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A 16.5-year-old, distance runner, female gender-assigned at birth, who identifies as male, presented with menstrual dysfunction and impaired athletic performance. The cause of the menstrual dysfunction and decreased athletic performance was identified as inadequate energy availability, largely motivated by a desired avoidance of menstruation and further development of secondary sex characteristics. The patient achieved significant weight gain (4.75 kg) in the year after presentation and resumed normal menses. When evaluating and treating transgender athletes for menstrual dysfunction and inadequate energy availability, psychological motivators related to the complex interplay between gender identity, disordered eating, and athletic performance must be addressed.

The overdiagnosis of thyroid nodules and indolent thyroid cancers represents an increasing burden on health services, with thyroid ultrasound (US) imaging often representing the initial entry point into the thyroid nodule diagnostic pathway. The aim of this study was to retrospectively review thyroid US referrals to a single Irish hospital to determine if the stated indications for imaging had been appropriate, to review the results of the scans, and to assess the follow-up required in each case. Patient demographics, scan indications, results, and outcomes were retrospectively reviewed for all patients undergoing thyroid ultrasound from 2012 to 2016. Data were analyzed using GraphPad Prism and expressed in mean ± standard deviation. In total, 318 patients (mean age 53 ± 15 years, 85% female) had at least one ultrasound. Most US scans were performed for appropriate indications in order to follow up known thyroid nodular disease and/or malignancy (34.3%), to assess new thyroid goiters or discrete neck lumps (33.3%), and to follow up incidental findings from other imaging modalities (12.6%). However, scans were also requested (in the absence of any palpable goiter or mass) for choking/neck pain/swallowing complaints (12.3%), hypo/hyperthyroidism (6.6%), and miscellaneous reasons (0.6%) that were deemed either potentiallyor likelyinappropriate. Of these scans, approximately half of the identified nodule(s) were deemed unlikely to be related to the stated symptoms, but which subsequently required follow-up imaging ± biopsy. No cases of malignancy were identified. In our center, a significant percentage of thyroid US scans along with their subsequent follow-up were potentially avoidable.

N-Alkyl perfluorooctane sulfonamides have been widely used as surfactants on fabrics and papers, fire retardants, and anticorrosion agents, among many other commercial applications. The broad use, global distribution, and environmental persistence of these compounds has generated considerable interest regarding potentially toxic effects. We have previously reported that perfluorooctanesulfonamidoacetate (FOSAA) and N-ethylperfluorooctanesulfonamidoacetate (N-EtFOSAA) induce the mitochondrial permeability transition (MPT) in vitro, resulting in cytochrome crelease, inhibition of respiration, and generation of reactive oxygen species. By synthesizing the corresponding methyl esters of FOSAA and N-EtFOSAA (methyl perlfuorinated sulfonamide acetates), we tested the hypothesis that the N-acetate moiety of FOSAA and N-EtFOSAA is the functional group responsible for induction of the MPT. Swelling of freshly isolated liver mitochondria from Sprague−Dawley rats was monitored spectrophotometrically and membrane potential () was measured using a tetraphenylphosphonium-selective (TPP) electrode. In the presence of calcium, 40 M FOSAA and 7 M N-EtFOSAA each induced mitochondrial swelling and a biphasic depolarization of membrane potential. Mitochondrial swelling and the second-phase depolarization were inhibited by cyclosporin-A or the catalyst of K/Hexchange nigericin, whereas the first-phase depolarization was not affected by either. In contrast, the methyl esters of FOSAA and N-EtFOSAA exhibited no depolarizing or MPT inducing activity. Results of this investigation demonstrate that the carboxylic acid moiety of the N-acetates is the active functional group, which triggers the MPT by perfluorinated sulfonamides.

Glutathione (GSH), glutathione S-transferases (GSTs), and the multidrug resistance-associated protein 1 (MRP1) have been independently studied for their contributions to drug resistance. Single cDNA transfection experiments have provided inconsistent and disparate conclusions with respect to the importance of GSH and GST in conferring a resistant phenotype. Because these three proteins can act as a concerted coordinated pathway, we reasoned that equivalent increases may be required for enhanced resistance to be expressed. We have assembled these proteins together, or in various combinations, to determine whether they show cooperativity in determining drug response. Increased expression through single cDNA transfection of GSTpi, gamma-glutamylcysteine synthetase (gamma-GCS) (regulatory plus catalytic subunits), or MRP1 enhanced resistance to a number of anticancer drugs. Cotransfection of GSTpi and GCS, gave higher resistance to doxorubicin, etoposide, and vincristine than with either alone. Resistance toward chlorambucil and ethacrynic acid was similar in cells overexpressing either component or overexpressing GST alone. Coexpression of GSTpi with MRP1 conferred significant resistance above that seen for MRP1 alone to chlorambucil, etoposide, ethacrynic acid, and vincristine. The combination of GCS and MRP1 did not afford additional resistance above MRP1 alone. When all three were transfected, significantly higher levels of resistance were found for doxorubicin and etoposide. These results support the concept that coordinate enhancement of focal thiol elements of detoxification pathways provides a more efficient protective phenotype than do single components alone.

