Oral administration of non-absorbable delayed release 6-mercaptopurine is locally active in the gut, exerts a systemic immune effect and alleviates Crohn's disease with low rate of side effects: results of double blind Phase II clinical trial

Therapy for Crohn's disease (CD) with thiopurines is limited by systemic side effects. A novel formulation of fixed-dose, delayed-release 6-mercaptopurine (DR-6MP) was developed, with local effect on the gut immune system and minimal absorption. The aim of this study was to evaluate the safety and efficacy of DR-6MP in patients with moderately severe CD compared to systemically delivered 6-mercaptopurine (Purinethol). Seventy CD patients were enrolled into a 12-week, double-blind controlled trial. The primary end-point was the percentage of subjects with clinical remission [Crohn's Disease Activity Index (CDAI) < 150] or clinical response (100-point CDAI reduction). Twenty-six (56·5%) and 13 (54·2%) subjects from the DR-6MP and Purinethol cohorts, respectively, completed the study. DR-6MP had similar efficacy to Purinethol following 12 weeks of treatment. However, the time to maximal clinical response was 8 weeks for DR-6MP versus 12 weeks for Purinethol. A higher proportion of patients on DR-6MP showed clinical remission at week 8. A greater improvement in Inflammatory Bowel Disease Questionnaire (IBDQ) score was noted in the DR-6MP group. DR-6MP led to a decrease of CD62(+) expression on T cells, implying a reduction of lymphocyte adhesion to site of inflammation. DR-6MP was safer than Purinethol, with significantly fewer adverse events (AEs). There was no evidence of drug-induced leucopenia in the DR-6MP group; the proportion of subjects who developed hepatotoxicity was lower for the DR-6MP. Non-absorbable DR-6MP is safe and biologically active in the gut. It is clinically effective, exerting a systemic immune response with low systemic bioavailability and a low incidence of side effects.

Toilet reading habits in Israeli adults

Although toilet reading (TR) is a common habit, the effect of TR on bowel movements is neglected in the medical literature. Our hypothesis was that TR provides a distraction and acts as an unconscious relaxation technique and allows an easier defecation process. The aim of this study was to assess how common is TR and to map the reading/playing toilet habits in the Israeli adult population. In addition, we aimed to explore a possible connection between TR and the nature of bowel habits in general and constipation and haemorrhoids in particular. Five hundred adults who represent the diverse demographic backgrounds have been asked to fill an anonymous short questionnaire. The subjects were questioned regarding their demographic details, their TR and playing habits, their bowel habits, whether they suffer from haemorrhoids and whether they use some sort of faecal softener. We found that TR is common and involves 52.7% of the population. Males, younger age, secular population, higher education level and white collar workers compose the TR profile. Although toilet readers spent significantly more time in the toilets, no differences were noted for the type or frequency of stools. Nevertheless, the TR group considered themselves to be less constipated (8.0%vs 13.7%) and had more haemorrhoids (23.6%vs 18.2%). These differences, however, were not significant. Toilet reading is a common and benign habit. It is involved with a longer time spent in the toilet. It seems to be more for fun and not necessarily to solve or due to medical problems.

Clinical trial: randomized-controlled clinical study comparing the efficacy and safety of a low-volume vs. a high-volume mesalazine foam in active distal ulcerative colitis

BACKGROUND

Rectally administered mesalazine (mesalamine; 5-aminosalicylic acid) is the first-line therapy for treatment of distal ulcerative colitis. Recently, a high-volume 5-aminosalicylic acid foam has been shown to be as effective and safe as standard 5-aminosalicylic acid enema.

AIM

To study the efficacy and safety of a low-volume vs. a high-volume 5-aminosalicylic acid foam.

METHODS

In this investigator-blinded study, patients with active distal ulcerative colitis [Clinical Activity Index (CAI) > 4, Endoscopic Index > or = 4] were randomized to receive 2 x 1 g/30 mL low-volume (n = 163) or 2 x 1 g/60 mL high-volume 5-aminosalicylic acid foam (n = 167) for 42 days. Primary end point was clinical remission (CAI < or = 4) at the final/withdrawal visit (per-protocol).

RESULTS

330 patients were evaluable for efficacy and safety by intention-to-treat, 290 for per-protocol analysis. Clinical remission rates at week 6 (per-protocol) were 77% on low-volume foam vs. 77% on high-volume foam (P = 0.00002 for non-inferiority). The low-volume foam was associated with a lower frequency of severe discomfort, pain and retention problems.

CONCLUSIONS

Low-volume 5-aminosalicylic acid foam is as effective and safe as a high-volume 5-aminosalicylic acid foam in the treatment of active distal ulcerative colitis, but offers compliance advantages compared to the high-volume preparation.

An outbreak of Mycobacterium jacuzzii infection following insertion of breast implants

BACKGROUND

Surgical wound infections caused by rapidly growing mycobacteria developed in 15 women after insertion of breast implants from August to November 2003 at a single medical center.

METHODS

A case-control study was conducted that included the identified patients, as well as women who underwent breast operations at the same center who did not develop infections. The study was accompanied by an extensive environmental investigation. Isolates were identified by standard bacteriological methods and by comparison of their 16S rRNA, HSP65, RPOB, SODA, and RECA gene sequences. Isolates were compared by random amplified polymorphic DNA analysis and by pulsed-field gel electrophoresis.

RESULTS

The risk factors for infection included surgery performed by 1 specific surgeon (odds ratio, 21.3; 95% confidence interval, 3.64-125.6). Identical strains of mycobacteria were isolated from the infected wounds of the patients; from the eyebrows, hair, face, nose, ears, and groin of this particular surgeon; and from this surgeon's outdoor whirlpool. The isolates exhibited a biochemical profile overlapping that of Mycobacterium wolinskyi, but their sequences of 16S rRNA and HSP65, RPOB, SODA, and RECA genes differed. We propose the name "Mycobacterium jacuzzii" for this new species. DNA fingerprints of cultured isolates from the surgical wounds, areas of the surgeon's body that grow hair, and the surgeon's whirlpool were identical. When the surgeon discontinued his use of the whirlpool and began cleaning the hairy areas of his body with a shampoo containing triclosan, the outbreak ended.

CONCLUSIONS

This outbreak brings to light the possibility of the colonization of human skin and human-to-human transmission of environmental mycobacteria during surgery that involves implant insertion.

