Remotely monitored physical activity from older people with cardiac devices associates with physical functioning.

INTRODUCTION: Accelerometer-derived physical activity (PA) from cardiac devices are available via remote monitoring platforms yet rarely reviewed in clinical practice. We aimed to investigate the association between PA and clinical measures of frailty and physical functioning. METHODS: The PATTErn study (A study of Physical Activity paTTerns and major health Events in older people with implantable cardiac devices) enrolled participants aged 60 + undergoing remote cardiac monitoring. Frailty was measured using the Fried criteria and gait speed (m/s), and physical functioning by NYHA class and SF-36 physical functioning score. Activity was reported as mean time active/day across 30-days prior to enrolment (30-day PA). Multivariable regression methods were utilised to estimate associations between PA and frailty/functioning (OR = odds ratio, ß = beta coefficient, CI = confidence intervals). RESULTS: Data were available for 140 participants (median age 73, 70.7% male). Median 30-day PA across the analysis cohort was 134.9 min/day (IQR 60.8-195.9). PA was not significantly associated with Fried frailty status on multivariate analysis, however was associated with gait speed (ß = 0.04, 95% CI 0.01-0.07, p = 0.01) and measures of physical functioning (NYHA class: OR 0.73, 95% CI 0.57-0.92, p = 0.01, SF-36 physical functioning: ß = 4.60, 95% CI 1.38-7.83, p = 0.005). CONCLUSIONS: PA from cardiac devices was associated with physical functioning and gait speed. This highlights the importance of reviewing remote monitoring PA data to identify patients who could benefit from existing interventions. Further research should investigate how to embed this into clinical pathways.

Surgical solutions for refractory J-pouch inlet obstruction.

AIM: Many surgeons consider total proctectomy with ileal pouch-anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients. METHODS: A retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal-pouch anastomosis for J-pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra-operative findings, type of surgical intervention and postoperative outcomes. RESULTS: Surgical interventions were performed on eight patients with J-pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarily anastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow-up of 36.5 months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred. DISCUSSION: J-pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J-pouches being performed, awareness of novel surgical techniques is important.

Postpartum peripheral neuropathy due to vitamin B12 deficiency, potentially precipitated by nitrous oxide use.

Neurological dysfunction which would concern the anaesthetist on labour ward is typically associated with neuraxial blocks. However, an appreciation of other causes is crucial. We present a case of peripheral neuropathy secondary to vitamin B12 deficiency, which highlights the importance of a thorough neurological examination, alongside an understanding of neurological pathophysiology. This is crucial for initiating appropriate referral, subsequent investigations and treatment. Neurological dysfunction secondary to vitamin B12 deficiency may be reversible, following prolonged rehabilitation, so prevention is the best approach, which may require modification of anaesthetic techniques. In addition, at-risk patients should be screened and treated prior to nitrous oxide use, with alternative methods of labour analgesia advised in very high-risk individuals. The incidence of vitamin B12 deficiency may increase in the future potentially linked to a rise in plant-based diets, so this picture may be more commonly seen. Added vigilance by the anaesthetist is imperative.

Relationship of endothelial function and atherosclerosis to treatment response in late-life depression.

OBJECTIVE: Treatment response in late-life depression has been linked to cerebrovascular disease notably via the vascular depression hypothesis. This study investigated the relationship between endothelial function and atherosclerosis and treatment response to antidepressant monotherapy. METHODS: Twenty five patients with late-life depression were compared with 21 non-depressed control subjects in a case control study. Nine of the depressed subjects were responders to antidepressant monotherapy and 16 were not. Vascular measures included assessment of carotid intima media thickness (IMT) representing atherosclerosis and biopsied small artery dilatation to acetylcholine to assess endothelial function in a subset of subjects. RESULTS: There were no group differences in vascular risks or sociodemographic variables. There was a significant group difference (responders versus non-responders versus controls) on both IMT and endothelial function (p < 0.01 and p < 0.05, respectively) with a significant difference between controls and non-responders (p < 0.001) on IMT and between controls and responders (p < 0.05) and control versus non-responders (p < 0.05) on endothelial function but no significant difference between responders and non-responders. On both IMT and endothelial function, there was a gradient across groups, with control subjects having best vascular structure or function, non-responders worse and responders in-between. CONCLUSIONS: The results are consistent with a hypothesis that poorer antidepressant response in later life depressive disorder may be linked to an underlying vascular dysfunction and pathology. The study is small, and the results require replication but if confirmed, trials with vasoprotective medication aimed at improving vascular function in order to alter the prognosis of late-life depression would be a rational development.

Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator.

This is a report of adenocarcinoma arising in an ileal pouch after restorative proctocolectomy (RPC) with rectal mucosal stripping performed by Cavitron Ultrasonic Surgical Aspirator (CUSA) for ulcerative colitis. The CUSA was introduced to simplify and optimize ileal pouch-anal anastomosis with mucosectomy and has been shown to shorten the operative time and reduce blood loss. Its use however, may increase the number of pathology specimens made uninterpretable on account of tissue ablation. In the present case, even though preoperative colonoscopy had clearly shown dysplasia, the surgical pathology report could not detect any neoplasia in the specimen; hence, the patient was not surveyed for pouch cancer. Six years later, the patient presented with intestinal obstruction caused by cancer. While protocols for universal pouch surveillance remain somewhat controversial, we conclude on the basis of this case and a review of the literature that in RPC with mucosectomy performed by CUSA, pouch cancer surveillance is particularly important because remnants of rectal epithelium may have been left behind and tissue ablation may have made the surgical pathology report uninterpretable.

Effect of local therapy for the treatment of superficial esophageal cancer in non-operative candidates.

Surgical resection is the current standard treatment for patients with early stage cancer of the esophagus. In a subset of these patients, comorbidities prohibit the operative risks of a potentially curative esophagectomy. Such patients may be candidates for local endoscopic treatment. We sought to look at a large cohort of patients with clinically localized esophagus cancer to determine whether high-risk patients survive significantly longer after endoscopic therapy than those who receive no local treatment. T0 or T1, N0 esophageal cancer (EC) patients who did not receive surgery or radiation were identified from the Surveillance, Epidemiology, and End Results cancer registry (1998-2003). The patients were assigned into two groups: local endoscopic therapy (excisional biopsy, photodynamic, local destruction, thermal laser, polypectomy, electrocautery, or cryoablation) versus no endoscopic therapy. Differences in survival were calculated using the Kaplan-Meier method, and a multivariate Cox regression analysis adjusting for potential confounders was used to analyze the effect of local therapy on survival. The study cohort included 166 T0 or T1, N0 EC patients. (75% male; 50% >70 years old). Tumors were adenocarcinoma (60%), squamous cell carcinoma (24%), and other (16%). The 4-year disease-specific survival rate was 84% for patients receiving local therapy compared with 64% for patients receiving no therapy (P < 0.01). On multivariate analysis, patients receiving local therapy had a significantly lower hazard of EC-related death (P = 0.04). There was no difference in survival curves for deaths secondary to causes other than EC. Local endoscopic therapy significantly prolonged survival in high-risk patients with clinical T0 or T1, N0 EC and is a reasonable alternative for those patients who are not candidates for potentially curative esophagectomy.

Are consecutive nightly recordings required for valid evaluation of sleep-associated erections?

We questioned the need for more than one RigiScan recording for accurate assessment of sleep-associated penile erections and determine the necessity of consecutive nightly recordings for valid evaluation of sleep-associated erections. Men complaining of erectile dysfunction (ED) and referred to RigiScan evaluation for the first time participated. Recordings were performed at the patient's home during two consecutive nights, and data on test time, number of erections, erection duration, minimal and maximal base and tip tumescence and rigidity were retrieved for both nights. Normal erectile function was defined with the recording of at least one erection (70 out of 100% tip rigidity lasting for at least 10 min during either night). The main outcome measures were RigiScan recordings. Group 1 consisted of 29 men (mean age 42.4+/-13.8 years, range 22-71) who had normal erections, all during the first night. Group 2 consisted of 26 men (mean age 48.6+/-13.5 years, range 25-70) who failed to fulfill both criteria for normal erection. In Group 2, only the values for penile base rigidity and erection duration were normal during the first night: the parameters of maximal base tumescence, tip rigidity, number of effective erections and duration of effective erections that were impaired during the first night were significantly worse (P<0.01) during the second night. The required information for the diagnosis of psychogenic ED was obtained during the first night in >50% of the participants. Men with normal erections during the first night can be spared the inconvenience and cost of re-testing. Consecutive night recording should be reserved for patients whose recorded data during the first night did not fulfill the criteria for normal erection.

Sexual dysfunction in women partners of men with erectile dysfunction.

