Cecal volvulus with acute appendicitis in a 33-year-old male managed by manual detorsion, cecopexy, and appendectomy: A case report.

INTRODUCTION: A volvulus is a serious surgical emergency caused by torsion or hyper-flexion of the bowel loop and its mesentery on a fixed point. Cecal volvulus is an uncommon cause of intestinal obstruction, accounting for just 1-1.5 % of all cases of bowel obstruction. CASE PRESENTATION: A 33-year-old intellectually disabled male presented to the emergency department with complaints of generalized abdominal pain, absolute constipation, and non-projectile vomiting. He had a grossly distended and rigid abdomen with generalized tenderness and guarding. The abdomen was hyper-resonant. Bowel sounds were hypoactive. Digital rectal examination revealed an empty and collapsed rectum with no stool staining of the finger. Laboratory reports showed leukocytosis and neutrophilia. Radiographic imaging was consistent with acute intestinal obstruction. Laparotomy was performed, and cecal volvulus with viable bowel and acute appendicitis was diagnosed intra-operatively. Manual detorsion, cecopexy, and appendectomy were performed. The patient had an uneventful postoperative course. The patient is still on follow-up since June 2023, and no complication has occurred. CLINICAL DISCUSSION: Cecal volvulus is an uncommon cause of intestinal obstruction with multiple etiologies. The annual incidence of cecal volvulus is estimated to be between 2.8 and 7.1 cases per million. Cecal volvulus may lead to life-threatening complications such as bowel ischemia and perforation. CONCLUSION: Diagnosis of cecal volvulus must be made promptly to prevent bowel gangrene and perforation. In this case, manual detorsion and cecopexy were performed as the bowel was viable per-operatively due to early surgical intervention.

Influence of guar gum and chitosan enriched with lemon peel essential oil coatings on the quality of pears.

Pear is a typically climacteric fruit and highly perishable with a low shelf life owing to extreme metabolic activity after harvesting. The present study aimed to reduce weight loss and improve the firmness of pear during storage. The lemon peel essential oil (LPEO) has gained considerable attention due to being the richest source of bioactive compounds that behaved as a natural antioxidant agent, being cost-effective, and being generally recognized as safe. Edible coatings equipped with a natural antioxidant agent and renewable biopolymers have gained more research fame owing to their involvement in the direction of biodegradability and food safety. In this work, edible skin coating materials (ESCMs) embedded by chitosan (1%) and guar gum (2%) were fabricated, and afterward, five concentrations of LPEO (1, 1.5, 2, 2.5, and 3.0%) were incorporated individually into the ESCMs. Findings revealed that LPEO-ESCMs significantly reduced the weight loss and improved the firmness of pear up to 45 days of storage at 4 ± 2°C. Furthermore, the LPEO-ESCMs have enhanced the antioxidant capacity, antibacterial efficiency, and malondialdehyde level of pear during storage time. It was concluded that 3% of LPEO-ESCMs improved the overall acceptability of pear fruits. Taken together, the novel insights of guar gum and chitosan-based ESCMs entrapped with LPEO will remain a subject of research interest for researchers in the future.

Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled.

Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant. Methods: This is a single-center retrospective analysis comparing the outcomes of 20 adult kidney transplant recipients subjected to ERAS pathway with 20 adult recipients operated before ERAS with traditional standard of care. Results: There were no significant differences between both groups regarding age, gender, race, dialysis status, living donor percentage, cold ischemia time, and warm ischemia time. Median hospital stay for ERAS patients was 2 d. Overall median pain scores were significantly lower in the ERAS group versus non-ERAS group (morning after surgery pain score 2 versus 5; peak pain score 4.5 versus 10; lowest pain score 0 versus 2; P = 0.0001). ERAS patients had earlier ambulation (walking) and oral nutrition (regular diet) (first versus second day postoperatively in traditional group). Earlier bowel movement was observed in ERAS patients. There were no significant differences in graft function or 30-d readmission rates between both groups. Conclusions: Implementation of ERAS pathway in kidney transplantation is feasible. Using ERAS is associated with less pain, earlier ambulation and advancement of oral nutrition, and short hospital stay.

