Multimodal imaging and genetic characteristics of autosomal recessive bestrophinopathy

PURPOSE

To report the ocular manifestations, multimodal imaging characteristics and genetic testing results of six patients with autosomal recessive bestrophinopathy (ARB).

METHODS

This was an observational case series including 12 eyes of 6 patients who were diagnosed with ARB. All patients underwent a complete ophthalmic examination including refraction, slit-lamp biomicroscopy, dilated fundus examination, fundus autofluorescence, optical coherence tomography and electrooculography. BEST1 gene sequencing was also performed for all patients.

RESULTS

The mean age was 22.8years and the male-female ratio was 0.50. All ARB patients had a hyperopic refractive error. A spectrum of fundus abnormalities, including multifocal yellowish subretinal deposits in the posterior pole, subfoveal accumulation of vitelliform material and cystoid macular edema, was observed. Fundus autofluorescence imaging demonstrated marked hyperautofluorescence corresponding to the yellowish subretinal deposits. Optical coherence tomography revealed serous retinal detachment, intraretinal cysts, brush border appearance caused by elongation of the outer segments of photoreceptors, and hyperreflective dome-shaped deposits at the level of the retinal pigment epithelium. Fundus fluorescein angiography showed hyperfluorescence with staining of the yellowish subretinal deposits. Electrooculography showed reduced Arden ratio in all patients. In addition, biallelic pathogenic variants in the BEST1 gene were detected in all patients.

CONCLUSION

ARB is a rare autosomal recessive inherited retinal disorder with biallelic pathogenic variants in the BEST1 gene and may present with a wide range of ocular abnormalities that may not be easily diagnosed. Multimodal retinal imaging in conjunction with EOG is helpful to establish the correct diagnosis.

Status of estrogen receptor expression and epigenetic methylation in Leydig cells after exposure to metalloestrogen - selenium

The trace element selenium (Se) is essential for the maintenance of spermatogenesis and fertility. A growing volume of evidence shows that Se is necessary for testosterone synthesis, and Se can stimulate Leydig cell proliferation. However, Se can also act as a metalloestrogen, which can mimic estrogen and activate the estrogen receptors. This study aimed to investigate Se effect on estrogen signaling and the epigenetic status of Leydig cells. Mouse Leydig cells (MA-10) were cultured in a medium supplemented with different Se concentrations (4, 8µM) for 24hours. Next, cells were assessed for morphological and molecular (qRT PCR, western blot, immunofluorescence) analyses. Immunofluorescence revealed strong immunosignal for 5-methylcytosine in both control and treated cells, with a stronger signal in the 8μM treated group. qRT-PCR confirmed an increased expression of methyltransferase 3β (Dnmt3b) in 8μM cells. Analysis of the expression of γH2AX (a marker for double-stranded DNA breaks) revealed an increase in the DNA breaks in cells exposed to 8μM Se. Selenium exposure did not affect the expression of canonical estrogen receptors (ERα and ERβ), however, an increase in membrane estrogen receptor G-protein coupled (GPER) protein expression was observed. To sum up, in a high concentration (8μM) Se affects GPER expression (non-genomic estrogen signaling) in Leydig cells possibly via acting on receptor protein and/or its binding. This causes DNA breaks and induces changes in Leydig cell methylation status, especially in de novo methylation which is mediated by Dnmt3b.

Use of biochemical and protein profiles of seminal plasma to prediction of semen quality and fertility in stallions

The identification of various substances in seminal plasma has opened the way to study their functionality. It was aimed to identify the electrophoretic protein profile (EPP) and biochemical parameters (BP) of seminal plasma (SP) as predictors of semen quality and fertility in stallion. Forty-six ejaculates from 7 fertile stallions, aged between 6-26 years, were collected from May to July and 117 mares were used to obtain fertility data. For each ejaculate, volume, sperm motility, concentration were determined and seminal plasma samples were collected to perform one- -dimensional electrophoresis and biochemical profiling. Following the estrus detection, mares were inseminated with fresh sperm. Pregnancy rates and foal rates were recorded. The concentration of 15-18 kDa molecular weight (MW) proteins has shown a positive correlation with sperm concentration and foal rate. Besides, a strong positive correlation was found between sperm concentration and 23-28 kDa MW proteins (r=0.77). The volume of 19-22 kDa MW proteins was negatively correlated with pregnancy and foal rate. Similarly, the volume of high MW proteins (173-385 kDa) correlated negatively with sperm motility and foal rate. Apart from the protein profile, while Magnesium and Glucose levels were negatively correlated with sperm quality and foal rate, Cholesterol level was a positive indicator of the quality of semen as well as the foaling rate. Moreover, the total protein level was correlated negatively with the sperm concentration whereas triglyceride was correlated positively. In conclusion, EPP and BP of seminal plasma are valuable clinical tools as predictors of fertility and semen quality in the stallion.

