Internal anal sphincter activity after restorative proctocolectomy for ulcerative colitis: a study using continuous ambulatory manometry

PURPOSE

The aim of this study was to further investigate continuous ambulatory anal manometry which has recently been introduced as a method for studying anorectal activity in ambulant patients, thereby avoiding many of the potential drawbacks of static techniques.

METHOD

In this study continuous ambulatory manometry was used to assess the activity of the internal anal sphincter in patients who had undergone restorative proctocolectomy, and, in particular, to compare patients who had undergone conventional mucosal proctectomy with sutured endoanal, ileoanal anastomosis with patients who had undergone restorative proctocolectomy with preservation of the entire anal canal by means of stapled, end-to-end, ileoanal anastomosis without mucosectomy.

RESULTS

Evidence of basal internal sphincter activity was found in only 38 percent of patients after mucosal proctectomy with sutured endoanal anastomosis, whereas all patients after restorative proctocolectomy with stapled end-to-end anastomosis and all control individuals showed such activity of the internal sphincter. Similarly, the number of sampling episodes seen in patients after mucosal proctectomy with endoanal anastomosis was significantly less (median, 0.0/hours (0-30/hours)) than the number of sampling episodes observed in patients after end-to-end anastomosis (median, 4.5/hours (1-48/hours)) or in control individuals (median, 5.6/hours (0-31/hours)) (P < 0.001).

CONCLUSIONS

These results suggest that the internal anal sphincter is damaged in the course of mucosal proctectomy and endoanal anastomosis. In contrast, after restorative proctocolectomy with stapled, end-to-end anastomosis normal function of the internal sphincter is preserved.

Identification of melanoma cell surface antigens immunogenic in mice

Active immunization to B16 melanoma cells or vaccines induces anti-melanoma immune responses in syngeneic mice. The immunogenic antigens stimulating immunity to this tumor have not been identified. In this study we detected several B16 melanoma antigens immunogenic in syngeneic mice using as probes antimelanoma antibodies induced by immunization to B16 melanoma vaccines. These antigens were identified by SDS-PAGE and autoradiographic analysis of specific immunoprecipitates. They were cell-surface components with approximate molecular weights of 41, 46, 50, 75, 80, and 104 KD. All these antigens were expressed by syngeneic and xenogeneic melanomas and by some unrelated syngeneic tumors but not by normal syngeneic cells, xenogeneic melanocytes, or by B16 melanoma cells obtained from fresh tumors or grown in defined medium. The antigens were distinct from murine viral antigens expressed by B16 melanoma cells and from components of the culture medium used to grow cells for vaccine production. These results indicate that several B16 melanoma cell-surface antigens are immunogenic in syngeneic mice. Expression of these antigens appears to be related to malignant transformation as they were found on all melanomas studied, and some other cancers, but not on normal cells.

The results of modified use of chemotherapy for patients with metastatic breast cancer

We investigated whether modifying standard chemotherapy with 5-fluorouracil, doxorubicin and cyclophosphamide (FAC) could improve the outcome of patients with advanced breast carcinoma. We changed the conventional FAC treatment as follows: firstly, we administered oestrogens during the delivery of chemotherapy. Secondly, we administered 5-fluorouracil by continuous infusion. Thirdly, we limited chemotherapy treatment to 12 cycles and did not continue treatment during remissions. We evaluated this modified treatment in 63 patients and compared its results to other treatments results given at this institution. We found that the modified treatment improved the quality of life and survival of premenopausal breast cancer patients.

Early response gene signalling cascades activated by ionising radiation in primary human B cells

We have used a panel of 13 protein kinase C-responsive immediate early gene probes to dissect the cellular signalling pathways activated by ionising gamma radiation in primary human B cells. Of these 13 genes, a delayed transient induction was observed for only 8: c-fos, c-jun, jun-B, jun-D, c-myc, ergI/krox 24 and two 'anonymous' genes, 3L3 and 19A. Expression of c-myc and c-fos mRNAs was paralleled by the appearance of their encoded proteins suggesting that these oncoproteins may couple radiation signalling to cellular responses. Of three protein kinase C-coupled transcription factors examined by gel retardation assay, (AP1, NF kappa B, EgrK/Krox24) only NF kappa B and, to a lesser extent, AP1 was stimulated in response to irradiation. These observations are not obviously compatible with a simple model invoking protein kinase C in radiation signalling in primary B cells and suggest that the pleiotropic effects of ionising radiation on this cell type are mediated through a distinct cellular signalling cascade.

