Dynamic anal manometry in the assessment of patients with obstructed defecation

Patients with obstructed defecation show no consistent abnormalities when assessed by standard anorectal physiologic methods. With a recently developed technique for dynamic anal manometry, we studied 13 female patients with obstructed defecation and 20 healthy volunteers. Seven parameters of anal function were measured. There were no differences between the median values for the two groups. Seven patients (54 percent; 95 percent confidence limits, 25-81 percent) had anal compliance below the normal range, either during opening or closing of the sphincter at rest (five patients), during squeeze (one patient), or both (one patient). Opening and closing pressures of the sphincter at rest, maximal closing pressure during squeeze, and anal hysteresis were normal. Standard anal manometry did not show any differences between patients and controls. Rectal compliance was lower in patients with obstructed defecation, median difference 5 ml/cm H2O (95 percent confidence limits, 1-9 ml/cm H2O). In conclusion, the more detailed method of dynamic anal manometry shows that some patients with obstructed defecation have a less compliant anal sphincter and a less compliant rectum, but in many patients no abnormal findings can be made.

Cave vulgantem morbum--tuberculosis

This study investigates the circumstances surrounding all cases of tuberculosis found at autopsy in Auckland during the period 1975-1992. Cases were placed in one of six categories according to the medical history and autopsy findings. Of the 34 cases in the study 22 were clinically undiagnosed prior to autopsy. Of these, six exhibited respiratory symptoms that should have led to a diagnosis and three reported unexplained chronic symptoms such as weight loss for which tuberculosis should at least have been considered. Only 10 cases were correctly diagnosed before death. The autopsy plays an important role in finding undiagnosed cases of tuberculosis, as patient contacts may then be followed up. The vital role of post-mortem examination in medical audit and public health is, once again, demonstrated.

Defecographic findings in patients with anal incontinence and constipation and their relation to rectal emptying

PURPOSE

The aim of this study was to examine defecographic findings in patients with anal incontinence and constipation and to compare these findings with rectal emptying.

METHODS

One hundred seventy-five preoperative defecographies documented on videotape in patients with either anal incontinence or constipation were retrospectively reviewed. The examinations were evaluated with respect to anatomic abnormalities of the rectum or anal canal. The results were compared with a semi-quantitative assessment of rectal emptying as it appeared on the video sequence after one minute of strain.

RESULTS

Anatomic abnormalities were found equally in incontinent and constipated patients, except for failure to open the anal canal, which was found only in constipated patients. Rectal intussusception was the most frequent finding. Abnormal defecograms were found in both sexes. Enteroceles, sigmoidoceles, and large rectoceles were found only in women. The presence of intussusception, lacking relaxation of the puborectalis muscle, and rectocele did not correlate with poor rectal emptying. Poor rectal emptying was also found in 19 of 58 patients with normal defecograms.

CONCLUSIONS

Anatomic abnormalities of the rectum may be demonstrated independently of the clinical symptoms and are not always correlated to impaired rectal emptying. Since they may also be found in healthy controls, surgical correction of these abnormalities should be considered only with great caution.

Environmental factors related to the outcome of panic disorder. A seven-year follow-up study

The purpose of this study was to examine factors related to the outcome of naturalistically treated panic disorder. In order to achieve this we followed up 69 patients 7 years after they had presented at a psychiatric clinic. At follow-up, the patients were generally doing well despite persisting symptoms. Patients who were more severely ill at the time of initial assessment had a worse outcome. These patients had more severe panic and agoraphobic symptoms, had illnesses of longer duration, and more often had histories of major depression. Among the developmental variables examined, separation from a parent by death or divorce was strongly related to poor outcome. Other factors associated with poor outcome included high interpersonal sensitivity, low social class, and unmarried marital status. The findings show that, for this chronic illness, measures of severity and chronicity predict more severe and persisting symptoms. They also indicate that outcome is importantly related to the social environment in which the illness develops and with which it interacts.

