[Modern echocardiography: possibilities and limitations]

Echocardiography has revolutionized the cardiac evaluation in non-invasive cardiology. Two-dimensional and colour Doppler echocardiography have the potential to provide quantitative insighths into the hearts anatomy, valve and ventricular function in a excellent time and spacial resolution. In addition integration of Doppler allows the quantification of stenotic lesions and hemodynamics. Stressechocardiography has gained wide acceptance for the evaluation of ischemia. Reduced echoquality can be overcome by latest probe technology (harmonic imaging and postprocessing), transesophageal echocardiography and echocontrast studies. However echocontrast will be used for myocardial perfusion imaging also. Three dimensional echocardiography is ready for clinical application. Good formation and continuous training in echocardiography according to international guidelines will help to reduce interobserver and intraobserver variability.

Long-term outcomes of breast cancer patients after endoscopic axillary lymph node dissection: a prospective analysis of 52 patients

BACKGROUND

Reports on long-term outcomes after endoscopic axillary lymph node dissection (ALND) of breast cancer patients are still lacking in the medical literature. The objective of this prospective study was to assess the oncological and functional outcomes in breast cancer patients after endoscopic ALND.

METHODS

Fifty-five breast cancer patients were prospectively enrolled, of whom 52 were available for follow-up with a median of 71.9 months (range 11-96). The following oncological and functional endpoints were evaluated during follow-up at several time points: occurrence of local, axillary and distant metastases, seroma or infection, shoulder mobility (range of motion), numbness, pain, presence of lymphoedema as well as restriction in activities of daily living.

RESULTS

In 52 patients endoscopic ALND of level I and II was successfully performed. Two port-site metastases (2/52, 4%) occurred, one of which in a patient with negative axillary lymph nodes. The same patient suffered from the only axillary recurrence (1/52, 2%). Three patients (3/52, 6%) developed lymphoedema. No other functional adverse events (shoulder mobility, pain, numbness, hypertrophic scar) were noticed at the end of the observation period.

CONCLUSION

The present investigation with long-term follow-up after endoscopic ALND--the first one in the literature--reveals minor morbidity, good functional and cosmetic results. In contrary to conventional surgery, the endoscopic procedure is associated with the occurrence of port-site metastases, not seen in the open approach. Axillary recurrences do not appear more frequently when compared with results after conventional ALND. In the meantime the less invasive sentinel lymph node (SLN) biopsy is the established standard technique in evaluating the axillary lymph node status.

Plexopathie bilatérale après un foudroiement

INTRODUCTION

The consequences of lightning injuries on the peripheral nervous system are widely unknown.

CASE REPORT

We report on a 31 year-old woman who developed a bilateral brachial plexopathy 15 days after a lightning strike. The patient recovered progressively.

CONCLUSION

Peripheral neuropathies due to lightning strikes are probably unrecognized in most of the cases, because occurrence may be delayed and only few patients were adequately investigated. Pathophysiological hypotheses are unclear and lean on experimental studies using electrical current.

Prévalence de la dépression dans la sclérose en plaques. Revue et méta-analyse

INTRODUCTION

The aim of this paper was to review and summarize the data about the frequency of depression during multiple sclerosis (MS).

MATERIAL AND METHODS

We performed a metaanalysis to combine the results of the studies which compared the frequency of depression in MS patients with the prevalence in patients with other chronic diseases. Eight controlled studies were identified via manual and computerized search of the Medline and PsychInfo databases. Given the various ways these studies reported their results, we used statistical procedures based on the combination of significance levels (the method of adding Zs and the method of adding ts). An additional statistical procedure, Cohen's d, was performed to estimate the effect of size.

RESULTS

The two statistical methods yielded highly significant summary statistics: z=4.15 and z=3.98, respectively (p<0.0001). The effect of size (Cohen's d), which ranged from 0.02 to 0.70 with an average of 0.29 (95 percent confidence interval: 0.09-0.49), can be considered as medium and hence clinically meaningful.

CONCLUSION

These results suggest that the association between MS and depression is specific, that is not just casual nor due to the nonspecific factors inherent in every chronic disease.

