Do systemic symptoms predict the risk of kidney scarring after urinary tract infection?

BACKGROUND AND AIMS

In the NICE guideline on childhood urinary tract infection (UTI), it is assumed that the presence or severity of systemic symptoms, especially fever, predicts for renal scarring, and different management is recommended accordingly. We aimed to test this hypothesis by retrospective case note analysis.

DESIGN AND SUBJECTS

Notes of children aged under 5 years referred with a first UTI who were assessed for scarring were reviewed.

MAIN OUTCOME CRITERIA

Ability to predict for single or multiple scarring from age, sex, fever, vomiting or anorexia or malaise, or need for hospitalisation, within the age bands used by NICE.

RESULTS

There were 51 (65% girls) scarred and 140 (69% girls) unscarred children. Fever, systemic symptoms and hospitalisation were all commoner among younger children (<6 months vs 6 months-3 years vs >3 years; fever 0.67 vs 0.38 vs 0.38; systemic symptoms 0.78 vs 0.62 vs 0.43; hospitalisation 0.67 vs 0.29 vs 0.19; p<0.001 for all). Having vomiting, anorexia or malaise at presentation correlated weakly with single or multiple renal scarring (R(2) = 0.03; p = 0.02), but sex, age, fever or hospitalisation did not (p>0.5 for all). Sensitivity and specificity data, and plots of proportionate reduction of uncertainty showed that none of these variables was useful for predicting any scarring in children aged <3 years and that they were only weakly predictive in older children.

CONCLUSIONS

Clinical signs at presentation in childhood UTI cannot be used to predict for mild or multiple scarring, and should not be used to guide management. NICE's recommendation to do so is not justified.

Does antenatal pelvic dilation predict renal scarring?

Moderate antenatal renal pelvic dilation (5-15 mm) may suggest vesicoureteric reflux, but it is not known to predict renal scarring. Dimercaptosuccinic acid scans on such children aged over 4 years showed a scarring rate (0/133 boys, 1/56 girls) similar to our local population. Investigation and treatment of moderate dilation may not be required.

Estimation of glomerular filtration rate in paediatric cancer patients using 51CR-EDTA population pharmacokinetics

Estimation of glomerular filtration rate (GFR) using the clearance of chromium 51 EDTA ((51)Cr-EDTA) (or other radiolabelled isotopes) is reliable, but invasive and not always practicable. Mathematical models have been devised for estimating GFR using readily obtainable patient characteristics. Unfortunately, these models were developed using various patient populations and may not provide the optimal prediction of GFR in children with cancer. The current study uses population pharmacokinetics to determine the relationship between (51)Cr-EDTA clearance, and patient covariates in 50 paediatric cancer patients. These models were validated using a separate group of 43 children and were compared with previously published models of renal function. Body size was the major determinant of (51)Cr-EDTA clearance and inclusion of weight or surface area reduced the residual variability between individuals (coefficient of variation) from 61 to 32%. Serum creatinine was the only other parameter that significantly improved the model. Mean percentage error values of -5.0 and -1.1% were observed for models including weight alone or weight and creatinine, respectively, with precision estimates of 21.7 and 20.0%. These simple additive models provide a more rationale approach than the use of complex formulae, involving additional parameters, to predict renal function.

Evaluation of local invasion by oesophageal carcinoma--a prospective study of prone computed tomography scanning

The aim of this study was to assess the value of prone computed tomography compared with the traditional supine position, in the assessment of invasion of adjacent mediastinal structures by oesophageal cancer. A prospective, single blind case-case comparative study of signs of local tumour invasion was conducted. Sixty nine consecutive patients undergoing computed tomography for preoperative staging of oesophageal carcinoma were studied. Computed tomography scanning of the thorax was performed in the standard supine followed by prone position; in 39 patients the computed tomography findings were correlated with the surgical findings. Four established radiological signs used to assess mediastinal invasion were scored in each case. Based on the radiological scoring system, there was a significant down staging in the probability of aortic invasion in 12 of the 69 cases (p<0.05). A similar improvement in accuracy was seen in the cases undergoing surgery; of the 38 cases who did not have aortic invasion at operation, 10 cases were scored as high for aortic invasion on the supine scans compared with only three on the prone position (p<0.05). Prone scanning was not of significant additional value in the assessment of major airway or pericardial invasion. Modification of the computed tomography protocol to include scanning in the prone position will improve the accuracy of the preoperative staging of patients with oesophageal malignancy and reduce the chance of overstaging disease. Especially in centres where endoscopic ultrasound is not available, our modification may reduce the chance of denying patients potentially curative operations.

