Complete Erosion of an Aortobifemoral Bypass Graft Limb into Duodenum.

A 67-year-old male with a history of aortobifemoral bypass graft (ABF) for critical limb ischemia 10 months prior at a regional hospital was transferred to our center with 1 week history of rigors and 3 months of a chronic discharging left groin sinus. Two months prior he had a right-sided ureteric stent inserted for ureteric obstruction. Routine bloods revealed an acute-on-chronic renal injury and subsequent noncontrast computed tomography (CT) demonstrated left-sided hydroureter and hydronephrosis suggestive of extrinsic compression by the left bypass graft limb. A new left-sided ureteric stent was inserted and the right exchanged with no gross signs of infection. His impaired renal function precluded intravenous contrast and so a CT with oral contrast showed circumferential oral contrast and gas surrounding the right limb of his ABF. Urgent gastroscopy revealed periprosthetic erosion with the ABF limb traversing the distal third part of the duodenum. He underwent bilateral axillofemoral bypass grafts, laparotomy with explantation of the ABF, and primary duodenojejunostomy. Bilateral ureters were compressed by overlying graft limbs. Bilateral groins were infected with frank pus on exploration and were associated with impending anastomotic disruption of his previous ABF distal anastomoses. His postoperative course was complicated by colonic ischemia with perforation leading to irreversible multiorgan failure. This patient was remarkably well on presentation with life-threatening pathology. He had no abdominal symptoms or gastrointestinal bleeding. This case demonstrates the diagnostic and management difficulties of periprosthetic erosions and the consequences of graft tunneling superficial to ureters.

Mfn2 deletion in brown adipose tissue protects from insulin resistance and impairs thermogenesis.

BAT-controlled thermogenic activity is thought to be required for its capacity to prevent the development of insulin resistance. This hypothesis predicts that mediators of thermogenesis may help prevent diet-induced insulin resistance. We report that the mitochondrial fusion protein Mitofusin 2 (Mfn2) in BAT is essential for cold-stimulated thermogenesis, but promotes insulin resistance in obese mice. Mfn2 deletion in mice through Ucp1-cre (BAT-Mfn2-KO) causes BAT lipohypertrophy and cold intolerance. Surprisingly however, deletion of Mfn2 in mice fed a high fat diet (HFD) results in improved insulin sensitivity and resistance to obesity, while impaired cold-stimulated thermogenesis is maintained. Improvement in insulin sensitivity is associated with a gender-specific remodeling of BAT mitochondrial function. In females, BAT mitochondria increase their efficiency for ATP-synthesizing fat oxidation, whereas in BAT from males, complex I-driven respiration is decreased and glycolytic capacity is increased. Thus, BAT adaptation to obesity is regulated by Mfn2 and with BAT-Mfn2 absent, BAT contribution to prevention of insulin resistance is independent and inversely correlated to whole-body cold-stimulated thermogenesis.

Overlooked diseases of the vagina: a directed anatomic-pathologic approach for imaging assessment.

The vagina can easily be overlooked at ultrasonography (US), computed tomography (CT), or magnetic resonance (MR) imaging performed for nongynecologic indications. Even when gynecologic disease is suspected, the vagina may be underevaluated at routine pelvic US due to probe positioning and at CT due to poor vaginal tissue characterization. Although MR imaging offers excellent tissue characterization, radiologists must focus on the vaginal area to recognize any incidental findings. A directed anatomic-pathologic approach to assessing the vagina at US, CT, and MR imaging is recommended so that pertinent findings are not missed. This approach requires a knowledge of the anatomy and embryologic development of the vagina, as well as an understanding of congenital, developmental, and postoperative vaginal disease entities. In addition, it is important to understand the strengths and limitations of each imaging modality with respect to vaginal assessment. By remembering to "look beyond" the uterus and cervix to the vagina, radiologists can improve their perception and interpretation of vaginal anatomy and disease.

Pseudoaneurysm of the thoracic aorta following botulinum toxin injection to the esophagus.

