Experience with perirectal fistulas in patients with Crohn's disease

The experience of the senior author has been reviewed in dealing with perianal fistulas in patients with Crohn's disease. Early surgical therapy was advocated, the theory being, that perianal fistulas start as intersphincteric fistulas. This fistula is easily controlled surgically by fistulotomy with partial internal anal sphincterotomy. Delay in surgical treatment, especially in Crohn's patients, results in more complicated fistulas that may require colostomy or proctectomy. The presence of Crohn's disease did not affect the healing of fistulotomy. In our series fistulotomy was the treatment of choice in patients with 26 fistulas; 18 of 19 went on to full healing. We conclude that early fistulotomy, before an intersphincteric fistula has time to blossom fistulotomy, before an intersphincteric fistula has time to blossom into a more difficult management problem, is the treatment of choice in patients with Crohn's disease who have perianal fistulas Read at the XIIth, Biennial Congress of the International Society of University Colon and Rectal Surgeons, Glasgow, Scotland, July 10 to 14, 1988. Work performed at the Orlando Regional Medical Center, Orlando, Florida.     

Treatment of hypertension with felodipine in patients with concomitant diseases

Coexisting medical conditions often complicate the selection of antihypertensive drugs. Felodipine, a new vascular-selective calcium antagonist with demonstrated antihypertensive efficacy, has not been found to alter lipid profiles in hypertensive patients. Studies in additional patient populations have yielded insights into the effects of the drug on other diseases that may coexist with hypertension. In individuals with stable angina pectoris or congestive heart failure, acute administration of felodipine reduces systemic vascular resistance and increases cardicac output and total coronary blood flow; myocardial contractility is not depressed at doses that produce a clinically significant reduction in vascular resistance. In patients with coronary stenoses, the drug increases vessel diameter in the vicinity of obstructive lesions. Single-dose and long-term studies in patients with exertional angian have found that felodipine reduces anginal frequency and improves exercise tolerance. In patients with congestive heart failure, chronic dosing with felodipine produces a persistent reduction in vascular resistance and an increase in cardiac output, both at rest and during exercise. Symptomatic improvement and increased exercise tolerance have been noted in some studies. In patients with Raynaud's phenomenon, felodipine has been assoicated with a dose-dependent improvement in symptomatology. Among individuals with exercise-induced bronchospasm, the drug has no effect on resting bronchial tone and may exert some positive effects during exercise. In hypertensive patients with Type II diabetes, felodipine has not been found to raise glucose levels significantly. The data obtained thus far suggest that felodipine is safe for use in hypertensive patients with a variety of concomitant diseases.     

Cardiovascular considerations with anthracycline use in patients with cancer

Anthracyclines are important chemotherapeutic agents that are used for the treatment of various malignancies in both adults and children, but their usefulness has been limited by cardiotoxicity that is usually dose related. Oxidative injury appears to be the cause of myocardial dysfunction when using these drugs. Screening for early myocardial injury with troponin testing, echocardiography, and radionuclide examinations has reduced the incidence of chronic cardiac dysfunction. Various anthracycline analogues have been developed that have less cardiotoxicity. Dexrazoxane, an iron chelator, and the radioprotective agent amifostine protect against cardiac injury, thus allowing the use of higher doses of anthracyclines. Other strategies that have been evaluated are dietary glutamine supplementation and the use of the antioxidant probucol.     

Prick-prick with fresh foods in patients with latex allergy.

