Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review.

Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.

Clinical and morphological symptoms of gangrenous appendicitis in children with laboratory-confirmed novel coronavirus infection

Over recent years, amid the novel coronavirus disease (COVID-19) pandemic the prevalence of appendicitis in children has increased. However, its morphological characteristics are not described completely. The article elucidates clinical and morphological features of gangrenous appendicitis in hospitalized children with laboratory-confirmed COVID-19 diagnosis. The authors present the clinical, laboratory, instrumental and morphological findings in schoolchildren with gangrenous appendicitis associated with SARS-CoV-2, confirmed by nasopharyngeal swab PCR-testing. The disease was characterized by an acute onset, rapid development of abdominal pain syndrome and typical inflammatory changes in the clinical blood analysis: moderate leukocytosis (15.6×109/l), pronounced neutrophilia (82.2%), and thrombocytopenia (103 to 144×109/l). All patients had echographic signs of inflammatory transformation of the appendix which was removed on the first day of hospitalization (the first day of the disease) by laparoscopic technique. The examination of the removed biomaterial revealed a tendency to thrombosis in the small vessels of the process and ulcerative changes accompanied by necrosis. There is a discussion of the relationship between the development of gangrenous appendicitis and the clinical course of COVID-19 infection. It is necessary to continue investigations, perform in-depth analysis of the factors causing pathological changes, and to clarify the role of SARS-CoV-2 disease with the aim of preventing the spread of COVID-19. © 2023, Meditsina-Inform LLC. All rights reserved.

Atrio-Ventricular Conduction Abnormalities in Multisystem Inflammatory Syndrome in Children

Purpose of study Since mid-April 2020 in Europe and North America, clusters of pediatric cases with a newly described severe systemic inflammatory response with shock have appeared. Patients had persistent fevers >38.5 C, hypotension, features of myocardial dysfunction, coagulopathy, gastrointestinal symptoms, rash, and elevated inflammatory markers without other causes of infection. The World Health Organization, Centers for Disease Control, and Royal College of Paediatrics associated these symptoms with SARS-CoV-2 as multisystem inflammatory syndrome in children (MIS-C). Cardiac manifestations include coronary artery aneurysms, left ventricular systolic dysfunction evidenced by elevation of troponin-T (TnT) and pro-B-type naturietic peptide (proBNP), and electrocardiogram (ECG) abnormalities. We report the clinical course of three children with MIS-C while focusing on the unique atrioventricular (AV) conduction abnormalities. Case #1:19-year-old previously healthy Hispanic male presented with abdominal pain, fever, and non-bloody diarrhea for three days. He was febrile and hypotensive (80/47 mmHg) requiring fluid resuscitation. Symptoms, lab findings, and a positive COVID-19 antibody test were consistent with MIS-C. Methylprednisolone, intravenous immunoglobulin (IVIG), and enoxaparin were started. He required epinephrine for shock and high flow nasal cannula for respiratory distress. Initial echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with normal appearing coronaries. Troponin and proBNP were 0.41 ng/mL and proBNP 15,301 pg/mL respectively. ECG showed an incomplete right bundle branch block. He eventually became bradycardic to the 30s-50s and cardiac tracing revealed a complete AV block (figure 1a). Isoproterenol, a B1 receptor agonist, supported the severe bradycardia until the patient progressed to a type 2 second degree AV block (figure 1b). A second dose of IVIG was administered improving the rhythm to a type 1 second degree AV block. An IL-6 inhibitor, tocilizumab was given as the rhythm would not improve, and the patient soon converted to a first-degree AV block. Cardiac magnetic resonance imaging showed septal predominant left ventricular hypertrophy and subepicardial enhancement along the basal inferior/anteroseptal walls typical for myocarditis. Case #2: 9-year-old previously healthy Hispanic male presented after three days of daily fevers, headaches, myalgias, diffuse abdominal pain, and ageusia. He was febrile, tachycardic, and hypotensive (68/39 mmHg). Hypotension of 50s/20s mmHg required 3 normal saline boluses of 20 ml/kg and initiation of an epinephrine drip. Severe hypoxia required endotracheal intubation. After the MIS-C diagnosis was made, he was treated with IVIG, mehtylprednisolone, enoxaparin, aspirin, and ceftriaxone. Due to elevated inflammatory markers by day 4 and patient's illness severity, a 7-day course of anakinra was initiated. Initial echocardiogram showed mild tricuspid and mitral regurgitation with a LVEF of 35-40%. Despite anti-inflammatory therapy, troponin and proBNP were 0.33 ng/mL and BNP of 25,335 pg/mL. A second echocardiogram confirmed poor function so milrinone was started. Only, after two doses of anakinra, LVEF soon normalized. Despite that, he progressively became bradycardic to the 50's. QTc was prolonged to 545 ms and worsened to a max of 592 ms. The aforementioned therapies were continued, and the bradycardia and QTc improved to 405 ms. Patient #3: 9-year-old African American male presented with four days of right sided abdominal pain, constipation, and non-bilious non-bloody emesis. He had a negative COVID test and unremarkable ultrasound of the appendix days prior. His history, elevated inflammatory markers, and positive COVID- 19 antibody were indicative of MIS-C. He was started on the appropriate medication regimen. Initial ECG showed sinus rhythm with normal intervals and echocardiogram was unremarkable. Repeat imaging by day three showed a decreased LVEF of 50%. ECG had since changed to a right bundle branch block. Anakinra as started and steroid dosing was increased. By day 5, he became bradycardic to the 50s and progressed to a junctional cardiac rhythm. Cardiac function normalized by day 7, and anakinra was subsequently stopped. Thereafter, heart rates ranged from 38-48 bpm requiring transfer to the pediatric cardiac intensive care unit for better monitoring and potential isoproterenol infusion. He remained well perfused, with continued medical management, heart rates improved. Methods used Retrospective Chart Review. Summary of results Non-specific T-wave, ST segment changes, and premature atrial or ventricular beats are the most often noted ECG anomalies. All patients initially had normal ECGs but developed bradycardia followed by either PR prolongation or QTc elongation. Two had mild LVEF dysfunction prior to developing third degree heart block and/or a junctional escape rhythm;one had moderate LVEF dysfunction that normalized before developing a prolonged QTc. Inflammatory and cardiac markers along with coagulation factors were the highest early in disease course, peak BNP occurred at approximately hospital day 3-4, and patient's typically had their lowest LVEF at day 5-6. Initial ECGs were benign with PR intervals below 200 milliseconds (ms). Collectively the length of time from initial symptom presentation till when ECG abnormalities began tended to be at day 8-9. Patients similarly developed increased QTc intervals later in the hospitalization. When comparing with the CRP and BNP trends, it appeared that the ECG changes (including PR and QTc elongation) occurred after the initial hyperinflammatory response. Conclusions Although the mechanism for COVID-19 induced heart block continues to be studied, it is suspected to be secondary to inflammation and edema of the conduction tissue. Insufficiency of the coronary arterial supply to the AV node and rest of the conduction system also seems to play a role. Although our patients had normal ECG findings, two developed bundle branch blocks prior to more complex rhythms near the peak of inflammatory marker values. Based on the premise that MIS-C is a hyperinflammatory response likely affecting conduction tissue, our group was treated with different regimens of IVIG, steroids, anakinra, and/or tocilizumab. Anakinra, being an IL-1 inhibitor, has been reported to dampen inflammation in viral myocarditis and tocilizumab has improved LVEF in rheumatoid arthritis patients. Based on our small case series, patient's with MISC can have AV nodal conduction abnormalities. The usual cocktail of IVIG and steroids helps;however, when there are more serious cases of cardiac inflammation, adjuvant immunosuppresants like anakinra and toculizumab can be beneficial. (Figure Presented).

