Does Spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?

BACKGROUND: After emergency department (ED) discharge, Spanish-speaking patients with limited English proficiency are less likely than English-proficient patients to be adherent to medical recommendations and are more likely to be dissatisfied with their visit. OBJECTIVES: To determine if integrating a longitudinal medical Spanish and cultural competency curriculum into emergency medicine residency didactics improves patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency. METHODS: Our ED has two Emergency Medicine Residency Programs, University Campus (UC) and South Campus (SC). SC program incorporates a medical Spanish and cultural competency curriculum into their didactics. Real-time Spanish surveys were collected at SC ED on patients who self-identified as primarily Spanish-speaking during registration and who were treated by resident physicians from both residency programs. Surveys assessed whether the treating resident physician communicated in the patient's native Spanish language. Follow-up phone calls assessed patient satisfaction and adherence to discharge instructions. RESULTS: Sixty-three patients self-identified as primarily Spanish-speaking from August 2014 to July 2015 and were initially included in this pilot study. Complete outcome data were available for 55 patients. Overall, resident physicians spoke Spanish 58% of the time. SC resident physicians spoke Spanish with 66% of the patients versus 45% for UC resident physicians. Patients rated resident physician Spanish ability as very good in 13% of encounters - 17% for SC versus 5% for UC. Patient satisfaction with their ED visit was rated as very good in 35% of encounters - 40% for SC resident physicians versus 25% for UC resident physicians. Of the 13 patients for whom Spanish was the language used during the medical encounter who followed medical recommendations, ten (77%) of these encounters were with SC resident physicians and three (23%) encounters were with UC resident physicians. CONCLUSION: Preliminary data suggest that incorporating Spanish language and cultural competency into residency training has an overall beneficial effect on patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency.

Nonsurgical causes of pneumoperitoneum.

The radiographic manifestation of free air in the peritoneal cavity suggests serious intra-abdominal disease and the need for urgent surgical management. Yet, about 10% of all cases of pneumoperitoneum are caused by physiologic processes that do not require surgical management. We retrospectively reviewed cases of nonsurgical causes of pneumoperitoneum at the 2 teaching hospitals of a university medical center between January 1990 and December 1995. Successful management by observation and supportive care without surgical intervention was defined as the diagnostic feature of nonperforation. Failure of a laparotomy to delineate a surgical cause or to result in a reparative procedure is congruent with a nonsurgical cause of pneumoperitoneum. During this period, 8 patients (6 men and 2 women; mean age, 61 years) were identified with nonsurgical causes of pneumoperitoneum. Two patients underwent negative laparotomy, and the other 6 were successfully managed nonoperatively and discharged from the hospital. In 6 patients, a cause of the pneumoperitoneum was identified. The causes may be grouped under the following categories: postoperatively retained air, thoracic, abdominal, gynecologic, and idiopathic. In our review of the literature, 61 of 139 reported cases underwent surgical treatment without evidence of perforated viscus. To avoid unnecessary surgical procedures, both primary medicine physicians and surgeons need to recognize nonsurgical causes of pneumoperitoneum. Conservative management is warranted in the absence of symptoms and signs of peritonitis.

Risk factors in patients undergoing major nonvascular abdominal operations that predict perioperative myocardial infarction.

BACKGROUND: Perioperative myocardial infarction (PMI) is an uncommon but serious complication of major abdominal surgery. Identifying the patients at risk may potentially reduce morbidity and mortality. In this study we determined risk factors associated with PMI in patients undergoing abdominal, nonvascular surgery (ANVS). METHODS: The utility of risk factors for PMI using Goldman's criteria and nine other variables were compared in patients diagnosed with PMI after ANVS (group I) and a control group (group II) matched for age, gender, and type of operation. RESULTS: Thirty-four patients, 21 men and 13 women, with a mean age of 70 years were diagnosed with PMI, which was associated with a 41% mortality rate (14 of 34). Risk factors for PMI included poor general condition, congestive heart failure, abnormal cardiac rhythm, smoking, previous myocardial infarction (MI), and emergent operation. CONCLUSION: Although PMI following ANVS is uncommon, the mortality rate remains high. Patients classified as Goldman's class III and IV, or with a history of cigarette smoking, previous MI, or angina merit further evaluation in order to reduce the incidence of this complication.

