FIRST-LINE TREATMENT IN ACUTE NON-DYSENTERIC DIARRHOEA: CLINICAL COMPARISON OF LOPERAMIDE OXIDE,LOPERAMIDE AND PLACEBO

SUMMARY The use of antimicrobial agents for the treatment of acute diarrhoea has become more common with the introduction of quinolone compounds, which are active against most types of bacterial pathogens. Despite the fact that such drugs have been used for empirical therapy or even for prophylaxis, current opinion would restrict their use to specific groups of patients who are likely to show particular benefit from them. Non-specific therapy seems a more appropriate initial treatment for cases of acute, non-dysenteric diarrhoea. Clinical trial data are presented here comparing the effects of loperamide oxide 1 and 2 mg to those of placebo and loperamide 2 mg in this condition. All the drug preparations were significantly superior to placebo, in particular reducing the time to complete relief of symptoms to about 24 hours, as opposed to 45 hours on placebo treatment. Of these preparations, loperamide oxide 1 mg is to be preferred, as it produces fewer constipation-like episodes after treatment. The introduction of loperamide oxide 1 mg represents a useful advance in the non-specific treatment of acute, non-dysenteric diarrhoea.     

On the mechanism of the effects of potassium restriction on blood pressure and renal sodium retention

Dietary potassium restriction increases sodium and chloride retention, whereas potassium administration promotes both diuresis and natriuresis. In epidemiologic and clinical studies, potassium intake is inversely related to blood pressure and is lower in blacks than in whites. The present studies examined the mechanism by which potassium restriction fosters sodium conservation and the impact of race on this response. Twenty-one healthy black and white men and women ingested an isocaloric, potassium-restricted diet (20 mmol/d) containing 180 mmol/d of sodium with and without a potassium supplement (80 mmol/d) for 9 days on two occasions. Additionally, eight of these subjects ingested the same diets for 3 days followed by a water load to determine free water clearance before and during the early phase of dietary potassium restriction. During potassium restriction, mean arterial pressure (MAP) derived from 24-hour blood pressure measurements was higher (85.7 +/- 1.6 mm Hg v 82.0 +/- 1.3 mm Hg; P < 0.001), cumulative sodium excretion lower (984 +/- 59 mmol/d v 1,256 +/- 58 mmol/d; P < 0.001), and weight greater (71.1 +/- 2.1 kg v 69.3 +/- 2.2 kg; P < 0.001). Blacks displayed no greater increase in MAP, although they excreted less sodium overall and less potassium on the potassium-supplemented diet. After a water load, minimum urine osmolality (Uosm) was lower (53.0 +/- 3.0 mOsm/L v 65.6 +/- 3.5 mOsm/L; P = 0.01) and free water clearance greater (4.44 +/- 0.59 mL/min v3.72 +/- 0.58 mL/min; P = 0.009) during potassium restriction. In conclusion, in healthy, normotensive subjects, potassium restriction was associated with an increase in blood pressure and volume expansion effected by increased renal sodium and chloride retention. Potassium restriction was also associated with increased free water clearance and enhanced diluting capacity consistent with augmentation of Na+, K+:2Cl- cotransporter activity in the thick ascending limb of Henle. This mechanism may play an important role in the renal adaptation required for potassium conservation, but at the expense of sodium chloride retention and an elevation in blood pressure.     

Immunoconglutinin and complement changes in steroid sensitive relapsing nephrotic syndrome of children

Elevation of serum immunoconglutinin was detected in patients in relapse with steroid sensitive nephrotic syndrome. The significance of this evidence of immunological disturbance is discussed in relation to the aetiology of the disease.     

Circulating immune complexes in onchocerciasis.

Circulating immune complexes were detected in sera of patients with both localized and generalized onchocerciasis by a 125I-Clq binding assay but not by the IgG latex agglutination inhibition method. Gel filtration of sera demonstrated high molecular weight Clq-reactive material(greater than 2 x 10(6) Daltons) which contained IgM but no IgG. Antibody titres to Onchocerca volvulus antigen were higher in patients with generalized disease than in those with the localized form. The lack of correlation between antibody titres and levels of immune complexes suggests that these immune complexes contain antigens other than those derived exclusively from the parasite. Although few of the symptoms of this disease are likely to be due to deposition of circulating immune complexes, the depression of delayed hypersensitivity reactions to the parasite found in patients with generalized onchocerciasis may be due to IgM immune complexes exerting an immuno-regulatory role on T cell function.     

