Altered structural and effective connectivity in anorexia and bulimia nervosa in circuits that regulate energy and reward homeostasis.

Anorexia and bulimia nervosa are severe eating disorders that share many behaviors. Structural and functional brain circuits could provide biological links that those disorders have in common. We recruited 77 young adult women, 26 healthy controls, 26 women with anorexia and 25 women with bulimia nervosa. Probabilistic tractography was used to map white matter connectivity strength across taste and food intake regulating brain circuits. An independent multisample greedy equivalence search algorithm tested effective connectivity between those regions during sucrose tasting. Anorexia and bulimia nervosa had greater structural connectivity in pathways between insula, orbitofrontal cortex and ventral striatum, but lower connectivity from orbitofrontal cortex and amygdala to the hypothalamus (P<0.05, corrected for comorbidity, medication and multiple comparisons). Functionally, in controls the hypothalamus drove ventral striatal activity, but in anorexia and bulimia nervosa effective connectivity was directed from anterior cingulate via ventral striatum to the hypothalamus. Across all groups, sweetness perception was predicted by connectivity strength in pathways connecting to the middle orbitofrontal cortex. This study provides evidence that white matter structural as well as effective connectivity within the energy-homeostasis and food reward-regulating circuitry is fundamentally different in anorexia and bulimia nervosa compared with that in controls. In eating disorders, anterior cingulate cognitive-emotional top down control could affect food reward and eating drive, override hypothalamic inputs to the ventral striatum and enable prolonged food restriction.

[Obstructive jaundice du to sludge in the common bile duct]. / Verschlussikterus durch Sludge im Ductus choledochus.

HISTORY AND FINDINGS: A 21-year-old woman developed increasing jaundice with severe pruritus and weight loss after a bout of dyspepsia. She had been taking contraceptives for 4 years (ciproteronacetate 2 mg, ethinylestradiol 0.035 mg). INVESTIGATIONS: Laboratory tests at first suggested cholestatic hepatitis (serum bilirubin > 5 mg/dl, predominantly indirect bilirubin, SGOT 77 U/l, SGPT 154 U/l, gamma-GT 138 U/l, alcaline phosphatase 630 U/l). Ultrasonography showed a gall bladder filled with biliary sludge and dilatation of the common bile duct and the smaller biliary passages. A tumour-like space-occupying lesion was noted near the papilla: it was not fixed and had no vascular supply. Endoscopic retrograde cholangiopancreatography (ERCP) also demonstrated a mobile space-occupying lesion in the common bile duct near the papilla and markedly dilated biliary passages. DIAGNOSIS, TREATMENT AND COURSE: The tumour-like obstruction was removed by balloon catheter after papillotomy. It consisted of several jelly-like viscous streaky bile without calculi. The procedure was complicated by subsequent pancreatitis which, however, soon subsided. Within a few days the jaundice disappeared and the pruritus ceased. At the same time the liver functions returned to normal. Ultrasonography no longer showed obstructed biliary passages and sludge. CONCLUSIONS: Obstructive jaundice may be due not only to strictures gall stones and benign or malignant tumours but also to thickened sludge in the biliary tract in women on oral contraceptives. The obstruction can be demonstrated by ERCP and removed by interventional procedures (i.e. endoscopic papillotomy).

["Benign" monoclonal gammopathy and chronic lymphatic leukemia in a patient with Noonan syndrome]. / "Benigne" monoklonale Gammopathie und chronisch lymphatische Leukämie bei einem Patienten mit Noonan-Syndrom.

HISTORY: At the age of 32 a "benign" monoclonal gammopathy of lightchain kappa with Bence Jones protein is diagnosed in a man born 1934. In addition a Noonan-syndrome is found. COURSE: Twenty-four years later he gradually develops a chronic lymphatic leukaemia (B-CLL) which up to now does not need treatment (October 1996). The neoplastic B-cells exprime monoclonal lightchain lambda on the cellmembrane and in the cytoplasma undetectable by immunefixation in the serum. Irrespective of that the known monoclonal gammopathy exprimes IgG-kappa without an increase in the number of plasmacells in the bonemarrow. CONCLUSION: There are hints that the congenital Noonan-syndrome can be associated with B-cell disorders.

[Non-tropical pyomyositis]. / Nichttropische Pyomyositis.

This is a report on a 51-year-old man with all the symptoms of a non-tropical pyomyositis, namely a prodromal stage with lassitude, associated with a high fever and diffuse joint and muscle pain followed by the gradual development of a full-blown invasive stage. In the suppurative stage, the extensive pus is caused by staphylococcus aureus located in the extensor muscle of the right thigh.

Macrolipasemia: a rare cause of persistently elevated serum lipase.

This report describes a variant form of lipase found in a patient with cryptogenic liver cirrhosis. Serum lipase in this patient showed persistently increased activity with simultaneously normal activity of amylase. Results of exclusion chromatography demonstrate that the lipase activity in the serum of this patient eluted as a macromolecule. Since macromolecular complexes were not fixed by protein A, it seems unlikely that lipase is attached to IgG. Tests of the sera from 20 patients with raised serum lipase activity in acute pancreatitis or an acute episode of chronic pancreatitis revealed, in two patients, that a small but reproducible proportion of the total lipase activity eluted in the region of the macrolipase. In addition, 10% and 18% of the total lipase activity was found in the elution region of the macrolipase in two commercial pooled sera used for quality control. The results show that, in rare cases, macrolipasemia must be considered a possible cause of raised serum lipase activity.

[Contraceptive pancreopathy]. / Ovulationshemmer-Pankreopathie.

PIP: In a private practice an increasing number of young women or girls are being observed with sudden onset of acute stomach pains of unknown origin. Clinically the pancreas is sensitive to pressure and there is an alpha-amylase elevation in the urine often accompanied by moderate leukocytosis. A slight elevation of the transaminase count is usual in such cases. There are no indications of alchohol abuse or pancreatic disorders in the anamnese and x-rays reveal an adequately functionning gall bladder without stones. Without exception all the women have been on oral contraceptives. With spasmolytics and a diet low in fats the symptoms disappear, often without discontinuation of the contraceptive. More data are needed on this problem, and prospective research should determine which additional factors must be present for the activation of such pancreatic disorders.^ieng