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PubMed2005

Laparoscopic nephrectomy using Ligasure system: preliminary experience.

BACKGROUND AND PURPOSE: The advent of laparoscopic surgery has created new technical challenges and problems. Recently, a new commercially available vessel-sealing technology, the Ligasure system, was introduced. The aim of our study was to compare the effectiveness of this new system with earlier methods in a group of patients affected by renal-cell carcinoma. PATIENTS AND METHODS: A series of 30 patients underwent laparoscopic radical nephrectomy for clinically localized renal-cell carcinoma. We always used a transperitoneal approach with a three-trocar technique. Patients were randomly divided in two groups: 15 underwent conventional laparoscopic radical nephrectomy, while 15 underwent laparoscopic nephrectomy using the Ligasure system, which is a bipolar radiofrequency generator. Information analyzed included intraoperative blood loss, operative time, conversion rate, and postoperative course. Statistical analysis was performed with commercially available software. The two groups were compared in term of clinical and pathologic variables using Student's t-test. Differences were considered significant at p < 0.05. RESULTS: No statistically significant differences were observed between the two groups for baseline characteristics. No conversion occurred in either group. Statistically significant differences were observed between conventional and Ligasure nephrectomy regarding mean intraoperative blood loss (485 mL and 100 mL, respectively; p < 0.05) and mean operative time (164 minutes and 68 minutes, respectively p < 0.05). No statistically difference was observed in the postoperative discharge time. CONCLUSION: The Ligasure vessel-sealing system seems to produce a consistent, reliable, permanent seal of veins, arteries, and tissue bundles by fusing the collagen in vessel walls. By reducing sutures and the number of instrument exchanges in the operating theatre, the Ligasure decreases operating time and blood loss. This new energy-based vessel-ligation device appears to be effective in advanced laparoscopic procedures.

Blood Loss, Surgical↗
PubMed2007

Factors influencing sputum smear and culture conversion time among patients with new case pulmonary tuberculosis.

Sputum smear and culture conversion are important indicators for the effectiveness of treatment and the infectivity of the patient. The aim of this study was to identify the factors influencing both sputum smear and culture conversion time among patients with new case pulmonary tuberculosis (TB). The study was conducted in a reference hospital in Turkey in which 737 patients with pulmonary TB were hospitalised between January 2000 and 2005. We evaluated 306 (193 men and 113 women) human immunodeficiency virus-negative patients diagnosed with new case pulmonary TB. Factors associated with both sputum smear and culture conversion time (days) were investigated. Patients with diabetes mellitus (DM), cavitary disease, radiologically extensive disease had longer sputum smear and culture conversion time than the other groups. In addition, old age, male sex, smoking and thrombocytosis were found to be significantly associated with sputum smear conversion time. In the logistic regression analysis, the presence of DM and extensive disease were determined as independent factors associated with persistent sputum smear and culture positivity at the end of 2 months. The presence of DM and extensive disease were found to be independent risk factors influencing both sputum smear and culture conversion time in pulmonary TB. Sputum smear and culture examinations should be considered together to assess the poor prognosis.

Adolescent↗
PubMed1991

L1 gene conversion or same-site transposition.

DNA sequence analysis of the same chromosomal region from two haplotypes of Mus musculus and from the related species M. caroli and M. pahari reveals the presence of long interspersed sequence one (LINES-1, or L1) elements residing at the same nucleotide position in the two most distantly related of the species (M. musculus and M. pahari). The DNA sequence of each of these L1 elements is more similar to that of other L1 elements from its own species than to the other. Thus, the L1 sequence at each of these sites is recent with respect to the divergence of the species. This could be a result of recent gene conversion of L1 elements inherited from a common ancestor or of two recent independent L1 insertion events at the same nucleotide position in the two species. Such specificity of insertion would be quite different from the apparent randomness of other characterized L1 insertion events, such as those in the beta-globin locus. If the recent L1 sequences arose at this site by gene conversion of an ancestral L1 element, then the absence of an L1 element at this location in the M. caroli chromosome examined could arise either from its precise deletion from M. caroli or from the segregation into M. caroli of a polymorphic chromosome present in the ancestral population which was missing this L1 element.

Animals↗
PubMed1998

Characterization of growth factor responsiveness and alterations in growth factor homeostasis involved in the tumorigenic conversion of mouse oval cells.