Evaluation of topical pharyngeal anaesthesia by benzocaine lozenge for upper endoscopy

BACKGROUND

Among the randomized controlled trials evaluating the effect of pharyngeal anaesthesia only some suggest benefit. Spray is irritating for some people and leaves bitter taste in the throat. We hypothesized that delivering the local anaesthetic as a sucking lozenge would benefit the patients in terms of decreasing anxiety and will improve procedure performance and patient tolerance.

AIM

To determine whether benzocaine/tyrothricin sucking lozenges with conscious sedation is superior to conscious sedation alone, with respect to procedure performance and tolerance in patients undergoing upper endoscopy.

METHODS

One hundred and seventy-four adult patients undergoing upper endoscopy with conscious sedation completed the study. They were randomized to receive sucking lozenge containing benzocaine or placebo before the procedure. Patients were asked to rate prestudy anxiety, tolerance for topical pharyngeal anaesthesia, comfort during endoscopy, degree of difficulty of intubation, postprocedure throat discomfort and willingness to undergo subsequent examinations using a 10-cm visual analogue scale. Endoscopists were asked to estimate the ease of oesophageal intubation and procedure performance.

RESULTS

No significant statistical differences regarding all the points studied were found between the groups.

CONCLUSIONS

Topical pharyngeal anaesthesia with benzocaine/tyrothricin lozenges with conscious sedation has no advantages over conscious sedation alone in patients undergoing upper endoscopy.

Tuberculosis outbreak among students in a boarding school

Tuberculosis (TB) outbreaks present a public health challenge. Six cases of active TB emerged in a boarding school in Israel during 1 yr. An epidemiological outbreak investigation was performed, followed by implementation of control measures. The investigation included interviews, tuberculin skin test (TST) and chest radiographs of the students. Close contact (n = 155) was defined as being in the same class or dormitory with a patient. Remote contact (n = 246) was defined as being in the school. An epidemiological association was detected among five of the cases and a distinct pattern was found in molecular analysis. TST was performed in 398 (99.2%) students. Repeated (two-step) TST was applied to the close contacts. The degree of contact, country of origin and previous bacille Calmette-Guérin vaccination were significantly associated with TST reactions. Preventive directly observed therapy was completed by 157 (91.3%) students. During 5 yrs follow-up, no additional cases emerged. While investigating a tuberculosis outbreak, the definition of degree of contact is a significant predictor for detecting positive tuberculin test. Immigration from an endemic country, as well as previous bacille Calmette-Guérin vaccination have a major effect on tuberculin skin-test results. The directly observed therapy approach was found to be successful in preventing further morbidity.

Budesonide foam versus budesonide enema in active ulcerative proctitis and proctosigmoiditis

BACKGROUND

Rectal budesonide is an effective treatment of active ulcerative proctitis or proctosigmoiditis.

AIM

To compare the therapeutic efficacy, tolerability and safety, and patient's preference of budesonide foam vs. budesonide enema.

METHODS

Patients with active ulcerative proctitis or proctosigmoiditis (clinical activity index > 4 and endoscopic index > or = 4) were eligible for this double-blind, double-dummy, randomized, multicentre study. They received 2 mg/25 mL budesonide foam and placebo enema (n = 265), or 2 mg/100 mL budesonide enema and placebo foam (n = 268) for 4 weeks. Primary endpoint was clinical remission (clinical activity index < or = 4) at the final/withdrawal visit (per protocol).

RESULTS

A total of 541 patients were randomized--533 were evaluable for intention-to-treat analysis and 449 for per protocol analysis. Clinical remission rates (per protocol) were 60% for budesonide foam and 66% for budesonide enema (P = 0.02362 for non-inferiority of foam vs. enema within a predefined non-inferiority margin of 15%). Both formulations were safe and no drug-related serious adverse events were observed. Because of better tolerability and easier application most patients preferred foam (84%).

CONCLUSION

Budesonide foam is as effective as budesonide enema in the treatment of active ulcerative proctitis or proctosigmoiditis. Both budesonide formulations are safe, and most patients prefer foam.

Do forceps biopsies truthfully reflect the nature of endoscopically uncovered polypoid lesions of the colon?

BACKGROUND

Total excision of colonic polyps is not always attainable and in some patients it is clinically contraindicated. Also, a resected polyp may be lost at any step between its endoscopic removal and its embedding in paraffin. The aim of this study was to compare the histological features of colonic polyps as analysed by the study of biopsy-forceps obtained samples with those assessed on scrutinizing the totally resected growths.

PATIENTS AND METHODS

This prospective study included a cohort of 59 patients in whom, in the course of an elective colonoscopy, a total excision of a 6 mm-sized or larger polyp was called for. Sizeable biopsies were obtained by means of an Olympus Multibyte forceps prior to the total polypectomy. Subsequent to the study of the polypectomy specimens, the forceps biopsy samples were submitted for histological examination. The pathologists were blinded as to the source of the tissue they were studying. The diagnoses rendered by evaluating the biopsy samples and polypectomy specimens of each patient were contrasted with each other.

RESULTS

Major discrepancies between the histological features of the fragments captured by the biopsy-forceps and the factual nature of the totally removed polyps were uncovered in 11 (18.6%) of 59 cases. Intriguingly, the grade of the tumours was underrated in all the 11 cases, as judged by contrasting the tentative diagnoses of the forceps-biopsies with the decisive diagnoses of the polypectomies. Importantly, 2 adenocarcinomas would have been missed by just looking at the forceps-retrieved sample.

CONCLUSIONS

In our experience, a discordance of 18.6% is to be expected between the diagnoses rendered after examining forceps-biopsies of and totally excised colonic polyps. Nevertheless, it is advisable to procure biopsies prior to the excision of the growths, because on those occasions in which patients' growths cannot be removed or have not been retrieved for one reason or another, a small forceps-captured tissue sample correctly reflects the characteristics of the polyp in 81.4% of the cases. Finally, the biopsies may be discarded in the event that total removal was successful.

Outcome and early complications of ERCP: a prospective single center study

BACKGROUND/AIMS

ERCP has been used since 1968 both as a diagnostic and as a therapeutic procedure. In the last ten years several less invasive imaging methods have developed which allow visualization of bile ducts and pancreatic ducts; therefore ERCP has become mainly a therapeutic tool. The aim of the study was to prospectively evaluate the early outcome of ERCP when used essentially as a therapeutic tool.

METHODOLOGY

All patients referred to our unit between April 1 1998 and March 31 2000 were included in the study. The indication for the procedure, number of cannulations, duration of procedure, performance of endoscopic sphinterotomy or pre-cut, insertion of stent and the final outcome were recorded. All patients were visited (in-patients) or contacted by phone (outpatients) 24 hours and one week after the procedure. If a complication occurred the patient was followed until it was resolved.