Clinical assessment of the anal continence plug

Recently, promising results with different modifications of an anal continence plug were reported in a pilot study. We have performed a clinical assessment of the plug preferred by the majority of patients in this study in an ambulatory group of patients incontinent to liquid and solid stool. Nine of 14 patients (64 percent; 95 percent confidence interval: 35-87 percent) were continent when they used the plug. In 43 percent (18-71 percent), the plug occasionally slipped out, and 71 percent (42-92 percent) experienced discomfort to a varying degree, which caused 11 patients to withdraw from the study before the end of the planned study period. No correlation was found between the results of anorectal physiology studies and the benefit or inconvenience of using the plug. The overall conclusion is that the majority of patients would use the plug under special circumstances because it eliminates the fear of fecal leakage but that local discomfort, possibly due to the material, would prevent its daily use.

Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. An endosonographic study

Follow-up was performed two to six years after anal dilatation for fissure-in-ano in 32 consecutive patients who had not undergone additional anal surgery. All patients were interviewed and asked specifically about impairment of flatus or fecal control and its possible relation to the anal dilatation. Anal dilatation was followed by minor anal incontinence in 12.5 percent of the patients. Anal endosonographic follow-up was accepted by 20 patients, and sphincteric defects were found in 13 (65 percent) of those. Two patients with anal incontinence had internal sphincter defects. Sphincteric defects were also found in 11 of the 18 continent patients who underwent sonography: internal sphincter defects in nine, external sphincter defect in one, and combined defects of both sphincter muscles in one. In conclusion, anal dilatation results in sphincter damage in more than half of patients, but few of them develop anal incontinence.

Massasauga rattlesnake bites in Iowa

Historically, bites from swamp rattlesnakes in Iowa have been mild, but a bite in eastern Iowa in 1990 produced life threatening thrombocytopenia. Only four populations of massasauga rattlesnakes have been verified in Iowa.

Biosynthesis of 10 kDa and 7.5 kDa insulin-like growth factor II in a human rhabdomyosarcoma cell line

In the present study we have analysed the expression of insulin-like growth factor II (IGF-II) in the human rhabdomyosarcoma cell line IN157.IN157 cells express high levels of three IGF-II mRNAs of 6.0 kb, 4.8 kb and 4.2 kb. In contrast, normal skeletal muscle expresses a negligible amount of IGF-II mRNA. Two forms of IGF-II with molecular masses of 7.5 kDa and 10 kDa, corresponding to the mature IGF-II and IGF-II with a C-terminal extension of 21 amino acids (IGF-IIE21), were secreted into the culture medium at amounts of 17 ng/ml (2.3 nM) and 15 ng/ml (1.5 nM), respectively. IN157 cells also produce IGF binding protein-2. The bioactivity of recombinant IGF-IIE21 was compared with human IGF-I and IGF-II. IGF-I, IGF-II and IGF-IIE21 bound with high affinity to human IGF-I receptors (Kd approximately 1 nM), whereas the human IGF-II/mannose 6-phosphate (IGF-II/Man 6-P) receptor bound IGF-II and IGF-IIE21 with Kd values of 0.5 nM and 2 nM, respectively, and IGF-I with about 500 times lower affinity. IGF-II and IGF-IIE21 stimulated DNA synthesis via the IGF-I receptor, whereas the IGF-II/Man 6-P receptor mediated their rapid internalization and inactivation. During culture of IN157 cells about 50% of their IGF-I receptors were occupied by endogenous IGF-II. We conclude that IN157 cells express high levels of bioactive 10 kDa IGF-II and 7.5 kDa IGF-II that may stimulate the proliferation of rhabdomyosarcomas by interaction with IGF-I receptors on the cells.

