Olanzapine and olanzapine-fluoxetine combination treatment and bipolar I depression.
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Antipsychotic Agents↗
Biomedical subjects
A B Williams
Publications and source records attributed to A B Williams.
Rewarming of healthy volunteers after induced mild hypothermia: a healthy volunteer study.
OBJECTIVES: The study compares the efficacy of two active and one passive warming interventions in healthy volunteers with induced mild hypothermia. METHODS: Eight volunteers were studied in a random order crossover design. Each volunteer was studied during re-warming from a core temperature of 35 degrees C with each of: a radiant warmer (Fisher & Paykel); a forced air warmer (Augustine Medical), and a polyester filled blanket, to re-warm. RESULTS: No significant differences in re-warming rates were observed between the three warming devices. It was found that the subject's endogenous heat production was the major contributor to the re-warming of these volunteers. Metabolic rates of over 350 W were seen during the study. CONCLUSIONS: For patients with mild hypothermia and in whom shivering is not contraindicated our data would indicate that the rate of re-warming would be little different whether a blanket or one of the two active devices were used. In the field, this may provide the caregiver a useful choice.
Adult↗
The clinical course of fistulating Crohn's disease.
AIM: To determine the clinical characteristics, management and outcome of Crohn's fistulas from the time of first presentation. METHODS: Patients treated for fistulas 6 years previously were assessed for disease demographics, fistula characteristics and treatment from first presentation to final follow-up. RESULTS: Eighty-seven patients with active Crohn's fistulas were evaluated. The median age was 35 years and the median duration of Crohn's disease was 8 years at study entry. Disease was ileo-colonic or colonic in 85%, and 65% had rectal involvement. A single fistula was present in one-third and multiple fistulas in two-thirds; 65% of fistulas were perianal; 80% of fistulas were complex. After a median follow-up from the last treatment of 5.9 years, 68% of patients showed healing of all fistulas, 18% showed healing of some fistulas and 14% showed no healing of fistulas. The fistula site did not influence healing. Perianal and recto-vaginal fistulas took a median of 2.6 years to heal. Half of the complex fistulas required a stoma, resection or proctectomy. CONCLUSIONS: Healing is usually achieved. However, morbidity is great and healing is slow. Proctectomy is required in one-fifth of patients, and perineal healing is often slow. Defining the perianal fistula anatomy as complex or simple determines the likelihood of healing and the type of surgical approach required.
Adult↗
Magnetic resonance imaging for primary fistula in ano.
BACKGROUND: This was a prospective study designed to determine the therapeutic impact of magnetic resonance imaging (MRI) in primary fistula in ano, and to assess its effect on outcome. METHODS: Thirty patients with suspected primary fistula in ano underwent preoperative MRI, and the findings were revealed during surgery following examination under anaesthesia (EUA). Any effect on operative approach was noted. Outcome was assessed at a median of 12 months. RESULTS: Two patients had sinuses, one had no sepsis and 27 had fistulas: five superficial, seven intersphincteric, 14 trans-sphincteric and one suprasphincteric. MRI and EUA agreed in 15 patients and MRI findings altered the surgical approach in a further three (10 per cent); two of the latter patients were believed to have a sinus at EUA, which MRI correctly identified as a fistula, allowing definitive treatment. The therapeutic impact of MRI was therefore 10 per cent. Persisting disagreement between MRI and EUA in 12 patients mostly related to minor discrepancies in classification. Only one patient required further unplanned surgery, which was for skin-bridging rather than any new sepsis. CONCLUSION: In experienced hands, MRI has a therapeutic impact of 10 per cent for primary fistula in ano, precipitating surgery that is likely to reduce recurrence in a small, but important, proportion of patients.
Adolescent↗
Potential clinical implications of direction of a trans-sphincteric anal fistula track.
