Overexpression of Human Soluble Epoxide Hydrolase Exacerbates Coronary Reactive Hyperemia Reduction in Angiotensin-II-Treated Mouse Hearts.

ABSTRACT: Coronary reactive hyperemia (CRH) is impaired in cardiovascular diseases, and angiotensin-II (Ang-II) exacerbates it. However, it is unknown how Ang-II affects CRH in Tie2-sEH Tr (human-sEH-overexpressed) versus wild-type (WT) mice. sEH-overexpression resulted in CRH reduction in Tie2-sEH Tr versus WT. We hypothesized that Ang-II exacerbates CRH reduction in Tie2-sEH Tr versus WT. The Langendorff system measured coronary flow in Tie2-sEH Tr and WT. The hearts were exposed to 15-second ischemia, and CRH was assessed in 10 mice each. Repayment volume was reduced by 40.50% in WT treated with Ang-II versus WT (7.42 ± 0.8 to 4.49 ± 0.8 mL/g) and 48% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (5.18 ± 0.4 to 2.68 ± 0.3 mL/g). Ang-II decreased repayment duration by 50% in WT-treated with Ang-II versus WT (2.46 ± 0.5 to 1.24 ± 0.4 minutes) and 54% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (1.66 ± 0.4 to 0.76 ± 0.2 minutes). Peak repayment flow was reduced by 11.2% in WT treated with Ang-II versus WT (35.98 ± 0.7 to 32.11 ± 1.4 mL/g) and 4% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (32.18 ± 0.6 to 30.89 ± 1.5 mL/g). Furthermore, coronary flow was reduced by 43% in WT treated with Ang-II versus WT (14.2 ± 0.5 to 8.15 ± 0.8 mL/min/g) and 32% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (12.1 ± 0.8 to 8.3 ± 1.2 mL/min/g). Moreover, the Ang-II-AT 1 -receptor and CYP4A were increased in Tie2-sEHTr. Our results demonstrate that Ang-II exacerbates CRH reduction in Tie2-sEH Tr mice.

Rectovaginal fistula surgery with horizontal mattress and running suture after unsuccessful first repair: a report of two cases.

Rectovaginal fistula (RVF) repair after failed primary repair is uncommon. Patients with RVF experience physiological and sexual dysfunction with a significantly high risk of intravaginal infection and sepsis. There are many surgical procedures available for RVF repair. We performed an improvised transvaginal repair technique. Methods: We report two cases of recurring RVF after failed primary repair. Patient 1 developed RVF because of a failed vaginoplasty due to cosmetic reasons, while patient 2 developed RVF because of a fourth-degree perineal rupture repair post-delivery. We used a combination of horizontal mattress and running suture with the addition of diverting colostomy. Both surgeries went successfully and there were no complications. Outcomes: RVF repair using a combination of horizontal mattress and running suture went successfully and there were no complications. Both patients were able to be discharged after a short stay. Long-term evaluation was done by physical and supporting examinations for 2-3 months. Both patients showed excellent wound healing and physiological function. Conclusions: The combination of a transvaginal horizontal mattress and running suture in the posterior to anterior fashion with diverting colostomy is a safe and effective procedure for recurring RVF repair.

Combination of Cattell-Braasch and Kocher maneuver in laparotomy for diverticular resection in the third part of the duodenum: a case report.

A duodenal diverticulum is an outpouching of all or partial layers of the duodenal wall. Duodenal diverticulum complications such as bleeding, diverticulitis, pancreatitis, choledochal occlusion, and perforation can develop. Localization of the diverticulum in the third part of the duodenum is rare. Surgical intervention with a combination of Cattell-Braasch and Kocher maneuvers in laparotomy is currently emerging as a viable option. Case presentation: The authors report a case of a 68-year-old male with chief complaints of black stool and recurring epigastric pain. Barium follow-through showed diverticulum at the third part of the duodenum. Surgery with a combination of Cattell-Braasch and Kocher's maneuvers using a linear stapler was successful, and there were no intraoperative or postoperative complications. Postoperative barium follow-through showed no diverticulum residue. The patient had no more complaints of black stools nor epigastric pain. Clinical discussion: Symptomatic duodenal diverticulum is a rare case with a very small chance of complications. Due to its lack of specific symptoms, imaging examinations play a better role in diagnosis. Surgical intervention is also rarely performed due to the small chance of complications. Diverticulectomy with the use of Cattell-Braasch and the extended Kocher maneuver results in better duodenum exposure, and the usage of a linear stapler also made the surgery safer and quicker to perform. Conclusion: The authors propose that a diverticulectomy of the third part of the duodenum performed with a combination of the Cattell-Braasch and Kocher maneuvers with the use of a linear stapler as a safe procedure.

