Jejunouterine fistula: a case report

Jejunouterine fistula is a rare type of fistulous communication between the small intestine and the genital tract. This fistula may result from pelvic tumours, obstetric or surgical intervention and inflammatory disease. Cross-sectional imaging modalities, including ultrasonography, magnetic resonance imaging (MRI) and computed tomography (CT), are useful investigations which may demonstrate the site and track of the fistula. Traditional contrast investigations, including hysterosalpingography, are also helpful. Surgical resection of the fistula with primary anastomosis is curative in the majority of cases.     

A prepaid healthcare scheme in rural Africa

Healthcare providers in Africa are having to increasingly rely on the resources of the populations they serve. An 8-year experience with one of the first rural-based health insurance schemes in East Africa is described. Initial difficulties included adverse selection of members with chronic ill health, fraudulent claims and overuse of health services, leading to considerable financial losses. External technical assistance introduced member tracking and regular reports, reduced adverse selection, fraud and overuse of services to a minimum, and achieved financial stability. Local market research and a comprehensive marketing plan is essential for the overall success of an insurance plan. Health insurance in this part of Africa is likely to assist middle income earners rather than the poor.     

Benzo[a]pyrene at an environmentally relevant dose is slowly absorbed by, and extensively metabolized in, tracheal epithelium

While tobacco smoke has been conclusively identified as a lung carcinogen, there is much debate over which smoke constituent(s) are primarily responsible for its carcinogenicity. Previous studies in our laboratory suggested that highly lipophilic carcinogens are slowly absorbed in the thicker epithelium of the conducting airways, potentially allowing for substantial local metabolism. The bioactivation of polycyclic aromatic hydrocarbons in airway epithelium may, hence, be important in tobacco smoke-induced carcinogenesis. In the present study, the hypothesis of slow absorption and substantial local metabolic activation of highly lipophilic carcinogen in airway epithelium was tested in dogs. A single dose of tritiated benzo[a]pyrene (BaP) dissolved in a saline/phospholipid suspension was instilled in the trachea, just anterior to the carina. At intervals of a few minutes up to 30 min over a 3-h period, blood samples were drawn from the azygous vein, which drains the area around the point of instillation, and from the systemic circulation. Tissue samples were taken at the end of the experiment. The concentration of BaP with depth into the tracheal mucosa was determined with autoradiography. BaP was slowly absorbed into the trachea with a half-time of approximately 73 min, which is consistent with diffusion-limited passage through the epithelium and lead to local doses in the tracheal epithelium that were more than a 1000-fold those of other tissues. The long retention of BaP in the epithelium provided the local metabolizing enzymes with high substrate levels over a long period, resulting in extensive metabolism. At 3 h after the exposure, 23% of the BaP-equivalent activity remained in the tracheal mucosa. Of this fraction, 13% was parent compound, 28% was organic extractable, 31% was water-soluble, and 28-7% of the instilled dose was bound to tracheal tissues. These results explain the tendency of highly lipophilic carcinogens, such as BaP, to induce tumors at the site of entry and, furthermore, indicate that the highly lipophilic components of tobacco smoke and polluted air may be the most important contributors to lung tumors of the conducting airways.      

Need for follow up in coeliac disease

The use of follow up studies was evaluated in 128 patients with coeliac disease during their first visit to a department for adults. The original diagnosis had been made in childhood in all patients. Fifty eight (45%) of the subjects were following a gluten free diet, 23 (18%) were following a gluten free diet but with occasional gluten consumption, and 47 (37%) had adopted an unrestricted, gluten containing diet for a mean of 11.2 years. There was no correlation in individual subjects between the presence of symptoms, biochemical and immunological abnormalities, severity of histological findings, and the amount of dietary gluten, despite the greater frequency of symptoms in the group following an unrestricted diet than in the other two groups. Short stature and epilepsy with cerebral calcifications only occurred in patients following an unrestricted diet. As only diagnosis based on two or three biopsy samples and regular follow up correlated positively with dietary compliance, it is suggested that a histologically confirmed diagnosis of coeliac disease and regular lifelong follow up are essential in the management of these patients.     

Elderly Patients with Suppressed Serum TSH but Normal Free Thyroid Hormone Levels Usually Have Mild Thyroid Overactivity and are at Increased Risk of Developing Overt Hyperthyroidism

The clinical and biochemical characteristics of 15 elderly patientswith low levels of thyrotrophin (TSH) (<0.1 mU/L) but normalfree tri-iodothyronine, (T3) and free thyroxine (T4) (groupS) were compared with 10 euthyroid subjects (group E) and 10hyperthyroid patients (group T). Free T3 and free T4 were significantlyhigher (p<0.05) in group S(6.3±0.5 and 18.6±1.0pmol/l, respectively) than in group E(4.6±0.3, 12.6+0.6).In common with elderly hyperthyroid patients (group T)patientsin group S had few signs or symptoms of thyrotoxocosis, butthe Wayne score (clinical index of hyperthyroidism) was higherin group S than in euthyroid subjects (p<0.05). Thyroid microsomal,thyrogolobulin or thyrotrophin receptor antibodies were commonin group T (n=9)but not in groups S(n=2) or E(n=1). This suggestsa low prevalence of Graves' disease in group S compared to groupT. Combined thyrotrophin releasing hormone (TRH; 200 µgi.v.) and gonadotrophin releasing hormone GnRH; 100 µgi.v.) tests were performed; no cases of low TSH due to hypopituitarismwere identified in group S. During a mean of 7.9 (4–12)months of observation TSH reverted to the normal range (>0.2mU/L)in 7 of 15 patients in group S; thyroid hormone concentrationsrose above the normal range in four, however, only two patientsrequired treatment for hyperthyroidism. It is unlikely thatthe suppressed TSH of patients in group S was due to mild thyroidhormone excess; although this is often a transitory phenomenon,these patients are at increased risk of developing overt hyperthyroidism.     

