Fas and Fas ligand enhance the pathogenesis of experimental allergic encephalomyelitis, but are not essential for immune privilege in the central nervous system

Mutations of CD95 and CD95L, lpr and gld, respectively, are associated with spontaneous autoimmune disease and alteration of immune privilege. In lpr or gld animals these processes would be expected to exacerbate experimental allergic encephalomyelitis (EAE), an animal model of the autoimmune demyelinating disease multiple sclerosis. However, here we show that the lpr and gld mutations did not overcome the MHC-defined limits of disease and, surprisingly, did not exacerbate the pathology of EAE on a sensitive haplotype. In fact, the mutations dramatically ameliorated clinical signs of EAE without affecting the development of a Th1 response or inflammatory cell infiltration into the central nervous system. Fewer apoptotic cells were detected in inflammatory lesions of lpr mice than in wild-type lesions of similar severity. Our results indicate that CD95L is not an instrumental component of immune privilege in the central nervous system, and that functional CD95 and CD95L are important for the progression of clinical disease.

Crystal structure and resonance Raman studies of protocatechuate 3,4-dioxygenase complexed with 3,4-dihydroxyphenylacetate

The crystal structure of the anaerobic complex of Pseudomonas putida protocatechuate 3,4-dioxygenase (3,4-PCD) bound with the alternative substrate, 3,4-dihydroxyphenylacetate (HPCA), is reported at 2.4 A resolution and refined to an R factor of 0.17. Formation of the active site Fe(III).HPCA chelated complex causes the endogenous axial tyrosinate, Tyr447 (147beta), to dissociate from the iron and rotate into an alternative orientation analogous to that previously observed in the anaerobic 3,4-PCD.3,4-dihydroxybenzoate complex (3, 4-PCD.PCA) [Orville, A. M., Lipscomb, J. D., & Ohlendorf, D. H. (1997) Biochemistry 36, 10052-10066]. Two orientations of the aromatic ring of HPCA related by an approximate 180 degrees rotation within the active site are consistent with the electron density. Resonance Raman (rR) spectroscopic data from Brevibacteriumfuscum 3,4-PCD.HPCA complex in solution reveals low frequency rR vibrational bands between 500 and 650 cm-1 as well as a band at approximately 1320 cm-1 which are diagnostic of a HPCA. Fe(III) chelate complex. 18O labeling of HPCA at either the C4 or C3 hydroxyl group unambiguously establishes the vibrational coupling modes associated with the five-membered chelate ring system. Analysis of these data suggests that the Fe(III)-HPCAO4 bond is shorter than the Fe(III)-HPCAO3 bond. This consequently favors the model for the crystal structure in which the C3 phenolic function occupies the Fe3+ ligand site opposite the endogenous ligand Tyr408(Oeta) (108beta). This is essentially the same binding orientation as proposed for PCA in the crystal structure of the anaerobic 3,4-PCD.PCA complex based solely on direct modeling of the 2Fo - Fc electron density and suggests that this is the conformation required for catalysis.

Mechanisms of insulin-induced relaxation of the canine proximal stomach after proximal gastric vagotomy

The aim of this study was to determine whether insulin-induced relaxation of the proximal stomach after proximal gastric vagotomy is mediated by vagal release of antral gastrin. In six conscious, fasted dogs following proximal gastric vagotomy, the effects of intravenous insulin (1 U/kg) and intravenous gastrin (1 microg/kg) on proximal gastric motility, as measured by a gastric barostat, on plasma glucose, and on plasma gastrin, as measured by radioimmunoassay, were assessed 1 hour before and for 2 hours after injection. The effects of a cholecystokinin (CCK)-A receptor antagonist and a CCK-B receptor antagonist on insulin-induced or gastrin-induced relaxation of the proximal stomach and on plasma glucose and gastrin were also determined. Intravenous insulin decreased plasma glucose (before [mean +/- SD], 97 +/- 5 mg/dl vs. after, 45 +/- 3 mg/dl; P <0.05), increased plasma gastrin (before, 240 +/- 59 pg/ml vs. peak after, 387 +/- 85 pg/ml; P <0.05), and relaxed the proximal stomach (100% +/- 0% barostat volume vs. 202% +/- 15% volume; P <0.05). Exogenously administered gastrin also relaxed the proximal stomach without decreasing plasma glucose. CCK-B blockade diminished, but did not abolish, the gastric relaxation caused by insulin or gastrin, whereas CCK-A blockade had little effect. It was concluded that insulin-induced relaxation of the proximal stomach after proximal gastric vagotomy is mediated, in part, by vagal release of antral gastrin.