Five mouse oval cell lines were investigated in regards to their growth and differentiation factor (GDF) responsiveness and to changes in their GDF responsiveness following tumorigenic conversion. In all 59 GDFs and 11 comitogens were evaluated with variable responsiveness, depending on the mouse oval cell line under study, observed. Analysis of oval cell GDF responsiveness during tumorigenic conversion revealed that tumorigenic variants displayed alterations in GDF responsiveness which correlated with tumorigenicity. In addition, analysis of autocrine/paracrine growth factor production demonstrates that most tumorigenic variants produce growth factors. These studies demonstrate for the first time that (1) mouse oval cells respond to a wide variety of GDFs including various members of the interleukin, chemokine, stem cell factor, EGF, FGF, PDGF, TGF-beta, VEGF, insulin, CSF, TNF, HGF, and IFN growth and differentiation factor families in addition to multiple comitogens and (2) during tumorigenic conversion mouse oval cells undergo alterations which result in both alterations in GDF responsiveness and the autocrine/paracrine production of multiple GDFs.

Animals↗
PubMed1999

Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy.

OBJECTIVE: To determine the incidence and prognostic significance of documented eradication of breast cancer axillary lymph node (ALN) metastases after neoadjuvant chemotherapy. SUMMARY BACKGROUND DATA: Neoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. METHODS: One hundred ninety-one patients with locally advanced breast cancer and cytologically documented ALN metastases were treated in two prospective trials of doxorubicin-based neoadjuvant chemotherapy. Patients had breast surgery with level I and II axillary dissection followed by additional chemotherapy and radiation treatment. Nodal sections from 43 patients who were originally identified as having negative ALNs at surgery were reevaluated and histologically confirmed to be without metastases. An additional 1112 sections from these lymph node blocks were obtained; half were stained with an anticytokeratin antibody cocktail and analyzed. Survival was calculated using the Kaplan-Meier method. RESULTS: Of 191 patients with positive ALNs at diagnosis, 23% (43 patients) were converted to a negative axillary nodal status on histologic examination (median number of nodes removed = 16). Of the 43 patients with complete axillary conversion, 26% (n = 11) had N1 disease and 74% (n = 32) had N2 disease. On univariate analysis, patients with complete versus incomplete histologic axillary conversion were more likely to have initial estrogen-receptor-negative tumors, smaller primary tumors, and a complete pathologic response in the primary tumor. The 5-year disease-free survival rates were 87% in patients with preoperative eradication of axillary metastases and 51% for patients with residual nodal disease after neoadjuvant chemotherapy. Of the 39 patients with complete histologic conversion for whom nodal blocks were available, occult nodal metastases were found in additional nodal sections in 4 patients (10%). At a median follow-up of 61 months, the 5-year disease-free survival rates were 87% in patients without occult nodal metastases and 75% in patients with occult nodal metastases. CONCLUSIONS: Neoadjuvant chemotherapy can completely clear the axilla of microscopic disease before surgery, and occult metastases are found in only 10% of patients with a histologically negative axilla. The results of this study have implications for the potential use of sentinel lymph node biopsy as an alternative to axillary dissection in patients treated with neoadjuvant chemotherapy.

Antimetabolites, Antineoplastic↗
PubMed1983

Spontaneous H-2 mutants provide evidence that a copy mechanism analogous to gene conversion generates polymorphism in the major histocompatibility complex.

The analysis of H-2K products from spontaneously generated major histocompatibility complex (MHC) mutants and of the primary structure of other class I antigens suggests the genetic hypothesis that diversity in the MHC results from a copy mechanism analogous to gene conversion. The hypothesis was tested by making precise structural predictions about three partially characterized MHC mutants (bm1, bm3, and bm8). The predictions were based on consensus sequences among class I genes that differ from H-2Kb in the same region of the molecule as do the Kb mutants. In two cases (bm3 and bm8) we successfully predicted the correct amino acid substitution at positions known to be altered but for which the specific nature of the substitution had not been determined. In two additional cases (bm1 and bm8) we predicted and found both new mutation sites and the specific amino acid substitutions. The positions and identifications of the variant amino acids were determined by radiolabeled amino acid sequence analysis and DNA restriction endonuclease analysis. The interaction of MHC genes through a copy mechanism to generate diversity permits the introduction of multiple nucleotide base substitutions into class I sequences by a single genetic event. Such a mechanism may account in part for the large structural divergence among alleles of MHC loci and the high degree of MHC polymorphism among wild mice.

