Changes in cortisol and corticosteroid receptors during dynamic salinity challenges in Mozambique tilapia.

In estuarine environments, euryhaline fish maintain a narrow range of internal osmolality despite daily changes in environmental salinity that can range from fresh water (FW) to seawater (SW). The capacity of euryhaline fish to maintain homeostasis in a range of environmental salinities is primarily facilitated by the neuroendocrine system. One such system, the hypothalamic-pituitary-interrenal (HPI) axis, culminates in the release of corticosteroids such as cortisol into circulation. Cortisol functions as both a mineralocorticoid and glucocorticoid in fish because of its roles in osmoregulation and metabolism, respectively. The gill, a key site for osmoregulation, and the liver, the primary storage site for glucose, are known targets of cortisol's actions during salinity stress. While cortisol facilitates acclimation to SW environments, less is known on its role during FW adaptation. In this study, we characterized the responses of plasma cortisol, mRNA expression of pituitary pro-opiomelanocortin (pomc), and mRNA expression of liver and gill corticosteroid receptors (gr1, gr2, and mr) in the euryhaline Mozambique tilapia (Oreochromis mossambicus) under salinity challenges. Specifically, tilapia were subjected to salinity transfer regimes from steady-state FW to SW, SW to FW (experiment 1) or steady state FW or SW to tidal regimen (TR, experiment 2). In experiment 1, fish were sampled at 0 h, 6 h, 1, 2, and 7 d post transfer; while in experiment 2, fish were sampled at day 0 and day 15. We found a rise in pituitary pomc expression and plasma cortisol following transfer to SW while branchial corticosteroid receptors were immediately downregulated after transfer to FW. Moreover, branchial expression of corticosteroid receptors changed with each salinity phase of the TR, suggesting rapid environmental modulation of corticosteorid action. Together, these results support the role of the HPI-axis in promoting salinity acclimation, including in dynamically-changing environments.

Prognosis of CT-derived Fractional Flow Reserve in the Prediction of Clinical Outcomes.

PURPOSE: To examine the prognostic implication of fractional flow reserve (FFR) derived from coronary CT (FFRCT) in routine clinical practice. MATERIALS AND METHODS: Patients referred for FFRCT analysis at a single center between October 2015 and June 2017 were retrospectively included and followed up for rates of invasive angiography and clinical events. Two hundred seven patients underwent successful FFRCT analysis with seven lost to follow-up, leaving 200 (mean age ± standard deviation, 62.4 years ± 10.0; 49 [24.5%] women) patients for analysis. At coronary CT angiography, patients were categorized as having significant stenosis (SS) in the presence of a diameter stenosis greater than or equal to 50% (hereafter, SS positive) and flow limitation in the presence of a postlesion (that is, FFRCT measured 2 cm to the distal aspect of the lesion) FFRCT less than 0.80 (hereafter, FFRCT positive). Vessel-oriented clinical events (VOCEs) were defined as vessel-related late revascularization (>90 days), myocardial infarction, and cardiac mortality. RESULTS: At CT angiography, 130 (65%) studies were SS positive and 63 (31.5%) were FFRCT positive. At median follow-up of 477 days (range, 252-859 days), there were 26 VOCE end points in 22 patients: 22 revascularizations and four nonfatal myocardial infarctions. VOCE end points occurred in zero of 58 (0%) of SS-negative and FFRCT negative patients, in eight of 79 (10.1%) of SS-positive and FFRCT-negative patients, in zero of 12 (0%) of SS-negative and FFRCT-positive patients, and in 18 of 51 (35.3%) of SS-positive and FFRCT-positive patients (log-rank χ2 = 30.1; P < .001). At multivariable Cox regression, both FFRCT (hazard ratio per 0.1 decrease, 1.54 [95% confidence interval: 1.1, 2.2] P = .013) and stenosis (hazard ratio per unit increase, 2.16 [95% confidence interval: 1.25, 3.72] P = .006) were independently associated with VOCE. CONCLUSION: Stenosis and FFRCT are independent predictors of intermediate-term outcomes. In the absence of a stenosis greater than 50%, a positive FFRCT result is not associated with an increased intermediate risk.© RSNA, 2019Supplemental material is available for this article.See also commentary by Fairbairn and Bull in this issue.

