Postpartum anal incontinence in women with and without obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

Postpartum anal incontinence is common and distressing for women. We sought to look at the prevalence of anal incontinence in women who sustained obstetric anal sphincter injuries (OASI) compared with women who did not, and factors leading to these symptoms during the postpartum period.

METHODS

A total of 129 primiparous women sustaining OASI were compared with 131 women who did not (controls). They were contacted at approximately 6-10 weeks postpartum to obtain information on their symptoms of anal incontinence (AI). The data underwent univariate and multivariate analysis.

RESULTS

There was no difference in the prevalence of AI symptoms, occurring in 30% of women with OASI, and 23% of women without at 6-10 weeks postpartum; however, in women with high-grade tears the prevalence was 59%. Severe OASI (grade 3c and 4) was associated with an increased prevalence of both AI and severe AI, whereas forceps delivery and increasing maternal age were associated with an increased prevalence of severe AI only.

CONCLUSION

Women with less severe (grade 3a and 3b) OASI do not experience a higher prevalence of AI than women without OASI in the postpartum period. Higher grade (3c and 4) tears, forceps delivery and increasing maternal age are associated with higher rates of AI. These factors should be avoided where possible to reduce postpartum AI. All women should be warned of the 23-30% chance of experiencing some mild AI in this period. Whether these symptoms are transient or long-lasting requires further investigation.

Incidence and risk factors for fatal pulmonary embolism after major trauma: a nested cohort study

BACKGROUND

Venous thromboembolism is common after major trauma. Strategies to prevent fatal pulmonary embolism (PE) are widely utilized, but the incidence and risk factors for fatal PE are poorly understood.

METHODS

Using linked data from the intensive care unit, trauma registry, Western Australian Death Registry, and post-mortem reports, the incidence and risk factors for fatal PE in a consecutive cohort of major trauma patients, admitted between 1994 and 2002, were assessed. Non-linear relationships between continuous predictors and risk of fatal PE were modelled by logistic regression.

RESULTS

Of the 971 consecutive trauma patients considered in the study, 134 (13.8%) died after their injuries. Fatal PE accounted for 11.9% of all deaths despite unfractionated heparin prophylaxis being used in 44% of these patients. Fatal PE occurred in those who were older (mean age 51- vs 37-yr-old, P=0.01), with more co-morbidities (Charlson's co-morbidity index 1.1 vs 0.2, P=0.01), had a larger BMI (31.8 vs 24.5, P=0.01), and less severe head and systemic injuries when compared with those who died of other causes. Sites of injuries were not significantly related to the risk of fatal PE. Fatal PE occurred much later than deaths from other causes (median 18 vs 2 days, P=0.01), and the estimated attributable mortality of PE was 49% (95% confidence interval 36-62%).

CONCLUSIONS

Fatal PE appeared to be a potential preventable cause of late mortality after major trauma. Severity of injuries, co-morbidity, and BMI were important risk factors for fatal PE after major trauma.

Improved coagulation and blood conservation in the golden hours after cardiopulmonary bypass

The Hemobag (HB) technique allows the open-heart team to safely concentrate the residual cardiopulmonary bypass (CPB) circuit contents and return a high volume of concentrated clotting factors and blood cells back to the patient as autotransfusion. Hematocrit, platelet count, fibrinogen concentration ([Fib]), prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR) were compared between two prospective convenience groups of cardiac surgical patients whose residual circuit blood was processed by the HB (n=10) or by the Cell Saver (CS; n=10) at two times after CPB: (a) after acute normovolemic hemodilution (ANH) infusion and protamine administration and (b) after admission to the intensive care unit (ICU), approximately 1 hour after CPB and HB content infusion. Minimal cell processing was also used in the HB patients to conserve blood. "Golden hours" is defined as the first few hours after CPB and protamine sulfate administration and extend into the ICU, when maintaining hemostasis is vital during cardiac surgery and is the most susceptible period for blood product administration and the opportunity to improve patient outcome. Except for PTT, all parameters changed significantly from the ANH infusion and protamine administration to approximately 1 hour after HB blood infusion and arrival in the ICU. Fibrinogen (p = .048) and hematocrit (p = .046) were significantly higher in the HB group compared with the CS group at the end of the golden hour despite infusion of significantly more allogeneic blood products (p = .070) and more washed red blood cells (RBCs; p = .001) in the CS group. All but one of the HB patients did not receive any allogeneic blood products during the golden hours. Use of the HB technique for salvaging blood is associated with significant increases in the patient's protein and cellular concentrations and lowered coagulation times in the important, first few golden hours after CPB, and except for one patient, without the addition of expensive and precarious allogeneic blood products.

