Massive Haematochezia due to Splenic Artery Bleeding into the Colon: Unusual Manifestation of Advanced Pancreatic Cancer.

We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula).

[Consensus approach: Prior to the construction of an evaluation scale of risk constipation patients hospitalized for nursing practice]. / Approche par recherche de consensus : un préalable à la construction d'une échelle d'évaluation du risque de constipation des patients hospitalisés destinée à la pratique infirmière.

BACKGROUND: Constipation is a frequent issue during hospitalization. Multiple causes such as the existence of irregular habits, lack of exercise as well as medical history have been identified. Drugs such as strong painkillers, central nervous system therapies and treatments of the digestive tract are a major cause of constipation. Additionally, unbalanced diet, fluid deficiency, and anxiety may aggravate constipation. The consideration of all these risk factors being under the responsibility of nurses. The difficulty to take into account such a multifactorial aetiology in nursing practice and the fact that there is no easy to use and validated tool to assess the risk of constipation in current nurse practice has led us to consider the development of a Risk Assessment scale of Constipation in Patient Hospitalized (ERCoPH) to facilitate preventive management of this trouble. We present here the first step of the elaboration of this scale, the identification of risk factors through a consensus approach after a systematic literature review. METHODS: The key informants consensus-based approach proposed by Pineault and Daveluy is based on five steps: (1) a literature review to identify risk factors for constipation; (2) the elaboration of a questionnaire containing the factors identified in the first step; (3) pre-select a panel of experts; (4) submission the questionnaire to the panel; (5) analysis the results of the consensus survey. Only factors that received a rating>6 by at least 80 % of the experts were retained. RESULTS: The systematic literature review identified 69 risk factors submitted to the 23 experts of the panel. Fifteen risk factors were retained after analyzing the answers of the experts. The Scientific Committee added eight risk factors because of their importance in the literature and decided to group together some factors of the same domain. CONCLUSION: A total of 19 risk factors were selected and grouped by major class (age, physical activity, medication, social data, food/hydration, medical and surgical history and environmental data). These factors have been tested among 300 patients enrolled in different clinical settings as part of the construction and validation of ERCoPH.

Imaging and lipidomics methods for lipid analysis in metabolic and cardiovascular disease.

Cardiometabolic diseases exhibit changes in lipid biology, which is important as lipids have critical roles in membrane architecture, signalling, hormone synthesis, homoeostasis and metabolism. However, Developmental Origins of Health and Disease studies of cardiometabolic disease rarely include analysis of lipids. This short review highlights some examples of lipid pathology and then explores the technology available for analysing lipids, focussing on the need to develop imaging modalities for intracellular lipids. Analytical methods for studying interactions between the complex endocrine and intracellular signalling pathways that regulate lipid metabolism have been critical in expanding our understanding of how cardiometabolic diseases develop in association with obesity and dietary factors. Biochemical methods can be used to generate detailed lipid profiles to establish links between lifestyle factors and metabolic signalling pathways and determine how changes in specific lipid subtypes in plasma and homogenized tissue are associated with disease progression. New imaging modalities enable the specific visualization of intracellular lipid traffic and distribution in situ. These techniques provide a dynamic picture of the interactions between lipid storage, mobilization and signalling, which operate during normal cell function and are altered in many important diseases. The development of methods for imaging intracellular lipids can provide a dynamic real-time picture of how lipids are involved in complex signalling and other cell biology pathways; and how they ultimately regulate metabolic function/homoeostasis during early development. Some imaging modalities have the potential to be adapted for in vivo applications, and may enable the direct visualization of progression of pathogenesis of cardiometabolic disease after poor growth in early life.

Percutaneous Image-Guided Cryoablation as Second-Line Therapy of Soft-Tissue Venous Vascular Malformations of Extremities: A Prospective Study of Safety and 6-Month Efficacy.

PURPOSE: To report the safety and short-term efficacy of percutaneous image-guided cryoablation performed as second-line therapy of venous vascular malformations (VVM) of extremities. MATERIALS AND METHODS: In this non-blinded, no-randomized trial, cryoablation was proposed in 14 patients presenting with symptomatic VVM for recurrences after treatment. Eligibility criteria were: cryoablation feasible, localization at least 5 mm from skin and nerves, absence of contra-indication for anesthesia. Safety was evaluated by the common terminology criteria for adverse events (AE). Clinical response was assessed by evaluating pain at day 7, month 2 and 6 using visual analog scale; quality of life before cryoablation and at 2 and 6 months after using questionnaire. Evolution of volume was evaluated by MRI at 6 months. Comparison was performed using the Wilcoxon test. RESULTS: A technical success was observed in all cases. While 11 patients (78.6%) presented AE (13 grade 1-2 and 3 grade 3), only two severe AE (grade 3) related to cryoablation occurred in two patients (14.3%) during the 6-month follow-up: one immediate sciatic paralysis and one delayed paresthesia. A clinical response was observed in 12 patients (85.7%) at 6 months. Pain decreased significantly from 42.5 ± 14.2 mm before the intervention to 11.8 ± 17.9 mm at 6 months (P = 0.002). A significant decrease in the mean volume from 12.8 ± 14.3 to 3 ± 2.7 cm3 was observed at 6 months (P = 0.002). CONCLUSION: Percutaneous cryoablation is a promising alternative treatment for sclerotherapy-resistant venous malformations. However, to improve safety, careful patient selection and treatment planning will be mandatory.

