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Notes: Summary. A pseudo-tumour due to metallosis is described in association with an iso-elastic hip replacement. This is a relatively rare lesion which may be difficult to diagnose. Scintigraphy and radiography may be helpful in distinguishing the lesion from a primary or secondary neoplasm, but the presence of osteolysis adjacent to the prosthesis will suggest the true nature of the lesion.

Notes: Abstract The Pongkor gold-silver epithermal deposit with reserves of at least 98 tonnes of gold and 1026 tonnes of silver, average grades 16.4 g/t Au and 171.2 g/t Ag is one of the most recent and largest gold and silver discoveries in Indonesia, proven within a short period (1988–1991). 40Ar/39Ar dating on adularia samples give an age of 2.05 ± 0.05 Ma. The deposit is of the low-sulfidation epithermal type and consists of four main mineralized quartz veins located close to the internal rim of a volcano-tectonic depression (caldera). This resulted from an explosive ignimbritic eruption that produced pyroclastic flows and accretionary lapilli with rare intercalations of epiclastic rocks. This volcanic unit unconformably overlies Miocene subaqueous volcanic andesitic rocks with interbedded epiclastic rocks. The mineralized bodies are thick (average 4.2 m), steeply dipping, quartz-carbonate-adularia veins with a very low sulfide content (〈0.5 wt.%). Their genesis is related to an extensional episode within a tectonic corridor showing NW-SE and NNE-SSW conjugate strike-slip faults, the major vein being located on the inner rim of the caldera. The vein fill reveals four successive stages of deposition marked by a specific facies: (1) carbonate-quartz breccia with dominant quartz and calcite and minor kutnahorite, rhodochrosite, and rhodonite (CQ facies), (2) a network of banded quartz and former carbonate transformed into manganese oxides through supergene alteration (MOQ facies), (3) banded opaline milky quartz (BOQ facies), and (4) grey, locally banded, sulfide-rich quartz breccia cutting all the other types (GSQ facies). Adularia was deposited at the same time as the quartz. The mineralogy and internal structures of the veins (crustiform banding, vugs, collapse breccia) clearly indicate a dilational context, which is common in low-sulfidation epithermal systems. Gold and silver grades, as well as sulfide mineral abundances, increase steadily through stages 1 to 4, locally reaching 1 kg/t in the GSQ facies. The sulfides are dominated by pyrite, accompanied by common acanthite-aguilarite, polybasite-pearceite and electrum in which the gold content ranges from 48 to 74 wt.%. Sphalerite, galena, chalcopyrite and hessite are fairly rare, although present within the CQ facies. The fluid inclusions of the four facies show homogenization temperatures ranging from 150 to 382 °C, indicating boiling of a hydrothermal fluid with an initial temperature of around 205 °C; no marked difference is seen in the GSQ facies, which has the highest gold content. Salinities are low, generally below 1 wt.% eq. NaCl. Lead isotope compositions of the associated volcanic rocks and the mineralization are very similar, 206Pb/204Pb between 18.706 and 18.814␣and between 18.744 and 18.801 respectively, demonstrating a genetic link between the Pliocene volcanism and the auriferous hydrothermal activity. The isotopic signature suggests that the source of the mineralization and associated volcanic rocks is an underlying ancient continental crust that melted and remobilized during the Pliocene volcanic and hydrothermal events. These conclusions seem applicable to the entire Bayah Dome. The existence of both a tectonic corridor and a caldera favoured channelling of the hydrothermal fluids and the deposition of primary ore in the veins. Late intense weathering of the ore deposit, to depths of 250 m below the surface, has given rise to manganese oxide layers, limonite zones, and silver micronuggets within the veins, as well as to gold enrichment.

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Notes: Abstract We report on a patient who presented at 5 years of age with a hemiparesis due to a middle cerebral artery infarction. An embolism had originated from a mycotic aneurysm located in the internal carotid artery. For several months prior to admission he had been suffering from therapeutically resistant candidiasis of the mouth and nails. Family history revealed chronic mycotic infections of the skin, hair, nails and mouth in the father and paternal grandmother suggestive of chronic mucocutaneous candidiasis with autosomal dominant mode of inheritance. Clipping of the aneurysm, after 3 months of anti-mycotic treatment, followed by sustained treatment with itraconazole and fluconazole, led to a favourable outcome. Conclusion Chronic mucocutaneous candidiasis can be associated with an intracranial aneurysm and complicated by cerebral infarction.

