Effects of the ketogenic diet on cognition: a systematic review

INTRODUCTION

Ketogenic diet (KD) therapy has been used as a dietary intervention in drug-resistant epilepsy for several years. Research currently suggests that KD therapy may carry neuroprotective and cognition enhancing effects for individuals with non-epileptic conditions as well as for healthy individuals. Therefore, KD may have potential as a non-invasive, nutritional treatment approach for difficult to manage conditions such as neurodegenerative illnesses or mood disorders. The aim of this review is to summarize the available evidence on ketogenic interventions and the resulting cognitive outcomes.

MATERIALS AND METHODS

The paper was based on PRISMA 2020 guidelines. The search was conducted in June 2021 on the following databases: CENTRAL, PubMed, EMBASE, PsycInfo, Web of Science. The search yielded 2014 studies, of which 49 were included.

RESULTS

There were 22 animal studies assessing murine models and 27 studies on humans. The primary indications in these studies were epileptic conditions, neurodegenerative disorders, cognitive impairment, and healthy populations.

DISCUSSION

Administration of KD seems to confer cognitive-enhancing effects in areas such as working memory, reference memory and attention. Studies found that KD treatment in animals has the potential to alleviate age-related cognitive decline. Over 80% of the 27 human studies reported a favourable effect of intervention, and none reported a detrimental effect of KD. While these findings suggest that KD may improve the functioning of certain cognitive domains, definitive conclusions were limited by studies with small sample sizes, the absence of controls and randomization, and the lack of objective measures of cognition.

The effect of lifestyle interventions on depressive symptom severity in individuals with type-2 diabetes: A meta-analysis of randomized controlled trials

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a severe metabolic condition which is commonly comorbid with depression. Lifestyle factors are involved in the pathophysiology of both conditions; however, the role of lifestyle interventions remains unclear.

OBJECTIVE

The objective of this study is to systematically review the literature on randomized controlled trials evaluating the effect of lifestyle interventions on depressive scores in patients with T2DM.

METHODS

A systematic search was conducted in computerized databases before October 2022. A random-effects model was used to investigate the effect of lifestyle interventions on depression scores and meta-regression was conducted to assess the influence of age and disease onset.

RESULTS

Six trials met the eligibility criteria for inclusion. A statistically significant reduction in depression scores was found for groups receiving lifestyle interventions compared to controls (SMD = -0.49 [95%CI -0.89 to -0.08]; p = 0.0269]). Interventions increased in efficacy with the age of the participants but no significant correlation was found with years since disease onset. Participants in a control group receiving a less intense lifestyle intervention demonstrated improved depression scores when compared to those who received standard care or no intervention at all. Trial design and outcome measurement tools were heterogeneous between studies and limited data on antidepressant use was available which may introduce bias into the results.

CONCLUSION

Lifestyle interventions were effective at improving depressive symptom severity in patients with T2DM.

The concept of "metabolic jet lag" in the pathophysiology of bipolar disorder: implications for research and clinical care

Bipolar disorder (BD) is a potentially chronic mental disorder marked by recurrent depressive and manic episodes, circadian rhythm disruption, and changes in energetic metabolism. "Metabolic jet lag" refers to a state of shift in circadian patterns of energy homeostasis, affecting neuroendocrine, immune, and adipose tissue function, expressed through behavioral changes such as irregularities in sleep and appetite. Risk factors include genetic variation, mitochondrial dysfunction, lifestyle factors, poor gut microbiome health and abnormalities in hunger, satiety, and hedonistic function. Evidence suggests metabolic jet lag is a core component of BD pathophysiology, as individuals with BD frequently exhibit irregular eating rhythms and circadian desynchronization of their energetic metabolism, which is associated with unfavorable clinical outcomes. Although current diagnostic criteria lack any assessment of eating rhythms, technological advancements including mobile phone applications and ecological momentary assessment allow for the reliable tracking of biological rhythms. Overall, methodological refinement of metabolic jet lag assessment will increase knowledge in this field and stimulate the development of interventions targeting metabolic rhythms, such as time-restricted eating.

