Right-sided colonic diverticular disease as a source of lower gastrointestinal bleeding

Right-sided colonic diverticular disease is a distinct disease entity uncommon in the West. Occasionally, the condition may be complicated by hemorrhage and present as lower gastrointestinal bleeding. We report a series of 25 cases of bleeding right colon diverticulosis and discuss its presentation and management. Patients were selected from the colonoscopic reports of all 190 patients presented with suspected acute lower gastrointestinal bleeding in National University Hospital, Singapore, from 1988 to 1994. Fifty-seven patients (30%) had bleeding diverticulosis in which 25 patients (44%) suffered from right-sided disease. Sixty-four per cent of patients had a history of hypertension. Patients presented with either fresh blood in stools or melena. Fifteen patients (60%) required blood transfusion (median, 2 units). Colonoscopy showed blood clots in the right colon in 15 cases (60%) and active bleeding from the right colon diverticula in 3 patients (12%). The bleeding stopped spontaneously in 16 patients (64%). The other 9 patients required surgery because of continuous or recurrent bleeding. All had a right hemicolectomy performed. The hospital stay was 13 days in this group, compared with 5 days for those undergoing conservative treatment (P = 0.0004). There were no deaths. No patients had further bleeding episodes during a median 7-month follow-up.     

Additive effect of NOS inhibitor and neurotrophic factors on the survival of injured Clarke's neurons

The present study examined the effect of treatment with the NOS inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME) together with peripheral nerve (PN) graft or brain-derived neurotrophic factor (BDNF) on the survival of CN neurons at the L1 level of the spinal cord following hemisection at T11. In control animals 41% of CN neurons survived 15 days after the hemisection, and 48% of these expressed NOS. Treatment with either PN graft implantation or continuous infusion of BDNF increased the survival rate of CN neurons to 70%; 70% of these expressed NOS. Combined L-NAME and PN graft or L-NAME and BDNF improved the rescue rate up to 94%, but only approximately 33% expressed NOS. Our results suggest that the expression of NOS might adversely influence the neuroprotective function of neurotrophic factors on injured CN neurons in the spinal cord.     

Sprouting of axon-like processes from axotomized retinal ganglion cells is influenced by the distance of axotomy from the cell body and the mode of transplantation of the peripheral nerve

It is a well known fact that the proximity of an axonal lesion from the cell body influences the degree of neuronal survival: a lesion close to the cell body leads to more severe cell death and vice versa. On the other hand, experiments involving transplantation of a peripheral nerve (PN) to various central nervous system (CNS) regions to induce axonal regeneration have suggested that axonal regrowth is more vigorous when the grafting is performed closer to the cell body. It is not clear, however, whether it is the distance of the site of axotomy or the location of the trophic source (PN graft) or both from the cell body which dictates the vigorousness of axonal regrowth. Using either a model of transplantation of a PN to the retina or implantation of a short PN into the vitreous body of the eye of the adult hamster, we have demonstrated that sprouting of axon-like processes from retinal ganglion cells (RGCs) depends on the distance of axotomy from the cell body when the PN graft is maintained at a constant distance from the cell body. Moreover, it was found that the distance of axotomy at which sprouting of axon-like processes could be induced was different for the 2 paradigms: with the intravitreal PN model, sprouting was observed even after intracranial ON cut whereas it was absent in the PN grafting-to-retina paradigm. This suggests that extrinsic influence (in this case an intravitreal PN) can overcome to a certain extent the growth-suppressive effects due to a long distance of axotomy.     

Morphological changes of retinal ganglion cells regenerating axons along peripheral nerve grafts: a Lucifer Yellow and silver staining study

The morphology of the retinal ganglion cells (RGCs) with their axons regenerating along a peripheral nerve graft at different post-grafting periods was studied by the intracellular injection of Lucifer yellow (LY) and silver staining methods. Several morphological features which were observed on developing RGCs, but not mature RGCs, have also been observed in the regenerating RGCs studied by the intracellular injection of LY. These morphological features observed on the regenerating RGCs included intraretinal axonal branches and collaterals, spine-like processes on the dendrites and soma, and short processes on the soma. These results suggest that damaged mammalian RGCs may be able to recapitulate certain cellular events which occur during normal development provided the regenerating cells are given the proper stimulus and a favorable environment for regrowth. From the results of both LY injection and silver staining experiments, it was found that the dendrites of the regenerating RGCs were, in general, much simpler than that of control Type I RGCs. However, regenerating RGCs with different degree of dendritic complexity could be observed in all post-grafting periods studied, and the dendritic complexity seems to decrease continuously with the increase in the post-grafting time. These results suggest that the ability to regenerate an axon is not closely related to dendritic responses and the peripheral nerve does not seem to be able to prevent the deterioration and retraction of the dendrites.     