Appendicular flap transposition in case of the left ureters defects

Introduction & Objectives: The frequency of involvement in the oncological process of the ureters in case of pelvis tumors ranges from 15 to 20%. The use of the appendix as a plastic material for the reconstruction of extended ureteral defects (EUD), including left-sided ones, remains debatable. The main goal of this study is evaluating the clinical and functional results after EUD repair using patchy transposition of the appendix. Material(s) and Method(s): Since August 2019 to June 2021, 8 laparoscopic surgeries were performed to replace the EUD using flap transposition of the appendix. Of these, 6 on the left (75%), 2 on the right (25%). 7 women (87.5%) and 1 man (12.5%) were operated on. Mean age 53+/-10.6 years. Average BMI 25.9 kg/m2. Etiology EUD: 25% radiotherapy (n2), 50% iatrogenic surgery (n4), 12.5% (n1) primary ureteral cancer, 12.5% (n1) non-Hodgkin's lymphoma. In all cases, the first stage was a wide mobilization of the ileocecal angle, the appendix was disconnected with a 45 mm hardware suture, in case of left-sided lesion, the appendix was moved isoperistaltically under the mesentery of the sigmoid colon to the left side after preliminary maximum mobilization of the process on the vascular pedicle in the form of a "triangle". All patients received a 7Fr ureteral stent. CT urography was performed on the 3rd, 7th, 11th days. Dynamic nephroscintigraphy was performed on the 90th day. Result(s): The average length of diastasis is 4.6+/-1.7 cm. The average length of the mobilized appendix was 8+/-1.8 cm. Replacement of the ureter with an appendix and a flap of the bladder according to the Demel method was performed in 1 case (12.5%), according to the Boari method in 1 case (12.5%), in 6 (75%) cases an anastomosis was formed according to the "end-to-end" type. the end". The average duration of the operation was 251+/-40.9 min, blood loss was 121+/-56.7 ml. Median removal of the ureteral stent was 36+/-18.28 days. Duration of hospital stay was 14+/-5.2 days. Median follow-up 10+/-5.3 months. Early complications (<30 days): 2 cases of urinary edema (Clavien-Dindo II), 2 cases of ipsilateral hydronephrosis (Clavien-Dindo I-II). Late complications (>30 days): 1 case of partial failure of ureterocystoanastomosis against the background of Sars-Cov-2 infection (Clavien-Dindo IIIa), 1 case of non-functioning left kidney (Clavien-Dindo IVa). Dynamic nephroscintigraphy was performed in 68.4% of patients, the average isotope accumulation time was 4.23+/-0.25 minutes, the duration of the half-life was 14.26+/-0.52 minutes. Conclusion(s): Flap transposition with the appendix is a technically difficult but possible option for extended ureteral strictures. However, various pathological processes that have developed against the background of previous treatment potentially increase the risk of developing repeated strictures or anastomotic leaks. Therefore, given the small sample of patients, further research on this issue is required.Copyright © 2023.

