Complicated Appendicitis: A Surgical Controversy Concerning Risk Factors, Diagnostic Algorithm and Therapeutic Management

By surgeon’s perspective, complicated appendicitis is defined as perforated appendicitis, periappendicular abscess, gangrenous appendicitis or peritonitis, noted on radiological studies upon hospital admission, operative reports or pathology results of the surgical specimen. Despite that this clinical condition is truly common in everyday surgical routine, its causes and risk factors are still unclear. Some parameters have been associated with complicated appendicitis, like older age, type 2 diabetes, symptoms for longer duration, appendicoliths/fecaliths, delays in surgery after onset of symptoms and after admission. Furthermore, currently, there is no standard diagnostic algorithm for complicated appendicitis. To be specific, radiological findings lack sensitivity, intraoperative assessment may overestimate it while, histopathological examination is regarded as more specific diagnostic method. In addition, the optimal treatment for complicated appendicitis remains controversial between an immediate surgical operation (laparotomy/laparoscopy) or a trial of nonoperative management. Hereby, by reviewing the current literature, we would aim to clarify the risk factors and the diagnostic procedure of complicated appendicitis as well as to compare the operative management with the conservative one according to the type of complicated appendicitis, the success rate and the postoperative complications.

Gouty arthritis and kidney function outcomes and serum uric acid level variations in obese patients following bariatric surgery

Background Obesity is an independent risk factor for chronic kidney disease (CKD) and is the strongest known modifiable risk factor for hyperuricemia and gout. We aimed to discover the outcome of serum uric acid (SUA), gouty arthritis, and kidney function in obese patients after bariatric surgery and possible links with BMI variations. Methods Retrospective study has been performed in National Hospital in Riyadh, KSA, between Jan. 2018 to Jan. 2020. We studied only 98 patients who met our inclusion criteria. Patients followed-up at 1 month (for gouty attack only) postoperative, 3 months postoperative, and 6 months postoperative for body mass index (BMI), serum creatinine, dipstick urinalysis, SUA, and estimated glomerular filtration rate (eGFR). Radiological studies, medical history, follow up radiological studies, and clinical follow up were obtained from the hospital data system. Results A total of 98 patients with mean eGFR were 90.65 ± 29.34 ml/min/1.73 m2, mean SUA 5.56 ± 1.84 mg/dl, and mean BMI was 45.28 ± 7.25 kg/m2, at surgery. Mean BMI had decreased significantly to 38.52 ± 6.05 kg/m2 at 3 months and to 34.61 ± 5.35 kg/m2 at 6 months (P < 0.001). The mean GFR had improved significantly (99.14 ± 23.32 ml/min/1.73 m2) at 6 months (P < 0.001). Interestingly, proteinuria had resolved in 17 patients out of 23 patients at 6 months. Number of gouty attacks was decreased during the first month post-surgery (P < 0.001). SUA level was significantly decreased (4.32 ± 1.27 mg/dl) (P < 0.001). SUA showed significant negative correlations with eGFR at 3 months and positively significant correlations with BMI at 3 and 6 months. By multinomial logistic regression, BMI and initial eGFR were the independent predictive variables for the outcome of eGFR at 6 months, while male gender and initial SUA were the independent predictive variables on the outcome of SUA at 6 months. Postoperatively in gouty arthritis patients, the number of joints affected, patient global VAS assessment, and number of gouty attacks were significantly reduced (P < 0.001). Conclusion Bariatric surgery has been associated with reduction of BMI and subsequently reduction of SUA levels, gouty attacks, and improvement of eGFR.

A look at the problem of exposure of the population caused by X-ray diagnostics: approaches to analysis and forecasting

The article is devoted to the analysis of limitation of dose load on the population as a result of radiological researches. It is especially actual and represents rather high scientific and practical interest. In this regard, it is very important to have information about the state of the dose load of the population in separate regions and to rank types of diagnostics by the amount of their contribution to the total dose of medical exposure. The aim of the work was to study the state of dose load of the population of Zaporizhzhia region due to X-ray diagnostics, to develop approaches to analysis and forecasting regarding its limitation. Analytical, statistical calculation and logical generalization methods were used in the course of the work. We used the results of studies carried out in accordance with the regional “Program for the Protection of the Population of Zaporizhzhia Region from the Effect of Ionizing Radiation. The authors analyzed scientific publications (15 sources), including 9 Ukrainian and 6 foreign on the relevance of the problem of exposure of the population caused by X-ray diagnostics. The analysis of the results allowed to determine that in 2010-2014 the radiation dose of the population of Zaporizhzhia region due to X-ray diagnostics averaged 0.92 mSv year-1, in 2015-2016 the dose increased and amounted to 0.96 mSv year-1. The proposed approach to the analysis makes it possible to summarize and model data on radiological studies of the population over a long period of time, to identify persistent trends in the contribution of different types of radiation diagnostics to the dose of medical radiation. All this is necessary for the development, first of all, of measures to reduce the frequency of radiography, its replacement by other diagnostic methods. Priority tasks aimed at reducing the dose load of the population due to X-ray examinations are proposed.

