Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years

BACKGROUND

Slow transit constipation is characterised by prolonged colonic transit and reliance on laxatives. The pathophysiology is poorly understood and in its most severe form, total colectomy with ileorectal anastomosis is the final treatment option. We present a follow-up study of the long-term function in patients who had surgery for laxative-resistant slow transit constipation.

METHODS

A postal survey was sent to assess bowel frequency, abdominal pain, St Mark's continence score, satisfaction with procedure, likelihood to choose the procedure again, and long-term rates of small bowel obstruction and ileostomy. Longitudinal data from a subgroup studied 23 years previously are reported.

RESULTS

Forty-two patients (male = 2) were available for follow-up out of an initial cohort of 102. Mean time since surgery was 15.9 years (range 1.7-29.7) years. Fifty percent had < 4 bowel motions per day, most commonly Bristol stool 6, mean St Mark's score 7.45. Twenty-one percent had severe incontinence. Satisfaction and likelihood to choose surgery were high (median 10/10). There was a high rate of small bowel obstruction, suggesting pan-intestinal dysmotility in some cases. Conversion to ileostomy occurred in 8 patients. In the longitudinal follow-up in 15 subjects, continence deteriorated (p < 0.01), stool consistency softened (p < 0.01), and stool frequency fell (p < 0.01).

CONCLUSIONS

Satisfactory stool frequency was achieved in the long term, and although 21% had incontinence scores > 12, patient satisfaction was high. This is the longest reported follow-up of colectomy for slow transit constipation, with longitudinal outcomes reported. There was considerable attrition of patients, so larger, longitudinal studies are required to better ascertain the functional outcomes of these patients.

Pannexin-2 is expressed in the human colon with extensive localization in the enteric nervous system

BACKGROUND

Pannexin-2 (Panx2) is a member of the novel group of membrane spanning protein channels present in the central nervous system. Limited studies have examined Panx2 in the intestine, where it may have important physiological roles. The present study characterized Panx2 expression and localization in the human colon in health and disease states.

METHODS

Immunofluorescence determined Panx2 localization and co-localization, and quantitative real-time PCR and Western blot determined gene and protein expression in ulcerative colitis (UC), Crohn's disease (CD), and control human colon.

KEY RESULTS

Panx2 was widely expressed in myenteric and submucosal ganglia, particularly in the cytoplasm of neurons. Panx2 was also expressed on smooth muscle of the muscularis and blood vessels, some non-lymphoid leukocytes, mast cells, and mucosal epithelial cells. Co-localization of Panx2 occurred with β-tubulin, neuronal nitric oxide synthase, substance P, vesicular acetylcholine transporter, and calcitonin gene-related peptide, indicating widespread Panx2 expression in extrinsic and intrinsic neurons. Molecular studies revealed a 3.4-fold higher level of Panx2 mRNA in ascending compared to sigmoid muscularis (p < 0.05), despite similar protein levels. Similarly, UC muscularis showed a 35-fold up-regulation in Panx2 mRNA, but not in protein (p < 0.05).

CONCLUSIONS & INFERENCES

Here, we demonstrated the dense expression of Panx2 in the enteric nervous system and the co-localization of Panx2 with a spectrum of neuronal markers, indicating that Panx2 may be involved in mediating neurotransmission in the colon. The substantial increase in Panx2 mRNA in UC muscle but not protein suggests that the Panx2 translation process may be disrupted in UC.

Expression and localization of pannexin-1 hemichannels in human colon in health and disease

BACKGROUND

Pannexin-1 (Panx1) proteins can function as channels for adenosine triphosphate (ATP) release, but there have been limited studies investigating their potential role in the human intestine. The aim of this study was to characterize Panx1 expression and distribution in the human colon and its potential involvement in inflammatory bowel diseases (IBD).

METHODS

Human colon segments were dissected into mucosa and muscularis layers, and evaluated for Panx1 expression by real-time PCR and Western blotting. Immunohistochemistry was conducted to localize the cellular distribution of Panx1 in intact tissues.

KEY RESULTS

In the colonic muscularis of ulcerative colitis (UC), Panx1 mRNA expression showed a 3.5-fold reduction compared with control (P = 0.0015), but no change was seen in UC mucosa. In contrast, down-regulation of Panx1 mRNA was observed in both muscularis and mucosa of Crohn's disease (CD), showing a 2.7- and 1.8-fold reduction, respectively (P < 0.05). There was reduced Panx1 protein expression in CD muscularis, but no change in CD mucosa, UC muscularis, or UC mucosa. Pannexin-1 immunoreactivity was mainly localized to enteric ganglia, blood vessel endothelium, erythrocytes, epithelial cells, and goblet cells. Inflammatory bowel disease samples showed a similar overall pattern of Panx1 staining, but in UC myenteric ganglia, there was a significant reduction in Panx1 immunoreactivity. Significant Panx1 positive leukocyte infiltrations were seen at the sites of inflammation.

CONCLUSIONS & INFERENCES

The presence of Panx1 in the colon and changes to its distribution in disease suggests that Panx1 channels may play an important role in mediating gut function and in IBD pathophysiology.

Abstract P1-01-04: Tc 99m Tilmanocept and Sulfur Colloid Injection: A comparison of preoperative imaging and intraoperative lymphatic mapping of breast cancer patients – Localization rate and degree of localization

Background: Preoperative imaging (PI) in conjunction with intraoperative lymphatic mapping (ILM) in breast cancer (BC) patients (pts) is standard for pt staging. As part of the ILM procedure, pts are evaluated post-injection (inj.) of a radiotracing agent/presurgically with PI. During ILM, the surgeon utilizes the inj. of a dye and/or a non-specific colloidal agent, such as Sulfur Colloid Injection (SCI) which may be detected intraoperatively. An ideal ILM agent such as the receptor-targeted (CD206) Tc 99m Tilmanocept provides for rapid (&lt;10 min) and tissue-specific localization in tumor draining nodes.

The objective of this evaluation of SCI and Tilmanocept was two-fold: 1) to contrast performance by assessing successful PI by post-inj. time interval and overall, and 2) to contrast localization rate and degree of localization (in vivo findings) in BC pts.

Materials/Methods: A retrospective clinical site review of SCI PI of 141 BC pts and a prospectively designed evaluation (two Phase 3 clinical trials, same clinical site) of Tilmanocept PI of 88 BC pts were completed in order to contrast post-inj time interval to successful PI (both immediate and overall). Successful immediate PI was defined as localization (hot spot identified) in &lt;10 minutes and &lt;15 minutes for Tilmanocept and SCI, respectively.

A statistical review (a meta-analysis and pooled analysis) contrasted prospective trials for Tilmanocept which included 148 (T1-4/N0/M0) BC pts with benchmarking based on regulatory documents and clinical reports of SCI. This evaluation included 963 pts from trial documented databases. Localization rate (percentage of pts with nodal localization) and degree of localization (number of nodes per pt) were determined for both SCI and Tilmanocept.

Results: After inj. of Tilmanocept, 100% (22/22 immediate; 88/88 overall) of pts demonstrated localization. After inj. of SCI, 90.1% (127/141) and 91.5% (129/141) of pts exhibited localization immediately and overall, respectively.

Localization rate and degree of localization with the benchmark for SCI, H0, are provided in Table 1 (significance is considered &lt;0.025).

