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1.
J Ultrasound ; 2020 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-32356219

RESUMO

De Garengeot's hernia is a rare condition defined by the herniation of the vermiform appendix within a femoral hernia sac. We report a case of an 80-year-old woman admitted to our emergency department complaining of pain in the right groin. This symptomatology, present for 2 days, increased in the following 12 h. Ultrasonography (US) and contrast-enhanced computed tomography (CECT) were performed, which showed the herniation of the vermiform appendix in the femoral hernia sac. Doppler ultrasonography (DUS) and CECT were the fundamental imaging investigations for this diagnosis. The management of De Garengeot's hernia is surgical through herniorrhaphy, which makes it possible to repair the femoral hernia and perform an appendicectomy in case of appendicitis.

2.
Ned Tijdschr Geneeskd ; 1642020 May 14.
Artigo em Holandês | MEDLINE | ID: mdl-32406636

RESUMO

Recently, the revised guideline 'Guideline for diagnostics and treatment of acute appendicitis' was published by the Dutch Surgical Society. A patient with limited clinical symptoms and low suspicion of appendicitis can be assessed again at a later time, during which ultrasound diagnostics can be repeated. Following an inconclusive ultrasound scan in children who possibly have appendicitis, it is no longer recommended to perform diagnostic laparoscopy; rather, MRI diagnostics are indicated. In young adults with possible appendicitis, in whom a diagnosis cannot be established using ultrasound, the advice is to use MRI diagnostics instead of CT imaging; this particularly applies to women of child-bearing age. For patients with appendicitis an appendectomy remains the recommended treatment, although one can consider treating adults with suspected simple appendicitis with antibiotics alone. It is important that this decision is made in consultation with the patient. Laparoscopic appendectomy reduces the number of wound infections and admission length, and is therefore usually preferred over open method appendectomy. If a patient with appendicitis is 24-28 weeks pregnant,consultation with a specialist centre is indicated regarding the obstetric management and possibly referral.

3.
AJR Am J Roentgenol ; : 1-6, 2020 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-32406773

RESUMO

OBJECTIVE. The objective of our study was to determine the accuracy of ultrasound (US) and CT in diagnosing appendicitis at our institution while taking into account the number of indeterminate examinations in accordance with the Standards for Reporting Diagnostic Accuracy (STARD) guidelines. MATERIALS AND METHODS. We retrospectively evaluated 790 patients who underwent US, CT, or both for evaluation of suspected appendicitis between May 1, 2013, and April 30, 2015. Patient characteristics and US and CT examination results were recorded. The reference standard was histopathology or 3 months of medical record follow-up if surgery was not performed; 3 × 2 tables were generated, and sensitivity, specificity, overall test yield, and accuracy were calculated according to STARD guidelines. For surgical cases, time to surgery (one-way ANOVA) was compared among patients who underwent US alone, CT alone, or both US and CT. RESULTS. A total of 473 of 562 US examinations had indeterminate findings (overall test yield, 15.8%); sensitivity and specificity in the 89 diagnostic examinations were 98.5% and 54.2%, respectively. Thirteen of 522 CT examinations were indeterminate (overall test yield, 97.5%); sensitivity and specificity in the remaining 509 CT examinations were 98.9% and 97.2%, respectively. Taking indeterminate studies into account, the accuracy was 13.7% for US and 95.6% for CT. The negative appendectomy rates were 17.7% (11/62) for US and 3.3% (9/276) for CT (p = 0.0002). Time to surgery was longer for patients who underwent US and CT (mean ± SD, 17.7 ± 8.9 hours) than US alone (12.9 ± 6.4 hours; p = 0.002) but was not longer for patients who underwent CT alone (16.3 ± 8.4 hours; p = 0.45). CONCLUSION. At our institution, a large proportion of US examinations are indeterminate for appendicitis. CT is the preferred first-line imaging test for evaluating appendicitis in nonobstetric adult patients.

