Alterations in treatment technique and early therapeutic interven

Alterations in treatment technique and early therapeutic intervention may help to reduce or eliminate radiation-induced skin side-effects and associated pain. Krasin, M. J. et al. (2009). Clinical Oncology 21, 781-785 (C) 2009 The Royal College of Radiologists. Published by Elsevier

Ltd. All rights reserved.”
“We have studied the polarization-electric-field hysteresis, the dielectric permittivity dispersion, the piezoelectric PXD101 in vivo properties, the electric-field-induced strain, and the interrelations between these properties for bismuth ferrite (BiFeO3) ceramics. The results indicate that the domain-wall movement in BiFeO3 is strongly inhibited by charged defects, most probably acceptor-oxygen-vacancy defect pairs. The domain-wall find more mobility can be considerably increased by preventing the defects from migrating into their stable configuration; this can be achieved by thermal quenching from above the Curie temperature, which freezes the disordered defect state. Similarly, Bi2O3 loss during annealing at high temperatures contributes to depinning of the domain walls and an increase in the remanent polarization. The possible defects causing the pinning effect are analyzed and discussed. A weakening of the contacts between the grains in the ceramics and crack propagation were observed during poling with constant field at 100 kV/cm. This is probably caused by an electrically induced

strain associated with ferroelastic domain reversal. A relatively large piezoelectric d(33) constant of 44 pC/N was obtained by “”cyclic poling,”" in which the electric field was released after each applied cycle with the purpose to relax the mechanical

stresses and minimize the problem of cracking. (C) 2010 American Institute of Physics. [doi:10.1063/1.3490249]“
“The aim of the study was to evaluate the clinical and functional outcomes of laparoscopic sacrocolpopexy, in particular Nocodazole in vitro its effect on female sexual function.

A retrospective observational study of women undergoing laparoscopic sacrocolpopexy between February 2005 and March 2009 was undertaken. Pelvic organ support was assessed objectively using the pelvic organ prolapse quantification scale (POP-Q). Functional outcomes were assessed using the International Consultation on Incontinence questionnaire for vaginal symptoms (ICIQ-VS), both preoperatively and at 6-36 months postoperatively.

Eighty-four women with a mean age of 65 years (range, 49-78 years) were studied. At follow-up in clinic, all women had good vault support (mean point C, -8.9; range, 10 to -8). Subjective improvements in prolapse symptoms and sexual well-being were observed with significant reductions in the respective questionnaire scores.

Our results confirm previous findings that laparoscopic sacrocolpopexy is a safe and efficacious surgical treatment for post-hysterectomy vaginal vault prolapse.

The first sample (S1) was collected after lesions were radiograph

The first sample (S1) was collected after lesions were radiographically visible, and the second sample (S2) was collected after SBE-β-CD solubility dmso apical negative pressure irrigation (group 1) or conventional irrigation/triantibiotic dressing (group 2). All samples were seeded in a culture medium for anaerobic bacteria. Colony-forming unit counts were analyzed statistically by the Mann-Whitney test (alpha = .05).

Results. Microorganisms were present in 100% of canals of both groups in S1. In S2, microorganisms were absent in 88.6% of group 1′s canals and 78.28% of group 2′s canals. There was no significant difference between the groups in either S1 (P = .0963) or

BIX 01294 datasheet S2 (P = .0566). There was significant (P < .05) bacterial reduction from S1 to S2 in both groups.

Conclusion. In immature teeth with apical periodontitis, use of the EndoVac system can be considered

to be a promising disinfection protocol, because it provided similar bacterial reduction to that of apical positive pressure irrigation (conventional irrigation) plus intracanal dressing with the triantibiotic paste, and the use of intracanal antibiotics might not be necessary. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e42-e46)”
“The Pacific lamprey (Entosphenus tridentatus) is an anadromous fish that is of conservation concern in North America and Asia. Data on Pacific lamprey population structure are scarce and conflicting, impeding conservation efforts. We optimized 12 polymorphic microsatellite loci for the Pacific lamprey. Three to 13 alleles per locus were observed in a sample of 51 fish collected from the West Fork Illinois River, Oregon. Observed heterozygosity ranged from 0.235 to 0.902 and expected heterozygosity ranged from 0.214 to 0.750. Cross-species