Distinct differences in tachykinin gene expression in ulcerative colitis, Crohn's disease and diverticular disease: a role for hemokinin-1?

BACKGROUND

In the intestine, the tachykinins substance P (SP) and neurokinin A (NKA) are found in neurons and have key roles in motility, secretion, and immune functions. A new tachykinin, hemokinin (HK-1), has been identified in non-neuronal cells in recent years and its role in intestinal inflammation is unclear. We aimed to examine the expression of genes encoding tachykinin peptides and receptors in colon from patients with ulcerative colitis (UC), Crohn's disease (CD), and acute diverticular disease (DD).

METHODS

Human colon segments were dissected into mucosa and muscle, and evaluated for tachykinin and tachykinin receptor gene expression by real-time PCR.

KEY RESULTS

In UC mucosa, the TAC4 gene (encoding HK-1) was 10-fold more abundant than in control mucosa (P < 0.01). Similarly, TAC1 (encoding SP and NKA) and TACR1 (encoding NK1 receptor) displayed 6-fold and 12-fold upregulation, respectively, in UC mucosa, but no change occurred in UC muscle. In contrast to UC, no difference was observed for any tachykinin genes in CD mucosa. In CD muscle, expression of TAC1 (P < 0.01), TAC4 and TACR1 (both P < 0.05) were moderately upregulated. In DD, there was a decrease in TACR1 (P < 0.05), and TACR2 (encoding NK2 receptor, P < 0.0001) in muscle compared with control. Histological staining showed increased collagen fibers between muscle bundles in DD smooth muscle.

CONCLUSIONS & INFERENCES

We provide evidence for the first time that HK-1, like SP, may be involved in the pathophysiology of inflammatory bowel disease. Distinctly different expression patterns of tachykinin-related genes occur in UC, CD and DD.

THE SOURCE OF LIPID ACCUMULATION IN L CELLS

Strain L cells accumulate lipid, concurrent with cessation of protein synthesis, in the stationary phase of growth from the extracellular medium and as a result of de novo synthesis. Cells which have been more severely damaged with an amino acid analogue also accumulate lipid from the extracellular medium, but synthesize very little lipid from labeled acetate. The possible roles which lipid accumulation may play in the cell are discussed.

Postanal repair--do the long-term results justify the procedure?

OBJECTIVE

Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long-term continence after PAR and relate this to patient satisfaction and quality of life.

METHOD

Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life.

RESULTS

One-hundred one patients from four surgeons were identified. Fifty-four patients were excluded because of loss to follow-up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow-up of 9.1 years (2.2-18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0-5), 26% moderate (CCS 6-12), and 48% (n = 27) severe incontinence (CCS 13-24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow-up, and being able to distinguish flatus and stool.

CONCLUSIONS

In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long-term subjective outcome, despite the fact that many patients have a high incontinence score.

Detection of chromosomal aberrations by fluorescence in situ hybridization in cervicovaginal biopsies from women exposed to diethylstilbestrol in utero

Epidemiologic studies have associated estrogens with human neoplasms such as those in the endometrium, cervix, vagina, breast, and liver. Perinatal exposure to natural (17beta-estradiol [17beta-E(2)]) and synthetic (diethylstilbestrol [DES]) estrogens induces neoplastic changes in humans and rodents. Previous studies demonstrated that neonatal 17beta-E(2) treatment of mice results in increased nuclear DNA content of cervicovaginal epithelium that precedes histologically evident neoplasia. In order to determine whether this effect was associated with chromosomal changes in humans, the frequencies of trisomy of chromosomes 1, 7, 11, and 17 were evaluated by the fluorescence in situ hybridization (FISH) technique in cervicovaginal tissue from 19 DES-exposed and 19 control women. The trisomic frequencies were significantly elevated in 4 of the 19 (21%) DES-exposed patients. One patient presented with trisomy of chromosomes 1, 7, and 11, while trisomy of chromosome 7 was observed in one patient. There were two patients with trisomy of chromosome 1. Trisomy of chromosomes 1, 7, 11, and 17 was not observed in the cervicovaginal tissue taken from control patients. These data suggest that DES-induced chromosomal trisomy may be an early event in the development of cervicovaginal neoplasia in humans.

Prospective manometric assessment of botulinum toxin and its correlation with healing of chronic anal fissure

INTRODUCTION

The efficacy and pharmacokinetics of botulinum toxin for chronic anal fissure continues to be debated. Addressing both issues we prospectively assessed the manometric impact of botulinum toxin on internal anal sphincter pressure, correlating this impact with chronic anal fissure healing.

METHODS

Sixty patients with chronic fissures were assessed. Fifty-seven patients had a total of 20 units of botulinum toxin injected into the intersphincteric groove at four o'clock and eight o'clock. Patients were prospectively assessed with a linear analog pain score, bleeding score, clinical fissure score, modified St. Mark's continence score, and anorectal manometry. Each parameter was reassessed two weeks following treatment and again at three months.

RESULTS

Fifty-six patients (30 female), median age 43 (range, 17-80) years, were followed for a median of five (range, 3-15) months with fissure healing assessed 12 weeks after treatment. Physical healing and symptom control were dependent on the baseline maximum anal resting pressure and baseline fissure score (P = 0.003, P = 0.009, respectively). Although maximum anal resting pressure fell by 17 (mean, range, 0-71) percent, pressure reduction did not correlate with clinical outcome (P > 0.2). Seventeen patients reported a mean 17 percent increase in continence score. There was no correlation between deterioration in continence and baseline or subsequent reduction in maximum anal resting pressure.

CONCLUSION

Patients with Grade 1 lower-pressure fissures are more likely to heal following treatment with 20 units of botulinum toxin. Healing does not appear to be dependent on a reduction in maximum anal resting pressure.

Manometric effect of topical glyceryl trinitrate and its impact on chronic anal fissure healing

INTRODUCTION

The duration of physiologic action of topical glyceryl trinitrate in the management of anal fissure has been the source of some controversy. This study was designed to assess the manometric effect of glyceryl trinitrate on internal sphincter resting tone with continuous monitoring.

METHODS

Twenty-seven patients with a chronic anal fissure were assessed with fissure, pain, bleeding, and continence scores. Twenty-two were randomized to 1 cm of topical 0.2 percent glyceryl trinitrate paste, applied to the lower anal canal. Five patients were randomized to 1 cm of water-soluble lubricating jelly to the lower anal canal. Continuous stationary six radial channel water perfusion anorectal manometry was performed for 5 minutes before treatment and then for a further 30 minutes. The 22 glyceryl trinitrate patients were then advised to apply topical 0.2 percent glyceryl trinitrate, three times daily, for eight weeks. Twenty-four hours after completing treatment, all baseline assessments were repeated. The lubricant jelly cohort was discharged from the study after the initial assessment.

RESULTS

During the initial manometric assessment, 21 glyceryl trinitrate patients (95 percent) had 20 percent or more reduction in mean and maximum anal resting pressure after treatment. However, there was no statistical difference at 20 minutes compared with 0 minutes (P > 0.1). After eight-week treatment, 16 patients (73 percent) reported symptom resolution and 15 (67 percent) were found to be healed on examination. Clinical healing and resolution of symptoms positively correlated with a higher pretreatment maximum anal resting pressure in the mid anal canal (P < 0.0001), lower fissure score (P < 0.0001), and greater percentage reduction of the maximum resting pressure after application of glyceryl trinitrate (P < 0.001). The mean and maximum anal resting pressure at Week 8 was not significantly different from the baseline values (P > 0.05). During continuous manometry, the anal resting pressure did not significantly change in the patients treated with lubricating jelly.