Lower extremity iatrogenic nerve injury due to compression during intraabdominal surgery.

BACKGROUND: latrogenic nerve injury due to poor positioning and external compression is a common surgical complication. However, sciatic neuropathy from external compression and femoral nerve injury after self-retaining retraction are less-published complications. METHODS: Surgical Morbidity and Mortality Reports from 1986 through 1995 were reviewed to identify femoral and sciatic neuropathies following intraabdominal vascular and general surgeries. RESULTS: Two sciatic and 5 femoral neuropathies were reported, an incidence of approximately 0.17% of abdominal cases. Sciatic injuries were attributed to external compression, whereas femoral neuropathies were due to compression by self-retaining retraction. The 3 female and 4 male patients had a mean age of 53.4 years, and no patient had a prior history of peripheral neuropathy. Mean operating time for sciatic injuries was 8.2 hours, versus 4.3 hours for femoral neuropathies. Both patients with sciatic neuropathy had complete resolution of symptoms, compared with 1 femoral neuropathy patient. Two femoral neuropathies were permanent, 1 had partial resolution and 1 had improvement at 4 months but was lost to follow-up. CONCLUSIONS: Sciatic and femoral compression neuropathies are rare but serious complications of abdominal surgery. When retracting in the deep pelvis, consideration should be given to using small, well-padded retractor blades and repositioning these regularly. Prevention of sciatic nerve compression requires careful padding of the table surface, especially for longer cases.

Contemporary medical therapy for gastroesophageal reflux disease.

Gastroesophageal reflux disease is a chronic disorder that requires long-term therapy in most patients. The appropriate medical therapy should be individualized to the severity of symptoms, the degree of esophagitis and the presence of other acid-reflux complications. Lifestyle changes should form the basis of any therapeutic approach. In patients with mild to moderate disease, initial therapy with histamine H2-receptor antagonists in conventional dosages is suggested. Prokinetic agents are potentially useful in patients with impaired esophageal or gastric motor function, but their efficacy as single agents does not appear to surpass that of standard doses of H2 blockers. Sucralfate, a cytoprotective agent, is an additional therapeutic option. For patients with more severe disease, omeprazole and lansoprazole provide unequaled healing rates and accelerated symptom relief. In most patients, maintenance therapy is vital. Surgery is indicated in patients whose disease is refractory to medical therapy and in those who develop complications not amenable to medical therapy.

Site-specific pharmacokinetics and pharmacodynamics of intramuscular meperidine in elderly postoperative patients.

OBJECTIVE: To examine and compare the pharmacokinetics and pharmacodynamics of meperidine when administered intramuscularly at gluteal and deltoid sites in elderly postoperative patients. DESIGN: Prospective, randomized investigation. SETTING: Tertiary care university teaching hospital. PATIENTS: Fourteen patients 60 years of age or older who were undergoing general surgery. INTERVENTION: A single dose of meperidine 0.75 mg/kg given intramuscularly at either a deltoid or gluteal site. MAIN OUTCOME MEASURES: Pharmacokinetic (based on concentration-time curves) and pharmacodynamic (i.e., pain scales, need for additional pain medication) comparisons were made, based on site of meperidine injection. RESULTS: No statistically significant differences were found in the maximum plasma concentration, volume of distribution, or clearance of meperidine by site of injection. Substantial interpatient variability in pharmacokinetic parameters was noted for both sites (range of maximum concentrations: 191-500 ng/mL gluteal, 166-374 ng/mL deltoid). Although pain scores were similar for the two groups, four of the patients in the group given gluteal injection required additional breakthrough pain management within 4 hours of meperidine injection compared with one patient in the group given deltoid injection. CONCLUSIONS: There is no obvious relationship between meperidine pharmacokinetic and pharmacodynamic parameters, regardless of intramuscular injection site. Breakthrough pain is common when patients are given intramuscular injections postoperatively, particularly when the gluteal route is used. When meperidine is used for analgesia in elderly postoperative patients, consideration should be given to more rapid and predictable routes (e.g., intravenous injection) of meperidine administration.

