Differential effects of sacral anterior root stimulation on anal sphincter and colorectal motility in spinally injured man

The motility responses of the sigmoid colon, rectum and external anal sphincter to sequential electrical stimulation of the anterior sacral roots (S2, S3 and S4) were studied in five patients with traumatic spinal cord injury. Identical and reproducible results were obtained. S2 stimulation provoked isolated low-pressure colorectal contractions. S3 stimulation initiated high-pressure colorectal motor activity which appeared peristaltic and was enhanced with repetitive stimuli. This response appeared to be frequency-dependent. S4 stimulation increased colonic and rectal tone. External sphincter activity was stimulated in increasing order from S2 to S4. These observations directly elucidate the central control of colorectal motility and may have implications in the treatment of severe constipation following spinal injury.

Function of the anal sphincters after chronic radiation injury

Anorectal manometry was done in 10 men with chronic radiation proctitis and symptoms of urgency, frequency, and occasional incontinence of faeces. They were compared with 10 asymptomatic age and sex-matched controls. The maximum resting anal canal pressure and the physiological sphincter length were significantly lower (p less than 0.01) in the irradiated group. The rectosphincteric reflex was absent in one patient and showed abnormalities of recovery in four others, who had received radiotherapy. The squeeze pressure of the external sphincter was not significantly different. These results indicate that dysfunction of the internal anal sphincter may contribute to patients' anorectal symptoms after pelvic radiotherapy. Histological evidence suggests that damage to the myenteric plexus is mainly responsible. The manometric function of the external sphincter remains relatively unaffected.

Anorectal function following colo-anal sleeve anastomosis for chronic radiation injury to the rectum

Anorectal manometry and electrophysiological studies of the pelvic floor were performed in eight patients who had undergone anterior resection of the rectum with mucosal proctectomy and colo-anal sleeve anastomosis for radiation rectal injury. There is a severe reduction in the compliance of the neorectum and in the maximal tolerable volume. Maximum basal anal canal pressure and physiological sphincter length are also significantly reduced although the 'squeeze' pressure of the external anal sphincter and the latency of the pudendo-anal reflex were unaffected. Four patients had an absent rectosphincteric reflex, four patients involuntarily expelled the test balloon at the maximal tolerable volume during a proctometrogram and four patients demonstrated increased EMG activity of the pelvic floor on straining and on rectal distension. These abnormalities help to explain many of the patients' symptoms. Histological abnormalities of the myenteric plexus were a prominent feature in all the excised specimens and may be responsible for some of the functional abnormalities.

Reproducibility of the proctometrogram

The reproducibility of a method of measuring rectal distensibility by continuous controlled fluid inflation with a balloon has been evaluated in 15 patients. The volume at sensation threshold, constant sensation and maximal tolerance, the pressures at these volumes and rectal compliance were measured. The mean coefficients of variation of the seven variables measured ranged from 4.7%-7.9%. The expected correlation between rectal compliance and maximal tolerable volume was confirmed (r = 0.85, p less than 0.001). The high reproducibility makes this investigation reliable for use in clinical practice and research.

Correlation of clinical and manometric abnormalities of rectal function following chronic radiation injury

Continuous fluid-inflation proctometrograms were performed in men with the symptoms of chronic radiation proctitis and in age and sex-matched control subjects (n = 10). Rectal volumes and compliance were measured. There was a significant reduction in the rectal volumes at sensory threshold, constant sensation and maximal tolerance and in rectal compliance (P less than 0.01). Comparable pressure measurements did not demonstrate significant differences. The maximum tolerable volume, symptomatic and sigmoidoscopic scoring correlated to rectal compliance (r = 0.77, -0.8, -0.73; P less than 0.01, less than 0.01, less than 0.02, respectively). Reduction in volume and compliance is often not obvious radiologically. Histological evidence suggests that smooth muscle hypertrophy and myenteric plexus damage are contributory.

Correlation of clinical and manometric abnormalities of rectal function following chronic radiation injury

Continuous fluid-inflation proctometrograms were performed in men with the symptoms of chronic radiation proctitis and in age and sex-matched control subjects (n = 10). Rectal volumes and compliance were measured. There was a significant reduction in the rectal volumes at sensory threshold, constant sensation and maximal tolerance and in rectal compliance (P less than 0.01). Comparable pressure measurements did not demonstrate significant differences. The maximum tolerable volume, symptomatic and sigmoidoscopic scoring correlated to rectal compliance (r = 0.77, -0.8, -0.73; P less than 0.01, less than 0.01, less than 0.02, respectively). Reduction in volume and compliance is often not obvious radiologically. Histological evidence suggests that smooth muscle hypertrophy and myenteric plexus damage are contributory.

