Protocol of a multicentric prospective cohort study for the VALIDation of the IBD-disk instrument for assessing disability in inflammatory bowel diseases: the VALIDate study.

BACKGROUND: Inflammatory Bowel Diseases (IBD) affect psychological, family, social and professional dimensions of patients' life, leading to disability which is essential to quantify as part of Patient-Reported Outcomes (PROs) newly included in the targets to reach in IBD patients. Up to now, the IBD-Disability Index (IBD-DI) was the only validated tool to assess disability, but it is not appropriate for use in clinical practice. The IBD Disk was developed, a shortened and self-administered tool, adapted from the IBD-DI, in order to give immediate representation of patient-reported disability. However, the IBD Disk has not been validated yet in clinical practice. The aims of the VALIDate study are to validate this tool in a large population of IBD patients and to compare it to the already validated IBD-DI. METHODS: The VALIDate study is an ongoing multicentric prospective cohort study launched in April 2018 in 3 French University Hospitals (Nantes, Rennes, Angers), with an objective to reach a sample of 400 patients over a period inclusion of 6 months. Each patient will fill in the two questionnaires IBD Disk and IBD-DI at baseline, then between 3 and 12 months later, during a follow-up visit. Clinical and socio-demographic data will also be collected. During these two consultations, gastroenterologists and patients will evaluate disease activity thanks to a semi-quantitative 4-grade scale, named respectively PGA (Physician Global Assessment) and PtGA (Patient Global Assessment). This cohort will allow to evaluate the validity of the IBD Disk with respect to the IBD-DI in order to generalize its use for clinical practice. Other psychometric criteria of the IBD Disk will also be analysed as its reliability or its discriminant capacity. Close attention will nonetheless be needed to minimize the number of lost to follow-up patients between baseline and follow-up. DISCUSSION: The VALIDate study is the study designed to validate the IBD Disk, a visual tool easily useable in daily practice to assess disability in IBD patients. The results of this trial should enable the diffusion of this tool. TRIAL REGISTRATION: The trial is registered in ClinicalTrials.Gov with registration number NCT03590639. First posted: July 18, 2018.

Identifying avoidable switchboard delays in England's NHS hospitals: phase one of the national SWITCH project.

BACKGROUND: Inter-hospital communication frequently requires mediation via a switchboard. Identifying and eliminating switchboard inefficiencies may improve patient care. METHODS: All 175 acute hospital switchboards in England were contacted six times. Call contents and duration were recorded. No clinician calls or bleeps were connected. RESULTS: The mean delay before contacting a switchboard operative was 55±46 seconds. 115 hospitals (66%) used automated switchboards; 34 of these (30%) had infection control messages. Robot operators introduced an additional 40 second delay versus humans (mean 70.3±28 versus 29.8±23 seconds, p<0.0001). Multivariate analysis identified robot operators (HR 5.1, p<0.0001) and infection control messages (HR 2.9, p=0.003) as predictors of delays over 60 seconds. CONCLUSIONS: There are significant avoidable delays in contacting switchboard operatives across England. Quality improvement is underway.

Human papillomavirus does not play a role in the Barrett esophagus: a French cohort.

The role of human papillomavirus (HPV) in Barrett's esophagus (BE) has been examined but remains unclear. The purpose of the study is to dispute the connection between HPV and BE in a prospective case-control study. Biopsies were performed above and inside the Barrett's segment for BE patients and in the distal third of the esophagus for control patients for histological interpretation and for virological analysis. Biopsies for virological analysis were placed in a virus transport medium and immediately frozen in liquid nitrogen. Virological analysis involved real-time PCR using the SyBr® green protocol with modified SPF10 general primers. A total of 180 patients (119 control and 61 BE, respectively) were included. In BE patients, 31, 18, and 12 patients had, respectively, no dysplasia, low-grade dysplasia, and high grade dysplasia. Overall, nine were found to be HPV positive: five were control patients and four BE patients. HPV positive status was not associated with BE. No factors were associated with HPV, in particular the degree of BE dysplasia. HPV infection appears unlikely to be significant in the etiology of BE compared with control patients. (ClinicalTrials.gov, Number NCT02549053).

