Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years.

BACKGROUND: Slow transit constipation is characterised by prolonged colonic transit and reliance on laxatives. The pathophysiology is poorly understood and in its most severe form, total colectomy with ileorectal anastomosis is the final treatment option. We present a follow-up study of the long-term function in patients who had surgery for laxative-resistant slow transit constipation. METHODS: A postal survey was sent to assess bowel frequency, abdominal pain, St Mark's continence score, satisfaction with procedure, likelihood to choose the procedure again, and long-term rates of small bowel obstruction and ileostomy. Longitudinal data from a subgroup studied 23 years previously are reported. RESULTS: Forty-two patients (male = 2) were available for follow-up out of an initial cohort of 102. Mean time since surgery was 15.9 years (range 1.7-29.7) years. Fifty percent had < 4 bowel motions per day, most commonly Bristol stool 6, mean St Mark's score 7.45. Twenty-one percent had severe incontinence. Satisfaction and likelihood to choose surgery were high (median 10/10). There was a high rate of small bowel obstruction, suggesting pan-intestinal dysmotility in some cases. Conversion to ileostomy occurred in 8 patients. In the longitudinal follow-up in 15 subjects, continence deteriorated (p < 0.01), stool consistency softened (p < 0.01), and stool frequency fell (p < 0.01). CONCLUSIONS: Satisfactory stool frequency was achieved in the long term, and although 21% had incontinence scores > 12, patient satisfaction was high. This is the longest reported follow-up of colectomy for slow transit constipation, with longitudinal outcomes reported. There was considerable attrition of patients, so larger, longitudinal studies are required to better ascertain the functional outcomes of these patients.

Idiotype-like determinants on human T lymphocytes alloactivated in mixed lymphocyte culture.

T cells alloactivated in 5-d MLC with an HLA-DR-different stimulator acquire the capacity of stimulating the autologous mixed lymphocyte response (AMLR). We have demonstrated that activation of AMLR by allosensitized T cells is determined by the expression of the idiotype receptor for the stimulating HLA-DR alloantigen. This has been shown in experiments in which purified, OKT-3-positive T cell suspensions were first primed for 9 d with AMLR-activated T lymphoblasts, then tested in secondary AMLR with autologous lymphoblasts sensitized to various HLA-DR alloantigens. Accelerated memory responses were induced only by autologous lymphoblasts that had been sensitized against the same HLA-DR specificity as the primary AMLR stimulators. This response was not inhibited by a mouse monoclonal antibody recognizing Ia-like determinants, and was not triggered by human allogeneic resting peripheral blood lymphocytes. Thus, recognition of alloactivated T lymphoblasts in secondary AMLR seems to be specific for the idiotype-like determinants expressed by the autologous stimulators.

Postanal repair--do the long-term results justify the procedure?

OBJECTIVE: Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long-term continence after PAR and relate this to patient satisfaction and quality of life. METHOD: Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life. RESULTS: One-hundred one patients from four surgeons were identified. Fifty-four patients were excluded because of loss to follow-up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow-up of 9.1 years (2.2-18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0-5), 26% moderate (CCS 6-12), and 48% (n = 27) severe incontinence (CCS 13-24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow-up, and being able to distinguish flatus and stool. CONCLUSIONS: In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long-term subjective outcome, despite the fact that many patients have a high incontinence score.

Synthesis of RNA in mammalian cells during mitosis and interphase.

Chinese hamster cells in the mitotic and G(1) phases of the growth cycle were incubated for 30 or 60 min in suspension tissue culture and pulse-labeled with tritiated uridine. After appropriate chases, washes, and extractions, it was found that all incorporation into the nucleic acid may be accounted for by those cells in interphase. An average of 410 counts was found for incorporation into the cell population (approximately 2.0 x 10(5) cells) of which over 80% of the cells was initially in mitosis. The increasing number of cells leaving mitosis and entering interphase during the 30 min incubation was theoretically able to account for 470 counts. In addition, short-pulse labeling experiments have shown a consistent linear relationship between the percentage of cells in division and the incorporation of the isotope, which strongly suggests that, if 100% of the cells were in mitosis, the counts would be essentially zero. Thus, the entire label may be attributed to those cells in interphase where portions of the chromosomal material are known to be already extended.

