Etiological factors and temporomandibular treatment outcomes: the effects of trauma and psychological dysfunction

This paper examines the effect of trauma and psychological dysfunction as etiological factors in temporomandibular disorder (TMD). It employs a thoroughly validated measurement system, the TMJ Scale, to determine the effects of traumatic temporomandibular joint injury as well as pre-treatment stress and psychological dysfunction levels upon presenting symptom levels. It also addresses these parameters for the eventual treatment outcome. During the course of the study, 754 patients were evaluated at the author's practice, which is limited to the diagnosis and Phase I treatment of temporomandibular dysfunction. Of those individuals, 693 (91.9%) were found to have clinically treatable temporomandibular disorders. At the time of this study, 201 consecutive patients (29%) have completed treatment and were deemed to have reached Maximum Medical Improvement (MMI). The validated measurement system of the TMJ Scale was readministered to this post treatment population. Data analysis revealed that trauma patients did not differ from non-trauma patients in initial symptom levels, nor in levels of symptom improvement (with the exception of a higher palpation pain level reported by the trauma patients). Stress and psychological dysfunction were predictive of higher initial symptom perception levels, but were not significantly related to treatment outcomes. These findings have important implications for practitioners in the field of temporomandibular studies. If it can be confirmed that psychological variables have no impact on treatment outcome, it would be difficult to justify the now frequently employed "dual axis" classifications and major emphasis placed on psychological treatment for temporomandibular patients.     

Results of biofeedback in constipated patients: a prospective study

PURPOSE: The aims of this study were to assess the results of biofeedback treatment in constipated patients and to identify variables that might be used to predict the outcome. METHOD: Twenty-eight patients (5 men; median age, 46 (range, 22-72) years) with any degree of paradoxical activation measured with thin hook needle electromyography in the external sphincter or puborectalis muscle were included. The symptom duration varied between 1 and 30 (median, 9) years. The patients had eight outpatient training sessions with electromyography-based audiovisual feedback. All patients were followed up prospectively with a validated bowel function questionnaire from which a symptom index was created. RESULTS: At three months, nine patients had no improvement and underwent other treatments. The remaining 19 patients were followed up for a median of 14 (range, 12-34) months. Twelve patients (43 percent) stated they had improved rectal emptying. A good result was associated with increased stool frequency (P < 0.05), improved symptom index (P < 0.01), and reduction of laxative use (P < 0.05). A long symptom duration, a high pretreatment symptom index, and laxative use were related to a poor result (P < 0.01-0.05). The improved group had less perineal descent (P < 0.05), and a prominent puborectalis impression on defecography tended to be more common (P = 0.06). CONCLUSION: With the use of wide inclusion criteria, biofeedback was successful in 43 percent of patients, with a treatment effect lasting at least one year. The results suggest that biofeedback should be used as the initial treatment of constipated patients with a paradoxical puborectalis contraction.     

Immunology and growth faltering of Anga children, Papua New Guinea: preliminary work

BACKGROUND: Between 1985 and 1989, only one centre in Sweden combined preoperative radiotherapy with total mesorectal excision (TME) in the primary treatment of rectal cancer. The aim of this study was to investigate whether this change in primary treatment had an impact on the outcome. METHOD: The survival rate of 94,262 patients with colorectal cancer from the total Swedish population between 1960 and 1989 was analysed. RESULTS: A continuous improvement in relative survival rate occurred during the first year of follow-up for both colonic and rectal cancer. Some improvement was also seen during follow-up years 2-5, but this was much more pronounced during the last period (1985-1989) for rectal cancer in the county of Uppsala. The improvement was particularly marked during follow-up years 3-5. CONCLUSION: There are strong indications from this study that altered primary treatment for rectal cancer results in improved long-term survival.     