Phosphorus concentration and loading reductions following changes in fertilizer application and formulation on managed turf.

Excess phosphorus, particularly in surface waters can lead to severe eutrophication. Identifying source areas, quantifying contributions, and evaluating management practices are required to address current and future water quality concerns. A before-after study was conducted from 2003-2010 on a sub-watershed of Northland Country Club Golf Course in Duluth, MN to demonstrate the impacts of two different phosphorus management approaches (Period 1: traditional application and timing using commercially available synthetic blends; Period 2: reduced rate, low dose applications, and organic formulations). Outflow median dissolved reactive phosphorus (DRP) and total phosphorus (TP) stream concentrations were significantly less in Period 2 compared to Period 1. There was no statistical difference in the mean TP loading in Period 1 (0.25 kg ha(-1) year(-1)) compared to Period 2 (0.20 kg ha(-1) year(-1)) or between the DRP loading in Period 1 (0.15 kg ha(-1) year(-1)) compared to Period 2 (0.09 kg ha(-1) year(-1)). However, by switching to organic phosphorus formulations and reducing application rates by greater than 75%, substantial reduction in DRP and TP concentrations was achieved. Based on these findings it is recommended that turf managers (parks and recreation to golf courses) explore the feasibility of altering their fertility management related to phosphorus by including organic formulations, low dose applications, and overall rate reductions. Additionally, it is recommended that the fertilizer industry develop and make more readily available commercial blends with lesser to zero amounts of phosphorus.

The Bcl-2 repertoire of mesothelioma spheroids underlies acquired apoptotic multicellular resistance.

Three-dimensional (3D) cultures are a valuable platform to study acquired multicellular apoptotic resistance of cancer. We used spheroids of cell lines and actual tumor to study resistance to the proteasome inhibitor bortezomib in mesothelioma, a highly chemoresistant tumor. Spheroids from mesothelioma cell lines acquired resistance to bortezomib by failing to upregulate Noxa, a pro-apoptotic sensitizer BH3-only protein that acts by displacing Bim, a pro-apoptotic Bax/Bak-activator protein. Surprisingly, despite their resistance, spheroids also upregulated Bim and thereby acquired sensitivity to ABT-737, an inhibitor of anti-apoptotic Bcl-2 molecules. Analysis using BH3 profiling confirmed that spheroids acquired a dependence on anti-apoptotic Bcl-2 proteins and were 'primed for death'. We then studied spheroids grown from actual mesothelioma. ABT-737 was active in spheroids grown from those tumors (5/7, ∼70%) with elevated levels of Bim. Using immunocytochemistry of tissue microarrays of 48 mesotheliomas, we found that most (33, 69%) expressed elevated Bim. In conclusion, mesothelioma cells in 3D alter the expression of Bcl-2 molecules, thereby acquiring both apoptotic resistance and sensitivity to Bcl-2 blockade. Mesothelioma tumors ex vivo also show sensitivity to Bcl-2 blockade that may depend on Bim, which is frequently elevated in mesothelioma. Therefore, mesothelioma, a highly resistant tumor, may have an intrinsic sensitivity to Bcl-2 blockade that can be exploited therapeutically.

micro-XANES and micro-XRF investigations of metal binding mechanisms in biosolids.