Toxaphene congeners in the Canadian Great Lakes basin: temporal and spatial food web dynamics

Samples of a top predator fish species, lake trout (Salvelinus namaycush) and predominant forage species including smelt (Osmerus mordax), alewife (Alosa pseudoharengus), slimy sculpin (Cottus cognatus), deepwater sculpin (Myoxocephalus quadricornis) and lake herring (Coregonus artedii) were, collected from throughout 4 of the 5 Great Lakes (Superior, Huron, Erie and Ontario) (Fig. 1). Lake trout were also collected from three isolated lake systems (Lakes Nipigon, Simcoe and Opeongo), all located within the basin. All the samples were analysed for body burdens of total toxaphene and 22 toxaphene congeners. In addition, from each of the Great Lakes sites samples of major invertebrate dietary items, which included Mysis relicta, Diporeia hoyi and plankton, were similarly analysed. Whole lake trout samples, archived at -80 degrees C, were reanalysed to determine historical trends of toxaphene congeners plus carbon and nitrogen stable isotope signatures. The Lake Superior food web consistently had the highest levels of total toxaphene of all the Great Lakes monitored. The primary source of toxaphene to Lake Superior has been identified as atmospheric transport and deposition from sites in the southern US, Mexico and Central America (Hoff, R.M., Strachan, W.M.J., Sweet, C.W., Chan, C.H., Shackelton, M., Bidleman, T.F., Brice, K.A., Burnison, D.A., Cussion, S., Gatz, D.F., Harlin, K., Schroeder, W.H., 1996. Atmospheric deposition of toxic chemicals to the Great Lakes: A review of data through 1994. Atmospheric Environ. 30, 3505-3527). Of the offsystem lakes surveyed. Lake Nipigon, situated due north of Lake Superior and with a Lake Basin area of about 6% of Lake Superior (Hendendorf, C.E., 1982. J. Great Lakes Res. 8(3), 379-412) had total toxaphene levels in lake trout equivalent to about 50% of those found in lake trout from Lake Superior. Temporal trend toxaphene congener analysis was conducted on archived whole fish samples collected over the period 1980 through to the 1990's. Initially a nonachlorobornane congener (Parlar #50) was predominant, with congeners #40, #62 and #21 being the next most prominent in the 1980 samples. Samples from the 1990's showed a significant decline in the presence of lower chlorinated congeners #40 and #21. Analysis of total toxaphene in food webs, indicated elevated levels in lower trophic level species such as Diporeia and Cottus sp. which have a benthic association. The stable isotope temporal trend 13C signature identified a significant shift in the lake trout diet over the period 1993 to 1996.

Characterisation and partial purification of the GABA(B) receptor from the rat cerebellum using the novel antagonist [3H]CGP 62349

The novel GABA(B) receptor antagonist [3H]CGP 62349 binds rat cerebellar synaptosomal membranes with high affinity at a single population of sites (K(d) = 0.9 nM, B(max) = 760 fmol/mg protein). Solubilisation with 1% Triton X-100/0.5 M NaCl/10% glycerol resulted in a marked increase in [3H]CGP 62349 binding (K(d) = 0.5 nM, B(max) = 1285 fmol/mg protein). Competition of [3HCGP 35348 = CGP 36742. The GABA(A) ligand isoguvacine did not displace [3H]CGP 62349 binding. Partial purification of [3H]CGP 62349 binding sites was obtained by sucrose density centrifugation and a predominant protein in the peak binding fraction was recognised by an anti-GABA(B) receptor antibody and had a molecular weight similar to the recombinant expressed GABA(B)R1a. These results demonstrate that [3H]CGP 62349 provides a useful additional tool for further characterisation of the pharmacology and biochemistry of the native GABA(B) receptor.