Significance of circumferential resection margin involvement after oesophagectomy for cancer

This study examined the influence of tumour involvement of the circumferential resection margin on subsequent local recurrence after oesophagectomy. Fifty patients were studied: 36 men and 14 women of median age 62 (range 44-83) years. Each patient had undergone oesophagectomy at which all macroscopic disease had been removed. Pathological specimens were sectioned tangentially at 0.5-1.0-cm intervals to permit microscopic examination of the circumferential resection margin. Patients were followed and investigated by endoscopy with biopsy and imaging techniques only if symptomatic. Twenty of the 50 specimens demonstrated involvement of the circumferential resection margin. At median follow-up of 36 (range 24-52) months, eleven of these 20 patients had developed histologically proven local recurrence compared with only four of the remaining 30 in whom the resection margin was clear of tumour (P < 0.01). Circumferential spread of oesophageal cancer appears to be a significant cause of local tumour recurrence.

Carriage of adhesive Escherichia coli after restorative proctocolectomy and pouch anal anastomosis: relation with functional outcome and inflammation

Restorative proctocolectomy with pelvic ileal reservoir is a well accepted option for the surgical treatment of ulcerative colitis. Acute pouchitis is a common complication and resembles acute ulcerative colitis. Patients with ulcerative colitis carry Escherichia coli that adhere to epithelial cells and thus this study examined whether acute pouchitis is associated with the carriage of adhesive E coli. E coli isolated from stool samples from 24 patients (median age 34 years, range 16-64; 13 men, 11 women) who had had restorative proctocolectomy with pelvic ileal reservoir were examined by means of the buccal epithelial cell adhesion assay. Patients were studied at a median of 12 months (range 7-21) after operation. Eight of 24 patients had acute pouchitis at the time of study. Adhesive E coli were detected in nine of 24 patients with a pelvic ileal reservoir compared with none of 12 controls (p < 0.05). The buccal epithelial cell adhesion index was inversely related to the degree of acute pouchitis (rs = 0.46, p = 0.024) and to the functional outcome (rs = -0.49, p = 0.022). Carriage of adhesive E coli was not related to the design of the reservoir. By contrast with ulcerative colitis, acute pouchitis is not associated with the carriage of adhesive E coli.

Inhibition of proliferation, activation and function of human natural-killer-cells in-vitro by secreted products of lovo, a colorectal-cancer cell-line

It has previously been suggested that some tumours may elaborate substances which can suppress the functional activity of lymphokine activated killer (LAK) cells. We have investigated the effects of secreted products from the colorectal cancer cell line LoVo on the pattern of expression of T lymphocyte subsets and natural killer cell phenotype and activation antigens during in vitro treatment of mixed populations of human peripheral blood mononuclear cells with recombinant human IL-2 (rhIL-2). Tumour cell line products inhibited the proliferation of cells expressing the NK cell antigen CD56 and of cells expressing the CD8 T cell subset antigen. Increased expression of the IL-2 receptor alpha chain component CD25, and the activation associated antigens CD71 and HLA-DR induced by rhIL-2 was inhibited by the presence of tumour cell products. Enhanced cytotoxic activity against standard target. cell lines Daudi and K562 induced by treatment with rhIL-2 was diminished by tumour cell supernatants. These mechanisms may contribute to the resistance of some tumours to immune response modulation treatment regimens which depend upon induction of lymphokine activation responses by rhIL-2.

Vascular abnormalities in non-insulin-dependent diabetes mellitus identified by arterial waveform analysis

PURPOSE

The arterial pressure waveform is derived from the complex interaction of the left ventricular stroke volume and the physical properties of the arterial circulation. Widespread abnormalities in the physical characteristics of the arterial vessels associated with diabetes mellitus can produce consistent changes in the shape of the pressure pulse waveform, providing information about arterial structure and tone that can be quantitated by pulse contour analysis.

PATIENTS AND METHODS

We analyzed intraarterial brachial artery waveforms in 28 patients with non-insulin-dependent diabetes mellitus and 22 control subjects matched for age and sex. A computer-based assessment of the diastolic pressure decay and a modified Windkessel model of the circulation were employed to quantify changes in arterial waveform morphology in terms of the large-artery compliance (C1), the oscillatory diastolic waveform (C2), inertance, and systemic resistance.

