Selective recruitment of lymphocyte subsets to the inflamed appendix

Total lymphocyte counts and the distribution of lymphocyte subsets were determined in peripheral venous blood and appendiceal mononuclear cells from 60 patients who underwent appendicectomy for the clinical diagnosis of appendicitis. A significant peripheral lymphopenia was observed in the 46 patients with histologically confirmed acute appendicitis which was accompanied by an increase in the appendiceal lymphocyte concentration. There was an even greater depletion of CD45RO+ (memory) T lymphocytes in peripheral blood and an increase in the inflamed appendix. Reciprocal changes were observed in the CD45RA+ (naive) T lymphocyte subset. These changes were reflected in the local arterial and venous CD45RA and CD45RO T lymphocyte subsets. Proliferation studies showed an expanded functional repertoire of T lymphocytes in the inflamed appendix. Selective recruitment of memory T lymphocytes from the peripheral blood to the inflamed appendix was demonstrated.

Long-term results of treatment of peptic stricture of the oesophagus with the Angelchik prosthesis

An Angelchik prosthesis was inserted in 43 patients with a peptic stricture above a hiatus hernia; 16 showed columnar lining of the oesophagus below the stricture. The mean preoperative bore of strictures was 8.7 mm. Within months, and without dilatation, 33 strictures shortened, 35 widened and of these 13 disappeared with a mean bore of 11.7 mm. In the long term, three more strictures resolved but three recurred. Final measurements gave a mean bore of 12.2 mm. The mean follow-up was 3.5 years. Symptomatic and radiological assessments suggested that the prosthesis was less effective when sited in the chest.

Measuring change in surgical practice

We reviewed the work of a single general surgical firm over six years--about 11,500 patient episodes. Although the workload remained approximately constant, a severe reduction in the number of available beds was accompanied by a marked change towards shorter duration of stay. This affected particularly the elective cases. Previous authors, when trying to predict requirement of hospital beds, have accepted that duration of stay and number of beds available are independent variables; this was not what we observed.

McBurney's point--fact or fiction?

Anthropometric measurements were performed on 51 normal, supine, barium enema examinations to determine the position of the lower pole of the caecum and the base of the appendix relative to palpable bony landmarks (the anterior superior iliac spine and the symphysis pubis). Four quadrants were defined (iliac, umbilical, inguinal and pelvic) by the intersection of the right lateral line and the interspinous line (the line joining the left and right anterior superior iliac spines). The position of the lower pole of the caecum was iliac in 12%, inguinal in 37%, and pelvic in 51%. The appendix or appendix stump was visualised on 53% of the barium examinations. The position of the appendix was iliac in 15%, umbilical in 15%, inguinal in 11%, and pelvic in 59%. The positions of the lower pole of the caecum and base of the appendix are lower and more medial than previously described. 70% of appendices were found to lie inferior to the interspinous line, contrary to established surgical teaching, which assumes McBurney's point to be the surface landmark for the appendix.

Pursuing efficiency in surgical practice

To examine fluctuations in numbers of patients on surgical wards the dates of admission from January of each of the 5556 patients admitted from 1 January 1985 to 31 December 1987 were examined during computerised audit of a single surgical firm. The numbers of patients under the care of the firm fluctuated widely, often exceeding the 38 beds nominally available. Duration of stay varied from two days or less (3062 admissions) to more than a month (163 admissions). One patient was in hospital for 278 days. The patients admitted for more than a month (2.9% of the total) filled 28% of the beds; not all these patients were elderly. A further increase in throughput of patients undergoing elective operations might be achieved by always admitting patients on the day of operation, and perhaps by discharging patients even sooner than at present. Efficiency would increase but so would overall costs.

On the nature of the receptor mediating the action of 5-hydroxytryptamine in potentiating responses of the mouse urinary bladder strip to electrical stimulation

