Search

Pouchitis is a poorly defined syndrome that is unique to patients with an ileal reservoir. During a prospective follow-up review of 215 patients who underwent ileal pouch-anal anastomosis, pouchitis was diagnosed in 30 patients (14 percent). Based on the clinical course, two distinct patterns of pouchitis were recognized: patients who experienced two or fewer episodes (Group 1-18 patients) and patients who experienced at least three episodes (Group 2-12 patients). Histopathologic review of resected colons revealed a preponderance of indeterminate colitis in patients in Group 2 (58.3 percent) compared with patients in Group 1 (0 percent). In Group 1; 88.9 percent of patients responded to therapy with metronidazole. Only 25 percent of patients in Group 2 responded to metronidazole alone. Most patients in Group 2 required sulfasalazine, topical steroids, or both. Of the 30 patients with pouchitis, four (13.3 percent) had a distinct endoscopic pattern of distal inflammation. This subset of patients with short strip pouchitis was successfully treated with topical steroid preparations. The clinical differences suggest different causes of pouchitis in these two groups.

(1999). Don't You See How Blessed I Am: Letisha's Story. Chaplaincy Today: Vol. 15, No. 1, pp. 60-61.

Perianal hidradenitis suppurativa, a chronic recurrent inflammatory disease of apocrine glands, adjacent anal canal skin, and soft tissues, is characteristically ignored and misdiagnosed. A retrospective analysis of 43 patients with perianal hidradenitis suppurativa was performed; 40 patients (93 percent) were male and 3 (7 percent) were female, with a median age at presentation of 29 years. Symptoms, including pain, swelling, purulent discharge, and pruritus, had been present for a median of six years. Diagnoses at the time of presentation included pilonidal disease (28 percent), anal fistula (37 percent), and perirectal abscess (16 percent). Associated medical conditions included diabetes (12 percent) and obesity (12 percent), and 70 percent of the patients were smokers. Once the correct diagnosis was established, 72 percent of patients had wide local excision with healing by secondary intention, and 28 percent of patients had incision and drainage or limited local excision. Although 67 percent of the patients had recurrence of disease after initial treatment, wide excision was more successful in preventing recurrence. Skin grafting failed uniformly, and colostomy was rarely necessary. Despite its relatively common occurrence, perianal hidradenitis suppurativa is infrequently diagnosed correctly and recurs in many patients despite appropriate surgical treatment, making the disease a source of frustration for surgeon and patient alike.

The authors reviewed their experience with 12 patients (median age, 38 years; range, 24 to 66 years) who had bleeding stomal varices. Stomal variceal bleeding occurred between 1 and 11 years (median, 5.5 years) after creation of the stoma. Control of bleeding initially consisted of direct pressure; recurrent bleeding occurred in one patient who died before definitive therapy could be performed. The remaining 11 patients underwent a total of 18 additional procedures for control of bleeding stomal varices, including 9 local procedures, 8 portosystemic shunts, and 1 liver transplantation. Seven patients were dead of hepatic failure a median of 4 years (range, 1 to 9 years) after treatment. Recurrent bleeding occurred in three patients after local treatment and in one patient after a portosystemic shunt. Bleeding stomal varices are a manifestation of severe liver disease and portal hypertension. Although local procedures may be effective for initial control of bleeding, recurrent bleeding often occurs. Mortality is high because of the severity of the underlying liver disease.

The authors retrospectively reviewed the records of 50 patients whose initial diagnosis of Crohn's disease was made after the age of 50 years on the basis of strict histopathologic criteria. Progress of the 32 women and 18 men with a median age of 60 years (range, 50 to 78 years) was followed for a median of 95.5 months (range, 81.1 to 236.6 months). The most common presenting signs and symptoms were abdominal pain (82 percent), diarrhea (70 percent), weight loss (56 percent), bleeding from the gastrointestinal tract (26 percent), abdominal mass (16 percent), and fistula (14 percent). Initial operations performed were ileocolic resection (38 percent), proctocolectomy (16 percent), small bowel resection (10 percent), colostomy (2 percent), and a variety of segmental resections of the colon (34 percent). The overall recurrence rate of disease in patients in whom all obvious disease was resected, based on distribution of disease, was 80 percent (ileocolitis), 38 percent (ileitis), and 35 percent (colitis). Crohn's disease more often affects the distal gastrointestinal tract in older age groups. After resection, however, the clinical course is similar to that of the younger population. The high recurrence rate of Crohn's colitis is probably a result of the large number of initial segmental resections.