Reconstitution of SCID mice with haemopoietic precursors: a detailed analysis of gamma delta T-cell reconstitution

A well-known characteristic of gamma delta T cells is that they are produced in waves during ontogeny, with cells expressing T-cell receptor V gamma 5 appearing early in fetal thymic ontogeny, followed by V gamma 6, then by other gamma delta T-cell types. In addition, evidence exists to suggest that the potential of haemopoietic precursors to generate different types of gamma delta T cells changes in ontogeny. We have used these observations as the basis for an extensive study of the potential for haemopoietic precursors isolated from fetal liver, neonatal spleen and adult bone marrow to reconstitute severe combined immunodeficient (SCID) mice. Mice that were reconstituted as newborns with fetal liver cells most closely resembled normal C.B-17 mice with respect to both lymphocyte numbers and subsets, while mice reconstituted with adult bone marrow had fewer cells than normal mice. This deficit spanned both T and B cells in all organs examined. Among the gamma delta T-cell subsets examined, the ability to reconstitute V gamma 4+ cells was particularly dependent on the ontogenic age of the reconstituting presursors, with fetal liver cells having the greatest capacity to generate V gamma 4+ cells, and adult bone marrow cells the least. The vast majority of the T cells produced in the reconstituted mice were of donor origin, and the level of reconstitution was found to be dependent upon some factor other than the presursor frequency.

A psychoeducational program for patients with trauma-related disorders

The authors describe the development and implementation of a psychoeducational program for patients with a wide range of trauma-related symptoms and disorders. The psychoeducational intervention is designed to facilitate coping, promote self-understanding, and enhance reflectiveness. Using attachment theory as the overarching conceptual framework, the authors educate patients about the nature of trauma, the effects of trauma on development, trauma-related psychiatric disorders, and a range of treatment approaches to trauma. They describe groups for adult inpatients and adults in partial hospital treatment, and for adolescents in either inpatient, residential, or outpatient treatment.

Initial route of antigen administration alters the T-cell cytokine profile produced in response to the mouse pneumonitis biovar of Chlamydia trachomatis following genital infection

A Th1-type response develops following vaginal infection with the mouse pneumonitis biovar of Chlamydia trachomatis (MoPn). Since the type of response, i.e., Th1 versus Th2, can be influenced by factors present during T-cell activation, we examined the effects of different routes of MoPn administration on the cytokine profile and resistance against infection following a MoPn vaginal challenge. A dominant Th1-type cytokine profile developed in mice given live MoPn via the intranasal, oral, and vaginal routes with ratios of gamma interferon-secreting cells to interleukin 4-secreting cells greater than 10. In contrast, mice injected subcutaneously produced a Th2-type profile with a gamma interferon/interleukin 4 ratio of only 0.7. These mice also had significantly higher anti-MoPn immunoglobulin G1 serum titers, confirming a Th2-type cytokine profile. Exposure of mice to live MoPn, by any route prior to vaginal challenge, resulted in a shortened course of infection. However, the subcutaneous group resolved the vaginal infection more slowly, with 60% (6 of 10 mice) of the mice still isolation positive 12 days after challenge compared with only 20% of mice given live MoPn by other routes. Administration of UV-inactivated MoPn did not provide protection against a vaginal challenge. The decreased ability to clear infection was not associated with a shift in the cytokine profile, since intranasal and oral administration of UV-inactivated MoPn resulted in a predominant Th1-type response. Taken together, these data indicate that the initial route of MoPn administration can direct the type of response produced after a local MoPn infection and thus influence the ability of the immune response to protect against subsequent infection.

