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Chlamydial infections.
Infections due to Chlamydia are exceedingly important and common in emergency medicine, perhaps more so than any other single infectious agent. Recent studies have documented Chlamydia as a major cause of such commonly seen entities as urethritis, epididymitis, cervicitis, conjunctivitis, and neonatal pneumonia. Because clinical diagnosis and treatment is usually straightforward, and the already tremendous incidence of these "outpatient" infections is certain to increase, emergency physicians must become familiar with their diagnosis and management.
[Solitary rectal ulcer inflammation, infection, ischemia or motor disorder?].
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Probability of late rectal morbidity in 125I prostate brachytherapy.
PURPOSE: Rectal toxicity is a concern in prostate brachytherapy because it is difficult to avoid delivering a dose equal to, or greater than, the prescription dose to the anterior surface of the rectum. The purpose of this study was to define the probability that a patient will experience Grade 2 (bleeding/ulceration) late rectal morbidity after 125I prostate brachytherapy according to the rectal dosimetry. METHODS AND MATERIALS: Ninety-eight consecutive patients who received monotherapy 125I prostate implants for treatment of Stage T1-T2, favorable-risk adenocarcinoma of the prostate were evaluated for Radiation Therapy Oncology Group Grade 2 late rectal morbidity. All reported incidences of late morbidity were retrospectively confirmed by colonoscopy. All patients had at least 15 months follow-up after implantation. The median follow-up was 32 months (range 15-54). The rectal dosimetry was based on a CT scan obtained at 3-9 weeks after implantation. The rectum was contoured on each CT image between the base and apex of the prostate. A dose-surface histogram was compiled for each implant, and the relative surface area that received a dose > or =100, > or =150, > or =200, > or =300, > or =400, and > or =500 Gy was recorded. The probability of developing late rectal toxicity was calculated by logistic regression analysis as a function of dose and the percentage of the rectal surface that received that dose. RESULTS: Of the 98 patients, 10 developed Grade 2 late rectal morbidity. The percentage of the rectal surface that received 100, 150, 200, and 300 Gy was significantly greater (p < or =0.02) for patients who experienced late rectal morbidity. The probability of late rectal morbidity increased with both the dose and the percentage of the rectal surface that received that dose. The probability was < or =1% when 20%, 7%, and 0% of the rectal surface received 100, 150, and 200 Gy, respectively. The probability increased to < or =5% when 31%, 19%, and 9% of the rectal surface received these doses. The probability of late rectal morbidity can also be expressed in terms of the maximal rectal dose. The probability of late morbidity was 0.4%, 1.2%, and 4.7% when the maximal rectal dose was 150, 200, and 300 Gy, respectively. CONCLUSION: The percentage of the rectal surface that receives a dose > or =100 Gy is predictive of Grade 2 (bleeding/ulceration) late rectal morbidity after 125I prostate brachytherapy. The probability of late morbidity depends on both the dose and the percentage of the rectal surface that received that dose. Our results indicate that the rectum can tolerate doses of 100, 150, and 200 Gy to approximately 30%, 20%, and 10% of the rectal surface with a < or =5% risk of late morbidity. Our results also indicate that the practical guideline for limiting the incidence of late morbidity to 1%, 3%, or 5% is to keep the maximal rectal dose to <200, 250, and 300 Gy, respectively.
Spontaneous improvement in late rectal mucosal changes after radiotherapy for prostate cancer.
PURPOSE: To describe the natural history of mucosal changes, in particular the development of telangiectases in the rectum, after radiotherapy (RT) for prostate cancer. METHODS AND MATERIALS: Twenty patients undergoing local-field, nonconformal RT for prostate cancer underwent flexible sigmoidoscopy every 6 months for up to 3 years after RT completion. Telangiectasis was scored as absent, single, multiple, or multiple confluent. The site and circumferential extent were also documented. The patients filled in a diary to document the symptoms they were experiencing, including rectal bleeding. RESULTS: Of the 20 patients, 12 developed multiple telangiectases, and 10 of these had rectal bleeding, which in all cases was mild. Telangiectasis was most commonly seen between 4 (anorectal junction) and 8 cm from the anal verge. In 5 patients, 4 of whom had multiple telangiectases, spontaneous resolution occurred. CONCLUSION: Late radiation effects in the rectum do not appear to be permanent in all cases. This first prospective prolonged evaluation may provide an explanation for the observation that rectal bleeding resolves in a large proportion of patients with mild symptoms after RT. The reasons for improvement in the late radiation changes in the rectum compared with the permanent changes seen in organs such as the skin are unknown.
[Perianal streptococcal dermatitis].