Intracellular distribution and stability of a luminescent rhenium(i) tricarbonyl tetrazolato complex using epifluorescence microscopy in conjunction with X-ray fluorescence imaging.

Optical epifluorescence microscopy was used in conjunction with X-ray fluorescence imaging to monitor the stability and intracellular distribution of the luminescent rhenium(i) complex fac-[Re(CO)3(phen)L], where phen = 1,10-phenathroline and L = 5-(4-iodophenyl)tetrazolato, in 22Rv1 cells. The rhenium complex showed no signs of ancillary ligand dissociation, a conclusion based on data obtained via X-ray fluorescence imaging aligning iodine and rhenium distributions. A diffuse reticular localisation was detected for the complex in the nuclear/perinuclear region of cells, by either optical or X-ray fluorescence imaging techniques. X-ray fluorescence also showed that the rhenium complex disrupted the homeostasis of some biologically relevant elements, such as chlorine, potassium and zinc.

Multidisciplinary care management has a positive effect on paediatric obesity and social and individual factors are associated with better outcomes.

AIM: The RePPOP Aquitaine network, which was established in south-west France to prevent and treat paediatric obesity, has developed a multidisciplinary approach based on multicomponent lifestyle interventions and family-based actions. This study assessed the impact of its care management programme and investigated the factors associated with better outcomes. METHODS: The impact of the RePPOP care management programme was assessed by changes in the body mass index (BMI) Z score, between baseline and the end-of-care management. We focused on 982 overweight or obese children (59.9% girls) with a mean age of 10.64 years and a range of 2.4-17.9 years. A multivariate analysis examined the independent factors associated with better outcomes. RESULTS: At the end-of-care management programme, 75.5% of children had decreased their BMI Z score. Initial characteristics significantly associated with better outcomes were as follows: the age at baseline between five years and 15 years of age, playing sport at a club, being followed up by RePPOP for longer than 10 months, no parental obesity and no academic difficulties. CONCLUSION: This study confirmed that multidisciplinary treatment had a significant positive effect on paediatric obesity and that social and individual factors affected the efficiency of the care management.

Unprecedented staining of polar lipids by a luminescent rhenium complex revealed by FTIR microspectroscopy in adipocytes.

Fourier transform infrared (FTIR) microspectroscopy and confocal imaging have been used to demonstrate that the neutral rhenium(i) tricarbonyl 1,10-phenanthroline complex bound to 4-cyanophenyltetrazolate as the ancillary ligand is able to localise in regions with high concentrations of polar lipids such as phosphatidylethanolamine (PE), sphingomyelin, sphingosphine and lysophosphatidic acid (LPA) in mammalian adipocytes.

Atg9 is required for intraluminal vesicles in amphisomes and autolysosomes.

Autophagy is an intracellular recycling and degradation process, which is important for energy metabolism, lipid metabolism, physiological stress response and organism development. During Drosophila development, autophagy is up-regulated in fat body and midgut cells, to control metabolic function and to enable tissue remodelling. Atg9 is the only transmembrane protein involved in the core autophagy machinery and is thought to have a role in autophagosome formation. During Drosophila development, Atg9 co-located with Atg8 autophagosomes, Rab11 endosomes and Lamp1 endosomes-lysosomes. RNAi silencing of Atg9 reduced both the number and the size of autophagosomes during development and caused morphological changes to amphisomes/autolysosomes. In control cells there was compartmentalised acidification corresponding to intraluminal Rab11/Lamp-1 vesicles, but in Atg9 depleted cells there were no intraluminal vesicles and the acidification was not compartmentalised. We concluded that Atg9 is required to form intraluminal vesicles and for localised acidification within amphisomes/autolysosomes, and consequently when depleted, reduced the capacity to degrade and remodel gut tissue during development.

Recurrent High-Flow Arterio-Venous Malformation of the Thyroid Gland.

