Long acting injectable aripiprazole: An observational study

Introduction

Several trials have shown the efficacy of long acting injectable (LAI) second-generation anti-psychotics compared with other anti-psychotics. LAI aripiprazole is a novel therapeutic tool in the management of patients with schizophrenia.

Aims

The present study aimed to evaluate the clinical outcomes of patients who initiated treatment with LAI aripiprazole, by comparing their clinical outcomes prior and after initiating treatment with LAI aripiprazole.

Methods

This observational, retrospective, mirror study assessed a series of socio-demographic and clinical variables during the 12 months prior to commencing LAI aripiprazole, while on another anti-psychotic medication, and the first 12 months of LAI aripiprazole. The sample included a series of consecutive patients receiving LAI aripiprazole at the Doctor Peset university hospital health area, in Valencia (Spain). The variables analyzed in the study included: emergency room visits, number and average length of hospitalizations, relapse, rate of abandonment of treatment and number of anti-psychotics needed as maintenance treatment.

Results

The preliminary analysis showed a reduction in the rate of emergency room visits and the number of relapse and total hospitalizations while on LAI aripiprazole; however, there is no a reduction of the average length of hospitalizations. A reduction in the number of anti-psychotics as maintenance treatment was not appreciated, however, there was an improvement in treatment adherence.

Conclusions

The preliminary results showed that LAI aripiprazole is an useful option that could suppose a benefit concerning treatment adherence, a decreased in number of relapses and hospitalizations and use of health resources.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Late-Onset Schizophrenia: a Case Report

Introduction

Late-onset psychoses are a heterogeneous group of disorders whose nosology has been controversial throughout history. Several methodological limitations have made difficult the comparison among studies and, as a consequence, the research interest has been little, leading to the absence of late-onset schizophrenia and paraphrenia in current official classifications.

Aims and methodology

To highlight the specific symptoms of late-onset schizophrenia as well as its differences with other psychoses though the study of a case report.

Results

A 70-year-old woman developed psychotic symptoms during the last seven years, consisting of auditory and olfactory hallucinations, telepathic phenomena and injury delusions, erotomania and thought control, with a high level of systematization and fantasy. She was admitted in an inpatient unit. She was treated with risperidone and the psychotic symptoms got better. At the time of hospital discharge, hallucinations and delusional thoughts had disappeared and no behavioral or emotional disorder was observed. Some weeks later, risperidone had to be substituted by paliperidone due to side effects, such as tremor, sialorrhea and parkinsonism.

Conclusions

Late-onset schizophrenic psychosis is not as exceptional as it has been traditionally considered. One of the main problems is that current classifications do not include specific diagnostic categories for cases of late or very-late-onset psychoses. It would be necessary that future ICD-11 and DSM-V classifications will include different-age criteria when diagnosing mental disorders.

Pediatric obsessive-compulsive disorder: A case report

Introduction

Obsessive compulsive disorder (OCD) in childhood was first described by Legrand du Saulle in late XIX century, however, a systematic study in pediatric population was not made until 1986, by Rapoport. It is has been documented in scientific literature that younger patients usually hide their symptoms because of shame or that they do not find their obsessions and compulsions excessive, so that they feel them in an egosyntonic way, delaying diagnosis until several years after their first symptoms.

Aims and methodology

To highlight the specific symptoms in Pediatric OCD and review its treatment and approach through the study of a case report.

Results

A 11-year-old boy was referred by his paediatrician to a child mental outpatient service for behavioural disturbances in the last few months. For the last three years, he had been performing rituals of cleaning, order and checking, increasingly complex and with a significant impact on his life, to the point of not being able to go to school and have other members of his family involved. He also had religious and catastrophic obsessions that generated him important distress. He was treated with high doses of sertraline and low doses of risperidone, and cognitive-behavioral psychotherapy with exposure response prevention and training in relaxation techniques were associated to the treatment. The patient improved partially.

Conclusions

This case illustrates the delay in the diagnosis of Pediatric OCD itself as well as the complexity when treating this disorder.

Psychoactive substance abuse and personality disorders in psychiatric inpatients

Introduction

Comorbidity between Substance Use Disorder (SUD) and other psychiatric disorders, known as Dual Diagnosis, is an issue of growing interest in Mental Health. The high association between Personality Disorders (PD) and substance use is reported in scientific literature. However, not many studies have been published regarding the prevalence of this disorder in a psychiatric unit. AIMSTo determine the prevalence of substance abuse among patients with a Personality Disorder in a psychiatric unit.