Size matters: gastric pouch size correlates with weight loss after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Over the past 20 years, there has been an ongoing discussion about the importance of gastric pouch size as a key factor influencing weight loss after bariatric surgery. This analysis aimed to determine the relationship between initial gastric pouch size and excess weight loss (EWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Between August 2002 and March 2005, 320 LRYGB were performed at Yale New Haven Hospital. The patients' demographics were entered into a longitudinal, prospective database. Upper gastrointestinal series were routinely performed on postoperative day 1. Pouch size was measured as area (cm2) on an anteroposterior radiograph at maximum pouch distention. Linear regression analysis was performed to determine the association between pouch size and weight loss at 6 and 12 months postoperatively. Adjustments were made for age, gender, and preoperative body mass index (BMI).

RESULTS

The mean age of the patients was 41.2 years. Of the 320 study patients, 261 were women (81.6%) and 59 were men (18.4%). The mean preoperative BMI was 51.1 kg/m2; the mean 6-month EWL was 50.5%; the mean 12-month EWL was 62.5%; and the mean pouch size was 63.9 cm2. A statistically significant, negative correlation between pouch size and EWL was found at 6 months (beta = -0.241; p < 0.01) and at 12 months (beta = -0.302; p < 0.02). The findings show that male gender (beta = 0.147; p < 0.04) and preoperative BMI (beta = 0.190; p < 0.01) are positively correlated with pouch size.

CONCLUSION

The analysis demonstrates that initial gastric pouch size is not the only significant component for successful weight loss after LRYGB. Male gender and increased preoperative BMI were identified as factors predicting pouch size. Efforts to standardize small pouch size for all patients seems important to the success of surgical therapy for morbid obesity.

[Superior vena cava thrombosis in a patient on hemodialysis]

We present a patient with end-stage renal disease on maintenace hemodialysis through a permanent catheter (Permcath) on the right subclavian vein. One month after the catheter placement the patient exhibited a superior vena cava syndrome due to a pericatheter thrombosis. The patient was initially managed with anticoagulation with early clinical improvement. Nevertheless, the reappearance of the symptoms forced the removal of the catheter and percutaneous angioplasty of the superior vena cava. After those measures and anticoagulation with coumarin the patient remains stable with complete clinical resolution and angiographical improvement.

Isolation of respiratory bovine coronavirus, other cytocidal viruses, and Pasteurella spp from cattle involved in two natural outbreaks of shipping fever

OBJECTIVE

To identify cytocidal viruses and Pasteurella spp that could be isolated from cattle involved in 2 natural outbreaks of shipping fever.

ANIMALS

105 and 120 castrated male 4- to 8-month-old feedlot cattle involved in 1997 and 1998 outbreaks, respectively.

PROCEDURES

Nasal swab specimens and blood samples were collected, and cattle were vaccinated on arrival at an order-buyer barn from 4 local auction houses. Four days later, they were transported to a feedlot, and additional nasal swab specimens and blood samples were collected. Nasal swab specimens were submitted for virus isolation and bacterial culture; blood samples were submitted for measurement of respiratory bovine coronavirus (RBCV) hemagglutinin inhibition titers.

