Seasonal changes in sex and adrenal steroid hormones of gopher tortoises (Gopherus polyphemus).

We sampled a population of gopher tortoises (Gopherus polyphemus) from May to October 1997 to determine seasonal cycles of steroid hormones (testosterone, T; 17beta-estradiol, E; and progesterone, P) and related them to observations of mating behavior. In males, plasma T levels peaked in July and August and remained elevated through October. This coincides with the reported time of peak mating and spermatogenesis, indicating that males display an associated pattern of reproduction. In females, E levels were high in September and October. Plasma T levels in females were elevated in May, decreased to basal levels in June and July, and rose again in August and September. Elevated E and T levels correspond to the reported time of peak vitellogenic activity, indicating that females also display an associated cycle. Plasma P in females remained basal throughout the active season, suggesting that ovulation occurs in late winter. We also determined levels of corticosterone (B) to assess the influence of capture stress on tortoises and correlated B levels with tortoise activity patterns and sex steroid levels. We found no seasonal variation in levels of B in males or females. Plasma B levels were not correlated with levels of T or E, but were positively correlated with female P levels. Further, we found no relationship between plasma B levels in males and mean distance moved, mean number of burrows used, or mean home range size. However, there was a significant negative correlation between plasma B levels and male body size. In females, there was no relationship between B levels and mean distance moved, but B levels were significantly negatively correlated with the number of burrows females occupied. Lastly, there was no relationship between levels of B and the number of minutes required to obtain blood from an animal. However, B levels increased with the length of time that a tortoise spent in a trap, suggesting that trapped tortoises do exhibit capture stress.

The role of low progesterone and tension as triggers of perimenstrual chocolate and sweets craving: some negative experimental evidence.

Approximately half of the 40-50% of North American women who crave chocolate or sweets do so principally in the perimenstrum, the part of the menstrual cycle surrounding the onset of menstruation. We test two hypotheses about the events that trigger these cravings: 1) the premenstrual drop in progesterone levels; or 2) dysphoria or tension in the perimenstruum. Chocolate craving, sweets craving, and other perimenstrual symptoms were rated daily for six menstrual cycles by a sample of women with severe premenstrual syndrome (PMS). Forty-four women satisfied criteria for cyclicity in chocolate craving, and 44 for sweet craving, determined during the first two cycles. Thirty-four subjects satisfied criteria for craving of both chocolate and sweets. After placebo treatments during the third cycle, subjects were randomly assigned, double blind, to administration of placebo, oral micronized progesterone, or alprazolam (a tranquillizer). Treatments were administered from the beginning of the third week to the second day postonset of menstruation during the fourth to sixth months of study. Neither progesterone nor alprazolam decreased chocolate or sweets craving.

Ileal pouch-anal anastomosis in children with ulcerative colitis.

SUMMARY: : This study is a retrospective review of all pediatric patients with ulcerative colitis who underwent colectomy and ileal pouch-anal anastomosis (IPAA) between 1982 and 1992 at the Cleveland Clinic Foundation. The purpose of the review was to determine the effectiveness of IPAA in treating children with ulcerative colitis. Demographic, preoperative, and surgical data were abstracted from archival research of medical records. Quality-of-life information was obtained from patient or parent interviews. Ninety-one children were identified during the study period with a median age of 14.2 years. The principal indication for colectomy was intractable symptoms despite vigorous medical therapy. J-pouches (n = 51) and S-pouches (n = 38) were most commonly constructed. Median follow-up was 1.9 years after ileostomy closure. Thirty early complications (occurring within 30 days of pouch construction) were documented in 21 patients, and 57 late complications (occurring after 30 days) were documented in 34 patients. Small bowel obstruction was the most common early postoperative complication and accounted for 13 of 30 early complications; reoperation was required in four of nine patients. Pouchitis was the most frequent late complication (15 episodes in 12 patients), followed by perineal infection (14 episodes in eight patients), and anastomotic stricture (10 episodes in nine patients). Pouch type, age at colectomy, and disease interval from colectomy to pouch construction were analyzed with relation to the frequency of pouchitis, anastomotic stricture, sepsis, and incontinence. An S-pouch had been used in eight of nine patients with an anastomotic stricture (p = 0.004). The disease interval and age at initial surgery had no bearing on the presence of late complications. The pouches of four female patients were excised as a result of pelvic infection and were subsequently converted to continent ileostomies. Quality-of-life information was obtained for 78 patients. Daytime continence was complete in 67 (86%) children and nocturnal continence was complete in 56 (72%) patients. Seventy-three (94%) patients were very satisfied with their quality of life after IPAA. We conclude that IPAA is an effective surgical procedure for children with ulcerative colitis and results in a relatively normal pattern of defecation with a good long-term functional outcome. Early postoperative complications are common, but only a few patients require further hospitalization or surgery. The most common late complication is pouchitis, which responds to medical treatment. Continence is preserved in the majority of the children, and overall satisfaction with the operation is high.

