An unusual presentation of perforated appendicitis in epigastric region

INTRODUCTION

Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation.

PRESENTATION OF CASE

A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver.

DISCUSSION

While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality.

CONCLUSION

Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.     

The effect of postoperative positive end-expiratory pressure on postoperative bleeding after off-pump coronary artery bypass grafting

Introduction

To compare postoperative prophylactic use of two positive end-expiratory pressure (PEEP) levels in order to prevent postoperative bleeding in patients undergoing off-pump coronary artery bypass grafting (CABG) surgery.

Material and methods

Sixty patients undergoing an elective off-pump CABG operation were included in this prospective, nonrandomized clinical trial. Patients were divided into two groups as receiving either 5 cm H₂O (group 1) or 8 cm H₂O PEEP (group 2) after the operation until being extubated. Chest tube outputs, use of blood products and other fluids, postoperative hemoglobin levels, accumulation of pleural and pericardial fluid after the removal of chest tubes, and duration of hospital stay were recorded and compared.

Results

Low- and high-pressure PEEP groups did not differ with regard to postoperative chest tube outputs, amounts of transfusions and crystalloid/colloid infusion requirements, or postoperative hemoglobin levels. However, low-pressure PEEP application was associated with significantly higher pleural (92 ±37 ml vs. 69 ±29 ml, p = 0.03) and pericardial fluid (17 ±5 ml vs. 14 ±6 ml, p = 0.04) accumulation. On the other hand, high-pressure PEEP application was associated with significantly longer duration of hospitalization (6.25 ±1.21 days vs. 5.25 ±0.91 days, p = 0.03).

Conclusions

Prophylactic administration of postoperative PEEP levels of 8 cm H₂O, although safe, does not seem to reduce chest-tube output or transfusion requirements in off-pump CABG when compared to the lower level of PEEP. Further studies with larger sample sizes are warranted to confirm the benefits and identify ideal levels of PEEP administration in this group of patients.     

Effects of thyroxin therapy on cardiac function in patients with subclinical hypothyroidism: index of myocardial performance in the evaluation of left ventricular function

OBJECTIVE: We investigated the effects of thyroxine (T4) therapy on the cardiac function in subclinical hypothyroidism (SHT) by using the index of myocardial performance (IMP) and the conventional echocardiographic parameters. METHODS: Forty-five SHT patients (F/M:38/7, age 39.9+/-7.9) and 29 healthy subjects (F/M:25/4, age 38.3+/-8.6) were studied. Patients were randomly assigned, in a double-blind manner to receive T4 therapy (group I) or a placebo (group II) and for a period of up to 12 months, were followed up using thyroid function tests and both conventional and Doppler echocardiographic measurements. RESULTS: At the baseline, the SHT patients has a significantly higher isovolumic relaxation time (IRT) (98.3+/-23.7 vs. 81.7+/-14.7<0.01), IMP (0.52+/-0.06 vs. 0.42+/-0.05; P<0.001), A max (late mitral peak velocity) (83.4+/-12.6 vs. 74.3+/-13.5; P<0.01) and significantly lower (early mitral peak velocity) Emax/Amax ratio (1.19+/-0.18 vs. 1.34+/-0.17; P<0.01) than the individuals in the control group. In group I, the thyroid hormone profile became normalized after 1 year of L-T4 therapy, but there was no significant change in the left ventricular (LV) morphology or systolic function. After 1 year of follow-up, group I showed a significant reduction of MPI (0.53+/-0.05 vs. 0.42+/-0.07; P<0.001), Amax (84.2+/-13.7 vs. 74.5+/-11; P<0.001) and IRT (98.6+/-23.7 vs. 82.9+/- 23.3; P<0.001) along with a normalization of the E/A ratio (1.17+/-0.16 vs. 1.33+/-0.19; P<0.001). Conversely, no change was observed in group II. CONCLUSIONS: An impairment of left ventricular diastolic function, which may be reversible with T4 therapy, was observed in the SHT patients, and IMP may be useful in the evaluation of LV myocardial dysfunction in these patients.     