Published information concerning costs of the various university disciplines is scanty, and Deans of Nursing have to rely on information that is transmitted to them by their university administrators. This paper provides some hard facts of comparative costs at one university, where, after an examination of the various factors involved, it was found that when judged by a) the cost of producing a section of a course, Nursing ranked 21 out of 28; b) the cost/student/section, regardless of level, Nursing ranked 19 out of 28; and c) the cost/student/section of the highest level undergraduate courses, Nursing ranked one out of 28. It was therefore concluded that financial arguments cannot be used to deprive nurses of the university education received by all other professionals.

Anorectal manometry was performed with a multilumen continuously perfused catheter in nine women with fecal incontinence after vaginal delivery. All patients had a third-degree or fourth-degree perineal laceration. The median age was 30 (range, 24 to 38) years. Anal manometry revealed low resting and squeeze pressures with a mean pressure of 28.7 +/- 5.3 mm Hg (normal, 60 to 80 mm Hg) and 42.5 +/- 5.9 mm Hg (normal, 100 to 150 mm Hg), respectively. Seven of nine patients had specific anterior quadrant defects demonstrated by cross-sectional analysis of the sphincter. In addition, five patients had evidence of global defects of the sphincter or relatively low pressures in other portions of the sphincter. Follow-up manometric data were obtained in four patients after reconstruction of the sphincter and demonstrated a mean improvement of resting and squeeze pressures of 5.1 mm Hg and 16.0 mm Hg, respectively. Although specific anterior defects may be expected with the history of obstetric trauma, the presence of global defects of the sphincter was unexpected and may support the role of injury to the innervation of the musculature of the pelvic floor as a contributing cause of fecal incontinence after childbirth. Anal manometry provides a quantitative assessment of sphincter function and dysfunction and is an important part of the preoperative assessment of patients with fecal incontinence from obstetric injuries.

The authors describe the use of a new self-retaining retractor to facilitate the mucosal proctectomy aspect of the ileal pouch-anal anastomosis.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

• We reviewed the treatment outcome in 40 patients undergoing full-thickness local excision (seven patients) or electrocoagulation (33 patients) for adenocarcinoma of the rectum. Patients were followed up for a minimum of 5 years or until death (mean follow-up, 7.6 years). Twenty-two patients (55%) survived 5 years free of disease or were free of disease at the time of death due to other causes following local treatment. Eight (62%) of 13 patients with persistent or locally recurrent disease were successfully treated with additional local therapy, rectal resection, or combined radiation therapy and chemotherapy. Overall, 30(75%) of 40 patients embarking on a program of local treatment for carcinoma of the rectum survived 5 years free of disease or were free of disease at the time of death due to other causes. ( Arch Surg. 1993;128:545-550)

• Fibrotic strictures of the small bowel are known to cause chronic bowel obstruction in patients with Crohn's disease. Strictureplasty without resection permits relief of bowel obstruction and preservation of bowel length. The records of 13 patients who underwent 52 strictureplasties for Crohn's disease at the Lahey Clinic Medical Center, Burlington, Mass, from 1982 through 1989 were reviewed to determine the results of this surgical intervention. Nine patients were treated with strictureplasty only, while the remaining 4 patients underwent concomitant small-bowel resection for stenosed areas not amenable to strictureplasty. One early complication occurred in a patient in whom a pelvic abscess developed. In a median follow-up period of 2 years (range, 0.5 to 7 years), 9 patients were rehospitalized because of obstruction from Crohn's enteritis. Four patients required further surgery, 3 patients underwent strictureplasty at a newly stenosed area of small bowel, and 1 patient required resection of the initial strictureplasty. Strictureplasty is an effective surgical option for patients with Crohn's disease who have symptomatic small-bowel strictures. (Arch Surg. 1990;125:715-717)

Since the advent of pediatric interventional catheterization, the necessity of multiple cardiac surgeries has been reduced. Therefore, the morbidity and mortality of multiple thoracotomies in infancy is also minimized. The role of the critical care nurse in the cardiac catheterization laboratory has become a necessity and a challange. With courage and skill, the risk of interventional catheterization can be minimized and the results are rewarding.

4-Allylazetidin-2-one, prepared from penta-1,4-diene and chlorosulphonyl isocyanate, has been used to synthesise the parent 7-oxo-1-azabicyclo[3.2.0] hept-2-ene-2-carboxylate system of the naturally occurring olivanic acids, using an intramolecular Witting reaction to construct the 2,3-double bond. Cyclisation of ketones derived from the 4-allyl grouping produced 3-substituted derivatives, while use of the azetidin-2-one prepared from hexa-1,5-diene and chlorosulphonyl isocyanate has given the homologous 8-oxo-1-azabicyclo[4.2.0]oct-2-ene system.

