Delayed Extrahepatic Biliary Leak: A Rare Presentation 9 Years Post-Laparoscopic Cholecystectomy.

BACKGROUND Biliary leaks are an important cause of the acute abdomen condition, carrying significant levels of morbidity and mortality. They are most commonly the result of acute iatrogenic or blunt trauma, with an identifiable cause. In comparison, spontaneous and delayed biliary leaks are rare phenomena occurring in the absence of recent surgery, endoscopic intervention, or trauma. Here we report the case of a 77-year-old woman presenting with acute abdominal pain, distension, and rigors caused by an extrahepatic biliary leakage 9 years after laparoscopic cholecystectomy. CASE REPORT Laparoscopic hepatobiliary intervention, rather than open surgery, is associated with increased risk of biliary tree injury, including biliary leaks, which typically arise in the immediate postoperative period. This report concerns a 77-year-old woman presenting with acute abdominal pain, distension, and rigors due to extrahepatic biliary leakage 9 years following elective laparoscopic cholecystectomy for cholelithiasis. Computed tomography (CT) showed large-volume abdominopelvic ascites with no obvious source. Intra-abdominal exploration revealed a large biloma with 2 lacerations in the gallbladder fossa. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) found only a vague leak in the extrahepatic biliary tree, with no focal defect or retained biliary calculi. Intra-abdominal drainage and common bile duct (CBD) stenting were performed. Repeat ERCP undertaken 3 months later, however, identified a calculus within the CBD. CONCLUSIONS The patient's rare presentation of biliary leakage 9 years after cholecystectomy raises the question of whether the condition was delayed or spontaneous in nature. The biliary calculus identified 3 months following the leakage raises the possibility of retained biliary calculi.

A case of atrial fibrillation complicated by complete atrioventricular block.

Atrial fibrillation and complete atrioventricular block are two well-established arrhythmias that can share common aetiologies and risk factors. Although the two arrhythmias can co-exist, only a limited number of cases of atrial fibrillation complicated by complete atrioventricular block have been reported. Correct recognition is essential due to the risk of sudden cardiac death. A 78-year-old female with known atrial fibrillation presented with a 1-week history of shortness of breath, chest tightness and dizziness. On assessment, she was bradycardic with a heart rate of 38 bpm, despite the absence of any rate-limiting medication. Electrocardiography revealed an absence of P waves with a regular ventricular rhythm, consistent with a diagnosis of atrial fibrillation complicated by complete atrioventricular block. This case highlights the diagnostic electrocardiography features of co-existing atrial fibrillation with complete atrioventricular block that are often misinterpreted, leading to a delay in correct diagnosis and initiation of definitive management. Upon diagnosis, it is essential to exclude the reversible causes of complete atrioventricular block before considering permanent pacing. In particular, this includes rate-limiting medications in patients with pre-existing arrhythmias such as atrial fibrillation and electrolyte disturbances.

How dietary amino acids and high protein diets influence insulin secretion.

Glucose homeostasis is the maintenance and regulation of blood glucose concentration within a tight physiological range, essential for the functioning of most tissues and organs. This is primarily achieved by pancreatic secretion of insulin and glucagon. Deficient pancreatic endocrine function, coupled with or without peripheral insulin resistance leads to prolonged hyperglycemia with chronic impairment of glucose homeostasis, most commonly seen in diabetes mellitus. High protein diets (HPDs) are thought to modulate glucose homeostasis through various metabolic pathways. Insulin secretion can be directly modulated by the amino acid products of protein digestion, which activate nutrient receptors and nutrient transporters expressed by the endocrine pancreas. Insulin secretion can also be modulated indirectly, through incretin release from enteroendocrine cells, and via vagal neuronal pathways. Additionally, glucose homeostasis can be promoted by the satiating effects of anorectic hormones released following HPD consumption. This review summarizes the insulinotropic mechanisms by which amino acids and HPDs may influence glucose homeostasis, with a particular focus on their applicability in the management of Type 2 diabetes mellitus.

A 60-Year-Old Woman with a 6-Week History of Shortness of Breath and Intermittent Chest Pain Due to Chronic Thromboembolic Pulmonary Disease Undetected by Computed Tomography Pulmonary Angiography (CTPA) and Diagnosed by Ventilation-Perfusion Imaging.

