Management of patients with Streptococcus milleri brain abscesses

OBJECTIVES

We evaluated the efficacy of cefotaxime in the management of brain abscesses caused by Streptococcus milleri. Twenty two patients with a S. milleri brain abscess were treated with metronidazole and cefotaxime, in accordance with recent recommendations by the British Society Of Antimicrobial Chemotherapy (BSAC). Seven patients who had Glasgow Coma Scales < or =11 also received rifampicin and high dose cefotaxime. The clinical response of the patients was determined.

METHOD

A retrospective study at the Queen Elizabeth Hospital, Birmingham covering the period April 1996-March 2004 was carried out. Neurosurgical and anti-microbial therapeutic approaches were reviewed. Any evidence of improvement of clinical features and radiological disappearance of brain abscesses were determined.

RESULTS

Outcome was assessed using the Glasgow Outcome Score (GOS) at 3 and 6 months from the time of surgical intervention. Eighteen patients (82%) had a good outcome by 6 months, with an outcome score of 4-5. Thirteen patients resumed normal life despite minor deficits (GOS 5), while a further five patients had moderate disability though remained independent (GOS 4). One patient had a GOS of 3 and there were three deaths (14). The minimum time to radiological resolution of the abscess was within 1 month in six cases (27) These all represented solitary lesions that required a single drainage procedure in conjunction with 4 weeks of intravenous cefotaxime and metronidazole. Ten cases (45%) had resolution within 4 months and a further three cases took at least 6 months from the time of surgery to show radiological clearance.

CONCLUSIONS

This cohort of patients responded favourably to the guidelines recommended by the BSAC. This was confirmed by the Glasgow Outcome Score (GOS 4-5) at 6 months review. Cefotaxime at a higher dose with rifampicin was prescribed for patients presenting with a decreased conscious level (GCS 8-11), subsequent failure of anticipated clinical improvement or clinical deterioration. There was no clinically significant difference in GOS between the two treatment groups. An algorithm for management of brain abscess is presented, based on our clinical experience and review of the literature.

In vivo role of 20-hydroxyecdysone in the regulation of the vitellogenin mRNA and egg development in the American dog tick, Dermacentor variabilis (Say)

Injection of the hormone 20-hydroxyecdysone (20-E) into partially fed (virgin) female adults of the American dog tick, Dermacentor variabilis, while they are attached and feeding on the rabbit host, initiated the expression of the vitellogenin (Vg) gene, and Vg protein secretion and uptake by the ovary. The induction of egg production by 20-E in this bioassay was dose dependent in the range of 1-50 times the concentration normally found in a replete, vitellogenic female. Ticks examined 4 d after the 50 x treatment were still attached to the host, had numerous enlarged vitellin-filled (brown) oocytes in their ovaries, but had not engorged to repletion. The ovaries reached weights similar to those found in untreated, replete (mated) females (pre-oviposition) while solvent-injected controls demonstrated no increase in oocyte size or increase in ovary weight. An increase in the levels of a putative Vg protein was observed in hemolymph samples collected 1, 2 and 3d post-20-E injection but was not observed in the corresponding solvent controls as determined by native PAGE. Analysis of the ecdysteroid-induced protein by tryptic digestion-mass fingerprinting and BLASTP found that the putative Vg had the strongest match to GP80 (U49934), the partial sequence for the vitellogenin protein from Boophilus microplus. A partial Vg cDNA was cloned and sequenced from replete females of D. variabilis with a high similarity to GP80. Using this message as a probe, Northern blots conducted with RNA collected from partially fed, virgin females 1, 2 and 3d post-20-E injection showed upregulation of the Vg mRNA on all 3 days. Controls injected with solvent only showed no Vg mRNA. Injections with juvenile hormone III did not stimulate Vg expression, oocyte growth or full engorgement. These studies indicate that ecdysteroids and not JH can initiate expression of the Vg gene, Vg protein synthesis and release into hemolymph, and Vg uptake into developing oocytes under bioassay conditions mimicking normal feeding on the host.

Targeting the subthalamic nucleus for deep brain stimulation: technical approach and fusion of pre- and postoperative MR images to define accuracy of lead placement

OBJECTIVES

To define the role of magnetic resonance imaging (MRI) and intraoperative electrophysiological recording in targeting the subthalamic nucleus (STN) in Parkinson's disease and to determine accuracy of electrode placement.

