Severe acute visceral pain from varicella zoster virus

Varicella zoster virus infection often will not present in the characteristic dermatomal distribution of vesicles in patients who have undergone bone marrow transplantation. We cared for a 51-yr-old man with severe abdominal pain after bone marrow transplantation for non-Hodgkin's lymphoma. The diagnosis of varicella zoster was not entertained until he developed a diffuse vesicular rash several days after the onset of pain. We report this case to alert others who may be consulted regarding pain management options for similar oncology patients. IMPLICATIONS: We report a patient with lymphoma, prior bone marrow transplant, and acute visceral pain for whom IV opioids in large doses proved inadequate. An interventional pain management technique was considered until characteristic varicella vesicles appeared over the patient's trunk. We report this case to alert others who treat oncology patients that the diagnosis of visceral zoster should be considered when patients who have undergone bone marrow transplantation present with severe visceral pain.     

Evaluation of the role of the asialoglycoprotein receptor in the clearance of UK-279,276 (recombinant neutrophil inhibitory factor)

1. UK-279,276 or recombinant neutrophil inhibitory factor (rNIF) is a glycoprotein that has been investigated as an intravenous treatment for stroke. Previous data indicate that the asialoglycoprotein receptor (ASGPR) in the liver might have a role in the uptake and clearance of UK-279,276 from plasma in rats and dogs. 2. Biliary elimination of sialo UK-279,276 can be inhibited by the co-administration of asialo fetuin, a known substrate for ASGPR. These data are in keeping with sialo UK-279,276 being cleared by ASGPR. 3. In vitro experiments have demonstrated that asialo UK-279,276 (Sialo UK-279,276 treated to remove the sialic acid residues present on the glycans) shows a significantly greater uptake in rat, dog and human precision-cut liver slices than the sialylated protein. The addition of asialo fetuin to precision-cut liver slice incubations (rat, dog and man) containing asialo UK-279,276 reduced the uptake to levels similar to those seen for the sialylated protein. These data support the potential role of the ASGPR in the clearance of UK-279,276 in rat, dog and man.     

Family therapy in the hospital treatment of children and adolescents

Psychiatric hospitalization is sometimes necessary for seriously symptomatic or out-of-control children and adolescents. In the past, individual therapists, hospital therapists, and family therapists thought that family therapy and individual hospital treatment could not be combined effectively. Today, however, family involvement, participation, and therapy are considered essential components of short-term and extended hospital treatment for young people. The author presents Bowen family systems theory as a basis for informed family therapy in a psychiatric hospital setting. Bowen therapy with patients and close family members elicits significant information, reduces tension, expands options, and facilitates solutions for young patients and their families.     

Sensitivity of quality of life domains and constructs to longitudinal change in a clinical trial comparing salmeterol with placebo in asthmatics

The quality of life (QOL) benefits of salmeterol versus placebo were compared in a double-blind, multicentre study using the Living with Asthma Questionnaire (LWAQ) which was scored in three different ways. First, the overall LWAQ score showed that salmeterol enhanced QOL compared to placebo. Second, when the LWAQ was analysed in terms of its two construct subscales we found, as predicted previously, that the Problem construct was more sensitive to longitudinal change compared with the Evaluation construct. Third, when the LWAQ was analysed in terms of its 11 domain subscales we found a significant improvement for salmeterol compared with placebo on three domains, Sport, Sleep, and Work and other activities. Analysing clinical trial results in terms of construct subscales and domain subscales provides different kinds of information each of which is useful. Analysis in terms of overall QOL scores is less informative.     

Atretic esophagus: transgastric balloon-assisted hydrostatic dilation

Esophageal atresia may be associated with a long interval or gap between the upper and lower pouches. Despite a variety of procedures to elongate the esophagus, surgeons have been unable to achieve esophageal continuity in many patients. Three infants with esophageal atresia and long gaps recently underwent hydrostatic dilation of the distal esophageal pouch followed by primary anastomosis. The technique entailed passing a balloon-tipped catheter through a gastrostomy site to the distal esophageal pouch. The balloon was inflated to a diameter sufficient to occlude the distal esophagus. Dilute contrast material was then infused under fluoroscopic visualization to a maximal pressure of 145 cm H2O. Dilations were performed daily over a 2-week period, followed by surgery. Primary anastomosis was accomplished in all patients. The promising results in these patients should stimulate other investigators to assess this technique in infants with this challenging surgical problem.     

Imaging of the gallbladder, 1987

Gallbladder disease, and the patients with symptoms suggestive of gallbladder disease, remains a widespread clinical problem that requires investigation by imaging techniques. Sonography, and to a lesser extent cholescintigraphy, has facilitated the evaluation of these patients and allows the diagnosis of cholelithiasis, and its principal complication of cholecystitis, with a high degree of reliability and accuracy. Interventional techniques are being developed that may provide nonsurgical approaches to improved therapy of gallbladder calculi and their complications.     

Anorectal function after abdominal rectopexy: parameters of predictive value in identifying return of continence

Posterior abdominal rectopexy was performed in 12 patients with a full-thickness rectal prolapse: 9 had faecal incontinence. The prolapse was successfully controlled in all cases and six of nine patients were rendered continent. Physiological studies in patients were compared with age- and sex-matched controls. Preoperative anal pressures were significantly lower than in controls at rest (R), during maximum pelvic floor contraction (Sq) and attempted defaecation (St) (R, P less than 0.005; Sq, P less than 0.005; St, P less than 0.005). Anorectal angles were significantly more obtuse in patients than in controls (R, P less than 0.05; St, P less than 0.025). None of these parameters changed significantly after abdominal rectopexy. Median rectal emptying significantly decreased after operation (preoperative 83 per cent/min; postoperative, 58 per cent/min, P less than 0.05). Median perineal descent during attempted defaecation also significantly decreased after operation (preoperative, 8.5 cm; postoperative, 7.1 cm; P less than 0.025). Parameters which predicted return of continence included: delayed leakage during the saline infusion test (P less than 0.025), a narrow anorectal angle during pelvic floor contraction (P less than 0.025), minimal pelvic floor descent during contraction (P less than 0.05), and a long anal canal at rest (P less than 0.05) and during pelvic floor contraction (P less than 0.025).     

Alpha-adrenoceptor responsiveness in the aged rat

The effects of ageing on vascular alpha 1- and alpha 2-adrenoceptors were examined using anaesthetised and pithed young (3-7 months) and old (21-24 months) Sprague-Dawley rats. In pithed animals, the pressor and cardioinhibitory effects of the alpha 2-adrenoceptor agonist xylazine were significantly reduced in old animals (8- and 6-fold shift), but the pressor effects of the alpha 1-adrenoceptor agonist amidephrine were not significantly altered by ageing. In anaesthetised rats, the pressor response to the mixed alpha-adrenoceptor agonist noradrenaline (NA) was not significantly altered, and the pressor potency of the alpha 1-adrenoceptor agonist amidephrine was only slightly reduced (1.7-fold shift) in old animals. In the presence of cocaine (1 mg kg-1) the pressor potency of NA was markedly reduced (13-fold shift) in old animals. In the presence of prazosin (1 mg kg-1) to eliminate alpha 1-adrenoceptor-mediated responses, the pressor potency of NA was markedly reduced in old as animals as compared to young animals (16-fold shift). The neuronal uptake blocker cocaine (1 mg kg-1) significantly potentiated the pressor response to NA only in young. In summary, we have found a reduced alpha 2-adrenoceptor-mediated pressor and cardioinhibitory responsiveness and a reduced neuronal uptake of NA in old animals with little change in alpha 1-adrenoceptor-mediated vascular responsiveness.