CONCLUSIONS

In those patients with a lower fissure score, a higher mid anal canal anal resting pressure, and a greater resting pressure reduction after glyceryl trinitrate application, a favorable clinical outcome can be expected with glyceryl trinitrate treatment. However, because the physiologic response has resolved in fewer than 20 minutes, the dosing regime should be reassessed.

Laparoscopic or transanal repair of rectocele? A retrospective matched cohort study

PURPOSE

The aim of the study was to analyze the functional and physiologic outcome of patients undergoing laparoscopic rectocele repair compared to a matched cohort undergoing transanal repair.

METHODS

Forty patients with a rectocele who had undergone laparoscopic pelvic floor repair by a laparoscopic gynecologist were matched for age and rectocele size with 40 patients who had undergone a transanal repair by a colorectal surgeon. All patients had clinical evidence of a symptomatic rectocele. All patients were assessed postoperatively with a quality of life (SF-36) score, a modified St. Mark's continence score, a urinary dysfunction score, a Watt's sexual dysfunction score, and a linear analog patient satisfaction score. Fifteen patients in each group had also undergone preoperative and postoperative anal manometry.

RESULTS

At 44 months median follow-up, the transanal approach resulted in significantly more patients reporting bowel symptom alleviation (P < 0.002) and higher patient satisfaction (P < 0.003). The bowel symptom improvement was also sustained over a significantly longer period (P < 0.03). Only 11 patients (28 percent) in the laparoscopic group reported more than 50 percent improvement in their bowel symptoms compared to 25 patients (63 percent) in the transanal group. On univariate analysis of 50 percent bowel symptom improvement, a larger rectocele (P < 0.009), transanal repair (P < 0.02), and presenting with obstructive defecation rather than fecal incontinence (P < 0.03) were statistically significant. Rectocele size (P < 0.012) and treatment cohort (P < 0.006) remained significant on multivariate analysis. Postoperatively, bowel symptom alleviation correlated with patient satisfaction in both groups (P < 0.015). Although not statistically significant, five patients (13 percent) in the transanal group developed postoperative fecal incontinence, which was associated with a low maximum anal resting pressure preoperatively that was further diminished postoperatively (P > 0.06). Only one patient (3 percent) in the laparoscopic group reported a decline in fecal continence, but four patients (10 percent) reported worsening of their symptoms of obstructed defecation. Postoperative dyspareunia was reported by 24 patients in total (30 percent), with significantly more in the transanal group (P > 0.05).

CONCLUSIONS

The transanal repair results in a statistically greater alleviation of bowel symptoms and greater patient satisfaction scores. However, this approach may have a greater degree of functional co-morbidity than the laparoscopic rectocele repair.

Proliferative responses observed following vancomycin treatment in renal proximal tubule epithelial cells

Vancomycin (VAN) is a glycopeptide antibiotic used to treat gram-positive infections. Nephrotoxicity is a common side effect observed with vancomycin therapy. However, the mechanism of vancomycin-induced nephrotoxicity has not been fully characterized. In this study we examined the effect of vancomycin on cellular proliferation in renal proximal tubule cells. A dose- and time-dependent increase in cell number and total cellular protein was observed following vancomycin exposure. Vancomycin exposure also caused an increase in BrdU incorporation followed by the accumulation of renal proximal tubule cells in G(2)/M phase of the cell cycle. These effects were inhibited by pretreatment with the mitogen-activated protein kinase inhibitor, PD098059, suggesting an association between the cell proliferative effect of VAN and the induction of the mitogen-activated protein kinase signaling pathway. Mitochondrial function in renal proximal tubule cells was assessed using oxygen consumption and ATP concentrations. We observed an increase in oxygen consumption and ATP concentrations following short-term exposure to vancomycin. Together, our data suggest that vancomycin treatment produces alterations in mitochondrial function that coincide with a cell proliferative response in renal proximal tubule epithelial cells.

Long-term follow-up of dynamic graciloplasty for faecal incontinence

OBJECTIVE

This paper presents the long-term morbidity, function and quality of life data for patients who have undergone dynamic graciloplasty (DGP) for faecal incontinence.

PATIENTS AND METHODS

All patients (n = 38) who had undergone DGP at one institution between 1993 and 2003 are presented. Thirty-three were available for long-term follow-up (median 60 months) and completed a telephone questionnaire assessing quality of life (QOL), bowel and sexual function and patient satisfaction. All patients had interval anorectal physiology studies.

RESULTS

At a median follow-up of 5 years, 72% had pain, swelling or paraesthesia in the donor leg and 27% had sexual dysfunction. Sixteen percent of patients had been converted to an end-colostomy for persisting incontinence and 11% for obstructed defaecation. All other patients have a normally functioning graciloplasty. Sixteen percent of patients reported a faecal continence score < 12. Of those patients with a functioning graciloplasty, 50% had obstructed defaecation and 64% reported that their bowel dysfunction had a negative impacted on their QOL. Age, medical comorbidity and anal manometry did not correlate with functional outcome. Quality of life scores and patient satisfaction scores correlated significantly with continence scores. There was a trend toward higher QOL and satisfaction scores with conversion to colostomy compared with a continence score > 12. Sixty percent of patients rated their satisfaction with DGP as 50% or better on a visual analogue scale, and this correlated strongly with the continence score at the time of the assessment (P < 0.001).

CONCLUSION

Dynamic graciloplasty significantly improves patient quality of life and anal continence for some patients. Despite increased experience, morbidity remains high and long-term continence scores are poor in a majority of cases. Obstructed defaecation is a significant problem after graciloplasty and antegrade colonic enemas may be needed. Significant prognostic factors for obstructed defaecation remain to be identified. The mechanism of both continence failure and surgical morbidity remains poorly defined in many patients and requires further investigation. The individual patient can expect a 16% chance of normal faecal continence at 5 years, with at least one surgical morbidity as a result of the procedure.

Epilepsy in Cortical Dysplasia: Factors Affecting Surgical Outcome

PURPOSE

To determine the factors influencing the outcome of cortical dysplasia resection for medically refractory epilepsy.

MATERIAL AND METHODS

13 patients underwent craniotomy for resection of epileptogenic foci using electrographic and MRI guidance. All patients had had seizures for more than 2 years and were on 3 or more antiepileptic medications. Their preoperative evaluation included MRI, neuropsychological evaluation including the WADA test, video EEG monitoring and intraoperative electrocorticography. Invasive preoperative monitoring was employed in 8 cases. The Engel outcome classification system was used. The mean follow-up time was 60.1 months with a minimum follow-up of 24 months.