We evaluated 113 female partners of men with erectile dysfunction (ED) attending a sexual dysfunction clinic in order to define sexual dysfunction among these women. In all, 51 (45%) women denied having any sexual dysfunction. The other 62 (55%) responded to questions classifying their complaint(s) according to the international classification of female sexual dysfunction (FSD) in the following topics (40/62, 65%, reported having more than one problem): decreased sexual desire (n=35, 56%), sexual aversion (none), arousal (n=23, 37%) and orgasmic disorders (n=39, 63%), dyspareunia (n=19, 31%), vaginismus (n=3, 5%), and noncoital sexual pain (none). Many female partners of men with ED report having some form of sexual disorder, mostly orgasmic problems and decreased sexual desire. Therefore, for optimal outcome of ED treatment, evaluation and treatment of male and FSD should be addressed as one unit within the context of the couple, and be incorporated into one clinic of sexual medicine.

An unusual case of a brain abscess arising from an odontogenic infection.

A brain abscess that originates from an odontogenic infection, although rare, can at times be difficult to diagnose, especially in the context of pain and trismus. We report a rare case of odontogenic infection as a result of an infected maxillary third molar, causing an infratemporal and temporalis collection, resulting in a brain abscess with concurrent cerebritis. This is a clinical case review documenting an uncommon but potentially fatal complication.

The use of temozolomide in recurrent malignant gliomas.

Gliomas are the most common primary intracerebral tumours and over 60% of these are malignant. Standard treatment in the UK for patients with a good performance status consists of surgery and postoperative radiotherapy, however, recurrence is almost inevitable. Treatment of recurrent malignant gliomas (MG) is limited to further surgery, chemotherapy and novel biological therapies. The response rate to standard chemotherapy protocols for recurrent MG is less than 30%. Temozolomide (Temodar-US, Temodal-Rest of World) is an oral alkylating agent with a similar chemical structure to dacarbazine, and has recently been licensed in the UK for second line treatment of recurrent MG. Several phase II studies and one randomised trial suggest that Temozolomide improves time to progression and quality of life but not overall survival. The drug is well tolerated with dose limiting myelosuppression and thrombocytopenia occurring in less than 10% of patients at current dosage schedules. A randomised trial comparing Temozolomide with best first line adjuvant chemotherapy (PCV) is about to start recruiting patients. Further clinical studies investigating its role in neoadjuvant treatment or in combination with radiotherapy or other chemotherapeutic approaches are ongoing.

The extra-intestinal complications of Crohn's disease and ulcerative colitis: a study of 700 patients.

The records of a series of 700 patients with inflammatory bowel disease, 498 with Crohn's disease and 202 with ulcerative colitis, have been analyzed to determine the relative incidence and characteristic features of their extra-intestinal manifestations. The group with Crohn's disease included 62 with colitis, 223 with ileocolitis, and 213 with regional enteritis. A consideration of the clinical patterns and an understanding of their pathophysiology suggested a subdivision into two main groups: one "colitis related" and one related to the pathophysiology of the small nonspecific third group. Group A, colitis related, comprises joint, skin, mouth, and eye disease. The complications might be immunologically determined, were closely associated with active inflammation, and often responded to medical or surgical treatment of the underlying bowel disease. They occurred in 36% of the entire series of patients: joints were involved in 23%, skin in 15%, and mouth and eye each in 4%. Pyoderma gangrenosum was observed most often in ulcerative colitis and erythema nodosum most often in granulomatous colitis. The incidence of Group A complications was higher in disease involving the colon (42%) than in disease restricted exclusively to the small bowel (23%). There were interrelationships among the various members of Group A, with multiple manifestations occurring in a third of affected patients. Group B, related to small bowel pathophysiology, includes malabsorption, gallstones, kidney stones, and non-calculous hydronephrosis and hydroureter. Disorders in this group were generally related to the severity of the disease in the small bowel and tended to persist even in the absence of active inflammation. In contrast to Group A, this group occurred most frequently in small bowel disease, and least in colonic disease. Malabsorption was virtually confined to the patients with small bowel disease (10% incidence), while gallstones and renal stones were also both more frequent in Crohn's disease (11% and 9% respectively), the latter usually in association with small bowel resection or ileostomy. Group C, found in a small percentage of patients, consists of nonspecific complications, including osteoporosis (3%), liver disease (5%), peptic ulcer (10%), and amyloidosis (1%).

Amyloidosis and inflammatory bowel disease. A 50-year experience with 25 patients.

