Pre-pregnancy BMI, gestational weight gain, and telomere length in amniotic fluid: a causal graph analysis.

Previous investigations have suggested a potential association between pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) with telomere length (TL) in various tissues of pregnant women and newborns. Nonetheless, as association does not imply causation, our objective was to investigate the causal connections among pre-pregnancy BMI, GWG, and TL in amniotic fluid. The analysis included 136 mother-child pairs from the Mamma & Bambino cohort, and three causal graph models were developed to depict the interconnections between pre-pregnancy BMI, GWG, and TL. Causal graph analysis was conducted utilizing the do-operator to estimate the causal effect of GWG and the controlled direct effect of pregestational BMI. We revealed that transitioning from non-adequate to adequate GWG had a positive impact on the probability of having "long" TL (i.e., a value greater than the population median) in all three models. When considering the effect of pre-pregnancy BMI, the highest probability of "long" TL was observed in normal weight women with adequate GWG. In contrast, the effect of adequate GWG became minimal among overweight women. These results shed light on the potential causality between pre-pregnancy BMI, GWG, and TL in amniotic fluid, emphasizing the importance of appropriate weight management before and during pregnancy for optimal TL outcomes.

The intertwining of healthcare-associated infections and COVID-19 in Italian intensive care units: an analysis of the SPIN-UTI project from 2006 to 2021.

BACKGROUND: Although healthcare-associated infections (HAIs) pose an extraordinary burden on public health, the impact of coronavirus disease 2019 (COVID-19) is still a matter of debate. AIM: To describe trends of HAIs in Italian intensive care units (ICUs) from 2006 to 2021, and to compare characteristics and outcomes of patients with or without COVID-19. METHODS: We evaluated patients participating in the 'Italian Nosocomial Infections Surveillance in Intensive Care Units' (SPIN-UTI) project, who were admitted to ICUs for more than 48 h. Data regarding diagnosis, clinical conditions, therapies, treatments and outcomes of COVID-19 patients were also collected. FINDINGS: From a total of 21,523 patients from 2006 to 2021, 3485 (16.2%) presented at least one HAI. We observed an increasing trend for both the incidence of patients with HAI and the incidence density of HAIs (P-trend <0.001). Compared with the pre-pandemic period, the incidence density of HAIs increased by about 15% in 2020-2021, with pneumoniae being the greatest contributors to this increase (P-trend <0.001). Moreover, incidence of HAIs was higher in ICUs dedicated to COVID-19 patients (P<0.001), who showed a greater risk of HAIs and death than patients without COVID-19 (P-values <0.001). Accordingly, the mortality in ICUs increased over the years and doubled during the pandemic (P-trend <0.001). Notably, co-infected patients had higher mortality (75.2%) than those with COVID-19 (66.2%) or HAI (39.9%) alone, and those without any infection (23.2%). CONCLUSIONS: Our analysis provides useful insight into whether and how the COVID-19 pandemic influenced HAI incidence and death in Italian ICUs, highlighting the need for evaluation of the long-term effects of the pandemic.

Cluster analysis identifies patients at risk of catheter-associated urinary tract infections in intensive care units: findings from the SPIN-UTI Network.

BACKGROUND: Although preventive strategies have been proposed against catheter-associated urinary tract infections (CAUTIs) in intensive care units (ICUs), more efforts are needed to control the incidence rate. AIM: To distinguish patients according to their characteristics at ICU admission, and to identify clusters of patients at higher risk for CAUTIs. METHODS: A two-step cluster analysis was conducted on 9656 patients from the Italian Nosocomial Infections Surveillance in Intensive Care Units project. FINDINGS: Three clusters of patients were identified. Type of admission, patient origin and administration of antibiotics had the greatest weight on the clustering model. Cluster 1 comprised more patients with a medical type of ICU admission who came from the community. Cluster 2 comprised patients who were more likely to come from other wards/hospitals, and to report administration of antibiotics 48 h before or after ICU admission. Cluster 3 was similar to Cluster 2 but was characterized by a lower percentage of patients with administration of antibiotics 48 h before or after ICU admission. Patients in Clusters 1 and 2 had a longer duration of urinary catheterization [median 7 days, interquartile range (IQR) 12 days for Cluster 1; median 7 days, IQR 11 days for Cluster 2] than patients in Cluster 3 (median 6 days, IQR 8 days; P<0.001). Interestingly, patients in Cluster 1 had a higher incidence of CAUTIs (3.5 per 100 patients) compared with patients in the other two clusters (2.5 per 100 patients in both clusters; P=0.033). CONCLUSION: To the authors' knowledge, this is the first study to use cluster analysis to identify patients at higher risk of CAUTIs who could gain greater benefit from preventive strategies.