The quick spread of AIDS and other contagious infectious diseases has resulted in what was first voluntary, and subsequently recommended and compulsory, use of protection from contact with blood or bodily fluids. This protection has been especially widespread in the healthcare field. In the in vivo diagnosis of food allergy, it has been proven that the skin prick-prick test is sometimes more sensitive than skin prick test with commercial extracts. The aim of our study was to prove that handling fresh foods prepared for the prick-prick test with latex gloves can tamper with the results in patients with latex allergy. Statistically significant differences were found (p <0.001) between patients and controls in the prick-prick tests against the different foods after handling with latex gloves. No significant differences were found in controls for each prick-prick test for food with or without manipulation with latex gloves. Significant differences were found in the group of patients when performing prick-prick with the different foods before and after manipulation with latex gloves. We also observed that there were significant differences in prick-prick test between patients with latex sensitization and nonsensitized controls, and that the results of prick-prick test varied for each patient depending on whether or not foods had been handled with latex gloves.     

Exploring coronary atherosclerosis with intravascular imaging

Coronary angiography has been widely used for five decades to evaluate a range of vascular pathologies and triage patients to therapeutic interventions. The inability to directly visualize the artery wall with conventional angiographic techniques has stimulated development of a number of intravascular imaging modalities. These approaches have the potential to provide a more comprehensive characterization of the burden, composition and functionality of atherosclerotic plaque, neointimal hyperplasia and allograft vasculopathy that develop within coronary arteries. The ability to use these modalities in vivo and in a serial fashion has provided a greater insight into the factors that underlie the disease process and guide therapeutic interventions.     

Immunomodulation of atherosclerosis with a vaccine

Experimental observations have established that the innate and adaptive immune mechanisms both have roles in the modulation of atherosclerosis. The complex function that the immune system has in the pathophysiology of atherosclerosis is highlighted by the fact that both proatherogenic and atheroprotective effects of immune activation can be demonstrated. An immune response to the protein and lipid components of oxidized LDL cholesterol has been observed in experimental models, and immunization with these antigens has generally reduced atherosclerosis. The findings suggest the tantalizing possibility that an atheroprotective vaccine can be developed. Our laboratories have identified several antigenic epitopes in the human apolipoprotein B100 component of LDL cholesterol. Active immunization with some of these epitopes has reduced atherosclerosis in hyperlipidemic mice. We believe, therefore, that a vaccine based on apolipoprotein B100-related peptide could have a role in reducing atherosclerosis. In this review, we discuss the possible immunologic mechanisms by which vaccines against atherosclerosis might work and the ways in which such treatment might be most effectively administered.     

The adult with a Fontan operation

Since 1971, the Fontan operation has been performed for the repair of single-ventricle physiology. This ingenious operation commits a single ventricle to the systemic circulation and takes advantage of cardiovascular and respiratory physiology to propel deoxygenated blood to the lungs, thus minimizing right-to-left shunting and cyanosis. Initially performed as a right atrial to pulmonary artery anastomosis, the Fontan operation has gone through evolutionary steps that have resulted in progressive improvements in mortality, morbidity, and outcomes. Inclusion of the right atrium in the slow-flowing Fontan circuit results in progressive dilation and incessant arrhythmias. This spurred forth efforts to create modifications that partially or completely exclude the atrium from the Fontan circuit. The transcatheter completion of the Fontan operation has been performed in a small number of patients and we expect minimally invasive, transcatheter, and hybrid interventions to play an important role in the future management of these patients.     

Reduction of proteinuria with angiotensin receptor blockers

Renal pathophysiology is elicited by activation of angiotensin II type 1 (AT(1)) receptors at all stages of renovascular disease. Angiotensin receptor blockers (ARBs) that specifically block the AT(1) receptor offer the potential to prevent or delay progression to end-stage renal disease independently of reductions in blood pressure. Proteinuria--an early and sensitive marker for progressive renal dysfunction--is reduced by ARB use in patients with type 2 diabetic nephropathy and microalbuminuria or macroalbuminuria. Retrospective analysis of data available from early trials has confirmed this finding and has shown that albuminuria reduction is associated with lessening of cardiovascular risk. The ARB telmisartan is equivalent to enalapril in preventing glomerular filtration rate decline, and equivalent to valsartan in reducing proteinuria. Telmisartan is more effective than conventional therapy in lowering the risk of transition to overt nephropathy in hypertensive and normotensive patients. An additive effect has been seen in smaller studies when telmisartan has been added to lisinopril therapy, and high-dose telmisartan reduces albuminuria better than low-dose telmisartan. Similar data were obtained with other ARBs such as candesartan, losartan, valsartan, or irbesartan. These data support the proposition that blockade of the renin-angiotensin system beyond that required for maximum blood pressure reduction provides optimum renal protection.     

