The role of the duodenal microflora as a determinant of persistent diarrhoea

It has been suggested that proliferation of enterobacteriaceae and/or anaerobes in the duodenum of some children with acute diarrhoea determines whether the episode becomes persistent. A review of published studies and the comparison of cultures of duodenal aspirates from Peruvian children with acute and persistent diarrhoea and diarrhoea-free children did not support this hypothesis. Although many children had enterobacteriaceae and/or anaerobes cultured there was no correlation with clinical and nutritional outcome. Age, nutritional status, the environment and the aetiology of the episode were determinants of the duodenal microflora independent of diarrhoea. Culture of the duodenal aspirates did not increase the yield of enteropathogens which were isolated more frequently from stools than from the duodenum. Despite the presence of a single strain or serotype of enterobacteriaceae suggesting that these bacteria were colonizing the duodenum, we were unable to demonstrate any adherence mechanisms in the majority of them. Two often bacteria with no other evidence of virulence caused diarrhoea in the RITARD rabbit model.     

Contraception for the diabetic woman

Because of their vascular and metabolic risks for diabetic women, pregnancies must be carefully programmed to occur before the onset of degenerative diabetic manifestations. Diabetic women need an effective contraceptive method without undesirable side effects. The numerous side effects of combined oral contraceptives (OCs) are due to both the estrogens and progestins. Combined OCs have a diabetogenic effect whose mechanism is not clearly understood. Blood sugar levels are elevated under OCs and the insulin response is retarded and exaggerated. The number and affinity of insulin receptors are reduced. Norsteroid- derived progestins increase the state of insulin resistance. Combined OCs usually increase triglyceride levels. Changes in the level of high- density lipoprotein cholesterol under combined OCs vary with the estrogen and progestin content. Synthetic estrogens increase platelet aggregability, and blood pressure increases during OC use. Use of combined OCs represents increased vascular risk for diabetic women, with the risk of thrombosis multiplied by 4. Low dose progestin pills permit continued secretion of a small amount of luteinizing hormone and follicle stimulating hormone which may cause a relative hyperestrogenism and undesirable side effects. The secondary effects are often poorly tolerated. Use of this type of pill is limited except among diabetic women, 25% of whom are users. The failure rate is estimated at .2-2%. Standard-dosed norsteroids are unsuitable for diabetic women because of their metabolic and vascular side effects. 2nd and 3rd generation progestins have yielded more promising results. IUDs are used by about 12% of the overall female population but 32% of diabetic women, mostly multiparas, despite the increased risk of infection. Local methods have a higher failure rate and their success depends on patient compliance with instructions. 14% of diabetic women in a recent survey reported having undergone tubal ligation, which is not strictly speaking a contraceptive method. Combined OCs should be avoided in insulin- dependent diabetics because of their metabolic and vascular effects. Diabetic retinopathy should be added to the list of absolute contraindications to these methods. Low-dose progestins can be used in insulin-dependent diabetics or if they are poorly tolerated a standard dose pill can be substituted. IUD is the method of choice for older, multiparous insulin-dependent diabetics. Sterilization may be considered, especially if pregnancy is absolutely contraindicated. Combined OCs are formally contraindicated for noninsulin-dependent diabetics. Low-dose progestins could be tried. IUDs are suitable for multiparas.     

Surgical strategies in very-low-birthweight neonates with necrotizing enterocolitis

Very-low-birthweight (VLBW) neonates are more prone to complications and death than term infants are. In a 15-year period, 19 neonates with VLBW were operated on for necrotizing enterocolitis (NEC). Indications for operation were pneumoperitoneum in 12 and deterioration of general condition in 7. Bowel resection and intestinal diversion was performed in 12, a lateral enterostomy at the site of perforation was created in 5, and 2 neonates with necrosis of the whole bowel underwent an exploratory laparotomy without any further surgical treatment. Surgical complications were found in one-third of the patients. The mortality rate was significantly higher when the ileum was affected. The survival rate was 68%. Prior to 1984 the survival rate was 37% (3/8); subsequently, it has improved to 91% (10/11) as a result of improved intensive therapy.     

Hypertrophic repair of articular cartilage in experimental osteoarthrosis.

Section of the anterior cruciate ligament has been performed in the knee of 11 mature dogs. The macroscopically normal cartilage from patella and femoral trochlea of animals killed from 2 to 32 weeks after operation was used for histological, histomorphometrical, and biochemical analysis. Previously undescribed degenerative lesions of the superficial matrix were observed, and there was evidence for secondary healing of these lesions. An early and progressive decrease in superficial cell density and a later progressive increase in cartilage thickness without any change in the cell density of the middle and deep cartilage layers was found. A slight increase in water content with no reduction in glycosaminoglycan content was observed. The results suggest that joint laxity results initially in superficial degenerative changes and later in hypertrophic regenerative changes due to cell proliferation and increased matrix synthesis. Hypertrophic remodeling of articular cartilage in response to abnormal mechanical stresses is postulated.