Peroxisome proliferator-activated receptor-gamma activation by thiazolidinediones induces adipogenesis in bone marrow stromal cells

The thiazolidinediones improve insulin sensitivity in animal models and have promise as potent oral antidiabetic agents. Their clinical use has been limited because of the resulting anemia and cardiac hypertrophy. Some compounds of this class have been reported to induce bone marrow fat accumulation in animals, and this effect could account for the observed anemia. We examined the biological mechanism contributing to this phenomenon. The thiazolidinediones BRL49653 and pioglitazone induced adipocyte differentiation in the BMS2 bone marrow stromal cell line in a dose- and time-dependent manner. These actions were further enhanced by the presence of glucocorticoids and other adipogenic agonists. The thiazolidinediones increased the mRNA levels of adipocyte-specific genes, including that of their receptor, the peroxisome proliferator-activated receptor-gamma (PPAR gamma). In contrast, mRNA levels of genes encoding other PPAR family members (PPAR alpha, PPAR delta, or NUC-1) were unchanged or decreased. Thiazolidinedione treatment of primary bone marrow stromal cells elicited a comparable dose-dependent response. Using a polyclonal antibody, PPAR gamma was detected in protein lysates from adipose-rich bone marrow. Thus, thiazolidinedione directly regulates bone marrow stromal cell differentiation; induced PPAR gamma expression may play a key regulatory role in this process.

The function of adipocytes in the bone marrow stroma: an update

The adipocyte is the most abundant stromal cell phenotype in adult human bone marrow. Four hypotheses may explain their function. First, adipocytes may serve a passive role, simply occupying excess space in the bone marrow cavity. Second, they may play an active role in systemic lipid metabolism. Third, adipocytes may provide a localized energy reservoir in the bone marrow. Or fourth, marrow adipocytes may contribute directly to the promotion of hematopoiesis and influence osteogenesis. This article reviews recent findings concerning bone marrow adipocyte morphology and physiology, the transcriptional and cytokine mechanisms regulating their differentiation, and the interrelationships existing between bone marrow adipocytes, hematopoiesis, and osteogenesis. Overall, these data lend support to a "plastic" model of bone marrow stromal cell differentiation; adipocytes may share common functions with stromal stem cells, osteoblasts, and hematopoietic supportive cells.

Disconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis

The aim of this retrospective study was to determine the outcome of patients with a dysfunctional pelvic ileal reservoir in whom disconnection of an ileal pouch-anal anastomosis (IPAA), pouch revision and reanastomosis had been carried out. There were 23 patients (15 women). At the revision operation functional problems were found to be due to a long efferent spout (nine patients), sepsis and/or fistula (four), a redundant blind limb (three), a twisted pouch (three), anastomotic problems (three) or no reservoir (one). The pouch was salvaged in 16 patients and a new pouch was constructed in seven. The pouch-anal anastomosis was resutured in 22 patients and stapled in one. Postoperative complications (all minor) occurred in six patients. Two patients underwent two revision of IPAA. At a median follow-up of 5 (range 1-10) years, 11 patients reported good to excellent function, five reported fair function and one reported recurrent pouchitis. Revision surgery was unsuccessful in six of 23 patients (three had gross incontinence, two excessive bowel movements and one Crohn's disease), and they subsequently underwent pouch excision. It is concluded that revision of an ileal reservoir and IPAA can be undertaken safely with good results in carefully selected patients.

Changing referral patterns for surgical treatment of ulcerative colitis

OBJECTIVE

To determine whether referral patterns for surgical treatment among patients with chronic ulcerative colitis have changed in recent years, especially in view of the introduction of a new operation, the ileal pouch-anal anastomosis (IPAA).

MATERIAL AND METHODS

Between January 1976 and December 1986, 981 patients underwent proctocolectomy at Mayo Clinic Rochester. Brooke ileostomy (N = 300), colectomy with ileorectal anastomosis (N = 33), proctocolectomy with Kock pouch (N = 180), or ileal pouch-anal anastomosis (IPAA) (N = 468) was performed. The indications for surgical intervention were categorized as emergent or elective, the latter including intractability, cancer, and cancer prophylaxis. For analysis, the duration from diagnosis of disease to operation, indications for surgical treatment, and types of operation were subdivided into pre-IPAA era (before 1981) and post-IPAA era (from 1981 onward) for the entire group and for distant versus local patients.