Dietary patterns and school performance: evidence from a sample of adolescents in Sicily, Italy.

BACKGROUND: Academic success in adolescence is a strong predictor of future wealth, productivity and health. While unhealthy dietary habits might be detrimental for academic outcomes, a positive association between healthy diet and school performance was found in adolescents worldwide. STUDY DESIGN: A total of 213 adolescents (15 to 18 years old; 48% boys), attending three high schools in the urban area of Eastern Sicily, were enrolled in a cross-sectional study. METHODS: Dietary data and informations about weekly consumption of main meals were collected administering a Food Frequency Questionnaire. The Mediterranean Diet Score and Principal Component Analysis were used to identify a priori and a posteriori dietary patterns, respectively. School performance was assessed through school marks, using the previous year as reference. RESULTS: The Mediterranean Diet Score was weakly but positively correlated with performance in Italian, Science and Physical Education (p-values < 0.05). Similarly, the adherence to the prudent dietary pattern weakly positively correlated with marks in Mathematics. In contrast, we demonstrated a weak but significant negative correlation between adherence to the western dietary pattern and the performance in several subjects. The energy dense dietary pattern was instead negatively correlated with mark in Italian. We also showed that adolescents regularly eating all main meals have a better performance in several subjects, when compared to those who skipped at least one meal. CONCLUSION: The promotion of healthy diet in youth should be a priority for Public Health, in order to improve adolescents' quality of life and prevent negative health and social outcomes later in life.

The impact of social determinants and lifestyles on dietary patterns during pregnancy: evidence from the "Mamma & Bambino" study.

BACKGROUND: During pregnancy, maternal dietary patterns play a critical role in determining maternal and new-born health. Recent evidence highlighted the influence of either social determinants and lifestyles on the adherence to different dietary patterns. STUDY DESIGN: In this cross-sectional analysis, we evaluated the association of social determinants and lifestyles with maternal dietary patterns in the "Mother & Child" cohort, a prospective study that enrols mother-child pairs from Catania, Italy. METHODS: Dietary patterns were derived using Food Frequency Questionnaire and Principal Component Analysis. Logistic regression models were used to evaluate the association between socio-demographic factors (i.e., age, educational level and employment status), lifestyles (i.e., smoking status, body mass index, use of folic acid, multivitamin and multi-mineral supplements) and dietary patterns. RESULTS: Overall, 332 women were enrolled and the following dietary patterns were derived: the "western" dietary pattern, characterized by high intake of red meat, fries, dipping sauces, salty snacks and alcoholic drinks; the second one, named "prudent", characterized by high intake of potatoes, raw and cooked vegetables, legumes, rice and soup. Multivariable analysis showed that young age, low educational level and smoking were positively associated with the adherence to the western dietary pattern. In contrast, pre-gestational body mass index was negatively associated with the adherence to the prudent dietary pattern. CONCLUSION: Our results raise the need of strategies for promoting healthy dietary habits among women in their reproductive age, which might also help control their body weight before and during pregnancy. These strategies should be prioritized to young women of low educational level, who generally share other unhealthy behaviours.

Tubulo-squamous polyp of the vagina. A case with cellular, "angiomyofibroblastic-like" stroma.

Tubulo-squamous polyp is an infrequent, apparently benign lesion which has recently been described in the vagina. Histologically, it is characterized by an epithelial component, consisting of squamous nests and tubules, embedded in a hypocellular fibrous stroma. Here, we report an unusual histological variant showing a cellular stroma, as an additional histologic feature, which could lead to confusion with other site-specific lesions of the vagina. A brief review of the literature on this entity is also provided.

First Report of a Decline and Wilt of Young Olive Trees Caused by Simultaneous Infections of Verticillium dahliae and Phytophthora palmivora in Sicily.

