The usefulness of small-bowel manometry in the diagnosis of gastrointestinal motility disorders

Motility disorders of the gastrointestinal (GI) tract have traditionally been diagnosed by excluding mechanical small-bowel obstruction. In order to diagnose GI motility disorders in a positive fashion, small-bowel manometry was performed on 15 patients who were referred to the authors with intestinal motility disorders. Intestinal manometry was performed after first positioning a 200-cm multilumen tube into the small intestine. Ports located at 10-cm intervals were perfused with sterile water and connected to pressure transducers to record intraluminal pressures with a multichannel chart recorder. This low compliance water perfusion manometry system allowed examination of both fasting and postprandial motility. Intestinal manometry was able to assist in the diagnosis of two patients that had true mechanical small-bowel obstruction. One patient had a stenosis of the gastrojejunostomy and three patients had a functional gastric outlet obstruction secondary to a motility disorder in the Roux limb. One patient had a functional obstruction from a reversed jejunal loop and eight patients were identified as having intestinal pseudo-obstruction. We found intestinal manometry was a helpful adjunct in the diagnosis of GI motility disorders.     

Variability in vibration perception threshold among sites: a potential source of error in biothesiometry

Vibration perception threshold was measured with a biothesiometer by a single observer at both medial malleoli and both big toes in 110 diabetic patients aged 15-65 selected at random and in 64 non-diabetic subjects aged 20-65. The vibration perception threshold showed appreciable individual variation both between contralateral sites and between ipsilateral sites, differing by at least 30% between the big toes in 26 (24%) of the diabetic patients and 16 (25%) of the non-diabetic group. Variability between sites was significantly greater in the diabetics than the normal subjects. The vibration perception threshold exceeded published normal values at one or more sites in 22 of the diabetic patients but at all four sites in only four. The wide variability in vibration perception threshold among sites may be due to the tissue characteristics locally and, in diabetic patients, possibly to asymmetric neuropathy. Biothesiometer readings at single or unilateral sites may be unrepresentative or misleading.     

Symptoms versus flow rates versus urodynamics in the selection of patients for prostatectomy

Many prostatectomies are performed on the basis of symptoms alone; 39% of patients referred by their family doctors and 23% of patients who were on waiting lists for prostatectomy of other hospitals, but who had not undergone any urodynamic investigations, were found to be unobstructed on urodynamic criteria. A screening peak urinary flow rate of 12 ml/s or less was associated with urodynamic evidence of obstruction in 95% of cases; 35% of patients with symptoms of outflow obstruction and a flow rate greater than 12 ml/s were also found to be obstructed. One year post-operatively, 84% of patients who were selected for surgery on combined symptomatic and urodynamic criteria were pleased symptomatically with their result. The failure of detrusor instability to resolve following prostatectomy was associated with symptomatic failure of treatment. Residual obstruction was demonstrated in 5 patients who had undergone prostatectomy and were asymptomatic at this time. This study illustrates that objective measures are necessary in the assessment of patients prior to prostatectomy in order to select only patients who are obstructed. The importance of a screening flow rate is emphasised. All patients who underwent surgery had cystometric evidence of obstruction but the symptomatic results of surgery were no better than the results in patients who had been assessed according to non-urodynamic selection criteria. We have thus failed to identify a need for routine cystometry in the pre-operative assessment of these patients. Cystometry does, however, have a role in assessing patients with pre-operative flow rates greater than 12 ml/s and in those who remain symptomatic following prostatectomy.     

Drug control strategies of United States law enforcement

The American approach to drug control is conditioned by several national characteristics, including fragmentation of the law enforcement system, a 12,000-mile international boundary and a legal system that restricts police authority to search, arrest, detain, eavesdrop and maintain intelligence files. Drug problems in the United States, though, are by all accounts greater than in any other country. Enforcement has traditionally emphasized street-level arrests, investigation of distribution networks, crop eradication and smuggling interdiction. These practices can be shown to produce arrests and seizures, but there is little evidence to show that they reduce drug supply or drug abuse. More contemporary and promising approaches include community policing, problem-oriented policing, financially oriented investigations, increased international co-operation and a renewed emphasis on drug demand reduction. The most pressing needs in law enforcement are (a) improved intelligence-gathering and analysis and (b) research on the illicit drug industry and on the effectiveness of drug control strategies.     

Fractured talar beaks

The talar beak is a well-described secondary sign of talocalcaneal coalition but is not pathognomonic of the condition and may be seen in other causes of restricted or abnormal subtalar motion. We present an unusual complication of talar beaks in two patients who sustained fractures through their beaks. One of the patients described did not have a talocalcaneal coalition but had developed a beak following a compound fracture dislocation of the ankle joint complicated by infection, a previously undescribed predisposing cause.     

Distinct P-glycoprotein precursors are overproduced in independently isolated drug-resistant cell lines.

A family of P-glycoproteins are overproduced in multidrug-resistant cells derived from the murine macrophage-like line J774.2. To determine whether individual family members are overproduced in response to different drugs, the P-glycoprotein precursors in several independently isolated cell lines, which were selected for resistance to vinblastine or taxol, were compared. Individual cell lines selected with vinblastine overproduced P-glycoprotein precursors of either 120 or 125 kDa. Taxol-selected cell lines overproduced either the 125-kDa precursor or both precursors simultaneously. Two similar but distinct peptide maps for the mature P-glycoproteins were observed. These maps corresponded to each precursor regardless of the drug used for selection. One vinblastine-resistant cell line switched from the 125- to the 120-kDa precursor when grown in increasing concentrations of drug. This change coincided with the overexpression of a distinct subset of mRNA species that code for P-glycoprotein. It is concluded that precursor expression is not drug-specific. These data suggest that individual overproduced P-glycoprotein family members are translated as distinct polypeptides. The results may help to explain the diversity in the multidrug-resistant phenotype.     

Multicentric reticulohistiocytosis. Detailed immunophenotyping confirms macrophage origin

A case study of multicentric reticulohistiocytosis is presented with extensive immunohistochemical studies of the infiltrate in both paraffin and cryostat sections. These studies showed that the cells are of monocyte/macrophage origin. B- and T-cell gene rearrangement analysis of multicentric reticulohistiocytosis was also performed and showed a germline configuration.