RESULTS

More continence-preserving operations were done in 1981 and thereafter (76%) than before 1981 (46%). In the later segment of the study period in comparison with before 1981, fewer operations were done for emergent reasons (4% versus 8%) and a greater percentage of operations were done for elective indications, especially intractability (74% versus 61%). With the advent of IPAA in 1981, patients underwent operation sooner after the diagnosis was made (7.4 years versus 8.6 years before 1981). A smaller proportion of patients underwent operation for cancer prophylaxis during 1981 through 1986 (19%), however, than before 1981 (28%).

CONCLUSION

Referral patterns for surgical treatment of patients with ulcerative colitis have changed in recent years--patients are being referred for operation sooner, before complications develop that necessitate emergent procedures. Although the changed referral pattern may be due to the availability of IPAA, other factors may also have a role.

Oral tolerance in EAE: reversal of tolerance by T helper cell cytokines

Oral administration of myelin basic protein (MBP) inhibits clinical and histopathological manifestations of experimental autoimmune encephalomyelitis (EAE), but only partially reduces serum anti-MBP antibody titers. We report here that orally administered MBP alters the isotypic distribution of anti-MBP antibody-forming cells (AFC) among various lymphoid tissues, with the most profound differences seen in mucosal tissues. We observed an isotype-selective reduction in anti-MBP IgA but not IgM AFC frequencies in Peyer's patches. The anti-MBP IgA AFC frequencies could be reconstituted by addition of interleukin 4 (IL-4) and interleukin 5(IL-5). The cytokines did not appear to generate de novo responses since no increases in anti-MBP lgA AFC frequencies were observed in control cultures. These results indicate that decreased antibody production, as a result of oral antigen administration, can be reversed by exposure to the appropriate cytokines.

Functional characteristics of canine pylorus in health, with pyloroplasty, and after pyloric reconstruction

The aim was to determine whether pyloroplasty decreases the strength of pyloric contractions and speeds gastric emptying of solids, while subsequent pyloric reconstruction restores these abnormalities to the control. In conscious dogs, pyloroplasty decreased the strength of pyloroduodenal pressure waves measured with a perfused sleeve sensor [mean +/- SEM pyloroduodenal motility index: control (N = 7) = 1116 +/- 351 mm Hg x sec/10 min; pyloroplasty (N = 7) = 43 +/- 19 mm Hg x sec/10 min; P < 0.05], and caused rapid gastric emptying of solids measured scintigraphically (mean +/- SEM half-emptying time: control = 246 +/- 14 min, pyloroplasty = 176 +/- 16 min; P < 0.05). The frequencies of pyloroduodenal waves and gastric emptying of liquids, however, were unchanged. Pyloric reconstruction restored the postpyloroplasty patterns to the control. In conclusion, pyloroplasty decreased the strength of pyloroduodenal contractions and sped gastric emptying of solids, while pyloric reconstruction restored the altered patterns to the control.

A well-deserved break: respite programs offered by California's statewide system of Caregiver Resource Centers

This article describes the range of respite care options that are helping families of cognitively impaired adults under the auspices of California's statewide system of Caregiver Resource Centers. Types of respite provided include in-home care, adult day care and other group care programs, and overnight respite options outside the home, ranging from short-term care of the patient in a facility to weekend retreats designed for caregivers. The hallmarks of the program are flexibility, choice, and consumer control.

