Surgical management of diverticulitis

Presented is the authors' experience with 182 patients treated primarily by the one-stage primary resection or two-stage resection. (Hartmann operation). One hundred thirty five patients undergoing primary resection had an associated mortality rate of 2.2 per cent. Of 44 patients operated upon using the Hartmann operation for complicated diverticulitis (obstruction, perforation, abscess formation, or fistula formation) the mortality rate was 4.5 per cent. Primary resection in an elective setting is associated with the lowest mortality and morbidity; however, marked inflammation, obstruction and/or peritonitis preclude primary anastomosis. In the urgent setting the staged operation is associated with acceptable morbidity and mortality.     

Dissociation and Traumatic Experiences in Eating Disorders

The aim of this study was to investigate the presence of trauma and dissociative experiences in a group of patients with eating disorders. One hundred and three patients were assessed at the beginning of inpatient treatment, using the Dissociation Questionnaire (DIS-Q) and a semi-structured interview. DIS-Q scores were compared for patients and a group of 112 high school graduating students serving as controls. Of the patients 37.8 per cent reported traumatic experiences. The highest trauma rate was among patients with bulimic symptoms. Notable differences were found between the patients and the control group in terms of the total DIS-Q score and on all subscales. Twenty patients (19.4 per cent) demonstrated pathological dissociative experiences (versus 3.6 per cent in the control group). Among patients, the highest total DIS-Q scores were displayed by bulimic patients, whereas the lowest were found in obese patients. Our data support the hypothesis that trauma-induced dissociative experiences may influence the development of eating disorders, at least for certain subgroups of eating disorders (i.e. underweight and normal weight bulimic subjects).     

Bacteriological study of drinking water during epidemic of cholera in Delhi

Sixty drinking water samples collected from various sources in different areas of Delhi during epidemic of cholera and gastroenteritis were analysed for bacteriological standards. Only 27 (45 per cent) samples were found to be satisfactory for human consumption. Remaining thirty-three (55 per cent) samples showed presence of coliform organisms with MPN value ranging from 10 to 1800+ per 100 ml. Among these positive samples, 31 (93.9 per cent) samples contained faecal coli. Twenty out of thirty (66.6 per cent) Hand pump, 9 out of 21 (42.8 per cent) Taps 2 out of 4 (50 per cent) Tube well and 2 out of 5 (40 per cent) of miscellaneous sources showed contamination with coliform organisms.     

Cockroaches as vectors of pathogenic bacteria

One hundred and thirty two cockroaches of species Blattella germanica--96 from hospital ward (test group) and 36 from residential areas (control group) were caught during Nov. 1985 to Nov. 1986. A variety of pathogenic and non-pathogenic bacteria were isolated from test and control group of insects. Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus faecalis, and Micrococci were isolated only from the test group of cockroaches. A high percentage (98.95 per cent) of test cockroaches were found to be carriers of various microorganisms as compared to the control group (80.55 per cent), the difference being statistically significant (p less than 0.001). Quantitative analysis in this study revealed that higher number of microorganisms are carried by test group of insects in the hospital environment. This, thereby suggests that these insects can play an important role in the etiology of hospital acquired infections.     

A study of the course of rheumatic heart disease

In this study of the course of 160 cases of rheumatic heart disease, it was disclosed that at the time of examination at the Mayo Clinic 81 per cent of the patients were less than fifty years of age. The disease occurred most commonly in the fifth decade, forty-seven cases (29 per cent). Only seventeen patients (19 per cent) were more than fifty. The sex incidence was equal, and no striking differences were found in a comparison of the data divided on the basis of sex. The first attack occurred before the age of thirty in 136 cases (85 per cent) and before the age of twenty in 103 cases (64 per cent). The primary infection occurred in only five cases (3 per cent) after the fortieth year. The average age at the time of death was thirty-two years.The cases were divided into three groups for comparative study according to the clinical diagnosis of valvular involvement. In Group I with mitral involvement there were 124 cases, in Group II with aortic involvement twenty-one cases, and in Group III with both mitral and aortic involvement, fifteen cases. In Group I, fifty-one patients were males and seventy-three females; the first rheumatic infection occurred before the thirtieth year in 106 cases (85 per cent), and in only three cases (3 per cent) was the first attack after the fortieth year. The average age at death was thirty years. In Group II there were nineteen males and two females; rheumatic infection occurred before the thirtieth year in seventeen cases (81 per cent); the average age at death was forty-three years. In Group III there were ten males and five females; in thirteen (86 per cent) the initial rheumatic infection occurred before the thirtieth year; the average age at death was thirty-two years.Recurrent rheumatic infections were most prevalent in the first decade of life in which they occurred in sixteen cases (55 per cent). The greatest number of attacks in any one case was eight. There was no instance of recurrent infection after the thirtieth year. There was only one instance of recurrent infection in Group II. No constant relationship is revealed in this study between the number of attacks of rheumatic fever and the age at which death occurred. There is little difference between the incidence of recurrent infection in the two sexes. In sixty-two cases (39 per cent) there was congestive failure at the time of examination. Auricular fibrillation occurred in sixty cases (38 per cent). Death from gradual heart failure occurred in 147 cases, while sudden death occurred in eight cases. Five patients died from subacute bacterial endocarditis.     