amplification produced 8 to 12 polymorphic loci in four other Entosphenus species and in the western brook lamprey NU7026 (Lampetra richardsoni). Two loci appear to be diagnostic for distinguishing Entosphenus from Lampetra. These markers will be valuable for evaluating population structure and making conservation decisions for E. tridentatus and other lamprey species.”
“Ferroelectric (FE)/semiconductor heterostructures are very promising for future electronic devices. This paper examined several kinds of devices based on heterostructures made from FE and GaN semiconductor. Results showed that although two-dimensional electron gas (2DEG) density in GaN could be tuned by the polarization of FE, it was harsh to enhance the 2DEG greatly for a practical structure even in theory. We proposed that beside the device process, structure design of the device was also important to 2DEG characteristics. To keep or enhance the 2DEG density need novel materials and/or device structures.

It will be important to develop methods of addressing this potent

It will be important to develop methods of addressing this potential barrier Vadimezan ic50 (such as detailed explanation and supervised practice) if these methods are to be successfully implemented.”
“To describe the health-related quality of life (HRQOL) of grade-five students in Alberta,

Canada, and to assess how this correlates with sociodemographic and neighbourhood characteristics.

In 2008, we conducted a comprehensive population-based survey among 3,421 grade-five students aged primarily 10-11 years from 148 schools and their parents that included questions on sociodemographic and neighbourhood factors. The HRQOL of the students was assessed using the EQ-5D Canadian English child version (EQ-5D-Y). We applied multilevel multivariable linear regression to examine the independent importance of sociodemographic and neighbourhood factors for the EQ-5D-Y index and EQ-5D-Y Visual Analogue Scale (VAS) score.

In five EQ-5D-Y dimensions, problems with ‘walking’, ‘looking after myself’, ‘usual activities’, ‘pain or discomfort’ and ‘worried, sad or unhappy’ were reported by 8.1% (n = 288), 6.5% (n = 215), 11.8% (n = 431), 46.0% (n = 1600), and 37.7% (n = 1292) of students, respectively. Their mean EQ-5D-Y index was 0.86 and mean EQ-5D-Y VAS was 80.4. Children from families reporting

higher educational attainment reported selleck chemical higher HRQOL both in terms of a higher EQ-5D-Y index and in terms of a higher EQ-5D-Y VAS. Also, children residing in neighbourhood characterized as providing good satisfaction and facilities reported higher HRQOL.

Public health initiatives to improve HRQOL among children selleck kinase inhibitor are suggested to take into account the influence of different sociodemographic and neighbourhood characteristics such that priority is given to those residing in towns, rural areas and dissatisfying neighbourhoods with poor access to recreational facilities and stores for fresh products.”

objective of this study was to assess the factor structure of nine health-related quality of life (HRQOL) survey items among people with and without disabilities or functional limitations (FL) and determine whether factor loadings were similar for the two groups.

Data were from US states and territories in the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). Confirmatory factor analyses assessed fit of the data to a previously found factor structure.

A two-factor structure was confirmed, conceptually representing physical and mental health. Although this structure fit data for both people with and without FL, factor loadings were significantly different for the two groups. In all but one instance, factor loadings were higher for people with FL than for people without FL.

Results suggest that people with and without FL conceptualize physical and mental HRQOL similarly. However, the nine items analyzed appear to be a better reflection of the latent constructs of physical and mental HRQOL in the population of people with FL than those without FL.

The electrical properties were determined by four-point-probe bul

The electrical properties were determined by four-point-probe bulk conductivity measurements. (C) 2011 Wiley Periodicals, Inc. J Appl Polym

Sci, 2012″
“We studied the atomic arrangements and phase diagrams of two-dimensional (2D) Bi-Pb binary films on a Rh(111) surface with low-energy electron diffraction (LEED), scanning tunneling microscopy (STM), and Auger electron spectroscopy. The 2D binary films exhibited incommensurate (4 x 4) LEED patterns with any compositional ratio of Bi:Pb. Atomically resolved STM images revealed that the binary films formed hexagonal, close-packed structures in a 2D solid solution alloy. We found that the 2D binary films followed the Hume-Rothery rule. The interatomic distance decreased linearly from 0.359 nm to 0.342nm with CDK inhibitor review increasing proportions of Pb. This indicated that the lattice constant of the 2D binary films followed Vegard’s law. (c) 2011 American Institute of Physics. [doi: 10.1063/1.3650883]“
“Cultural niche construction is a uniquely potent source of selection on human populations, and a major cause of recent human evolution. Previous theoretical analyses have not, however, explored the local effects of cultural niche construction. Here, we use spatially explicit coevolutionary models to investigate how cultural processes could drive selection on human genes by modifying

