Endoscopically placed caecostomy buttons: a trial ACE procedure

The use of the antegrade continence enema (ACE) is becoming more widespread. Preliminary studies have been promising, but the procedure is not universally successful. A colonoscopic insertion of a caecostomy button is a relatively minor procedure. This allows the ACE to be used for a trial period to assess whether a permanent procedure would be beneficial. If successful, enemas can be continued by the caecostomy, or a formal ACE can be performed. We report a series of five patients who underwent staged endoscopic insertion of a MIC-KEY caecostomy button, and we discuss the technical aspects of the procedure.

Long-term results of the antegrade continent enema procedure for constipation in adults

OBJECTIVE

The aim of this study was to evaluate the long-term results of the Antegrade Continent Enema (ACE) procedure for treating severe constipation in adults.

METHODS

Over 10 years 37 ACE conduits were created in 32 patients (median age 35 years, 26 women) with constipation caused by slow transit, obstructed defaecation or both. Conduits were created from the appendix (n = 20, 54%), ileum (n = 10, 27%), neoappendix caecostomy (n = 5, 14%) or colon (n = 2, 5%). Clinical records were retrospectively reviewed to determine outcome.

RESULTS

After a median follow up of 36 (range 13-140) months, 28 (88%) required at least one further procedure on a primary conduit, including reversal in 19 (59%). Five patients had a second conduit fashioned, two successfully. Conduit type and constipation cause did not significantly influence the rates of ACE reversal or major revision. Ileal conduits were associated with fewer minor revision procedures for stenosis (1 in 7 patients) than appendix conduits (21 in 20 patients). There was one (3%) serious complication. Satisfactory ACE function was ultimately achieved in 47% of patients, at last follow up. After ACE reversal, 9 (28%) patients underwent formation of an end stoma and 3 patients had a colectomy.

CONCLUSIONS

Revision procedures are common, but approximately half of patients can expect satisfactory long-term ACE function. ACE conduit reversal does not preclude subsequent alternative surgical strategies to treat this difficult condition.

Ethoxyresorufin-O-deethylase induction in trout exposed to mixtures of polycyclic aromatic hydrocarbons

This study investigated whether ethoxyresorufin-O-deethylase (EROD) activity in rainbow trout exposed to mixtures of polycyclic aromatic hydrocarbons (PAHs) could be predicted from induction equivalency factors (IEF). The test PAHs were classified into strong and weak inducers on the basis of similar exposure-response curves. Induction equivalency factors of strong inducers, based on benzo[k]fluoranthene (BkF) as the reference compound, ranged from 0.03 to 0.16. Trout exposed to mixtures of strong inducers (2, 4, and 6 equipotent parts) at 0.32-, 1.0-, or 3.2-nM BkF-equivalents showed exposure-dependent increases in EROD activity, consistent with an additive interaction. The extent of activity did not vary greatly among mixtures and single PAHs at a given induction equivalent quantity (IEQ). Induction equivalency factors could not be calculated for weak inducers because the range of induction was too low. Hence, each weak inducer was added to mixtures at concentrations that induced EROD activity fivefold. These mixtures appeared additive because binary and quaternary mixtures caused about 10- and 20-fold induction, respectively. Strong inducers mixed the same way also showed additivity. In contrast, EROD induction by mixtures containing both strong and weak PAHs was 800 to 900% greater than expected, suggesting synergistic interactions. Therefore, if mixtures are composed of PAHs that behave similarly, IEFs may be a suitable approach for assessing risk. However, for mixtures that contain PAHs of differing potency and efficacy, bioassays will be a more reliable measure of risk than IEFs.