Respiratory enzymes and mitochondrial morphology of HeLa and L cells treated with chloramphenicol and ethidium bromide.

Exposure of HeLa and L cells to chloramphenicol causes a progressive dose-dependent decrease in cytochrome oxidase and succinate-cytochrome c reductase activities, concomitant with an increase in the amount of cytochrome c. At 2-3 days, the specific activities of the enzymes have fallen to about one-half of control values; the mitochondria appear swollen. By day 5, enzyme activities are about one-quarter of control values; the mitochondria are more swollen, with disorientation and disintegration of cristae. By day 6-8, after three generations, growth has stopped, enzyme activities are approximately the same as on day 5, and cytochrome c content has reached 170% of control value. Mitochondria show severe changes, cristae being affected more than peripheral inner membrane. The number of profiles continues to be nearly normal. After 30 days, cytochrome oxidase activity remains low but now there are mitochondria in intermediate and condensed configuration. There is a gradual accumulation in the cytoplasm of smooth membrane elements. If chloramphenicol is removed, cells recover. Ethidium bromide treatment for up to 8 days yields results virtually identical to those obtained with chloramphenicol. Cells treated with 10(-4)M KCN show a decrease in cytochrome oxidase activity to about one-third of control value and an elevated amount of cytochrome c. Only a small number of mitochondria appear damaged. Autochthonous mitochondrial syntheses appear to be essential for the organization of the cristae. When cytochrome oxidase activity is impaired, a regulatory mechanism for cytochrome biosynthesis geared to mitochondrial function may be lacking, resulting in an increase in cytochrome c content.

Antibody synthesis initiated in vitro by paired explants of spleen and thymus.

Primary in vitro synthesis of antibody has been achieved with a mouse spleen-thymus organ culture system 54 hours after it was incubated for 18 hours with coliphage R17.

Amplification of T cell blastogenic responses in healthy individuals and patients with acquired immunodeficiency syndrome.

Human immunodeficiency virus (HIV) infection is associated with a profound impairment of T cell function. Hence, enhancement of T cell reactivity to viral and bacterial antigens is important in the treatment of patients with AIDS. To develop tools for amplifying T cell reactivity, we have immunized mice with human helper T cell clones and selected monoclonal antibodies (MAbs) that enhance in vitro blastogenic responses. MAb NDA5, which recognizes the leukocyte common antigen CD45, amplifies human T cell responses to mitogens and soluble antigens including HIV-1 glycoprotein (gp)-120 and peptides derived from the HIV-1 gp-120 sequence. In the presence of MAb NDA5, peripheral blood mononuclear cells (PBMC) from healthy, HIV-1-seronegative individual displayed augmented blastogenic responses to HIV-1 gp-120 and to HIV-1 gp-120 synthetic peptides. In vitro memory responses to various vaccines and to alloantigens were also enhanced in cultures with MAb. Similarly, the response of PBMC from AIDS patients to pokeweed mitogen, HIV-1 gp-120, and tetanus toxoid was enhanced with MAb NDA5. The finding that the in vitro immune response of patients with AIDS can be amplified with MAb NDA5, suggests that the in vivo immune response of immunodeficient individuals can also be enhanced.

Pannexin-2 is expressed in the human colon with extensive localization in the enteric nervous system.

