Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study.

INTRODUCTION: Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland. AIM: The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed. METHODS: All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively. RESULTS: 20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome. CONCLUSION: Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Supratherapeutic dabigatran: a cause of life-threatening haemorrhage.

In this case report, we present a rare case of life-threatening gastrointestinal haemorrhage associated with deranged coagulation due to supratherapeutic levels of dabigatran. Dabigatran is a potent, synthetic, reversible non-peptide thrombin inhibitor which is increasingly used for stroke prevention in patients with non-valvular atrial fibrillation. It is generally accepted that dabigatran dosing does not require titration or the monitoring of plasma levels due to its predictable pharmacokinetics and pharmacodynamics. However, this case report challenges this viewpoint while identifying an important knowledge gap in relation to the effect of altered gastrointestinal motility on the absorption of direct oral anticoagulants. Furthermore, it demonstrates the successful use of high-dose idarucizumab in a critical care setting. Idarucizumab is a monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.

Traumatic thoracoabdominal hernia repair using a novel chest-wall reconstruction technique: a case report.

Thoracoabdominal hernia following blunt trauma is extremely rare. Abdominal viscera are more likely to herniate into the thorax if there is traumatic diaphragmatic rupture. We report the case of a patient presenting with a traumatic thoracoabdominal hernia containing part of the right lobe of the liver and the hepatic flexure of the colon. The hernia migrated cranially, to protrude through a seventh intercostal defect despite the diaphragm remaining fully intact. The need for early multispecialty (thoracic and hepatobiliary) surgical repair is highlighted, with improvements in surgical outcome for a complex trauma case by using a novel chest-wall reconstruction technique.

Mesenteric lipodystrophy - An unusual intraabdominal mass.

INTRODUCTION: We report the case of a 21 year old female with underlying facial lipodystrophy who presented with left lower abdominal pain, weight gain and altered bowel habit. PRESENTATION OF CASE: Subsequent investigation showed a large (21cm×18cm×8cm) intraabdominal mass. At laparotomy, it was completely excised and was seen to arise from the transverse mesocolon and following histology revealed it to be mesenteric lipodystrophy. DISCUSSION: Mesenteric lipodystrophy is a rare clinical entity, and part of a spectrum of disorders of sclerosing mesenteritis. This is the first reported case in a patient with pre-existing facial lipodystrophy. CONCLUSION: Herein we describe a case of mesenteric lipodystrophy, discuss its management and review of the literature.

Isolated first rib fracture with minimal trauma.

BACKGROUND: The traditional teaching states that upper rib fractures are associated with severe trauma and a high risk of neurovascular insult. MATERIAL AND METHODS: We present the case of an 18-year-old male who sustained an isolated, uncomplicated fracture of the first rib by falling on his elbow during a soccer match. CONCLUSION: This case illustrates that an uncomplicated upper rib fracture can occur with minor trauma. The term "rebound" fracture is proposed for this type of rib injury.

The random blood glucose level, a risk factor for mortality after acute myocardial infarction, in non-diabetic patients.

The Correlation between blood glucose level and cardio-vascular events is well established in diabetic patients. In this study, fifty three non diabetic (M:30F:23), patients after acute myocardial infarction were studied for mortality in the following two years, retrospectively. Every patient had random venous glucose estimated on admission. This glucose level was correlated with all cause mortality. At the end of 2 years, 13 patients died and 40 remained alive. There was a significant difference of blood glucose between those who died and remained alive. The difference between the mean blood glucose level is between 0.6 mmol/L and 3.8 mmol/L higher for patients who died (mean = 8.62); compared with those that were still alive (mean = 6.69). This difference was particularly observed in the group of anterior wall infarction. The subgroup analysis also revealed that the difference between the mean blood glucose levels is 9 mmol/L for female patients with heart failure compared with those who did not suffer from heart failure (mean 6.8). The study concludes that, the higher glucose level is associated with increased all cause mortality in the following 2 years of first acute myocardial infarction.

Assessing the written information given to families prior to their attendance at a child development centre.

This paper describes an analysis of the written information given to parents of pre-school children with developmental delay prior to their attendance at a Child Development Centre. Texts were analysed for their readability and human interest, and the usefulness of the information was assessed through consultation with parent consumers. The discussion of the results includes suggestions for staff who are involved in the development of client leaflets and booklets.