The correlation of the radiologic extent of lung transplantation edema with pulmonary oxygenation

OBJECTIVE

The study set out to evaluate the relationship between the efficiency of pulmonary oxygenation and the extent of the reimplantation response as revealed on chest radiography after bilateral lung transplantation.

MATERIALS AND METHODS

Postoperative chest radiographs of 31 patients who had undergone bilateral lung transplantation were evaluated for the extent of the reimplantation response. For each patient, the contemporaneous oxygenation indexes (partial pressure of oxygen in arterial blood divided by fraction of inspired oxygen) were calculated and correlated with a radiographic score produced from the evaluation of chest radiographs.

RESULTS

The method of evaluating chest radiographs for the extent of the reimplantation response was shown to be reproducible. Although mean oxygenation indexes were found to decrease with increasing radiographic scores, this trend was not statistically significant.

CONCLUSION

Although the extent of the reimplantation response on the early postoperative chest radiography inversely correlated with the oxygenation efficiency of the transplanted lungs, this finding was not statistically significant.

New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid: follow up study

OBJECTIVE

To determine up to what age children remain at risk of developing a new renal scar from a urinary tract infection.

DESIGN

Follow up study. Families of children who had normal ultrasound scans and scanning with dimercaptosuccinic acid (DMSA) after referral with a urinary tract infection when aged 3 (209) or 4 (220) were invited to bring the children for repeat scans 2-11 years later. A history of infections since the original scan was obtained for children not having a repeat scan.

SETTING

Teaching hospital.

SUBJECTS

Children from three health districts in whom a normal scan had been obtained at age 3-4 years in 1985-1992 because of a urinary tract infection.

MAIN OUTCOME MEASURE

Frequency of new renal scars in each age group.

RESULTS

In each group, about 97% of children either had repeat scanning (over 80%) or were confidently believed by their general practitioner or parent not to have had another urinary infection. The rate of further infections since the original scan was similar in the 3 and 4 year old groups (48/176 (27%)) and 55/179 (31%)). Few children in either group known to have had further urinary infections did not have repeat scanning (3/209 (1.4%) and 4/220 (1.8%)). In the 3 year old group, 2.4% (5/209) had one or more new kidney scars at repeat scanning (one sided 95% confidence interval up to 5.0%), whereas none of the 4 year olds did (one sided 95% confidence interval up to 1.4%). The children who developed scars were all aged under 3.4 years when scanned originally.

CONCLUSIONS

Children with a urinary tract infection but unscarred kidneys after the third birthday have about a 1 in 40 risk of developing a scar subsequently, but after the fourth birthday the risk is either very low or zero. Thus the need for urinary surveillance is much reduced in a large number of children.

The Great Lakes Fisheries Specimen Bank: a Canadian perspective in environmental specimen banking

Since 1977 the Canadian Department of Fisheries and Oceans (DFO) has maintained a specimen bank for retrospective chemical analyses. The Great Lakes Fisheries Specimen Bank (GLFSB) is a complementary activity to the department's ongoing Great Lakes Contaminants Surveillance Program that has annually, since 1977, monitored levels of metals and organochlorines in aquatic biota throughout the Canadian Great Lakes. Past activities have focused on defining the effects of long-term frozen storage on the integrity of organochlorine residues in archived biological tissues. Archived samples have been reanalyzed for total PCBs, PCB congeners including co-planar PCBs, dioxin and furan isomers, and 22 toxaphene congeners. More recently, archived samples of predatory fish have been analyzed for stable isotopes of nitrogen (delta 15N) and carbon (delta 13C), as indicators of historical changes in food web dynamics. A catalogue or user-guide has recently been completed describing all information associated with samples stored in the GLFSB.