Clinical presentation and management of iatrogenic colon perforations.

BACKGROUND: Because iatrogenic colonic perforation is uncommon, surgical management of this complication has been based on the civilian trauma experience. In this study, we determine the incidence, clinical presentation, and management of colonic perforations resulting from colonoscopy or barium enema. PATIENTS AND METHODS: The medical records of all patients with colorectal perforations due to barium enema or colonoscopy seen over a 5-year period were reviewed. RESULTS: Twenty-one patients, 12 males and 9 females aged 66 +/- 16 years, undergoing evaluation for polyps and bleeding (11), diverticulosis (4), diarrhea (2), or miscellaneous indications (4) sustained colonic perforation from colonoscopy (18; 0.20%) or barium enema (3; 0.10%). Abdominal pain, 66% (13), and fever, 24% (5), were the most frequent symptoms encountered and extraluminal air, 67% (14), the most common radiologic finding. The site of perforation was the rectosigmoid in 62% (13) of patients. Eighteen patients underwent surgery; 11 within 24 hours (group I) and 7 patients within 6.0 +/- 4 days (group II). Fifty percent (9 of 18) had primary repair or resection with anastomosis without mortality. Of the 6 patients initially treated nonoperatively, 3 subsequently underwent surgery. Both deaths, one in group I and one in group II, occurred in patients who had colonic diversion for perforation following colonoscopy. CONCLUSION: We conclude that in the absence of significant contamination either primary repair or resection and anastomosis can be performed with acceptable morbidity for iatrogenic perforations of the colon.

Aspiration pneumonia following surgically placed feeding tubes.

BACKGROUND: The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted. PATIENTS AND METHODS: We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph. RESULTS: Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant). CONCLUSIONS: There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals.

Abdominal wall hernias in patients with abdominal aortic aneurysmal versus aortoiliac occlusive disease.

BACKGROUND: This study was undertaken to determine the incidence of ventral incisional hernias (VIHs) and inguinal hernias (IHs) in patients with abdominal aortic aneurysmal (AAA) versus those with aortoiliac occlusive disease (AIOD). PATIENTS AND METHODS: The medical records of 193 patients (128 with AAA and 65 with AIOD) who had undergone elective aortic reconstruction were reviewed to determine the number and location of abdominal wall hernias (AWHs). RESULTS: Forty-one AWHs (28 IHs and 13 VIHs) were detected in patients with AAA compared to 13 (11 IHs and 2 VIHs) in patients with AIOD. There was a significantly greater incidence of VIHs in patients with AAA versus patients with AIOD (10% versus 3%, P < 0.05) and recurrent AWHs (28% versus 19%, P < 0.01), but not of IHs (22% versus 17%). CONCLUSION: Patients with AAA have a higher incidence of VIHs and recurrent AWHs--without a corresponding increase in patient-related risk factors--than patients without aneurysm, suggesting that as yet unidentified etiologic factors may contribute to the development of AWHs in these patients.

Surgical treatment of symptomatic biliary stones in patients with cystic fibrosis.

Patients with cystic fibrosis have a high incidence of cholelithiasis. However, few studies have addressed the operative therapy for cholelithiasis in this group of patients with poor pulmonary function. We reviewed six patients with cystic fibrosis who were treated for symptomatic biliary stones. Five patients underwent cholecystectomy for chronic cholecystitis. One patient with extremely poor pulmonary status presented with choledocholithiasis and cholangitis, which was successfully treated with endoscopic sphincterotomy followed by ursodeoxycholic acid therapy. Five of these six patients had significant relief of their symptoms. One patient never recovered completely from the operation and eventually died from continued pulmonary deterioration. We conclude that in patients with cystic fibrosis and symptomatic biliary stones, careful attention to pulmonary care can afford safe, elective cholecystectomy. More conservative treatment is indicated in patients with marginal pulmonary reserve.