In summer 2008, leaf chlorosis, defoliation, exceptional fruit set, twig dieback, and wilt were observed on 4-year-old olive (Olea europea L.) trees cv. Tonda Iblea in a drip-irrigated orchard in eastern Sicily. Rot of fine roots was associated with these symptoms and on ~15% of symptomatic trees rot extended to the crown and basal stem. Trees declined slowly or collapsed suddenly with withered leaves still attached. Incidence of affected trees was ~10%. A fungus identified as Verticillium dahliae Kleb. was isolated from the xylem of main roots and basal stem. An oomycete identified as Phytophthora palmivora (Butler) Butler was isolated from roots and basal trunk bark. Both pathogens were recovered from symptomatic trees with mean frequency of positive isolations per tree of 80 and 30% for V. dahliae and P. palmivora, respectively. To isolate V. dahliae, wood chips were surface disinfested in 0.5% NaOCl for 1 min and plated onto potato dextrose agar (PDA). The fungus was identified on the basis of microsclerotia, verticillate arrangement of phialides on conidiophores, and hyaline single-celled conidia. Ten monoconidial isolates were characterized by PCR using primer pairs INTND2f/INTND2r and DB19/espdef01 (3). Only 824-bp amplicons, diagnostic of the virulent, nondefoliating V. dahliae pathotype, were obtained. P. palmivora was isolated on selective medium (2) and pure cultures were obtained by single-hypha transfers. Colonies grew on PDA between 10 and 35°C (optimum at 27°C). Chlamydospores and elliptical to ovoid, papillate, caducous (mean pedicel length = 5 µm) sporangia (length/breadth ratio of 1.8) were produced on V8 juice agar. All isolates were paired with reference isolates of P. nicotianae and produced gametangia only with isolates of the A2 mating type. PCR amplicons of a representative isolate generated using primers ITS 6 and ITS 4 (1) were sequenced and found to be identical to those of a reference isolate of P. palmivora (GenBank No. AY208126). Pathogenicity of V. dahliae (IMI 397476) and P. palmivora (IMI 397475) was tested on 6-month-old rooted cuttings of olive cv. Tonda Iblea. Ten cuttings were transplanted into pots with steam-sterilized soil and inoculum of P. palmivora (4% vol/vol) produced on wheat kernels. Ten olive cuttings were inoculated with V. dahliae by injecting the stem with 150 µl of a conidial suspension (107 conidia ml-1) and 10 cuttings were stem inoculated with V. dahliae and transplanted into soil infested with P. palmivora. Controls were 10 noninoculated cuttings transplanted into steam-sterilized soil. Pots were kept in a greenhouse (25 ± 3°C) for 4 months. No aerial symptoms were observed on cuttings transplanted into soil infested with P. palmivora. However, root dry weight was reduced by 40% in comparison with the controls. Cuttings inoculated solely with V. dahliae had a 15% reduction in height compared with the controls but only four cuttings wilted. All cuttings inoculated with P. palmivora and V. dahliae wilted, indicating a synergism between the two pathogens. Controls remained healthy. Each pathogen was reisolated solely from inoculated cuttings and both pathogens were reisolated from cuttings with double inoculations. A similar syndrome 'seca' (drying) was reported in Spain (4). References: (1) D. E. L. Cooke et al. Fungal Genet. Biol. 30:17, 2000. (2) H. Masago et al. Phytopathology 67:425, 1977. (3) J. Mercado-Blanco et al. Plant Dis. 87:1487, 2003. (4) M. E. Sánchez-Hernández et al. Eur. J. Plant Pathol. 104:34, 1998.

[Species of the genus Eimeria (Apicomplexa: Eimeriidae) in giant anteaters (Myrmecophaga tridactyla Linnaeus, 1758) in captivity]. / Espécies do gênero Eimeria (Apicomplexa: Eimeriidae) em Tamanduás-bandeira (Myrmecophaga tridactyla Linnaeus, 1758) em cativeiro.