RESULTS

No differences were found in heart rate, mean arterial pressure, cardiac output, or stroke volume between groups. The mean oscillary arterial compliance estimate was significantly reduced in diabetic subjects versus controls: 0.02 (95% confidence interval [CI], 0.01 to 0.03) mL/mm Hg versus 0.08 (95% CI, 0.04 to 0.12) mL/mm Hg (p < 0.001). Oscillatory compliance values were uniformly reduced in the diabetic subjects regardless of the presence or absence of physical complications of the disease. No differences in large-artery compliance, inertance, or systemic resistance were found between groups. No positive correlations were found between indices of glycemic control, the known duration of diabetes, and any of the hemodynamic variables.

CONCLUSIONS

Quantitative changes in the arterial pressure pulse waveform, reflected by a reduced oscillatory compliance estimate, were found in patients with non-insulin-dependent diabetes mellitus. This estimate appears to act as an early marker for the vascular abnormalities associated with diabetes before complications of the disease become clinically apparent. By contrast, no changes in large-artery compliance were found in this patient population free from clinically obvious macrovascular disease.

Gastric cancer: a curable disease in Britain

OBJECTIVE

To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer.

DESIGN

Prospective audit of all cases of gastric cancer treated during 1970-89.

SETTING

Department of surgery, general hospital.

SUBJECTS

493 consecutive patients with gastric adenocarcinoma.

MAIN OUTCOME MEASURES

Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection.

RESULTS

207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%.

CONCLUSIONS

These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.

The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions

OBJECTIVES

The purpose of this study was to implement and evaluate the effectiveness of a long-term tobacco use prevention program for junior high school students that used college undergraduate change agents and telephone boosters.

METHODS

A psychosocial intervention combining refusal skills training, contingency management, and other tobacco use prevention methodologies such as telephone and mail boosters was implemented in 11 junior high schools in San Diego County, California. Eleven other junior high schools served as controls. Of the 2668 participants, 57% were White/non-Hispanic, 24% were Hispanic, and 19% were of other racial/ethnic groups. College undergraduates served as change agents for both the classroom and booster interventions, the latter of which was delivered in the third (ninth-grade) year of the program.

RESULTS

At the end of the third year, the prevalence of tobacco use within the past month was 14.2% among the intervention students and 22.5% among the controls, yielding an odds ratio of 0.71 for analysis at the school level.

CONCLUSIONS

Both college undergraduate change agents and direct one-to-one telephone interventions appear to provide cost-effective tobacco-related behavior modification.

Voltage- and space-clamp errors associated with the measurement of electrotonically remote synaptic events

1. The voltage- and space-clamp errors associated with the use of a somatic electrode to measure current from dendritic synapses are evaluated using both equivalent-cylinder and morphologically realistic models of neuronal dendritic trees. 2. As a first step toward understanding the properties of synaptic current distortion under voltage-clamp conditions, the attenuation of step and sinusoidal voltage changes are evaluated in equivalent cylinder models. Demonstration of the frequency-dependent attenuation of voltage in the cable is then used as a framework for understanding the distortion of synaptic currents generated at sites remote from the somatic recording electrode and measured in the voltage-clamp recording configuration. 3. Increases in specific membrane resistivity (Rm) are shown to reduce steady-state voltage attenuation, while producing only minimal reduction in attenuation of transient voltage changes. Experimental manipulations that increase Rm therefore improve the accuracy of estimates of reversal potential for electrotonically remote synapses, but do not significantly reduce the attenuation of peak current. In addition, increases in Rm have the effect of slowing the kinetics of poorly clamped synaptic currents. 4. The effects of the magnitude of the synaptic conductance and its kinetics on the measured synaptic currents are also examined and discussed. The error in estimating parameters from measured synaptic currents is greatest for synapses with fast kinetics and large conductances. 5. A morphologically realistic model of a CA3 pyramidal neuron is used to demonstrate the generality of the conclusions derived from equivalent cylinder models. The realistic model is also used to fit synaptic currents generated by stimulation of mossy fiber (MF) and commissural/associational (C/A) inputs to CA3 neurons and to estimate the amount of distortion of these measured currents. 6. Anatomic data from the CA3 pyramidal neuron model are used to construct a simplified two-cylinder CA3 model. This model is used to estimate the electrotonic distances of MF synapses (which are located proximal to the soma) and perforant path (PP) synapses (which are located at the distal ends of the apical dendrites) and the distortion of synaptic current parameters measured for these synapses. 7. Results from the equivalent-cylinder models, the morphological CA3 model, and the simplified CA3 model all indicate that the amount of distortion of synaptic currents increases steeply as a function of distance from the soma. MF synapses close to the soma are likely to be subject only to small space-clamp errors, whereas MF synapses farther from the soma are likely to be substantially attenuated.(ABSTRACT TRUNCATED AT 400 WORDS)

