Recurrent Sphingomonas paucimobilis -bacteraemia associated with a multi-bacterial water-borne epidemic among neutropenic patients.

A cluster of septicaemias due to several water-related species occurred in a haematological unit of a university hospital. In recurrent septicaemias of a leukaemic patient caused by Sphingomonas paucimobilis, genotyping of the blood isolates by use of random amplified polymorphic DNA-analysis verified the presence of two distinct S. paucimobilis strains during two of the separate episodes. A strain of S. paucimobilis identical to one of the patient's was isolated from tap water collected in the haematological unit. Thus S. paucimobilis present in blood cultures was directly linked to bacterial colonization of the hospital water system. Heterogeneous finger-printing patterns among the clinical and environmental isolates indicated the distribution of a variety of S. paucimobilis clones in the hospital environment. This link also explained the multi-microbial nature of the outbreak.

Budesonide enema in active haemorrhagic proctitis--a controlled trial against hydrocortisone foam enema.

BACKGROUND: The aim was to compare budesonide enema, 2 mg/100 mL (Entocort) and hydrocortisone acetate foam enema, 125 mg (Colifoam) in patients with active haemorrhagic proctitis. METHODS: The trial was a controlled, randomized, investigator-blind study with two parallel groups. Endoscopy, histology and diary cards were used to assess the response to therapy. Safety was assessed by laboratory tests and adverse event recording. RESULTS: Seventy-two patients were included. Investigations were made before treatment and after 2 and 4 weeks. Both treatment groups showed statistically significant improvement in endoscopic scores but significant differences between the groups were not found. In the hydrocortisone group, plasma cortisol was significantly lowered after 4 weeks compared with budesonide. Bowel habits and quality of life variables did not differ between the treatments. The recorded adverse events were mild or moderate and may have been due to the proctitis. CONCLUSIONS: These results suggest that budesonide enema is as effective as hydrocortisone foam enema, but without the potential for side-effects associated with suppression of plasma cortisol.

Sucralfate as maintenance treatment for the prevention of duodenal ulcer recurrence.

Eighty-eight patients with endoscopically proven and healed duodenal or pyloric ulcer were randomly allocated into a double-blind, placebo-controlled, 12-month maintenance trial to determine whether sucralfate, 1 g twice daily, can be used to prevent a recurrence of ulceration. The patients were assessed endoscopically at three, six, and 12 months, or earlier if a symptomatic relapse occurred. Serum aluminum levels were also monitored. Sixteen patients were excluded from the study during the follow-up: nine of 41 in the sucralfate group, and seven of 47 in the placebo group. The groups did not differ with respect to age, sex, or smoking. The cumulative relapse rates in the sucralfate group were 28 percent after three months, 33 percent after six months, and 45 percent after 12 months, as compared with 49 percent (p less than 0.05), 64 percent (p less than 0.01), and 68 percent (p less than 0.05), respectively, in the placebo group. It is concluded that 1 g sucralfate twice daily is more effective than a placebo and is safe for the maintenance treatment of duodenal and pyloric ulcer disease.

Screening for colorectal carcinoma in cancer family syndrome kindreds.

Screening for colorectal carcinoma (CRC) was organized for 236 asymptomatic family members in 22 Finnish cancer family syndrome (CFS) kindreds, and 58% (137) of the subjects accepted the invitation. Double-contrast colonography and sigmoidoscopy or colonoscopy were used. In 137 subjects aged 20-65 years, with 3 or more first-degree relatives with CRC, one screening visit showed a colonic neoplasm in 12 (9%) subjects. Two had carcinoma (Dukes A and B), and 10 subjects one or more adenomas. Two of the subjects not attending screening (2%) developed Dukes C colon carcinoma during the study period, and one of them died of cancer. Continued screening of 34 patients with a previously identified CFS showed metachronous colorectal tumours in 12 (35%) cases: 9 operable carcinomas and 9 adenomas within 3 years. The preliminary result of screening on the basis of CFS was encouraging. Effective and continuous screening, however, requires centralized organization. The continued follow-up of identified CFS cases effectively revealed metachronous colorectal tumours at a curable stage, but its benefit was burdened by a high rate of advanced malignancies other than CRC.

Ranitidine versus anticholinergic/antacid for duodenal ulcer. A randomized, endoscopically controlled, single-blind multicentre trial.