The parasitism of the two giant anteaters adults (Myrmecophaga tridactyla), one male and one female, infected naturally with Eimeria escomeli, E. tamanduae e E. marajoensis was related in the present research. In E. escomeli oocysts were 23.9 +/- 1.89 by 19.7 +/- 1.60 microm and its sporocysts were 11.47 +/- 1.25 by 6.48 +/- 0.80 microm. In E. tamanduae oocysts were 23.52 +/- 0.95 by 20.59 +/- 0.92 microm and its sporocysts were 12.19 +/- 0.65 by 7.15 +/- 0.55 microm. In E. marajoensis oocysts were 13.5 +/- 1.7 by 13.1 +/- 1.8 microm and its sporocysts were 7.4 +/- 0.58 by 5.4 +/- 0.8 microm. Eimeria escomeli was described before parasitizing giants anteater from Bolivia, and it was point out as the first time in Brazil. The presence of E. tamanduae and E. marajoensis parasitizing giant anteaters indicate the possibility of having co-infection of them among animals of the family Myrmecophagidae.

Aspecific inflammatory lesion (histiocytosis?) simulating intramedullary astrocytoma. Case report.

We report an exceptional case of aspecific inflammatory lesion of the thoracic spinal cord simulating an intramedullary glial tumor. Patient history was characterized by progressive spastic paraparesis with urinary incontinence; MR imaging (T4-T5) showed an enhancing intrinsic mass lesion. Myelotomy enabled partial resection of grayish astrocytoma-like tissue. Only light microscope examination was possible and disclosed aspecific inflammatory tissue composed of eosinophils, lymphocytes and histiocytes. After the operation, the patient improved promptly and no further therapy was administered. Control MRI after four months, one year and two years showed complete disappearance of the intramedullary mass lesion and the patient remained clinically stable with no other signs of disease. Since electron microscopic as well as immunohistochemical studies were not available, a definitive histological diagnosis was not possible. However on the basis of some clinical similarities with cases of isolated histiocytosis X of the CNS reported in the literature, we suggest that a diagnosis of isolated intramedullary eosinophilic granuloma could be reasonable.

Chemoenzymatic synthesis of spacer-linked oligosaccharides for the preparation of neoglycoproteins.

In the present work, the combination of chemical and enzymatic methods to obtain neoglycoproteins is described. Three bovine serum albumin (BSA)-conjugates, BSA-[GalNAc alpha-], BSA-[Gal(beta 1-3)GalNAc(alpha-], and BSA-[Neu5Ac(alpha 2-3)Gal(beta 1-3)GalNAc(alpha-], were prepared. alpha GalNAc derivatives were galactosylated employing crude beta-galactosidase from bovine testes. The use of oversaturated donor solutions (pNP beta Gal) enhanced the yields up to 60%. This method was verified using divalent structures as acceptors, that rendered di- and tri-galactosylated products. Further treatment of the disaccharides with CMP-Neu5Ac and alpha 2-3 sialyltransferase from pork liver led to formation of trisaccharides. Finally, mono-, di-, and trisaccharides were coupled to BSA employing a thiolic group introduced into the protein for Michael addition to a maleinimide group in the spacer-arm of the saccharide components. The results were monitored by HPLC and MALDI-TOF.

Conjugation of 5-azido-3-oxapentyl glycosides with thiolated proteins through the use of thiophilic derivatives.

5-Azido-3-oxa-pentyl beta-D-galactopyranoside was prepared from diethylene glycol monochlorohydrin and used as a model of oligosaccharide hapten. After deprotection, a series of amides bearing thiophilic groups had been obtained through the terminal amino function and essayed in coupling reactions with thiolated BSA. Also several Lewis human blood group oligosaccharides had been conjugated with thiolated BSA demonstrating the usefulness of the methodology.

Galactosylation with beta-galactosidase from bovine testes employing modified acceptor substrates.

In this study beta1-3 linked analogues of the T-antigen determinant were synthesized in preparative scale by transgalactosylation using beta-galactosidase from bovine testes to give synthetic antigens. Acceptors with modifications of the sugar residue such as alpha-glycosylated spacers, as well as GlcNAc-alphaOR- and 2dGal-alphaOR-substrates opened further possibilities for galactosylation.

Distinction between diffuse cutaneous malignant follicular center cell lymphoma and lymphoid hyperplasia by computerized nuclear image analysis.

