Bile duct emptying in response to fat: a validation study

Fatty meal sonography has been suggested to assess patients with biliary pain after cholecystectomy, but the effects of gallbladder removal on biliary dynamics has not been studied prospectively. Before elective cholecystectomy, 25 patients had their common hepatic ducts' diameter measured by ultrasonography before and after a fat stimulus. In 23, tests were repeated 1 month, 1 year, and 5 years after surgery. In preoperative studies, 5 patients showed dilatation after fat and 2 of these had stones in the common bile duct. However, another 4 patients with stones or sludge in the duct did not show dilatation, so that the response to fat was a poor indicator of patients requiring common bile duct exploration. No patient had major symptoms after surgery. At 1 month and 12 months, the response to fat was variable with more than half of those tested showing no decrease in duct size. A more consistent pattern emerged at 5 years, when 14 of 18 patients tested showed a decrease in common hepatic duct after fat; 3 were unchanged and 1 increased by 1 mm. The response to fat was less consistent and more difficult to measure in the common bile duct, even 5 years after operation. It was concluded that not all patients with indications for exploration of the common bile duct on operative cholangiography show a dilatation response to fat on preoperative testing. Also, fatty meal sonography should be used with caution because the response to fat in asymptomatic patients soon after operation is unpredictable, with occasional patients showing dilation without apparent obstruction. Measurement of common hepatic duct is preferred to common bile duct and increases in diameter of 1 mm are probably not significant.

Pre-operative ultrasound measurement of bile duct diameter: basis for selective cholangiography

In this prospective study, prior to cholecystectomy, the diameter of the common hepatic duct was measured; duct size was then compared with probability of finding stones at operation. Of 115 patients entering the study, 36 had stones removed from the common duct at the time of cholecystectomy but only three (8%) were demonstrated by ultrasonography. No stones were found in ducts less than or equal to 3 mm in size (31% patients). Only two of 26 patients with ducts measuring 4 mm had stones. As duct size increased, so did the probability of stones and all patients with ducts greater than or equal to 9 mm in diameter had stones. It is concluded that pre-operative ultrasound provides a reliable basis for a policy of selective cholangiography.

Changes in bile duct diameter after cholecystectomy: a 5-year prospective study

In this prospective study, we have measured with ultrasound the diameter of the common hepatic duct and the common bile duct in a series of 24 patients having elective cholecystectomy. Preoperative measurements by ultrasound were compared with measurements taken directly from operative cholangiograms and excellent correlation was observed (r = 0.938). Studies were repeated 1 mo, 12 mo, and 5 yr after operation. Of 21 patients returning for study at 5 yr, there were 4 patients with 1-mm ducts before surgery who showed an increase in the size of the common hepatic duct but in none was the final measurement greater than 4 mm. Mean common hepatic duct diameter (n = 21) increased from 3.95 mm before to 4.48 mm 5 yr after surgery (p = 0.24, paired t-test). Common bile duct was more easily seen after cholecystectomy and of 13 ducts satisfactorily measured 1 and 5 yr after surgery, 7 showed an increase in size (mean common hepatic duct 1 yr = 4.77 mm, 5 yr = 5.92 mm, p = 0.059, paired t-test). Significant dilatation of the common hepatic duct was seen in only 2 of 21 patients, but a strong trend to minor dilatation was observed in the common bile duct after cholecystectomy.

Comparison of mandelate dehydrogenases from various strains of Acinetobacter calcoaceticus: similarity of natural and 'evolved' forms