Superfused mouse bladder strip responded to electrical stimulation (ES) by twitch contractions. These contractions were potentiated by 5-hydroxytryptamine (5-HT; 0.03-3.0 microM). Three tryptamine analogues were tested for their ability to potentiate the responses to ES and their relative activities were compared with values in the literature. 5-Carboxamidotryptamine was more potent than 5-HT, N-omega-methyl 5-HT was about equipotent, and alpha-methyl 5-HT was much less potent. Exogenous noradrenaline did not reduce the effect of 5-HT, although it reduced the response of the tissue to ES. The maximum increase in tissue tension evoked by 5-HT was unaltered by phentolamine (1 microM) or bretylium (25 microM). These results show that 5-HT did not act on the bladder by inhibiting the release of catecholamines from intrinsic nerves. The effect of 5-HT proved very resistant to attempts to block it with conventional 5-HT antagonists. Several antagonists were studied including ketanserin, methysergide, methiothepin, and MDL 72222 but even at concentrations as high as 1 microM none of them exhibited any marked inhibitory effect against the action of 5-HT. At 10 microM some compounds showed activity, but none abolished the effect except methiothepin - and its action was not surmountable by increasing the concentration of 5-HT. Thus the effect of 5-HT on the bladder was not mediated by 5-HT receptors of types 'M', 'D' or 5-HT2.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for purinergic transmission in mouse bladder and for modulation of responses to electrical stimulation by 5-hydroxytryptamine

Electrical stimulation (ES) contracted superfused mouse bladder, and 10(-7) M tetrodotoxin (TTX) abolished the twitches without impairing responses to acetylcholine (ACh) or beta,gamma-methylene ATP. ES acted largely through nerves which were not cholinergic, adrenergic or histaminergic. They may be purinergic because the bladder was contracted by stable analogues of ATP, and after desensitisation by a high concentration of alpha,beta-methylene ATP the response to ES was selectively reduced. 5-Hydroxytryptamine (5-HT) at 0.03-3 X 10(-6) M and tetraethylammonium (TEA) at 0.1-10 X 10(-3) M potentiated responses to ES, on average by 64% and 182%. Pempidine had no effect on responses to ES. The action of TEA was different from that of 5-HT; potentiation of responses was greater than could be produced by 5-HT, and whereas 5-HT did not increase responses to ACh, TEA markedly increased twitch tensions. The mode of action of 5-HT is not clear.

A quantitative assessment of results with the Angelchik prosthesis

The Angelchik antireflux prosthesis was assessed in 15 unpromising patients, 12 of whom had peptic strictures of the oesophagus. Radiological techniques were used to show the effect of the device on gastro-oesophageal reflux, and on the bore and length of strictures. Twelve months later (range 6-24) most patients were well satisfied with the operation, and all considered it had been worthwhile; there was radiological evidence of reduction in reflux and remission of strictures. The device never surrounded the oesophageal sphincter; in all but 1 case it encircled a tube of stomach.

Loss of 5-hydroxytryptamine from mammalian circulating labelled platelets

1. Platelets were obtained from three species of animal: rats, rabbits and dogs. They were labelled with (111)In oxine to tag individual platelets and with (14)C-labelled 5-hydroxytryptamine (5-HT). Doubly labelled platelets from rabbits and dogs were returned to their donors; in the case of rats the platelets were injected intravenously into other, identical rats. At time intervals from 2 to 64 hr, blood samples were drawn and platelets were collected. (111)In and (14)C were separately counted. In some experiments animals received the 5-HT precursor, 5-hydroxytryptophan (5-HTP) I.P. (for rats and rabbits) or subcutaneously (for dogs) in a dose of 20 mg/kg daily to accelerate synthesis of 5-HT.2. (111)In disappeared in approximately an exponential fashion in all experiments and the rate of disappearance was not affected by treatment with 5-HTP. The half-life for (111)In in four control rats was 18.7 hr and in five rats treated with 5-HTP was 17.8 hr. In rabbits the half-life was 20.4 hr for eight control and 21.2 hr for seven treated with 5-HTP. In the dogs the half-life was 21.0 hr for control and 27.7 hr for experiments with 5-HTP. In control rats, the (14)C behaved like the (111)In. However, in control rabbits the half-life for (14)C was 38.0 hr which is significantly longer than for (111)In (P < 0.005). (14)C also disappeared more slowly than the (111)In in the dogs.3. In all species treatment with 5-HTP accelerated the disappearance of the (14)C approximately three-fold. This was not a reserpine-like effect because the platelets contained more, not less 5-HT than usual.4. In an attempt to discover the fate of 5-HT disappearing from circulating platelets, experiments were made in which platelets from one rat were doubly labelled, and were then injected into two other rats from the identical strain; one of the recipients received daily I.P. injections of 20 mg/kg of 5-HTP. The other rat in each pair acted as a control.5. Results from twelve control rats showed that the (14)C/(111)In ratio in several tissues deviated from that found in platelets. Deviations occurred in both directions; in the spleen, liver and kidney the ratio was significantly lower than in the platelets (P < 0.01), whereas in the adrenals, thyroid, bladder and gut the ratio was significantly higher (P < 0.05 for thyroid, < 0.01 for others). In the gut, however, the ratio was significantly raised (P < 0.01) only at 5 hr.6. Administration of unlabelled 5-HTP to another twelve rats greatly reduced the (14)C in platelets. Under these conditions many tissues in addition to those above had a higher ratio of (14)C/(111)In than platelets. These tissues included muscle, skin, salivary gland, kidney, heart, aorta, testis and seminal vesicle. As with platelets, the absolute counts of (14)C/g of tissue decreased significantly after 5-HTP administration (platelets by 67%, brain by 56%, pancreas by 49%, lungs by 39%, liver by 37%, kidney by 29%, testis by 23% and seminal vesicle by 22%). On the other hand, there were significant rises of 93% in the skin and 21% in the muscle. Paper chromatography showed that 73-86% of the (14)C in tissues still behaved like 5-HT, except in the bladder and adrenals which contained unidentified material.7. It is concluded that under normal conditions platelets deposit 5-HT in specific tissues, notably gut, adrenals and thyroid. When unlabelled 5-HTP is administered, the labelled 5-HT is deposited in a variety of tissues, and especially in the skin.