BACKGROUND: The longitudinal direction of a trans-sphincteric anal fistula track through the anal sphincter complex may have implications regarding fistulotomy. METHODS: The angle of the track of trans-sphincteric fistulas relative to the longitudinal axis of the anal canal was measured before operation by means of magnetic resonance imaging (MRI) in 46 patients. This was compared with the findings at operation. RESULTS: The track passed cranially as well as laterally at an acute angle (less than 90 degrees ) in 23 patients while it passed either transversely or caudally at an obtuse angle (90 degrees or more) in the remaining 23. The internal opening was significantly higher in relation to the dentate line (above in eight patients, at the dentate line in 14 and below in one patient) when the track was acute than when it was obtuse (above in one, at the dentate line in 17 and below in five patients) (P = 0.004). The fistula track crossed the sphincter at a median angle of 35 degrees, 95 degrees and 132 degrees from internal openings sited above, at and below dentate line level respectively (P = 0.002). CONCLUSION: Fistula tracks passed cranially and laterally through the sphincter complex in half of these patients, and were most acutely angled on MRI when internal openings were situated above the dentate line. Preoperative MRI might alert surgeons to the potential hazard of fistulotomy being more extensive than anticipated from simple palpation of the level of the internal opening.
Adolescent↗
Response of fistulating Crohn's disease to infliximab treatment assessed by magnetic resonance imaging.
AIMS: To assess fistula track healing after infliximab treatment using magnetic resonance imaging. METHODS: Magnetic resonance imaging and clinical evaluation were performed before and after three infliximab infusions given over a 6-week period. Magnetic resonance images were evaluated for abscesses and fistula tracks. Paired magnetic resonance image examinations were rated 'better', 'unchanged' or 'worse'. Magnetic resonance imaging and clinical outcomes were then compared. RESULTS: Of the 12 referred patients, pre-treatment magnetic resonance imaging detected abscesses in three (two not treated). Of the 10 treated patients, seven had peri-anal fistulas, two of whom also had recto-vaginal fistulas, and three had abdominal wall entero-cutaneous fistulas. After infliximab, four were in remission, one had a response and five were non-responders. One developed a peri-anal abscess. Magnetic resonance imaging improved in six, was unchanged in two and was worse in two. In four of the six with improvement in magnetic resonance imaging, the fistula track resolved, but two of these had clinically persistent entero-cutaneous fistulas. The clinical outcome and magnetic resonance imaging correlated in seven of the 10 patients; in three (two entero-cutaneous and one peri-anal), there was discordance. CONCLUSIONS: Magnetic resonance imaging identifies clinically silent sepsis. Fistulas may persist despite clinical remission. Clinical response to infliximab and clinical correlation with magnetic resonance imaging were poor in patients with abdominal entero-cutaneous fistulas.
Abscess↗
Home-based study of anti-HIV drug regimen adherence among HIV-infected women: feasibility and preliminary results.
Collection of antiretroviral medication adherence data in the homes of HIV-infected people may have methodological advantages that can improve data quality. However, the feasibility of this approach has not been established. In addition, data on adherence, and its predictors, among HIV-infected women have been limited. Sixty-three HIV-positive women who were prescribed at least one antiretroviral drug in the last month were interviewed in their homes. A standard instrument was used to collect data on all antiretroviral medications prescribed and taken in the three days prior to the interview. Data were also collected on factors thought potentially to affect the ability to be adherent. The results of this study suggest that it is feasible to conduct home-based adherence research. Sixty-seven per cent reported taking all prescribed antiretroviral medication doses. One-third took a sub-optimal dose putting themselves at increased risk of treatment failure and the selection of resistant HIV strains. Unintentional reasons for missing doses were most commonly reported. An ability to describe the intended effect of antiretroviral therapy on HIV viral load was the best predictor of adherence. This finding is consistent with other research suggesting that adherence is associated with an understanding and belief in the effectiveness of antiretroviral therapy.
Acquired Immunodeficiency Syndrome↗
Endosonographic anatomy of the normal anal canal compared with endocoil magnetic resonance imaging.