In previous work it had been shown that Acinetobacter calcoaceticus wild-type strain NCIB 8250 had only an L-mandelate deydrogenase but it could give rise to mutants that contained an evolved D-mandelate dehydrogenase; conversely, wild-type strain EBF 65/65 had only a D-mandelate dehydrogenase but gave rise to mutants that possessed an evolved L-mandelate dehydrogenase. Several other wild-type strains of A. calcoaceticus have now been shown to grow on both enantiomers of mandelate. In every case the L-mandelate dehydrogenases were found to be much more heat-stable and insensitive to inhibition by p-chloromercuribenzoate than were the D-mandelate dehydrogenases when measured in bacterial extracts. All the D-mandelate dehydrogenases in the wild-type strains were inactivated to about the same extent by an antiserum that had been raised in a rabbit against an evolved D-mandelate dehydrogenase. An evolved D-mandelate deydrogenase (from a mutant strain derived from strain NCIB 8250) and an original D-mandelate dehydrogenase (from a mutant strain derived from strain EBF 65/65) were purified to homogeneity by the same procedure and were indistinguishable as judged by immunological cross-reactivity of the native and the sodium-dodecyl-sulphate-denatured enzymes, solubility in cholate, net charge at pH 7.5, pI value, salting-out properties, Mr value, apparent K(m) value for D-mandelate, heat-stability and sensitivity to p-chloromercuribenzoate. The most likely explanation for the appearance of evolved mandelate dehydrogenases in strains of A. calcoaceticus is that cryptic genes become expressed.

Purification and properties of L-mandelate dehydrogenase and comparison with other membrane-bound dehydrogenases from Acinetobacter calcoaceticus

L-Mandelate dehydrogenase was purified from Acinetobacter calcoaceticus by Triton X-100 extraction from a 'wall + membrane' fraction, ion-exchange chromatography on DEAE-Sephacel, (NH4)2SO4 fractionation and gel filtration followed by further ion-exchange chromatography. The purified enzyme was partially characterized with respect to its subunit Mr (44,000), pH optimum (7.5), pI value (4.2), substrate specificity and susceptibility to various potential inhibitors including thiol-blocking reagents. FMN was identified as the non-covalently bound cofactor. The properties of L-mandelate dehydrogenase are compared with those of D-mandelate dehydrogenase, D-lactate dehydrogenase and L-lactate dehydrogenase from A. calcoaceticus.

The evolution of morphologic changes in the gallbladder before stone formation in mice fed a cholesterol-cholic acid diet

Mice were fed a lithogenic diet containing 1% cholesterol and 0.5% cholic acid, and the sequence of morphologic changes in the gallbladder was followed. Histologic changes were studied with light microscopy and cell proliferation with autoradiography. Mucus glycoprotein production was studied with a spectrum of glycoprotein histochemical stains and electron-microscopic morphometry of membrane-bound mucus secretory granules. There was a rapid and early increase in cell proliferation of the epithelial cells and an increase in mucus production, which took place long before any observable cholesterol crystal precipitation. The gallbladder epithelial cells showed early focal pseudostratification and large numbers of degenerative cells. These changes culminated in glandular metaplasia and the formation of Rokitansky-Aschoff sinuses later in the gallstone induction phase. These observations clearly indicated that gallbladder epithelial injury had taken place before gallstone formation. The authors hypothesize that the consequences of these cellular changes play a contributory role in causing gallstone formation.

Further observations in lincomycin-induced cholelithiasis in guinea-pigs

Further experiments are reported on Lincomycin-induced cholelithiasis in guinea-pigs. The biochemical events in the bile and blood, and the chemical composition of gallstones, have been studied. The gallstones resemble human pigment stones in chemical composition. The clear hepatic bile and the normality of the bile salt--phospholipid--cholesterol equilibrium, the rise in beta-glucuronidase and hexosamine levels with the gallbladder, have reaffirmed that epithelial injury is most probably the primary lithogenic factor. Ligation of the cystic duct and the construction of a common hepatic duct-duodenum bypass did not prevent the development of acute cholecystitis, suggesting the lithogenic factor was mediated through the blood circulation and not through the enterohepatic circulation of bile.

Estimating ventilation/perfusion distributions from inert gas data: a Bayesian approach

In recent years, experimental techniques using inert gas studies have been developed for determining essentially continuous distributions of the ventilation/perfusion ratio over a lung. Mathematically, the technique requires the recovery of 'smooth' solutions of grossly underdetermined systems of linear equations. This paper investigates the use of Bayesian smoothing techniques and shows that, provided the true underlying distribution of ventilation/perfusion ratios is relatively smooth and well-behaved, it is possible to recover reliable estimates of such distributions.