RESULTS

Postoperatively, all 6 patients younger than 18 years were seizure free. Among 7 patients older than 18 years, 6 were class II and 1 was class III. Based on their preoperative MRI studies, among the patients with abnormal studies, 2 were class I, 5 were class II and 1 was class III. Among patients with normal studies, 4 were class I and 1 class II. Regarding the ictal EEG findings, among patients with localizing findings, 4 were class I and 5 were class II. Among patients with no localization in their ictal EEG, 2 were class I, 1 class II and 1 class III. Regarding the invasive preoperative monitoring of the 7 patients with localizing findings, 5 were class I and 2 were class II. The only patient with nonlocalizing findings was class II. Finally, among the patients with no invasive preoperative monitoring, 3 were class I, 1 was class II and 1 was class III.

CONCLUSION

Cortical resection is an effective treatment modality in patients with medically refractory epilepsy. In our series, the outcome was better in patients less than 18 years old and patients with normal preoperative MRI studies.

Pathophysiology of altered consciousness during seizures: Subtraction SPECT study

BACKGROUND

The mechanisms underlying altered consciousness during seizures are poorly understood. Previous clinicopathologic studies suggest a role for the thalamus and upper brainstem in consciousness mechanisms.

OBJECTIVE

To examine blood flow changes associated with altered consciousness during seizures.

METHODS

Seventy-one patients with epilepsy who underwent video-EEG monitoring and ictal/interictal SPECT were studied. Patients were divided into three groups depending on their conscious state during seizures: 1) complete impairment of consciousness (CI), 2) no impairment of consciousness (NI), or 3) uncertain impairment of consciousness (UI). The distribution of blood flow changes during these seizures was assessed by subtraction (ictal - interictal) SPECT co-registered to MRI. Conscious state was assessed in relation to secondary ictal hyperperfusion in subcortical regions (i.e., thalamus and upper brainstem).

RESULTS

Impairment of consciousness showed a strong association with secondary hyperperfusion in the thalamic/upper brainstem region (p = 0.01), occurring in 92% (45/49) of CI, 69% (9/13) of UI, and 11% (1/9) of NI.

CONCLUSIONS

These findings are consistent with a role for the thalamus and upper brainstem in consciousness mechanisms. The authors suggest that the spread of epileptic discharges or a trans-synaptic activation (diaschisis) of these structures is an important mechanism in the alteration of consciousness during seizures. Variance in the results may be due to differences in timing of radioisotope injection, sensitivity of the subtraction SPECT technique, and the ability to clinically assess the conscious state.

Transanal endoscopic microsurgery excision: is anorectal function compromised?

PURPOSE

Transanal endoscopic microsurgery is a new technique that has not yet found its place in routine practice. The procedure results in dilation of the anal sphincter with a large-diameter operating sigmoidoscope, sometimes for a prolonged period. The purpose of the present study was to assess the effect of transanal endoscopic microsurgery on anorectal function.

METHODS

Eighteen consecutive patients undergoing transanal endoscopic microsurgery excision of rectal tumors, of whom 13 were available for evaluation, were included. Continence was scored by a numeric scale before surgery and at three and six weeks after surgery. Anorectal physiology studies were performed preoperatively and six weeks postoperatively with manometry, pudendal nerve motor terminal latency, anal mucosal electrosensitivity, rectal balloon volume studies, and endoanal ultrasound.

RESULTS

There was a significant reduction in mean anal resting pressure (104 +/- 32 cm H2O before surgery, 73 +/- 30 cm H2O after surgery; P = 0.0009). There was no significant change in squeeze or cough pressure, pudendal nerve terminal motor latency, anal mucosal electrosensitivity, or rectal balloon study volumes. Fall in resting pressure was significantly correlated with length of operating time (r2 =0.39, P = 0.047). There was no significant change in mean continence score after surgery.

CONCLUSION

Transanal endoscopic microsurgery results in a reduction in internal sphincter tone. This did not affect continence in a short-term study.

Gender awareness among Veterans Administration health-care workers: existing strengths and areas for improvement

In response to the growing number of women within the Veterans Health Administration (VHA), along with the challenge of meeting their health-care needs in a historically male-focused setting, VHA has supported a variety of research projects aimed at evaluating and improving the status of women's health and health-care experiences. While these efforts have primarily focused on aspects of care such as the availability and accessibility of services and the provision of timely care, this study focused on the contribution of interpersonal aspects of care. Specifically, staff gender awareness, conceptualized as health-care workers' gender-role ideology or attitudes, gender sensitivity, and knowledge was examined. Findings revealed both strengths and weaknesses in domains of staff gender awareness and significant relationships between staff demographics and gender awareness components.

Measuring exposure to racism: development and validation of a Race-Related Stressor Scale (RRSS) for Asian American Vietnam veterans

This article describes the development and validation of the Race-Related Stressor Scale (RRSS), a questionnaire that assesses exposure to race-related stressors in the military and war zone. Validated on a sample of 300 Asian American Vietnam veterans, the RRSS has high internal consistency and adequate temporal stability. Hierarchical regression analyses revealed that exposure to race-related stressors accounted for a significant proportion of the variance in posttraumatic stress disorder (PTSD) symptoms and general psychiatric symptoms, over and above (by 20% and 19%, respectively) that accounted for by combat exposure and military rank. The RRSS appears to be a psychometrically sound measure of exposure to race-related stressors for this population. Race-related stressors as measured by the RRSS appear to contribute uniquely and substantially to PTSD symptoms and generalized psychiatric distress.

Arrhythmias in neurofibromatosis. A case report and review of the literature

Patients with neurofibromatosis have a higher incidence of anatomic cardiac abnormalities. However, there is little data regarding incidence of arrhythmias in this population. It is known that these patients have a higher mortality than the normal population, and it is possible that some deaths may be due to preventable causes such as cardiac arrhythmias. We report a patient with neurofibromatosis who was treated for a refractory seizure disorder for 8 years. However, video/EEG monitoring demonstrated that the patient had recurrent syncopal seizures secondary to sinus node dysfunction. Complete resolution of symptoms occurred after a permanent pacemaker implantation. We believe this is the first reported case of sinus node dysfunction associated with neurofibromatosis.

Relationships among alcohol use, hyperarousal, and marital abuse and violence in Vietnam veterans

Alcohol use (frequency and quantity) and the hyperarousal feature of PTSD were examined in relation to male-perpetrated marital abuse and violence using data from 376 couples who participated in the National Vietnam Veterans Readjustment Study. Veteran's self-reported hyperarousal was significantly associated with partner's report of physical violence and psychological abuse toward her. Differential relationships were found between veteran's self reported drinking frequency and drinking quantity and the outcomes; of the two components, only the average quantity consumed per occasion was independently related to husband-to-wife violence. Moreover, a complex interaction emerged between hyperarousal and the two dimensions of alcohol consumption in predicting violence, with the relationship between hyperarousal and violence varying as a function of both drinking frequency and drinking quantity.

