Biomedical subjects
Publications and source records attributed to D E Beck.
The balloon expulsion test is a simple and inexpensive method to evaluate a patient's ability to expel and retain stool. In conjunction with other methods, it assists in identifying patients with outlet obstruction or incontinence. A simplified method of performing a balloon expulsion test is described.
Surgeons have developed many methods for the repair of direct inguinal hernias. The Cooper's ligament (McVay) repair and the Shouldice repair are widely used techniques. To determine the recurrence rates with differing techniques performed in a surgery residency program, we conducted a prospective randomized study for elective adult direct inguinal herniorrhaphies. Three hundred and eight elective direct inguinal herniorrhaphies in 269 adult patients were performed by residents in general surgery supervised by staff surgeons. Patients had yearly follow-up physical examinations (compliance rate of 87 percent) during an average follow-up period of 36.4 months. The recurrence rate was 8.8 percent for the McVay repair and 6.6 percent for the Shouldice repair (not significant). Bilateral inguinal hernias (repaired six weeks apart) had a recurrence rate of 12.8 percent, while the recurrence rate for unilateral repairs was 5.6 percent (p = <0.05). We found no significant difference in recurrence rates between the McVay and Shouldice herniorrhaphy techniques. However, there was an increase in hernia recurrence with either technique when bilateral direct inguinal herniorrhaphies were performed.
Sulfate free-electrolyte lavage solution is a new osmotically balanced electrolyte gut lavage solution for colon surgery that has been formulated for improved taste and reduced water and electrolyte changes. Sixty patients were prospectively randomized to receive a 1-day preparation with sulfate free-electrolyte lavage solution or a 3-day preparation using a clear liquid diet, cathartics, and enemas. The patient groups were similar in age, race, male-female ratio, and the types of colonic resections performed. Colonic cleansing was better with sulfate free-electrolyte lavage solution (100% vs 63% "good" to "excellent" cleansing). Patient tolerance evaluated by a questionnaire showed more overall discomfort with sulfate free-electrolyte lavage solution but no difference between the preparations in individual symptoms of fullness, cramping, nausea, or vomiting. One patient developed a low level of serum potassium after a cathartic and enema preparation, while there were no complications with sulfate free-electrolyte lavage solution. Patient taste questionnaires showed a slight preference for sulfate free-electrolyte lavage solution (53%) over a polyethylene glycol electrolyte lavage solution (47%). This study confirms that sulfate free-electrolyte lavage solution is a safe and effective method of preoperative colonic cleansing.
Leiomyomas of the intestine are rarely found in the pediatric population. The authors' review of the literature revealed only three colonic leiomyomas previously described. The authors present the first reported case of a child with lower gastrointestinal hemorrhage secondary to a colonic leiomyoma. Pathologic aspects of intestinal leiomyomas are discussed along with the difficulty in histologic differentiation from leiomyosarcomas. Wide resection is recommended for spindle cell neoplasms of the intestine owing to difficulty in differentiating benign from malignant tumors.
A mail survey of 300 members of The American Society of Colon and Rectal Surgeons (ASCRS) was conducted to document the current methods of bowel preparation in use. Two hundred six questionnaires (69 percent) were returned. The majority of respondents (104 or 51 percent) used cathartics and enemas as the primary method of mechanical bowel cleansing. Eighty-nine (43 percent) used a PEG lavage, eight (4 percent) used mannitol, and one physician used a saline lavage method. Almost all the responding surgeons believed that their method of preparation was well tolerated by patients, provided good cleansing, and was associated with few complications. Most patients were admitted one day before surgery. All respondents used perioperative antibiotics, with the most common pattern being a combination of oral and parenteral agents. Surgeons using PEG lavage did more colonic resections per month and were fewer years out of their residency. This current pattern of preoperative bowel preparation has changed from previous surveys.
A retrospective review of 677 patients who tested positive for the human immunodeficiency virus, evaluated from January 1986 to February 1988, demonstrated 119 patients (18 percent) with anal condylomata. Demographics of these patients were similar to the total human immunodeficiency virus group; ages ranged from 19 to 86 years (mean, 25 years). Ninety-four percent of patients were men, 62 percent were white, 30 percent were black, and 10 percent were other races, primarily Hispanic. Ten percent of the patients admitted to homosexual activity and 2 percent admitted to intravenous drug abuse. Sixty percent of the population had another sexually transmitted illness. The majority of patients were in early Walter Reed Classes (Stage I or II). With follow-up of 4 to 26 months (mean = 12 months), the recurrence rate for anal condylomata was 26 percent after local treatment with podophyllin and 4 percent after fulguration and excision. There were no operative complications. Our study confirmed that anal condylomata and sexually transmitted diseases are common in patients who test positive for the human immunodeficiency virus and that patients who test positive for the human immunodeficiency virus with early Walter Reed stages can be expected to do well with appropriate therapy.