BACKGROUND: Pannexin-2 (Panx2) is a member of the novel group of membrane spanning protein channels present in the central nervous system. Limited studies have examined Panx2 in the intestine, where it may have important physiological roles. The present study characterized Panx2 expression and localization in the human colon in health and disease states. METHODS: Immunofluorescence determined Panx2 localization and co-localization, and quantitative real-time PCR and Western blot determined gene and protein expression in ulcerative colitis (UC), Crohn's disease (CD), and control human colon. KEY RESULTS: Panx2 was widely expressed in myenteric and submucosal ganglia, particularly in the cytoplasm of neurons. Panx2 was also expressed on smooth muscle of the muscularis and blood vessels, some non-lymphoid leukocytes, mast cells, and mucosal epithelial cells. Co-localization of Panx2 occurred with ß-tubulin, neuronal nitric oxide synthase, substance P, vesicular acetylcholine transporter, and calcitonin gene-related peptide, indicating widespread Panx2 expression in extrinsic and intrinsic neurons. Molecular studies revealed a 3.4-fold higher level of Panx2 mRNA in ascending compared to sigmoid muscularis (p < 0.05), despite similar protein levels. Similarly, UC muscularis showed a 35-fold up-regulation in Panx2 mRNA, but not in protein (p < 0.05). CONCLUSIONS & INFERENCES: Here, we demonstrated the dense expression of Panx2 in the enteric nervous system and the co-localization of Panx2 with a spectrum of neuronal markers, indicating that Panx2 may be involved in mediating neurotransmission in the colon. The substantial increase in Panx2 mRNA in UC muscle but not protein suggests that the Panx2 translation process may be disrupted in UC.

Decreased serum ionized calcium and normal vitamin D metabolite levels with anticonvulsant drug treatment.

Alterations in vitamin D metabolism are generally thought to account for the hypocalcemia and osteopenia caused by long term treatment with anticonvulsant drugs. Regional variation in the incidence and severity of anticonvulsant drug-induced bone disease has been attributed to differences in sunlight exposure, with most reports coming from areas with limited sunshine or from institutionalized patients. Serum ionized calcium levels in 109 ambulatory adult epileptic outpatients receiving chronic anticonvulsant drug therapy in Georgia were decreased [4.73 +/- 0.02 (+/-SE) vs. 4.97 +/- 0.01 mg/dl; P less than 0.001). Immunoreactive PTH concentrations were increased (5.5 +/- 0.4 vs. 4.0 +/- 0.3 microliterEq /ml; P less than 0.005), while bone mineral content was reduced, averaging only 88.8% of the predicted normal values. Hypocalcemia and osteopenia occurred in spite of normal mean levels of serum 25-hydroxyvitamin D and 1,25-dihydroxy-vitamin D. The indirect relationship between serum concentrations of antiepileptic drugs and the serum ionized calcium level, and the lack of correlation with vitamin D metabolite levels suggested that hypocalcemia was independent of the effect of the drugs on vitamin D metabolism. Bone biopsies revealed increased osteoid but normal calcification front formation, accelerated mineralization rate, and decreased mineralization lag time indicative of increased skeletal turnover, rather than osteomalacia.

Misdiagnosis of complex absence seizures.

Video-EEG monitoring disclosed absence seizures in five patients who were treated for partial seizures. Analysis of the historical and video data showed the presence of several potentially misleading ictal manifestations as follows: unidirectional head and/or eye turning, symmetric clonic activity, urinary incontinence, loss of balance causing injuries, focal clonic activity, and de novo automatisms. Without EEG correlation, complex absence seizures may be difficult to differentiate from other types of seizures. When correctly diagnosed, appropriate therapy may improve seizure control.

The P3 evoked potential and transient global amnesia.

The P3 evoked potential has been linked to memory mechanisms, but its neuronal generators are uncertain. Transient global amnesia (TGA) is a disorder of recent memory that has been postulated to result from ischemia or focal seizures in the medial temporal lobes and/or thalamus. To our knowledge, this is the first report of a recording of P3 evoked potential and sphenoidal electroencephalogram during TGA. The tonal P3 was not decremented in comparison to P3 recordings one month and two years after recovery. Sphenoidal electroencephalogram was normal. The results suggest that the neuronal networks which generate the tonal P3 are not involved in the part of the memory system affected by TGA.

Stimulus timing effects on Wada memory testing.