A Comparison of Functional Connectivity in the Human Brainstem and Spinal Cord Associated with Noxious and Innocuous Thermal Stimulation Identified by Means of Functional MRI

The somatosensory system is multidimensional and processes important information for survival, including the experience of pain. The brainstem and spinal cord serve pivotal roles in both transmitting and modulating pain signals from the periphery; although, they are studied less frequently with neuroimaging when compared to the brain. In addition, imaging studies of pain often lack a sensory control condition, failing to differentiate the neural processes associated with pain versus innocuous sensations. The purpose of this study was to investigate neural connectivity between key regions involved in descending modulation of pain in response to a hot, noxious stimulus as compared to a warm, innocuous stimulus. This was achieved with functional magnetic resonance imaging (fMRI) of the brainstem and spinal cord in 20 healthy men and women. Functional connectivity was observed to vary between specific regions across painful and innocuous conditions. However, the same variations were not observed in the period of anticipation prior to the onset of stimulation. Specific connections varied with individual pain scores only during the noxious stimulation condition, indicating a significant role of individual differences in the experience of pain which are distinct from that of innocuous sensation. The results also illustrate significant differences in descending modulation before and during stimulation in both conditions. These findings contribute to a deeper understanding of the mechanisms underlying pain processing at the level of the brainstem and spinal cord, and how pain is modulated.

Psilocybin-Assisted Psychotherapy as a Potential Treatment for Eating Disorders: a Narrative Review of Preliminary Evidence

Eating disorders (ED) are a group of potentially severe mental disorders characterized by abnormal energy balance, cognitive dysfunction and emotional distress. Cognitive inflexibility is a major challenge to successful ED treatment and dysregulated serotonergic function has been implicated in this symptomatic dimension. Moreover, there are few effective treatment options and long-term remission of ED symptoms is difficult to achieve. There is emerging evidence for the use of psychedelic-assisted psychotherapy for a range of mental disorders. Psilocybin is a serotonergic psychedelic which has demonstrated therapeutic benefit to a variety of psychiatric illnesses characterized by rigid thought patterns and treatment resistance. The current paper presents a narrative review of the hypothesis that psilocybin may be an effective adjunctive treatment for individuals with EDs, based on biological plausibility, transdiagnostic evidence and preliminary results. Limitations of the psychedelic-assisted psychotherapy model and proposed future directions for the application to eating behavior are also discussed. Although the literature to date is not sufficient to propose the incorporation of psilocybin in the treatment of disordered eating behaviors, preliminary evidence supports the need for more rigorous clinical trials as an important avenue for future investigation.

Is there a place for dietetic interventions in adult ADHD?

Current treatments for Attention-Deficit/Hyperactivity Disorder (ADHD) in adults are limited by lack of response and side effects in about one third of the individuals. Changes towards a healthier lifestyle could have a positive impact beyond the relief of specific symptoms. However, it is not clear if nutritional interventions influence mental health and cognition. The objective of this study was to summarize the available literature addressing the impact of different diets in ADHD. The most promising dietetic approaches in ADHD are diets considered to be healthy (Mediterranean-type; DASH) and the Few-Foods Diet for children. Studies should take into account the presence of multiple confounders, biases associated with difficulties in blinding participants and researchers, and search for possible mechanisms of action, so we can have better evidence to guide clinical mental care of adults with ADHD.

Characterizing eating behavioral phenotypes in mood disorders: a narrative review

Mood disorders, including depressive and bipolar disorders, represent a multidimensional and prevalent group of psychiatric illnesses characterized by disturbances in emotion, cognition and metabolism. Maladaptive eating behaviors in mood disorders are diverse and warrant characterization in order to increase the precision of diagnostic criteria, identify subtypes and improve treatment strategies. The current narrative review synthesizes evidence for Eating Behavioral Phenotypes (EBP) in mood disorders as well as advancements in pathophysiological conceptual frameworks relevant to each phenotype. Phenotypes include maladaptive eating behaviors related to appetite, emotion, reward, impulsivity, diet style and circadian rhythm disruption. Potential treatment strategies for each phenotype are also discussed, including psychotherapeutic, pharmacological and nutritional interventions. Maladaptive eating behaviors related to mood disorders are relevant from both clinical and research perspectives, yet have been somewhat overlooked thus far. A better understanding of this aspect of mood disorders holds promise to improve clinical care in this patient group and contribute to the subtyping of these currently subjectively diagnosed and treated disorders.

