Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas.

OBJECTIVE: Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques. METHOD: We retrospectively analysed a prospectively entered database composed of 146 patients (112 M; 34 F), undergoing operations for CF of cryptoglandular origin. The patients were divided in two groups: Group A: (EAF); n = 71 patients; Group B: (ISR); n = 75 patients. RESULTS: Forty-two fistulas (28.7%) were recurrent, 98 trans-sphincteric (TS) and 37 suprasphincteric (SS). Twenty-six (17.7%) patients had some degree of preoperative continence disturbances, 11 in Group A vs 15 in Group B (P = 0.47). After a mean follow up of 13 months (12-60), fistula persisted or recurred in 13 (18.3%) patients in Group A vs eight (10.6%) in Group B (P = 0.19) irrespective of the fistula type (TS or SS). Thirty-one (43.6%) patients in Group A vs 16 (21.3%) in Group B presented postoperative continence disturbances (P < 0.001). No changes were observed with the Faecal Incontinence Quality of Life Scale (FIQLS). Group A patients had a significant reduction of maximal rest pressure after surgery. After ISR, no significant changes in pressures were observed. CONCLUSION: Immediate sphincter repair can be a therapeutic option in selected cases of CF, mainly when associated with incontinence or increased risk factors.

Estudio cooperativo nacional sobre la utilización de aspiración nasogástrica y alimentación precoz en cirugía colorrectal / Nationwide cooperative study on the utilization of nasogastric aspiration and early feeding in colorectal surgery

Introducción. El objetivo de este estudio fue evaluar la seguridad y eficacia de la sonda nasogástrica y la alimentación oral precoz en cirugía colorrectal. Pacientes y métodos. Hemos realizado un estudio multicéntrico, prospectivo y no aleatorizado que incluía a pacientes sometidos a cirugía colorrectal electiva. Los grupos de estudio fueron: grupo 1: sonda nasogástrica postoperatoria; grupo 2: sin sonda nasogástrica y dieta oral progresiva habitual, y grupo 3: sin sonda nasogástrica y alimentación oral precoz. Las variables analizadas fueron: presencia de náuseas y vómitos, necesidad de colocación de la sonda nasogástrica, tolerancia a la dieta oral, día de comienzo de peristalsis audible, inicio de tránsito para gases y heces, uso de fármacos antieméticos, grado subjetivo de bienestar postoperatorio y aparición de complicaciones. Resultados. Al final del estudio se recibieron 406 encuestas. La distribución ha sido: grupo 1: 200 pacientes (49,3 por ciento), grupo 2: 152 pacientes (37,4 por ciento) y grupo 3: 54 pacientes (13,3 por ciento). La aparición de peristaltismo audible, el inicio de tránsito a gases y heces, así como la tolerancia a la alimentación oral, fueron más precoces en los grupos 2 y 3 (sin sonda nasogástrica) que en el grupo 1, con diferencias estadísticamente significativas (p < 0,05). El grado de comodidad postoperatoria fue mayor en los grupos sin sonda nasogástrica. Las complicaciones aparecieron de forma similar en todos los grupos. Conclusiones. La alimentación oral precoz y la restricción del uso de sonda nasogástrica en cirugía colorrectal electiva son seguras y sin desventajas en relación con el uso sistemático de SNG y dieta oral progresiva (AU)

Encouragement during maximal exercise testing of type A and type B scorers.

The influence of verbal encouragement during assessment of maximal oxygen consumption of subjects scoring as Type A and Type B on the Jenkins Activity Survey, Form T was examined. Fourteen Type A and 12 Type B scorers performed two randomly assigned tests on a motor-driven treadmill with and without verbal encouragement during testing. Treadmill time, oxygen consumption (VO2), heart rate, and respiratory exchange ratio at exhaustion were examined. Verbal encouragement led to significantly greater treadmill time, VO2, and respiratory exchange ratio for Type B scorers when compared with the non-encouragement trial. Treadmill time, VO2, heart rate, and respiratory exchange ratio at exhaustion were not different between treatments for the Type A scorers. Type A scorers ran significantly longer without encouragement than Type B scorers; however, when encouragement was provided, treadmill time for Type A and Type B scorers did not differ significantly. The results suggest that attainment of maximal effort is not dependent on verbal encouragement for Type A scorers, whereas verbal encouragement is necessary to assure attainment of maximal physiologic effort for those individuals scoring as Type B.