Integration of Weather Research and Forecasting (WRF) model with regional coastal ecosystem model to simulate the hypoxic conditions.

Regional ocean models require accurate weather data for atmospheric boundary conditions such as air temperature, wind speed, and direction to simulate the coastal environment. In this study, a numerical modelling framework was developed to simulate different physical, chemical, and biological processes in a semi-enclosed coastal ecosystem by integrating the Weather Research and Forecasting (WRF) model with a 3D hydrodynamic and ecosystem model (Ise Bay Simulator). The final analytic data of the global forecast system released by the National Centers for Environmental Prediction with a 0.25° horizontal resolution was used as an atmospheric boundary condition for the WRF model to dynamically downscale the weather information to a spatial and temporal fine resolution. This modelling framework proved to be an effective tool to simulate the physical and biogeochemical processes in a semi-enclosed coastal embayment. The WRF-driven ecosystem simulation and recorded Automated Meteorological Data Acquisition System (AMeDAS)-driven ecosystem simulation results were further compared with the observed data. The performance of both the recorded AMeDAS and WRF generated weather datasets were equally good, and more than 80% of the variation in bottom dissolved oxygen for shallow water and more than 90% for deep water was reproduced.

Comparison of auditory brainstem response and auditory steady state response audiometry by evaluating the hearing thresholds obtained in children with different severity of hearing loss.

OBJECTIVES: To compare the hearing thresholds obtained with auditory brainstem response (ABR) and auditory steady state response (ASSR) audiometry in children with hearing loss. METHODS: Hearing thresholds were obtained by ABR and ASSR in children who presented with suspicion of deafness at Ear, nose & throat department of Al-Nafees Medical College Hospital Islamabad, between January to August 2018. The mean hearing thresholds obtained by two tests were compared within each category of severity of deafness. Time taken by both tests was also compared. RESULTS: A total of 57 patients (114 ears) were included in the study. Among them 27 (47.4%) were male and 30 (52.6%) were female. The mean age of patients at presentation was 42 months (±30.9) with age range from one to 12 years. Mean hearing thresholds obtained by click ABR, chirp ABR, ASSR (1, 2, 4 kHz) & ASSR (0.5, 1, 2, 4 kHz) was 56.25 (±27.61), 58.88 (±27.44), 58.03 (±21.26) & 56.35 (±22.86) respectively. Mean thresholds were comparable between click ABR & ASSR (1, 2, 4 kHz) and between chirp ABR & ASSR (0.5, 1, 2, 4 kHz) in all degrees of hearing loss categories except in those patients with normal hearing thresholds. The mean time taken by clicks ABR, chirp ABR and ASSR were four minutes seven seconds, three minutes 15 seconds and 16 minutes and 7 seconds respectively. CONCLUSIONS: Hearing thresholds obtained by ABR and ASSR are comparable in all categories of severity of hearing loss. The time taken by ABR is less as compared to ASSR.

Kidney Biopsies May Help Predict Renal Function After Liver Transplantation.

BACKGROUND: Renal biopsy has been proposed to determine the cause or reversibility of renal failure for patients with end-stage liver disease and may be useful in the kidney allocation. Nevertheless, little data exist to validate the usefulness of kidney biopsies in this patient population. METHODS: We evaluated the utility of renal biopsies in a cohort of 59 consecutive liver transplant candidates with renal impairment of unclear etiology referred to determine the need for simultaneous liver kidney transplantation (SLK) versus liver alone transplantation (LAT). Pathological diagnoses, patient outcomes and the usefulness of biopsy results in predicting renal recovery were analyzed. RESULTS: Our biopsy complication rate was relatively low with only 2.9% and 4.2% serious complications occurring with transjugular and percutaneous renal biopsies, respectively. The most common pathological diagnoses on renal biopsies were membranoproliferative glomerulonephritis (23%) followed by IgA nephropathy (19%) and acute tubular injury (19%). Simultaneous liver kidney transplantation was recommended for patients with greater than 40% global glomerular sclerosis, or with interstitial fibrosis greater than 30% or for patients on hemodialysis for 2 months or longer. The best histological predictor for posttransplant glomerular filtration rate in the LAT group was the extent of global glomerulosclerosis (P = 0.0001). Based on biopsy criteria, we were able to avoid kidney allocation to 70% of our patients with renal dysfunction. Over the first year posttransplant, SLK and LAT patients had comparable estimated glomerular filtration rates. Kaplan-Meier survival analysis did not demonstrate a difference in patient survival between patients who underwent LAT versus SLK. CONCLUSIONS: Renal biopsy can be relatively safe in this population, may help elucidate the etiology of renal failure, may predict post-LAT kidney function, and may be helpful in kidney allocation for liver transplant candidates.

