Definition Of Pathology Research Articles

Defining Normal: Constructions of Race and Gender in the DSM-IV Casebook

This article explores the ways in which the DSM-IV Casebook constructs gender and race/ethnicity in depictions of individuals with mental illness. Analyses indicated that the case studies were gendered in accordance with socially sanctioned descriptions of women and men, with women more likely to be described negatively and in terms of physical attractiveness, and that women of color in particular were more likely to be sexualized. We argue that the studies in the Casebook contribute to a gendered and raced conceptualization of mental illness, and that these explicit definitions of pathology reflect implicit definitions of normalcy.

Closing remarks and treatment guidelines

The human epidermal growth factor receptor HER2 or C-erbB-2/neu is a tyrosine kinase membrane receptor, which when activated, induces a phosphorylation cascade in cytoplasmic kinases leading to increased protein transcription and cellular growth. HER2 plays an important role in the biology of breast cancer, an observation that has led to the selection of HER2 as a potential target for breast cancer treatment. Trastuzumab (Herceptin®) is the first anti-HER2 monoclonal antibody that has shown a survival benefit in metastatic breast cancer patients with HER2-positive tumours (Norton et al., Proc ASCO 2000 18, 127a (abstract 483)). Tumour HER2 status should no longer be ignored because of its direct implications for the optimal management of breast cancer patients. A high priority for future research is to refine and standardise HER2 testing in order to minimise false-negative results. Furthermore, this procedure would overcome current issues relating to test reproducibility between pathology laboratories and definitions of HER2 positivity. In the meantime, a HER2-positive status on testing using any approved technique has implications for clinical practice (Fig. 1 ). The treatment algorithm given in Fig. 1 considers the lack of level 1, evidence-based studies that demonstrate convincingly the value of HER2 as a predictive marker for resistance or sensitivity to classic forms of breast cancer therapy (Piccart et al., Eur J Cancer 2000, 36, 1755–1761). In addition, the algorithm incorporates the available data from 1999–2000, which were generated from prospective trials exploring the value of trastuzumab both as a single agent and in combination with chemotherapy.

The future of magnetic resonance-based techniques in neurology.

Magnetic resonance techniques have become increasingly important in neurology for defining: 1. brain, spinal cord and peripheral nerve or muscle structure; 2. pathological changes in tissue structures and properties; and 3. dynamic patterns of functional activation of the brain. New applications have been driven in part by advances in hardware, particularly improvements in magnet and gradient coil design. New imaging strategies allow novel approaches to contrast with, for example, diffusion imaging, magnetization transfer imaging, perfusion imaging and functional magnetic resonance imaging. In parallel with developments in hardware and image acquisition have been new approaches to image analysis. These have allowed quantitative descriptions of the image changes to be used for a precise, non-invasive definition of pathology. With the increasing capabilities and specificity of magnetic resonance techniques it is becoming more important that the neurologist is intimately involved in both the selection of magnetic resonance studies for patients and their interpretation. There is a need for considerably improved access to magnetic resonance technology, particularly in the acute or intensive care ward and in the neurosurgical theatre. This report illustrates several key developments. The task force concludes that magnetic resonance imaging is a major clinical tool of growing significance and offers recommendations for maximizing the potential future for magnetic resonance techniques in neurology.

A Relational Perspective on “Gestalt Therapy and the Phenomenological Method”

Abstract Van De Riet's paper recapitulates the arguments outlining the incompatibility of phenomenological reduction with field theory and then advocates for its continued usefulness as long as we recognize its limitations. This response focuses on two important goals accomplished by bracketing: (1) a non-normative definition of pathology and (2) a non-judgmental attitude on the part of the therapist, and then goes on to explore how these can also be accomplished in other ways within a relational, dialogic framework.

Infiltraciones locales en atención primaria

Bronchiolitis obliterans is a clinical entity which results from a variety of etiologies and has a detrimental impact on patients’ quality of life when it remains undiagnosed and untreated. Due to its non-pathognomic clinical symptoms and signs, physicians often proceed to radiological examination, especially with high resolution chest tomography. Histological examination reveals constrictive bronchiolitis, the pathological definition of bronchiolitis obliterans. Due to an almost normal aspect of the lung parenchyma this condition can be missed. However, its recognition and the identification of a possible exposure are important for removing the patient from the incriminating agent. We present a case of constrictive bronchiolitis in a metal-cutting worker, highlighting the principal findings of this disease.