First person account: schizophrenia--adrift in an anchorless reality.

The article that follows is part of the Schizophrenia Bulletin's ongoing First Person Accounts series. We hope that mental health professionals--the Bulletin's primary audience--will take this opportunity to learn about the issues and difficulties confronted by consumers of mental health care. In addition, we hope that these accounts will give patients and families a better sense of not being alone in confronting the problems that can be anticipated by persons with serious emotional difficulties. We welcome other contributions from patients, ex-patients, or family members. Our major editorial requirement is that such contributions be clearly written and organized, and that a novel or unique aspect of schizophrenia be described, with special emphasis on points that will be important for professionals. Clinicians who see articulate patients, with experiences they believe should be shared, might encourage these patients to submit their articles to First Person Accounts, Division of Clinical and Treatment Research, NIMH, 5600 Fishers Lane, Rm. 18C-06, Rockville, MD 20857.

Changes in transmyocardial impedance during prolonged ventricular fibrillation. Implications for current flow and delivered energy during DC countershock.

Transthoracic resistance (TTR) and transmyocardial resistance (TMR) were measured during 10 minutes of uninterrupted ventricular fibrillation (VF) in a canine model. TMR was measured at 10- to 50-second intervals with two wire-mesh patch electrodes in 16 dogs. TTR was measured through two identical low-impedance electrodes. A monophasic exponentially truncated pulse with a duration of 5 msec was used for measurement of TMR as well as TTR. Low-energy pulses of 100 V were used for TMR measurements and pulses of 300 V for TTR measurements. TMR showed an increase of 22.8 +/- 5.14 omega (from 96.2 +/- 12.3 omega) after 600 seconds of uninterrupted VF (p less than 0.0006). TTR showed a change of 2.4 +/- 1.94 omega, which was not statistically significant in comparison with the initial value of 69.0 +/- 11.4 omega. A mathematical model was developed to predict energy delivered to the heart after a transthoracic shock. Observed values of TMR and TTR were used in this model. With the use of this model, the predicted fall in transmyocardial current after 600 seconds of uninterrupted VF and 19.3%, and the fall in energy delivered to the heart was 14%. Our study suggests that increase in TMR may contribute to the observed lack of successful defibrillation during prolonged VF.

Plasma disposition and tolerance of aditoprim in horses after single intravenous injection.

Aditoprim, a broad spectrum antimicrobial agent acting as a reversible dihydrofolate reductase inhibitor, was intravenously injected into four 12 to 24-year old horses at a dosage of 5 mg/kg b. w. Blood samples were collected over a 48-hour period after drug injection, and the separated plasma samples were assayed for aditoprim by high performance liquid chromatography. The body temperature, heart rate, respiration rate, and behaviour were recorded during the experiment. The bilirubin and urea concentrations were also determined in several plasma samples, and liver function tests were carried out. The concentrations of aditoprim in the plasma of horses were higher than the MIC of this drug against recently isolated pathogens for 6-13 h (Pasteurella haemolytica A 1) to 48 h (E. coli). The main pharmacokinetic characteristics of aditoprim in horses were: a large volume of distribution, reaching a mean value of 7.8 l/kg; a mean plasma clearance of 5.0 l/min; a plasma elimination half-life of 12 h. The clinical observations, blood chemistry, and liver function tests all demonstrated that the drug was well tolerated by the horses, although it was injected intravenously as a 25% solution. It was concluded that the 25% aditoprim injection solution could be used in horses without adverse effects at 5 mg/kg. Furthermore, aditoprim should demonstrate good antibacterial effects in horses when intravenously injected once a day.

Carprofen in veterinary medicine. I. Plasma disposition, milk excretion and tolerance in milk-producing cows.

Carprofen, a non-steroidal anti-inflammatory drug (NSAID), was injected intravenously in six cows after calving, either as a single or a daily dose of 0.7 mg/kg for five days. Carprofen was well tolerated by the cows at this dose rate, the milk production and biochemical variables remaining within the normal ranges. The plasma elimination half-life of carprofen ranged from 44.5 to 64.6 h after repeated daily injections. These values are longer than those reported for other NSAIDs used in veterinary medicine, e.g. flunixin and phenylbutazone. The volume of distribution and the clearance values calculated after a single intravenous injection amounted to 0.09 l/kg and 9.0 ml/min. The concentration of carprofen in milk collected twice daily (morning and evening) was, in general, below the sensitivity limit of the analytical method (25 ng/ml) up to five days after the last carprofen injection; the concentration of carprofen reached about 30 ng/ml in only a few milk samples collected after the fourth or fifth injection. This indicates that carprofen is poorly excreted in the milk.

