FOXP3+ regulatory T-cell counts correlate with histological response in Crohn's colitis treated with infliximab

Crohn's disease is a chronic inflammatory bowel disease of unknown aetiology. Mucosal inflammatory dysregulation is likely important, with increased production of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNFα). The chimeric monoclonal antibody, infliximab, inhibits TNFα and promotes intestinal mucosal healing. Despite this, many patients still require surgical intervention. Patients who have undergone colonic resection post-infliximab therapy, show markedly variable morphological response to treatment. FOXP3+ CD4+ regulatory T-cells have been shown to have a protective role in autoimmune/inflammatory diseases and their sequestration to the bowel is found in those treated with infliximab. We examined the immunohistochemical profile of lymphoid aggregates in tissue sections from post-infliximab Crohn's colitis resection specimens, classified as morphological responders or non-responders, defined in relation to the absence/presence of mucosal ulceration and active inflammation, and a control group. Results indicated no significant diffences in CD68-positive cell counts but increased FOXP3-positive (P = 0.02) and CD4-positive (P = 0.05) cell counts in responders versus non-responders. Untreated control scores were similar to non-responders. Although based on small study numbers, our results suggest an association between upregulation of FOXP3+/CD4+ regulatory T-cells and morphological response to infliximab therapy. This represents a possible quantitative methodology for monitoring therapeutic response to infliximab therapy, based on immunohistochemical evaluation of endoscopic biopsy specimens.

British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus

These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

BOB CAT: a Large-Scale Review and Delphi Consensus for Management of Barrett’s Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia

OBJECTIVES: Barrett’s esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD). METHODS: We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations. RESULTS: In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients. CONCLUSIONS: In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.

Colorectal cancer risk following adenoma removal: a large prospective population-based cohort study

Background: Randomised controlled trials have demonstrated significant reductions in colorectal cancer (CRC) incidence and mortality associated with polypectomy. However, little is known about whether polypectomy is effective at reducing CRC risk in routine clinical practice. The aim of this investigation was to quantify CRC risk following polypectomy in a large prospective population-based cohort study.

Methods: Patients with incident colorectal polyps between 2000 and 2005 in Northern Ireland (NI) were identified via electronic pathology reports received to the NI Cancer Registry (NICR). Patients were matched to the NICR to detect CRC and deaths up to 31st December 2010. CRC standardised incidence ratios (SIRs) were calculated and Cox proportional hazards modelling applied to determine CRC risk.

Results: During 44,724 person-years of follow-up, 193 CRC cases were diagnosed amongst 6,972 adenoma patients, representing an annual progression rate of 0.43%. CRC risk was significantly elevated in patients who had an adenoma removed (SIR 2.85; 95% CI: 2.61 to 3.25) compared with the general population. Male sex, older age, rectal site and villous architecture were associated with an increased CRC risk in adenoma patients. Further analysis suggested that not having a full colonoscopy performed at, or following, incident polypectomy contributed to the excess CRC risk.

Conclusions: CRC risk was elevated in individuals following polypectomy for adenoma, outside of screening programmes.

Impact: This finding emphasises the need for full colonoscopy and adenoma clearance, and appropriate surveillance, after endoscopic diagnosis of adenoma.

Randomized comparison of unfractionated heparin with corticosteroids in severe active inflammatory bowel disease

BACKGROUND: Heparin therapy may be effective in steroid resistant inflammatory bowel disease.

AIM: A randomized pilot study, to compare unfractionated heparin as a first-line therapy with corticosteroids in colonic inflammatory bowel disease.

METHODS: Twenty patients with severe inflammatory bowel disease (ulcerative colitis, n=17; Crohn's colitis, n=3) were randomized to either intravenous heparin for 5 days, followed by subcutaneous heparin for 5 weeks (n=8), or high-dose intravenous hydrocortisone for 5 days followed by oral prednisolone 40 mg daily, reducing by 5 mg per day each week (n=12). After 5 days, non-responders in each treatment group were commenced on combination therapy. Response to therapy was monitored by: clinical disease activity (ulcerative colitis: Truelove and Witt Index; Crohn's colitis: Harvey and Bradshaw Index), stool frequency, serum C-reactive protein and alpha1 acid glycoprotein, endoscopic and histopathological grading.

