Severe Malnutrition Associated with α-Heavy Chain Disease: Response to Tetracycline and Intensive Nutritional Support

A 20-yr-old black male was admitted with a 5-month history of profound weight loss and diarrhea. Appetite and dietary intake had been remarkably well preserved up until the week before admission. The severity of his depletion was evidenced by a body weight of only 38% of standard, multiple electrolyte deficiencies, and reduced metabolic expenditure, protein turnover, protein synthesis, and pancreatic function. Immunological defects included diminished lymphocyte numbers, lymphocyte transformation, gamma-globulin concentration, and cell-mediated immunity. A diagnosis of alpha-heavy chain disease (alpha-HCD) was made on endoscopic duodenal biopsy and serology--lymphoma being excluded by scanning and laparotomy. Treatment consisted initially of intravenous nutrition (because of the extreme malnutrition, severe diarrhea, and malabsorption of fluid, electrolytes, carbohydrates, and fat) and oral tetracycline. Response was dramatic, with a doubling of body weight within 6 wk, and resolution of malabsorption. He was discharged on a normal diet and long-term oral tetracycline (250 mg/day), and at 1-yr follow-up, nutritional status and gut function were normal despite persistence of duodenal mucosal abnormalities and markers of alpha-HCD and bacterial overgrowth. These results suggest that the malabsorption initially identified in this patient was not due simply to the mucosal abnormalities that characterize alpha-HCD, but was more a consequence of the superimposition of nutrient maldigestion and absorption resulting from the extreme state of protein deficiency and its effects on gut and pancreatic function.     

Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial

BACKGROUND: Continence services in the UK have developed at different rates within differing care models, resulting in scattered and inconsistent services. Consequently, questions remain about the most cost-effective method of delivering these services. AIM: To evaluate the impact of a new service led by a continence nurse practitioner compared with existing primary/secondary care provision for people with urinary incontinence and storage symptoms. DESIGN OF STUDY: Randomised controlled trial with a 3- and 6-month follow-up in men and women (n = 3746) aged 40 years and over living in private households (intervention [n = 2958]; control [n = 788]). SETTING: Leicestershire and Rutland, UK. METHOD: The continence nurse practitioner intervention comprised a continence service provided by specially trained nurses delivering evidence-based interventions using predetermined care pathways. They delivered an 8-week primary intervention package that included advice on diet and fluids; bladder training; pelvic floor awareness and lifestyle advice. The standard care arm comprised access to existing primary care including GP and continence advisory services in the area. Outcome measures were recorded at 3 and 6 months post-randomisation. RESULTS: The percentage of individuals who improved (with at least one symptom alleviated) at 3 months was 59% in the intervention group compared with 48% in the standard care group (difference of 11%, 95% CI = 7 to 16; P<0.001) The percentage of people reporting no symptoms or 'cured' was 25% in the intervention group and 15% in the standard care group (difference of 10%, 95% CI = 6 to 13, P = 0.001). At 6 months the difference was maintained. There was a significant difference in impact scores between the two groups at 3 and 6 months. CONCLUSIONS: The continence nurse practitioner-led intervention reduced the symptoms of incontinence, frequency, urgency and nocturia at 3 and 6 months; impact was reduced; and satisfaction with the new service was high.     

消化道平滑肌肿瘤超微结构观察

对20例消化道平滑肌肿瘤的电镜观察,发现并非所有病例均具有平滑肌细胞超微结构特征。7例见有肌微丝及相应的致密体,5例见有胞膜下增厚的致密斑,4例见有胞膜下吞饮小泡及膜外间断基底膜。上述改变出现于4例平滑肌瘤中的3例,10例高分化平滑肌肉瘤中的4例,6例分化较差平滑肌肉瘤及1例上皮样平滑肌瘤未发现。其他如内质网的扩张、线粒体的变形及糖元核醣体的广泛分布等改变亦可见到。     

