrous LH surge. However, spontaneous ovulation on the day of estrus was unaffected in these animals. Bmal1(-/-) females were also deficient in the proestrous FSH surge, which, like the LH surge, is GnRH-dependent. In the absence of circadian or external timing cues, Bmal1(-/-) females continued to cycle in constant darkness albeit with increased cycle length and time spent in estrus. Because pituitary gonadotropes are the source of circulating LH and FSH, we assessed hypophyseal circadian clock function and found that female pituitaries rhythmically express clock components throughout all cycle stages. To determine the role of the gonadotrope clock in the preovulatory LH and FSH surge process, we generated mice that specifically lack BMAL1 in gonadotropes (GBmal1KO). GBmal1KO females exhibited a modest elevation in both proestrous and baseline LH levels across all estrous stages. BMAL1 elimination from gonadotropes also led to increased variability in estrous cycle length, yet GBmal1KO animals were otherwise reproductively normal. Together our data suggest that the intrinsic clock in gonadotropes is dispensable for LH surge regulation but contributes to estrous cycle robustness. Thus, clocks in the suprachiasmatic nucleus or elsewhere must be involved in the generation of the LH surge, which, surprisingly, is not required for spontaneous ovulation.

Effectiveness of endoclips for the treatment of stigmata of recent hemorrhage in the colon of patients with acute lower gastrointestinal tract bleeding.

AIMS AND METHODS: Coaptive thermo coagulation (CTC) for the treatment of stigmata of recent hemorrhage (SRH) in the colon is risky. We evaluated the safety and effectiveness of endoclips in 13 patients with acute lower gastrointestinal bleeding (GIB). Thirty-day re-bleeding and complication rates were comparable to a historical cohort of 41 patients (group 2) who underwent CTC/IE (injection epinephrine) for the management of acute lower GIB. RESULTS: There was no difference in the 30-day re-bleeding rates in the two groups. In group I, immediate hemostasis was successful in all patients. Three of 13 patients (23.1%) developed re-bleeding. In group II, 41 patients from six prior studies underwent CTC and/or IE for the treatment of HRS where 12 (29.3%) developed re-bleeding. There were no immediate complications. CONCLUSIONS: Endoclip deployment is as effective as CTC and/or IE for treatment of SRH in the colon.

A comparison of the consensus and clinical definitions of pancreatitis with a proposal to redefine post-endoscopic retrograde cholangiopancreatography pancreatitis.

OBJECTIVES: We evaluated the correlation between the consensus and clinical definitions of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP), with the objective of updating and revising the definition of post-ERCP pancreatitis (PEP). METHODS: Three hundred patients were subjected to serial serum amylase & lipase levels testing and abdominal computed tomography scan for abdominal pain after ERCP. Main outcome measures included the correlation between consensus and clinical definitions. RESULTS: Using consensus criteria, 25 patients had acute pancreatitis (11 of mild and 14 of moderate severity). Forty-three patients had acute pancreatitis using the clinical definitions (18 of mild and 25 of moderate severity). At 4 hours, serum hyperamylasemia of under 1.5-fold and at 12 hours a serum hyperamylasemia of under 2-fold had a negative predictive value of 0.94 for development of PEP. Serum hyperamylasemia following ERCP had a poor positive predictive value for PEP. CONCLUSIONS: Clinical and consensus definitions are poorly correlated; use of the latter leads to significant underrecognition of PEP. The adoption of clinical definition results in uniformity of diagnosis of pancreatitis for clinical care and research. Serum amylase levels at 4 and 12 hours after ERCP have a high negative predictive value for PEP.

Prospective randomized trial of EUS versus ERCP-guided common bile duct stone removal: an interim report (with video).