Cellular origin and rate of endothelial cell coverage of PTFE grafts.

To determine the origin, cell type present, and rate of endothelial cell coverage of PTFE grafts, 5-cm segments of 4-mm-diameter, 60-microns PTFE grafts were implanted end-to-end bilaterally in the carotid arteries of greyhound dogs. An external jugular vein wrap was applied to the outer surface of one of the PTFE grafts; the contralateral PTFE graft, which was unwrapped, served as its control. Two dogs each were sacrificed at 3, 5, 7, 14, 21, 28, and 35 days postimplantation. Anastomotic endothelial ingrowth was analyzed using scanning electron microscopy. Microvessel ingrowth was documented in longitudinal H&E sections. Cell identity was established by immunohistochemistry with factor VIII antibody, Ulex europaes, leukocyte common antigen, and antibodies to alpha-actin, desmin, vimentin, and basic fibroblast growth factor. All grafts were patent at the time of harvest. Endothelial cell migration from the native artery adjacent to the anastomosis commenced at 7 days, extended to 5 mm beyond the proximal and distal anastomoses by 14 days and to 1.0 cm by 35 days. Endothelialization of the mid-portion of the wrapped grafts occurred via microvessel ingrowth, a process which began at 7 days. Microvessels reached the luminal surface by 28 days and an endothelial cell monolayer was established by 35 days. Wrapping the external surface of the graft with vein increased the rate of graft healing. Basic fibroblast growth factor was detectable by immunohistochemistry at the vein wrap-graft interface in the first 14 days.

Stereotactic fine-needle aspiration cytology of nonpalpable breast lesions: an analysis of 258 consecutive aspirates.

BACKGROUND: The role of stereotactic fine-needle aspiration cytology (SFNAC) in the diagnosis of nonpalpable breast lesions is poorly defined. PATIENTS AND METHODS: Data were prospectively collected from 225 consecutive patients with nonpalpable breast lesions who had aspiration cytology followed by immediate surgical excision. RESULTS: Between 1988 and 1993, 258 such procedures were performed. The results of 84 (33%) were interpreted as benign, 84 (33%) as atypical, 28 (11%) as suspicious for malignancy, and 49 (19%) as malignant. In all, 88 (34%) surgical specimens were malignant. SFNAC had an 80% sensitivity, a 96% specificity, a 91% positive predictive value, and an 89% negative predictive value. There were 18 false-negative and 7 false-positive aspirates. CONCLUSIONS: SFNAC for diagnosing nonpalpable breast lesions is moderately sensitive and highly specific, and has a high positive and negative predictive value. In conjunction with mammography and clinical assessment, the procedure is useful for determining which patients with nonpalpable breast lesions may require surgical biopsy.

Contraindications and complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a commonly performed procedure for the removal of symptomatic gallstones. Compared with open cholecystectomy, laparoscopic cholecystectomy is associated with less postoperative pain, earlier discharge from the hospital and a more rapid recovery. However, there are specific contraindications to the procedure, including empyema of the gallbladder, gangrenous cholecystitis, coagulopathy, portal hypertension and peritonitis. Complications from laparoscopic cholecystectomy include common duct injury, bleeding, bile leakage and wound infection. An understanding of these issues allows the family physician to more appropriately select patients for laparoscopic removal of the gallbladder.

Risk of nonshunt abdominal operation in the patient with cirrhosis.