Methodology

A retrospective descriptive study was carried out among all patients admitted to our psychiatric unit during one year. The data collected from the discharge clinical records of patients were: demographic variables, personal psychiatric history and substance use, urine tests and clinical diagnoses at discharge.

Results

We obtained a sample of 334 patients. There was comorbidity between Mental Disorder and SUD in 10.17% of subjects; including 4% diagnosed with Personality Disorder (80% belong to Cluster B). 53.3% of patients with PD substance abuse was reported. Excluding nicotine dependence and benzodiazepines, the most common substances used were cannabis (50%), alcohol (37.5%) and cocaine (25%).

Conclusions

This study shows that Personality Disorder is the Mental Disorder most commonly associated with SUD, among inpatients in our psychiatric unit. In order to detect cases of Dual Diagnosis, we suggest optimize recording in clinical history substance use and systematic urine tests in all patients admitted, which would benefit from specific treatment for their condition.

Selective versus non-selective neural stimulation in the monitoring of muscular relaxation during general anesthesia

AIM

The depth of muscular relaxation during general anesthesia is monitored through the analysis of the contraction evoked by selective electrical stimulation of a peripheral nerve. The aim of this study was to compare the method of selective stimulation (SS) to a new method based on non-selective electrical stimulation (NSS) delivered over the muscle.

METHOD

Electrical stimuli were delivered as train-of-four impulses to the ulnar nerve (SS) and to the ventral aspect of the contralateral forearm (NSS). The muscular responses of the adductor pollicis brevis (SS) and the forearm supinator longus (NSS) were studied at 30-60 s intervals with piezoelectric transducers before and after the administration of atracurium bolus doses of 0.5 mg/kg to patients under general anesthesia. SS and NSS evoked muscular responses were quantitized as percentages of the control response and compared with linear correlation and concordance analysis.

RESULTS

Twenty patients were studied. Basal and post-atracurium muscular responses were similar for the SS and the NSS methods. Precision between SS and NSS was >85% and accuracy >92%. Concordance was: basal <15%, relaxation <5%, recovery <10%.

CONCLUSION

NSS is equivalent to SS for muscular relaxation monitoring during general anesthesia. This has important implications to simplify muscular relaxation monitor design.

[Central venous catheter location by endocavitary ECG: an alternative to chest radiography]

BACKGROUND

The location of a central venous catheter is checked with a chest radiograph. Right endocavitary electrocardiography (ECG), a technique in which the catheter is connected to the ECG recorder wire to record ECG in DII, might be an alternate method to check the position of the catheter. When the catheter enters the right atrium, there is a large increase in the amplitude of P wave. The aim of this study was to compare the efficacy of endocavitary ECG against the chest radiography as a method to check the position of a central catheter, and to determine whether the ECG method can replace the radiological method.

MATERIAL AND METHODS

One-hundred central catheters which location was checked by ECG and by chest X-ray entered the study. Efficacy of endocavitary ECG, delay between catheter insertion and radiological check, and the cost of the two methods were studied.

RESULTS

Endocavitary ECG determined that de catheter was in a correct position in 80 cases and malpositioned in 20 cases. ECG check agreed with radiological check in 93 catheters. There were 4 false-positive and 3 false-negative cases. The efficacy of endocavitary ECG was 93% (sensitivity: 82%; specificity: 81%; positive predictive rate: 95%; negative predictive rate: 85%). Catheter location was checked immediately on insertion by ECG in all cases, while radiological check was delayed 32 +/- 25 min in the emergency department and 68 +/- 206 min in the admitted patients. The cost of the ECG method was less than that of the radiological method.

CONCLUSIONS

The check of the position of a central venous catheter by endocavitary ECG is taster, cheaper, and of similar efficacy to the radiological method. Endocavitary ECG can replace chest X-rays to check the position of the catheter in more than 90% of cases.

Ileo-cecal junction: a valve or a sphincter? An experimental study in the opossum

The characteristics of the ileo-junction (UIC) were examined in seven opossums in vivo, and the effect of the UIC on colo-ileal reflux in eight opossums in vitro. Electromyography and intraluminal manometry were studied during intestinal distensions, and administration of phenylephrine, isoproterenol and carbachol. In vitro studies used preparations of ileum, UIC, and colon, attached to a propulsion evaluation system. Fluid flow across the UIC was studied basally and after phenylephrine, isoproterenol and carbachol. A high pressure zone in the UIC was not observed in vivo. Colonic distension increased the pressure and electrical spike bursts in the ileum and UIC, while ileal distension had the opposite effect. Myoelectric and contractile activities were inhibited by adrenergic agonists and stimulated by carbachol. In vitro studies demonstrated aborally migrating ileal contractions initiated by fluid injections into the ileum, and cecal contractions elicited by fluid injections into the colon. The UIC only prevented colo-ileal reflux when it was undergoing contraction as part of ileal or colonic activity. These findings suggest that the opossum UIC does not have valvular properties and ileal fluid propulsion is the main factor in the prevention of colo-ileal reflux.