Pharmacological versus sensory factors in the satiation of chocolate craving.

This is the first experimental study directed at differentiating between physiological or sensory accounts of the satiation of nondrug cravings, using chocolate craving, the most common craving in North America. At the onset of craving, chocolate cravers consumed a chocolate bar, the caloric equivalent in "white chocolate" (containing none of the pharmacological components of chocolate), the pharmacological equivalent in cocoa capsules, placebo, and no treatment conditions had virtually no effect. White chocolate produced partial abatement, unchanged by the addition of all the pharmacological factors in cocoa. This result indicates no role for pharmacological effects in the satisfaction of chocolate craving. It also suggests a role for aroma independent of sweetness, texture, and calories.

Associated ulcerative colitis, sclerosing cholangitis, and insulin-dependent diabetes mellitus.

We report two young men with clinical and laboratory evidence of macroscopic ulcerative colitis, sclerosing cholangitis, and insulin-dependent diabetes mellitus. The first patient presented at age 15 with vomiting, abdominal pain, weight loss, and abnormal liver function test results. Liver biopsy and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated sclerosing cholangitis. Colonoscopy with biopsy revealed ulcerative colitis which responded to sulfasalazine. Diabetes occurred at age 18 and insulin therapy was begun. The second patient was 19 at presentation with diarrhea, hematochezia, and weight loss. Proctosigmoidoscopy revealed ulcerative colitis, and sulfasalazine led to clinical remission. Three months later he developed diabetes requiring insulin therapy. At age 28, he developed elevated alkaline phosphatase, and ERCP revealed sclerosing cholangitis. At age 37 he expired from adenocarcinoma that metastasized to the liver. Literature review revealed only one possible case report of this association with microscopic asymptomatic ulcerative colitis in that patient. Statistical analysis suggests that this association is real rather than a chance occurrence. An autoimmune process may be involved and a specific histocompatibility locus antigen (HLA) type may exert a regulatory influence.

The spectrum of eosinophilic gastroenteritis. Report of six pediatric cases and review of the literature.

Eosinophilic gastroenteritis is an inflammatory disease of unknown etiology characterized by infiltration of the gastrointestinal tract with eosinophilic leukocytes, accompanied by varying abdominal symptoms and usually by peripheral blood eosinophilia. We report our experience with six pediatric cases presenting to the Cleveland Clinic Foundation over the past eight years. Unusual findings in our patients included ascitic fluid without eosinophilia and eosinophilic pericarditis (one patient), and eosinophilic cholecystitis (one patient). Endoscopic examination and biopsy helped to establish the diagnosis in all patients. Bone marrow aspiration supported the diagnosis by demonstrating eosinophilia and identifying reactivation of the disease, even in cases without peripheral eosinophilia. All six patients responded promptly to prednisone. Diagnosis is challenging and eosinophilic gastroenteritis may be more common than is recognized. This series of cases significantly expands the spectrum of the disease in children, and documents the usefulness of diagnostic endoscopy in this condition.

Management of inflammatory bowel disease: 30 years of observation.

Management of inflammatory bowel disease has become more precise and effective in the last 30 years, ensuring long, productive lives for most patients. Data such as family history, duration of disease, the onset of complications, and type of therapy are presented from 450 patients with inflammatory bowel disease treated during a 10-year period ending in 1984. The incidence of general complications over three decades is compared. Perianal disease and intestinal obstructions dominate complications of Crohn's disease. The most common nongastrointestinal complication for patients with either disease is monarticular large joint arthritis. Approximately 75% of patients with Crohn's disease will eventually undergo surgery. In the first decade of data collection, 50% of patients with ulcerative colitis had surgery; in the second decade, 26%; and in the third decade, 39%. The changing percentages correspond initially to advances in medical therapy and then to advances in surgical therapy.

Management of children and adolescents with inflammatory bowel disease.

The management of children and adolescents with inflammatory bowel disease requires all the skills offered by the health care team. This article reviews the principles of therapy, the specifics of therapy, and the attitudes of the authors relating to long-term management of these patients. Specific recommendations relating to nutritional support for patients are also made. A pertinent updated bibliography is also given.