The Northland Health Scheme

The Northland Health Scheme, proposed by the Special Advisory Committee on Health Service Organisation (Sachso), is about to become a reality. On 20 February 1978 cabinet approved the setting up of a steering committe in Northland to propose a Health Board structure, establish further working parties to consider local aspects of the scheme, initiate the formation of service development groups, assist SACHSO in developing legislation, and take any other steps that seemed appropriate. The chairman of this committee was named on 1 March and others who have agreed to serve are listed in the New Zealand Medical Journal of 22 March (News, 1978). It is now, therefore, an appropriate moment to scrutinise carefully what is proposed and the principles that underlie the proposals.

Carbohydrate moieties of glycoproteins in human hepatic and gall-bladder bile, gall-bladder mucosa and gall stones

1. The soluble glycoproteins of human bile, gall-bladder mucosa and gall stones have been extracted and hydrolysed, and the monosaccharides analysed by gas-liquid chromatography.

2. Human biliary glycoproteins contained 55–75% of carbohydrate, the major monosaccharide components being galactose, fucose and N-acetylglucosamine, accounting for 70–85% of all the monosaccharides. Mannose, glucose, N-acetylgalactosamine and N-acetylneuraminic acid (sialic acid) were also present. N-Acetylneuraminic acid was present in large amounts in the gall-bladder mucosa and bile of one ulcerated and markedly inflamed gall bladder.

3. The proportion of monosaccharides in soluble glycoproteins of mucosa and bile were not different in samples from subjects with or without gall stones.

4. Gall stones were analysed for cholesterol, calcium and bilirubin and classified as ‘cholesterol stones’ (7/10) and ‘pigment stones’ (3/10). Both cholesterol and pigment stones contain a variable amount of glycoprotein. The pattern of carbohydrate constituents was similar to that present in the gall-bladder mucosa and bile in the same subject. There was also no major difference between the pattern found in ‘cholesterol’ and ‘pigment’ stones.

5. Evidence and argument are presented suggesting that some glycoprotein is secreted by the gall bladder and incorporated into gall stones. This calls for further work upon the influence of these carbohydrate-rich macromolecules on cholesterol solubilization in mixed micelles.

Epithelial cell proliferation in diverse models of experimental cholelithiasis

Proliferation of the epithelial cells of the gall bladder during the initial stages of experimental cholelithiasis has been studied by autoradiography. Rabbits taking a diet with 1% dihydrocholesterol added showed a rise in labelling index from 1.5%-19% by three days. Mice taking a 1% cholesterol 0.5% cholic acid diet showed a similar rise from less than 1% to 15-21% at two and five days. Guinea-pigs receiving lincomycin showed a rise from less than 1% to 6% after 24 hours. These changes, which appear well before the appearance of gall stones, together with previous reports of enhanced mucous secretion during lithogenesis, make it clear that in these laboratory models of cholelithiasis the gall bladder is abnormal well before stones form.

Benign postoperative jaundice complicating severe trauma

Five patients are described in whom deep jaundice developed following severe trauma. Only two of the patients showed acute renal failure. All showed the adult respiratory distress syndrome. The livers at autopsy were enlarged and showed centrilobular congestion and cholestases. This syndrome, which is closely analogous, to that described as "benign postoperative jaundice", is more closely associated with the hypoxic hypoxia of acute respiratory failure than with the stagnant hypoxia of acute circulatory failure. It is accentuated by transfusion, and often by disseminated intra-vascular coagulation.

