World J

Surg 2013,37(5):1051–1059.PubMedCrossRef Competing interests The authors declare that they have no competing interests. Authors’ contributions “RRI drafted the manuscript. FAM, WB, AL, NOD-like receptor inhibitor LA, FC, AP, EEM reviewed the draft and made corrections and revisions”. All authors read and approved the final manuscript.”
“Introduction Acute appendicitis has been the most common intra-abdominal condition requiring operation. Emergency appendectomy at the time of diagnosis was the standard of care for treatment of acute appendicitis during last century. Any delay in operation has been believed to increase postoperative morbidity or progress to complicated appendicitis such as perforated appendicitis or periappendiceal abscess [1, 2]. However, the concept of emergency appendectomy has been recently challenged by studies which suggested that acute appendicitis could be treated medically, or delaying surgery did not show any increasing morbidity [3–7]. On the other hand, there are other studies which supported that appendicitis needed emergency surgical procedure and delay in surgery increased complication and length of Selleck S3I-201 hospital stay [8–10]. The controversy still exists about the timing of operation for appendicitis. The aim of this study was to compare the

outcomes between early appendectomy and delayed appendectomy and assess the feasibility of delayed operation. Materials and methods Patients This study was designed as a retrospective, observational study at a single institution. The medical records of patients with acute appendicitis who received operation between check details January 1, 2011 and December 31, 2011, were retrospectively reviewed. We

excluded the following patients: (1) those who were under 16 years or over 65 years old, (2) those who underwent other surgical procedures along with appendectomy, such as cholecystectomy or oophorectomy, (3) pregnant women, and those with severe other medical disease requiring intensive care, (4) those who underwent incidental, interval, and negative appendectomies. The patients were then divided into two groups for comparison: Group A, those with a time from arrival to incision less than 8 hours and Group B, those with a time from arrival to incision longer than 8 hours. Data collection The data were collected from the electronic medical records (EMR). The following parameters check were included: demographics, duration from onset of symptoms to visit our hospital, time from arrival to diagnosis as appendicitis, time form diagnosis to operation, initial vital signs, initial laboratory findings, method of appendectomy, combined drainage procedures, pathologic findings, postoperative laboratory findings, time to a soft diet, postoperative complications, length of hospital stay, hospital costs, and readmissions within 30 days of surgery. We analyzed preoperative, operative, and postoperative clinical data obtained from each group.

The scale contains 11 dichotomous items, representing short-term effects of a day of work. All items were recoded in such a way that higher scores indicate ‘more complaints’, i.e. a higher need for recovery. The recoded scores are presented selleck chemicals in a range from 0 to 100. The Cronbach’s alpha of the scale is 0.78 (Jansen et al.

2002). Examples of items in the scale are ‘I find it hard to relax at the end of a working day’ and ‘Because of my job, at the end of the working day, I feel rather exhausted’ (Van Veldhoven and Broersen 2003). In the present study, the upper quartile was used to define a contrast between employees with a high versus low-medium need for recovery, which corresponds with a cut-off point of 6 on the 11-item scale as recommended by Broersen et al. (Broersen find protocol et al. 2004). The level of need for recovery was determined in each questionnaire (T0, T1, T2, T3, T4, T5, T6). Demographic and health factors Employees provided information on gender, age, educational level and the presence of a long-term illness through self-report in the questionnaires. Employees were divided into five age groups, that is, 18–25, 26–35, 36–45, 46–55 and 56–65 years. Smoking

status was assessed by a single dichotomous item (“Do you smoke every day?”). Characteristics of the private situation Living situation was operationalized as living alone (yes/no). Work–family conflict was measured by one dichotomous item asking employees whether they were able to adequately combine work and family life. Work characteristics Regarding working hours, employees were amongst others asked for their working hours per week, categorized as >40, 36–40, 26–35, 16–25 and <16 h per week. Also, information on overtime was collected using an item on frequent overtime

(yes/no). A Dutch version of the Job Content Questionnaire was used to measure psychological job demands and decision latitude (Karasek 1985). Psychological job demands were assessed by the sum of five items (Chronbach’s alpha 0.69). Decision latitude (Chronbach’s alpha 0.81) was measured by the sum of two subscales: skill discretion and decision authority. The response options Loperamide varied from “strongly disagree” to “strongly agree” on a four-point scale. The total score was then divided into tertiles, resulting in low, medium and high levels of psychological job demands or decision latitude. To assess whether employees perceived their work as physically Temsirolimus supplier demanding, one item of the Dutch questionnaire on Work and Health (VAG; Gründemann et al. 1993) was used. Statistical analysis Because the distribution of need for recovery was skewed to the left, Poisson regression analyses were conducted to test differences in mean levels of need for recovery in the cross-sectional analyses.