Role of cytochrome P450-epoxygenase and soluble epoxide hydrolase in the regulation of vascular response.

The role of cytochrome P450-epoxygenase has been seen in cardiovascular physiology and pathophysiology. The aberration in CYP450-epoxygenase genes occur due to genetic polymorphisms, aging, or environmental factors, that increase susceptibility to cardiovascular diseases (CVDs). The actual role played by the CYP450-epoxygenases is the metabolism of arachidonic acid (AA) and linoleic acid (LA) into epoxyeicosatrienoic acids (EETs) and epoxyoctadecaenoic acid (EpOMEs) metabolites (oxylipins) and others, which is involved in vasodilation and myocardial-protection. But the genetic polymorphisms in CYP450-epoxygenases lose their beneficial cardiovascular effects of oxylipins, and the soluble epoxide hydrolase (sEH) antagonizes beneficial oxylipins into diols. Like sEH converts EETs into dihydroxyeicosatrienoic acid (DHETs), EpOMEs into dihydroxyoctadecaenoic acid (DiHOMEs), and reverses its beneficial effects, and the sEH gene (Ephx2) polymorphisms cause the enzyme to become overactive and convert epoxy-fatty acids into diols, making them vulnerable to CVDs, including hypertension. Other, enzymes like ω-hydroxylases (CYP450-4A11 & CYP450-4F2)-derived oxylipins from AA, ω-terminal-hydroxyeicosatetraenoic acids (19-, 20-HETE), lipoxygenase-derived oxylipins, mid-chain hydroxyeicosatetraenoic acids (5-, 11-, 12-, 15-HETEs), and the cyclooxygenase-derived prostanoids (prostaglandins: PGD2, PGF2α; thromboxane: Txs, oxylipins) are involved in vasoconstriction, hypertension, inflammation, and cardiac toxicity. Also, there are significant interactions were seen between adenosine receptors [adenosine A2A receptor (A2AAR) and adenosine A1 receptor (A1AR)] with CYP450-epoxygenases, ω-hydroxylases, sEH, and their derived oxylipins in the regulation of the cardiovascular response. Moreover, polymorphisms exist in CYP450-epoxygenases, ω-hydroxylases, sEH, and the adenosine receptor genes in populations associated with CVDs. This chapter will discuss the role of oxylipins' interactions with adenosine receptors in cardiovascular function/dysfunction in mice and humans.

Effectiveness and predictors of conversion in mini-laparotomy cholecystectomy in developing country: a cohort retrospective study.

BACKGROUND: Mini laparotomy cholecystectomy (MLC) is an alternative surgical procedure in conditions where laparoscopic cholecystectomy (LC) is not feasible. MLC is a simpler and easier technique compared to LC. MLC involves smaller skin incision, low morbidity rate, and early return to oral diet. MLC has the potential to be the preferred surgical technique in developing countries due to its low cost and availability. METHOD: A cohort retrospective study was performed on 44 patients who underwent mini laparotomy cholecystectomy due to ineligibility for LC. Patients were documented for successful mini laparotomy or conversion to laparotomy cholecystectomy. There are pre-operative aspects recorded and analyzed to formulate predictor factors for conversion surgery, as well as intra-operative and post-operative aspects. Patients also filled evaluation questionnaire based on Likert Scale about their satisfaction towards result of MLC. RESULT: MLC is performed in 31 (70.5%) patients while 13 (29.5%) patients underwent conversion to open cholecystectomy. There were no complications nor mortalities observed during and after the surgery. Greater BMI, higher leucocyte count, higher bilirubin level, increasing severity of adhesion, and chronic cholecystitis were found to be statistically significant (p < 0.05) in the conversion surgery group. MLC also resulted in shorter post-operative hospitalization compared to conversion surgery. Patients showed great satisfaction towards the cosmetic aspect and recovery period after MLC procedure. CONCLUSION: MLC is an effective surgery procedure for cholelithiasis and can be safely performed in patients with complication such as cholecystitis and gallbladder adhesion although these conditions increase the risk of conversion surgery.