[Efficacy of the ilioinguinal and iliohypogastric block in the treatment of the postoperative pain of inguinal herniorrhaphy]

INTRODUCTION

The ileoinguinal-ileohypogastric block (IHB) improves pain control in inguinal hernioplasty.

OBJECTIVE

To determine the efficacy of the IHB on the treatment of postoperative pain in inguinal herniorrhaphy, and to compare the effect of its use before and after incision for diminishing pain and postponing the first dose of analgesia.

PATIENTS AND METHODS

Sixty-eight patients scheduled for inguinal herniorrhaphy with mesh were enrolled and distributed randomly in 4 groups as follows: 1) IHB before incision using 0.25 ml/kg bupivacaine 0.5% with no vasoconstrictor; 2) IHB after incision with the same dose of bupivacaine; 3) IHB before incision with 0.25 ml/kg of serum; and 4) IHB after incision with 0.25 ml/kg of serum. Pain was evaluated on visual analog scales employing facial expressions and verbal description, a patient questionnaire and time elapsing between surgery and the first dose of analgesia. The evaluations were performed in the postoperative recovery unit and on the ward 8 and 24 hours after surgery.

RESULTS

The total overall score for postoperative pain was lower in the bupivacaine group than in the placebo group (9.2 +/- 4.4 and 1.5 +/- 3.9, respectively; p = 0.026). The first dose of analgesia was given to those who received placebo between the second and third hour after surgery, whereas it was given between the fourth and fifth hour to the bupivacaine group. No significant differences were found between infiltration before and after incision.

CONCLUSIONS

IHB decreases pain, delaying the need for a first dose of analgesic and improving patient comfort. Its use is therefore recommended for relief of postoperative pain.

Gallbladder dyskinesia in acalculous biliary colic

AIMS

To test the hypotheses that: 1) postprandial gallbladder emptying might be abnormal in patients with acalculous biliary colic; and 2) that hymecromone, a drug that increases bile flow and relaxes biliary muscle might improve symptoms.

METHODS

Twenty-four women were studied. Twelve patients presented recurrent biliary type of pain in the absence of gallstones, and persistence of contrast in the gallbladder, 24 hours after an oral cholecystogram, suggesting cholesterolosis. Twelve healthy volunteers used as controls had no symptoms and the gallbladder was not visible the day after an oral cholecystogram. Gallbladder emptying induced by an oral meal was studied with ultrasound in both groups before and after the administration of hymecromone.

RESULTS

Gallbladder volumes were similar in both groups (23 +/- 10 ml vs. 31 +/- 11 ml; NS). Gallbladder emptying in the control group was simple exponential (R2 = 0.948 +/- 0.059) with a rate of 32 +/- 16 minutes. Gallbladder emptying was bimodal in patients. Gallbladder volume increased to 120% in the first 10 minutes, to empty exponentially thereafter (R2 = 0.964 +/- 0.040. Rate: 29 +/- 22 minutes). This resulted in a marked reduction in gallbladder volume emptied at 40 minutes when compared to controls (30% +/- 27% vs. 54% +/- 14%; p = 0.012). Pretreatment of controls with hymecromone induced an emptying pattern similar to that of patients. In patients, emptying after hymecromone did not change but symptoms were improved.

CONCLUSIONS

An abnormal emptying pattern of the gallbladder was identified in patients with acalculous biliary colic, and hymecromone was partly effective to reduce pain, despite a minor effect on gallbladder emptying pattern.

Mathematical analysis of epidural space location

BACKGROUND

The location of epidural space for local anaesthetic injection can be difficult. The aim of this study was to define the mathematical function of the pressure changes in the syringe during puncture of the epidural space. Knowledge of pressure changes might be of help to the anesthetist who attempts to ascertain the location of the needle, and it is essential to the design of a device with which to locate epidural space.

METHODS

Epidural punctures were performed in 20 patients, using an 18-Tuohy needle connected to a 10 ml syringe. The epidural space was located by the loss of resistance technique. Pressure variations within the injection system during epidural puncture were measured and digitized at 250 Hz. Pressure curves were analyzed for amplitude and rate of a decay after entry of the needle into the epidural space.

