Crohn's disease presenting with acute colonic perforation.

Crohn''s disease is well known for its multiple intestinal complications. The chronic nature and fibrous inflammation which invariably accompanies this disease explains the relative rarity of free intestinal perforation. The true incidence of free bowel perforation is difficult to assess but 1-2% is the anticipated occurrence during the course of illness. We present a case of Crohn''s disease which presented for the first time with acute colonic perforation, an extremely rare entity, and review the current world literature.     

Quality of life after myocardial revascularization. Effect of increasing age.

The effect of increasing age on quality of life, survival, and risk of reoperation was studied in 2479 patients followed up prospectively 2 to 20 years after myocardial revascularization. Quality of life was determined from annual questionnaires, which we used to calculate a health status index from the patient's symptomatic status and subjective response to the operation, which was graded between zero and 1.00 (asymptomatic). Four age groups were studied: age 49 years or less (AG40), 50 to 59 years (AG50), 60 to 69 years (AG60), and 70 years or older (AG70). Associated problems (left ventricular aneurysm, valve disease, acute myocardial infarction) necessitating treatment were present in 17% (61/361) of AG40 patients, 19% (165 of 859) of AG50 patients, 23% (213/927) of AG60 patients, and 31% (102/332) of AG70 patients. The hospital mortality rate was higher in older patients undergoing combined procedures but not in patients undergoing coronary bypass grafts only. Probability of survival and health status indexes were calculated excluding patients with valve disease and cardiogenic shock. Probability of survival was significantly better (p less than 0.001 by the Wilcoxon test) in patients less than age 60 than in those 60 years or older, but in patients with an ejection fraction greater than or equal to 0.40, probability of survival at 12 years was 0.64 (age less than 60) versus 0.62 (age greater than or equal to 60). The actuarial risk of reoperation, calculated as the difference between probability of survival and probability of survival without reoperation, progressively increased in younger patients but not in patients aged 60 years or older. At 15 years, the reoperation rates were 26% (AG40), 14% (AG50), 5% (AG60), and 7% (AG70). Mean health status index for years 1 to 5 was 0.85 in AG40 patients, 0.84 in AG50 patients, 0.89 in AG60 patients, and 0.90 in AG70 patients; for years 6 to 10, 0.81, 0.80, 0.86, and 0.89; and for years 11 to 15, 0.77, 0.78, 0.84, and 0.84, respectively. Thus quality of life after myocardial revascularization is better, improvement lasts longer, and reoperation rate is less in patients aged 60 years or older.     

INTRA-AORTIC BALLOON RUPTURE CAUSING FEMORAL ENTRAPMENT

Rupture of an intra-aortic balloon counterpulsator (IABCP) demands immediate removal. We report a case of thrombus formation within a Datascope IABCP secondary to IABCP rupture, necessitating surgical exploration for removal. There is a disturbing pattern of balloon ruptures with this type of IABCP.     

Success and failure in penile prosthesis surgery: two cases highlighting the importance of psychosocial factors

Two cases, carefully selected from a longitudinal, prospective investigation of the relationship between psychosocial variables and postsurgical adjustment to a penile prosthesis implantation, were studied intensively. In both cases, the patient and sexual partner were assessed, presurgically, on a number of psychological, marital, and sexual functioning variables; their subsequent satisfaction with the prosthesis, and their psychological, marital, and sexual adjustment were measured at 6 and 12 months postsurgery. Despite many similarities in medical aspects of the surgery, for one couple a successful outcome was evidenced, whereas the other couple demonstrated a therapeutic failure despite the technical success of the surgery. Psychosocial differences between the couples were identified as they may relate to the discordant outcomes observed. Clinical implications of these results are discussed, as are the strengths and weaknesses of our methodological approach.     

Testing the Theoretical Fit of an Abseiling Harness: A Study of an Australian Primary and Secondary Prevention Program

A theoretical model of prevention addressing adolescents at-risk of offending was developed then utilised to assess a primary and secondary prevention program. The study of the wilderness-based practise was conducted between September 1992 and October 1994, adopting a pre-post-follow-up quasi-experimental design using waiting periods to establish treatment and control groups. Maturational changes were gauged over a 12 month period of 44 male and 18 female voluntary Australian adolescents between the ages of 15 and 25 years. Significant differences between the treatment and control groups in the psychometric areas of general self-esteem and self-actualisation were found establishing positive program effect on participants. Further, the long term effect of this program in preventing participants initial contact with court proceedings or reducing further involvement respectively, over a twelve month period was substantiated. It was shown that following this experience post program goals of employment and education for adolescents at-risk were positively influenced.     