Assessment and management of ulcerative colitis in children

The incidence of ulcerative colitis in school-age children in most parts of Europe has been steady at 1.5-2.0 per 100,000 children per year for the last 20-30 years. In comparison to adults, abdominal pain is a relatively frequent presenting symptom in children in addition to rectal bleeding, bloody diarrhoea or diarrhoea. Distribution of disease in children is generally more extensive (ratio rectal:left sided:extensive 25:30:45). There are remarkably few clinical trials of therapy in children and reasons for this are discussed. Subjective indices of disease severity and activity are unreliable in children. Objective measures such as endoscopy are of value to define the extent of ulceration and histopathological features; a test of gut protein loss using whole gut lavage gives an objective index of disease activity. Principles of medical management in children are generally the same as in adults with the additional need for scrupulous attention to nutrition and growth, and psychological factors. Reassuring results of a review of the health status of young adults who had developed ulcerative colitis in childhood are presented. Twenty-four of 27 considered themselves fully fit although nine of the patients had a permanent ileostomy.     

Significance of asymptomatic microhaematuria in men

Injuries of the colon and rectum are common surgical problems. Lesions can be classified into four groups according to the site of damage and the presence of sphincter tears: 1. intraperitoneal perforation without sphincter damage 2. intraperitoneal perforation with sphincter damage 3. extraperitoneal perforation without sphincter damage 4. extraperitoneal perforation with sphincter damage From 1990 to 1998, 11 patients, 7 males and 4 females presenting an anal and/or rectal trauma were admitted in Geneva University Hospital. 8 patients were admitted as an emergency, the 3 others had been transferred to correct an incontinent post traumatic pathology. No mortality. A terminal colostomy was performed in all patients with intraperitoneal injury and in 5 patients with combined extraperitoneal and anal sphincter injury. All sphincter lesions were sutured as an emergency (6 cases). In 3 patients we performed an overlapping sphincteroplasty. 2 patients with persisting incontinence were cured by a dynamic stimulated graciloplasty. The choice of treatment of anorectal trauma includes broad spectrum antibiotherapy, cleaning of the rectum, sphincter repair. A terminal diverting colostomy and laparotomy must be achieved in case of intraperitoneal injury, large extraperitoneal lesion, severe perineal laceration with or without pelvic fracture.     

Omeprazole treatment of chronic duodenal ulceration

Omeprazole, a substituted benzimidazole, is an acid pump inhibitor, introduced for treatment of chronic duodenal ulceration. In a study of 116 patients with endoscopically documented chronic duodenal ulcers, omeprazole affected healing in 77 (66.3%) patients after two weeks and 106 (91.4%) patients after four weeks, with symptoms relief in 102 (88%) patients within the first week of treatment. There was significantly higher healing rate in females (p < 0.05) and diffuse ulceration rather than single ulcers (p < 0.05). In meta-analysis comparing omeprazole to other antiulcer drugs reported in this country, there was a significant higher healing rate (p < 0.01) and symptom relief (p < 0.01) in favour of omeprazole. It proved to be effective and safe for the short term treatment of chronic duodenal ulceration.     

Tumors originating in the muscularis mucosae of the recto-sigma

Tumours arising from the muscular layer of the bowel are uncommon and extremely rare when localized in colon and rectum. Most of them arise from the external muscular layer or muscularis propria. Tumours originating in muscularis mucosae or in the vascular system are uncommon. Two hundred rectal leiomyomas and leiomyosarcomas have been described. Tumours originated in the muscularis mucosae are polypoid, pedunculated, benign and most of them will be treated by a polypectomy without recurrence. However leiomyomas arising from the muscularis propia have a 60% of recurrence after local treatment and in some cases the recurrence will be a metastatic leiomyosarcoma. Three tumours arising from muscularis mucosae of the rectum and sigma are presented. All three were diagnosed and removed by colonoscopy. Two were diagnosed as leiomyomas. The third was a low grade leiomyosarcoma and an anterior resection was performed as definitive treatment.     