RESULTS

93 of 105 cattle and 106 of 120 cattle developed signs of respiratory tract disease during 1997 and 1998, respectively, and RBCV was isolated from 81 and 89 sick cattle, respectively, while at the order-buyer's barn or the day after arrival at the feedlot. During the 1997 outbreak, bovine herpesvirus 1 was isolated from 2 cattle at the order-buyer's barn and from 5 cattle 7 and 14 days after arrival at the feedlot, and parainfluenza virus 3 was isolated from 4 cattle 14 days after arrival at the feedlot. During the 1998 outbreak, bovine herpesvirus 1 was isolated from 2 cattle at the order-buyer's barn and on arrival at the feedlot and from 5 cattle 7 and 14 days after arrival at the feedlot, and parainfluenza virus 3 was isolated from 1 animal the day of, and from 18 cattle 7 and 14 days after, arrival at the feedlot. Pasteurella spp was cultured from 4 and 6 cattle at the order-buyer's barn and from 92 and 72 cattle on arrival at the feedlot during the 1997 and 1998 outbreaks, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that RBCV may play a causative role in outbreaks of shipping fever in cattle. More than 80% of the sick cattle shed RBCV at the beginning of 2 outbreaks when the Pasteurella spp infection rate was low.

Care of the patient with interstitial cystitis: current theories and management

Interstitial cystitis is a disease process that has only come into focus over recent years. Researchers are looking for a cause of this painful and frustrating disorder of the bladder, but currently, only theories exist. Nurses must understand the pathophysiology of the disease and the dysfunction of the bladder to educate and assist the patient in the management of this chronic process. This report provides the nurse with information and education on the symptoms, pathophysiology, nursing diagnoses, and potential treatment modalities.

Analysis of multiple copies of geminiviral DNA in the genome of four closely related Nicotiana species suggest a unique integration event

Previously, we discovered multiple direct repeats of geminivirus-related DNA (GRD) sequences clustered at a single chromosomal position in Nicotiana tabacum (tobacco). Here we show that, in addition to tobacco, multiple copies of these elements occur in the genomes of three related Nicotiana species, all in the section Tomentosae: N. tomentosiformis, N. tomentosa and N. kawakamii, but not in 9 other more distantly related Nicotiana species, nor in various other solanaceous and non-solanacous plants. DNA sequence analysis of 18 GRD copies reveal 4 distinct, but highly related, sub-families: GRD5, GRD3 and GRD53 in tobacco; GRD5 in N. tomentosiformis and N. kawakamii; and GRD2 in N. tomentosa. In addition to novel sequences, all elements share significant but varying lengths of DNA sequence similarity with the geminiviral replication origin plus the adjacent rep gene. There is extended sequence similarity to REP protein at the deduced amino acid sequence level, including motifs associated with other rolling circle replication proteins. Our data suggest that all GRD elements descend from a unique geminiviral integration event, most likely in a common ancestor of these Tomentosae species.

Decreased immunoglobulin deposition in tumors and increased immature B cells in p53-null mice

Recent studies have hinted that there may be a relationship between p53 and the immune response. In preliminary experiments, we found significantly decreased levels of immunoglobulin deposition in 13 of 16 p53-null tumors compared with 2 of 17 tumors derived from p53 +/- mice. We further explored the effect of p53 on B-cell development and function. p53-null mice contained more splenic white pulp and more immature B cells in the bone marrow compared with p53 +/- mice. p53-null B cells were hyperresponsive to proliferative challenge but were not more resistant to signal-induced apoptosis. Several p53 DNA-binding sites were localized to the regulatory regions of immunoglobulin heavy and light chain genes, including the KII site, which serves as an enhancer for rearrangement of the mouse kappa chain J cluster genes. Levels of p53 protein and the kappa chain sterile transcript increased after exposure of pre-B cells to the DNA damaging agents etoposide and Adriamycin. Our observations suggest that p53 may be involved in B-cell maturation and may relay certain stress signals to affect B-cell function.

Expression of the human mismatch repair gene hMSH2 in normal and neoplastic tissues

Hereditary nonpolyposis colorectal cancer is caused by inherited mutations of mismatch repair genes. We developed monoclonal antibodies to the prototype human mismatch repair gene hMSH2 and used them to detect an immunoreactive protein of M(r) 100,000 in mismatch-proficient cell lines. In addition, a M(r) 150,000 protein coimmunoprecipitated with the hMSH2 gene product in cell lines expressing hMSH2. Immunohistochemistry demonstrated that the hMSH2 protein was exclusively nuclear. Whereas the hMSH2 protein was expressed in a variety of tissues, the most striking pattern was observed in esophageal and intestinal epithelia, where expression was limited to the replicating compartment. Neoplastic cells within benign and malignant mismatch repair-proficient tumors expressed the protein, but no hMSH2 immunoreactivity was observed in the colorectal tumors of patients with germline hMSH2 mutation. These results have implications for tumorigenic mechanisms and, potentially, for diagnosis.