Previous studies have demonstrated that thyroid hormones in vitro stimulate microsomal protein synthesis in cell-free systems, but the effect was found to be indirect and dependent on the presence of mitochondria in the incubation system. The mitochondrial requirement has recently been questioned by Carter et al. ((1971) J. Biol. Chem. 246, 4973), who claimed to observe direct stimulations by thyroxine in cell-free liver systems lacking mitochondria. The system used by them contained higher Mg2+ concentrations, lower microsomal concentrations, and uniformly labeled l-[14C]valine of very high specific activity. We have examined this effect and confirmed the stimulation of 14C incorporation into protein but found that it bears no relationship to protein synthesis. The effect is not observed with tRNA-14C-amino acid as the source of 14C-amino acid. It is not inhibited by cycloheximide, puromycin, or ribonuclease, and is, in fact, enhanced in their presence. It exhibits no dependence on microsomes or ATP and is maximum in their absence. The effect is not diluted out by dilution of the l-[U-14C]valine with unlabeled l-valine. Chromatographic analysis of hydrolysates of the labeled protein reveals that the thyroxine stimulation is on the incorporation not of the 14C-amino acid but of a radioactive contaminant present in the l-[U-14C]valine. Purification of the 14C-amino acid by ion exchange chromatography before use reduces or eliminates both the base-line incorporation and the thyroxine effect. Similar spurious incorporation and thyroxine stimulations are observed with l- and d-[1-14C]valine, but they are almost negligible compared to those observed with l-[U-14C]valine. The thyroxine effect reported by Carter et al. is, therefore, not on protein synthesis but on the energy-independent incorporation of a radioactive contaminant of the l-U-14C-amino acid into cell sap protein. It is, in fact, obscured by protein synthesis and was unmasked by them when they reduced protein synthesis by lowering the microsomal concentration and compensated for the reduced 14C incorporation by using l-U-14C-amino acid of high specific activity.

This article is an outline of the author's work as a volunteer counsellor, and describes some of the methods used and insights obtained in dealing with the special problems of counselling in non-institutionalised and unstructured settings. The general background of this type of counselling and the counselling methods used are illustrated with reference to a case study; there is also an overall evaluation of the contribution that this kind of counselling offers in contrast to more formal and institutionalised counselling methods.

Ample information in experimental animals indicates a relationship between inhibition of thyroid-pituitary homeostasis and the developmental thyroid follicular cell neoplasms. This is generally the case when there are long-term reductions in circulating thyroid hormones which have triggered increases in circulating thyroid stimulating hormone. Such hormonal derangements leading to neoplasms have been produced by different regimens, including dietary iodide deficiency, subtotal thyroidectomy, and administration of natural and xenobiotic chemical substances. The carcinogenic process proceeds through a number of stages, including follicular cell hypertrophy, hyperplasia, and benign and sometimes malignant neoplasms. Given the interrelationship between the thyroid and pituitary glands, conditions that result in stimulation of the thyroid can also result in stimulation of the pituitary, with the development of hyperplastic and neoplastic changes. The progression of events leading to thyroid (and pituitary) neoplasms can be reversed under certain circumstances be reestablishing thyroid-pituitary homeostasis. Most chemicals that have induced follicular cell tumors seem to operate through inhibition of the synthesis of thyroid hormone or an increase in their degradation and removal. For some of these compounds, it appears that genotoxic reactions may not be playing a dominant role in the carcinogenic process. A seemingly small group of thyroid carcinogens seems to lack influence on thyroid-pituitary status and may in part be operating via their genotoxic potential. In contrast with the well-established relationship between thyroid-pituitary derangement and follicular cell neoplasms in animals, the state of information in humans is much less certain. At this time, ionizing radiation is the only acknowledged human thyroid carcinogen, a finding well established in experimental systems as well. Although humans respond to goitrogenic stimuli as do animals, with the development of cellular hypertrophy, hyperplasia, and under certain circumstances nodular lesions, disagreement exists as to whether malignant transformation occurs in any predictable manner. It would seem that if humans develop thyroid tumors following long-term derangement in thyroid-pituitary status, they may be less sensitive than the commonly used animal models.