Truncated GLP-1 (proglucagon 78-107-amide) inhibits gastric and pancreatic functions in man

We studied the effect of intravenous infusion of synthetic truncated GLP-1 (proglucagon 78-107-amide) on fasting and postprandial gastric acid secretion, gastric emptying, and pancreatic secretion of trypsin and lipase in eight normal volunteers using marker dilution and aspiration technique. The infusion resulted in a plasma concentration of 110 +/- 14 pmol/liter (mean +/- SEM). Truncated GLP-1 significantly inhibited postprandial acid secretion by 43 +/- 11% in spite of unchanged plasma gastrin concentration. Gastric emptying rate decreased significantly; 50% emptying time increased from 16 +/- 2 min to 30 +/- 5 min. Postprandial trypsin and lipase outputs were significantly inhibited by 47 +/- 17% and 40 +/- 9% during truncated GLP-1 infusion. Pancreatic enzyme output was linearly correlated to gastric emptying, and truncated GLP-1 did not affect this relationship, suggesting that the effect on pancreatic secretion was secondary to the effect on gastric emptying. Postprandial insulin and glucagon concentrations were similar with and without truncated GLP-1 infusion in spite of significantly lower blood glucose levels (5.2 +/- 0.2 versus 3.7 +/- 0.3), indicating that GLP-1 stimulated insulin secretion and inhibited glucagon secretion. In conclusion, our results suggest that truncated GLP-1 act as a physiological inhibitor of gastric and pancreatic functions in man.

Endosonographic evaluation of patients with anal incontinence: findings and influence on surgical management

OBJECTIVE

Endosonography using an anal probe gives detailed information about the internal and external anal sphincters. The goals of this study were to evaluate findings at anal endosonography in patients with anal incontinence and to study whether endosonography might replace needle electromyographic mapping in providing information on the external anal sphincter. Furthermore, we compared the type of sphincter damage found by endosonography with the anal canal pressures and studied the value of endosonography for selecting the most effective surgical treatment.

SUBJECTS AND METHODS

Forty-eight patients with incontinence for either gas (17 patients) or feces (31 patients) were studied. Nineteen patients had idiopathic incontinence, 29 were incontinent as a result of previous obstetrical or surgical trauma. Endosonography and measurement of anal canal pressures were performed in all patients; 40 had needle electromyography. The endosonograms were evaluated without knowledge of the clinical findings, and the endosonographic findings were correlated with the results of needle electromyography, with the anal pressures, and with the type of surgery subsequently performed. In 30 patients, surgery was subsequently planned on the basis of the results of endosonography and the anophysiologic examinations.

RESULTS

Endosonograms showed defects of the external sphincters in 27 patients, 12 of whom had internal sphincter defects also. One patient had an abnormal thinning of the external sphincter. Eight patients had defects of the internal sphincter as the only finding. Twenty-two of the patients with sonographically detected defects or thinning of the external sphincter had electromyography, which showed defects of the external sphincter in 18; four defects in the middle and upper anal canal were not found. The sphincteric defects found by endosonography did not correlate with the anal canal pressures. Sphincter reconstruction was offered to most patients who had damage to the external sphincter; patients with isolated defects in the internal sphincter or intact internal and external sphincters were offered a number of other surgical procedures.

CONCLUSION

Endosonography can be used in place of the invasive electromyographic mapping for detecting defects of the external sphincter, and endosonography also gives additional information on the internal sphincter, which cannot be obtained by other means. No correlation between the anal pressures and the type of sphincter damage found by endosonography can be demonstrated. The main reason for performing endosonography is to detect defects in the external sphincter, for which surgical reconstruction is most likely to be done, whereas visualization of internal sphincter defects seems to have no influence on surgical management and does not lead to any specific treatment.

Sphincter rupture in childbirth

Thirty-eight women with rupture of the anal sphincter occurring during childbirth were followed for 3-12 months. Nineteen had complete rupture of the external anal sphincter, 14 had a lesion involving more than half of the sphincter muscle and five had a superficial rupture. Fourteen patients presented with continence disturbances: nine to solid or liquid faeces and five to flatus. Incontinence was present in nine women 3 months after childbirth. Anal manometry and electromyography were performed in patients 3-5 days after delivery and repeated at 3, 6 and 12 months. Manometry and electromyography were also performed in 16 control subjects who were nulliparous or had given birth more than 2 years previously and 24 primiparous controls, who were investigated at 3-5 days and at 3 months. There were significant differences between both incontinent and continent patients compared with nulliparous and primiparous controls. Primiparous control subjects had decreased anal squeeze pressure as well as decreased electromyographic activity on the first days after delivery compared with nulliparous controls. After 3 months no differences were found. Continence disturbances are frequent after sphincter rupture; these patients should be monitored after delivery and those with persisting incontinence offered sphincter repair.