Role of Special Coagulation Studies for Preoperative Screening of Thrombotic Complications in Simultaneous Pancreas-Kidney Transplantation.

BACKGROUND: Vascular thrombosis is a well-known complication after simultaneous pancreas-kidney (SPK) transplantation procedures. The role of preoperative special coagulation studies to screen patients at high risk for vascular thrombosis is unclear and not well studied. METHODS: This study reports a retrospective medical record review of 83 SPK procedures performed between April 2007 and June 2013 in a single institution. All SPK transplantation recipients underwent preoperative screening for hypercoagulable state. RESULTS: Eighteen of 83 patients (21.69%) were diagnosed with vascular thrombosis of the pancreas. Of the 23 patients with at least 1 positive screening test, only 4 had a thrombotic event (17.39%). On the other hand, 14 of 60 patients with negative screening tests developed vascular thrombosis (23.33%). The hypercoagulable screening workup had a positive predictive value of 17.39% and a negative predictive value of 76.67%. The workup also demonstrated low sensitivity (22.22%) and specificity (70.77%). CONCLUSION: No differences were seen in patient or graft survival between groups at 12 months. This retrospective study did not show any benefit of using special coagulation studies to rule out patients at risk for vascular thrombosis after SPK transplantation.

Posttransplant nephrocalcinosis is associated with poor renal allograft function: a single-center experience.

BACKGROUND: Nephrocalcinosis, characterized by intratubular and/or parenchymal deposition of calcium phosphate and calcium oxalate crystals, is frequently seen in renal allograft biopsies; however, the clinical consequence of this histologic finding remains unknown. Kidney transplant recipients with good allograft function usually demonstrate improvement in biochemical parameters; however, persistent hyperparathyroidism remains prevalent in this population of patients. We identified renal allografts with nephrocalcinosis and evaluated the effects on renal allograft function and survival. METHODS: We conducted a single-center, retrospective review of kidney allograft biopsies performed at our center from December 1, 2006 to November 30, 2012. Biopsies with nephrocalcinosis as the primary diagnosis were included in the final analysis. Biochemical parameters at the time of biopsy included serum creatinine, phosphate, calcium, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D, and albumin. Serum creatinine was measured at 1, 3, 6, and 12 months after nephrocalcinosis was diagnosed. The use of calcimimetics, vitamin D analogs, active vitamin D, and bisphosphonates was also reviewed. RESULTS: We identified 12 patients with nephrocalcinosis as the primary diagnosis on renal biopsy. The average age of these patients was 52.2 ± 11.9 years, and the average time since transplantation was 2.3 ± 2.7 years. The baseline serum creatinine was 1.37 ± 0.4 mg/dL before the onset of acute kidney injury (AKI). Mean iPTH and 25-hydroxy vitamin D at the time of AKI were 495.66 ± 358.9 pg/mL and 19.9 ± 13.3 ng/mL, respectively. Renal function deteriorated in all patients, and mean serum creatinine at 12-month follow up was 2.37 ± 1.3 mg/dL (P=0.028). One patient progressed to end-stage renal disease at the end of the study period. CONCLUSION: The histologic finding of nephrocalcinosis is associated with poor renal allograft function. Metabolic abnormalities including hyperparathyroidism persist in renal allograft recipients despite normal allograft function and may be associated with the development of nephrocalcinosis in renal transplant recipients.