One hundred and forty-nine patients with endoscopically documented duodenal or prepyloric ulcer were randomly allocated to treatment with ranitidine, 150 mg twice daily (75 patients), or glycopyrrobromide, 2 mg three times daily, and antacid suspension, 60 ml/day, with a buffering capacity of 480 mmol/day (74 patients). The patients underwent a thorough prestudy symptom analysis, and endoscopy was performed by an observer who was unaware of the treatment in use. After 4- and 8-week courses of treatment the patients were re-evaluated. Sixty-nine patients in the ranitidine group and 66 in the anticholinergic/antacid group completed the trial. Complete ulcer healing was obtained in 60 of the 69 patients (87%) in the ranitidine group and in 50 of the 66 patients (76%) in the anticholinergic/antacid group after 4 weeks of treatment and in 65 (94%) and in 61 (92%), respectively, after 8 weeks of treatment. Forty-three patients had troublesome side effects of either anticholinergic or antacid treatment, and three patients had to interrupt the treatment. There were no serious side effects of ranitidine. This study suggests that ranitidine causes faster ulcer healing than the combination of anticholinergic and antacid. The results show that ranitidine is an effective and safe drug for duodenal ulcer healing, with no troublesome side effects.

Quantitative radioisotope measurement of duodenogastric reflux in patients with ulcer or gastrectomized for ulcer.

In this work the duodenogastric reflux was quantified as the amount of radioactivity entering the stomach after an i.v. administration of 99mTc-HIDA in ulcer patients and in patients who had undergone BI gastrectomy. The results were compared with visual evidence of gastric activity in the gamma camera images and biochemical determination of gastric bile reflux. The method is useful in quantifying the reflux if the activity is above the background activity. It allows the determination of an upper limit for the reflux when the reflux is evident visually. Only two or three images are needed for the quantitation. No correlation was found between biochemical measurement of fasting bile reflux in the stomach and radioisotopic quantification.

Sucralfate and alginate/antacid in reflux esophagitis.

The efficacy of sucralfate and of an alginate/antacid compound was compared in a randomized, double-blind 6-week trial in patients with symptomatic, endoscopically confirmed macroscopic reflux esophagitis. Of the 68 patients who completed the study, 36 received sucralfate and 32 alginate/antacid. Significant symptomatic improvement occurred in both treatment groups: almost 70% of the patients became symptom-free or improved. Esophagitis healed completely in 53% of the patients receiving sucralfate and in 34% of the alginate/antacid patients, as measured with endoscopic criteria (p greater than 0.05). Our results indicate that sucralfate seems to be at least as effective as alginate/antacid in relieving symptoms and in healing macroscopic lesions. As a safe, locally active mucosal protecting agent, sucralfate is a promising new drug for the treatment of reflux esophagitis and deserves further trials over longer periods.

Gastritis, duodenogastric reflux and bacteriology of the gastric remnant in patients operated for peptic ulcer by Billroth I operation.

Of 101 patients undergoing Billroth I gastrectomy (BI) 14 years previously, we were able to investigate 39. General abdominal symptoms, haematological status, basal (BAO) and maximal (MAO) hydrochloric acid secretion were studied before (I) and 1 year (II) and 14 years (III) after the operation. Stump mucosa morphology was investigated before the operation and 14 years afterward. Duodenogastric reflux with radioisotope and fasting bile reflux methods and stump bacteriology were studied at the last follow-up and compared with those of controls who had had peptic ulcer 15 years ago. Only 10% of the operated patients could be classified as Visick Grade III, the others being Grades I-II. At the time of the follow-up, mean body weight had not changed. Serum iron was better at 14 than one years after the operation. BAO and MAO decreased significantly after the operation, but these decreases did not continue during the postoperative period. Duodenogastric reflux was significantly greater in the gastrectomized patients than in the controls. Neither the progression of gastritis nor the degree of postoperative gastritis correlated with the reflux. Of the operated patients, 6% had normal stump mucosa and 80% had atrophy. From the stump we cultured colonic bacteria in 44% of the patients, pharyngeal flora in 71% and Candida in 56%. The stomach bacteriology of the controls was: 10% colonic, 35% pharyngeal flora and 30% Candida. The general status of BI-patients remains good. Although gastritis progresses to atrophy and duodenogastric reflux increases, the reflux and atrophy do not seem to be related. In spite of increasing atrophy hydrochloric acid secretion continues.