Elimination of the Roux stasis syndrome using a new type of "uncut Roux" limb

BACKGROUND

The Roux stasis syndrome, a syndrome of nausea, vomiting, abdominal pain, and postprandial fullness that follows Roux-en-Y gastrojejunostomy, is thought to result from the jejunal transection performed during the construction of a conventional Roux limb. The purpose of this study was to test a new type of "uncut" Roux limb construction, in which a neuromuscular bridge maintains neuromuscular continuity between the proximal jejunum and the Roux limb, while a jejunojejunostomy provides distal diversion of pancreaticobiliary secretions

METHODS

After a distal hemigastrectomy, 5 dogs underwent the uncut Roux operation, while 5 others had a Billroth II reconstruction (controls). Three weeks later, recordings of jejunal myoelectrical activity and assessment of gastric emptying and bile reflux were performed in fully conscious dogs

RESULTS

In the dogs with uncut Roux limbs, jejunal pacesetter potentials propagated aborally across the neuromuscular bridge, although their frequency was slightly slower distal to the bridge (proximal 19.5 +/- 0.7 cpm versus distal 18.8 +/- 1.1 cpm; P < 0.05). No frequency change occurred across the comparable area of jejunum of the controls. Both groups had similar rates of gastric emptying. Only small amounts of bile acids were found in gastric aspirates from dogs with uncut Roux limbs.

CONCLUSIONS

A new uncut Roux operation eliminated the Roux stasis syndrome by preserving neuromuscular continuity between the proximal jejunum and the Roux limb, and yet provided near-total diversion of bile from the gastric remnant.

Early clinical results with the uncut Roux reconstruction after gastrectomy: limitations of the stapling technique

BACKGROUND

The aim of this study was to review our early clinical experience with the uncut Roux gastrectomy, a modified Billroth II gastrojejunostomy in which four rows of staples occlude the afferent jejunal lumen, while biliary and pancreatic secretions are diverted distally through a jejunojejunostomy.

METHODS

Between September 1991 and April 1993, 9 women and 5 men underwent uncut Roux gastrectomy for gastric adenocarcinoma (5), postvagotomy or idiopathic gastroparesis (7), Roux stasis syndrome (1) or anastomotic ulceration with gastric outlet obstruction (1). Subsequently, patients were seen or contacted by phone within the 6 months prior to March 1994.

RESULTS

Eight of the 14 patients (57%) had excellent results with stable weight and no nausea, vomiting, heartburn, abdominal pain, or postprandial symptoms. One patient continued to have early satiety and vomiting but maintained stable weight for 19 months postoperatively. Five patients (36%) had poor results with alkaline reflux gastritis or esophagitis. All 5 had documented staple line dehiscence. Four of them were reoperated on and converted to a standard Roux operation with relief of symptoms.

CONCLUSIONS

The uncut Roux operation prevents the Roux stasis syndrome, but the current technique has an unacceptably high incidence of dehiscence of the staple lines with subsequent reflux gastritis or esophagitis.

Germinal center T cells exhibit properties of memory helper T cells

Potential roles of germinal center (GC) T cells in immune memory were investigated by examining T cells in GCs lymph nodes (LNs) following immunization with myelin basic protein (MBP). MBP preferentially stimulates T cells expressing the V beta 8 TCR family in B10.PL mice. By staining lymph nodes with peanut agglutinin, GCs were first identified 8 days after immunization and could still be detected 50 days later. When T cells within GCs were examined at Day 8, the majority (> 90%) were CD45RB-negative and a large percentage (20%) had already proliferated several days before as determined by bromodeoxyuridine (BrdU) incorporation. When BrdU+ V beta 8+ cells were examined in various areas of LNs 3 and 8 weeks after immunization, BrdU+ V beta 8+ cells were approximately fourfold more frequent in GCs than other areas of LNs. When GCs were examined for IL-4 mRNA+ cells using an in situ hybridization method, only 0.01% of GC cells expressed IL-4 mRNA, corresponding to about 1% of GC T cells. Shortly following restimulation with MBP, the frequency of cells expressing IL-4 mRNA increased fivefold. Taken together, these findings indicate that GC T cells possess characteristics associated with memory T cells.