4.
Ulus Travma Acil Cerrahi Derg ; 26(3): 389-395, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32436977

RESUMO

BACKGROUND: This study aims to investigate the role of thiol/disulfide homeostasis parameters in the diagnosis of acute appendicitis and to determine whether it is beneficial to use these parameters in combination with the modified Alvarado and RIPASA scoring systems. METHODS: This study was prospectively carried out on 265 patients who presented to the emergency department with the complaint of right lower quadrant pain between 01.07.2017 and 31.12.2017, and met the inclusion criteria of this study. Oxidative stress markers were evaluated on two groups. The relationship between these parameters and the modified Alvarado and RIPASA scoring systems was analyzed. RESULTS: The mean levels of disulfide, disulfide/native thiol and disulfide/total thiol were found to be significantly higher in the appendicitis group (p<0.001). The mean levels of native thiol, total thiol and native thiol/total thiol were significantly lower in the same group (p<0.001, 0.001 and 0.007, respectively). The mean levels of disulfide, disulfide/native thiol and disulfide/total thiol were recorded to be significantly higher in the high-risk group according to the results of RIPASA (p=0.016, 0.003 and 0.001, respectively). CONCLUSION: Thiol/disulfide homeostasis parameters can be used with the modified Alvarado and RIPASA scoring systems in the diagnosis of acute appendicitis.

5.
Biomed Res Int ; 2020: 3896263, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32337245

RESUMO

Acute appendicitis is one of the most common acute abdomens, but the confident preoperative diagnosis is still a challenge. In order to profile noninvasive urinary biomarkers that could discriminate acute appendicitis from other acute abdomens, we carried out mass spectrometric experiments on urine samples from patients with different acute abdomens and evaluated diagnostic potential of urinary proteins with various machine-learning models. Firstly, outlier protein pools of acute appendicitis and controls were constructed using the discovery dataset (32 acute appendicitis and 41 control acute abdomens) against a reference set of 495 normal urine samples. Ten outlier proteins were then selected by feature selection algorithm and were applied in construction of machine-learning models using naïve Bayes, support vector machine, and random forest algorithms. The models were assessed in the discovery dataset by leave-one-out cross validation and were verified in the validation dataset (16 acute appendicitis and 45 control acute abdomens). Among the three models, random forest model achieved the best performance: the accuracy was 84.9% in the leave-one-out cross validation of discovery dataset and 83.6% (sensitivity: 81.2%, specificity: 84.4%) in the validation dataset. In conclusion, we developed a 10-protein diagnostic panel by the random forest model that was able to distinguish acute appendicitis from confusable acute abdomens with high specificity, which indicated the clinical application potential of noninvasive urinary markers in disease diagnosis.

6.
BMC Pediatr ; 20(1): 151, 2020 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-32248803

RESUMO

BACKGROUND: Unusual clinical presentation of acute appendicitis in preschool children leads to misdiagnosis and complications. We aimed to analyze the influence of age on clinical presentation, laboratory findings and complications in preschool children with acute appendicitis. METHODS: From January 2012 until December 2017, 29 children younger than 6 years of age (median 50 months) with acute appendicitis were enrolled in this retrospective study. Patients were grouped according to their age: group 1: < 48 months (n = 13); group 2: > 48 months (n = 16), their clinical data, laboratory results and complications were compared. RESULTS: In group 1, duration of nausea and vomiting was longer, alteration of general state was more frequent and pain in the right fossa iliaca less frequent than in group 2 (p = 0.026, p = 0.000 and p = 0.029, respectively). Heart rate was higher in group 1 than in group 2 (p = 0.012). Leucocyte and polynuclear neutrophil counts were lower in group 1 than in group 2 (p = 0.028 and = 0.004, respectively) but C-reactive protein levels were not different between groups. In the whole cohort however, C-reactive protein at admission value correlated negatively with age (p = 0.025). Abdominal ultrasound allowed diagnosis in 19/29 patients (65.5%), without any difference between groups. Appendicular perforation was more frequent in group 1 than in group 2 (p = 0.003). Perforation was also related to longer hospital stay (p = 0.018). Peritonitis occurred in 21/29 (72%), post-operative ileus in 5/29 (17%) and sepsis in 4/29 (14%) patients without any difference between groups. In the whole cohort, hospital stay correlated negatively with age (p = 0.000). There was no mortality. CONCLUSIONS: Among preschool children, those younger than 48 months present with longer duration of pre-admission symptoms indicating longer infection course than in older children. Altered general state and higher degree of tachycardia in the younger reflect higher systemic repercussions of the illness. Less specific abdominal pain and dissociation of the inflammatory markers with lower leucocyte- and neutrophil counts and higher C-reactive protein levels in the younger may contribute to further diagnosis delay and higher rate of perforation in these patients.

