Diagnosis and treatment of epiploic appendagitis in a Middle Eastern country: An observational retrospective analysis of 156 cases

BACKGROUND

Epiploic appendagitis (EPA) is an uncommon emergency surgical condition that causes acute abdominal pain, rendering a list of differential diagnoses. Therefore, careful examination and imaging tools are required. EPA is a self-limiting condition that can be resolved in 1-2 weeks and rarely needs surgical intervention. Its low incidence makes EPA less well-known among the public and some medical professionals, and it is frequently under-diagnosed. We aimed to explore the incidence, clinical presentation, modalities of imaging to diagnose and options for treating EPA.

METHODS

An observational retrospective analysis was conducted between 2016 and 2022 at a tertiary hospital in an Arab Middle Eastern country.

RESULTS

There were 156 EPA cases diagnosed over six years, with a mean age of 33 years. Males represented 82% of the cohort. The entire cohort was treated non-operatively except for eight patients who had surgical intervention using open or laparoscopic surgery. The diagnosis was made by a computerized tomographic scan (CT). However, plain X-ray, abdominal ultrasound, and magnetic resonance imaging (MRI) were performed initially in a few selected cases to rule out other conditions. No specific blood test indicated EPA; however, a histopathology examination was diagnostic. No mortality was reported in the study cohort.

CONCLUSION

This is the most extensive study analyzing EPA patients from the Middle East. EPA is a rare and mostly self-limiting acute abdominal disorder; however, early ultrasound and CT scan can pick it up quickly after a high index of suspicion.

A Case Report on Biliary Ascariasis

Biliary Ascariasis occurs when Ascaris lumbricoides worms invade the biliary system. It may cause biliary obstruction, cholangitis, cholecystitis, or acute pancreatitis. We report a case of a 37-year-old female patient who presented with a history of upper abdominal pain, nausea, vomiting, and weight loss for two weeks. Ultrasound showed dilated common bile duct with linear tubular echogenic structure in the common bile duct and bowel loops. Endoscopic Retrograde Cholangio pancreatography (ERCP) revealed large adult worms confirming the diagnosis of Ascariasis.

ODP042 Hereditary Pheochromocytoma with a Novel Mutation in the Succinate Dehydrogenase Subunit A gene

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumorswith a diverse clinical presentation. Pathogenic variants in the genes encoding different subunits of the succinate dehydrogenaseenzyme complex that plays a central role in energy metabolism,have been linked to hereditary PPGL syndromes. Here wereport a rare case of hereditary pheochromocytoma with a novel mutation in the succinate dehydrogenase subunit A (SDHA) gene. A middle aged woman presented with left sided abdominal pain and was incidentally found to have bilateral adrenal lesions on abdominal imaging. She denied any symptoms of catecholamine excess but her plasma metanephrines level was elevated. Family history was significant for breast cancer in her motherand sister. Computed tomography (CT) scan of the abdomen showed bilateralbulky adrenal glands with a lesion in theleft adrenal gland. Magnetic resonance imaging (MRI) abdomen was performed for further characterization, the lesion measured approximately 2.8×2.6 cm with imaging characteristics suggestive of pheochromocytoma. Iodine-131 Metaiodobenzylguanidine (MIBG) whole body scan showed abnormal focal radiotracer uptake at the left adrenal gland, and she then underwentleft sided robotic adrenalectomy. Following surgery, the patient had symptomatic relief. Histopathology confirmed the diagnosis of pheochromocytoma measuring 2×2×1.5 cm with PASS (Pheochromocytoma of the Adrenal gland Scaled Score) score of 1/10, due to cellular monotony. Genetic testing revealed that she was positive for a pathogenic mutation in the SDHA gene consistent with the diagnosis of hereditary PPGL syndrome. Genetic testing was performed for the patient due to her presentation with bilateral adrenal masses and family history of cancers. Guidelines recommend genetic testing for patients with features that indicate a high likelihood of a hereditary cause for PPGL, including positive family history, syndromic features, and multifocal, bilateral, or metastatic disease. SDHA mutated PPGLs have diverse phenotypes and may be at high risk of metastasis. They are also associated with extra-adrenal tumors, include gastrointestinal stromal tumours (GIST), pituitary adenomas, papillary thyroid carcinoma, renal carcinoma and breast carcinoma. The detection of susceptibility genes for hereditary PPGL syndromes has key implications, for surveillance to detectextra-adrenal disease and recurrent tumors, as well as for consideration of genetic testing forfamily members.