PATIENTS AND METHODS

We implanted 54 electrodes into the STN in 27 patients. Target planning was done by coordinate guidelines and visualising the STN on MRI and defined in relation to the mid-point of the AC-PC line. Intraoperative microelectrode recording was used. We adjusted electrode positions for placement in the centre of the STN electrical activity and verified this on postoperative MRI in 16 cases, which were fused to the preoperative images to measure actual error in electrode placement in the three axes.

RESULTS

Based on coordinate calculation and MRI localisation, the mean of the target was 11.5 mm lateral, 2.5 mm posterior and 4.1 mm inferior to the mid-point of the AC-PC line. Fifty good electrophysiological recordings of the STN (average length 4.65 mm) were achieved and target point adjusted in 90% of lead placements. The mean of the final target after electrophysiological correction was 11.7 mm lateral, 2.1 mm posterior, and 3.8 mm inferior to the mid-point. The distance from the centre of the electrode artefact to the final target used after electrophysiological recording on the fused images was 0.48 mm, 0.69 mm, and 2.9 mm in the x, y, and z axes, respectively. No postoperative MRI related complication was observed.

CONCLUSION

Both direct visualisation of the STN on MRI and intraoperative electrophysiological recording are important in defining the best target. Individual variations exist in the location of the STN target. Fewer tracks were required to define STN activity on the side operated first. Our current stereotactic method of electrode placement is relatively accurate.

Oxygen saturation as a screening test for critical congenital heart disease: a preliminary study

The aim of this study was to assess the utility of arm and leg oxygen saturation as a candidate screening test for the early detection of ductal-dependent left heart obstructive disease. We measured arm and leg oxygen saturation in 2876 newborns admitted to well baby nurseries and 32 newborns with congenital heart disease. Fifty-seven newborns in the well baby nurseries (0.02%) had an abnormal test (leg saturation less than 92% in room air or 7% lower saturation in the leg than in the arm). Four of the 57 had critical congenital heart disease, including 1 with coarctation of the aorta. Of the 32 newborns with congenital heart disease, 11/13 (85%) with left heart obstructive disease had abnormal oxygen saturation tests, as did 15/19 (79%) with other forms of congenital heart disease. Pulse oximetry deserves further study as a screening test for critical congenital heart disease.

Spontaneous extradural haematoma associated with craniofacial infections: case report and review of the literature

A 17-year-old male with occult cleft palate presented with depressed-consciousness due to spontaneous frontal extradural haematoma associated with sinusitis. Craniotomy, evacuation of the haematoma and drainage of the frontal sinuses led to a full recovery. Spontaneous extradural haematomas secondary to craniofacial infections are very rare; this appears to be the first described with a coexisting congenital palatal abnormality. The diagnosis should be considered when signs of infection are present with depressed consciousness as a delay in treatment may result in death.

Systemic indicators of inorganic arsenic toxicity in four animal species

The effect of arsenic compounds depends on the chemical form and is specific for certain organs. The lack of specific biological indicators for the effects of each arsenic species makes it difficult to differentiate their toxicity. Five prospective biological indicators of systemic toxicity were examined at time points ranging from 15 min to 24 h using male Sprague-Dawley rats, B6C3F1 mice, Golden-Syrian hamsters, and Hartley guinea pigs, following intraperitoneal dosing with 0.1 and 1 mg/kg sodium arsenite. Rats and mice were also dosed with 1 mg/kg sodium arsenate. Total blood arsenic levels were determined in all animal species to show that exposure occurred and as an index of the severity of the change is an indicator of toxicity. Total blood arsenic levels were increased in all animal species. This increase was dose, arsenic species, and animal dependent. Renal pyruvate dehydrogenase activity was significantly decreased at early time points in mice, hamsters, and guinea pigs, and at later time points in rats dosed with arsenite. Rats and mice dosed with arsenate also exhibited PDH decrease at early time points. Blood hematocrit and glucose were increased in the rat and guinea pig, respectively, after arsenite administration. Creatinine and urea nitrogen were found to be unresponsive to arsenic in most animal species. Data suggested that the mouse and secondly the hamster appear to be the most appropriate animal models for the study of acute arsenic toxicity.