Stimulation of mucus output from rat colon in vivo

Sodium chloride (155 mM) and N-acetyl cysteine (6 mM) were recirculated through the colons of anaesthetized rats. Mucus accumulated in the perfusion fluid which was changed at intervals to allow mucus output to be estimated by measurement of hexose. The output of mucus could be stimulated by intravenous administration of the cholinergic drugs carbachol and bethanechol; this effect was inhibited by atropine. Mucus output could also be stimulated by intravenous 5-hydroxytryptamine. This was not a muscarinic cholinergic effect because atropine did not prevent it. Neither did methysergide inhibit it; but chlorpromazine did. Precursors of 5-hydroxytryptamine, 5-hydroxytryptophan and L-tryptophan, also stimulated mucus output if given in high dosage. The results suggest that in this preparation mucus output can be stimulated by two distinct mechanisms, one cholinergic, the other involving 5-hydroxytryptamine and perhaps 5-hydroxytryptophan.

Controlled trial of cimetidine in upper gastrointestinal haemorrhage

One hundred and one patients were studied in a double-blind controlled trial to assess the role of oral cimetidine in preventing the continuation or recurrence of acute upper gastrointestinal haemorrhage from various sources, chiefly peptic ulcer. The dose of cimetidine was 800 mg on entering the study followed by 400 mg six hourly. The source of bleeding was identified endoscopically in 96% of patients, peptic ulcer comprising 70%. Bleeding continued or recurred in 11 of 51 (21.5%) of patients on cimetidine and in 12 of 50 (24%) of patients on placebo. Analysis of the effect of cimetidine according to age or severity of bleeding showed no significant advantage for the drug.

Some properties of 5-hydroxytryptamine receptors in the hindquarters of the rat

1 The rat hindquarter preparation, as described, responds with reproducible vasoconstriction to noradrenaline and tryptamines. 2 The receptors involved in these responses are distinct. 3 Evidence of heterogeneity of tryptamine receptors was not obtained. 4 The 5-hydroxytryptamine (5-HT) antagonists, methysergide and cyproheptadine, although very potent, displayed antagonism of a non-competitive type whereas a series of phenothiazines and phentolamine displayed competitive antagonism against 5-HT. 5 For the phenothiazines the order of increasing potency was promazine less than chlorpromazine less than triflupromazine.

The pathology of a cricopharyngeal dysphagia

The paper describes the changes in the cricopharyngeal muscle in seven cases of dysphagia resulting from obstruction at this level which was relieved by myotomy. Histological features included degeneration and regeneration in the muscle fibres with interstitial fibrosis which was severe in some of the cases. It is considered that this restrictive fibrosis is the cause of the dysphagia and that it is secondary to muscle fibre damage, the cause of which is at present obscure. Minor degrees of muscle damage and regeneration were seen rarely in controls and fibrosis was never present. There was no evidence of underlying vascular or neurological disease in six cases; the seventh had a previous history of scleroderma but this was not thought to be the cause of the cricopharyngeal lesion. The age incidence ranged from 1 to 5 years at the onset of dysphagia; in six of the seven it was 50 years or more.

