Muhlenberg Regional Medical Center

The levator syndrome consists of the symptoms of pain, pressure or discomfort in the region of the rectum, sacrum, and coccyx. The patients often have gluteal discomfort and high rectal distress. Sitting may aggravate the disorder. Tenderness upon motion of the coccyx is not an important part of this syndrome. Therefore, the term “coccygodynia” should not be used. The syndrome affects women more frequently than men, and occurs most often in the fourth, fifth and sixth decades of life. Although the symptoms are at times vague, the diagnosis is easily made by those who suspect its presence. Tenderness of the levators is always present and most often unilateral and on the left. Its etiology is unclear. In a significant proportion of patients concomitant anorectal disease such as fissure and hemorrhoids is present. Massage with or without diathermy, hot sitz baths, and muscle relaxants such as diazepam have proven to provide effective treatment, and the recurrence rate after therapy is low.

Lysyl oxidase (LOX), a copper-dependent amine oxidase, has been implicated in tumor suppression and cell growth regulation. The chromosomal locus of LOX, 5q23, is affected by loss of heterozygosity (LOH) in colon cancer, suggesting that the LOX gene could be affected by LOH and consequently, loss or reduction of LOX function contribute to the tumorigenic process. Identification of microsatellite markers within the LOX locus has allowed us to map the LOX gene within the 5q23.1 region. Analysis of this locus and flanking loci in matched tumor and blood DNA samples from a panel of colorectal cancer patients, demonstrated that 38% (16/42) of informative samples were affected by LOH or allelic imbalance. Furthermore, 75% (6/8) of these tumor samples were shown to have significantly reduced LOX mRNA levels. Similar reduction in LOX levels were detected in a panel of matched normal colon and colon tumor samples. Tumor samples demonstrating LOH by RFLP, were subject to mutational analysis, including RT-PCR, exonic deletion detection by PCR, cDNA and genomic DNA sequencing, and were found to have a spectrum of alterations and mutations affecting the LOX gene. These results confirm that loss or reduction of LOX function during tumor development is a direct consequence of somatic mutations and is associated with colon tumor pathogenesis.

Two hundred thirty-two patients with anal abscesses were followed from six months to 13 years after incision and drain-age was done as an office procedure. Most of these (88 per cent) were evaluated more than two years after the onset of their initial disease. One hundred fifty-four (66 per cent) went on to develop fistula-in-ano, while 78 (34 per cent) had no further problem. Our study encourages us to continue to incise and drain these abscesses in the office, reserving hospitalization for those who later develop fistulas.

Two variant spectrins have been described in hereditary elliptocytosis (HE) and pyropoikilocytosis (HPP). Both are characterized by increased susceptibility of the alpha I (N-terminal) 80-kD domain to mild tryptic digestion, yielding peptides of 46-50 or 65-68 kD (T50a and T68 in our terminology). In this report we add a third unstable spectrin alpha I domain found in three kindreds with HE; alpha IT80 in this type of spectrin is cleaved by mild tryptic digestion to a 50-kD peptide (T50b) distinguished from T50a by its more basic isoelectric point. All three spectrins show impaired self-association to form oligomers. Intermediate tryptic peptides of the three unstable alpha I domains from HE spectrins were characterized by monoclonal immunoblotting and I125 limit peptide mapping and affinity purified using polyclonal anti-alpha IT80. Partial amino acid sequences of alpha I domain peptides were obtained from two unrelated patients for each of the three variant spectrins. T50a results from cleavage at arginine 250 or lysine 252 of alpha IT80; a proline replaced the normal leucine or serine at residues 254 and 255, respectively. T50b and a 19-kD peptide result from cleavage at arginine 462 or arginine 464; a proline replaced the normal residue 465 (in T19b) in one of the two patients studied. T68 results from cleavage at arginine 131. In both 68-kD peptides examined, a leucine is inserted at residue 150. The relationship of the sequence changes to the new tryptic cleavages, to the current model of alpha I domain structure, and to defective spectrin self-association is discussed.