Selective recovery of living microfilariae from Onchocerca volvulus nodules. Determination of optimal conditions for their culture in vitro for excretory/secretory products

A method for the selective recovery of living microfilariae from Onchocerca volvulus nodules is described. The microfilariae migrate through solidified agar gel into overlayering Hanks balanced salt solution (HBSS). The highest recovery rates of the worms were obtained with 0.3 and 0.4% agar. Optimal conditions for in vitro cultures of the larvae in HBSS were established; pH range 7.0-7.5, glucose concentration 2-5 mg/ml for long term cultures, osmolality 200-309 mOsmoles/l, temperature 4 degrees C for prolonged cultures and 24-28 degrees C for overall best yield of excretory/secretory products (ESP). Subculturing of the larvae reduced contamination of ESP with human serum protein to minimal amounts after 9 recultures done within 96 h.     

Clinical Experience with Autobiotherapy of Malignant Tumor Disease: A Preliminary Report

It has been proposed that the elimination of excess scar tissue from the body is achieved by specialized killer cells, which are activated by vascular changes in the scar tissue. The malignant tumor is, according to this theory, considered to be a special type of excess scar tissue of fetal or near fetal age, the fetal blood supply of which prevents the activation of those specialized killer cells which were believed to eliminate excess scar tissue. Therefore, it is assumed that if the specialized killer cells of a malignant tumor patient are activated artificially, they would cause malignant tumor regression in vivo. This method of treatment is called autobiotherapy because it utilizes biological products from the patient to treat his own malignant tumor. Preliminary evidence is presented in support of autobiotherapy of malignant tumor disease.     

Small bowel obstruction in the virgin abdomen: time to challenge surgical dogma with evidence

Background

Although adhesions account for more than 70% of small bowel obstruction (SBO), they are thought to be less likely aetiologies in patients without previous abdominal surgery. Expedient surgery has historically been advocated as prudent management in these patients. Emerging evidence appears to challenge such a dogmatic approach.

Methods

A retrospective analysis was performed in all SBO patients with a virgin abdomen admitted between January 2012 and August 2014. Patients with obstruction secondary to abdominal wall hernias were excluded. Patient demographics, clinical presentation, management strategy and pathology involved were reviewed.

Results

A total of 72 patients were included in the study. The majority of patients were males (66.7%), with a median age of 58 years (range: 23–101). Abdominal pain (97%) and vomiting (86%) were the most common presentations while abdominal distention (60%) and constipation (25%) were reported less frequently. Adhesions accounted for the underlying cause in 44 (62%) patients. Other aetiologies included gallstone ileus (n = 5), phytobezoar (n = 5), intussusception (n = 4), internal herniation (n = 4), newly diagnosed small bowel tumour (n = 3), mesenteric volvulus (n = 3), stricture (n = 3) and Meckel's diverticulum (n = 1). Twenty‐nine (40%) patients were successfully managed conservatively while the remaining 43 (60%) underwent surgery. The intraoperative findings were in concordance with the preoperative computed tomography scan in 76% of cases.

Conclusion

Adhesions remain prevalent despite the absence of previous abdominal surgery. Non‐operative management is feasible for SBO in a virgin abdomen. Computed tomography scan can be a useful adjunct in discerning patients who may be treated non‐operatively by elucidating the underlying cause of obstruction.     

Robotics confers an advantage in right hemicolectomy with intracorporeal anastomosis when matched against conventional laparoscopy

Comparisons between robotic and laparoscopic right hemicolectomy have been confounded by variations in operative technique. This study evaluates the two procedures after standardizing the intraoperative steps and perioperative management. Patients who underwent robotic right hemicolectomy with intracorporeal bowel anastomosis between July 2015 and June 2017 were matched with a laparoscopic group. Perioperative management was in accordance to an enhanced recovery protocol. Outcomes and histopathological data were compared. Thirty-two patients were included. Amongst the patients who did not undergo complete mesocolic excision, the median operative time did not differ between the two groups (p = 0.413). The robotic group recorded a statistically shorter time for intracorporeal anastomosis (13 vs 19 min, p = 0.024). Postoperative recovery and complication rates were similar, except for a greater lymph node harvest in the robotic group (41 vs 31, p = 0.038). Robotic surgery achieves short-term results comparable to existing conventional laparoscopy, notwithstanding the advantages of enhanced ergonomics.