RESULTS: The response rates were similar in both treatment groups: clinical activity index (heparin vs. steroid; 75% vs. 67%; P=0.23), stool frequency (75% vs. 67%; P=0.61), endoscopic (75% vs. 67%; P=0.4) and histopathological grading (63% vs. 50%; P=0.67). Both treatments were well-tolerated with no serious adverse events.

CONCLUSION: Heparin as a first line therapy is as effective as corticosteroids in the treatment of colonic inflammatory bowel disease. Large multicentre randomized comparative studies are required to determine the role of heparin in the management of inflammatory bowel disease.

Microstructure design of Titanate-based electroceramics

Electrocerâmicos são uma classe de materiais avançados com propriedades eléctricas valiosas para aplicações. Estas propriedades são geralmente muito dependentes da microestrutura dos materiais. Portanto, o objectivo geral deste trabalho é investigar o desenho da resposta dieléctrica de filmes espessos obtidos por Deposição Electroforética (EPD) e cerâmicos monolíticos, através do controlo da evolução da microestrutura durante a sinterização de electrocerâmicos à base de titanatos. Aplicações sem fios na indústria microelectrónica e de comunicações, em rápido crescimento, tornaram-se um importante mercado para os fabricantes de semicondutores. Devido à constante necessidade de miniaturização, redução de custos e maior funcionalidade e integração, a tecnologia de filmes espessos está a tornar-se uma abordagem de processamento de materiais funcionais cada vez mais importante. Uma técnica adequada neste contexto é EPD. Os filmes espessos resultantes necessitam de um passo subsequente de sinterização que é afectada pelo substrato subjacente, tendo este um forte efeito sobre a evolução da microestrutura. Relacionado com a miniaturização e a discriminação do sinal, materiais dieléctricos usados como componentes operando a frequências das microondas em aplicações na industria microelectrónica de comunicações devem apresentar baixas perdas dieléctricas e elevadas permitividade dieléctrica e estabilidade com a temperatura. Materiais do sistema BaO-Ln2O3- TiO2 (BLnT: Ln = La ou Nd), como BaLa4Ti4O15 (BLT) e Ba4.5Nd9Ti18O54 (BNT), cumprem esses requisitos e são interessantes para aplicações, por exemplo, em estações de base para comunicações móveis ou em ressonadores para telefones móveis, onde a miniaturização dos dispositivos é muito importante. Por sua vez, o titanato de estrôncio (SrTiO3, STO) é um ferroeléctrico incipiente com constante dieléctrica elevada e baixas perdas, que encontra aplicação em, por exemplo, condensadores de camada interna, tirando partido de fronteiras de grão altamente resistivas. A dependência da permitividade dieléctrica do campo eléctrico aplicado torna este material muito interessante para aplicações em dispositivos de microondas sintonizáveis. Materiais à base de STO são também interessantes para aplicações termoeléctricas, que podem contribuir para a redução da actual dependência de combustíveis fósseis por meio da geração de energia a partir de calor desaproveitado. No entanto, as mesmas fronteiras de grão resistivas são um obstáculo relativamente à eficiência do STO para aplicações termoeléctricas. Para além do efeito do substrato durante a sinterização constrangida, outros factores, como a presença de fase líquida, a não-estequiometria ou a temperatura de sinterização, afectam significativamente não apenas a microestrutura dos materiais funcionais, mas também a sua resposta dieléctrica. Se adequadamente compreendidos, estes factores podem ser intencionalmente usados para desenhar a microestrutura dos electrocerâmicos e, desta forma, as suas propriedades dieléctricas. O efeito da não-estequiometria (razão Sr/Ti 0.995-1.02) no crescimento de grão e resposta dieléctrica de cerâmicos de STO foi investigado neste trabalho. A mobilidade das fronteiras de grão aumenta com a diminuição da razão Sr/Ti. A resistividade do interior dos grãos e das fronteiras de grão é sistematicamente diminuída em amostras não-estequiométricas de STO, em comparação com o material estequiométrico. O efeito é muito mais forte para as fronteiras de grão do que para o seu interior. Dependências sistemáticas da não-estequiometria foram também observadas relativamente à dependência da condutividade da temperatura (muito mais afectada no caso da contribuição das fronteiras de grão), à capacitância do interior e fronteiras de grão e à espessura das fronteiras de grão. Uma anomalia no crescimento de grão em cerâmicos de STO ricos em Ti foi também observada e sistematicamente analisada. Foram detectadas três descontinuidades na dependência do tipo Arrhenius do crescimento de grão relativamente à temperatura com diminuições no tamanho de grão a temperaturas em torno de 1500, 1550 e 1605 °C. Além disso, descontinuidades