Erythrocyte zinc protoporphyrin determination for screening for lead exposure

Free erythrocyte protoporphyrin (FEP), erythrocyte zinc protoporphyrin (EZP) and blood lead concentrations were measured in 150 male subjects, 110 of whom were employed in industries where lead exposure was possible. Eighty-seven per cent of these 110 workers had blood lead levels above the maximum safe level of 40 micrograms/dl, which suggests that the factory control of lead toxicity is inadequate. The AVIV dedicated front-face fluorometer (AVIV instruments, New Jersey, USA), which measures EZP, was evaluated as a simple, rapid method of screening for lead accumulation. EZP concentrations agreed well with conventional estimations of FEP (r = 0,987, P less than 0,0001), and both correlated well with the blood lead concentration (r = 0,558, P less than 0,0001 for EZP; r = 0,633, P less than 0,0001 for FEP). The specificity of the EZP level as a screening test was found to be high (98%) and the sensitivity moderately good (83%). In view of the ease and speed of operation of this portable fluorometer, it should prove useful as an aid to the detection of early lead intoxication.

Erythrocyte pyrimidine-5'-nucleotidase activity as a sensitive indicator of lead exposure

Since the red cell enzyme pyrimidine-5'-nucleotidase (PN) is inhibited by lead, we examined the feasibility of using the activity of this enzyme as a measure of lead exposure. Erythrocyte PN activity was measured in 110 blood samples obtained from subjects working in industries which utilize lead and 40 control subjects. The measurements were then compared with a number of traditional indices of lead poisoning. These included blood and urine lead concentrations and free erythrocyte protoporphyrin, erythrocyte zinc protoporphyrin, urinary coproporphyrin and urinary delta-aminolaevulinic acid levels. There was a highly significant negative correlation between erythrocyte PN activity and blood lead concentration (-0,83; P less than 0,0001), which was greater than that for any of the other measurements. It was therefore concluded that erythrocyte PN activity is an excellent indicator of lead exposure.

Surgical aspects of intestinal injury due to pelvic radiotherapy

Seventy-one patients with intestinal injury secondary to pelvic irradiation had predominantly large bowel lesions. Seventeen cases were treated conservatively and 54 came to surgery, 28 patients having more than one operation. Following this essentially salvage surgery there were more ileal than colonic anastomotic leaks. Thirty-four patients died during the follow-up period (2-12 years), 19 from recurrent malignancy, and nine as a result of continuing radiation effects. Seventy per cent of the patients who had a radiation fistula died as a result of malignancy. Of 42000 cases of pelvic malignancy treated by irradiation over the decade 1972-1982, surgical referrals for complications constituted 1.7%, with an overall radiation-related mortality of 0.2%. It is our opinion that colostomy alone has little part to play in this condition, and a policy based on excisional surgery is suggested.

Mechanical properties of the colon: comparison of the features of the African and European colon in vitro

The tensile properties of the colon have been examined using methods which gave repeatable results. They showed little change after storage in salt for up to five weeks. The burst strength remained unchanged along the length of the colon. The tensile strength fell distally, as the thickness of the colonic wall increased. The width at burst decreased distally as did the internal diameter. The visco-elastic property of stress relaxation was constant in all regions. The tensile property of the colon was well developed at birth, but fell with age as did the width at burst and the internal diameter. Stress relaxation was unaffected. Because there may be a mechanical abnormality of the colonic wall in diverticular disease and as Europeans are prone to this condition while Africans are not commonly affected, European and African colons were compared. The tensile strength in a Kampala group was greater than in an Edinburgh one, but fell significantly in both groups with age. The width at burst was greater in the Kampala group, but also declined with age. Stress-relaxation was similar in both groups. In view of the similar properties in childhood of colons from Edinburgh and Kampala, the strength of the adult African compared with European colons may derive later from environmental factors such as diet. There were, however, no differences between the colons with and without diverticular disease in European subjects over the age of 50 years.

