Serial evaluation of the thoracic aorta in patients with a bicuspid aortic valve: a magnetic resonance angiography study.

BACKGROUND: Bicuspid aortic valve (BAV) is associated with an arteriopathy leading to a progressive dilatation of the aortic root. Recent studies have shown that the whole thoracic aorta is affected by this arteriopathy. Longitudinal data regarding the progression of this arteriopathy in the whole thoracic aorta has not been reported before. PATIENTS AND METHODS: In this retrospective study 40 patients (mean age 28.5 +/- 9.1 years) had 2 MR-angiographies (mean interval 37.1 +/- 15.2 months). In 23 patients the aortic valve was regurgitant, in 1 stenotic, in 4 combined aortic stenosis / regurgitation was found, while in 12 the valve function was normal. Aortic diameters were measured at 6 different, standardized anatomical points. The influence of demographic and clinical parameters was assessed. RESULTS: A significant increase of the diameter was observed at the aortic root (35.4 +/- 5.6 mm --> 39.1 +/- 6.5 mm, p < 0.001), the ascending aorta (37.3 +/- 8.0 mm --> 39.5 +/- 8.5 mm, p = 0.001), proximal to the innominate artery (29.4 +/- 6.1 mm --> 31.6 +/- 6.8 mm, p = 0.008), and the descending aorta (20.2 +/- 2.4 mm --> 21.6 +/- 4.2 mm, p = 0.03). There was no significant increase proximal (24.0 +/- 5.7 mm --> 24.6 +/- 5.3 mm, p = 0.44) and distal to the left subclavian artery (21.4 +/- 4.6 mm --> 21.9 +/- 4.5 mm, p = 0.19). These observations were independent of the presence of arterial hypertension, a previous operation, gender, and functional status of the aortic valve. CONCLUSIONS: The progressive dilatation of the aortic root and ascending aorta that can be observed in patients with BAV was not found in the more distal parts of the thoracic aorta with the exception of the descending aorta in this study. If the dilatation of the descending aorta bears any clinical significance can't be answered with the current data. A prospective study should be performed to confirm these results.

[CMV-enterocolitis as a cause for repeated intestinal intussusceptions in an adult patient after liver transplantation?]. / CMV-Enterokolitis bei einer erwachsenen lebertransplantierten Patientin als Ursache rezidivierender Invaginationen?

Intestinal intussusception in the adult is often idiopathic but also known to be associated with chronic inflammatory bowel disease, coeliac disease, tumours or previous abdominal operations. A 22-year-old women after liver transplantation due to Crigler Najar Syndrome suffered from repeated episodes of abdominal pain. The diagnosis of repeated self-limited intestinal intussusceptions was made by computed tomography and ultrasonography. A laparoscopy revealed no cause for the intussusceptions. During a new episode of abdominal pain caused again by an intussusception a colonoscopy was performed that showed aspects of a discreet colitis. In the biopsies CMV was detected by qualitative PCR, while blood tests for CMV pp65 antigen were negative. A therapy with gancyclovir was initiated which lead to remission of the patient's symptoms. A colonoscopy six weeks later showed a completely normal colon, while in the biopsies CMV was not detectable. After a follow-up of one year the patient has not suffered from any further episodes. This case demonstrates the role of chronic intestinal CMV infection as a possible causative factor for repeated intussusceptions in immunosuppressed patients. Whenever possible a PCR for CMV in colon biopsies should be carried out to detect an intestinal CMV infection because as shown in our case results for immunohistopathology and CMV pp65 can be negative despite a chronic infection.

Fulminant hepatic failure due to chemotherapy-induced hepatitis B reactivation: role of rituximab.

Hepatitis B virus reactivation during immunosuppressive therapies can lead to liver failure with very limited treatment options available. We report here on two cases of severe hepatitis B reactivation during chemotherapy including rituximab for B cell lymphoma which were treated with liver or liver-cell transplantation. Liver function was normal and HBV infection was unknown in both patients before chemotherapy was started. Impaired liver function became apparent after 4 and 6 courses of chemotherapy, respectively, and both patients experienced fulminant hepatic failure despite antiviral treatment with lamivudine or entecavir. Patient A underwent liver transplantation after documentation of complete remission of the lymphoma and survived without any evidence for hepatitis B recurrence. Patient B received 4 courses of hepatocyte transplantation but did not survive. These cases underline the importance of anti-HBc screening in patients receiving immunosuppressive treatments in particular when rituximab is given. Pre-emptive antiviral treatments should be administered since delayed antiviral treatment is frequently unable to prevent liver failure.

Dilatation of the entire thoracic aorta in patients with bicuspid aortic valve: a magnetic resonance angiography study.

BACKGROUND: The presence of a bicuspid aortic valve (BAV) might be associated with a progressive dilatation of the aortic root and ascending aorta. However, involvement of the aortic arch and descending aorta has not yet been elucidated. PATIENTS AND METHODS: Magnetic resonance angiography (MRA) was used to assess the diameter of the ascending aorta, aortic arch, and descending aorta in 28 patients with bicuspid aortic valves (mean age 30 +/- 9 years). RESULTS: Patients with BAV, but without significant aortic stenosis or regurgitation (n = 10, mean age 27 +/- 8 years, n.s. versus control) were compared with controls (n = 13, mean age 33 +/- 10 years). In the BAV-patients, aortic root diameter was 35.1 +/- 4.9 mm versus 28.9 +/- 4.8 mm in the control group (p < 0.01). The diameter of the ascending aorta was also significantly increased at the level of the pulmonary artery (35.5 +/-5.6 mm versus 27.0 +/- 4.8 mm, p < 0.001). BAV-patients with moderate or severe aortic regurgitation (n = 18, mean age 32 +/- 9 years, n.s. versus control) had a significant dilatation of the aortic root, ascending aorta at the level of the pulmonary artery (41.7 +/- 4.8 mm versus 27.0 +/- 4.8 mm in control patients, p < 0.001) and, furthermore, significantly increased diameters of the aortic arch (27.1 +/- 5.6 mm versus 21.5 +/- 1.8 mm, p < 0.01) and descending aorta (21.8 +/- 5.6 mm versus 17.0 +/- 5.6 mm, p < 0.01). CONCLUSIONS: The whole thoracic aorta is abnormally dilated in patients with BAV, particularly in patients with moderate/severe aortic regurgitation. The maximum dilatation occurs in the ascending aorta at the level of the pulmonary artery. Thus, we suggest evaluation of the entire thoracic aorta in patients with BAV.

How international are leading general paediatric journals?

The composition of the editorial boards of leading general paediatric journals was assessed. The board members' country of current affiliation was classified according to the Human Development Index. The results showed that only a very small number of the board members are based in the developing world.

Introduction and evaluation of a modular seminar system in gross anatomy teaching at the Hannover Medical School.

We present a new modular seminar system which has been introduced into the gross anatomy teaching at the Hannover Medical School. It consists of seven modules with a clinical emphasis. The new modular seminar system was evaluated by an anonymous questionnaire. The results showed that the seminar system as a whole, and the different modules with one exception were highly appreciated by the students. The evaluation also revealed that the main reason for the success of a module is the manner of the teaching and learning rather than the clinical relevance. Taking into account the results of this evaluation we describe the appropriate style of teaching for use in a seminar. The success of this new approach to small group instruction in Germany should encourage other teachers of anatomy and other undergraduate subjects to consider new methods of teaching.