Diagnostic accuracy would be improved by developing more categories of "non-disease"

Studies on the ways in which doctors think have shown the importance of intuitive processes in the formulation of a diagnosis. They have also suggested that intuitively generated diagnoses are used to aid the memory of relevant clinical facts during a clinical consultation. Only some symptoms and signs can be ordered into or subsumed under a diagnostic label. Others, which have not been thought of as constituting a disease, will tend to be lost from memory. If a diagnosis were to be thought of, not as the label of a disease but as a mental construct by means of which data are ordered and remembered, that is, as an invention whose utility is to be judged by the degree to which clinical thinking is facilitated, it would become reasonable to develop diagnoses to cover larger areas of clinical phenomenology. Some examples of the usefulness of such diagnoses of "non-disease" are given ant it is suggested that clinical thinking might be improved by the wider use of the concept.

TMJ dysfunction--principles of the clinical examination

Determining if head pain is related to occlusal disharmony can be a challenge. A brief outline of the clinical examination of these patients was presented. Gross interceptive occlusal contacts should be corrected in all patients. The evaluation of signs and symptoms is the basis for determining whether to "adjust" the asymptomatic patient. Consideration should be given to the intensity of the occlusal disharmony, the level of anxiety, and the patient's adaptive response.

Treatment of vaginal candidiasis with miconazole

An open trial was carried out in 50 women with clinical signs and mycological evidence of vaginal candidiasis to compare the effectiveness of treatment with 2% miconazole cream with that of nystatin pessaries. Both groups were given intravaginal treatment for 14 days and were followed up at monthly intervals for 3 months. Relief of symptoms and clinical signs was comparable in the two groups but the mycological cure rate at 1 month was higher with miconazole. At 2 and 3 months, however, there was no significant difference between the cure rate obtained with the two treatments in the patients still included in the study.

Lincomycin-induced cholecystitis and gallstones in guinea pigs

Guinea pigs given lincomycin 60 mg per kg per day showed a striking increase in the renewal of epithelial cells in the gallbladder. This was detectable after only 24 hr of treatment. By 48 hr a precipitate consisting predominantly of calcium and bilirubin had formed in the gallbladder. Gallbladder bile glycoprotein concentrations rose progressively. At 8 days epithelial dysplasia was marked. Treatment was discontinued at 9 days. The guinea pigs that survived beyond 34 days showed that new tubuloalveolar glands had formed focally in the body and fundus of the gallbladder. Multiple calcium-containing stones were present. The failure to culture bacteria from bile, the failure of the bile salt pattern to change, and the progressive nature of the epithelial injury suggested that the changes resulted from a direct toxic effect and were not dependent on the antibiotic activity of this drug. It was concluded that damage to the epithelium of the gallbladder preceded the formation of a precipitate and initiated histological changes which culminated, at the time that the precipitate became organized into stones, in impressive glandular metaplasia.

Diazoxide-induced renin release in diagnosis of remediable renovascular hypertension

In hypertensive patients with unilateral renal artery stenosis, intravenous diazoide increased renal vein renin activity more on the involved side than on the contralateral side, whereas, in a group with predominantly unilateral renal parenchymal disease, the increase in renal vein was similar for both kidneys. In patients with bilateral renal artery stenosis, the use of diazoxide was helpful in lateralizing the dominant ischaemic lesion. Diazoide administration appears to be a safe, rapid and convenient method of increasing the sensitivity of the renal vein renin test used in predicting the outcome of surgical treatment of renovascular hypertension. Bilateral renal vein renin determination of established value in the diagnosis of functional renal ischaemia. 1-4 However, in the use of this procedure to predict the efficacy of corrective surgery, false positive and false negative results still occur. Thus, various manoeuvres which stimulate renin release have been employed to improve the sensitivity of the test. 5-7 We report a new application the practical approach to of this procedure in the diagnosis of renal hypertension, which both basal and stimulated levels of renal venous renin activitity can be measured during a brief period of bilateral renal vein catherization.

Partial biliary obstruction with cholangitis producing a blind loop syndrome

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Subcutaneous Emphysema with Asthma

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RHEUMATIC ENDOCARDITIS IN CHILDREN: ITS DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

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ACRODYNIA

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