Challenges of Retrograde Ureteroscopic Procedures in Overweight Patients.

BACKGROUND: Obesity and urolithiasis are both prevalent conditions that have an impact on the healthcare system. The ureteric diameter and accessibility play a crucial role in the management of urolithiasis in both overweight and normal weight patients. Studies have shown that obesity can lead to changes in ureter diameter where excessive body fat can exert pressure on the kidneys, causing them to enlarge in size and this enlargement can result in a compression of the adjacent structures, including the ureter. The aim of this study is to assess the incidence of intraoperative challenges faced during retrograde ureteroscopic procedures in overweight patients with ureteric and renal calculi. METHODS: We retrospectively reviewed patients who underwent retrograde ureteroscopic surgery (RURS) for urolithiasis from 1st January 2021 until 30th August 2023. The outcome and any complications were documented and compared with the patient's Body Mass Index (BMI). All patients who undergo RURS in our facility have to have a Non-Contrast CT scan prior to surgery. Procedural success was determined by the ability to obtain access to the stone site intraoperatively and stone-free status in kidney, ureter, and bladder (KUB) X-ray post-operatively. Post-operative complications were recorded up to two weeks post-operatively and classified according to the Calvein Dindo Classification. RESULTS: Our total sample size was 146 patients out of which 75 were overweight and 71 were normal weight patients. In 34 (45%) of overweight patients' access to the ureter was restricted due to a narrow ureteric orifice with ureteroscopy not successful; on the contrary 13 (18%) of normal weight patients faced this same issue. This was statistically significant with a p-value of .004. The stone clearance rates were 91% and 95% in overweight and normal weight patients respectively, which is higher in normal weight patients however this difference was not found to be a statistically significant finding (p-value .028). Overweight patients had 12% Grade I and 8% Grade II complications whereas normal weight patients had 11% Grade I complications and 1.4% Grade II with no higher-grade complications. CONCLUSION: Retrograde ureteroscopic procedures are a safe treatment modality for patients with urolithiasis in both overweight and normal weight populations. They are shown to have similar success rates between both populations once ureteric access is obtained. However, access failure rates are shown to be slightly higher in overweight patients. Hence, further preoperative patient counselling and technical considerations should be undertaken.

Evaluating Antimicrobial Effectiveness of Gold Nanoparticles against Streptococcus oralis.

Biofilm includes many microorganisms that causes the periodontal diseases. The increased drugs resistance against the infectious diseases is a major issue owing to excessive using of a broad spectrum of antibiotics. Recently, metallic nanoparticles (NPs) are being administered to control the growth of different types of microorganisms. For instance, gold nanoparticles (Au NPs) are found to be successful to control and limit the bacterial pathogenicity in the oral cavity without any cytotoxic effects on the human body. Aim. In this paper, it was aimed to detect the antibacterial effect of Au NPs and compare with chlorhexidine (CHX) against Streptococcus oralis (S. oralis) in dental plaque of patients with chronic periodontitis. Materials and Methods. First, supragingival and subgingival plaque samples were collected from the patients suffering from periodontal disease and incubated under aerobic or/and anaerobic conditions. Second, the morphological examination, and biochemical test by Vitec 2 machine are used to confirm the S. oralis species. Third, the synthesis of Au NPs was carried out by seed growth method and their properties were characterized. Finally, the antimicrobial effect of the Au NPs against S. oralis was evaluated by Agar well diffusion method for different Au NPs concentrations (100, 50, 25, 12.5, 6.25, 3.125, 1.562, 0.781, 0.391, 0.195, and 0.097 ppm). CHX was used as the positive control and distilled water as the negative control. The antibacterial activity data were statistically analyzed by least significant difference (LSD) using the Statistical Program for Social Science (SPSS) version 22. Results. The Au NPs with an average particles size of 43 nm, polycrystalline face-centered cubic structure were characterized. The Au NPs at 100 ppm concentration had similar antibacterial effect of CHX for inhibiting the growth of S. oralis, with no significant difference. Conclusions. The Au NPs as an antibacterial agent could be equally effective against S. oralis similar to the CHX when used at higher concentration.