Comparison of anal dilatation versus no dilatation with a standardized dilator in reducing pain after hemorrhoidectomy: a randomized control trial.

BACKGROUND: Post-operative pain is the main problem of hemorrhoidectomy. An adequate pain management can promote early mobilization, fast recovery, and reduce hospitalization costs. This study aimed to investigate the role of preoperative anal dilatation using a standardized anal dilator in reducing post-operative pain. METHOD: This study was conducted using randomized prospective trial with a total of 40 subjects, who were divided into 2 groups. The first group received preoperative anal dilatation using a 33 mm anal dilator for 20 min, while the second group did not. The post-operative anal pain, edema, bleeding, and incontinence were observed in the first, second, and seventh day. RESULT: The post-operative pain was significantly lower in the preoperative anal dilatation group for all days of observation (p < 0.05). The difference of post-operative bleeding and edema between groups were not significant. Fecal incontinence was initially significantly higher in the preoperative anal dilatation group, but the difference was insignificant at the seventh day (p = 0.500). CONCLUSION: Preoperative anal dilatation significantly reduced post-operative pain. The side effect of fecal incontinence was only temporary until the seventh day after surgery. Trial Registration This trial was registered on Thai Clinical Trials Registry (TCTR) with TCTR identification number TCTR20220314002, on 14/03/2022 (retrospectively registered).

A Case of Severe Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis Successfully Treated With High Dose Steroids and Ganciclovir.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematological disorder characterized by immune dysregulation with multiple organ involvement and carries a poor prognosis. The occurrence of HLH can be familial or sporadic, which is triggered by causes like infection or malignancy. This case report is about a 47-year-old male who presented to the hospital with a fever, chills, night sweats, and unintentional weight loss. He was found to have severely elevated ferritin, and computed tomography showed cirrhosis, a normal sized spleen, and retroperitoneal lymphadenopathy. He underwent an extensive battery of tests to identify the etiology. Meanwhile, he had recurrent fevers with worsening transaminitis and septic shock, requiring admission to the ICU. Blood tests for Epstein-Barr virus (EBV) deoxyribonucleic acid (DNA) and immunoglobulin G (IgG) were positive. Due to high suspicion of HLH, he was started on intravenous methylprednisone 1000 mg daily for three days with clinical improvement. A bone marrow biopsy showed hemophagocytosis and he was diagnosed with EBV-associated HLH. He was continued on steroids with oral prednisone and continued to clinically improve. He was later tapered off steroids over the course of five months. HLH is a rapidly progressive and fatal condition that requires prompt treatment, and thus a high index of suspicion is needed to make a timely diagnosis.

Crosstalk between adenosine receptors and CYP450-derived oxylipins in the modulation of cardiovascular, including coronary reactive hyperemic response.