Spectroscopy and serial diffusion MR findings in hGH-Creutzfeldt-Jakob disease

This report describes the magnetic resonance imaging (MRI) findings in two patients fulfilling the diagnostic criteria for human growth hormone Creutzfeldt-Jakob disease, who initially had pronounced bilateral DWI/FLAIR (diffusion weighted imaging/fluid attenuated inversion recovery) hyperintensities in the basal ganglia, with decreased apparent diffusion coefficient (ADC) values (range, 58-82% of normal). MRI spectroscopy, obtained in one case, showed decreased N-acetyl aspartate/creatine (NAA/Cr) ratio in the atrophic vermis (0.79; normal: mean, 1.20; SD, 0.13), despite the lack of DWI/FLAIR signal changes, whereas NAA/Cr was normal in the putamina (1.6; normal: mean, 1.56; SD, 0.17), despite striking DWI signal changes and decreased ADC values (60% of normal). Serial DWI, obtained in the other case, showed a progressive disappearance of DWI hypersignal of the basal ganglia replaced by pronounced atrophy. Data from these two patients suggest that restricted diffusion associated with a normal NAA value might indicate spongiform changes of still viable cells, and that any subsequent regression of the DWI signal changes, atrophy, or decreased NAA values could be related to progressive neuronal death.

Aberrant tendinous chords with tethering of the tricuspid leaflets: a congenital anomaly causing severe tricuspid regurgitation

OBJECTIVE

To define the entity of tricuspid regurgitation caused by tethering of the tricuspid valve leaflets by aberrant tendinous chords.

DESIGN

Retrospective study.

SETTING

Tertiary care centre (university teaching hospital).

PATIENTS

10 patients with unexplained severe tricuspid regurgitation.

METHODS

The last 13 500 echocardiographic studies from our facility were reviewed to identify patients with severe unexplained tricuspid regurgitation. Tethering was defined by the presence of aberrant tendinous chords to the tricuspid valve leaflets limiting the mobility of the tricuspid leaflet and resulting in incomplete coaptation and apical displacement of the regurgitant jet origin. Aberrant tendinous chords were defined as those inserting at the clear zone of the tricuspid leaflet and not originating from the papillary muscle. Patients fulfilling the diagnostic criteria for Ebstein's anomaly were excluded.

RESULTS

10 patients with aberrant tendinous chords tethering one or more tricuspid valve leaflets were identified. There were short non-aberrant tendinous chords in seven patients, five of whom also had right ventricular or tricuspid annulus dilatation.

CONCLUSIONS

Tethering of the tricuspid valve leaflets by aberrant tendinous chords can be the sole mechanism of congenital tricuspid regurgitation. It is often associated with short non-aberrant tendinous chords, which may develop secondary to right ventricular or tricuspid annulus dilatation. Awareness of tethering as a cause of tricuspid regurgitation may be important in planning reconstructive surgery.

Early asymptomatic recurrence of cervical artery dissection: three cases

Cervical artery dissection (CAD) recurrences are rare but the risk could be higher during the first month. Twenty-seven consecutive patients admitted for an acute CAD were investigated using a standardized imaging protocol. An early asymptomatic recurrence was observed in three patients 49 to 53 days after the initial diagnosis. Anticoagulation was maintained and the prognosis remained good. Early CAD recurrences may have been underestimated previously, because asymptomatic recurrences seem to be more frequent than symptomatic ones.

[Bilateral amyotrophic neuralgia (Parsonage Turner syndrome) with HIV seroconversion]

We report a unusual case of neuralgic amyotrophy (NA) occurring during the seroconversion stage of an HIV infection. Combined with previously published cases, our observation suggests that NA associated with HIV could belong to the group of early multiplex mononeuritis. Neurologists should be aware of HIV infection when managing a patient with NA.

[Acute ischemia of the hand in a drug addict after accidental intra-arterial injection]

We report a case of a 31-year-old male drug addict with acute ischaemia of the right hand after inadverted intraarterial injection of suspended tablets into brachial artery. He was successfully treated with intraarterial administration of urokinase (250'000 IU as bolus, then continuous infusion of 250'000 IU per 12 hours), papaverin (40 mg i.v. 3 x every 4 hours), systematic heparinisation and with axillary plexus anesthesia (Bupivacain 0.25%, 10 ml/h). Treatment options are discussed reviewing recent publications. Early onset of treatment is mandatory for a good outcome.

