Biomedical subjects
Publications and source records attributed to P N Foster.
Two cases of bradycardia following the intra-operative use of ketorolac given intravenously (i.v.) to children are reported. We examine why this may not have been previously reported and make recommendations regarding its use.
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Akathisia has been described following the use of droperidol for antiemetic prophylaxis. In a double-blind, placebo-controlled study, we investigated both the incidence of akathisia and its relationship to the dose of droperidol (0.5 or 1 mg). One hundred and twenty healthy women undergoing day-case gynaecological surgery were anaesthetised with propofol, fentanyl, isoflurane and droperidol according to group. Patients were assessed by structured telephone interview at 24 h. There was an increasing incidence of both restlessness (p = 0.01) and unpleasant restlessness (p = 0.02) between the groups on Chi-squared testing. Compared to the control group, those women given droperidol 1 mg suffered more restlessness (p = 0.001) and unpleasant restlessness (p < 0.01). No statistical difference could be demonstrated between the two droperidol groups. We conclude that droperidol may commonly cause akathisia and may not, therefore, be an appropriate prophylactic antiemetic for day-case anaesthesia.
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Twenty-one patients with Crohn's disease were followed prospectively for 24 weeks to examine the effect of a low-dose cyclosporin regime on renal function (initial dose 5 mg/kg reduced by 1 mg/kg every two months to a maintenance of 2 mg/kg). Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured by radioisotope clearance at 0, 6 and 24 weeks. GFR and ERPF fell significantly (mean GFR at baseline: 120.9 ml/min/1.73 m2; at six weeks: 100.9 ml/min/1.73 m2; mean ERPF at baseline: 497.3 ml/min/1.73 m2; at six weeks: 398.5 ml/min/1.73 m2). Following dose reduction, the ERPF remained lower than baseline (mean 408.6 ml/min/1.73 m2), and there was a trend towards the GFR remaining low (mean 111.8 ml/min/1.73 m2). Serum creatinine rose significantly (median pretreatment 72 mumol/liter; median at four weeks 86 mumol/liter) but returned to baseline after dose reduction. Plasma cyclosporin levels and serum creatinine did not help predict the extent of changes in renal function. At low doses, cyclosporin causes changes in renal hemodynamics that may not be reversed by dose reduction.
OBJECTIVE: To determine whether azathioprine can prevent relapse in ulcerative colitis. DESIGN: One year placebo controlled double blind trial of withdrawal or continuation of azathioprine. SETTING: Outpatient clinics of five hospitals. SUBJECTS: 79 patients with ulcerative colitis who had been taking azathioprine for six months or more. Patients in full remission for two months or more (67), and patients with chronic low grade or corticosteroid dependent disease (12) were randomised separately. 33 patients in remission received azathioprine and 34 placebo; five patients with chronic stable disease received azathioprine and seven placebo. MAIN OUTCOME MEASURE: Rate of relapse. Relapse was defined as worsening of symptoms or sigmoidoscopic appearance. RESULTS: For the remission group the one year rate of relapse was 36% (12/33) for patients continuing azathioprine and 59% (20/34) for those taking placebo (hazard rate ratio 0.5, 95% confidence interval 0.25 to 1.0). For the subgroup of 54 patients in long term remission (greater than six months before entry to trial) benefit was still evident, with a 31% (8/26) rate of relapse with azathioprine and 61% (17/28) with placebo (p less than 0.01). For the small group of patients with chronic stable colitis (six were corticosteroid dependent and six had low grade symptoms) no benefit was found from continued azathioprine therapy. Adverse events were minimal. CONCLUSIONS: Azathioprine maintenance treatment in ulcerative colitis is beneficial for at least two years if patients have achieved remission while taking the drug. Demonstration of the relapse preventing properties of azathioprine has implications for a large number of patients with troublesome ulcerative colitis, who may benefit from treatment with azathioprine.
The responses of peripheral blood B cells to mitogenic stimulation were examined in 12 splenectomized subjects without residual splenic function, as determined by pitted erythrocyte counts. These were compared to a group of healthy controls matched for age and sex. Polyclonal anti-immunoglobulin evoked a normal transient elevation in intracellular free Ca2+ in splenectomized subjects, thereby suggesting that the early events of the signal transduction pathway are not impaired. However, mitogenic stimulation by pre-treatment with phorbol ester and culture in presence of a calcium ionophore (Ionomycin) resulted in reduced uptake of 3H-thymidine and subsequent proliferation. Nevertheless, entry into the mitotic cycle, as assessed by expression of Ki67, was slightly, but not significantly impaired. Unlike in normal controls, where up to 7% of freshly-isolated B cells were Ki67+, almost no Ki67+ peripheral B cells were observed in splenectomized subjects. The data are consistent with the hypothesis that peripheral B cells in splenectomized subjects are in a reduced state of activation compared with normal controls and require additional growth factor stimulation before they can undergo mitosis.