Impact of balloon inflation pressure on cell viability with single and multi lumen catheters.

Infusion catheters, when used in combination with balloons, are subjected to pressure created by inflation of the balloon. The compression can reduce the catheter flow area and cause elevated shear stresses in the fluid. A model and experiments were developed with a range of applied balloon pressures to investigate whether such situations may cause cell lysis during stem-cell infusion through single-lumen catheters. It was found that for balloon inflation pressures in excess of ~7 atm, it is possible for cell injury to occur, although the critical pressure depends on the fluid viscosity. The study was then applied to a multi-lumen catheter which was designed to resist compression. That device was able to handle very elevated balloon pressures and flow rates before cell lysis became a concern.

Early-effect of bariatric surgery (Scopinaro method) on intestinal hormones and adipokines in insulin resistant Wistar rat.

Bariatric surgery consists in duodenal exclusion from the food passage in obese patients with coexistent type 2 diabetes. Nowadays bariatric surgery is considered the most effective method of glycemic index normalization and insulin resistance reduction. Recent results on obese and non-obese rats showed remission of type 2 diabetes symptoms within few days after the surgery. The aim of the present work was to analyze the mechanisms of neuro-hormonal regulation responsible for early normalization of metabolic syndrome after bariatric surgery. In present study the concentration of selected intestinal hormones and adipokines in blood plasma and gastrointestinal tissues were analyzed. Study was conducted on Wistar rats. Animals were divided into three groups (each n=6): control (SH) shame-operated rats; animals in which visceral fat tissue was extracted (LP); and rats in which Scopinaro bariatric surgery was performed (BPD). Immunochemistry analysis of blood plasma showed decrease of insulin concentration in BPD and LP and increase of polypeptide YY (PYY) in BPD group as compared to the control. In duodenal mucosa homogenates the tendency to reduce insulin in LP and BPD group, and increase PYY and visfatin in BPD group was observed. Histometry analysis showed reduction of mucosa thickness in excluded segments of gastrointestinal tract in BPD group as compared to the SH and LP. Concluding, model studies on rats allowed better understanding of mechanisms important for early normalization of glycemic index and insulin resistance reduction in rats.

A child with rotor syndrome and Capillaria philippinensis: case report and review of literature.

This paper reported Capillaria philippinensis in an Egyptian child based on clinical and laboratory diagnosis. The patient was successfullly treated with albendazole.

[Intramasseteric hemangioma operated by intraoral approach]. / Hémangiome du masséter opéré par voie intra-orale.

INTRODUCTION: Hemangiomas are benign vascular tumors, of unknown origin. Skeletal muscle localization account for less than 1% of cases. Masseter muscle localization is most common in head and neck (36%). In this case, treatment is usually surgery via an extra-oral approach which imposes parotidectomy with dissection of facial nerve branches. We report a case of intramasseteric hemangioma operated via an intraoral approach and we describe the benefits of this approach. CASE REPORT: A 34-year-old male patient with no prior history of trauma consulted for left masseter swelling having evolved for several years. Clinical examination revealed a soft, painless, well-defined swelling, about 5cm long, with a positive Wattle sign in the left cheek. The CT exam suggested a vascular lesion, located in the deep bundle of the masseter muscle. Preoperative embolization was followed by surgical exeresis via an intraoral approach. The post-operative evolution was uneventful. No recurrence was observed at one year of follow-up. DISCUSSION: Intraoral intramasseteric hemangioma exeresis is possible and does not seem to lead to more complications than with the facial approach. It prevents the significant drawbacks due to cutaneous incision, parotidectomy, and dissection of facial nerve branches via a facial approach.