Screening for chitin degrading bacteria in the environment of Saudi Arabia and characterization of the most potent chitinase from Streptomyces variabilis Am1.

Forty-six promising chitinolytic isolates were recovered during a screening for chitinolytic bacteria in the environment of Saudi Arabia. The top three isolates belonged to the genus Streptomyces. Streptomyces variabilis Am1 was able to excrete the highest amount of chitinases, reaching the maximum at 84 h with 0.5% yeast extract and nitrogen source and 2% galactose as a carbon source. Purification of chitinase by DEAE-Cellulose and Sephadex G75 improved the specific activity to 18.6-fold and the recovery to 23.8% and showed a mass at 56 kDa. The optimal catalysis of the purified chitinase was at 40 °C and pH 8 with high thermostability and pH stability as reflected by a midpoint temperature value of 66.6 °C and stability at pH 4-9. The protein reagents SDS, EDTA, and EGTA significantly inhibited the enzyme and the EDTA-chelated chitinase restored its activity after the addition of Fe2+ ions suggesting a metallo-chitinase type with ferric ions as cofactors. Chitinase exerted high antifungal activity against some phytopathogenic fungi. Interestingly, the tested Streptomyces were able to produce chitosan nanocubes along with chitosan from chitin degradation which may be an additional power in their antifungal activity in nature. This work also reveals the importance of unexplored environments as a pool of promising microorganisms with biotechnological applications.

Clostridium paraputrificum Bacteremia in a Patient with Human Immunodeficiency Virus Infection: A Case Report and Literature Review.

Clostridium paraputrificum (C. paraputrificum) is clinically important due to its association with underlying medical conditions. Infection with C. paraputrificum may worsen HIV prognosis, leading to acquired immunodeficiency syndrome. However, it is not frequently isolated and its susceptibility to antibiotics has not been well studied. Our report examines the case of a patient with human immunodeficiency virus (HIV) infection, who was diagnosed with Clostridium paraputrificum bacteremia. A 59-year-old male was admitted to hospital with a medical history of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and neck pain. Following episodes of high fever, the patient received a full work up to test for sepsis. Blood culture revealed bacterial growth, and MALDI-TOF mass spectrometry confirmed the diagnosis of Clostridium paraputrificum bacteremia. The patient received treatment with meropenem and vancomycin antibiotics, which cleared the infection after 48 hours; however, inflammatory markers remained high. To date, a limited number of reported cases of C. paraputrificum exist; thus, this case report contributes valuable information to the literature to improve our understanding of its action and resistance profiles and aid future bacteremia management.

Addition of transglutaminase enzyme in camel milk yoghurt to increase its sensorial aspects.

Camel milk was obtained from A-block UVAS Ravi Campus Pattoki. After pasteurization at 72 °C (15 sec) it was cooled to 42 °C, then glutathione treated transglutaminase enzyme was added with the concentration of 0.5 g/300 mL, 1 g/300 mL, 1.5 g/300 mL, 2 g/300 mL while control sample with the addition of 1.5 g/300 mL gelatin. Then inoculation of milk was done with standard cultures of Yoghurt Lactobacillus delbrueckii subsp bulgaricus and Streptococcus thermophilus at the rate of 2% for 3-4 hours at 42 °C. Samples were stored at 4 °C and were analyzed on 1st day and 28th day of storage. In our findings, there was slight increase in sensorial properties of all the samples. It was also observed that syneresis was reduced with the increase of enzyme quantity.

A Rare Combination of Arterial and Venous Thrombosis as a Sequalae of COVID-19.