Surgical results in 657 patients with colorectal cancer

Six hundred fifty-seven patients with colorectal cancer who were operated upon at the Second Department of Surgery, Helsinki University Central Hospital during the period 1966 to 1975 had a 40.5 per cent crude five-year survival rate and 54.2 per cent relative (corrected) rate. The survival rates of patients with Dukes' A lesions were 80.7 per cent, Dukes' B, 61.6 per cent, Dukes' C, 40.4 per cent, and Dukes' D, 2.7 per cent. One hundred two patients (15.5 per cent) underwent emergency operations; 91 were occlusive cancers, eight were perforations and three were cancer bleedings. The operative mortality for the whole series was 6.5 per cent (4.7 per cent in elective and 16.7 per cent in emergency operations). A definite improvement of the five-year survival rates could be seen in both the colonic and rectal cancer series. This was due to earlier detection of the disease, reflecting a decreasing number of palliative operations. Patients at high risk for colorectal cancer (inflammatory bowel disease, inherited intestinal polyposis, cancer family syndrome, multiple colorectal cancers, and neoplastic polyps) might benefit from more effective cancer surveillance and prophylactic surgery to find and treat cancers in earlier stages, to prevent recurrences, and to facilitate follow-up. The controversial findings on postoperative adjuvant therapy presented in this study indicate the need for further controlled studies to define the patients who really benefit from it.     

Effects of physical training on the denervated human heart after orthotopic cardiac transplantation

Three patients who had undergone an orthotopic cardiac transplantation followed a course of supervised intermittent physical training (60 to 80 per cent of the maximum load) involving three weekly sessions of thirty minutes, for a period of 150 +/- 80 days. During maximal effort, we observed increases of 50 per cent in the load in watts (0.05 less than p less than 0.1), 40 per cent in oxygen consumption (0.1 less than p less than 0.2), 10 per cent in heart rate (p = 0.5) and 21 per cent in systolic blood pressure (0.7 less than p less than 0.8). The respiratory equivalent for oxygen decreased by 21 per cent (0.025 less than p less than 0.05) and the respiratory quotient by 5 per cent (0.4 less than p less than 0.05). For a given submaximal effort (30 watts) the following decreases were observed: 9 per cent in oxygen consumption (V'O2) (0.1 less than p less than 0.2), 32 per cent in the minute ventilation (V'E) (0.05 less than p less than 0.1), 22 per cent in the respiratory equivalent for oxygen (REO2) (0.025 less than p less than 0.05), 8 per cent in the respiratory quotient (RQ) (0.2 less than p less than 0.3) and 11 per cent in the heart rate (HR) (0.1 less than p less than 0.2). The systolic blood pressure (SBP) increased by 6 per cent (0.2 less than p less than 0.3). No changes were observed in these parameters in the postoperative follow-ups (10 to 24 months) of two patients who did not undergo physical training. Physical training is, therefore, necessary in the process of physical readaptation of patients after orthotopic cardiac grafts.     