Peptides derived from pro-growth hormone-releasing hormone activate p38 mitogen-activated protein kinase in GH3 pituitary cells

Posttranslational processing of the pro-growth hormone-releasing hormone (proGHRH) peptide can result in the formation of at least two peptide products: GHRH and the C-terminal peptide, GHRH-related peptide (GHRH-RP). While cyclic adenosine monophosphate transduces many of the actions of GHRH, other pathways also have been implicated in its actions. The aims of this study were to examine and characterize the activation of mitogen-activated protein kinase (MAPK) pathways by GHRH, and GHRH-RP in pituitary-derived GH3 cells, as well as the activation of the transcription factors that serve as substrates for these kinases. GHRH rapidly increased p44/p42 MAPK activity in GH3 cells in a protein kinase A-dependent and a protein kinase C-independent manner and stimulated the activation of the transcription factor Elk-1. By contrast, GHRH-RP and p75-92NH2 had no effect on p44/p42 MAPK phosphorylation in these cells. Additionally, we determined that all three peptides, GHRH, GHRH-RP, and p75-92NH2, rapidly and specifically increase phosphorylation of p38 MAPK and stimulate the activation of the nuclear factor CHOP. These are the first studies to demonstrate the activation of Elk-1 by GHRH and the activation of p38 MAPK and CHOP by GHRH, GHRH-RP, and p75-92NH2. We conclude that members of the GHRH family of peptides differentially activate multiple intracellular signaling pathways and suggest that the biologic actions of GHRH may be far more diverse than previously thought.

Posttraumatic stress disorder and depression symptomatology in a sample of Gulf War veterans: a prospective analysis

The authors examined the relationship over time of posttraumatic stress disorder (PTSD) and depression symptoms in a sample of Gulf War veterans. A large sample (N = 2,949) of Gulf War veterans was assessed immediately following their return from the Gulf region and 18-24 months later. Participants completed a number of self-report questionnaires including the Mississippi Scale for Combat-Related PTSD (T. M. Keane, J. M. Caddell, & K. L. Taylor, 1988) and the Brief Symptom Inventory (L. R. Derogatis & N. Melisaratos, 1983) at both time points and an extended and updated version of the Laufer Combat Scale (M. Gallops, R. S. Laufer, & T. Yager, 1981) at the initial assessment. A latent-variable, cross-lag panel model found evidence for a reciprocal relation between PTSD and Depression. Follow-up models examining reexperiencing, avoidance-numbing, and hyperarousal symptoms separately showed that for reexperiencing and avoidance-numbing symptoms, the overall reciprocal relation held. For hyperarousal symptoms, however, the association was from early hyperarousal to later depression symptoms only.

Differential cognitive and behavioral effects of carbamazepine and lamotrigine

BACKGROUND

The relative cognitive and behavioral effects of lamotrigine compared with the older standard antiepileptic drugs (AED) are uncertain.

OBJECTIVE

To directly compare the cognitive and behavioral effects of carbamazepine and lamotrigine.

METHODS

The cognitive and behavioral effects of carbamazepine and lamotrigine were assessed in 25 healthy adults using a double-blind, randomized crossover design with two 10-week treatment periods. During each treatment condition, subjects received either lamotrigine (150 mg/day) or carbamazepine (mean 696 mg/day) adjusted to a dose to achieve midrange standard therapeutic blood levels (mean 7.6 microg/mL). Subjects were tested at the end of each AED treatment period and in three drug-free conditions (two pretreatment baselines and a final posttreatment period [1 month after last AED]). The neuropsychological test battery included 19 measures yielding 40 total variables.

RESULTS

Direct comparison of the two AED revealed significantly better performance on 19 (48%) variables for lamotrigine but none for carbamazepine. Differences spanned both objective cognitive and subjective behavioral measures, including cognitive speed, memory, graphomotor coding, neurotoxic symptoms, mood factors, sedation, perception of cognitive performance, and other quality-of-life perceptions. Comparison of carbamazepine with the nondrug average revealed significantly better performance for nondrug average on 24 (62%) variables but none for carbamazepine. Comparison of lamotrigine with nondrug average revealed better performance on one (2.5%) variable for nondrug average and on one (2.5%) variable for lamotrigine.

CONCLUSION

Lamotrigine produces significantly fewer untoward cognitive and behavioral effects than carbamazepine at the dosages used in this study.

Posttraumatic stress disorder and retrospectively reported stressor exposure: a longitudinal prediction model

There has been recent concern about the degree to which posttraumatic stress disorder (PTSD) symptomatology influences reports of prior exposure to highly stressful life events. In this longitudinal study of 2,942 male and female Gulf War veterans, the authors documented change in stressor reporting across 2 occasions and the association between change and PTSD symptom severity. A regression-based cross-lagged analysis was used to examine the relationship between PTSD symptom severity and later reported stressor exposure. Shifts in reporting over time were modestly associated with PTSD symptom severity. The cross-lagged analysis revealed a marginal association between Time 1 PTSD symptom severity and Time 2 reported stressor exposure for men and suggested that later reports of stressor exposure are primarily accounted for by earlier reports and less so by earlier PTSD symptomatology.

Safety, efficacy and acceptability of a new power toothbrush: a 3-month comparative clinical investigation

PURPOSE

To compare the safety and efficacy of a new power toothbrush (Braun Oral-B D17) with an ADA reference manual toothbrush.

MATERIALS AND METHODS

110 healthy subjects, 18-65 yrs of age, with a mean plaque index of > or = 1.80 and a gingival index of > or = 1.00, were enrolled in this 3-month, randomized, parallel-group, examiner-blind study. Oral soft and hard tissues were examined for safety, and plaque, gingivitis and bleeding were measured to evaluate efficacy. Measurements were made at baseline and after 1 and 3 months of product use. Following the baseline visit and randomization, subjects were instructed to brush twice daily for 2 mins with their assigned brush.

RESULTS

101 subjects completed the study with evaluable data for all time periods, 52 in the D17 group and 49 in the manual group. None of the nine withdrawals from the study were related to product use and no product-related adverse effects were reported. There was no clinically significant soft or hard tissue abrasion observed at any time point in either group. After 1 and 3 months, significant reductions from baseline in whole mouth and interproximal plaque, gingivitis and bleeding were observed in both groups. A comparison of the two groups revealed that the whole mouth and approximal plaque indices were reduced to a significantly greater extent in the D17 group after both 1 and 3 months. The whole mouth gingival index was also reduced to a greater extent in the D17 group at 1 and 3 months, but a difference in the approximal gingival index was only apparent after 3 months. With respect to the bleeding index, there was a significant difference between the two groups for the whole mouth at both 1 and 3 months, but the differences in favor of the D17 for approximal values did not achieve statistical significance. In conclusion, the D17 was found to be safe and had increased efficacy with respect to reduction of plaque and gingivitis, compared with a manual toothbrush.

Posttraumatic stress disorder and depression symptomatology in a sample of Gulf War veterans: a prospective analysis

The authors examined the relationship over time of posttraumatic stress disorder (PTSD) and depression symptoms in a sample of Gulf War veterans. A large sample (N = 2,949) of Gulf War veterans was assessed immediately following their return from the Gulf region and 18-24 months later. Participants completed a number of self-report questionnaires including the Mississippi Scale for Combat-Related PTSD (T. M. Keane, J. M. Caddell, & K. L. Taylor, 1988) and the Brief Symptom Inventory (L. R. Derogatis & N. Melisaratos, 1983) at both time points and an extended and updated version of the Laufer Combat Scale (M. Gallops, R. S. Laufer, & T. Yager, 1981) at the initial assessment. A latent-variable, cross-lag panel model found evidence for a reciprocal relation between PTSD and Depression. Follow-up models examining reexperiencing, avoidance-numbing, and hyperarousal symptoms separately showed that for reexperiencing and avoidance-numbing symptoms, the overall reciprocal relation held. For hyperarousal symptoms, however, the association was from early hyperarousal to later depression symptoms only.