Coronavirus disease 2019 (COVID-19) has been a devastating condition claiming millions of lives, crippling countless people, and causing economic turmoil all over the world since the outbreak started in Wuhan Province of China in December 2019. Numerous papers have been published in the literature about COVID-19-related complications affecting almost all systems in the human body. One of the severe complications of this disease is thromboembolism, which affects both the arterial and venous systems and is well documented. There are few reports about both arterial and venous system involvement in the same patient. Herein, we report the case of COVID-19, who presented with critical limb ischemia caused by both arterial and venous thrombosis.

A comparison of three thromboprophylaxis regimens in critically ill COVID-19 patients: An analysis of real-world data.

Introduction: Thrombotic complications of coronavirus disease 2019 (COVID-19) have received considerable attention. Although numerous conflicting findings have compared escalated thromboprophylaxis doses with a standard dose to prevent thrombosis, there is a paucity of literature comparing clinical outcomes in three different anticoagulation dosing regimens. Thus, we investigated the effectiveness and safety profiles of standard, intermediate, and high-anti-coagulation dosing strategies in COVID-19 critically ill patients. Methodology: This retrospective multicenter cohort study of intensive care unit (ICU) patients from the period of April 2020 to August 2021 in four Saudi Arabian centers. Inclusion criteria were age ≥ 18 years, diagnosis with severe or critical COVID-19 infection, and receiving prophylactic anticoagulant dose within 24-48 h of ICU admission. The primary endpoint was a composite of thrombotic events, with mortality rate and minor or major bleeding serving as secondary endpoints. We applied survival analyses with a matching weights procedure to control for confounding variables in the three arms. Results: A total of 811 patient records were reviewed, with 551 (standard-dose = 192, intermediate-dose = 180, and high-dose = 179) included in the analysis. After using weights matching, we found that the standard-dose group was not associated with an increase in the composite thrombotic events endpoint when compared to the intermediate-dose group {19.8 vs. 25%; adjusted hazard ratio (aHR) =1.46, [95% confidence of interval (CI), 0.94-2.26]} or when compared to high-dose group [19.8 vs. 24%; aHR = 1.22 (95% CI, 0.88-1.72)]. Also, there were no statistically significant differences in overall in-hospital mortality between the standard-dose and the intermediate-dose group [51 vs. 53.4%; aHR = 1.4 (95% CI, 0.88-2.33)] or standard-dose and high-dose group [51 vs. 61.1%; aHR = 1.3 (95% CI, 0.83-2.20)]. Moreover, the risk of major bleeding was comparable in all three groups [standard vs. intermediate: 4.8 vs. 2.8%; aHR = 0.8 (95% CI, 0.23-2.74); standard vs. high: 4.8 vs. 9%; aHR = 2.1 (95% CI, 0.79-5.80)]. However, intermediate-dose and high-dose were both associated with an increase in minor bleeding incidence with aHR = 2.9 (95% CI, 1.26-6.80) and aHR = 3.9 (95% CI, 1.73-8.76), respectively. Conclusion: Among COVID-19 patients admitted to the ICU, the three dosing regimens did not significantly affect the composite of thrombotic events and mortality. Compared with the standard-dose regimen, intermediate and high-dosing thromboprophylaxis were associated with a higher risk of minor but not major bleeding. Thus, these data recommend a standard dose as the preferred regimen.

Tocilizumab effectiveness in mechanically ventilated COVID-19 patients (T-MVC-19 Study): a multicenter real-world evidence.