APC binds to the novel protein EB1

Mutations of the APC gene play a critical role in both sporadic and familial forms of colorectal cancer. The vast majority of these mutations result in the loss of the carboxyl terminus of the protein. To further elucidate the function of APC, we searched for cellular proteins that associate with its carboxyl terminus. One million human cDNA clones were screened with the use of the interaction trap two-hybrid system, and 67 clones were found to have a phenotype suggestive of an APC-interacting protein. Nucleotide sequence analysis revealed that 48 of these clones were derived from a single novel named EBI. The association of APC and EB1 proteins was confirmed with in vitro binding assays. mAbs against EB1 were then produced and used to demonstrate the association of APC and EB1 in vivo. The EB1 gene was predicted to encode a 268-amino acid protein without significant homology to proteins with known function. However, searches of nucleotide databases did identify evidence for at least two related human genes and a yeast homologue. This conservation suggests an essential function for EB1 that might provide clues to the mechanism through which APC suppresses colonic neoplasia.

Topological control of p21WAF1/CIP1 expression in normal and neoplastic tissues

The p53-regulated gene product p21WAF1/CIP1 is the prototype of a family of small proteins that negatively regulate the cell cycle. To learn more about p21WAF1/CIP1 regulation in vivo, monoclonal antibodies were developed for immunohistochemistry. These revealed that p21WAF1/CIP1 expression followed radiation-induced DNA damage in human skin in a pattern consistent with its regulation by p53. A detailed comparison of the human, rat, and mouse p21WAF1/CIP1 promoter sequences revealed that this induction was probably mediated by conserved p53-binding sites upstream of the transcription start site. In unirradiated tissues, p21WAF1/CIP1 expression was apparently independent of p53 and was observed in a variety of cell types. Moreover, there was a striking compartmentalization of p21WAF1/CIP1 expression throughout the gastrointestinal tract that correlated with proliferation rather than differentiation. As epithelial cells migrated up the crypts, the Ki67-expressing proliferating compartment near the crypt base ended abruptly, with the coincident appearance of a nonproliferating compartment expressing p21WAF1/CIP1. In colonic neoplasms, this distinct compartmentalization was largely abrogated. Cell cycle inhibitors are thus subject to precise topological control, and escape from this regulation may be a critical feature of neoplastic transformation.

Endocrine tumors of the small and large intestine

Among endocrine tumors arising in the intestinal tract, midgut argentaffin EC cell carcinoids, duodenal gastrin cell tumors and rectal trabecular L cell carcinoids, in order of decreasing frequency, are those better represented. Together they account for more than 80% of such tumors. Duodenal somatostatin cell tumors, gangliocytic paragangliomas and poorly differentiated neuroendocrine carcinomas, are also well defined tumor entities. The carcinoid syndrome with intermittent flushing, hypotension and diarrhea, and the Zollinger-Ellison syndrome with severe peptic ulcer disease, are the only hyperfunctional syndromes consistently found in association with these tumors. The carcinoid syndrome arises in about 10% of intestinal carcinoids, usually in their advanced metastatic stage. The Zollinger-Ellison syndrome occurs in association with about 40% of gastrin cell tumors, including small intramural growths. Tumor prognosis depends on mode and site of presentation, histology, cell type(s), size, level of invasion, metastases (especially distant metastases) and associated clinical syndrome or background disease.

Multiple focal nodular hyperplasia of the liver associated with hemihypertrophy and vascular malformations

A case of multiple focal nodular hyperplasia of the liver occurring in a 22-year-old woman with musculoskeletal hemihypertrophy and anomalous vascular supply to the liver is described. The patient had Klippel-Trénaunay-Weber syndrome and abdominal pain and tender massive hepatomegaly. Visceral angiography showed marked dilatation of the celiac axis and both the main trunk and peripheral branches of the hepatic artery. Large abdominal veins drained from the dome of the liver into the hepatic veins. The vascular anomalies were evident on contrast-enhanced computed tomography and magnetic resonance imaging. Multiple focal nodular hyperplasia was confirmed by laparoscopic liver biopsy. The findings in this patient support the concept that multiple focal nodular hyperplasia characteristically occurs in a syndromic form and is induced by an irregular arterial supply in the liver, with localized hyperfusion that leads to nodular areas of hepatocyte hyperproliferation.

