Pseudotumor of the bladder as a manifestation of uncomplicated appendicitis

We report the case of a 67-year-old woman who presented with an apparent bladder tumor and complaints of increased urinary frequency and postvoiding pain. Her diagnostic work-up revealed conflicting findings regarding the source of her bladder disease, and laparoscopy was required to make the final diagnosis of appendicitis. The presentation of appendicitis can be disguised and is often a difficult diagnosis.

The IBD1 locus for susceptibility to Crohn's disease has a greater impact in Ashkenazi Jews with early onset disease

OBJECTIVE

Recent studies have suggested that a susceptibility gene located on chromosome 16 and designated IBD1 may contribute to the development of Crohn's disease (CD). However, these findings were observed in predominantly non-Jewish populations; in the three studies where Ashkenazi Jews were included for analysis, the results have been widely divergent. Because Ashkenazi Jews are known to have a higher incidence of the disease than non-Jews, we sought to determine whether this previously reported linkage could be extended to the Ashkenazi population. In addition, we examined whether Ashkenazi Jewish patients with an early age of onset (< or = 21 yr) showed greater evidence of linkage to this locus.

METHODS

Linkage analysis for the IBD1 region was performed on 123 Ashkenazi Jewish CD patients distributed among 53 families. Only patients with four Jewish grandparents were considered to be Jewish. Of the 123 Ashkenazi Jewish patients, 75 (61%) had an age of onset < or = 21 yr.

RESULTS

Ashkenazi Jews showed only modest evidence of linkage (nonparametric linkage 1.63, p = 0.05) to the IBD1 locus. However, when the Ashkenazi population was subdivided on the basis of age of onset, there was a striking increase in linkage in families where affected individuals had an age of onset < or = 21 yr (nonparametric linkage 3.02, p = 0.002). In contrast, there was no evidence of linkage in the Jewish families where all affected individuals had an age of onset > 21 yr.

CONCLUSIONS

The IBD1 gene plays a greater role in conferring susceptibility to CD in Jews with early onset disease than in Jews with late onset disease.

Intermittent, luteal phase nefazodone treatment of premenstrual dysphoric disorder

Three outpatients who fulfilled full DSM-IV diagnostic criteria for premenstrual dysphoric disorder (PDD) were successfully treated with intermittent (luteal phase) nefazodone. They received the medication at low doses of up to 100 mg/day (50 mg b.i.d.), for 2 weeks through the luteal phase of the menstrual cycle only. All the patients reported a marked symptomatic improvement, including full remission of their emotional symptoms, and two achieved in addition full remission of their somatic symptoms. Side-effects reported during the treatment were mild. The use of luteal phase nefazodone seems to be a promising treatment strategy for the management of PDD. It offers advantages over daily dosing throughout the menstrual cycle, such as reduced incidence and severity of side-effects, and avoids the stigma that may accompany the continuous use of psychopharmacological treatment, with the advantage that compliance may be improved.

Final results of a randomized trial comparing the NIR stent to the Palmaz-Schatz stent for narrowings in native coronary arteries

The NIR stent is a novel second generation tubular stent that was designed to overcome some of the limitations of the earlier Palmaz-Schatz (PS) stent design. The NIR Vascular Advanced North American (NIRVANA) trial randomized 849 patients with single coronary lesions to treatment with the NIR stent or the PS stent. The study was an "equivalency" trial, designed to demonstrate that the NIR stent was not inferior to (i.e., equivalent or better than) the PS stent, for the primary end point of target vessel failure (defined as death, myocardial infarction, or target vessel revascularization) by 9 months. Successful stent delivery was achieved in 100% versus 98.8%, respectively, with a slightly lower postprocedural diameter stenosis (7% vs. 9%, p = 0.04) after NIR and PS stent placement, respectively. Major adverse cardiac events (death, myocardial infarction, repeat target lesion revascularization) were not different at 30 days (4.3% vs. 4.4%). The primary end point of target vessel failure at 9 months was seen in 16.0% of NIR versus 17.2% of PS patients, with the NIR proving to be equal or superior to the PS stent (p <0.001 by test for equivalency). Angiographic restudy in 71% of a prespecified cohort showed no significant difference in restenosis (19.3% vs 22.4%). Thus, the NIR stent showed excellent deliverability with slightly better acute angiographic results and equivalent or better 9-month target vessel failure rate when compared with the PS stent.