Late effects of proximal gastric vagotomy compared with antrectomy and selective vagotomy for chronic duodenal ulcer. A randomized study with 5-year follow-up.

Twenty-three patients who had been given a proximal gastric vagotomy and 29 patients who had had an antrectomy were examined periodically for 5 years after their operations for duodenal ulcers. Five years after surgery, 83% of the proximal gastric vagotomy patients and 86% of the antrectomy and selective vagotomy patients were included in Visick grades I-II. We found 4/24 recurrent ulcers in the vagotomy group and 1/29 in the antrectomy group; in addition 3 of the antrectomy patients had to be reoperated. Acid secretion was reduced by 54% in the vagotomy patients and by over 90% in the antrectomized patients. In the group that had had a proximal gastric vagotomy, maximal acid secretion in the insulin test decreased by 78%. Body weight did not decrease and haematological status did not worsen in either group. Intestinal absorption of fat, xylose and vitamin B12, serum calcium levels and urinary excretion did not change during the follow-up. One year after the operation, the level of serum alkaline phosphatase had risen, and urinary excretion of hydroxyproline had increased in the resected group but after five years, these values were unchanged. Mineral density of bone unchanged decreased significantly in both groups. We conclude that during five years after surgery antrectomy with selective vagotomy does not cause more metabolic disturbances than proximal gastric vagotomy, but is followed by more mechanical problems than proximal gastric vagotomy.

Finnish registry for familial adenomatosis coli.

Collecting of patients diagnosed to have familial adenomatous polyposis coli (FPC) in Finland and a centralized systematic screening of their family members were undertaken by the Depts. of Surgery of the five Finnish university hospitals. In all, 160 FPC patients belonging to 50 families could be identified, and they had 178 descendants at 50% risk. The frequency of FPC was 5.63 X 10(-5) (1:18,000), which may represent an underestimate. It gives rise, however, to four new FPC patients in Finland every year. The distribution of the origin of the FPC families was even over central Finland, but small aggregates, probably branches of the same families, were found. Of the 50 families, 28 (56%) had at least 2 affected members, whereas 22 had only 1. The gene penetrance was estimated to be 80-89% at minimum. Children of solitary FPC patients must be considered to have the same risk of inheriting the gene as do those of established familial patients. The necessity of a permanent national centralized organization for the screening and management of FPC is emphasized.

Sucralfate, and cimetidine for gastric ulcer.

Eighty consecutive patients with endoscopically proven gastric ulcer were randomly assigned to treatment with sucralfate, 1 g four times daily, or cimetidine, 200 mg three times daily and 400 mg at night. The patients were endoscoped after four and eight weeks by an examiner who was unaware of the treatment in use. Of the 40 patients assigned to each treatment group, 2 in the sucralfate and 4 in the cimetidine group were withdrawn due to the finding of gastric cancer in the biopsies. Two patients in the sucralfate and 3 patients in the cimetidine group interrupted treatment. Complete ulcer healing was found after four weeks of treatment in 17 of the 36 patients (47%) in the sucralfate and in 16 of the 33 patients (48%) in the cimetidine group. The cumulative healing rate after 8 weeks of treatment was 80% in the sucralfate group and 73% in the cimetidine group. There were no serious side effects, but it was necessary to discontinue treatment with cimetidine in two subjects because of rash in one and dizziness in the other. The results suggest that sucralfate is an effective and safe drug for the treatment of gastric ulcer and that its efficacy is equivalent to that of cimetidine.

Squamous cell papilloma of the esophagus: a tumour probably caused by human papilloma virus (HPV).

The third well-documented case of an oesophageal squamous cell papilloma in the literature is studied by light microscopy and using an indirect immunoperoxidase-PAP technique. Human papilloma virus (HPV) antigens were found within the nuclei of the superficial dyskeratotic cells and of koilocytes, both of which are characteristic cells found in HPV lesions elsewhere in the body. The findings are discussed in the light of current concepts of HPV lesions in general. It is suggested that this tumour is potentially malignant and that the possible role of HPV in human oesophageal carcinogenesis deserves further study.