7.
Emerg Med Clin North Am ; 38(2): 383-400, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32336332

RESUMO

More than half of pediatric malpractice cases arise from emergency departments, primarily due to missed or delayed diagnoses. All providers who take care of children in emergency departments should be aware of this risk and the most common diagnoses associated with medicolegal liability. This article focuses on diagnosis and management of high-risk diagnoses in pediatric patients presenting to emergency departments, including meningitis, pneumonia, appendicitis, testicular torsion, and fracture. It highlights challenges and pitfalls that may increase risk of liability. It concludes with a discussion on recognition and management of abuse in children, including when to report and decisions on disposition.


Assuntos
Emergências , Imperícia , Gestão de Riscos , Adolescente , Fatores Etários , Apendicite/diagnóstico , Apendicite/terapia , Criança , Maus-Tratos Infantis/diagnóstico , Maus-Tratos Infantis/terapia , Pré-Escolar , Medicina de Emergência/legislação & jurisprudência , Medicina de Emergência/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Meningite/diagnóstico , Meningite/terapia , Pneumonia/diagnóstico , Pneumonia/terapia , Torção do Cordão Espermático/diagnóstico , Torção do Cordão Espermático/terapia , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia
8.
Pediatr Surg Int ; 36(6): 735-742, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32314055

RESUMO

INTRODUCTION: There is a tendency toward nonoperative management of appendicitis resulting in an increasing need for preoperative diagnosis and classification. For medical purposes, simple conceptual decision-making models that can learn are widely used. Decision trees are reliable and effective techniques which provide high classification accuracy. We tested if we could detect appendicitis and differentiate uncomplicated from complicated cases using machine learning algorithms. MATERIALS AND METHODS: We analyzed all cases admitted between 2010 and 2016 that fell into the following categories: healthy controls (Group 1); sham controls (Group 2); sham disease (Group 3), and acute abdomen (Group 4). The latter group was further divided into four groups: false laparotomy; uncomplicated appendicitis; complicated appendicitis without abscess, and complicated appendicitis with abscess. Patients with comorbidities and whose complete blood count and/or pathology results were lacking were excluded. Data were collected for demographics, preoperative blood analysis, and postoperative diagnosis. Various machine learning algorithms were applied to detect appendicitis patients. RESULTS: There were 7244 patients with a mean age of 6.84 ± 5.31 years, of whom 82.3% (5960/7244) were male. Most algorithms tested, especially linear methods, provided similar performance measures. We preferred the decision tree model due to its easier interpretability. With this algorithm, we detected appendicitis patients with 93.97% area under the curve (AUC), 94.69% accuracy, 93.55% sensitivity, and 96.55% specificity, and uncomplicated appendicitis with 79.47% AUC, 70.83% accuracy, 66.81% sensitivity, and 81.88% specificity. CONCLUSIONS: Machine learning is a novel approach to prevent unnecessary operations and decrease the burden of appendicitis both for patients and health systems. LEVELS OF EVIDENCE: III.