Summary There are many technics for treating condyloma acuminatum. None is entirely satisfactory. The viral etiology and the probable venereal transmission make most methods difficult at best. Our method of using bichloracetic acid has given us a more satisfactory cure rate, with a minimum of discomfort, no scarring, and less prolonged convalescence. Future improvement in the management of condyloma acuminatum will depend upon the development of a suitable vaccine based on the positive identification of these growths as specific infectious lesions caused by a virus. Oral or injectable medication would attack the lesion directly, be easier to apply, be less painful, and allow vectors to be treated more easily. However, until such a vaccine is introduced, the clinician will continue to see condyloma acuminatum and will need therapeutic tools that cause few complications and minimum discomfort and have a reasonable degree of success in removing the warts.

Presented is the authors' experience with 182 patients treated primarily by the one-stage primary resection or two-stage resection. (Hartmann operation). One hundred thirty five patients undergoing primary resection had an associated mortality rate of 2.2 per cent. Of 44 patients operated upon using the Hartmann operation for complicated diverticulitis (obstruction, perforation, abscess formation, or fistula formation) the mortality rate was 4.5 per cent. Primary resection in an elective setting is associated with the lowest mortality and morbidity; however, marked inflammation, obstruction and/or peritonitis preclude primary anastomosis. In the urgent setting the staged operation is associated with acceptable morbidity and mortality.

Intraspinal air: a CT finding of epidural abscessH Kirzner, YK Oh and SH LeeAudio Available | Share

The use of a Dacron-reinforced Silastic graft in the perineal repair of rectal procidentia offers a simple technique for elderly and debilitated patients. Experience with this procedure in nine patients, followed for two years, indicates that this elastic material appears to have substantial advantages over wire or synthetic mesh in the perineal repair of rectal procidentia.

OBJECTIVE: To determine in adult medical patients the incidence of deep venous thrombosis (DVT) resulting from femoral venous catheterization (FVC). METHODS: A prospective, observational study was performed at a 420-bed community teaching hospital. Heparin-coated 7-FR cm femoral venous catheters were inserted unilaterally into a femoral vein. Each contralateral leg served as a control site. Age, gender, number of FVC days, DVT risk factors, administration of DVT prophylaxis, and DVT formation and site were tabulated for each patient. Venous duplex sonography was performed bilaterally on each patient within 7 days of femoral venous catheter removal. RESULTS: Catheters were placed in 29 men and 13 women. Femoral DVT was identified by venous duplex sonography in 11 (26.2%) of the FVC legs and none (0%) in the control legs. Posterior tibial and popliteal DVT was identified in both the FVC and control legs of 1 patient. DVT formation at the site of FVC insertion was highly significant (p = 0.005). There were no statistically significant associations with age (p = 0.42), gender (p = 0.73), number of DVT risk factors (p = 0.17), number of FVC days (p = 0.89), or DVT prophylaxis (p = 0.99). CONCLUSION: Placement of femoral catheters for central venous access is associated with a significant incidence of femoral DVT as detected by venous duplex sonography criteria at the site of femoral venous catheter placement. Physicians must be aware of this risk when choosing this vascular access route for adult medical patients. Further studies to assess the relative risk for DVT anf its clinical sequelae when using the femoral vs other central venous catheter routes are indicated.