[Maxilla-mandibular brown tumors as a first sign of parathyroid adenoma]. / Tumeurs brunes maxillomandibulaires révélant un adénome parathyroïdien.

OBJECTIVES: Through a novel observation of parathyroid adenoma revealed by brown tumors of the jaws and a review of the literature, the authors describe this rare mode of primary hyperparathyroidism discovery. MATERIAL AND METHODS: The patient was a 23-year-old woman who consulted for a recurrent tumefaction of the maxillary; histology showed reparative giant cell granuloma. RESULTS: The clinical examination found an osseous tumefaction in continuity with the zygomatic bone and a gingival tumefaction on the mandible symphysis. The radiological findings showed two osteophytic lesions: mandibular and maxillary. The phosphocalcic metabolism was disturbed and the parathormone rate was high. The etiologic search consisted of a MRI of the neck, which showed a mass behind the thyroid gland, suggesting a parathyroid adenoma. The diagnosis was confirmed at surgical exploration. After removal of this tumor, the blood calcium rate dropped sharply and the bone tumefaction progressively regressed. CONCLUSION: Brown tumors are a rare mode of parathyroid adenoma discovery, and the jaw location is exceptional. The diagnosis is based on the parathormone rate, and radiological exams generally find the etiology. Treatment is based on surgery of the parathyroid adenoma.

[Papillary adenocarcinoma on ectopic thyroid tissue]. / Adénocarcinome papillaire sur tissu thyroïdien ectopique.

OBJECTIVES: To report a case of papillary adenocarcinoma occurring on ectopic thyroid tissue in the hyoid bone region. MATERIAL AND METHODS: A 57-year-old patient consulted for a cervical mass appearing 1 year before, with no signs of compression. The thyroid function was normal. RESULTS: The examination showed a firm tumefaction, fixed on the hyoid bone, with undetermined limits, measuring approximately 8 cm. The thyroid gland was in the normal pretracheal position. The cervical tomodensitometry objectified an osteolytic process centered on the hyoid bone with a fleshy zone of tissue density and calcifications. Cervical MRI provided a more precise assessment of the extension of the mass and confirmed the integrity of the other structures, in particular the endo-larynx. The tumor was totally resected via a cervical approach. The pathologic study suggested a papillary adenocarcinoma on ectopic thyroid tissue. The treatment was completed by a total thyroidectomy with normal histological results. CONCLUSIONS: Papillary adenocarcinoma on ectopic thyroid is a very rare situation. Its diagnosis is histological. Its treatment is primarily surgical, sometimes associated with radioiodine I-131 therapy.

FibroMeters: a family of blood tests for liver fibrosis.

FibroMeters are blood tests for liver fibrosis with several specificities: two main diagnostic targets (fibrosis stage and area of fibrosis); adaptation to specific causes; and results confirmed by an expert system. Thus, FibroMeters comprise six different tests: one for staging and one for quantitation of liver fibrosis in each of the three main causes of chronic liver disease-chronic viral hepatitis, alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). FibroMeters display a high overall diagnostic accuracy and are the only tests to correctly classify 100% of HCV patients without fibrosis or with cirrhosis. They have 90% predictive values in a higher proportion of patients than with other usual blood tests. A 90% correct classification is available in 100% of HCV patients with the following reliable diagnostic intervals: F0/1, F1/2, F2+/-1, F3+/-1. In real-life conditions, the reproducibility of FibroMeters is higher than that of liver biopsy or ultrasonographic elastometry. FibroMeters are robust tests with the most stable diagnostic performance across different centers. Optional tests are also available, such as a specific one for cirrhosis, which has a diagnostic accuracy of 93.0% (AUROC: 0.92) and a 100% positive predictive value for diagnosis of HCV cirrhosis. Determination by FibroMeters of the area of fibrosis - the only direct, non-invasive, quantitative measurement of liver fibrosis - are especially useful for following-up cirrhosis as it correlates well with clinical events. FibroMeters are also very accurate in HVB or HIV-HCV co-infected patients. The tests specific for ALD and NAFLD also have a high diagnostic accuracy (AUROCs: 0.96 and 0.94, respectively, for significant fibrosis).

