Antimicrobial resistance of Campylobacter isolates from retail meat in the United States between 2002 and 2007.

The emergence of antimicrobial resistance in Campylobacter spp. has been a growing public health concern globally. The objectives of this study were to determine the prevalence, antimicrobial susceptibility, and genetic relatedness of Campylobacter spp. recovered by the National Antimicrobial Resistance Monitoring System (NARMS) retail meat program. Retail meat samples (n = 24,566) from 10 U.S. states collected between 2002 and 2007, consisting of 6,138 chicken breast, 6,109 ground turkey, 6,171 ground beef, and 6,148 pork chop samples, were analyzed. A total of 2,258 Campylobacter jejuni, 925 Campylobacter coli, and 7 Campylobacter lari isolates were identified. Chicken breast samples showed the highest contamination rate (49.9%), followed by ground turkey (1.6%), whereas both pork chops and ground beef had <0.5% contamination. The most common resistance was to doxycycline/tetracycline (46.6%), followed by nalidixic acid (18.5%), ciprofloxacin (17.4%), azithromycin and erythromycin (2.8%), telithromycin (2.4%), clindamycin (2.2%), and gentamicin (<0.1%). In a subset of isolates tested, no resistance to meropenem and florfenicol was seen. C. coli isolates showed higher resistance rates to antimicrobials, with the exception of doxycycline/tetracycline, than those seen for C. jejuni. Pulsed-field gel electrophoresis (PFGE) fingerprinting resulted in 1,226 PFGE profiles among the 2,318 isolates, with many clones being widely dispersed throughout the 6-year sampling period.

Prospective study of the effects of postanal repair in neurogenic faecal incontinence.

The most important factor associated with a good result in the surgical treatment of neurogenic faecal incontinence by postanal repair is considered to be restoration of the obtuse anorectal angle. Sixteen patients (14F:2M; median age 59 years) with neurogenic faecal incontinence confirmed by a raised fibre density in the external anal sphincter underwent postanal repair. Pre- and postoperative manometric assessment was performed in 16 and radiological assessment in 12. Normal ranges for these parameters were established in age and sex matched control subjects. Continence was improved in 14 (88 per cent) patients, 6 (38 per cent) of whom regained normal continence, at a minimum of 15 months follow-up. A successful outcome was associated with no significant change in basal (pre-operative 35 (10-85) cmH2O, postoperative 44 (12-105) cmH2O; n.s.) or voluntary (pre-operative 43 (5-150) cmH2O, postoperative 32 (12-180) cmH2O; n.s.) components of anal canal pressure. There was a small but significant increase in sphincter length (pre-operative 2 (0-3) cm, postoperative 2.5 (0-3.5) cm; P less than 0.01). There was no significant change in the anorectal angle at rest (pre-operative 96 (90-110) degrees, postoperative 107 (79-118) degrees; n.s.) in the patients in whom continence was restored and five of these patients had resting anorectal angles within the normal range (75-94 degrees). Thus postanal repair need not be restricted to patients with widening of the anorectal angle since its beneficial effects do not appear to be related to reduction of this angle.

The role of pelvic floor denervation in the aetiology of idiopathic faecal incontinence.

Weakness of the muscles of the pelvic floor and external anal sphincter may in theory be caused by a traction injury to the pelvic nerves incurred as a result of the excessive perineal descent that accompanies straining in the descending perineum syndrome (DPS). To investigate the role of this weakness in the aetiology of idiopathic faecal incontinence (IFI), measurements of perineal position, puborectalis mean fibre density (MFD), anal canal pressures, rectal sensation, capacity, and compliance were made in continent (DPS alone, n = 20) and incontinent (DPS + I, n = 19) patients with DPS, and a group of age and sex matched control subjects (n = 20). Perineal descent on straining was greater in DPS alone than in DPS + I. Puborectalis MFD was raised by similar degree in both DPS groups compared with the control subjects, and external anal sphincter function, assessed as voluntary squeeze pressure, was impaired by similar degree in DPS + I and DPS alone compared with the control subjects. Maximal basal anal canal pressure and rectal compliance were significantly reduced in DPS + I compared with DPS alone and the control subjects. Thus IFI did not result from progression of neurogenic muscle weakness, but occurred when there was also diminished internal anal sphincter tone and reduced rectal compliance.

Anorectal function in the solitary rectal ulcer syndrome.

The anorectal function of nine patients with solitary rectal ulcer syndrome (SRUS) (5 F: 4 M, median age, 27 (range, 19-41 years) and nine control subjects (5 F: 4 M, median age, 47 (35-66) P less than 0.01) has been investigated by a new technique that radiologically visualizes the anorectum during voiding of a semisolid contrast medium, while simultaneously measuring intrarectal pressure and anal sphincter EMG activity. A degree of rectal prolapse was demonstrated in eight of the SRUS patients; six of these lesions were clinically occult. Abnormal failure of the anal sphincter to relax on voiding was present in seven of the SRUS patients. These abnormalities resulted in the SRUS patients requiring a greater increase in intrarectal pressure (median, 100 cm water) to void than the control subjects (median, 65 cm water, P less than 0.01). This combination of high intrarectal pressure and rectal prolapse during staining seems to be the cause of SRUS.