semelhantes foram também observadas na dependência da energia de activação relativamente à condutividade das fronteiras de grão e na espessura das fronteiras de grão, avaliadas por Espectroscopia de Impedância. Estas notáveis coincidências suportam fortemente a formação de diferentes complexos de fronteira de grão com transições entre os regimes de crescimento de grão observados, que podem ser correlacionados com diferentes mobilidades de fronteira de grão e propriedades dieléctricas. Um modelo é sugerido, que se baseia na diminuição da fase líquida localizada nas fronteiras de grão, como o aumento da temperatura de sinterização, um cenário compatível com um fenómeno de solubilidade retrógrada, observado anteriormente em metais e semicondutores, mas não em cerâmicos. A EPD de filmes espessos de STO em substratos de folha de Pt e a sinterização constrangida dos filmes fabricados foram também preliminarmente tratadas. Filmes espessos de STO foram depositados com êxito por EPD sobre substratos de Pt e, depois de sinterizados, atingiram densidades elevadas. Um aumento da densificação e do tamanho de grão assim como o alargamento da distribuição de tamanho do grão foram observados com a diminuição da razão Sr/Ti, tal como anteriormente observado em amostras cerâmicas. Grãos equiaxiados foram observados para todas as composições, mas um certo grau de anisotropia na orientação dos poros foi detectado: os poros revelaram uma orientação vertical preferencial. Este trabalho focou-se também na sinterização constrangida do sistema BLnT (Ln = La ou Nd), nomeadamente de filmes espessos de BLT e BNT sobre substratos de folha de platina, e na relação do desenvolvimento de anisotropia microestrutural com as propriedades dieléctricas. As observações durante a sinterização constrangida foram comparadas com cerâmicos monolíticos equivalentes sinterizados livremente. Filmes espessos de BLnT (Ln = La ou Nd) com elevada densidade foram obtidos por EPD e subsequente sinterização constrangida. A anisometria cristalográfica do material em conjunto com um passo de sinterização constrangida resultou em grãos alongados e microestruturas anisotrópicas. O efeito do stress do substrato durante a sinterização constrangida originou graus mais elevados de anisotropia (grãos e poros alongados e orientação preferencial, bem como textura cristalográfica) nos filmes sinterizados relativamente aos cerâmicos equivalentes sinterizados livremente, não obstante o estado equivalente das amostras em verde. A densificação dos filmes de BLnT (Ln = La ou Nd) é retardada em comparação com os cerâmicos, mas depois de longos tempos de sinterização densidades semelhantes são obtidas. No entanto, em oposição a observações na sinterização constrangida de outros sistemas, o crescimento do grão em filmes de BLnT (Ln = La ou Nd) é favorecido pelo constrangimento causado pelo substrato. Além disso, grãos e poros alongados orientados paralelamente ao substrato foram desenvolvidos durante a sinterização constrangida de filmes espessos. Verificou-se uma forte correlação entre a evolução de grãos e poros, que começou assim que o crescimento do grão se iniciou. Um efeito da tensão do substrato no aumento do crescimento de grão, bem como um forte “Zener pinning”, origina microestruturas altamente texturizadas, o que também é observado a nível cristalográfico. Efeitos marcantes da anisotropia microestrutural foram também detectados nas propriedades dieléctricas dos filmes de BLnT (Ln = La ou Nd). Juntamente com o aumento da razão de aspecto dos grãos, do factor de orientação e do grau de textura cristalográfica, a permitividade relativa é ligeiramente diminuída e o coeficiente de temperatura da permitividade evolui de negativo para positivo com o aumento do tempo isotérmico de sinterização. Este trabalho mostra que a não-estequiometria pode ser usada para controlar a mobilidade das fronteiras de grão e, portanto, desenhar a microestrutura e as propriedades dieléctricas de electrocerâmicos à base de STO, com ênfase nas propriedades das fronteiras de grão. O papel da não-estequiometria no STO e dos complexos de fronteira de grão no desenvolvimento microestrutural é discutido e novas oportunidades para desenhar as propriedades de materiais funcionais são abertas. As observações relativamente à sinterização constrangida apontam para o efeito de tensões mecânicas desenvolvidas devido ao substrato subjacente no desenvolvimento da microestrutura de materiais funcionais. É assim esperado que a escolha adequada de substrato permitia desenhar a microestrutura de filmes espessos funcionais com desempenho optimizado. “Stress Assisted Grain Growth” (SAGG) é então proposto como uma técnica potencial para desenhar a microestrutura de materiais funcionais, originando microestruturas anisotrópicas texturizadas com propriedades desejadas.