High prevalence of antibodies to intestinal epithelial antigens in patients with inflammatory bowel disease and their relatives.

STUDY OBJECTIVE: To assess whether healthy members of families of patients with inflammatory bowel disease share an immune reactivity to gut epithelial cell antigens. DESIGN: Assessment of immune reactivity against epithelial-cell-associated components (ECAC). METHODS: Detection of specific anti-ECAC serum antibodies by antibody-dependent cellular cytotoxicity (percent specific lysis) and by immunoblotting (Western blots). PATIENTS: Index cases (131) and first-degree relatives in 17 families with 2 or more affected members, and 13 with only 1 member affected. MAIN RESULTS: Compared with a gastrointestinal disease control group (0.5% +/- 0.8%), specific lysis against ECAC-C (colon-derived) among patients with inflammatory bowel disease was significantly greater in both multiply affected (8.4% +/- 8.2%; P less than 0.01) and singly affected (5.2% +/- 5.4%; P less than 0.05) families. In contrast, specific lysis by patients with other inflammatory processes of the small and large bowel (1.1% +/- 1.4%) or autoimmune disease (0.7% +/- 1.0%) did not differ from that of the gastrointestinal disease control group. Among relatives of patients with inflammatory bowel disease (index cases), specific lysis was also significantly higher than in the control group (4.8% +/- 5.5% for multiply affected, P less than 0.01, and 4.3% +/- 5.5% for singly affected, P less than 0.05). Relatives of patients with chronic inflammatory liver disease had a level of lysis (0.6% +/- 0.9%) similar to that of controls. The prevalence of antibodies to ECAC-C was 69.7% among patients with chronic inflammatory bowel disease, and 55.7% among relatives; both prevalences were significantly higher than that of the control group (8.0%, P less than 0.001). Using small-bowel-derived ECAC, the prevalence of antibodies among patients with inflammatory bowel disease and relatives was also significantly higher than that of controls. Reactivity of sera was directed to a 160- and a 137-kilodalton macromolecule. CONCLUSIONS: Immune sensitization to intestinal epithelial antigens is common in families with chronic inflammatory bowel disease; its high frequency among asymptomatic relatives suggests it may represent a primary phenomenon, perhaps predisposing individuals to gut tissue injury.

A survey of Cleveland Clinic training-program alumni. Implications for evaluation of graduate medical education.

The graduate of a medical training program is in a unique position to evaluate that program in comparison with the realities of medical practice. A survey of alumni of the Cleveland Clinic's graduate training programs was conducted in September 1986. The alumni's perceptions of the quality of their programs and the educational services provided by the Division of Education are discussed in relation to the educational administrative structure and evaluation process at The Cleveland Clinic Foundation. The need for such evaluation methods, as well as additional techniques to provide a comprehensive evaluation system in graduate medical education, is emphasized.

A peer review process to assess the quality of graduate medical education.

Accreditation standards for graduate medical education require the internal evaluation of programs. In this paper, the authors describe a system of peer review instituted to meet these requirements and report on the supporting administrative structure and outcome of the peer review process. Although time-consuming and in some cases causing apprehension among staff members and residents, the experience of a peer review process was useful for staff members, residents, and administrators. Peer review was found to be effective in identifying program strengths and weaknesses and in increasing communication among staff members and between administrators and staff members about the teaching programs.

Marketing issues in continuing medical education.

Marketing is an important component of continuing medical education (CME). However, marketing is more than the identification of methods to recover costs of delivering programming. It focuses on meeting the needs and desires of physician participants, identifying an appropriate location, satisfying the goals of a sponsoring institution, and making an effect on the quality of care given by receivers and deliverers of CME. This paper discusses these issues as well as describes results of a survey designed to gather opinions on CME activities from alumni of training programs of a large, referral-based, multispecialty group practice. The data suggest that CME programs should be targeted to certain specialty groups as determined by field of training rather than practice specialty. Physicians' preferences for CME activities held at resort settings should be considered. Finally, participation in CME may itself be a marketing tool for a sponsoring institution to increase referrals.

Dumping syndrome in children.

Dumping syndrome developed in seven children after gastric surgery, (Nissen fundoplication in six, Whipple procedure in one). The patients ranged from age 10 months to 13 years, and four of the seven were neurologically impaired. The diagnosis was made by demonstrating an abnormal response to an orally administered glucose challenge. The pediatric literature records only eight cases, but we believe that dumping syndrome is more common in children than once believed. Dietary management can often dramatically diminish the associated symptoms.