The role of CT in decision for acute appendicitis treatment

PURPOSEAcute appendicitis is the most common cause of acute abdomen requiring surgery. Although the standard treatment has been surgery, it has been seen in recent years that treatment is possible with antibiotics and non-operative observation. In this study, our aim is to determine whether the computed tomography (CT) findings in patients diagnosed with acute appendicitis can be used for directing treatment.METHODSA retrospective analysis was conducted on 138 patients with acute appendicitis who underwent CT between 2015 and 2019. In this study, medical treatment group (n = 60) versus surgical treatment group (n = 78) and successful antibiotic treatment group (n = 23) versus unsuccessful antibiotic treatment group (n = 14) were compared. Appendiceal wall thickness, appendiceal diameter, the severity of mural enhancement, intra-abdominal free fluid, the severity of periappendiceal fat stranding, size of pericecal lymph node, appendicolith, adjacent organ findings, and the CT appendicitis score of groups were compared with Pearson Chi-square and Mann–Whitney U tests. Multivariable logistic regression was used to identify predictors of surgical treatment, expressed as odds ratios (ORs) with 95% CIs. Diagnostic efficacies of appendiceal diameter, the CT appendicitis score, and the developed model were quantified by receiver operating characteristic curves.RESULTSAppendiceal diameter (P < .001), adjacent organ findings (P = 0.041), the CT appendicitis score (P < .001), the severity of periappendiceal fat stranding (P = .002), appendicolith (P = .001), and intra-abdominal free fluid (P < .001) showed statistically significant differences between the medical and surgical treatment groups. According to the logistic regression test, if the patients are with appendiceal diameter ≥13 mm (OR = 5.1, 95% CI: 1.58-16.50), appendicolith (OR = 4, 95% CI: 1.17-13.63), and intra-abdominal free fluid (OR = 3.04, 95% CI: 1.28-7.20), surgeons should prefer surgical treatment. The area under the curves for the CT appendicitis score, the appendiceal diameter, and the model were 0.742 (95% CI: 0659-0824), 0.699 (95% CI: 0.613-0.786), and 0.745 (95% CI: 0.671-0.819), respectively. As the successful and unsuccessful medical treatment groups were compared, the only significant parameter was the severity of mural enhancement (P = .005).CONCLUSIONCT findings may be helpful in patients with uncomplicated acute appendicitis whose treatment surgeons are indecisive about. We can recommend surgical treatment in cases with appendix diameter ≥13 mm, intra-abdominal free fluid, appendicolith, high CT appendicitis score, and severe mural enhancement.

Main points

• Although medical treatment has proven to be a successful method of treatment of uncomplicated acute appendicitis, there is still controversy over which treatment to apply.
• It is intended that the computed tomography (CT) appendicitis score, which carries the information of all CT parameters, gives us an idea about the severity of acute appendicitis, such as the Alvarado score.
• CT findings may be helpful in acute appendicitis cases about whose treatment surgeons are indecisive, and surgical treatment may be preferred in patients with appendiceal diameter ≥13 mm, intra-abdominal free fluid, appendicolith, high CT appendicitis score, and severe mural enhancement.

Acute appendicitis is the most common cause of acute abdomen requiring surgical treatment. The lifelong risk of acute appendicitis is approximately 6%-7%. Appendicectomy has been the standard treatment of acute appendicitis since it was first reported by McBurney in 1889, and the general acceptance since the 19th century has been that in the absence of surgery, the disease often progresses from uncomplicated to perforated appendicitis.¹ The shift in surgical technique from open to laparoscopic appendicectomy has resulted in reduced length of hospital stay and morbidity and earlier postoperative recovery, but irrespective of the technique, there are risks associated with appendicectomy, including surgical site and intra-abdominal infections, incisional hernia, and peritoneal adhesions.^2-4 Therefore, there is increasing interest in a more conservative approach such as treating appendicitis with antibiotics alone, and randomized controlled trials have been performed in recent years in which antibiotic therapy has been evaluated, and meaningful results have been obtained.^5-9 With these developments in recent years, different treatment approaches have emerged. A case diagnosed with uncomplicated acute appendicitis by imaging methods can be treated with antibiotics or surgery.¹⁰ But, there is still controversy about which treatment should be applied for uncomplicated acute appendicitis.¹¹ In the present study, we aimed to predict the treatment by comparing the computed tomography (CT) findings of the patients with uncomplicated acute appendicitis evaluated by surgeons and treated with antibiotics or surgery.     

Effects of hypotonic swelling on the cellular distribution and expression of pI(Cln) in human nonpigmented ciliary epithelial cells.