Surgical treatment and late results in 1226 cases of colorectal cancer

One thousand two hundred twenty-six cases of colorectal cancer were treated surgically between 1956 and 1978. Seven hundred ninety-eight cases (65.08 per cent) were rectal, 74.3 per cent of which were located extraperitoneally. Dukes' C2 cases and cases with distant metastasis constituted 39.15 per cent, and Dukes' A cases, 9.22 per cent. Resectability rate was 75.1 per cent (77.6 per cent for rectal cancer). Two hundred and four cases (32.96 per cent) of rectal excision were restorative resections. Of the combined excisions for extraperitoneal lesions in females, 84.8 per cent were posterior pelvic exenterations. The overall operative mortality rate was 2.93 per cent. The mortality rate for 921 cases of resection was 1.73 per cent, for rectal resection, 0.8 per cent, and for curative rectal resection, 0.63 per cent. The follow-up rate was 94.13 per cent. The five-and ten-year survival rates for rectal resection were 53.08 +/- 2.29 per cent and 47.65 +/- 2.44 per cent; for curative rectal resection. 66.91 +/- 2.54 per cent and 60.27 +/- 3.03 per cent; and for Dukes' A cases, 98.05 +/- 1.35 per cent and 96.39 +/- 2.13 per cent. The five-and ten-year survival rates for colonic resection were 59.79 +/- 2.04 per cent and 52.18 +/- 3.49 per cent; for curative colonic resection, 72.79 +/- 3.39 per cent and 62.06 +/- 4.17 per cent; and for Dukes' A cases, both 100 per cent. Besides the extent of spread and degree of malignancy of a lesion, the local immunologic reaction of the host is also important in prognosis. The more lymphocytic infiltration in and around the cancer, the more follicular hyperplasia and sinus histiocytosis in regional lymph nodes, the better is the prognosis. The problem of anal preservation in radical resection of rectal cancer and the problem of improvement of results in the treatment of extraperitoneal rectal cancer are discussed in detail.     

Prevalence of resistant Staphylococcus aureus at Aurangabad

Seven hundred and eighty three isolates of Staphylococcus aureus isolated from pus (586), blood (78), sputum (25), urine (23), cerebrospinal fluid (23) and various other body fluids (48) were subjected to in-vitro antimicrobial susceptibility testing by modified Kirby-Bauer method. Almost all the isolates were resistant to penicillin (99.62 per cent) and ampicillin (99.62 per cent). Resistance to erythromycin, tetracycline and cotrimoxazole was observed in 88.5, 87.62, and 80.85 per cent isolates respectively. Resistance to gentamicin was 68.32 per cent. Resistance to most of the commonly used antimicrobial agents indicates a need to replace these drugs with other agents and maintenance of surveillance to detect changing patterns of resistance.     

CORONARY RISK FACTOR OUTCOMES FOLLOWING CORONARY ARTERY BYPASS SURGERY

The coronary risk factor status of patients prior to and following coronary artery bypass surgery (CABG) has been poorly investigated. Two consecutive series of CABG patients were surveyed following CABG. One hundred and thirty patients were assessed immediately following CABG and 530 patients were assessed 12–30 months following CABG. For the long-term post-CABG group, over 80% of those who had ever smoked had ceased. Sixty-four per cent of these males and 50% of females were classified as being overweight. Twenty-five per cent of males and 34% of females reportedly had high serum cholesterol (i.e. 6.5 mmol/L). Comparing these CABG data with age-adjusted National Heart Foundation Risk Factor Prevalence Survey data, there was a higher prevalence of ex-smokers, overweight, hypertension, and elevated cholesterol. It was concluded that on most coronary risk factors, except for smoking, these CABG patients had a worse profile than the general Australian community. This problem warrants further research and the development of appropriate treatment programs.     

Respiratory allergies and skin test reactivity in high school students in Tenerife, Canary Islands, Spain.

The prevalence of skin test reactivity to 22 aeroallergens and of allergic respiratory diseases was determined in 501 high school students on the island of Tenerife, Spain. Two hundred seventy-seven students (55.2%) had at least one positive prick skin test (wheal > or = 2 mm). Two hundred sixteen students (43.1%) had symptoms of upper or lower respiratory tract allergies [24 (4.7%) had asthma with or without rhinitis and 192 (38.3%) seasonal or perennial rhinitis alone]. Two hundred eighty-five students (56.8%) were asymptomatic. One hundred per cent of the students with asthma, 87.5% of the students with rhinitis and 27.7% of the asymptomatic students had at least one positive skin test. The prevalence of positive skin tests was significantly higher in symptomatic than in asymptomatic students (p = 0.0001). One hundred seventy students (33.9%) had a family history of respiratory allergic diseases. The prevalence of positive skin tests among these students was significantly higher than in students without such history (p = 0.0001). Thus, there is a high prevalence of allergic respiratory diseases and skin test reactivity to aeroallergens among high school students in Tenerife. Significant correlations were found between family history, positive skin tests and respiratory allergic symptoms.     