Proton magnetic resonance spectroscopic observations of epilepsia partialis continua in children

We performed magnetic resonance spectroscopy in three pediatric patients (two boys and one girl, ages 11 to 17 years) with epilepsia partialis continua. Single-voxel proton magnetic resonance spectroscopy was performed on each patient. Data were acquired from voxels of 4 or 8 cm3 from the affected hemisphere and from contralateral homologous regions. The spectral peaks of several metabolites (N-acetyl-aspartate, choline, creatine, and lactate) were measured. Neuropathologic findings revealed Rasmussen's syndrome in two children and gliosis in one. We observed increased lactate-to-creatine ratios and reduced N-acetyl-aspartate-to-creatine ratios in the affected hemispheres in all three children with epilepsia partialis continua. These data support previous reports. The largest increase in the lactate-to-creatine ratio was detected in a patient with Rasmussen's syndrome and ongoing epilepsia partialis continua at the time of measurement. The other two patients had an increase in the lactate-to-creatine ratio and a decrease in the N-acetyl-aspartate-to-creatine ratio in the affected area. The increased lactate-to-creatine ratio was associated with recurrent focal seizures from different underlying pathologies.

Oral sodium phosphate solution is a superior colonoscopy preparation to polyethylene glycol with bisacodyl

PURPOSE

The aim of this study was to compare the efficacy and patient tolerance of two bowel preparations for colonoscopy.

METHODS

Three hundred twenty-three consecutive patients undergoing colonoscopy were randomly assigned to receive either oral sodium phosphate, or 2 liters of polyethylene glycol solution preceded by the stimulant laxative bisacodyl. Patients were asked to record the effects of the preparation, noting any vomiting, nausea, or abdominal pain, and to determine a discomfort rating on a scale of 1 to 5. One hundred sixty-nine patients were assigned to the oral sodium phosphate solution, and 154 to polyethylene glycol with bisacodyl. Surgeons were blinded to the preparation used and rated the quality of the bowel preparation on a scale of 1 to 5.

RESULTS

Ninety-nine percent of patients in the sodium phosphate group drank all of the solution as opposed to 91 percent of patients in the polyethylene glycol with bisacodyl group. Patients in the sodium phosphate group reported significantly less discomfort (P = 0.002). No significant difference was reported for vomiting, nausea, or abdominal pain associated with the preparations. The quality of bowel cleansing was considered by the colonoscopists significantly better for the sodium phosphate group than the polyethylene glycol with bisacodyl group (P < 0.000001).

CONCLUSIONS

Colonoscopy preparation with sodium phosphate solution is better tolerated and more effective than polyethylene glycol with bisacodyl.

Prognostic implication of contralateral secondary electrographic seizures in temporal lobe epilepsy

PURPOSE

Interhemispheric propagation of seizures in temporal lobe epilepsy is frequently noted during intracranial EEG monitoring. We hypothesized that a distinct secondary electrographic seizure (DSES) in the temporal lobe contralateral to primary seizure onset may be an unfavorable prognostic indicator.

METHODS

We reviewed intracranial depth electrode EEG recordings, 1-year outcome, and medical records of 51 patients (M 29, F 22: age 15-64 years) who underwent anterior temporal lobectomy during 1988-96. We defined DSES as a seizure that spread to the contralateral temporal lobe and produced distinct contralateral EEG features. The distinct feature was focal involvement of one or two electrode contacts at onset, which starts and evolves independently from the ipsilateral temporal lobe. We considered DSES as the predominant seizure pattern when it occurred in more than one half of the patients' recorded seizures.

RESULTS

Only nine of 19 (47%) patients with predominant DSES had a 1-year seizure-free outcome, whereas 27 of 32 (84%) patients without predominant DSES had a 1-year seizure-free outcome (p < 0.01). Bitemporal independent seizures were more common in patients with predominant DSES (9/19 versus 0/32; p < 0.001).

CONCLUSION

Our results suggest that distinct contralateral secondary electrographic seizure is a predictor of unfavorable outcome and is also more likely to be associated with bitemporal seizures.

Posttraumatic stress disorder and retrospectively reported stressor exposure: a longitudinal prediction model

There has been recent concern about the degree to which posttraumatic stress disorder (PTSD) symptomatology influences reports of prior exposure to highly stressful life events. In this longitudinal study of 2,942 male and female Gulf War veterans, the authors documented change in stressor reporting across 2 occasions and the association between change and PTSD symptom severity. A regression-based cross-lagged analysis was used to examine the relationship between PTSD symptom severity and later reported stressor exposure. Shifts in reporting over time were modestly associated with PTSD symptom severity. The cross-lagged analysis revealed a marginal association between Time 1 PTSD symptom severity and Time 2 reported stressor exposure for men and suggested that later reports of stressor exposure are primarily accounted for by earlier reports and less so by earlier PTSD symptomatology.

A 13-year experience with epilepsy surgery

Between 1985 and 1997, 563 therapeutic craniotomies were performed: 311 anterior temporal (ATL) and 158 extramesial temporal (XMT) resections, 67 callosotomies, 20 hemispherectomies and 7 multiple subpial transections. Sixty-seven percent of nonlesional ATL cases were seizure free (SF), and 76% of nonlesional ATL cases < or =18 years old were SF. Seventy-eight percent of lesional ATL cases with complete resection were SF. Seventy-three percent of lesional cases < or =18 were SF. Thirty-seven percent of nonlesional XMT cases were SF. Seventy percent of XMT lesional cases with complete resection were SF, and 82% of lesional XMT cases < or =18 were SF. Of the anterior callosotomy cases, there was a > or =90% decrease in generalized tonic-clonic seizures in 50% of patients, and in tonic seizures, drop attacks, absence and myoclonic seizures in approximately 60-70% of patients. Of 20 hemispherectomies, 65% were SF. Of 7 multiple subpial transections, 29% were SF.

Coping with Gulf War combat stress: mediating and moderating effects

The authors examined relationships between method of coping with combat-related stress and psychological symptoms among Gulf War Army personnel (N = 1,058). Participants were surveyed on return from the Gulf region (Time 1) with the Coping Responses Inventory (R. Moos, 1990) and a measure of combat exposure. Outcomes were symptom measures of posttraumatic stress disorder (PTSD) and depression. At Time 2 (18-24 months) participants completed the same symptom measures and an index of postwar stress. Higher proportions of approach-based coping in the war zone were related to lower levels of psychological symptoms. Combat exposure moderated the effects of coping on Time 1 PTSD. Coping predicted changes in symptoms of depression but not PTSD. Combat exposure affected changes in depression through postwar stress but had a direct negative effect on PTSD.

A quantifiable alternative to double data entry

Recent articles in this journal have questioned the effectiveness of double data entry to enhance the quality of clinical trials data entered into the computer from case report forms. Although double data entry is widely used, no definitive agreement has been reached as to how to model and quantify the time/cost involved to perform double data entry and the exact gain in data quality derived from its use. In this paper, an alternative to the verification step of double data entry is described. This alternative procedure involves the verification of a sample of records from the data set created from the single entry of the data into the computer. The sampling procedure used for this alternative procedure is known in the statistical quality control literature as a continuous sampling plan. This type of secondary check of the data has the following advantages: (1) it is easily performed by data entry personnel, (2) the cost/time necessary to perform the check along with the gain in quality of the data set can be computed, and (3) the sampling plan can be constructed to attain data quality goals set by the data management staff. Examples of how to select the parameters for this type of data quality assurance procedure are given in the paper.