RESULTS

722 ERCP procedures were performed on 534 patients (59% females), mean age 63.4 years (range 3 to 98 years). The procedure was performed with a therapeutic intention in 95% of cases because of suspicion of: cholelithiasis (58%), tumor of pancreas/bile ducts (30%), post-cholecystectomy bile leak or bile duct stenosis (6%) or treatment of chronic pancreatitis (1%). The overall success rate of selective duct cannulation was 92%. Endoscopic sphincterotomy was performed in 375 procedures (52%), pre-cut in 152 (21%) and stent inserted in 180 (25%). Among the 701 procedures with complete information 76 complications occurred in 73 patients (10.8%): pancreatitis 4.3%, perforation 1.3%, sepsis 3.7%, bleeding 1.4%. Most of the complications (63/701, 9%) were mild to moderate. Procedure-related mortality was 0.6% due to perforation (1 patient), and sepsis (3 patients). The main factors influencing the complication rate were the difficulty of the examination, performance of an invasive procedure or the operator.

CONCLUSIONS

In the era of therapeutic ERCP, the risk of severe complication from the procedure is low--1.8% (including a mortality rate of 0.6%) when using the appropriate technique in experienced and skilled hands.

The antioxidative effect of the bacteria Dienococcus radiophilus against LDL lipid peroxidation

BACKGROUND

Lipid peroxidation is an important process in the development of atherosclerosis. Thus agents with antioxidant properties may play an important role in the inhibition of atherosclerosis.

OBJECTIVES

In this study we aimed to show that the lipid extract of the bacteria Deinococcus radiophilus (leDR) has antioxidant properties against LDL oxidation.

RESULTS

This antioxidant effect was shown in both transition metal ion and free radical generating systems. We also showed that leDR can protect LDL from UV light-induced oxidative damage. The antioxidative capacity of leDR is partly due to copper ion chelation.

CONCLUSION

We conclude that some specific bacteria constituent has the ability to inhibit LDL oxidation and, thus, to attenuate atherogenesis.

Natural beta-carotene for the prevention of post-ERCP pancreatitis

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly used procedure. Pancreatitis is its most common complication. As the injury may be mediated by oxidative stress, it could be ameliorated by antioxidants.

METHODS

We conducted a double-blind trial, giving the patients a single dose of natural beta-carotene or placebo, 12 hours prior to procedure, and monitoring them for 24 hours post-procedure for procedure complications, antioxidant levels, and plasma oxidation.

RESULTS

The overall incidence of acute pancreatitis according to our definition was 9.6%. The incidence of pancreatitis was not significantly different between the beta-carotene group (10%) and the placebo group (9.4%). Four patients in the placebo group had severe pancreatitis (2.22%), but none in the beta-carotene group. This difference is statistically significant.

CONCLUSION

We did not see a reduction in the incidence of post-ERCP pancreatitis, but there may be some protective effect of treatment with beta-carotene regarding the severity of disease.

Octreotide for Enterocutaneous Fistulas of Crohn’s Disease

Crohn’s disease is a chronic, life-long disease and has many troublesome complications. Fistulas are a part of Crohn’s disease, and although there are many therapeutic modalities used in treating these fistulas they are only partially successful. As we are still very far from being able to cure it, the aim is to improve the patients’ quality of life and to reduce the iatrogenic harm that may be caused by various treatment modalities. Somatostatin is an inhibitor of intestinal secretion and has been used to treat pancreatic and surgical fistulas. Therefore, we decided to treat enterocutaneous fistulas using somatostatin.

METHODS: Five patients with Crohn’s disease were treated with four daily injections of 300 µg octreotide. The total period of treatment was eight weeks.

RESULTS: Closure of fistulas was achieved in four of the five patients.

CONCLUSION: Somatostatin may have a role in treating Crohn’s disease enterocutaneous fistulas and may prevent surgery or prolonged immunosuppressive therapy.

Measles is more prevalent in Crohn's disease patients. A multicentre Israeli study

The question whether there is a transmissible pathogenetic agent as a cause for Crohn's disease, remains unanswered. Measles virus has been the subject of many intensive studies, in the attempt to find a role for it in the pathogenesis of inflammatory bowel disease. Whether an early infection with measles virus may predispose to Crohn's disease in later life is still not clear. We conducted a large scale multicentre study, in order to obtain sufficient data to answer this question. To do so, we compared inflammatory bowel disease patients, with Crohn's disease or ulcerative colitis, with two matched control groups: clinical controls, and community controls. A total of 531 patients, 271 with ulcerative colitis and 260 with Crohn's disease were interviewed, as well as 903 matched controls. Blood from 104 inflammatory bowel disease patients and 50 controls was tested for antibodies to measles virus. We did not find any differences related to measles vaccination, either in Crohn's disease or in ulcerative colitis. Exposure to measles in childhood was more frequent in Crohn's disease patients than in their controls, the difference being statistically significant (p < 0.05) in relation to community controls. The presence of IgG antibodies to measles virus was higher in patients with Crohn's disease than in patients with ulcerative colitis or controls (p = 0.084). Another observation of interest was the finding that Crohn's disease patients who had measles in childhood, more frequently had large bowel disease than those who had not had measles. These data lead us to postulate that there may be a role for measles infection in Crohn's disease, even if, at present, this role remains unclear.

Effects of current cigarette smoking on clinical course of Crohn's disease and ulcerative colitis

Cigarette smoking worsens Crohn's disease (CD) but ameliorates ulcerative colitis (UC). In Israel, where there is no epidemiological association of smoking with CD, we examined the effects of current smoking on the course of CD and UC. Patients at nine public hospitals completed a questionnaire detailing their smoking history, disease course and treatments; subjects altering their smoking habit after the onset of disease were excluded. Sixty-four smokers and 144 nonsmokers had CD, and 34 smokers and 158 nonsmokers had UC. No differences were found between CD smokers and nonsmokers for hospitalizations, operations, and requirement for corticosteroid and immunosuppressive treatment. By contrast, UC smokers had less extensive disease than nonsmokers (P < 0.02) and fewer hospitalizations (P = 0.01) and operations (P = 0.025). Our results agree with a minority of studies showing no adverse effect of smoking on the course of CD, and confirm the protective effect of smoking in UC.