Diagnostic value of Q-waves in inferior myocardial infarction

Forty-eight patients with proved, healed, inferior myocardial infarction were studied to determine the electrocardiographic characteristics of this syndrome, the correlation between electrocardiographic abnormalities and angiographic findings, and to determine the value of recording Lead III during inspiration to identify abnormal Q-waves.The diagnosis of inferior myocardial infarction (IMI) was established by the presence of two of the following three criteria: (1) past history of acute infarction, associated with typical acute electrocardiographic changes and compatible clinical data, (2) total occlusion or more than 80 per cent occlusion of the right coronary artery, and (3) contraction abnormalities of the inferior left ventricular wall.Fifteen per cent of patients with inferior myocardial infarction had diagnostic Q-waves in all the three limb Leads II, III, and aV_F, and 29 per cent of patients had no diagnostic Q-waves in any of the three limb leads. Relative frequency of diagnostic Q-waves in inferior myocardial infarction were found to be 70, 43, and 15 per cent in Leads III, aV_F, and II, respectively.One hundred per cent correlation was noted between left ventricular inferior wall asynergy and presence of diagnostic Q-waves in all the limb Leads II, III, and aV_F, but the correlation was low (54 per cent) when none of the limb Leads II, III, and aV_F revealed diagnostic Q-waves.Obtaining Lead III in deep inspiration to differentiate an abnormal Q-wave due to inferior myocardial infarction from a benign Q-wave was not found to be a reliable measure and could result in false-negative diagnosis of inferior myocardial infarction in a significant number of patients.     

Acute central chest pain in the elderly. A review of 296 consecutive hospital admissions during 1976 with particular reference to the possible role of beta-adrenergic blocking agents in inducing substernal pain.

Two hundred and ninety-six patients were admitted to geriatric medical beds in Cardiff in 1976 with acute central chest pain. One hundred and eighty-six (63 per cent) had a confirmed acute myocardial infarction. Of the 37 per cent without evidence of cardiac infarction, 32 per cent were on beta-blocking drugs. The possible role of adrenergic blocking agents in producing acute central chest pain is discussed.     

Isolation of Gardnerella vaginalis from routine genito-urinary tract specimens

Routine screening of 2374 high vaginal swabs yielded 132 cultures (5.6 per cent) which were positive for Gardnerella vaginalis. Thirty-four of the strains were isolated together with Candida albicans and 46 with Trichomonas vaginalis. One hundred and twenty (90.9 per cent) of the isolates were from females between the ages of 16 and 40 years. One hundred and nineteen (90 per cent) patients sought medical advice because of a history of discharge (88) or inflammation (31). The other 13 (10 per cent) had some other complaint or underlying disease. All 132 strains hydrolysed hippurate and fermented starch. Ninety-three (70.5 per cent) were isolated from swabs without clue cells. Seventy-seven were from nonpurulent samples; the remainder were from samples with varying numbers of pus cells. All but two strains appeared sensitive to metronidazole when tested with discs containing 50 micrograms, but none when discs contained 5 micrograms of the drug. During the study C. albicans was isolated from 571 swabs (24 per cent) and T. vaginalis was found in 112 (4.7 per cent); in 19 (0.8 per cent) swabs both were detected. Five of 71 (7 per cent) specimens of uncentrifuged urine with more than 100 pus cells/microliter and two of 30 (6.6 per cent) seminal fluids with moderate numbers of pus cells yielded moderate to profuse growth of G. vaginalis. The patients concerned were not receiving antibiotics and other significant organisms had not been found by conventional cultural techniques.     

Subendocardial and transmural myocardial infarction: a five year survival study.

Two hundred seventy-six patients (median age 66 years) were discharged from the hospital following an acute myocardial infarction. Based on their electrocardiograms, they were divided into the following three groups: group 1, 127 patients with transmural infarction, i.e., with Q-wave development; group 2, 98 patients with subendocardial infarction, i.e., with S-T segment changes but without Q-wave development; and group 3, 51 patients with nondiagnostic electrocardiograms but with typical symptoms and enzymatic changes. The five year survival rates were not statistically significantly different (59 per cent, group 1; 51 per cent, group 2; and 41 per cent, group 3). Within the three groups, we found a statistically significant lower survival for (1) patients who were above 65 years of age, (2) patients who had a preadmission history of cardiovascular disease, (3) patients who had heart failure and arrhythmias during treatment in the hospital; and (4) patients who needed medical treatment on discharge. Thirteen per cent of the patients in the latter two catagories died suddenly within the first year. Thirty-three per cent of the patients with all these factors survived five years compared to 83 per cent of the patients with none of these factors. The electrocardiographic changes suggesting transmural or subendocardial infarction were not associated with differences in the long-time prognosis.     

