Twice Bitten, Thrice Shy: A Case of Recurrent Isolated Cardiac Sarcoidosis in the Transplanted Heart.

We present a case of recurrent isolated cardiac sarcoidosis, 3 years post-heart transplantation. The case highlights the scarcity of data on the utility of immunosuppression in cardiac sarcoidosis and, in particular, raises questions about the optimal immunosuppression regimen in transplant recipients. (Level of Difficulty: Advanced.).

Vitamin C deficiency in an Australian cohort of metropolitan surgical patients.

Vitamin C is an essential micronutrient in the human diet. While large population studies measuring vitamin C have been performed in other countries, there are few studies of deficiency in the Australian population. This study aimed to quantify vitamin C deficiency, identify scorbutic symptoms and examine dietary associations in a cohort of preoperative general surgical patients. Vitamin C levels were determined in a cohort of patients referred to a single surgeon between January 2011 and December 2013. Baseline data were collected along with data on fruit consumption, weekly citrus fruit intake and presence of scorbutic symptoms. A total of 309 patients were included in the study and 21.4% of our cohort showed a vitamin C level ≤11.4 µmol/L (deficient). Mean citrus fruit intake was significantly higher in the normal vitamin C groups (>28.4 µmol/L) and patients with vitamin C levels ≤28.4 were more likely to consume no fruit (p=0.0004) which was also significant on multivariate analysis. Neither age nor gender appeared predictive of suboptimal vitamin C levels. No symptoms were significantly related to vitamin C levels on multivariate analysis. Vitamin C deficiency was common in Australian adults attending a surgical practice within south western Sydney. Review of the Australian recommended daily allowance for vitamin C is suggested, not only in clinically well patients but particularly in ICU and hospital inpatients. Larger studies examining the prevalence and impact of vitamin C deficiency in the Australian population are required to further investigate these findings.

Unusual presentation of left sided acute appendicitis in elderly male with asymptomatic midgut malrotation.

INTRODUCTION: Acute appendicitis in the setting of midgut malrotation is uncommon. Midgut malrotation commonly presents within the first month of life. A minority remain asymptomatic and may present with concomitant abdominal pathology making diagnosis difficult. PRESENTATION OF CASE: This paper reports a rare case of a 73-year-old male diagnosed with acute appendicitis and asymptomatic MM .The patient underwent a laparoscopic appendectomy, but had an unplanned return to theatre for washout of post-operative intra-abdominal haematoma. DISCUSSION: Midgut malrotation is commonly described by the stringer classification and type 1a is the most common in adults. There have only been a handful of documented cases of acute appendicitis with midgut malrotation occurring in the adult population. Previous delay in diagnosis has led to a delay in definitive management. Both laparoscopic and open surgery has been used in the past. CONCLUSION: Acute appendicitis with malrotation should be considered in elderly patients presenting with atypical signs and symptoms. Imaging offers significant advantage for timely and definitive management.

Plain Radiography May Be Safely Omitted for Selected Major Trauma Patients Undergoing Whole Body CT: Database Study.

Introduction. Whole body CT is being used increasingly in the primary survey of major trauma patients. We evaluated whether omitting plain films of the chest and pelvis in the primary survey was safe. We compared the probability of survival of patients and time to CT who had plain X-rays to those who did not. Method. We performed a database study on major trauma patients admitted between 2008 and 2010 using data from Trauma, Audit and Research Network (TARN) and our PACS system. We included adult major trauma patients who has an ISS of greater than 15 and underwent whole body CT. Results. 245 patients were included in the study. 44 (17.9%) did not undergo plain films. The median time to whole body CT from the time of admission was longer (47 minutes) in patients having plain films, than those who did not have plain films performed (30 minutes), P < 0.005. Mortality was increased in the group who received plain films, 9.5% compared to 4.5%, but this was not statistically significant (P = 0.77). Conclusion. We conclude that plain films may be safely omitted during the primary survey of selected major trauma patients.