Double-blind comparison of cimetidine and placebo in the maintenance of healing of chronic duodenal ulceration

Patients suffering from chronic duodenal ulceration were allocated at random to treatment with either cimetidine (400 mg twice daily) or matching placebo for six months. Before entry to the trial all patients were shown to have healed ulcers on endoscopy. Most of the patients had participated in a one-month trial of cimetidine during which their ulcers healed. The trial showed that four of 29 patients relapsed on maintenance treatment with cimetidine, which therefore did not confer complete immunity from relapse. However, cimetidine treatment was very much better than placebo treatment, on which 18 of 31 patients relapsed. Of the 22 patients who relapsed clinically, 20 were submitted to endoscopy and 19 of these were shown to have ulcerated again. Endoscopy at the end of the trial showed that ulcers had also redeveloped in five of 28 asymptomatic patients. Length of previous dyspeptic history had no bearing on the results of the trial but there was evidence that relapse on placebo was less likely if the ulcer had originally healed on a high dose of cimetidine. Clinical relapse was associated with worsening duodenitis. Symptoms, clinical observation, and laboratory tests showed no important abnormalities in the patients.

Histamine H2-receptor antagonist in treatment of peptic ulcer

Cimetidine promotes the healing of duodenal ulcer, but prolonged use (perhaps in low dosage) seems to be necessary in many cases to prevent relapse. H2 receptors are widely distributed in body tissue, but important effects of blockade of the extragastric receptors have not been detected. Nor has serious toxicity been noted. Cimetidine probably will become a familiar, much-used, and valuable drug.

Bioassay and radioimmunoassay of gastrin and significance of gastrin degradation products

Inactivation of gastrin was studied (a) in vitro by incubation with a high-speed supernatant fraction of rat small bowel mucosa and (b) in vivo by perfusing gastrin through the small bowel vascular bed in anaesthetized dogs. In both types of experiment there was a highly significant loss in the bioactivity of gastrin, but no significant change in its immunoreactivity. This showed that gastrin was inactivated by a subtle chemical change which rendered the molecule biologically inactive, yet left its immunoreactivity unimpaired.

Drugs for peptic ulcer

Conservative management of peptic ulcer relies on the use of drugs as an adjuvant to the time-honored measures of avoiding stress, reducing gastric secretion, and regulating the diet. Alkalies neutralize acid and anticholinergic drugs partly inhibit secretion.. Both are widely used but are often inadequate to control symptoms. Carbenoxolone appears to have a more specific effect in promoting healing of gastric ulcers and has now been used for 15 years. Its role in the treatment of gastric ulcer can be critrically examined, particularly in relation to how this influences surgical management. Recently introduced compounds know as histamine H2-receptor antagonists have a profound effect in inhibiting gastric secretion. Early experience in patients with duodenal ulcer indicated the efficacy of these compounds in promoting healing. These potent new drugs are likely to influence strongly the management of patients with duodenal ulcer, and this may affect the indications for surgery.

Treatment of duodenal ulcer with cimetidine

In a small open trial nineteen patients with active duodenal ulceration shown by fibreoptic endoscopy were treated with a 6-week course of cimetidine 1.6 g daily. Seventeen had healed ulcers on repeat endoscopy at 6 weeks. Seven of these have relapsed symptomatically within a month of withdrawal of cimetidine. No statistically significant change in the haemoglobin, white-blood-cell count, urea and electrolytes, or liver-function tests was associated with treatment. Plasma-creatinine showed a very small but significant rise but the mean level remained within the normal range. The significance of this is not clear.

Pharmacological evaluation of cimetidine, a new histamine H2-receptor antagonist, in healthy man

Cimetidine, a new H2-receptor antagonist, was safely administered to eighteen healthy man by the intravenous, intraduodenal or oral route. 2 When gastric secretion was maximally stimulated by either histamine or pentagastrin, the simultaneous administration of cimetidine produced marked inhibition of both acid and pepsin secretion. 3 Cimetidine was well absorbed by mouth and had a blood half-life of 2 hours. 4 Cimetidine was rapidly excreted via the kidneys and about 70% of the excreted material was unchanged drug. 5 Clinical evaluation of cimetidine in patients with peptic ulceration is recommended.

Inactivation of pentagastrin by the liver

Pentagastrin is deamidated to pentagastrin acid by high-speed supernatant preparations obtained from rat, dog and human liver. The product, which contains all the amino acids in the parent substance, is biologically inactive. Experiments with pentagastrin labelled with carbon 14 indicate that this reaction also occurs in intact dogs.