Adenosine is a ubiquitous endogenous nucleoside or autacoid that affects the cardiovascular system through the activation of four G-protein coupled receptors: adenosine A1 receptor (A1AR), adenosine A2A receptor (A2AAR), adenosine A2B receptor (A2BAR), and adenosine A3 receptor (A3AR). With the rapid generation of this nucleoside from cellular metabolism and the widespread distribution of its four G-protein coupled receptors in almost all organs and tissues of the body, this autacoid induces multiple physiological as well as pathological effects, not only regulating the cardiovascular system but also the central nervous system, peripheral vascular system, and immune system. Mounting evidence shows the role of CYP450-enzymes in cardiovascular physiology and pathology, and the genetic polymorphisms in CYP450s can increase susceptibility to cardiovascular diseases (CVDs). One of the most important physiological roles of CYP450-epoxygenases (CYP450-2C & CYP2J2) is the metabolism of arachidonic acid (AA) and linoleic acid (LA) into epoxyeicosatrienoic acids (EETs) and epoxyoctadecaenoic acid (EpOMEs) which generally involve in vasodilation. Like an increase in coronary reactive hyperemia (CRH), an increase in anti-inflammation, and cardioprotective effects. Moreover, the genetic polymorphisms in CYP450-epoxygenases will change the beneficial cardiovascular effects of metabolites or oxylipins into detrimental effects. The soluble epoxide hydrolase (sEH) is another crucial enzyme ubiquitously expressed in all living organisms and almost all organs and tissues. However, in contrast to CYP450-epoxygenases, sEH converts EETs into dihydroxyeicosatrienoic acid (DHETs), EpOMEs into dihydroxyoctadecaenoic acid (DiHOMEs), and others and reverses the beneficial effects of epoxy-fatty acids leading to vasoconstriction, reducing CRH, increase in pro-inflammation, increase in pro-thrombotic and become less cardioprotective. Therefore, polymorphisms in the sEH gene (Ephx2) cause the enzyme to become overactive, making it more vulnerable to CVDs, including hypertension. Besides the sEH, ω-hydroxylases (CYP450-4A11 & CYP450-4F2) derived metabolites from AA, ω terminal-hydroxyeicosatetraenoic acids (19-, 20-HETE), lipoxygenase-derived mid-chain hydroxyeicosatetraenoic acids (5-, 11-, 12-, 15-HETEs), and the cyclooxygenase-derived prostanoids (prostaglandins: PGD2, PGF2α; thromboxane: Txs, oxylipins) are involved in vasoconstriction, hypertension, reduction in CRH, pro-inflammation and cardiac toxicity. Interestingly, the interactions of adenosine receptors (A2AAR, A1AR) with CYP450-epoxygenases, ω-hydroxylases, sEH, and their derived metabolites or oxygenated polyunsaturated fatty acids (PUFAs or oxylipins) is shown in the regulation of the cardiovascular functions. In addition, much evidence demonstrates polymorphisms in CYP450-epoxygenases, ω-hydroxylases, and sEH genes (Ephx2) and adenosine receptor genes (ADORA1 & ADORA2) in the human population with the susceptibility to CVDs, including hypertension. CVDs are the number one cause of death globally, coronary artery disease (CAD) was the leading cause of death in the US in 2019, and hypertension is one of the most potent causes of CVDs. This review summarizes the articles related to the crosstalk between adenosine receptors and CYP450-derived oxylipins in vascular, including the CRH response in regular salt-diet fed and high salt-diet fed mice with the correlation of heart perfusate/plasma oxylipins. By using A2AAR-/-, A1AR-/-, eNOS-/-, sEH-/- or Ephx2-/-, vascular sEH-overexpressed (Tie2-sEH Tr), vascular CYP2J2-overexpressed (Tie2-CYP2J2 Tr), and wild-type (WT) mice. This review article also summarizes the role of pro-and anti-inflammatory oxylipins in cardiovascular function/dysfunction in mice and humans. Therefore, more studies are needed better to understand the crosstalk between the adenosine receptors and eicosanoids to develop diagnostic and therapeutic tools by using plasma oxylipins profiles in CVDs, including hypertensive cases in the future.

A new technique for surgical haemorrhoidectomy without post-operative complication: A case series.