Crohn's disease associated with autoimmune neutropenia

We report a 29-year-old woman with a 20-year history of Crohn's disease and neutropenia. Because of repeated complications of Crohn's disease, she has undergone three intestinal resections and also has had recurrent skin abscesses, sinusitis, and pneumonia. Persistent neutropenia has been noted throughout the course of her disease, and antineutrophil antibodies have been detected in her serum and that of her younger brother, who also has Crohn's disease and neutropenia. We discuss autoimmune neutropenia in the context of other autoimmune manifestations of Crohn's disease and speculate as to its possible contributory role in the pathogenesis of Crohn's disease.     

Issues and challenges with antithrombotic therapy in diabetic patients with acute coronary syndromes

Diabetes mellitus is associated with significant morbidity and mortality in the setting of acute coronary syndromes. This increased risk is attributable, in large part, to the derangements in coagulation that can accompany the diabetic disease state. Patients with diabetes mellitus have disturbances in endothelial function, platelet function, and coagulation factors. Until recently, there has been little direct exploration of therapeutic measures to improve outcome specifically among diabetic patients with acute coronary syndromes. Fortunately, antithrombotic therapies that have proven benefit in the general population also seem to be beneficial among patients with diabetes, although optimal dosing for improved safety and efficacy in this population has yet to be established for many of these agents. Primary prevention strategies and strict attention to risk factor modification hold the greatest promise for improving long-term outcome.     

分析老年糖尿病患者应用甘精胰岛素联合阿卡波糖治疗的效果

目的探讨甘精胰岛素联合阿卡波糖在老年糖尿病患者中的临床疗效。方法选取该院2018年7月—2019年7月收治的113例老年糖尿病患者作为研究对象,经随机数字表法,划分A组(n=56,阿卡波糖)和B组(n=57,甘精胰岛素+阿卡波糖),比较两组临床疗效、血糖指标。结果B组患者临床治疗总有效率显著高于A组;经治疗,B组患者空腹血糖(FBG)、餐后2 h血糖(2 hPG)、糖化血红蛋白(HbAlc)水平明显低于A组。两组之间比较差异有统计学意义(P<0.05)。结论在老年糖尿病患者中应用甘精胰岛素+阿卡波糖,临床疗效显著,使患者的空腹血糖、餐后2 h血糖、糖化血红蛋白等指标得到了明显改善,安全性强。     

The Elderly Patient with Asthma

Treatment of the elderly patient who has asthma requires a special orientation on the part of the physician. He must be distinctly aware that asthma in the elderly is no different than asthma in any other age group. There does not appear to be any validity to the observation of different etiologies or different modes of therapy that are applicable to any age group. There are differences in frequency, of course. The pediatric patient is less apt to have occupational asthma and the elderly patient is less apt to have repeated episodes of asthma due to viral infections to which he has developed immunity over the years. Certain pitfalls must be avoided, however.     

Ogilvie's syndrome associated with herpes zoster infection

Acute colonic pseudo-obstruction that occurs in the setting of an underlying medical condition is known as Ogilvie's syndrome. The etiology of Ogilvie's syndrome is unknown, and associated medical illnesses are varied and often extra-abdominal. While herpes zoster infection has been reported to cause constipation and hypomotility, the association with massive colonic distention has not so far been described. We present a patient with Ogilvie's syndrome in the setting of herpes zoster infection. There was no evidence of other active illnesses, and the patient has continued to do well since the resolution of the zoster. We believe that this is the first reported association of Ogilvie's syndrome and herpes zoster infection.     