Brachial plexopathy associated with systemic sclerosis

Neurological involvement is uncommon in systemic sclerosis. Most of the reported cases concern trigeminal neuropathy or peripheral nerve entrapment. We report a third case of brachial plexopathy, presumably related to vasculitis, in a patient with systemic sclerosis, which improved after cyclophosphamide therapy.

[Stiff limb syndrome associated with Hashimoto's encephalopathy: improvement after corticotherapy]

Stiff limb syndrome is a recently described variant of stiff man syndrome and is characterized by limb stiffness and spasms. Unlike stiff man syndrome, stiff limb syndrome is rarely associated with anti GAD antibodies, poorly improves after symptomatic treatment, and has a relapsing and remitting course. Both stiff man and stiff limb syndromes are frequently associated with auto-immune diseases. We report a case of a 70-year old man who presented with a stiff limb syndrome associated with symptoms highly suggestive of Hashimoto's encephalopathy. The signs of encephalopathy dramatically resolved after corticosteroid treatment, and remissions was complete after 12 months. The stiff limb syndrome had a remitting course despite symptomatic treatment including diazepam, baclofen and vigabatrin and immunomodulating treatments including corticoid and intravenous immunoglobulins.

Respective potencies of Botox and Dysport: a double blind, randomised, crossover study in cervical dystonia

OBJECTIVES

Botulinum toxin type A is a potent neuromuscular paralyzing agent used in various disorders including cervical dystonia. Two preparations of botulinum toxin are now commercially available ( Dysport and Botox), but much controversy remains about their respective potencies. The aim of the study was to compare the efficacy of Botox with two different ratios of Dysport.

METHODS

A double blind, randomised, three period cross over study involving 54 patients with cervical dystonia was performed. The patients received the following treatments in a randomised order: Botox at the usually effective dose, Dysport at a dose of 1:3 (conversion factor of 3 between Botox and Dysport units-that is, one Botox unit=three Dysport units) and at a dose of 1:4 (conversion factor of four). The improvement of the Tsui (primary outcome criteria) and of the TWSTRS pain scales between baseline and a control visit 1 month after each of the three injections, as well as the incidence of adverse events, were assessed.

RESULTS

Comparison of the Tsui scores and of the TWSTRS pain scores showed a better effect on impairment and pain with Dysport 1:3 (p=0.02 and 0.04, respectively) and 1:4 (p=0.01 and 0.02, respectively) than with Botox. The number of adverse events was higher with both Dysport treatments. The most frequent adverse event was dysphagia, found in 3%, 15.6%, and 17.3% (Botox, Dysport 1:3 and 1:4, respectively) of the patients. No adverse event required withdrawal of therapy or specific management.

CONCLUSIONS

Dysport 1:3 (and Dysport 1:4 to a greater extent) is more efficient than Botox for both impairment and pain in cervical dystonia although with a somewhat higher incidence of minor adverse effects. This strongly suggests that the most appropriate conversion factor between Botox and Dysport units is less than 3 in cervical dystonia.

Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm

BACKGROUND AND PURPOSE

Patent foramen ovale (PFO) has been identified as a potential risk factor for stroke, but the mechanisms of PFO-associated stroke remain unsettled. The aim of our study was to evaluate possible differences in stroke risk factors and stroke patterns between patients with and without PFO that may give clues to the mechanism of PFO-associated stroke.

METHODS

This prospective, multicentric study involved 581 young cryptogenic stroke patients. The presence of PFO and atrial septal aneurysm was assessed by transesophageal echocardiography and reviewed independently by 2 experienced sonographers. Clinical, brain, and vascular imaging findings were reviewed by 2 neurologists and 2 neuroradiologists.

RESULTS

Of the 581 stroke patients, 267 (45.9%) had PFO. Patients with PFO were younger (OR, 0.95; 95% CI, 0.93 to 0.97) and less likely to have traditional risk factors such as hypertension (OR, 0.49; 95% CI, 0.28 to 0.85), hypercholesterolemia (OR, 0.56; 95% CI, 0.34 to 0.93), or current smoking (OR, 0.67; 95% CI, 0.47 to 0.97). Features suggestive of paradoxical embolism, such as Valsalva-provoking activities or deep vein thrombosis, were not more frequent in patients with PFO. Migraine was more common in patients with PFO (27.3%) than in those without PFO (14.0%). PFO (OR, 1.75; 95% CI, 1.08 to 2.82), particularly when associated with atrial septal aneurysm (OR, 2.71; 95% CI, 1.36 to 5.41), was significantly associated with migraine after adjustment for age and sex.