A Possible Antidepressive Effect of Dietary Interventions: Emergent Findings and Research Challenges

Purpose

Despite recent advancements in the treatment of depression, the prevalence of affected individuals continues to grow. The development of new strategies has been required and emerging evidence has linked a possible antidepressant effect with dietary interventions. In this review, we discuss recent findings about the possible antidepressant effect of dietary interventions with an emphasis on the results of randomized controlled trials.

Recent findings

A high consumption of refined sugars and saturated fat and a low dietary content of fruits and vegetables has been associated with the development of depression. There is evidence supporting a small to moderate beneficial effect of a Mediterranean-type diet in depression. In addition, new dietary protocols are being studied for their use as possible interventions, such as the ketogenic diet, Nordic diet, and plant-based diet.

Summary

Lifestyle interventions surrounding diet and nutrition are a relatively affordable way to enhance response to treatment and to be employed as an adjunct in mental health care. Most studies, however, are limited by the difficulty in controlling for the placebo effect. Mediterranean-style diets seem to be the most promising as an adjunctive treatment for mood disorders. Larger randomized controlled trials that could assess predictors of response to dietary interventions are needed to establish a clear positive effect of diet and guide clinical care and nutritional recommendations concerning mental health care.

Magnetization transfer ratio for the assessment of perianal fistula activity in Crohn's disease

OBJECTIVES

Assessment of perianal fistulas is important to guide management of Crohn's disease (CD). Our objectives were to analyze the feasibility of magnetization transfer (MT) imaging to assess fistulas and to evaluate its contribution in assessing disease activity.

METHODS

During 15 months, all patients referred for perianal fistulas in CD underwent 3T-MRI including diffusion, T2/T1-weighted gadolinium-enhanced sequences and MT sequences (one with an off-resonance saturation pulse of 800 and one with 1200 Hz). We collected Van Assche score, fistula activity signs by analyzing T2, diffusion and contrast enhancement. We calculated MT ratio (MTR) with a ROI in the largest fistula.

RESULTS

Twenty-nine patients (mean 34.9 years, range 17-53) were included. Van Assche score was 11.7, range 4-21. In 22 patients, the fistula presented with a bright T2 and diffusion signal with contrast enhancement, and was characterized as active. Mean MTR was respectively 47.2 (range 12-68) and 34.3 (range 11-57) at 800 and 1200 Hz. MTR at 800 Hz was significantly lower in non-active (34, range 12-55) than in active fistulas (51, range 24-68) (p < 0.02).

CONCLUSIONS

MTR is feasible for the assessment of fistulas in CD and in the future could be used to help identify active and non-active fistulas.

KEY POINTS

• MTR is feasible for the assessment of perianal fistulas in CD. • MT allows quantitative imaging of perianal fistula activity in CD. • MTR could be used to help identify active and non-active fistulas in CD.

Intact neurobehavioral development and dramatic impairments of procedural-like memory following neonatal ventral hippocampal lesion in rats

