Biomedical subjects
Publications and source records attributed to G D Dunn.
An elderly woman with a history of cholelithiasis was seen for right upper quadrant pain and jaundice. During her evaluation, she was found to have extensive choledocholithiasis and a cholecystoduodenal fistula. Successful management was accomplished with cholecystectomy, removal of the common bile duct stones, and by creating a choledochoduodenostomy where the fistula had been present.
A 54-year-old woman with multiple abdominal operations including cholecystectomy and partial small bowel resection was admitted to the hospital because of pain in the right upper quadrant. Multiple common bile duct stones-the largest one measuring approximately 2 cm-were seen during endoscopic retrograde cholangiogram. The patient was successfully treated with endoscopic sphincterotomy and placement of a nasobiliary catheter for intracholedochal irrigation with a saline solution.
Endoscopic sclerotherapy is used to obliterate esophageal varices in an attempt to decrease bleeding episodes. First reported in the 1940s, sclerotherapy has recently enjoyed renewed interest because surgical shunting procedures, though effective in preventing rebleeding, are associated with significant mortality and provide no increase in long-term survival. Sclerotherapy, using a flexible endoscope, has been used in 30 patients at Vanderbilt University and the VA Medical Center, Nashville, Tenn. We present our clinical experience, compare our results with those of other groups, and discuss other approaches to the management of bleeding varices.
We have reported two cases of double pylorus or duplicated pyloric channel as an unusual complication of peptic ulcer disease. It is usually noted as an incidental finding on x-ray films or at endoscopy. Double pylorus seems to be an acquired lesion arising from gastric ulceration and does not necessarily require surgical correction.
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The pleuropulmonary complications of pancreatitis are protean. The subject of pancreatic pleural effusions has received avid attention in the recent literature with the demonstration of pancreaticopleural fistulization by endoscopic retrograde cholangiopancreatography. Surgical intervention has been efficacious when nonoperative management has failed. We report the successful nonoperative management of a case of alcohol-related pancreatitis complicated by bilateral pleural effusions, and then review the literature.
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Essential fatty acid (EFA) deficiency has become a clinical problem since the advent of fat-free total parenteral nutrition (TPN). The following study was done to determine the minimum fat requirements for patients receiving continuous TPN solution. Seventy-seven patients who had 97 courses of TPN of at least 14 days duration were prospectively studied. The following fat supplementation was given: a) none, b) 10% soybean oil emulsion intravenously at fixed dosage, c) fat from an oral diet, or d) intravenous and oral fat. No patient was EFA deficient before the onset of TPN. EFA deficiency was prevented when at least 3.2% of total calories were given as intravenous fat or at least 15% as oral fat. Lesser amounts of fat decreased the rate of EFA deficiency development but did not prevent it from occurring. The 7.7 g/day of linoleic acid provided in 1000 ml per week of 10% soybean oil emulsion provides adequate fat to prevent EFA deficiency.
The phospholipid fatty acid composition of erythrocytes from patients with cystic fibrosis with pancreatic insufficiency, patients with cystic fibrosis with normal pancreatic enzyme function, and normal subjects was determined. Increased percentages of palmitoleic acid and total eicosatrienoic acid and a decreased percentage of linoleic acid were observed only in the cystic fibrosis patients with pancreatic insufficiency.
The effects of caffeine (250 mg orally) on plasma free fatty acids (FFA), urinary catecholamines, and drug binding were studied in 16 normal subjects (six men, five women on oral contraceptives, and five women not on oral contraceptives). FFA doubled 1 hr after caffeine, and remained elevated for at least 4 hr. with elevation of each FFA. Urinary excretion of epinephrine and dopamine increased (p<0.05) in the first 2 hr. returning to baseline in the next 2 hr. Plasma binding of chlordiazepoxide, diaxepam, and propranolol was estimated in each of the hourly plasma samples after caffeine; there was no change in percent unbound drug in any of the samples. In vitro addition of oleic acid to plasma samples of four subjects caused a step-wise increase in percent unbound fraction of all three drugs whereas in vitro addition of caffeine did not further alter drug binding. In our study circulating plasma FFA and urinary catecholamine levels were elevated after caffeine ingestion. In spite of a rise in FFA, there was, however, no change in plasma binding of chlordiazepoxide, diazepam, or propranolol.