Introduction: Hemorrhoids are a common coloproctology problem and among 10% of cases need surgical intervention. However, the established surgical interventions still have many complications. Case presentation: We reported three female patients, who presented with circular 3rd degree internal hemorrhoids. The surgical treatment was performed with pre-operative anal dilatation using a 33 mm dilator for 20 minutes, followed by triangle incision above the dentate line. The hemorrhoid excision was performed, and the wound was sutured with simple interrupted radial sutures using a multifilament absorbable 3-0 thread. There were neither complaints of pain, bleeding, anal incontinence, anal stenosis, wound dehiscence, nor recurrence at the first, second, and fourth weeks of follow-ups in all patients. Discussion: Post-operative bleeding, pain, and anal incontinence are common after an open hemorrhoidectomy, while suture breakage and anal stenosis were reported after the old technique of closed hemorrhoidectomy. Stapled hemorrhoidectomy had less complications but requires a relatively more expensive cost for the device itself. We performed a combination of preoperative anal dilatation, above dentate line triangle incision, and simple interrupted radial sutures to treat the patients with 3rd degree internal hemorrhoids, which resulted in no post-operative complications within the first month of follow-up. Conclusion: A combination of preoperative anal dilatation, above dentate line triangle incision, and radial suture technique is a simple and effective surgical option for treating a 3rd degree hemorrhoid.

Lymphoplasmacytic Lymphoma with Only Lambda Light Chain Monoclonal Paraprotein Expression.

Introduction: Lymphoplasmacytic lymphoma (LPL) is a rare low-grade B-cell neoplasm that accounts for approximately 2% of all haematological malignancies. Most patients have the clinical syndrome of Waldenstrom macroglobulinemia (WM), which is defined as LPL with an associated immunoglobulin M (IgM) serum monoclonal protein. Roughly 5% of LPL patients secrete non-IgM paraproteins (e.g., IgG, IgA, kappa, lambda) or are non-secretory. Case description: We report the case of a 41-year-old woman who was diagnosed with non-IgM LPL with lambda light chain monoclonal paraprotein production and normal serum immunoglobulin levels. The MYD88 L265P mutation was detected on fluorescence in-situ hybridization (FISH) analysis of the bone marrow. The patient underwent treatment with a combination of ibrutinib and rituximab. There was an initial response but she died 8 months after diagnosis. Discussion: Non-IgM LPL poses diagnostic and therapeutic challenges to clinicians as it is an exceptionally rare malignancy with a heterogeneous clinicopathological presentation and scarce literature. Among non-IgM LPL cases, those with lambda light chain production are even more rare. To the best of our knowledge, none have been reported to date. The addition of MYD88 L265P testing to the diagnostic armamentarium of non-IgM LPL cases is advisable for potential therapeutic reasons. LEARNING POINTS: Our case report and literature review provide insight into non-IgM lymphoplasmacytic lymphoma (LPL), an extremely rare malignancy.Our case report highlights the importance of the need for new treatments for non-IgM LPL.

Perceived stress, academic self-concept, and coping mechanisms among pharmacy students following a curricular revision.

INTRODUCTION: Pharmacy students experience high levels of perceived stress. Data regarding the impact of curricular revision on students' stress level are lacking. The primary objective of this study was to compare perceived stress, academic self-concept, and coping strategies between pharmacy students prior to and following a curricular revision. Secondary objectives included determining university resources used by students to deal with stress. METHODS: Students in the first, second, and third years of the pharmacy curriculum were asked to complete a survey, including the 14-item Perceived Stress Scale (PSS-14), Brief COPE, and Academic Self-Concept Scale (ASCS), and questions regarding use of university resources. Responses to the PSS-14, Brief COPE, and ASCS were compared to a student cohort prior to the curricular revision. RESULTS: Perceived stress was reduced to a small, statistically significant degree following a curricular revision. In both cohorts, increased stress was statistically significantly correlated with decreased academic self-concept. Students reported increased use of self-distraction, along with decreased use of active coping, substance abuse, and planning, as coping strategies when compared to the previous cohort. Approximately half of the student cohort reported no use of university resources. The most commonly used resources were financial aid and mental health services. CONCLUSIONS: Perceived stress decreased following the revision of a Doctor of Pharmacy curriculum. The most common coping strategies were positive and comparable with strategies reported by students in the former curriculum. The impact of curricular changes on student stress and the use of university resources in health professions students warrant further study.

Effectiveness of tutorial videos combined with online classes in surgical knotting course during COVID-19 pandemic: A cohort study.