BACKGROUND: Vascular malformations and hemangiomas of the thyroid gland are rare disorders. The first case of a patient with recurrent high-flow arterio-venous malformation of the right thyroid gland involving the right endolarynx is presented. PATIENT FINDINGS: In June 2013, a 42-year-old female patient presented to the surgical department with recurrent hoarseness and a soft, vibrating mass on the right side of her neck. In 1993, she underwent right subtotal hemithyroidectomy with embolization on the day before surgery for a high-flow arterio-venous malformation of the thyroid gland. Diagnostic work-up in 2013 demonstrated a complex recurrent high-flow arterio-venous malformation on the right side of her neck involving the endolarynx. Full function of the right vocal fold could not be ascertained. The lesion was embolized again and excised the following day. Intraoperative gross bleeding and scar tissue prevented visualization and monitoring of the recurrent laryngeal nerve. Gross bleeding was also noted on hemithyroidectomy after embolization in 1993. No therapy was needed for the endolaryngeal part of the lesion. Histology showed large arterio-venous malformations with thyroid tissue. She remains well without signs of recurrence 18 month later but with a definitive voice handicap. SUMMARY: This is the first report of a recurrent high-flow arterio-venous malformation originally developing from the right thyroid gland involving the right endolarynx. Counseling, diagnostic, and therapeutic work-up of the patient was possible only with an interdisciplinary team. The endolaryngeal part of the hemangioma dried out after embolization and completion hemithyroidectomy. Her hoarseness has greatly improved but a definitive voice handicap remains. CONCLUSION: High-flow arterio-venous malformations of the thyroid gland are a rare disease, and recurrent lesions have not been reported. Interdisciplinary management of these patients is mandatory due to the complex nature of the underlying pathology. Recurrence might develop after long free intervals.

[Psychogenic aphonia. A challenging diagnosis?]. / Psychogene Aphonie. Eine schwierige Diagnose?

BACKGROUND: Based on clinical experience in the treatment of psychogenic aphonic patients, the study aimed to analyse the time interval between symptom onset and diagnosis using concrete data and to identify the cause of delayed diagnosis. PATIENTS AND METHODS: The medical records of 14 patients (all female) with psychogenic aphonia first diagnosed at the ENT department of the Saarland University Clinic were evaluated in a retrospective study. RESULTS: The time interval between symptom onset and the diagnosis of psychogenic aphonia ranged from 1 to 32 weeks, with a mean time interval of 9 weeks. In addition to all patients consulting an ENT specialist, additional diagnostic procedures (primarily imaging) were performed in 6 of 14 patients before the correct diagnosis was made. In all, 13 patients had previously undergone some form of therapy, 11 of these receiving antibiotic treatment. CONCLUSIONS: The study confirms that unnecessary instrument-based"over-diagnosis", as well as ineffective treatment attempts lead to significant delays in the diagnosis of psychogenic aphonia and hence delays in the initiation of causal treatment.

[Subjective and objective hearing test results for children with orofacial clefts]. / Audiometrische Daten subjektiver und objektiver Hörprüfungen bei Kindern mit orofazialen Spaltbildungen--eine prospektive Längsschnittuntersuchung.

OBJECTIVE: The hearing status of children with orofacial clefts was analysed using objective hearing tests over an average of 38.7 months following soft palate closure. We investigated the influence of: timing of closure, type of cleft, importance of grommets insertion and concomitant craniofacial syndromes such as Pierre Robin (PRS). MATERIAL AND METHODS: 70 children were selected for prospective audiometric testing twice yearly. RESULTS: The average age at surgical closure was 8.3 months. More than half had PRS, but their hearing levels were not significantly different from those who did not. Neither did cleft type or timing of closure seem to have any influence. The portion of children with a hearing level better than 30 dB increased after repair from 38.6% to 81.4%--significant at 0.001 and remained stable more than 24 months later. In the group of children with concomitant grommets insertion, it was also found that also more than 80% achieved longstanding normal hearing. CONCLUSIONS: There is no long lasting hearing loss which has any relevance to speech. The only intervention of any consequence is insertion of pressure equalising/tympanostomy tubes (grommets) in cases of primary palatal clefts when hearing is substantially impaired at the time of soft palate closure.

[Postoperative complications after recrossectomy of the saphenofemoral junction]. / Postoperative Komplikationen nach inguinaler Re-Krossektomie.