delta-opioid receptor mobilization of intracellular calcium in SH-SY5Y cells: lack of evidence for delta-receptor subtypes

delta-opioid receptor agonists mobilize intracellular Ca2+([Ca2+]i) in SH-SY5Y cells when applied in the presence of muscarinic agonists. The putative delta 1 receptor agonist [D-Pen2,D-Pen5]-enkephalin (DPDPE) elevated [Ca2+]i with an EC50 of 11 nM and the putative delta 2 agonist deltorphin II elevated [Ca2+]i, with an EC50 of 14 nM. The maximal elevations of [Ca2+]i caused by both agonists were not different, nor were maximally effective concentrations of DPDPE (1 microM) and deltorphin II (1 microM) applied together more effective than either agonist applied alone. The elevations of [Ca2+]i caused by DPDPE (1 microM) and deltorphin II (1 microM), in the presence of carbachol, desensitized rapidly with continued opioid exposure and the cross-desensitization between PDPDE and deltorphin II was complete. The putative delta 1 selective antagonist 7-benzylidenenaltrexone (BNTX) and the putative delta 2 selective antagonist naltriben both reduced the elevations of [Ca2+]i caused by DPDPE (30 nM) and deltorphin II (10 nM), by greater than 50% at concentrations of less than 10 nM. In SH-SY5Y cells delta-receptor mediated elevation of [Ca2+]i is mediated by a population of receptors, which does not discriminate between agonists and antagonists purportedly selective for delta 1 or delta 2 receptors.

Computerized planimetry in the objective assessment of the antispasmodic effect of Zamifenacin in double contrast barium enemas

A prospective, randomized, double-blind study was undertaken to evaluate Zamifenacin 30 mg (Pfizer Ltd), a novel, orally-administered, gut-specific muscarinic receptor antagonist, as an adjuvant to the double contrast barium enema examination (DCBE). Zamifenacin was compared with placebo in terms of side-effects and colonic tone. Analysis of colonic tone was carried out by two independent observers, using a subjective grading system and also by an objective method using computerized planimetry. Interobserver variability was also assessed. Zamifenacin is safe and well tolerated but at the prescribed dose is an ineffective antispasmodic for DCBE. Subjective assessment of colonic tone was shown to be of limited value whilst the objective analysis using computerized planimetry was reliable and highly reproducible.

How reliable are ultrasound measurements of renal length in adults?

Ultrasound assessment of patients with renal impairment commonly includes measurement of bipolar renal length. Reduction in length is considered to indicate chronic renal disease and is a factor in deciding whether to proceed to renal biopsy. To date, no published data are available on interobserver and intraobserver variation in sonographic renal length measurement in adults. Bilateral renal lengths were measured in 20 adult subjects, with no history of renal disease, by three experienced operators, on two separate occasions. Limits of agreement for replicate measurements by each ultrasonographer and for replicate measurements by each pair of ultrasonographers were determined. Values of repeatability (a measure of intraobserver variation) and reproducibility (a measure of interobserver variation) were calculated for all renal length measurements, and for right and left renal lengths separately. Results indicate that replicate renal length measurements differ by less than 1.85 cm in 95% of cases, and the magnitude of variations is similar when measurements are made by either single or different ultrasonographers, and are similar for right and left renal length measurements. This suggests that sonographic bipolar renal length measurements in normal adult kidneys are reasonably reliable. In diseased kidneys, however, in which identification of renal poles is difficult, interobserver and intraobserver variation may be much greater.

Computed tomography evaluation of renal parenchymal volume in patients with chronic pyelonephritis and its relationship to glomerular filtration rate

The measurement of renal parenchymal volume using a calibrated computed tomography image processing method has been evaluated clinically on a cohort of patients with chronic pyelonephritis. Comparison of renal volume with function as assessed by 99Tcm DTPA renography demonstrated a simple linear relationship in patients who were normotensive and aproteinuric. The implications of this result on the interpretation of prognostic factors determining declining renal function in chronic pyelonephritis are discussed.

Preparation of the colon for double-contrast barium enema: comparison of Picolax, Picolax with cleansing enema and Citramag (2 sachets)--a randomized prospective trial

A randomized prospective trial was undertaken on 196 consecutive patients referred for double-contrast barium enema examination to assess the relative efficacy of three colon cleansing regimes: Citramag (2 sachets), Picolax and Picolax with a preliminary cleansing enema. Each of the regimes was preceded by a 5 day low residue diet. The radiographs from the examinations were assessed on a double-blind basis. The quality of bowel preparation was significantly poorer (P < 0.001) in the group receiving the preliminary cleansing enema, notably with respect to mucosal coating, compared with the other two groups. The quality of the preparation was slightly better in the group receiving Picolax alone than in the Citramag group (P < 0.01), the difference being most apparent in the proximal colon. The laxatives were equally well tolerated. The study has formed the basis of a departmental audit. As a result, the bowel preparation has been standardized to a 5 day period of dietary restriction followed by 2 Picolax sachets. This measure has improved efficiency within the department with no sacrifice in quality.