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients. BACKGROUND: In hypertensive type 2 diabetic patients, treatment with angiotensin-converting enzyme (ACE) inhibitors is associated with a lower incidence of cardiovascular events than those treated with calcium channel-blocking agents. However, the long-term renal effects of ACE inhibitors in these patients remain inconclusive. In 1989, we commenced a placebo-controlled, double-blind, randomized study to examine the anti-albuminuric effects of enalapril versus nifedipine (slow release) in 102 hypertensive, type 2 diabetic patients. These patients have been followed up for a mean trial duration of 5.5 +/- 2.2 years. We examined the determinants, including the effect of ACE inhibition on clinical outcomes in these patients. METHODS: After a six-week placebo-controlled, run-in period, 52 patients were randomized double-blind to receive nifedipine (slow release) and 50 patients to receive enalapril. After the one-year analysis, which confirmed the superior anti-albuminuric effects of enalapril (-54%) over nifedipine (+11%), all patients were continued on their previously assigned treatment with informed consent. They were subdivided into normoalbuminuric (N = 43), microalbuminuric (N = 34), and macroalbuminuric (N = 25) groups based on two of three 24-hour urinary albumin excretion (UAE) measurements during the run-in period. Renal function was shown by the 24-hour UAE, creatinine clearance (CCr), and the regression coefficient of the yearly plasma creatinine reciprocal (beta-1/Cr). Clinical endpoints were defined as death, cardiovascular events, and/or renal events (need for renal replacement therapy or doubling of baseline plasma creatinine). RESULTS: In the whole group, patients treated with enalapril were more likely to revert to being normoalbuminuric (23.8 vs. 15.4%), and fewer of them developed macroalbuminuria (19.1 vs. 30.8%) compared with the nifedipine-treated patients (P < 0.05). In the microalbuminuric group, treatment with enalapril (N = 21) was associated with a 13.0% (P < 0.01) reduction in 24-hour UAE compared with a 17.3% increase in the nifedipine group (N = 13). In the macroalbuminuric patients, enalapril treatment (N = 11) was associated with stabilization compared with a decline in renal function in the nifedipine group, as shown by the beta-1/Cr (0.65 +/- 4.29 vs. -1.93 +/- 2.35 1/micromol x 10-3, P < 0.05) after adjustment for baseline values. Compared with the normoalbuminuric and microalbuminuric patients, those with macroalbuminuria had the lowest mean CCr (75.5 +/- 24.1 vs. 63.5 +/- 21.3 vs. 41.9 +/- 18.5 mL/min, P < 0.001) and the highest frequency of clinical events (4.7 vs. 5.9 vs. 52%, P < 0. 001). On multivariate analysis, beta-1/Cr (R2 = 0.195, P < 0.001) was independently associated with baseline HbA1c (beta = -0.285, P = 0.004), whereas clinical outcomes (R2 = 0.176, P < 0.001) were independently related to the mean low-density lipoprotein cholesterol (beta = 2.426, P = 0.018), high-density lipoprotein cholesterol (beta = -8.797, P = 0.03), baseline UAE (beta = 0.002, P = 0.04), and mean CCr during treatment (beta = -0.211, P = 0.006). CONCLUSION: In this prospective cohort analysis involving 102 hypertensive, type 2 diabetic patients with varying degrees of albuminuria followed up for a mean duration of five years, we observed the importance of good metabolic and blood pressure control on the progression of albuminuria and renal function. Treatment with enalapril was associated with a greater reduction in albuminuria than with nifedipine in the entire patient group, and especially in those with microalbuminuria. In the macroalbuminuric patients, the rate of deterioration in renal function was also attenuated by treatment with enalapril.     

Failed Caesarean Section: An Obstetrician's Nightmare

EDITORIAL COMMENT: In medicine, human judgment is fallible, but obstetrics is the discipline in which an error of judgment is most rapidly revealed, to the obstetrician, the patient and the labour ward staff, due to the unpredictability of the duration of labour and imminence of delivery in any individual patient. When the editor was a house officer he was called to the antenatal ward because a multipara, near term had abdominal pain. Vaginal examination revealed an undiluted cervix, but within the minute or so it took a walk to the handbasin to wash his hands the woman had delivered a live baby into the bed. It is always wise, and should be a routine. unless operating in haste for an emergency such as bleeding from placenta praevia, to perform a vaginal examination after anaesthesia is established before commencing Caesarean section in a woman in labour. The editor has performed many safe easy-forceps deliveries in this circumstance, in theatre, in women in whom Caesarean section was planned for cephalopelvic disproportion with or without fetal distress. This finesse is more important if the consultant has agreed to perform a Caesarean on the findings recorded by others, but the fact remains that labour and delivery can accelerate most unexpectedly. We accepted this case report for publication, not merely because it is the first such case reported, but also for the opportunity it provided to stress to readers the need for final evaluation of the stage of labour before Caesarean section, when the conditions are most favourable for assessment. Nonetheless, as this case tells us. it is possible for labour and delivery to proceed faster than the obstetrician can perform a Caesarean section.     