BACKGROUND: This study aimed to evaluate the effectiveness of tocilizumab in mechanically ventilated patients with coronavirus disease 2019 (COVID-19). RESEARCH DESIGN AND METHODS: This retrospective multicenter study included adults (≥18 years) diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by real-time polymerase chain reaction (RT-PCR) from nasopharyngeal swab, and requiring invasive mechanical ventilation during admission. Survival analyses with inverse propensity score treatment weighting (IPTW) and propensity score matching (PSM) were conducted. To account for immortal bias, we used Cox proportional modeling with time-dependent covariance. Competing risk analysis was performed for the extubation endpoint. RESULTS: A total of 556 (tocilizumab = 193, control = 363) patients were included. Males constituted the majority of the participants (69.2% in tocilizumab arm,74.1% in control arm). Tocilizumab was not associated with a reduction in mortality with hazard ratio [(HR) = 0.82,95% confidence interval (95%CI): 0.62-1.10] in the Inverse propensity score weighting (IPTW) analysis and (HR = 0.86,95% CI: 0.64-1.16) in the PSM analysis. However, tocilizumab was associated with an increased rate of extubation (33.6%) compared to the control arm (11.9%); subdistributional hazards (SHR) = 3.1, 95% CI: 1.86-5.16). CONCLUSIONS: Although tocilizumab was not found to be effective in reducing mortality, extubation rate while on mechanical ventilation was higher among tocilizumab treated group.

Prototheca zopfii as a Cause of Pneumonia and Disseminated Infection in Febrile Neutropenia: A Case Report and Literature Review.

BACKGROUND Prototheca spp. are common and found in various environments, including animal and human intestines, on the skin and in respiratory tissues, and colonizing fingernails. Few strains pathogenic for humans have been discovered. Here, we describe an infection by the pathogenic fungus species Prototheca zopfii in a patient. The infection was initially classified as a fungus based on colony morphology, fungal staining results, and growth in some fungi culture media (Sabouraud dextrose agar [SDA]). Reports of Prototheca spp. infections are increasing, often with poor outcomes. The use of matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS) technique for identification has been widely described. Phenotypic identification depends on microscopic examination of the direct wet mount and after subculturing in blood and SDA using different stains that show a typical morphological characteristic of Prototheca spp. CASE REPORT A 48-year-old woman was diagnosed with a P. zopfii infection after 22 days of hospitalization in the critical care unit. The patient had profound febrile neutropenia and absolute neutrophil count (ANC) was zero, associated with hypotension and disseminated intravascular coagulation (DIC) 10 days after receiving the first cycle of chemotherapy for metastatic breast adenocarcinoma. Unfortunately, the patient died within 2 days of the initiation of treatment with amphotericin B. CONCLUSIONS This case report highlights algae infections as a possible opportunistic infection type in patients with profound neutropenia, and we discuss the use of MALDI-TOF MS-based technology in detecting such infections and predicting poor prognosis, especially in patients with the disseminated form with underlying febrile neutropenia.

Malignant Glandular Triton Tumor Arising in the Radial Nerve with Prolonged Survival: A Case Report and Review of the Literature.

Divergent differentiation is a well-known phenomenon in malignant peripheral nerve sheath tumors (MPNST) which occurs approximately in 15% of these tumors, usually towards mesenchymal elements. Differentiation towards epithelial components, however, is quite uncommon, and even exceptionally rare is concomitant mesenchymal and glandular differentiation. To our knowledge, only 14 cases of MPNST with both mesenchymal (rhabdomyoblastic) and glandular differentiation had been reported, and only two of these tumors had frankly malignant glandular components. Herein, we report the third such case. A 26-year-old male, without any of the stigmata of NF1, presented with a 2-year history of pain in his left shoulder and an elbow swelling of six-month duration. The tumor was initially diagnosed clinically as a neurofibroma at a local hospital. The patient underwent excision of the mass there, and pathological examination at that hospital showed the tumor to be MPNST. Six months later, the patient was referred to our hospital, a tertiary care medical center, with recurrent swelling at the same location. Histopathological material from the referral hospital was reviewed, and the tumor was diagnosed as MPNST with rhabdomyoblastic differentiation or malignant triton tumor (MTT) that contained in addition foci of malignant glandular epithelium. The patient refused any surgical intervention. He received three cycles of chemotherapy followed by radiotherapy with excellent response and marked reduction in the size of the tumor. The patient had prolonged survival for 10 years following the initial resection of the tumor.