Micro-X-ray fluorescence (micro-XRF) microprobe analysis and micro-X-ray absorption near-edge structure (micro-XANES) spectroscopy were employed to identify Fe and Mn phases and their association with selected metals in two biosolids (limed composted [LC] and Nu-Earth) before and after treatment to remove organic carbon (OC). Spatial correlations derived from elemental mapping of XRF images showed strong correlations between Fe and Cd, Cr, Pb, or Zn (r2= 0.65-0.92) before and after removal of most of the OC. The strong correlation between Fe and Cu that was present in intact samples disappeared after OC removal, suggesting that Cu was associated with OC coatings that may have been present on Fe compounds. Except for Fe and Cr, the spatial correlations of metals with Mn were improved after treatment to remove OC, indicating that the treatment may have altered more than the OC in the system. The Fe micro-XANES spectra of the intact biosolids sample showed that every point had varying mixtures of Fe(II and III) species and no two points were identical. The lack of uniformity in Fe species in the biosolids sample illustrates the complexity of the materials and the difficulty of studying biosolids using conventional analytical tools or chemical extraction techniques. Still, these microscopic observations provide independent information supporting the previous laboratory and field hypothesis that Fe compounds play a major role in retention of environmentally important trace elements in biosolids. This could be due to co-precipitation of the metals with Fe, adsorption of metals by Fe compounds, or a combination of both mechanisms.

Methods for speciation of metals in soils: a review.

The inability to determine metal species in soils hampers efforts to understand the mobility, bioavailability, and fate of contaminant metals in environmental systems, to assess health risks posed by them, and to develop methods to remediate metal contaminated sites. Fortunately, great strides have been made in the development of methods of species characterization and in their application to the analysis of particulates and mixtures of solid phases in physics, analytical chemistry, and materials science. This manuscript highlights a selection of the analytical methods available today offering the greatest promise, briefly describes the fundamental processes involved, examines their limitations, points to how they have been used in the environmental and geochemical literature, and offers some suggested research directions in the hope of stimulating further investigation into the application of these powerful tools to the problems outlined above.

Trace element chemistry in residual-treated soil: key concepts and metal bioavailability.

Trace element solubility and availability in land-applied residuals is governed by fundamental chemical reactions between metal constituents, soil, and residual components. Iron, aluminum, and manganese oxides; organic matter; and phosphates, carbonates, and sulfides are important sinks for trace elements in soil-residual systems. The pH of the soil-residual system is often the most important chemical property governing trace element sorption, precipitation, solubility, and availability. Trace element phytoavailability in residual-treated soils is often estimated using soil extraction methods. However, spectroscopic studies show that sequential extraction methods may not be accurate in perturbed soil-residual systems. Plant bioassay is the best method to measure the effect of residuals on phytoavailability. Key concepts used to describe phytoavailability are (i) the salt effect, (ii) the plateau effect, and (iii) the soil-plant barrier. Metal availability in soil from metal-salt addition is greater than availability in soil from addition of metal-containing residuals. Plant metal content displays plateaus at high residual loadings corresponding to the residual's metal concentration and sorption capacity. The soil-plant barrier limits transmission of many trace elements through the food chain, although Cd (an important human health concern) can bypass the soil-plant barrier. Results from many studies that support these key concepts provide a basis of our understanding of the relationship between trace element chemistry and phytoavailability in residual-treated soils. Research is needed to (i) determine mechanisms for trace element retention of soil-residual systems, (ii) determine the effect of residuals on ecological receptors and the ability of residuals to reduce ecotoxicity in metal-contaminated soil, and (iii) predict the long-term bioavailability of trace elements in soil-residual systems.

Use of fish liver PLHC-1 cells and zebrafish embryos in cytotoxicity assays.