Amyloidosis is a rare but serious complication of inflammatory bowel disease (IBD), especially Crohn's disease (CD). It occurred in 15 of our 1709 patients with CD (0.9%) (706 with ileocolitis, 310 with colitis, and 693 with enteritis), but in only 1 of our 1341 patients with ulcerative colitis (UC) (0.07%), admitted to The Mount Sinai Hospital between 1960 and 1985. Eleven of the patients with CD who had amyloidosis had ileocolitis, 2 colitis, and 2 ileitis; these figures represent a frequency within each group of 1.6%, 0.6%, and 0.3%, respectively. Amyloidosis was thus associated 4.4 times more often with CD of the colon than with pure small bowel disease. We have added to this group of 15 patients the 5 cases of CD that were originally reported by Werther et al in 1960, plus another 4 (2 with UC and 2 with CD) who have been seen since 1985, making a total of 25 patients in this series, 22 with CD and 3 with UC. There was a striking male preponderance, 16 of 22, among patients with CD, although 2 of the 3 patients with UC were female. Amyloid disease was diagnosed at a mean age of 40 years, 15 years (range, 1-42) after the onset of CD. Six major forms of amyloidosis occurred: nephropathy, enteropathy, cardiomyopathy, hepatosplenomegaly, thyroid mass, and generalized amyloidosis. Renal disease with proteinurea and/or renal insufficiency occurred in 18 of the 22 patients with CD and in all 3 with UC. Nephropathy was by far the most common lethal manifestation of IBD-associated amyloidosis in this series. Nephrotic syndrome developed in 15 patients with CD and was accompanied by renal failure, the major contributor to mortality, in 10 of the 13 patients who died. Amyloidosis may be associated with suppurative or other extraintestinal manifestations of IBD. Fifteen of the 22 patients with CD who had amyloidosis also had suppurative complications of their bowel disease, although the other 7 had no recognizable suppuration. Extraintestinal manifestations were also common in this series, occurring in 12 of 22 patients with CD and in 2 of the 3 patients with UC; 6 of the 18 patients with nephrotic syndrome also had arthritis. However, there is no evidence that patients with IBD with amyloidosis have extraintestinal manifestations more frequently than do IBD patients without amyloidosis. Earlier reports of amyloid associated with IBD came from autopsy series. In recent years, biopsy has allowed diagnosis to be made during life.(ABSTRACT TRUNCATED AT 400 WORDS)

Rectal cancer and inflammatory bowel disease: natural history and implications for radiation therapy.

PURPOSE: There exists little information concerning the natural history of rectal cancer in patients with inflammatory bowel disease (IBD). In addition, the tolerance of pelvic irradiation in these patients is unknown. We analyzed the largest series of patients with IBD and rectal cancer in order to determine the natural history of the disease as well as the effect and tolerance of pelvic irradiation. METHODS AND MATERIALS: A retrospective analysis of 47 patients with IBD and rectal cancer treated over a 34-year period (1960-1994) was performed. Thirty-five patients had ulcerative colitis and 12 patients had Crohn's disease. There were 31 male patients and 16 female patients. The stage (AJC) distribution was as follows: stage 0 in 5 patients, stage I in 13 patients, stage II in 7 patients, stage III in 13 patients, and stage IV in 9 patients. Surgical resection was performed in 44 patients. In two of these patients, preoperative pelvic irradiation was given followed by surgery. Twenty of these patients underwent postoperative adjuvant therapy (12 were treated with chemotherapy and pelvic irradiation and 8 with chemotherapy alone). Three patients were found to have unresectable disease and were treated with chemotherapy alone (2 patients) or chemotherapy and radiation therapy (RT) (1 patient). Radiation complications were graded using the RTOG acute and late effects scoring criteria. Follow-up ranged from 4 to 250 months (median 24 months). RESULTS: The 5-year actuarial results revealed an overall survival (OS) of 42%, a disease-free survival (DFS) of 43%, a pelvic control rate (PC) of 67% and a freedom from distant failure (FFDF) of 47%. DFS decreased with increasing T stage with a 5-year rate of 86% for patients with Tis-T2 disease compared to 10% for patients with T3-T4 disease (p < 0.0001). The presence of lymph node metastases also resulted in a decrease in DFS with a 5-year rate of 67% for patients with NO disease compared to 0% for patients with N1-N3 disease (p < 0.0001). DFS decreased with increasing histopathologic grade with 5-year DFS rates of 71%, 52%, and 24% for grades 1, 2, and 3 respectively (p = 0.03). The T and N stages showed a statistically significant effect on pelvic control, with 5-year PC rates of 60% for Tis-2 versus 26% for T3-4 (p = 0.002) and 79% for NO versus 51% for N1-3 (p = 0.007). The histopathologic grade of the tumor did not significantly affect pelvic control. An analysis of high-risk patients (30) with T3-T4 or N1-N3 disease revealed at 5 years an OS of 9%, a DFS of 10%, a PC rate of 26%, and FFDF of 20%. In this subset of patients, there was a trend toward improved pelvic control in patients receiving RT (14 patients) with a 5-year PC of 60% compared to a rate of 23% for those patients not irradiated (16 patients). Acute complications (grade 3 or >) were noted in three patients (20%) receiving pelvic irradiation +/- chemotherapy and these included two cases of grade 3 skin reactions and one case of grade 4 gastrointestinal toxicity. Two patients (13%) developed small bowel obstruction at 2 and 4 months, respectively, postirradiation which were managed conservatively. There were no long-term complications in patients irradiated. CONCLUSION: Treatment results are comparable to those historically reported for non-IBD-related rectal cancer although the subset of high-risk patients appeared to have a poorer outcome. In light of this finding and the ability of these patients to tolerate chemotherapy and pelvic irradiation, aggressive adjuvant therapy should be given to IBD-associated rectal cancer patients with high-risk features.

