Sub-inner limiting membrane hemorrhage in a patient with Terson syndrome

PURPOSE

To report a case of bilateral Terson Syndrome with sub inner limiting membrane hemorrhage associated with a rare finding: perimacular fold.

METHODS

The patient, a 34 years old female with aneurysmal subarachnoid hemorrhage and bilateral Terson syndrome was admitted to the Ophthalmology department, complaining of blurred vision. Core vitrectomy, hyaloid detachment, peeling of the ILM and aspiration of the sub inner limiting membrane hemorrhage was performed. Once the inner limiting membrane of the left eye was peeled off, we noticed a particular aspect: the perimacular fold.

RESULT

Although our patient suffered from a massive vitreous haemorrhage the postoperative outcome was favorable with a final best corrected visual acuity of 20/30.

CONCLUSIONS

In patients with billateral Terson syndrome we recommend early surgery, especially if the neurological status allows it, a good visual acuity being helpful for the neurophysical rehabilitation of the patient.

HIV-positive men who have sex with men are at high risk of development of significant liver fibrosis after an episode of acute hepatitis C

Acute hepatitis C virus infection remains a major health concern in human immunodeficiency virus(HIV)-infected men who have sex with men (MSM). New direct-acting antiviral agent (DAA) combination therapy has not yet been approved for the treatment for acute hepatitis C virus(HCV), thereby potentially causing deferral of HCV treatment. Therefore, we aimed to study the course of liver disease after an episode of acute HCV. This study is a retrospective single-centre cohort of HIV-positive MSM with acute HCV infection. Liver fibrosis was estimated by Fibroscan^® and Fibrotest^® . Liver-related and non-liver-related outcomes were documented. Overall 213 episodes of acute HCV infection in 178 men were documented. Median follow-up for all included patients was 38.7 months. Spontaneous HCV clearance was found in 10.8% of patients, which was significantly associated with older age, lower HCV RNA levels, and higher ALT levels upon initial acute HCV diagnosis. Treatment with interferon-based therapy was initiated in 86.3% of cases, resulting in a sustained virological response(SVR) rate of 70.7%. After 3 years' follow-up, significant liver fibrosis of METAVIR F2 stage or higher was found in 39.4% of patients after first acute HCV diagnosis. Higher age, physician-declared alcoholism, and nonresponse to acute HCV therapy were independently associated with higher fibrosis stages. Ten patients died during the observation period (IR 1.4/100 patient-years) and four during interferon treatment. Significant liver fibrosis is a common finding in HIV-positive MSM following acute HCV infection despite high treatment uptake and cure rates, suggesting the need for close liver disease monitoring particularly if HCV treatment is deferred.

Diagnostic performance of FibroTest, SteatoTest and ActiTest in patients with NAFLD using the SAF score as histological reference

BACKGROUND

Blood tests of liver injury are less well validated in non-alcoholic fatty liver disease (NAFLD) than in patients with chronic viral hepatitis.

AIMS

To improve the validation of three blood tests used in NAFLD patients, FibroTest for fibrosis staging, SteatoTest for steatosis grading and ActiTest for inflammation activity grading.

METHODS

We pre-included new NAFLD patients with biopsy and blood tests from a single-centre cohort (FibroFrance) and from the multicentre FLIP consortium. Contemporaneous biopsies were blindly assessed using the new steatosis, activity and fibrosis (SAF) score, which provides a reliable and reproducible diagnosis and grading/staging of the three elementary features of NAFLD (steatosis, inflammatory activity) and fibrosis with reduced interobserver variability. We used nonbinary-ROC (NonBinAUROC) as the main endpoint to prevent spectrum effect and multiple testing.

RESULTS

A total of 600 patients with reliable tests and biopsies were included. The mean NonBinAUROCs (95% CI) of tests were all significant (P < 0.0001): 0.878 (0.864-0.892) for FibroTest and fibrosis stages, 0.846 (0.830-0.862) for ActiTest and activity grades, and 0.822 (0.804-0.840) for SteatoTest and steatosis grades. FibroTest had a higher NonBinAUROC than BARD (0.836; 0.820-0.852; P = 0.0001), FIB4 (0.845; 0.829-0.861; P = 0.007) but not significantly different than the NAFLD score (0.866; 0.850-0.882; P = 0.26). FibroTest had a significant difference in median values between adjacent stage F2 and stage F1 contrarily to BARD, FIB4 and NAFLD scores (Bonferroni test P < 0.05).

CONCLUSIONS

In patients with NAFLD, SteatoTest, ActiTest and FibroTest are non-invasive tests that offer an alternative to biopsy, and they correlate with the simple grading/staging of the SAF scoring system across the three elementary features of NAFLD: steatosis, inflammatory activity and fibrosis.