Appendectomy is more frequent but not a risk factor in Crohn's disease while being protective in ulcerative colitis: a comparison of surgical procedures in inflammatory bowel disease

OBJECTIVE

Appendectomy was shown to be protective in patients with ulcerative colitis (UC). There are fewer data in Crohn's disease (CD). Other operations were less studied. The aim of this study was to investigate the prevalence of appendectomy, cholecystectomy, and tonsillectomy, including their timing, in patients with inflammatory bowel disease in comparison to controls.

METHODS

Two hundred seventy-one patients with UC and 260 with CD, 475 clinic controls, and 428 community controls were interviewed.

RESULTS

Appendectomy was found in 5.5% patients with UC, in 11% of clinic controls (p < 0.05), and 7.7% of community controls (p = not significant). The differences were more significant for appendectomy before onset of disease. Appendectomy was performed in 19.2% of patients with CD, in 10.9% of clinic controls, and in 10.1% of community controls (p < 0.01). However, there were no significant differences when only appendectomy before onset of disease was considered. Cholecystectomy was found in 1.5% of patients with UC, in 6.1% of clinic controls (p < 0.01), and in 4.5% of community controls (p = not significant). The difference remained significant when confined to operations performed before disease onset. No such difference was found in patients with CD. No significant difference was found in the prevalence of tonsillectomy between patients and controls.

CONCLUSIONS

Appendectomy is protective in UC; it is more frequent, but not a risk factor in CD. The role of cholecystectomy should be investigated further.

A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions

BACKGROUND & AIMS

Wireless capsule endoscopy is a new, painless method of imaging the entire small bowel. It has not been compared with push enteroscopy. We compared the sensitivity, specificity, and safety of capsule and push enteroscopy in detecting small-bowel lesions.

METHODS

Nine to 13 radiopaque, colored beads (3-6 mm diameter) were sewn in random order inside 9 canine small bowels, half within the first meter, and confirmed on x-ray. After recovery, the number, order, and color of beads were assessed in 23 capsule enteroscopies and 9 push enteroscopies in a random order. The surgeons, push enteroscopists, capsule video interpreters, and pathologist were blinded to the others' findings.

RESULTS

The capsules identified more beads than push enteroscopy (median, 6 [range, 2-9] vs. 3 [range, 2-6 beads]; P < 0.001). The sensitivity of the capsule was 64% compared with 37% for push enteroscopy. The specificity was 92% for capsule enteroscopy and 97% for push enteroscopy. The capsules identified significantly more beads beyond the reach of the push enteroscope (median, 4 [range, 2-7] vs. 0; P < 0.0001). Hair, ingested plastic, ulceration, submucosal swelling, and worms were clearly identified by the capsule. The capsules passed safely through the animals with no significant histologic findings.

CONCLUSIONS

Wireless capsule endoscopy detected more abnormalities in the small bowel than push enteroscopy.

Left hydronephrosis caused by Crohn disease successfully treated conservatively

We report the case of a 35-year-old man who presented with fever, diarrhea, and a left abdominal mass. Diagnostic studies confirmed Crohn disease and revealed an abdominal mass obstructing the left ureter with hydroureter and hydronephrosis. The patient was successfully treated conservatively, with corticosteroids and mesalamine, A review of the literature indicates a predominance of right ureteral involvement in Crohn disease, associated with a high incidence of ileocecal disease. Most of these patients were treated surgically, with resection of ileocecal lesion and/or ureterolysis. Ureteral obstruction as a complication of Crohn disease is discussed, with emphasis on conservative treatment.

Passive smoking in patients with inflammatory bowel disease: an Israeli multicentre case-control study

BACKGROUND

The association between smoking and inflammatory bowel disease (IBD) is well established. There are, however, no large scale studies of passive smoking in inflammatory bowel disease and this has never been surveyed in the Jewish population of Israel.

AIM

To study the passive smoking exposure of Jewish IBD patients in Israel in a large scale multicentre study.

METHODS

Patients with established IBD, aged 18-70 years, were interviewed regarding smoking and other habits. Two controls, one clinic and one neighbourhood, matched by age, sex, community group, and education, were sought for each subject.

RESULTS

Five hundred and thirty-four patients (273 ulcerative colitis (UC) and 261 Crohn's disease (CD)), 478 clinic controls and 430 community controls were interviewed. There were no significant differences in the passive smoking habits between IBD patients and their controls. Fifty-one percent of UC patients, 50% of the clinic controls and 58% of the community controls were exposed to passive smoking at home (NS); similar results were found among CD patients (50%, 55% and 56%, respectively). When a quantitative exposure index was used UC patients were significantly less exposed to passive smoking than were their community controls (7.46 +/- 8.40 vs 9.36 +/- 9.46, n = 229, P< 0.031). There was no difference in the exposure to passive smoking among CD patients and their controls. No differences in exposure to passive smoking were found when UC patients who had never smoked were compared with their controls. When the quantitative index was used 'never-smoked' CD patients tended to be less exposed to passive smoking at home than their community controls (5.40 +/- 7.60 vs 8.04 +/- 8.72, P < 0.05).

CONCLUSION

There is a lack of association between passive smoking and IBD in Jewish patients in Israel. When a quantitative exposure index was used UC patients were found to be less exposed to passive smoking than their community controls.

Severe pulmonary disease in association with Crohn's disease in a 13-year-old girl

Pulmonary manifestations of Crohn's disease are infrequent in adults and even less common in children. Our literature search found only a few cases of Crohn's disease causing pulmonary manifestations in children. We report on the case of a 13-year-old girl in whom severe pulmonary disease was found four years after the onset of Crohn's disease. Open lung biopsy uncovered bronchiolitis obliterans and granulomatous lung disease. Aggressive treatment has yielded gradual improvement. This case emphasizes the importance of recognizing the association, the differential diagnosis, and treatment implications.

Severe pulmonary disease in association with Crohn's disease in a 13-year-old girl

Pulmonary manifestations of Crohn's disease are infrequent in adults and even less common in children. Our literature search found only a few cases of Crohn's disease causing pulmonary manifestations in children. We report on the case of a 13-year-old girl in whom severe pulmonary disease was found four years after the onset of Crohn's disease. Open lung biopsy uncovered bronchiolitis obliterans and granulomatous lung disease. Aggressive treatment has yielded gradual improvement. This case emphasizes the importance of recognizing the association, the differential diagnosis, and treatment implications.

Lack of association between smoking and Crohn's disease but the usual association with ulcerative colitis in Jewish patients in Israel: a multicenter study

OBJECTIVE

The association between smoking and inflammatory bowel disease (IBD) is well established, but data in Jewish patients in Israel were discrepant. The aim of this study was to examine the smoking habits of Jewish IBD patients in Israel in a large scale, multicenter study.