Genotyping of clinical Serratia marcescens isolates: a comparison of PCR-based methods

The polymerase chain reaction (PCR)-based procedures of randomly amplified polymorphic DNA (RAPD) and repetitive element (RE)-based PCR were used to amplify total DNA prepared from each of 62 clinical Serratia marcescens isolates. Three different random primers, designated 1060, 1254 and 1283, were used individually in RAPD-PCR. Primers representing enterobacterial repetitive intergenic consensus (ERIC) sequences, extragenic palindromic (REP) elements, and polymorphic GC-rich repetitive sequences (PGRS) constituted the repetitive element-PCR. We were able to generate 40, 40 and 58 genotypic groupings using the 1060, 1254 and 1283 RAPD primers, respectively. Using the ERIC, REP and PGRS primers, 19, 54 and 60 unique genotypic profiles were yielded, respectively. The PGRS primers, which were developed to amplify GC-rich repetitive sequences in the genome of Mycobacteria, were the most discriminatory. These data indicate that both of these PCR-based approaches are a valid means of discriminating strain differences among isolates of S. marcescens and the amount of differentiation depends on the primer used. These techniques should prove useful for routine surveillance or in examining outbreaks of S. marcescens in clinical settings.

Calreticulin and calsequestrin are differentially distributed in canine heart

Cardiac sarcoplasmic reticulum (SR) consists of three continuous yet distinct regions: longitudinal, corbular, and junctional. Ca(2+)uptake, catalyzed by the Ca(2+)-dependent ATPase, is thought to occur throughout the SR whereas Ca(2+)release occurs in the region of the junctional SR. In the SR, Ca(2+)is stored in a complex with Ca(2+)-binding proteins such as calsequestrin. In the present study, the distribution of the high-affinity calcium-binding protein, calreticulin, in canine cardiac SR was determined and compared with the distribution of other SR proteins. Three types of distribution were observed. Many proteins, including the Ca(2+)-ATPase and two mannose-containing glycoproteins (52 and 131 kDa), were present in all subfractions. These proteins were absent or depleted from the sarcolemma-enriched fraction. The ryanodine receptor/Ca(2+)release channel and calsequestrin were localized to the junctional SR. Calreticulin immunoreactivity was detected in fractions containing longitudinal SR but not in fractions enriched in sarcolemma or junctional SR. Hence calreticulin is present in a unique vesicular fraction and the Ca(2+)-binding proteins calreticulin and calsequestrin display different patterns of distribution in canine heart.

The pivotal role of deep vein thrombophlebitis in the development of acute disseminated staphylococcal disease in children

Deep vein thrombophlebitis (DVT) and septic pulmonary emboli (PE) are rare in children. The association of DVT and acute disseminated staphylococcal disease (DSD) during childhood has not been previously reported. We report 3 children who developed a triad of DVT, septic PE, and acute osteomyelitis with Staphylococcus aureus cultured from blood and bone. One child succumbed, while 2 survived following prolonged, morbid hospitalizations. The rapid clinical deterioration observed in these patients might be caused by the aggressiveness of staphylococcal infection combined with an ongoing showering of septic emboli from the ileo-femoral DVT. We suggest that infected DVT with septic PE had a pivotal role in the development of DSD in these children. The presence of this triad should prompt aggressive treatment with the appropriate antibiotics, anticoagulation, surgical drainage, and assisted ventilation when indicated.

Access site management after aortic valvuloplasty using a suture mediated closure device: clinical experience in 4 cases

Management of the femoral access site following percutaneous balloon aortic valvuloplasty is often associated with significant vascular morbidity. In an effort to reduce vascular complications, a novel method of suture mediated closure device deployment was employed in four patients that underwent aortic valvuloplasty at our institution. Delivery of the sutures to the access site took place prior to the intervention in all patients. This pre-close technique allowed the sutures to be placed utilizing the 10 French (Fr) closure device prior to expanding the access site to a 14 Fr size. This was done to facilitate adequate tissue capture, thereby assuring successful hemostasis following sheath removal. The technique was successful in all patients and none of the patients suffered vascular complications. This new access site management method was successful in achieving hemostasis and provided improved patient recovery in this small group of patients as compared to our usual experience.