CONCLUSIONS

Differences in stroke risk factors and stroke patterns suggest that different stroke mechanisms occur in patients with and without PFO. PFO is significantly and independently associated with migraine, and this association is even stronger in patients with PFO and atrial septal aneurysm.

[Cecum volvulus--a frequently misdiagnosed disease picture. Results of a retrospective study of 26 patients and review of the literature]

BACKGROUND

Cecal volvulus represents a rare disease which causes acute or chronic intermittent mechanical obstruction. Diagnosis of the acute form of cecal volvulus is often established too late with resulting high morbidity and mortality. This study characterizes the typical clinical symptoms, radiological signs and the frequent concomitant diseases, based on a rather large number of patients. We specifically evaluated possible differences concerning clinical presentation, therapy and postoperative course of patients with vital bowel as opposed to necrotic cecum.

PATIENTS AND METHODS

26 consecutive patients hospitalised with cecal volvulus from January 1984 until February 2000 were retrospectively evaluated. Patients with vital intestine (n = 14) were compared to those with necrotic cecum (n = 12).

RESULTS

38% of patients underwent previous abdominal surgery, 34% suffered from other acute disease, in 38% cecal volvulus was associated with a neuropsychiatric disorder. 58% of the patients showed symptoms of intestinal obstruction. The clinical pattern of patients with necrotic cecum was not significantly different from those of patients with vital intestine. Diagnosis of cecal volvulus could be established in 77% by plain abdominal X-ray alone or by an additional contrast enema.

CONCLUSIONS

Knowledge of the characteristic pattern of history, physical findings, plain abdominal X-ray and the frequently with cecal volvulus associated diseases most often allows to establish diagnosis of cecal volvulus without delay and other diagnostic procedures. Astonishingly we found no major difference between vital and necrotic cecum with regard to clinical presentation and postoperative course.

Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both

BACKGROUND

Patent foramen ovale and atrial septal aneurysm have been identified as potential risk factors for stroke, but information about their effect on the risk of recurrent stroke is limited. We studied the risks of recurrent cerebrovascular events associated with these cardiac abnormalities.

METHODS

A total of 581 patients (age, 18 to 55 years) who had had an ischemic stroke of unknown origin within the preceding three months were consecutively enrolled at 30 neurology departments. All patients received aspirin (300 mg per day) for secondary prevention.

RESULTS

After four years, the risk of recurrent stroke was 2.3 percent (95 percent confidence interval, 0.3 to 4.3 percent) among the patients with patent foramen ovale alone, 15.2 percent (95 percent confidence interval, 1.8 to 28.6 percent) among the patients with both patent foramen ovale and atrial septal aneurysm, and 4.2 percent (95 percent confidence interval, 1.8 to 6.6 percent) among the patients with neither of these cardiac abnormalities. There were no recurrences among the patients with an atrial septal aneurysm alone. The presence of both cardiac abnormalities was a significant predictor of an increased risk of recurrent stroke (hazard ratio for the comparison with the absence of these abnormalities, 4.17; 95 percent confidence interval, 1.47 to 11.84), whereas isolated patent foramen ovale, whether small or large, was not.

CONCLUSIONS

Patients with both patent foramen ovale and atrial septal aneurysm who have had a stroke constitute a subgroup at substantial risk for recurrent stroke, and preventive strategies other than aspirin should be considered.

Advanced breast biopsy instrumentation for the evaluation of impalpable lesions: a reliable diagnostic tool with little therapeutic potential

OBJECTIVE

To assess the potential of advanced breast biopsy instrumentation (ABBI) to clarify the diagnosis of impalpable mammographic lesions and to remove the entire malignant lesions with clear margins.

DESIGN

Prospective assessment in a consecutive series of patients.

SETTING

University hospital, Basel, Switzerland.

SUBJECTS

139 patients presenting with 144 impalpable microcalcifications or solid nodular densities evident on screening and follow-up mammograms that were suspicious of malignancy.

MAIN OUTCOME MEASURES

Feasibility, sensitivity, efficiency in obtaining definitive diagnoses in an outpatient clinic under local anaesthesia, feasibility of complete removal of a primary malignancy, and intervention-related morbidity.