Conduction tissue in congenital heart surgery

The anatomy of the cardiac conduction system in normal and malformed hearts reconstructed from histological serial sections is reviewed. The sinus node and its arterial supply are located in the right superior cavoatrial junction except in hearts with left-sided juxtaposition of the atrial appendages, mirror-image, and isomeric arrangements of the atria. In the presence of normally positioned atrial and ventricular septal structures, the triangle of Koch is a useful guide to the location of the atrioventricular node and the penetrating bundle. In hearts with isolated ventricular septal defects, it is necessary to distinguish between a perimembranous defect and a muscular inlet defect. The conduction axis runs in the area of fibrous continuity at the posteroinferior edge of a perimembranous defect but in the anterosuperior rim of a muscular inlet defect. In most hearts with tetralogy of Fallot, the danger area is the region of aortic-mitral-tricuspid fibrous continuity where the axis penetrates. In hearts with atrioventricular septal defects, the lack of contiguity between atrial and ventricular septum results in a posterior displacement of the nodal triangle and coronary sinus and an elongation of the nonbranching bundle. Hearts with abnormally located atrioventricular nodes and conduction axes are mainly those with atrioventricular discordance, ambiguous atrioventricular connection in presence of left-hand pattern ventricular topology, hearts with univentricular atrioventricular connection to a morphologically left or indeterminate ventricle, and hearts with a straddling tricuspid valve. The location of the atrioventricular node is governed by the orientation of the ventricular septum and by the pattern of ventricular topology.

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Resumen Se revisa la anatomía del sistema de conducción cardiaca en los corazones normales y con malformaciones a la luz de la reconstrucción a partir de cortes histológicos seriados. El nódulo sinusal y su irrigación arterial está ubicado en la unión cavoatrial derecha, excepto en corazones con yuxtaposición izquierda de las auriculillas o con alteraciones en imagen en espejo e isoméricas de las aurículas. En presencia de estructuras septales atriales y ventriculares normalmente ubicadas, el tríangulo de Koch es una guía útil para la localización del nódulo atrioventricular y la penetración del haz. En corazones con defectos septales ventriculares aislados es necesario distinguir entre un defecto perimembranoso y un defecto del tracto muscular de entrada. El haz de conducción avanza en el área de continuidad fibrosa sobre el borde posteroinferior de un defecto perimembranoso, en el filo anterosuperior de un defecto del tracto muscular de entrada. En la mayoría de los corazones con tetralogía de Fallot el área de peligro se encuentra en la región del trígono fibroso aórticomitral y tricuspídeo sobre el cual penetra el haz de conducción. En corazones con defectos septales atrioventriculares la falta de continuidad entre el septo atrial y el ventrícular resulta en un desplazamiento posterior del triángulo de Koch y del seno coronario y en una elongación del haz no ramificado. Corazones con nódulos atrioventriculares y haces de conducción anormalmente ubicados son principalmente aquellos con discordancia atrioventricular, con conexión atrioventricular ambigua en presencia de un patrón izquierdo de arquitectura ventricular, corazones con conexión atrioventricular univentricular a un ventrículo morfológicamente izquierdo o indeterminado y corazones con válvula tricuspídea cabalgante. La ubicación del nódulo atrioventricular está determinada por la orientación del septo ventricular y por el patrón de la arquitectura ventricular.

