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August 1980, Volume 30, Issue 8

Special Communication

Selected Abstracts

Patients\' Reactions to Their Investigations. C. Hawkins (Queen Elizabeth Hosp, Birmingham, England) Br. Med. T- 2:638-640 (Sept. 15) 1979.
Five hundred four patients who had had hospital examinations were interviewed to find out how much information they had been given about the tests; their reactions before, during, and after the test; and any after effects. In 74% of cases the tests had been satisfactorily explained. Patients were told more about complicated procedures, such as cardiac catheterization, than about routine ones, such as venepuncture or barium meal examinations. The comments physicians made while performing the examinations were generally reassuring. About one half of the patients had pain or discomfort during the tests, and more complained of after effects. Only 5% said they would refuse the test again, though 36% said they would agree reluctantly. Hospitals might consider issuing information sheets to support the physician\'s explanation and to dispel myths.
Localization of Gastrinomas by Transhepatic Portal Catheterization and Gastrin Assay. F. Burcharth et al (Herlev Hosp, Herlev Copenhagen, Denmark) Gastroenterology 77:444-450 (Sept.) 1979.
Gastrinomas were localized by concurrent blood sampling in the hepatic vein and portal vein tributaries in ten of 12 patients with Zollinger-EIlison syndrome. Six patients were subsequently operated on: five had pancreatoduodenal resection and one had laparotomy at which metastases were found. Four of the resections were probably curative as the patients have done well without treatment since surgery, with concentrations of gastrin in serum near zero. The observation period ranged from 17 to 20 months. The transhepatic catheterization of the hepatic vein and portal vein tributaries with blood sampling for gastrin determination permits the verification of the diagnosis of Zollinger-EIlison syndrome and the localization of the gastrinomas.
Chronic-Persistent Hepatitis and Pregnancy. D.S. Infeld et al (R.R. Varma, Milwaukee County General Hosp, Milwaukee, WI 53226) Gastroenterology 77:524-527 (Sept.) 1979.
The course and possible risks of pregnancy were evaluated in seven women, aged 20 to 30 years, who had chronic-persistent hepatitis (CPH). Ten pregnancies occurred during the follow-up period.  Four of the fetuses were aborted electively for nonmedical reasons. The other six pregnancies resulted in normal spontaneous vaginal deliveries at term. Each of the women experienced uneventful prenatal and postnatal courses, and the neonates were all healthy and normally developed at birth. There was no biochemical or clinical evidence to suggest worsening liver disease during pregnancy. Normal menstrual patterns when not pregnancy and normal biphasic basal body temperature patterns in four women suggested that ovulation and fertility were not impaired significantly. Pregnancy in women with CPH seems safe for both mother and fetus alike.
The Effects of Pentagastrin in Achalasia and Diffuse Esophageal Spasm. R.C. Orlando (Univ of North Carolina at Chapel Hill, Chapel Hill, NC 27514) and E.M. Bozymski. Gastroenterology 77:472-477 (Sept.) 1979.
The effects of subcutaneous pentagastrin (6 ug/kg) on esophageal motility were recorded in patients with achalasia, in patients with idiopathic diffuse esophageal spasm (IDES), and in healthy subjects. In achalasia and IDEA, pentagastrin produced an increase in mean lower esophageal sphincter pressure, amplitude of contractions, esophageal pressure, and repetitive wave activity. Also, chest pain or dysphagia occurred after pentagastrin administration in four of nine patients with IDES and in seven of 12 patients with achalasia. After comparing these obs rvations with those of healthy subjects, the authors tested the potential for pentagastrin-induced motility changes to improve ability to diagnose IDES by administering pentagastrin to 22 patients with clinically suspected esophageal motor disease but in whom routine radiological and manometric studies were nondiagnostic. In none of the 22 did symptoms or manometric changes develop to help establish the diagnosis of IDES. This was true despite addiional studies in ten patients that failed to provide an alternative to IDES as the diagnosis.
Autonomic Nervous System Disturbance in Patients on Chronic Hemodialysis. C. Bach et al (Chaim Sheba Medical Center, Tel-Hashomer, Israel) Isr J Med Sci 15:761-764 (Sept.) 1979.
To demonstrate autonomic nervous system (ANS) disturbances in patients receiving long-term intermittent hemodialysis, simple noninvasive tests were used. These included the Valsalva maneuver ratio, measurement of the changes in blood pressure and pulse rate after standing up from the supine position, the finger-immersion test, and calculating the R-R interval ratio of the 30th to the 15th beat on the ECG after standing. In all the patients who were compared with normal volunteers, some ANS disturbances were present, as evidenced by at least three positive tests of the five described. The Valsalva maneuver ratio was positive in only 58% of the cases.
Lithium-Induced Nephrogenic Diabetes Insipidus. J. Rapoport et al (Rambam Univ. Technion Institute of Technology, Haifa, Israel) Isr J Med Sci 15:765-771 (Sept.) 1979.