The difficult differential diagnosis between the diffuse variants of cutaneous lymphoid hyperplasia (CLH; synonym; pseudolymphoma) and malignant follicular center cell lymphomas (FCCL) often requires a multidisciplinary approach. Eighteen CLH and 11 FCCL, diagnosed by conventional histology and immunophenotyping and subsequently examined with a polymerase chain reaction to show clonal immunoglobulin heavy-chain gene rearrangements, were subjected to a novel type of automated nuclear image analysis. Of all nuclear parameters tested in azure A-stained semithin sections, the mean nuclear profile area (TN) of lymphoid cells was the best criterion to distinguish between CLH and FCCL (p = 9 x 10(-6)). Additional distinctive features, in the order of decreasing significance, were the SD of TN; all chromatin textural parameters combined; and the light and the dark fractions of the central nuclear profile areas. Parameters related to the chromatin pattern were independent of nuclear profile size in FCCL, but not in CLH. Two lesions registered as CLH displayed the nuclear characteristics favoring this diagnosis, but showed B-cell monoclonality at the DNA level. In conclusion, computerized nuclear image analysis is a helpful additional diagnostic tool in the evaluation of diffuse CLH and cutaneous FCCL.

Apoptotic index: discriminant feature for the differentiation of cutaneous diffuse malignant follicular center cell lymphomas from lymphoid hyperplasia.

Diffuse subtypes of cutaneous lymphoid hyperplasia (CLH; n = 18) and primary malignant follicular center cell lymphoma of the skin (FCCL, n = 11) were diagnosed by conventional histology, immunophenotyping on paraffin sections, and gene rearrangement analysis. We then counted on semithin, Azur A-stained sections of resin-re-embedded biopsy specimens the relative numbers of apoptotic bodies among all lymphoid cells (apoptotic index [AI]). The diagnostic value of AI was compared to that of mitotic indices (MI) and percentages of various cell types in the cutaneous infiltrate. Features of cellular infiltrates distinguishing to two groups of lesions, in the order of decreasing significance, were percent large lymphoid cells, percent medium-sized lymphoid cells (both higher in FCCL); percent small lymphoid cells, percent epithelioid/giant cells, and percent histiocytes/macrophages (all three higher in CLH). However, of all parameters tested, AI had the greatest discriminant value (median in FCCL 1.11%, in CLH 0.14%; p = 8 x 10(-6)). Two cases, diagnosed as CLH with all morphologic and immunologic methods used, showed B-cell monoclonality at the DNA level. Linear discriminant analysis determined the following order of distinctive power of variables: 1) AI; 2) MI; 3) percent small lymphoid cells; 4) percent medium-sized lymphoid cells; 5) percent large lymphoid cells; 6) percent epithelioid/giant cells; and 7) percent histiocytes/macrophages. The present study thus establishes AI as an important parameter in the differentiation of diffuse CLH from diffuse cutaneous FCCL.

Gastric intestinal metaplasia type III cases are classified as low-grade dysplasia on the basis of morphometry.

The aim of this study was to try to place gastric intestinal metaplasia, type III (type III IM) in the stepwise chain of events from atrophic gastritis to cancer. A number of dysplastic, periulcer regenerative, and type III IM lesions were qualitatively diagnosed (and graded) blindly and independently by several pathologists. These lesions were further analysed by means of quantitative parameters, with the aim of differentiating dysplastic from regenerative changes. Inconsistencies between the qualitative and quantitative classification (about 7 per cent of cases) were eliminated and homogeneous groups (low-grade dysplasia, high-grade dysplasia, regenerative changes) were obtained. These cases were taken as the gold standard against which type III IM was compared. The results indicate that the great majority (91.4 per cent) of cases of type III IM fulfil the nuclear and architectural criteria for low-grade dysplasia.

Prognostic factors in invasive cervical carcinomas associated with human papillomavirus (HPV). Quantitative data and cytokeratin expression.