OBJECTIVE: To determine the effects of presenting Wada memory stimuli at different times after intracarotid amobarbital injection on Wada memory asymmetries. DESIGN: Wada memory asymmetries from three timing series were related to the laterality of eventual temporal lobectomy. SETTING: Academic institution epilepsy surgery program. PATIENTS: Forty-three patients with complex partial seizures who later underwent anterior temporal lobectomy (left temporal lobectomy, 24 patients; right temporal lobectomy, 19 patients). No patient included had abnormalities on magnetic resonance imaging scans to suggest a lesion other than gliosis. RESULTS: Memory performance for objects whose presentation began approximately 45 seconds after amobarbital administration differentiated laterality of seizure onset. Memory for items presented later and after partial return of language (on average 3 minutes 40 seconds postinjection) also differed as a function of ipsilateral vs contralateral injection, but at a lower level of statistical significance. Memory for items presented last during the procedure (on average 6 minutes postinjection) discriminated seizure groups at a still lower level of statistical significance. When used to predict lateralized temporal lobe impairment in individual patients, early object memory performance was significantly better than memory performance employing either middle (56%) or late (43%) stimulus presentation timings. CONCLUSION: The results of early object memory testing are superior to those obtained from stimulus presentation later in the procedure in documenting temporal lobe dysfunction associated with a lateralized seizure onset.

Complexes of soluble HLA antigens and anti-HLA autoantibodies in human sera: possible role in maintenance of self-tolerance.

The MHC plays an essential role in regulating the process of self-nonself discrimination. T cells recognize nonself antigens only in the context of self-MHC gene products. It is not clear, however, whether B cells are also endowed with immune receptors for self-MHC antigens. We have explored the existence of antibodies against self-MHC antigens (HLA) in the human by analyzing the specificity of anti-HLA antibodies developed by a population of 727 dialysis patients who had been monitored monthly over a period of 3-78 months. Anti-HLA autoantibodies were identified by serum screening in 119 patients. Twenty-five of these 119 patients had not been exposed to alloantigens before, indicating that the production of anti-HLA autoantibodies is not necessarily stimulated by allogeneic HLA antigens. Cross-matching of sera with autologous lymphocytes, confirmed the autoreactive nature of these anti-HLA antibodies which were of IgM or of IgG isotype in approximately equal numbers of patients. The fine specificities of anti-HLA autoantibodies was ascertained in studies which showed that antibodies can be adsorbed, and the eluted, from the membranes of target cells carrying then relevant HLA antigen. Since the antibodies characterized in our studies may be functionally active in vivo we examined the possibility that their level is controlled by anti-idiotypic antibodies or by soluble HLA antigens. We found that the titer of anti-HLA autoantibodies increased significantly if soluble HLA antigens were depleted from the serum. Our data suggest that circulating HLA antigens form immune complexes with anti-HLA autoantibodies and contribute to the maintenance of self-tolerance by inhibiting antibody binding to membrane HLA antigens. The finding that the immune repertoire includes B cells with receptors for self-MHC opens new perspectives for the study of network perturbations in autoimmune diseases.

Age-related changes in normal human basement membrane.

Basement membranes were studied in the seminiferous tubules of the male, and capillaries of the pectoralis muscles in "normal" males and females. Age-related changes in basement membrane thickness were investigated on electromicrographs by quantitative morphometry. Specimens obtained from either autopsies or surgical procedures were divided into four different age groups ranging from age 16 to age 87 years. The results show a statistically significant increase in the basement membrane thickness correlated with age, in basement membranes associated with both mesenchymal (capillaries) and epithelial (testes) tissue. A comparison of capillary basement membrane in the pectoralis muscle and seminiferous tubule basement membrane in the male show a constant increase in thickness until the age of 60 years, following which only slight increases were noted. The basement membrane thickness in capillaries of the pectoralis muscle in females showed linear increases throughout the lifespan, although at a lower rate than in the male; at age 80 years, it had the same thickness as the male. A comparison of basement membrane thickness between the youngest and oldest groups showed an increase of approximately 50% in all tissues studied.

Reactivation of DNA synthesis in aging diploid human skin fibroblasts by fusion with mouse L karyoplasts cytoplasts and whole L cells.