BACKGROUND: The hazards of operative treatment for variceal hemorrhage and intractable ascites in patients with cirrhosis are well known. Much less information is available on the morbidity and mortality in these patients after abdominal operations not directly related to the sequelae of portal hypertension. STUDY DESIGN: We reviewed the records of 77 consecutive histologically proved cases of cirrhosis in patients undergoing 85 general surgical, abdominal procedures during a ten year period. Logistic regression analysis was done on 32 preoperative and intraoperative variables with relation to postoperative outcome. RESULTS: There were 47 men and 30 women, with a mean age of 61 years (range of 28 to 86 years). The 30-day mortality rate was 18 percent (15 of 77 patients). Emergent operation was associated with a mortality rate of 32 percent (11 of 35 patients) compared with 8 percent (four of 50 patients) after elective procedures (p < 0.05). Extensive complications occurred in 28 percent of patients (24 patients; 14 percent after elective operative treatment and 49 percent after emergent procedures). The mortality rate was greatest after gastric procedures (38 percent). Other factors of statistical significance (p < 0.05) associated with poor postoperative outcome included cachexia, preoperative transfusion of fresh frozen plasma, and intraoperative platelet transfusion. Surprisingly, operative blood loss, presence of ascites, and operative time were not associated with increased complications or death. CONCLUSIONS: We conclude that elective, nonshunt abdominal operations can be performed with acceptable morbidity and mortality rates in selected patients with cirrhosis.

Subcapsular hematoma after laparoscopic cholecystectomy, associated with ketorolac administration.

Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. Its adverse effect profile is different from that of the opioid analgesics; in particular, in its lack of respiratory depressive actions. However, ketorolac has risks associated with its perioperative administration, including episodes of substantial gastrointestinal bleeding. A patient undergoing elective laparoscopic cholecystectomy developed a subcapsular hepatic hematoma shortly after receiving a dose of injectable ketorolac. No evidence of parenchymal injury was found on laparoscopy, which argues against iatrogenic trauma. Clinicians should be aware that ketorolac may cause or aggravate bleeding, and it should be used with caution in perioperative patients.

Factors influencing the safety of colostomy closure in the elderly.

Although colostomy closure is a commonly performed surgical procedure, there remains concern that the attendant risks may be misjudged, especially in the elderly. The purpose of this study was to evaluate the safety of performing colostomy closure and to define the factors that may influence morbidity and mortality in patients over the age of 70. Three hundred seven patients (178 males, 129 females) underwent colostomy closure over a 5-year period. The mean age was 52 years and 84 (27%) of the patients were 70 years or older. The indications for colostomy included diverticulitis, 115 (38%); malignancy, 47 (15%); perforation 35 (11%); trauma, 34 (11%); congenital anomalies, 26 (8%); obstruction, 13 (4%); bleeding, 6 (2%); colovesical fistulae, 6 (2%); polyps, 2 (0.7%); and miscellaneous, 23 (8%). An end colostomy was performed in 193 (63%) patients and a transverse loop colostomy in the remaining 114 (37%). There were no deaths. Complications occurred in 27 (9%) patients: 17 were directly related to colostomy closure (8 wound infections, 3 intraabdominal abscesses, 3 small bowel obstructions, 2 anastomotic strictures, and 1 anastomotic leak) while 10 were nonsurgical. Risk factors statistically associated with increased morbidity included age > 70 years (13% versus 5%), end versus loop colostomy (10% versus 2%), an operative time > 2 hr, and estimated blood loss > or = 500 ml (P < 0.05). ASA classification was only predicative of postoperative complications in patients over 70 years of age. We conclude that although colostomy closure can be performed without mortality, the increased morbidity associated with this procedure in patients 70 years or older necessitates careful preoperative assessment.

Albumin and prealbumin concentrations in patients receiving postoperative parenteral nutrition.

This prospective, nonrandomized study was conducted to compare the increases in albumin and prealbumin concentrations in postoperative patients given adequate nutrition support. All surgery patients at least 18 years of age and who required parenteral nutrition were included. Of 86 patients evaluated, 16 met all criteria for study entry. Blood for albumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then weekly. Blood for prealbumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then twice weekly. Albumin concentrations increased from 2.00 +/- 0.35 to 2.21 +/- 0.42 g/dl (NS). Prealbumin concentrations increased from 11.97 +/- 6.31 to 17.29 +/- 8.93 mg/dl (p = 0.017). All but one prealbumin concentration was in the normal range for our laboratory when parenteral nutrition was discontinued. None of the albumin concentrations were ever in the normal range. The prealbumin concentration is a better indicator than albumin of nutrition status in the postoperative patient. Since prealbumin concentrations typically rise into the normal range within a week after adequate caloric supplementation, clinicians may avoid unnecessary increases in protein-calorie intake and laboratory testing of nutrition status by using this measurement.

Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis.

The diagnosis of acute appendicitis is usually made from the history and physical examination. Recently, abdominal ultrasonography (US), laparoscopy, computerized tomography (CT), and barium enema (BE) have been used in the preoperative evaluation of patients with presumed appendicitis in order to improve the diagnostic accuracy. However, the usefulness of these tests in verifying the diagnosis of appendicitis has not been established. We reviewed the medical records of 203 patients who underwent appendectomy. One hundred patients were surgically treated before 1984 (group I) and 103 patients underwent surgery after 1988 (group II). Patients in group II were more likely to have preoperative US, laparoscopy, CT, or BE (24 in group II versus 3 in group I, p < 0.05). When groups I and II were compared, the rates of perforation (27% versus 20%), normal appendectomy (8% versus 11%), and the interval between admission and operation (12.2 hours versus 10.7 hours) and length of hospitalization (5.0 days versus 5.1 days) were not significantly different. We concluded that although adjunctive testing may be beneficial in selected patients, its routine use in patients suspected of having appendicitis cannot be advocated at present.

Age- and gender-related differences in 24-hour esophageal pH monitoring of normal subjects.

Twenty-four-hour esophageal pH monitoring is currently the most sensitive test for diagnosing gastroesophageal reflux. Little is known, however, about the effect of aging and gender on esophageal acid exposure in asymptomatic individuals. Thirty asymptomatic volunteers underwent 24-hr esophageal pH monitoring. Fifteen were < 65 years (eight female, seven male) and 15 were > or = 65 years (seven female, eight male). In this asymptomatic group no significant difference was seen by age, while males were found to have significantly more esophageal acid exposure than females. The need for sex-specific normal 24-hr pH monitoring values is suggested. Thirty percent of these asymptomatic subjects were abnormal by conventional 24-pH criteria. The clinical importance of these "silent refluxers" is unknown.

Clinical utilization and complications of sural nerve biopsy.

Surgeons frequently perform sural nerve biopsy as part of the work-up of patients with peripheral neuropathy. The indications for the procedure, therapeutic value, and complications associated with the procedure have received little attention in the surgical literature. A retrospective chart review of 60 patients with the suspected diagnosis of peripheral neuropathy undergoing sural nerve biopsy was performed. Vasculitis was suspected in 29 (48%) patients undergoing biopsy. This diagnosis was confirmed in 6 of the 29 patients and resulted in the alteration of therapy in 31% of patients with this suspected diagnosis. In 27 (45%) patients, the etiology of their peripheral neuropathy was unknown. Twelve (44%) patients in this group had sural nerve pathology; however, no change in therapy was required. Ten patients in our series had associated malignant tumors; some of these patients were diagnosed after referral for sural nerve biopsy. Twenty-five (42%) patients remained undiagnosed after biopsy. Nerve conduction studies were performed in 14 (22%) patients. Thirteen patients with abnormal lower extremity nerve conduction studies had 6 normal and 7 abnormal biopsy results. The one patient with a normal study had a normal nerve biopsy result. There were six (10%) patients with wound infections, seven (12%) patients with delayed wound healing, and three (5%) patients with new onset of chronic pain in the distribution of the sural nerve, for an overall complication rate of 27%. There was no correlation between the preoperative use of antibiotics, type of local anesthetic used, or length of nerve excised and complication rate. We conclude that the complication rate after sural nerve biopsy is significant. Strict criteria should be employed in selecting patients for sural nerve biopsy including a careful neurologic history and physical examination, nerve conduction studies, appropriate work-up for vasculitis if suspected, and implementation of a search for malignancy if this is not apparent. If the diagnosis is still in question, then sural nerve biopsy would seem appropriate, especially in patients with suspected vasculitis.