Corynebacterium pseudotuberculosis is a cause of human necrotising granulomatous lymphadenitis

Corynebacterium pseudotuberculosis is a well recognised pathogen of farm animals, particularly sheep and goats. Human infection is a rare occurrence. This report describes suppurative lymphadenitis occurring in an adolescent boy who had contact with farm animals. The histological differential diagnosis of suppurative granulomatous lymphadenitis is discussed, and the importance of lymph node culture is stressed.

Dietary 1,25-dihydroxycholecalciferol has variable effects on the incidences of leg abnormalities, plasma vitamin D metabolites, and vitamin D receptors in chickens divergently selected for tibial dyschondroplasia

Three experiments were conducted to examine the efficacy of dietary 1,25-dihydroxycholecalciferol [(1,25-(OH)2D3)] on the development of tibial dyschondroplasia (TD) in chickens divergently selected for high (HTD) and low (LTD) incidences of TD. In Experiment 1, chickens from the two lines were fed two calcium levels (0.75 and 1.0%), with and without 5 micrograms/ kg dietary 1,25-(OH)2D3. In Experiment 2, both lines were fed diets containing 1.0% calcium and 0, 5, 10, or 15 micrograms/kg 1,25-(OH)2D3. The addition of 1,25-(OH)2D3 did not reduce the overall incidence of TD in Experiment 1, but did reduce the incidence of severe TD from 69 to 48% in the chickens receiving the 0.75% calcium diet. In this experiment, LTD chickens had higher plasma phosphorus and bone ash. No line differences were noted between plasma vitamin D metabolites or intestinal vitamin D receptors. In Experiment 2, 5 micrograms/kg of 1,25-(OH)2D3 decreased the incidence of TD from 94 to 76% and number three scores from 69 to 44% (P < or = 0.001). Higher amounts of 1,25-(OH)2D3 further decreased TD, but there was a reduction in body weight above 5 micrograms/kg. Plasma 25-hydroxycholecalciferol [25-(OH)D3] and 1,25-(OH)2D3 were higher and intestinal vitamin D receptors were lower in HTD chickens than in LTD chickens. Plasma 1,25-(OH)2D3 was not affected by dietary treatment, but 25-(OH)D3 was reduced by dietary 1,25-(OH)2D3. Experiment 3 was conducted to examine effects of line and dietary 1,25-(OH)2D3 on plasma vitamin D metabolites and intestinal and growth plate receptors. No effect of genetic line or dietary 1,25-(OH)2D3 was observed for vitamin D receptors concentration or plasma 1,25-(OH)2D3 levels. Plasma 25-(OH)D3 was reduced when 1,25-(OH)2D3 was fed. These results indicate that HTD chickens are somewhat responsive to dietary 1,25-(OH)2D3, but this treatment failed to prevent the lesion in a large portion of the population.

The effects of ultraviolet light and cholecalciferol and its metabolites on the development of leg abnormalities in chickens genetically selected for a high and low incidence of tibial dyschondroplasia

Four experiments were conducted to investigate the effects of ultraviolet (UV) light exposure and several cholecalciferol metabolites on the development of tibial dyschondroplasia (TD) and other parameters associated with vitamin D metabolism in chickens selected for high (HTD) and low (LTD) incidence of TD. In Experiment 1, exposure of chickens to UV light reduced the incidence and severity of TD more in LTD chickens than in HTD chickens, as evident by the significant interactions (P < 0.10 and 0.04). In Experiment 2, the addition of cholecalciferol to diets that were deficient in cholecalciferol linearly decreased the incidence of vitamin D rickets and increased bone ash, but increased the incidence of severe TD. The LTD chickens had a higher maximal bone ash of 40.0 +/- 0.7% than did the HTD chickens, which had a maximal bone ash of 37.0 +/- 0.7%. In Experiment 3, the addition of 5 micrograms/kg of 25-hydroxycholecalciferol [25-(OH)D3], 1-alpha-hydroxycholecalciferol, or 1,25- dihydroxycholecalciferol decreased the incidence and severity of TD in the LTD chickens and had no effect on TD in HTD chickens. In Experiment 4, increasing dietary 25-(OH)D3 increased plasma 25-(OH)D3 levels in both lines, but HTD chickens had higher plasma 25-(OH)D3 levels at 20 and 40 micrograms/kg of dietary 25-(OH)D3. The incidence and severity of TD were reduced in the LTD chickens by dietary 25-(OH)D3, but little effect was noted in HTD chickens. The LTD chickens reached a maximal bone ash at 9.7 +/- 1.9 micrograms/kg and HTD chickens reached the same bone ash at 33.0 +/- 7.0 micrograms/kg. These results indicate that UV light and vitamin D metabolites are not effective in preventing TD in HTD chickens, but that altered vitamin D metabolism does exist between HTD and LTD chickens.