Neonatal ventral hippocampal lesions (NVHL) in rats are considered a potent developmental model of schizophrenia. After NVHL, rats appear normal during their preadolescent time, whereas in early adulthood, they develop behavioral deficits paralleling symptomatic aspects of schizophrenia, including hyperactivity, hypersensitivity to amphetamine (AMPH), prepulse and latent inhibition deficits, reduced social interactions, and spatial working and reference memory alterations. Surprisingly, the question of the consequences of NVHL on postnatal neurobehavioral development has not been addressed. This is of particular importance, as a defective neurobehavioral development could contribute to impairments seen in adult rats. Therefore, at several time points of the early postsurgical life of NVHL rats, we assessed behaviors accounting for neurobehavioral development, including negative geotaxis and grip strength (PD11), locomotor coordination (PD21), and open-field (PD25). At adulthood, the rats were tested for anxiety levels, locomotor activity, as well as spatial reference memory performance. Using a novel task, we also investigated the consequences of the lesions on procedural-like memory, which had never been tested following NVHL. Our results point to preserved neurobehavioral development. They also confirm the already documented locomotor hyperactivity, spatial reference memory impairment, and hyperresponsiveness to AMPH. Finally, our rseults show for the first time that NVHL disabled the development of behavioral routines, suggesting dramatic procedural memory deficits. The presence of procedural memory deficits in adult rats subjected to NHVL suggests that the lesions lead to a wider range of cognitive deficits than previously shown. Interestingly, procedural or implicit memory impairments have also been reported in schizophrenic patients.

Fistulizing perianal Crohn's disease: contrast-enhanced magnetic resonance imaging assessment at 1 year on maintenance anti-TNF-alpha therapy

BACKGROUND

The aim of the study was to assess perianal fistulas by magnetic resonance imaging (MRI) in patients with severe fistulizing Crohn's disease (CD) using maintenance antitumor necrosis factor alpha (TNF-α) therapy and to correlate MRI changes with clinical outcome.

METHODS

Perineal MRI before and after a 1-year scheduled anti-TNF-α maintenance therapy was performed in 20 patients (14 females; mean age = 33.7). The Van Assche score (i.e., number of fistulas, localization, and extension, importance of T2 hyperintensity, presence of abscess) was calculated. Fistula track contrast enhancement was also used. Clinical outcome was defined as no response, response, or remission.

RESULTS

Response and remission were observed in respectively 40% and 35% of cases. The Van Assche score varied from 13.8 (7-20) to 6.13 (0-12) in patients with a response or remission (P < 0.05). The T2 hyperintensity follow-up value decreased in patients in response or remission (P < 0.01). T2 hyperintensity disappeared or decreased in 14 out of 15 patients in clinical response or remission as compared to one among the five nonresponding patients (P < 0.01). The decrease in Van Assche score and hyperintensity value was not significantly different in patients in remission compared to those with response. Only one patient in clinical remission had a persisting contrast enhancement on MRI, whereas contrast enhancement persisted in all other patients not in remission (P = 0.002).

CONCLUSIONS

The clinical benefit of maintenance anti-TNF-α therapy in perianal CD is associated with a significant improvement of the Van Assche score, particularly T2 hyperintensity. The disappearance of contrast enhancement was the only semiological MR feature associated with remission.

[Role of defecography in female posterior pelvic floor abnormalities]

Pelvic floor abnormalities often impact significantly the quality of life and result in a variety of symptoms, including chronic pelvic pain, fecal incontinence, and obstructed constipation. Fluoroscopic defecography and MR defecography enable identification of rectocele, rectal prolapse, enterocele, sigmoidocele with high prevalence in female patients with obstructed constipation, fecal incontinence, and chronic pelvic pain. In this manuscript, we describe the techniques and indications of the two techniques of defecography. We discuss the abnormalities of the posterior pelvic floor compartment at the origin of constipation, incontinence, chronic pelvic pain. Finally we compare the data obtained by clinical examination and defecography, remembering that 50% of enterocele and 100% of sigmoidocele are missed at clinical examination.

Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear

BACKGROUND

Disruption of the anal sphincter occurs in 0.6%-6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third-degree obstetric tear in order to compare the findings with the clinical outcome.

METHODS

Twenty-one women aged 27-41 (mean 31.5 years) who had undergone primary suture of a third-degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery.