Ectopic jejunal pacemakers after jejunal transection and their relationship to transit

The hypothesis was that orally moving pacesetter potentials distal to a site of jejunal transection and anastomosis would slow transit through jejunum containing them and that reoperation with excision of bowel containing these pacesetter potentials would restore transit to the control. In six conscious dogs with jejunal serosal electrodes for recording myoelectric activity and a jejunal perfusion/aspiration catheter for measuring transit, jejunal pacesetter potential frequency decreased distal to a midjejunal transection and anastomosis from 18.7 +/- 0.3 (SE) cycles/min (cpm) proximal to the site to 14.4 +/- 0.6 cpm distal to the site (P < 0.05). In addition, orally propagating pacesetter potentials occurred > 25% of the time in a 37 +/- 7 cm length of bowel distal to the site during fasting and after feeding. Transit through the segment with the orally moving pacesetter potentials was slowed during feeding (half time before and after transection, 7.7 +/- 1.1 and 13 +/- 2.0 min, respectively, P < 0.05). Resection of the segment with the abnormal pacesetter potentials shortened the length of bowel containing them to 24 +/- 2 cm (P > 0.05) and restored transit to the control. In conclusion, orally moving pacesetter potentials distal to a canine jejunal transection and anastomosis slowed transit through the segment of bowel containing them. Resection of the segment restored transit to the control.

Effect of electrical stimulation on gastric electrical activity, motility and emptying

The aim was to measure the effect of gastric electrical stimulation on the frequency of canine antral pacesetter potentials (PPs), the strength of antral contractions, and the rate of gastric emptying while fasting, after feeding and with pentagastrin stimulation. Four conscious dogs with a stimulating electrode placed 10 cm proximal to the pylorus and recording electrodes and strain gauges placed 7, 5 and 3 cm proximal to the pylorus underwent myoelectric and strain gauge recordings while fasting, after feeding (250 ml 5% dextrose labelled with polyethylene glycol), and during pentagastrin infusion (0.5 micrograms kg-1 min-1) on four separate days. On each day, electrical stimulation was done using one of four stimulation frequencies (0, 6, 30 and 1200 stimuli per minute [s.p.m.]). Stimulation at 6 and 30 s.p.m. increased the fasting and fed PP frequency, whereas 1200 s.p.m. stimulation did not. Feeding decreased the maximum driven frequency, and pentagastrin increased it. Neither the motility index nor the gastric emptying rate were consistently changed by stimulation at any frequency. In conclusion, canine proximal antral stimulation at 6 and 30 s.p.m. sped PP frequency during fasting and after feeding, but stimulation over a wide range of frequencies had little effect on gastric contractions and emptying.

Increased stem cell factor release by hemangioma-derived endothelial cells

BACKGROUND

Capillary hemangiomas, the most common tumors in young children, consist of proliferating capillary vessels and endothelial cells. These tumors also contain large numbers of mast cells, compared with the normal surrounding skin or tissue. We have recently shown that stem cell factor (SCF), the gene product of the murine steel locus, can act as a chemoattractant for mast cells. In this study, we investigated whether SCF might be involved in the recruitment and maintenance of mast cells in hemangiomas.

EXPERIMENTAL DESIGN

Cultured endothelial cells derived from a murine hemangioma were compared with normal vascular endothelial cells for the ability to produce and release SCF, a mitogen for mast cells.

RESULTS

Conditioned medium from hemangioma-derived endothelial cells stimulated the proliferation of cultured mast cells. This proliferative activity was potentiated by interleukin-3. The same conditioned medium was unable to stimulate proliferation of mast cells expressing a defective receptor for SCF. The medium was also unable to stimulate proliferation when it was preincubated with neutralizing antibodies specific for SCF. Immunoprecipitation and Western blot analysis of the conditioned media from hemangioma cells and normal endothelial cells demonstrated the 31,000 molecular weight SCF in hemangioma-conditioned medium only. In addition, proliferative activity for mast cells could not be demonstrated in the conditioned medium of the normal endothelial cells, although Northern blot analysis indicated that both normal and hemangioma-derived endothelial cells express SCF mRNA. Reverse transcriptase-polymerase chain reaction techniques were used to amplify the DNA sequence coding for the proteolytic cleavage site used for release of SCF. Results indicated that both normal and hemangioma-derived endothelial cells express the same transcript for SCF.

CONCLUSIONS

Our data suggest that increased release of SCF is a property of hemangioma-derived endothelial cells that may account for the high numbers of mast cells observed in hemangioma tissue. This increased release of SCF is not due to alternate splicing of SCF transcripts by hemangioma cells.