RECIST 1.1, mRECIST 1.1: RADIOLOGICAL ASSESSMENT OF TUMOR RESPONSE TO CHEMOTHERAPY (literature review)

Определение изменений опухолевого роста является важной характеристикой клинической оценки терапии рака - как уменьшение размеров опухоли (объективный ответ), так и прогрессирование заболевания являются полезными конечными точками клинических исследований. Критерии RECIST были впервые опубликованы в 2000 г. и с тех пор начали применяться в мировой онкологической практике для оценки эффективности лечения. В 2009 году критерии RECIST 1.0 были пересмотрены и дополнены новыми данными RECIST 1.1 (2009 г.). Учитывая применение химиотаргетной терапии и особенности ответа на нее опухоли, предложены SACT критерии, модифицированные критерии RECIST (mRECIST) как способ адаптации критериев RECIST. Современные знания критериев оценки лечения солидных опухолей поможет лучевым диагностам правильно интерпретировать результаты исследований. В работе представлен обзор научных исследований по критериям оценки опухолевого ответа на лечение по данным радиологических исследований. Determining of tumor changes is an important characteristic of the clinical evaluation of cancer therapy - both tumor shrinkage (objective response) and disease progression are useful endpoints of clinical trials. The RECIST criteria were first published in 2000 and since then have been used in the global oncological practice to assess the effectiveness of treatment. In 2009, the RECIST 1.0 criteria were revised and supplemented with new data from RECIST 1.1 (2009). Taking into account the use of target chemotherapy and the peculiarities of the tumor response to it, the SACT criteria and modified RECIST criteria (mRECIST) are proposed as a way to adapt the RECIST criteria. Modern knowledge of the criteria for ASSESSMENT OF TUMOR RESPONSE will help radiologyst to correctly interpret the research results. The paper provides an overview of scientific studies on the criteria for evaluating tumor response to treatment based on radiological studies.

Food quality and safety as the keys to the health of future generations

The material for the research were publications of scientists, reporting documentation of ZHRSLSPS, RSLSPS, SLVSE of Zhytomyr and Zhytomyr region, food samples. Radiological studies were performed on the device USC Gamma-plus № 0502 BG. The content of radionuclides in mushrooms was determined on RUG-91. In 2020, 210183 samples were tested, including 90 in excess. As in previous years, the excess was found in 19 samples of milk from the Narodytsya district (103–180 Bq/kg). The gifts of the forest remain the most polluted. The specific activity of 3 samples of fresh mushrooms from Novohrad-Volynskyi district was 610 Bq/kg, 642 Bq/kg, and 819 Bq/kg (with DR 500 Bq/kg), 4 samples from Yemilchyn district – 531–761 Bq/kg, 2 samples from Luhyny district – 760 Bq/kg and 827 Bq/kg. The most significant number of exceedances in the level of contamination of fresh mushrooms was found in Narodytsky, Ovruch, Malyn, and Olevsk districts, slightly less – in Luhyny. In particular, of the 25 samples of fresh mushrooms from Narodytsya district, 23 (621–2000 Bq/kg, DR exceeded 1.2–4 times) were detected, 28 % of fresh mushroom samples in Ovruch district were exceeded at 530–916 Bq/kg, of the 48 samples from Olevsk district exceedances were in 3 samples and, accordingly, their specific activity was at the level of 983 Bq/kg, 1994 Bq/kg and 2125 Bq/kg, i.e., 1.1, 3.9 and 4 times higher for DR-2006. In Malyn district, 50 % of samples of fresh mushrooms showed an excess of 631–1450 Bq/kg (1.3–2.9 times). In the Luhyny district, the excess was found in 18 % of samples (760 Bq/kg – 827 Bq/kg). The specific activity of samples of dried mushrooms from Novohrad-Volynskyi district was 2725 and 3018 Bq/kg, respectively, Yemilchynsky – 2608–3080 Bq/kg, Ovruch – 2820 Bq/kg and 2850 Bq/kg, Narodytsky – 3425 Bq/kg. The specific activity of 2 samples of wild animal meat from Narodytskyi district was 800 and 1400 Bq/kg (exceeding 2–3.5 times), 1 sample from Ovruch – 433 Bq/kg. Of the 109 samples of beekeeping products studied during this period, exceedances were detected in 1.8 %, the specific activity was 264 Bq/kg (Narodytskyi district) and 1920 Bq/kg (Ovruch district), respectively. In 2020, no excesses were found in samples of other products. Given that the consumption of food, even with low specific activity, leads to an increase in internal exposure, the research results indicate a threat to the health of present and future generations and the need for decision-making at the state level.