Inaccuracy of glomerular filtration rate estimation from height/plasma creatinine ratio

Use of a height/plasma creatinine formula to estimate glomerular filtration rate (GFR) is simpler and less invasive than renal or plasma clearance methods. The aim of this study was to determine whether these formulas enabled accurate prediction of GFR measured from the plasma clearance of 51Cr labelled ethylenediaminetetra-acetic acid (51Cr-EDTA). Thirty nine patients underwent GFR measurement at least six months after potentially nephrotoxic chemotherapy. Altman-Bland analysis was performed on the measured GFR and that estimated simultaneously using the original and a modified Counahan-Barratt formula and the Schwartz formula. The limits of agreement of the estimated GFR with the measured GFR were unacceptably wide in each case, despite highly significant correlation coefficients. The bias was smallest for the modified Counahan-Barratt formula. Use of these formulas to estimate GFR in children is insufficiently accurate for research purposes and has limitations in clinical practice. Furthermore, use of correlation coefficients to evaluate different methods of measuring GFR is inappropriate.

Urea kinetic modeling: comparing the options

In this study 6 commercially produced kinetic modeling packages utilizing a variable volume, single pool urea model, as well as formulae to determine the delivery of therapy, have been compared by applying to each the same set of rigorously collected data for a group of 12 patients. Comparison of the kinetically derived parameters (urea generation rate [G], urea distribution volume [V], delivery of therapy [Kt/V], and normalized protein catabolic rate [nPCR]) showed that the values obtained for both G and V differed between packages owing to the numerical methods and the clearance used in the solution of the differential equations. Although a broad agreement between the values established for Kt/V and nPCR was noted, the 95% limits of agreement indicated that it would be prudent to exercise caution when comparing results established by different modeling packages.

Evaluation of "Gastromiro" for bowel opacification during computed tomography: comparison with diatrizoate and barium sulphate

A new oral formulation of iopamidol, "Gastromiro", was evaluated as a bowel contrast agent during abdominal computed tomography (CT). Comparison was made with the well established agents sodium/meglumine diatrizoate ("Urografin 370") and dilute barium sulphate ("E-Z CAT") in a randomized, blind study of 150 consecutive patients undergoing abdominal and/or pelvic CT. Parameters assessed included quality of bowel opacification, artefact generation, contrast-medium palatibility, side effects and cost. No significant difference was found between the three contrast media in stomach- or small-bowel opacification. E-Z CAT was superior at opacifying the caecum/ascending colon. No compelling reason to choose a particular agent was found in the other assessed parameters, but cost is a significant factor.

The direct measurement of glomerular filtration rate from the continuous monitoring of DTPA clearance

A method of measuring glomerular filtration rate is proposed, intended for use during gamma camera renography and involving the continuous monitoring of DTPA activity in blood, a single blood sample, and a urine collection. Data obtained from experiments using a CsI scintillation detector are presented and used to demonstrate the validity of the method. In a comparison with a direct measurement of renal clearance of DTPA the proposed method showed an average overestimate of 13% compared to an overestimate of 30% for an uncorrected single-compartment model calculation of filtration rate. Some limited data using a gamma camera to monitor the DTPA activity in blood are also presented.

Survey of general practitioners' opinions on the role of radiology in patients with low back pain

Ninety general practitioners responded to a questionnaire about the role of radiology in patients with low back pain. Their clinical indications for requesting radiographs were mostly in agreement with the opinions of radiologists, but nearly 80% requested investigations for their own or patients' reassurance. Understanding of the terms used by radiologists was good, although 25% thought that acute disc prolapse could be demonstrated on plain films. Previous training in radiology did not seem to influence knowledge. When general practitioners understood radiological terms they had clear therapeutic and specialist referral preferences. Poorly understood terms and those with which they were familiar but unclear about the implications for management were also identified.