Presentation: No date and time listed

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

PURPOSE

The timing of treatment for Gartland type III supracondylar fractures has been an area of contention as it was previously thought to be a surgical emergency. The aim of this systematic review and meta-analysis is to clarify whether there is a difference in perioperative outcomes between early and delayed treatment for Gartland type III supracondylar humeral fractures in children.

METHODS

Literature search and study selection were performed according to the PRISMA process. The early surgery (ES) and delayed surgery (DS) groups were defined by the authors of each study included, based on the time to surgery. The primary outcome was the risk of conversion to open reduction. The secondary outcome was perioperative complication risks.

RESULTS

A total of 14 studies met the eligibility criteria (n = 1263 patients), of which 665 (52.7%) patients had undergone early surgery, while 598 (47.3%) had delayed surgery. On meta-analysis, there was no significant difference between ES and DS for the outcome of open reduction conversion risk. There was also no significant difference for the secondary outcomes of post-operative compartment syndrome, iatrogenic nerve injury, vascular injury, and surgical site infection.

CONCLUSION

Despite the limitations in the literature, evidence exists to support the notion that a delayed approach to the surgical treatment of Gartland type III supracondylar humeral fractures in children does not result in an increased risk of converting to open reduction and perioperative complications.

Hereditary Pheochromocytoma With a Mutation in the Succinate Dehydrogenase Subunit A Gene

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with diverse clinical presentations. Pathogenic variants in the genes encoding different subunits of the succinate dehydrogenase enzyme complex that plays a central role in energy metabolism have been linked to hereditary PPGL syndromes. Here we report a rare case of hereditary pheochromocytoma with a novel mutation in the succinate dehydrogenase subunit A (SDHA) gene. 

A middle-aged woman presented with left-sided abdominal pain and was incidentally found to have bilateral adrenal lesions on abdominal imaging. Imaging characteristics were suggestive of pheochromocytoma. She denied any symptoms of catecholamine excess but her plasma metanephrines level was elevated. Iodine-131 metaiodobenzylguanidine (131I-MIBG) whole-body scan showed abnormal focal radiotracer uptake at the left adrenal gland, and she then underwent left-sided adrenalectomy. Following surgery, the patient had symptomatic relief and histopathology confirmed the diagnosis of pheochromocytoma. Genetic testing revealed that she was positive for a pathogenic mutation in the SDHA gene consistent with the diagnosis of hereditary PPGL syndrome. 

The detection of susceptibility genes for hereditary PPGL syndromes has key implications, for surveillance to detect extra-adrenal disease and recurrent tumors, as well as for consideration of genetic testing for family members.

A Case Report on Fish Bone Perforating Meckel’s Diverticulum Mimicking Appendicitis

Meckel’s diverticulum (MD) is the most frequent congenital abnormality of the digestive tract. Although it is silent, it can rarely come up as a complicated case including but not limited to obstruction, inflammation, and neoplasm. Perforation as a consequence of MD is extremely infrequent and mostly related to foreign objects. We report a case of a 24-year-old man who presented to the emergency department with signs and symptoms suggestive of acute appendicitis. Computed tomography (CT) of the abdomen demonstrated foreign body perforation from a protrusion outside the small bowel. The patient underwent laparoscopy and a fish bone perforating MD was found which was removed.

Rare presentation of chronic recurrent multifocal osteomyelitis of the Iliac wing mimicking Ewing's sarcoma

This report describes a case of chronic recurrent multifocal osteomyelitis (CRMO) in an 11-year-old girl, involving the iliac bone as an initial, solitary site. Atypical imaging features were suspicious of a bone tumour, such as Ewing's sarcoma. Chronic recurrent multifocal osteomyelitis is a great masquerader and can present atypically. Radiologists should be familiar with both typical and atypical presentations, to determine an accurate diagnosis and guide appropriate management. Timely diagnosis may avoid invasive bone biopsy and inappropriate long-term antibiotic prescription for children.

Ameliorative effect of metformin on cyclophosphamide-induced memory impairment in mice

OBJECTIVE

Cyclophosphamide (CYP) is a chemotherapeutic agent that is widely used as an adjuvant cancer treatment. Unfortunately, this drug is associated with secondary side effects, including cognitive impairment up to 70% of cancer survivors. The mechanism of this memory impairment is unclear. Thus, to understand the cognitive impairments caused by this chemotherapeutic agent, a clinically relevant dose to cancer treatment was used in mice to establish the chemobrain models, and the spatial memory of these mice was assessed using multiple behavior tests. In addition, metformin (MET) is widely used as an anti-diabetic drug and protects against oxidative stress and hepatotoxicity. Thus, this study tested the protective effects of MET in the chemobrain models.