BACKGROUND: Pediatric perianal streptococcal dermatitis (PSD) is a well-defined clinical entity. However, its highly uniform presentation remains surprisingly unrecognized by many practitioners 33 years after its first description. CASE REPORT: A seven-year-old girl had a three-week history of perianal and vulva redness with well-defined margins. Functional symptoms associated perirectal tenderness and pain during defecation, which was responsible for constipation. At onset she also presented with a sore throat, which resolved spontaneously, and she had been complaining for a few days about a perioral impetigo. She received mycostatin unsuccessfully for an alleged candidiasis. Positive cultures for group A beta-hemolytic streptococci from both perirectal and perioral swabs confirmed the diagnosis of PSD. Therapy with amoxicillin (50 mg/kg/d) was prescribed for ten days. Perianal lesions were cleared by day 2. CONCLUSION: Since PSD can masquerade as candidiasis, psoriasis, seborrheic dermatitis, inflammatory bowel disease or even sexual abuse, it remains an underdiagnosed entity. This situation leads to delayed diagnosis and treatment which in turn might increase the frequency of secondary complications related to streptococcal infections (i.e., post-streptococcal acute nephritis and rheumatism, guttate psoriasis, etc.).
Rare sexually transmitted disease hits Europe.
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Rectal function following brachytherapy with or without supplemental external beam radiation: results of two prospective randomized trials.
PURPOSE: To evaluate the effect of isotope and supplemental external beam radiation therapy (XRT) on brachytherapy-related rectal morbidity, using prospective, patient-administered quality of life (QOL) assessments. METHODS AND MATERIALS: Two hundred thirteen consecutive patients (median follow-up 22 months) were implanted on 2 prospective randomized brachytherapy trials evaluating the effect of isotope for low-risk patients and different doses of supplemental XRT for patients with higher risk features. Treatment-related rectal morbidity was evaluated by modified Radiation Therapy Oncology Group (RTOG) criteria and the multifactorial Rectal Function Assessment Score (R-FAS). Clinical, treatment and dosimetric parameters evaluated included patient age, diabetes, hypertension, tobacco consumption, clinical stage, prostate ultrasound volume, elapsed time since implant, hormonal manipulation, supplemental XRT, isotope, treatment planning volume, and values of the minimum dose received by 90% of the prostate gland (D90), the percent prostate volume receiving 100%, 150%, and 200% of the minimum peripheral dose (V(100/150/200)), rectal implant doses (V(75/100/125/150) and D(5/10/25/50)) and rectal XRT doses (D(5/10/25/50/75)). RESULTS: Using the RTOG instrument, rectal morbidity peaked at 1 month. The pre- and most recent postimplant median RTOG scores were 0 and 0, respectively. The pre- and postimplant R-FAS scores were 2.41 and 3.83, respectively. With time, the rectal scores for both instruments improved and approached baseline. In multivariate analysis, only the rectal dosimetry variable D5 predicted for bowel function when using the R-FAS instrument. No clinical, treatment, or dosimetric parameters predicted for bowel function when using the RTOG survey. No patient required surgical intervention for rectal complications. CONCLUSIONS: The multifactorial R-FAS elucidated fine gradations in bowel function of a severity less than RTOG Grade 3 morbidity. Of multiple clinical, treatment, and dosimetric parameters evaluated, only the minimum dose received by 5% of the rectum (D5) correlated with rectal dysfunction via the R-FAS instrument, while none of the evaluated parameters predicted for bowel dysfunction using the RTOG survey. Following permanent prostate brachytherapy, the ability to discern subtle changes in rectal function is dependent on the sensitivity of the survey instrument.
Possible role of mucosal mast cells in the recovery process of colitis induced by dextran sulfate sodium in rats.
To clarify the role of mucosal mast cells in the lesion sites of colitis induced by dextran sulfate sodium (DSS) in rats, we investigated the histological changes and alterations relevant to mucosal mast cells in the spontaneous recovery process of colitis. Oral administration of 4% DSS solution for 11 days resulted in surface epithelial loss, crypt loss and goblet cell depletion in the rectal mucosa. A marked infiltration of inflammatory cells into the mucosa, which was consistent with a significant increase in myeloperoxidase (MPO) activity, was observed. In addition, mucosal mast cell number and rat mast cell protease (RMCP) I and II levels in the rectum increased at day 0 after DSS treatment, and most of the mucosal mast cells were degranulated. After replacing 4% DSS solution with water, re-epithelialization and restoration of goblet cells were observed at day 5 and day 10, respectively, but crypt damage was hardly recovered even at day 20. The elevated myeloperoxidase activity was significantly decreased from day 5 after DSS treatment. The increased number of mucosal mast cells was further elevated up to about 1.5-fold at day 10 and day 20 after DSS treatment and little degranulation was observed. In the spontaneous recovery process, the increased rat mast cell protease II level in the rectum was maintained for 20 days, while the increased rat mast cell protease I level was gradually decreased and recovered to control level. These results suggest that proliferated mucosal mast cells remained for 20 days, although most of infiltrated inflammatory cells disappeared in spontaneous recovery process of colitis. It may therefore be presumed that proliferated mucosal mast cells play a role in spontaneous recovery process of the colitis induced by DSS.
Changing trends of gonococcal infection in homosexual men in Edinburgh.