Thiopurine antimetabolites have been in clinical use for more than 40 years, yet the metabolism of thiopurines remains only partially understood. Data from our previous pediatric phase 1 trial of continuous i.v. infusion of thioguanine (CIVI-TG) suggested that TG was eliminated by saturable mechanism, with conversion of the drug to an unknown metabolite. In this study we have identified this metabolite as 8-hydroxy-thioguanine (8-OH-TG). The metabolite coeluted with the 8-OH-TG standard on HPLC and had an identical UV spectrum, with a lambda(max) of 350 nm. On mass spectroscopy, the positive ion, single quad scan of 8-OH-TG yielded a protonated molecular ion at 184 Da and contained diagnostic ions at m/z 167, 156, 142, and 125 Da. Incubation of TG in vitro with partially purified aldehyde oxidase resulted in 8-OH-TG formation. 8-OH-TG is the predominant circulating metabolite found in patients receiving CIVI-TG and is likely generated by the action of aldehyde oxidase.

OBJECTIVE--To evaluate the efficacy of gamolenic acid provided by evening primrose oil in treating hot flushes and sweating associated with the menopause. DESIGN--Randomised, double blind, placebo controlled study. SETTING--District general hospital and teaching hospital. SUBJECTS--56 menopausal women suffering hot flushes at least three times a day. INTERVENTION--Four capsules twice a day of 500 mg evening primrose oil with 10 mg natural vitamin E or 500 mg liquid paraffin for six months. MAIN OUTCOME MEASURES--Change in the number of hot flushes or sweating episodes a month. RESULTS--56 diaries were analysed, 28 from women taking gamolenic acid and 28 from those taking placebo. Only 18 women given gamolenic acid and 17 given placebo completed the trial. The mean (SE) improvement in the number of flushes in the last available treatment cycle compared with the control cycle was 1.9 (0.4) (P < 0.001) for daytime flushes and 0.7 (0.3) (P < 0.05) for night time flushes in women taking placebo; the corresponding values for women taking gamolenic acid were 0.5 (0.4) and 0.5 (0.3). In women taking gamolenic acid the only significant improvement was a reduction in the maximum number of night time flushes (1.4 (0.6); P < 0.05). CONCLUSION--Gamolenic acid offers no benefit over placebo in treating menopausal flushing.

Background. Fetal volvulus is a rare, yet life-threatening condition that requires skilful diagnosis and management. Volvulus occurs when bowel loops become twisted and the twisting of the mesenteric artery leads to congestion, impaired venous return, and bowel necrosis. Case Description. We present a case of fetal ileal volvulus suspected on third trimester ultrasound, complicated by premature labour, small bowel necrosis, and meconium peritonitis. Progressive dilatation and decreased peristalsis of echogenic bowel were noted in the early part of the third trimester. Daily surveillance ultrasound was performed and spontaneous labour occurred at 32 weeks’ gestation. A proactive postnatal approach guided by prenatal sonographic findings allowed prompt treatment and an urgent laparotomy was performed for an ileal volvulus with necrosis and meconium peritonitis. A segment of small bowel volvulus was resected and an end-to-end anastomosis was performed with uneventful recovery. Discussion. Clinically signs of fetal midgut volvulus are not pathognomonic, such as intestinal dilatation, abdominal mass, ascites, peritoneal calcifications, or polyhydramnios; thus, the diagnosis is often challenging. Complications reported in the literature include perforation and haemorrhagic ascites, which may lead to anaemia, hypovolemia, heart failure, and fetal demise. Conclusion. This case highlights the importance of assessing the fetal bowel as a part of routine third trimester ultrasound. The case describes the complexity of diagnosis in the fetus, important considerations along with multidisciplinary team approach to management.

The article focuses on the PITCHf/x project launched by Sportvision. Using three high-speed cameras, PITCHf/x measures the release, velocity, spin, and movement of every pitch at 60 points on the way to home plate. It also categorizes the pitches, be they fastballs, cutters, curves, sliders, or change-ups, and makes all the data publicly available. With PITCHf/x, broadcasters no longer have to guess about pitch type or movement because that information is now apparent to them and to viewers.

Preeclampsia and the variant HELLP syndrome are systemic conditions associated with vascular changes resulting in vasoconstriction. Most commonly, patients present with elevated blood pressure and proteinuria, with a background of complaints such as headache, scotoma, and right upper quadrant pain. The systemic vascular changes experienced can target any organ system, oftentimes with more than one organ system being involved. We present the case of a patient admitted with HELLP syndrome who subsequently developed multisystem organ dysfunction, including placental abruption, disseminated intravascular coagulopathy, acute renal failure, colitis, abdominal ascites, pancreatitis, and the development of pancreatic and colonic abscesses.

The article focuses on the negative operating income for Major League Baseball team Boston, Massachusetts Red Sox. According to Forbes.com, the team had reportedly gathered -1.1 million dollars and was one of the top six highest spenders committed to 296 million dollars. Moreover, it notes that despite of the team's ups and downs and its overall value, Red Sox had remained in a long-standing institution that has experiencing positive trend.

Clinical experiences are vital to all types of healthcare educational programs. Supervised clinical experiences provide the opportunity for the learner to apply didactic knowledge and theory to real world situations and hone skills necessary for entry into practice. Nurse anesthesia programs utilize a wide variety of clinical sites to expose student registered nurse anesthetists to experiences that will prepare them clinically, academically and professionally to enter practice as a Certified Registered Nurse Anesthetist. This article describes the process of developing a clinical site. A thorough evaluation will determine the types of experiences meant to be offered at the site, the resources available to house and educate the students, and how to evaluate the effectiveness of the clinical site. Open communication between the clinical coordinator and the program director or designee is essential to ensure success of the clinical site. The Council on Accreditation of Nurse Anesthesia Educational Programs has resources available to guide those interested in becoming a clinical site, as well as for program administrators who seek to add new experiences to their programs.