Mucopiocelo fronto-etmoidal, a propósito de um caso clínico

O mucocelo é uma lesão quística, benigna, expansiva dos seios perinasais. A sobreinfecção deste, designada de mucopiocelo, pode levar a um período de crescimento rápido, com maior risco de complicações. Relata-se o caso clínico de uma doente do sexo feminino, 59 anos, que recorreu ao Serviço de Urgência após crise inaugural de convulsão tónico-clónica generalizada, com queixas de aumento de volume periorbitário direito e febre desde há 1 semana. Apresentava à direita celulite orbitária e proptose ínfero-externa, com área de flutuação na parte medial da pálpebra superior, oftalmoplegia e quemose do olho direito acompanhada de rinorreia mucopurulenta. Realizou TC que demonstrou volumoso abcesso subperiosteal direito, ao nível da parede medial da órbita, tendo como ponto de partida aparente as células etmoidais anteriores homolaterais e seio frontal direito. Colocou-se a hipótese de mucopiocelo fronto-etmoidal. Foi submetida a drenagem de urgência do abcesso e a cirurgia endoscópica nasal com marsupialização da lesão fronto-etmoidal. Verificou-se resolução completa do quadro clínico. Apesar de consideradas lesões benignas, os mucocelos, apresentam potencial destrutivo, principalmente se infectados, necessitando, por vezes, de intervenção cirúrgica de urgência. A abordagem endoscópica destas lesões reafirma-se como tratamento de eleição.

Safe dissection of the distally based anterolateral thigh flap.

Background The distally based anterolateral thigh (ALT) flap is an interesting reconstructive solution for complex soft tissue defects of the knee. In spite of a low donor site morbidity and wide covering surface as well as arch of rotation, it has never gained popularity among reconstructive surgeons. Venous congestion and difficult flap dissection in the presence of a variable anatomy of the vascular pedicle are the possible reasons.Methods An anatomical study of 15 cadaver legs was performed to further clarify the blood supply of the distally based ALT. Our early experience with the use of preoperative angiography and a safe flap design modification that avoids distal intramuscular skeletonization of the vascular pedicle and includes a subcutaneous strip ranging from the distal end of the flap to the pivot point is presented.Results The distally based ALT presents a constant and reliable retrograde vascular contribution from the superior genicular artery. Preoperative angiography reliably identified and avoided critical Shieh Type II pedicled flaps. The preservation of a subcutaneous strip ranging from the distal flap end to the upper knee was associated with the absence of venous congestion in a short case series.Conclusions Preoperative angiography and a flap design modification are proposed to allow the safe transfer of the distally based ALT to reconstruct soft tissue defects of the knee.