Pressure and prolapse--the cause of solitary rectal ulceration.

The cause of solitary rectal ulceration has been investigated using a method that radiologically visualises rectal voiding whilst simultaneously measuring intrarectal pressure and external anal sphincter electromyographic activity. Control subjects and patients with the solitary rectal ulcer syndrome, both with and without mucosal ulceration, have been studied. A high incidence of rectal prolapse (94%) was present in the patients who voided. Overactivity of the anal sphincter during evacuation contributed to the fact that patients with mucosal ulceration required higher intrarectal pressures to void than the controls and the patients without mucosal ulceration. The results indicate that a combination of rectal prolapse and a high voiding pressure may act to cause the mucosal ulceration in this syndrome by exposing the rectal wall to a high transmural pressure gradient.

New method for the dynamic assessment of anorectal function in constipation.

A new dynamic technique for the investigation of anorectal function has been developed. This involves radiological visualization of the rectum during voiding of a semisolid radio-opaque contrast medium, and simultaneous measurement of the intrarectal pressure and electrical activity of the external anal sphincter. The method has been used to study patients (n = 16) with profound difficulty passing formed stool. It has demonstrated an abnormal increase in the activity of the puborectalis and superficial and sphincter muscles during voiding in these patients, compared with normal subjects (n = 6). The inability to void was associated with failure to widen the anorectal angle on straining.

Evidence from dynamic integrated proctography to redefine anismus.

The role of anismus in the aetiology of defective rectal evacuation was investigated by dynamic integrated proctography in 20 controls and 71 constipated patients. Normal parameters were defined and compared between 21 constipated patients with poor evacuation during proctography (< 40 per cent of contrast evacuated; group 1) and 50 who evacuated fully (> 90 per cent of contrast evacuated; group 2). Nine patients in group 1 failed to evacuate. Radiological abnormalities of the rectum were recorded in all groups but obstructed evacuation was not observed. Anismus (defined as a recruitment of puborectalis electromyogram (EMG) activity of > 50 per cent) was significantly more common in group 1 than group 2 patients (14 of 21 versus 12 of 50, P < 0.01) and present in seven of those unable to evacuate. Eight patients in group 1 failed to raise intrarectal pressure > 50 cmH2O compared with two in group 2 (P < 0.001). Six patients in group 1 demonstrated both anismus and inability to raise intrarectal pressure, which may combine to cause defective evacuation. EMG recruitment alone is insufficient to diagnose anismus. Definition should be based on three criteria: demonstration of puborectalis EMG recruitment of > 50 per cent; evidence of an adequate level of intrarectal pressure (> 50 cmH2O) on straining; and presence of defective evacuation.

Comparison of digital and manometric assessment of anal sphincter function.

Anal sphincter function was assessed by digital examination and anal canal manometry in 66 patients and controls. Digital scores were allotted by using visual analogue scales for basal and squeeze sphincter function and were compared with the corresponding pressures. There were good correlations between digital basal score and maximum basal pressure (Spearman rank correlation coefficient rs = 0.56, P less than 0.001), and digital squeeze score and maximum squeeze pressure (rs = 0.72, P less than 0.001). There were wide ranges of sphincter function on digital and manometric assessment with considerable overlap between patient groups. Digital scores detected differences in sphincter function between patient groups as accurately as manometry. The sensitivities and specificities of digital scores and anal canal manometry in segregating continent and incontinent patients were similar. It was concluded that digital estimation was equally as good as assessment of anal sphincter function as anal canal manometry.

Treatment of anismus in intractable constipation with botulinum A toxin.

In seven patients with anismus the striated sphincter muscle complex was selectively weakened by local injection of Clostridium botulinum type A toxin. Symptom scores improved significantly and correlated with a significant reduction in the maximum voluntary and canal squeeze pressure and a significant increase in the anorectal angle on straining. Botulinum A toxin seems to be promising treatment for some patients with anismus.

Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis.

Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure and low RAP has been found to correlate with minor leakage of faeces or mucus. Our hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA: each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH2O (60-116 cmH2O) to 70 cmH2O (25-104 cmH2O, P less than 0.01), whereas after MP + PTA maximal RAP decreased from 85 cmH2O (70-125 cmH2O) to 40 cmH2O (22-80 cmH2O, P less than 0.003). RAP after EEA was significantly greater than RAP after MP + PTA (P less than 0.001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the pre-operative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than pre-operative pressure (P less than 0.001) and the sphincteric high pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA 58 per cent of patients experienced minor faecal leakage (P less than 0.01). These findings suggest that the entire anal canal should be kept intact in the course of conservative proctocolectomy for ulcerative colitis.