An advanced toothbrush with improved plaque removal efficacy

PURPOSE

To compare the plaque removal efficacy and safety of a new advanced manual toothbrush, the Oral-B CrossAction, with seven other toothbrushes.

MATERIALS AND METHODS

Seven independent, cross-over design clinical studies were conducted using the same examiner who was blind to the identity of the test products and treatment assignments. In each study, approximately 75 healthy adult subjects from a general population brushed with their randomly assigned toothbrush (CrossAction or comparison brush) at Visit 1 for 1 min without supervision or instruction in brushing technique. Subjects returned after a 1-week washout period and brushed with the alternate toothbrush (Visit 2). Plaque was evaluated before and after brushing using the Rustogi Modified Navy Plaque Index. Statistical analyses were conducted by an independent statistician who remained blind to the identity of all test products.

RESULTS

Each of the toothbrushes tested provided significant (P < or = 0.0001) reductions in plaque scores after a single brushing. In each of the studies, the CrossAction toothbrush removed significantly (P < or = 0.0001) greater amounts of whole mouth, gingival margin, and approximal plaque than the compared toothbrush. All toothbrushes were found to be safe, with no changes in oral tissues or restorations observed over the course of each study. The results from these studies were consistent, demonstrating that the CrossAction toothbrush significantly enhances the ability of subjects to remove more plaque during normal brushing compared to seven other toothbrushes.

A 3-month comparative investigation of the safety and efficacy of a new toothbrush: results from two independent clinical studies

PURPOSE

To compare the efficacy of a new toothbrush featuring a novel brush head design with those of two established toothbrushes by measuring plaque and gingivitis over a period of 12 weeks.

MATERIALS AND METHODS

The Oral-B CrossAction toothbrush was compared with the Dr. Best InterDent and Crest DeepSweep toothbrushes in two independent, parallel-group, examiner-blind clinical studies. Each study involved approximately 100 healthy individuals from a general population. At baseline, after 23-25 hrs of no oral hygiene, oral hard and soft tissues were examined and whole mouth, marginal and approximal plaque scores and whole mouth gingivitis scores were recorded. Subjects in the two studies were asked to use their assigned toothbrush twice a day. No instruction in brushing technique or brushing time was given. After a period of 6 weeks and finally after 12 weeks, subjects in the studies were reassessed for oral tissue status, and their plaque and gingival indices were rescored.

RESULTS

In each of the two studies, the tested toothbrushes significantly reduced levels of plaque and gingivitis. The CrossAction toothbrush was, however, more effective in reducing both plaque and gingivitis over 12 weeks, the differences in favor of the CrossAction being statistically significant. All the toothbrushes tested in this investigation were found to be safe with no evidence of hard or soft tissue trauma.

Peritonectomy and intraperitoneal chemotherapy in appendiceal and colorectal cancer

BACKGROUND

Peritoneal spread of gastrointestinal malignancies has been regarded as an incurable disease, and treatment has been aimed at short-term palliation. The use of cytoreductive surgery, including peritonectomy procedures and intraperitoneal chemotherapy, has been proposed with the intention of prolonging survival, and perhaps curing patients with peritoneal carcinomatosis from appendiceal and possibly colon cancers. A series of eight patients who have undergone this procedure at St George Hospital is presented, and the results obtained by other groups are reviewed.

METHOD

Eight patients fitted the criteria for peritoneal carcinomatosis between January 1996 and November 1998. In seven patients this was secondary to appendiceal or colon cancer. and one patient had signet ring cancer of the uterus. The surgical treatment involved removing all macroscopic evidence of disease, and this was followed by early postoperative intraperitoneal chemotherapy.

RESULTS

The eight patients (seven female, one male) ranged in age from 25 to 67 years. There were seven complications, including two patients with pelvic abscesses, and one patient who developed Tenchkoff catheter occlusion. There were three deaths, one due to pelvic sepsis after 30 days, and the other two were due to metastatic disease. Of the remaining five patients, two have developed recurrence and three remain disease-free.

CONCLUSION

The results of peritonectomy and intraperitoneal chemotherapy for appendiceal tumours are encouraging. The role in colorectal cancer is less clear, although there are some reports that suggest a benefit.

Course and predictors of posttraumatic stress disorder among Gulf War veterans: a prospective analysis

Rates and predictors of posttraumatic stress disorder (PTSD) over time are not well understood. This study is the first to look at the rates of PTSD immediately following war and 2 years later using a large cohort (N = 2,949) of Gulf War veterans. Using a cut score to indicate presumptive PTSD, 3% of participants exceeded the cutoff at Time 1 compared with 8% at Time 2. Those who exceeded the cutpoint at Time 1 were up to 20 times more likely to exceed the cutpoint at Time 2 than those who did not exceed the cutpoint at Time 1. Women and those with high levels of combat exposure were at increased risk for PTSD at both times. Being young, being single, and having previous combat experience were associated with increased risk at Time 1 only, whereas reservists and enlisted personnel were at increased risk at Time 2 only. These findings indicate that, although low initially, rates of PTSD increased substantially over time.

Differential cognitive effects of carbamazepine and gabapentin

PURPOSE

The cognitive effects of the newer antiepileptic drugs (AEDs) compared with the older standard AEDs are uncertain.

METHODS

We directly compared the cognitive effects of carbamazepine (CBZ) and gabapentin (GBP) in 35 healthy subjects by using a double-blind, randomized crossover design with two 5-week treatment periods. During each treatment condition, subjects received either GBP, 2,400 mg/day, or CBZ (mean, 731 mg/day) adjusted to a dose to achieve midrange standard therapeutic blood levels (mean, 8.3 microg/ml). Subjects were tested at the end of each AED treatment period and in four drug-free conditions [two pretreatment baselines and two post-treatment washout periods (1 month after each AED)]. The neuropsychological test battery included 17 measures yielding 31 total variables.

RESULTS

Direct comparison of the two AEDs revealed significantly better performance on eight variables for GBP, but none for CBZ. Comparison of CBZ and GBP to the nondrug average revealed significant statistical differences for 15 (48%) of 31 the variables. Pairwise follow-up analyses of the 15 variables revealed significantly better performance for nondrug average on 13 variables compared with CBZ, and on four compared with GBP. GBP was better than nondrug average on one variable.

CONCLUSIONS

Although both CBZ and GBP produced some effects, GBP produced significantly fewer untoward cognitive effects compared with CBZ at the dosages used in this study.

Course and predictors of posttraumatic stress disorder among Gulf War veterans: a prospective analysis

Rates and predictors of posttraumatic stress disorder (PTSD) over time are not well understood. This study is the first to look at the rates of PTSD immediately following war and 2 years later using a large cohort (N = 2,949) of Gulf War veterans. Using a cut score to indicate presumptive PTSD, 3% of participants exceeded the cutoff at Time 1 compared with 8% at Time 2. Those who exceeded the cutpoint at Time 1 were up to 20 times more likely to exceed the cutpoint at Time 2 than those who did not exceed the cutpoint at Time 1. Women and those with high levels of combat exposure were at increased risk for PTSD at both times. Being young, being single, and having previous combat experience were associated with increased risk at Time 1 only, whereas reservists and enlisted personnel were at increased risk at Time 2 only. These findings indicate that, although low initially, rates of PTSD increased substantially over time.