Proliferating cell nuclear antigen (PCNA) expression in chronic lymphocytic leukemia (CLL)

Chronic Lymphocytic Leukemia (CLL) is usually an indolent disorder which in some patients assumes an aggressive clinical course. In order to assess at presentation the prognosis of a given patient, several staging systems and prognostic variables have been proposed including the expression of the Proliferating Cell Nuclear Antigen (PCNA). PCNA is a 36 kd nuclear protein, the regulation of which is cell cycle-dependent. In CLL, PCNA levels correlate with cell proliferation, clinical stage and the lymphocyte doubling time (LDT). Furthermore, preliminary data suggests that PCNA expression may also predict response to Fludarabine-based chemotherapy. Since PCNA is a cofactor for Delta DNA polymerase, PCNA overexpression in CLL may also reflect the intrinsic DNA repair activity of the leukemic cells and thus their resistance to chemotherapy. Further studies aiming at modulation of PCNA expression in CLL cells may clarify this issue and may offer a future new therapeutic strategy with which to treat this disorder.

Restorative proctocolectomy with end to end pouch-anal anastomosis in patients over the age of fifty

This study was to examine whether 'fit' patients over the age of 50 who require elective surgery for ulcerative colitis are suitable candidates for restorative proctocolectomy, providing that they are continent before operation and that the anal sphincter is preserved in its entirety without stripping of the mucosa or endoanal anastomosis. Between 1986 and 1991, 18 patients 50 to 66 years old (median 55 years: nine men) underwent restorative proctocolectomy with end to end ileoanal anastomosis without mucosal stripping (12 quadruplicated (W), four duplicated (J), two no reservoir). The results were compared 12 (range three to 24) months later with those of 18 matched patients who were less than 50 years of age (median 34 years). In patients over 50, median resting anal pressure was 88 (range 44-131) cm water before and 80 (47-138) cm water after the operation (NS). In patients under 50, median resting anal pressure was 76 (51-128) cm water before and 77 (36-137) cm water after operation (NS). Resting anal pressure in older patients did not differ significantly from that in younger patients either before or after the operation. Both sensory and reflex anal functions were preserved as well after operation in the older patients as in the younger ones. The clinical results in patients over 50 were slightly inferior to the results for the younger patients, but the difference was small and not significant. Hence age alone is not a contraindication to restorative surgery provided that the anal sphincter is preserved in its entirety.

Healthcare foodservice report 1993. Getting ready for reform. Interview by Mitchell Schechter

Hospital foodservice directors & dietitians are facing the greatest challenge of their careers -- to prepare, along with their institutions, for the most thoroughgoing reform of America's healthcare system ever proposed. Healthcare institutions across the country are seeking the means to offer enhanced patient services & gain competitive advantages by forming new alliances, new patient-centered care systems & cost-reduction programs. To aid in these efforts, their foodservices are developing comprehensive cross-training schemes, inter-departmental teams with other service groups & new ways to cut operating subsidies. Here's how five hospital foodservice departments are using cost controls, revenue building, quality management processes & enhanced efficiencies to help their institutions prepare for the changes ahead.