A shift in pH to ~7.5 in the intestinal mucus during physiological stress can lead to activation of multiple siderophore-related genes that directly impact microbial virulence. We show for the first time

that suppression of siderophore-related virulence expression in P. aeruginosa can be achieved without providing iron by creating conditions of local phosphate sufficiency at pH 6.0. These findings may have significant therapeutic implications given that there is reluctance to provide excess iron in the face of life threatening infection. Understanding the local cues that activate virulence of common pathogens that colonize the gut during critical illness may lead to new insight into their pathogenesis. Acknowledgements We thank IWP-2 ic50 Irina Morozova for her technical assistance, Pierre Cornelis for ΔPvdD/ΔPchEF double mutant, and Michael Vasil for permission SAR302503 to interpret and present his data (Ochsner et al., 2002) in Figure 4 for discussion purposes. We thank Jaejung Kim, Siming Shou, and Ashwin Vishnuvardhana, the University of Chicago Core Functional Genomics Facility for processing and statistical analysis of microarray data. This study was funded by NIH RO1 GM062344-11 (JA). References 1. Shimizu K, Ogura H, Goto M, Asahara T, Nomoto K, Morotomi M, Yoshiya K, Matsushima A, Sumi Y, Kuwagata

Y, et al.: Altered gut flora and environment in patients with severe SIRS. J Trauma 2006,60(1):126–133.PubMedCrossRef 2. Hayakawa M, Asahara T, Henzan N, find more Murakami H, Yamamoto H, Mukai N, Minami Y, Sugano M, Kubota N, Uegaki S, et al.: Dramatic Changes of the Gut Flora Immediately After Severe and Sudden Insults. Dig Dis Sci 2011,58(8):2361–2365.CrossRef 3. Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, et al.: International study of the prevalence and outcomes of infection in intensive care units. Jama 2009,302(21):2323–2329.PubMedCrossRef 4. Okuda J, Hayashi N, Okamoto M, Sawada S, Minagawa S, Yano Y, Gotoh N: Translocation

of Pseudomonas aeruginosa from the intestinal tract is mediated by the binding of ExoS to an Na, K-ATPase regulator, FXYD3. Infect Immun 78(11):4511–4522. 5. Wu click here L, Holbrook C, Zaborina O, Ploplys E, Rocha F, Pelham D, Chang E, Musch M, Alverdy J: Pseudomonas aeruginosa expresses a lethal virulence determinant, the PA-I lectin/adhesin, in the intestinal tract of a stressed host: the role of epithelia cell contact and molecules of the Quorum Sensing Signaling System. Ann Surg 2003,238(5):754–764.PubMedCrossRef 6. Zaborina O, Kohler JE, Wang Y, Bethel C, Shevchenko O, Wu L, Turner JR, Alverdy JC: Identification of multi-drug resistant Pseudomonas aeruginosa clinical isolates that are highly disruptive to the intestinal epithelial barrier.

Hormone preparation Lyophilised progesterone and 17βBTK inhibitor manufacturer -estradiol (Sigma-Aldrich, St. Louis, MO, USA) were solubilised in absolute ethanol to 1 mg/ml stock. Serum levels of female sex hormones, estradiol and progesterone, fluctuate throughout the menstrual cycle. In this study mean physiological concentrations of 17β-estradiol (200 pg/ml) and progesterone

(20 ng/ml), adapted from Williams Textbook of Endocrinology were further diluted using phenol red-free 1× DMEM/F12 medium (Invitrogen), supplemented with 10% charcoal/dextran-treated FBS (Hyclone). Once the ECC-1 cells had reached 100% confluence, average physiological concentrations of 17β-estradiol, progesterone, and a combination of 17β-estradiol and progesterone (1:1) were added to respective flasks. This hormone exposure