The prognostic significance of psychosocial factors in women with breast cancer

One hundred and thirty three recently diagnosed breast cancer patients completed a self-administered questionnaire which measured 16 psychosocial variables. After 4 years, three variables (expressive activities at home, extroversion, low anger) were significant prognostic factors for overall survival independent of clinical and other psychosocial factors; likewise three variables (expressive activities at home, expressive activities away from home, low cognitive disturbance) were significant independent prognostic factors for disease-free survival. These findings support the prognostic importance of the social emotional network.     

Hyperbilirubinemia, jaundice and anergy.

A prospective study of delayed hypersensitivity response was carried out in jaundiced patients. One hundred and seventy-seven subjects were studied. Fifty-nine were controls and one hundred and eighteen were patients with hepato-pancreato-biliary pathology and biliary tract obstruction. A multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subjects into one of three groups: immunocompetent, relatively anergic and anergic. In the control group 76.3 per cent of the subjects were immunocompetent as opposed to 16.1 per cent of the patients (p less than 0.0001). Twenty-four per cent of the control subjects and eighty-four per cent of the patients presented anergy or relative anergy (p less than 0.0001). Among the patients no difference could be found in the index of anergy between malignant and benign pathology. We have found, moreover, that patients with a mean bilirubin level of 12 mg/dl showed a change in the delayed hypersensitivity response, with development of anergy or relative anergy.     

Relationship between endoscopic hiatus hernia and gastroesophageal reflux symptoms

Little is known about the relationship between hiatus hernia (HH) and gastroesophageal reflux symptoms (GERS). Nine hundred and thirty patients submitted to gastroscopy because of symptoms completed a self-administered questionnaire. Fourteen per cent showed esophagitis (ES) and 17% HH. Forty-nine per cent of the patients with HH had endoscopic ES, and 60% of those with ES had HH. The severity of ES was dependent (p less than 0.05) on both the presence and the size of HH. After exclusion of patients with peptic ulcer and malignancy, patients with and without HH and ES were compared with regard to the presence of single symptoms and a weighted GERS score based on symptoms proven to be typical for ES. Only borderline differences were found between patients with ES and HH and those with ES and no HH. The former group, however, presented with significantly (p less than 0.001) more GERS than the patients with HH only. Nevertheless, the patients with HH as the only pathologic finding had significantly (p less than 0.01) more GERS than the patients with no major endoscopic abnormality. This study indicates a close association between HH and gastroesophageal reflux disease and supports the clinical significance of an endoscopically detected HH.     

Role of serial pleural biopsies in the diagnosis of pleural effusions.

One hundred fifty-five cases of pleural effusion underwent a percutaneous pleural biopsy by the Cope needle. In the face of an inconclusive result in the first attempt, biopsy was repeated for upto three times. Diagnostic yields of biopsy in tuberculous and malignant effusion were 93.5 per cent and 66.7 per cent, respectively. When combined with pleural fluid cytology, a definite diagnosis of malignancy could be established in 80.95 per cent cases. Serial pleural biopsies significantly increased the diagnostic yield.     

Response of persons with and without intravascular thrombosis to a heparin tolerance test

The coagulation time of 1 c.c. of venous blood placed in a 10 by 75 mm. Wassermann-type glass tube and inverted every thirty seconds has been obtained on fifty control subjects and seventy patients before and after the intravenous injection of 25 mg. of heparin in 2.5 c.c. of liquid.The results of the determinations of coagulation time on samples of venous blood withdrawn at ten-minute intervals for variable periods indicated that the maximal response to the intravenous injection of heparin occurred ten minutes after injection.Of the individuals without evidence of intravascular thrombosis, including the control subjects, 5 per cent were hyper-reactors; 88 per cent, normal reactors; 7 per cent hyporeactors, and none were nonreactors.Of the individuals with evidence of intravascular thrombosis (categories 1 to 4 in Table III), none were hyper-reactors, 31 per cent were normal reactors, 30 per cent were hyporeactors and 39 per cent were nonreactors.