The effects of different PMSG doses on estrus behavior and pregnancy rate in Angora goats

Artificial insemination protocols depend on efficient behavioral estrus detection and insemination time in Angora goat. Therefore, we aim to determine the accuracy of an estrus scoring system in Angora goats with different PMSG doses during the breeding season. Does (n: 260) were randomly divided into three groups: group-1 (n: 93), group-2 (n: 85) and group-3 (n: 82). All animals received an intravaginal sponge on day 0 for 11 days, and on the day of sponge insertion 150 μg prostaglandin F2Α was administered. Pregnant mare's serum gonadotropin was injected 300, 400 and 500 IU intramuscularly 24 h before sponge removal to groups 1, 2 and 3, respectively. Estrus signs were detected with a teaser buck, 24 h after sponge removal according to a visual scoring system. Artificial insemination was performed with 0.25 ml fresh diluted semen at 43 to 45 h after sponge removal. Differences were observed within PMSG groups in terms of standing, tail wagging, courtship behavior, vaginal discharge and vaginal hyperemia (P<0.001). Nevertheless, the most accurate indicators of estrus that result in pregnancy were tail wagging and courtship behavior followed by standing estrus (P<0.05). According to the results obtained, 300 IU PMSG dose is sufficient, both to inseminate at a fixed time (43 to 45 h after sponge removal) and to record the estrus behavior by teaser male 24 h after sponge removal. Higher PMSG doses (400 to 500 IU) altered the timing of ovulation; specifically, 500 IU dose shortened the duration of estrus behaviors. In conclusion, even though the different doses of PMSG displayed similar effects on estrus synchronization and pregnancy rates, we concluded that tail wagging, courtship behavior and standing heat are the most reliable estrus signs for artificial insemination in Angora goat.

Intravitreal aflibercept therapy in eyes with chronic central serous chorioretihopathy: Short term results

OBJECTIVES

To evaluate the short term efficacy and tolerability results of intravitreal aflibercept injection as a treatment option for eyes with chronic central serous chorioretinopathy (CSCR).

MATERIAL AND METHODS

A prospective longitudinal study. Ten eyes of 10 patients with chronic CSCR who had been followed for >6months after the first intravitreal injection of aflibercept were recruited for the study. The best corrected visual acuity (BCVA) and central macular thickness (CMT) values obtained by spectral-domain optical coherence tomography were recorded at baseline and the first, third, and sixth months after the injection.

RESULTS

The mean logMAR BCVA was 0.70±0.25 at baseline. At the first, third, and sixth months after the injection, the mean logMAR BCVA were 0.39±0.36, 0.32±0.39, and 0.29±0.34, respectively. The mean and median BCVA over the entire follow-up period was significantly improved compared with baseline BCVA (P<.05 for each one). The mean CMT was 449.30±142.53μm at baseline. It was measured as 302.60±72.28μm on the first month, 294.30±72.85μm on the third month, and 294.60±83.84μm on the sixth month after the injection. The mean and median CMT during the entire follow-up period was significantly decreased compared with baseline CMT (P<.05 for each one). None of the patients had any serious ocular or systemic side effects over the course of the study.

CONCLUSIONS

Short term results of this study demonstrate that intravitreal aflibercept may be used as a treatment option to improve the BCVA and reduce the CMT in chronic CSCR.