Collagenous Gastritis: A Case Report, Morphologic Evaluation, and Review

Collagenous gastritis is rare; there are only four previous case reports. Histologic features seem to overlap with the other “collagenous enterocolitides”; however, pathologic criteria are not yet established for the diagnosis of collagenous gastritis. We describe an additional case of ostensible collagenous gastritis in a patient who initially presented with celiac sprue and subsequently developed colonic manifestations of mucosal ulcerative colitis. Endoscopic biopsies of the stomach revealed deposition of patchy, very thick bandlike subepithelial collagen in gastric antral mucosa, focal superficial epithelial degeneration, numerous intraepithelial lymphocytes, and a dense lamina propria lymphoplasmacytic infiltrate. Image analysis evaluation of gastric antral biopsies demonstrated a mean thickness of subepithelial collagen of 27.07 μ. Morphologic comparison was made with age-matched control groups of 10 patients who had normal gastric mucosal biopsies and 10 patients who had “chronic” gastritis, which revealed mean subepithelial collagen measures of 1.37 μ and 1.19 μ, respectively. We compared these morphologic findings with those of all previous case reports of collagenous gastritis and propose a pathologic definition based on the limited combined data. It seems that subepithelial collagen is dramatically thickened in reported cases of collagenous gastritis, with a cumulative mean measure of 36.9 μ. It is also apparent from this and previous reports that the thickened subepithelial collagen is accompanied by a chronic or chronic active gastritis and sometimes intraepithelial lymphocytes and surface epithelial damage. Recently described associations of lymphocytic gastritis, sprue, and lymphocytic colitis as well as collagenous and lymphocytic colitis suggest a common pathogenesis that empirically may include collagenous gastritis in the same disease spectrum. We propose that collagenous gastritis can be confidently identified by using analogous defined features of collagenous colitis: subepithelial collagen more than 10 μ in a patchy distribution, lamina propria lymphoplasmacytic infiltrates, intraepithelial lymphocytes, and surface epithelial damage. Collagenous gastritis also seems to have the same spectrum of associated clinical findings as collagenous colitis, including frequent coexistence of celiac sprue, watery diarrhea syndrome, and female predominance.

Accrual rate-limiting factors in a Swedish randomised ductal carcinoma in situ (DCIS) trial — a demographic study

In the last two decades the introduction of mammographic screening in the Western world has increased the number of diagnosed ductal carcinomas in situ (DCIS) considerably. In situ carcinoma of the breast is considered a heterogeneous disease, the natural history of which is not well known. Thus, appropriate treatment needs to be established. For this reason, a randomised trial studying the effect of breast conserving operation with or without postoperative radiotherapy was instituted in Southern Sweden in 1987. The aim of the present study was to assess patient accrual, identify limiting factors, and evaluate possible ways to influence these factors in order to increase patient accrual. Between 1987 and 1992, 331 patients had been registered with DCIS in the Regional Tumour Registry, 96 of which had been randomised. All 331 were subjected to chart review studying clinical data, mammography reports, cytology and pathology reports to identify inclusion and exclusion criteria according to the design of the trial. It was found that 5% (18/331) had an incorrect diagnosis of DCIS. According to the trial protocol 52% were not eligible (162/313). Fifty-eight per cent ( n=88) of the 151 eligible patients had been correctly randomised. The most common reason for exclusion was lesion size. In 21% (66/313) the lesion was ‘too large’. Several other limiting factors were identified such as in cytological and pathological definitions and reports, lack of information/awareness in certain physicians, patient reluctance to participate, which in turn may be influenced by the previous factor. With increased information to participating hospitals and considering the above given facts it should be possible to increase accrual from the 28% noted in the present consecutive demographic study to at least one-third of the diagnosed cases of DCIS.

Relationship and significance of greatest percentage of tumor and perineural invasion on needle biopsy in prostatic adenocarcinoma.