RESULTS

Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P < 0.01). The presence of an external sphincter defect was associated with anal incontinence in 91.7%. Surgical repair was identified on endosonography in 88% continent women and in 25% incontinent women (P < 0.03). The combination of a visible surgical repair and absence of defect was highly associated with normal continence (91.7%). Squeezing pressures were higher in continent women (87 +/- 23 cm H2O) than in incontinent women (48 +/- 36 cm H2O; P = 0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome.

CONCLUSION

After primary repair of a third-degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.

Neuroprotective properties of topiramate in the lithium-pilocarpine model of epilepsy

The lithium-pilocarpine model reproduces the main characteristics of human temporal lobe epilepsy. After status epilepticus (SE), rats exhibit a latent seizure-free phase characterized by development of extensive damage in limbic areas and occurrence of spontaneous recurrent seizures. Neuroprotective and antiepileptogenic effects of topiramate were investigated in this model. SE was induced in adult male rats by LiCl (3 mEq/kg) followed 20 h later by pilocarpine (25 mg/kg). Topiramate (10, 30, or 60 mg/kg) was injected at 1 and 10 h of SE. Injections were repeated twice a day for six additional days. Another group received two injections of diazepam on the day of SE and of vehicle for 6 days. Neuronal damage was assessed at 14 days after SE by cell counting on thionin-stained sections. Occurrence of spontaneous recurrent seizures (SRS) was videorecorded for 10 h per day in other groups of rats. In diazepam-treated rats, the number of neurons was dramatically reduced after SE in all subregions of hippocampus and layers II-IV of ventral cortices. At all doses, topiramate induced a 24 to 30% neuroprotection in layer CA1 of hippocampus (p < 0.05). In CA3b, the 30-mg/kg dose prevented neuronal death. All rats subjected to SE became epileptic. The latency (14-17 days) to and frequency of SRS were similar in topiramate- and diazepam-treated rats. The high mortality in the 30 mg/kg topiramate group (84%) was possibly the result of interaction between lithium and topiramate. In conclusion, topiramate displayed neuroprotective properties only in CA1 and CA3 that were not sufficient to prevent epileptogenesis.

Operative stress response is reduced after laparoscopic compared to open cholecystectomy: the relationship with postoperative pain and ileus

Our objective was to determine the least invasive surgical procedure; to do this we compared postoperative pain, duration of ileus, and level of neurohormonal stress response after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). Postoperative recovery of patients was faster after LC than OC but comparison of the neurohormonal stress response after laparoscopic and open surgical procedures revealed conflicting results. Forty-one consecutive patients with noncomplicated gallstones were randomized for LC (N = 25) and OC (N = 16). The stress level was evaluated in patients before surgery by the Hamilton anxiety scale. Postoperative pain was assessed by a visual analogic scale (VAS) pain score and by the amount of analgesic drugs (propacetamol) administered, while the duration of ileus was determined by the delay between surgery and the time to first passage of flatus as well by the colonic transit time (CTT) measured by radiopaque markers. Plasma concentrations of anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), beta-endorphin (BE), neurotensin (NT), and aldosterone (Ald) were measured before and during surgery as well as 2 and 5 hr after the surgery (D0) and on the day following surgery (D1). Urinary cortisol (uCOR) and urinary catecholamine metabolites were assessed before surgery, during D0, and on D1. Patient characteristics, the duration of surgery, and the doses of anesthetic drugs were not different in LC and OC. In LC patients the VAS pain score and the doses of postoperative antalgics were lower (P < 0.05), the time to first passage of flatus was shorter (P < 0.001), and the CTT tended to be shorter (54 +/- 12 hr vs 81 +/- 17) compared to OC patients. Patients who required the highest doses of postoperative antalgics had the longest delay to first passage of flatus (P < 0.01). During surgery, all neurohormonal parameters increased compared to the preoperative period (P < 0.05), and only plasma NT concentrations were lower during LC than OC (P < 0.05). During the postoperative period, ACTH, BE, Aid, catecholamines, and uCOR concentrations were lower in LC than in OC (P < 0.05). Concentrations of hormonal parameters were higher when the duration of surgery increased (P < 0.05). A greater need for propacetamol to relieve pain was associated with a greater increase in BE, ACTH, and urinary catecholamine levels (P < 0.05-P < 0.005). When the time to first passage of flatus was delayed, levels of BE, ACTH, and catecholamines and NT concentrations were increased (P < 0.05-P < 0.005). In conclusion, LC is less invasive because this surgical procedure induces a shorter neurohormonal stress response than OC, even if the peroperative response is not different. Postoperative pain levels and the duration of ileus are associated with BE, ACTH, and catecholamine levels and NT concentrations, suggesting the importance of hormones in postoperative functional recovery.