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Résumé L'anatomie du système de conduction du coeur normal et du coeur siège de malformations reconstituée à partir de coupes sériées histologiques est exposée. Le sinus nodal et sa vascularisation sont situés au niveau de la partie supérieure de la jonction auriculo-ventriculaire droite sauf dans certains cas: coeur avec juxtaposition des auricules du côté gauche, image en miroir et dispositions isomères des oreillettes. Lorsque les cloisons auriculaire et ventriculaire occupent une situation normale, le triangle de Koch constitue un repère utile pour localiser le noyau auriculo-ventriculaire et le faisceau de His. En cas de défects septaux ventriculaires isolés, il est nécessaire de distinguer les défects périmembraneux et les défects musculaires. L'axe nerveux conducteur chemine dans la zone de continuité fibreuse au bord postéroinférieur du défect périmembraneux mais il chemine au bord antéro-supérieur du défect musculaire. En cas de tétralogie de Fallot, le danger se situe souvent au niveau de la zone fibreuse de continuité aortique-mitrale-tricuspide où pénètre l'axe conducteur. En cas de coeur porteur d'un défect septal auriculo-ventriculaire, le défaut de continuité entre la cloison ventriculaire et la cloison auriculaire entraîne le déplacement postérieur du triangle nodal et du sinus coronaire ainsi que l'élongation du faisceau. Les coeurs qui présentent une anomalie du siège des noyaux auriculo-ventriculaires et des nerfs conducteurs sont principalement ceux qui sont le siège d'une anomalie auriculo-ventriculaire, d'une connexion auriculo-ventriculaire ambiguë en cas d'une disposition ventriculaire de type gauche, d'une connexion auriculo-ventriculaire univentriculaire avec une morphologie ventriculaire gauche ou indeterminée, d'une valve tricuspide en fourche. Le siège du noyau auriculo-ventriculaire est fonction de l'orientation du septum ventriculaire et de l'architecture ventriculaire.

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Supported by the British Heart Foundation.     

Short-term chemoprophylaxis with ceftizoximevs. Five-day aminoglycoside with metronidazole in ‘contaminated’ lower gastrointestinal surgery

In a prospective, open, randomized controlled trial, 173 patients requiring surgery for potentially contaminated lower gastrointestinal surgery were allocated to receive either two doses of ceftizoxime (2 gm) with one dose of metronidazole (1.5 gm) or gentamicin 3 mg/kg/day for five days with one dose of metronidazole (1.5 gm). Eighty-nine patients received ceftizoxime and 84 patients received gentamicin. The groups were comparable with respect to diagnosis, procedure, type of anastomosis, and wound closure. The incidence of withdrawal due to failure to respond to the study drug (11.5 percent) was equivalent in the two groups. There was no difference in the overall incidence of postsurgical infection between the ceftizoxime and metronidazole group (22.2 percent) and the gentamicin and metronidazole group (25.7 percent). The incidence of wound infection (ceftizoxime and metronidazole, 6.9 percent; gentamicin and metronidazole, 10 percent) and deep sepsis (ceftizoxime and metronidazole, 15.3 percent; gentamicin and metronidazole, 15.7 percent) was similar.     

Acute pouchitis and deficiencies of fuel

PURPOSE: Acute pouchitis is a troublesome complication after restorative proctocolectomy. Deficiency of fuel, especially short chain fatty acids (SCFA), produced by anaerobic bacterial fermentation of saccharides, is implicated in ulcerative and diversion colitis. Our hypothesis was that SCFA deficiency occurs in acute pouchitis, and correction of the deficiency is associated with resolution of pouchitis. METHODS: Thirty-two patients were studied, 10 with histologically confirmed acute pouchitis and 22 with healthy pouches. Stool concentrations of SCFA (acetic, propionic, butyric, and valeric acids) were determined by gas-liquid chromatography. Quantitative bacteriologic studies of stool were carried out, and four-quadrant pouch biopsies were assessed by a pathologist who was unaware of the clinical state. Patients with pouchitis were treated for six weeks with metronidazole and given dietary advice to increase their intake of fermentable saccharides. RESULTS: Stool concentrations of SCFA were significantly less in pouchitis patients compared with patients with healthy pouches (340 mol/g (range, 124–492) vs.93 (range, 44–136) P<0.01). No differences in anaerobic or aerobic counts were seen. Resolution of pouchitis was associated with a significant increase in SCFA, but anaerobic counts fell. CONCLUSION: Deficiency of SCFA is implicated in acute pouchitis Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.