Systematic review with meta-analysis: direct comparisons of biomarkers for the diagnosis of fibrosis in chronic hepatitis C and B

BACKGROUND

Blood tests and transient elastography (TE), proposed as alternatives to biopsy for identifying advanced fibrosis (METAVIR-stage-F2 or greater) or cirrhosis, have never been compared using an intention to diagnose approach, with direct comparisons only, and Bayesian approach.

AIM

To permit more appropriate comparisons.

METHODS

From an overview of articles (2002-2014), we selected studies that directly compared the diagnostic accuracy of FibroTest, aspartate aminotransferase-platelet ratio index (APRI), FIB4 or TE, with biopsy as a reference, in patients with chronic hepatitis C (CHC) or B (CHB). Investigators abstracted and checked study details and quality by using pre-defined criteria. Bayesian method in intention to diagnose was the primary outcome.

RESULTS

Of 1321 articles identified, 71 studies including 77 groups according to aetiology (All-CB) were eligible: 37 Only-C, 28 Only-B and 12 Mixed-C-B. There were 185 direct comparisons between the area under the ROC curves (AUROCs), 99 for the diagnosis of advanced fibrosis and 86 for cirrhosis. In All-CB, Bayesian analyses revealed significant AUROCs differences in identifying advanced fibrosis in favour of FibroTest vs. TE [credibility interval: 0.06(0.02-0.09)], FibroTest vs. APRI [0.05 (0.03-0.07)] and for identifying cirrhosis TE vs. APRI [0.07 (0.02-0.13)] and FIB4 vs. APRI [0.04(0.02-0.05)]. No differences were observed between TE and FibroTest, for identifying cirrhosis in All-CB, and in sub-groups (Only-C, Only-B, Mixed-CB) for both cirrhosis and fibrosis.

CONCLUSIONS

In CHC and CHB, APRI had lower performances than FIB-4, TE and FibroTest. TE had lower performance than FibroTest for identifying advanced fibrosis in All-CB, without significant difference for identifying cirrhosis in all groups.

Prognostic value of liver fibrosis and steatosis biomarkers in type-2 diabetes and dyslipidaemia

BACKGROUND

In cardiometabolic disorders, non-alcoholic fatty liver disease is frequent and presumably associated with increased mortality and cardiovascular risk.

AIM

To evaluate the prognostic value of non-invasive biomarkers of liver fibrosis (FibroTest) and steatosis (SteatoTest) in patients with type-2 diabetes and/or dyslipidaemia.

METHODS

A total of 2312 patients with type-2 diabetes and/or dyslipidaemia were included and prospectively followed up for 5-15 years. The cardiovascular Framingham-risk score was calculated; advanced fibrosis and severe steatosis, were defined by FibroTest >0.48 and SteatoTest >0.69, respectively, as previously established.

RESULTS

During a median follow-up of 12 years, 172 patients (7.4%) died. The leading causes of mortality were cancer (31%) and cardiovascular-related death (20%). The presence of advanced fibrosis [HR (95% CI)] [2.98 (95% CI 1.78-4.99); P < 0.0001] or severe steatosis [1.86 (1.34-2.58); P = 0.0002] was associated with an increased risk of mortality. In a multivariate Cox model adjusted for confounders: the presence of advanced fibrosis was associated with overall mortality [1.95 (1.12-3.41); P = 0.02]; advanced fibrosis at baseline [n = 50/677; 1.92 (1.04-3.55); P = 0.04] and progression to advanced fibrosis during follow-up [n = 16/127; 4.8 (1.5-14.9); P = 0.007] were predictors of cardiovascular events in patients with type-2 diabetes. In patients with a Framingham-risk score ≥20%, the presence of advanced fibrosis was predictive of cardiovascular events [2.24 (1.16-4.33); P < 0.05].

CONCLUSIONS

Liver biomarkers, such as FibroTest and SteatoTest, have prognostic values in patients with metabolic disorders. FibroTest has prognostic value for predicting overall survival in patients with type-2 diabetes and/or dyslipidaemia. In type-2 diabetes, FibroTest predicted cardiovascular events and improved the Framingham-risk score.

Efficacy and safety of lixisenatide once daily vs. placebo in people with Type 2 diabetes insufficiently controlled on metformin (GetGoal-F1)

AIMS

To assess the efficacy and safety of one- and two-step dose-increase regimens of lixisenatide once daily in participants with Type 2 diabetes mellitus insufficiently controlled with metformin.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, multi-centre study enrolling participants with Type 2 diabetes (n = 484) treated with metformin. Participants were randomized to receive either lixisenatide in a one-step dose increase or a two-step dose increase vs. placebo for 24 weeks, followed by a ≥ 52-week variable double blind period. Primary outcome was HbA1c reduction at week 24.