As a part of a larger programme to search for the prognostic factors in cervical cancer, quantitative morphometry, demonstration of AgNORs and expression of different cytokeratin polypeptides (SK2-27, SK1, A 53-B/A2) were used to study a series of 85 cervical squamous cell carcinomas, previously analysed for the presence of human papillomavirus (HPV) DNA by in situ hybridization and polymerase chain reaction (PCR). The following nuclear profile parameters were calculated: nuclear area, perimeter, maximum diameter, ellipsoidity (form Ell), regularity (form Ar) and roundness (form Pe). In each case, the number of small (< 3 microns), large (> 3 microns), the total number and the ratio large/small AgNORs were registered. The cancer cell density and the lymphoid cell density were assessed. In the survival analysis, neither the expression of different cytokeratin polypeptides or the pattern of cytokeratin staining proved to be an independent variable. Similarly, none of the nuclear profile parameters analysed possessed an independent prognostic value in the survival analysis. The ratio of large/small AgNORs proved to be a significant independent prognostic predictor (p = 0.0104), second only to the lymphoid cell density. Also the total number of AgNORs was a prognostic indicator. This suggests that AgNOR size and ratio reflect tumor proliferation also in cervical squamous cell carcinoma, as shown in other human malignancies. Similarly, the density of cancer cell nuclei proved to be an independent prognostic predictor (p = 0.0601) in that the tumours in patients with longer survival showed lower density of the nuclei.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitatively evaluated ultrastructural findings can add to the differential diagnosis between keratoacanthoma and well differentiated squamous cell carcinoma.

The differential diagnosis between keratoacanthoma (KA) and well differentiated squamous cell carcinoma (WDSCC) is not always easy to perform. Seven cases of KA and seven cases of WDSCC have been here analyzed by morphometry on ultrastructural sections and compared with normal epidermis. Parameters expressing the cohesivity among epithelial cells (numerical and surface density of desmosomes; volume density of intercellular space) were significantly different in KA and WDSCC, so that they may be useful in differential diagnosis. The Authors also questioned the nature of KA, suggesting a continuum between this lesion and WDSCC.

Bronchiolo-alveolar carcinoma: an analysis of survival predictors.

Macroscopic and microscopic features of tumours have been analysed in 37 bronchiolo-alveolar carcinomas. Lymphocytes, Langerhans cells, collagen (mature and/or myofibroblastic), were quantitatively or semiquantitatively evaluated. Histology, stage, type of fibrosis, nuclear profile features (area and shape factors), amount and type of mucin secreted, number of mitoses, Langerhans cells, myofibroblasts and LeuM1+ cells were not related to survival. Gross morphology of the tumour and, to a lesser extent, lymphoid infiltrates (in particular UCHL1+ and L26+ peritumoral lymphoid cells) were the only variables significantly related to survival. Estimated survival functions were computed according to Cox's model: well demarcated tumours behaved significantly better than poorly demarcated tumours and even more so than diffuse or multiple mass. Lymphoid infiltrates were significantly more represented in and around well demarcated tumours: however, their survival predicting value was less than that of the gross type.

Morphometry and the differential diagnosis between peripheral neuroepithelioma and neuroblastoma.

The differential diagnosis based on morphology between neuroblastoma (NB) and peripheral neuroepithelioma (PN) is difficult, since these tumors share many architectural and cytological features. In this study, a morphometrical approach to this diagnosis is made by using nuclear (shape factors) and tissue (volume density of nuclei and stroma) parameters. Quantitative morphological analysis adds important information, which when used with clinical and biochemical data facilitates the distinction. In the majority of cases, nuclei of PN are significantly less round than those of NB and their profile is much more irregular. The density of neoplastic nuclei is significantly higher in PN. However, in a certain number of cases, even the morphometrical study confirms how difficult it may be to differentiate these two neoplastic entities, since the values of parameters are largely overlapping. This suggests the existence of a "continuum" of changing features between NB and PN, which may substantiate the hypothesis of a common histogenesis.

Morphometric distinction of low- and high-grade dysplasias in gastric biopsies.

Substantial agreement has previously been demonstrated between qualitative and morphometric grading of gastric dysplasia. In the present study, a further attempt is made to quantitatively define the dysplastic changes in relation to associated benign or malignant changes of gastric mucosa. In total, 232 cases were studied and were associated with benign peptic ulcer (89 cases), histologically proven gastric cancer (88 cases), and gastritis-associated mild, moderate, and severe dysplasias (55 cases). The analysis showed that one discriminant function consisting of seven morphometric features is sufficient to separate the regenerative and cancer-associated cases. The classification results obtained on the basis of this discriminant function in both training and testing sets are encouragingly similar, indicating that the classification is reliable. This was further confirmed by the results of the application of this rule in the mild, moderate, and severe dysplasia biopsies (the above-mentioned gastritis-associated cases) used in a previous study. The quantitative analysis permits two grades, instead of three, to be distinguished: low-grade and high-grade dysplasia.