[Prolapse and urinary incontinence in women : place of the general practitioner]. / Prolapsus et incontinence urinaire chez la femme : la place du médecin généraliste.

The ageing of the population, having access to good quality of care, will result in an increase in the prevalence of pelvic floor diseases. Those persons, often in good general health, may experience difficulties in accepting functional pathologies, associated with loss in quality of life. One out of 2 women will have a pelvic floor problem and 1 out of 9 will have a surgical perineal procedure before the age of 80 years. The unitary character of the pelvic floor, a complex functional anatomic region, is often forgotten, essentially because the patients complain about one main pathology like urinary incontinence, genital prolapse, constipation and sexual disorders or chronic pain and will consult one specific specialist. Our role as health care professionals is to be aware of those associated pathologies and to obtain an optimal quality of care. The actual evolution towards specific clinical pathways with the integration of office provided care outside the hospital, needs to become the new standard of care. We try to give an overview of the different preventive, diagnostic and therapeutic options, available in a general practitioner's office. Taking care of the pelvic floor needs to be done in a global and pluridisciplinar setting. Referring towards specialised centres as well as the integration of the general practitioner, especially for the more complex cases, is essential.

Le vieillissement de la population ayant un accès à des soins de santé de qualité, mène à une augmentation de la prévalence des pathologies du périnée. Ces personnes, souvent en bonne santé, auront des difficultés à accepter des pathologies fonctionnelles associées à une perte de qualité de vie car ces pathologies du périnée représentent un large éventail de pathologies fonctionnelles. On estime qu'une femme sur 2 aura un jour un problème périnéal, 1 sur 9 devra subir une intervention chirurgicale périnéale avant l'âge de 80 ans. Le caractère unitaire du périnée, région anatomique fonctionnelle complexe, est malheureusement souvent oublié, au départ parce que les patientes se présentent chez leur médecin pour une plainte bien spécifique sans se rendre compte de cette unité et de l'association de différents symptômes comme l'incontinence urinaire, le prolapsus génital, la constipation et des troubles sexuels et douloureux. Notre rôle en tant que professionnel de santé est de ne pas négliger ces plaintes associées, afin d'avoir une qualité de soin optimale. L'évolution actuelle vers le développement des trajets de soin avec l'intégration standardisée des soins en extrahospitalier est évidente. Nous avons tenté dans cet article de donner une revue des moyens préventifs, diagnostiques et thérapeutiques applicables dans le cabinet du médecin généraliste. La prise en charge du périnée devrait toutefois avoir lieu de manière globale et de préférence pluridisciplinaire. La référence vers les centres pluridisciplinaires comme également l'intégration du médecin généraliste dans les trajets de soin, surtout pour les cas plus complexes, est essentielle.

Hepatic schistosomiasis with massive splenomegaly: a case report and literature review.

Schistosomiasis is a parasitic disease caused by Schistosoma species. Intestinal and hepatic schistosomiases are the most common forms of chronic disease. We describe a case of a 26-year old patient from Eritrea who was referred to our hospital with abdominal pain and diarrhea. The diagnosis of hepatosplenic schistosomiasis was made by liver biopsy and the patient was treated with praziquantel. Hepatic schistosomiasis is characterised by deposition of schistosomal eggs in the liver which results in a host cell immune response and leads to granuloma formation and neoangiogenesis. This is hallmarked by different grades of periportal fibrosis with portal hypertension leading to splenomegaly. Normal liver architecture is preserved and periportal fibrosis can be reversible if treated adequately and timely. With a recent native schistosomiasis cluster report from France and the expected influx to Europe of persons from regions endemic for schistosomiasis, increased awareness of this disease in healthcare practitioners is needed. We review the epidemiology, pathogenesis, clinical presentation and treatment of schistosomiasis.

Stopping nucleos(t)ide analogue treatment in Caucasian hepatitis B patients after HBeAg seroconversion is associated with high relapse rates and fatal outcomes.