METHODS

Patients with established IBD aged 18-70 yr were interviewed in relation to smoking and other habits. Two controls (one clinic and one neighborhood control matched by age, sex, community group, and education) were sought for each subject.

RESULTS

A total of 534 patients (273 ulcerative colitis [UC], and 261 Crohn's disease [CD]), along with 478 clinic controls and 430 neighborhood controls, were interviewed. There was no significant difference in the smoking habits between CD patients and their controls. Of patients with CD, 24.5% were current smokers, as compared to 19.9% of clinic controls and 25.2% of neighborhood controls (NS). The odds ratio for CD in current smokers was 1.30 (95% confidence interval 0.85-1.99) versus clinic controls, and 0.96 (0.63-1.46) versus neighborhood controls. There were also no significant differences in the proportion of ex-smokers between the groups. Only 12.9% of UC patients were current smokers versus 21.9. % Clinic controls, and 26.4% community controls (p<0.005). The proportions of ex-smokers were higher in UC patients 29.7% versus 25.9%, and 19.5% in their respective controls (p<0.001 vs. community controls). No significant differences were found in the proportions of never-smokers between IBD patients and controls. All the above trends were similar in four different parts of the country. The proportion of current smokers in UC decreased with the extent of disease (19.7% in proctitis, 13.6% in left-sided, and 4.5% in total colitis) (p<0.05). Patients with UC were more likely to be light smokers(1-10 cigarettes/day), whereas patients with CD were more likely to be moderate smokers (11-20 cigarettes/day) in comparison to their controls.

CONCLUSIONS

The lack of association between smoking and CD has now been established in Jewish patients in Israel. The association was found in UC. The stronger genetic tendency in CD may contribute to this discrepancy.

Linear EUS for bile duct stones

BACKGROUND

Radial scanning endoscopic ultrasonography (EUS) has been shown, in experienced hands, to be a safe and accurate means of detecting bile duct stones. We compared linear array EUS with endoscopic retrograde cholangiopancreatography (ERCP), in our first 50 cases, to evaluate efficacy of this examination as well as the learning curve for this indication.

METHODS

A retrospective study was conducted on 50 patients with suspected choledocholithiasis. We compared results of EUS with those of ERCP as a reference. First a linear EUS examination was performed followed by ERCP, at a median interval of 31 days (range 3 to 162 days).

RESULTS

The average age of patients was 56 years (range 26 to 76); 48% were women. Fifteen (30%) had undergone cholecystectomy, a mean of 8.5 years (range 1 to 22) before the EUS. EUS compared with ERCP had a 97% sensitivity, 77% specificity, and 90% accuracy. In 14% of patients EUS provided an additional or alternative diagnosis: chronic pancreatitis (n = 3), duodenitis (2), bile duct stricture (1), chronic gastritis (1). No complications were encountered due to EUS.

CONCLUSIONS

We found in this early experience that linear array EUS is a reasonably safe and accurate means of detecting choledocholithiasis. Linear array EUS, despite the learning curve, seems to be about equivalent to radial EUS in accuracy. Appropriate use of this less invasive technique may possibly replace the use of diagnostic ERCP.

Drug-resistant pulmonary tuberculosis in Israel, a society of immigrants: 1985-1994

SETTING AND OBJECTIVES

Drug-resistant tuberculosis was uncommon in Israel until 1985, when the waves of immigration began. We studied the incidence and clinical course of resistant pulmonary tuberculosis nationwide.

DESIGN

Isolates of Mycobacterium tuberculosis between 1985 and 1994 were surveyed. Data on 150 patients with resistance and 110 patients with drug-sensitive disease were reviewed. Ethnic origin, type of resistance, radiological findings and outcome were analysed.

RESULTS

In total, 16.7% of the isolates showed resistance to at least one drug; 58% had resistance to multiple drugs. In 67% of the patients the resistance was primary. Most patients were immigrants from the former USSR and from Ethiopia; none were Israeli-born Jews. Mortality with resistance was 10%, and was highest (14%) with multiple drug resistance. Mortality among drug-resistant cases was lowest (3%) among Ethiopian Jews. Cavities and extensive disease were more common with drug resistance.

CONCLUSION

Drug resistance has become relatively common in Israel due to immigration from the former USSR and Ethiopia. It is more extensive radiologically and carries a poorer outcome.

Budesonide versus prednisone in the treatment of active Crohn's disease. The Israeli Budesonide Study Group

BACKGROUND & AIMS

Budesonide (BUD) is a potent steroid that undergoes extensive first-pass metabolism. BUD incorporated in a pH-dependent formulation has been proposed as an alternative treatment for Crohn's disease (CD). The aim of this study was to compare the efficacy and safety of BUD and prednisone (PRED) in the treatment of active CD involving the terminal ileum and/or the colon.

METHODS

Patients with mild to moderately active CD were included in a randomized, double-blind, double-dummy controlled trial. Patients received either 9 mg BUD once daily for 8 weeks or 40 mg PRED once daily for the first 2 weeks tapered gradually to 5 mg/day by the end of the study. Disease activity, quality of life, and laboratory parameters were recorded.

RESULTS

One hundred patients received BUD, and 101 patients received PRED. By intention-to-treat analysis, treatment efficacy defined as Crohn's Disease Activity Index of <150 at completion was 51% and 52.5% for the BUD and PRED groups, respectively. Twice as many responded to treatment with no side effects in the BUD compared with the PRED group (30% vs. 14%) (P = 0.006). Most of the decrease in CDAI scores occurred during the first 2 weeks.

CONCLUSIONS

BUD is as effective as PRED in the treatment of CD involving the terminal ileum and right colon. BUD has significantly fewer steroid-related adverse reactions.

Methotrexate in chronic active Crohn's disease: a double-blind, randomized, Israeli multicenter trial

BACKGROUND

At present only one large controlled study has indicated that parenteral methotrexate may be effective in chronic active Crohn's disease (CD).

AIM

To evaluate the effectiveness of oral methotrexate in chronic steroid-dependent CD.

PATIENTS

Patients with active CD, who have received steroids and/or immunosuppressives for at least 4 months during the preceding 12 months and with a current Harvey-Bradshaw index of > or = 7 were studied.

METHODS

Methotrexate (12.5 mg weekly) or 6-mercaptopurine (50 mg daily), or placebo were given during the 9 months of the trial in addition to steroids and 5-aminosalicylic acid as clinically indicated.