The utility of transesophageal echocardiography in determining the source of arterial embolization

Arterial embolism is frequently of a cardiac source. Arterial-arterial and paradoxical embolization also occurs. Failure to identify the origin may subject the patient to an important series of events. Herein we describe seven cases in which transesophageal echocardiography (TEE) was uniquely valuable in identifying the source or mechanism and in which conventional echocardiography and aortography were nondiagnostic. We conducted a chart review of patients with arterial emboli definitively diagnosed after undergoing TEE. Seven patients (mean age 68 years) were included in the study. Peripheral embolization occurred in four patients, visceral embolization occurred in one, and two experienced cerebrovascular events. Five patients had transthoracic echocardiography and six had aortography; none of these identified the source of embolization. All were diagnosed by TEE. Mobile aortic thrombus was the primary source in three patients, paradoxical embolization occurred in two, and two others had a combination of findings. Two patients received operative management with one mortality, and five received nonoperative management. The source of arterial emboli remains obscure in some patients. TEE can be valuable in identifying sources or mechanisms of embolization when angiography and conventional echocardiography are negative.

Initial results of solitary pancreas transplants performed without regard to donor/recipient HLA mismatching

BACKGROUND

We hypothesized that solitary pancreas transplants could be performed successfully even in the presence of poor HLA matching if an aggressive approach were taken with regard to immunosuppressive protocol and the performance of allograft biopsy.

METHODS

Seven pancreas-after-kidney transplants and seven pancreas transplants alone were performed without consideration given to the degree of HLA mismatching (MM) using tacrolimus (FK506)/mycophenolate mofetil (MMF)/prednisone maintenance therapy. Mean (+/-SD) total HLA MM was 4.8+/-1.2. All patients were followed for at least 6 months. The first four cases were induced with ATGAM for 7 to 10 days. In the remaining 10 cases, an ultrasound-guided percutaneous needle biopsy was attempted on a protocol basis 10 days after completing induction with OKT3 for 7 (n=2) or 14 (n=8) days.

RESULTS

Overall patient survival, graft survival, and incidence of acute rejection requiring treatment were 86, 79, and 50%, respectively. Two patients receiving ATGAM developed grade III-IV rejection at 3 weeks. Both patients receiving OKT3 for 7 days developed early grade III rejection. However, only three of eight patients receiving OKT3 for 14 days developed rejection requiring treatment. Protocol biopsy was successfully performed in six of seven patients and uncovered three cases of otherwise undetectable grade III-IV rejection.

CONCLUSIONS

Although based on a small number of cases, our results suggest that solitary pancreas transplants with a poor HLA match can be performed with an acceptable rejection incidence and graft survival rate using an OKT3/FK506/MMF/prednisone regimen with protocol biopsy.

Ingested interferon-alpha prevents allograft islet transplant rejection

BACKGROUND

Ingested interferon (IFN)-alpha is a biological response modifier in experimental autoimmune encephalomyelitis and multiple sclerosis, and prevents type 1 diabetes in nonobese diabetic mice. Islet transplantation possesses significant potential advantages over whole-gland transplantation because it is simple, may achieve insulin independence, and has clear advantages over exogenous insulin therapy. Therefore, we examined whether ingested IFN-alpha, administered to islet allograft recipients, could prevent islet allograft rejection.

METHODS

Recipient C3H mice (H2k) were made diabetic and either untreated or treated with 10-1000 international units (IU) of ingested murine IFN-alpha daily from day -7 through day +14 after transplantation for a total of 21 days. Seven days after diabetes induction, recipients received allograft islets isolated from C57BL.10 donors (H2b) under the kidney capsule and were followed for overt diabetes via elevated blood glucose.

RESULTS

Control recipients and recipients fed 1000 IU all became diabetic by day 13, whereas mice ingesting IFN-alpha had delayed rejection for up to 27 (10 IU) to 29 days (100 IU) after islet transplantation. Treatment of recipients of islet allografts with ingested IFN-alpha doubles the time period before rejection compared with control mice. The feeding period with daily IFN-alpha was doubled from 21 days to 42 days in total, 7 days before transplantation and 35 days after transplantation.

CONCLUSION

Treatment of recipients of islet allografts with prolonged ingested IFN-alpha prevents rejection in a subset of recipients. Ingested IFN-alpha may prevent rejection if given continuously after transplantation.