Aortic pseudoaneurysms are uncommon and are usually secondary to penetrating trauma. We describe the presentation and management of an elderly woman who suffered a pseudoaneurysm of the descending thoracic aorta several days after receiving botulinum toxin injection to the esophagus. Urgent thoracic endovascular aortic repair was performed, and long-term antibiotic therapy was commenced. Despite a slow initial clinical recovery, she returned to an independent lifestyle, with radiographic resolution of the pseudoaneurysm seen at follow-up. This case illustrates that endovascular aortic repair is a suitable and safe treatment option for this unusual presentation.

Severe diverticulitis after heart, lung, and heart-lung transplantation.

BACKGROUND: In this study, we reviewed our experience with severe diverticulitis in patients who have undergone heart and/or lung transplantation to assess whether transplant recipients are at increased risk of having severe diverticulitis compared with the general population. METHODS: We reviewed the records of patients who underwent heart and/or lung transplantation from 1984 to 2000, inclusive, and identified patients with severe diverticulitis that required surgery or that resulted in death. We compared this incidence with the incidence of such complications in the general population, served by the same institution during a 2-year period, 1999 to 2000. RESULTS: A total of 953 patients underwent transplantation in the study period. The mean follow-up was 57 months, a total follow-up of 4528 patient-years. Nine patients (mean age, 54 years) had severe diverticulitis that required surgical intervention (8 patients) or that resulted in death (1 patient died without surgical intervention). During 1999 to 2000, 16 patients (mean age, 66 years) from the general population were treated for severe diverticulitis that required surgical intervention, 3 of whom died. From census and area health data, we found that the study institution serves approximately 90000 people older than 40 years, with a total follow-up of 180000 patient-years. The incidence rate ratio for severe diverticulitis when comparing the transplant with the non-transplant groups was 22.2 (95% confidence interval; 9.9-50.0; p < 0.001). CONCLUSIONS: Patients with severe diverticulitis who have undergone heart and/or lung transplantation can be treated surgically with a small mortality rate. Transplant recipients probably are at substantially increased risk of experiencing severe diverticulitis.

Benzodiazepines and anxiety sensitivity in panic disorder.

1. Benzodiazepines were discontinued in 16 patients who had recovered from panic disorder with agoraphobia after exposure treatment. 2. Drug discontinuation yielded a significant decrease in anxiety sensitivity and state anxiety in these long-term users. 3. Several likely explanations for the findings are discussed. 4. In the short term, treatment of panic disorder with benzodiazepines may lower anxiety symptoms. However, in the long run, it may decrease the individual tolerance to anxiety and discomfort.

[Truncular auriculo-ventricular block disclosing isolated corrected transposition of great vessels]. / Bloc auriculo-ventriculaire tronculaire révélateur d'une transposition corrigée des gros vaisseaux isolée.

A case of atrioventricular and ventriculo-arterial discordance with L-transposition of the great arteries (corrected transposition of the great arteries), complicated by complex atrioventricular block is reported. The points of interest in this case were the association of an atrioventricular block and isolated corrected transposition, revealing the underlying malformation, and the intrahisian location of the block which seems only to have been reported on three previous occasions in this context.

[Germinoma (ectopic pinealoma) with double location : supra-sellar and the cerebellum without pineal tumour (author's transl)]. / Germinome (pinéalome ectopique) a double localisation : supra-sellaire et cérébelleuse sans tumeur pinéale.

The now nine years old girl with growth retardation, started to be ill with otitis and then diabetes insipidus of central origin at 1974. A treatment with lysin-vasopressin is prescribed. The PNEG in May 1976 shows a little, pea like, suspicious, supra-sellar nodule who is not surgically explored since they was no ophtalmologic symptoms and because a normal CT scan. Corticoid and thyroid substitutive therapy is added until September 1977 when the general status becomes impaired and vomiting starts. Also because some visual loss, a new neuroradiological study is performed showing a supra-sellar tumour and a fourth ventricle mass. The CT scan asserts the double intracranial expansive process and a posterior fossa craniotomy is done with subtotal resection of a vermian tumour and Torkildsen drainage. The histology is : Immature Dysembryoma (seminoma type) or germinoma. The follow-up was good under hormonal care. X Rays Therapy over the posterior fossa, the suprasellar region, the brain and the spinal channel was instaured. Four months later, the CT scan shows normal sized ventricles and no tumour mass at all. This case gives the authors opportunity for comments and to study the concerned literature.