RESULTS

Lixisenatide one-/two-step once daily significantly improved HbA1c at week 24 compared with placebo (P < 0.0001) and allowed more participants to achieve HbA1c < 53 mmol/mol (< 7.0%) (P ≤ 0.0005). Improvements were observed in fasting plasma glucose (-0.5/-0.6 vs. +0.1 mmol/l; P < 0.001) and body weight (-2.6/-2.7 vs. -1.6 kg; P < 0.005). At week 24, adverse events were reported by 67.7/70.8/65.6% of participants treated with lixisenatide one-/two-step/placebo, respectively--nausea and vomiting being reported most frequently. Symptomatic hypoglycaemia occurred in 1.9/2.5% of participants on one-/two-step lixisenatide and 0.6% with placebo, with no severe episodes. Lixisenatide continued to be efficacious and well tolerated during the variable double-blind extension period of at least 52 weeks.

CONCLUSIONS

Lixisenatide one- or two-step dose-increase regimens significantly improved glycaemic control and decreased body weight over 24 weeks and during a long-term extension period without increasing hypoglycaemia. The study confirmed that tolerability in the one-step group was at least similar to the two-step dose increase, with nausea/vomiting and hypoglycaemia frequency being lower in the one-step regimen.

A non-contact method based on multiple signal classification algorithm to reduce the measurement time for accurately heart rate detection

Non-contact methods for the assessment of vital signs are of great interest for specialists due to the benefits obtained in both medical and special applications, such as those for surveillance, monitoring, and search and rescue. This paper investigates the possibility of implementing a digital processing algorithm based on the MUSIC (Multiple Signal Classification) parametric spectral estimation in order to reduce the observation time needed to accurately measure the heart rate. It demonstrates that, by proper dimensioning the signal subspace, the MUSIC algorithm can be optimized in order to accurately assess the heart rate during an 8-28 s time interval. The validation of the processing algorithm performance was achieved by minimizing the mean error of the heart rate after performing simultaneous comparative measurements on several subjects. In order to calculate the error the reference value of heart rate was measured using a classic measurement system through direct contact.

Multifocal choroidal metastases from thyroid carcinoma: a case report

We present the case of a 62-year-old female patient, with follicular variant of papillary thyroid carcinoma, which presented to our department for a severe decrease in vision at right eye level. Despite a complex therapy, that included a near-total thyroidectomy, thyroid I-131 ablation, suppressive therapy with LT4, and external beam radiotherapy with cobalt- 60, the patient developed multiple lung, mediastinal, liver, and bone metastases, followed after 1 year, by multifocal choroidal metastases. The complex ocular investigations performed for the diagnosis and follow-up of the choroidal metastases are presented. A review of the literature was also performed. The rarity of choroidal metastases in patients with thyroid carcinoma imposes, for their detection, periodic ocular examinations.

[Serous macular detachment associated with circumscribed choroidal hemangioma: a case report]

INTRODUCTION

Choroidal hemangiomas are benign vascular hamartomas that typically present from second to fourth decade of life, when they can cause visual disturbance due to exudative retinal detachment. They represent uncommon benign choroidal vascular tumors, usually occuring sporadically in the absence of systemic disease.

MATERIAL AND METHODS

We report the case of a young female patient, presenting a juxtapapillary circumscribed choroidal haemangioma complicated with serous macular detachment. The patient underwent photodynamic therapy with verteporfin (PDT). Systematic follow-up using ophthalmoscopy, ultrasonography, Fluorescein angiography and Indocyanine green angiography was performed.

RESULTS

The patient presented regression with flattening of tumour, resolution of the subretinal fluid, and significant improvement of vision.

DISCUSSIONS, CONCLUSIONS

Mostly asymptomatic, the choroidal hemangiomas can be associated with serous retinal detachment, leading to reduced vision and metamorphopsia; in those cases, the long term visual prognosis is poor, even in adequately treated patients. PDT is effective in eliminating the subretinal fluid and improving vision in patients with circumscribed choroidal hemangioma.

Ossification of the choroid: three clinical cases and literature review of the pathogenesis of intraocular ossification

OBJECTIVE

A presentation of the clinical and pathogenic aspects of choroidal ossification.

CASES PRESENTATION

We report three clinical cases of choroidal ossification: choroidal osteoma, ossified choroidal hemangioma and total ossification of the choroid. The three patients underwent complete eye examination. The optical microscopy of a sample of ossified choroidal tissue revealed a spongy, osseous structure consisting of circular osseous lamellae, osteocytes, canaliculi and adipose tissue with microfoci of calcification.

DISCUSSION

Choroidal ossification is characterized by reduced frequency of occurrence, accessible clinical diagnosis, and unspecified pathogenesis. Several of the factors identified in the pathogenesis of intraocular ossification may play a role in the ossification of the choroid: chronic inflammatory cells, bone morphogenetic proteins, growth factors and mesenchymal stem cells. In addition to these factors, pericytes have a special role in the pathogenesis of choroidal ossification. Under the influence of bone morphogenetic proteins and growth factors, mesenchymal stem cells differentiate into osteoblasts. They secrete bone matrix (osteoid), whose regeneration and remodeling lead to the formation of bone tissue. The spongy bone structure of choroidal tissue points to a model of endoconjunctive/desmal ossification.