Evaluation and improvement of a reliable diagnosis of cirrhosis by blood tests.

OBJECTIVE: To evaluate the rates of reliable diagnosis of cirrhosis by two usual blood tests. METHODS: Reliable diagnosis was mainly evaluated by comparing rates of positive (PPV) and negative (NPV) predictive values with FibroTest and FibroMeters, as either standard test or specifically designed for cirrhosis, in 1056 patients with chronic hepatitis C. RESULTS: Using the diagnostic limits provided by fibrosis stage scales, the PPV for cirrhosis was: standard FibroMeters: 68.5% versus FibroTest: 37.1%. Using 95% PPV, the cirrhosis detection rate was: specific FibroMeter: 26.1% versus FibroTest: 2.0% (P<10(-3)). The cirrhosis detection rate increased from 26 to 65% by performing liver biopsy in 8% of patients with indeterminate results on specific FibroMeter between 95% NPV and PPV. On the other hand, specific FibroMeter provided three intervals of 95% reliable diagnosis with no biopsy: less than or equal to 95% NPV: no cirrhosis (threshold: diagnosis); significant fibrosis; and greater than or equal to 95% PPV: cirrhosis. CONCLUSION: The detection rate and PPV for cirrhosis using fibrosis scales were fair for standard FibroMeter and poor for FibroTest. Around one-fourth of cases of cirrhosis are detected by the 95% PPV of specific FibroMeter, and around two-thirds by performing an additional liver biopsy in only 8% of patients. Finally, specific FibroMeter can avoid liver biopsy by classifying patients into three categories: no cirrhosis; significant fibrosis; and cirrhosis.

Mitochondrial DNA A3243G mutation involved in familial diabetes, chronic intestinal pseudo-obstruction and recurrent pancreatitis.

AIMS: To report on a family with five members who carry the A3243G mutation in mitochondrial tRNA for leucine 1 (MTTL1) and present with diabetes, chronic intestinal pseudo-obstruction (CIPO) and recurrent pancreatitis, and to screen for this mutation in a cohort of 36 unrelated patients with recurrent pancreatitis. METHODS: The mutation was quantified in several tissue samples from patients. Respiratory chain activity was studied in muscle biopsies and fibroblast cultures. In addition, the thymidine phosphorylase gene (TP) involved in mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) and three genes involved in chronic pancreatitis - PRSS1, SPINK1 and CFTR - were sequenced in affected patients. Finally, the MTTL1 gene was examined in 36 unrelated patients who had recurrent pancreatitis, but no mutations in the PRSS1 and SPINK1 genes. RESULTS: Heteroplasmy for the mtDNA A3243G mutation was found in all tissue samples from these patients, but no mutations were found in the genes coding for thymidine phosphorylase, PRSS1, SPINK1 and CFTR. Also, none of the 36 unrelated patients with recurrent pancreatitis were carrying any MTTL1 mutations. CONCLUSION: The mtDNA A3243G mutation associated with the gastrointestinal manifestations observed in the affected family should be regarded as a possible cause of CIPO and unexplained recurrent pancreatitis. However, the mutation is probably only weakly involved in cases of isolated recurrent pancreatitis.