BACKGROUND: COVID-19 pandemic has changed medical education from offline courses to online formats. Nowadays, offline skill demonstration lessons becomes unfeasible. This study assess the effectiveness of tutorial videos and online classes in delivering knowledge and skill in basic surgical knotting to medical students. METHODS: A group of medical students (n = 95) was divided into two groups: the first group was allowed to watch the tutorial video that we have been made and uploaded into YouTube (https://www.youtube.com/watch?v=WyfOVGhAeVA) while the other group did not watch the video. All participants submitted a demonstration video to show their knotting skill. These videos were graded and made into the first evaluation. Then, all participants attended online classes for the surgical knotting skills via Zoom application. Participants submitted another demonstration video after the online classes. The videos were assessed, and the results were analyzed. RESULTS: The experimental group (n = 50) who watched the tutorial video prior to class scored higher in the first video than the control group (n = 39) with a meanscore of 10.850 versus 7.462, p = 0.000*, In the second video, the assessment showed no significant difference between the two groups with meanscore of 11.220 versus 10.897, p = 0.706. CONCLUSION: The combination of tutorial videos and online classes is the optimal teaching method for surgical knotting skills.

Gallbladder adhesion degree as predictor of conversion surgery, common bile duct injury and resurgery in laparoscopic cholecystectomy: A cross-sectional study.

BACKGROUND: The gold-standard treatment for cholecystectomy, laparoscopic cholecystectomy, has remarkably variable outcomes and conversion rates. We investigated the gallbladder adhesion degree as a predictor of conversion surgery, common bile duct injury, and resurgery. METHODS: We reviewed 157 medical records and video recordings of laparoscopic cholecystectomy on patients with cholelithiasis with or without cholecystitis at three hospitals in Yogyakarta, Indonesia from January 2016 to December 2018. The degree of gallbladder adhesion is classified into 4 categories: no adhesion, <50% adhesion, 50%-buried GB, and completely buried GB. RESULTS: One hundred fifty seven patients were involved in this study, of whom 58 were males and 99 females with average age 49.2. Eighty-one patients out of 157 patients (51.6%) had gallbladder adhesion comprising of 61/157 (38.9%) with <50% adhesion and 20/157 (12.7%) 50%-buried GB. There is one incidence each of conversion surgery, CBD injury, and resurgery. The degree of GB adhesion has low degree of correlation with conversion surgery, CBD injury, and resurgery wirh r value of 0.156, 0.041, and 0.156 respectively. There is significant correlation between the degree of GB adhesion and conversion surgery and resurgery with p value of 0.032, and 0.032 respectively. There is no significant correlation between degree of GB adhesion and CBD injury with p value of 0.453. CONCLUSION: The degree of GB adhesion has low degree of correlation with conversion, CBD injury and resurgery. This study also showed that patients with high degree of gallbladder adhesion are still eligible for laparoscopic procedure performed by an experienced surgeon.

Omental plug using double horizontal mattress suture for gastric perforation on elderly patients with boey score 3: A case series.

INTRODUCTION: Gastric perforation is a life-threatening condition. Patients with gastric perforation with Boey score 3 has very high mortality rate. Immediate source control is required for primary repair and preventing further complications. Furthermore, elderly patients pose a greater risk of morbidity and mortality in cases of gastric perforation, especially during and after emergency surgery. CASE PRESENTATION: We present two cases of elderly patients with gastric perforation with Boey score 3. We performed omental plugging technique with double horizontal mattress suture type. In these cases, we decided not to perform biopsy and margin freshening of the perforation. DISCUSSION: We performed omental plugging technique because we are confident that it could cover the perforation completely without causing gastric outlet obstruction. An emergency source control surgery can be effectively done with this omental plugging procedure. During surgery, margin freshening and biopsy is not performed to perform source control more quickly. This surgical procedure aligned with "quick in-quick out" concept that we adopted for treating patients with gastric perforation. Omental plugging also allows patient to undergo ERAS program for better and faster recovery. The patients were discharged from the hospital without further complications and long-term follow-up showed good results. CONCLUSION: Omental plugging has the least risk of complications than other perforation repair techniques and can be done for small and large perforation. Based on our case series, omental plug with double mattress suture is an effective and safe procedure to be performed in elderly patients with gastric perforation with Boey score 3.

