Biomedical subjects
Publications and source records attributed to J R Lee.
A consecutive series of 33 grossly obese individuals treated by gastric partitioning is described. There was no operative mortality. Weight loss at one year was 19% of original body weight and little loss occurred thereafter. Radiological assessment of the proximal compartment demonstrated progressive postoperative enlargement.
A satisfactory bowel preparation is essential for adequate double contrast barium enema and colonoscopy. Efficient preparation is also important for reducing the risk of anastomotic dehiscence and sepsis in elective colorectal surgery. Traditional preparation by starvation, purgation and enemas is time consuming, unpleasant for patients, and in our experience results in a satisfactory preparation in only 23% of patients. Elemental diets are inefficient when used for only five days. Whole bowel irrigation with a nasogastric tube enables patients to be in hospital for only one day before operation and provides a satisfactory result in 61% of patients. Whole bowel irrigation is not recommended for stenosing tumours. Irrigation with saline causes sodium and water retention and the use of a balanced electrolyte solution (eg, Ringer's lactate) reduces the risk of these side effects. Oral mannitol has become popular but in our experience results in a satisfactory preparation in only 41% of patients. Mannitol is fermented by E coli to potentially explosive gas mixtures unless oral antimicrobials (neomycin and metronidazole) are used immediately before operation. Polyethylene glycol also causes osmotic catharsis without the risk of explosion. We currently favour nasogastric irrigation with polyethylene glycol and a balanced electrolyte solution, but there is still a place for traditional preparation over five days for patients with stenosing tumours of the left colon.
A retrospective analysis of the effect of oral and intravenous hyoscine N butylbromide (Buscopan) on the dimensions of the large bowel during double contrast barium enema (DCBE) examination was made and compared with corresponding measurements without Buscopan. It was found that 20 mg oral Buscopan did not alter colonic dimensions but 20 mg Buscopan intravenously allowed significantly greater distension of the large bowel. The colonic length was greater after intravenous Buscopan but not to a highly significant degree. It is concluded that Buscopan is not effective when given orally. No side effects have been observed with intravenous Buscopan, even in elderly patients. Buscopan given intravenously seems to be a safe and effective drug for use during DCBE examinations.
Anorectal function has been assessed in 53 patients with Crohn's disease by measurement of resting and squeeze anal canal pressures and the maximum volume tolerated during distension of a balloon in the rectum. Radiographs of the rectum from barium enema examination were also reviewed to assess rectal capacity. Thirty-three patients have had a colectomy and ileorectal anastomosis for Crohn's colitis of whom 13 now have a stoma because they either required a protectomy (n=9) or where closure of a loop ileostomy had not been possible (n=4) because of severe anorectal disease. The maximum tolerated volume was less than 150 ml in 12 of 13 patients who now have a stoma compared with none of the 20 patients who have a functioning anastomosis. Although the correlation between a radiological assessment of rectal capacity and the maximum tolerated volume was poor, a severely contracted rectum was associated with the need for a stoma in six of seven patients compared with only two of 13 patients who did not have radiological signs of a narrow rectum.
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Peroperative frozen sections and cytological material have been obtained in 39 consecutive gastro-oesophageal resections between October 1978 and February 1980. Material from the proximal edge of the resected specimen was unreliable because of 3 false positive cytology results and 1 false positive frozen section report. Frozen section (no errors) was shown to be significantly more accurate than cytology (6 errors) when material was obtained from the distal oesophagus. Fatal anastomotic dehiscence occurred in only 1 of 30 resections when the excision was adequate. Where the results of frozen section were acted upon, in 5 of 9 patients with an inadequate excision, only 1 fatal dehiscence occurred compared with fatal dehiscence in all 4 patients where a second excision was not performed. These results indicate that frozen section of the distal oesophagus should be used to determine the extent of oesophageal resection in operations for gastro-oesophageal cancer.
Three methods of bowel preparation used prior to double contrast barium enemas were compared by a randomised trial in 60 patients. Evaluation was by radiological review and from a patient questionnaire. The preparations included X-Prep liquid with colonic washout, oral mannitol alone and oral mannitol with colonic washout. Adequacy of preparation as judged by faecal residue was significantly better after X-Prep than in either group receiving mannitol. The more severe purgation with mannitol did not result in better clearance of the large bowel and the addition of a colonic washout to mannitol did not reduce faecal residue. Side-effects and adverse comments were more common after mannitol. Diarrhoea was significantly less after X-Prep than after mannitol.