Serum prostate-specific antigen (PSA) levels and the biopsy Gleason sum are used along with clinical staging to predict prostatectomy pathology results for men with localized prostate cancer. The additional predictive value of perineural invasion (PNI) in pretreatment prostate needle biopsies for evaluating tumor stage in this setting is controversial. The current study evaluates the independent predictive value of PNI for tumor staging in a cohort of 632 men who underwent radical retropubic prostatectomies for clinically localized adenocarcinoma of the prostate between the years 1994 and 1998. None of these men received hormonal or radiation therapy before surgery. In addition to the Gleason sum, biopsy results contained detailed information regarding tumor burden: 1) total number of biopsy cores involved by adenocarcinoma, 2) greatest percentage of any single biopsy involved by prostate carcinoma (GPC), and 3) total percentage of cancer added over all cores (TPC). The presence or absence of any PNI was recorded. Pretreatment factors were analyzed in a univariate and multivariate fashion to determine their predictive value using the TNM tumor stage (pT2 vs pT3) and the modified tumor staging system, which includes surgical margin status (pT2 vs pT3 or positive surgical margin) as end points. Univariate analysis revealed a significant association between pT3 disease and several preoperative factors including age, Gleason sum, serum PSA, digital rectal examination, PNI, GPC, TPC, and the total number of positive cores (p <0.01). Multivariate analysis indicated that serum PSA, Gleason sum, age, and GPC contributed significantly to predicting pT3 disease with odds ratios of 2.7 (95% CI, 1.7-4.3), 2.3 (95% CI, 1.7-3.1), 1.7 (95% CI, 1.1-2.7), and 1.7 (95% CI, 1.4-2.1) respectively. PNI was significant in multivariate analysis only when GPC and TPC were not considered, due to a significant interaction between GPC and PNI (p <0.0001, Wilcoxon's rank sum test). These predictive factors showed a similar relationship to adverse pathology when an alternative definition of adverse pathology was used that included positive surgical margins (pT3 or any positive margin). In the interaction between GPC and PNI, GPC was more significant than PNI in predicting pT3 disease. However, PNI added additional information when adverse pathology was defined more broadly as pT3 or any positive margin.

Germ cell cancer.

The publication of the proceedings of Fourth Workshop on Carcinoma in situ was an impressive leap in our understanding of the interaction between prenatal and postpubertal factors in the development of germ cell cancer as well as increased insight into the molecular events that are involved in the development of these tumors. From this work, physicians are increasingly accepting that estrogen-mediated prenatal priming of germ cells generates a predisposition to postpubertal cyclin D2-driven initiation of full mitotic cell cycle replication of a tetraploid p53-expressing meiotically arrested pachytene spermatocyte that is under increased gonadotrophin drive because of testicular atrophy inducing events. From this new knowledge, new markers, eg, FGF4, CD30, and OCT-4, of embryonal carcinoma cells are identifying alternative ways of identifying poor risk tumors and leading to renewed interest in study of histopathology of these tumors. With greater attention to late events and increasing confirmation that chemotherapy is better than radiation even in seminoma and that seminoma is more chemosensitive than nonseminoma, a renewed clinical need exists for improved pathologic definition to reduce unnecessary usage of chemotherapy and maximize its benefits. With the failure of vinblastine, ifosfamide, and cisplatin to show any benefit over BEP (bleomycin, etoposide, and cisplatin) in the Southwest Oncology Group trial, re-examination of approaches to treatment of poor risk disease is emphasized as the priority for future trials.

The falling mortality from coronary heart disease: a clinicopathological perspective

Objective(1) To compare mortality estimates based on clinicopathological diagnoses of death from acute coronary heart disease with official estimates of coronary heart disease mortality; (2) to compare present day mortality...

Clinical Pathology of Pancreatic Disorders.

Clinical Pathology of Pancreatic Disorders. John A. Lott, ed. Totowa, NJ: Humana Press, 1997, 218 pp. $99.50. ISBN 0-89603-475-5. As the Preface indicates, the emphasis of this book is on the clinical laboratory definition of pancreatic pathology. Laboratory scientists have become increasingly aware of the important influence of biochemical tests on the correct diagnosis of pancreatic disorders. This publication would make an appropriate addition to information regarding the laboratory aspects of this pathology. Eight different authors contributed the five chapters, discussing clinical and biochemical topics concerning various pancreatic diseases. The first chapter, …

How to use Chlamydia antibody testing in subfertility patients.