was continued throughout the duration of chlamydial infection. Although the physiological ARRY-438162 clinical trial concentration of progesterone is higher than estradiol, in this study a combination of 1:1, estradiol and progesterone, was chosen as starting point to merely determine the effect of both hormones together. Cells were then incubated for 24 hrs before continuance of experiments. C. trachomatis serovar D growth and propagation C. trachomatis serovar D was grown, maintained and further propagated to create C. trachomatis serovar D stock. C. trachomatis check details was semi-purified from the infected HEp-2 cells via sonication and vortexing. ECC-1 cells were used for C. trachomatis serovar D titration. Infected cells were stained utilising the CelLabs Chlamydia Cel LPS staining kit, containing the fluorescein isothiocyanate (FITC)-labelled mouse monoclonal antibody specific for chlamydial lipopolysaccahride (LPS) (CelLabs, Brookvale, Australia), according to manufacturer’s instructions. RNA Extraction Total RNA was extracted 48 hrs post infection L-gulonolactone oxidase from infected ECC-1 cells using the Trizol®

reagent protocol (Invitrogen) and then treated with DNase. Eukaryotic RNA was removed from total RNA using the Dynabead (poly A+ purification kit) (Dynal Biotech ASA, Oslo, Norway) according to manufacturer’s instructions and the bacterial mRNA re-suspended in DEPC water. Approximately 2 μl of the bacterial mRNA solution was removed to determine the quality and quantity of RNA, using a NanoDrop® Spectrophotometer (NanoDrop Technologies®, Wilmington, DE, USA) and associated NanoDrop ND-1000 3.2.1 software (Coleman Technologies Inc., Glen Mills, PA, USA). Extracted RNA was determined to be of high purity, as indicated by the absorbance ratio (A260:A280) being very close to 2.00. The quantity of RNA extracted indicated amplification was not required prior to microarray analysis as the concentration of RNA was sufficient for our experiments. Whole transcriptome analysis by Affymetrix microarray The bacterial mRNA was sent to the AGRF (Australian Genome Research Facility, Melbourne, Australia) for microarray analysis.

Xenogeneic cells or molecules have been widely employed as vaccines because they tend to break the tolerance [6, 10, 12, 14, 17, 18, 22, 24, 28]. To show that tumor endothelium specific molecules are targeted, we plan to identify antigen molecules recognized by isolated

antibodies in the present study by a proteomics strategy [1]. In addition, effects of the isolated antibodies on tumor vasculature including antibody-dependent cytotoxic activity and also the BIIB057 role of cellular immunity in the response to vaccination should be explored as CTL activities to vaccinated endothelial cells in other settings have been shown [23, 24]. To apply the vaccine therapy using an autologous endothelial cell line to human, development of the cell line from a patient is a next subject. Practically, culture of umbilical KU-57788 vein endothelial cells (HUVECs) on a close genetic background may be a good candidate. Recently, a pilot study of HUVECs vaccine in cancer patients with promising results in brain tumors but not in colorectal cancer was reported [29]. No prominent adverse effect observed in the study may facilitate wider application of HUVECs vaccine

to AZD9291 ic50 various cancers including melanoma. However, some tumor endothelium specific antigens are reported to appear in the vasculature of wound healing tissue [27], possible adverse effects of endothelial cell vaccine on wound healing remains to be clarified. CYTH4 Conclusion Vaccination with a syngeneic endothelial cell line Tpit/E inhibited subcutaneous tumor growth as well as appearance of lung metastasis and elongated survival period of C57BL mice challenged with B16/F10 melanoma, and elicitation of specific antibodies to Tpit/E cells was demonstrated. Acknowledgements This work was supported in part by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), HAITEKU (2004–2008) and Musashino Joshigakuin Special Fund.

References 1. Yoshiura K, Nakaoka T, Nishishita T, Sato K, Yamamoto A, Shimada S, Saida T, Kawakami Y, Takahashi TA, Fukuda H, Imajoh-Ohmi S, Oyaizu N, Yamashita N: Carbonic anhydrase II is a tumor vessel endothelium-associated antigen targeted by dendritic cell therapy. Clin Cancer Res 2005, 11: 8201–8207.CrossRefPubMed 2. Folkman J: What is the evidence that tumors are angiogenesis dependent? J Natl Cancer Inst 1990, 82: 4–6.CrossRefPubMed 3. Scappaticci FA: Mechanisms and future directions for angiogenesis-based cancer therapies. J Clin Oncol 2002, 20: 3906–3927.CrossRefPubMed 4. Bergers G, Benjamin LE: Tumorigenesis and the angiogenic switch. Nat Rev Cancer 2003, 3: 401–410.CrossRefPubMed 5. Neri D, Bicknell R: Tumour vascular targeting. Nat Rev Cancer 2005, 5: 436–446.CrossRefPubMed 6.