Adenosine diphosphate glucose pyrophosphorylase genes in wheat: differential expression and gene mapping

A full-length cDNA clone representing the large (shrunken-2) subunit of ADP-glucose pyrophosphorylase (AGP; EC 2.7.7.27) has been isolated from a cDNA library prepared from developing grain of hexaploid wheat (Triticum aestivum L., cv. Chinese Spring). The 2084-bp cDNA insert contains an open reading frame of 1566 nucleotides and primer-extension analysis indicated that the 5' end is 10 nucleotides shorter than the mRNA. The deduced protein contains 522 amino acids (57.8 kDa) and includes a putative transit peptide of 62 amino acids (6.5 kDa). The similarity of the deduced protein to the small subunit of AGP and to other AGP genes from plants and microorganisms is discussed. Northern hybridisation shows that the Agp1 genes (encoding the small subunit in the wheat endosperm) and the Agp2 genes (encoding the large subunit in the wheat endosperm) are differentially expressed in the wheat grain. Transcripts from both gene sets accumulate to high levels in the endosperm during grain development with the majority of the expression in the endopsperm rather than the embryo and pericarp layers. Although enzyme activity is detected in developing grains prior to 10 d post anthesis, only the Agp1 genes are active at this time (the Agp2 genes are not expressed until 10 d post anthesis). The possibility that the enzyme expressed during early grain development is a homotetramer of small subunits is discussed. The Agp1 and Agp2 genes are arranged as triplicate sets of single-copy homoeoloci in wheat. The Agp2 genes are located on the long arms of chromosomes 1A, 1B and 1D, about 80 cM from the centromere. The Agp1 genes have been mapped to a position just distal to the centromere on the long arms of chromosomes 7A, 7B and 7D.

WAF1/CIP1 is induced in p53-mediated G1 arrest and apoptosis

The tumor growth suppressor WAF1/CIP1 was recently shown to be induced by p53 and to be a potent inhibitor of cyclin-dependent kinases. In the present studies, we sought to determine the relationship between the expression of WAF1/CIP1 and endogenous regulation of p53 function. WAF1/CIP1 protein was first localized to the nucleus of cells containing wild-type p53 and undergoing G1 arrest. WAF1/CIP1 was induced in wild-type p53-containing cells by exposure to DNA damaging agents, but not in mutant p53-containing cells. The induction of WAF1/CIP1 protein occurred in cells undergoing either p53-associated G1 arrest or apoptosis but not in cells induced to arrest in G1 or to undergo apoptosis through p53-independent mechanisms. DNA damage led to increased levels of WAF1/CIP1 in cyclin E-containing complexes and to an associated decrease in cyclin-dependent kinase activity. These results support the idea that WAF1/CIP1 is a critical downstream effector in the p53-specific pathway of growth control in mammalian cells.

Enterocolic lymphocytic phlebitis. Clinical, radiologic, and pathologic features

Venous compromise as a cause of ischemic colitis and enteritis is infrequent. Enterocolic lymphocytic phlebitis, a rare cause of such compromise, to our knowledge has been reported in only three patients. We describe a patient with this condition who had hematochezia and a cecal mass that was mistaken endoscopically and radiologically for carcinoma and required resection. The mass, which was ulcerated, was due to intense submucosal edema. The patient had no history of taking hydroxyethylrutoside, a drug used in Europe in treating varicose veins that has been implicated in all three previously reported cases. This entity is characterized by a mixed T- and B-cell vasculitis affecting veins exclusively in the wall and mesentery of the colon and small bowel, without systemic involvement, leading to fibrointimal proliferation, thrombosis, venous occlusion, and subsequent edema and ischemic necrosis. It should be distinguished from other enterocolic phlebitides, including Behçet disease, systemic lupus erythematosus, and myointimal hyperplasia of mesenteric veins, and can be treated by local excision of the affected bowel.

