Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients.

AIM: Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence. METHOD: The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate. RESULTS: Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years. CONCLUSION: The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

Treatment of sewage sludge using electrokinetic geosynthetics.

The treatment and disposal of sewage sludge is one of the most problematical issues affecting wastewater treatment in the developed world. The traditional outlets for sewage sludge are to spread it on agricultural land, or to form a cake for deposit to landfill or incineration. In order to create a sludge cake, water must be removed. Existing dewatering technology based on pressure can only remove a very limited amount of this water because of the way in which water is bound to the sludge particles or flocs. Several researchers have shown that electrokinetic dewatering of sludge is more efficient than conventional hydraulically driven methods. This involves the application of a dc voltage across the sludge, driving water under an electrical gradient from positive (anode) electrode to negative (cathode) electrode. However, there have been several reasons why this technique has not been adopted in practice, not least because the, normally metallic, anode rapidly dissolves due to the acidic environment created by the electrolysis of water. This paper will describe experimentation using electrokinetic geosynthetics (EKG): polymer-based materials containing conducting elements. These have been used to minimise the problem of electrode corrosion and create a sludge treatment system that can produce dry solids contents in excess of 30%. It will suggest different options for the treatment of sludges both in situ in sludge lagoons and windrows, and ex situ as a treatment process.

A novel layered titanoniobate LiTiNbO5: topotactic synthesis and electrochemistry versus lithium.

A new layered titanoniobate, LiTiNbO5, an n = 2 member of the A(x)M(2n)O(4n+2) family, has been synthesized using a molten salt reaction between HTiNbO5 and an eutectic "LiOH/LiNO3". This compound crystallizes in the P2(1)/m space group with a = 6.41 A, b = 3.77 A, c = 8.08 A, and beta = 92 degrees . It exhibits |TiNbO5|(infinity) layers similar to HTiNbO5, but differs from the latter by a "parallel configuration" of its |TiNbO6|(infinity) ribbons between the two successive layers. The topotactic character of the reaction suggests that exfoliation plays a prominent role in the synthesis of this new form. This new phase intercalates reversibly 0.8 lithium through a first-order transformation leading to a capacity of 94 mAh/g at a potential of 1.67 V vs Li/Li+.

Na2[(VO)2(HPO4)2C2O4].2H2O: crystal structure determination from combined powder diffraction and solid-state NMR.

The vanadyl oxalatophosphate Na2[(VO)2(HPO4)2C2O4].2H2O has been synthesized by hydrothermal treatment. Its structure has been determined and refined by combining X-ray powder diffraction and solid-state NMR techniques. It crystallizes with monoclinic symmetry in space group P2(1), a = 6.3534(1) A, b = 17.1614(3) A, c = 6.5632(1) A, beta = 106.597(1) degrees . The structure is related to that of (NH4)2[(VO)2(HPO4)2C2O4].5H2O, which was previously reported. The vanadium phosphate framework consists of infinite [(VO)(HPO4)] chains of corner-sharing vanadium octahedra and hydrogenophosphate tetrahedra. The oxalate groups ensure the connection between the chains to form a 2D structure. The sodium ions and the water molecules are located between the anionic [(VO)2(HPO4)2C2O4]2- layers. The thermal decomposition has been studied in situ by temperature-dependent X-ray diffraction and thermogravimetry. It takes place in three stages, where the first two correspond to water removal and the last to the decomposition of the oxalate group and water elimination, leading to the final product NaVOPO4.

Effect of left renal vein division during aortic surgery on renal function.