CONCLUSIONS

The knowledge of the clinical aspect of ossification of the choroids is required for the differential diagnosis with the posterior pole affections, and also for the prevention and treatment of secondary complications.

Myxoid/round cell conjunctival liposarcoma. A case report

PURPOSE

To present a rare case of conjunctival myxoid liposarcoma, subtype round cells, that had a seven years follow up.

CLINICAL OBSERVATION

A 61-year-old female patient presents with a palpable, non-painful tumor, on the superior temporal bulbar conjunctiva of the right eye. The initial examination detects a fleshy tumor, orange in color, under the superior temporal bulbar conjunctiva, as well as two oval-shaped hyperpigmented conjunctival lesions, near the limbus at 10 o'clock, causing moderate blepharoptosis. Vision was normal, there was no diplopia, proptosis, afferent pupillary defect or lymphadenopathy; there was no orbital involvement in MRI. An isolated 15/15 mm tumor, with no connections with the eye socket, was excised. Histopathology revealed a poorly differentiated myxoid liposarcoma. Five recurrences occurred, of which four were treated by local excision and the last required exenteration. Repeat histopathology detects lipoblasts, small round cells, with immunohistochemistry positive for CD34, S100 and vimentin. The last two rapidly evolving and large recurrences, as well as pulmonary metastasis and finally death of the patient, underlined the aggressive character of round cell conjunctival liposarcoma.

CONCLUSIONS

Conjunctival myxoid liposarcoma is characterized by numerous local recurrences, but the speed of the succession and volume of the recurrences may suggest a change in the underlying histopathological aspect, that is definitory for the therapeutical and prognostic approach of the case.

[Upside-down stomach and hiatal hernia]

Hiatal hernias represent a special variant of diaphragmatic hernia in which there is a transdiaphragmatic migration of the stomach through the esophageal hiatus. There are 4 types admitted--sliding (type I), paraesophageal (type II), mixt-combining elements for both previous types (type III) and complex (type IV) and represents at most 5-15% from all hiatal hernias. Upside-down stomach is a special form of organoaxial volvulus of the entire stomach in a sac of mixt hiatal hernia (type III) or complex (type IV). There are asymptomatic forms, but the majority of the patients present signs of gastroesophageal reflux and up to one third may show complications such as bleeding, acute volvulus with obstruction or perforation. Surgical intervention is the only treatment option for the gastric volvulus and offers a durable resolution. The ideal surgical technique, the gold standard, consists in reduction of the stomach in the gastric lodge, resection of the sac and calibration of the hiatus adding a gastropexy or antireflux procedure.

Prognosis of colorectal cancer: clinical, pathological and therapeutic correlation

INTRODUCTION

Significant progress in the knowledge of carcinogenesis and natural history of colorectal carcinoma (CRC), especially in polyp-cancer sequention and time for transition, are important prerequisites for a new approach to diagnosis. Surgical resection is the mainstay therapy for colorectal cancer, and pathologic assessment of the resected specimen provides data for assessment of outcome and rationale for adjuvant therapy. A pathology report includes TNM stage, tumor type, histologic grade, status of resection margins, and vascular invasion.

AIM

The purpose of this paper was to highlight the pathological features and their correlations with postoperative evolution and prognosis of this cancer.

PATIENTS AND METHODS

Data was collected using the database system of the Emergency County Hospital of Craiova, Romania. A total of 302 patients from January 2003 to December 2005 were included.

RESULTS

The average survival for the entire group was 44.35 ± 28.94 months, and the D'Agostino-Pearson test for batch distribution showed abnormal distribution with two peaks, separated by a group of five patients who survived between 37 and 8 months. Fifty-one (38.05%) patients presented a median survival of 73.54 ± 10.47 months.

CONCLUSIONS

Factors that contribute to a favorable prognosis in CRC are vegetant gross tumors and papillary microscopic forms, G1 and G2 degree of differentiation and disease diagnosed in stages I and II.

[Subcutaneous fat tissue drainage in obese pregnant women after caesarean section]

The authors have analyzed the outcome of cesarean section celiotomy in obese pregnant women. The occurrence of postoperative wound infections, eventually dehiscence, in 2015 pregnant women who underwent caesarean section in a 3-year interval at the Craiova 1st Clinic of Obstetrics was studied. The analysis revealed the relation between postoperative wound infection and its topography, the type of fat tissue drainage (if done), and skin suture. The authors present a very effective method of subcutaneous drainage in obese pregnant women after cesarean section.