Management of gallstone-induced severe acute cholecystitis and pancreatitis in the second trimester of pregnancy during covid-19 pandemic: A case report.

INTRODUCTION: Gallstone-induced severe acute cholecystitis with acute pancreatitis during pregnancy can be life-threatening both for the mother and fetus. Surgical approach is recommended in this complicated disease to prevent morbidity and mortality. During COVID-19 pandemic, additional precautions are needed when dealing with abdominal complaints. PRESENTATION OF CASE: We present a 37-year-old female patient, pregnant at 22 weeks gestational age, who complained of fever, diffuse abdominal pain, and shortness of breath. Laboratory examination results revealed anemia, leukocytosis and an increase in amylase level. SARS-CoV-2 antibody is non-reactive. Imaging strongly suggested cholelithiasis and cholecystitis. The patient was given antibiotics for three days but there was no significant improvement. Open cholecystectomy with subcostal (Kocher) incision was performed. Patient was released from the hospital without post-operative complications. DISCUSSION: Treatment of gallstone induced severe acute cholecystitis with acute pancreatitis during pregnancy is challenging with the surgical complications. In the second and third trimester of pregnancy, it is more difficult to perform laparoscopic cholecystectomy because of the size of uterus. Laparoscopic procedure is also not recommended in early Covid-19 pandemic period. Therefore, open cholecystectomy with Kocher incision becomes the surgery of choice to avoid preterm birth. CONCLUSIONS: Based on our case, open cholecystectomy with Kocher incision is a safe and effective procedure for pregnant patients with cholelithiasis, cholecystitis, and pancreatitis.

Clinical findings and management of diaphragmatic rupture with hernia caused by safety body harness: A case report.

INTRODUCTION: Acute blunt traumatic diaphragmatic rupture (BTDR) caused by falling from a height is rare. Transabdominal diaphragmatic repair in an acute setting following BTDR requires good clinical decision-making and diagnostic tests. CASE PRESENTATION: A 36-year-old male was involved in a work accident. He fell from a 30-m radio transmitter tower while wearing an attached safety body harness. He arrived in the emergency room with complaints of breathing difficulty, abdominal and pelvic pain. We discovered a diaphragmatic rupture with abdominal organ herniation based on the imaging. We decided to perform an emergency laparotomy. We discovered a 12cm diaphragmatic defect on the anteromedial side of the left during surgery. We carried out the evacuation by suction and controlled the bleeding in the wound at the edge of the diaphragm. On postoperative day 4 (POD), the patient complained of dyspnea, and chest radiology revealed a hemothorax in the left lung. We then installed a water-sealed drainage (WSD) until POD 6. On the following day, his complaint was resolved, the WSD was removed and the patient was discharged uneventfully. DISCUSSION: Abdominal CT scan can be helpful in determining early diagnosis of traumatic diaphragm rupture with abdominal organ herniation, allowing for prompt surgical intervention to minimize morbidity and mortality. Furthermore, reinforced sutures might be useful to prevent recurrence of the symptoms. CONCLUSION: In conclusion, injury due to wearing a safety body harness when falling can be a potential cause of BTDR. Management of BTDR transabdominally is a safe and effective procedure.

Spontaneous cystic biloma after laparoscopic cholecystectomy treated conservatively: A case report.

INTRODUCTION: Biloma forms due to common bile duct (CBD) injury as a laparoscopic cholecystectomy complication. Spontaneous localized biloma forming cysts in the biliary duct is rare. PRESENTATION OF CASE: We report a 47-year-old male with complaint of a painful lump in the upper abdomen two months after laparoscopic cholecystectomy. Magnetic resonance cholangiopancreatography (MRCP) found a large epigastric cyst mass, without any signs of CBD injury. Patient was managed with percutaneous drainage in the outpatient clinic and kept the contents of the drainage bag for evaluation. After two months follow-up the outcome was favorable. DISCUSSION: Biloma forming cysts is a very rare complication post laparoscopic cholecystectomy. Biloma most common occurs as free fluid in the abdominal cavity. Clinical diagnostics, intraoperative historical evaluation and support with MRCP may determine the treatment options. Decision to manage with non-operative procedures by percutaneous drainage and evaluations of the patient in the outpatient clinic had a favorable outcome. CONCLUSION: Post laparoscopic biloma cysts are a very rare case. Management with percutaneous drainage in an outpatient clinic and ambulatory drainage is an effective and safe procedure.