Amino Acid Sequence↗
PubMed2006

Robotic-assisted laparoscopic prostatectomy: first 100 patients with one year of follow-up.

OBJECTIVES: To report our initial experience of 100 patients with robotic-assisted laparoscopic radical prostatectomy. Continued technological advances have expanded our armamentarium of minimally invasive devices and techniques to offer our patients. Robotic-assisted laparoscopic radical prostatectomy has been adopted at many centers. METHODS: This was a nonrandomized prospective study evaluating our initial 100 patients who underwent robotic-assisted laparoscopic radical prostatectomy. The follow-up data were obtained prospectively using the validated Rand 36-item health survey, version 2, and the University of California, Los Angeles, Prostate Cancer Index preoperatively and at 1, 3, 6, and 12 months postoperatively. Patients who required open conversion were excluded from the outcome analysis. Patients who received a sural nerve graft were excluded from the operative analysis. RESULTS: The average age and body mass index of all patients were 58.4 years (range 42 to 70) and 28.5 kg/m2 (range 18.1 to 50.6), respectively, with a median follow-up of 12 months. The average prostate-specific antigen level was 6.07 ng/mL. Seven patients required conversion to an open technique, and four underwent sural nerve grafting. The positive surgical margin rate was 16% (15 of 92). Using the Rand 36-item health survey, version 2, and the University of California, Los Angeles, Prostate Cancer Index health surveys, the average percentage of return to baseline urinary function was 52%, 70%, 79%, and 84% at 1, 3, 6, and 12 months, respectively. The overall average percentage of return to baseline sexual function was 51%, 58%, 66%, and 80% at 1, 3, 6, and 12 months, respectively. CONCLUSIONS: Robotic-assisted laparoscopic radical prostatectomy is a safe and efficient method for achieving prostate cancer control even during the initial learning curve for this procedure.

Adult↗
PubMed1994

Exposure of emergency department personnel to tuberculosis: PPD testing during an epidemic in the community.

STUDY OBJECTIVE: The present epidemic of tuberculosis has increased the risk of transmission of tuberculosis to health care workers in general and emergency department staff in particular, who often treat patients with tuberculosis before their diagnosis. The purpose of this study was to determine the risk of tuberculosis exposure among the nursing and physician staff of an urban ED. DESIGN: Observational study of self-reported purified protein derivative (PPD) skin test results and tuberculosis exposure. SETTING: Urban, public ED. PARTICIPANTS: Attending physicians, resident physicians, and registered nurses. INTERVENTIONS: None. RESULTS: Questionnaires were sent to all attending physicians, resident physicians, and registered nurses in the ED at Harbor-UCLA Medical Center requesting information on the subject's present and prior PPD status, known exposure to tuberculosis, and duration of time and average number of hours worked in the ED. Ninety-six of 129 questionnaires (74%) were returned. Five of the respondents had been immunized with Bacillus of Calmette and Guerin vaccine (BCG) and 10 of the respondents were PPD positive before beginning work in the ED. Of the other 81 respondents, 31% (25 of 81) had become PPD positive while working in the ED. The majority of these conversions (15 of 25) occurred in the first 6 months of 1993. A Kaplan-Meier survival analysis revealed nearly a 40% risk of PPD conversion after 60 months of full-time work in the ED. CONCLUSION: As measured by self-reported PPD status, a high rate of exposure to tuberculosis has been observed among the ED staff at Harbor-UCLA Medical Center. The highest rate of PPD conversion has been noted most recently, suggesting that there has been a significant increase in staff exposure to tuberculosis during 1992 and the beginning of 1993. Systematic monitoring of PPD conversion rates among ED staff is necessary to determine the adequacy of ED respiratory isolation procedures during the current tuberculosis epidemic.

California↗
PubMed1979

Procollagen synthesis and processing in periodontal ligament in vivo and in vitro. A comparative study using slab-gel fluorography.