[Leber stellate neuroretinitis: two cases]

INTRODUCTION

Described by Leber (1916), this clinical syndrome is characterized by unilateral decrease of visual acuity, papilledema and macular star. The condition concerns the young adult, has a favorable prognosis, and unspecified pathogeny.

OBSERVATIONS AND METHODS

We report the case of two young adults (25 and 27 years), examined because of decreased visual acuity in the left eye, installed 2-3 weeks after a flu-like syndrome. Ophthalmoscopy reveals papilledema and macular star (lipid exudates). Fluorescein Angiography showed abnormal permeability at the optic disc, and the absence of vascular changes in the macular area. Campimetry, cranio-orbital imaging, and serological tests were carried out.

RESULTS

Campimetry revealed a centrocecal unilateral scotoma. Serological tests for Bartonella hensellae, Lyme disease, leptospirosis, and toxacara were negative. The cranio-orbital imaging was normal. Considering the syndrome to be idiopathic, no treatments have been performed; the visual acuity and papilledema resolved after 4 and respectively 6 weeks, and the macular exudates after 8 and respectively 12 months.

DISCUSSIONS, CONCLUSIONS

The optic disc edema, with or without macular star, unsuitable called Leber's stellate neuroretinitis, forms a group of diseases with heterogenous clinical aspect, and unspecified pathogenesis. Overall, it is necessary to remember that it is a diagnosis of exclusion, targeting infectious pathology in children, and a vascular or demyelinating process in adult patients. The favorable prognosis is making the cortisone therapy unnecessary in idiopathic forms, but requires a specific therapy in infectious forms.

[Gastrointestinal stromal tumor in the cecum--a rare cause of ileo-cecal-colic invagination]

The gastrointestinal stromal tumors (GIST) are the rares mesenchymal tumors of the gastrointestinal tract (1-3% of all gastrointestinal neoplasias). The frequency of their location on the rectocolic site is quoted with the values lower than 10% of all GIST. The authors present a patient case 55 years aged, who presented a gastrointestinal stromal tumor cecal located. This tumor determined the invagination of the cec into the ascendent colon and then into transverse colon drawing the last ileal ansa and leading to an ileo-cecal-colic invagination, without development of a occlusive syndrome. We performed a computed tomography and an irigography. These investigations showed the complications of the case, but it could not find out a cause of the invagination. We discuss in our article the problem regarding find out the type of the tumor and its origin too. We also discuss about the therapy, etiopathogeny, evolution and prognosis of the GIST.

[Post traumatic entero-mesenteric venous infarct]

The paper presents a case of entero-mesenteric venous infarct, occurred in a man of 34 years, discovered intraoperator, when to intervene surgically in emergency surgery for acute abdomen of peritonitic type. The etiology of this venous infarct was posttraumatic, the patient underwent an abdominal aggression with seven days prior to onset of symptoms. In literature, the posttraumatic etiology is found in a small number compared to the large number of abdominal contusion, intimal lesional factor beeing associated with blood thickness. Paraclinical investigations were not significant in terms of preoperator diagnosis, surgical intervention (backward and forward thrombectomy of superior mesenteric vein with Fogarty probe and venosuture) having a favorable evolution. This intervention is practiced as an exception on the basis of the idea that venous thrombosis spreads to mezenteric vein and its collaterals followed by extensive arterial thrombosis and total compromise of intestinal viability.

[Idiopatic parafoveolar telangiectasia associated with pseudoviteliform lesion, basal laminar drusen and optic nerve head drusen]

BACKGROUND

We present a case with bilateral optic disc drusen, associated in one eye with idiopathic parafoveal telangiectasis (Group 1B), basal laminar drusen, and foveal pseudovitelliform lesion.

PATIENT

A 45-years old female patient, which complained about a deterioration of vision at the right eye, was ophthalmologically examined.

RESULTS

The examination revealed a bilateral optic disc drusen, and on the right eye a macular haemorrhage. An examination after 2 months revealed a good vision, the resorption of the macular haemorrhage, idiopathic parafoveal telangiectasis, basal laminal drusen, and a foveal pseudovitelliform lesion.

CONCLUSIONS

The association is of importance because of the rarity of the haemorrhagic complication in the idiopathic parafoveal telangiectasis (Group IB), the possibility of a pathogenic correlation, and the difficulty of differential diagnosis with the optic disc drusen complicated with retinal haemorrhages. This association was not found in the literature we consulted.

[Multiple optic disc--myth or reality]

OBJECTIVE

To study the clinical aspects of multiple optic papilla.

CLINICAL OBSERVATION

We present 2 cases with multiple optic papilla. First case, with an aspect of duplicated double papilla, where at the supranumerary papilla we noticed a cilioretinal artery. The second case, with pseudo-double papilla, in context of a medium myopia, with visualization of the choroidal circulation.