Case management in the community setting

This article describes a federally funded nurse managed community health organization that treats the elderly. The innovative community-focused model uses the nurse as case manager to provide health promotion, screening, and early interventions to clients enrolled in the Community Nursing Organization (CNO). It explains the advantages of integrating advanced practice nurses into the nursing staff to provide both direct care to clients and teaching/conculation to the nursing staff. The CNO demonstrates that advanced practice nurses possess autonomous practice skills and are able to integrate preventive and curative care across practice sites.

Effects of phytase and 1,25-dihydroxycholecalciferol on phytate utilization and the quantitative requirement for calcium and phosphorus in young broiler chickens

Three experiments were conducted to determine the effects of supplementing 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and a commercial phytase product on Ca and P requirements of 0- to 21-d-old broiler males. These experiments were conducted with four levels of dietary Ca and P in corn-soybean diets with and without supplementation of 5 micrograms/kg of 1,25-(OH)2D3, 600 units/kg of phytase, and the combination of these supplements. The results show that these levels of phytase and 1,25-(OH)2D3 can replace up to 0.1% of the inorganic P for criteria such as BW, bone ash, and plasma P. Both supplements increased phytate P retention, whereas higher levels of Ca and P decreased phytate P retention. The addition of 1,25-(OH)2D3, but not phytase, reduced Ca requirements and decreased the incidence of tibial dyschondroplasia. The combination of these levels of phytase and 1,25-(OH)2D3 replaced 0.2% inorganic P for criteria such as BW, bone ash, and P rickets. Total dietary P requirements are estimated to be between 0.55 and 0.60% at the levels of phytase and 1,25-(OH)2D3, listed above, or 0.45% when the combination is added. The Ca requirements are estimated to be 0.77% when 1,25-(OH)2D3 is added to the diet and 0.9 to 0.95% when phytase is added.

Additive effects of 1,25-dihydroxycholecalciferol and phytase on phytate phosphorus utilization and related parameters in broiler chickens

Two experiments were conducted to compare the effects of supplementation with 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and a commercial phytase on P utilization by broiler males. Experiment 1 was conducted with three levels of total dietary P (0.45,0.55, and 0.65%) in corn-soybean meal diets supplemented with 5 micrograms/kg of 1,25-(OH)2D3, 600 units/kg of phytase, or the combination of these supplements in a factorial arrangement from 0 to 21 d in battery brooders. A second experiment was conducted with a similar design except that it was carried out in floor pens for a period of 35 d. In Experiment 1, maximal BW was obtained at 0.65% P in chicks receiving the basal diet, 0.55% P in chicks receiving phytase or 1,25-(OH)2D3, and 0.45% P in chicks fed both supplements. Bone ash for chicks receiving the basal, phytase, 1,25-(OH)2D3, and combination treatments at 0.45% total dietary P were 26.6, 34.9, 35.1, and 38.8%. There were significant interactions between phytase and 1,25-(OH)2D3 for BW, bone ash, and incidence of rickets. Similar results were noticed in Experiment 2, with the exception that 1,25-(OH)2D3 had little influence on BW from 0 to 3 wk, likely due to slightly higher dietary P. From 3 to 5 wk, BW and bone ash were increased by each supplement and further increased by their combination. These interactions suggest different mechanisms of action for these supplements in influencing phytate P utilization.

Staying one step ahead--development of an electronic record

Participation in a demonstration program allowed the VNS of New York to develop its own electronic records system. This description of the process and the resulting system should give a good picture of the ultimate benefits of such a system.