Neutrophil hypochlorous acid production is impaired in multiple organ failure patients with candidaemia; reversal with antifungal agents

OBJECTIVE AND DESIGN: Neutrophil-derived hypochlorous acid (PMN-HOCL) is a potent bactericidal and fungicidal agent. Neutrophils from patients with multiple organ failure (MOF) have an altered ability to inhibit Candida albicans. Conversely antifungal agents are effective in decreasing mortality in MOF patients with fungaemia. We determined the effect on the rate of production of PMN-HOCL in a series of MOF patients with C. albicans fungaemia when antifungal agents are administered. SUBJECTS AND METHODS: Eleven patients with MOF were recruited. Four patients had culture-positive C. albicans fungaemia (group 1) and 7 patients with MOF but without C. albicans fungaemia acted as controls (group 2). HOCL assays were performed on peripheral blood PMN obtained from group 1 and group 2 patients. RESULTS: The maximum PMN-HOCL production rate for group 1 increased from 0.24 nmol/million PMN/min to 0.8 nmol/million PMN/min after treatment with antifungal agents (p < 0.01) (Mann-Whitney U test) whereas the PMN-HOCL kinetic (rate) curves for group 1 post-treatment and for group 2 were similar (student's-t-test). CONCLUSIONS: These findings suggest that antifungal treatment improve PMN-HOCL production in MOF patients with C. albicans fungaemia and may improve the effectiveness in eradicating the organism.     

Methamphetamine dependence increases risk of neuropsychological impairment in HIV infected persons.

Both HIV infection and methamphetamine dependence can be associated with brain dysfunction. Little is known, however, about the cognitive effects of concurrent HIV infection and methamphetamine dependence. The present study included 200 participants in 4 groups: HIV infected/methamphetamine dependent (HIV+/METH+), HIV negative/methamphetamine dependent (HIV-/METH+), HIV infected/methamphetamine nondependent (HIV+/METH-), and HIV negative/methamphetamine nondependent (HIV-/METH-). Study groups were comparable for age, education, and ethnicity, although the HIV-/METH- group had significantly more females. A comprehensive, demographically corrected neuropsychological battery was administered yielding a global performance score and scores for seven neurobehavioral domains. Rates of neuropsychological impairment were determined by cutoff scores derived from performances of a separate control group and validated with larger samples of HIV+ and HIV- participants from an independent cohort. Rates of global neuropsychological impairment were higher in the HIV+/METH+ (58%), HIV-/METH+ (40%) and HIV+/METH- (38%) groups compared to the HIV-/METH- (18%) group. Nonparametric analyses revealed a significant monotonic trend for global cognitive status across groups, with least impairment in the control group and highest prevalence of impairment in the group with concurrent HIV infection and methamphetamine dependence. The results indicate that HIV infection and methamphetamine dependence are each associated with neuropsychological deficits, and suggest that these factors in combination are associated with additive deleterious cognitive effects. This additivity may reflect common pathways to neural injury involving both cytotoxic and apoptotic mechanisms.     

Prevention of sexually transmitted HIV infection: A meta-analytic review of teh behavioral outcome literature

Social learning theory-based models have recently provided the foundation for a series of twelve controlled human immunodeficiency virus (HIV) risk reduction intervention studies that have examined sexual behavior change. These interventions have been tested with adolescents, gay and bisexual men, inner-city women, college students, and seriously mentally ill adults. We report the first meta-analysis of these intervention studies. We found that, as expected, the mean weighted effect of HIV-risk reduction interventions on behavioral outcomes was positive and strongly significant (d₊=0.25). Moreover, the studies’ effect sizes were consistently positive, ranging from 0.11 to 0.53, and were largest when the outcomes were measured close in time to the intervention. We discuss other methodological challenges that, if solved, should enhance the success of future HIV-risk reduction interventions.