A comparison of magnetoencephalography, MRI, and V-EEG in patients evaluated for epilepsy surgery

PURPOSE

To determine the efficacy and relative contribution of several diagnostic methods [ictal and interictal scalp and intracranial EEG, magnetic resonance imaging (MRI), and magnetoencephalography (MEG)] in identifying the epileptogenic zone for resection.

METHODS

This was a prospective study using a masked comparison-to-criterion standard. Fifty-eight consecutive patients with refractory partial epilepsy from two university comprehensive epilepsy programs were studied. Patients who were evaluated for and underwent epilepsy surgery were recruited. The main outcome measure was the efficacy of each diagnostic method to identify the resected epileptogenic zone, when referenced to surgical outcome.

RESULTS

MEG (52%) was second only to ictal intracranial V-EEG in predicting the epileptogenic zone for the entire group of patients who had an excellent surgical outcome (seizure free or rare seizure). In a subanalysis, for patients who had temporal lobe surgery, this same relation was seen (MEG, 57%, ictal intracranial V-EEG, 62%). With extratemporal resection, ictal (81%) and interictal (75%) intracranial EEG were superior to MEG (44%) in predicting the surgery site in those patients with an excellent outcome. Finally, for all patients who had a good surgical outcome, MEG (52%) was better than ictal (33%) or interictal (45%) scalp VEEG in predicting the site of surgery.

CONCLUSIONS

These results indicate that MEG is a very promising diagnostic method and raise the possibility that it may obviate the need for invasive EEG in some cases or reduce the length of scalp EEG evaluation in others.

Randomized trial of preoperative cimetidine in patients with colorectal carcinoma with quantitative assessment of tumor-associated lymphocytes

BACKGROUND

Previous studies have suggested that cimetidine, a histamine-2 receptor antagonist with immunostimulatory effects, may improve survival in patients with colorectal carcinoma. This effect may be apparent by an increase in the number of peritumoral lymphocytes. A prospective, double blind, randomized, placebo-controlled trial of a short course of preoperative treatment with cimetidine in patients with colorectal carcinoma was performed to assess the effect of cimetidine on survival and on the number of peritumoral lymphocytes.

METHODS

One hundred and twenty-five patients who were scheduled to undergo elective colon or rectal excision for carcinoma were randomized to receive either placebo or cimetidine preoperatively for 5 days. In addition to standard histopathology, immunohistochemistry and computer video image analysis were used to assess the number of peritumoral lymphocytes in an objective manner. Interim survival analysis according to the Kaplan-Meier method was performed.

RESULTS

A trend toward a survival advantage in the group of patients receiving cimetidine (800 mg twice daily) compared with the placebo group was observed (P = 0.20, log rank test) that was most marked in patients with replication error negative tumors (P = 0.04). Similarly, in these two groups there was a trend toward an increase in the number of patients with a conspicuous lymphocytic infiltration (P = 0.10, chi-square test). However, there was no difference in the number of peritumoral lymphocytes as measured by image analysis.

CONCLUSIONS

Based on the results of the current study, a short course of preoperative treatment with cimetidine does appear to have an effect on patient survival; however, the exact mechanism is unknown. The failure of this study to demonstrate a clear increase in the local lymphocyte response does not exclude an immunologic mechanism of action.

Randomized trial of preoperative cimetidine in patients with colorectal carcinoma with quantitative assessment of tumor-associated lymphocytes

BACKGROUND

Previous studies have suggested that cimetidine, a histamine-2 receptor antagonist with immunostimulatory effects, may improve survival in patients with colorectal carcinoma. This effect may be apparent by an increase in the number of peritumoral lymphocytes. A prospective, double blind, randomized, placebo-controlled trial of a short course of preoperative treatment with cimetidine in patients with colorectal carcinoma was performed to assess the effect of cimetidine on survival and on the number of peritumoral lymphocytes.

METHODS

One hundred and twenty-five patients who were scheduled to undergo elective colon or rectal excision for carcinoma were randomized to receive either placebo or cimetidine preoperatively for 5 days. In addition to standard histopathology, immunohistochemistry and computer video image analysis were used to assess the number of peritumoral lymphocytes in an objective manner. Interim survival analysis according to the Kaplan-Meier method was performed.

RESULTS

A trend toward a survival advantage in the group of patients receiving cimetidine (800 mg twice daily) compared with the placebo group was observed (P = 0.20, log rank test) that was most marked in patients with replication error negative tumors (P = 0.04). Similarly, in these two groups there was a trend toward an increase in the number of patients with a conspicuous lymphocytic infiltration (P = 0.10, chi-square test). However, there was no difference in the number of peritumoral lymphocytes as measured by image analysis.

CONCLUSIONS

Based on the results of the current study, a short course of preoperative treatment with cimetidine does appear to have an effect on patient survival; however, the exact mechanism is unknown. The failure of this study to demonstrate a clear increase in the local lymphocyte response does not exclude an immunologic mechanism of action.

Partners' ratings of combat veterans' PTSD symptomatology

The current study examined the concordance of combat veterans' scores on the Mississippi Scale for Combat-Related PTSD, with scores on a parallel version of that instrument completed by partners to assess veterans' symptoms. Further, the study examined the impact of quality of the marital relationship on score concordance. Bivariate and multiple regression were used with a sample of 466 veteran-partner dyads obtained from the National Vietnam Veterans Readjustment Study. There was moderate agreement in symptom reporting between veterans and their partners and little evidence to suggest that the quality of the relationship impacted upon the association between partner and veteran scores.

Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables

Relationships among pretrauma risk factors (e.g., family instability, childhood antisocial behavior), war-zone stressors (e.g., combat, perceived threat), posttrauma resilience-recovery variables (e.g., hardiness, social support), and posttraumatic stress disorder (PTSD) symptom severity were examined. Data from a national sample of 432 female and 1,200 male veterans were analyzed using structural equation modeling. For both genders, direct links to PTSD from pretrauma, war-zone, and posttrauma variable categories were found; several direct associations between pretrauma and posttrauma variables were documented. Although war-zone stressors appeared preeminent for PTSD in men, posttrauma resilience-recovery variables were more salient for women. Researchers, policymakers, and clinicians are urged to take a broad view on trauma and its sequelae, especially regarding possible multiple exposures over time and the depletion and availability of important resources.

Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables

Relationships among pretrauma risk factors (e.g., family instability, childhood antisocial behavior), war-zone stressors (e.g., combat, perceived threat), posttrauma resilience-recovery variables (e.g., hardiness, social support), and posttraumatic stress disorder (PTSD) symptom severity were examined. Data from a national sample of 432 female and 1,200 male veterans were analyzed using structural equation modeling. For both genders, direct links to PTSD from pretrauma, war-zone, and posttrauma variable categories were found; several direct associations between pretrauma and posttrauma variables were documented. Although war-zone stressors appeared preeminent for PTSD in men, posttrauma resilience-recovery variables were more salient for women. Researchers, policymakers, and clinicians are urged to take a broad view on trauma and its sequelae, especially regarding possible multiple exposures over time and the depletion and availability of important resources.