Notes: Abstract   Objective: To investigate whether the level of initial flow rate alters the work of breathing in chronic obstructive pulmonary disease (COPD) patients ventilated in pressure support ventilation (PSV). Design: Prospective study. Settings: Medical ICU in University hospital. Patients: Eleven intubated COPD patients. Methods: We modulated the initial flow rate in order to achieve seven different sequences. In each sequence, the plateau pressure was reached within a predetermined time: 0.1, 0.25, 0.50, 0.75, 1, 1.25 or 1.50 s. The more rapidly the pressure plateau was achieved, the higher was the initial flow rate. In each patient, the pressure support level was an invariable parameter. The order of the seven sequences for each patient was determined randomly. Measurements and results: Ten minutes after application of each initial flow rate, we measured the following parameters: inspiratory work of breathing, electromyogram (EMG) of the diaphragm (EMGdi), breathing pattern, and intrinsic positive end-expiratory pressure (PEEPi). Comparison between the means for each sequence and each variable measured was performed by two-way analysis of variance with internal comparisons between sequences by Duncan’s test. The reduction of the initial flow rate induced a progressive increase in the values of the work of breathing, EMGdi, and mouth occlusion pressure (P 0.1). In contrast, the reduction of the initial flow rate did not induce any significant change in tidal volume, respiratory frequency or PEEPi. Conclusion: As the objective of PSV is to reduce the work of breathing, it seems logical to use the highest initial flow rate to induce the lowest possible work of breathing in COPD ventilated patients.

Notes: Summary The purpose of this study was to demonstrate that the laparoscopic Stoppa procedure by the transabdomino-preperitoneal route is possible with results similar to those of an open procedure, and that there are two learning curves: one for the posterior route described by Stoppa, and the second for the laparoscopic route. After describing their laparoscopic inguinal hernia repair experience, the authors report their technique, used since 1991 and discuss its indications and limitations. After a series of 800 patients and 920 operations, they consider the laparoscopic procedure now to be their standard method in inguinal hernia repair. The laparoscopic route implies minimal access but not minimal surgery. Finally, to shorten the learning curve, the authors suggest that beginners assist at 20 operations and operate on 20 to 30 patients assisted by a surgeon experienced in laparoscopic inguinal hernia repair.

Notes: Abstract Background: With the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease, this consensus development conference set out to summarize the actual state of the art. Methods: A multidisciplinary panel of international experts (n= 16) was selected to take part in the consensus process. Prior to the conference, all experts were asked to answer a series of questions on diverticular disease. The consensus statement compiled out of these evaluations was modified during a joint meeting of the panel members, then presented for discussion in a public session, and finally revised by the expert panel. The finalized statement was mailed to all panel members for approval (Delphi method). Results: Asymptomatic diverticulosis, diverticular disease (with actual or recurrent symptoms), and complicated diverticular disease were defined separately. No agreement was reached on whether barium enema or colonoscopy is the better choice as an initial diagnostic tool in uncomplicated cases. In complicated cases, computed tomography is recommended for diagnosis. After two attacks of diverticular disease, elective resection should be considered. For patients in whom a concomitant carcinoma cannot be excluded and those with chronic complications (fistula, stenosis, or bleeding) surgery is also indicated. Laparoscopic sigmoid colectomy is recommended only for uncomplicated and, after percutaneous drainage of abscesses, Hinchey stage I and II cases. Conclusions: Laparoscopic surgery has already begun to influence the management of diverticular disease, but the randomized controlled trials needed to support therapy decisions are largely missing.

Notes: Abstract Three unrelated patients with congenital arthrogryposis and brittle bones, the main neonatal signs of Bruck syndrome, are presented. In infancy and early childhood recurrent fractures of ribs and long bones and persistent Wormian bones in the calvarium are reminiscent of osteogenesis imperfecta (OI) even with white sclerae, normal dental quality and normal hearing as important clinical negatives. The diagnosis was made before two years of age in two, and in adolescence in the third patient. The latter's radiologically documented long-term natural course reveals slow progressivity of osteopenia and growth deficiency, worsening tendon contractures and pterygia in addition to increasing spine and pelvis deformation. Mental development remains normal. Bruck syndrome is monogenic and probably due to homozygosity of an as yet unidentified gene. As no alteration in the collagens I and III is detected and molecular screening reveals no mutation in the COL1A1 and COL1A2 genes, the pathogenesis of this severe disorder of connective tissue remains largely unknown.