Two cases of Rapunzel syndrome in adult males

Trichobezoar are foreign bodies formed from undigested hairs that accumulate in the gastrointestinal tract and cause obstruction. Trichobezoar are usually found in the stomach but when the tail of the bezoar extends into the small intestine it is referred to as Rapunzel syndrome. Patients are usually females and have a history of psychiatric illness. However, in this study, we present two cases of Rapunzel syndrome in adult male patients that were managed with surgery. Trichobezoar should be considered in all patients with a history of psychiatric illness presenting with abdominal symptoms regardless of gender.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Emphysematous cholecystitis in a patient with porcelain gallbladder

Our case uniquely presents a patient with two rare gallbladder disease entities occurring simultaneously. The patient presented to hospital with abdominal pain and was subsequently diagnosed with emphysematous cholecystitis and porcelain gallbladder. After initial conservative management failed, cholecystectomy was performed, and the patient recovered well post-operatively and was discharged home.

Diverticulitis complicated by colovenous fistula formation and pylephlebitis

Acute diverticulitis is associated with a range of complications including fistula formation. Colovenous fistula formation, where there is a fistula between the inferior mesenteric vein and colon, is an extremely rare and serious complication of diverticulitis. Pylephlebitis, which is defined as infective suppurative thrombosis of the portal vein, is another uncommon complication of any intra-abdominal source of infection, including diverticulitis. Both complications are independently associated with significant morbidity and mortality. We report a case of a patient with acute diverticulitis who subsequently developed both colo-venous fistula and pylephlebitis and was successfully managed conservatively.

A case of mesenteric panniculitis in a patient with Tangier disease

Mesenteric panniculitis is a rare disease caused by idiopathic inflammation of adipose tissue, most commonly affecting the mesentery of the small bowel. We present a unique case of mesenteric panniculitis in a patient with Tangier disease; a rare genetic disorder caused by mutations in the ABCA1 gene, leading to deficiency of high-density lipoprotein in the blood and accumulation of cholesterol esters within various tissues. The accumulation of cholesterol esters in body tissues in patients with Tangier disease may contribute to the pathogenesis of mesenteric panniculitis; although there is limited evidence to support this hypothesis due to the rarity of concurrent disease.

The impact of Oncotype DX testing on adjuvant chemotherapy decision making in 1-3 node positive breast cancer

BACKGROUND

Oncotype DX testing has reduced the use of adjuvant chemotherapy in node-negative early breast cancer but less is known about its impact in node positive patients.

AIM

This study aimed to investigate the impact of Oncotype DX gene assay testing on the decision to offer adjuvant chemotherapy in oestrogen positive, human epidermal growth factor receptor 2 negative, 1-3 lymph node positive patients.

METHODS

Retrospective review of all node positive patients who underwent Oncotype DX testing at a single centre. Clinicopathological data, as well as estimated survival benefit data (from the PREDICT tool), was evaluated by a multidisciplinary group of surgeons and oncologists. Treatment decisions based on clinicopathological data were compared to recurrence scores (RS). A cut off RS > 30 was used to offer adjuvant chemotherapy.

RESULTS

The 69 patients were identified, of which 9 (13%) had an RS > 30 and assigned a high-genomic risk of recurrence. The 32 patients (46.4%) were offered adjuvant chemotherapy. Overall based on the use of the RS, the decision to offer adjuvant chemotherapy changed in 36% of patients, and ultimately 24 patients (34.7%) would have been spared chemotherapy.

CONCLUSION

Using clinicopathological data alone to make decisions regarding adjuvant chemotherapy in node positive breast cancer leads to overtreatment. Additional information on tumour biology as assessed by the Oncotype DX RS helps to select those patients who will benefit from adjuvant chemotherapy and spare patients from unnecessary chemotherapy.

Complicated Acute Cholecystitis: The Role of C-Reactive Protein and Neutrophil-Lymphocyte Ratio as Predictive Markers of Severity

Objectives The clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC. Methods We identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC. Results A total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient's age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days. Conclusion CRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.