Maladie de Kimura: a propos d'un cas

Introduction : La maladie de Kimura ou lymphogranulome eosinophile est une pathologie inflammatoire chronique tres rare; d'etiologie inconnue. Nous rapportons un cas de maladie de Kimura a localisation parotidienne et a travers une revue de la litterature; rappelons les principales caracteristiques cliniques; paracliniques; therapeutiques et evolutives de cette pathologie. Materiel et methodes : Patient de 17 ans qui a consulte devant l'apparition d'une tumefaction de la region parotidienne gauche evoluant depuis un an et sans paralysie faciale. Resultats : L'echographie cervico-parotidienne a revele une parotide gauche hypertrophiee siege de multiples nodules hypoechogenes. La tomodensitometrie cervico-faciale a mis en evidence une glande parotide gauche augmentee de taille et de structure heterogene nodulaire sans adenopathies cervicales. La cytopontion etait non concluante. Le patient a beneficie d'une parotidectomie exofaciale gauche et l'etude anatomopathologique de la piece operatoire revenue en faveur de la maladie de Kimura. Les suites operatoires etaient simples. Le recul est d'un an sans recidive. Discussion : La Maladie de Kimura se caracterise cliniquement par des nodules sous cutanes de localisation cervicofaciale; une augmentation du volume des glandes salivaires et des adenopathies satellites. Son diagnostic est histologique reposant sur l'identification d'une hyperplasie follicullaire avec des abces a polynucleaires eosinophiles. Le traitement est chirurgical le plus souvent mais dans certains cas la cortico- therapie est proposee. Ce diagnostic doit cependant rester a l'esprit devant toute masse cervico-faciale

Fibrinogen angers with a new deletion (gamma GVYYQ 346-350) causes hypofibrinogenemia with hepatic storage.

INTRODUCTION: This study reports a family with chronically abnormal blood liver function tests (LFT) and congenital hypofibrinogenemia. The proposita had cirrhosis initially related to alcohol abuse and chronic viral hepatitis C (HCV), but abnormal LFT persisted even when alcohol intake was stopped and despite HCV treatment was efficient based on serum RNA negative testing. RESULTS: Needle biopsy specimens of the proposita and her brother showed eosinophilic intra-cytoplasmic inclusions that reacted strongly with fibrinogen antisera on direct immunofluorescence. Electron microscopic examination showed that the rough endoplasmic reticulum was filled with inclusions that consisted of densely packed, curved tubular structures arranged in a fingerprint-like pattern. Coagulation studies revealed low functional and antigenic fibrinogen concentrations suggestive of hypofibrinogenemia. Amplification and DNA sequencing showed a heterozygous deletion of the a7690 to g7704 nucleotides of the gamma chain gene in the 3'end of exon 8 (g 7690_7704del14; Genbank access M10014); this deletion encompassed the splicing site at position 7703 and predicts in a new putative consensus splicing sequence (AATGgtatgtt). RNA was extracted from a liver specimen from the proposita's brother. The cDNA obtained by reverse transcription polymerase chain reaction confirmed the usage of a newly generated donor site at position 7688 of the genomic sequence resulting in an in-frame heterozygous 5 amino acid deletion (GVYYQ 346-350; p.G372_Q376del) and that this mutation is responsible for a new splicing site at position 7688 of the genomic sequence. CONCLUSION: we suggest that the molecular defect in fibrinogen Angers results in an impaired assembly and causes defective secretion and hepatic storage of fibrinogen.

Angiogenic gene therapy in patients with nonrevascularizable ischemic heart disease: a phase 2 randomized, controlled trial of AdVEGF(121) (AdVEGF121) versus maximum medical treatment.

