The long and short of flexible sigmoidoscopy: does it matter?

Physicians performing fiberoptic sigmoidoscopy may choose between a 35 and 60 cm instrument. Confusion and dispute exist concerning the advantages of one over the other. In an effort to resolve this question, 100 consecutive symptomatic patients were examined in an outpatient sigmoidoscopy clinic. Both the Olympus OSF-30 and Olympus OSF-60 flexible sigmoidoscopes were used on each patient alternately. Mean examination time, patient tolerance, diagnostic findings, instrument cost, physician training time, and insertion length were recorded and compared. The longer scope detected five more polyps and 25 additional cases of diverticulosis which were located beyond the reach of the shorter scope. The increased number of findings with the longer scope was expected; however, the increased number of polyps was not statistically significant. The additional number of findings with the longer scope was expected and with increased number of examinations the increased number of polyps may prove to be statistically significant. Neither instrument can substitute for colonoscopy in the overall management of colorectal neoplasms. We conclude that with adequate training and cost control, either instrument can be used for screening proctosigmoidoscopy; but the trend suggests a greater number of polyps are detected with the longer instrument.

Course and complications of endoscopic variceal sclerotherapy: a prospective study of 50 patients.

Fifty consecutive patients with bleeding esophageal varices were treated with endoscopic variceal sclerotherapy (EVS) using the free hand method and a flexible fiberoptic endoscope. During the study period, November 1981 through April 1984, 11 patients (22%) rebled after the initiations of EVS and six patients were lost to follow-up. Obliteration of esophageal varices was achieved in 14 patients and none of these patients rebled for a mean follow-up time of 305 days. Survival curves generated by Willcoxson life table analysis demonstrated 51% 1-year survival for all patients, 21% for Child's class C patients, and 100% for Child's A and B patients. The complications associated with EVS were ulcerations 78%, strictures 20%, fever 44%, and perforations 2%. This study indicates that EVS is a safe and effective treatment for acute variceal hemorrhage and obliteration of esophageal varices can be achieved. Once varices are obliterated rebleeding may not occur. Survival in Child's A and B patients may be improved with EVS but the survival in Child's C patients is unaffected.

Inability of thoracic duct drainage to prevent hyperacute rejection.

Serum and lymph albumin and Ig levels were measured during 6 weeks of lymphocyte depletion by thoracic duct drainage (TDD) in 21 patients prior to renal allotransplantation. In ten of these patients, the amount of protein lost from all sources (blood sampling, dialysis, and lymph centrifugation) was measured. The total amount of albumin lost was significantly greater than the amount of IgG lost. However, serum IgG declined at a faster rate and to a greater extent than albumin. Hyperacute or acute humoral rejection occurred in 14 grafts in 10 patients prepared by TDD despite negative crossmatch tests. These data suggest that removal of lymphocytes by TDD, rather than protein loss alone, affects IgG levels. On the other hand, TDD and IgG depletion do not prevent hyperacute or acute humoral rejection. This is most likely due to the inability of currently employed crossmatch tests to predict accurately which patients will manifest antibody-mediated graft rejection.

Cholera on the Texas Gulf Coast.

Cholera is being increasingly recognized in the Gulf Coast region. This report describes two cholera cases of classic clinical presentation. Both cases were caused by toxigenic Vibrio cholerae, one of an 01 serotype and one of a non-01 serotype. Vibrio cholerae was also isolated from the home environments of both patients. These findings indicate that cholera continues to be detected on the Gulf Coast, that non-01 V cholerae infections may be clinically indistinguishable from V cholerae 01 infections, and that both 01 and non-01 V cholerae strains are capable of survival in Gulf Coast environments.

Follicular carcinoma of the thyroid metastatic to the kidney 37 years after resection of the primary tumor.

A case is described of thyroid carcinoma presenting as renal metastases 37 years after initial resection of the primary. Thyroid carcinoma metastatic to the kidney detected during life is rare, only 2 cases having been reported to date. An additional feature of this case is that the patient had donated the contralateral kidney for transplantation before discovery of the metastases. Metastatic thyroid carcinoma is reviewed and the implication of organ donation in patients with thyroid carcinoma is discussed.

Renal transplantation after thoracic duct drainage.

Forty-seven patients treated by at least 28 days of thoracic duct drainage (TDD) before cadaveric renal transplant are compared with 63 patients treated with standard immunosuppression. The TDD patients were begun on half the dosage of steroids, and at 30 days were receiving approximately two-thirds the dose that the non-TDD patients received. Acute rejection occurred in 35% of the TDD group, as compared with 61% of the non-TDD group. Graft survival in the TDD patients was twice as good as the non-TDD patients at all time intervals. The patient survival rates were not significantly different between the two groups. TDD pretransplant favorably affects cadaveric renal allograft survival for at least five years.

Serum ferritin assay and bone-marrow iron stores in patients on maintenance hemodialysis.

Fifty-five patients on maintenance hemodialysis underwent bone-marrow aspirations for evaluation of iron stores that were to be compared to concomitant measurements of hematocrit, red blood cell volume, serum iron concentration, total iron binding capacity, transferrin saturation, and serum ferritin concentration. In 42 patients (76.4%), the bone marrow iron stores were found to be absent or deficient. Mean hematocrit for the total group was 26.4%, and red blood cell volume measurement showed a mean value of 41.1% of predicted normal. Results also indicated that serum ferritin was the best predictor of iron storage levels, with diagnostic thresholds of 80 to 350 ng/ml derived from statistical analysis of the data. Other hematologic parameters studied had significantly less correlation with bone-marrow iron stores.

Results of parathyroidectomy for autonomous hyperparathyroidism.