RESULTS

Pressure increased as the needle passed through skin, subcutaneous fat and muscle. The maximal pressure was observed when the needle perforated the ligamentum flavum (689 +/- 124 cm H2O). When the needle entered the epidural space, an exponential decrease in pressure was observed in all patients (R2 = 0.99; tau = 2.1 +/- 0.9 seconds). End-residual pressure was 22 +/- 12 cm H2O. The change in pressure observed when the needle entered the epidural space fitted a negative exponential function (y = e-x/2.08).

CONCLUSIONS

Pressures within the injection system for epidural puncture can reach 1100 cm H2O. Location of the epidural space is characterized by an exponential decay to and end-residual pressure below 50 cm H2O, with a constant time of approximately 2 seconds.

Influence of the menstrual cycle and of menopause on the gastric emptying rate of solids in female volunteers

The aim of this study was to assess the influence of the normal menstrual cycle and of menopause on the gastric emptying rate of solids. Gastric emptying was studied in 15 premenopausal and ten postmenopausal women with an isotopic technique after the ingestion of a radiolabelled test meal. Premenopausal women were studied twice: within 1 week prior to menses and again 1 week after onset of menses. Postmenopausal women were studied only once. The emptying curves of the solid component of the meal fitted a linear model. The half-emptying time was 78 +/- 5 min during the follicular phase, 75 +/- 7 min during the luteal phase and 76 +/- 6 min in postmenopausal women (differences not statistically significant). The mean percentages of the meal retained in the stomach at different time intervals were also similar in the three groups. These results suggest that the menstrual cycle does not influence the gastric emptying rate of solids, which remains unchanged in relation to the follicular phase or after menopause.

Effects of pentagastrin and of the somatostatin analog (SMS 201-995) on growth of CT26 in vivo adenocarcinoma of the colon

This study was done to investigate the effects of pentagastrin and of somatostatin analog (SMS 201-995) on growth of CT26 adenocarcinoma of the colon implanted in mice. Eighty Balb C mice were inoculated subcutaneously with 100,000 cells. Four groups of 20 mice each were treated with 0.1 milliliters of saline solution every eight hours; 250 micrograms per kilogram of pentagastrin every eight hours; 100 micrograms per kilogram of SMS 201-995 every 12 hours; 250 micrograms per kilogram of pentagastrin every eight hours, plus 100 micrograms per kilogram of SMS 201-995 every 12 hours. Tumoral weight, volume and deoxyribonucleic acid (DNA) content and mean survival rates were determined for each group. Control mice had tumors weighing 1,619 +/- 179 milligrams, of 1.47 +/- 0.2 milliliters to the third power and with 12.9 +/- 1.1 milligram of DNA, at 30 days after inoculation. The mean survival rate was 42.5 days. Pentagastrin administration increased the three parameters of tumoral growth by 40 percent and reduced survival time to 29.6 days (p < 0.01), while SMS 201-995 inhibited growth by 40 percent and prolonged survival time to 48.5 days (p < 0.01). Simultaneous administration of both peptides had no effects. These data suggest that pentagastrin has a trophic effect and SMS 201-995 an inhibitory effect on CT26 adenocarcinoma in mice.

Anatomy of the bilioduodenal junction of the opossum

Prevention of reflux is a major function of the terminal biliary duct system at its junction with the duodenum. We examined this area via scanning electron microscopy and light microscopy to explore anatomic features that might play such a role in the Virginia opossum, a species with a highly developed sphincter of Oddi (SO). The terminal apparatus, most of which consists of a dilated extramural ampulla, has a lumen with abundant folds. Mucus is produced by the lining epithelium and by a plethora of glands. Three muscle layers constitute the SO: an inner longitudinal, an outer circular, and a less consistent outermost longitudinal. The terminal apparatus forms an acute angle and narrows as it enters the duodenum; at this point, the SO becomes continuous with the muscularis externa of the intestine. Four anatomical features with potential antireflux properties may be identified: mucus production, luminal folds, and the narrow opening and oblique course of the intramural duct.

Bacterial flora of the gastrointestinal tract of opossums

The bacterial flora of the stomach, small intestine, cecum and bile from 20 healthy opossums (Didelphis virginiana) captured from the wild was studied. Results showed that their gastrointestinal flora was similar to that found in other small mammals but, in addition, opossums are heavily colonized by Salmonella spp., which might adversely affect their adequacy as laboratory animals for some experimental protocols.