local resources. We show that cultural ISRIB in vitro learning, expressed in local niche construction, can trigger a process with dynamics

that resemble runaway sexual selection. Under a broad range of conditions, cultural niche-constructing practices this website generate selection for gene-based traits and hitchhike to fixation through the build up of statistical associations between practice and trait. This process can occur even when the cultural practice is costly, or is subject to counteracting transmission biases, or the genetic trait is selected against. Under some conditions a secondary hitchhiking occurs, through which genetic variants that enhance the capability for cultural learning are also favoured by similar dynamics. We suggest that runaway cultural niche construction could have played an important role in human evolution, helping to explain why humans are simultaneously the species with the largest relative brain size, the most potent capacity for niche construction and the greatest reliance on culture.”
“Background: Pneumococcal disease is a leading cause of morbidity and mortality worldwide. The aim of this study was to investigate the association between specific pneumococcal serotypes and mortality from invasive pneumococcal disease (IPD).

Methods and Findings: In a nationwide population-based cohort study of IPD in Denmark during 1977-2007, 30-d mortality associated with pneumococcal serotypes was examined by multivariate logistic regression analysis after controlling for potential confounders. A total of 18,858 IPD patients were included.

3 mu m to 1 0 mu m: similar to 5 x 10(14) cm(-3)) even after anne

3 mu m to 1.0 mu m: similar to 5 x 10(14) cm(-3)) even after annealing at 1000 degrees C. The concentration of all these defects generated by RIE, except for the IP4 (HK0) center, remarkably decreases by thermal oxidation. In addition, the HK0 center can also be reduced significantly by a subsequent annealing

at 1400 degrees C in Ar. (C) 2010 American Institute of Physics. [doi:10.1063/1.3460636]“
“Infection with the hepatitis C virus commonly occurs in patient groups who have difficulty accessing conventional medical care, reducing their chance of successful antiviral therapy. Managed care networks (MCNs) have been suggested as a mechanism of improving access to care; however, there is little evidence to support their use in patients with hepatitis C. The aim of this study was Entinostat price to evaluate the impact of a MCN for patients with hepatitis C. This was a retrospective cohort study of all individuals in our area who had received a positive

hepatitis C antibody test between August 1994 and June 2008. The MCN introduced a new referral pathway, which included nonmedical referrals and outreach nurse-led clinics. These interventions were introduced in 2004 and evaluated in 2008. After the introduction of the MCN, the proportion of individuals who accessed care increased from 61% (280/430) to 82.4% (721/875). There was an increase in nonmedical referrals with 81 (18.3%) being directly GW786034 referred from Drug Problem Services and 75 (17%) from the Prison Service. The changes to referral did not have a negative impact GDC-0941 datasheet on treatment outcomes as the number who completed treatment increased from 66.1% (43/65) to 73.7% (98/133) and the sustained virological response increased from 50.7% (33/65) to 60.9% (81/133). This study provides

evidence that the collaboration of health care professionals within a network can have a radical effect in improving access to care in a traditionally hard to reach population. This has been achieved with little additional resource, but rather working smarter with existing staff.”
“We explore a new geometry allowing effective excitation of the lowest antisymmetric standing spin wave mode in ferromagnetic metallic films with symmetrical boundary conditions. The approach is based on the use of a coplanar waveguide with the ferromagnetic film, Permalloy (Py), playing the role of the signal line. In addition, we study a signal line which is a sandwich of Py inside two nonmagnetic metallic films. We find that the thickness and conductivity of the metal films can significantly alter the amount of absorption, at ferromagnetic resonance, between the symmetric and antisymmetric spin wave modes. The experimental results are supported by numerical calculations indicating the origin of the strength of the absorption. (C) 2010 American Institute of Physics. [doi:10.1063/1.

Prevention efforts in France should focus on reducing not only fo

Prevention efforts in France should focus on reducing not only food-borne but also person-to-person transmission.”