MATERIALS AND METHODS

Four groups of mice, which weighed about 18-30 g, were collected and divided into 4 groups: control, CYP, MET, and CYP+MET groups. A 100 mg/kg dose of CYP was administered intraperitoneal (on alternate days) for a total of 4 doses. MET was dissolved in the mice's drinking water bottles at a 5 mg/ml concentration from day zero to the end of the treatment period. The mice's memory was tested using hippocampal-dependent tests, including the Y-maze, novel object recognition, and elevated plus maze tests. These tests were performed for three consecutive days after 24 h of the last dose of CYP.

RESULTS

The mice treated with CYP exhibited a decline in memory function in all the behavioral test studies, and this decline was significant in the Y-maze test. However, this decline was rescued by MET administration.

CONCLUSIONS

The clinically relevant model suggests that CYP treatment causes a decline in mice models spatial memory that might be improved by MET administration.

Agenesis of the piriformis muscle: A case report with review of literature

Agenesis of the piriformis muscle is an extremely rare occurrence. Knowledge about this anatomic variant is important because of its close proximity with the sciatic nerve and sacral plexus. The piriformis muscle also serves as an important anatomic landmark for image-guided intervention and hip surgery. We report a case of piriformis muscle agenesis in a 28-year-old woman, incidentally detected on magnetic resonance imaging of the lumbosacral spine and pelvis, performed for low back pain.

Bilateral Epiploic Appendagitis: A Rather Benign but Diagnostically Challenging Cause of Acute Abdominal Pain

Epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. It is a benign and self-limited condition but mimics other underlying causes of acute abdominal pain like acute diverticulitis, acute appendicitis, acute cholecystitis, etc. Inaccurate diagnosis can lead to iatrogenic adverse outcomes. To the best of our knowledge, the present report represents the first case of bilateral EA involving both cecum and descending colon. The patient presented with symptoms of bilateral iliac fossa pain. Conservative management and close outpatient follow up resulted in a successful clinical outcome with no recurrence of symptoms. This article illustrates that clinicians and radiologists should include this etiology among differential diagnoses of patients presenting with acute abdominal pain, as it might prevent unnecessary hospitalizations, antibiotic therapy, and unwarranted surgical interventions.

Epithelioid Hemangioendothelioma of the Ulnar Artery Presenting with Neuropathy

We present a rare case of epithelioid hemangioendothelioma arising from the wall of ulnar artery in distal forearm. The presentation was interesting in a 34-year-old man, with progressively worsening symptoms of ulnar neuropathy. A mass was seen arising from the ulnar artery on imaging with ultrasound and magnetic resonance imaging. Soft tissue epithelioid hemangioendothelioma in extremities almost always arise from the veins. Existing literature do not have elaborated imaging findings of epithelioid hemangioendothelioma arising from the arterial wall. The aim of this paper is to briefly review the interesting presentation and imaging features of this rare entity. Knowledge of such vascular tumor would avoid the mishap during surgery. Our case will add an interesting presentation of such rare pathology to the existing literature.

Po uptake in microalgae at different seawater pH: An experimental study simulating ocean acidification

Climate change effects such as ocean acidification (OA) are known to affect the trace metal distribution. This experimental study provides the first data on ²⁰⁹Po uptake rates and ²¹⁰Po concentration in five microalgae species under different pH scenarios. The experiment was conducted in replicates at three pH conditions 8.2, 8.0, and 7.5, representing the current and future climate change scenario as per IPCC RCP8.5. The ²⁰⁹Po uptake in the phytoplankton was highest in Thalassiosira weissflogi, i.e. 83% of the ²⁰⁹Po tracer was taken up at 8.2 pH whereas the lowest uptake was observed in Dunaliella salina equivalent to 20% at 7.5 pH. Similar behavior was observed in ²¹⁰Po concentrations in these microalgae, where ²¹⁰Po ranged between 3.16 ± 0.03 and 11.6 ± 0.04 Bq kg^-1 wet weight (ww), with the highest in the Thalassioria weissflogi at 8.2 pH, and the lowest in Dunaliella salina at 7.5 pH. The difference in ²⁰⁹Po uptake and ²¹⁰Po concentration was statistically significant (p < 0.001) both among species and the pH treatments in the order: Thalassiosira weissflogi > Tetraselmis suecica > Chaetoceros muelleri > Isochrysis galbana > Dunaliella salina and 8.2 > 8.0 > 7.5. A higher concentration of ²⁰⁹Po in seawater was measured at low pH condition in all the experimental tanks. Though the data clearly show the difference in concentration and uptake of polonium at different pH conditions, it is not known if lower pH is affecting the adsorbed or absorbed fraction. A detailed investigation will be required to understand the process as it can have a significant effect on biomagnification and marine food chain transfer under changing climatic scenarios.