5G selleck compound illumination using the BQP method. The calculated solar cell parameters are shown in Table 3. Also, the calculated quantum efficiencies are shown in Figure 7. The simulated quantum efficiencies are

multiplied by 0.12 for comparison with the experimental one. The calculated short-circuit current densities (J sc) and quantum efficiencies are much higher than those of the experimental results. There are two possible reasons. The first reason is due to the difference of the doping concentration in a Si-QDSL layer. In an actual solar cell, the phosphorus concentration in the Si-QDSL absorber layer is more than 1 × 1019 cm-3 due to the high-temperature annealing process [34]. From the simulations, the J sc and the quantum efficiency in the whole wavelength region becomes lower if the phosphorus concentration in the Si-QDSL layer increases. The phosphorus in the Si-QDSL layer degrades the J sc due to the reduction of the electrical mTOR activation field in the Si-QDSL layer. Unfortunately, simulations were not possible when the dopant concentration in the Si-QDSL was higher than 1 × 1017 cm-3 due to the convergence problem of the BQP calculations. It is expected that J sc will decrease more if the dopant concentration becomes higher. We previously reported that the quantum efficiency Selleckchem AZD5153 in the whole wavelength region decreases as the dopant concentration in the Si-QDSL increases from experiments and the simulations using classical model [35], which is similar to

the results of the BQP method. The second reason is due to the optical losses in the n-type poly-Si layer. In this calculation, the surface roughness of the textured quartz substrate was not taken into account. The effective optical path length in the n-type layer of the simulated structure should be shorter than that of the actual solar cell structure. As a result, the simulated quantum efficiency in the short-wavelength region is higher than that of the experimental because of the low optical absorption loss in the n-type poly-Si layer. Even though the J sc mismatch, the absorption edge can be estimated from the simulated quantum efficiency. The calculated quantum efficiencies

at the long-wavelength region are in agreement with those of the experimental one. This suggests that the absorption edge of the solar cell can be theoretically reproduced using this simulation. Moreover, the absorption edge was estimated (-)-p-Bromotetramisole Oxalate to be 1.49 eV, which is quite similar to the absorption edge of the Si-QDSL estimated from the optical measurements. This indicates that the photogeneration in the Si-QDSL solar cell is thought to be the contribution from Si-QDs, and it is possible to fabricate the solar cells with silicon nanocrystal materials, whose bandgaps are wider than that of a crystalline silicon. Conclusions The fundamental optical properties of Si-QDSLs were investigated, and the solar cell structure using the Si-QDSL as an absorber layer was fabricated and characterized.

However, 4 of the 23 primer pairs (P1, P7, P8 and P10) failed to produce amplicons with the infected plant DNA sample from Jiangxi and Guangdong Province, Selleckchem Quisinostat China (Table 2). Primer pair P3 produced no amplicon with Jiangxi sample, and produced unspecific amplicon with the Guangdong sample (with an altered PCR product size, data not shown). Interestingly, all these 5 primer pairs target the genes located in prophage region of the Las genome (Additional file 3). These primers (P1, P3, P7, P8 and P10) based on prophage genes could detect Las from Florida, but not from

Jiangxi and Guangdong province, China. This is consistent with previous report [44], that prophage was detected in only 15.8% of the 120 HLB diseased citrus samples acquired in Guangdong Province, China, but was detected in 97.4% of the 39 Las positive citrus samples acquired in Yunnan Province, China. This suggests that those prophage genes are not universally present in all strains of Las. Alternately, the prophage sequences were found to be highly variable among the strains tested. Conclusions We have successfully designed 18 novel primer pairs, which are specific to Las. These primers will provide an additional arsenal to qRT-PCR based detection

of Las-infected plants and psyllids. Compared to the commonly used primers based on 16S rDNA selleck kinase inhibitor and β-operon, the 18 primers developed in this study have comparable sensitivity. Moreover, GPX6 these primers could successfully