Quality of life after restorative proctocolectomy with a pelvic ileal reservoir compares favorably with that of patients with medically treated colitis

There remains some reluctance among physicians to refer patients for restorative proctocolectomy (RP). They argue that their patients would be worse off with a pouch because of the attendant problems of urgency and frequent bowel actions. The aim of this study was to compare quality of life in patients who had undergone RP with that of patients with ulcerative colitis on long-term medical treatment. A detailed questionnaire and the Hospital Anxiety and Depression (HAD) test were completed by 103 patients who had undergone RP and by 95 patients with ulcerative colitis on medical treatment and in remission attending a gastroenterology clinic. Patients with a pouch had a greater frequency of bowel action [five times per 24 hours (range, 4-7) vs. two times per 24 hours (range, 1-3); P < 0.001] but less urgency of defecation [12/103 (11.7 percent) vs. 69/95 (72.6 percent); P < 0.001] than patients with medically treated colitis. Efficiency of evacuation, discrimination between flatus and feces, use of perianal pads, and perianal soreness were similar. Use of antidiarrheal medication was more common in the pouch group [53 of 103 patients (51.5 percent) vs. 3 of 95 patients (3.2 percent); P < 0.05], whereas use of topical steroids was more common in medically treated patients [40 of 95 patients (47.1 percent) vs. 9 of 103 patients (8.7 percent); P < 0.05]. Limitation of social activity and HAD scores were significantly higher in medically treated patients. Quality of life for patients with a pouch appears to be as good as that for patients with medically treated colitis.

The administration of supplementary oxygen to prevent hypoxia during upper alimentary endoscopy

A prospective, randomized, controlled trial was conducted in 200 consecutive patients undergoing endoscopy of the upper alimentary tract. One hundred patients received supplementary oxygen at 4 liters/minute through nasal cannulae, while 100 patients received no additional oxygen. Within each of these two groups, 50 patients were sedated with midazolam and 50 patients with diazepam suspension ("Diazemuls"). The patients' weights were recorded and correlated with their height to assess whether they were over or under their ideal weight. Oxygen saturation was recorded at baseline and throughout the endoscopic procedure. The principal finding of this study was that hypoxia (oxygen saturation less than 93%) was prevented in all cases by the administration of 4 liters/minute of oxygen, whereas 48 of the 100 patients who did not receive oxygen exhibited falls in oxygen saturation to less than 93% (p < 0.0001). Those with the highest risk were the obese patients (p < 0.01). There was no significant difference between the two sedative drug groups in either frequency or severity of associated hypoxia (p = 0.77, patients not given oxygen; p = 0.31, patients receiving oxygen). The cost of administering oxygen during upper gastrointestinal endoscopy would be an average of 95 pence ($1.60) per patient. In conclusion, the administration of oxygen during endoscopy is a worthwhile prophylactic measure to prevent hypoxia and its potential adverse effects.

Serotonin inhibits induction of long-term potentiation at commissural synapses in hippocampus

This study tests the effect of serotonin (5-HT) (1 microM) on the induction of long-term potentiation (LTP) at the commissural/associational (C/A)-CA3 synapse. The C/A input to CA3 was measured by field potentials in rat hippocampal slices. At the concentration used 5-HT had little or no effect on synaptic transmission, but suppressed the induction of LTP. Similar results were observed in normal saline and in saline containing picrotoxin (10 microM) and bicuculline (10 microM) to block GABAA inhibition. Perfusion with methysergide (1 microM), a 5-HT antagonist, had no effect on synaptic transmission, but partially blocked the effect of 5-HT on LTP. The block of LTP by 5-HT could be overcome by using a higher intensity of stimulation suggesting that 5-HT might hyperpolarize the postsynaptic neurons to inhibit LTP induction. We conclude that the activation of serotonergic receptors inhibits the induction of LTP at the C/A-CA3 synapse.

An immediate early human gene encodes an Id-like helix-loop-helix protein and is regulated by protein kinase C activation in diverse cell types

Transcription factors characterized by the presence of a helix-loop-helix (HLH) domain play a central role in the regulation of cell growth/differentiation and tumorigenesis. We report here the cDNA sequence of a human early-response gene, designated HLH 1R21, encoding a 15-kDa HLH protein that lacks a basic, DNA-binding domain and which by a number of criteria appears to be the human homologue of mouse HLH 462. Like its murine counterpart, HLH 1R21 protein functions as an Id (inhibitor of DNA binding) transcription factor by inhibiting the binding of E2A-containing protein complexes to muscle creatine kinase E-box enhancer oligonucleotide in vitro. However HLH 1R21 does not inhibit the binding of HLH Max protein to a Max-binding oligonucleotide in vitro, indicating that it has limited promiscuity in its ability to antagonize the function of other HLH transcription factors. In addition, HLH 1R21 mRNA transcripts are regulated by phorbol ester treatment of a diverse range of human cell lines and, when overexpressed in mouse NIH3T3 cells, HLH 1R21 induces a morphologically transformed phenotype.