PURPOSE: This study was designed to clarify the sonographic anatomy of the normal anal canal by comparison with endoanal magnetic resonance imaging, to determine agreement between these imaging modalities and interobserver error in measuring layer thickness. METHODS: Three-dimensional endosonographic and endocoil magnetic resonance images of the anal canal were obtained in four males and five nulliparous females aged 22 to 34 years. Images were analyzed at similar levels throughout the canal using a graphics-overlay technique to compare sonographic with magnetic resonance images. Measurements were taken at one level for agreement analysis between modalities and for interobserver variability in the measurement of the thickness of the main anal canal layers. RESULTS: The muscularis submucosae ani, muscle bundles in the longitudinal muscle layer, and puboanalis were identified on sonography. The outer border of the external sphincter was demarcated by an interface reflection with ischioanal fat. Clarification of the external sphincter anatomy allowed excellent correlation (Ri = 0.96) for the assessment of thickness. There was excellent correlation for the interobserver measurement of the external and internal sphincters and the submucosal width on endosonography, but there was poor correlation for the longitudinal muscle (0.12). CONCLUSION: The overlay technique has improved endosonographic interpretation, and measurement of external sphincter thickness has been validated both by comparison with magnetic resonance and on interobserver agreement.
Adult↗
Assessment of third degree tears using three-dimensional anal endosonography with combined anal manometry: a novel technique.
Three-dimensional anal endosonography has enabled sagittal and coronal reconstructions of the anal canal to be matched with longitudinal pressure data, to present a combined picture of structure and function. This novel technique has been applied to a group of women with a clinical diagnosis of a third degree tear. Endosonography showed that only 68% of women had ultrasound evidence of sphincter damage. Anal canal anatomy and pressure profile did not differ significantly between those with and those without sphincter damage, but the anterior external anal sphincter and the puborectalis tended to be shorter and the pressures were lower in those with sphincter disruption.
Adult↗
Alteration of anal sphincter morphology following vaginal delivery revealed by multiplanar anal endosonography.
OBJECTIVE: To assess morphologic change in the anal sphincters in the absence of endosonographic evidence of trauma after vaginal delivery. DESIGN: Prospective observational study. SETTING: District general hospital. POPULATION: Consecutively booked nulliparous pregnant women attending antenatal clinic. METHODS: All women were examined using three-dimensional anal endosonography, simple manometry and had questionnaire assessment of incontinence before and after delivery. MAIN OUTCOME MEASURES: Components of the anal canal were measured in the axial, sagittal and coronal planes and paired pre- and post-delivery examinations were compared. Any changes were related to changes in continence and anal canal manometry. RESULTS: Twenty-two women had a vaginal delivery and no endosonographic evidence of perineal trauma after delivery. After delivery, there was significant shortening of the length of the anterior external anal sphincter [EAS] (mean 21.7 vs 20.5 mm, P = 0.02) when measured in the sagittal plane, which increased in anterior angulation with respect to the axis of the anal canal (10 degrees vs 13.8 degrees, P = 0.03). In the axial plane, no change was seen in the thickness of any of the sphincter components after delivery. None of these morphologic changes correlated with changes in manometry or continence score. CONCLUSIONS: Anal sphincter morphology changes after an otherwise atraumatic vaginal delivery. This change does not correlate with any functional symptoms.
Anal Canal↗
Endoanal ultrasound.
This pictorial review demonstrates the normal anatomy and abnormalities that are readily demonstrated with endoanal ultrasound of the anal sphincters.
Anal Canal↗
Anal sphincter damage after vaginal delivery using three-dimensional endosonography.
