Total duodenal diversion for treatment of reflux esophagitis uncontrolled by repeated antireflux procedures

The operations of Nissen, Hill, and Belsey are adequate in controlling esophaegeal reflux in the majority of patients. In a small percentage however, objective and subjective evidence of esophagitis persists in spite of repeated operations to restore lower esophageal sphincter competency. These failures are then usually treated by operative procedures of great magnitude involving organ interposition. Repeated antireflux operations directed to the gastroesophageal area may in some instances result in impairment of blood supply with an increased risk of both esophageal and gastric fistulae. In the past many observers have felt that reflux esophagitis resulted solely from the effects of acid-pepsin secretions bathing the distal esophagus. Recently experimental and clinical data have indicated the importance of duodenal contents in the etiology and perpetuation of reflux esophagitis. During a recent two year period, 6 patients with persistent reflux esophagitis uncontrolled by repeated antireflux procedures have been seen on our service. These 6 patients, underwent 12 unsuccessful antireflux operations elsewhere. Three of the 6 patients had also been subjected to vagotomy-antrectomy for a coexisting duodenal ulcer. A marked lowering of gastric acidity took place but esophageal reflux and esophagitis persisted. These three patients were treated on our service by takedown of the Billroth I anastomosis, closure of the duodenal stump and diversion of the duodenal contents into a Roux-en-Y limb. Three other patients who had undergone unsuccessful antireflux procedures alone were subjected to antral resection, Roux-en-Y diversion and transthoracid vagotomy. This simplified appraoch to the treatment of persistent esophageal reflux uncontrolled by repeated antireflux procedures has given satisfactory results. The operation should be considered when technical considerations preclude further surgical attempts to perform another effective antireflux operation. Total duodenal diversion should, however, not be considered as the primary operation for the patient suffering from reflux esophagitis. However, in circumstances discussed above this direct approach appears preferable to major resectional procedures.     

The role of insulin and glucagon in the regulation of basal glucose production in the postabsorptive dog

The aim of the present experiments was to determine the role of insulin and glucagon in the regulation of basal glucose production in dogs fasted overnight. A deficiency of either or both pancreatic hormones was achieved by infusin somatostatin (1 mug/kg per min), a potent inhibitor of both insulin and glucagon secretion, alone or in combination with intraportal replacement infusions of either pancreatic hormone. Infusion of somatostatin alone caused the arterial levels of insulin and glucagon to drop rapidly by 72+/-6 and 81+/-8%, respectively. Intraportal infusion of insulin and glucagon at rates of 400 muU/kg per min and 1 ng/kg per min, respectively, resulted in the maintenance of the basal levels of each hormone. Glucose production was measured using tracer (primed constant infusion of [3-3H]glucose) and arteriovenous difference techniques. Isolated glucagon deficiency resulted in a 35+/-5% (P less than 0.05) rapid and sustained decrease in glucose production which was abolished upon restoration of the plasma glucagon level. Isolated insulin deficiency resulted in a 52+/-16% (P less than 0.01) increase in the rate of glucose production which was abolished when the insulin level was restored. Somatostatin had no effect on glucose production when the changes in the pancreatic hormone levels which it normally induces were prevented by simultaneous intraportal infusion of both insulin and glucagon. In conclusion, in the anesthetized dog fasted overnight; (a) basal glucagon is responsible for at least one-third of basal glucose production, (b) basal insulin prevents the increased glucose production which would result from the unrestrained action of glucagon, and (c) somatostatin has no acute effects on glucose turnover other than those it induces through perturbation of pancreatic hormone secretion. This study indicates that the opposing actions of the two pancreatic hormones are important in the regulation of basal glucose production in the postabsorptive state.     