"Inside out" - An exceptional intussusception

Introduction: We present the first case of appendiceal intussusception associated with myeloid sarcoma in a young patient. Minimally invasive techniques used along the clinical course are highlighted. Case description: A 2.5-year-old boy was admitted after three weeks of COVID-19 infection with ongoing symptoms of MIS-C. Due to constipation, distended belly and vomiting, US was done which showed ileocolic intussusception. After unsuccessful hydrostatic reduction laparoscopic exploration was performed, where the vermiform appendix was found to be thickened and partially intussuscepted into the coecum. The ileocecal region was exteriorized transumbilically. After manual reduction of the intussusception, a long, thickened, fragile appendix was removed. Histopathology revealed myeloid sarcoma. Bone marrow investigation identified acute myeloid leukemia. During the oncological treatment, laparoscopic cholecystectomy was necessary due to cholecystitis and cholelithiasis. The child recovered uneventfully in terms of surgical complications, with good cosmetic result. Conclusion(s): No similar case in childhood was found in the English literature. Unusual symptoms and radiological findings of intussusception can conceal unexpected disorders. Minimally invasive technique offered advantages in the treatment of the presented patient and can be recommended to treat intussusception or cholelithiasis, if applicable, during an ongoing oncological treatment as well.Copyright © 2023 The Authors

Progress of the Panama Meeting of the Convention on International Trade in Endangered Species of Wild Fauna and Flora

Background: The 19th meeting of the Conference of the Parties (CoP 19) to the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) took place in Panama from the 14th to the 25th of November 2022. The meeting was attended by 2,500 delegates representing more than 160 Parties and observers to the Convention. The COVID-19 pandemic impacted all CITES Parties and significantly disrupted the implementation of CITES. The CoP shared the actions and the experiences of the Parties, the Secretariat, the Committee members and observers in the face of the COVID-19 pandemic. Progress: Delegates reviewed 52 proposed amendments to the Appendices and discussed 91 agenda items. There was the highest proportion of proposals for new Appendix II species but the lowest number of revising annotation proposals the CoP 19 has considered in nearly 25 years. The CoP updated the regulation of international trade in over 600 species of animals and plants. In the adopted proposals, international trade in 50 species of freshwater turtles, 158 species of glass frogs, 100 species of sharks and rays, 150 species of trees and dozens of species of roseroots will be regulated as the newly revised lists are enforced. The CoP adopted the financing and the cost of the programme of work for the triennium 2023‒2025, with an overall budget being 6.1% higher compared to the triennium 2020‒2022. The Conference further refined compliance and enforcement requirements for elephants, big cats, totoaba and other wildlife species threatened with extinction. With the implementations of engagement of indigenous peoples and local communities, livelihoods-related issues have been relatively slow and hampered. Parties vigorously debated proposed amendments to the Rules of Procedure and criteria for the amendments of CITES Appendices, but no substantive amendments were adopted. A pilot version of the World Wildlife Trade Report and the Assessment Report on the Sustainable Use of Wild Species: Policy-Maker Summary were discussed and heard. CITES has added several new topics in the CoP to address new challenges, such as the role of CITES in reducing the risk of future zoonotic diseases associated with the international wildlife trade. The CoP 19 recommends interdisciplinary research to analyze the role of CITES in the conservation and sustainable use of forests. The Parties resolved to work on building gender equality into the international trade in wildlife, recognizing that women are often guardians of wildlife and biodiversity but, just as often, are not recognized or benefit from this trade. Prospects: Regardless of the challenges posed by the COVID-19 pandemic, China's CITES authorities made thorough preparations for the CoP, conducting research two years in advance and drafting a proposal a report which was submitted to the CoP 19, organized pre-session and in-session consultations with scientific authorities, collected information from all parties, and actively led the discussions in working groups, presenting a positive view of China in prioritizing ecological civilization and fulfilling its responsibilities as a major country. CITES will celebrate its 50th anniversary in 2023. The record 365 decisions in CoP 19 demonstrate that CITES Parties continue to take action to address the unprecedented pressures on species due to overexploitation and illegal trade. © 2023, Chinese Academy of Sciences. All rights reserved.