9.
Medicine (Baltimore) ; 99(14): e19807, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32243414

RESUMO

RATIONALE: Very severe aplastic anemia (vSAA) with active infections is always fatal. Adequate infection control before hematopoietic stem cell transplantation is recommended. PATIENT CONCERNS: A 38-year-old woman with vSAA suffered from acute perforated appendicitis and invasive pulmonary fungal infection, and she failed to respond to intense antimicrobial therapies. DIAGNOSIS: She was diagnosed with refractory vSAA with stubborn acute perforated appendicitis and invasive pulmonary fungal infection. INTERVENTIONS: We successfully completed an emergent reduced intensity conditioning-matched unrelated donor (MUD)-peripheral blood stem cell transplantation (PBSCT) as a salvage therapy in the presence of active infections. The conditioning regimens consisted of reduced cyclophosphamide 30 mg/kg/day from day-5 to day-3, fludarabine 30 mg/m/day from day-5 to day-3 and porcine-antilymphocyte immunoglobulin 15 mg/kg/day from day-4 to day-2 without total body irradiation. Cyclosporin A, mycophenolate mofetil and short-term methotrexate were administered as graft-versus-host disease (GVHD) prophylaxis. Neutrophils and platelets were engrafted on day+15 and day+21. Appendiceal abscess and severe pneumonia developed after neutrophil engraftment, which were successfully managed with intense antimicrobial therapy and surgical intervention. OUTCOMES: Only limited cutaneous chronic GVHD was observed 5 months after transplantation. The patient still lives in a good quality of life 2 years after transplantation. LESSONS: Active infections may be no longer a contraindication to hematopoietic stem cell transplantation for some patients with vSAA.


Assuntos
Anemia Aplástica/terapia , Transplante de Células-Tronco de Sangue Periférico/métodos , Doença Aguda , Adulto , Anemia Aplástica/microbiologia , Apendicite/microbiologia , Feminino , Humanos , Pneumopatias Fúngicas/microbiologia , Doadores não Relacionados
10.
Acad Emerg Med ; 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32239713

RESUMO

OBJECTIVES: Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. METHODS: This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. RESULTS: Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). CONCLUSION: Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.

11.
Eur Radiol ; 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32240354

RESUMO

OBJECTIVES: To test whether the difference in sensitivity or specificity between 2-mSv CT and conventional-dose CT (CDCT) for the diagnosis of appendicitis differs across subgroups of adolescents and young adults with suspected appendicitis. MATERIALS AND METHODS: We used the per-protocol analysis data of a trial conducted between Dec 2013 and Aug 2016, including 2773 patients (median age [interquartile range], 28 [21-35] years) and 160 radiologists from 20 hospitals. We defined subgroups by sex, body size, clinical risk scores for appendicitis, time of CT examination (i.e., working vs. after hours), CT machines, radiologists' experience, previous site experience in 2-mSv CT, and site practice volume. We drew forest plots and tested for additive or multiplicative interaction between radiation dose and subgroup attributes. If any subgroup had fewer than 200 patients, we considered the results from that subgroup not meaningful. RESULTS: For most subgroups, the 95% CIs for the differences in sensitivity and specificity were 4.0 percentage points or narrower and contained the minute overall between-group differences. There was no significant interaction on sensitivity or specificity. A few subgroups, including those of extreme body sizes, high appendicitis inflammatory response scores, and hospitals with small appendectomy volume, were regarded to have insufficient numbers of patients. CONCLUSIONS: There was no notable subgroup heterogeneity, which implies that 2-mSv CT can replace CDCT in diverse populations. Further studies are needed for the subgroups for which we had only small data. KEY POINTS: • The minute difference in sensitivity or specificity between the 2-mSv CT and conventional-dose CT (typically 7 mSv) groups were consistent across various patient or hospital characteristics. • These results indicate that 2-mSv CT can replace conventional-dose CT in diverse populations. • Further studies are needed to confirm whether 2-mSv CT can replace conventional-dose CT in patients of extreme body sizes, high appendicitis inflammatory response scores, or hospitals with small appendectomy volume, as those subgroups in our data included limited numbers of patients.