In an attempt to explain the recent resurgence of homosexually-acquired gonorrhoea in the Lothian region of Scotland the number of infections and pattern of infection (urethral, rectal and pharyngeal) of all gonococcal isolates from homosexual men attending the Department of Genitourinary Medicine at Edinburgh Royal Infirmary between 1985 and 1990 were analysed. Serovar typing data were available from infections acquired between January 1986 and December 1990. A correlation between one serovar, Bacejk/Brpyust, and the overall pattern of gonorrhoea was observed. The number of infections caused by minor serovars also correlated with rates of gonococcal infection. The number of minor serovars isolated, which may represent strains from other geographical locations, is related to the total incidence of gonorrhoea. It is possible that the incidence of Bacejk/Brpyust may be determined by the size of the infected pool of gonorrhoea. The most likely explanation for the recent increase in gonorrhoea is a change in sexual behaviour and/or an influx of strains from other geographical areas.
Antioxidant effects of aminosalicylates and potential new drugs for inflammatory bowel disease: assessment in cell-free systems and inflamed human colorectal biopsies.
BACKGROUND: The therapeutic efficacy of 5-aminosalicylic acid in inflammatory bowel disease may be related to its antioxidant properties. AIM: To compare in vitro the antioxidant effects of conventional drugs (5-aminosalicylic acid, corticosteroids, metronidazole), with new aminosalicylates (4-aminosalicylic acid, balsalazide) and other potential therapies (ascorbate, N-acetylcysteine, glutathione, verapamil). METHODS: Compounds were assessed for efficacy in reducing the in vitro production of reactive oxygen species by cell-free systems (using xanthine/xanthine oxidase, with or without myeloperoxidase) and by colorectal biopsies from patients with ulcerative colitis using luminol-amplified chemiluminescence. RESULTS: 5-aminosalicylic acid and balsalazide were more potent antioxidants than 4-aminosalicylic acid or N-acetyl-5-aminosalicylic acid in cell-free systems. 5-aminosalicylic acid (20 mM) and balsalazide (20 mM) inhibited rectal biopsy chemiluminescence by 93% and 100%, respectively, compared with only 59% inhibition by 4-aminosalicylic acid (20 mM). Hydrocortisone, metronidazole and verapamil had no significant effect on chemiluminescence in any system. Ascorbate (20 mM) inhibited chemiluminescence by 100% in cell-free systems and by 60% in rectal biopsies. N-acetyl cysteine (10 mM), and both oxidized and reduced glutathione (10 mM), completely inhibited chemiluminescence in cell-free systems, but not with rectal biopsies. CONCLUSIONS: The antioxidant effects of compounds varies between cell-free systems and inflamed colorectal biopsies. The effect of drugs on the chemiluminescence produced by these two assay systems is useful for screening potentially new antioxidant treatments for inflammatory bowel disease. Ascorbate seems worth further study as a novel therapy.
Anorectal functional disorders in the absence of anorectal inflammation in patients with Crohn's disease.
BACKGROUND: Histological alterations in the enteric nervous system (ENS) have been described in patients suffering from Crohn's disease (CD). The aim of this study was to investigate whether patients with CD without rectal inflammation have abnormal anorectal function compared with healthy volunteers. METHODS: Fifty-four patients with CD and 26 healthy volunteers were examined by anorectal manometry and answered a standardized questionnaire. No patient had active CD in the rectum as determined by endoscopy. RESULTS: Maximum anal resting and squeeze pressures did not differ between patients and healthy volunteers. The rectoanal inhibitory reflex was absent in 24 of 54 patients and two of 26 healthy volunteers (P < 0.05). The first sensation to distension of the rectal balloon was reported at mean(s.e.m.) 57.9(4.4) ml by patients and 37.5(2.2) ml by healthy volunteers (P < 0.01). The standardized interview revealed additional disorders of anorectal function in patients with CD. CONCLUSION: Anorectal function appears to be altered in many patients with CD even in the absence of macroscopic anorectal disease. This may be due to a disorder of the ENS.
Challenge of chronic radiation-induced rectal bleeding.
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From symptom to diagnosis: clinical distinctions among various forms of intestinal inflammation.
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[Ulcerative colitis. Follow-up study of 160 patients observed for an average of 10 and one-half years (author's transl)].
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[Solitary ulcer of the rectum].
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[Transcutaneous perianal ultrasound (PAUS) for the imaging of fistulas and abscesses in Crohn's disease].
Pelvic MRI and transanal ultrasound constitute the gold standard for the imaging of perianal inflammatory lesions in Crohn's disease. Perianal ultrasound (PAUS), however, is rarely considered in recent literature. In contrast to the established methods, perianal ultrasound represents an easy, cost-effective and at the same time sensitive method for the imaging of perianal abscesses and fistulas. This article illustrates the performance of perianal ultrasound and shows typical images of pathological findings such as abscesses and fistulas. PAUS is especially useful for acute diagnostics to rule out perianal abscesses and for follow-up evaluation of fistula treatment. For example, complications such as abscesses can be detected in a timely manner.
[Ulcerative colitis. Maintenance therapy].
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