RESULTS

Eighty-four patients were included (methotrexate, 26 patients; 6-mercaptopurine, 32 patients; placebo, 26 patients). The proportion of patients entering first remission as well as the proportions of patients relapsing after first remission were not significantly different between the groups. The mean Harvey-Bradshaw index and the mean monthly steroid dose were also similar. However, when each patient was evaluated as his or her own control, the reduction in steroid dose, the general well being, and the reduction in abdominal pain were significantly better in the methotrexate treated patients.

CONCLUSIONS

Methotrexate at a weekly oral dose of 12.5 mg was found to be moderately better than 6-mercaptopurine and placebo in patients with chronic active CD.

Modification of in vivo and in vitro TNF-alpha, IL-1, and IL-6 secretion by circulating monocytes during hyperbaric oxygen treatment in patients with perianal Crohn's disease

Treatment of perianal inflammatory lesions in Crohn's disease (CD) is unsatisfactory and novel treatment modalities are pursued. We have recently reported a good clinical effect of hyperbaric oxygen (HBO) treatment in perianal CD. In the present study, seven patients with perianal CD were subjected to daily sessions of HBO in a multiplace hyperbaric chamber. Each patient received a total of 20 sessions during a time period of 1 month, and IL-1, IL-6, and TNF-alpha measurements were done several times during the initial sessions and after completing therapy. Pretreatment cytokine levels were elevated in patients compared to age-matched 10 normal controls. During the first 7 days of treatment, IL-1, IL-6, and TNF-alpha levels in supernatants of LPS-stimulated monocytes derived from patients' peripheral blood were decreased compared to pretreatment levels. Parallel measurements of serum IL-1 levels revealed an initial elevation and thereafter decreased levels, which remained low throughout the first week of HBO treatment. After completion of therapy, cytokine levels increased to pretreatment values. We conclude that alterations in secretion of IL-1, IL-6, and TNF-alpha may be related to the good clinical effect of HBO treatment in CD patients with perianal disease.

Triamcinolone improves outcome in Crohn's disease strictures

PURPOSE

This study was undertaken to examine the effect of local injection of potent steroids on recurrence of Crohn's disease strictures.

METHODS

Ten patients with colonic strictures attributable to Crohn's disease were treated by dilation and injection of triamcinolone. Five of them had postoperative strictures.

RESULTS

Patients were followed for 1.5 to 3 years. Two patients required additional dilation and injection of steroids after one year. Eight patients remained well.

CONCLUSION

Local injection of steroids improves outcome in strictures caused by Crohn's disease.

Failure of cefonicid prophylaxis for infectious complications related to endoscopic retrograde cholangiopancreatography

We performed a controlled study to evaluate the role of cefonicid in preventing infectious complications related to retrograde cholangiopancreatography (ERCP). Consecutive patients were randomized to receive prophylaxis with cefonicid (1 g intravenously) 1 hour before the procedure or to be untreated controls. During a 26-month period, 179 ERCPs, including 93 therapeutic procedures, were performed on 164 patients. Prophylaxis was administered before 88 procedures (49%). The rate of bacteremia among treated patients was similar to that among controls (3% vs. 2%, respectively; P = .4). The rate of cholangitis was also similar among both groups (8% vs. 2%, respectively; P = .07). There were no episodes of sepsis, and none of the patients died. The rate of bacteremia was also similar among patients undergoing diagnostic procedures and patients undergoing therapeutic procedures, but all cases of cholangitis occurred in the latter group (0 vs. 10%, respectively; P = .002). Nevertheless, the rate of cholangitis was not significantly changed by the use of prophylaxis (14% among treated patients vs. 5% among controls, P = .12). Therefore, infectious complications could not be prevented by cefonicid prophylaxis.

Methotrexate in chronic active ulcerative colitis: a double-blind, randomized, Israeli multicenter trial

BACKGROUND & AIMS

Uncontrolled studies have suggested that methotrexate may be effective in patients with active ulcerative colitis. The aim of this study was to evaluate the effectiveness of oral methotrexate in chronic steroid-dependent ulcerative colitis in a randomized, double-blind multicenter trial.

METHODS

Patients with active ulcerative colitis who have received steroids and/or immunosuppressives for at least 4 months during the preceding 12 months with a current Mayo Clinic score of > or = 7 were included in the study. Methotrexate (12.5 mg) or placebo was added to their treatment once weekly for 9 months.

RESULTS

Sixty-seven patients were included (methotrexate, 30 patients, placebo, 37 patients). The proportion of patients entering first remission (methotrexate, 46.7%; placebo, 48.6%), the time to reach first remission (methotrexate, 4.1 +/- 1.9 months; placebo, 3.4 +/- 1.7 months), as well as the proportions of patients having a relapse after first remission (methotrexate, 64.3%; placebo, 44.4%) were not significantly different between the two groups. The mean Mayo Clinic score, the mean monthly steroid dose, and the proportion of abnormal laboratory results during the study were also similar.

CONCLUSIONS

Methotrexate at a weekly oral dose of 12.5 mg was not found to be better than placebo in the induction or maintenance of remission in patients with chronic active ulcerative colitis.

Consumption of red wine with meals reduces the susceptibility of human plasma and low-density lipoprotein to lipid peroxidation

The effect of consumption of red or white wine (11% alcohol) with meals on the propensity of plasma and low-density lipoprotein (LDL) to undergo lipid peroxidation was studied in 17 healthy men who were divided into two groups: 8 received 400 mL red wine/d for 2 wk, and 9 received a similar amount of white wine. Red wine consumption for 2 wk resulted in a 20% reduction in the propensity of plasma to undergo lipid peroxidation (in the presence of a free-radical-generating system) as determined by the thiobarbituric acid reactive substances (TBARS) assay. In parallel, red wine consumption reduced the propensity of the volunteers' LDL to undergo lipid peroxidation (in response to copper ions) as determined by a 46%, 72%, and 54% decrease in the content of TBARS, lipid peroxides, and conjugated dienes in LDL, respectively, as well as by a substantial prolongation of the lag phase required for the initiation of LDL oxidation. On the contrary, dietary consumption of white wine for 2 wk resulted in a 34% increase in plasma's propensity to undergo lipid peroxidation and also in a 41% increased propensity of the LDL to undergo lipid peroxidation. The antioxidant effect of dietary red wine on plasma lipid peroxidation was not secondary to changes in the plasma vitamin E or beta-carotene content but could be related to the elevation of polyphenol concentration in plasma and LDL. Thus, some phenolic substances that exist in red wine, but not in white wine, are absorbed, bind to plasma LDL, and may be responsible for the antioxidant properties of red wine.