12.
World J Emerg Surg ; 15(1): 27, 2020 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-32295644

RESUMO

BACKGROUND AND AIMS: Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS: This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS: The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

13.
Sci Rep ; 10(1): 3958, 2020 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-32127625

RESUMO

The development of deep learning algorithms for complex tasks in digital medicine has relied on the availability of large labeled training datasets, usually containing hundreds of thousands of examples. The purpose of this study was to develop a 3D deep learning model, AppendiXNet, to detect appendicitis, one of the most common life-threatening abdominal emergencies, using a small training dataset of less than 500 training CT exams. We explored whether pretraining the model on a large collection of natural videos would improve the performance of the model over training the model from scratch. AppendiXNet was pretrained on a large collection of YouTube videos called Kinetics, consisting of approximately 500,000 video clips and annotated for one of 600 human action classes, and then fine-tuned on a small dataset of 438 CT scans annotated for appendicitis. We found that pretraining the 3D model on natural videos significantly improved the performance of the model from an AUC of 0.724 (95% CI 0.625, 0.823) to 0.810 (95% CI 0.725, 0.895). The application of deep learning to detect abnormalities on CT examinations using video pretraining could generalize effectively to other challenging cross-sectional medical imaging tasks when training data is limited.

14.
World J Emerg Surg ; 15(1): 19, 2020 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-32156296

RESUMO

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

15.
J Invest Surg ; : 1-15, 2020 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-32167385

RESUMO

Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

16.
Medicine (Baltimore) ; 99(10): e19358, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32150076

RESUMO

INTRODUCTION: Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR > 1.7 or PT > 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9. PATIENT CONCERNS: A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92. DIAGNOSIS: Acute ischemic stroke. INTERVENTIONS: The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered. OUTCOME: The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life. CONCLUSION: The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients.


Assuntos
Segurança do Paciente/normas , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/normas , Varfarina/efeitos adversos , Idoso , Apendicite/complicações , Apendicite/cirurgia , Feminino , Fibrinolíticos/normas , Fibrinolíticos/uso terapêutico , Humanos , Coeficiente Internacional Normatizado/métodos , Complicações Pós-Operatórias/tratamento farmacológico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/métodos , Resultado do Tratamento , Varfarina/uso terapêutico
17.
Ulus Travma Acil Cerrahi Derg ; 26(2): 191-196, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32185759

RESUMO

BACKGROUND: Acute appendicitis (AA) is one of the major causes of acute abdomen pain. Various laboratory markers have been studied for diagnosis of AA, but none of them have shown superiority to physical examination or imaging. GCP-2/CXCL6 is a chemokine expressed by macrophages and epithelial and mesenchymal cells during inflammation. The present study aims to investigate the diagnostic role of GCP-2/CXCL6 in AA patients. METHODS: In this cross-sectional study, the serum level of GCP-2/CXCL6 was measured in 56 AA patients and 32 healthy control subjects. Also, hs-CRP and white blood cell count (WBC) levels of the patient and control groups were evaluated. RESULTS: GCP-2/CXCL-6, hs-CRP and WBC levels of the AA group were significantly higher than the control group (p<0.05 for all comparisons). Among AA group, GCP-2/CXCL6 levels were higher in complex AA (gangrenous, abscess and perforation) ones when compared to non-complex AA (p<0.05). A strong positive correlation was found between GCP-2/CXCL6 levels and hs-CRP levels (r=0.756, p=0.003) and a moderate positive correlation between GCP-2/CXCL6 levels and WBC count (r=0.468, p=0.003). CONCLUSION: GCP-2/CXCL6 can be a useful marker in AA diagnosis and discrimination of complex cases, especially if combined with other laboratory markers and imaging techniques.

