Coronary revascularization without extracorporeal circulation. An alternative therapy (preliminary report)]

Direct myocardial revascularization techniques has earned great acceptance in the treatment of ischemic coronary syndromes in the past two decades. Almost since its beginnings the procedure was done with the aid of extracorporeal circulation, since the technical accessibility with cardiac standstill further helped to evolve the procedure. As years went by, complications due to the use of the pump became evident, such as microembolism, bleeding disorders, and others. Besides this, there is a special group of patients, those with high surgical risk, with preexisting pulmonary, hepatic or cerebral disease, who benefit a great deal when bypass grafting procedure is done without the pump. In this article we delineate the indications, contraindications, and the procedure itself based in our personal experience, reporting our first five patients with this technique.     

Clinical course of symptomatic duodeno-jejunal Crohn's disease

AIMS: To describe retrospectively the characteristics of inaugural, symptomatic Crohn's disease of the upper gastrointestinal tract. METHODS: Eighteen patients (12 male and 6 female) with symptomatic Crohn's disease of the upper intestinal tract and without previous distal localisation were studied. RESULTS: Mean age of patients at diagnosis (21.3 years) was less than that usually reported in Crohn's disease. The time elapsed from first symptoms to diagnosis (mean = 29.8 months) was remarkably long for some patients, mainly as a result of an unusual clinical presentation. Abdominal pain and weight loss were the most common presenting features; diarrhea was rarely the main symptom. Persistent anorexia and weight loss without digestive symptoms had led to a diagnosis of anorexia nervosa in 4 patients. Zollinger-Ellison syndrome was the initial diagnosis in 3 other patients. Sixteen patients were followed during at least 2 years. All were treated with steroids for their first attack and 75 % required immunosuppressive therapy for steroid dependence. At the end of follow-up, 6 patients only were in remission without treatment or under mesalamine. CONCLUSION: Crohn's disease with initial symptomatic lesions of the upper gastrointestinal tract occurs mainly in young male patients. The clinical presentation may be very unusual, leading to misdiagnosis. The clinical course is close to that of diffuse jejunoileitis.     

Nursing management of ventilation and sedation in patients suffering from septic shock

A significant number of intubated, ventilated and sedated patients suffering from septic shock develop acute respiratory distress syndrome (ARDS). The supervision by a multidisciplinary team optimises both the management of ventilation and the sedation analgesia of the patient. The nursing supervision and care related to this pathology are specific.     

Good outcome with early empiric treatment of neural larva migrans due to Baylisascaris procyonis

We report a remarkably good outcome in a 14-month-old boy with early clinical diagnosis and aggressive empirical treatment of neural larva migrans caused by the raccoon roundworm Baylisascaris procyonis. He presented with fever, meningismus, lethargy, irritability and asymmetric spastic extremity weakness. Early findings of marked blood and cerebrospinal fluid eosinophilia and of diffuse white matter signal abnormality in the brain and spinal cord on MRI suggested a parasitic encephalomyelitis. Rapid presumptive treatment with albendazole and high-dose steroids halted progression of clinical signs. The diagnosis was confirmed by 2 sequential enzyme-linked immunosorbent assay studies positive for B procyonis serum immunoglobulin G and by Western blot. Field examination with soil sampling yielded infective Baylisascaris eggs. Repeat MRI 3 months later showed atrophy and diffuse, chronic white matter abnormalities, discordant with the marked clinical improvement in this interval. At 10 months, residual neurologic deficits included subtle paraparesis and moderate language delay. This case is the first in which spinal involvement in human Baylisascaris infection was clinically suspected and confirmed by neuroimaging. Importantly, early diagnosis and aggressive treatment of Baylisascaris meningo-encephalitis and myelitis with albendazole and high-dose steroids likely contributed to the good outcome in this patient, in contrast with previous reports.     

Dermatitis herpetiformis (author's transl)]

Detailed investigations of 9 patients with dermatitis herpetiformis are presented. In all cases cutaneous lesions were controlled by dapsone alone or by dapsone and gluten free diet. Granular IgA deposits were found in 7 patients, linear IgA deposits in one, and C3 component of complement in one. 3 patients out of 8 tested, carried the specific HLA-B8 antigen. Despite an extensive investigation, no malabsorption was detected. Jejunal biopsies were performed in 8 cases. Jejunal villous flattening was observed in one patient. It improved after a 2 months gluten free diet on subsequent jejunal biopsies. D. H. seems peculiar in France as compared with case reports from other countries: low prevalence of gluten sensitive enteropathy; rare occurrence of the specific HLA-B8 antigen; incidence of D. H. seems to be low in France. It is noticeable that french incidence of coeliac disease is low as well. This suggests a genetic difference in the investigated population (low prevalence of HLA-B8 antigen) and/or different alimentary habits, particularly a low dietary gluten amount.