RESULTS

The ABBI procedure was successful in 135/144 (94%); an accurate diagnosis was made in 129/130 patients followed up (99%), sensitivity for malignant lesions was 31/32 (97%) and there were 2 complications (2%). Margins of the biopsy cylinder contained a malignant lesion in 26/31 (84%).

CONCLUSIONS

Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low morbidity. As in other published series margins were often not clear of tumour and therefore the therapeutic use of the ABBI procedure is limited.

[Significance of endoscopic axillary dissection in invasive breast carcinoma after introduction of the "sentinel lymph node" method]

Axillary clearance provides prognostic information, determines adjuvant therapy and reduces axillary recurrences. However significant morbidity may follow axillary dissection. Patients with small tumors (pT1a-c) may benefit from new less invasive (endoscopic lymph node dissection) or more selective (sentinel lymph node biopsy) axillary procedures which recently have been introduced. In this prospective study the axilloscopic approach was evaluated.

PATIENTS AND METHODS

55 clinically node negative patients (mean age: 60 years [30-86]) had endoscopic axillary surgery by one single surgeon (1.1996-6.1998). After axillary liposuction individual lymph nodes (level I + II) were identified and removed under direct vision by means of a laparoscope (successful procedure in 95%; n = 52). Patients were followed every four months according to a institution based follow up protocol. Results of 51 patients (1 refused) were analyzed after a median follow up of 22 (7-37) months by self-evaluation questionnaire, interview and clinical examination (including: range of motion of the shoulder joint, circumferences of the upper extremities).

RESULTS

An average of 13.3 (5-25) lymph nodes was endoscopically removed. Patients (n = 16; 31%) had involved nodes with a mean of 3.1 nodes positive per individuum. Seromas necessitated needle aspiration in 8 patients (15%). There were no hematomas and one low grade infection (2%). After a median follow up period of 22 (7-37) months no axillary relapse but one trocar site implantation metastasis (1/55, 2%) was detected and resected. No lymph edema was observed. Early range of motion of the shoulder joint was excellent.

CONCLUSION

This technique allows the removal of an adequate number of lymph nodes for staging as well as for regional control. The morbidity is low and the medium-term follow-up results are promising. The atraumatic and very well tolerated endoscopic axillary dissection is being replaced by the selective sentinel lymph node procedure.

[The Advanced Breast Biopsy Instrumentation (ABBI) for evaluation of mammographically suspicious, non-palpable findings of the breast: a reliable diagnosis with minor therapeutic potential]

BACKGROUND

Stereotactic biopsy techniques supersede conventional hook-wire localization followed by open excision to clarify the dignity of nonpalpable mammographic lesions. The advanced breast biopsy instrumentation (ABBI) allows stereotactically guided excision of a specimen up to 20 mm in diameter on an outpatient basis under local anaesthesia.

METHODS

Demographic information, mammographic and pathological findings, complications, subsequent interventions and sensitivity as well as efficiency of a series of 144 planned ABBI procedures were documented (largest published single institution series).

RESULTS

The ABBI procedure was successfully performed in 93.8% (135/144); accurate diagnosis was made in 99.3% (134/135), sensitivity for malignant lesions was 96.9% (31/32) and morbidity was 1.5%. Consistent with other published series margins of the biopsy cylinder containing a malignant lesion were involved in 83.9% (26/31).

CONCLUSIONS

Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low incidence of morbidity. The therapeutic use is of limited potential.

[Validation study of the sentinel lymph node (SLN) method in invasive breast carcinoma. Personal data and review of the literature]

BACKGROUND

Axillary lymph node dissection (ALND) is an integral part in the therapy of breast cancer. Axillary lymph node involvement and tumour size are the most important prognostic factors. Restriction of ALND to level I and II (Berg) reduced high morbidity. The increasing proportion of patients with early breast cancer and negative axillary nodes led to a more selective method to avoid unnecessary ALND. The sentinel lymph node (SLN)--the first draining lymph node of a tumour--represents the status of the axilla. A negative SLN prevents from further completion ALND.

PATIENTS AND METHODS

From 9/97 to 1/99 44 patients with invasive breast cancer underwent a prospective trial of lymphatic mapping with isosulfanblue and/or lymphoscintigraphy with 99m technetium-labelled human colloid. During the operation a hand-held gamma probe was used for detection. The SLN was removed selectively and examined by routine histopathology (H&E) and immunohistochemistry (IHC). ALND of level I and II was performed in all patients for correlation.