Heat shock proteins (HSPs) indicate exposure to cellular stress and adverse cellular effects, thus serving as biomarkers of these effects. The highly conserved Hsp70 proteins are expressed under proteotoxic conditions, whereas small HSPs are expressed in response to stressors acting on the cytoskeleton and cell signaling pathways. Poeciliopsis lucida hepatocellular carcinoma line 1 (PLHC-1) cells have been used extensively for studying effects of cytotoxicity. A number of assays have been developed to examine DNA levels, protein levels, growth rate, morphological changes, and viability. The boundary between sub-lethal and lethal effects of particular stressors has been determined. The methodology and analytical framework for these techniques along with sample assays using cadmium stressed PLHC-1 cells are described. A range of methodologies have been developed in the past decade that allow the analysis and interpretation of gene expression and function in vivo in zebrafish embryos, and many of these are now being applied to the development of embryotoxicity assays. Here we provide the theoretical background and methodology for utilizing Hsp70 expression as an indicator of toxicity in the zebrafish embryo. Hsp70 expression is activated in a tissue-specific manner in zebrafish larvae following exposure to a number of different toxicants, including cadmium. This has allowed the development of an hsp70/eGFP reporter gene system in stable transgenic zebrafish that serves as a reliable yet extremely quick indicator of cell-specific toxicity in the context of the multicellular, living embryo.

Psychopathology in people with epilepsy and intellectual disability; an investigation of potential explanatory variables.

OBJECTIVES: There are few studies on epilepsy and psychopathology in people with intellectual disability (mental retardation) despite epilepsy prevalence rates that are thirty times higher than in the general population. The aims of this study, therefore, were to identify reliable, epilepsy-specific predictors of psychiatric and behavioural disorder in these patients, and to investigate reliable predictors of carer stress. METHODS: A database of 685 patients was compiled, from which 250 were randomly selected. Structured interviews were completed on 186 of these 250 patients (74%) (108 men, 78 women; mean age (SD) 35.5 (10.1)) comprising descriptive, clinical and functional components, and validated measures of psychopathology for which comparative data were available. Logistic and linear regression methods were used to identify predictors. RESULTS: One-third of patients with epilepsy and intellectual disability met criteria for possible psychiatric disorder, particularly affective/neurotic disorder; twice the comparison rates for intellectual disability alone. Behavioural problem levels, however, were lower than population norms. Regression models explaining modest amounts of variance (R(2)< or =24%) suggested certain seizure phenomena (greater seizure severity, more seizures in past month, lesser tendency to loss of consciousness during seizures) as particular risk factors for psychiatric disorder. General disability factors such as level of intellectual, sensory or motor disability and side effects of medication, however, contributed more to explaining behavioural problems. Around half of the family carers reported significant stress, and one-third exhibited clinically significant anxiety symptoms. Younger carers were more stressed, and side effects from patients' medication also contributed to carer stress. CONCLUSIONS: Although epilepsy in itself may be a risk factor for psychopathology in a minority of people with intellectual disability, some epilepsy-specific factors may predict psychiatric disorder. Behavioural problems need to be considered separately from psychiatric disorder because general factors, more closely associated with disability, are stronger predictors of their occurrence.

Management and long-term follow-up of hepatic cysts.

PURPOSE: To provide an algorithm for the management of hepatic cysts through an analysis of our series over 16 years. METHOD: We reviewed the surgical management and outcome of patients with hepatic cysts between 1984 and 2000 at a single institution. Data were collected by chart review, telephone interview, and follow-up hepatic ultrasonography. RESULTS: Forty-four patients (36 females, 8 males) underwent a total of 46 operations for hepatic cysts (mean size 12.0 +/- 5.2 cm) with a mean follow-up of 5.1 +/- 4.0 years. We treated 28 simple cysts, 4 polycystic liver disease (PCLD), 7 cystadenomas, 2 hydatid cysts, 1 cystadenocarcinoma, 1 endometrioma, and 1 hepatic foregut cyst. Operations included simple drainage, wide unroofing (open and laparoscopic), and hepatic resection. Four patients experienced a symptomatic recurrence after definitive treatment; 3 of these patients had PCLD. Four of the 7 patients with cystadenomas had undergone previous operations that required subsequent definitive resection without a recurrence. CONCLUSIONS: The preoperative distinction between simple cysts and cystadenomas/cystadenocarcinomas can be difficult, yet the management is different. Unroofing is a safe and effective operation for patients with simple cysts. Patients with PCLD frequently have recurrences. Cystadenomas should be completely resected owing to the likelihood of recurrence after partial excision and the risk of eventual cystadenocarcinoma. We present a treatment algorithm for the preoperative evaluation and management of hepatic cysts based on the largest number of patients with the longest follow-up reported to date.