Recurrence of Crohn's disease in end ileostomies.

: It appears well established that the recurrence rates following operations for Crohn's disease of ileum and colon are higher after anastomotic operations than after an end ileostomy. To obtain further information regarding the rate of recurrence following end ileostomy we reviewed the charts of 182 patients: 117 with involvement of the ileum as well as the colon, and 65 with Crohn's colitis only, who were operated upon at the Mt. Sinai Hospital during 1952-1984. They were followed until death or the first ileostomy revision or the last contact. Of the ileocolitis group, 50 patients (43%), and of the colitis group, nine patients (14%) required an ileostomy revision. Of the 50 with ileocolitis, 34 (29%) and four of the colitis group (6.2%) had revisions done primarily for recurrent Crohn's disease at or near the stoma. The estimated overall cumulative probability of recurrence was 50% twenty years following ileostomy, and was significantly higher in the ileocolitis group than in the colitis group (64% vs. 15%; p < 0.001), with mean follow-up durations of 6.5 and 7.5 years, respectively. The probability of ileostomy revision for any reason was also significantly higher for patients with ileocolitis (74% vs. 34%; p < 0.001). We conclude that the site of initial Crohn's disease plays a role in the recurrence of disease in an end ileostomy, with a better outlook for patients with colonic involvement alone.

Rarity of fistulas in Crohn's disease of the jejunum.

: To compare the fistulizing tendency of Crohn's disease of the jejunum versus the ileum, we reviewed the records of 1,920 patients with Crohn's disease admitted to the Mount Sinai Hospital between 1960 and 1994. Fifty-eight of the cases (3%) had jejunal involvement. Of these 58 patients, six (10%) had fistulas originating from the jejunum. Four of the cases of jejunal fistulas came from a subgroup of 41 patients who had both jejunum and distal ileum involvement (10%); by contrast, there were 12 cases of ileal fistulas in the same subgroup (29%, p = 0.05). As another measure of the relative rarity of jejunal versus ileal fistulization, there were 252 cases of ileal fistulas in our overall series among 723 patients with distal ileal Crohn's disease (34%), compared with the 10% (six of 60) incidence of jejunal fistulization (p = 0.001). Only 50% (316) of our cases of jejunal fistulization were spontaneous, compared with 86% of a random sample (43 of 50) from our 252 cases of fistulas with ileitis. The development of jejunal fistulas did not appear to depend upon the presence of stricturing; they were nearly as common among nonstricturing cases (two of 27, 7%) as among stricturing cases (four of 31, 13%; p = NS). The inherent proclivity of Crohn's disease to fistulize thus appears to increase with a progressively distal location in the gastrointestinal tract.

Familial polyposis coli. Management by total colectomy with preservation of continence.

Two cases of familial polyposis coli were managed by total colectomy and endorectal pull-through with excellent long-term results. The performance of a temporary loop ileostomy is advisable to prevent anastomotic complications. In addition, it avoids the excessive diarrhea and perianal excoriation that frequently occur in the early postoperative period until full continence is regained. This is the only method that allows the preservation of rectal function and prevents the occurrence of rectal cancer. It should be considered as a real alternative to either subtotal colectomy and ileorectal anastomosis or total colectomy with construction of an ileostomy.