Erythrocytosis, embolism in a woman with antiphospholipid antibodies: A diagnostic challenge.

Systemic thromboembolism, along with acute multiorgan failure, should raise clinical suspicion for CAPS. Timely management, even in suspected cases, can have a significant impact on mortality.

Comparison between camcorder, frontal head and temporal mounted action-cam in digestive surgery: Documentation and educational alternative during COVID-19 pandemic.

OBJECTIVE: COVID-19 pandemic has made impact both in clinical and educational settings. The number of surgeries has decreased; thus, the surgery videos of all cases are important for both documentation and education. This study aimed to compare three kinds of cameras in recording digestive surgery. METHODS: We compared three cameras: Panasonic HV-770 Full HD Camcorder, Sony FDR-X3000 Action-cam, and Ordro EP7 Hands-Free FPV Camera. Each camera was used in several recording for superficial and visceral digestive surgeries and we compared the following: operation field, image focus, surgeon's comfort, practicality, and record settings. RESULTS: Camcorder needs 10-15 min to set up and longer dismounting time, has steady vantage view and focus, good image quality, can be zoomed, but the recording may be obstructed by the surgeon's head. Action camera needs 5-10 min to set up and the dismounting time was equal between Camcorder and Ordro. Action camera depicts surgeon's vision, however, zoom could not be applied while recording. Sony FDR-X3000 used in this study had good image quality, but the use of this camera in a long surgery may generate neck stiffness due to its weight. Ordro EP7 was comfortable in any surgery but it had inferior image quality compared to the others. CONCLUSIONS: Panasonic HC-V770 and Sony FDR X3000 had good image quality, where camcorder excelled in longer surgeries due to its comfort, action-cam excelled for shorter surgeries due to ease of use and settings. Ordro EP7 was the most comfortable among all but has lowest image quality.

Adenosine A2A receptor and vascular response: role of soluble epoxide hydrolase, adenosine A1 receptor and angiotensin-II.

Previously, we have reported that the coronary reactive hyperemic response was reduced in adenosine A2A receptor-null (A2AAR-/-) mice, and it was reversed by the soluble epoxide hydrolase (sEH) inhibitor. However, it is unknown in aortic vascular response, therefore, we hypothesized that A2AAR-gene deletion in mice (A2AAR-/-) affects adenosine-induced vascular response by increase in sEH and adenosine A1 receptor (A1AR) activities. A2AAR-/- mice showed an increase in sEH, AI AR and CYP450-4A protein expression but decrease in CYP450-2C compared to C57Bl/6 mice. NECA (adenosine-analog) and CCPA (adenosine A1 receptor-agonist)-induced dose-dependent vascular response was tested with t-AUCB (sEH-inhibitor) and angiotensin-II (Ang-II) in A2AAR-/- vs. C57Bl/6 mice. In A2AAR-/-, NECA and CCPA-induced increase in dose-dependent vasoconstriction compared to C57Bl/6 mice. However, NECA and CCPA-induced dose-dependent vascular contraction in A2AAR-/- was reduced by t-AUCB with NECA. Similarly, dose-dependent vascular contraction in A2AAR-/- was reduced by t-AUCB with CCPA. In addition, Ang-II enhanced NECA and CCPA-induced dose-dependent vascular contraction in A2AAR-/- with NECA. Similarly, the dose-dependent vascular contraction in A2AAR-/- was also enhanced by Ang-II with CCPA. Further, t-AUCB reduced Ang-II-enhanced NECA and CCPA-induced dose-dependent vascular contraction in A2AAR-/- mice. Our data suggest that the dose-dependent vascular contraction in A2AAR-/- mice depends on increase in sEH, A1AR and CYP4A protein expression.