Progress of the Panama Meeting of the Convention on International Trade in Endangered Species of Wild Fauna and Flora

Background: The 19th meeting of the Conference of the Parties (CoP 19) to the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) took place in Panama from the 14th to the 25th of November 2022. The meeting was attended by 2,500 delegates representing more than 160 Parties and observers to the Convention. The COVID-19 pandemic impacted all CITES Parties and significantly disrupted the implementation of CITES. The CoP shared the actions and the experiences of the Parties, the Secretariat, the Committee members and observers in the face of the COVID-19 pandemic. Progress: Delegates reviewed 52 proposed amendments to the Appendices and discussed 91 agenda items. There was the highest proportion of proposals for new Appendix II species but the lowest number of revising annotation proposals the CoP 19 has considered in nearly 25 years. The CoP updated the regulation of international trade in over 600 species of animals and plants. In the adopted proposals, international trade in 50 species of freshwater turtles, 158 species of glass frogs, 100 species of sharks and rays, 150 species of trees and dozens of species of roseroots will be regulated as the newly revised lists are enforced. The CoP adopted the financing and the cost of the programme of work for the triennium 2023‒2025, with an overall budget being 6.1% higher compared to the triennium 2020‒2022. The Conference further refined compliance and enforcement requirements for elephants, big cats, totoaba and other wildlife species threatened with extinction. With the implementations of engagement of indigenous peoples and local communities, livelihoods-related issues have been relatively slow and hampered. Parties vigorously debated proposed amendments to the Rules of Procedure and criteria for the amendments of CITES Appendices, but no substantive amendments were adopted. A pilot version of the World Wildlife Trade Report and the Assessment Report on the Sustainable Use of Wild Species: Policy-Maker Summary were discussed and heard. CITES has added several new topics in the CoP to address new challenges, such as the role of CITES in reducing the risk of future zoonotic diseases associated with the international wildlife trade. The CoP 19 recommends interdisciplinary research to analyze the role of CITES in the conservation and sustainable use of forests. The Parties resolved to work on building gender equality into the international trade in wildlife, recognizing that women are often guardians of wildlife and biodiversity but, just as often, are not recognized or benefit from this trade. Prospects: Regardless of the challenges posed by the COVID-19 pandemic, China's CITES authorities made thorough preparations for the CoP, conducting research two years in advance and drafting a proposal a report which was submitted to the CoP 19, organized pre-session and in-session consultations with scientific authorities, collected information from all parties, and actively led the discussions in working groups, presenting a positive view of China in prioritizing ecological civilization and fulfilling its responsibilities as a major country. CITES will celebrate its 50th anniversary in 2023. The record 365 decisions in CoP 19 demonstrate that CITES Parties continue to take action to address the unprecedented pressures on species due to overexploitation and illegal trade. © 2023, Chinese Academy of Sciences. All rights reserved.

Abdominal Pain in the Female Patient: Always Consider Your Differentials

Steadman, L., Coles, K., & Kopf, S. (2023). Abdominal pain in the female patient: Always consider your differentials. Pediatric Nursing, 49(1), 45-47.

Perforated Appendicitis Presenting as a Soft Tissue Infection of the Thigh: An Example of Successful Non-Operative Management.

Perforated appendicitis is a rare but serious clinical scenario typically requiring urgent surgical intervention. Herein, we discuss the case of a 62-year-old woman with COVID-19 and ruptured retrocecal appendicitis presenting as a right lower extremity soft tissue infection that was successfully managed using non-operative measures. This unique case illustrates the feasibility of conservative care - rather than urgent surgical intervention - in the treatment of an atypical presentation of complicated appendicitis in a high-risk patient.

Case report: Covid-19 and disseminated tuberculosis coinfection unveiling catastrophic antiphospholipid antibody syndrome: An association or de novo phenomenon