Sarcomatous Transformation of Recurrent Scapular Osteochondroma in a Patient with the Hereditary Multiple Osteochondromas: A Case Report and Literature Review

Hereditary multiple osteochondromas (HMO) is an autosomal dominant disease diagnosed by the presence of two or more than two osteochondromas on radiographs. The majority of cases are asymptomatic. The presence of bony growth, pain, and compression of the surrounding structure are the usual presentations. Malignant transformation into chondrosarcoma is the most feared complication. A rapid increase in size, recurrence after the surgical excision, and infiltrating mass may suggest the conversion into chondrosarcoma. Radiological imaging helps in diagnosing malignant transformation. MRI is the investigation of choice to exclude cancer. We hereby present a case of multiple osteochondromas with suspected malignant transformation due to rapidly increasing painful osseous swelling.

Heterotopic Pregnancy - A Diagnostic Challenge. Six Case Reports and Literature Review

Heterotopic pregnancy is defined as the simultaneous presence of intrauterine and ectopic pregnancies. It is a rare condition, but due to the increasing use of artificial reproductive techniques, the incidence of heterotopic pregnancy is increasing. Most of the patients with heterotopic pregnancy have a previous history of infertility or tubal diseases. In this case series, we are presenting six cases of heterotopic pregnancy. Three of them had a history of assisted reproductive technique: one patient had in vitro fertilization with three embryos transferred, and two patients received follicular stimulating hormone therapy. In one of the cases, heterotopic pregnancy was missed on an initial transabdominal scan, and in the following weeks, it was diagnosed on transvaginal ultrasound. Five patients underwent laparoscopic salpingectomy, and one patient had laparotomy and then a salpingectomy was done. Follow-up ultrasound scans for intrauterine pregnancy (IUP) showed abortion of the IUP, except in one patient who delivered a healthy full-term baby via spontaneous vaginal delivery. Therefore, there is a need to develop diagnostic criteria to rule out heterotopic pregnancy if the patient underwent any type of assisted reproductive techniques. We are emphasizing the need for more careful scanning of the adnexa via transvaginal ultrasound, especially in high-risk patients, even if the intrauterine gestation is confirmed.

Concentration of 210Po and 210Pb in macroalgae from the northern Gulf

This baseline study highlights the 210Po and 210Pb concentration in seven macroalgae species from the northern Gulf that are frequently washed ashore during the bloom season from February to April. The highest concentrations of 210Po and 210Pb were 2.947 ± 0.032 and 1.057 ± 0.145 Bq kg-1 wwt, respectively, in brown algae Sargassum boveanum, and the lowest in green algae Ulva prolifera with 1.533 ± 0.058 and 0.170 ± 0.069 Bq kg-1 wwt, respectively. A 210Po enrichment was observed in both brown and green algae species, with the 210Po/210Pb ratio being >1 for all the samples. The mean concentration of 210Po in all species was an order of magnitude higher than 210Pb, and the difference in mean concentration is statistically significant (p < 0.001). At the same time, the mean concentration of dissolved 210Po and 210Pb in seawater was 0.28 ± 0.01 and 0.52 ± 0.01Bq m-3 with a 210Po/210Pb ratio of 0.54 ± 0.02 indicating that 210Po was absorbed from water and more concentrated by macroalgae. The measured concentration factor (CF) for 210Po in these macroalgae for the northern Gulf varied between 5 × 103-1 × 104, higher than the IAEA recommended value of 1 × 103 which suggests that a revision of that value may be needed. The field derived CFs for 210Pb vary between 3 × 102-1.8 × 103, comparable to the ICRP recommended value of 2 × 103.