Development of the First Disease Activity Index for Eosinophilic Esophagitis: Update on the EEsAI in 2011

Background a nd Aims: T he international E EsAI study g roupis currently developing the first activity index (EEsAI) specificfor Eosinophilic Esophagitis (EoE). Goal: To develop, evaluateand validate the EEsAI.Methods: T he d evelopment comprises three phases: 1.Selection of candidate items; 2. Evaluation of the activity indexin a f irst patient cohort; and 3. V alidation in a s econd EoEpatient cohort. Focus group interviews with patients were usedin p hase 1 to generate p atient r eported outcomes ( PRO)according to guidelines o f regulatory authorities ( FDA andEMA), whereas the section of biologic items was developed byDelphi r ounds of i nternational E oE experts from E urope andNorth America.Results: The EEsAI has a modular composition to assess thefollowing components o f EoE activity: p atient reportedoutcomes, endoscopic activity, histologic activity, laboratoryactivity, a nd quality of life. D efinitions f or all aspects o fendoscopic and histologic appearance were established byconsensus rounds among EoE experts. Symptom assessmenttools were created that take into account d ifferent foodconsistencies as w ell as f ood avoidance and specificprocessing strategies. T he EEsAI is evaluated in a c ohort ofadult EoE patients since March 2011.Conclusions: After successful validation, the EEsAI will allowto standardize outcome assessment in E oE t rials which w illlikely lead to its wide applicability.

Chirurgie

2007 was marked by a growing trend towards minimal invasive surgery and enhanced recovery, especially in visceral surgery. In comparison to the laparoscopic revolution in the eighties, Natural orifice transluminal endoscopic surgery (NOTES) must be watched on closely, and will probably have to be taken into account in a near future. Minimal invasive procedures in oesophageal cancer surgery have proved both efficient and oncologically safe. Implementation of Fast track protocols now permits a much faster patient's return to normal daily activity. In hepatobiliary and pancreatic surgery, multidisciplinary efforts have been done to better select patients, widen the indications and increase efficiency.

Age, smoking and overweight contribute to the development of intestinal metaplasia of the cardia.

AIM: To assess the role of Helicobacter pylori (H. pylori), gastroesophageal reflux disease (GERD), age, smoking and body weight on the development of intestinal metaplasia of the gastric cardia (IMC).¦METHODS: Two hundred and seventeen patients scheduled for esophagogastroduodenoscopy were enrolled in this study. Endoscopic biopsies from the esophagus, gastroesophageal junction and stomach were evaluated for inflammation, the presence of H. pylori and intestinal metaplasia. The correlation of these factors with the presence of IMC was assessed using logistic regression.¦RESULTS: IMC was observed in 42% of the patients. Patient age, smoking habit and body mass index (BMI) were found as potential contributors to IMC. The risk of developing IMC can be predicted in theory by combining these factors according to the following formula: Risk of IMC = a + s - 2B where a = 2,...6 decade of age, s = 0 for non-smokers or ex-smokers, 1 for < 10 cigarettes/d, 2 for > 10 cigarettes/d and B = 0 for BMI < 25 kg/m² (BMI < 27 kg/m² in females), 1 for BMI > 25 kg/m² (BMI > 27 kg/m² in females). Among potential factors associated with IMC, H. pylori had borderline significance (P = 0.07), while GERD showed no significance.¦CONCLUSION: Age, smoking and BMI are potential factors associated with IMC, while H. pylori and GERD show no significant association. IMC can be predicted in theory by logistic regression analysis.

Mitral regurgitation.

Mitral regurgitation (MR) involves systolic retrograde flow from the left ventricle into the left atrium. While trivial MR is frequent in healthy subjects, moderate to severe MR constitutes the second most prevalent valve disease after aortic valve stenosis. Major causes of severe MR in Western countries include degenerative valve disease (myxomatous disease, flail leaflet, annular calcification) and ischaemic heart disease, while rheumatic disease remains a major cause of MR in developing countries. Chronic MR typically progresses insidiously over many years. Once established, however, severe MR portends a poor prognosis. The severity of MR can be assessed by various techniques, Doppler echocardiography being the most widely used. Mitral valve surgery is the only treatment of proven efficacy. It alleviates clinical symptoms and prevents ventricular dilatation and heart failure (or, at least, it attenuates further progression of these abnormalities). Valve repair significantly improves clinical outcomes compared with valve replacement, reducing mortality by approximately 70%. Reverse LV remodelling after valve repair occurs in half of patients with functional MR. Percutaneous, catheter-based to mitral valve repair is a novel approach currently under clinical scrutiny, with encouraging preliminary results. This modality may provide a valuable alternative to mitral valve surgery, especially in critically ill patients.

