Constipation, diarrhea, and irritable bowel syndrome.

Constipation, diarrhea, and irritable bowel syndrome are commonly encountered in the primary care practice. Most episodes of constipation and diarrhea are benign and self-limited. Patients with chronic constipation should undergo a screening evaluation to exclude organic disease, after which most can be managed successfully with dietary modification and fiber supplementation. The cause of chronic diarrhea usually can be discerned clinically, with irritable bowel syndrome, inflammatory bowel disease, and lactose intolerance being diagnosed most frequently. Irritable bowel syndrome is a functional gastrointestinal disorder characterized by abdominal pain and disordered defecation, which is successfully managed with a strong physician-patient relationship and periodic pharmacologic intervention.

Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population.

PURPOSE: Since 1991 we have performed more than 300 anatomical radical perineal prostatectomies at Brooke Army and Wilford Hall Medical Centers, and were initially aware of 8 patients who presented with unsolicited postoperative fecal incontinence. We determined the incidence of fecal and urinary incontinence following radical prostatectomy, defined parameters to identify patients at risk for fecal complaints following radical prostatectomy, and estimated the impact of fecal incontinence on lifestyle and activities. MATERIALS AND METHODS: Initially a validated 26-question telephone survey was used to evaluate 227 patients who had previously undergone radical prostatectomy at 1 of our 2 institutions. Based on results of the telephone survey a national survey was mailed to 1,200 radical prostatectomy patients randomly selected from a nationwide database of Department of Defense health care system beneficiaries. All patients had undergone radical perineal or retropubic prostatectomy at least 12 months before being contacted for the survey. RESULTS: Responses to the telephone survey from 227 patients revealed that fecal incontinence was a problem after radical retropubic (5%) and perineal (18%) prostatectomy and less than 50% of those with fecal incontinence had told the physician. Our mail survey (response rate 80% and 78% usable for analysis, 784 radical perineal and 123 perineal) strongly indicated that fecal incontinence after radical prostatectomy is a problem nationwide. Frequency of fecal incontinence (daily, weekly, monthly or less than monthly occurrences) was significantly higher among radical perineal (3, 9, 3 and 16%) compared to retropubic prostatectomy (2, 5, 3, and 8%) patients (p=0.002). Fecal incontinence had a significant negative effect on patient social or entertainment activities (p=0.029), and travel and vacation plans (p=0.043). Radical perineal compared to retropubic prostatectomy patients were more likely to wear a pad for stool leakage (p=0.013), experienced more accidents (p=0.001), had larger amounts of stool leakage (p=0.002) and had less formed stools (p=0.001). Of radical perineal prostatectomy patients only 14% and of retropubic only 7% with fecal incontinence had ever told a health care provider about it, even when the incontinence was severe. Responses to our survey concerning urinary incontinence showed that radical perineal prostatectomy patients had a lower rate of urinary incontinence immediately after prostatectomy compared to retropubic (79 versus 85%, p=0.043). A higher proportion of perineal patients reported that all urinary leakage had ceased, that is full continence had returned (perineal 70%, retropubic 53%, p=0.001). A smaller proportion of perineal patients found it necessary to wear a pad to protect from urinary incontinence (perineal 39%, retropubic 56%, p=0.004). CONCLUSIONS: Fecal incontinence following radical prostatectomy occurs more frequently than previously recognized. In general fecal incontinence among radical perineal and retropubic prostatectomy patients surpasses the expected incidence rate of 4% for this age group (60 to 70 years) but incidence is significantly higher for radical perineal prostatectomy patients. However, radical perineal prostatectomy patients have a significantly lower incidence of urinary incontinence than those treated with retropubic prostatectomy. Surgeons who perform radical retropubic and perineal prostatectomy should be aware of the possibility of fecal and/or urinary incontinence and associated symptoms.

Intraoperative abandonment of ileal pouch to anal anastomosis--the Mayo Clinic experience.