Silicone based polyurethane materials: a promising biocompatible elastomeric formulation for cardiovascular applications.

The biocompatibility of a new material for cardiovascular applications constituted by a poly(ether)urethane (PEtU) and a silicone [polydimethylsiloxane (PDMS)] was evaluated. The achieved material shows properties similar to both polyurethanes and silicones. The material was transformed into porous membranes by a spray-deposition technique. Since any material preparation and manufacturing procedure may introduce some toxicity, in vitro cytotoxicity screening tests were carried out. Human umbilical vein endothelial cells (HUVECs) and a mouse fibroblasts cell line (L929) were cultivated with extracts obtained from materials containing 10, 40 and 100% (w/w) of PDMS. The commercially available Estane 5714-F1 and Cardiothane 51 were used as controls. Extracts were incubated up to 72 hours with HUVECs and L929 cells. The cytotoxic effect was evaluated by light microscopy, cell viability (MTT reduction and neutral red uptake) and proliferation (5-bromo-2'-deoxyuridine incorporation) tests. In vivo studies were carried out using materials containing the same PDMS percentages as for in vitro experiments. The same commercial controls were used. Results obtained with cell culture studies agreed with those obtained in the in vivo experiments and showed that the material preparation and manufacturing procedure do not introduce any toxicity in the products at each PDMS concentration investigated.

Light microscopy evaluation of polyurethane vascular grafts porosity by Sudan Black B staining.

In small-diameter vascular grafts, the porosity of the internal surface plays an important role because it affects initial thrombus deposition and therefore the graft's patency. As well as many other studies reported in the literature we have carried out a study of the relationship between porosity and the manufacturing parameters of polyurethane (PU) grafts by standard scanning electron microscopy (SEM) analysis. However, SEM was not completely satisfactory for evaluating the 'sponge-like' uptake of water by the graft due to the unavoidable water loss and metal coating during preparation. In fact this preparation produces artefacts of the three-dimensional porous structure. To avoid this problem we investigated the possibility of observing the graft's internal surface through a stereomicroscope after it had absorbed water. We looked into a simple staining procedure which preferentially colours the PU graft fibres with respect to the void areas. After testing different kinds of stains, we eventually found that Sudan Black B, which usually stains for all kinds of lipid, turned out to be an excellent stain for the water-loaded PU grafts when diluted with ethanol. This staining procedure, coupled with a computerized image analysis system, allowed us to evaluate the degree of void and average void size of the graft internal surface and to correlate these data with graft density and manufacturing parameters.

[Value of simultaneous monitoring of esophageal and gastric pH in infants]. / Intérét de l'enregistrement simultané des pH oesophagien et gastrique chez le nourrisson.

Simultaneous monitoring of esophageal and gastric pH in infants makes clear some peculiarities of digestive physiology and improves the sensibility of the simple method, usual mean of diagnosis of GER. In that way, a gastro-esophageal pH gradient is showed; gradient absolutely necessary to a good interpretation of this test. In twenty-two infants, younger than one year, continuous and extended monitoring of esophageal and gastric pH was realised with a specially-designed-combination microelectrode. Results pointed out that, after a meal, especially a milked meal, the post prandial period isn't suitable for the diagnosis of GER. Indeed, the gastric acidity is buffered, sometimes during many hours: that decreases or cancels the gastro-esophageal pH gradient. Besides, transient neutralisation periods of gastric acidity may occur, perhaps related with duodenogastric-biliary reflux. Before two months, the gastric pH is less acid that involves, one more time, on insufficient gastro-esophageal pH gradient for the diagnosis of GER.

Life events and prodromal symptoms in bulimia nervosa.