A total of 398 consecutive patients underwent surgery for an aneurysm or occlusive disease of the aorta at Norfolk and Norwich Hospital between December 1994 and October 1998. It was necessary to divide the left renal vein in 58 (14.6%) cases. We examined the effect of this division on the mortality rate and renal function. Renal function was assessed by measuring serum creatinine pre-operatively, peri-operatively and long-term postoperatively. There was no significant difference in the mortality rate between patients who had the left renal vein divided (LRVD) and in whom the left renal vein remained intact (LRVI)--31% versus 32%, P = 0.83. There was no significant difference in the pre-operative serum creatinine level between both groups (107 +/- 21 mumol/l in LRVD versus 103 +/- 29 mumol/l in LRVI, P = 0.14). There was an insignificant rise in the mean serum creatinine 7 days postoperatively (111 +/- 21 mumol/l in LRVD versus 107 +/- 31 mumol/l in LRVI, P = 0.05). The mean serum creatinine returned back to the pre-operative level at 30 days postoperatively (106 +/- 16 mumol/l in LRVD and 105 +/- 29 mumol/l, P = 0.20). After 1 month, there was no significant difference in the number of patients who had a sustained elevation of serum creatinine level (7.5% in LRVD versus 2.7% in LRVI, P = 0.11). We feel that division of the left renal vein is a safe and helpful procedure during juxtarenal aortic surgery.

Influence of human immunodeficiency virus infection on chronic hepatitis B in homosexual men.

The aim of this study was to assess the influence of human immunodeficiency virus (HIV) infection on chronic hepatitis B. In a series of 132 (65 anti-HIV positive) homosexual non-drug addicted men with chronic hepatitis B, the liver function was assessed with biochemical tests; the degree of hepatitis B virus (HBV) replication was assessed with serum HBV DNA level and with immunoperoxidase staining of hepatitis B core (HBc) antigen on liver specimens; and the severity of liver lesions was assessed with an histology activity index. Anti-HIV-positive and anti-HIV-negative patients were not different for serum aspartate transaminase activity, bilirubin, prothrombin, and histology activity index. Anti-HIV-positive patients had lower serum alanine transaminase activity levels (P =.0001), lower serum albumin levels (P =.0009), and higher serum HBV DNA levels (P =.01). There was a higher prevalence of cirrhosis in anti-HIV-positive patients (P =.04). In homosexual men with chronic hepatitis B, HIV infection is associated with a higher level of HBV replication and a higher risk for cirrhosis without increased liver necrotico-inflammatory process.

[Hemorrhoids. Review]. / La maladie hémorroïdaire. Revue.

Correct definition of haemorrhoidal disease allows the estimation of the incidence and the therapeutic choices. The term "haemorrhoidal disease" should be used specifically for symptoms secondary to abnormalities of the intern haemorrhoidal plexus. The classification of severity is useful but difficult to apply to individual cases. The aetiopathogenesis remains unclear. Many arguments are in favour of a progressive degeneration of the fibromuscular structure of the internal haemorrhoidal plexus responsible for his prolapse in the anal canal. Most patients suffering from haemorrhoids are relieved by simple dietary advice. Moderate prolapsing haemorrhoids are significantly improved by rubber band ligation. Surgical haemorrhoidectomy remains the procedure of choice in patients with advanced prolapsing haemorrhoids.

[Anal surgery in Crohn disease]. / Chirurgie anale dans la maladie de Crohn.

For twenty years, opinions concerning local surgery of anal lesions in Crohn's disease have changed in practice and in the literature. We have reviewed 209 patients, usually in remission of disease, with at least 6 months' follow-up, who underwent local surgery for various anal lesions from 1974 to 1992. In this study, our indications and results are discussed and compared to the literature. Results of partial haemorrhoidectomy are successful. In anorectal stenosis, with rectal involvement, surgery improves the symptoms and can avoid or delay proctectomy. Results of surgery for simple fistulas appear to be identical in cases with or without Crohn's disease. In complex and suprasphincteric fistulas, seton management improves chronic suppuration, occasionally cures the lesion and reduces the number of tracts. After seton drainage, transanal rectal advancement flaps can be performed, but the results of this procedure have yet to be confirmed.

[Hyperthyroidism: a possible factor of cholestasis associated with hyperemesis gravidarum of prolonged evolution]. / L'hyperthyroïdie: un facteur possible de cholestase associée aux vomissements gravidiques incoercibles d'évolution prolongée.

We report two cases of hyperemesis gravidarum with hyperthyroidism and jaundice. The cessation of vomiting associated with supportive care was followed by complete recovery in 5 weeks. Hyperthyroidism occurs in 60% of hyperemesis gravidarum, but jaundice is uncommon. The association of jaundice and hyperthyroidism suggests that hyperthyroidism is a possible factor of cholestasis in patients with hyperemesis gravidarum.