The surgical procedure for recurrences at the saphenofemoral junction represents a great challenge for the surgeon due to the complex anatomic variability, the broad range of causes and the mostly extreme scar tissue. The incidences of postsurgical minor and major complications after recrossectomy in the groin area are determined and the clinical outcomes are analysed in this article. After specific and precise presurgical clinical and sonographical diagnoses having been undertaken a cutaneous incision is performed in the groin with the aid of tumescent local anaesthesia combined with total intravenous anaesthesia. From the proximal site any scar tissue exsisting is meticulously removed, the femoral vein is set free and the still remaining stump of the long saphenous vein or of the neovasculate as well as all left over varicose side branches of the saphenofemoral junction are removed. Within this special surgical procedure the stump of the long saphenous vein or the neovasculate are completely removed and, thereafter, a continuous longitudinal suture of the femoral vein is performed. Uncomplicated minor bleeding complications (haematoma in large extension or disseminated) appear quite frequently, lymphatic minor complications (conservatively treatable lymph oedema, lymphatic fistulae or lymphatic cysts) occur from time to time; major complications such as bleeding complications with the necessity of surgical reintervention occur only in sporadic cases and can be avoided by exact presurgical diagnosis, by meticulous special surgical technique matching the operation site as well as by regular and frequent postsurgical follow-ups. Absolute preconditions to achieve the very best results in the long run are the exact procedures of diagnosis and surgical technique. Performed by experienced phlebosurgeons or vascular surgeons, the recrossectomy of the saphenofemoral junction represents a low-risk surgery for the patient and is a singular and possibly time-consuming challenge for the surgeon.

Eggs of the Australian saltmarsh mosquito, Aedes camptorhynchus, survive for long periods and hatch in instalments: implications for biosecurity in New Zealand.

The Australian saltmarsh mosquito, Aedes camptorhynchus (Diptera: Culicidae), is a significant biting pest and disease vector and is the subject of an eradication programme in New Zealand (NZ), where it has been resident for more than 10 years. To better understand the ecology of this common and widespread pest, we studied egg longevity and hatching patterns in the laboratory. By regularly testing for the presence of viable embryos, we found that eggs may last more than 15 months when stored dry (13% viable at this time). Eggs display instalment hatching, with no more than 56% of a batch hatching upon first inundation. Further hatching may occur for at least six inundations and some unhatched eggs may remain viable even after this. Variation in hatching rates can be observed using different water types, with weaker hatching media stimulating lower hatching rates spread over more inundations. By applying average hatching rates to a non-linear model of natural egg attrition, we showed that egg batches exposed to three inundations should be exhausted (zero live eggs present) in approximately 11 months at the conditions tested here. These findings have implications for the current eradication programme for Ae. camptorhynchus in NZ and for our understanding of the ecology of a widespread and common disease vector in Australia.

[Dysphagia in children with cerebral palsy--fiberoptic-endoscopic findings]. / Dysphagie bei Kindern mit Infantiler Zerebralparese--Fiberoptisch-endoskopische Befunde.

OBJECTIVE: Cerebral Palsy (CP) is associated frequently with swallowing disorders. By means of fiberoptic endoscopy, pathological findings in dysphagic patients with CP have been intended to be described, to be quantified, and to be related to selected anamnestic aspects. PATIENTS AND METHODS: Swallowing competency has been analysed endoscopically in 54 patients with spastic tetraparesis (range of age: 3 months to 15 years and 11 months). RESULTS: Over 60% of all patients examined endoscopically showed deficits in terms of penetration (24%) or aspiration (39%) of saliva. Two-thirds of the patients who have been tested with food had a penetration or aspiration of food, more than half of them without airway protection by cough reflex. Patients who have been fed orally before examination reported aspirations of food for 40%. Interestingly, about 40% of the children without history of pneumonia had aspirations of saliva and food. Drooling phenomena where associated with aspirations of saliva in 54% and with aspiration of food in 53% of our patients. CONCLUSIONS: Fiberoptic endoscopy is useful to detect a potentially dangerous penetration or aspiration of saliva, secretions and food. Thereby it enables the physician to change airway and feeding management. This is of special importance as children who formerly have been fed orally without suspicion of risks and pneumonia anamnesis turned out to have severe swallowing deficits. A close connection between appearance of drooling phenomena and aspiration of saliva and food has also to be considered in children with CP.

[Accidental abdominal needlestick injury incurred while discarding a disposal container]. / Akzidentelle abdominelle Nadelstichverletzung bei der Entsorgung eines Abwurfcontainers.

Needlestick injuries routinely occur in everyday clinical practice. Adequate instruction of employees in health care and correct prophylaxis against exposure could conspicuously reduce the incidence. Successful prevention of chronic infectious diseases comprises strict vaccination plans and substantial knowledge of post-exposure prophylaxis. The introduction of self-securing cannulas and injection instruments represents an important technological advance.