OBJECTIVE: To determine the incidence and functional consequences of external sphincter trauma compared with other perineal structures using a novel imaging technique, three-dimensional endosonography. METHODS: Fifty-five nulliparous women (mean age 30 years, range 18--47 years) had three-dimensional anal endosonography, anal manometry, and questionnaire assessment of continence at a median gestation of 33 weeks (23--42 weeks) and 10 weeks (7--22 weeks) after delivery. RESULTS: There was ultrasound evidence of postpartum trauma in 13 of 45 women who had a vaginal delivery (29%, confidence interval [CI] 16%, 44%), involving the external sphincter in five (11%, CI 4%, 24%), the puboanalis in nine (20%, CI 10%, 35%), and the transverse perineii in three (7%, CI 1%, 18%). In four, more than one structure was damaged. External sphincter trauma was associated with a significant decrease in squeeze pressure (P =.035) and an increase in incontinence score (P =.02) compared with those without trauma. Tears to the puboanalis or transverse perineii only did not affect pressure or incontinence scores. Coronal imaging of the external anal sphincter was a useful adjunct to the assessment of trauma. CONCLUSION: The overall incidence of trauma to the sphincter complex was similar to that of previous reports, although actual damage to the external sphincter was less common and represented the only functionally significant component.
Adolescent↗
Assessment of external anal sphincter morphology in idiopathic fecal incontinence with endocoil magnetic resonance imaging.
The failure of external anal sphincter repair may relate to sphincter atrophy where muscle fibers are replaced by fat, seen on MRI due to the differing signals returned by fat and muscle tissue. Manometry, electrophysiology, and MRI with an endocoil were performed on 34 fecally incontinent patients with intact sphincters on endosonography. The area of the external sphincter was measured in the midcoronal plane, and the percentage fat content calculated. Sphincter muscle area correlated strongly with squeeze pressure (P < 0.001) but not with percentage fat content. There was no relationship between percentage fat and age, weight, anal sensation, squeeze pressure, sphincter length or width, or pudendal nerve terminal motor latency. There was a trend for smaller sphincters to contain a higher percentage fat content (P = 0.059). MRI has established a relationship between function and external sphincter bulk, but not fat content, although smaller muscles may contain more fat.
Adolescent↗
Endocoil magnetic resonance imaging quantification of external anal sphincter atrophy.
BACKGROUND: Anal function depends on the integrity and quality of the sphincter muscles. The diagnosis of external anal sphincter atrophy on endocoil magnetic resonography has been associated with poor outcome from sphincter repair, although the imaging criteria for atrophy remain unclear. METHODS: Women with intact sphincters on endosonography and either normal (more than 60 cm H(2)O) (n = 9) or low (n = 16) squeeze pressures had endocoil magnetic resonography and electromyography. The area and fat content of the external anal sphincter and puborectalis were measured on mid-coronal magnetic resonography and images were graded as showing normal, intermediate or advanced atrophy. The definition of the external anal sphincter on endosonography and the thickness of the internal anal sphincter were also assessed. RESULTS: Women with a normal anal squeeze pressure had a larger external anal sphincter cross-sectional area (mean(s.d.) 240(56) versus 193(62) mm(2); P = 0.01) with a lower mean fat content (mean(s.d.) 23(4) versus 30(6) per cent; P < 0.001) than those with low squeeze pressures. There was an overall correlation between squeeze pressure, cross-sectional area (r = 0.32, P = 0.02) and fat content (r = - 0.51, P < 0.001). Patients with a thin (less than 2 mm) internal anal sphincter and/or a poorly defined external sphincter on endosonography were more likely to have atrophy (positive predictive value 74 per cent). CONCLUSION: : Potential endosonographic markers for external anal sphincter atrophy are suggested, and a visual scale for endocoil magnetic resonographic assessment has been validated.
Adult↗
Multiplanar anal endosonography--normal anal canal anatomy.