Conformationally constrained analogs of protein kinase inhibitor (6-22)amide: effect of turn structures in the center of the peptide on inhibition of cAMP-dependent protein kinase

The high-affinity interaction between protein kinase inhibitor (PKI)(6-22)amide(Thr6-Tyr-Ala-Asp-Phe-Ile-Ala-Ser-Gly-Arg-Thr-Gly- Arg-Arg-Asn- Ala-Ile22-NH2) and the catalytic subunit of cAMP-dependent protein kinase requires both the N-terminal Thr6 to Ile11 sequence of the inhibitor peptide and its C-terminal pseudosubstrate site comprised of Arg15 to Ile22. Small angle X-ray scattering data indicate that PKI(6-22)amide has a compact, rather than extended, structure in solution (Reed J et al., 1989, Biochem J 264:371-380). CD spectroscopic analysis of the PKI peptide led to the suggestion that a beta-turn structure might be located in the -Ala12-Ser-Gly-Arg15-connecting sequence in the middle of the molecule (Reed J, Kinzel V, Cheng HC, Walsh DA, 1987, Biochemistry 26:7641-7647). To investigate this possibility further, conformationally constrained and flexible analogs of PKI(6-22)amide were synthesized and used to study the structure-function relationships of this central portion of the inhibitor. (Des12-14)PKI(6-22) amide exhibited over a 200-fold loss in inhibitory activity. Replacement of the omitted -Ala12-Ser-Gly14-sequence with aminocaprylic acid yielded an analog that regained more than 90% of the lost binding energy. The D-alanine14 PKI analog was as potent as the parent peptide, whereas the beta-alanine14 and the sarcosine14 analogs were only 10-fold less active. Several peptides that promoted a beta-turn structure at residues 12-15 showed about 200-fold decreases in inhibitory activity. Two constrained analogs that could not assume a beta-turn conformation were only 30-fold less potent than PKI(6-22)amide. Thus, the structure of the central connecting portion of the PKI peptide, encompassing residues 12-15, greatly influences its ability to effectively bind to and inhibit the catalytic subunit. We conclude, however, that a formal beta-turn at this position is not required and is actually detrimental for a high-affinity interaction of PKI(6-22)amide with the enzyme. These results are interpreted in light of the Fourier-transform infrared spectra of the peptide analogs and the crystal structure of the peptide bound at the active site of the protein kinase (Knighton DR et al., 1991b, Science 253:414-420).

Heat-stable inhibitor protein derived peptide substrate analogs: phosphorylation by cAMP-dependent and cGMP-dependent protein kinases

The phosphorylation of substrate peptides derived from PKI, the heat-stable inhibitor protein of the cAMP-dependent protein kinase (PKA), has been studied with both PKA and the cGMP-dependent protein kinase (PKG) using a variety of substitution and deletion analogs. On the basis of Km, kcat and kcat/Km values, (Ser21)PKI alpha(14-22) amide (numbering based upon native PKI alpha) is the most effective peptide substrate yet discovered for either kinase, although other peptides, while phosphorylated considerably less efficiently by PKG, are more specific. Although the inhibitory peptide corresponding to this sequence (i.e., with an Ala at position 21) is a much more potent inhibitor of PKA than of PKG (approximately 250-fold), PKG actually exhibits a 60% higher kcat than does PKA with the (Ser21)PKI alpha(14-22) amide substrate peptide, with only a 20-fold higher Km value. The two key PKI residues within this peptide which were found to be essential for substrate activity with both kinases were Arg18 (P-3) and Ile22 (P+1). The Arg19 (P-2) residue, which contributes significantly to both PKI-based peptide inhibitors and substrates of PKA, was only a more minor contributor to PKG substrate efficacy. Of particular note, the Phe10 (P-11) residue, which contributes very substantially to high affinity binding of both PKI and longer PKI peptide inhibitors, neither positively nor negatively affects the kinetics of either PKA or PKG with PKI-based substrates.(ABSTRACT TRUNCATED AT 250 WORDS)

Molar and incisor changes with Wilson rapid molar distalization

The purpose of this study was to determine the magnitude and direction of maxillary and mandibular first molar and incisor changes that occur during Class II molar correction with Wilson "rapid molar distalization." Nineteen patients (13 females, 6 males) were selected from the clinic at Loma Linda University Department of Orthodontics. All patients received maxillary bimetric distalizing arches (BDA), and either a mandibular three-dimensional lingual arch, with or without a passive 0.016 x 0.016-inch utility arch, or a traditional edgewise full banded and bonded arch. The arches were activated with open coil spring and Class II intermaxillary elastics. A total of five activations were completed or until visual inspection revealed a Class I molar relation. Prestudy and poststudy lateral cephalometric radiographs were taken with molar bands cemented. Dental changes were determined, with Ricketts superimpositions. The mean change in molar relation measured at the occlusal plane was 4.1 mm. The mean maxillary molar distalization was 2.16 mm, with 7.8 degrees of tip. The rate of maxillary molar movement was 0.56 mm per month. The mean mandibular molar mesial movement was 1.38 mm. The maxillary incisors protruded a mean of 0.3 mm, and extruded a mean of 1.6 mm. Except for the edgewise sample, all mandibular molars moved mesially further than the incisors, reducing the mandibular arch length. The presence of erupted maxillary second molars did not correlate with the rate of maxillary first molar movement, magnitude of movement, or amount of tipping that occurred.