Results of sphincteroplasty in 86 patients with anal incontinence

PURPOSE

This study was designed to analyze critically the short-term and long-term outcome of sphincteroplasty and to identify high-risk factors.

METHODS

Eighty-six patients with fecal incontinence associated with an ultrasound defect of the external anal sphincter were treated by anal sphincteroplasty. Clinical and physiologic assessment was made before surgery, and clinical evaluation was made three months and an average of 40 months after surgery.

RESULTS

The evaluation of 86 patients three months after surgery showed that 42 patients were totally continent (49 percent), 28 were incontinent for gas (33 percent), and 16 still had fecal incontinence (19 percent). Seventy-four patients (86 percent) were contacted 40 months after surgery. Twenty-one patients (28 percent) were totally continent, 17 were incontinent to gas (23 percent), and 36 were incontinent to feces (49 percent). Forty-six percent of patients felt they were clearly improved after surgery. Poor results were associated with an internal anal sphincter defect.

CONCLUSIONS

Our study suggests that in the long term, one-third of patients are totally continent after sphincteroplasty. One-half of patients are satisfied, but only if their incontinence to feces has totally disappeared. Results of sphincteroplasty deteriorate with time. One factor in poor prognosis is the presence of an associated defect of the internal anal sphincter.

Anal endosonography after sphincter repair: specific patterns related to clinical outcome

BACKGROUND

This study evaluates the endosonographic patterns of the anal sphincter after sphincteroplasty to define specific postoperative findings and to identify factors related to clinical outcome after sphincter repair.

METHODS

Thirty-one incontinent patients (29 women, two men; mean age = 57 years) who underwent surgical repair for an external sphincter defect were studied postoperatively by endosonography. Twenty patients were found to improve after surgery.

RESULTS

Postoperative endosonograms showed specific images: direct visualization of the surgical process was represented by the "overlapping sign" in 17 cases and the "end-to-end suture" in four cases. These echographically favorable cases were associated with improvement after surgery in 18 of 21 patients (p < 0.005). Persistent defects were reduced in five patients and unchanged in five other patients and were associated with poor outcome in eight of 10 patients (p < 0.005).

CONCLUSIONS

Postoperative endosonography of the external anal sphincter presented some specific endosonographic aspects. The association between anal endosonographic findings and clinical outcome suggests the use of this procedure to assess patients following sphincteroplasty.

Prevalence of anal sphincter defects revealed by sonography in 335 incontinent patients and 115 continent patients

OBJECTIVE

The aim of this study was to compare the prevalence of anal sphincter defects on anal sonography of incontinent and continent patients.

SUBJECTS AND METHODS

Four hundred sixty-eight consecutive subjects who underwent anal sonography were studied. The prevalence of anal sphincter defects was calculated in 335 incontinent patients, 115 continent patients, and 18 asymptomatic female volunteers. All subjects answered a questionnaire about childbirth and proctologic surgery.

RESULTS

The prevalence of anal sphincter defects revealed on sonography was 65% in the 335 incontinent patients. The prevalence of anal sphincter defects in incontinent patients was 88% in patients with a history of childbirth and proctologic surgery and 62% with childbirth alone. The prevalence of anal sphincter defects revealed on sonography was 43% in continent patients and 22% in asymptomatic volunteers. The prevalence of anal sphincter defects in continent patients with a history of childbirth and proctologic surgery was 92% and was 41% with childbirth alone. We found no difference in the prevalence of sphincter defects according to the age and sex of patients.