Surgery for ulcerative colitis in elderly persons: changes in indications for surgery and outcome over time.

HYPOTHESIS: Medical therapy has changed the indications for surgery over the last 4 decades. Advances in perioperative care have significantly improved the outcome. DESIGN: The medical records of all patients 65 years and older who underwent surgery for ulcerative colitis during a 40-year period were analyzed retrospectively. SETTING: Tertiary referral center. PATIENTS: One hundred thirteen consecutive patients 65 years and older who underwent surgery for ulcerative colitis between January 1, 1960, and June 30, 1999. MAIN OUTCOME MEASURES: Changes in elective and urgent indications for surgery. Changes over time in outcome and the factors that brought about these changes. Predictors of poor outcome in an elderly population with ulcerative colitis. RESULTS: One hundred thirteen patients were divided into 3 cohorts of 38, 38, and 37 consecutive patients admitted to the hospital during the periods 1960 through 1984, 1985 through 1993, and 1994 through 1999, respectively. Indications for surgery and morbidity and mortality rates have changed with time. Dysplasia has replaced carcinoma as a major indication for elective surgery (P =.001). Toxic megacolon has become significantly less common as an indication for urgent surgery (P =.001). Surgery-associated adverse outcomes have decreased significantly from 50% (13% deaths, 37% major complications) to 27% (3% deaths, 24% major complications) (P =.04). Male sex, an albumin level of 2.8 g/dL or less, and urgent surgery were found to be independent predictors of poor outcome. CONCLUSIONS: In our referral center, the indications for urgent and elective surgery have changed during the past 4 decades from toxic megacolon and carcinoma, to disease refractory, to medical therapy and dysplasia, respectively. Morbidity and mortality have decreased dramatically over time. Urgent procedures, low levels of albumin, and male sex are all predictors of poor outcome.

Alpha-adrenergic blocker for posthernioplasty urinary retention. Prevention and treatment.

In a prospective, randomized study, 102 patients over the age of 60 years underwent inguinal hernioplasty. We compared a group of 58 patients who received phenoxybenzamine hydrochloride with a control group of 44 patients. The phenolsulfonphthalein test was performed in all patients. Twenty-six (25.5%) of the 102 patients developed acute urinary retention after the hernioplasty; all of them were in the control group. All of these 26 patients had pathological phenolsulfonphthalein test. In 21 of these 26 patients, urinary retention disappeared within 48 hours following phenoxybenzamine administration.

Correlation of presence of granulomas with clinical and immunologic variables in Crohn's disease.

Approximately 50% of patients with Crohn's disease have epithelioid granulomas present in the diseased intestine. Some studies have associated the presence of granulomas with a good prognosis. In this prospective study, 44 patients with Crohn's disease requiring surgery were followed up for five years. Twenty-two patients (50%) had granulomas. Patients with granulomas were younger and had a shorter duration of disease. They also had more extensive disease and a greater degree of peripheral lymphopenia. Follow-up showed a trend toward greater recurrence rate in the patients with granulomas. It seems that patients with aggressive and extensive Crohn's disease are not protected from the development of symptomatic early recurrence by the presence of epithelioid granulomas.

Surgery and its sequelae in Crohn's colitis and ileocolitis.

Indications for surgery, operative procedures, and the early and late sequelae of surgery for Crohn's ileocolitis have been studied in a series of 250 patients admitted to Mount Sinai Hospital, New York, between 1960 and 1975. The most common indications for surgery were small-bowel obstruction in ileocolitis, and medical intractability in Crohn's colitis. Early postoperative complications (within 30 days of surgery) followed 79 operative procedures (15%), and were most commonly wound infections (7%), intra-abdominal abscess (2.6%), and postoperative intestinal obstruction (2.4%). Late sequelae (30 days to 15 years following surgery) included intestinal obstruction in 36 patients, external fistulae in 41 patients, and ileostomy problems in 19 patients, and were most frequently caused by recurrent disease in the terminal portion of the ileum. Mortality following surgery for Crohn's disease may be subdivided into two groups, early and late. All eight early postoperative deaths were secondary to sepsis, present in every instance prior to operation. The eight late deaths were caused by metastatic cancer in six and recurrent disease in two. Resection of excluded segments of bowel, as in four of the patients in this series, will reduce the late cancer risk.