Effect of galactose and sugar substitutes on blood insulin levels in normal and obese individuals

Eighteen male patients between the ages of 25 and 50 were given on a double blind randomized basis (A) 40 gms. galactose (B) 50 gms. arabinogalactan and 0.11 gm. sodium saccharin (C) 2 gm. methyl cellulose and 0.083 gm. sodium saccharin and (D) 4 gm. galactose, all in 200 ml water. Blood glucose, galactose and insulin levels were determined during a six hour period before and after ingestion. The three first mentioned solutions tasted equally sweet, the fourth was essentially tasteless. None of these feedings altered plasma insulin or glucose levels. It appears that in contrast to other conclusions reached by earlier investigators sweet taste is unable to induce insulin secretion through neurogenic pathways.     

Letter: Reliability of transcutaneous PO2 with Roche Oxygen Monitor 5300 at 44 C in newborn infants with RDS

A microtiter cell-culture method was developed and used to titrate virus isolates for characterization. Virus dilutions and chicken kidney cell suspensions were dispensed into the wells of disposable microculture plates, with infectivity endpoints being determined microscopically on the fifth or sixth day, or by reading crystal-violet-stained monolayers on day 6. With this method, 37 candidate avian adenoviruses isolated from diagnostic accessions were characterized as avian adenoviruses (AAV). The criteria used for characterization were production of round-cell cytopathic effect, resistance to chloroform treatment, inhibition by 5-bromodeoxyuridine, and the presence of an antigen showing identity with a known AAV by precipitation in agar gel. Statistical anlaysis of eight replicate titrations of three AAV indicated that the titration method was highly reproducible. Use of the microculture method for titrations gave substantial savings in indicator cells, media, incubator space, culture dishes, and time.     

Cathepsin D from horse spleen. I. Purification and study of certain physicochemical properties

Horse spleen cathepsin D (3.4.23.5.) was purified from crude extract by sodium chloride and ethanol precipitation, column chromatography fractionation on DEAE cellulose and CM Sephadex, re-chromatography on DEAE cellulose and gel filtration. The enzyme has been purified about 3.000 folds with a yield of 30 per cent. The purified enzyme seems to be homogeneous on Sephadex G100, one protein band is apparent on disc electrophoresis. Determined by dansylation the N-terminal amino acid is glycine. A molecular weight of 42,500 +/- 3,000 was obtained with Sephadex G100 gel filtration and light scattering measurements. Amino acid analysis and chemical determinations were performed: cathepsin D is a glycoprotein (2 or 3 osamine residues) including 344 amino acids and 4 disulfide bonds. Spectrophotometric data show that E1cm/1 mg/ml = 1.01 at lambda = 280 nm. ORD measurements indicate about 20 per cent of helicoidal content in the molecule.     

Mothers as volunteers in an oncology clinic

Mothers of children who had died of cancer were successfully utilized as volunteers in a pediatric oncology clinic to provide emotional support and practical assistance to other children afflicted with the same disease and to their families. At the start of the program these volunteers were carefully interviewed to determine their willingness and their emotional ability to participate on a consistent basis. Following an eight-week training program with a psychiatrist, a social worker, and a nurse, they began working in a large pediatric oncology clinic one day a week. Over an 18-month period they have become valuable members of the oncology team by helping to improve communications, to alleviate frustrations, and in giving additional emotional support to the children and their families.     

Myocardial function during hypoxia in the presence of different buffers

Electrically driven rabbit left atria were exposed to 20 min periods of either hypoxia or anoxia in the presence of a bicarbonate-phosphate buffer, a Tris buffer [tris (hydroxymethyl) aminomethane hydrochloride] or combination of both. The bicarbonate-phosphate buffer system was shown to be important for tissue survival during hypoxia or anoxia whereas recovery was diminished in the presence of Tris only. Stimulus threshold and arrhythmias were shown to increase for atria in Tris. Oxygen consumption determinations on both spontaneously beating right atria and quiescent left atria showed no difference between pre- and post-hypoxia or between different buffers. Tris was shown to elicit a positive inotropic effect without an increase in O2 consumption.