A silver nanocomposite biomaterial for blood-contacting implants

Cardiovascular implants must resist infection and thrombosis. A nanocomposite polymeric material [polyhedral-oligomeric-silsesquioxane-poly(carbonate-urea)urethane; POSS-PCU] demonstrates ideal properties for cardiovascular applications. Silver nanoparticles or nanosilver (NS) are recognized for efficient antibacterial properties. This study aims to determine the influence of NS integrated POSS-PCU on thrombogenicity. Silver nitrate was reduced with dimethylformamide and stabilized by the inclusion of fumed silica nanoparticles to prevent aggregation of NS and were incorporated into POSS-PCU to form a range of POSS-PCU-NS concentrations (by weight); 0.20% (NS16), 0.40% (NS32), 0.75% (NS64), and 1.50% (NS128). Surface wettability was determined with sessile-drop water contact angles. Platelets were introduced onto test samples and Alamar Blue (AB), mitochondrial-activity assay, quantified the degree of platelet adhesion whilst platelet-factor-4 (PF4) ELISA quantified the degree of platelet activation. Thromboelastography (TEG) determined the profiles of whole blood kinetics while hemolysis assay demonstrated the degree of blood compatibility. Increasing levels of NS induced greater hydrophilicity. A concentration dependant decrease in platelet adhesion and activation was observed with AB and PF4 readings, respectively. TEG demonstrated that the antithrombogenic properties of POSS-PCU were retained with POSS-PCU-NS16, and enhanced with POSS-PCU-NS32, but was reduced with POSS-PCU-NS64 and POSS-PCU-NS128. POSS-PCU-NS64 and POSS-PCU-NS128 demonstrated a hemolytic tendency, but no hemolysis was observed with POSS-PCU-NS16 and POSS-PCU-NS32. Overall, POSS-PCU-NS32 rendered potent antithrombogenic properties.

Differential cytopathology and kinetics of measles oncolysis in two primary B-cell malignancies provides mechanistic insights

Clinical trials using vaccine measles virus (MV) as anticancer therapy are already underway. We compared the oncolytic potential of MV in two B-cell malignancies; adult acute lymphoblastic leukemia (ALL, an aggressive leukemia) and chronic lymphocytic leukemia (CLL, an indolent leukemia overexpressing Bcl-2) using patient-derived material. In vitro, distinct cytopathological effects were observed between MV-infected primary ALL and CLL cells, with large multinucleated syncytia forming in ALL cultures compared to minimal cell-to-cell fusion in infected CLL cells. Cell viability and immunoblotting studies confirmed rapid cell death in MV-infected ALL cultures and slower MV oncolysis of CLL cells. In cell lines, overexpression of Bcl-2 diminished MV-induced cell death providing a possible mechanism for the slower kinetic of MV oncolysis in CLL. In vivo, intratumoral MV treatment of established subcutaneous ALL xenografts had striking antitumor activity leading to complete resolution of all tumors. The antitumor activity of MV was also evident in disseminated ALL xenograft models. In summary, both ALL and CLL are targets for MV-mediated lysis albeit with different kinetics. The marked sensitivity of both primary ALL cells and ALL xenografts to MV oncolysis highlights the tremendous potential of MV as a novel replicating-virus therapy for adult ALL.

Nanosilver as a new generation of nanoproduct in biomedical applications

Nanosilver (NS), comprising silver nanoparticles, is attracting interest for a range of biomedical applications owing to its potent antibacterial activity. It has recently been demonstrated that NS has useful anti-inflammatory effects and improves wound healing, which could be exploited in developing better dressings for wounds and burns. The key to its broad-acting and potent antibacterial activity is the multifaceted mechanism by which NS acts on microbes. This is utilized in antibacterial coatings on medical devices to reduce nosocomial infection rates. Many new synthesis methods have emerged and are being evaluated for NS production for medical applications. NS toxicity is also critically discussed to reflect on potential concerns before widespread application in the medical field.