DISCUSSIONS AND CONCLUSIONS

The diagnosis of multiple optic papilla is difficult. Its support requires the presence of multiple conditions: double papillary margins, central vascularization with separate emergence, synchronous vascular pulsation, imagistic and morphopathologic arguments. So far no clinical case with those required conditions was ever published.

Evaluation of FibroTest-ActiTest in children with chronic hepatitis C virus infection

FibroTest-ActiTest (FT-AT) has been validated in adults with chronic hepatitis C virus (HCV) infection as a noninvasive alternative to liver biopsy (LB), but there are few data of its use in children. The objective of the present study was to evaluate FT-AT in children with HCV infection and to compare FT-AT analysis with liver histology. A total of 43 serum samples from 38 children with chronic HCV infection were analyzed retrospectively. Histological evaluation was performed according to the METAVIR scoring system. In 16 of the children, 21 serum samples were tested with FT-AT and compared to 21 LB (serum/LB pairs) in nontransplanted and liver-transplanted children. FT-AT was also measured in 22 infected children without LB and in 50 healthy controls. FT-AT values in controls were comparable to those of healthy adults, validating the adult FT-AT parameters in children. In most infected children (74%), the FT-AT score was <or = A1-F1. Concordance between FT-AT and METAVIR scores was found in 10 pairs and discordance in 11. FT-AT/METAVIR concordance was better in non-transplanted (8/13 pairs, 62%) than in transplanted (2/8 pairs, 25%) children. A prospective evaluation of FT-AT in non-transplanted children with chronic HCV infection would be worthwhile in future.

[Diabetus mellitus and pregnancy]

OBJECTIVE

The evaluation of diabetic retinopathy during pregnancy.

MATERIAL AND METHODS

Retrospective study regarding 16 pregnant patients, with type 1 diabetes mellitus and variable retinal changes before the pregnancy: without retinal changes (5 cases), minimal diabetic retinopathy (7 cases), severe diabetic retinopathy (3 cases), proliferative diabetic retinopathy with panphotocoagulation before the pregnancy (1 case). The patients had a complete general and ocular investigation.

RESULTS

The patients without retinal changes were not influenced by pregnancy; the patients with minimal changes presented an aggravation of the diabetic retinopathy with an amelioration post-partum in 3 from the 7 cases; the patients with severe diabetic retinopathy suffered an aggravation in 1 from the 3 cases; the patients with proliferative diabetic retinopathy with panphotocoagulation before the pregnancy did not present any important changes during pregnancy.

CONCLUSIONS

The pregnancy represents a risk factor in the evolution of retinal changes in diabetic patients. The monitoring of the retinal changes and of the patients during the pregnancy is strongly recommended.

[Diffuse choroidal hemangioma associated with serous retinal detachment]

A 53-years old patient, with the diagnosis of diffuse choroidal hemangioma, partially ossified, associated with serous exudative retinal detachment, secondary to the choroidal neovessels, is presented. Aspects of differential diagnosis with the choroidal osteoma associated with serous exudative retinal detachment are discussed.

Diagnostic value of serum protein profiling by SELDI-TOF ProteinChip compared with a biochemical marker, FibroTest, for the diagnosis of advanced fibrosis in patients with chronic hepatitis C

BACKGROUND

FibroTest has been validated for the diagnosis of liver fibrosis in patients with chronic hepatitis C.

AIM

To compare FibroTest with a new proteome-based model for the prediction of advanced liver fibrosis.

METHODS

Sera from 191 consecutive patients with simultaneous liver biopsy and FibroTest on fresh sera were used for retrospective mass spectrometry analysis. A new fibrosis index was constructed combining proteomic peaks, selected on differential expression according to fibrosis stages in logistic regression analyses. The main end point was the diagnosis of advanced fibrosis on liver biopsy.

RESULTS

Eight out of 1000 peaks were selected for the construction of the proteomic index. The area under the receiver operating curve (AUROC) of the proteomic index was 0.88 (95% CI: 0.82-0.92), significantly greater than the FibroTest AUROC of 0.81 (95% CI: 0.74-0.86; P = 0.04); the AUROC of the proteomic and FibroTest combination was 0.88 (95% CI: 0.83-0.92). Seven of the eight selected peaks were highly associated with the FibroTest score, with different patterns of association with the five components of FibroTest.

CONCLUSIONS

A proteomic index combining eight peaks had an excellent accuracy value for the diagnosis of advanced fibrosis in patients with chronic hepatitis C. However, despite a statistical significance, the small improvement delivered by proteomics impairs clinical applications because of its cost and its variability compared with the well validated FibroTest.

Variability of the area under the receiver operating characteristic curves in the diagnostic evaluation of liver fibrosis markers: impact of biopsy length and fragmentation

BACKGROUND

The area under the receiver operating characteristic (ROC) curve is widely used as an estimate of the diagnostic value for fibrosis markers. Biopsy length and fragmentation are known as risk factors of false positive or false negative of biopsy but their quantitative impact on area under the receiver operating characteristic curve variability has not been assessed.