BACKGROUND: Some forms of gastric intestinal metaplasia (GIM) may be precancerous but the cellular phenotype that predisposes to gastric carcinogenesis is not well characterised. Mucin staining, as a means of differentiating GIM, is difficult. A monoclonal antibody, mAb Das-1 (initially called 7E(12)H(12)), whose staining is phenotypically specific to colon epithelium, was used to investigate this issue. METHODS: Using mAb Das-1, by a sensitive immunoperoxidase assay, we examined histologically confirmed GIM specimens from two countries, the USA and Japan. A total of 150 patients comprised three groups: group A, GIM (fields away from the cancer area) from patients with gastric carcinoma (n=60); group B, GIM with chronic gastritis (without gastric carcinoma) (n=72); and group C, chronic gastritis without GIM (n=18). RESULTS: Fifty six of 60 (93%) patients with GIM (both goblet and non-goblet metaplastic cells) from group A reacted intensely with mAb Das-1. Cancer areas from the same 56 patients also reacted. In contrast, 25/72 (35%) samples of GIM from patients in group B reacted with mAb Das-1 (group A v B, p<0.0001). None of the samples from group C reacted with the mAb. CONCLUSIONS: Reactivity of mAb Das-1 is clinically useful to simplify and differentiate the phenotypes of GIM. The colonic phenotype of GIM, as identified by mAb Das-1, is strongly associated with gastric carcinoma.

Seven patients with necrotizing soft tissue infections of the perineum are described. Predisposing factors related to infection were present in four patients (diabetes mellitus, multiple myeloma, HIV, and a poorly defined immunodeficiency syndrome). Anaerobic and facultative anaerobic bacteria were cultured in each case. Two patients required skin graft closure of the debrided wounds, with the remaining wounds closed by contracture and epithelialization. A diverting sigmoid colostomy to facilitate wound care was performed on one patient who had complete dissolution of all anal sphincters. The role of hyperbaric oxygen therapy in four patients was of uncertain value.

A procedure for the outpatient management of acute hemorrhoidal disease is presented. Treatment, using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (2) decrease edema, (3) treat appropriately the internal hemorrhoidal disease, and (4) treat the external thrombosis if present. Adequate treatment of the acute disease will, in a significant proportion of patients, avoid further surgical intervention. Eperience with results of this modality of treatment in patients is presented.

Summary The Hartmann procedure would appear to offer many advantages and few disadvantages in treating those cases of sigmoid diverticulitis complicated by obstruction or pelvic or intraperitoneal abscesses, with or without perforation and diffuse peritonitis.

OBJECTIVE: To test an alternative flexible approach to traditional fixed intermediate and intensive care to minimize transfers of patients. METHODS: Patients admitted to a 28-bed nursing unit with intermediate care potential and a 12-bed intensive care unit at a 300-bed teaching community hospital were studied. The group included 524 patients with a discharge diagnosis code for mechanical ventilation. During eight 3-week cycles, 1073 transfers of patients were tabulated. A plan-do-study-act method was used to improve weaning from mechanical ventilation and reduce the number of inappropriate days in intensive care. Admissions and transfers to the 2 units for all patients during the eight 3-week cycles were compared over time. Length of stay and mortality were noted for all patients treated with conventional and noninvasive ventilation. RESULTS: Direct admissions to the flexible intermediate unit increased with no overall change in admissions to the intensive care unit. Fewer patients needed conventional ventilation, and more in both units were treated with noninvasive ventilation. The median number of transfers per patient treated with mechanical ventilation decreased from 1.94 to 1.20. Length of stay and mortality also decreased among such patients. Some cost savings were attributable to the decrease in the number of transfers. Transfers out of the hospital directly from the intensive care unit increased from 2.24% to 4.43%. CONCLUSIONS: In a community teaching hospital, flexible care policies decreased the number of in-hospital transfers of patients treated with mechanical ventilation.

Summary Two cases of massive hemorrhage from colonic diverticula are reported in which an eroded artery has been demonstrated as the source of bleeding. Eight previously reported cases have been reviewed. Diverticula of the ascending colon and cecum appear to have a predilection for arterial rupture and subsequent massive bleeding. The importance is stressed of bowel sterilization in patients with massive gastrointestinal hemorrhage in whom surgery is anticipated. The value of multiple colotomies and segmental clamping of the colon while attempting to determine the site of hemorrhage, as described by Maynard and Voorhees, is emphasized. The following theory of the causation of arterial erosion in diverticulosis is advanced: The diverticula grow larger, as they become filled by feces or fecaliths, and impinge on the adjacent artery. When this occurs, pulsations of the artery against the diverticulum filled by the unyielding fecal mass causes pressure necrosis of the intervening walls of the artery and the diverticulum, with resultant hemorrhage into an apparently uninflamed diverticulum.

