Listeria Rhombencephalitis Complicating Anti-TNF Treatment during an Acute Flare of Crohn's Colitis.

Patients with Crohn's disease often require the use of immunosuppressant drugs to control disease activity. Such medication includes steroids, azathioprine, and biologic therapy. These suppress the immune response, and the patient is more susceptible to infection. We present a case of a 69-year-old gentleman with a history of Crohn's colitis who had ongoing symptoms of diarrhoea in spite of standard treatment. Biologic therapy was considered to be the next step, and screening for infection was undertaken prior to use. Three days following anti-TNF treatment, he became drowsy, and examination revealed pyrexia, slurred speech, and nystagmus. Investigation revealed presence of Listeria rhombencephalitis. He demonstrated poor neurological recovery. Listeria monocytogenes is an infection commonly associated with food sources. Some patients develop a self-limiting diarrhoeal illness, but in the immunosuppressed population, the clinical features may be more sinister. Cotrimoxazole prophylaxis is already recommended for those on triple immunosuppression. We propose the early initiation of this treatment, including where biologic use is anticipated. In those on multiple immunosuppressants, a diet similar to that followed in pregnancy may minimise risk of acquiring this infection. Clinicians must always have a high index of suspicion for opportunistic infection in such immunocompromised patients.

Mirizzi's syndrome: a diagnostic dilemma.

A 62-year-old male presented with a history of upper abdominal discomfort. Past history included asymptomatic gallstones. Abdominal ultrasound and CT demonstrated gallstones within a thick-walled gallbladder, and intra and extrahepatic duct dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture within the mid-portion of the common bile duct. At laparotomy, a single large stone was found causing external compression of the common bile duct causing a Mirizzi's-type stricture. At repeat ERCP, cholangiogram showed no evidence of stricture. Clinicians should be aware that no definite clinical signs distinguish Mirizzi's syndrome and surgical exploration is often required for diagnosis.

Natural history of asymptomatic bile duct stones at time of cholecystectomy.

OBJECTIVES: There is little data on the natural history of asymptomatic bile duct stones and hence there is uncertainty on the management of asymptomatic bile duct stones discovered incidentally at the time of laparoscopic cholecystectomy. We retrospectively reviewed a group of patients who had previously underwent laparoscopic cholecystectomy, but who did not have a pre-operative suspicion of intra-ductal stones, to determine if any biliary complications had subsequently developed. A group of patients who had no pre-operative suspicion of intra-ductal stones, but routinely underwent intraoperative cholangiogram (IOC) at time of cholecystectomy, served as the control group. METHODS: A telephone questionnaire was completed by each patient's family practitioner in 59 of 79 (75%) patients who underwent laparoscopic cholecystectomy. In the remaining 20 patients additional information was obtained from hospital records and from the central services agency (CSA). These patients had no pre-operative suspicion of bile duct stones and therefore did not undergo an IOC or ERCP. The control group (73 patients) had no pre-operative suspicion of bile duct stones but had a routine IOC performed to define the biliary anatomy. RESULTS: 59 patients were followed up for an average of 57 months (range 30-78 months) after laparoscopic cholecystectomy. None of these patients developed pancreatitis, jaundice, deranged liver function tests (LFT's), or required ERCP or other biliary intervention. In the additional 20 patients where no information was available from the family practitioner, 11 patients had follow up appointments with no documentation of biliary complications or abnormal LFT's. 19 of 20 patients were traceable through the CSA and were all alive. Only 1 patient was untraceable and therefore unknown if biliary complications had developed. In the control group, 4 of 73 (6%) patients had intraductal stones detected and extracted. Thus the prevalence of asymptomatic bile duct stones during the time of cholecystectomy in our population was 6%. CONCLUSIONS: Asymptomatic bile duct stones discovered at the time of cholecystectomy do not appear to cause any biliary complications over a 5-year follow up. Incidental bile duct stones found in patients undergoing laparoscopic cholecystectomy may not need to be removed.

Contributions to behavioral treatment from studies on programmed access to alcohol.

Major developments in research involving the alcohol-alcoholic interaction are presented against a backdrop of the traditional perspective of alcoholism. Studies explaining the effects of alcohol, factors influencing drinking patterns, the significance of alcohol for the alcoholic, expectations regarding alcohol use and its affective and social consequences, the parameters of alcohol use, the question of control of alcoholism, and a number of treatment related issues are reviewed. It is concluded that much of this research is provocative and may recommend a reassessment of current thinking about the nature of alcohol abuse and dependence. Such a reassessment, however, is seen to be difficult to make, for the task likely will require a paradigmatic shift.

Behavioral treatment methods for alcoholism.

This chapter offers a review of the behavioral methodology directed to the treatment of alcoholism. Beginning with an outline of the theoretical bases of behavior therapy and assessment, a review with some historical perspective is undertaken of the chemical, electrical, and covert aversion treatments of alcoholism. Thereafter, the procedures of the social skills-training strategies (including marital skills and assertiveness training) are presented, followed by a discussion of the relaxation and desensitization techniques. The operant methodologies are illustrated by contingency contracting and the community-reinforcement approaches. Within the broad-spectrum procedures, a description of self-control training and an example of a broad-spectrum treatment study are offered. It is noted that although the merits of these various techniques are becoming widely recognized in the alcoholism treatment literature, the behavior therapeutic approaches to alcoholism have yet to receive widespread public acceptance. It is anticipated that future studies of treatment effectiveness will contribute to an increasing appreciation of the advantages of behavioral therapies to the management of alcohol abuse and dependence.

Abstinence and controlled drinking in the treatment of problem drinkers.

Issues regarding abstinence and restricted drinking as treatment goals are discussed. It is argued that therapies oriented to both controlled drinking and abstinence are needed. Problems with differential assignment of patients to treatment modalities are considered, and tentative guidelines for the selection of treatment goals are proposed.

Fallibility of urine drug screens in monitoring methadone programs.

Urine specimens containing five different drugs, each at three levels of concentration with zero to five drugs in a specimen, were sent to two "approved" laboratories. In only 46.9% and 13.8%, respectively, were all drugs present correctly identified and no false-positive results reported. With some allowances, the results improved to 53.8% and 49.4%. If these tests are to be continued then (1) the fallibility of these tests should be known by all treatment personnel, (2) laboratories should be licensed rather than merely approved, and (3) maintenance of the license should be made contingent on passing "blind" proficiency tests.

Attitudes toward alcohol as predictors of self-estimated alcohol consumption in college students.

The purpose of the present investigation was to examine the relationship between attitudes toward alcohol use and self-estimated drinking behavior. The results indicated that attitudes can reliably predict variations in self-reported drinking behavior. The implication of these findings for treatment and future research is discussed.