RESULTS

The SLN were identified in 41 of 44 patients (93%). 2.4 SLN per patient were harvested, overall 17.6 axillary lymph nodes. Of the 41 patients, 21 patients had positive, 20 patients negative SLN. In the 20 patients with negative SLN only one patient (5%) had metastatic disease on complete dissection (negative predictive value of 95%). In 17 patients with positive axillary lymph nodes 16 were found to have positive SLN, only one SLN was negative (false negative rate of 5.9%). In two of 41 patients micrometastases were detected by IHC. Lymphoscintigraphy revealed drainage to the axilla and internal mammary nodes in two of 28 cases (7%).

SUMMARY

Our validation study proves the reproducibility and reliability of the SLN procedure. A multidisciplinary approach is indispensable. The SLN procedure has the potency for becoming the selection criterion whether to perform an ALND or not. Multiple sections and IHC staining improve the detection rate of metastatic disease. Ongoing long time investigations will determine the impact on overall survival. Our own data are discussed in an extended review of the literature.

[Small breast carcinomas--less axillary surgery?]

In view of introducing less invasive or selective axillary procedures for small breast cancers we investigated our own pT1 tumor patients. The incidence of pT1 carcinoma, the nodal involvement of pT1a, b and c, the axillary relapse and the overall survival were analyzed. From 1983 till 1997 185 consecutive patients have been treated for breast cancers with a diameter of < or = 20 mm. The survival data after Kaplan-Meier are based on a cohort of 117 patients with a median follow up of at least seven years. There were seven patients with a pT1a carcinoma, 30 with a pT1b and 148 with pT1c carcinoma. On an average 16 axillary lymph nodes were counted by the pathologists. The axillary involvement clearly depends on the size of the primary tumor: no nodal involvement in patients with pT1a carcinoma, 10% in patients with pT1b carcinoma and 30% in patients with pT1c carcinoma. Not one single axillary relapse was detected after this follow up time. The overall ten years survival for patients with pT1a was 100%, 91% for pT1b, but only 74% for pT1c carcinoma. Screening mammography is expected to detect more small breast cancers in pN0 stage. Risks and benefits of axillary dissection have to be carefully evaluated. Axillary involvement of small breast cancers is rare. Only a minority of patients will benefit from routine axillary lymphadenectomy, while the majority runs the risk of complications. The sentinel lymph node (SLN) procedure offers a selective approach to this dilemma.

[The window in the falciform ligament. A rare case of hernia of the small intestine through the falciform ligament]

The most common causes for small-bowel obstructions with subsequent strangulation are intra-abdominal adhesions and external hernias. We report an unusual case of strangulated small-bowel hernia through a congenital window in the falciform ligament. The diagnosis and surgical treatment are discussed.

Evaluation of magnetic resonance cholangiography in the management of bile duct stones

HYPOTHESIS

Magnetic resonance cholangiography (MRC) offers the potential for accurate, noninvasive detection of common bile duct stones (CBDSs) before cholecystectomy, and for a consequent reduction in the incidence of preoperative negative diagnoses associated with endoscopic retrograde cholangiography (ERC).

DESIGN

Prospective cohort study: MRC results were correlated with ERC (high-risk patients) or intraoperative cholangiography (moderate-risk patients).

SETTING

A university hospital providing primary, secondary, and tertiary care.

PATIENTS

Seventy patients with suspected CBDSs scheduled to undergo elective cholecystectomy between April 15, 1997, and September 30, 1998. Forty patients were considered at high risk and 30 at moderate risk for CBDSs, according to results of liver function tests and sonograms of the upper abdomen.

MAIN OUTCOME MEASURES

Confirmation or exclusion of CBDSs by MRC was assessed by a panel of radiologists who were unaware of the ERC results. Results of ERC and intraoperative cholangiography were analyzed by the investigating gastroenterologists or surgeon.