Epidural analgesia shortens postoperative ileus after ileal pouch-anal canal anastomosis

PURPOSE

A retrospective study was conducted to determine whether epidural analgesia would speed recovery from postoperative ileus in patients undergoing ileal pouch-anal canal anastomosis.

METHODS

Among 85 patients who underwent proctocolectomy with ileal pouch-anal canal anastomosis at the Mayo Medical Center between January 1, 1991 and October 31, 1992, 44 were treated for postoperative pain with continuous infusion of epidural fentanyl citrate supplemented by intravenous morphine on request, while 41 controls were given only systemic morphine sulfate as needed.

RESULTS

The patients in the two groups were matched and similar with regard to preoperative and operative risk factors and postoperative morbidity. No operative mortality occurred. Epidural fentanyl analgesia resulted in less need for nasogastric suction and intravenous fluids, more rapid discharge of fecal content, more rapid return to oral intake, and shorter hospitalization.

CONCLUSION

Epidural analgesia with fentanyl citrate shortened postoperative ileus after proctocolectomy and ileal pouch-anal canal anastomosis.

Impact of therapeutic endoscopy on the treatment of bleeding duodenal ulcers: 1980-1990

Therapeutic endoscopy (TE) has provided a new means for treating peptic ulcer disease, prompting a reevaluation of surgery's role. The aim of this study was to determine if surgical therapy of bleeding duodenal ulcers has changed since the advent of TE. This retrospective review involved consecutive time periods during which TE was (1985-1990) and was not (1980-1984) widely available. Exclusion criteria were prior gastric surgery, nonpeptic conditions, and untreated ulcers. Inclusion standards were met by 252 patients (180 men, 72 women) whose mean age was 67 years. Patients were grouped by the initial therapeutic intervention. Groups were similar in age, medical condition (mean APACHE II score 16), and morbidity. Seventy-five patients had surgery alone during 1980-1984 and 38 during 1985-1990. TE was initially performed on 134 patients during 1985-1990. Bleeding (n = 30) and perforation (n = 1) prompted emergent operation in 23% of cases following TE. Thus 69 (38 + 31) patients underwent surgery between 1985 and 1990. Preprocedure transfusions averaged 4.1 units in the endoscopic group and 8.2 units in the operative groups (p < 0.0001). Disagreement existed between the endoscopic and surgical descriptions of ulcer location in 53% of cases. Emergent surgery was required in 45% of hemodynamically unstable patients versus 14% of stable patients who initially underwent TE (p < 0.0001). Sixty-one percent of incompletely visualized TE-treated lesions required operation, and 18% of well visualized ulcers underwent operation (p < 0.0001). Hospital mortality was similar (8% versus 16%) in the endoscopic and operated groups (p = 0.7). Mean follow-up was 540 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of Meckel's diverticulum. An epidemiologic, population-based study

OBJECTIVE

The authors determined whether Meckel's diverticulum, discovered incidentally at operation, should be removed.

SUMMARY BACKGROUND DATA

It is not clear from the medical literature whether the risk of an incidental Meckel's diverticulectomy is greater than the risk of leaving the diverticulum in place.

METHODS

The authors used the medical experience of Olmsted County, Minnesota residents for the period 1950 to 1992 to answer the question.

RESULTS

During the period, 58 residents developed Meckel's complications that required diverticulectomies. The incidence of complications was 87 per 100,000 person-years, and the lifetime risk (to 80 years of age) of developing them was 6.4%. The risks were similar throughout the period and at all ages of life, but were greater among men (124 per 100,000 person-years) than women (50 per 100,000 person-years, p < 0.05). Diverticulectomies for complications carried an operative mortality and morbidity of 2% and 12% and a cumulative risk of long-term postoperative complications of 7%, whereas incidental diverticulectomies done in 87 residents during the period carried corresponding rates of only 1%, 2%, and 2%, respectively.

CONCLUSIONS

Meckel's diverticula discovered incidentally at operation should be removed for most patients, regardless of age.