UNLABELLED: The ECG is a 12-lead-vector system and is known to contain redundant information. Factor analysis (FA) is a statistical technique that improves measured data and eliminates redundancy by identifying a minimum number of factors accounting for variance in the data set. OBJECTIVE: To identify the minimum number of lead-vectors required to predict the 12-lead ECG. METHODS: A total of 104 ECGs were obtained from 24 normal men, 22 normal women, and 28 men and 30 women with variable pathologies. Each ECG lead was simultaneously acquired and digitized, resulting in a voltage-time data array stored for mathematical analysis. Each array was factor-analyzed to identify the minimum number of lead-vectors spanning the ECG data space. The 12-lead ECG was then predicted from this minimum lead-vector set. ANOVA was used to test for statistical significance between normal and pathologic data groups. RESULTS: FA revealed that 3 lead-vectors accounted for 99.12%+/-0.92% (95% CI+/-0.18%) of the variance contained in the 12-lead ECG voltage-time data for all 104 cases. There were no statistically significant differences between men and women (99.25%+/-0.66% vs 98.98+/-1.11%; p=0.139). Statistically significant differences were noted between normal and acute myocardial infarction ECGs (99.5%+/-0.27% vs 98.66+/-1.25%; p=0.00003). The measured and predicted leads were almost identical. A 3-dimensional spatial ECG derived from the 3-lead-vector set resulted in variable curved surfaces that differed by pathology. CONCLUSIONS: The 12-lead ECG can be derived from only 3 measured leads and graphed as a 3-D spatial ECG. This type of data processing may lead to instantaneous acquisition and may enhance the diagnostic capability of the ECG from routine bedside telemetry equipment.

Multidisciplinary teams are different from the traditional team format in that representation and participation from various disciplines characterize the structure. In April 1996, a multidisciplinary group from Muhlenberg Regional Medical Center's intensive care unit learned methodology at the Institute for Health Care Improvement (IHI) Breakthrough Series in Adult Intensive Care. With the format learned, improvements in diverse areas such as ventilator management, intermediate care, clinical laboratory utilization, and others were accomplished. Continued support from an expert staff and utilization of on-line communication tools characterized this 15-month quality improvement endeavor. The end of the breakthrough series spurred the development of a hospital-wide collaborative cost containment team.

Conclusion A case report of a tubular duplication of the distal ileum and entire colon with no connection to the parent organ is presented. The diagnosis was confused, making surgical management difficult. Technical aspects of the operative procedure are discussed. © The ASCRS 1971

The present study evaluated the Ventrescreen Mono enzyme immunoassay (Ventrex Laboratories) and Monolatex (Wampole Laboratories) for detection of infectious mononucleosis-specific heterophil antibodies by comparing test results on sera of 247 symptomatic patients. The purpose of this study was to compare not only the two different test systems but also the two different methods they represent for accuracy in detecting infectious mononucleosis-specific heterophil antibodies. Discrepancies in the test results of the two kits were arbitrated by determining the Epstein-Barr virus antibody profiles of the samples. The study showed that the Ventrescreen Mono enzyme immunoassay is as good as the Monolatex test for detecting heterophil antibodies. After discrepancies were resolved, the sensitivity and specificity of the Ventrescreen assay were 100 and 98%, respectively.

A redesigned admitting procedure includes simplifying and compressing all processes that occur during the first 24 hours after admission. Centralizing admissions procedures resulted in reducing actual admitting time to 80 minutes. Decreased length of stay is indicated as a probable result of the redesign.