INTRODUCTION: Volume acquisition during anal ultrasound enables multiplanar imaging of the anal canal. The normal ultrasonic multiplanar appearance of the anal canal is described and gender differences in canal anatomy are highlighted. METHODS: Ten male and 12 female normal volunteers (mean ages 31.5 years (s.d. 5.9) and 31.2 (s.d. 6.7)) had three-dimensional anal endosonography (3-D AES). Each volume dataset was seeded in the axial plane facilitating multiplanar identification of known anatomical structures. RESULTS: The anterior external anal sphincter (EAS) was significantly longer in men than women 30.1 mm (3.9) vs 16.9 mm (7.4) (P < 0.001). There was no difference in the length of the puborectalis 24.7 mm (6.4) vs 24 mm (5) (P=0.78) in men compared with women. The cranial extent of the anterior EAS was tilted forward in both sexes. The angle formed by the anterior EAS and the longitudinal axis of the anal canal was more acute in men than in women (11.1 degrees vs 18.6 degrees; P=0.007). Dataset volume seeding of familiar structures in the axial plane allowed the multiplanar endosonographic anatomy to be described. CONCLUSIONS: Multiplanar AES has enabled detailed longitudinal measurement of the components of the anal canal and has revealed important gender differences. The multiplanar ultrasonic appearance of the normal anal canal has been described for the first time.
Journal Article↗
Adherence to HIV regimens: 10 vital lessons.
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Antiretroviral Therapy, Highly Active↗
Dantrolene reduces serum TNFalpha and corticosterone levels and muscle calcium, calpain gene expression, and protein breakdown in septic rats.
The effects of dantrolene on serum TNFalpha and corticosterone levels and on muscle calcium, calpain gene expression, and protein breakdown were studied in rats with abdominal sepsis induced by cecal ligation and puncture. Treatment of rats with 10 mg/kg of dantrolene 2 h before and 8 h after induction of sepsis reduced serum TNFalpha and corticosterone, muscle calcium levels, mRNA levels for m- and mu-calpain, and the muscle specific calpain p94, as well as total and myofibrillar protein breakdown rates, determined as release of tyrosine and 3-methylhistidine, respectively, from incubated extensor digitorum longus muscles. The results support the concept that increased calcium concentrations may be an important mechanism of sepsis-induced muscle protein breakdown. The data also indicate that other mechanisms, in addition to reduced muscle calcium concentrations such as decreased levels of TNFalpha and glucocorticoids, may contribute to the anti-catabolic effects of dantrolene during sepsis. The observations are important from a clinical standpoint because they suggest that the catabolic response in skeletal muscle during sepsis may be prevented by treatment with a calcium antagonist.
Animals↗
Gender differences in the longitudinal pressure profile of the anal canal related to anatomical structure as demonstrated on three-dimensional anal endosonography.
BACKGROUND: Anal canal squeeze pressure is assumed to be due to external sphincter contraction, but the contribution of other muscles has not been explored. METHODS: Ten male and ten nulliparous female asymptomatic subjects had three-dimensional anal endosonography and manometry. Incremental squeeze pressures at 0. 5-cm intervals, expressed as a percentage of the maximum pressure recorded anywhere in the canal, were related to the following anatomical levels: puborectalis, overlap between external anal sphincter (EAS) and puborectalis, external and internal anal sphincters, and external anal sphincter only. Levels were determined by coronal and sagittal endosonographic reconstructions. RESULTS: Puborectalis was the same length in men and women (median 23.9 versus 27.1 mm) but represented a greater proportion of the anal canal in women (45 versus 61 per cent; P = 0.02). At the level of puborectalis alone, the pressure generated as a proportion of maximum anal canal pressure was 71 (range 32-100) per cent in men and 62 (range 32-100) per cent in women. At the level of the EAS alone, the pressure was 60 (4-98) per cent in men and 82 (41-100) per cent in women; where the external sphincter was overlapped by puborectalis, the pressure was 98 (60-100) per cent in men and 75 (47-100) per cent in women. CONCLUSION: Maximal anal canal squeeze pressure is found where the puborectalis overlaps the EAS. This segment represents a significant proportion of anal canal length in women.
Anal Canal↗