Screening for tubal factor subfertility by means of Chlamydia antibody testing (CAT) was introduced into the initial work-up of subfertile couples several years ago. The results reported, however, are heterogeneous, and no uniformity exists in cut-off levels of titres, or in definitions of tubal factor subfertility. We performed a prospective cohort study to evaluate the implications of varying the definitions of tubal pathology and of modifying the cut-off levels on the clinical impact of CAT in predicting tubal factor subfertility. In 227 consecutive patients who attended our fertility clinic, the Chlamydia IgG antibody titre was determined and related to tuboperitoneal abnormalities at laparoscopy as a reference standard. According to received operating characteristic (ROC) curve analysis, a titre of 16 is the optimum cut-off level. Increasing the cut-off level improves specificity and positive likelihood ratio (LR+), at the expense of sensitivity and negative LR (LR-). Changing the definition of tubal factor subfertility from unspecified tuboperitoneal abnormalities into extensive adhesions and/or bilateral distal tubal occlusion improves LR+, LR- and kappa significantly. We conclude that CAT is more accurate in predicting severe distal tubal pathology than unspecified tuboperitoneal abnormalities. Although from a statistical point of view a titre of 16 is the optimum cut-off level, from a clinical point of view 32 or 64 may be preferable, depending on the aim of screening and the inception cohort.

Subcortical vascular dementia: Epidemiology and risk factors

Uncertainties in the clinical and pathological definition of vascular dementia (VaD) have impeded the development of valid epidemiological studies. VaD occurs in the same age category than Alzheimer's disease (AD) and Alzheimer pathology is found in up to 20 % of patients with VaD. The most currently used criteria for VaD are those summarized by the National Institute of Neruological Disorders and Stroke and the “Association Internationale pour la Recerche et l'Enseignement en Neursciences” (NINDS-AIREN): they require criteria for dementia, clinical or radiological evidence for a vascular pathology of the brain, and a temporal relationship between both. Descriptive epidemiological studies usually include VaD of any type. Small subcortical infarcts account for one sixth of all ischemic strokes, but this proportion is probably higher in patients with VaD. The sex-specific prevalence rates of VaD over the age of 60 in Europe is 2.6 % for men and 2.1 % for women. The prevalence increases steeply with age, but patients with AD and coincidental vascular lesions of the brain are often included. The incidence rate of VaD increases approximately from 20/100.000 between 60 and 69 years to 700/100.000 over 80. There was an overall decline in incidence of VaD over the last 2 decades. The incidence of new-onset dementia is increased after an ischemic stroke. However, VaD probably accounts for only half of dementia occurring after stroke. Approximately one sixth of stroke patients have pre-existing dementia. Subcortical VaD are due to subcortical infarcts, leukoencephalopathies or both. Subcortical infarcts are likely to be the cause of dementia in (i) strategic subcortical (e.g., thalamic) infarcts with previous normal cognitive functioning; (ii) lacunar state; and (iii) cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). The first 2 types are usually the consequence of lipohyalinosis of the small perforating arteries; their main risk factor is arterial hypertension. CADASIL is an autosomal dominant inherited disorder. White matter abnormalities are often associated with risk factors for stroke such as age, arterial hypertension, cardiac diseases and diabetes mellitus. The main risk factor of subcortical VaD is arterial hypertension. Further studies should now determine whether its treatment can reduce the risk of subcortical VaD.

Are acoustic neuromas encapsulated tumors?

In articles and chapters on the subject of acoustic neuroma, it is almost invariably stated that they are well-encapsulated tumors. During surgical procedures, blunt mechanical dissection defines a natural subsurface cleavage plane that leaves intact a several millimeter thick rind of tumor surface. Occasionally, as a concession to neural integrity, less than complete resection is elected, leaving behind this "capsular" remnant. To clarify the nature of the surface of acoustic neuromas and to test whether this long held description is indeed correct, a microscopic analysis of 10 surgical specimens was performed. A wedge was harvested from the free surface of the tumor in the mid cerebellopontine angle that included a large, undisturbed section of the tumor surface. Histologic analysis showed that for most of the tumor surface only an extremely thin (3 to 5 microm) layer of connective tissue envelops the tumor. Neoplastic Schwann cells, which extend essentially to the margin of the tumor, were found to be somewhat flattened and compressed in the vicinity of the surface. Although acoustic neuromas are surrounded by a continuous layer of connective tissue, it is so exceptionally thin (on average less than the diameter of a red blood cell) that its edge cannot be visualized intraoperatively by a surgeon. Because the pathologic definition of a capsule is a thick, enveloping layer of connective tissue that is both micro- and macroscopically evident, it must be concluded that acoustic neuromas are nonencapsulated, at least in the conventional sense of the term. The surface peel observed intraoperatively is surgically produced during tumor debulking by cleaving of the looser central component from the more compressed portion of neoplastic cells that lies immediately beneath the free margin of the lesion.