Background: Disseminated infections such as tuberculosis are known to result in a systemic inflammatory response leading to thrombosis, with increasing reported cases of thrombotic event being observed in patients infected with covid-19. This is the first reported case on co-infection with COVID-19 pneumonia and disseminated tuberculosis causing catastrophic antiphospholipid syndrome (CAPS). Method(s): The report highlighted the challenges in the diagnosis and management which include the use of corticosteroid in setting of systemic infections. Another diagnostic dilemma was to explain the cause of myositis by tuberculous or autoimmune. Case Presentation: We report a 26-year- old man with HbE trait thalassemia who reported unintentional weight loss, night sweats for 1 month prior to the diagnosis of covid-19 infection on 10th March 2022. Seven days later, he was hospitalized for suspected perforated appendix. Computed tomography (CT) abdomen revealed hepatosplenomegaly, prostatitis, seminal vesiculitis. Multiple matted abdominal lymph nodes were not amenable for biopsy. Soon, he appeared toxic, dyspneic required non-invasive ventilation with bilateral parotitis. He had raised erythrocyte sedimentation (ESR) 52 mm/hour, C-reactive protein (CRP) 221 mg/dl, lactate dehydrogenase (LDH) 730U/L. Direct Coomb's antibody was positive but did not have any form of haemolysis. Complement 3 (0.45 g/L) and complement 4 (0.1 g/L) levels were low. Serum IgG4, procalcitonin, anti-nuclear antibody, cultures and virology were negative. Sputum for acid fast bacilli (AFB) was positive on Auramine O stain but the Ziehl-Nelson (ZN) stain and tuberculous PCR (GeneXpert) were negative. Diagnosis of disseminated tuberculosis was made but his abdominal pain persisted despite being on anti-tuberculous therapy (ATT), and he had new evidence of splenic infarct. CT angiogram also revealed celiac trunk and superior mesenteric artery thrombosis. Antiphospholipid (aPL) test was positive for lupus anticoagulant, beta 2 glycoprotein 1 and anti-cardiolipin antibodies. Therapeutic anticoagulation and plasma exchange were initiated for probable CAPS followed by intravenous immunoglobulin and corticosteroid. Thereafter, the patient developed severe bilateral pelvic girdle pain with evidence of myositis on the MRI (Figure 2). Serum creatine kinase was never elevated. Anti-PL- 7 and anti Ro-52 were borderline elevated. He recovered well and ambulant before discharged home. Conclusion(s): Our case highlight the complexicity of presentation of CAPS who manifested as multiple arterial thrombosis. The diagnosis of disseminated tuberculosis relied strongly on microbiological, imaging and clinical presentation as histopathological evidence was not feasible. Management challenges were deciding on corticosteroid in disseminated infection and the need for confirmation of persistent positive aPL test and to monitor myositis symptom to help guide decision making. (Figure Presented).

Re-audit of a bespoke alerting system for significant unexpected cancer on radiological examinations

Category: Other Background to the audit: There is increasing recognition of the timely communication of unexpected findings on radiological exams. National organisations such as The Royal College of Radiologists (RCR),1 National Patient Safety Association (NPSA)2 and Parliamentary and Health Service Ombudsman (PHSO)3 have made best practice recommendations. A common theme is the risk to patients posed by a lack of a reliable auditable alerting system. We launched an in-house alerting system for significant scan findings at our tertiary hospital using alert hashtags. These are parsed by an algorithm and our administrative team inform the referrer and ping the relevant multidisciplinary team (MDT). Standard: 1. Local standard: patients placed on cancer pathway within two working days of alert - 100%. 2. National cancer waiting standard:4 patients seen within two weeks after MDT referral - 93%. 3. Faster diagnosis standard:5 patients informed of cancer or not within 28 days - 75%. Indicator: n/a Target: n/a Methodology: Retrospective data collection electronic health records (EHR) and emails from the radiology alert account. Results of first audit round: June 2021. 186 reports with #alertcancer. 83.7% of patients placed on cancer pathway within two working days of alert, 97.1% seen within two weeks, 68.4% informed of cancer within 28 days. 12% of reports did not specify MDT resulting in a mean 1.5-day delay. 16.5% of referrers and 26% of MDTs did not acknowledge alert. These were within clinical commissioning group (CCG) and NHS England waiting times. First action plan: Education such as screensavers to include the specific MDT in report and reminder to clinicians to acknowledge receipt of alerts. Results of second audit round: 100 patients with #alertcancer December 2021. 94.9% standard 1, 88.9% standard 2, 51.8% standard 3. Drop in standard 2 and 3 but COVID peak and winter pressures. Performance exceeded CCG and NHS England waiting times. Second action plan: Moving towards a seamless automated alerting system avoiding single point of failure of emails and reliance on manual alerting by administrative staff. References: 1. The Royal College of Radiologists. Standards for the communication of radiological reports and fail-safe alert notification. London: The Royal College of Radiologists, 2016. Ref. no. BFCR(16)4. 2. National Patient Safety Association. NPSA Safer practice notice 16 (SPN 16): early identification of failure to act on radiological imaging reports (appendix 1). London: National Patient Safety Association, 2007. 3. Parliamentary and Health Service Ombudsman. Unlocking solutions in imaging: working together to learn from failings in the NHS. PHSO, July 2021. (accessed 19 April 2022). 4. Cancer waiting times. (accessed 15 Nov 2021). 5. Faster diagnosis standard. (accessed 19th April 2022). Copyright © 2022

The Effect Of Current And Previous Novel Coronavirus 2019 Infection On Diagnosis And Complication Rate Of Acute Appendicitis