Determination of aditoprim, a new dihydrofolate reductase inhibitor, in the plasma of cows and pigs.

A selective and sensitive high-performance liquid chromatographic method was developed for the determination of aditoprim, a new dihydrofolate reductase inhibitor, in the plasma of cows and pigs. The compound and its internal standard were extracted with chloroform from plasma buffered at pH 9 and chromatographed on a muBondapak reversed-phase column with a mixture of acetonitrile and 0.5% ammonium carbonate aqueous solution and detected by UV absorption. Aditoprim can be quantitatively extracted from plasma. The limit for quantitative determination was ca. 0.050 micrograms/ml with a standard deviation of +/- 0.006 micrograms/ml and an accuracy of +/- 3%. The assay was linear over the concentration range 0.1-5.0 micrograms/ml (precision 0.007-0.09 micrograms/ml), and the day-to-day accuracy was better than +/- 3.5%. No interference was observed from either metabolite(s) or coadministered sulphonamides. The new procedure was compared with a microbiological assay by analysing plasma samples from pigs treated with aditoprim. The two methods gave similar results in the range 0.5-5.0 micrograms/ml.

Determination of Ro 14-1761, a new third-generation cephalosporin, in the plasma and milk of cattle by column switching high-performance liquid chromatography.

A sensitive and specific high-performance liquid chromatographic procedure was developed for the determination of the third-generation cephalosporin Ro 14-1761 in cow plasma and milk. The molecular structure of the new antimicrobial was very close to that of ceftriaxone, but the high-performance liquid chromatographic methods available for the latter could not be used as Ro 14-1761 adsorbed and/or degraded during the chromatographic process. Furthermore, the high-performance liquid chromatographic technique derived for ceftriaxone was not sensitive enough for our purposes. In the new assay, the plasma (milk) protein was precipitated with acetonitrile after dilution of the sample with water. For low concentrations (less than or equal to 10 micrograms/ml), the supernatant obtained after centrifugation was concentrated by extracting acetonitrile with methylene chloride. Quantification was performed by column switching high-performance liquid chromatography with UV detection (274 nm) using ion-pair reversed-phase chromatography. Ethylenediaminotetraacetic sodium salt had to be added to the mobile phase (1.2 mM) to prevent adsorption and/or degradation of the cephalosporin on the analytical column. The selectivity of the chromatographic separation was enhanced by heating the column to ca. 50 degrees C. The drug recovery was better than 85%. The limit for quantitative determination in both milk and plasma was 0.1 microgram of Ro 14-1761 per millilitre with an accuracy of 1% (coefficient of variation 10%). The overall accuracy and precision were 1-10% in the 0.1-100 micrograms/ml concentration range.

Metabolic studies of ornidazole in the rat, in the dog and in man.

1. Ornidazole, labelled with 14C in the imidazole ring, administered orally to rats, dogs and men was largely excreted in the urine, predominantly as metabolites, with less than 4% of the drug being excreted unchanged. Free and conjugated metabolites were found in the ratio of approx. 1 : 2. 2. The pattern of free ornidazole and metabolites was different in the three species: while ornidazole predominated in man, ornidazole and metabolite M1 in the dog, the most extensive metabolic pattern was found in the rat. 3. The following metabolites were identified: M1, 1-chlorlo-3-(2-hydroxymethyl-5-nitro-1-imidazolyl)-2-propanol; M2, 2-methyl-5-nitroimidazole; M3, N-(3-chloro-2-hydroxypropyl)acetamide: M4, 3-(-2-methyl-5-nitro-1-imidazolyl)-1, 2-propanediol; M5, acetamide. 4. The formation of metabolite M3 and M5 indicated cleavage of the imidazole ring between N-1/C-5 and C-2/C-3. Other ring scissions were not observed. Metabolites carrying a free amino group were not detected. On the basis of the structures identified, a scheme is suggested for the metabolism of ornidazole.