Homicide offenders in Auckland, New Zealand

In the 14-year period from 1976 to 1989, 183 homicide offenders have been recorded in Auckland, New Zealand. Data accessed from police files show that Maori and Polynesians made up the majority of the offenders. Almost all offenders were male, and the largest proportion was between 20 and 24 years of age. Racial differences were noted in the methods used to commit the homicide, in the offender-victim relationship, and in whether the offender acted alone. The majority of offenders were not convicted of murder, but were convicted on lesser charges.

Rectal endosonography in the evaluation of stenotic rectal tumors

Preoperative evaluation of stenotic rectal tumors is important since they often involve adjacent organs and thus may require additional therapy. Previous reports on endosonographic staging have excluded stenotic tumors because they could not be fully visualized with the available equipment. In this study, we have evaluated the role of endosonography in staging stenotic rectal tumors, with special attention to the use of forward-looking endoprobes. Preoperative staging was performed in 28 patients with stenotic rectal tumors. Tumor extension was evaluated according to the TNM classification, and the results were compared with surgical and histopathologic findings. Endosonography accurately assessed tumor extension in two T2 tumors, 14 T3 tumors, and seven T4 tumors. Three T2 tumors were overstaged, and two T4 tumors were staged as T3. The accuracy was 82 percent. Twenty-two tumors were subject to histopathologic evaluation of lymph nodes. Lymph nodes larger than 1 cm had been seen by endosonography in eight patients, five of whom had nodal metastases. Lymph nodes smaller than 1 cm or no lymph nodes were found in 14 patients, four of whom had nodal metastases. In conclusion, full sonographic visualization of stenotic rectal tumors and thus evaluation of tumor extension can be achieved by using forward-looking endoprobes.

Anal endosonographic findings in patients with obstructed defecation

Anal endosonography, including measurements of anal sphincter size, was performed in 16 patients with obstructed defecation. The findings were compared with those at defecography and anal manometry. Patients with rectocele and intussusception had a normal endosonographic appearance. One patient with puborectalic spasm had normal sonography. There was no correlation between sphincter size and anal manometry. The external sphincter muscle was thicker and the cross-sectional area larger in patients with obstructed defecation than in healthy controls (p < 0.05). Two patients with sphincter spasm and impaired rectal emptying at defecography had clearly thickened internal sphincters which may be the cause of their defecatory disorder. Three patients with previous anal dilatation or hemorrhoidectomy had sphincteric defects. Anal endosonography may be considered in patients with obstructed defecation to identify patients with internal sphincter hypertrophy.

Flow cytometric measurement of RNA synthesis using bromouridine labelling and bromodeoxyuridine antibodies

Nuclear RNA synthesis can be analysed by flow cytometry of cells labelled with 5-bromouridine (BrUrd) and stained with anti-bromodeoxyuridine (BrdUrd) antibody and FITC-conjugated secondary antibody. A panel of 5 different commercially available anti-BrdUrd antibodies was tested on cells of a HL-60 human leukemia cell line, stained as a methanol-fixed nuclear suspension. The BrUrd-induced fluorescence signals were highest with the antibody ABDM (Partec), moderate but reproducible with B-44 (Becton Dickinson), variable or low with BR-3 and IU-4 (Caltag), and not detectable with Bu20a (DAKO). Treatment of BrUrd-labelled nuclei with ribonuclease before staining with antibodies indicated that ABDM and B-44 antibodies specifically recognized BrUrd-substituted RNA, whereas BR-3 and IU-4 antibodies also bound to BrUrd-unlabelled RNA. Combined analysis of BrUrd and DNA contents demonstrated the variation of RNA synthesis during the cell cycle. The BrUrd incorporation was high in the S and G2 phase, variable in G1, and negligible in mitosis. Similar results were obtained using other cell types.