210Po concentration in selected diatoms and dinoflagellates in the northern Arabian Gulf

Marine phytoplankton is a primary producer in the ocean that forms the base of the marine food web and supports the pelagic food chain. The two dominant groups of phytoplankton observed in northern Gulf waters are diatoms and dinoflagellates. The diatoms outnumber dinoflagellates in the Gulf waters. This study presents baseline information on the concentration of ²¹⁰Po among selected phytoplankton in the northern Gulf. The concentration among diatoms varies between 6.99 and 11.4 Bq kg^-1 wwt, whereas a higher concentration range of 8.51-15.41 Bq kg^-1 wwt was observed among dinoflagellates. The diatoms analyzed includes Thalassiosira spp. - 10.2-11.4 Bq kg^-1 wwt; Chaetoceros spp. - 6.99-7.14 Bq kg^-1 wwt; Rhizosolenia spp. - 9.12-9.95 Bq kg^-1 wwt. The analyzed dinoflagellate genera include Gymnodinium spp. - 8.51-8.78 Bq kg^-1 wwt; Noctiluca spp. - 15.2-15.4 Bq kg^-1 wwt; and Karenia spp. - 14.1-14.9 Bq kg^-1 wwt. The ²¹⁰Po concentration in seawater shows a seasonal variation, with a higher concentration range of 0.70 and 0.58 mBq L^-1 during summer and autumn, whereas a lower range in concentration of 0.38 and 0.30 mBq L^-1 occurring during winter and spring. The resultant computed concentration factors vary between 2 ∗ 10⁴-5 ∗ 10⁴ demonstrating a significant ²¹⁰Po enrichment in the base of the pelagic food chain.

Outcomes of involuntary hospital admission. Satisfaction with treatment and the effect of involuntary admissions on patients

Introduction

Involuntary hospitalization in those presumed to be mentally ill has been a common practice. Although some patients are hospitalized for aggression, two-thirds of the patients are hospitalized because of the threat they pose to themselves. Although these patients require risk assessment and evaluation for possible presence of mental illness, the question is how much these patients will benefit from involuntary admission and what the long-term outcome would be.

Method

All patients admitted involuntary to the psychiatric ward in Kingston, Canada, and psychiatrists involved in their care were interviewed to see whether they think the involuntary admission was helpful. All patients were asked to fill-out MacArthur AES to assess their satisfaction with hospitalization.

Results

Although psychiatrists frequently reported that the admission was justified, only 29 out of 81 patients reported being explained to why they had been admitted involuntarily. Also, there was a significant difference in AES scores between those who were and were not given an explanation for admission. In addition, psychiatrists more often reported that the involuntary admission worsened the therapeutic relationship which was significantly associated with involuntary admission that was not explained to patients.

Discussion

The results of our study shows that patients admitted involuntarily often feel disappointed with staff and mental health system. It could lead to feeling of hopelessness, frustration and low self-esteem. If explained, some patients who present with risk to self might accept voluntary admissions, that will improve therapeutic alliance with psychiatrists and increase satisfaction from hospitalization. Result of this study could improve the decision making process for involuntary admissions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Autoimmune haemolytic anaemia due to Omeprazole

A 72-year-old lady who was prescribed Omeprazole for gastroesophageal reflux developed an allergic reaction within two days, which manifested initially as a generalised rash and marked eosinophilia. This was followed by a fall in haemoglobin without any obvious bleeding. Investigations pointed to drug related intravascular haemolysis as the cause. She made an uneventful recovery after omitting Omeprazole and treatment with steroids. Omeprazole should be considered amongst other recognised causes of drug-induced haemolysis

The dual-wave bolus feature in continuous subcutaneous insulin infusion pumps controls prolonged post-prandial hyperglycaemia better than standard bolus in Type 1 diabetes

The dual-wave bolus delivers a combination of an immediate normal pre-meal insulin bolus (approximately 3 min) followed by an extended (or square-wave) bolus that is evenly delivered over several hr as programmed by the patient. The purpose of this study was to compare post-prandial glycaemic excursions following a high-fat meal after administration of insulin by normal vs dual-wave bolus. During this prospective, cross-over, repeated measures study, subjects with diabetes and treated with insulin pump therapy were evaluated using the continuous glucose monitoring system (CGMS) following three combinations of meal and bolus type. A control meal or a high-fat meal was given in place of the evening meal on three separate occasions and comparisons were made between: a) the control meal with normal insulin bolus delivery, b) the high-fat meal with normal insulin bolus delivery, and c) the high-fat meal with dual-wave insulin bolus delivery. Although mean baseline CGMS values were similar in each of the three combinations of meal and bolus type (p=0.54) and in the three hr immediately following the meal (p=0.64, p=0.83, p=1.0), when compared to the control meal/normal bolus and high-fat meal/dual-wave bolus combinations, CGMS profiles disclosed significantly elevated post-prandial glucose in hr 5 through 14 (p<0.05) following the high-fat/normal bolus combination. Prolonged post-prandial glycaemic excursions are identified using the CGMS. Treating post-prandial hyperglycaemia with dual-wave insulin delivery may help manage chronic hyperglycaemia in patients with diabetes.