AIM

To assess these relationships to better compare the fibrosis markers.

METHODS

The area under the ROC curves of FibroTest for the diagnosis of fibrosis was estimated in patients with chronic hepatitis C using an integrated database including 1312 patients with FibroTest and biopsy. To take into account the biopsy length, we used two adjustment factors: one in which an observed area under the ROC curve could be adjusted according to the relative area under the receiver operating characteristic curve of a biopsy of a given length vs. the entire liver and one taking into account the prevalence of each fibrosis stage defining advanced and non-advanced fibrosis.

RESULTS

The mean biopsy length was smaller for cirrhosis (F4, 16 mm) vs. F3, (18 mm, P=0.01) and F0 (19 mm, P=0.01). The mean number of fragments was higher for cirrhosis (F4=4.1 fragments) vs. all the other stages (F0=1.9, F1=1.9, F2=1.9, F3=2.3; P<0.001 vs. F4). The FibroTest area under the ROC curves for the diagnosis of advanced fibrosis, adjusted for stages' prevalence, ranged from 0.80 to 0.98 depending on biopsy length and fragmentation, respectively.

CONCLUSION

The comparison of the area under the ROC curves of fibrosis markers should take into account the biopsy length and fragmentation.

Screening for liver disease using non-invasive biomarkers (FibroTest, SteatoTest and NashTest) in patients with hyperlipidaemia

BACKGROUND

Mortality related to complications of cirrhosis is increasing in patients with insulin-resistance factors. Hyperlipidaemic patients have multiple risk factors of insulin resistance. It is impossible to perform liver biopsy in such a large number of hyperlipidaemic patients to identify patients with advanced liver fibrosis or with steatohepatitis (non-alcoholic steatohepatitis, NASH).

AIMS

To use the non-invasive biomarkers, FibroTest (FT), SteatoTest and NashTest, and to assess the prevalence of advanced liver disease in a large population of hyperlipidaemic patients.

METHODS

A consecutive cohort of hyperlipidaemic patients was followed prospectively in a lipid centre and the sera were analysed retrospectively.

RESULTS

A total of 2834 subjects were included: 1909 hyperlipidaemic patients and 925 blood donors (BD). Advanced fibrosis was identified by FT in 53/1909 (2.8%) hyperlipidaemic patients vs. 0/925 BD (0%) (P < 0.0001); advanced steatosis in 569/1893 hyperlipidaemic patients (30.1%) vs. 8/164 (4.9%) BD (P < 0.0001) and NASH in 132/1893 (7%) vs. 0/164 (0%), respectively (P < 0.0001). There was a highly significant and linear association between the number of metabolic syndrome factors and liver disease prevalence - the highest being for type 2 diabetics: advanced steatosis 66%, NASH 24% and advanced fibrosis 6%. CONCLUSIONS The prevalence of fibrosis, steatosis and NASH in hyperlipidaemic patients appears to be high (3%, 30% and 7%, respectively). Biomarkers could be useful for screening of advanced fibrosis and NASH in patients with several metabolic syndrome factors, to prevent liver mortality.

[Wyburn-Mason syndrome]

INTRODUCTION

The Wyburn-Mason or Bonnet, Dechaume, and Blanc syndrome is a rare congenital anomaly formed of malformations of the retinal vessels, orbito-cerebral vessels, and, rarely, facial vessels.

CASE REPORT

Male patient, 19 years old, examined because of a severe visual loss and exophthalmos at the left eye. The ophthalmoscopic examination reveals extensive retinal arterio-venous malformations, also confirmed at orbito-cerebral level by ultrasound and MRI DISCUSSION: The Wyburn-Mason syndrome is due to arterio-venous anastomosis, being included in the phakomatosis group. Clinically we describe 3 groups of severity. Aspects of differential diagnosis, pathogeny, and treatment are discussed.

CONCLUSIONS

The Wyburn-Mason syndrome can be suspected in cases of facial angioma, exophthalmos, or decreased visual acuity. The diagnosis imposes additional examinations with orbito-cerebral imagery.

[Retinal capillary hemangioma]

The retinal capillary hemangiomas are evolutive tumors which, solitary or multiple, present a vast clinical appearance, described under generic name of "retinal angiomatosis". We present the case of a young male patient with solitary retinal capillary hemangioma, localized in the interpapilo-macular region. The exofitic tumors were characterized by a particular arrangement of the tumoral vascular network: superficial (in the superior area) and profound (in the inferior area). This double vascular localization explains the spotted aspect of the fluorescent tumor, and also the phenomenon of "choroidal adoption".

Complications hémorragiques des druses de la papille

INTRODUCTION

The hemorrhagic complications of the optic disk drusen are rare and interesting because of their functional implications, the difficulty of the differential diagnosis and the uncertain pathogeny.