Background: Severe Acute Respiratory Syndrome Coronavirus-type 2 (SARS-CoV-2) was identified as the RNA virus causing 'Coronavirus Disease 2019' (COVID -19). Diagnostic test of choice had varying degree of sensitivity, with serology test being of use in giving idea on the timing of the infection. This pandemic associated with delay in providing care to many surgical emergencies, with more complicated presentations found. Aim of study: To estimate the effect of current and previous COVID 19 infections on the diagnosis and rate of complications of acute appendicitis. Patients & methods: A prospective case control study was conducted at Al-Kindy teaching hospital department of general surgery over 18 months The studied sample were collected from all admitted patients suffering from signs of acute appendicitis and had positive serology test result for COVID 19. Other 100 cases of appendicitis without COVID 19 symptoms and negative serology and polymerase chain reaction considered control group. According to the serology results the case group further divided into previous infection and current infection. Result(s): Two hundred fifteen cases were included in our study 19.1% had current infection, 34.4% had previous infection, 46.5% the control group. Cases of COVID 19 had increased duration of symptoms before seeking medical care. This duration was single independent predictor of the development of perforated appendicitis. While readmission rate was higher in cases of COVID 19 and this related to the complications of appendicitis other than COVID 19 infection. COVID 19 infection was single independent predictor of increased hospital stay. Conclusion(s): COVID 19 infection per se not associated with increase in complication rate. It was associated with delayed in seeking medical care. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

The effect of the COVID-19 pandemic on acute appendicitis cases

The COVID-19 outbreak has affected healthcare systems around the world, and has led to changes in the clinical and treatment approaches to all diseases. To reveal the reflection and negative effects of the psychological trauma associated with the COVID-19 pandemic among those with acute appendicitis. A retrospective analysis is made of the data of patients admitted to the emergency departments in our city (Trabzon, Turkey) and taken into operation. Comparative analysis of two patient groups diagnosed with acute appendicitis in our region was included in our study: In the COVID-19 pandemic period (Group 2);and on the same dates a year ago (Group 1). Groups 1 and 2 comprised 231 and 144 patients, respectively (p<0.001). There was no statistically significant difference in the type of anesthesia between the groups (p=0.280). There was no statistically significant difference between the groups in terms of median duration of surgery (p=0.239). There was a statistically significant difference in the pathological diagnoses of Groups 1 and 2 (p<0.001). Considering the pathological diagnoses, a significant difference was established in the duration of hospital stay of the cases, which was longer in patients diagnosed with perforated appendicitis (p<0.001). It is apparent that during the COVID-19 outbreak, hospitals are associated with increased transmission risk, causing people to delay their referral to the emergency department, and leading to an increase in irreversible complications and mortality rates. Copyright © 2022 Ondokuz Mayis Universitesi. All rights reserved.

The Simple Things: Using Simulation Models to Improve Junior and Undergraduate Surgical Teaching in a DGH

Aims: Many clinical activities remain cancelled or uncertain in The CoVID world. We established a Surgical Skills Club in our DGH, where students and juniors are rotated far from their home institution. We also aimed to improve our undergraduate teaching by incorporating new surgical Sim sessions. Method(s): We established a weekly Surgical Skills Club by trainees, and promoted this through MedEd to all juniors, students and ANps. We used a combination of higher-fidelity models owned by The hospital and low fidelity models designed by ourselves such as lap-appendix and hernia. We utilised social media to share ideas. We recorded attendance and sought written feedback. We also set up dedicated simulation sessions as part of ongoing undergraduate teaching. Result(s): Anonymous feedback was documented weekly via app/online. For skills club, 100% of attendees documented experience as "great" or "good" (options great, good, average, fair, poor). Attendance varied from 2-15 each week. The best attendance was a formalised session with consultant input. For undergraduate Sim, 100% of attendees rated experience as "great" or "good". All attendees agreed Sim teaching improved their experience of surgery. 20% stated it made them consider a career in surgery. Conclusion(s): Surgical simulation is an excellent tool for improving experience of general surgery especially in a CoVID environment, and can widen access to surgical training by allowing juniors to explore their skills in a controlled, informal environment. Lap Skills gave students real-world confidence. A combination of low fidelity models provided The best experience showing that The barrier of cost can be broken.

2022 Adult Immunization Schedule Updates

Each year, the U.S. Centers for Disease Control and Prevention (CDC) releases the adult vaccine schedule. The 2022 adult vaccine schedule has several changes which will be discussed in the following manuscript. The Advisory Committee on Immunization Practices reviews the preliminary schedules usually at their October or November meetings. The following professional societies also approve the adult schedules prior to the 2022 publications: American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Nurse-Midwives (ACNM), American Academy of Physician Assistants (AAPA) and the Society for Healthcare Epidemiology of America (SHEA). Once the final draft is approved by the CDC, it is published in the Morbidity and Mortality Weekly Report (MMWR) and released to healthcare providers and the general public with a cover page, tables, notes and—new for the 2022 schedule—an appendix with contraindications and precautions for the different approved vaccines.