Comparison of precontrast, postcontrast, and delayed CT scanning for the staging of rectal carcinoma

An attempt is made to establish the most appropriate examination procedure for staging rectal carcinoma by computed tomography (CT). Twenty-two patients with rectal carcinoma had CT performed preoperatively. The following three CT sequences were performed in all patients: a precontrast scan with 10-mm slices; a rapid sequence scan with 5-mm slices during bolus injection of contrast medium; and a postcontrast scan after a 10-min delay. Tumor extension and the presence of perirectal lymph nodes were evaluated separately and independently in all three CT sequences according to the TNM classification. All patients had surgical follow-up and the CT scans were compared to the surgical and histopathological findings. There was no significant difference in diagnostic outcome in the three CT procedures. Information obtained by frontal and lateral scout views were compared, and the lateral scout view proved more informative than the frontal scout view. For staging rectal carcinoma, narrow slice scanning and intravenous contrast media are superfluous and should be reserved for special cases. We recommend the use of lateral scout views.

Internal rectal intussusception: results of surgical repair

Twenty-four patients with obstructed defecation due to rectal intussusception diagnosed by defecography were treated with rectopexy either by the Wells technique (9 patients) or by Orr's operation (15 patients). After follow-up from one to eight years, defecography demonstrated disappearance of the intussusception in 22 patients. None of the patients were completely relieved of their symptoms. Nine (41 percent; 95 percent confidence limits: 21-64) were improved and 13 were unchanged (59 percent; 95 percent confidence limits: 36-79), with no difference between the two procedures. One patient with solitary rectal ulcer was improved, and the ulcer disappeared. Four patients with moderate preoperative incontinence became continent postoperatively, but obstructed defecation was only improved in two of these patients. It is concluded that rectal intussusception is probably a secondary phenomenon in patients with obstructed defecation and that a conservative attitude toward surgery should be adopted.

Physiological variation in rectal compliance

The volume (V) of air inflated in a latex balloon placed in the rectum and the corresponding pressures (P) were measured in 48 subjects (24 men and 24 women) at three points: (1) earliest defaecation urge; (2) constant defaecation urge; and (3) maximum tolerable volume (MTV). The rectal pressures in all three cases were higher in men than in women. Woman aged over 60 years had higher rectal compliance (delta V/delta P) than men in the same age group, while no difference was found between men and women below the age of 60 years. Day-to-day variation of the measurements was tested in ten subjects. Reproducibility was good only for MTV (95 per cent confidence interval 57-183 per cent). Reproducibility of rectal compliance decreased with increasing values for this parameter. No such trend was found for the other parameters. In conclusion, MTV is a reproducible parameter and suitable for clinical use in evaluation of patients with faecal incontinence or constipation.

Endonucleolysis in the turnover of insulin-like growth factor II mRNA

The overlapping transcription units constituting the rat insulin-like growth factor II (IGF-II) locus generate multiple mRNAs by using different promoters. Three promoters have been identified, giving rise to 4.6-, 3.8-, and 3.6-kilobase mRNAs. The latter, originating from promoter P3, is the most abundant IGF-II mRNA in the rat liver cell-line BRL-3A. Moreover, a non-polyadenylated 1.2-kilobase (kb) transcript and a 1.8-kb tail fragment are prominent transcripts at steady-state. In this study, we show that the 1.8-kb tail fragment is uncapped and sediments as a 30 S ribonucleoprotein particle, and is thus not actively engaged in protein synthesis. In contrast, both the 3.6-kb mRNA and the 1.2-kb transcript cosediment with polysomes. In the presence of cytoplasmic extracts, the full-length 3.6-kb mRNA is cleaved into the 1.8-kb tail fragment and a similar-sized upstream fragment. The cleavage occurs between a putative hairpin and a phylogenetically conserved guanosine-rich region which forms a stable higher order RNA structure in the presence of K+. We suggest that endonucleolysis is the initial step in IGF-II mRNA decay and that this event may participate in the post-transcriptional regulation of IGF-II production.