Short-chain fatty acids in the treatment of radiation proctitis: a randomized, double-blind, placebo-controlled, cross-over pilot trial

PURPOSE: Treatment of chronic radiation proctitis remains unsatisfactory. Short-chain fatty acids are the preferred energy source for the colonic epithelium. We aimed to determine for the first time whether topical butyric acid enemas relieve symptoms and improve the macroscopic and microscopic findings in chronic radiation proctitis. METHODS: A randomized, double-blind, placebo-controlled, cross-over pilot trial compared patients given two weeks of butyric acid enemas (40 mmol) twice per day with those given placebo, with a one-week washout period; 15 patients were randomized and 12 completed both arms of the trial. A total symptom score combined six symptom items per week (rectal pain, episodes of rectal bleeding, amount of blood passed, days with diarrhea, number of stools, and urgency). Symptom, endoscopic, and histologic scores were obtained at the beginning of the study and again at the last week of each treatment arm. RESULTS: Total symptom score at baseline (median, 5.5) improved for those patients receiving active treatment (median, 3.5), but compared with placebo (median, 4.5), the change was not significant. Endoscopic appearances were largely unaltered by active treatment. Histology was abnormal in 82 percent of patients receiving placebo compared with 55 percent of those given butyric acid enemas (P = not significant). CONCLUSION: Butyric acid enemas do not appear to be superior to placebo in the treatment of chronic radiation proctitis.     

Healing of chronic antral gastritis: effect of sucralfate and colloidal bismuth subcitrate

BACKGROUND: Colloidal bismuth subcitrate (CBS) causes endoscopic and histological improvement in gastritis and eradication of Helicobacter pylori in patients with non-ulcer dyspepsia (NUD). The effect of sucralfate, a cytoprotective drug, on endoscopic and histologic gastritis and H pylori clearance is not clear. We studied the effect of CBS and sucralfate on these features in patients with NUD. METHODS: Sixty three patients with NUD and H pylori infection were randomized to receive one of the following for four weeks: (i) CBS (240 mg twice daily) (Group 1); (ii) placebo I, similar in size, color and shape to CBS (Group 2); (iii) sucralfate (2.0 g twice daily) (Group 3) and (iv) placebo II, similar to sucralfate (Group 4). Symptoms, endoscopic and histological findings and H pylori status were assessed before and after treatment. RESULTS: Similar symptomatic improvement was observed with each treatment, indicating a placebo effect. Significant endoscopic and histological improvement was observed with CBS only. CBS was better than sucralfate in inducing endoscopic and histological improvement. Clearance rate of H pylori was 46.6% with CBS, 16.6% with its placebo, 33.3% with sucralfate and 13.3% with its placebo. CONCLUSION: CBS is more effective than sucralfate in inducing endoscopic and histologic healing of H pylori-related gastritis among NUD patients.     

Stage I rectal cancer: identification of high-risk patients

BACKGROUND: Stage I rectal cancer (T1, T2 N0) is currently treated by surgical resection alone. Despite adequate surgical resection, approximately 10-15% of patients will develop recurrence. Identification of patients at high risk for recurrence could potentially lead to an improvement in outcome by selection of these patients for adjuvant therapy. METHODS: Between June 1986 and September 1996, 211 patients with primary rectal cancer (stage I) were treated by radical surgical resection alone. The medical data of all patients were entered into a database and prospectively followed. The following 10 prognostic factors were correlated with recurrence and tumor-related mortality: patient factors: age, gender, and preoperative carcinoembryonic antigen level; tumor factors: location from the anal verge (< 6 cm vs. > or = 6 cm), T stage (T1 vs. T2), intratumoral blood vessel invasion (BVI), intratumoral lymphatic vessel invasion, presence of tumor ulceration, and histologic differentiation; and treatment-related factors: extent of surgical resection--abdominal perineal resection versus low anterior resection. Univariate analysis of the effect of the prognostic factors on recurrence and tumor-related mortality were performed by the method of Kaplan-Meier and log rank test. Independent prognostic factors were determined by a multivariate analysis performed using the Cox proportional hazards model. RESULTS: The overall 5-year actuarial recurrence was 12% and tumor-related mortality was 10%. Independent predictors of recurrence were male gender and BVI. Independent predictors of tumor-related mortality were male gender, BVI, and poorly differentiated tumors. CONCLUSIONS: Despite radical resection, patients with stage I rectal cancer with male gender, BVI, and poorly differentiated tumors should be considered high-risk patients.     

