Extracellular matrix (ECM) proteins have been shown to regulate mammary epithelial cell proliferation, differentiation, and apoptosis in vitro. However, little is known about the hormonal regulation and functional role of ECM proteins and integrins during mammary gland development in vivo. We examined the temporal and spatial localization and hormone regulation of collagen I, collagen IV, laminin, and fibronectin. Among these ECM proteins only fibronectin changed appreciably. Fibronectin levels increased 3-fold between the onset of puberty and sexual maturity, remaining high during pregnancy and lactation. This increase occurred specifically in the epithelial basement membrane. Fibronectin was decreased 70% by ovariectomy and increased 1.5- and 2-fold by estrogen or estrogen plus progesterone treatment, respectively. The fibronectin-specific integrin, alpha(5)beta(1), was localized in myoepithelial cells; it increased 2.2-fold between puberty and sexual maturity and decreased in late pregnancy and lactation. The basal localization of alpha(5)beta(1) was notably increased in pubertal and adult virgin mice. alpha(5)beta(1) concentrations decreased 40-50% after ovariectomy in pubertal and adult mice, which was reversed by estrogen plus progesterone treatment in adult mice. The high basal expression of alpha(5)beta(1) during active proliferation and the low expression in nonproliferating and lactating glands indicate that fibronectin signaling may be required for hormone-dependent proliferation in the mammary gland.

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Introduction: Repair of inguinal hernia is one of the commonest performed surgical procedures worldwide. Usually, a seroma develops in large inguinoscrotal hernias. Generally, a seroma is a cause of significant distress for the patient since it may recur. If the possibility of seroma formation is discussed with the patient before surgery, it may go a long way in alleviating the patient's distress. Seromas are common after large hernia repair and direct hernia repair. Materials and methods: In this observational study, 50 patients were randomly selected from LG. Hospital (AMC MET Medical College, Ahmedabad, India) who went through TAPP hernioplasty for an inguinoscrotal hernia after a complete explanation of conversion to open as well as post-operative seroma formation. Since all cases were indoor patients, they were initially reviewed on the next day morning after the operation and the next examination time point was seven days later for seroma development. All the patients were followed up at 6 weeks and then every month for 6 months up to 1 year. Results: Out of 50 patients, 44 (88%) patients had an indirect hernia and 6 (12%) patients had a direct hernia. The seroma developed in only three patients (6%) who were managed conservatively with only medicines. Within the follow-up period, no patients had pain, seroma, and recurrence. Conclusion:In some cases of large scrotal hernia, the distal sac was difficult to be inversed or the hernia sac even adhered firmly to the ipsilateral testicle and other structures. In those cases, avoiding inverting the distal sac and leaving the distal sac in place means to avoid dissecting out the distal sac observed lesser occurrence of the seroma. That suggests that the laparoscopic method can help prevent or decrease the chance of the development of seroma in the unilateral inguinoscrotal hernia.

Introduction: Numerous studies have shown that per oral endoscopic myotomy (POEM) is a very effective treatment for patients with achalasia. Limited data has also indicated that POEM is effective in treatment for some non-achalasia esophageal motility disorders, such as esophageal-gastric outlet obstruction and diffuse esophageal spasm. We report for the first time the outcome of POEM for patients with atypical chest pain. Methods: Three patients were enrolled: a 72yo female, 87yo male and 73yo female. All patients had a long history of chest pain for at least 5 years. They ranked the pain from 2 to 8 on a 1 to 10 pain scale. The pain was not associated with physical activity, but it was occasionally associated with eating. Only one patient had some dysphagia and no patients reported regurgitation symptoms. All patients were evaluated by multiple doctors over the years, including primary care providers, cardiologists, and gastroenterologists. Cardiac chest pain was ruled out by their cardiologists. They all tried maximal anti-acid therapy, including proton pump inhibitors twice a day for a prolonged period, without any significant improvement. They also tried anti-spasmodic medications, such as hyoscyamine, with limited effect. All patients had esophageal manometry without conclusion. Barium swallow studies showed tertiary contraction and therefore suggested esophageal dysmotility. POEM was discussed with the patients who then provided consent to undergo the procedure (Table ). Results: All three POEMs were successful; the average procedure time was 20 minutes. Only circular muscle myotomy was performed and longitudinal muscle was left intact. Each myotomy was 10 cm in length. There were no postprocedural complications. Postop day 1, all patients were chest pain free and were discharged in the afternoon. Follow up times were 93, 42, and 5 days; pts continued to remain chest pain free. One out of 3 patients described a burning type of chest pain consistent with heartburn and was promptly relieved with anti-acid therapy. Conclusion: From this pilot study, POEM may be a therapeutic modality for patients with refractory atypical chest pain. Further studies with increased sample size and long-term outcome assessments are needed to determine the efficacy of POEM in the treatment of atypical chest pain.

of symptoms for several years, which had always been attributed to her high prothrombin time. When symptoms persist and worsen, it is important to obtain more history and broaden one's differential to look at other possible causes. Many presentations will have a multifactorial aspect, and the use of specialists for further analysis should be utilized. In this case, the use of GI, nephrology and Rheumatology allowed for segments of clinical data to form the diagnosis of granulomatosis with polyangiitis.

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