The survival of patients returning to hemodialysis (HD) following kidney transplant failure is unfavorable. However, the factors responsible

for this poor outcome are largely unknown; chronic inflammation due to failed allograft and malnutrition may GM6001 clinical trial contribute to morbidity and mortality. We aimed to compare the nutritional status and its relation with inflammation in patients on HD with and without previous kidney transplantation.


Forty-three patients with failed renal allografts (27 males; mean age 36 +/- 9 yr) and 40 never transplanted HD patients (24 males; mean age 39 +/- 9 yr) were included GW4869 in the study. Body weight, triceps (TSF), biceps (BSF), subscapular (SSSF), and suprailiac skinfold thicknesses (SISF); mid-arm, mid-arm muscle, hip and waist circumferences; as well as body mass indices (BMIs) were determined as anthropometric

parameters. Moreover, biochemical markers of nutritional status, including serum cholesterol and albumin as well as high-sensitive C-reactive protein (hs-CRP), as a marker of inflammation, were measured. Associations among these variables were analyzed.


There were no significant differences considering age, gender or duration of renal replacement therapy between the two groups. The TSF (p < 0.0001), BSF (p = 0.005), SSSF (p = 0.001), SISF (p < 0.0001) skinfold thicknesses; mid-arm (p = 0.003) and mid-arm muscle circumferences (p = 0.037) and BMIs (p = 0.001) of the patients with failed renal allografts were significantly lower than those CDK inhibitor of the never transplanted HD patients. Waist circumference was significantly lower as well (p = 0.028). Patients with failed transplants were characterized by lower serum albumin (p < 0.0001) and higher hs-CRP levels (p = 0.001) as compared with never transplanted HD patients.


This study confirms the concept that

retained failed allografts may induce chronic inflammation in chronic HD patients which may result in a worse nutritional status.”
“Pain intensity may be high in the postoperative period after spinal vertebral surgery. The aim of the study was to compare the effectiveness and cost of patient controlled analgesia (PCA) with tramadol versus low dose tramadol-paracetamol on postoperative pain. A total of 60 patients were randomly divided into two groups. One group received 1.5 mg/kg tramadol (Group T) while the other group received 0.75 mg/kg tramadol plus 1 g of paracetamol (Group P) intravenously via a PCA device immediately after surgery and the patients were transferred to a recovery room, Tramadol was continuously infused at a rate of 0.

6%) consists of stem cells, which are not originated from primord

6%) consists of stem cells, which are not originated from primordial germ cells. Absence of Oct-4

gene expression in more than half of the cases means probably the end of the productive journey of these cells, towards the oocyte.”
“Background: Bystander CPR rates are lowest at home, where 85% of out-of-hospital cardiac arrests occur. Z-VAD-FMK clinical trial We sought to identify barriers and facilitators to CPR training and performing CPR among older individuals most likely to witness cardiac arrest.

Methods: We selected independent-living Canadians aged >= 55 using random-digit-dial telephone calls. Respondents were randomly assigned to answer 1 of 2 surveys eliciting barriers and facilitators potentially influencing either CPR training or performance. We developed survey instruments using HSP990 the Theory of Planned Behavior, measuring salient attitudes, social influences, and control beliefs.

Results: Demographics for the 412 respondents (76.4% national response rate): Mean age 66, 58.7% female, 54.9% married, 58.0% CPR trained (half >10 years ago). Mean intentions to take CPR training in the next 6 months or to perform CPR on a victim were relatively high (3.6 and 4.1 out of 5). Attitudinal beliefs were most predictive of respondents’ intentions to receive training or perform CPR (Adjusted

OR; 95% CI were 1.81; 1.41-2.32 and 1.63; 1.26-2.04 respectively). Respondents who believed CPR could save a life, were employed, and had Tyrosine Kinase Inhibitor Library seen CPR advertised had the highest intention to receive CPR training. Those who believed CPR should be initiated before EMS arrival, were proactive in a group, and felt confident in their CPR skills had the highest intention to perform CPR.