Cisplatin-induced peptic ulcers, vagotomy, adrenal and calcium modulation

Cytochemical and autoradiographic studies in Wistar rats [Crl:(WI)BR] show that cisplatin treatment (9 mg/kg) inhibits the release of acetylcholine from the axonal endings of the stomach smooth muscle resulting in bloating of the stomach and ulceration. Cisplatin also induces corticosteroid release from the adrenal gland stimulating peptic ulceration. Vagotomy helps ameliorate the effect but not eliminate it. Calcium supplementation restores normal neuromuscular function to gastric smooth muscle, thereby eliminating the gastro-intestinal toxicity due to cisplatin.     

An assessment of the anatomical relationship between the pelvic plexus and the rectal wall to determine the indications for its preservation in surgery for rectal cancer

Preservation of the pelvic plexus in surgery for rectal cancer could shorten the distance between the cancer and the lateral resection margin, whereby the curability of the operation may be reduced. To clarify the indications for preserving the pelvic plexus in such surgery, the relationship of the pelvic plexus to the rectum and rectal cancer was investigated anatomically in 12 autopsied specimens and 12 surgical specimens. The rectum and anus were dissected with all the pelvic organs from autopsied cadavers and transverse sections were prepared at 10-mm intervals after fixation. The location of the pelvic plexus was then measured on the tissue preparations, and compared to that of surgical specimens from rectal cancers with concurrent resection of the pelvic plexus. The pelvic plexus was located from 3.3 +/- 1.2 cm above to 2.3 +/- 1.9 cm below the peritoneal reflection in the autopsied specimens. The average distances between the muscularis propria and the pelvic plexus in the autopsied specimens and surgical specimens were 8.3 +/- 3.5 mm and 14.7 +/- 4.5 mm, respectively, showing a significant difference (P < 0.05). Pelvic plexuses were located about 10 mm from the outer margin of rectal muscularis propria. These findings indicate that concurrent resection of the pelvic plexus may be required to secure sufficient surgical clearance in pT3 rectal cancers, especially those invading deeply beyond the muscularis propria (a2).     

Endorectal echography. Its usefulness in the study of neoplasms of the rectum

OBJECTIVE: To analyze prospectively the results of the first endorectal ultrasonographies performed at the Coloproctology Unit of the Hospital Mutua de Terrassa in patients with rectal tumors. METHODS: During the period between September 94 to June 95, 27 endorectal ultrasonographies were performed to patients with rectal tumors. The echographies were performed with a 360 degrees transducer. The ultrasound findings were compared to the histological results. RESULTS: Three patients were not treated surgically, and were excluded from the analysis. In addition, three patients with perianastomotic recurrence were excluded. Of the remaining 21 patients the level of penetration in the rectal wall was correctly identified in 17 (81%). The presence of metastatic nodes was correctly assessed in 19 of the 24 patients explored (78%). CONCLUSION: For the preoperative assessment of rectal tumors, endorectal ultrasonography offers a good accuracy even during the learning curve.     

Racemose angiomatosis. Comments on the article of D.E. Matsko and I.A.Sokolova. Racemose angioma of the nervous system: tumor or developmental defect? Vopr. onkol. 1966. V.42, No.6. p.91-96

Diversion colitis is thought to result from nutritional deficiencies secondary to fecal diversion. Symptoms include hemorrhagic purulent rectal discharge, abdominal pain, and tenesmus. 5-Aminosalicylic acid (5-ASA) and N-butyrate enemas have been reported to help this condition non-spinal cord injury (SCI) patients. We report the case of a 49-year-old C6 ASIA B tetraplegic man who had received colostomy because of intractable ileus 10 years earlier. He presented with a 2-week history of rectal pain and bleeding. Abdominal and rectal examination on admission were unremarkable. Colonoscopy showed a partial stricture 70cm proximally to the rectum. The colonic mucosa appeared granular and friable with evidence of linear ulceration. Histopathologic study was consistent with colitis. The patient developed fever, abdominal distention, and extensive retroperitoneal air after endoscopy, suggesting colonic perforation. He was treated with daily 5-ASA suppository and total parenteral nutrition for the presumed diagnosis of diversion colitis, and intravenous antibiotics for perforated colon. After 6 weeks of treatment with 5-ASA, the patient had decreased rectal pain and bleeding. This experience suggests that diversion colitis may be a cause of abdominal discomfort in SCI patients and that 5-ASA may be used in the management of diversion colitis.     