MATERIAL

and methods: Retrospective study of 6 cases with a complete general and ophthalmological examination, followed between 2 and 9 years.

RESULTS

The average age of the cases was 38.5 years (9-62 years). The visual acuity was slightly affected and reversible in the papillary hemorrhages (1 case), low and partial reversible in the extended hemorrhages (4 cases), severe affected and irreversible in the associations with a choroidal neovascular membrane with macular implications (1 case). We found three types of hemorrhages: papillary (1 case), peripapillary associated with choroidal neovascular membrane in acute (2 cases) and cicatricial stage (1 case), extended subretinal (2 cases). The papillary drusen were profound (4 cases) and superficial (2 cases). Ultrasonography showed the presence of the optic disk drusen in both eyes in all cases. The evolution followed on a period from 2 to 9 years, revealed the resorbtion of the hemorrhages between 3 and 6 months, the reversible visual acuity in the cases without macular implication, and the absence of recidiva or bilateralisation.

DISCUSSIONS AND CONCLUSIONS

The authors are presenting a number of clinical cases of papillary drusen complicated with hemorrhages, some of the cases being associated with choroidial neovascular membrane. Because of the clinical appearance, aspects of differential diagnosis with papillary edema of other etiologies are discussed. A role in the pathogeny is attributed to the direct or progressive compression of the retinal vascularisation which can provoke the erosion of the vessels and in some cases the appearance of the choroidal neovascular membrane. The suggested therapy is medical, surgical, or by photocoagulation, but the results are contradictory.

[Optic nerve drusen and angioid streaks in pseudoxanthoma elasticum]

The clinical study presents the association between optic disc drusen and angioid streaks in the context of pseudoxanthoma elasticum, in 8.5% (4 from 47) of the cases. The values are significantly higher compared to those from the normal population (0.34%). This result can be the consequence of pathogenic correlations between the two diseases, in which a role is attributed to the metabolic changes within the pseudoxanthoma elasticum. The starting point seems to be the accumulation of polyanions in the elastin of the cribriform plate, followed by disruption of axonal transport, mitochondrial extrusion and subsequent formation of optic disc drusen.

Intussusception of efferent intragastric loop after gastrojejunostomy--an exceptional cause of high occlusion and hematemesis

Jejunogastric intussusception (GI) is an extremely rare complication of gastrojejunostomy (GJS) that may appear any time after surgical intervention. Less than 200 cases have been reported so far, on very small series. Young female, 32, who 12 years ago was operated for a gastroduodenal disease that she doesn't know many details about. She presented severe pain in the superior abdominal segment posteriorly irradiated, incoercible biliary nausea followed by hematemesis. The endoscopic, imaging and biological explorations suggested a huge gastric tumor that occupied the whole stomach and was bleeding diffusely. The rapid acute evolution asked for the urgent laparotomy that emphasized: soft tumour mass, intragastrically mobile without any scar at the stomach or duodenum level; adherent to the posterior of the stomach we discovered a ball of jejunal loops that couldn't be undone. The anterior gastrotomy sets the diagnosis: JGI of the efferent loops of a GJS. We hardly managed to reduce the intussusception, without resection, the loop being absolutely viable. In order to prevent a relapse, and because the anastomosis was not justified it was taken down. JGI in a patient presenting GJS must be taken into consideration in the presence of epigastric pain that would not cease, biliary nausea followed by hematemesis and rapid deterioration of general health status.

[Surgical management of acute pancreatitis. One hundred years of evolution]

The aim of the paperwork is to present the evolution of surgical management of acute pancreatitis for a period of more than a century, by using the literature data that reveal the important moments in the knowledge of patho-etiology, in clarifying the definition and classification and, last but not least, in the progress of biological and image exploration, the right timing and the permanent development of surgical procedures so that the general mortality should decrease up to 10-15%, as it nowadays. The need for surgical intervention in acute pancreatitis is the controversy that appeared during this period. Until the mid of the 20th century, mainly on the basis of the clinic diagnosis, only the severe cases were recognized and became subjects of surgical exploration, with disastrous results. A great step forward was the dosage of urinary and serum amylase that allowed the non-surgical diagnosis of the disease, so that some patients could be treated successfully without surgery. Introduction of prognosis criteria by Ranson, the dosage of C-reactive protein together with CT scanning of the injury: interstitial - edematous or necrosis,the fine needle aspiration for bacteriology and the adoption of a definition and unitary classification resulted in a major change in therapy, in general, and in the surgical procedures. Necrosectomy combined with a drainage method, practised and developed by Beger since 1982, becomes a surgical dogma. Minimally invasive procedures became a reliable alternative to classic procedures due to the diversity and permanent development of laparoscopic, endoscopic and radiologic techniques.