High- and low-risk prostate cancer treated with 3D CT-guided brachytherapy: 1-to 5-year follow-up

PURPOSE

To provide a preliminary report of 301 patients treated for prostate carcinoma with three-dimensional CT-guided transischiorectal stereotactic brachytherapy using either iodine-125 or palladium-103 seeds as monotherapy.

PATIENTS AND METHODS

Patients with clinical stage T1, T(2ab), or T(3ab) disease with prostate volumes 23 to 180 cm3 and serum prostate specific antigen (PSA) concentrations of 0.9 to 143 ng/mL had seeds placed 10 mm apart under CT guidance. No androgen blockade was used postoperatively, but 47% of the patients had hormonal therapy preoperatively.

RESULTS

At 12 to 63 months (median 26 months) of follow-up, PSA concentrations had decreased to <2 ng/mL in 90% of the patients and to <1 ng/mL in 83%. Four patients underwent transurethral resection or incision at least 12 months after implantation; none became incontinent. Three patients had rectal ulceration that lasted for several months.

CONCLUSIONS

Computed tomography-guided transischiorectal brachytherapy allows accurate placement of radionuclide seeds in prostate glands of all sizes. The early results, as judged by serum PSA, are encouraging.

HLA class II alleles associated with susceptibility and resistance to Crohn's disease in the Jewish population

Previous studies have suggested that susceptibility to Crohn's disease (CD) is associated with the histocompatibility complex (HLA) class II alleles DR1, DQ5, and DR13 in the Caucasian population, DR7 in the French and German populations, and DR4 and DQ4 in the Japanese population. However, little is known about the relationship between HLA class II alleles and CD in the Jewish population since these previous studies included few Jewish individuals. In order to determine whether the HLA associations observed with predominantly non-Jewish populations were also present in the Jewish CD population and whether there were any HLA class II alleles uniquely associated with CD in the Jewish population, 132 CD patients, of which 82 were Ashkenazi Jewish, were HLA-typed using serologic and DNA methods. Ethnically matched controls were similarly typed. No association with DR1 or DR13 was observed in the Jewish CD population although an association with DR13 (OR [odds ratio] = 5.3, p = 0.02) was observed in the non-Jewish CD population. However, an association with DR15 (OR = 2.7, p = 0.03), which is normally associated with ulcerative colitis, was observed in the Jewish, but not non-Jewish, CD group. In addition, a strong negative association was observed with DR3, which was especially striking in the Jewish population (OR = 0.35, p = 0.025); similar negative associations with DR3 have been observed by others using non-Jewish populations. Furthermore, a significant negative association with DR7 (OR = 0.45, p = 0.04) was observed in the Jewish, but not non-Jewish, population. Consistent with this was the negative association with DQ2 (OR = 0.38, p = 0.005), which is in strong linkage disequilibrium with both DR3 and DR7, in the Jewish, but not non-Jewish, population. These studies support previous suggestions that susceptibility to CD in Jewish and non-Jewish populations is determined by distinct genes and provide further support to the hypothesis that a gene on the DR3 haplotype may protect against CD. Furthermore, protection is conferred by the same or another gene found on Jewish, but not non-Jewish, DR7 haplotypes.

Stimulation of 90- and 70-kDa ribosomal protein S6 kinases by arginine vasopressin and lysophosphatidic acid in rat cardiomyocytes

Arginine vasopressin (AVP) and lysophosphatidic acid (LPA) have been shown to stimulate protein kinase C (PKC) and mitogen-activated protein (MAP) kinases and the proliferation of vascular smooth muscle cells. However, the actions of these two agents in cardiomyocytes are less well understood. To investigate the signal transduction pathways of AVP and LPA, freshly isolated adult rat cardiomyocytes were examined. Both AVP and LPA induced concentration- and time-dependent stimulation of the phosphotransferase activities of p90 ribosomal S6 kinases (RSK) and their upstream activators, extracellularly regulated kinases (ERK) 1 and 2. The activation of ERK1 and ERK2 by LPA was PKC- and phosphatidylinositol 3-kinase (PI 3-kinase)-dependent. However, AVP-induced activation of RSK2, a downstream substrate of ERK1 and ERK2, was PKC-dependent and PI 3-kinase-independent. AVP and LPA were also observed to increase the phosphotransferase activity of p70 ribosomal protein S6 kinase (p70 S6K) in a time- and concentration-dependent manner. The activation of p70 S6K by LPA and AVP was PI 3-kinase-dependent. PKC was necessary in AVP- but not in LPA-induced activation of p70 S6K. Since RSK and p70 S6K have been implicated in the regulation of translational control of protein synthesis, we concluded that AVP and LPA may stimulate the growth of cardiomyocytes through these two protein kinase cascades.