In a patient with lithium-induced nephrogenic diabetes insipidus, in whom detailea in­vestigations of distal tubular function were performed, clearance of free water during water diuresis was found to be augmented. This suggests proximal suppression of sodium reabsorption by lithium. Reaosorption of free water during high solute clearance was impaired. Acidification of the urine after ammonium chloride loading was abnormal, and this was corrected by sodium sulfate infusion. The cellular mechanism of lithium was studied by means of indomethacin, an inhibitor of prostaglandin synthesis. That indomethacin caused a partial reversal of the nephrogenic diabetes insipidus suggested that the primary cellular action of lithium may be to inhibit the formation of cyclic AMP in the collecting duct cell, although a direct action of indomethacin in increasing solutes in the renal medulla could not be ruled out. The lithium-induced polyuria may be due partially to an enhancement by lithium of renal prostaglandin action.
Esophageal Replacement in Children.Wolfstein et al (Chaim Shaba Medical Center, Tel-Hashomer, Israel) Isr J Med Sci 15:742-745 (Sept.) 1979.
Esophageal replacement continues to be a challenging surgical problem. Currently advocated methods entail using reversed gastric tube or colon for the interposition. Between 1969 and 1978, 11 children, aged 1 to 16 years, underwent esophageal reconstruction. All the operations were performed in one stage. The right-sided colon was used in seven children and reversed gastric tube was used in four. Temporary salivary fistula and cervical anastomotic stricture were the most common operation-related complications. On the follow-up visit, at least six months after surgery, all of the children were able to eat a normal diet. The use of reversed gastric tube avoids intestinal resection, preserves the ileocecal valve, shortens the operative period, and preserves the possibility of an alternative procedure (colon interposition) if technical failure occurs. On the basis of this limited experience the authors advocate the use of reversed gastric tube for esophageal replacement.
Does the Nephrotic Syndrome Increase the Risk of Cardiovascular Disease? V.J. Wass et al (Guy\'s Hosp. London, England) Lancet 2:664-667 (Sept. 29) 1979.
Cardiovascular mortality and morbidity were assessed, after a mean follow-up period of five years, in an unselected series of 159 adults who had the nephrotic syndrome between 1972 and 1975. Sixty percent of the deaths were attributed to terminal renal failure, and the incidence of deaths from ischemic heart disease (IHD) was not significantly above normal. The proportion of patients experiencing angina and intermittent claudication and the prevalence of ischemic ECG changes did not differ significantly from those of a London control population. At follow-up, hypertension was significantly more common in male nephrotic patients than in control subjects. Earlier reports of a greatly increased incidence of IHD in unselected patients with the nephrotic syndrome were not confirmed. Routine treatment of hyperlipidemia in the nephrotic syndrome is not recommended.
Glomerulonephritis. K. Rebaiz et al (Groupe Hospitalier Pitie-Salpetriere, Paris, France) Nouv Presse Med 8-2801-2805 (Sept. 17) 1979.
The value of the immunologic tests performed routinely was evaluated in 91 patients with various histological types of glomerulonephritis. An antigen possibly involved in the pathogeny of renal disease was found in 24% of cases. However, in most instances no direct link between the presence of this antigen and the disease could be observed. Systematic examination for antigens should be restricted to dosages of antistreptolysin and antinuclear antibodies and to determination of Hbs antigen. Immune complexes, which were observed in many cases, were of no discriminant value for the clinician. Dosages of the complement fractions and the determination of cryoglobulins can be helpful for diagnosis, follow-up, and treatment. These results justify a restricted use of routine immunological tests in patients with glomerulonephritis.
Cholesterol Homeostasis in the Rat With a Portacaval Anastomosis. A. Prolia et al (E.H. Ahrens, Jr. Rockefeller Univ, Memorial Sloan-Kettering Cancer Center, New York, NY 10021) Proc CNati Acad Sci USA 76:4654-4657 (Sept.) 1979.
Studies were undertaken to determine the effect of portacaval anastomosis on cholesterol homeostasis in rats fed sucrose-lard under conditions of normal body growth. Four to six weeks after portacaval shunt surgery, decreases were found in plasma cholesterol and triglyceride concentrations, total liver weight, and hepatic microsomal protein concentration. Measurements of hepatic 3-hydroxy-3-methylglutary-coenzyme A reductase activity showed decreases in specific activity and total liver activity in rats with portacaval shunt, but the enzyme diurnal rhythm remained. Sterol balance measurements showed a 22% decrease in whole body cholesterol synthesis rate compared with control rats. These metabolic studies, coupled with postmortem data, showed diminished bile acid synthesis, unchanged fecal neutral steroid excretion, and decreased net tissue accumulation of cholesterol during growth. The decreased whole body cholesterol synthesis rate ultimately led to a diminished total carcass cholesterol concentration in the rats with shunts.
Chronic Subdural Hematoma Presenting as Transient Neurologic Deficits. J.E. Welsh et al (Dept. of Neurosurgery, Univ. of Virginia, Charlottesville, VA 22908) Stroke 10:564-567 (Sept.-Oct.) 1979.
Four patients with symptoms of transient neurological dysfunction were found to have chronic subdural hematomas. The frequency of these episodes diminished substantially after evacuation of the hematoma. The effects of vascular compromise caused by the chronic subdural hematoma and to cardiovascular events, more commonly implicated in transient ischemic attacks (TIAs), may be additive. The inclusion of computerized axial tomographic scan in examination of some patients with presumed TIAs is recommended.

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