BACKGROUND: Completion of the ileal pouch to anal anastomosis (IPAA) is neither always possible nor advisable based on intraoperative findings. This study was undertaken to document the incidence of and reasons for intraoperative abandonment of IPAA in a series of over 1,700 attempts. STUDY DESIGN: A retrospective review of the Mayo Clinic surgical index from January 1981 through December 1995. Patients with the preoperative diagnosis of chronic ulcerative colitis or familial adenomatous polyposis for whom IPAA was planned but not completed are the subject of this report. Comparison is made to patients with a completed IPAA from the Mayo Clinic IPAA registry. RESULTS: During a 15-year period, 1,789 IPAA attempts were made. Intraoperative abandonment occurred in 74 (4.1%). Patients in whom the operation was abandoned were older than patients in whom it was not (38 versus 33 years, p < 0.01), with age older than 40 years conferring a relative risk of 1.87 versus age younger than 40 (95% confidence interval, 1.19-2.94%). IPAA was abandoned for technical reasons in 32 (43%), intraoperative diagnosis of Crohn's disease in 27 (36%), colorectal cancer in 10 (14%), mesenteric desmoid in 3 (4%), and miscellaneous reasons in 2 (3%) patients. Fifty-one (69%) patients underwent proctocolectomy and ileostomy and 23 (31%) underwent sphincter preserving procedures. Of these, 2 underwent subsequent successful IPAA. CONCLUSIONS: Preoperative counseling for IPAA should include discussion of the risk of intraoperative abandonment (4.1%). Older patients are at increased risk. If the IPAA is abandoned for reversible reasons, preservation of the anal sphincter preserves the option of a subsequent IPAA.

A phase II trial of didemnin B in myeloma. A Cancer and Leukemia Group B (CALGB) study.

Didemnin B is a member of a class of compounds, derived from a marine source, undergoing phase II study. Twenty-two patients with relapsed myeloma were treated with didemnin B at an initial dose of 4.9 mg/m2, given once every 28 days. All were evaluable for toxicity, and 15 were evaluable for myeloma response. No tumor regressions occurred in the 15 patients evaluable for response. Vomiting was the major toxicity, occurring in 73% of patients despite vigorous pre- and post-treatment medication with at least three intravenous antiemetics. Two instances of grade 4 hypersensitivity reaction occurred. We conclude that didemnin B has no activity at this dose and schedule in myeloma that has relapsed after one or two prior therapeutic regimens.

Forces for reforming the U.S. health care system: a review of the cost and access issues.

In recent years, a spate of health care reform proposals have emerged on the American agenda. Although the elements of the reform proposals often vary substantially, most of the initiatives are fuelled by two common concerns: rising health care expenditures and a growing uninsured population. National health spending, for example, commands an increasing share of U.S. gross national product despite numerous cost-containment efforts initiated by public and private payers throughout the 1980s. And the uninsured population continues to grow--by an estimated 30 percent between 1978 and 1989. To facilitate understanding of the public policy options being considered to address these concerns, the article examines U.S. health care expenditure data and some of the causes of rising health care costs. The article also discusses the demographic characteristics of the uninsured population, the reasons why they lack health coverage, and the health consequences associated with being uninsured.

Proposals to reform the U.S. health care system: a critical review.

The objective is to provide an overview and analysis of the current discussion of ways to reform the U.S. health care system. A common analytic framework is needed to evaluate the alternative approaches that are being advocated. Such a framework, organized around seven general questions, is developed and discussed. The analytic framework is then applied to five specific reform proposals, selected to be representative of the range of options being considered. The results are used to identify the basic choices that are inherent in the current discussion of health system reform. A discussion of the political realities of the health system reform movement in the U.S. concludes that an incremental reform measure will be implemented at the federal level in the near future and that the reform measure will give the federal government increased control over the health care sector. However, the pressure for more fundamental reform will continue to grow.

Ichthyosis and delusions of lizard invasion.

We report the case of a young man who developed a delusion that his body was being invaded by a lizard during an acute psychotic episode. This occurred in the context of ichthyosis presenting as scaling on his arms and legs, which he believed to be the growth of the lizard's skin.