Diploid human skin fibroblasts derived from an 82-year-old donor with a 21-28 cell population doubling (CPD) range (where 28 CPD marked the end of the in vitro life span of the cells) were fused with whole L cells, L karyoplasts and L cytoplasts. The proportion of human nuclei incorporating tritiated thymidine after fusion was measured autoradiographically. Statistically significant increases in the labeling indices were found in the human nuclei in hybrid, heterodikaryon and cybrid cells when compared to control unfused human cells. Fusion of human diploid fibroblasts with human cytoplast derived from cells of the same CPD showed no significant changes in the labeling indices of the human nuclei.

A correlation between aging and DNA repair in human epidermal cells.

Ultraviolet-induced unscheduled DNA synthesis (i.e. repair synthesis) in human epidermal cells was measured as a function of age. Normal mammary skin specimens were obtained at surgery from 36 female patients, ranging in age from 17 to 77 years. The enzymatically isolated epidermal cells were analyzed for two parameters: (1) the number and percentage of cells carrying out repair synthesis, and (2) the rate of ultraviolet-induced unscheduled thymidine incorporation in individual cells. The results show that the percentage of epidermal cells capable of DNA excision repair synthesis does not decrease significantly with age, but that the rate of unscheduled DNA synthesis in individual cells decreases to a highly significant degree with advancing age.

Partial complex status epilepticus.

We studied the clinical features, ictal manifestations, and EEG phenomena of eight patients with partial complex status epilepticus documented by video/EEG. Age at the time of status was 18 months to 56 years. All patients had had previous seizures, and seven had previous episodes of status. In three patients, status consisted of confusion associated with continuous focal electrographic ictal activity. Five patients had confusion, aphasia, motor phenomena, or automatisms associated with recurrent partial electrographic seizures. Data from 17 previously reported cases were comparable with our 8 patients.

Pseudoseizures: ictal phenomena.

Videotapes of 71 pseudoseizures from 27 patients were reviewed and clinical phenomena were recorded. Twenty patients demonstrated decreased response to verbal stimuli; 15 described subjective phenomena; 22 had motor activity; 14 semipurposeful movements simulating epileptic automatisms; 19 alimentary phenomena; 9 respiratory change; and 12 nonverbal vocalization. Episodes could be divided into four major ictal patterns. Fifteen patients had bilateral motor episodes; three had unilateral motor episodes; eight had episodes with multiple behavioral phenomena; and three demonstrated episodes with an impaired response but no observable behavior. Eighteen of the 20 patients with multiple episodes had a stereotyped pattern. Individual phenomena often simulated epileptic activity; rarely did complete episodes closely resemble epileptic seizures.

The effect of electrical stimulation of medial temporal lobe structures in epileptic patients upon ACTH, prolactin, and growth hormone.

We measured ACTH, cortisol, prolactin, and growth hormone concentrations in patients with temporal lobe epilepsy who were having depth electrode studies. During the collection period, electrical stimuli were applied to amygdala and hippocampus to establish after-discharge thresholds. After-discharges that lasted at least 10 seconds or seizures caused secretion of ACTH and prolactin but not growth hormone. Stimuli that did not produce after-discharges of this duration inhibited ACTH secretion, but had no effect on prolactin or growth hormone secretion.

Comparative cognitive effects of anticonvulsants.

We investigated the neuropsychological effects of carbamazepine, phenobarbital, and phenytoin in 15 partial complex epilepsy patients treated with each drug for 3 months, using a randomized double-blind, triple crossover design. Neuropsychological evaluation at the end of each treatment period included Digit Span, Selective Reminding Test, Digit Symbol, Finger Tapping, Grooved Pegboard, Choice Reaction Time, P3 evoked potential, and Profile of Mood States. Employing anticonvulsant blood levels and seizure frequencies as covariates, the only significant difference was for Digit Symbol. Performance with phenobarbital was significantly worse than with the other 2 anticonvulsants despite phenobarbital's having had the lowest overall blood levels. Our data show that patients receiving carbamazepine, phenobarbital, and phenytoin have comparable neuropsychological performance on most measures. The results suggest that the differential cognitive effects of anticonvulsants may be subtle.