BACKGROUND Chronic thromboembolic pulmonary disease (CTEPD) is the persistent occlusion of pulmonary arteries resulting from 1 or more thrombo-emboli. Its presentation is often non-specific, with exertional dyspnea and fatigue, yet if left undiagnosed risks of chronic thromboembolic pulmonary hypertension and right-sided cardiac failure can ensue. Computed tomography pulmonary angiography (CTPA) and ventilation/perfusion (V/Q) imaging are most commonly utilized for investigating CTEPD. This report is of a 60-year-old woman with a 6-week history of breathlessness and intermittent chest pain due to CTEPD, undetected by CTPA and diagnosed by V/Q imaging. CASE REPORT A 60-year-old woman presented with a 6-week history of breathlessness, intermittent chest pain, and reduced mobility. Her past medical history included chronic obstructive pulmonary disease, pulmonary sarcoidosis, and obesity. Screening tests for infective and ischemic cardiac etiologies were unremarkable. A calculated Wells score was 6, making CTEPD the main differential diagnosis, and she was commenced on therapeutic dose anticoagulation. A CTPA performed on day 2 of admission showed no evidence of acute thromboembolic pulmonary disease or CTEPD. Instead, V/Q scintigraphy on day 6 revealed a perfusion mismatch in the right lung apex, consistent with CTEPD. The patient improved clinically and was discharged on long-term apixaban. CONCLUSIONS A negative CTPA does not necessarily exclude CTEPD. The sensitivity of CTPA for CTEPD is lower than that of V/Q imaging, and can hence lead to false-negative results, as this case highlights. When there is a high clinical suspicion for CTEPD but a negative CTPA study, V/Q imaging should always be undertaken.

Why exercise has a crucial role in cancer prevention, risk reduction and improved outcomes.

INTRODUCTION: Exercise is one of several factors known to lower the risk of developing cancer, as well as improve outcomes in patients already diagnosed. People who exercise after cancer have lower rates of cancer complications, treatment toxicities, relapse and improved survival. This review highlights the supportive data and biochemical processes, which explain these potential benefits. SOURCES OF DATA: PubMed, Embase, Medline and Cochrane libraries were searched for papers which addressed the effects of exercise and physical activity on cancer for this review. The search terms used were physical activity, exercise and cancer up to February 2021. We also referred to the background research required for international exercise intervention study involving men with prostate cancer (INTERVAL-GAP4) and scrutinized references within the robust papers published on this subject to ensure we did not miss any clinically studies. One hundred and eighty eight papers were included. AREAS OF AGREEMENT: Exercise programmes mitigate many of the complications and risks associated with cancer, particularly thromboembolism, fatigue, weight gain, arthralgia, cognitive impairment and depression. AREAS OF CONTROVERSY: Molecular and biomarker changes, resulting from exercise, suggest that exercise elicits beneficial changes in insulin-related pathways, down-regulates inflammation and serum oestrogen levels, and enhances oxidative, immune and cellular repair pathways. Nonetheless, the evidence remains preliminary. GROWING POINTS: The timing, intensity and challenges of prehabilitation, adjunct and rehabilitation exercise programmes are being increasingly understood but their implementation remains sporadic. AREAS FOR DEVELOPING RESEARCH: More robust clinical trial data are needed to substantiate a causal effect of exercise on overall and cancer-specific survival. These studies are ongoing. Research evaluating the most cost-efficient ways of incorporating prehabilitation, adjunct and rehabilitation programmes into routine practice would be helpful to funding bodies and health care strategists.

A direct, versatile route to functionalized trialkoxysilanes.

The peroxide initiated radical addition of dithiocarbonates (xanthates) to trialkoxy vinylsilanes leads to functionalized trialkoxysilanes. Prior addition of the dithiocarbonates to an alkene before reaction with the vinylsilane can be used to increase the complexity of the final product.

Diastereodifferentiating the [2+2] photocycloaddition of ethylene to arylmenthyl cyclohexenonecarboxylates: stacking-driven enhancement of the product diastereoselectivity that is correlated with the reactant ellipticity.

Upon diastereodifferentiating the [2+2] photocycloaddition of ethylene to a series of p-substituted (-)-8-phenylmenthyl cyclohexenonecarboxylates, the diastereoselectivity was critically controlled by the nature of the substituent introduced to the chiral auxiliary, and the p-nitro-substituted substrate afforded the cycloadducts in 90% diastereomeric excess (de) and with 97% isolated yield. Detailed experimental and theoretical conformation analyses revealed that the stacking interaction of the aromatic auxiliary with the cyclohexenone moiety plays the decisive role in determining the substrate conformation and is, therefore, responsible for the dramatic enhancement of the de. Of particular interest, the product de was directly related to the ellipticity of the substrate, enabling us to "predict" the de prior to photoirradiation.