The effect of orally administered thyrotropin-releasing hormone on growth and carcass characteristics of seven- to ten-week-old broilers

In contrast to some earlier studies with young broiler chickens, several recent studies have shown growth responses to exogenous growth hormone (GH) administration in broiler chickens of advanced age (Vasilatos-Younken et al., 1988; Scanes et al., 1990). It was therefore of interest to determine whether intermittent feeding of thyrotropin-releasing hormone (TRH), a known GH secretagogue, would elevate plasma GH of 7- to 10-wk-old broilers and alter their growth characteristics. Four replicate pens of 15 males and four pens of 15 females 7 to 10 wk of age were given access to feed containing 3.5 mg/kg of TRH for four 2-h periods each 24 h with 4-h periods of feed removal between. Control groups either were fed the basal ration on the same intermittent schedule or had continuous access to it. Growth hormone concentrations, measured 45 to 75 min after the start of TRH feeding periods, were significantly elevated in males on the 1st day of the experiment and after 7, 14, and 21 days when they were 7, 8, 9, and 10 wk of age, respectively. Concentrations in females were elevated on the 1st day of treatment, but not thereafter. Treatment with TRH had no effect on BW or relative gain of males at any time. It significantly increased relative gain of females during the 1st wk, but not thereafter. There were no treatment effects on 10-wk shank length, Pectoralis major weight, Gastrocnemius weight, or liver weight in either sex, but the percentage fat pad of males fed TRH was lower than that of controls fed intermittently.

Solution structure of the cAMP-dependent protein kinase catalytic subunit and its contraction upon binding the protein kinase inhibitor peptide

Small-angle X-ray scattering and Fourier transform infrared (FTIR) spectroscopy experiments have been completed on the catalytic subunit of the cAMP-dependent protein kinase. Measurements were made both with and without the protein kinase inhibitor peptide, PKI alpha(5-22)amide. Binding of the peptide results in an overall contraction of the structure that is characterized by a decrease of 9% in radius of gyration and about 16% in the maximum linear dimension. Both the secondary structure content of the protein/peptide complex, as determined by FTIR, and the solution structure of this binary complex, as determined by X-ray scattering, agree well with the structural characteristics of this complex as elucidated by the crystal structure [Knighton, D.R., Zheng, J., Ten Eyck, L. F., Ashford, V.A., Xuong, N.H., Taylor, S.S., & Sowadsi, J. M. (1991a) Science 253, 407-414]. Further, the contraction of the structure observed by X-ray scattering upon inhibitor peptide binding is not accompanied by any detectable change in secondary structure content of the kinase. We have modeled the contraction of the kinase upon inhibitor peptide binding as a simple rotation of the large and small lobes seen in the crystal structure such that the cleft between them is closed. For a substrate these changes would then allow catalysis to ensue. The hinge for this movement occurs around a glycine that is one of the protein kinase family consensus amino acids.

Addition of enemas to oral lavage preparation for colonoscopy is not necessary

To evaluate whether the addition of enemas to oral electrolyte lavage is helpful for colonoscopic preparation, we conducted a prospective, randomized, observer-blinded trial to compare oral lavage plus enemas with oral lavage alone. The quality of preparation, mucosal visualization, and the volume of retained colonic fluid did not differ between the two groups. Twenty-two percent of the patients in the group who received oral lavage plus enemas compared with 12% of the patients in the group that only received oral lavage stated that they would refuse to repeat the preparation for future colonoscopic examination. Seventeen percent of the patients in the group that received oral lavage plus enemas demonstrated anorectal trauma or inflammation compared with only 5% in the group that received oral lavage alone (p = 0.09). These results indicate that the addition of enemas to oral lavage preparation for colonoscopic evaluation cannot be routinely recommended. However, enemas may be considered on an individual basis in the occasional patient unable to consume the complete oral lavage or in whom residual stool is found during colonoscopic evaluation after oral lavage preparation.