Late recurrence of light chain deposition disease after kidney transplantation treated with bortezomib: a case report.

BACKGROUND: Light chain deposition disease (LCDD) recurs frequently after renal transplantation with variable presentation. CASE REPORT: We report the case of a 67-year-old Caucasian female with recurrence of LCDD after living-donor kidney transplantation. Bone marrow biopsy revealed kappa light chain-restricted population of plasma cells, and the patient met the criteria for multiple myeloma. Her renal function progressively worsened and she became dialysis dependent. She received 1 cycle of bortezomib along with intravenous dexamethasone. She was able to discontinue dialysis within 2 months, and at 1 year follow-up her renal function was stable. CONCLUSION: Bortezomib has a role in the treatment of recurrent LCDD and multiple myeloma in kidney transplant patients. As opposed to traditional regimens, a short course may be beneficial.

Early nephrologist involvement in hospital-acquired acute kidney injury: a pilot study.

BACKGROUND: The optimal timing of nephrology consultation in patients with hospital-acquired acute kidney injury (AKI) is unknown. STUDY DESIGN: Prospective controlled nonrandomized intervention study. SETTING & PARTICIPANTS: We screened daily serum creatinine (SCr) levels of 4,296 patients admitted to the St. Louis Veterans Affairs Medical Center between September and November 2008 (control group) and January to May 2009 (intervention group). 354 patients (8.2%) met the definition of in-hospital AKI (SCr level increase of 0.3 mg/dL over 48 hours); 176 of whom met all inclusion criteria; 85 and 91 patients were enrolled in the control (standard care) and intervention groups, respectively. INTERVENTION: Early renal service involvement (EARLI), defined as a 1-time nephrology consultation within 18 hours of the onset of AKI. OUTCOME: Primary outcome defined as 2.5-fold increase in SCr level from admission. MEASUREMENT: Daily SCr until discharge. RESULTS: The 2 groups had similar characteristics at baseline and at the time of AKI. The intervention was completed at a mean of 13.1 ± 0.8 hours from the onset of AKI. Nephrology recommendations in the EARLI group included specific diagnostic, therapeutic, and preventative components. The primary outcome occurred in 12.9% of patients in the control group compared with 3.3% of patients in the EARLI group (P = 0.02). Patients in the EARLI group had a lower peak SCr level of 1.8 ± 0.1 versus 2.1 ± 0.2 mg/dL in controls (P = 0.01). LIMITATIONS: Single-center nonrandomized study of mostly US male veterans. CONCLUSIONS: Early nephrologist involvement in patients with AKI may reduce the risk of a further decrease in kidney function. A larger randomized trial is needed to confirm the findings.

Renal allograft biopsies in the era of C4d staining: the need for change in the Banff classification system.

C4d immunostaining in the peritubular capillaries (PTC) is a marker of antibody-mediated rejection (AMR). We evaluated the histopathologic diagnoses of 388 renal transplant biopsies since the implementation of routine C4d immunostaining at our center. Of these, 155 (40%) biopsies had evidence of acute cellular rejection (ACR), out of which 119 (77%) had pure ACR, 31 (20%) had ACR with concomitant features of AMR, and five (3%) had ACR with focal C4d staining. Sixty-four (16%) biopsies exhibited features of AMR [33 (52%) pure AMR, and 31(48%) concomitant AMR and ACR]. One hundred and fifty-five (40%) biopsies had features of interstitial fibrosis and tubular atrophy (IFTA). Of these, 20 (13%) had concomitant AMR [13 (8.5%) had pure AMR and seven (4.5%) had concomitant ACR and AMR]. Creatinine at the time of biopsy was higher in patients with mixed ACR and AMR and the clinical behavior of mixed lesions is more aggressive over time. Despite having a lower serum creatinine at the time of biopsy, patients with IFTA experienced gradual decline in graft function over time. The pathologic findings in renal allograft biopsies are often mixed and mixed lesions appear to have more aggressive clinical behavior. These findings suggest the need for change in the Banff classification system to better capture the complexity of renal allograft pathologies.