Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study.

INTRODUCTION: Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis. METHODS: The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon's preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay. RESULTS: 30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of-3.80% 97.5% CI (- 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1-4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001). CONCLUSIONS: Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.

Recurrent horner syndrome and persistent trigeminal artery.

INTRODUCTION: A persistent primitive trigeminal artery (PTA) is the most common type of fetal carotid-basilar anastomosis in adulthood; however, its prevalence is low and estimated between 0.1% and 0.7% in angiographic studies. PTA is usually diagnosed incidentally during an angiographic examination, though some symptomatic cases associated with cranial nerve dysfunction have been described. We describe the unusual association between PTA and ipsilateral Horner syndrome triggered by hypertensive crisis. CASE REPORT: A 40-year-old man presented to medical attention for recurrent episodes, over the last 3 years, characterized by hypertensive crisis (up to 220/150 mm Hg), dizziness, tachycardia, flushing of the forehead on the left side, ptosis, miosis, and conjunctival injection of the left eye without pain. Imaging revealed a left PTA originating from the carotid siphon with moderate ectasia of the proximal tract. We speculate that the recurrent Horner syndrome observed in our patient could be due to the disruption of the postganglionic peripheral fibers in the pericarotid plexus. Adequate antihypertensive therapy led to resolution of signs and symptoms. CONCLUSIONS: To our knowledge, we present the first case of persistent PTA and ipsilateral Horner syndrome during hypertensive crisis. Adequate antihypertensive therapy can be useful in patients bearing trigeminal artery variants.

Cytoskeleton reorganization and ultrastructural damage induced by gliadin in a three-dimensional in vitro model.

AIM: To evaluate the interplay between gliadin and LoVo cells and the direct effect of gliadin on cytoskeletal patterns. METHODS: We treated LoVo multicellular spheroids with digested bread wheat gliadin in order to investigate their morphology and ultrastructure (by means of light microscopy and scanning electron microscopy), and the effect of gliadin on actin (phalloidin fluorescence) and the tight-junction protein occludin and zonula occluden-1. RESULTS: The treated spheroids had deep holes and surface blebs, whereas the controls were smoothly surfaced ovoids. The incubation of LoVo spheroids with gliadin decreased the number of intracellular actin filaments, impaired and disassembled the integrity of the tight-junction system. CONCLUSION: Our data obtained from an "in vivo-like" polarized culture system confirm the direct noxious effect of gliadin on the cytoskeleton and tight junctions of epithelial cells. Unlike two-dimensional cell culture systems, the use of multicellular spheroids seems to provide a suitable model for studying cell-cell interactions.