Nodular hyperplasia of parathyroid gland in chronic kidney disease – A case report

Nodular hyperplasia of parathyroid gland is an advanced state commonly seen in a secondary and tertiary hyperparathyroidism. It shares similarities on histology with parathyroid adenoma creating a diagnostic dilemma. Adequate history, biochemical investigations and radiological studies majorly supports the accurate diagnosis. Identifying correct state of hyperparathyroidism is essential in a view of therapeutic management and its outcome.

High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands

Purpose Between 0.1—3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. Methods This is a retrospective study that included children (0–18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. Results The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66–12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. Conclusion One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children.

Medical Analysis for Surgeryon Patients Complaining of Sciatic Pain

A prospective researchwas performed on 50 patients submitted for radiological screening in Samarra general hospital complaining of chronic backache and sciatica. The study was completed for patients recommended by senior neurosurgeons, orthopedicians, &rheumatologist, to the radiological unit in Samarra public hospital from October 2016 to October 2017. Radiological studies were analyzed by senior radiologists of Samarra public hospital in conjunction with the recommending senior doctors. Patients who are operated on were all proven to have chronic Lateral Recess Syndrome both radiological and surgically.

Extensive Pneumocephalus Secondary to Petrous Bone Cholesteatoma

Pneumocephalus refers to air inside the cranium; however, otogenic pneumocephalus is rarely reported in the literature. The neurological presentations of pneumocephalus include headache, lethargy, confusion, disorientation, and seizure. Here, we have reported a case of a 42-year-old woman with extensive pneumocephalus and cerebrospinal fluid leak secondary to petrous bone cholesteatoma. She presented to the emergency department with sudden headache and left ear discharge. Physical examination revealed watery otorrhea through a hole in the tympanic membrane. Radiological studies demonstrated extensive soft tissue in the left middle ear and mastoid extending to the internal auditory canal. Free intracranial air was observed, and bony destruction was seen in the cochlea, vestibule, and semicircular canals. The patient was managed surgically via the transotic approach and fully recovered. Although otogenic pneumocephalus is rarely encountered in clinical practice, early diagnosis and urgent management are important to prevent fatal complications.

Cost awareness of radiological studies among doctors at Universitas Academic Hospital in Bloemfontein, South Africa

Background: South Africa has high healthcare expenses. Improving cost-consciousness could decrease government expenditure on healthcare.Objectives: To determine cost awareness of radiological studies among doctors at a tertiary hospital. The objective was met by assessing the accuracy of cost estimation according to the level of training and speciality, whether participants had received prior education/training related to cost awareness and if they had a desire to learn more about the cost of radiological imaging.Method: A cross-sectional survey was conducted in six clinical departments at Universitas Academic Hospital using an anonymous questionnaire that determined doctors’ cost awareness of five radiological studies. Each radiological study was answered using six different cost ranges, with one correct option. Costs were based on the Department of Health’s 2019 Uniform Patients Fee Schedule (UPFS).Results: In total, 131 (67.2%) of 195 questionnaires distributed to registrars and consultants were returned. Overall, low accuracy of cost estimation was observed, with 45.2% of the participants choosing only incorrect options. No participant estimated all five costs correctly. Only the Internal Medicine clinicians demonstrated a significant difference between registrars and consultants for the number of correct answers (median 0 and 1, respectively) (p = 0.04). No significant differences were found between specialities stratified by registrars/consultants. Most participants (88.6%) would like to learn about imaging costs. Only 2.3% of the participants had received prior education/training related to cost awareness of radiological studies.Conclusion: Doctors were consistently inaccurate in estimating the cost of radiological studies. Educating doctors about the cost of radiological imaging could have a positive effect on healthcare expenditure.