Are acoustic neuromas encapsulated tumors?

In articles and chapters on the subject of acoustic neuroma, it is almost invariably stated that they are well-encapsulated tumors. During surgical procedures, blunt mechanical dissection defines a natural subsurface cleavage plane that leaves intact a several millimeter thick rind of tumor surface. Occasionally, as a concession to neural integrity, less than complete resection is elected, leaving behind this “capsular” remnant. To clarify the nature of the surface of acoustic neuromas and to test whether this long held description is indeed correct, a microscopic analysis of 10 surgical specimens was performed. A wedge was harvested from the free surface of the tumor in the mid cerebellopontine angle that included a large, undisturbed section of the tumor surface. Histologic analysis showed that for most of the tumor surface only an extremely thin (3 to 5 μm) layer of connective tissue envelops the tumor. Neoplastic Schwann cells, which extend essentially to the margin of the tumor, were found to be somewhat flattened and compressed in the vicinity of the surface. Although acoustic neuromas are surrounded by a continuous layer of connective tissue, it is so exceptionally thin (on average less than the diameter of a red blood cell) that its edge cannot be visualized intraoperatively by a surgeon. Because the pathologic definition of a capsule is a thick, enveloping layer of connective tissue that is both micro- and macroscopically evident, it must be concluded that acoustic neuromas are nonencapsulated, at least in the conventional sense of the term. The surface peel observed intraoperatively is surgically produced during tumor debulking by cleaving of the looser central component from the more compressed portion of neoplastic cells that lies immediately beneath the free margin of the lesion. (Otolaryngol Head Neck Surg 1997;117:606-9.)

Left Ventricular Aneurysm: Modified Linear Closure Technique

To understand the role of surgery in the treatment of patients with a ventricular aneurysm, one must first consider the criteria used to define the presence of an aneurysm. Angiographically, an aneurysm may be defined as an area of the ventricle which is demarcated from the surrounding chamber by hypokinesis, akinesis, or dyskinesis. An angiographic aneurysm^' may relate anatomically to an obvious sac of thin scar (classic pathological definition of an aneurysm) or it may correspond to a region of mixed scar and viable muscle which may be of variable thickness. In the latter case, it may not be obvious whether this region would benefit more from revascularization with the hope of recruiting hibernating myocardium and improving regional wall motion, or from resection with ventricular reconstruction. Preoperative perfusion scans and positron emission tomography have been used in attempts to separate scar tissue from viable nonfunctioning myocardium. Echocardiography and nuclear magnetic resonance may help to assess the extent of thinning in the target area. However, in these cases, we believe that the final decision with regards to appropriate intervention

Lipiodol-CT for hepatocellular carcinoma

Lencioni et al. have nicely presented a positive predictive value of Lipiodol CT for intrahepatic metastasis of hepatocellular carcinoma (HCC) based on 32 consecutive patients undergoing hepatectomy [1]. Lipiodol-CT has been generally regarded as a highly sensitive examination to detect intrahepatic metastases because these mostly occur in hypervascular HCC (advanced or classic HCC, histopathologically moderately or poorly differentiated) and have a similarly hypervascular character. However, there has been no direct confirmation of high sensitivity and specificity by this method. Theoretically and clinicopathologically, Lipiodol is distributed in loci according to their vascularity. Long-term deposits are noted in the necrotic area of the tumor and liver parenchyma, especially after embolization [2]. Thus, any hypervascular nodular lesion such as small cavernous hemangioma and focal nodular hyperplasia and nontumorous area such as focal inflammation and arterioportal shunt could be false-positive cases of intrahepatic metastasis, although the durations of deposit are different case by case [2]. Such cases have been sporadically reported [3, 4]. Lencioni et al. have defined a positive finding of intrahepatic metastasis at Lipiodol-CT as a small, rounded, well-delineated retention less than 2 em in diameter but have not described any pathologic definition or finding. In general, intrahepatic metastases are present in cases with HCC associated with portal tumor thrombus, multiple in number, small in size, and located adjacent to the main tumor [5]. However, intrahepatic metastasis is not a self-evident lesion, especially in patients at high risk for HCC who often have multicentricoccurring tumors of different or same subtype. Even when using DNA analysis, pathologists cannot necessarily confirm whether or not a particular lesion is an intrahepatic metastasis [5, 6].