19.
West Afr J Med ; 37(2): 183-188, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32150638

RESUMO

BACKGROUND: Laparoscopic surgery is a relatively new and expanding field of surgical therapy in Ondo state. This is a multi-centre study cataloguing the work of the authors in Ondo State, Nigeria. AIM: To determine the indications, operative findings, and interventions at Laparoscopy in our resource challenged settings. PATIENTS AND METHODS: Medical records of all patients who had laparoscopic procedure at the Federal Medical Centre, Owo, Ondo State Specialist hospital, Okitipupa, University of Medical Sciences Teaching Hospital, Ondo, George and Martins Medical Centre, Ore and Mishmael Hospitals and Clinics, Akure from December, 2009 to December, 2018 were reviewed. Data on patient's age, gender, indications for surgery, duration of hospital stay, outcome of surgery were analyzed. Challenges and adaptations were also noted. RESULTS: One hundred and eighty-one (181) laparoscopic procedures were done, but only 152 had complete records for review. The median age was 35.5 years (mean = 33.7±11.4years; age range of 8 month -72 years). There were more males 88(57.9%) than females, 64(42.1%). Laparoscopy was purely diagnostic (n=28,18.4%), therapeutic (n=118, 77.6%) or both (n=6, 3.9%). Cholecystectomy (n=76, 50%) and appendicectomy (n=37, 24.3%) were the two most common procedures done. In the paediatric patients, patent processus vaginalis (hernia), cryptorchidism and indeterminate sex (gender) were common indication. Challenges encountered were power failure (n=3, 2%), equipment failure (n=4, 2.6%) and difficult dissection (n=4, 2.6%). The mean duration of surgery was 96.96(±25) minutes (diagnostic), 150 (±57.6) minutes (therapeutic); while the mean duration of hospital stay was one day (diagnostic) and 2.3(±1.7) days for therapeutic interventions. CONCLUSION: Laparoscopic service is achievable with adequate motivation, males appear to benefit more in our setting, and the service transcends all aged groups.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Colecistectomia Laparoscópica/métodos , Doenças da Vesícula Biliar/cirurgia , Laparoscopia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Colecistectomia , Feminino , Hospitais Especializados , Hospitais de Ensino , Humanos , Lactente , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Nigéria , Complicações Pós-Operatórias , Adulto Jovem
20.
JAMA Netw Open ; 3(3): e200612, 2020 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-32150270

RESUMO

Importance: Appendicitis may be missed during initial emergency department (ED) presentation. Objective: To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. Design, Setting, and Participants: In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis. Main Outcomes and Measures: Potentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis. Results: Of 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, 3.23-4.14; fever, AOR, 5.00; 95% CI, 3.79-6.60; diarrhea, AOR, 4.27; 95% CI, 3.39-5.38; and constipation, AOR, 4.17; 95% CI, 3.08-5.65; children, abdominal pain, AOR, 2.42; 95% CI, 1.93-3.05; nausea and/or vomiting, AOR, 2.55; 95% CI, 1.89-3.45; fever, AOR, 4.12; 95% CI, 2.71-6.25; diarrhea, AOR, 2.17; 95% CI, 1.18-3.97; and constipation, AOR, 2.19; 95% CI, 1.30-3.70) were more likely to have missed appendicitis. Adult patients who received computed tomographic scans at the initial ED visit (abdominal pain, AOR, 0.58; 95% CI, 0.52-0.65; nausea and/or vomiting, AOR, 0.63; 95% CI, 0.52-0.75; fever, AOR, 0.41; 95% CI, 0.29-0.58; diarrhea, AOR, 0.83; 95% CI, 0.58-1.20; and constipation, AOR, 0.60; 95% CI, 0.39-0.94) were less likely to have missed appendicitis. Conclusions and Relevance: Regardless of age, a missed diagnosis of appendicitis was more likely to occur in women, patients with comorbidities, and patients who experienced abdominal pain accompanied by constipation. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.

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