Serum leptin level in women with unexplained infertility

INTRODUCTION: The aim of this study was to compare serum levels of leptin in women with unexplained infertility with fertile subjects. MATERIAL AND METHOD: Serum leptin levels of 27 infertile and 30 fertile women on day 3 of the menstrual cycle were assessed and compared in this prospective age and body mass index (BMI) comparable controlled study. RESULTS: The mean age in the infertile group was 29.3 (range, 23-38), while this figure was 28.9 (range, 19-39) in the fertile group; the mean BMIs were 24.5 (range, 20.6-27.8) and 25.0 (range, 21.8-28.7), respectively. The mean serum leptin level was significantly higher in women with unexplained infertility compared with fertile subjects. Considering normal weight subjects, mean serum leptin levels were increased significantly in the unexplained infertile group compared with the fertile group (7.2 (range, 4.3-10.4) versus 3.5 (range, 1.9-6.2)ng/ml, respectively; p<0.0001, Mann-Whitney U-test). The significant increase in serum leptin levels was observed also in overweight patients (6.8 (range, 1.3-5.2) versus 3.3 (range, 4.2-8.9)ng/ml, respectively; p<0.0001, Mann-Whitney U-test). CONCLUSION: A significant difference in serum leptin levels between unexplained infertile and fertile women suggests that this cytokine may be involved in pathophysiology of unexplained infertility.     

A Systematic Characterization Approach for Vacuum Bag Only Prepregs towards an Accurate Process Design

Aerospace-grade composite parts can be manufactured using Vacuum Bag Only prepregs through an accurate process design. Quality in the desired part can be realized by following process modeling, process optimization, and validation, which strongly depend on a primary and systematic material characterization methodology of the prepreg system and material constitutive behavior. The present study introduces a systematic characterization approach of a Vacuum Bag Only prepreg by covering the relevant material properties in an integrated manner with the process mechanisms of fluid flow, consolidation, and heat transfer. The characterization recipe is practiced under the categories of (i) resin system, (ii) fiber architecture, and (iii) thermal behavior. First, empirical models are successively developed for the cure-kinetics, glass transition temperature, and viscosity for the resin system. Then, the fiber architecture of the uncured prepreg system is identified with X-ray tomography to obtain the air permeability. Finally, the thermal characteristics of the prepreg and its constituents are experimentally characterized by adopting a novel specimen preparation technique for the specific heat capacity and thermal conductivity. Thus, this systematic approach is designed to provide the material data to process modeling with the motivation of a robust and integrated Vacuum Bag Only process design.     

Effectiveness and safety of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate single-tablet combination among HIV-infected patients in Turkey: results from a real world setting

BackgroundEfficacy of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil (E/C/F/TDF) in treatment-naïve and experienced patients with HIV infection was demonstrated in phase 3 trials. The primary objective of this study was to evaluate effectiveness and safety of E/C/F/TDF in real world settings.MethodsRetrospective, observational data collected by the Turkish ACTHIV-IST study group between May 2015 and December 2016 were analysed.ResultsA total of 387 patients were prescribed E/C/F/TDF; 210 patients with available data at 6th month were eligible; 91.5% were male, and mean age was 35.2 (SD: 10.8) years; 54.0% of males identified themselves as MSM. Sixty-three percent (133) of the study population were treatment-naïve patients, and 37% (77) were treatment experienced. HIV RNA level was below 100 copies/mL in 78.9% of treatment-naïve patients and 89.9% of treatment experienced patients at month 6. Median increase in CD4 T lymphocyte count was 218 copies/mL in treatment-naïve patients and remained stable or increased in treatment experienced patients. Adverse events were observed in 15% of the patients, and the regimen was discontinued in only six patients.ConclusionReal world data on the effectiveness and safety of E/C/F/TDF is comparable with the phase 3 trial results Adverse events are uncommon and manageable.     

The relationship between chronic kidney disease and SYNTAX score

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease and death. We evaluated the association between CKD and severity of coronary artery stenosis by calculating SYNTAX Score in patients with left main coronary artery and/or 3-vessel coronary artery disease. Coronary angiograms of 217 patients were assessed. Chronic kidney disease was staged using the estimated glomerular filtration rate (eGFR, mL/min per 1.73 m(2)) prior to coronary angiography. Patients were divided into 5 groups according to the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines (14). Patients with eGFR >90 mL/min per 1.73 m(2) (group 1), patients with eGFR 60 to 89 mL/min per 1.73 m(2) (group 2), patients with eGFR 30 to 59 mL/min per 1.73 m(2) (group 3), patients with eGFR >15 to < 30 per 1.73 m(2) and dialysis patients with eGFR < 15 per 1.73 m(2) were combined as group 4. The risk of significant lesion complexity increased progressively with decreasing kidney function (P = .001). Estimated glomerular filtration rate was a strong predictor of higher SYNTAX Score.     

Immune-mediated neurological syndromes in SARS-CoV-2-infected patients

Journal of Neurology - Evidence of immune-mediated neurological syndromes associated with the severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection is limited. We therefore...