Gastric emptying of two radiolabelled antacids

The rate of gastric emptying of two antacids, magaldrate and Maalox, was investigated using scintigraphy. Successful labelling of the antacids was carried out with 99mTc. The stability of the 99mTc-labelled antacids was satisfactory and there was no difference in antacid capacity between the labelled and unlabelled antacids. The studies were carried out on 15 healthy male volunteers. After an eight hour fast each subject ingested a standardised meal of 95.7 MJ (400 kcal). One hour later 10 ml of one of the two antacids previously labelled with 99mTc was administered. Serial detection by anterior and posterior projection of the amount of antacid retained in the stomach was performed to determine gastric emptying of antacid. One week later the study was repeated under the same conditions with the other antacid also labelled with 99mTc. The mean (SD) percentages of antacid retained in the stomach fit a linear model with a t1/2 of 86.6 (15.3) minutes for magaldrate and 52.3 (5.2) minutes for Maalox (p less than 0.01). When the mean percentages of retention at six time intervals were compared for both antacids, it was found that Maalox emptied much faster (p less than 0.01 at 15 and 30 minutes, p less than 0.02 at 45, 60, 75, and 90 minutes).

Transduodenal sphincteroplasty with transampullary septectomy for stenosing papillitis

The papilla of Vater and its sphincter of Oddi, lying at the confluence of the bile and pancreatic ducts in man, have long been suspected as a source of upper abdominal pain. Enlarging the opening of the transpapillary segment of the bile and major pancreatic ducts by using a transduodenal sphincteroplasty with transampullary septectomy resulted in death in a patient with a peripapillary diverticulum and pancreas divisum. Eight-six patients followed for 1 to 10 years experienced a 75% success rate. Thirty-six patients had a marked stenosis of their duct of Wirsung, suggesting that their pain was primarily from the pancreas. The remainder had either a generalized narrowing (40 patients) or a normal (7 patients) papilla. Pain was not satisfactorily resolved in patients with an associated pancreas divisum, chronic pancreatitis, and recurrent episodes of acute pancreatitis with alcoholism.

Immunological sensitization of opossum gallbladder by naturally acquired stomach roundworm infection

1. The opossum gallbladder develops an immediate type hypersensitivity as a result of chronic infection with the gastric nematode, Physaloptera turgida. 2. Hypersensitization is evident from a change in net transepithelial ion transport in response to parasite-derived antigen. 3. The antigen-induced change in ion transport involves mediation by histamine and possibly prostaglandins and is independent of intrinsic neural modulation. 4. The functions of the gallbladder epithelium are influenced by reactions of local immune elements that are part of the common mucosal immune system.

Choledochoduodenal flow: effect of the sphincter of Oddi in opossums and cats

The aim of this study was to test in vivo (a) whether the sphincter of Oddi acts as a resistor or also as a pump, (b) the effect of an IV infusion of cholecystokinin (CCK) on choledochoduodenal flow, and (c) the ability of the choledochoduodenal junction to prevent duodenobiliary reflux in two animal species, opossums (n = 11) and cats (n = 8). Opossums were implanted with bipolar electrodes on the sphincter of Oddi and the adjacent duodenum. Cats were not. Experiments were performed in vivo using a propulsion evaluation system to test whether the Sphincter of Oddi was able to pump fluid from the bile duct to the duodenum against pressure gradients. In 5 opossums and 4 cats, choledochoduodenal flow was evaluated during the IV infusion of CCK (20 ng.kg-1.min-1). The opossum sphincter of Oddi moved fluid against duodenal pressure gradients of 6-45 cm H2O. The spike-burst frequency (6.4 +/- 1.7 min-1) was maximal at peak bile duct pressures and decreased as bile duct pressure decreased (4.9 +/- 1.6 min-1; P less than 0.001). Pressure pulses in the bile duct were observed at a frequency that correlated with sphincter of Oddi spike-burst frequency (r = 0.84; P less than 0.001). In cats, choledochoduodenal flow occurred only along a hydrostatic gradient; the sphincter of Oddi never acted as a pump but only as a resistor. Infusion of CCk significantly increased the frequency of sphincter of Oddi contractions in opossums, but the transfer of fluid from bile duct to duodenum was significantly reduced. In cats, the rate of fluid flow from the bile duct to the duodenum during CCK infusion did not differ from control values. Reflux of duodenal fluid into the biliary tree was never observed, even at duodenal pressures as high as 100 cm H2O. In conclusion, in vivo, the sphincter of Oddi is able to pump fluid from the bile duct to the duodenum against a pressure gradient in opossums, but, in cats, choledochoduodenal flow requires a bilioduodenal pressure gradient. The increase in sphincter of Oddi contraction frequency induced by CCK in opossums resulted in a decrease in active transsphincteric flow. Duodenobiliary reflux could not be elicited in opossums and cats under the conditions of these experiments.