The use of azathioprine in ulcerative colitis is unclear. The authors present the details and outcome of 47 patients who received azathioprine for either a) severe, resistant disease otherwise requiring surgery (28 patients) or b) patients with steroid dependence who have been followed up for at least 12 months (19 patients). Duration of treatment ranged from one week to 66 months (median, 12 months). Of the patients in Group I, 13 (46 percent) achieved remission, 11 of whom had not relapsed during a median follow-up of 22 months (range, 12 to 58 months), and 15 underwent surgery one week to 12 months (median, five weeks) after commencing azathioprine. In Group II, steroids were withdrawn or reduced in 12 (63 percent) patients and three patients required colectomy. Side effects necessitating withdrawal of azathioprine occurred in 12 patients (hematologic effects, 6 patients; gastrointestinal effects, 4 patients; other effects, 2 patients). Two patients required a reduced dose of azathioprine because of leukopenia. The authors conclude that azathioprine is a valuable therapeutic option in selected patients with ulcerative colitis.
To determine whether the "congestive" gastropathy associated with portal hypertension showed distinctive histological features independent of inflammatory gastritis, endoscopic biopsy specimens of gastric mucosa from 23 patients with portal hypertension and 25 patients with non-ulcer dyspepsia were examined. Active chronic gastritis associated with Campylobacter pylori was found in three patients with portal hypertension compared with 13 patients with non-ulcer dyspepsia. The changes of reflux gastritis were seen in nine patients with portal hypertension compared with three patients with non-ulcer dyspepsia. Mucosal capillary dilatation, assessed on sections stained for factor VIII related antigen, a specific marker for endothelial cells, was significantly greater in biopsy specimens from patients with portal hypertension but this difference was not apparent on sections stained conventionally. The degree of capillary dilatation was unrelated to the presence of histological gastritis. These observations support the view that portal hypertension is associated with a distinctive gastropathy characterised by prominence and dilatation of mucosal capillaries.
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The value of intravenous aminophylline in accelerating recovery from premedication with diazepam was assessed against placebo in a randomized, double-blind trial. One hundred ten patients undergoing routine diagnostic upper gastrointestinal endoscopy received diazepam intravenously in a dosage sufficient to achieve adequate sedation. On completion of the endoscopy, patients received either aminophylline (1.5 mg/kg) or placebo. Recovery from sedation was assessed on clinical grounds by a nurse, objectively using a serial reaction time test, and by the patient on a visual analogue scale. The number of patients judged to be fully alert at 30 and 60 min after the procedure was significantly greater in the aminophylline group than in the placebo group. Compared with values obtained before sedation, the placebo group had significantly prolonged reaction times 30 min after completion of the endoscopy, whereas patients who received aminophylline did not. However, according to their self-assessments, patients in both groups felt more uncoordinated following sedation. Aminophylline appears to hasten recovery from sedation with diazepam, and its use may permit earlier mobilization of patients after endoscopy.
The association of achalasia like disorder of the oesophagus with von Recklinghausen's neurofibromatosis to our knowledge not previously reported is described in a 56 year old man who also had bladder dysfunction. At necropsy the oesophageal myenteric plexus showed ganglion cell depletion with nerve fibre hyperplasia probably the result of Schwann cell hyperplasia. We suggest that the disturbances of oesophageal and bladder function were a consequence of involvement of the autonomic nervous system by neurofibromatosis.
Radiotelemetric ambulatory 24 hour oesophageal pH measurement was carried out in 17 patients with symptomatic manometrically proven achalasia before and after pneumatic dilatation. Before dilatation an abnormally high percentage acid exposure time was present but typical episodes of gastro-oesophageal reflux occurred in only one patient. In nine patients who had a oesophageal food residue these values were significantly greater than those found in the remaining patients without retained food. Analysis of oesophageal food residues revealed that the low pH was predominantly caused by lactic acid. These findings indicate that preoperative oesophageal pH studies do not offer a valid means of selection of patients in whom an antireflux procedure should be combined with cardiomyotomy. Repeat studies one week after pneumatic dilatation showed a fall in the acid exposure time in patients with initial food residue presumably resulting from improved oesophageal emptying after treatment. A significant rise in acid exposure time after dilatation was seen in those patients without initial food residue presumably resulting from gastro-oesophageal reflux after therapeutic disruption of the lower oesophageal sphincter. Troublesome symptoms of gastro-oesophageal reflux were, however, uncommon after bag dilatation.
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We report a case of an adolescent girl who presented with painless massive ascites secondary to chronic pancreatitis and a ductal fistula. The diagnosis was delayed and an unnecessary laparotomy was performed, as initial evaluation of ascites did not include measurement of serum and ascitic amylase. Evidence of pancreatic abnormalities in asymptomatic relatives suggested an underlying hereditary pancreatitis. Hereditary pancreatitis presenting as pancreatic ascites, to our knowledge, has not been described previously.
We describe a patient with intestinal lymphangiectasia who developed hyposplenism and speculate that it resulted from chronic loss of lymphocytes into the gut.