Critical analysis of the use of skeletal surveys in patients with chronic renal failure

Skeletal radiology and bone histopathology were compared in 82 patients with renal failure. The performance of radiology in detecting lesions was assessed using interobserver studies which showed disappointing levels of agreement probably reflecting the subjective nature of the radiological signs. Radiology was very insensitive in detecting and grading hyperparathyroidism even when histology and serum biochemistry were floridly abnormal. The most useful radiographs for monitoring subperiosteal erosions and vascular and soft tissue calcification are identified.

Urographic findings in adults with chronic pyelonephritis

The radiological findings in a cohort of 138 adults with chronic pyelonephritis are presented and the following conclusions made. Scarring is commoner in the right kidney than the left and is found in the upper, middle and lower poles with decreasing frequency from above down. Agreement between observers in the grading of scarring in urograms taken without standardisation or routine tomography, is sufficiently high to justify the continued use of the intravenous urogram as a screening test but is not high enough to detect any progression of scars in the group over a 6.5-year period. Repetition of urograms seldom reveals the development of calculi or other new abnormalities and is not justified as a clinical routine. The combination of extensive bilateral renal scarring and proteinuria is associated with the worst renal function.

Ablative radioiodine therapy for hyperthyroidism: long term follow up study

A total of 225 patients were treated for hyperthyroidism with 555 MBq (15 mCi) radioiodine to ablate the thyroid and induce early hypothyroidism. The efficacy of this treatment in eradicating hyperthyroidism and problems of follow up were assessed one to six years later from case records and questionnaires. Information was received from 197 out of 219 live patients (90%) and from 160 doctors concerning 207 patients (92%). Only three patients were not traced and six had died since treatment. The modal time to hypothyroidism was three months, and 64% of patients were hypothyroid at one year; 5.6% had failed to become euthyroid within one year. Ninety five per cent of patients had been seen by the doctor and 82% had had a thyroid test done within the past two years. Most doctors preferred patients to be returned to their care once thyroxine treatment was stabilised. An ablative dose of 131I is recommended as an effective means of treatment which has clear advantages over conventional methods. Good communications and effective follow up should ensure success.

The effects of nutrition and trauma on whole-body protein metabolism in man

Whole-body protein metabolism was determined by a primed constant-rate infusion of L-[ 1-14C ]leucine in patients before and after elective surgery, the nutritional intake being carefully controlled and the surgical stress in individuals being assessed. Pre-operatively, whole-body protein flux (P less than 0.05) and synthesis (P less than 0.05), along with amino acid oxidation (P less than 0.01), increased with nutritional intake whereas protein breakdown remained unaltered. Whole-body protein balance also correlated with intake (P = 0.001). Postoperatively, whole-body protein metabolism was determined with patients either fasted (group 1) or fed (group 2) and the change in metabolism in each individual from a pre-operative study, carried out in the fed state, was calculated. Whole-body protein breakdown increased in both groups (group 1, + 0.91 +/- 0.74 g day-1 kg-1; mean +/- SD, n = 7: group 2, + 0.47, + 0.63 and + 1.01 g day-1 kg-1, n = 3), the change being significant in those fasted after surgery (P less than 0.05). However, the pattern of change in whole-body protein synthesis was entirely different in each group, rising in those fed throughout (+ 0.32, + 0.41 and + 0.66 g day-1 kg-1, n = 3) but falling in those fasted after surgery (-0.38, -0.80 and -1.33 g day-1 kg-1, n = 3). The changes in metabolism appeared more marked in those undergoing greatest surgical stress. Some of the factors involved in the calculations are discussed and their effects on the overall conclusions are considered. A concept of whole-body protein metabolism in the metabolic response to trauma is advocated whereby protein breakdown is largely obligatory to the response, whereas synthesis responds to substrate availability.