Engagement with an old theory.

The co-author of Disengagement Theory restates the central propositions, suggests new studies that might test its usefulness, and examines some of the controversy that has been generated over the years either by the theory itself or the context in which it was set forth. The four key propositions focus upon decreasing life space with advancing age, the individual's own anticipation and participation in this process, a change in style of interaction, and the momentum of the disengagement process once it has begun. Although some useful research has been done, the theory remains poorly operationalized and largely untested. A measure of life space variety is proposed, and attention also directed to neuro-physiological findings. Several misunderstandings and misapplications of Disengagement Theory are discussed, including the erroneous idea that disengaged people necessarily are either higher or lower in morale than others, and the unenlightening controversy over "activity versus disengagement."     

Cryoglobulinemia with acronecrosis not associated with hepatitis C infection: a case report

Cryoglobulinemia is a rare disease characterized by the production of monoclonal or polyclonal immunoglobulins that precipitate in cold temperature. While this phenomenon can be observed in a large number of disorders, it has been associated with hepatitis C virus infection in more than 90% of cases. The remaining 10%, called essential cryoglobulinemia, has been characterized by a more severe course and a failure to respond to conventional treatment. This article describes the case of a patient with essential cryoglobulinemia presenting with acronecrosis with a poor outcome, despite treatment, leading to amputation.     

Chronic stress associated with spousal caregiving of patients with Alzheimer's dementia is associated with downregulation of B-lymphocyte GH mRNA

BACKGROUND: It has been demonstrated that growth hormone (GH) is synthesized and secreted by human peripheral mononuclear cells (PBMC), and the expression of GH mRNA can be found throughout the human immune system. METHODS: We studied a population of female caregivers of patients with Alzheimer's dementia (AD) who suffered from the stress of caring for these patients. We utilized quantitative RT-PCR to determine GH mRNA levels in T- and B-cell populations from PBMC. Subjects were nine caregivers of AD patients and nine age- and sex-matched controls. RESULTS: In the control group we found a threefold greater GH mRNA expression in B cells than in T cells. This finding was consistent with our previous in situ hybridization observation, suggesting GH mRNA in predominately B-cell areas of immune organs in humans. We also found that the expression of GH mRNA from total peripheral blood mononuclear cells and B cells in caregivers was 50% and 60% respectively less than that in the control group. CONCLUSIONS: Because the B-cell population is the source of antibody production, our findings suggest that the decrease in B-cell GH mRNA may contribute to the poor immune response to influenza virus vaccination that has been reported previously in chronically stressed caregivers.     

Treatment of hematological malignancies with allogeneic nonmyeloablative stem cell transplantation: conditioning regimens with fludarabine

Allogeneic stem cell transplantation (alloSCT) is an accepted therapeutic option for various hematological malignancies. For many years, alloSCT was based on the concept that a myeloablative dose of chemoradiotherapy was necessary to allow successful donor stem cell engraftment. These high-dose regimens cause considerable toxicity in graft recipients and even the most intensive conditioning regimens do not reliably eliminate all malignant cells. During the last decade, it became clear that the curative potential of alloSCT was not solely due to the conditioning regimen but also to an immune response of donor cells against the malignancy, termed the graft-versus-leukemia (GVL) effect. The increasing evidence that the GVL effect is essential for the eradication of host tumor cells has led to the development of a new concept in alloSCT: the use of reduced intensity, nonmyeloablative conditioning regimens that allow exploitation of the GVL effect without the toxicity of myeloablative therapy. The purine analog fludarabine is immunosuppressive and has activity against many hematological malignancies. The introduction of nonmyeloablative fludarabine-based conditioning regimens has facilitated alloSCT, while limiting regimen-related morbidity and mortality in patients with susceptible hematological malignancies. This potentially curative approach extends the use of alloSCT to older patients and to those with comorbidities that preclude high-dose chemoradiotherapy. The purpose of this review is to summarize the results obtained with fludarabine-based nonmyeloablative conditioning regimens and alloSCT in patients with malignant hematological disorders.     