The trans- and cis-substituted β-lactam isomers of p-nitrobenzyl 3-(2-acetamidoethylthio)-6-ethyl-7-oxo-1-azabicyclo[3.2.0]heptane-2-carboxylate can be oxidised with iodobenzene dichloride–pyridine under anhydrous conditions to give the 3,4-unsaturated esters, which after isomerisation and deprotection afford the sodium salts of (±)-PS-5 and (±)-6-epi PS-5.

Publisher Summary This chapter discusses a steroid competition assay for determination of 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D. Vitamin D is known to undergo obligatory metabolism prior to generation of its biological response. The first step that occurs in the liver involves the introduction of a 25-hydroxyl group to give 25-hydroxyvitamin D [25-OH-D]. The second stage of metabolite transformation occurs in the kidney where 25-OH-D may be converted into either lα,25-dihydroxyvitamin D [1,25-(OH) 2 D] or 24R,25-dihydroxyvitamin D [24,25-(OH) 2 D]. Several methods for the determination of the plasma concentration of 25-OH-D have been reported. The method presented in this chapter provides for a rapid and simple assay of 25-OH-D in biological samples. Also because 24,25-(OH) 2 D 3 competes equally with 25-OH-D for their plasma binding protein, transcalciferan, it is possible to use this same assay with a modified sample purification scheme to effect a determination for this 24,25-dihydroxylated metabolite. With the use of a swinging-bucket rotor that can handle 48 tubes, it is now possible to extract and assay as many as 16 unknown samples at two concentrations in 1 day.

The β-lactams prepared from penta-1,4-diene and cyclohexa-1,4-diene by reaction with chlorosulphonyl isocyanate can be readily converted into the 7-oxo-1-azabicyclo[3.2.0]hept-2-ene ring system, using an intramolecular Witting reaction to form the 2,3-double bond.

Die Carbonsaure (I) reagiert zum Phenylthioester (II ), der in das Phosphoran (III) auf bekannte Weise ubergefuhrt wird.

Background Several studies have demonstrated increased inhospital mortality following weekend admission. We hypothesized that the presence of resident trainees reduces the weekend mortality trends. Methods We identified all patients with a non-elective hospital admission from 1/1/2003 through 12/31/2008. We abstracted vital status on discharge and calculated the Charlson comorbidity score for all inpatients. We compared odds of inpatient mortality following non-elective admission on a weekend day as compared to a weekday, while considering diagnosis, patient characteristics, comorbidity, hospital factors, and care at hospitals with resident trainees. Results Data were available for 48,253,968 patient discharges during the six-year study period. The relative risk of mortality was 15% higher following weekend admission as compared to weekday admission. After adjusting for diagnosis, age, sex, race, income level, payer, comorbidity, and weekend admission the overall odds of mortality was higher for patients in hospitals with fewer nurses and staff physicians. Mortality following a weekend admission for patients admitted to a hospital with resident trainees was significantly higher (17%) than hospitals with no resident trainees (p

The trans- and cis-substituted β-lactam isomers of p-nitrobenzyl 3-(2-acetamidoethylthio)-6-ethyl-7-oxo-1-azabicyclo[3.2.0]heptane-2-carboxylate can be oxidised with iodobenzene dichloride–pyridine under anhydrous conditions to give the 3,4-unsaturated esters, which after isomerisation and deprotection afford the sodium salts of (±)-PS-5 and (±)-6-epi PS-5.

Base-catalysed addition of thiols to 7-oxo-1-azabicyclo[3.2.0]hept-2-ene-2-carboxylates produces adducts of the saturated nucleus, which can be stereospecifically oxidised to α-chlorosulphoxides and then dehydrochlorinated to form antibacterially active sulphoxides of the corresponding unsaturated system.

The β-lactams prepared from penta-1,4-diene and cyclohexa-1,4-diene by reaction with chlorosulphonyl isocyanate can be readily converted into the 7-oxo-1-azabicyclo[3.2.0]hept-2-ene ring system, using an intramolecular Witting reaction to form the 2,3-double bond.

HUNTINGTON'S chorea is a well-recognized, genetically determined disease of autosomal dominant inheritance. Though usually considered to be a disorder having its onset between the ages of 20 and 40 years, there are many well-documented cases of this disease occurring in the teens and early childhood. 1,2 The presence of choreiform movements in a patient with progressive mental deterioration and a heredofamilial background of a similar nature makes the diagnosis of Huntington's chorea obvious in most cases. However, this disease may manifest itself in varying forms; without the proper family history, it can be confused with other diseases of the central nervous system. A recent study 3 of a patient and members of his family with unusual features of Huntington's chorea prompted us to further investigate the first generation offspring of those parents affected with the disorder. In the initial report only two children of affected parents were evaluated: a