differentiate Las from Lam, Laf and other common microbes associated with citrus. Methods Bioinformatics The nucleotide sequences of Las with accession number NC_012985 [29, 45], Lso with accession number NC_014774 [33], Lcr with accession number NC_019907 and comprehensive nucleotide (nt) database (26th July 2012) were downloaded from the NCBI ftp server (ftp.ncbi.nih.gov). The stand-alone BLAST [42, 43] was used to search the Las genes against nt, Lso and Lcr databases using a custom-made PERL script 1 (Additional file 1) by varying the E-value with all other parameters kept to a default value. The output files of the BLAST searches were further parsed using a second custom-made PERL script 2 (Additional file 2). Plant and psyllid materials and extraction of DNA Las infected citrus leaf samples with typical visible symptoms were collected from 2 years old infected sweet orange (Citrus sinensis) plants 4SC-202 in vitro maintained at the Citrus Research and Education Center (CREC), Lake Alfred, Florida, USA. As a negative control, the leaves from healthy citrus plants were collected from pathogen-free seedlings grown in the healthy plant greenhouse maintained at CREC, Lake Alfred, Florida, USA. The Laf and Lam infected samples were obtained from South Africa and Brazil respectively. The total DNA from the leaves of citrus was extracted using the protocol mentioned elsewhere [46].

Mayo Clin Proc 64:609–616PubMed 36. Bluman LG, Mosca L, Newman N, Simon DG (1998) Preoperative smoking habits and postoperative pulmonary complications. Chest 113:883–889CrossRefPubMed 37. Barrera R, Shi W, Amar D, Thaler HT, Gabovich N, Bains MS, White DA (2005) Smoking and timing of cessation: impact on pulmonary complications

after thoracotomy. Chest 127:1977–1983CrossRefPubMed 38. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff (2008) A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 35:158–176CrossRef 39. Niaura R (2008) Non-pharmacologic therapy for smoking cessation: characteristics and efficacy of current approaches. Am J Med 131:S11–S19CrossRef 40. Stead LF, LY333531 cost Perera R, Bullen C et al (2008) Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 1:CD000146PubMed 41. Hays JT, Ebbert JO (2008) Varenicline for tobacco dependence. N Engl J Med 359:2018–2014CrossRefPubMed

42. Gillespie WJ, Walenkamp GH (2010) Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Ipatasertib purchase Syst Rev 3:CD000244PubMed 43. Epstein SK, Faling LJ, Daly BD, Celli BR (1993) Predicting complications after pulmonary resection: preoperative exercise testing vs a multifactorial cardiopulmonary risk index. Chest 104:694–700CrossRefPubMed 44. American College of Physicians (1990) Preoperative pulmonary function testing. Ann Intern Med 112:793–794 45. Pellegrino R, Viegi G, Brusasco V et al (2005) Interpretative strategies for lung function Tryptophan synthase tests. Eur Respir J 26:948–968CrossRefPubMed 46. Warner DO, Warner MA, Offord

KP, Schroeder DR, Maxson P, Scanlon PD (1999) Airway obstruction and perioperative complications in smokers undergoing abdominal surgery. Anesthesiology 90:372–379CrossRefPubMed 47. Gass GD, Olsen GN (1986) Preoperative pulmonary function testing to predict postoperative morbidity and mortality. Chest 89:127–135CrossRefPubMed 48. Kroenke K, Lawrence VA, Theroux JF, Tuley MR (1992) Operative risk in patients with severe obstructive pulmonary disease. Arch Intern Med 152:967–971CrossRefPubMed 49. Alifano M, Cuvelier A, Roche DN, Lamia B, Molano LC, Couderc LJ, Marquette CH, Devillier P (2010) Treatment of COPD: from pharmacological to instrumental therapies. Eur Respir Rev 19:7–23CrossRefPubMed 50. Rabe KF, Hurd S, Anzueto A et al (2007) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 176:532–555CrossRefPubMed 51. Wilson R, Jones P, Schaberg T, Arvis P, Duprat-Lomon I, Sagnier PP (2006) Antibiotic treatment and factors influencing short and long term outcomes of acute exacerbations of chronic bronchitis. Thorax 61:337–342CrossRefPubMed 52.