p53 Mutation and MDM2 amplification in human soft tissue sarcomas

The p53 and MDM2 genes were analyzed in 24 human soft tissue sarcomas (11 malignant fibrous histiocytomas and 13 liposarcomas). Alterations of p53, consisting of point mutations, deletions, or overexpression, were detected in one-third (8 of 24) of the sarcomas. MDM2 gene amplification was detected in another 8 tumors, but no tumor contained an alteration of both genes. Monoclonal antibodies reactive with the human MDM2 gene product were developed, and immunohistochemical analysis revealed nuclear localization and overexpression of MDM2 in those tumors with amplified MDM2 genes. These data support the hypothesis that p53 and MDM2 genetic alterations are alternative mechanisms for inactivating the same regulatory pathway for suppressing cell growth.

Laparoscopically-assisted hysterectomy for the management of a borderline ovarian tumor: a case report

Borderline ovarian tumors account for 4% of ovarian neoplasms, an incidence which remains constant despite advancing age. Management for younger women can be unilateral oophorectomy, although simple hysterectomy with bilateral salpingo-oophorectomy is more appropriate for women beyond childbearing age. The authors report a laparoscopic approach to a case of borderline ovarian tumor.

Achalasia and hiatal hernia

Several reports have emphasized the rarity of hiatal hernia in achalasia, despite the lack of inherent incompatibility of the two conditions and despite the relatively high frequency of hiatal hernia in the general population. We reviewed the radiographs of 71 of 94 consecutive patients with manometrically proven achalasia referred to Yale-New Haven Hospital. Unequivocal hiatal hernia was seen in 10 (14.1%) patients and was seen in nine of 35 (25.7%) patients 51 years old or more. Review of the radiographic reports from these 10 patients indicated that only two were properly recognized as showing both achalasia and hiatal hernia. All five patients who underwent pneumatic dilatation had excellent results. We conclude that hiatal hernia in achalasia is frequently unrecognized and underreported but is not rare, with a frequency probably similar to that of the general population.

Classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings

Compared with classic achalasia, vigorous achalasia has been defined as achalasia with relatively high esophageal contraction amplitudes, often with minimal esophageal dilation and prominent tertiary contractions on radiographs, and with the presence of chest pain. However, no study using current manometric techniques has compared manometric, radiographic, and clinical findings in vigorous and classic achalasia or questioned the usefulness of making this distinction. Fifty-four cases involving patients with achalasia whose radiographic and manometric studies were performed within 6 months of each other were available for review. Patients with vigorous achalasia (n = 17), defined by amplitude greater than or equal to 37 mm Hg, and patients with classic achalasia (n = 37), defined as amplitude less than 37 mm Hg, had substantial overlap in radiographic parameters of esophageal dilation, tortuosity, and tertiary contractions. Manometric properties of repetitive waves and lower esophageal sphincter pressure and clinical aspects of chest pain, dysphagia, heartburn, and satisfactory responses to pneumatic dilation were similar in both forms of achalasia. A separate analysis of patients with mean contraction amplitude greater than 60 mm Hg revealed similar findings. It is concluded that use of amplitude as a criterion for classifying achalasia is arbitrary and of dubious value.

Expression of an antisense viral gene in transgenic tobacco confers resistance to the DNA virus tomato golden mosaic virus

Transgenic tobacco plants carrying a genetic cassette including an antisense DNA sequence of the virally encoded AL1 gene of the geminivirus tomato golden mosaic virus (TGMV) were constructed; AL1 encodes a protein absolutely required for TGMV DNA replication. These genetic cassettes also contained, on the same transcription unit, a gene encoding hygromycin resistance, which allowed selection for concomitant expression of the antisense gene. In transgenic lines, RNA transcripts of the predicted size and strand specificity were detected in antisense plants and sense controls. After infection of plants with TGMV, by agroinoculation, the frequency of symptom development was very significantly reduced in a number of antisense lines and correlated, broadly, with the abundance of antisense RNA transcript and with a reduction in viral DNA harvested from infected leaf tissue. We used an in vitro assay to study viral DNA replication in the absence of cell-to-cell spread; no replication was seen in five of the six antisense lines studied, in contrast to controls.