[Plasma lipid peroxidation: inhibited by drinking red wine but stimulated by white wine]

The effects of drinking red or white wine (11% alcohol) on the propensity of plasma and low density lipoprotein (LDL) to undergo lipid peroxidation (LP) was studied. 8 healthy men drank 400 ml of red wine a day for 2 weeks and 9 drank white wine similarly. The red wine supplementation resulted in a 20% similarly. The red wine supplementation resulted in a 20% reduction in the propensity of their plasma to undergo LP (in the presence of a free radical-generating system) and a 46% reduction in that of their LDL to undergo LP (in response to copper ions). Contrarily, drinking white wine for 2 weeks resulted in a 33% increase in propensity of plasma to undergo LP and in a 57% increase in that of LDL to undergo LP. The antioxidant effect of drinking red wine on plasma LP can be related to increase in plasma high density lipoprotein concentration, as well as to increase in plasma and LDL polyphenols. We conclude that some phenolic substance present in red, but not in white wine, may be responsible for the antioxidative properties of red wine supplementation for LDL LP, and thus may possess antiatherogenic properties.

A 10 year survey on Mycobacterium tuberculosis isolates in Israel and their drug resistance

An increased incidence of tuberculosis has been observed in Israel in 1985, 1986 and since 1990--years of large waves of immigrations. A very similar trend of disease was observed in the Mycobacterium Reference Laboratory of Israel, and consequently a survey was undertaken among the 1,181 bacteriologically confirmed tuberculosis cases newly registered there in 1983-92. The overall percent distribution of drug-resistant Mycobacterium tuberculosis during this period was 12.6% (7.3% resistant to one drug and 5.3% (multiple drug resistance). The highest percent distribution of drug-resistant bacilli was found among immigrants from the former Soviet Union (37.3%) and Ethiopia (16.2%). The highest incidence of disease was found in males and in patients aged > 30. Pulmonary disease was the most common form for all patients: among the extrapulmonary cases, the most frequently involved site was the genitourinary system in Israelis and the lymph nodes in Ethiopians. Most isolates fit into one variant by biochemical analysis, indicating the need for a more sensitive method to type M. tuberculosis for epidemiological purposes. The data included in this survey provide information useful for a national tuberculosis program.

Hyperbaric oxygen for perianal Crohn's disease

Perianal involvement in Crohn's disease is common (< or = 50%), distressing, and frequently refractory to treatment. Clinical features include painful induration and stenosis, discharging fistulas, and fissures. The pathogenesis of these lesions is unclear, but local ischemia and secondary anaerobic infection may play a role. Following three sporadic reports of successful treatment with hyperbaric oxygen (HBO), we undertook a trial of this method in 10 patients with refractory perianal disease. These patients' perianal Crohn's disease had not responded to treatment that included local medications, salicylates, corticosteroids, metronidazole, or 6-mercaptopurine were treated. Treatment was administered in a hyperbaric chamber at a pressure of 2.5 atm absolute. Each session lasted 90 min, and each course consisted of 20 daily sessions. Complete healing occurred in 5 patients after one to two courses. In an additional 2, after three courses, 1 patient improved but did not heal, and 2 did not improve. No adverse effects were noted by any of the 10 patients. Follow-up of 18 months did not reveal any recurrence. These preliminary results confirm that HBO therapy is a safe and efficient therapeutic option for perianal Crohn's disease.

Effect of dietary supplementation of red or white wine on human blood chemistry, hematology and coagulation: favorable effect of red wine on plasma high-density lipoprotein

Twenty healthy males were divided into two groups: 10 subjects were supplemented for 2 weeks with 400 ml of red wine (11% alcohol) per day and the other 10 subjects were given 400 ml of white wine (11% alcohol) per day for a similar period. Blood samples were drawn prior to wine supplementation, after 1 week and at the end of the study. No significant effects were found on plasma concentrations of urea, creatinine, bilirubin, creatine kinase, amylase, blood cell counts, platelet counts and platelet aggregation. Both red- and white-wine supplementation resulted in a transient minor reduction in plasma glucose concentration and in a minor elevation in blood coagulation properties such as prothrombin time and partial thromboplastin time. Red (but not white) wine resulted in an 11 and 26% increment in plasma triglyceride concentrations after 1 and 2 weeks of supplementation, respectively. Plasma cholesterol, as well as very-low- and low-density-lipoprotein levels did not change during the 2 weeks of red- or white-wine supplementation. The most impressive effect of red-wine intake was a significant (p < 0.01) increase in plasma high-density lipoprotein (HDL) cholesterol and in plasma apolipoprotein A-I concentrations by up to 26 and 12%, respectively. These effects were not observed after the intake of white wine. We conclude that the major effect of red-wine supplementation (about 40 g of alcohol per day for a period of 2 weeks) was a significant increase in plasma HDL concentration which may contribute to the reduced risk for cardiovascular diseases observed in red-wine drinkers.

Mycobacterium simiae infection in Israeli patients with AIDS

Mycobacterium simiae is an environmental organism that has rarely been associated with human disease. In Israel M. simiae is frequently isolated from clinical specimens, and it usually colonizes damaged lungs. Until now, only two cases of AIDS patients with M. simiae infection have been reported, and these patients were coinfected with Mycobacterium avium complex. Two Israeli patients with AIDS complicating hemophilia developed prolonged fever that was unresponsive to therapy with broad-spectrum antibiotics. One of them had cavitary pulmonary infiltrates. M. simiae was isolated from blood in both cases and from sputum and bone marrow in one case. The identity of the mycobacterium was confirmed at three reference laboratories. Both patients died of the infection. Thus, the possibility of M. simiae infection should be considered for AIDS patients who live in areas where this mycobacterium is prevalent.