School Teachers’ Perception towards using LMS-MOODLE in Teaching Science to Students of Aurangabad City

This paper describes the perception of school teachers of Aurangabad city towards teaching using the Open-Source Learning Management System (LMS) MOODLE in teaching science subjects. The Free and Open-Source (LMS) MOODLE has brought a dynamic pedagogical shift in Online Learning due to its nature of robust features and free availability. The outbreak of COVID-19 has forced formal and non-formal educational systems to adopt an Online teaching-learning platform for the transaction of information. In this study, teachers’ perception of using LMS-MOODLE in teaching science to secondary school students of Aurangabad city is studied. The research methodology adopted is the descriptive survey method, and the sample consists of 40 female and 45 male teachers of secondary school students of Aurangabad. In this research, a self-made perception scale (refer to appendix) is prepared with a 5-point Likert-type scale, the reliability of the test found by Cronbach (0.71). The data analysis shows that the perception among female and male school teachers of Aurangabad city, [U = 766.5, p =.23] in teaching science using LMS-MOODLE is almost the same. Further, the perception between groups, i.e., primary and secondary school teachers of Aurangabad city, [U = 878.5, p =.898] towards using LMS-MOODLE in teaching science was also found to be identical. The study results suggest that female and male school teachers have similar perceptions towards teaching science subjects by using LMS-MOODLE.Similarly, primary and secondary school teachers have identical perceptions towards teaching science subjects by using LMS-MOODLE. The most plausible reason for the similar perceptions among male and female teachers at the primary and secondary levels is the application of the Internet and technology in learning and teachingduring the pre-COVID-19 and post-COVID-19 pandemics and the social distancing implemented by the authority.

MIS-CM imicking Acute Appendicitis

Introduction: Abdominal pain is one of the most common complaints seen in the pediatric acute care setting. SARS-CoV-2 disease in children includes a hyperinflammatory syndrome called Multisystem Inflammatory Syndrome in Children (MIS-C). Gastrointestinal symptoms are most common in pediatric acute SARS-CoV-2 infection as well as in MIS-C. Case Description: A 13- year-old female presented with diffuse lower abdominal pain for 3-days. Pain was 10/10 in intensity, worsened with movement, and had associated constipation, anorexia, nausea, and vomiting. Exam showed an ill-appearing female with labile vitals and generalized lower abdominal tenderness with good bowel sounds. Ultrasound suggested features of acute appendicitis but a follow-up CT did not visualize the appendix. She was admitted to the inpatient unit after routine screening revealed positive SARS-CoV-2 antibody but negative PCR. She received IV fluid bolus, narcotic analgesics, and ampicillin-sulbactam preoperatively. Within hours, she spiked high-grade fevers (101.4F), sustained hypotension, and tachycardia with concern for sepsis secondary to a possible ruptured appendix. She underwent emergency diagnostic laparoscopy which revealed bile-tinged fluid in the lower quadrant, a mildly inflamed appendicular tip without perforation, and thickened mesenteric nodes within the inflamed distal ileum. Intra-operatively, she had persistent hypotension requiring fluid boluses and vasopressors. Her admission labs revealed elevated inflammatory markers, deranged coagulation profile, and elevated cardiac enzymes. Her differential diagnosis was then revised to include MIS-C and severe sepsis. Antibiotic coverage was broadened to Vancomycin and Meropenem. An Echocardiogram showed mitral regurgitation with moderately to severely decreased right and left ventricular systolic dysfunction with an ejection fraction of 32.8% The patient was then transferred to the pediatric cardiac critical unit where she received treatment with IVIG, steroids, and anticoagulants. Her clinical status and lab studies improved with EF > 50%. She was discharged from the intensive care unit after 7 days and has had an uneventful follow-up. Discussion: Differential diagnosis for acute lower abdominal pain in an adolescent female is broad. Similar cases with predominant GI symptoms and later generalized multisystem involvement have been reported, however, most were managed conservatively. Two reports have been published on MIS-C presenting as acute appendicitis, but neither had significant cardiac involvement. Our patient's presentation can easily be confused with an acute surgical abdomen but the pathology report confirmed a congested appendix without any fecoliths supporting either inflammation or vasculitis as the cause for her presentation, which is in concordance with the hyperinflammatory state that has previously been described in patients presenting with a history of past SARS-CoV- 2 infections. Conclusion: MIS-C can mimic serious pediatric illnesses including sepsis, acute abdomen, and Kawasaki disease. Clinicians should have a low threshold for suspecting MIS-C, as prompt treatment can be lifesaving. Universal screening for COVID-19 infection with PCR and antibody tests can expedite the diagnostic evaluation of severely ill children. Showing reactive wall thickening of the cecum and small bowel loops (red arrow) and enlarged mesenteric lymph nodes (yellow arrow). The appendix could not be visualized here.