Recurrent cholangitis secondary to oriental cholangiohepatitis

A Korean woman with a known mass in the left lobe of the liver and a normal gallbladder by ultrasound suffered recurrent cholangitis, which ultimately proved to be Oriental cholangiohepatitis. This disease, endemic to East Asia, has become widespread in the United States as immigration from that area has increased. The symptoms are identical to recurrent cholangitis associated with gallstones, but the natural history and definitive treatment are entirely different. The diagnosis should be suspected in patients with a history of parasitic infestation with Ascaris lumbricoides or Clonorchis sinensis or in those who have lived in an endemic area.

The forgotten surgical foreign body

Instruments and drains left in the abdomen following surgery may be responsible for bizarre and varied complications. The patient may remain asymptomatic for months or even years. Complications include adhesion formation, intestinal obstruction, abscesses, and erosion into the gastrointestinal tract. We report 3 patients in whom retained surgical material eroded into the duodenum and colon, respectively, and produced unusual radiologic findings and complications.

Genetic manipulation in cultivars of oilseed rape (Brassica napus) using Agrobacterium

The response of oilseed rape cultivars to infection with Agrobacterium tumefaciens and A. rhizogenes and the possibility of regenerating genetically transformed oilseed rape plants were examined. The frequency at which Agrobacterium induced galls or hairy-roots on in vitro cultured plants ranged from 10% to 70%, depending on the cultivar. From galls induced by the tumorigenic strain T37, known to be strongly shoot inducing on tobacco, roots developed frequently. Occasionally, shoots formed and some of these produced tumour cell specific nopaline. Attempts to grow the transformed shoots into plants have so far been unsuccessful. Whole plants transformed with Ri-T-DNA, however, were regenerated. These had crinkled leaves and abundant, frequently branching roots that showed reduced geotropism, similar to previously isolated Ri T-DNA transformed tobacco and potato plants. The transformed oilseed rape plants flowered, but failed to form seeds.

Ureterosigmoidostomy: the development of tumors, diagnosis, and pitfalls

The development of colon carcinoma after ureterosigmoidostomy has not received adequate attention in the radiologic literature. Two patients who had ureterosigmoidostomy and subsequently developed tumors are described. The third case is a patient with a ureterosigmoidostomy and a ureterocele that simulated the appearance of carcinoma in the sigmoid colon. This is the first report of this entity. Ureterosigmoidostomy patients need frequent follow-up studies since their incidence of carcinoma is significant. The use of barium to study the colon in this group of patients is controversial. Barium can potentially reflux into the kidney with fecal material, which can lead to fibrosis and impaired renal function. However, barium reflux up the ureter is usually of no significance except on those rare occasions when intrarenal reflux occurs and inflammatory changes may develop. The diagnosis of tumors in these patients, diagnostic pitfalls, and controversy regarding use of barium enemas in following these patients are discussed.

Biliary tract abnormalities in patients with arteriohepatic dysplasia

Arteriohepatic dysplasia is a congenital syndrome associated with life-long cholestasis. Because of symptoms suggesting extrahepatic biliary tract obstruction, we studied three patients with this syndrome by endoscopic retrograde cholangiopancreatogram (ERCP). All patients showed a decrease in the number of intrahepatic ducts. In addition, the intrahepatic ducts show attenuation with focal areas of dilatation. In one subject, this latter finding appeared to be a localized process. The extrahepatic ducts were also narrowed. One patient in this series was found to have gallstones and another cirrhosis. Although the relationship of these anomalies to the cholestasis seen in these patients is unclear, arteriohepatic dysplasis can be added to the list of processes associated with biliary tract abnormalities.

Tc-99m HIDA scintigraphy in segmental biliary obstruction

Segmental biliary obstruction as a result of primary or secondary hepatic malignancy has been reported with increasing frequency. For two representative patients, the clinical and Tc-99m HIDA scintigraphic findings in segmental biliary obstruction are described. The presence of photon-deficient dilated bile ducts in one segment of the biliary tree is highly suggestive of localized biliary obstruction and should be considered in the patient with suspected or proven hepatic malignancy despite the absence of jaundice.