The demonstration that angiogenic growth factors can stimulate new blood vessel growth and restore perfusion in animal models of myocardial ischemia has led to the development of strategies designed for the local production of angiogenic growth factors in patients who are not candidates for conventional revascularization. The results of recent clinical trials of proangiogenesis gene therapy have been disappointing; however, significant limitations in experimental design, in particular in gene transfer strategies, preclude drawing definitive conclusions. In the REVASC study cardiac gene transfer was optimized by direct intramyocardial delivery of a replication-deficient adenovirus-containing vascular endothelial growth factor (AdVEGF121, 4 x 10(10) particle units (p.u.)). Sixty-seven patients with severe angina due to coronary artery disease and no conventional options for revascularization were randomized to AdVEGF121 gene transfer via mini-thoracotomy or continuation of maximal medical treatment. Exercise time to 1 mm ST-segment depression, the predefined primary end-point analysis, was significantly increased in the AdVEGF121 group compared to control at 26 weeks (P=0.026), but not at 12 weeks. As well, total exercise duration and time to moderate angina at weeks 12 and 26, and in angina symptoms as measured by the Canadian Cardiovascular Society Angina Class and Seattle Angina Questionnaire were all improved by VEGF gene transfer (all P-values at 12 and 26 weeks < or =0.001). However, if anything the results of nuclear perfusion imaging favored the control group, although the AdVEGF121 group achieved higher workloads. Overall there was no significant difference in adverse events between the two groups, despite the fact that procedure-related events were seen only in the thoracotomy group. Therefore, administration of AdVEGF121 by direct intramyocardial injections resulted in objective improvement in exercise-induced ischemia in patients with refractory ischemic heart disease.

Chronic ischemic gastritis: case report of a difficult diagnosis and review of the literature.

Chronic ischemic gastritis is an unusual entity that is rarely distinguished from other forms of intestinal ischemia. On the basis of a case encountered and a subsequent review of the literature, the main features of this rare condition are described here. A better understanding and awareness of the disease should improve the diagnosis and ultimately also the prognosis.

Fractional flow reserve compared with intravascular ultrasound guidance for optimizing stent deployment.

BACKGROUND: Determination of fractional flow reserve (FFR) has been proposed as a means to assess stent deployment. In this prospective, multicenter trial, we evaluate the use of FFR to optimize stenting by comparing it with standard intravascular ultrasound (IVUS) criteria. METHODS AND RESULTS: Eighty-four stable patients with isolated coronary lesions underwent coronary stent deployment starting at 10 atm and increased serially by 2 atm until the FFR was >/=0.94 or 16 atm was achieved. IVUS was then performed. FFR was measured with a coronary pressure wire with intracoronary adenosine to induce hyperemia. The diagnostic characteristics of an FFR <0.94 to predict suboptimal stent expansion by IVUS, defined in both absolute and relative terms, were calculated. Over a range of IVUS criteria, the highest sensitivity, specificity, and predictive accuracy of FFR were 80%, 30%, and 42%, respectively. Receiver operator characteristic analysis defined an optimal FFR cut point at >/=0.96; at this threshold, the sensitivity, specificity, and predictive accuracy of FFR were 75%, 58%, and 62%, respectively (P=0.03 for comparison of predictive accuracy, P=0.01 for concordance between FFR and IVUS). The negative predictive value was 88%. Significantly better diagnostic performance was achieved in a subgroup that received higher doses (>30 microgram) of intracoronary adenosine during pressure measurements, suggesting that FFR might be overestimated in the other group. CONCLUSIONS: A fractional flow reserve <0.96, measured after stent deployment, predicts a suboptimal result based on validated intravascular ultrasound criteria; however, an FFR >/=0.96 does not reliably predict an optimal stent result. Higher doses of intracoronary adenosine than previously used to measure FFR improve these results.

In vivo magnetic resonance imaging and surgical histopathology of intracardiac masses: distinct features of subacute thrombi.