BACKGROUND: Little is known about the interaction of life events with prodromal symptoms in bulimia nervosa. METHODS: A semistructured research interview based on Paykel's Interview for Recent Life Events and on the Clinical Interview for Depression for eliciting prodromal symptoms was administered to 30 patients with bulimia nervosa and 30 healthy control subjects matched for sociodemographic variables. RESULTS: Patients reported significantly more stressful life events than controls. Most of the patients reported prodromal symptoms. Anorexia, low self-esteem, depressed mood, anhedonia, generalized anxiety and irritability were the most common prodromal symptoms. CONCLUSIONS: The prodromal phase of bulimia nervosa was found to be characterized by a combination of prodromal symptoms of affective type and stressful life events. Their joint occurrence may increase vulnerability to bulimia nervosa.

[11q trisomy: apropos of 2 cases]. / La trisomie 11q: à propos de deux cas.

The authors report two new cases of 11q trisomy, one due to a "classical" (11q; 22q) translocation, one due to a desequilibrated (8q; 11q) translocation (de novo). The 2 phenotypes are compared with the data of the literature on the 11q trisomy syndrome.

Hypochondriacal fears and beliefs in obsessive-compulsive disorder.

The relationship of obsessions and compulsions with hypochondriasis is receiving increasing attention, but has not been substantiated by adequate research. The Illness Attitude Scales (IAS), which identify hypochondriacal patients, were administered to 30 patients with DSM-IV obsessive-compulsive disorder and 30 healthy control subjects matched for sociodemographic variables. All IAS scales were significantly higher in patients with obsessions and compulsions. However, there were no significant differences between patients and controls in the number of subjects whose symptom intensity exceeded a clinical threshold for hypochondriasis and disease phobia. Furthermore, hypochondriacal fears and beliefs were poorly correlated with obsessions and compulsions. The results suggest the presence of mild abnormal illness behaviour in patients with obsessive-compulsive disorder, unlike the situation in patients with panic disorder and depression.

[Primary malignant tumor of the liver in children]. / Les tumeurs malignes primitives du foie chez l'enfant

Primary malignant tumours of the liver in children are rare. They occur in more than 50% of cases before the age of 2 years. The clinical signs are very often limited to a large mass in the right hypochrondrium. A search for alphafoetoprotein and arteriography are the most useful investigations for diagnosis. The pathology leads one to distinguish hepatoblastomas and hepatocarcinomas. The prognosis in these tumours remains poor for, in spite of progress in liver surgery, a cure is rarely possible. It is important for doctors to recognize the existence of this tumour pathology in order to give a chance for surgery to succeed in these young children. To illustrate this, 5 cases from Besançon are reported here.

Clinical correlates of major depression in Cushing's disease.

Major depression is a common, life-threatening complication of Cushing's syndrome, with no significant differences between pituitary-dependent and -independent forms. Little is known about the clinical correlates of depression; in particular, whether patients with Cushing's disease and major depression show some clinical features that are distinctive compared to those who are not depressed. The occurrence of major depression according to DSM-IV criteria was ascertained in 162 patients with pituitary-dependent Cushing disease. Major depression occurred in 88 of the patients (54%). It was significantly associated with older age, female sex, higher pretreatment urinary cortisol levels, relatively more severe clinical condition, and absence of pituitary adenoma. Patients with Cushing's disease and depression appeared to suffer from a more severe form of illness, both in terms of cortisol production and clinical presentation, compared to those who were not depressed. Because of these connections, the presence of depression is an important clinical feature that should not be neglected. The findings in this study may have implications for a better understanding of the pathophysiological role of depression associated with medical illness.

[Congenital generalized lipodystrophy. Lipid changes. Therapeutic trials]. / Lipodystrophie généralisée congénitale. Perturbations lipidiques. Essais thérapeutiques.

On the occasion of a new case of congenital generalized lipodystrophy the clinical features of this disease are reviewed. Furthermore, the frequent association of type V hypertriglyceridemia is emphasized. Various pathogenic hypotheses guide the therapeutic attempts, which are often unsuccessful.