Roentgen manifestations of carcinoma in the gastric remnant

Awareness of the increased incidence of carcinoma in the gastric remnant has not been accompanied by improved diagnosis or prolonged survival. The long latent period prior to development of tumor, the insidious nature of symptoms, and the anatomical distortion produced by surgery contribute to the difficulty in detection of these lesions. The radiological spectrum of carcinoma of the gastric remnant is discussed and both characteristic and unique radiographic features are illustrated.

Myxedema megacolon

The radiological findings on barium enema examination of 239 patients with thyroid deficiency (192 hypothyroid and 47 myxedematous) were reviewed. A new radiologic finding of transverse ridging superimposed on megacolon is described in myxedema and an explanation for this finding is postulated. The colonic findings associated with thyroid deficiency are presented.

Liquefactive necrosis of the pancreas: the pancreatic sac

The authors describe an unusual form of pancreatic necrosis in which the excavated necrotic core is surrounded by a shell of tissue and forms a sac which generally conforms to the axis and contour of the pancreas. This debris-containing sac could be misinterpreted on ultrasound and CT and is best defined by direct injection into the pancreatic duct.

Aphthoid ulcerations in gastric candidiasis

Tiny aphthoid erosions appear to represent the earliest detectable radiographic change in gastric candidiasis. In this report, the radiographic appearance of these lesions is correlated with gross and microscopic pathologic anatomy, and the progression of these ulcerations to deeper linear furrows is illustrated. It is hoped that the detection of the gastric candidiasis at this early stage will hasten therapy, and thus decrease the risk of fulminant infection in the immunocompromised host.

Cholangitis in a child due to biliary tract anomalies

A 29-month-old child with persistent cholangitis and steatorrhea complicating congenital hepatic fibrosis underwent radiographic evaluation of the biliary tree. Communicating intrahepatic cavernous ectasias were demonstrated by percutaneous transhepatic cholangiography, a procedure deemed safe in children of this age group. Unlike most patients with cholangitis, he had documented steatorrhea and growth failure which resolved following successful treatment with trimethoprim-sulfamethoxazole. Bacteriologic diagnosis was made by direct culture of liver tissue combined with duodenal intubation.

Diagnosis of annular pancreas with endoscopic retrograde cholangiopancreatography

Two patients with annular pancreas are described. The diagnosis was established unequivocally with endoscopic retrograde cholangiopancreatography before operation. In both patients there was pancreatitis of the annular pancreas. The first patient also had congenital absence of the ventral pancreas and pancreatic insufficiency. The second patient subsequently developed gastric outlet obstruction. The literature is reviewed.

Transient hypertrophic gastropathy in childhood: a protein-losing gastropathy distinct from Menetrier's disease

Transient hypertrophic gastropathy in a child with similarity of radiographic and clinical features to Menetrier's disease is described. Distinction from Menetrier's disease is emphasized as the condition is characterized by abrupt onset, short duration, eosinophila and good prognosis. The association with hypersensitivity as a possible etiology is more suggestive in this condition. The radiographic changes will often provide the first clue to this condition and rapid reversal of the gastric changes is diagnostic.

Clinical comparison of two contrast agents for oral cholecystography: radiologic efficacy and drug safety of iopanoic acid and iopronic acid

Oral doses of either iopronic acid (4.5 g Oravue, Squibb) or iopanoic acid (3 g Telepaque, Winthrop) were given to 98 patients requiring cholecystography. Radiographs were taken 13 to 16 hours after treatment showed good to excellent gallbladder opacification in 44 percent of patients after the first dose of iopronic acid and in an additional 29 percent after a second dose. Similar opacification occurred in 42 percent of patients after the first dose of iopanoic acid and in 34 percent after a second dose. Drug-related abnormalities in blood and urine tests occurred about equally in both groups and one patient in each group exhibited a clinically adverse reaction (diarrhea). Thus, the performance (radiographic efficacy and drug safety) of the new contrast agent, iopronic acid, was similar to a widely used drug, iopanoic acid.

Iatrogenic problems following gastric surgery

It is difficult to truly define iatrogenic complications in the postsurgical state in that the surgery is a condition originated by physician intervention and thus any problems that occur may be technically considered as physician created. In this article we attempt to demonstrate problems that occur both due to technical errors and the choice of operative procedure. In addition, unusual postsurgical anatomy is illustrated with the hope of avoiding further iatrogenic problems from lack of recognition.