Colonic lipomas are a rare source of massive lower gastrointestinal bleeding requiring operative intervention. A case of massive hemorrhage from cecal lipomatosis is presented. The methods of preoperative diagnosis and treatment are discussed.
With the adoption of mandatory testing for human immunodeficiency virus (HIV) in military personnel, a large number of HIV-positive individuals have been identified. From January 1986 to February 1988, 677 HIV-positive patients were evaluated at Wilford Hall USAF Medical Center. Most of these patients had disease in the Armed Forces Walter Reed stage I or II. Other sexually transmitted diseases were found in 407 patients (more than 60%). Of 163 patients (24%) with treatable anorectal conditions, 44 had nonsexually related anorectal conditions and 119 had anal condylomata. Patients with disease in early Walter Reed stages I and II did well with therapy of their anorectal diseases. We present our methods of evaluation, infection control, treatment, and results.
We reviewed the experience with breast cancer at Wilford Hall USAF Medical Center for the years 1978 through 1988. A total of 868 cases were identified in the Wilford Hall Tumor Registry; overall 5-year and 10-year survivals were 63% and 39%, respectively. Infiltrating ductal carcinoma represented the principal histologic category. The other predominant variants included invasive lobular carcinoma, lobular carcinoma in situ, and ductal carcinoma in situ. Until recently, most of these patients (90%) had modified radical mastectomy as their definitive surgical therapy, with chemotherapy reserved primarily for patients with advanced disease.
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The impact of the polyamine analogues, N1,N11-diethylnorspermine (DENSPM), N1,N12-diethylspermine (DESPM), and N1,N14-diethylhomospermine (DEHSPM) on the growth properties of L1210 murine leukemia cells is compared. The order of antiproliferative activity of the three compounds is shown to be DEHSPM greater than DESPM greater than DENSPM with average 96-h IC50 values of 0.06, 0.18, and 1.3 microM, respectively. Trypan blue exclusion suggests that the cytotoxic behavior of the compounds is not apparent until 96 h after exposure to the analogues. DEHSPM is shown to act more quickly and demonstrates the most profound cytotoxic effects at 144 h. Competitive uptake studies with spermidine reveal DESPM and DEHSPM to have essentially identical Ki values of 1.4 and 1.6 microM, respectively, while DENSPM indicates a substantially higher Ki value of 17 microM. Finally, although the analogues reduce the levels of putrescine, spermidine, and spermine in L1210 cells, if the concentration of polyamines in the cell, including analogues, is expressed on a nitrogen equivalence basis, the total cationic charge with which the polyamines are associated is conserved.
Intracellular nucleotides of Salmonella typhimurium were separated and quantified by high performance liquid chromatography (HPLC). Wild type and specially constructed strains of S. typhimurium, in which uridine and cytidine nucleotides could be manipulated independently, were used in this study. By varying growth conditions it was possible to create different concentrations of uridine and cytidine nucleotides in the cell. The specific activity of ATCase was determined for each condition. Generally, a direct correlation was found: at high nucleotide (UTP) concentrations, maximal repression of ATCase was usually seen; at low nucleotide (UTP) concentrations ATCase was derepressed. However, it was the ratio of the concentrations of UTP-to-CTP rather than either the concentration of UTP or CTP alone that best determined the extent of ATCase expression. This applied to all conditions in the present work as well as to all conditions in work hitherto reported by others. The ratio of UTP/CTP is proposed as a key regulatory parameter for pyr enzyme expression.
A 24-year-old woman with a two-year history of inflammatory bowel disease, with no anal or perineal involvement, underwent a proctocolectomy and ileostomy. Pathologic evaluation of the specimen revealed Crohn's colitis and unsuspected perianal Bowen's disease. The patient is free of Crohn's and Bowen's disease 6.5 years later. The association of perianal Bowen's disease with Crohn's colitis is discussed.