A combination of dodecylsulphate/polyacrylamide gel electrophoresis and fluorography has been used to quantify the synthesis of type I and type III collagens by periodontal ligament in situ and periodontal-ligament fibroblasts in vitro. The separation of 14C-labelled collagen alpha chains was achieved by introducing an interrupted reduction step, and the total radioactivity in the alpha-chain bands related to the fluorographic response by a series of standard curves. From these curves an accurate assessment of the relative amounts of type I and III collagen synthesized could be made. The same system also allowed the synthesis and processing of the respective procollagens to be analyzed. For the study in vivo, 200-g male rats were injected with 2 mCi [14C]glycine and killed 0.5-6 h later. Periodontal ligament was dissected from the mandibular molars and the newly-synthesized collagens extracted with 0.45 M sodium chloride. In the study in vitro, confluent monkey periodontal-ligament fibroblasts were cultured in the presence of [14C]proline and [14C]glycine. Analysis of labelled collagens showed a rapid conversion of type I procollagen to collagen but type III collagen was recovered as a procollagen intermediate both in vitro and in vivo. Analysis of duplicate samples after pepsin digestion showed type III collagen synthesis to comprise 15% of the total collagen synthesized in vivo and 20% in early subcultures in vitro. However, the proportion of type III synthesized by the fibroblasts decreased on subculturing. The data demonstrate that fibroblasts in vitro retain the basic characteristics of collagen synthesis and procollagen processing found in vivo, but the overall phenotypic expression of the cells is not stable in culture.

Animals↗
PubMed1993

Video analysis: a method of assessing changes in preverbal and early linguistic communication after cochlear implantation.

As the age of cochlear implantation in children decreases, there is an increasing need for methods to monitor the preverbal and early linguistic development of children fitted with these devices. One method that has been used successfully to monitor children wearing acoustic amplifying hearing aids entails the video recording over time of child-adult interactions in a conversational setting, and the subsequent methodical analysis of various aspects of the interaction. These aspects include eye contact, turn taking, autonomy, and auditory processing. The same method has been applied to children wearing the Nucleus 22-electrode cochlear implant system. An overview is given of the video analysis results for a group of 10 children studied from a period before implantation up to one year postimplantation. The results illustrate group changes in the various measures due to the provision of auditory information by the cochlear implant, plus the scatter of individual data. It is concluded that early indications of progress over time generally predict the level of functioning achieved at 12 months postimplantation. The method provides essential objective information, which enables discrete changes in behavior to be monitored realistically. Two case studies are presented to illustrate the application of the video analysis method to obtain information for clinical management of children with cochlear implants.

Child↗
PubMed2004

Factors that predict conversion in patients undergoing laparoscopic surgery for Crohn's disease.

BACKGROUND: To identify factors that would predict conversion in patients undergoing laparoscopic surgery for Crohn's disease. METHODS: Data were collected retrospectively. All procedures were performed by an experienced laparoscopic surgeon. RESULTS: Forty-eight patients underwent 57 laparoscopic procedures. Twenty-six of these procedures were for recurrent disease. The conversion rate was 42.3% (11 of 26) for recurrent disease and 13% (4 of 31) for primary disease. On univariate analysis age (P = 0.02), surgery for recurrence (P = 0.02), time from diagnosis (P = 0.03), and the presence of a clinical mass (P = 0.03) were factors that predicted conversion. On multivariate analysis these factors except time from diagnosis still remained significant. Patients who did not undergo a conversion had significantly better post operative outcomes. There was no difference in the incidence of major or minor complications or the number of resections in both groups. CONCLUSIONS: The conversion rate for the whole group was 28%. The rate is higher in patients who are over 40 years of age who are undergoing procedures for recurrence.

Adult↗
PubMed2002

Structural features of prions explored by sequence analysis. II. A PrP(Sc) model.

Prion diseases are neurodegenerative disorders associated with a conformational conversion of the prion PrP protein, in which the beta strand content increases and that of the a helix decreases. However, the structure of the pathogenous form PrP(Sc), occurring after conformational conversion of the normal cellular form PrP(C), is not yet known. From sequence analysis, we have previously proposed that helix H2 of the prion PrP(C) structure might be a key region for this structural conversion. More recently, we identified the TATA box-binding protein fold as a putative scaffold that may locally satisfy the predicted secondary-structure organisation of PrP(Sc). In the present analysis, we detail the schematic construction of PrP(Sc) monomeric and dimeric models, based on this hypothesis. These models are globally compatible with available data and therefore may provide further insights into the structurally and functionally elusive PrP protein. Some comments are also devoted to a comparison of the yeast Ure2p prion and animal prions.