Comparative study of the sodium salts of iodamide and iothalamate in clinical urography

In a comparative urographic study of the sodium salts of iodamide (Uromiro 300 Sodium) and iothalamate (Conray 420) the following conclusions have been made. (i) In subjects with radiologically normal kidneys and a creatinine clearance greater than 70 ml/min, nephrogram scores were significantly higher with iodamide (P less than 0.02). There were differences between the media in respect of total urogram scores and pyelogram scores but they were not statistically significant. (ii) In patients with radiologically normal kidneys and a spectrum of normal and abnormal renal function, performance scores for iothalamate showed no significant relationship with creatinine clearance. Results for iodamide, however, showed some relationship with creatinine clearance (nephrogram score r = 0.46, pyelogram score r = 0.38, total urogram score r = 0.49). A possible mechanism for this is proposed. (iii) Side-effects encountered in the study were mild and there were no significant differences between the contrast media in either the incidence or severity of the side-effects. (iv) Blood-pressure and pulse-rate profiles following iodamide were not significantly different from those following iothalamate. (v) Cardiac arrhythmias were mild and uncommon.

Increased incorporation of an infused labelled amino acid into plasma proteins as a means of assessing the severity of injury or activity of disease in surgical patients

Following injury there is increased synthesis of several plasma proteins. During a constant rate infusion of 1-(1-14C) leucine some of the labeled amino acid became incorporated into plasma proteins, the amount being readily determined after precipitation with perchloric acid. This value was correlated with the clinical state of the patient to see if an index of severity of injury could be derived. Before operation 6.7 +/- 0.5% (mean +/- SD, n = 16) of the infused labeled amino acid was incorporated in asymptomatic patients, irrespective of their dietary intakes, while in the presence of symptomatology this value rose, correlating with tumor staging in patients with colorectal neoplasia (r = 0.988, p = 0.001). It returned to normal following tumor resection, but was elevated in the presence of recurrence or residual disease. After operation it also rose, being maximal in the early postoperative period and following the more major surgical procedures, the increase correlating with the change in cortisol level in patients following cholecystectomy (r = 0.84, p less than 0.01; n = 8). The pattern of distribution of the label among the plasma proteins did not change with increased incorporation. The increase in incorporation of 1-(1-14C) leucine into plasma proteins would appear to offer a good index for severity of injury of activity of a disease state.

Inter-relationships between the absorptions of hydrocortisone, sodium, water and actively transported organic solutes in the human jejunum

The effect of intraluminal hydrocortisone (100 mg/l) on sodium and water transport in the small intestine was investigated by jejunal perfusion (flow rate 15 ml/min) of healthy subjects with normal saline and saline containing 56 mmol/l galactose or alanine. Minimal absorption of sodium and water occurred with normal saline and did not change significantly in the presence of hydrocortisone. Galactose and alanine enhanced sodium and water absorption and further significant increases occurred in the presence of hydrocortisone. Glucocorticoid induced increases in absorption were detected within 20-30 min, while plasma cortisol concentrations were in the normal range. 43% of the perfused dose of hydrocortisone was absorbed with normal saline (p less than 0.01). There was a significant positive correlation (p less than 0.0025) between hydrocortisone and water absorption. Thus, in the presence of actively absorbed organic solutes, hydrocortisone rapidly increased sodium absorption and the concurrent increase in water absorption appears to have facilitated passive absorption of hydrocortisone.

Comparative study of the methylglucamine salts of iodamide and iothalamate in clinical urography

In a comparative urographic study of the methylglucamine salts of iodamide (Uromiro 300) and iothalamate (Conray 280) the following conclusions have been made: (i) In subjects with radiologically normal kidneys and a creatinine clearance greater than 70 ml/min total urogram scores and nephrogram scores were higher with iodamide (not statistically significant). The improvement in performance was more marked in the nephrographic phase. (ii) In patients with radiologically normal kidneys and a spectrum of normal and abnormal renal function, total urogram scores and nephrogram scores showed no significant dependance on creatinine clearance. (iii) No correlations of note were observed between urographic performance and physical or biochemical parameters for either contrast medium. (iv) Side effects encountered in the study were mild and there were no significant differences between the contrast media in either the incidence or severity of the side effects. (v) Post-injection blood pressure profiles showed no significant differences between the media. (vi) Induced electrocardiographic abnormalities were uncommon and mild occurring in seven patients following iothalamate and three patients following iodamide.