Preferential inhibition of LDL oxidation by the all-trans isomer of beta-carotene in comparison with 9-cis beta-carotene

The synthetic all-trans isomer of beta-carotene was recently shown to possess antioxidant properties towards the formation of oxidized low density lipoprotein. In the present study, the binding of the all-trans and the 9-cis isomers of beta-carotene to plasma lipoproteins was investigated, and the effect of these isomers on the susceptibility of plasma lipoprotein to lipid peroxidation and on macrophage uptake of oxidized LDL were studied. Both the synthetic all-trans isomer of beta-carotene and the natural beta-carotene from the algae Dunaliella Bardawil [which is composed of the all-trans (70%) and the 9-cis (30%) isomers], were found to bind similarly to all plasma lipoproteins, following the incubation of beta-carotene with purified lipoproteins or with whole plasma. Incubation of the beta-carotene isomers with whole plasma, followed by separation of the lipoproteins, revealed substantial carotene binding to very low density lipoprotein (VLDL) and to LDL and limited binding to high density lipoprotein (HDL). Lipid peroxidation of VLDL and LDL were significantly inhibited by beta-carotene. The synthetic beta-carotene, however, was twice as effective as the Dunaliella beta-carotene in inhibiting LDL lipid peroxidation (following LDL incubation with copper ions). Cellular degradation of oxidized lipoproteins (mediated via the scavenger receptor) was decreased by 40% and 18%, respectively, when they were prepared by incubation in the presence of synthetic or natural beta-carotene; the control oxidized LDL was prepared in the absence of beta-carotene.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased susceptibility to undergo lipid peroxidation of chylomicrons and low-density lipoprotein in celiac disease

Gastrointestinal injury involves oxidative damage as the result of oxygen-derived free radicals which are formed during the inflammatory reactions. Chylomicrons which are synthesized by the intestine can thus be exposed to lipid peroxidation in celiac disease. Similarly, low-density lipoprotein (LDL) propensity to oxidation may be enhanced as a result of a direct or indirect effect of the oxidative process. To resolve these possibilities, plasma chylomicrons and LDL were isolated from a patient with celiac disease and from a control healthy subject before and 3 h after a fat-rich meal, and their propensity to copper-induced lipid peroxidation was then analyzed. The patient's chylomicrons, its LDL that was obtained before the fat-rich meal and its LDL that was obtained after the meal demonstrated 220, 39 and 48% elevation in their content of thiobarbituric-acid-reactive substances in comparison with the control lipoproteins. After a complete recovery of the patient's intestine, the susceptibility of the patient lipoproteins to in vitro oxidation returned toward normal levels. In the patient LDL fraction (obtained either before or after the fat-rich meal), but not in the patient's chylomicrons, the carotenoid content was reduced by 70%, vitamin E by 45%, and the LDL content of arachidonic acid was increased by 70% in comparison with the control lipoproteins. On recovery of the patient and return of the intestine to its normal morphology, normalization of all of these constituents was achieved.

Diseases of the intestine mimicking Crohn's disease

We describe five patients who were initially thought to have Crohn's disease and were treated accordingly. The original diagnosis was based upon clinical presentation, roentgenograms, and histological examination, but subsequent follow-up showed that diagnosis to be in error. The following diagnoses were established instead: tuberculosis, Actinomyces Israeli infection, reaction to gold therapy, metastatic cancer, and linitis plastica. We stress the importance of considering conditions that can mimic Crohn's disease.

Enhanced in vitro oxidation of plasma lipoproteins derived from hypercholesterolemic patients

In vitro oxidation of plasma lipoproteins, derived from either normolipidemic or hypercholesterolemic subjects, was performed in the presence of copper ions. Following this procedure, hypercholesterolemic low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL), and high-density lipoprotein (HDL) demonstrated greater propensity for oxidation than the corresponding normocholesterolemic lipoproteins. The oxidation was determined by the concentration of thiobarbituric acid-reactive substances (TBARS), which was 44%, 71%, and 54% greater in the patients' VLDL, LDL, and HDL in comparison to the normocholesterolemic lipoproteins, respectively. An associated reduction in trinitrobenzensulfonic acid (TNBS) reactivity in the patients' lipoproteins was noted. These changes were consistent whether expressed per lipoprotein protein or per concentration. Macrophage cholesterol esterification induced by oxidized LDL was substantially increased (up to 59%) when patients' lipoproteins were used, in comparison to control lipoproteins. A positive correlation was present between the LDL cholesterol to protein ratio, the extent of lipoprotein oxidation, and macrophage uptake of the oxidized lipoproteins. The lipoprotein content of pro-oxidant and antioxidant constituents was also analyzed. No measurable ferric or copper ions could be found in association with any of the lipoproteins. However, arachidonic acid content of the patients' LDL was 10.1% +/- 1.0% in comparison to 6.2% +/- 0.8% of total lipoprotein fatty acids in the control group (n = 5). Antioxidants such as vitamin E and carotenoids were significantly reduced in all patients' lipoproteins compared with those of controls. Thus, we suggest that increased cholesterol and arachidonic acid content and reduced concentration of antioxidants in lipoproteins of hypercholesterolemic patients may be responsible for the enhanced propensity for oxidation observed in these lipoproteins.

Mycobacterium avium-intracellulare in clinical specimens: etiological factor or contaminant?

The Mycobacterium avium-intracellulare (MAI) group comprised 10.5% of all nontuberculous mycobacteria isolated in the Mycobacterium Reference Laboratory, Tel Aviv, in an 11-year study period. From the Buirej Chest Hospital in Gaza, alone, 273 strains were isolated, representing 12.1% of the specimens from that hospital, while 149 strains (0.24% of all specimens) were isolated from all other institutions. Pulmonary disease was attributed to this organism in 22 patients, 17 of whom were hospitalized (initially for tuberculosis or another lung disease) in Buirej Hospital. The water was thought to be the source of contamination, since MAI strains, similar to those found in sputum, were isolated from it. In 1985, the water system was renovated and the MAI incidence in sputum from this hospital consequently declined.

[Actinomycosis imitating acute appendicitis]

Actinomycosis is a rare infection which can attack most parts of the body, even in normal individuals. In the gastrointestinal tract it may imitate acute appendicitis, Crohn's disease or tumors. We present a young soldier with appendiceal involvement who was mistakenly operated on. Because of its very good response to antibiotics, this infection should be recognized early and treated, to prevent prolonged, unnecessary suffering.

Topical pharyngeal anesthesia for easing endoscopy: a double-blind, randomized, placebo-controlled study

The aim of this work was to compare the efficacy of the Cetacaine topical anesthetic spray preparation to placebo. Cetacaine and placebo, from coded but otherwise identically packaged and scented sprays, were administered to 150 consecutive patients. After endoscopy, patients and physicians completed questionnaires evaluating the difficulty of the endoscopy. No statistically significant differences were found between the full formula and placebo-treated patient responses to the amount of cough or gag, or the degree of difficulty of intubation of the endoscope. Analysis of physician responses showed that in the subgroup of patients being endoscoped for the first time, the gastroscope was introduced more easily (p less than 0.05) when the premedication had been full formula rather than placebo.

Right heart failure as the sole presentation of carcinoid syndrome

We report the case of a woman with symptomatic right heart failure. Despite lack of the characteristic features of the carcinoid syndrome, echocardiographic and histologic investigations confirmed the diagnosis of carcinoid disease with cardiac involvement.