Pneumopericardium is an uncommon condition in the neonate and has not, to our knowledge, previously been reported in patients treated with high-frequency ventilation. The results of such treatment in 8 neonates seen in the Neonatal Intensive Care Unit, Wilford Hall USAF Medical Center, San Antonio, Texas, are presented. The mean gestational age was 35 weeks, and birth weight averaged 2.7 kg. The pneumopericardium developed while the patients were on high-frequency ventilation, and the diagnosis was confirmed with a chest radiogram. Treatment included pericardiocentesis with a needle catheter followed by placement of a 10F to 14F chest tube into the pericardial space. The pneumopericardium resolved in all 8 patients. Three of the newborns died of underlying disease; 5 survived and were discharged from the hospital. Pneumopericardium in the neonate is a life-threatening complication, and appropriate therapy includes drainage with a pericardial tube placed under direct vision.
Fourteen patients with chronic constipation due to colonic inertia were treated with total abdominal colectomy and ileorectal anastomosis at the Cleveland Clinic Foundation from 1981 to 1986. All patients were white women ranging in age from 28 to 64 years (mean 41 years). The duration of symptoms averaged 21 years (range six to 47 years) and the average time between bowel movements was ten days. The preoperative evaluation included barium enema in 12 patients and colonoscopy in five (some patients had both studies). Anorectal dysfunction was excluded by manometry in ten patients and by rectal biopsy in six. Colonic transit studies were accomplished in only two patients. The hospital stay averaged 13 days, and there was no operative mortality. Postoperative morbidity included one case of small bowel obstruction, necessitating operative correction on postoperative day 9. Follow-up ranged from three months to five years. At their last clinic visit, the patients averaged two bowel movements per day. All patients had excellent bowel control and were happy with the procedure.
Premalignant lesions of the anal margin include Bowen's disease (intraepithelial squamous cell carcinoma) and Paget's disease (intraepithelial adenocarcinoma). Our experience includes 11 patients with perianal Paget's disease and 37 patients with perianal Bowen's disease treated from 1957 to 1986. The patients with perianal Paget's disease were older, had a higher incidence of invasive cancer, and had a worse prognosis than those with perianal Bowen's disease. The characteristic appearance of these lesions and their failure to respond to conventional therapy should lead the clinician to obtain a biopsy, which readily establishes the diagnosis. Our experience confirms that adequate evaluation followed by wide local excision is the appropriate therapy. Close follow-up is recommended to identify recurrence of the perianal disease or development of other malignancies.
Over the past 11 years (1974 to 1985) ten patients with perianal Paget's disease were treated. The average age was 64 years and half were male. Two patients were diagnosed as an incidental finding after hemorrhoidectomy and the remainder presented with a symptomatic perianal rash (itching and moisture) that averaged two years in duration. Physical examination in these patients demonstrated characteristic lesions (seven with erythematous or ulcerated, whitish gray lesions and one with a papillary lesion). Three patients presented with invasive carcinomas and, despite aggressive therapy, all developed metastatic disease. Two patients had local excisions with minimal margins and developed associated invasive cancers at four and ten years after diagnosis. The remaining five patients were treated by wide local excision and skin grafts. At present all are free of disease. The characteristic appearance of this lesion and its failure to respond quickly to conventional therapy should lead the clinician to obtain a biopsy which readily establishes the diagnosis. Experience confirms that wide local excision is adequate therapy, but adequate initial evaluation and close follow-up are necessary to identify other malignancies that may develop.
Polyethylene glycol electrolyte lavage solution was compared with a 10 percent mannitol solution for preoperative colonic cleansing. Eighty patients were prepared randomly with one of these solutions on the afternoon prior to surgery. Colonic cleansing was better with polyethylene glycol electrolyte lavage (90 percent optimal cleansing vs. 75 percent). Analysis of hematologic, biochemical, and weight changes before and after the bowel preparation, demonstrated a mild subclinical dehydration with the use of mannitol. Evaluation of patient tolerance demonstrated more nausea, cramps, and abdominal pain with mannitol. Other symptoms were similar with both preparations. Colonic hydrogen gas was sampled during surgery, and two patients in the mannitol group had combustible levels. This study confirms that both 10 percent mannitol and polyethylene glycol electrolyte lavage are safe, effective methods of preoperative bowel cleansing. Better cleansing, patient tolerance, and lower hydrogen gas level make polyethylene glycol electrolyte lavage the preferred method.