Lymph node metastasis in gastric cancer in the upper third of the stomach--surgical treatment on the basis of the anatomical distribution of positive node

BACKGROUND/AIMS: Little is known about the most appropriate surgical procedure for gastric cancer in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for gastric cancer in the upper third of the stomach. METHODOLOGY: The clinicopathological characteristics of 115 node-positive gastric cancers in the upper third of the stomach were reviewed retrospectively and compared with those of 111 node-negative gastric cancers in the upper third of the stomach. RESULTS: Node-positive gastric cancers showed higher rates of peritoneal metastasis (p < 0.005), larger tumor sizes (p < 0.005), deeper tumor penetration (p < 0.005), higher rates of diffuse type in histology (p < 0.025), and more advanced histological stages (p < 0.005), than node-negative gastric cancers. Patients with node-positive gastric cancer demonstrated a poorer survival rate than those with node-negative gastric cancer (p < 0.005). Lymph node metastasis along the lower stomach was observed in cases of gastric cancer which had invaded beyond the muscularis propria of the stomach but not in those confined within the muscularis propria. No lymph node metastasis in the splenic hilum was found in association with gastric cancer when the depth was limited to the mucosa or the submucosa. CONCLUSION: The appropriate surgical procedures for the treatment of gastric cancer in the upper third of the stomach are as follows: a) proximal gastrectomy without splenectomy for gastric cancer when the depth is limited to the mucosa or the submucosa, b) proximal gastrectomy with splenectomy for gastric cancer when the depth of invasion extends to the muscularis propria, c) total gastrectomy with splenectomy for gastric cancer when the depth of invasion extends beyond the muscularis propria.     

Neuromuscular disorders associated with failure to wean from the ventilator

OBJECTIVE: To determine, by retrospective chart analysis, the frequency, type and significance of neuromuscular disorders in patients whose clinical features suggested a neuromuscular cause of failure to wean. BACKGROUND: Failure to wean is a common and difficult problem in critical care units. While a neuromuscular cause may be suspected in some patients, the frequency and type has not been determined utilizing comprehensive electrophysiological studies of limbs and the respiratory system. Such knowledge may aid in patient management and prognosis. METHODS: The clinical setting was a critical care/trauma centre that admits 1500 patients per year, approximately 500 being on ventilators for longer than five days. We analyzed the hospital charts of 40 patients admitted to the unit during three years, whose respiratory assessment suggested a neuromuscular cause for failure to wean from the ventilator. To investigate this possibility, we performed electrophysiological studies of the limbs and also of the respiratory system by phrenic nerve conduction and needle electromyography of the chest wall and diaphragm. The results were compared to 25 healthy controls. RESULTS: 38 of 40 patients (95%) had a neuromuscular disorder: 25--critical illness polyneuropathy, 2--Guillain-Barré syndrome, 4--diabetic and critical illness polyneuropathy, 2--uremic and critical illness polyneuropathy, 10--an abnormality of central drive, 5--unilateral phrenic nerve palsy, 3--a neuromuscular transmission defect, and 5--a primary myopathy. Fifteen (38%) had a combination of disorders. Patients with more severe polyneuropathy took longer to wean, a mean of 136 versus 52 days (p = 0.007). The severity of the polyneuropathy had no effect on mortality. CONCLUSIONS: Electrophysiological studies of limbs and the respiratory system are together valuable in confirming the presence, and identifying the specific type of neuromuscular cause for difficulty in weaning from the ventilator. This information is important in patient management and prognosis.     

Treatment of irritable bowel syndrome with Chinese herbal medicine: a randomized controlled trial