Synaptically activated increases in Ca2+ concentration in hippocampal CA1 pyramidal cells are primarily due to voltage-gated Ca2+ channels

Changes in intracellular Ca2+ concentration ([Ca2+]i) in the soma and dendrites of hippocampal CA1 pyramidal neurons were measured using intracellularly injected fura-2. A large component of the [Ca2+]i elevation caused by high frequency stimulation of the Schaffer collaterals was correlated with the Na+ spikes triggered by the excitatory postsynaptic potentials (EPSPs). These spikes were generated in the soma and proximal dendrites and stimulated Ca2+ entry through voltage-gated Ca2+ channels. Suppressing spikes by hyperpolarizing the soma or by injecting QX-314 revealed a smaller nonspike component of Ca2+ entry. A substantial fraction of this component was mediated by the action of the EPSPs on voltage-gated Ca2+ channels, because it persisted in 2-amino-5-phosphonovaleric acid and because it was usually reduced when Ca2+ channel activity was suppressed by hyperpolarization. Ca2+ entry through the N-methyl-D-aspartate receptor channel could not be detected with certainty, perhaps because it was highly localized.

Cytokine production and immune cell activation in melanoma patients treated with liposomal muramyl tripeptide (CGP 19835A lipid)

We conducted a pilot study using liposome-encapsulated muramyl tripeptide phosphatidylethanolamine (L-MTP-PE) preoperatively in patients with stage III or IV resectable melanoma who were at high risk for recurrence. Patients received L-MTP-PE for 1 month before surgery and then 5 months postoperatively. Several immune parameters were monitored during preoperative therapy to search for correlations with clinical (tumor) response. The 18 patients were classified into three groups according to their responses and disease-free intervals: no evidence of disease (NED) at week 24 of therapy, relapse during therapy and progressive disease on therapy noted at the time of surgery. Six of nine patients in the NED group demonstrated increased monocyte tumoricidal activity (MTA) during week 1 of therapy. MTA increased in three of the six patients in the relapse group. MTA did not increase in the three patients who had progressive disease on therapy. Plasma neopterin levels were elevated by 72 h following the first L-MTP-PE dose in all 18 patients. Circulating levels of tumor necrosis factor were elevated in 15 of 16 patients tested, and IL-6 levels were elevated in all 18 patients. Melanoma cells from all three patients with progressive disease at the time of surgery proliferated well in vitro, whereas tumor cells from 10 of the 15 patients in the other two groups did not proliferate. There were no discernible differences among the three groups in the magnitude of IL-2-induced proliferation of tumor infiltrating lymphocytes. However, IL-2-activated TILs from the NED group exhibited cytotoxicity against autologous tumor cells in vitro. In summary, whereas L-MTP-PE stimulated several immunologic responses in all patients, the only two parameters that correlated with clinical status were MTA and the tumor proliferation assay. These two biologic assays could serve to distinguish potential responders from nonresponders early in the course of treatment.

Effect of anorectal eversion during restorative proctocolectomy on anal sphincter function

Twenty-six patients underwent restorative proctocolectomy with end-to-end ileal pouch-anal anastomosis, without resection of the anal mucosa, by the eversion technique. Before surgery patients underwent tests of anorectal function. These were repeated a median of 8 (range 3-21) months after operation. The median (range) maximum resting anal pressure was 93 (36-149) cmH2O before and 71 (40-131) cmH2O after operation (P = 0.002). The median (range) maximum squeeze pressure before operation was 136 (73-280) cmH2O; it was 149 (69-290) cmH2O afterwards (P not significant). The median (range) length of the anal sphincter was 3.5 (2.5-4.5) cm before and 3.5 (2.0-4.5) cm after operation (P not significant). Thresholds for sensation in the upper, middle and lower thirds of the anal canal before and after operation were, respectively, 8.7 versus 8.7, 6.8 versus 7.4 and 4.2 versus 6.2 mA (P not significant). All 26 patients were continent, although one experienced minor leakage. Function of the anal sphincter is not significantly impaired by eversion of the rectum and anus during restorative proctocolectomy.