Early intervention programme for infants with Down's syndrome

This article describes an early intervention programme for infants with Down's syndrome (DS) implemented by a registered nurse. The purpose of this programme was to help the families cope with the realities of raising a child with DS and help the infant fulfil his/her maximum potential. Small groups of three-four families with their infants met weekly with the nurse for 2-hour sessions. Each session was divided into two parts: exercises and discussion of issues relating to DS. Implications for nursing practice, education and management are discussed.

Cyclic GMP-dependent and -independent regulation of MAP kinases by sodium nitroprusside in isolated cardiomyocytes

Sodium nitroprusside (SNP) elicits various physiological effects, in part through generation of the membrane permeable mediator nitric oxide (NO). In the heart, besides its role in regulating contractility, NO is involved in both protection from and induction of cellular damage. The present study investigated the role of SNP in the regulation of the mitogen-activated protein kinases (MAPKs) in isolated adult rat cardiomyocytes. SNP maximally activated Erk1, Erk2, p38 MAPK and MAPKAPK2 in 5-10 min. The activation of MAPKAPK2 by SNP was blocked by the soluble guanylyl cyclase inhibitor, 1H-[1, 2,4]oxadiazolol[4,3-a]quinoxalin-1-one (ODQ) and the p38 MAPK inhibitor, SB203580. The activation of Erk1 was insensitive to ODQ but completely blocked by the Mek1 inhibitor PD98059. The membrane-permeable homologue of cGMP, 8-Br-cGMP, also activated p38 MAPK (A(0.5) approximately 50 microM) but not Erk1 and Erk2. These results indicate that p38 MAPK and MAPKAPK2 are activated by SNP in cGMP-dependent pathways, while the Erk1 activation by SNP is independent of cGMP levels.

[Effects of knowledge acquisition on verbal linearization about spatial orientation]

This paper deals with determinants of linearization in spatial communication. The well-known linearization principles, such as the principle of natural order, primarily emphasize features of the given information. We assume that verbal linearization is in addition influenced by the speakers' knowledge acquisition. Six experiments with a total of 272 participants are reported here. A particular spatial constellation was presented to the participants, who were asked to talk about it afterwards. The linearizations then produced were defined as dependent variables. The results show that the linearizations were influenced by the speaker's experience with the configuration (according-to-experience effect) and also demonstrate the importance of the first encounter (anchor effect). Further characteristics of the effects mentioned above are described and discussed regarding memory research and psycho-linguistics.

Ischemia induced activation of heat shock protein 27 kinases and casein kinase 2 in the preconditioned rabbit heart

Protein kinase C (PKC), p38 MAP kinase, and mitogen-activated protein kinase-activated kinases 2 and 3 (MAPKAPK2 and MAPKAPK3) have been implicated in ischemic preconditioning (PC) of the heart to reduce damage following a myocardial infarct. This study examined whether extracellular signal-regulated kinase (Erk) 1, p70 ribosomal S6 kinase (p70 S6K), casein kinase 2 (CK2), and other hsp27 kinases are also activated by PC, and if they are required for protection in rabbit hearts. CK2 and hsp27 kinase activities declined during global ischemia in control hearts, whereas PC with 5 min ischemia and 10 min reperfusion increased their activities during global ischemia. Resource Q chromatography resolved two distinct peaks of hsp27 phosphotransferase activities; the first peak (at 0.36 M NaCl) appeared to correspond to the 55-kDa MAPKAPK2. Erk1 activity was elevated in both control and PC hearts after post-ischemic reperfusion, but no change was observed in p70 S6K activity. Infarct size (measured by triphenyltetrazolium staining) in isolated rabbit hearts subjected to 30 min regional ischemia and 2 h reperfusion was 31.0+/-2.6% of the risk zone in controls and was 10.3+/-2.2% in PC hearts (p<0.001). Neither the CK2 inhibitor 5,6-dichloro-1-beta-D-ribofuranosylbenzimidazole (DRB) nor the Mek1/2 inhibitor PD98059 infused during ischemia blocked protection by PC. The activation of CK2 and Erk1 in ischemic preconditioned hearts appear to be epiphenomena and not required for the reduction of infarction from myocardial ischemia.