Distant Ocular Manifestations after New Coronavirus Infection

Purpose. Theoretically substantiate and practically identify ocular manifestations after the transferred SARS-CoV-2 virus. Patients and methods. For the study we were invited patients who had recovered from SARS-CoV-2 at the hospital of V.M. Buyanova, the age from 20 to 65 years old in period from 2020 to 2021. The total number of patients was 68 people. The patients had with them the results of PCR tests or ELISA tests, or an extract from the hospital confirmed COVID-19 case and also a clinical blood test and CT scan of the chest organs for the period of illness. Before the start of the study, the patients were asked to fill out a questionnaire “Questionnaire for patients who have had a new coronavirus infection” (Appendix 1). For a detailed study of this group of people, each underwent visometry, pneumotonometry, B-scan, a slit lamp study and also a slit lamp study with a 60D lens using 0.5 % Mydriacyl eye drops in the absence of contraindications and pupillography. Results. As a result of the work carried out, we concluded that the virus is capable of causing inflammation of the choroid of the eyeball, uveitis. Moreover, in our study, we identified patients with acquired intermittent divergent strabismus, anisocoria, ptosis, and accommodation disorder. And, in this regard, we came to the conclusion that the coronavirus belongs to the group of neurotropic, as it is able to affect the nervous tissue and cause the above clinical picture. In other words, the virus negatively affects the somatic and autonomic innervation of the oculomotor nerve. As a result of these lesions, we get the corresponding tetrad of symptoms: heterotropy, mydriasis, ptosis, accommodation paralysis. Conclusions. One of the extraordinary complications of coronavirus infection is damage effect to the fibers of the oculomotor nerve, the signs include: strabismus, mydriasis, ptosis and accommodation paralysis. Thus, this clinical picture is associated with the affinity of the virus to the nervous tissue. And as a result, this ability of the virus can probably infect various areas of the brain, which will lead to corresponding complications, not only from the oculomotor nerve, but also from other cranial nerves with the manifestation of the corresponding symptoms, which in theory can aggravate the patient's condition, causing deep disturbances of motor and sensory innervation.

Reassessment of neutron contamination during breast treatment for different configurations

Purpose or Objective Early assessment of neutron contamination in IMRT applications was based on delivery techniques [1,2]. Recently these delivery techniques have been optimized and made more efficient with respect to the number of MU required for a certain dose. In fact, the number of MU for many IMRT or VMAT treatments required for a certain fraction dose are now comparable to those required for 3D-conformal techniques. Furthermore, with the Covid-19 pandemic, a new hypofractionated breast treatment protocol was introduced in our department, based on the “Fast Forward” protocol [3,5]. The implementation of higher daily doses demands for stricter constraints. This study was initiated in order to determine a strategy in minimising the out-of-field dose in clinical practice taking into account the risks and benefits related to different treatment techniques and photon energies. Materials and Methods To simulate realistic clinical conditions, an anthropomorphic phantom was used with a right breast prosthesis. The phantom was scanned and appropriate structures (body, breast, lung and PTV) were delineated. Plans were created using Field in Field (FiF), IMRT and VMAT techniques with different energies. The mean dose of the PTV was normalised to the prescribed fraction dose (5.2Gy) in all treatment plans. Surface scanning was used to position the phantom for treatment. Different detectors types were used for measurements (see Table 1). The measurements were performed at 3 positions: one in the lung and two on the surface at 10 cm and 20 cm respectively from isocentre. Results Figures 1 and 2 illustrate the out-of-field dose measurements associated with a specific configuration of delivery technique and beam energy. Application of 15MV, for all delivery techniques combined, produced more neutrons compared to the other energies used in this study, the neutron contribution to the total contamination was up to 13% for 15 MV at 20 cm from isocentre. FiF neutron contribution were comparable to IMRT even if it required the least MU. In terms of photon scatter contribution, VMAT showed the highest doses. The neutron contamination for 10 MV and 10 MV FFF was similar. Considering a treatment fraction of 5.2 Gy delivered in 15MV IMRT mode, a neutron contamination of 5mGy was observed, which can be considered comparable to a CBCT acquisition for patient positioning [4]. Conclusion As IMRT provides better dose homogeneity and OAR sparing it can be preferred over FiF considering comparable contributions in out-of-field dose contamination. For some complex cases, such as irradiating regional lymph nodes for a breast treatment, VMAT can be considered, as the small increase in out-of-field dose might be balanced against an optimal target coverage / OAR sparing. As expected, some neutron contribution can be observed for the higher energies, however, the low levels of it to the total contamination dose as observed in this study might warrant their use in favour of improved target coverage and skin sparing. Appendix (Figure Presented)(Table Presented)

Angiotensin-Converting Enzyme 2 and Furin Expression in the Appendix of Children with COVID-19.

Background: The sudden outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in more than 261 million infections and an estimated 5.1 million deaths. Some vital organs such as the kidneys, heart, intestines, and lungs could be damaged by SARS-CoV-2. Questions remain regarding the effect of SARS-CoV-2 on the mucous membrane of the appendix in children. The aim of this study was to evaluate the knowledge of cytologic processes in appendix tissue in children with coronavirus disease 2019 (COVID-19). Patients and Methods: Fragments of the appendices of children with confirmed COVID-19 (n = 42) were studied by real-time polymerase chain reaction (PCR) to determine the expression of SARS-CoV-2 RNA and genes encoding protein complexes: ACE-2 and Furin. Results: We found traces of coronavirus genetic material in the appendices of children with COVID-19. We also found increased expression of ACE-2 and Furin in the tissue, which indicates favorable conditions for coronavirus infection. Conclusions: Viral load in the appendices of children can be reported based on the results of real-time PCR for SARS-CoV-2 and the expression of ACE-2 and Furin.