Neuroprotection for optic nerve disorders.

The concept that optic nerve fiber loss might be reduced by neuroprotection arose in the mid 1990s. The subsequent research effort, focused mainly on rodent models, has not yet transformed into a successful clinical trial, but provides mechanistic understanding of retinal ganglion cell death and points to potential therapeutic strategies. This review highlights advances made over the last year. In excitotoxicity and axotomy models retinal ganglion cell death has been shown to result from a complex interaction between retinal neurons and Müller glia, which release toxic molecules including tumor necrosis factor alpha. This counteracts neuroprotection by neurotrophins such as nerve growth factor, which bind to p75NTR receptors on Müller glia stimulating the toxic release. Another negative effect against neurotrophin-mediated protection involves the action of LINGO-1 at trkB brain-derived neurotrophic factor (BDNF) receptors, and BDNF neuroprotection is enhanced by an antagonist to LINGO-1. As an alternative to pharmacotherapy, retinal defences can be stimulated by exposure to infrared radiation. The mechanisms involved in glaucoma and other optic nerve disorders are being clarified in rodent models, focusing on retrograde degeneration following axonal damage, excitotoxicity and inflammatory/autoimmune mechanisms. Neuroprotective strategies are being refined in the light of the mechanistic understanding.

Total aortic arch stenting--hemodynamical impact of carotid artery perfusion.

The aim of this experimental study is to evaluate the feasibility and the outcome of total endovascular stent implantation in the aortic arch. Indications for this operation-technique would be acute or chronic dissection of the aortic arch (non-A-non-B dissection) or type B dissection with retrograde extension. Four pigs were canulated via the distal abdominal aorta and a retrograde placement of a Djumbodis arch stent (4-9 cm) was controlled by using intravascular ultrasound and intracardiac ultrasound by the inferior cava vein and under radioscopic control. Cerebral perfusion, by using a flow meter placed on one prepared carotid artery, were controlled before, immediate post-procedural (<1 min), and in the early follow-up after aortic arch stent implantation. During the implantation process, especially during balloon inflation and deflation, mean carotid perfusion decreases slightly. A reactive increase of carotid perfusion after stent placements indicates transitory cerebral hypo-perfusion. Non-covered aortic arch stent implantation is technically feasible and could be a potential treatment option in otherwise inoperable arch dissections. The time required for balloon inflation and deflation causes an important risk of cerebral ischemia. The latter can be reduced by transaxillary perfusion.

Mutism and Amnesia following High-Voltage Electrical Injury: Psychogenic Symptomatology Triggered by Organic Dysfunction?

Background: Mutism and dense retrograde amnesia are found both in organic and dissociative contexts. Moreover, dissociative symptoms may be modulated by right prefrontal activity. A single case, M.R., developed left hemiparesis, mutism and retrograde amnesia after a high-voltage electric shock without evidence of lasting brain lesions. M.R. suddenly recovered from his mutism following a mild brain trauma 2 years later. Methods: M.R.'s neuropsychological pattern and anatomoclinical correlations were studied through (i) language and memory assessment to characterize his deficits, (ii) functional neuroimaging during a standard language paradigm, and (iii) assessment of frontal and left insular connectivity through diffusion tractography imaging and transcranial magnetic stimulation. A control evaluation was repeated after recovery. Findings: M.R. recovered from the left hemiparesis within 90 days of the accident, which indicated a transient right brain impairment. One year later, neurobehavioral, language and memory evaluations strongly suggested a dissociative component in the mutism and retrograde amnesia. Investigations (including MRI, fMRI, diffusion tensor imaging, EEG and r-TMS) were normal. Twenty-seven months after the electrical injury, M.R. had a very mild head injury which was followed by a rapid recovery of speech. However, the retrograde amnesia persisted. Discussion: This case indicates an interaction of both organic and dissociative mechanisms in order to explain the patient's symptoms. The study also illustrates dissociation in the time course of the two different dissociative symptoms in the same patient.