Update in medical therapy in inflammatory bowel disease: a clinician's view

Recent advances in the therapy of inflammatory bowel disease specifically directed against the inflammatory and immune mechanisms include an impressive and often overwhelming cornucopia of anti-inflammatory agents, immunomodulators, antibiotics, biologicals, topical therapies, nicotine, heparin, and nutritional supplements. The interface of one drug regimen into another may lead to confounding and often confusing programs of treatment. This review will attempt to offer a perspective of care and an update of specific remedies, but the aim is practicality and usefulness, not encyclopedic detail.

The protein Hrb57A of Drosophila melanogaster closely related to hnRNP K from vertebrates is present at sites active in transcription and coprecipitates with four RNA-binding proteins

The hnRNP K protein is among the major hnRNA-binding proteins with a strong preference for cytidine-rich sequences. We have cloned a Drosophila hnRNP protein closely related to this vertebrate protein. The protein first identified by the monoclonal antibody Q18 is encoded by a gene located in 57A on polytene chromosomes and has been consequently named Hrb57A. The amino acid sequence of the Hrb57A KH domains and their overall organisation in the protein are remarkably similar to the vertebrate proteins. As the hnRNP K in vertebrates the M(r) 55 000 Drosophila Hrb57A/Q18 protein strongly binds to poly(C) in vitro and is ubiquitously present in nuclei active in transcription. On polytene chromosomes it is found in many puffs and minipuffs. Hrb57A/Q18 specifically coprecipitates four other proteins: Hrb87F/P11 a Drosophila hnRNP A1 homologue, the hnRNA-binding protein S5, the RNA recognition motif-containing protein NonA and the RNA-binding zinc finger-containing protein on ecdysone puffs PEP/X4.

Gastric carcinoid tumours and pernicious anemia: case report and review of the literature

Patients with pernicious anemia are at risk of developing carcinoid tumours of the stomach. A patient with pernicious anemia and multifocal carcinoid tumours of the gastric fundus that regressed after antrectomy is presented. The frequent occurrence of gastric carcinoid tumours in patients with long-standing pernicious anemia suggests that surveillance gastroscopy and biopsies of the fundus might be indicated. Compete functional antrectomy may effectively cause these tumours to regress by removing their excessive gastrin hormonal stimulation. However, incomplete antrectomy can result in persistently elevated serum gastrin and failure of total disappearance of the carcinoid tumours.

Prediction of postdischarge complications by predischarge event recordings in infants with apnea of prematurity

OBJECTIVE

To determine whether predischarge event recording (PDER) can accurately identify preterm infants with resolving apnea of prematurity (AOP) at risk for postdischarge complications.

DESIGN

PDER was performed on infants with resolving AOP on caffeine, ready for discharge. The outcome of infants with normal recordings was compared with that of infants with abnormal recordings. Follow-up data were obtained for outcome.

RESULTS

Of the 106 infants, 74 had a normal PDER and 32 had an abnormal PDER (apneas lasting for > 20 seconds and/or a heart rate of < 80 beats per minute for > 5 seconds). Birth weight, gestational age at birth, length of stay, discharge weight, and duration of caffeine treatment after discharge were no different between groups. None of the normal PDER infants (0 of 74) had postdischarge complications, whereas 4 of 32 infants with an abnormal PDER had complications (p < 0.05, power = 0.7). The positive predictive value of a normal PDER and no postdischarge complications was 100%. The positive predictive value of an abnormal PDER and an adverse outcome was 12.5%.

CONCLUSION

Normal PDER accurately identifies infants at low risk for an adverse outcome.

Large bowel obstruction: an unusual presentation of salmonella enterocolitis in infancy

An infant with a large-bowel obstruction due to Salmonella B enterocolitis is presented. The clinical and radiologic findings were suggestive of Hirschsprung's disease with total colonic aganglionosis. Due to further deterioration, an ileostomy was performed. Pathologic examination disclosed ganglia in the colon. At laparatomy, 1 month later the colon, which was almost completely obliterated, was resected and an ileorectal anastomosis carried out. The patient remained a carrier of a multiple antibiotic-resistant group B Salmonella strain, and 2 months later died as a result of severe gastroenteritis.