Glycine Receptor Antagonism: Effects of ACEA-1021 on the Minimum Alveolar Concentration for Halothane in the Rat

Background: Glycine and glutamate binding sites are allosterically coupled at the N-methyl-n-aspartate (NMDA) receptor complex. Previous studies have shown that antagonism of glutamate at the NMDA receptor reduces the minimum alveolar concentration (MAC) for volatile anesthetics. 5-Nitro-6, 7-dichloro-2, 3-quinoxalinedione (ACEA-1021) is a competitive antagonist at the glycine recognition site of the NMDA receptor. The purpose of this study was to determine whether glycine receptor antagonism also reduces volatile anesthetic requirements in the rat.

Methods: In experiment 1, Sprague-Dawley rats were anesthetized with halothane in 50% Oxygen2 -balance Nitrogen2 and their lungs mechanically ventilated. They were randomly assigned to one of three groups according to the dose of ACEA-1021 administered (0, 20, or 40 mg/kg intravenously; n = 6). The bolus dose of ACEA-1021 was followed by a continuous intravenous infusion of vehicle or ACEA-1021 at 14 mg *symbol* kg sup -1 *symbol* h sup -1. Halothane MAC was then determined by the tail-clamp method. In experiment 2, awake rats were randomly assigned to groups according to the same dosages of ACEA-1021 as in experiment 1. Arterial CO2 tension and mean arterial pressure were recorded before and 5 and 30 min after the start of the infusion. The infusion was then stopped, and the time to recovery of the righting reflex was recorded.

Results: In experiment 1, ACEA-1021 decreased halothane MAC (mean + SD) in a dose-dependent manner (control, 0.95 plus/minus 0.15 vol%; ACEA-1021 20 mg/kg, 0.50 plus/minus 0.14 vol%; ACEA-1021 40 mg/kg, 0.14 plus/minus 0.16 vol%; P < 0.01). In experiment 2, arterial CO2 tension was increased by ACEA-1021 (control, 38 plus/minus 3 mmHg; ACEA-1021 20 mg/kg, 43 plus/minus 3 mmHg; ACEA-1021 40 mg/kg, 48 plus/minus 2 mmHg; P < 0.01). Mean arterial pressure was not affected by any dose of ACEA-1021. The righting reflex was abolished in rats receiving ACEA-1021 40 mg/kg only and recovered 30 plus/minus 7 min after discontinuation of the infusion.     

Primary tumours of the small intestine in Jamaica

A review of 60 patients with primary small bowel tumours seen at the University Hospital, Jamaica, during the 15 year period 1971-1985, revealed that adenocarcinoma was the commonest tumour (27%), followed by smooth muscle tumour (23%), and carcinoids (11%). There were 32 malignant and 28 benign tumours. The mean age at presentation was 56 years, with a range of 4 to 85 years. The most common clinical presentation was intestinal obstruction, followed by pain, weight loss, abdominal mass and intussusception. In the majority of patients the diagnosis was not made preoperatively, and 80% with adenocarcinoma had lymph node metastases. Increased awareness of the diagnosis in symptomatic patients may result in improved survival.     

Effects of short-term exposure to high-dose inhaled corticosteroids on novel markers of bone metabolism

Objectives: Novel assays have been developed for markers of type 1 collagen turnover. The aim of this study was to evaluate the effect of short-term exposure to inhaled corticosteroids on both the novel and conventional markers of bone metabolism. Methods: Nine healthy subjects received 2 weeks treatment with inhaled budesonide 800 μg per day in week 1, and 1600 μg per day in week 2, or fluticasone 750 μg per day in week 1 and 1500 μg per day in week 2, with a 1-week washout in between. Measurement of carboxy-terminal propeptide of type 1 collagen (PICP), carboxy-terminal telopeptide of type 1 collagen (ICTP), plasma alkaline phosphatase bone isoenzyme, and 24-h urinary calcium excretion were made at baseline and at the end of each 2-week treatment period. Results: ICTP was significantly reduced following treatment with budesonide but not fluticasone compared with baseline: baseline 4.2 μg⋅1⁻¹ budesonide 3.0 μg⋅1⁻¹, fluticasone 3.6 μg⋅1⁻¹. There were no significant changes in PICP compared with baseline after treatment with budesonide or fluticasone. The ratio of PICP:ICTP increased significantly after treatment with both budesonide and fluticasone compared with baseline: baseline 27.4, budesonide 43.7, t 42.6. There were no significant differences between the two treatments for any of the measured parameters. Conclusions: Thus, when using sensitive markers of collagen turnover, short-term inhaled corticosteroid therapy was found paradoxically to reduced bone resorption. Received: 26 June 1995/Accepted in revised form: 14 November 1995     

T and B Cells in Myelomatosis

Electron microscopy of erythropoiesis in aplastic anaemia has demonstrated some unique features of dyserythropoiesis at the ultrastructural level, which contribute to understanding of the morphological features which are seen in the light microscope. The findings provide further evidence for the presence of qualitative defects in erythropoiesis in aplastic conditions. The alterations seen included bi- and multinucleated cells, intercellular bridges containing microtubules, internuclear chromatin bridges, irregular nuclear shapes, juxta-nuclear and peripheral cisternal structures, ringed sideroblasts, a diversity of intranuclear inclusions, nuclear clefts in both eu- and heterochromatin, and a variety of anomalies of the nuclear membrane. The significance of the occurrence of these anomalies in aplastic anaemia is considered and the role of the nuclear membrane and of endoplasmic reticulum in the pathogenesis of aplastic anaemia is discussed.