Biliary and gut function following shock

The aim of this study was to characterize the alterations in gallbladder and intestinal function after hemorrhagic shock and blood reperfusion in opossums. Animals were subjected to a shock of 30 mm Hg of arterial blood pressure for 60 minutes and resuscitated with blood reinfusion. Gallbladder epithelial ion transport, gallbladder motility in vitro and in vivo, gastrointestinal motility, and flora of the stomach and small bowel were studied 2 and 24 hours after shock. Changes at 2 hours included decreased gallbladder contractility in vitro and decreased emptying in vivo, loss of coordination with intestinal motor activity, decrease in frequency of intestinal electrical slow waves, and reduced duration of the intestinal migrating motor complex cycle. By 24 hours, gallbladder epithelial permeability was increased and in vitro contractility remained reduced but the in vivo functions showed partial recovery. Gastrointestinal flora was not affected by these changes. These data demonstrate that hemorrhagic shock and reperfusion affect digestive motility. The early timing of the alterations observed and the partial recovery 24 hours post shock suggest an ischemia-hypoxia mechanism of injury.

Stenosis of the sphincter of Oddi

"Stenosing papillitis" is a descriptive term for an anatomic deformity of the papilla of Vater that is characterized by narrowing of the lower end of the bile duct and the proximal end of the duct of Wirsung. The defect is secondary to inflammation and fibrosis from the chronic passage of gallstones, episodes of acute pancreatitis, chronic pancreatitis, sclerosing cholangitis, peptic ulcer disease, and cholesterolosis. Patients with papillary stenosis from gallstones may present with episodes of severe upper-abdominal pain several years after cholecystectomy. The pain is often incapacitating, and patients are often addicted to narcotic analgesics. The work-up includes abdominal ultrasonography and CT scanning and endoscopic retrograde cholangiopancreatography even though the findings usually are normal. Liver and pancreatic enzymes are not frequently elevated with the painful episodes. Transendoscopic manometry may reveal elevated pressures within the papillary portion of the distal bile duct. Some patients are relieved of their pain by transduodenal sphincteroplasty and transampullary septectomy, thereby ablating the sphincter of Oddi around the bile and pancreatic ducts and enlarging their openings.

Gallbladder and gastrointestinal motility after hemorrhagic shock

The alterations in fasting gallbladder and gastrointestinal motility during hemorrhagic shock were investigated. Eight opossums implanted with a gallbladder cannula, gastrointestinal bipolar electrodes, and a carotid catheter were subjected to hemorrhagic shock of 30 mm Hg for 60 minutes by the removal of arterial blood. Shed blood was reinfused after the shock period. Fasting gallbladder volume and gastrointestinal electrical activity were studied before, immediately after, and 24 hours after hemorrhagic shock. Control measurements demonstrated a slow-wave frequency maximal in the duodenum (18.1 +/- 1.1 waves/min), with a plateau in the proximal third of the small bowel, decreasing thereafter. The migrating motor complex (MMC) had a duration of 118 +/- 28 minutes. The average volume of the gallbladder before shock was 5.4 +/- 1.5 ml. Gallbladder volume fluctuated with the MMC, being maximal during phase I and minimal in phase III. The volume of blood removed to reduce mean arterial pressure to 30 mm Hg was 45 +/- 5 ml/kg. Immediately after the shock and blood reinfusion, slow-wave frequency decreased by 40% in the antrum and 25% in the small bowel. The MMC was of shorter duration (91 +/- 22 minutes; p less than 0.05), and gallbladder volume increased to 7.0 +/- 1.7 ml (p less than 0.05). Fluctuations in gallbladder volume during the MMC were absent. Twenty-four hours after shock, slow-wave frequency, MMC, and gallbladder volume had returned to normal and were not different from control measurements. Ischemic damage to the gastrointestinal tract is postulated as the cause of gallbladder dysfunction and altered intestinal motility after hemorrhagic shock.