Hepatitis C virus infection in anti-HIV positive and negative French homosexual men with chronic hepatitis: comparison of second- and third-generation anti-HCV testing.

To determine the prevalence of hepatitis C virus (HCV) infection in homosexuals with chronic hepatitis, we tested for anti-HCV antibodies 113 (47 anti-HIV positive) French non-drug-addicted homosexual men admitted for chronic viral hepatitis. Anti-HCV were detected with second- and third-generation ELISAs (ELISA2 and ELISA3) and RIBAs (RIBA2 and RIBA3). Chronic hepatitis was related to non-A, non-B infection in four, to hepatitis D virus (HDV) infection in five and to hepatitis B virus (HBV) infection in 104 patients. Anti-HCV positivity was found in 50.4% and 12.4% of the 113 patients, with ELISA2 and ELISA3, respectively. Positivity with RIBA2 and RIBA3 was found in only six of the 57 ELISA2 positive patients (all six were ELISA3 positive). The high prevalence of positivity with ELISA2 not confirmed by RIBA2 or RIBA3 suggests false-positive results. ELISA2 positive results were more frequent with frozen serum samples than with fresh serum samples (62% vs 23.5%, p = 0.0003). However, even with fresh serum, ELISA2-positive RIBA-negative results remained frequent in anti-HIV positive patients. ELISA3 seems to give more specific results. We conclude that the prevalence of HCV infection, as assessed with RIBA, was 5.3% among French homosexual men with chronic hepatitis (3.8% after exclusion of transfused patients). This low prevalence suggests that homosexual transmission of HCV is relatively uncommon.

Recombinant alpha interferon for chronic hepatitis B in anti-HIV positive patients receiving zidovudine.

In this pilot study of the effects of interferon alfa in 10 anti-HIV positive, chronic hepatitis B patients treated with zidovudine (AZT), tolerance to interferon was good and similar to that in anti-HIV negative patients. After treatment, the HIV stage and CD4 lymphocyte count were unchanged. In two patients hepatitis B virus (HBV)-DNA and hepatitis B e antigen (HBeAg) disappeared and the serum alanine aminotransferase (ALT) returned to normal; loss of hepatitis B surface antigen (HBsAg) with absence of histopathological activity was observed after treatment in one of these patients. These preliminary results need to be confirmed by a larger study.

Herpesvirus infection of the respiratory tract in patients with alcoholic hepatitis.

Respiratory herpesvirus infections have rarely been described in alcoholics. We report four cases of severe respiratory herpesvirus infections in patients with alcoholic liver disease. Two were related to Herpes Simplex Virus and two to Cytomegalovirus. Both chronic alcoholism and severe liver disease induce immunosuppression, which might account for these unusual herpesvirus infections of the respiratory tract. These cases suggest that infections with herpesviruses should be considered in patients with alcoholic liver disease and pulmonary or tracheobronchial disease unresponsive to standard antibiotic therapy. Bronchoscopy, viral culture, and serological tests appear warranted, particularly given the existence of specific therapy.

Anal fissure: correlation between symptoms and manometry before and after surgery.

The study compared symptoms and manometric results in 76 patients (42 men and 34 women; median age: 45 years) before and at long-term follow-up (median time: 54 months) after fissurectomy with posterior midline sphincterotomy for anal fissure. The fissure healed in all cases. Sporadic loss of continence for flatus or for liquid stool occurred in 21 patients (27.6%) and soiling was present in 7 other patients (9.2%). Preoperative maximum resting anal pressure was significantly greater in the study group compared with 40 control subjects (p less than 0.001). Postoperative resting anal pressure fell significantly (p less than 0.001) and remained low on long-term assessment. Postoperative maximal squeeze pressure remained unchanged. No correlation could be found between preoperative and postoperative clinical symptoms (including continence) and anorectal manometry.

Pulsatile tinnitus: three cases of arteriovenous fistula treated by ligation of the occipital artery.

Pulsatile tinnitus resulting from an abnormal communication between the occipital artery and the transverse or lateral sinus is a rare clinical entity. We report three cases which presented over a period of three years who had such abnormalities demonstrated angiographically and were cured of their symptoms by exploration and ligation of the occipital artery.