BACKGROUND: Stopping nucleos(t)ide analogues (NA) after hepatitis B e antigen (HBeAg) seroconversion is associated with high relapse rates in Asian patients, but data in Caucasian cohorts are scarce. Clinical course, outcomes and immunological aspects of chronic hepatitis B infections differ substantially between distinct ethnicities. AIM: The aim of this study was to determine relapse rates, factors predicting relapse and clinical outcomes after nucleos(t)ide analogue cessation in a large, predominantly Caucasian cohort of chronic hepatitis B patients with nucleos(t)ide analogue-induced HBeAg seroconversion. METHODS: This is a nationwide observational cohort study including HBeAg positive, mono-infected chronic hepatitis B patients with nucleos(t)ide analogue-induced HBeAg seroconversion from 18 centres in Belgium. RESULTS: A total of 98 patients with nucleo(s)tide analogue-induced HBeAg seroconversion were included in the study. Of the 62 patients who stopped treatment after a median consolidation treatment of 8 months, 30 relapsed. Higher gamma-glutamyl transferase levels at both treatment initiation (HR 1.004; P = 0.001 per unit increment) and HBeAg seroconversion (HR 1.006; P = 0.013 per unit increment) were associated with an increased risk of clinically significant relapse in a multivariate Cox regression model. Treatment cessation led to liver-related death in 2 patients, of whom one showed a severe flare. Of the patients who continued treatment after HBeAg seroconversion, none relapsed or developed severe hepatic outcomes. CONCLUSION: Treatment withdrawal in Caucasian chronic hepatitis B patients after nucleos(t)ide analogue-induced HBeAg seroconversion results in viral relapses in more than half of patients with potential fatal outcomes. These real-world data further lend support to preferentially continue NA treatment after HBeAg seroconversion until HBsAg loss.

The risk of early occurrence and recurrence of hepatocellular carcinoma in hepatitis C-infected patients treated with direct-acting antivirals with and without pegylated interferon: A Belgian experience.

Recently, concerns were raised of high rates of HCC recurrence in patients treated with direct-acting antivirals (DAA) for hepatitis C infection. We investigated the HCC occurrence and recurrence rates within 6 months after treatment with DAA with or without pegylated interferon (PEG-IFN) in real life. This is a retrospective, multicenter cohort trial, executed in 15 hospitals distributed across Belgium. Populations were matched based on fibrosis score (Metavir F3-F4). Patients with a Child-Pugh score ≥ B were excluded. In total, 567 patients were included, of whom 77 were treated with PEG-IFN+DAA between 2008 and 2013 and 490 with DAA without PEG-IFN between 2013 and 2015. Patients treated with PEG-IFN+DAA (53±9y) were younger than patients treated with DAA without PEG-IFN (59±12y) (P=.001). 47% of patients treated with PEG-IFN+DAA were in the F4 stage vs 67% of patients treated with DAA without PEG-IFN (P=.001). Screening was inadequate in 20% of both patient groups (P=.664). The early occurrence rate of HCC was 1.7% and 1.1% in patients treated with DAA with and without PEG-IFN, respectively (P=.540). The early recurrence rate was 0% in patients treated with PEG-IFN+DAA and 15.0% in patients treated with DAA without PEG-IFN (P=.857). There is no difference in early occurrence of new HCC between patients treated with DAA with and without PEG-IFN. We did observe a high early recurrence rate of HCC in patients treated with DAA without PEG-IFN. However, these patients were at baseline more at risk for HCC. Finally, in 20%, screening for HCC was inadequate.

Thoracic aortic aneurysm complicated by secondary aortoesophageal fistula after thoracic endovascular aortic repair : a case report.

This is a case report of a patient with a thoracic aortic aneurysm (TAA) presenting with dysphagia and weight loss as primary symptoms. She was treated via thoracic endovascular aortic repair (TEVAR). The procedure was complicated with a secondary aortoesophageal fistula (AEF) for which open surgical repair of the esophageal defect was done. Long term (i.e. more than 30 days) antibiotics were given. The recovery was uneventful.

Belgian experience with triple therapy with boceprevir and telaprevir in genotype 1 infected patients who inject drugs.