Amino Acid Sequence↗
PubMed1991

An analysis of the oscillatory patterns in the central nervous system with the wavelet method.

This paper discusses a simple application of the wavelet transformation to analyse nerve cell impulse patterns. The action potentials converted into delta, or Dirac, functions were convoluted in the time domain with a modified Gauss (the negative of the second derivative of Gauss) function, varying in width between 0.6 and 384 ms. The width of the Gauss function was varied in 640 steps. Some parts of the transformation were extended, analysed and averaged in the frequency domain to explore oscillatory components of the impulse pattern. The sequences of action potentials of retinal ganglion cells evoked by short flashes are taken as examples. The present analysis demonstrate some properties of mathematical "microscopic" application to transient responses of the central nervous system (CNS), whereby the degree of magnification (steps of transformation) was varied.

Action Potentials↗
PubMed2002

Motor initiation and execution in patients with conversion paralysis.

Motor initiation and motor execution in four patients with conversion paralysis were investigated in a non-affected motor modality (speech). In line with the hypothesis of dissociated control in conversion disorder [Cognit. Neuropsychiatry 8 (1) (2001) 21] motor initiation, but not response duration, was expected to be impaired. The motor initiation times (reaction time: RT) and motor execution times (response duration: RD) were compared on four RT-tasks that required the production of a verbal response: a simple choice RT-task, a mental letter rotation task, and an implicit and an explicit mental hand rotation task. Because conversion disorder is expected to primarily involve an impairment in the initiation of movement, we expected the following task characteristics to uniquely affect RT and not RD: type of instruction (implicit versus explicit instructed imagery), angle of rotation, and target arm (affected versus non-affected arm). The results indeed showed the task characteristics to significantly affect the participants' RT and not their RD. It was concluded that conversion paralysis is associated with a specific impairment in the explicit initiation of processes with a spatial and motor component.

Adult↗
PubMed1988

Effect of cortisol on the in vitro hepatic conversion of thyroxine to triiodothyronine in brook charr (Salvelinus fontinalis Mitchill).

In vitro studies with liver homogenates of brook charr (Salvelinus fontinalis) demonstrate that the conversion of thyroxine (T4) to triiodothyronine (T3) is dependent upon temperature, pH, substrate, and homogenate concentration, supporting the hypothesis of an enzymatic hepatic T4 to T3 conversion. Dithiothreitol has a marked stimulatory effect on the rate of conversion. The kinetics of the conversion, determined by Lineweaver-Burke analysis suggest a Michaelis-Menten (Km) constant of 1.3 x 10(-8) M, and a maximum velocity (Vmax) of 0.42 pmol/mg protein/h. In brook charr given intraperitoneal implants of hydrogenated coconut oil containing cortisol at levels of 0, 5, and 50 mg/kg body weight, and sampled after 56 days, T4 to T3 conversion by homogenates of hepatic tissue in vitro was significantly (P less than 0.01) higher in the fish implanted with 50 mg/kg of cortisol than in either of the other two groups. However, plasma cortisol, L-thyroxine (T4) and triiodo-L-thyronine (T3) concentrations, plasma T3:T4 ratios and hepatosomatic index were not significantly different in the three treatment groups.

Animals↗
PubMed1985

Biochemical and clinical implications of proinsulin conversion intermediates.