High frequency oscillatory ventilation in infants with increased intra-abdominal pressure

AIMS—To describe the short term effect of high frequency oscillatory ventilation on infants with severe abdominal distension who could not be conventionally ventilated.METHODS—Eight infants (25 to 38 gestational weeks, birthweight 600-3200 g, postnatal age 1 to 190 days) with a variety of intra-abdominal pathologies, resulting in severe abdominal distension and failure of conventional ventilation, were studied.RESULTS—The oxygenation status of all infants significantly improved within an hour of changing from conventional to high frequency oscillatory ventilation. Infants who were hypercapneic on conventional ventilation also showed a reduction in PaCO₂. As a group, the mean (SD) PaO₂/FIO₂ improved from 4.99 (0.98) kpa to 11.55 (3.8) kpa (P = 0.002), and the PaCO₂ from 6.48 (2.12) kpa to 4.89 (1.22) kpa (P= 0.028). These improvements were sustained throughout the next 48 hours.CONCLUSION—High frequency oscillatory ventilation seems to be an effective rescue measure for infants with respiratory failure secondary to increased intra-abdominal pressure.     

Effects of Interleukin-12 on the Induction of Cytotoxic T Lymphocytes from the Regional Lymph Node Lymphocytes of Patients with Lung Adenocarcinoma

Lung cancer-specific cytotoxic T lymphocytes (CTL) were induced by repeated stimulations of regional lymph node lymphocytes (RLNL) in lung cancer patients with either autologous or HLA-A-locus-matched tumor cells. To investigate the effect of interleukin-12 (IL-12), IL-12 was added during the stimulation of RLNL from HLA A24 / adenocarcinoma patients with either autologous tumor cells or HLA A24-positive adenocarcinoma cells (PC-9) in combination with, or instead of interleukin-2 (IL-2), and then the cytotoxic activity, cytokine production and populations of the lymphocyte subsets were examined. The addition of IL-12, or the substitution of IL-2 by IL-12 was found to enhance the cytotoxic activity and the cytokine production (IFN-γ, GM-CSF) of the CTL as compared with IL-2 alone. The cytotoxic activity and cytokine production were both partially inhibited by anti-MHC-class I monoclonal antibody. The CTL thus induced by IL-12 had a higher proportion of CD3⁺/CD56⁺ cells than the CTL induced with IL-2 alone. The positively selected CD8⁺/CD56^– lymphocytes showed PC-9-specific cytotoxic activity, because the population did not show any cytotoxicity to K562 or A549 (HLA-A26/A30). However, the CD3⁺/CD56⁺ lymphocytes were cytotoxic to both PC-9 and K562. In conclusion, IL-12 is considered to be a useful cytokine for both the induction of lung-cancer specific CTL and the augmentation of non-MHC-restricted cytotoxicity against tumor cells, and may be applicable for adoptive immunotherapy using CTL.     

Frequency of bitemporal independent interictal epileptiform discharges in temporal lobe epilepsy

PURPOSE: Bitemporal interictal epileptiform discharges (IEDs) occur in < or =42% of scalp EEGs in patients with temporal lobe epilepsy (TLE) studied with routine EEGs or partial analysis of long-term recordings. METHODS: Twenty-eight patients with TLE demonstrating exclusively unilateral temporal IEDs on routine EEGs underwent 24-h continuous recording. The entire record was visually inspected for epileptiform discharges. We used continuous EEG to assess the significance of long-term recording in detecting bilateral IEDs. RESULTS: Twenty-two patients had left temporal IEDs; 21 had right temporal IEDs. Seventeen (61%) patients had IEDs originating from both the right and left temporal lobes. The probability of detecting bilateral independent IEDs was correlated with the duration of continuous EEG recording. There was no correlation between the number of IEDs originating from one side and the probability of detecting independent IEDs on the other side. The frequencies of IEDs were not correlated with the length of time since onset of epilepsy. CONCLUSIONS: The findings suggest that when long-term recordings are performed, the incidence of bilateral discharges in TLE is higher than previously reported in the literature and supports the view that TLE is commonly a bilateral disease.