Is Contralateral Exploration of the Kidney Necessary in Patients With Wilms Tumor?

Purpose Surgical exploration of the contralateral kidney in patients with Wilms tumor is standard practice. The introduction of modern imaging techniques (ultrasound, computerized tomography and magnetic resonance imaging) in place of excretory urography has led to a more accurate definition of intrarenal pathology. Is contralateral kidney exploration still necessary in patients with Wilms tumor? Materials and Methods We reviewed the records of 75 patients from 3 medical centers who were evaluated and treated for Wilms tumor in the last 14 years. All children underwent preoperative excretory urography, computerized tomography, ultrasound and/or magnetic resonance imaging. Results Seven bilateral Wilms tumors were diagnosed preoperatively and confirmed surgically, whereas extensive operative exploration of the contralateral kidney in the other 69 patients revealed no additional pathological condition. This concurred with preoperative radiological findings with 100 percent sensitivity and specificity. Furthermore, 1 month to 12 years of followup (mean 4.3 years) revealed no tumor in the contralateral kidney. The major postoperative complication was small bowel obstruction in 5 patients 15 to 180 days (mean 77.2) after explorative laparotomy. Conclusions In all patients preoperative radiological investigation was accurate in excluding bilaterality. With modern imaging techniques and effective chemotherapy extensive contralateral renal exploration may no longer be mandatory for managing Wilms tumor.

Intraoperative TEE assessment of ventricular septal defect with aortic regurgitation

It is desirable to repair but not replace the aortic valve in patients with ventricular septal defect and acquired aortic regurgitation. Precise definition of the valvar pathology with monitoring of its repair perioperatively would enhance the surgical management of this condition. Fourteen consecutive patients (age, 10.6 +/- 6 years; weight 29.7 +/- 5.7 kg) who underwent repair of ventricular septal defect with aortic regurgitation were studied by intraoperative transesophageal echocardiography. The severity of prolapse of each of the individual aortic cusps and its adjacent sinus was assessed and the valvar regurgitation quantified by Doppler-derived regurgitant indices. The echocardiographic and surgical findings were correlated and the preoperative and postoperative echocardiographic data were compared to assess the effectiveness of operation. Eight subarterial and six perimembranous defects were located accurately and their sizes (11.8 +/- 3.0 mm) correlated well (r = 0.80) with the surgical measurements. Transesophageal echocardiography detected prolapse of the aortic valve and its sinus in all 14 patients. The severity of the prolapse was severe in 10, moderate in 4, and mild in 5 leaflets. One the basis of these findings, together with the Doppler-derived mean regurgitant indices, exploration of the valve and valvuloplasty were executed appropriately in 12 of 14 patients. In all 14 patients, transesophageal echocardiography after bypass revealed no further cuspal prolapse and significant reduction of the mean regurgitant index (0.55 +/- 0.23 to 0.17 +/- 0.15, p < 0.0001). Residual ventricular septal defect was detected in 5 patients and the only patient with significant shunting who required reexploration was identified correctly. Intraoperative transesophageal echocardiography can assess effectively the surgical repair of ventricular septal defect with aortic regurgitation and provide information that directs and alters surgical plans to the benefit of patients.

Bowel dysfunction in multiple sclerosis

Bowel symptoms are seen in two thirds of multiple sclerosis (MS) patients, constipation and fecal incontinence, frequently coexisting, being the major symptoms. Since bowel symptoms are common in community, the need for precise definitions of pathology are stressed. Pathophysiological studies of bowel function are reviewed and the following hypothesis is suggested: Constipation is caused by a delay in colonic transit time, by a delay in the defecation reflex and by early external sphincter exitation. Fecal urgency/incontinence may be explained by impaired rectal sensation, not warning the patient to seek the toilet in time. Decrease in rectal compliance and in some patients abnormal rectal contractions may facilitate fecal expulsion and weak external sphincters allow leakage. Treatment options are commented and the need for treatment studies stressed.