Giant Abdominal Wall Endometrioma: A Case Report.

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. Endometriosis may involve a wide spectrum of anatomic locations, but it typically involves pelvic locations. We report the case of a 45-year-old woman who presented with a history of abdominal pain and swelling. She first noticed the swelling eight months prior to presentation, and it had gradually progressed in size. The patient reported that the swelling increased in size during menses. Physical examination revealed a well-defined firm mass to the right of the midline. The mass had a smooth surface but limited mobility after abdominal wall muscle contraction, suggesting an infiltration of the underlying muscular structures. The findings demonstrated by computed tomography of the abdomen confirmed the diagnosis of abdominal wall endometrioma. The patient underwent successful resection of the lesion with complete resolution of her symptoms.

Cardiovascular disease-related mortality risk in end stage renal disease and type 2 diabetes: A systematic review.

BACKGROUND: Patients with uncontrolled type 2 diabetes can have microvascular and macrovascular complications, including renal impairment and cardiovascular diseases. However, it is unknown how diabetes and renal disease could influence cardiovascular mortality. OBJECTIVE: This study aims at examining the medical literature to evaluate the risk of cardiovascular death in concomitant end stage renal disease with type 2 diabetes. METHOD: Medical literature was reviewed through Medline, PubMed, Embase, and Ovid database in the duration between 2009 and 2019. Searching terms included were a combination of "type 2 diabetes mellitus" AND "end-stage renal disease" AND "cardiovascular mortality". Following this, results were filtered to include only original research articles investigating cardiovascular mortality in concomitant diabetes and end-stage renal disease. Selected trials mentioned diabetes control as well as the follow-up duration of the included patients. RESULT: A total of 1508 articles were retrieved. Following the exclusion of articles on animals and including only trials on humans, 32 articles appeared. A total of eight articles were identified as eligible, covering a total of 2,06,492 diabetic patients with end-stage renal disease. All the studies were prospective studies, except for three studies that were retrospective. CONCLUSION: There is an elevated cardiovascular mortality risk in concomitant type 2 diabetes mellitus and end-stage renal disease, especially with uncontrolled blood glucose levels.

Relationship between human leukocyte antigen DRB1 and psoriasis in Iraqi patients.

OBJECTIVES: To investigate the role of Human leukocyte antigen (HLA) Class II DRB1 in susceptibility to psoriasis in Iraqi patients. METHODS: A cross-sectional comparative study including 40 patients with psoriasis attending the Department of Dermatology, Al-Kindy teaching hospital in Baghdad, Iraq, between September 2013-2015. Patient selection was carried out by the dermatologists. Ninety healthy individuals were included in the study. Human leukocyte antigen genotyping was carried out by the sequence specific oligonucleotide (SSO) method using Auto LiPA 48 (Innogenetics, Belgium) in the HLA typing research unit of the Al-Kindy College of Medicine, Baghdad, Iraq. RESULTS: There is an increased frequency of HLA-DRB1*0102, *0306 in psoriatic patients with psoriasis p-values=0.001, confidence interval(CI)=2.492-37.487 and odds ratio(OR)=9.666. Human leukocyte antigen-DRB1*1101 is significantly associated with plaque-type psoriasis with p=0.0434, CI=1.04-1.69, and OR=4.2. Human leukocyte antigen-DRB1*0102 is significantly associated with other types of psoriasis with p=0.018, CI=0.0223-0.701, and OR=0.125. CONCLUSION: Human leukocyte antigen-DRB1*0102 and *0306 are significantly associated with psoriasis. Human leukocyte antigen-DRB1*1101 is significantly associated with plaque-type psoriasis. Human leukocyte antigen-DRB1*0102 is significantly associated with other types of psoriasis rather than plaque-type psoriasis.

Primary paranasal sinus hyalinizing clear cell carcinoma: a case report.