Interpretation: Attitudinal beliefs were most predictive of respondents’ intention to complete CPR training or perform CPR on a real victim. Behavioral change techniques targeting these specific beliefs are most likely to make an impact. (C)

2013 Elsevier Ireland Ltd. All rights reserved.”
“Exposure to cadmium has been established to be carcinogenic for humans by the International Agency for Research on Cancer, but this is mainly based on studies with occupational exposures. The substantial 100 year long emission of cadmium by three zinc smelters in the Kempen area across the Dutch-Belgian border might have affected the incidence of cancer in this region. Following a study of increased risks of lung cancer due to cadmium emission (hazard ratio was 4.2 for high vs. low cadmium exposure areas in that study), we used data from the three regional population-based cancer registries, covering an area with 2.9 million inhabitants. Analyses of observed incidence were carried out for all cancers and cancer of the lung, kidney, bladder, prostate, testis, and breast separately.

Elongated heads, when detected as predominant abnormal form in sp

Elongated heads, when detected as predominant abnormal form in sperm samples, may affect fertilization in ICSI.”
“This study is AZD1208 price about evaluating safety and potential risk factors for complications following pelvic organ prolapse repair with the GYNECARE PROLIFT


This is a prospective observational study (Canadian Task Force II-1) performed in a tertiary referral center. A total of 114 women with pelvic organ prolapse, POP-Q stage a parts per thousand yen2, underwent a pelvic floor repair that included Prolift.

During a mean follow-up time of 7 months there were six procedure failures (5.3%) and 14 mesh exposures (12.3%), more commonly on the anterior vaginal wall. Age was inversely related to the risk of having late mesh exposure (p = 0.02) with an odds ratio of 1.99 (95% confidence interval 1.10-3.59) for each decrease of 10 years in age. Late mesh exposure was significantly more common in sexually active patients (p = 0.016).

Prolift repair has a high anatomical success rate. Young age and sexual activity are risk factors for mesh exposure.”
“Study Design. This study was a retrospective cohort study.

Objective. To examine the criteria recommended in the literature for the school-based scoliosis screening program in Hong Kong.

Summary of Background Data. School-based Akt inhibitor screening for scoliosis has been a controversy. Objectors to the policy were

concerned about the high over-referral and false-positive rates. Recommendations were then made for improvement, but the feasibility of these recommendations has not been studied.

Methods. The cohort consisted of students in

Grade 5 in 1995/1996 or 1996/1997 who underwent scoliosis screening in Hong Kong. Participants who had an angle of trunk rotation (ATR) >= 15 degrees, 2 or more moire lines, or presented significant clinical signs were referred for radiography. Screening histories and radiography records before the age of 19 years were extracted. The accuracy measures for different combinations of screening tests were examined.

Results. There were 115,178 students in the cohort, of which 3228 (2.8%) were referred for radiography. Among the 1406 students who displayed a curve >= 20 degrees during screening, 257 (18.3%) were boys and 336 (23.9%) were identified as 16 years or older, ruling out the suggestion of screening only 10-year-old girls. The sensitivity and positive predictive value for the current referral criteria were 88.1% and 43.6%, respectively. The sensitivity would drop substantially if the use of moire topography (39.8%) or clinical signs (55.5%) were discarded. With the inclusion of these 2 tests, the clinical effectiveness measures were robust to the cutoff for ATR, unless it was set below 10 degrees.

Conclusion. Selectively screening only premenarche girls was not feasible, as this screen would have missed a significant proportion of children with significant curvature.

Most of the normal human airway is lined by a pseudostratified ep

Most of the normal human airway is lined by a pseudostratified epithelium of ciliated cells, secretory cells and 6-30% basal cells, the proportion of which varies along

the proximal-distal axis. Epithelial abnormalities range from hypoplasia (failure to differentiate) to basal-and goblet-cell hyperplasia, squamous-and Fer-1 cell line goblet-cell metaplasia, dysplasia and malignant transformation. Mesenchymal alterations include thickening of the basal lamina, smooth muscle hyperplasia, fibrosis and inflammatory cell accumulation. Paradoxically, given the prevalence and importance of airway remodeling in lung disease, its etiology is poorly understood. This is due, in part, to a lack of basic knowledge of the mechanisms that regulate the differentiation, maintenance