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The records of 1,497 patients with histologically proven adenocarcinoma of the stomach were reviewed from Charity Hospital over the 25-year period, 1948 to 1973. The operability rate was 82% and the resectability rate was 48%. In this series gastric carcinoma predominated in males and Negroes. Necropsy studies indicate a similar frequency of involvement of various organs in patients not operated upon as well as those subjected to a prior operation, which suggests the need for some therapeutic endeavors aimed at a wider base than the primary organ. The five-year survival rate, 7.4 overall, varied from 2.0% after esophagogastrectomy to 22.1% after radical subtotal gastrectomy, and to 30.3% for those with localized disease. One hundred one patients survived five years or more, and 5.4% survived ten years or more after the diagnosis of gastric cancer. Radical subtotal gastrectomy gave the best results in this series, whether measured in terms of median survival, five-year survival, or operative mortality. Esophagogastrectomy and by-pass procedures had high mortality and low survival rates, and should be reserved for special conditions.
Alterations occur in the radiological appearance of the soft tissues after injury to the elbow joint. These are due to displacement of the intra-articular fat pads by capsular distension when an effusion is present. A prospective study of 89 consecutive elbow injuries was undertaken in an attempt to assess the usefulness and reliability of these changes in the diagnosis of minor elbow injuries and the assessment of their clinical progress. In 61 elbows (69 per cent) there was no radiological evidence of an effusion and no evidence of bony injury. All quickly returned to normal. In 28 elbows (31 per cent) radiological evidence of an effusion was present. Twenty-three (80 per cent) of these were also found to have a fracture in, or adjacent to the elbow joint. In 9 elbows the fracture could not be seen on the initial radiographs. Because of the presence of an effusion, repeat radiographs were taken and a fracture discovered. The presence of an effusion was associated with an increase in the time required for full recovery.
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Intraocular lenses were implanted in combination with penetrating keratoplasty in a series of patients followed for up to 2 years. During this period of observation there was little or no evidence that the simultaneous implantation of an intraocular implant adversely affected the corneal graft. Technique and results are described.
Optimal fluoridation has been defined as that fluoride exposure which confers maximal cariostasis with minimal toxicity and its values have been previously determined to be 0.5 to 1 mg per day for infants and 1 to 1.5 mg per day for an average child. Total fluoride ingestion and urine excretion were studied in Marin County, California, children in 1973 before municipal water fluoridation. Results showed fluoride exposure to be higher than anticipated and fulfilled previously accepted criteria for optimal fluoridation. Present and future water fluoridation plans need to be reevaluated in light of total environmental fluoride exposure.
1. The effects of changes in ventilation and/or alveolar P(CO2) on the baroreflex control of heart rate have been studied in seven experiments on six young men and women who had been trained to control tidal volume and respiratory frequency at various levels independent of alveolar P(CO2), during hyperoxia.2. Intravenous phenylephrine provoked transient rises of directly measured arterial pressure during which individual systolic pressures (P) were linearly related to the following pulse interval (I). Baroreflex sensitivity was expressed as the slope of the regression of I on P, and reflex setting (I(ref)) as I at a single reference arterial pressure (= mean P for the experiment).3. Voluntary control of breathing had little effect on heart rate and arterial pressure (baroreflex setting), but diminished reflex sensitivity.4. Hypercapnia regularly caused tachycardia at the reference pressure (i.e. baroreflex setting lowered). The response was completely or partly reproduced by change of P(A, CO2) at constant ventilation in four subjects but not in two others; in them change of ventilation at constant P(A, CO2) completely mimicked the effect of free-breathing hypercapnia.5. Values of baroreflex sensitivity were relatively scattered. Hypercapnia caused a fall in baroreflex sensitivity in three subjects whether ventilation was fixed or free to rise. After separating the effect of voluntarily controlling ventilation, ventilation per se was without effect on reflex sensitivity.6. It is concluded that hypercapnia and hyperpnoea have separate effects on the baroreflex, the relative magnitudes of which differ from one subject to another. Baroreflex setting and sensitivity vary independently in response to change of ventilation and of P(A, CO2).
1. Noradrenaline, dopamine, 5-hydroxytryptamine and 5-hydroxyindoleacetic acid concentrations in the mouse brain were measured 30 min after subcutaneous injection of doses of morphine ranging from 0.1 to 100 mg/kg: motor activity was also measured.2. The noradrenaline concentration in the mouse brain was reduced by moderate (2 to 20 mg/kg) but not by high (above 20 mg/kg) and low (below 2 mg/kg) doses of morphine.3. The dopamine concentration in the mouse brain was reduced by moderate (1 to 20 mg/kg) doses but was raised by high doses (above 20 mg/kg) of morphine.4. The 5-hydroxytryptamine concentration in the mouse brain was reduced by moderate (1 to 20 mg/kg) doses of morphine but not by high (above 20 mg/kg) and low (below 1 mg/kg) doses of morphine.5. The 5-hydroxyindoleacetic acid concentration was not affected by low doses (0.1 to 2 mg/kg), raised by a dose of 5 mg/kg, lowered by doses of 10-50 mg/kg and not affected by 100 mg/kg of morphine.6. These results are discussed with reference to the possible implication of changes in monoamines for the analgesic and behavioural effects of morphine.
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