BACKGROUND: EUS is being increasingly utilized for the diagnosis of choledocholithiasis and microlithiasis, especially in patients with biliary colic. Simultaneously, there is also a rising interest in the use of EUS for therapeutic interventions. OBJECTIVES: Our goal was to assess the effectiveness of EUS-directed common bile duct (CBD) stone removal to compare its safety and effectiveness with ERCP-directed intervention. DESIGN: Interim results of a prospective, randomized, single-center blinded clinical trial. SETTING: A single tertiary care referral center. PATIENTS: Fifty-two patients with uncomplicated CBD stones were prospectively randomized to CBD cannulation and stone removal under EUS or ERCP guidance. MAIN OUTCOME MEASUREMENTS AND INTERVENTIONS: Primary outcome measure was the rate of successful cannulation of the CBD. Secondary outcome measures included successful removal of stones and overall complication rates. RESULTS: CBD cannulation followed by stone extraction was successful in 23 of 26 patients (88.5%) in the EUS group (I) versus 25 of 26 patients (96.2%) in the ERCP group (II) (95% CI, -27.65%, 9.88%). Overall, there were 3 complications in the EUS group and 4 complications in the ERCP group. LIMITATION: The current study is an interim report from a single center report and performed by a single operator. CONCLUSIONS: Our preliminary analysis indicates that outcomes following EUS-guided CBD stone retrieval are equivalent to those following ERCP. EUS-related adverse events are similar to those following ERCP. ERCP and EUS-guided stone retrieval appears to be equally effective for therapeutic interventions of the bile duct. Additional studies are required to validate these preliminary results and to determine predictors of success of EUS-guided stone removal.

A decision support system to facilitate management of patients with acute gastrointestinal bleeding.

OBJECTIVE: To develop a model to predict the bleeding source and identify the cohort amongst patients with acute gastrointestinal bleeding (GIB) who require urgent intervention, including endoscopy. Patients with acute GIB, an unpredictable event, are most commonly evaluated and managed by non-gastroenterologists. Rapid and consistently reliable risk stratification of patients with acute GIB for urgent endoscopy may potentially improve outcomes amongst such patients by targeting scarce healthcare resources to those who need it the most. DESIGN AND METHODS: Using ICD-9 codes for acute GIB, 189 patients with acute GIB and all available data variables required to develop and test models were identified from a hospital medical records database. Data on 122 patients was utilized for development of the model and on 67 patients utilized to perform comparative analysis of the models. Clinical data such as presenting signs and symptoms, demographic data, presence of co-morbidities, laboratory data and corresponding endoscopic diagnosis and outcomes were collected. Clinical data and endoscopic diagnosis collected for each patient was utilized to retrospectively ascertain optimal management for each patient. Clinical presentations and corresponding treatment was utilized as training examples. Eight mathematical models including artificial neural network (ANN), support vector machine (SVM), k-nearest neighbor, linear discriminant analysis (LDA), shrunken centroid (SC), random forest (RF), logistic regression, and boosting were trained and tested. The performance of these models was compared using standard statistical analysis and ROC curves. RESULTS: Overall the random forest model best predicted the source, need for resuscitation, and disposition with accuracies of approximately 80% or higher (accuracy for endoscopy was greater than 75%). The area under ROC curve for RF was greater than 0.85, indicating excellent performance by the random forest model. CONCLUSION: While most mathematical models are effective as a decision support system for evaluation and management of patients with acute GIB, in our testing, the RF model consistently demonstrated the best performance. Amongst patients presenting with acute GIB, mathematical models may facilitate the identification of the source of GIB, need for intervention and allow optimization of care and healthcare resource allocation; these however require further validation.

A model-based analysis of chemical and temporal patterns of cuticular hydrocarbons in male Drosophila melanogaster.

Drosophila Cuticular Hydrocarbons (CH) influence courtship behaviour, mating, aggregation, oviposition, and resistance to desiccation. We measured levels of 24 different CH compounds of individual male D. melanogaster hourly under a variety of environmental (LD/DD) conditions. Using a model-based analysis of CH variation, we developed an improved normalization method for CH data, and show that CH compounds have reproducible cyclic within-day temporal patterns of expression which differ between LD and DD conditions. Multivariate clustering of expression patterns identified 5 clusters of co-expressed compounds with common chemical characteristics. Turnover rate estimates suggest CH production may be a significant metabolic cost. Male cuticular hydrocarbon expression is a dynamic trait influenced by light and time of day; since abundant hydrocarbons affect male sexual behavior, males may present different pheromonal profiles at different times and under different conditions.