BACKGROUND: Hyalinizing clear cell carcinoma (HCCC) is a rare low-grade tumour of salivary glands that was first described as a distinct entity in 1994 by Milchgrub et al. EWSR1-ATF1 fusion was found to be specific for this tumour. The majority of the reported cases of HCCC arise from minor salivary glands within the oral cavity. Primary HCCC of the paranasal sinus is extremely uncommon. To our knowledge, only three cases have been reported in the English literature. Herein, we present a case of HCCC of the posterior ethmoid/maxillary sinus. CASE PRESENTATION: A 63-year-old lady who presented with a long history of epistaxis. CT scan revealed a destructive mass in the left ethmoid/posterior maxillary sinus extending to the nasal cavity. Surgical excision was done and microscopic evaluation showed a tumour composed mainly of nests of clear epithelial cells separated by fibrocellular and hyalinized septa with extensive bone destruction. The tumour cells expressed CK5/6, EMA and p63 immunohistochemically but were negative for S100 protein, PAX-8, RCC and CK7. Sinonasal renal cell-like adenocarcinomas, myoepithelial carcinoma and metastatic renal cell carcinoma were excluded by radiological and immunohistochemical studies. Fluorescence in situ hybridization analysis revealed an EWSR1 gene rearrangement. Postoperative radiation was administrated and the patient did not show recurrence or distant metastasis 4 months after the surgery. CONCLUSION: Head and neck region have many tumours that demonstrate clear cell changes on histology. Thus, the differential diagnosis for HCCC is wide. Awareness of this rare entity and the possibility of it is arising in unusual location is necessary. EWSR1-AFT1 fusion, a consistent finding in HCCC, can be used to confirm the diagnosis.

Assessment of Cardiac Function in Fetuses of Gestational Diabetic Mothers During the Second Trimester.

Fetuses of diabetic mothers may have structural or functional cardiac abnormalities which increase morbidity and mortality. Isolated functional abnormalities have been identified in the third trimester. The aim of the present study was to assess fetal cardiac function (systolic, diastolic, and global myocardial performance) in the second trimester in mothers with gestational diabetes, and also to relate cardiac function with glycemic control. Mothers with gestational diabetes mellitus referred for fetal cardiac evaluation in the second trimester (between 19 and 24 weeks) from March 2015 to February 2016 were enrolled as case subjects in this study. Non-diabetic mothers who had a fetal echocardiogram done between 19 and 24 weeks for other indications were enrolled as controls. Functional cardiac variables showed a statistically significant difference in isovolumetric relaxation and contraction times and the myocardial performance index and mitral E/A ratios in the gestational diabetic group (p = 0.003). Mitral annular plane systolic excursion was significantly less in the diabetic group (p = 0.01). The only functional cardiac variable found abnormal in mothers with poor glycemic control was the prolonged isovolumetric relaxation time. Functional cardiac abnormalities can be detected in the second trimester in fetuses of gestational diabetic mothers and timely intervention can improve postnatal outcomes.

Association between human leukocyte antigen-DR and demylinating Guillain-Barre syndrome.

OBJECTIVE: To find an association between human leukocyte antigen (HLA) class II DRB1, DRB3, DRB4, and DRB5 alleles frequencies in a sample of Iraqi patients with Guillain-Barre syndrome (GBS) and compare with a healthy control group. METHODS: We performed a cross-sectional study consisting of 30 Iraqi Arab patients with GBS attending the Neurological Department in the Neuroscience Hospital, Baghdad, Iraq between September 2012 and June 2013. The control group comprised 42 apparently healthy volunteers. Human leukocyte antigen genotyping for HLA DRB1, DRB3, DRB4, and DRB5 was performed using the polymerase chain reaction-sequence-specific primers method. The allele frequencies were compared across both groups. Major histocompatibility complex (MHC)-class II HLA-DR genotyping and serotyping were performed by software analysis. RESULTS: We found increased frequencies of HLA genotype DRB1*03:01 (p=0.0009), DRB1*07:01 (p=0.0015), and DRB4*01:01 (p<0.0001) in patients with GBS compared with healthy controls. The HLA DR6 was increased in the control group (p<0.0001). CONCLUSION: Our results suggest an association between HLA-DRB1*03:01, DRB1*07:01, DRB4*01:01, and HLA DR3, DR7 and a susceptibility to GBS.