Adsorption of cadmium on biosolids-amended soils.

Debate exists over the biosolid phase (organic or inorganic) responsible for the reduction in phytoavailable Cd in soils amended with biosolids as compared with soils amended with inorganic salts. To test the importance of these two phases, adsorption isotherms were developed for soil samples (nine biosolids-amended soils and their five companion controls) and two biosolids samples from five experimental sites with documented histories of biosolids application. Subsamples were treated with 0.7 M NaClO to remove organic carbon. Cadmium nitrate was added to both moist soil samples and their soil inorganic fractions (SIF) in a 0.01 M Ca(NO3)2 solution at three pH levels (6.5, 5.5, and 4.5), and equilibrated at 22 +/- 1 degrees C for at least 48 h. Isotherms of Cd adsorption for biosolids-amended soil were intermediate to the control soil and biosolids. Decreasing pH did not remove the difference between these isotherms, although adsorption of Cd decreased with decreasing pH level. Organic matter removal reduced Cd adsorption on all soils but had little influence on the observed difference between biosolids-amended and control soils. Thus, increased adsorption associated with biosolids application was not limited to the organic matter addition from biosolids; rather, the biosolids application also altered the adsorptive properties of the SIF. The greater affinity of the inorganic fraction of biosolids-amended soils to adsorb Cd suggests that the increased retention of Cd on biosolids-amended soils is independent of the added organic matter and of a persistent nature.

Effects of pH on dechlorination of trichloroethylene by zero-valent iron.

The surface normalized reaction rate constants (k(sa)) of trichloroethylene (TCE) and zero-valent iron (ZVI) were quantified in batch reactors at pH values between 1.7 and 10. The k(sa) of TCE linearly decreased from 0.044 to 0.009l/hm(2) between pH 3.8 and 8.0, whereas the k(sa) at pH 1.7 was more than an order higher than that at pH 3.8. The degradation of TCE was not observed at pH values of 9 and 10. The k(sa) of iron corrosion linearly decreased from 0.092 to 0.018l/hm(2) between pH 4.9 and 9.8, whereas it is significantly higher at pH 1.7 and 3.8. The k(sa) of TCE was 30-300 times higher than those reported in literature. The difference can be attributed to the pH effects and precipitation of iron hydroxide. The k(sa) of TCE degradation and iron corrosion at a head space of 6 and 10ml were about twice of those at zero head space. The effect was attributed to the formation of hydrogen bubbles on ZVI, which hindered the transport the TCE between the solution and reaction sites on ZVI. The optimal TCE degradation rate was achieved at a pH of 4.9. This suggests that lowering solution pH might not expedite the degradation rate of TCE by ZVI as it also caused faster disappearance of ZVI, and hence decreased the ZVI surface concentration.

The social predictors of adolescent alcohol misuse: a test of the social development model.

OBJECTIVE: This study was conducted to investigate the ability of the social development model (SDM) to predict alcohol misuse at age 16 and to investigate the ability of the SDM to mediate the effects of alcohol use at age 14 on alcohol misuse at age 16. METHOD: The sample of 807 (411 males) is from the longitudinal panel of the Seattle Social Development Project which, in 1985, surveyed all consenting fifth-grade students from 18 elementary schools serving high-crime neighborhoods in Seattle, Washington. Alcohol use was measured at age 14, predictors of alcohol misuse were measured at age 15 and alcohol misuse was measured at age 16. Structural equation modeling was used to examine the fit of the model to the data. RESULTS: All factor loadings were highly significant and the measurement model achieved a good fit with the data (Comparative Fit Index [CFI] = 0.93). A second-order structural model fit the data well (CFI = 0.91) and also explained 45% of the variance in alcohol misuse at age 16. The SDM partially and significantly mediated the direct effect of age-14 alcohol use on age-16 alcohol misuse. CONCLUSIONS: The risk and protective processes specified by the SDM serve as potential targets for the prevention or reduction of adolescent alcohol misuse.