The propulsive behavior of the opossum sphincter of Oddi

This study investigates whether the phasic contractions of the opossum sphincter of Oddi (SO) delay bile flow by acting as a resistor or facilitate bile flow by acting as a pump. The common bile duct (CBD) and an adjacent segment of duodenum from eight opossums were studied in a propulsion evaluation system in vitro. This system required the production of hydrostatic work by the SO to transfer fluid from the CBD to the duodenum when the pressure in the duodenum was equal or greater than the pressure in the CBD. Fluid movement from the CBD to duodenum and duodenum to CBD was studied at pressure gradients up to 50 cmH2O before and after sodium nitroprusside (10(-7) M) inhibition of smooth muscle contractile activity. All preparations propelled fluid from the CBD to the duodenum against a pressure gradient ranging from 10 to 50 cmH2O. The SO emptied the CBD in a monoexponential fashion, with a time constant of 1.52 +/- 0.7 min, until CBD pressure was reduced to 8.5 +/- 3.2 cmH2O, when propulsion ceased. Superimposed on the CBD pressure waveform were pressure pulses of 1-2 cmH2O in amplitude that resulted from the contractions of the SO. CBD pressure was higher at the start than at the end of a periodic pressure pulse, whereas CBD pressure was stable between pulses. The frequency of the pressure pulses was greatest at the maximal CBD pressure (9.4/min) and decreased significantly when the basal pressure was reached (1.5/min, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Perineal necrotizing infection

Perineal necrotizing infection is a severe disease that ever since its first description by Fournier in 1883 has been referred to by many names prompted by its protean nature in terms of location and suspected etiology. We treated nine patients with PNI. The infection began as a perineal abscess of long evolution (7 days +/- 2 SD) in eight patients. The ninth patient had had an inguinal herniorrhaphy 3 days before. The cultures of the exudates and tissues always yielded aerobic and anaerobic mixed flora of colorectal origin, except in one instance, in which S. aureus and hemolytic streptococcus A were identified. The treatment was medical support and wide surgical debridement of the infected tissues. In six patients a left transverse colostomy was performed. Only one patient died, of septic shock. On the basis of the results in our series and on a review of the literature, it is our opinion that PNI is a mixed bacterial infection that despite its origin, clinical appearance and microbiologic findings, is highly uniform in terms of clinical course and treatment. Therapy is based on radical surgical debridement with excision of all necrotic tissue. The current plethora of terms seems impractical and confusing. We propose a rather comprehensive term perineal necrotizing infection for the sake of clarity.

Inhibition of sphincter of Oddi motility in Australian possum by cholic acid

The effect of intravenous administration of cholic acid on sphincter of Oddi (SO) and gallbladder motility was studied. Bolus doses of cholic acid, 20 to 60 mg/kg, produced inhibition of SO wave frequency, a fall in gallbladder pressure and enhanced bile flow. However, hydrocortisone, 10 and 20 mg/kg, produced comparable elevation in bile flow with no effect on SO and gallbladder motility. The effect of cholic acid on SO motility was not influenced by prior treatment with atropine. Phentolamine or propranolol administration did not influence SO wave frequency SO wave frequency, but subsequent injection of cholic acid resulted in a decrease in SO wave frequency. Gallbladder pressure was not influenced by atropine, phentolamine, or propranolol, and these agents did not influence the cholic acid-induced fall in gallbladder pressure. These findings suggest that bile acids influence the motility of the biliary tract.

[Gastric emptying in reflux esophagitis. Effect of metoclopramide and cinitapride]

The gastric emptying of solids was evaluated with radionuclide techniques in 16 patients with reflux esophagitis, demonstrated by two of the following methods: endoscopy, pathology, and/or pH measurement. The percentage of radionuclide remaining within the stomach was 80.8 +/- 17% after 45 minutes, 63.3 +/- 10% after 75 minutes, and 48.8 +/- 19% after 105 minutes, with a half time (T1/2) of gastric emptying of 103.4 +/- 6 minutes. These results showed significant differences in T1/2 with those from a control group of healthy individuals, the gastric emptying being slower in patients with esophagitis (103.4 min vs 85.3 min; p less than 0.01). Subsequently, a double blind study to assess the effect of metoclopramide and cinitapride on gastric emptying in patients with reflux esophagitis was carried out. Cinitapride accelerated the gastric emptying of solids with statistically significant differences when compared with placebo (84 min vs 104 min, p less than 0.05). In this study, metoclopramide showed a tendency to accelerate gastric emptying, although it did not achieve a significant difference with placebo.