PURPOSE: It has been proposed that pI(Cln), a highly acidic protein, is a candidate gene product related to the swelling-activated chloride (Cl-) channel Icl.swell in mammalian cells. However, no consensus has been reached as to whether this relationship is direct or indirect. Recently the cDNA for pI(Cln) was isolated from human ciliary epithelial cells. To learn more about the structure-function of pI(Cln) we attempted to: i) overexpress pI(Cln) as a fusion protein in bacteria; ii) carry out its purification; iii) generate polyclonal antibodies to study its expression and cellular localization in the ciliary epithelial cells; and iv) determine whether cell-swelling affects pI(Cln) expression in ciliary epithelial cells. METHODS: The open reading frame (ORF) of human pI(Cln) was subcloned in the pET-20b(+) plasmid and established as a recombinant vector in E. coli BL21(DE3)pLysS cells. Upon induction with iso-propyl-beta-thio-galactopyranoside (IPTG), pI(Cln) was isolated as a His-Tag fusion protein and purified to homogeneity. Polyclonal antibodies were raised in rabbits after immunization with pI(Cln) purified protein, and its expression and cellular distribution in ciliary epithelial cells determined by Western blot, immunoprecipitation and indirect immunofluorescence respectively. Cell-swelling effect on ciliary epithelial cells was carried out upon treatment of cultured cells with hypotonic solution up to 60 min and pI(Cln) expression measured by Northern and Western blot analysis. RESULTS: By Western blot analysis or immunoprecipitation, pI(Cln) antisera recognized a main band of 37-kDa in total cell extracts from ciliary body or metabolically labeled ciliary epithelial cells. By indirect immunofluorescence, pI(Cln) antibodies stained the cytoplasm of NPE in the intact tissue, and the perinuclear region of cultured ciliary epithelial cells. When subjected to hypotonic treatment, NPE cells did not induce translocation of pI(Cln) protein from the cytoplasm into the plasma membrane, nor changes in pI(Cln) expression at the protein level, but did down regulate up to 30% the level of pI(Cln) mRNA in continued hypotonic treatment. CONCLUSIONS: These observations indicate that, contrary to previous suggestions, the pI(Cln) protein is not likely to be in contact with the plasma membrane of ciliary epithelial cells, and its influence on Cl- -channel activity is more likely to be expressed indirectly, (i.e. through cytoskeletal restructuring).     

The association of carotid cavernous fistula with Graves’ ophthalmopathy

Graves’ ophthalmopathy (GO) is one of the frequent manifestations of the disorder which is an inflammatory process due to fibroblast infiltration, fibroblast proliferation and accumulation of glycosaminoglycans. Eye irritation, dryness, excessive tearing, visual blurring, diplopia, pain, visual loss, retroorbital discomfort are the symptoms and they can mimic carotid cavernous fistulas. Carotid cavernous fistulas are abnormal communications between the carotid arterial system and the cavernous sinus. The clinical manifestations of GO can mimic the signs of carotid cavernous fistulas. Carotid cavernous fistulas should be considered in the differential diagnosis of the GO patients especially who are not responding to the standard treatment and when there is a unilateral or asymmetric eye involvement. Here we report the second case report with concurrent occurrence of GO and carotid cavernous fistula in the literature.     

Diffusion-weighted imaging findings in brain death

Introduction

The purpose of the present study was to determine the role of diffusion-weighted imaging (DWI) and to investigate the use of DWI in the diagnosis of brain death (BD).

Methods

We prospectively evaluated 22 patients diagnosed with clinical BD (9 women, 13 men; mean age, 39.63?±?15.1?years; age range, 9–66?years). All clinical criteria for BD were present in all 22 patients before magnetic resonance imaging, including a positive apnea test. For all cases, DW images, T2-weighted images, and fluid-attenuated inversion recovery were obtained. Thirteen distinct neuroanatomical structures were selected for analysis in all the cases. For each region of interest, the mean, standard deviation, and range of the average apparent diffusion coefficient (ADCav) values were obtained.

Results

For BD patients, ADC values in all neuroanatomical structures were significantly lower than those for control subjects. We determined how ADC values in all structures were related to the diagnostic condition as well as the appropriate threshold ADC values to classify a subject as BD or control. The sensitivity, specificity, positive and negative predictive values, and correct classification rate of ADC cutoff values to distinguish BD from control groups were 100%.

Conclusions

DWI might be used as a noninvasive confirmatory test for the diagnosis of BD in the future.     

Do Anxiety and Depression Levels Affect the Inflammation Response in Patients Hospitalized for COVID-19

ObjectiveThe whole world is still struggling with the COVID-19 pandemic. Inflammation response, thought to be associated with severe illness and death, is an important research topic in COVID-19. Inflammation is also an essential condition explored in psychiatric illnesses. Our knowledge about the relationship between the inflammation response and psychiatric comorbidities in patients with COVID-19 is very limited. In this study, the relationship between anxiety and depression levels and inflammation response of patients with COVID-19 hospitalized in the hospital was examined. Methods175 patients were included in the study. Sociodemographic Data Form, Beck Depression Inventory and Beck Anxiety Inventory were applied to the patients. To evaluate the inflammation responses, blood sedimentation rate, C-reactive protein (CRP), procalcitonin, ferritin, neutrophil/lymphocyte ratio (NLR), and IL-6 levels were examined. ResultsIn our study, no relationship was found between anxiety and depression levels and inflammatory responses in patients hospitalized with a diagnosis of COVID-19. Anxiety and depression levels of women were higher than men, and NLR, ferritin, IL-6 levels were found to be lower than men. Anxiety levels increase with age. There is a positive correlation between NLR and ferritin levels and duration of hospitalization. ConclusionOur study examining the relationship of psychiatric comorbidities with the inflammation response and our increasing literature knowledge, together with studies evaluating the mental effects of COVID-19, suggest that determining the relationship between inflammation responses and psychiatric comorbidities in COVID-19, whose pathophysiology has not been clarified yet, maybe an essential step in interventions on the course of the disease.     

Endovascular Treatment of Aneurysms Associated with Fenestrated A1 Segment of Anterior Cerebral Artery: Report of Two Cases

Fenestration in A1 segment of anterior cerebral artery is a rare entity. Treatment of aneurysms derived from a fenestrated artery may be more challenging because the fenestrations provide specific difficulties. A thorough radiologic work‐up driven by high clinical suspicion is needed. Endovascular treatment, although it has been tried only once, ⁷ appears to be the treatment of choice. We successfully treated 2 cases using endovascular techniques and can conclude that endovascular treatment is a safe and effective treatment of aneurysms associated with this rare variation in the A1 segment of ACA.