CONCLUSION

Anal sonography can be used to identify sphincter defects in approximately two thirds of incontinent patients. Prevalence is greater in patients with a history of proctologic surgery. Because of the presence of sphincter defects in continent patients and in asymptomatic volunteers, caution should be used in attributing incontinence to anal sphincter defects alone.

[Celioscopic cholecystectomy. 2 cases of infectious complications]

Despite the low morbidity and mortality of laparoscopic cholecystectomy, trauma and infection have been reported. Such complications can produce a misleading clinical picture, as in two cases we observed. Case 1. A symptomatic 56-year-old female patient underwent laparoscopic cholecystectomy. During the operation, the gall bladder ruptured and the contents had to be aspirated from the abdominal cavity. The patient complained of hepatalgia 2 weeks after the operation, then was not seen again for more than 1 year when fever and hepatalgia did not respond to symptomatic treatment. An inter-hepato-renal collection (6 cm in diameter) was punctured under echography. Aspirate culture yielded Pseudomonas aeruginosa. Adapted antibiotic therapy was unsuccessful and surgery was required to empty the abscess then remove a fibrous conjunctive tissue formation. Case 2. A 55-year-old female patient with a history of complete remission after mammectomy for breast cancer underwent laparoscopic cholecystectomy in 1991. Two days after the operation, fever (39 degrees C) was accompanied by abdominal defence. Biliary peritonitis due to imperfect suture of the bile duct was repaired followed by peritoneal lavage-drainage. Per-operative blood samples revealed type 6 Pseudomonas aeruginosa. Despite adapted parenteral antibiotics, fever persisted at 39 degrees C and intense jaundice was observed. A second laparoscopy 14 days later showed inflammatory narrowing of the main bile duct which was drained into a small bowel loop. Eight days later computed tomography revealed multiple abscess in the liver. Transparietal cholangiography was performed and showed that the contrast medium entered the abscesses via the biliary canals. The state of sepsis persisted, jaundice worsened and hepatic encephalopathy developed with obnubilation and flapping tremor. After 1 month of general antibiotherapy, no improvement was seen on computed tomography images and needle biopsy of an abscess led to the identification of resistant type 6 P. aeruginosa. Antibiotics were adapted and administered iv with no clinical improvement. Selective catheterism of the hepatic artery via the femoral access was performed to allow intra-hepatic antibiotic delivery. Three weeks later clinical situation remained unchanged when acute respiratory distress highly suggestive of pulmonary embolism led to death. Autopsy was not performed. In both of these rare cases of infectious complications due to P. aeruginosa after laparoscopic cholecystectomy, the source of contamination remained unknown. Nosocomial infection was suspected.

Jejunal motility during cyclic total parenteral nutrition in patients with Crohn's disease

Our aim was to study the jejunal motility (a) in seven patients receiving longterm (median: 24 days) cyclic total parenteral nutrition (CTPN) for an acute exacerbation of Crohn's disease involving the ileum and/or the colon without any sign of occlusion and (b) in six healthy volunteers undergoing the same parenteral nutrition for one day after an overnight fast. Continuous recordings, lasting 20 hours, were carried out in patients after correction of their nutritional status and significant improvement of the Crohn's disease activity index. In five of the seven patients, we recorded seven to 14 phase III episodes (PIII) (median: 10), both more frequent and slower during the nocturnal part of the recording time as compared with diurnal. Seven to 18 PIIIs (median: 12) were found in controls. The overall duration of the motor activity was not different between these five patients and controls. In the remaining two patients, no PIII episode was recorded and 79% and 57% respectively of the whole recording time consisted of irregular motor activity. Our work therefore, shows that: (a) PIIIs remain and have a circadian variation in their periodicity and propagation velocity, in most of our patients undergoing longterm CTPN (b) CTPN does not determine a longer duration of motor rest of the small bowel in patients than in controls submitted for a short period of time to the same parenteral intake.