CONTEXT: Irritable bowel syndrome (IBS) is a common functional bowel disorder for which there is no reliable medical treatment. OBJECTIVE: To determine whether Chinese herbal medicine (CHM) is of any benefit in the treatment of IBS. DESIGN: Randomized, double-blind, placebo-controlled trial conducted during 1996 through 1997. SETTING: Patients were recruited through 2 teaching hospitals and 5 private practices of gastroenterologists, and received CHM in 3 Chinese herbal clinics. PATIENTS: A total of 116 patients who fulfilled the Rome criteria, an established standard for diagnosis of IBS. INTERVENTION: Patients were randomly allocated to 1 of 3 treatment groups: individualized Chinese herbal formulations (n = 38), a standard Chinese herbal formulation (n = 43), or placebo (n = 35). Patients received 5 capsules 3 times daily for 16 weeks and were evaluated regularly by a traditional Chinese herbalist and by a gastroenterologist. Patients, gastroenterologists, and herbalists were all blinded to treatment group. MAIN OUTCOME MEASURES: Change in total bowel symptom scale scores and global improvement assessed by patients and gastroenterologists and change in the degree of interference in life caused by IBS symptoms assessed by patients. RESULTS: Compared with patients in the placebo group, patients in the active treatment groups (standard and individualized CHM) had significant improvement in bowel symptom scores as rated by patients (P=.03) and by gastroenterologists (P=.001), and significant global improvement as rated by patients (P=.007) and by gastroenterologists (P=.002). Patients reported that treatment significantly reduced the degree of interference with life caused by IBS symptoms (P=.03). Chinese herbal formulations individually tailored to the patient proved no more effective than standard CHM treatment. On follow-up 14 weeks after completion of treatment, only the individualized CHM treatment group maintained improvement. CONCLUSION: Chinese herbal formulations appear to offer improvement in symptoms for some patients with IBS.     

An emotional exposure-based treatment of traumatic stress for people with chronic pain: Preliminary results for fibromyalgia syndrome.

Emotional trauma occurs in many patients with chronic pain, particularly fibromyalgia syndrome (FMS). Current cognitive-behavioral treatments for chronic pain have limited effects, perhaps because the trauma is not addressed, whereas emotional exposure-based treatments improve post-traumatic stress, but have not been tested on chronic pain. The authors present a novel, brief treatment protocol for people with chronic pain and unresolved trauma (Multi- Stimulus, Multi-Technique Emotional Exposure Therapy), which involves detecting avoidance of a range of emotion-related stimuli, implementing exposure techniques tailored to the patient's avoidances, and negotiating the process and therapeutic alliance. This treatment was pilot tested on 10 women with intractable FMS and trauma histories. Three months post-treatment, the sample showed moderate to large effects on stress symptoms, FMS impact, and emotional distress; and small-to-moderate improvements on pain and disability. Two patients showed substantial improvement, four made moderate gains, two showed modest improvement, and two did not benefit. This pilot study suggests that emotional exposure treatment for unresolved trauma may benefit some patients with FMS. Controlled testing of the treatment for FMS and other chronic pain populations is indicated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of intra-amygdala R(+) 7-OH-DPAT on intra-accumbens d-amphetamine-associated learning. II. Instrumental conditioning

BACKGROUND: Recurrence of rectal and colonic carcinoma remains substantial despite apparently curative surgery. Adjuvant therapy has been applied to improve prognosis. METHODS: This review evaluates the use of adjuvant therapy in the management of resectable rectal and colonic carcinoma. It assesses critically the evidence supporting the addition of radiotherapy, chemotherapy, chemoradiotherapy and other treatment modalities to optimal surgery. RESULTS: In the case of rectal tumours, preoperative is more effective than postoperative radiotherapy; It can significantly reduce the incidence of local tumour recurrence. A number of trials have tended towards showing a survival advantage and a recent large randomized trial has shown a significant improvement in survival in patients with Dukes C tumours. Postoperative chemoradiotherapy is associated with a survival benefit and is standard therapy in the USA, although it is associated with increased toxicity. The effectiveness of preoperative chemoradiotherapy is currently being investigated. Postoperative fluorouracil-containing chemotherapy has resulted in a survival advantage in patients with Dukes C colonic tumours; such therapy may be administered either systemically or intraportally. The evidence of benefit with rectal tumours is more limited. Immunotherapy has been studied to a limited extent and the use of a tumour-directed monoclonal antibody has produced a survival advantage in a single trial. CONCLUSION: Preoperative radiotherapy and postoperative chemoradiotherapy can produce a survival advantage in patients with Dukes C rectal carcinoma and reduce local recurrence. Postoperative fluorouracil-containing chemotherapy can produce a survival advantage in those with Dukes C colonic cancer. The optimal use and combination of adjuvant therapy remains uncertain.