Formation of chloropyromorphite in a lead-contaminated soil amended with hydroxyapatite.

Conversion of soil Pb to pyromorphite [Pb5(PO4)3Cl] was evaluated by reacting a Pb contaminated soil collected adjacent to a historical smelter with hydroxyapatite [Ca5(PO4)3OH]. In a dialysis experiment where the soil and hydroxyapatite solids were placed in separate dialysis bags suspended in 0.01 M NaNO3 solution a crystalline precipitate, identified as chloropyromorphite, formed on the dialysis membrane containing the soil. The aqueous composition of the solution indicated that dissolution of solid-phase soil Pb was the rate-limiting step for pyromorphite formation. Addition of hydroxyapatite to the soil caused a decrease in each of the first four fractions of sequential extractable Pb and a 35% increase in the recalcitrant extraction residue. After a 240-d incubation at field-moisture content there was a further increase in the recalcitrant extraction residue fraction of the hydroxyapatite-amended soil to 45% of the total soil Pb. The increase in the extraction residue fraction in the hydroxyapatite amended 0-d incubated soil as compared to the control soil illustrates that the chemical extraction procedure itself caused changes in extractability. Thus, the chemical extraction procedure cannot easily be utilized to confirm changes occurring in amended soils. The further increase after the 240-d incubation implies that the reaction also occurs in the soil during incubation. Extended X-ray absorption fine structure (EXAFS) spectroscopy indicated that after the 240-d incubation the hydroxyapatite treatment caused a change in the average, local molecular bonding environment of soil Pb. Low-temperature EXAFS spectra (chi data and radial structure functions--RSFs) showed a high degree of similarity between the chemical extraction residue and synthetic pyromorphite, providing additional evidence that the change of soil Pb to pyromorphite is possible by simple amendments of hydroxyapatite to soil.

Severe neutropenia as an adverse effect of methimazole in the treatment of hyperthyroidism.

Ms. K., a white, 47-year-old female with a history of hyperthyroidism had been treated with methimazole daily for a period of 9 years. She presented with a 2-day history of fever higher than 103 degrees F and cellulitis of the right arm after a scratch injury. White blood cell count (WBC) was noted at 0.4 x 10(3)/microL and neutrophils at 5.6%, indicating agranulocytosis. Methimazole was discontinued by the patient with the onset of symptoms. Appropriate intravenous antibiotic therapy and reverse isolation were provided in the acute-care setting, as well as administration of the granulocyte colony-stimulating factor (G-CSF) filgrastim. No recovery of the granulocyte count or improvement of clinical condition was noted until her sixth day of admission, at which time her WBC increased to 2.6 x 10(3)/microL. The administration of intravenous antifungals and antibiotics prevented overwhelming sepsis, while giving the G-CSF the opportunity to stimulate growth of granulocytes to finally fight the offending organisms and save this patient.

Benefits and safety of hepatic resection for colorectal metastases.