Mechanical properties of the rat colon: the effect of age, sex and different conditions of storage

The mechanical properties of the rat colon were studied in old and young Sprague-Dawley rats which were also grouped by sex. Different storage media were used. Rings of colonic tissue were submitted to pulls on an Instron 1026 tensiometer. Gender did not affect the properties of the young rat colon. The rat colon has a tensile strength of around 50 g/mm2 (which places it between the dog and the cat). It increased in strength from proximal to distal, though the rectum was weaker than the colon. The pre-strain of the rat colon was 10% and it was capable of stretching to 200% of its original dimensions. The strength and ability to stretch fell with age, although it initially increased, in the first year of life. Physiological saline at 4 degrees C preserved the burst strength, percentage elongation, hysteresis and Young's modulus between 25 and 100 g stress for up to 1 week. Young's modulus between 125 and 200 g fell progressively with each day of storage. Stress relaxation rose in the first 24 h and thereafter remained constant. Salt appeared to be a good long-term storage medium. Irradiation of the colons before storage did not affect the mechanical properties.

Effect of cobaltous chloride on aggregation of platelets from normal and afibrinogenaemic human blood

The aggregation of normal human platelets in vitro induced by ADP was severely inhibited after preincubation of platelet-rich plasma (PRP) with CoCl2. Platelets from a patient with congenital afibrinogenaemia did not aggregate until fibrinogen was added. This recovered response was also inhibited by CoCl2. The impairment of aggregation seemed to be due to the action of cobalt on surrounding fibrinogen and not to a direct action on the platelets themselves. These results illustrate another aspect of the potential toxicity resulting from the use of cobaltous salts in treating the anaemia of renal failure, in which bleeding disorders have been reported.

Anorectal profilometry with the microtransducer

The reproducibility of anal sphincter manometry has been evaluated in 17 patients with a continuous pull-through technique using a miniature transducer mounted on a 2mm diameter Dacron catheter. Comparison was made with a conventional station pull-through technique using a 4mm diameter waterfilled microballoon connected to an external transducer. Parameters measured with the microtransducer (maximum resting pressure, squeeze pressure, functional sphincter length, area under high pressure zone, amplitude of rectosphincteric reflex) showed mean coefficients of variation from 3.2 to 5.7 per cent. Pressures measured with the microballoon were uniformly higher than those obtained with the microtransducer. The functional sphincter length was significantly shorter when measured with the microballoon (P less than 0.001). The microtransducer provides a highly accurate and reproducible method of anorectal profilometry that avoids many of the drawbacks associated with fluid-filled systems.

Evaluation of the School Nurse Achievement Program: a follow-up survey of school nurses

The University of Colorado School Nurse Achievement Program (SNAP) is a national continuing education program for school nurses who want to increase and improve the services they provide to disabled students. In this article, the results of one of the evaluation studies conducted on SNAP--a six-month follow-up survey of graduates--are reported. Generally, the results indicated high perceived effectiveness of SNAP in terms of increasing school nurses' knowledge and skills related to working with disabled students. These findings should be of value to readers interested in SNAP, in particular, as well as to those interested in the role of the school nurse with disabled students.

Multivariate analysis of prognostic factors for operable rectal cancer

Previous reports have established that several variables are of prognostic importance in rectal cancer. The information from a Medical Research Council trial in seventeen centres in the United Kingdom was used to assess the simultaneous contribution of several of these factors in a multivariate analysis. In the preoperative assessment mobility of the tumour and the number of quadrants involved were predictive of the likelihood of a curative resection being possible. Among patients who had curative resections, prognosis was influenced by Dukes' classification, height of tumour, histological grade, and venous invasion. A scoring system based on these criteria was constructed and applied to this group of patients. It successfully defined five prognostic groups with 5-year survival rates ranging from 80% to 19%.

Colonic function in rural and urban populations of Turkey

Two Turkish populations, one with an urban background and the other rural, were compared in regard to their colonic function. Rural subjects consume a diet with higher fiber than urban people in Turkey. The rural group had a greater daily fecal output, faster intestinal transit, and lower intraluminal pressure, with a greater output of calcium in the feces than those living in an urban area in Turkey. The effects are similar to those described when fiber is added to the diet. Urban dwellers in Turkey who lack these effects are said to have a rising incidence of fiber-related diseases of the colon, such as diverticular disease.

Part II. Evaluation component. School nurse achievement program

The School Nurse Achievement Program is a national continuing education course for school nurses to increase and improve their services for disabled children. It is currently being developed under the auspices of the Department of Education, Office of Special Education in conjunction with the University of Colorado Health Sciences Center, School of Nursing. A description of a national needs survey of school nurses and resulting program goals, curriculum development, and course administration in twelve states appeared in last month's Journal. Formative and summative evaluation studies to aid in curriculum development and to examine changes in the school nurses' activities are described in Part II of this article.