Acute cholecystitis treated by early and delayed surgery. A controlled clinical trial.

100 patients with acute cholecystitis (AC) diagnosed by clinical, laboratory, and roentgenological examinations were randomly divided into 2 groups; early surgery (ES), operated within 7 days after the onset of acute symptoms, and delayed (DS), operated 2--3 months after the acute episode. Patients with elevated serum bilirubin and/or amylase were included in the trial. Two patients died during conservative treatment, and in 4 cases medical treatment was interrupted because of peritonitis, and in 3 cases because of increasing jaundice. Recurrence of AC was found in 24% of the patients in the DS group. There was no mortality in the ES group, but 2 patients died postoperatively in the DS group. Wound infection developed in 3 patients in the ES, and in 8 patients in the DS group. Retained stones remained in 3 cases of the DS and in 1 case of the ES group. The operative procedures were easier to perform in the ES group than in the DS, as estimated by the duration of operation. The operation time was 76.7 +/- 4.6 min (mean p S.E.) in the ES and 98.0 +/- 7.3 min in the DS group. There was a statistically significant difference between the 2 groups (p less than 0.01). The results suggest that early surgery in the treatment of acute cholecystitis is recommended. The complications of failed medical treatment can be avoided by early operation without added risk of mortality or complications.

The functional state of the gastrointestinal tract after ulcer surgery. A ten-year prospective follow-up study.

Of 35 patients operated upon for peptic ulcer and subjected to absorption tests before operation, 26 could be followed up with absorption tests for 1, 6, and 10 years after operation. The following operations had been performed on the latter: antrectomy with gastroduodenostomy in 10, antrectomy with selective vagotomy and gastroduodenostomy in 9, and other operations in 7. None had recurrence of the ulcer or disturbing abdominal complaints during the follow-up period. Ten years after operation there was an increase in the mean value of the Schilling test, and all patients had a normal serum B12 vitamin level. On the other hand, a decrease was noticed in the mean value of the d-xylose test and an increase in that of faecal dry-weight fat content. At the time of the 10th year follow-up examination, 6 patients had an impaired d-xylose absorption and 7 an impaired fat absorption. According to the increase in the mean body weight and the serum protein and haemoglobin concentration, the nutritional status had not worsened.

The effect of vitamin D2 treatment on bone mineral after partial gastrectomy.

A controlled clinical study of the effect of 1000 IU of calciferol daily for 8 months was performed on patients with postgastrectomy bone loss. The treatment produced no observable increase in bone mineral density measured by photon absorption.

Drug absorption in patients with T-tube after cholecystectomy.

The influence of bile flow on the absorption of tetracycline, doxycycline, sulphadimidine and cycloserine was studied in 13 volunteer patients with t-tubes in their main bile ducts after biliary surgery. Their hepatic functions and bile flows were estimated by giving I131 radioiodinated rose-bengal intravenously. About 80% radioactive tracer was recovered from the bile when the t-tube was open, so most of the bile was diverted outside the intestinal tract. Up to 4 hours after administration serum tetracycline levels were lower when the t-tube was open than when the t-tube was closed. In one patient the serum levels were so much reduced that therapeutic serum tetracycline levels could not be achieved. The serum doxycycline levels were fairly high and bile flow did not have any effect on absorption. The 24-hour biliary excretion of doxycycline was only about 15% of the urinary excretion. The absorption of sulphadimidine and cycloserine was not affected by the presence or absence of bile. The bile salts are important surfactants in man, and modify the absorption rate of tetracycline, but not of doxycycline, sulphadimidine and cycloserine. Even in the absence of intact bile flow therapeutic serum tetracycline levels can be expected with the doses currently used.

Effect of gastric surgery on the gastrointestinal drug absorption in man.

The effect of gastric surgery on the absorption of quinidine, ethambutol, and sulphafurazole was studied in 14 male patients, all serving as their own controls. Antrectomy with gastroduodenostomy (ABI) and selective vagotomy lowered the serum levels of all drugs significantly during the 6-hour test period. Excretion of drugs in 6-hour urine also decreased. Three patients showed practically no absorption up to 2 hours, and even therafter the absorption was lowered. Over one year after operation the urinary excretion of ethambutol, but not of the other drugs, was improved. ABI alone did not modify absorption. Preoperative gastric retention seemed to delay absorption.