Development of a technique for measuring the oxidation rate of a 14C-labelled substrate from 14CO2 production without the need for collection of expired air

1. A method is proposed for the determination of the rate of oxidation of 14C-labelled substrates in man from blood sampling only. 2. The method was verified by simulating release of 14C into the bicarbonate pool of patients by using a constant-rate infusion of sodium [14C]bicarbonate, the plasma level of total 14CO2 (d.p.m. ml-1 70 kg-1) correlating well (r = 0.878, P = 0.001) with the infusion rate (microCi/h). 3. Techniques involved in employing this method are discussed, particularly in the light of errors involved.

The effect of hydrocortisone on the transport of water, sodium, and glucose in the jejunum. Perfusion studies in normal subjects and patients with coeliac disease

During perfusion of an isotonic solution containing 56 mmol/l glucose and 122 mmol/l sodium chloride, net movements of water and sodium and glucose absorption were measured in the absence and presence of intraluminal hydrocortisone along 20-cm segments of proximal jejunum in five normal subjects and five patients with active coeliac disease. In normal subjects, the mean net absorption of water and sodium was significantly increased in the presence of hydrocortisone decreased. In the coeliac patients, the mean net secretion of water and sodium was significantly decreased. In neither group was the effect of hydrocortisone associated with a significant increase in glucose absorption. Similar changes in net movements of water and sodium occurred in both groups, even though absorption of hydrocortisone in coeliac patients was 44% of the control value. These results suggest that hydrocortisone may have exerted a local effect on the mucosal transport of water and sodium.

Chronic cholecystitis and the oral cholecystogram

Gallbladder image density at oral cholecystography has been compared with histological grading of the severity of chronic cholecystitis in resulting cholecystectomy specimens. (i) There was a linear relationship between gallbladder opacification and the grade of chronic cholecystitis. (ii) Removal of patients with either non-opacified gallbladders or abnormal liver function did not alter the linear trend. (iii) The occurrence of gallstones was independent of the degree of gallbladder opacification. (iv) The presence of gallstones did not correlate with the severity of chronic cholecystitis. A standardised oral cholecystographic technique with a grading system for gallbladder image density can be used as an index of the severity of chronic cholecystitis.

Whole body protein turnover, synthesis and breakdown in patients with colorectal carcinoma

As a basis for assessing protein metabolism in cancer patients, whole body protein turnover, synthesis and breakdown were measured preoperatively using a constant rate infusion of L-(1-14C) leucine in patients with differing stages of colorectal carcinoma. The levels of protein synthesis and breakdown were correlated with the extent of disease as measured by the percentage incorporation of the labelled amino acid into plasma protein (1) and the subsequent modified Dukes' classification (2). Eleven apyrexial patients were divided into two groups; 6 of whom had normal appetites while 5 were anorectic. Protein synthesis increased with advancement of disease in both groups, as did protein breakdown. Protein synthesis and breakdown were lower in the anorectic group, suggesting some degree of starvation adaptation. All patients were in positive balance, despite anthropometric data to support loss of host body protein. This suggests translocation of protein stores from muscle to areas of more rapid protein synthesis such as tumour. Remodelling of body protein is an important facet of metabolism in cancer patients.

Duodenal loop widening in pancreatic diseases

The magnitude of the duodenal loop in patients with a variety of pancreas-associated disease has been accurately measured and compared with those values encountered in a series of normal subjects in order to assess if any widening had occurred. Using a Student's t-test all the patients with pancreatic disease were indistinguishable from the control subjects at the 5% level, and the validity of this effect as a diagnostic tool is questioned.

Correlations between duodenal loop size and external body measurements

Measurements of the area, height and width of duodenal loops in male and female controls were correlated with their body height, weight, surface area, lean body mass and adjusted body surface area in order to assess the possibility of predicting loop size from body habitus. In male subjects the most marked correlations were between bodyweight and loop area (r = 0.58) and between true body surface area and loop area (r = 0.57). No relationship was observed between the size of the duodenal loop and body size in females.