No data have been reported yet on treatment outcome in persons who inject drugs (PWID) infected with hepatitis C virus treated with boceprevir or telaprevir in combination with peginterferon (Peg IFN) and ribavirin (RBV). Additionally, there are concerns about the safety of boceprevir and telaprevir in some subgroups of patients with hepatitis C (HCV). In a cohort of HCV patients infected with genotype 1 in Belgium, treatment outcome of patients infected due to IV drug use was analyzed and compared with patients who have no history of substance use. The study population consisted of 179 patients: 78 PWID and 101 controls treated with boceprevir (n = 79) or telaprevir (n = 100) additional to Peg IFN and RBV; 53 (30%) had advanced disease (F3, F4) and 79 (44%) had an antiviral therapy previously. There were no significant differences in the baseline characteristics between both groups, except that PWID patients were more frequently infected with genotype 1a (67% vs 21%), were younger and were predominantly male. Psychiatric complaints during follow-up occurred more frequently in the PWID patients: 24% versus 11% (P = .02). Treatment failure for other reasons than absence of viral response was 70% and 64% in PWID and non-PWID respectively. The sustained viral response (SVR) rates were similar in both groups (71% in PWID vs 72% in non-PWID); with a non-inferiority test with -5% margin there is a difference of -1% (95% CI [-15%, 13%]) and P = 0.30. There are no reasons to exclude PWID from treatment with boceprevir, telaprevir and novel antiviral therapies.

Hepatic amyloidosis increases liver stiffness measured by transient elastography.

Liver stiffness values in transient elastography (TE) have to be interpreted with caution. Steatosis, congestion, acute inflammation and extrahepatic cholestasis can indeed influence measurements. Obtained stiffness values in the cirrhotic range can also be present in the absence of fibrosis as in hepatic amyloidosis. Here we report two cases of systemic amyloidosis with hepatic involvement where high stiffness values were measured at TE. In fact, deposits of amyloid may increase the rigidity of the liver parenchyma resulting in higher liver stiffness values. Therefore, results of TE should always be interpreted in their clinical context and if inconsistent, the performance of a liver biopsy might be necessary.

Synthesis and biodistribution of [(11)C]R116301, a promising PET ligand for central NK(1) receptors.

N1-(2,6-Dimethylphenyl)-2-(4-{(2R,4S)-2-benzyl-1-[3,5-di(trifluoromethyl)[carbonyl-(11)C]benzoyl]hexahydro-4-pyridinyl}piperazino)acetamide ([(11)C]R116301) was prepared and evaluated as a potential positron emission tomography (PET) ligand for investigation of central neurokinin(1) (NK(1)) receptors. 1-Bromo-3,5-di(trifluoromethyl)benzene was converted in three steps into 3,5-di(trifluoromethyl)[carbonyl-(11)C]benzoyl chloride, which was reacted with N1-(2,6-dimethylphenyl)-2-{4-[(2R,4S)-2-benzylhexahydro-4-pyridinyl]piperazino}acetamide providing [(11)C]R116301 in 45-57% decay-corrected radiochemical yield. The total synthesis time, from end of bombardment (EOB) to the formulated product, was 35 min. Specific activity (SA) was 82-172 GBq/micromol (n=10) at the end of synthesis. N1-([4-(3)H]-2,6-Dimethylphenyl)-2-(4-{(2R,4S)-2-benzyl-1-[3,5-di(trifluoromethyl)benzoyl]hexahydro-4-pyridinyl}piperazino)acetamide ([(3)H]R116301) was also synthesized (SA: 467 GBq/mmol). The B(max) for [(3)H]R116301 measured in vitro on Chinese hamster ovary cell membranes stably transfected with the human NK(1) receptor was 19.10+/-1.02 pmol/mg protein with an apparent dissociation constant of 0.08+/-0.01 nM. Ex vivo, in vivo and in vitro autoradiography studies with [(3)H]R116301 in gerbils demonstrated a preferential accumulation of the radioactivity in the striatum, olfactory tubercule, olfactory bulb and locus coeruleus. In vivo, the biodistribution of [(11)C]R116301 in gerbils revealed that the highest initial uptake is in the lung, followed by the liver and kidney. In the brain, maximum accumulation was found in the olfactory tubercules (1.10+/-0.08 injected dose (ID)/g 20 min post injection (p.i.)) and the nucleus accumbens (1.00+/-0.12ID/g 10 min p.i.). Tissue/cerebellum concentration ratios for striatum and nucleus accumbens increased with time due to rapid uptake followed by a slow wash out (1.29 and 1.64, respectively, 30 min p.i.). A tissue to cerebellum ratio of 1.33 and 1.62 was also observed for olfactory bulb and olfactory tubercules, respectively (20 min p.i.). In summary, [(11)C]R116301 appears to be a promising radioligand suitable for the visualization of NK(1) receptors in vivo using PET.