RESULTS

Results of MRC were positive for CBDSs in 21 (52%) of 40 high-risk patients, a finding confirmed by preoperative ERC in 19 (90%) of 21 patients. Results of MRC were positive for CBDSs in 6 (20%) of 30 moderate-risk patients, all of which were confirmed by intraoperative cholangiography. Finally, CBDSs were present in 19 (48%) of 40 high-risk patients and 6 (20%) of 30 moderate-risk patients (P = .02). Overall sensitivity and specificity of MRC were 100% and 95.6%, respectively; the positive and negative predictive values were 92.6% and 100%, respectively.

CONCLUSIONS

Magnetic resonance cholangiography is a reliable, noninvasive method for the detection or exclusion of CBDSs, and seems to reduce the frequency of negative diagnoses associated with ERC. Magnetic resonance cholangiography revealed no CBDSs in 19 (48%) of 40 patients at high risk for CBDSs. Thus, MRC-based diagnosis has the potential to reduce the number of invasive preoperative diagnostic procedures and their associated risks and overall health care costs.

Weight loss of 146 kg with diet and reversal of severe congestive heart failure in a young, morbidly obese patient

This case report describes a weight loss of 146 kg primarily due to diet in a very obese patient with reversal of severe congestive heart failure.

Immediate effects of aortic valve replacement on left ventricular function and its determinants

Replacement of the aortic valve exposes the left ventricle to myocardial ischaemia and imposes on it abrupt changes in loading conditions and geometry. We studied the immediate changes in the left ventricular function of patients undergoing aortic valve replacement by transoesophageal echocardiography. Patients with aortic regurgitation responded to surgery with a decrease in global systolic function associated with a fall in preload. Patients with aortic stenosis showed an impairment in myocardial contractility and ventricular filling, and their global systolic function did not improve despite the marked reduction in afterload. This can be a consequence of inadequate myocardial protection and intra-operative ischaemic injury of the hypertrophic myocardium. Information provided by transoesophageal echocardiography contributes to optimal and individualized management of the period immediately after aortic valve replacement.

Immediate effects of mitral valve replacement on left ventricular function and its determinants

Patients undergoing mitral valve surgery are at risk of left ventricular failure in the immediate post-operative period. In order to understand better the mechanisms of post-operative haemodynamic instability, we used transoesophageal echocardiography to assess the immediate response of the left ventricle to mitral valve replacement for mitral regurgitation or stenosis. A decrease in left ventricular preload, despite adequate filling pressures, was common to both groups and suggests the presence of diastolic dysfunction. A marked impairment in global systolic pump function was observed only in the regurgitation group and correlated with the left ventricular afterload. Transoesophageal echocardiography provides valuable information on the individual changes in left ventricular function and its determinants after mitral valve replacement that are not reflected by haemodynamic measurements.

CD44 variant isoforms on blood leukocytes in chronic inflammatory bowel disease and other systemic autoimmune diseases

We have described recently that TNBS-induced colitis, an animal model of chronic inflammatory bowel disease (IBD), can be cured by treatment with anti-CD44v7. This finding led us to evaluate whether CD44v7 may be of functional importance in patients with IBD. Expression of CD44 variant isoforms (CD44v) has been evaluated on PBMC of 46 patients with IBD, 43 patients with autoimmune diseases not affecting the gastrointestinal tract, 26 patients with nonautoimmune disease, and 24 healthy donors. In all groups, expression of CD44v on freshly harvested PBMC was not above or was borderline above background levels. After in vitro stimulation, expression of CD44 standard (CD44s) and CD44v6 was strongly up-regulated. Exclusively on PBMC of patients with autoimmune disease, high expression of CD44v3 and CD44v7 was observed. CD44v3 and CD44v7 were mainly expressed on subsets of CD4+ lymphocytes, B cells, and monocytes; CD44v6 was predominantly detected on CD4+ and CD8+ cells. Considering functional activity, CD44v7 apparently exerted a dual effect. After culturing PBMC in the presence of anti-CD44v7, a higher percentage of cells produced IL-10. This was irrespective of whether the PBMC were derived from healthy donors or from patients with autoimmune disease or IBD. On the other hand, PBMC of all donors proliferated upon cross-linking of CD3 and CD44s or CD3 and CD44v6. Instead, costimulatory activity of CD44v7 was seen only in PBMC of patients with autoimmune disease and IBD. Because expression and function of CD44v7 in patients with systemic autoimmune disease and IBD have been much like the ones in mice suffering of TNBS-induced colitis, it is tempting to speculate that blockade of CD44v7 could also be of therapeutic relevance in the human diseases.