Radiotherapy with neoadjuvant chemotherapy

Neoadjuvant chemotherapy can be used before radiotherapy to combat microscopic metastatic loci and to facilitate irradiation. Improvement in the survival time by impeding the dissemination of metastases seems to be real for breast cancer, but has not been observed to date in randomized studies of ENT cancers. Neoadjuvant chemotherapy in Hodgkin's disease has improved survival time and tolerance to irradiation, allowing a lowering of the total doses used and the volumes irradiated. In breast and ENT cancers, it has become possible, due to tumor regression, to replace mutilating treatments with more conservative ones consisting of radiotherapy alone, without increasing the risk of local relapse. Indeed, it is in this domain that neoadjuvant chemotherapy is the most useful. Two important conditions must be met for its successful application: a) a sufficiently effective regimen must be chosen, in order to prevent tumor growth prior to irradiation (which would aggravate the prognosis); and b) an accurate identification and localization of the tumor before undertaking any treatment so as to not detract from the effectiveness of the radiotherapy.     

Communicating with patients with inflammatory bowel disease

Ulcerative colitis and Crohn's disease, the two main forms of inflammatory bowel disease (IBD), are chronic illnesses that affect hundreds of thousands of Americans. Patients with IBD suffer chronically from diarrhea, abdominal pain, gastrointestinal bleeding, malabsorption, and weight loss requiring continuous medical and surgical attention. Despite recent advances in therapy, IBD follows a course of exacerbations and remissions with approximately 25-50% of patients relapsing annually. Hence, these diseases are readily encountered in primary care and gastroenterology clinics. Though medical and surgical treatment options have improved significantly, little has been written about the psychosocial aspects of IBD. Currently, there is a paucity of data concerning effective communication methods enabling physicians to develop stronger rapport with patients suffering from IBD, the care of whom requires a multidisciplinary approach involving primary care physicians, gastroenterologists, and colorectal surgeons. Because IBD has a high morbidity, it is worthwhile to further investigate those social factors that will improve patients' quality of life. In this paper, we summarize some of the common problems that emerge when taking care of patients with IBD and provide initial guidelines based on the world literature regarding the management and education of patients with IBD. Both primary care physicians and specialists (gastroenterologists, colorectal surgeons) need to be aware of the questions and concerns of IBD patients and to be capable of dispensing the information in a clear and concise manner. Using the case scenario format, we review the most common aspects of communication for health care professionals taking care of IBD patients and suggest ways to establish and maintain long-term doctor-patient relationships. The two most significant interventions that dramatically improve quality of life and patient-physician relationships are proper patient education and appropriate treatment of concurrent depression and anxiety. We hope that our review will form a framework by which different members of the medical team learn their roles in the complex management decisions affecting IBD patients.     

Experience with Doppler investigations in vibration syndrome

The aim of this study was to examine the possibility of applying Doppler flowmetry in diagnosing vascular changes in workers exposed to vibration. Polish, directional, continuous-wave Doppler apparatus UDP-10, has been used for evaluation of multisegmental blood pressure, velocity flow tracing and for making an ultrasonic "map" of the upper limbs. The thermal test used in this investigation allowed us to distinguish functional and organic alterations in the hand arteries. The present study has been performed in 113 workers, employed in an iron casting company and exposed to vibration. The control group comprised 62 healthy men. Raynaud's phenomenon has been found in 34 workers. It has been confirmed that Doppler equipment is a safe, noninvasive technique, with a high percentage of diagnostic accuracy and is a great aid in establishing the severity of symptoms in patients with vasospastic disease. As a result of our study the diagram for diagnosing patients with vasospastic disease has been elaborated and presented in this work.