The relationship between helicobacter pylori infection and gastro-esophageal reflux disease.

BACKGROUND: Gastro-esophageal reflux disease is a common condition, affecting 25%-40% of the population. Increasing attention has been paid to the relationship between Helicobacter pylori infection and reflux esophagitis. AIM: The aim of this study was to investigate the association between CagA+ H. pylori and endoscopically proven gastro-esophageal reflux disease. PATIENTS AND METHODS: The study group included 60 hospital patients with gastro-esophageal reflux disease between 2007 and 2009 as compared with 30 healthy patients from a control group that was age and sex matched. Helicobacter pylori CagA+ was identified by an immunological test (Immunochromatography test) (ACON, USA). RESULTS: Helicobacter pyloriCagA+ was present in 42/60 (70%) of the patients with gastro-esophageal reflux disease and in 11/30 (36.6%) patients in the control group (p=0.002). The Odds ratio = 0.8004 with 95% Confidence Interval = from 0.3188 to 2.0094. The relative risk=1.35 that indicates an association between Helicobacter pylori and disease. CONCLUSIONS: The presence of Helicobacter pylori is significantly increased in patients with gastro-esophageal reflux disease as compared with the control group.

Long-term results of subtotal colectomy and evidence of noncolonic involvement in patients with idiopathic slow-transit constipation.

BACKGROUND: Patients with chronic idiopathic constipation can be difficult to manage either medically or surgically. We report our experience of long-term follow-up of 21 patients who had undergone colectomy with ileorectal anastomosis for difficult chronic idiopathic constipation. METHODS: The patients (19 female, 2 male) were aged 26-68 (median = 46) years and had undergone subtotal colectomy 5-12 (median = 8) years before their assessment. They answered a questionnaire about severity of abdominal pain, bloating, urgency, and straining. They also completed the hospital anxiety and depression questionnaire. Fifteen ulcerative colitis patients with panproctocolectomy and 13 colon cancer patients with colonic resection who had a similar follow-up period served as control groups. The following assessments were performed in chronic idiopathic constipation patients with subtotal colectomy: a) oesophageal manometry; b) scintigraphic gastric emptying test; c) review of barium follow-through; d) glucose H2 breath test; e) urodynamic studies; and f) autonomic function tests. RESULTS: Twenty-four per cent of patients with chronic idiopathic constipation had a family history of difficult constipation requiring hospital investigations and treatment. At the time of assessment abdominal pain, bloating, urgency, and straining at defecation were all significantly more frequent in patients with chronic idiopathic constipation with colectomy than in the control groups with colectomy. Seventy-one per cent of chronic idiopathic constipation patients had at least one episode of intestinal obstruction after subtotal colectomy, which is significantly higher (P < 0.01) than in the control groups (ulcerative colitis, 13%; colonic carcinoma, 8%). In patients with chronic idiopathic constipation, among those studied, 68% had some oesophageal motor dysfunction: 19% delayed gastric emptying; 10%, prolonged small-bowel transit on barium follow-through; 54%, abnormal urodynamic variables; and 14%, abnormal autonomic function tests. CONCLUSIONS: This study shows considerable morbidity in a selected cohort of patients with chronic idiopathic constipation who were sufficiently disabled by their symptoms to undergo subtotal colectomy. They had more abdominal and rectal symptoms and more frequent intestinal obstructive episodes than control groups with colonic resection. Evidence of generalized smooth-muscle dysfunction and familial occurrence of constipation suggests a primary chronic intestinal pseudo-obstruction-like disorder in some of these patients.