An ELISA for brown trout (Salmo trutta) vitellogenin and its use in bioassays for environmental estrogens

An enzyme linked immunosorbent assay (ELISA) was developed for the detection of the egg yolk precursor vitellogenin (Vg) in plasma of brown trout (Salmo trutta). Purified Vg from a 17 beta-estradiol-induced trout was used as the competing antigen in the ELISA which is based on polyclonal antibodies. The ELISA's performance was optimized and characterized. The assay's working range was (25-500 ng ml-1), its sensitivity was (10.5 ng ml-1), and it had an intra-assay coefficient of variation of less than 10% between 30 and 1000 ng ml-1. The ELISA was used in bioassays for the detection of environmental estrogens, including estrogen mimics, in whole and fractionated industrial waste waters. Those bioassays were based on intraperitoneal (i.p.) injection-, static renewal-, and flow through exposure systems. The response threshold of both bioassays is limited to 1-2 micrograms ml-1 Vg by a low level plasma interference that was regularly detected in plasma from non-induced male fish. The responsiveness of the bioassays was characterized using progressive doses of 17 beta-estradiol. The i.p.-based assay, which was responsive to at least 100 micrograms kg-1 of 17 beta-estradiol, was used to screen extracts of pulp mill effluent and black liquor for estrogenic effects. Neither extract induced Vg in our assay. The i.p. assay was also used to test 4-tert-octylphenol (OP) and the PAH derivative, retene, for estrogenic activity. OP induced Vg in the i.p.-exposed fish; no Vg induction was detected in the retene-exposed fish. The static renewal bioassay, which was responsive to at least 0.1 microgram ml-1 of 17 beta-estradiol over a 15-day exposure period, was used to screen whole pulp mill effluents for estrogenic effects. No Vg induction was detected in the effluent-treated fish.

Expression of schizophrenia in black Xhosa-speaking and white English-speaking South Africans

OBJECTIVE

To investigate whether schizophrenia manifests itself differently in Xhosa-speaking South Africans, compared with English-speaking white South Africans.

DESIGN

A comparative study of the presentation of schizophrenia in two groups of patients.

SETTINGS AND SUBJECTS

A sample of 63 patients (43 Xhosa-speaking and 20 English-speaking) admitted to a large psychiatric hospital for the first time with a diagnosis of schizophrenia.

OUTCOME MEASURES

The Present State Examination (PSE) was used to confirm the clinical diagnosis of schizophrenia. The Relatives' Rating of Symptoms and Social Behaviour (KAS-R) was used to obtain information on the behavioural and emotional expression of schizophrenia.

RESULTS

A significantly higher prevalence of aggressive and disruptive behaviour was reported by relatives of Xhosa-speaking patients with schizophrenia of recent onset compared with English-speaking patients. The PSE elicited significantly more delusions of persecution, sexual and fantastic delusions, self-neglect and irritability in the Xhosa-speaking patients.

CONCLUSION

Significant differences in the presentation of schizophrenia, but not its core symptoms, were identified in Xhosa-speaking blacks and English-speaking whites.

Pulmonary hypertension in systemic lupus erythematosus: a report of four cases

Overt pulmonary hypertension in systemic lupus erythematosus (SLE) is rarely reported. We have documented 4 such patients, all of whom had severe extrapulmonary manifestations of the disease and also Raynaud's phenomenon. The relationship between Raynaud's phenomenon and pulmonary hypertension in SLE is borne out by a review of the literature. A common vasospastic aetiology is suggested.

Non-neuropathic Gaucher disease presenting in infancy

The non-neuropathic form of Gaucher's disease was diagnosed in 11 children of non-Jewish ancestry in South Africa; all were under the age of 4. None had any neurological involvement and, apart from the precocious presentation and rapid course, the features in each resembled those of the classical 'adult' or chronic non-neuropathic form of Gaucher disease. By contrast, the condition presented after puberty in 24 out of 28 Ashkenazi Jews who were studied during the same investigation. Activity of beta-glucosidase was defective in both groups of patients and they could not be distinguished by histological criteria. Only one child with the infantile neuropathic form of Gaucher disease was identified during the survey. The preponderance of the atypical non-neuropathic form of the disorder in young children is of practical importance from the point of view of differential diagnosis in any child with hepatosplenomegaly.