We evaluated intracardiac masses in vivo, in situ and histologically to determine tissue properties revealed by magnetic resonance (MR) imaging. In 15 consecutive patients scheduled for cardiotomy, the cardiac chambers were studied preoperatively with MR imaging and echocardiography. Visual examination of one or more chambers was performed during cardiotomy for mitral valve replacement, aneurysmectomy, atrial septal repair and atriotomy. Six thrombi (1 atrial appendage, 5 ventricular) and 2 atrial myxomas were removed and subjected to histological analysis. All masses were detected preoperatively by MR imaging. The smallest was a subacute 3-mm mural clot in the left ventricle and was undetected by transesophageal and transthoracic echocardiography. The 3 subacute clots had homogeneously low MR signals, did not enhance with gadolinium and exhibited magnetic susceptibility effects; histopathology confirmed these clots to be avascular and laden with dense iron deposition related to hemoglobin breakdown products. The 3 organized clots had intermediate and heterogeneous MR signals and multiple areas of gadolinium enhancement. The 2 myxomas had low MR signals and gadolinium enhancement in the core and septal attachment; these areas had dense neovascular channels. Subacute thrombi appear to have MR features that are distinct from organized thrombi and myxomas, and MR images of subacute thrombi contrast sharply with normal cardiac structures, enabling detection of thin mural clots that may be echographically occult. These findings may be of value, because a subacute clot may be more likely than an organized thrombus to give rise to an embolus.

Urgent coronary bypass surgery for failed percutaneous coronary intervention in the stent era: Is backup still necessary?

BACKGROUND: Current practice guidelines for performance of percutaneous coronary intervention (PCI) in the United States mandate availability of on-site surgical backup. With the decreasing frequency of urgent coronary bypass surgery (UCABG) with newer technologies, it is unclear whether such backup continues to be necessary. METHODS: A database of 5655 consecutive patients undergoing PCI at a single center between August 1, 1992, and December 31, 1997, was analyzed. Outcomes were determined as well as clinical, lesion, and procedural characteristics of patients during 4 time periods preceding and during use of coronary stenting. RESULTS: Frequency of UCABG for failed PCI decreased from 2.2% to 0.6% in the most recent time period (P <.01) with no change in incidence of in-hospital death or myocardial infarction. Incidence of stenting progressively increased to 72% in the latest period. Patients requiring UCABG had a higher prevalence of acute coronary syndromes (95%) and type B lesions (79%), but these characteristics were also common in patients who did not undergo UCABG. Although coronary stents were available during the last 3 periods studied, only 30% of UCABG patients had lesions or complications amenable to stenting, and stenting attempts in these patients were all unsuccessful. Despite stenting and use of perfusion balloons and intra-aortic balloon pumps, only 40% of patients having UCABG were stable and pain free on transfer to the operating room. CONCLUSIONS: Although use of UCABG for a failed PCI is currently very low, there are no satisfactory predictors, patients requiring UCABG are frequently clinically unstable, and availability of stenting does not reliably eliminate the need for UCABG or result in a decrease in mortality. This small group of patients continues to require readily available surgical standby.

Capillaria philippinensis: an emerging parasite causing severe diarrhoea in Egypt.

Four cases with Capillaria philippinensis have been reported from Egypt during 1989-1992. The authors report here four other cases of severe diarrhoea caused by this parasite. A male and three female patients aged 12-45 years presented with severe diarrhoea of 1-7 months duration associated with vomiting and central abdominal colics. Stools were yellowish or greenish and voluminous. Anorexia was profound with loss of weight. Bilateral painless ankle oedema developed early in the course of the disease and two cases had ascites and bilateral pleural effusion at presentation. There was hyponatraemia, hypocalcaemia and marked hypokalaemia and hypoalbulinaemia. Small bowel series showed a rapid transit time in 3 cases and malabsorption pattern in one. Duodenal biopsies showed non-specific chronic inflammation while jejunal biopsies from one case revealed grade II villous atrophy with moderate cellular infiltration of lamina propria. The infection was diagnosed by finding the eggs, larvae and adult worms of C. philippinensis in stool. Patients were treated with mebendazole 400 mg/day in two divided doses for 28 days in addition to high protein diet and correction of electrolyte disturbance. Vomiting stopped on the second day of treatment, appetite improved and diarrhoea regressed by the fourth day. Unfortunately, one case died two days after admission due to marked hypokalaemia. Clinico-pathological and epidemiological aspects of this infection in Egypt are discussed.