BACKGROUND: Metastatic colorectal carcinoma to the liver is a potentially curable disease. The purpose of this study was to determine the safety and efficacy of hepatic resection for metastatic colorectal carcinoma. METHODS: One hundred twenty-one consecutive hepatic resections in 110 patients with metastatic colorectal cancer between January 1978 and September 1998 performed by a single surgeon were reviewed. RESULTS: The actuarial 5-year survival for all patients in the series was 46%. Of the patients operated on before 1993, the actual 5-year survival was 43% and actual disease-free 5-year survival was 28%. The actual 10-year survival was 27%, and of all patients operated on in the last 20 years, 48% are alive today. When comparing initial regional lymph node status, the 5-year survival was 54% for the patients with negative lymph nodes and 40% for patients with positive nodes. Only 18% of patients required a perioperative blood transfusion, and the median length of stay was 7 days. There were complications in 34% of cases, and the operative mortality was 4%. CONCLUSIONS: Hepatic resection for metastatic colon cancer is safe, and significant longevity and cure can be obtained after resection.

Serogroup B, electrophoretic type 15 Neisseria meningitidis in Canada.

Invasive meningococcal disease is nationally reportable in Canada. In recent years, a serogroup C genotype, designated electrophoretic type 15 (ET15), has been the most frequently isolated meningococcal genotype in Canada and has caused epidemics across the country. Between August 1993 and September 1995, there were 9 cases of invasive meningococcal disease caused by a variant of this genotype, expressing group B capsular polysaccharide. The appearance of serogroup B:ET15 was related temporally and geographically to mass immunization campaigns designed to control serogroup C meningococcal disease in Canada. Since there is no vaccine available to control serogroup B meningococcal disease, the appearance of this variant may have public-health significance if it demonstrates the same epidemic potential as its serogroup C counterpart.

Intraductal neoplasms of the pancreas.

BACKGROUND: Since 1980 a group of pancreatic tumors have been termed intraductal papillary mucinous tumors (IPMT). Because these tumors occupy an intraductal position they are demonstrated by pancreatography to reside in the main pancreatic duct (MPD) or side branch ducts (SBD). Lesions of IPMT result in abdominal pain or pancreatitis symptoms because mucin production or papillary growth results in ductal obstruction. Only 104 cases had been reported in the literature by 1996 but more are being presented in abstract form. We reviewed our own 33 cases to assist defining operative decision-making criteria. METHODS: All cases of IPMT between 1989 and 1997 were reviewed for clinical presentation, anatomy by endoscopic retrograde cholangiopancreatography and computed tomography, histologic findings, and long-term outcomes. RESULTS: Our cases were older (65 years) and presented with disease centered mainly in the head of the gland. Clinical presentation was epigastric pain (82%), pancreatitis (56%), weight loss (36%), diabetes (27%), and jaundice (9%). Operations were pancreatectomy in 31 (Whipple n = 15, total n = 5, distal n = 10, local n = 1), bypass only (n = 1), and no operation (n = 1). Malignancy was found in 14 of 33 (42%). Factors significantly associated (P <0.05 Fisher exact test) with malignancy were history of alcohol abuse or death from disease. Jaundice or presence in both MPD and SBD approached a significant association with malignancy but not abdominal pain, weight loss, diabetes, preoperative serum elevations of amylase, SGOT, CA-19-9, or CEA; diffuse MPD dilation, gland region, gross mucus in ducts or filling defects, cytology, calcifications, or a pancreatic mass. In 31 resected patients after a follow-up of 37 months (1 to 103) death had occurred in 6 of 13 malignant cases and 0 of 18 with benign disease. Three-year actuarial survival was 82% (all) and 56% (malignant). Symptom recurrence after resection was found in 6 of 31 at a mean of 13 months postoperatively and was associated with death from disease (P <0.05) or presence of pain preoperatively. CONCLUSION: Malignancy is common with IPMT and is more likely to be present with the clinical history of alcohol abuse or jaundice and if the tumor involves both the MPD and the SBD. The prognosis after resection is better than pancreatic cancer but the 19% recurrence of symptoms was equally seen with benign or malignant cases owing to residual disease in pancreatic remnants. The amount of resection should be extensive in patients likely to have malignancy (alcohol, jaundice, MPD+SBD). In those likely to redevelop symptoms, ie, those with preoperative pain, a careful assessment should be made via imaging studies for extent of disease.