The effectiveness and safety of the use of cimetidine as an adjunct to pancreatic enzymes was evaluated in eight patients with cystic fibrosis having pancreatic insufficiency. Cimetidine (300 mg, three times a day) was given for a 6-week period during which the patients demonstrated a significant weight gain (P < 0.05) and reduction of steatorrhea (P < 0.01). Data suggesting an early correction of the abnormal fatty acid composition of plasma lipids were observed. No side effects were apparent during the clinical trial. These results demonstrate the beneficial effects of the use of cimetidine in patients with cystic fibrosis and indicate the need for long-term clinical trials.
1 The effect of intravenous administration of 100 units of heparin on plasma of diazepam, chlordiazepoxide, oxazepam and lorazepam was examined in fourteen normal subjects and five patients with cirrhosis. 2 In normal non-fasted subjects heparin caused a rapid 150--250% rise in the free fraction of diazepam, chlordiazepoxide and oxazepam but no change of lorazepam. The changes in free fraction were slightly smaller, but still significant, when the subjects were fasted. 3 These change in free fraction occurred within 90 s of administration of heparin and binding had returned to baseline by 30 to 45 min. 4 In the cirrhotic subjects the response to heparin was variable. 5 The use of heparin during drug disposition studies may affect the estimation of pharmacokinetic parameters and possibly pharmacological effects which are dependent on the circulating unbound drug level.
The feeding of cholesterol-rich diets alters the serum lipoproteins of a number of mammalian species. These lipoproteins are characterized by the presence of several classes of particles enriched in cholesteryl esters and apolipoprotein E (apo E). It was the aim of this study to determine whether one or more of these particles arises by de novo hepatic synthesis by characterizing nascent lipoproteins isolated from the hepatic Golgi apparatus of hypercholesterolemic rats. Characterization of these lipoproteins afforded the opportunity to assess morphologic, biochemical, and biophysical properties of newly synthesized lipoproteins before enzymatic alterations and apoprotein transfer known to occur after secretion into the plasma compartment. Golgi very low density lipoproteins (VLDL, d < 1.006 g/ml) from hypercholesterolemic rats contained nearly four times the total cholesterol mass found in control Golgi VLDL. They exhibited electrophoretic mobility intermediate between beta and pre-beta and were devoid of apo C. A second population of hepatic Golgi lipoproteins was isolated from hypercholesterolemic rats at 1.006--1.040 g/ml d. These low density lipoproteins were smaller than VLDL, displayed beta electrophoretic mobility, were enriched in cholesteryl esters, and contained apo E as well as apo B. The fatty acid composition of the core lipids of the nascent lipoproteins was found to reflect that of dietary triglyceride. The liver of the hypercholesterolemic rat thus plays an active role in dietary-induced hypercholesterolemia by synthesizing a modified VLDL and a low density lipoprotein resembling serum low density lipoprotein.
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Detailed aerobic and anaerobic bacteriological studies on the operative specimen from a patient with antibiotic-associated pseudomembranous colitis revealed approximately 10(11) facultatively anaerobic bacteria, but less than 10(5) obligate anaerobes per g of involved colonic tissue. Fourteen isolates of Escherichia coli, three isolates of Pseudomonas aeruginosa, and two isolates of Streptococcus fecalis were identified. The majority of the organisms were resistant to most of the antibiotics that the patient had received. Examinations of E. coli for heat-labile and heat-stable enterotoxins and tissue invasiveness were negative, and enterotoxin tests on the P. aeruginosa isolates were negative. Inoculation of mice with the bacterial isolates revealed no unusual pathogenicity. These findings suggest that antibiotic-associated colitis is associated with a marked loss in anaerobic colonic flora, but the colitis could not be explained by the presence of enterotoxins, tissue invasiveness, and pathogenicity of remaining microorganisms.