Since a complete map of insulin-related peptides in humans requires consideration of proinsulin, Arg32/Glu33-split proinsulin, Arg65/Gly66-split proinsulin, des-Arg31,Arg32-proinsulin, des-Lys64, Arg65-proinsulin, and insulin, we applied high performance liquid chromatography coupled with radioimmunoassay to investigate the formation of proinsulin conversion intermediates in vitro and in vivo. Kinetic analysis of proinsulin processing by a mixture of trypsin and carboxypeptidase B (to stimulate in vivo processes) revealed (a) a rapid decline in proinsulin concommitant with formation of conversion intermediates, (b) formation of des-Arg31, Arg32-proinsulin and des-Lys64,Arg65-proinsulin in the ratio 3.3:1 at steady state, and (c) complete conversion of the precursor to insulin during extended incubation. Studies on normal human pancreas identified a similar ratio of des-Arg31,Arg32-proinsulin to des-Lys64,Arg65-proinsulin (approximately 3:1), whereas two insulinomas contained sizable amounts of des-Arg31,Arg32-proinsulin, but barely detectable amounts of des-Lys64,Arg65-proinsulin. None of the tissues contained measurable quantities of Arg32/Glu33- or Arg65/Gly66-split proinsulin. Analysis of plasma from three diabetic subjects managed by the intravenous infusion of human proinsulin revealed less than 1% processing of the circulating precursor to conversion intermediates and no processing of the precursor to human insulin. Nevertheless, analysis of plasma from the same subjects managed by the subcutaneous infusion of proinsulin revealed 4-11% processing of the precursor to intermediates that had the properties of des-Arg31,Arg32-proinsulin and Arg65/Gly66-split proinsulin. We conclude that (a) processing of proinsulin to insulin in vivo as in vitro likely occurs by preferential cleavage at the Arg32-Glu33 peptide bond in proinsulin, (b) proinsulin is inefficiently processed in the vascular compartment, and (c) subcutaneous administration of the precursor can result in the formation of conversion intermediates with the potential for contributing to biological activity.

Carboxypeptidases↗
PubMed2004

Quantitative proteomics: a review of different methodologies.

The present review attempts to cover the vast array of methods which have appeared in the last few years for performing quantitative proteome analysis. These methods are divided into two classes: those applicable to conventional two-dimensional map analysis, coupling orthogonally a charge-based step (isoelectric focusing) to a size-based separation [sodium dodecylsulfate (SDS)-electrophoresis] and those applicable to two-dimensional chromatographic protocols. The first method, although being by and large the most popular approach, can offer differential display of paired samples with relatively few methods, the oldest one being based on statistical analysis performed on sets of gels via powerful software packages, such as the MELANIE, PDQuest, Z3 and Z4000, Phoretix and Progenesis. Recent developments comprise analysis performed on a single gel containing mixed samples differentially labeled, either with fluorophors (Cy3 and Cy5) or with d(0)/d(3) acrylamide. Conversely, chromatographic approaches, which mostly rely on analysis not of intact proteins but of their tryptic digests, offer a panoply of differential labeling protocols, most of which rely on stable isotope tagging. Essentially, all possible reactions have been described, such as those involving Lys, Asp, Glu, Cys residues, as well as a number of methods exploiting differential derivatization of amine and carboxyl groups generated during proteolysis. All such methods are described and evaluated.

Amino Acid Sequence↗
PubMed2003

A novel semiquantitative polymerase chain reaction/enzyme digestion-based method for detection of large scale deletions/conversions of the CYP21 gene and mutation screening in Turkish families with 21-hydroxylase deficiency.

21-Hydroxylase deficiency is a recessively inherited disorder resulting from mutations in the CYP21 gene. The CYP21 gene is located along with the CYP21P pseudogene in the human leukocyte antigen major histocompatibility complex region on chromosome 6. Molecular diagnosis is difficult due to the 98% similarity of CYP21 and CYP21P genes and the fact that almost all frequently reported mutations reside on the pseudogene. Allele-specific PCR for the 8 most frequently reported point mutations was performed in 31 Turkish families with at least a single 21-hydroxylase-deficient individual. The allele frequencies of the point mutations were as follows: P30L, 0%; IVS2 (AS,A/C-G,-13), 22.5%; G110delta8nt, 3.2%; I172N, 11.4%; exon 6 cluster (I236N, V237E, M239K), 3.2%; V281L, 0%; Q318X, 8%; and R356W, 9.6%. Large deletions and gene conversions were detected by Southern blot analysis, and the allele frequencies were 9.6% and 22.5%, respectively. Sequence analysis of the gene, performed on patients with only 1 mutated allele, revealed 2 missense mutations (R339H and P435S). A novel semiquantitative PCR/enzyme digestion-based method for the detection of large scale deletions/conversions of the gene was developed for routine diagnostic purposes, and its accuracy was shown by comparison with the results of Southern blot analysis.

Adrenal Hyperplasia, Congenital↗