In both areas there is a large contingent of meso-hygrophilous species, favoured by the presence of surface water, probably due to the proximity of small springs. There are many putative host plants in both truffières: at Feudozzo (Abruzzo) poplar (Populus tremula L.), oak (Q. cerris), willow (Salix alba L., Salix apennina Skvortsov, Salix caprea L. and Salix purpurea L.), hornbeam (Carpinus

betulus L. and Carpinus orientalis Miller) and hazelnut (Corylus avellana L.); at Collemeluccio (Molise) poplar (P. nigra and P. canadensis L.), oak (Q. cerris), linden (Tilia platyphyllos Scop.), silver fir (Abies alba Miller), hazelnut (C. avellana) and hornbeam (O. carpinifolia). However, all T. magnatum collection occurred beneath A. alba. The geological substratum is represented by alternating argillaceous sandstone: CHIR98014 concentration at Feudozzo, the soil has a CaCO3 content ranging from 0.75 to Luminespib purchase 4.20% and a pH of 6.8-7.8; at Collemeluccio the soil has a CaCO3 content ranging from 1.69 to 2.64% and a pH of 6.8-7.4. As production areas are often of different dimensions and their

productivity varies considerably, in the experimental truffière productive plots of 300–500 m2 were selected on the basis of the confidential indications of their productivity provided by local truffle hunters and their real productivity was established over the three years of the study. A total of 39 plots (9 in Tuscany, 9 in Emilia Romagna, 9 in Molise and 12 in Abruzzo) were

identified and delimited. Details of the pedological and vegetative characteristics of each experimental truffière plot are described in the project website [36–38]. Assessment of truffle production We used trained dogs to assess truffle production every week in the T. magnatum season (September-December) RAS p21 protein activator 1 for three consecutive years (2008–2010). The truffles collected were numbered, weighed and recorded for each plot. Experimental layout Soil cores (1.6 cm diameter, 30 cm deep) were extracted using a disposable, cylindrical, polyvinyl chloride tube inserted inside a steel soil borer, purpose-built for this study. A set of 9 equidistant soil cores were taken from each plot along two diagonal lines, excluding a border area of 5 m on each side of the plot to minimize possible edge effects. Sampling was carried out in January 2009, 2010 and 2011 at the end of the annual white truffle season. The soil cores collected from each plot were pooled together to obtain a sample per plot for each year and any root fragments, stones or organic debris were carefully removed using a stereomicroscope. A control soil sample was also collected 200 m outside each experimental truffière from non-productive areas.

This compares to a major complication rate for modern catheter directed embolization of 1.3%. [14] Current literature suggests that the use of microcoils may be superior to particles for embolization. Although we exclusively used particles for embolization in our series, the use of microcoils may offer a more precise alternative with less risk of ischemia. [15] However, in our cases where precise localization is not possible particles may provide greater area of distal embolization

and the option of redo embolization if necessary. Chk inhibitor A common problem however is the positive scintigram with negative angiography. In hemodynamically unstable patients, Ryan et al reported positive RBC scintigraphy with negative angiography in 31% of their patients (5 out of 16 patients). Similarly, in a nonrandomized

series; Burgess et al reported this scenario AZD0156 in vitro in 27% of their patients (4 out of 15 patients). [16] In hemodynamically stable patients, Zink et al reported this scenario in 77.8% (14 out of 18 patients). [5] When vessels were embolized without the benefit of our technique as shown by Burgess et al there was an unfavorable outcome with two patients having proven ischemia and one having continued bleeding. [16] Although some of these bleeds resolve spontaneously, there have been two approaches to solving this dilemma of persistent bleeding that have been previously described. These include provocative bleeding techniques and carbon dioxide arteriography. [17, 18] Provocative bleeding techniques (utilizing intrarterial heparin, tolazoline and urokinase) have been limited (with relatively small series) because of the theoretical risk of uncontrolled bleeding when either (1) during active bleeding when the site is not localized arteriographically and (2) can be visualized

angiographically, but cannot technically embolized. In one series 6 out of 16 patients were provoked into bleeding. 5 of these patients had a positive red blood Leukotriene-A4 hydrolase cell scan, but only 3 out of these were able to undergo catheter directed embolization. [19] In another series of 7 patients 2 out of 7 patients were able to be provoked into bleeding with resultant surgical repair of the bleeding site. [18] Therefore, provocative bleeding can be a useful tool in diagnosis of colonic bleeding in the setting of positive scintigraphy and negative angiography. Carbon dioxide angiography is limited in patients who cannot suspend respiration and in patients who have excessive bowel gas motion. There have also been reports of bowel necrosis after hand delivery of carbon dioxide injection. [20] We therefore present a simple technique to address this difficulty. This technique consists of a metal marker (paper clip) that is placed on the abdomen during the scintigraphic study over the site of active extravasation.