and repair of the airway epithelium. Specifically, selleck inhibitor little is known about the proliferation and differentiation of basal cells, a multipotent stem cell population of the pseudostratified airway epithelium. This Perspective summarizes what we know, and what we need to know, about airway basal cells to evaluate their contributions to normal and abnormal airway remodeling. We contend that exploiting well-described model systems using both human airway epithelial cells and the pseudostratified epithelium of the genetically tractable mouse trachea will enable crucial discoveries regarding the pathogenesis of airway disease.”
“An environmental-friendly approach called high-shear mechanical milling was developed to de-crosslink ground tire rubber (GTR) and waste crosslinked polyethylene (XLPE). The realization of partial devulcanization of GTR and de-crosslinking of XLPE were confirmed by gel fraction measurements. Fourier transform ALK inhibitor cancer infrared spectral studies revealed that a new peak at 1723.3 cm(-1) corresponds to the carbonyl group (-C=O) absorption was appeared after milling. The rheological properties showed that the XLPE/GTR blends represent lower apparent viscosity after mechanical milling, which means that the milled blends

are easy to process. Thermoplastic vulcanizates (TPVs) could be prepared with these partially de-crosslinked XLPE/GTR composite powders through dynamic vulcanization. The mechanical properties of the XLPE/GTR composites increased with increasing cycles of milling. The raw XLPE/GTR blends could not be processed to a continuous sheet. After 20 cycles of milling, the tensile strength and elongation at break of XLPE/GTR (50/50) composites increased to 6.0 MPa and 185.3%, respectively. The tensile strength and elongation at break of the composites have been further improved to 9.1 MPa and 201.2% after dynamic vulcanization, respectively. Re-processability study confirmed the good thermoplastic processability of the TPVs prepared. (C) 2011 Wiley Periodicals, Inc.

magna than rac-metalaxyl according to the individual 24-h-LC(50)

magna than rac-metalaxyl according to the individual 24-h-LC(50) values, and sixfold toxic than rac-metalaxyl based on 24-h-EC(50) values. In the light of 48-h-LC(50) and EC(50), this difference in toxicity was more significant. As for adult zebrafish, there was no pronounced difference in acute toxicity, in addition, at sublethal level a different pattern in inducing Na(+),K(+)-ATPase LY2606368 cost activity between them was found. In general, R-metalaxyl seemed more toxic to aquatic organisms than rac-metalaxyl. (C) 2008 Wiley Periodicals, Inc. Environ Toxicol 24: 148-156, 2009.”
“A prospective, double-blind, randomized,

and placebo-controlled trial was conducted in patients with chronic temporomandibular disorder (TMD) to check the analgesic efficacy of infrared low-power GaAlAs diode laser applied to acupuncture points. Forty female subjects, ranging in age from 20 to 40 years, with diagnoses of chronic myofascial pain and arthralgia were randomly allocated to two groups: an experimental group (EG) who received the laser acupuncture as adjunct to reversible occlusal splint therapy and a control group (CG) who received a placebo laser associated with occlusal splint therapy. Both approaches were applied once a week for 3 months. Laser acupuncture was defined by the following parameters: 50-mW continuous radiation for 90 s to acupoints ST6, SI19, GB20, GB43, LI4, LR3, NT3, and EX-HN3; defining 4.5-J

energy; 1250-W/cm(2) density NU7026 nmr point; and 112.5-J/cm(2) total density. The outcome measurements included a symptom evolution assessment carried out by checking spontaneous and palpation pain intensity, which was indicated on a visual analog scale (VAS). All evaluations were made by an assessor who was blind to the treatment.

The symptom reduction was significant in both groups (EG: VAS = 0, n = 20; CG: VAS between 2 and 4, n = 18). The measurements showed significantly faster and lower pain intensity values in the EG (p a parts per thousand currency signaEuro parts per thousand 0.002), where there was a higher proportion of patients with remission of symptoms related to the action of laser acupuncture. For patients in whom conservative treatment was adopted, the laser acupuncture is a secure, click here noninvasive, and effective treatment modality because it improves the chronic pain associated with TMD and has no side effects.”
“This report describes the diagnosis and surgical management of a pulmonary valve cystic mass in a symptomatic 7-year-old boy. Cardiac valve cysts are extremely rare beyond the age of 6 months and typically not associated with symptoms. These lesions may grow, leading to progressive stenosis, regurgitation, or ventricular outflow tract obstruction. Therefore, these lesions should be monitored for change in size and/or, hemodynamic changes. Surgical intervention may be required for symptomatic patients.