Gastric emptying and bezoars

Bezoars are conglomerates of undigested material in the stomach, which appear as a late complication of gastric surgery and are presumably related to secondary motility changes. We studied the gastric emptying of a technetium-99m-(Tc 99m) labelled solid meal in 10 patients who presented with a bezoar 1 to 20 years after vagotomy and pyloroplasty, vagotomy and antrectomy, vagotomy and gastrojejunostomy, or hemigastrectomy. The results were compared with the emptying data of operated patients without bezoars. The gastric retention of Tc 99m-labelled solids at 45, 75, and 105 minutes was 85 +/- 15 percent (mean +/- SD), 79 +/- 17 percent, and 65 +/- 24 percent, respectively. No differences were found when results were compared with those of operated patients without bezoars. We concluded that factors other than the gastric digestive phase are the main contributors to bezoar formation.

Gastric emptying in marathon runners

Radionuclide gastric emptying studies using 99m-Tc human serum albumin egg omelette have been carried out in 10 long distance runners at rest and during a 90 minute run at sustained speed. Resting values are compared with controls comprising 10 sedentary subjects. Runners show a significantly accelerated basal gastric emptying (runners t 1/2 = 67.7 (5.9) min; sedentaries t 1/2 = 85.3 (4.5) min, p less than 0.001). The exercise had no significant effect on gastric emptying in these trained subjects (exercise t 1/2 = 66.8 (5.9) min, p = NS), suggesting adaptation to exercise.

Gastric emptying after truncal vagotomy and pyloroplasty

We have studied the gastric (fundic and antral) emptying of solids and liquids by a radionuclide method in 20 patients after truncal vagotomy and pyloroplasty (TVP) and in 10 control subjects. Gastric emptying of solids in TVP patients was similar to that of the control group (NS), but fundic emptying did not show a lag phase and was significantly faster. A significantly higher percentage of the solid fraction of the test meal filled the antrum (32 +/- 16% versus 20 +/- 9%; p less than 0.05), and this quantity was constant during the study period. Gastric emptying of liquids was greatly hastened after surgery. In 22 min 50 +/- 16% had left the stomach (versus 40 +/- 14% in controls; p less than 0.001). At 90 min the amount of liquid remaining in the stomach was similar to that in the control subjects. TVP accelerates fundic emptying of solids, which are transferred to an overfilled, paretic antrum. Liquids are emptied by a bimodal pattern with a precipitous initial emptying followed by a second slower phase.

Surgical gauze pseudotumor

Gauze forgotten at operations can be potentially life threatening, but such cases are seldom reported because of the medicolegal implications. We have presented a series of seven patients with long-term surgical gauze retention, four after pelvic operations, one after cholecystectomy, one after laryngectomy, and one after mastectomy. The median time interval between operation and gauze removal was 5 years. In three patients this was diagnosed as a tumoral mass, in three as an intestinal occlusion, and in one the gauze was found incidentally. All foreign bodies were removed and no patient died. The clinical and diagnostic aspects of retained surgical gauze have been discussed and the need for radiopaque markers in them have been emphasized.

Meckel's diverticulum: value of ectopic tissue

Cases of symptomatic Meckel's diverticulum treated surgically on an emergency basis during the last decade are reviewed. A series of 18 patients were divided into two groups depending on the presence or absence of ectopic tissue in the diverticulum. Group 1 consisted of five patients (28 percent) without ectopic tissue, and Group 2 consisted of 13 patients (72 percent) with ectopic tissue (8 gastric ectopia, 2 pancreatic ectopia, and 3 both gastric and pancreatic ectopia). Previous clinical records related to Meckel's diverticulum were found for 54 percent of the patients in Group 2 and for none of those in Group 1. The most common acute manifestations were intestinal occlusion (seven patients), digestive hemorrhage (five patients), and peritonitis (three patients). The postoperative course was 7 days in Group 1 and 15 days in Group 2 regardless of the surgical technique used. We conclude that the presence of ectopic tissue in patients with Meckel's diverticulum seems to be the main risk for occurrence of an acute nonmechanical complication. This complication appears more frequently and with more severity in young patients.

Thyroidal hemiagenesis

Three cases of thyroidal hemiagenesis have been reported. The patients were euthyroid and presented with adenomatous goiters; one uninodular and the others multinodular in the contralateral lobe. In two cases the diagnosis was established by the thyroid stimulation test and confirmed at operation. In one case, this test was not performed and the hemiagenesia was discovered at routine surgical exploration of the scintigraphically absent lobe. From our cases and review of the literature we have concluded that the anomaly is usually discovered while searching for a contralateral pathologic abnormality, a thyroid stimulation test is essential for a preoperative suspicion, it occurs more frequently among women and in the left lobe, and ours are the first cases reported from Spain.