Biomedical subjects
Publications and source records attributed to N I Ramus.
Thyroglossal duct cyst usually presents as a painless swelling in the mid-line of the neck. This is the first documented case of an acute presentation of hoarseness and multi-loculated swelling. It also contrasts the limitations of ultrasonography with the accuracy of magnetic resonance imaging in such atypical swellings.
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Eighty-one patients who underwent subtotal thyroidectomy for thyrotoxicosis had a 10 per cent incidence of symptomatic hypocalcaemia (corrected calcium less than 2.0 mmol/l) but only a 1.2 per cent incidence of prolonged hypocalcaemia. In the same patients only one had a transient right sided recurrent laryngeal nerve palsy. These results would seem to confirm the wisdom of lateral ligation of the inferior thyroid arteries to protect the recurrent laryngeal nerve. They lend no support to the suggestion that in order to protect parathyroid function this teaching be abandoned in favour of a policy of ligation of the arteries on the surface of the gland. Nevertheless, injury, devascularization or inadvertent removal of parathyroid tissue must still be the first practical consideration.
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Ten patients severely disabled by post-gastrectomy syndromes were allocated to two treatment groups. Those with predominant dumping received a 10-cm antiperistaltic jejunal interposition; those with predominant bile vomiting received a 20-cm isoperistaltic interposition. After follow-up for a minimum of 3 years, 6 patients remained virtually asymptomatic (Visick grades 1 and 2). There were 2 deaths from myocardial infarction, 6 months and 2 years after remedial surgery. One patient developed a stomal ulcer after successful treatment of dumping. Jejunal interposition appears to be a safe and relatively successful procedure. A short antiperistaltic loop is recommended for early dumping; for bile vomiting a longer isoperistaltic segment is a satisfactory alternative to Roux-en-Y conversion.
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The effect of highly selective vagotomy on pancreatic exocrine function and the release of gastrin and cholecystokinin was studied in 10 patients with endoscopically-proven duodenal ulceration. Cholecystokinin and gastrin concentrations in serum both increased significantly after highly selective vagotomy. Amylase concentration in the duodenal aspirate increased significantly after vagotomy, but trypsin concentration remained unchanged. The expected reductions in gastric acid secretion were noted. Thus highly selective vagotomy reduces acid secretion effectively in patients with duodenal ulcer without impairing the exocrine function of the pancreas.
Using two cholecystokinin (CCK) radioimmunoassays CCK has been shown to be heterogeneous (CCK-33 and CCK-8) after both exogenous infusion and endogenous release. CCK-39 (CCK variant) was not separated after endogenous CCK stimulation but was identified after the exogenous infusion of 16% pure CCK. The disappearance half-time of 16% pure CCK has been shown to be 2.4 min and one major organ of catabolism identified--the kidney. Degradation of CCK by whole blood occurred after standing for 2 h, but if separation was carried out immediately serum could be left for 6 h before any further degradation took place. Serum appeared to retain its CCK activity more reliably than plasma. Abnormalities in CCK release in duodenal ulcer disease, which are further altered by highly selective vagotomy (HSV), have been demonstrated. Pancreatic exocrine function was not significantly altered by HSV. CCK release and disappearance are more rapid in patients with duodenal ulceration. This observation may be aetiologically important since unopposed postprandial hypergastrinaemia in the absence of effective inhibition by CCK might lead to increased gastric acid production.
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The concentration of gastrin in serum and antral mucosa was studied in anesthetized dogs after electrical stimulation of the antral branch vagus nerve. Vagal stimulation caused immediate and sustained release of gastrin into the circulation. After stimulation for one hour, the gastrin concentration of antral mucosa increased significantly. This suggests that vagal release of gastrin triggers its rapid synthesis.
Three symptomatic cases of congenital solitary cyst are reported, one in the liver and two in the spleen. Recurrence of the hepatic cyst after partial excision and drainage was complicated by fistula formation between the cyst and the duodenum. The fistula was successfully closed at a second operation. Calcification of the cyst wall occurred in one of two epithelial cysts of the spleen in young women, which were treated by splenectomy. Besides their rarity, congenital solitary cysts of the liver and spleen have several other features in common. Isotopic and ultrasonic scanning assist diagnosis in both conditions.
Five dogs prepared with Heidenhain pouches received infusions of saline, GIP and VIP before and after a standard meat meal. Blood samples were obtained under basal conditions and at subsequent intervals for measurement of gastrin, insulin, GIP and VIP by radioimmunoassay. GIP and VIP infusions had no effect on basal levels of gastrin. GIP and VIP (in common with secretin and glucagon) were found to suppress food-stimulated release of gastrin and gastrin-stimulated acid secretion from the Heidenhain pouch. Insulin levels were significantly elevated during GIP and VIP infusions. Food released GIP (and perhaps VIP.
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We have developed a sensitive, specific and reproducible radioimmunoassay for cholecystokinin (CCK) with which basal levels of CCK of between 400-800 pg/ml have been measured in normal man, in patients with diabetes and with duodenal ulcer disease, and in normal dogs. After a meal, circulating levels of CCK rose to 1000-1200 pg/ml in human subjects. Release of CCK was more rapid in diabetic and duodenal ulcer patients than in normal subjects, but elevated postprandial levels persisted much longer in normal subjects. Patients with the Zollinger-Ellison syndrome had elevated values of cholecystokinin which rose after a meal. Lack of correlation between elevated basal levels of gastrin and CCK in patients with the Zollinger-Ellison syndrome suggest that the hypercholecystokininemia may be absolute. The disappearance half-time of exogenous CCK was about 21/2 minutes in normal subjects as well as in diabetic and duodenal ulcer patients. Studies in dogs demonstrated no uptake of basal levels of cholecystokinin by the kidney; on infusion of exogenous CCK-33, the kidney extracted 43% of the total CCK presented and 56% of the integrated CCK. We conclude that: 1) circulating basal and postprandial levels of CCK may be measured in a reproducible fashion; 2) postprandial release of CCK is more rapid in diabetic and duodenal ulcer patients than in normal man; 3) the disappearance half-time of exogenous CCK in man and dogs is about 21/2 minutes; 4) the kidney is a major site for uptake of CCK.
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