Autonomous hyperparathyroidism occurred in 15% of 152 patients maintained by long-term home dialysis during the past nine years. Twenty-two patients with elevated serum parathormone levels and progressive bone disease in the presence of normal serum phosphate and calcium levels were treated by subtotal parathyroidectomy. All had parathyroid hyperplasia. Eighteen of the 22 patients are presently alive and undergo dialysis. Symptoms of bone pain, pruritus, and muscle cramps had improved in three fourths of the patients. The serum parathormone level decreased from a preoperative average of 576 muLEq/mL to an average of 188 muLEq/mL postoperatively. All 18 patients, observed for six to 77 months, showed improvement in x-ray films of their bone disease. The autonomous hyperparathyroidism of end-stage renal disease is corrected by subtotal parathyroidectomy, and the effect is sustained.

Effect of thymosin on T-lymphocyte functions in patients with acute thermal burns.

Patients with severe thermal burns demonstrate a decreased cellular immunity. The purpose of this study was to ascertain whether thymosin enhances in vitro T-lymphocyte functions in such patients. Peripheral blood lymphocytes were obtained serially from 22 burned patients and 35 health adults. In vitro lymphocyte functions were evaluated by E-rosette formation, lymphocyte culture responses to PHA, Con A, PWM, PPD, SK-SD, mumps antigen, and tetanus toxoid, and mixed lymphocyte culture reactions. These tests were performed with and without in vitro addition of thymosin. Most of the parameters examined were significantly decreased in patients during the first 2 weeks postburn. The in vitro addition of thymosin significantly restored impaired lymphocyte responses, except in mixed lymphocyte culture reactions. These results demonstrate that thymosin enhances certain in vitro T-lymphocyte functions in burned patients. They further suggest that the administration of thymosin may restore decreased cell-mediated immunity in severely burned patients.

The risk of anticoagulation in hemodialysis patients.

The risks of intermittent anticoagulation with heparin for hemodialysis and longterm anticoagulation with warfarin to prevent clotting of arteriovenous shunts were assessed in a group of 125 home dialysis patients. Over a 7-year period, there were nine bleeding complications attributable to heparin anticoagulation for an incidence of one complication for every 40 patient year on dialysis. In contrast, 20 of 48 patients anticoagulated with warfarin for an average of 2 years each, had a total of 50 hemorrhagic complications requiring 542 days in the hospital and 15 operative procedures. Concersion to an alternative form of vascular access, the internal arteriovenous fistula, obviated the need for warfarin therapy and its unacceptably high complication rate in this population of patients.

Progressive multifocal leukoencephalopathy in renal transplant recipients.

Progressive multifocal leukoencephalopathy, a slowly progressive papovavirus infection of the CNS, has been reported in more than 110 patients to date, over half of whom have had either leukemia or lymphoma. Our patient is the fourth case of PML occurring after long-term immunosuppression for renal transplantation. We believe that PML is emerging as a potentially serious problem in renal transplant recipients.

The nephrotic syndrome associated with neoplasia: an unusual paraneoplastic syndrome. Report of a case and review of the literature.

The nephrotic syndrome complicating malignancy in the absence of renal vein thrombosis, amyloid or neoplastic infiltration of the kidney is an unusual occurrence. A case of diffuse, well differentiated, lymphocytic lymphoma and lipoid nephrosis documented by light microscopy, electron microscopy and immunofluorescent studies is reported. A review of the literature revealed 76 case reports in which the nephrotic syndrome was associated with neoplasia. The most frequently associated neoplasms are Hodgkin's disease, various carcinomas, nonHodgkin's lymphoma and leukemia in descending order. The most frequent renal lesion in patients with the nephrotic syndrome associated with various carcinomas is membranous glomerulonephritis (81 per cent) as opposed to patients with lymphomas or leukemias who have predominantly lipoid nephrosis (60 per cent). The evidence is reviewed suggesting that the lesions in membranous nephropathy are immunologically mediated by tumor or viral antigen-antibody complexes and in lipoid nephrosis perhaps by a defect in t-lymphocyte function.

Hyperparathyroidism in the maintenance dialysis patient.

At least one component of the secondary hyperparathyroidism of end stage renal failure is hyperphosphatemia. Since 1968, 101 patients were treated definitively in a home dialysis program, and 78 of the patients remain active. Despite maintenance of the serum phosphate level below 5 milligrams per cent, one-fourth eventually had progressive hyperparathyroidism develop, primarily manifested by bone disease. Serum calcium levels were generally normal and, except at the extremes, were not predictive. The incidence of hyperparathyroidism was not influenced by the age of the patient, but it increased with duration of dialysis. Hyperparathyroidism developed in 13 of 15 patients with serum parathormone levels greater than 500 but in only six of 56 patients with values less than 500. The single most important manifestation was progressive bone disease. Of 16 patients treated by subtotal parathyroidectomy, all had large hyperplastic parathyroid glands. All of the patients who were observed for longer than six months had progressive improvement in the bone disease. Hyperparathyroidism is a significant problem in the dialysis patient, despite phosphate control. Progressive bone disease and elevated serum parathormone levels are the most important indicators. The incidence is directly influenced by duration of dialysis. Subtotal parathyroidectomy is effective in reversing the bone changes.

Femoral neuropathy and ischemic colitis associated with amyloidosis in hemodialysis patients.

Renal failure is often the presenting problem with amyloidosis and it portends a generally poor prognosis. Two of 121 patients in a home dialysis program were found to have amyloidosis after they developed unusual complications, ischemic colitis and femoral neuropathy. Both ultimately died as a result of their disease. From the limited experience that is reported, it appears that renal transplantation offers a better alternative for long term therapy than hemodialysis.