Ureteral ectopy in the seminal vesicle associated with cyst formation and renal dysplasia: contribution of 3D-MRI.

A case of a congenital anomaly of the urinary tract in a 25-year-old Caucasian male is presented. Preoperative and pathologic findings demonstrated an ectopic ureter which terminated in a seminal vesicle cyst. Both structures formed an abortive common duct at the bladder base. The ipsilateral kidney was dysplastic. Findings on voiding cytourethrography, spiral CT, and MRI are discussed and correlated with pathologic findings. The authors suggest that MRI, especially with the use of 3D sequences, is the examination of choice in the evaluation of a complex congenital urogenital anomaly as presented.

Midgut volvulus in an adult patient.

The authors report on a case of midgut volvulus in a 27-year-old man who presented with bilious vomiting and acute abdominal pain. US demonstrated a reversal of the normal relationship between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV). A clockwise whirlpool sign, diagnostic for midgut volvulus, was not visualised. In a further assessment, upper gastrointestinal series demonstrated obstruction in the second part of the duodenum highly suspicious of Ladd's bands. Malpositioning of bowel structures, as already suggested by the reversal of the SMA and SMV on ultrasound, and a distinctive whirl pattern due to the bowel wrapping around the SMA was demonstrated on CT. Furthermore angiography revealed focal twisting of the SMA. US is the first imaging modality to perform in suspicion of midgut volvulus. When inconclusive, CT is in our opinion the next stage in the diagnostic work-up.

Proximal pulmonary artery aneurysm.

The authors report on a case of proximal pulmonary artery aneurysm detected on a routine chest X-ray. The scintigraphic and angiographic features of the condition are described and the importance of including the entity in the differential diagnosis of lung masses is stressed.

Peliosis hepatis presenting as a multifocal hepatic pseudotumor: MR findings in two cases.

Two cases of pseudotumoral peliosis hepatis are presented with emphasis on MRI findings. One patient had four individual lesions, the other had two. Image characteristics in both were: heterogeneic signal intensity on T1-weighted images (T1WI) with areas of high-, intermediate, and low signal intensity; heterogeneic signal intensity on T2WI with presence of numerous intralesional "cystic" hyperintense areas with a hypointense border. Signal intensities on T1WI were iso- to hypointense in one case and mild central hyperintensities were demonstrated in the other case, probably due to intra-lesional hemorrhage or diffuse accumulation of fresh clotting within the sinusoids. One case demonstrated early enhancement of the peripheral borders in the arterial phase, and both demonstrated enhancement in the portovenous and late phases. One case was studied with Gd-BOPTA and iron oxides and demonstrated enhancement with both products, suggestive for the presence of hepatocytes and Kupffer cells. This is the first report of the use of hepato-specific contrast agents in this entity. Spontaneous regression of the lesions was demonstrated on a follow-up MR examination in one case.

Renal macronodular tuberculoma: CT and MR findings in an asymptomatic patient.

We present the case of a 50-year-old man with a solitary mass lesion in the right kidney. Characteristics on ultrasound were a thick irregular hypoechoic wall and a slightly hyperechoic center. Computed tomography depicted the lesion as spontaneously hyperdense at its base. After administration of intravenous iodinated contrast only partial enhancement in the peripheral wall was seen. On MR imaging the lesion was hypointense on T1-weighted images, and T2-weighted images demonstrated a thick irregular hypointense peripheral wall and an intralesional fluid debris level. Gadolinium-chelates were not administered.