The quantitative assessment of alterations in lens transparency after transconjunctival 27-gauge microincision vitrectomy surgery

PurposeTo evaluate the baseline and post-vitrectomy lens densitometry values by a Scheimpflug camera in eyes with epiretinal membrane that were treated with 27-G microincision vitrectomy surgery (MIVS) without tamponade and to compare the results with those in fellow healthy eyes.Patients and methodsProspective case series. The lens densitometry measurements of 24 patients, who underwent 27-G MIVS without any tamponade for the treatment of epiretinal membrane, were taken preoperatively and on the first week, first month, and third month postoperatively with Pentacam HR-Scheimpflug imaging system.ResultsThe mean lens densitometry values at Zone 1 and average lens densitometry values significantly increased in the study eyes on the first month when compared with the preoperative values (P=0.011, P=0.033, respectively). Additionally, there were statistically significant differences regarding the mean lens densitometry values of Zone 1 and Zone 2, and also average lens densitometry values between the preoperative and third month postoperative values (P=0.003, P=0.021, P=0.009, respectively). However, the densitometry values of fellow eyes were similar at preoperatively and all the postoperative follow-up periods (P>0.05 for all).ConclusionsThis study suggests that 27-G MIVS might cause post-surgical lens density changes even in early postoperative months and vitreous may play an important role in protecting the transparency of the lens.

Crab claw pattern on corneal topography: pellucid marginal degeneration or inferior keratoconus?

PurposeTo evaluate the topographic, tomographic, and densitometric properties of patients with pellucid marginal degeneration (PMD) and inferior keratoconus.Patients and methodsRetrospective, comparative case series. Forty-seven eyes of 32 patients with crab claw patterns were identified from 2751 patients with corneal ectasia. They were divided into two groups, inferior keratoconus and PMD, based on clinical findings. The topographic, tomographic, and densitometric measurements were analyzed.ResultsPMD was detected in 11 eyes of eight patients (mean age 50.2±11.1 years), and inferior keratoconus was detected in 36 eyes of 24 patients (mean age 34.7±10.1 years). The control group consisted of 40 patients (33.1±4.6 years). The thinnest corneal point and maximum anterior and posterior elevation points were located lower in the PMD than in the inferior keratoconus (P<0.01). In the PMD, all deviation indices were higher than the controls (P<0.01), whereas the deviation indices, except Dt (P=0.960), were lower than the inferior keratoconus (P<0.01). The densitometry values of PMD were significantly higher than those of the controls in all zones and layers (P<0.01) and significantly higher than the densitometry values of inferior keratoconus in the 6-10 and 10-12 mm zones (P<0.05).ConclusionThere is a higher probability of a patient with crab claw pattern on the topography of having inferior keratoconus than having PMD. Therefore, analyzing only the anterior corneal surface is not sufficient in differential diagnosis. Tomographic and densitometric evaluations may facilitate the differential diagnosis.

Use of the neutrophil to lymphocyte ratio for prediction of in-stent restenosis in bifurcation lesions

OBJECTIVE

Percutaneous coronary interventions (PCI) are the preferred treatment for coronary artery disease, even though the development of in-stent restenosis (ISR) continues to be an important complication. Neutrophil to lymphocyte ratio (NLR) is indicative of the inflammatory process and can predict the short- and long-term prognosis of cardiovascular diseases. We investigated the relationship between ISR development and neutrophil-lymphocyte ratio (NLR) in bifurcation lesions in stable coronary artery disease (CAD) patients.

PATIENTS AND METHODS

We analyzed the clinical and angiographic data of 181 consecutive stable CAD patients who had undergone successful PCI to the true bifurcation lesion from January 2010-December 2012. Patients were divided into two groups based on the development of ISR (group 1, ISR -; group 2, ISR +).

RESULTS

NLR(after) (p < 0.001) and NLRΔ (p < 0.001) were significantly higher in group 2. NLRΔ was found to be significant independent predictor of ISR in the multivariate logistic regression analysis. A NLRΔ level > 0.58 mg/dL had 81.8% sensitivity and 93.5% specificity for the prediction of ISR, as identified by the ROC curve. A NLR(after) level > 3.43 predicted ISR with 45.5% sensitivity and 95.8% specificity. The comparison of ROC curve analysis demonstrated that NLRΔ was the strongest independent predictor of ISR (p = 0.001).

CONCLUSIONS

As a result, although drug eluting stent implantation is known to be recommended in the bifurcation lesion PCI in worldwide, we want to emphasize the usage of the NLR values in the prediction of ISR. So, we think that NLRΔ levels may be a useful marker for the prediction of ISR in patients who undergo bifurcation PCI.

The relationship between microalbuminuria and isolated coronary artery ectasia

AIM

Coronary artery ectasia (CAE), is at least 1.5 fold dilatation of at least one coronary segment due to congenital or acquired causes. In this study, we aim to investigate the relation of CAE with microalbuminuria, which is a marker of endothelial dysfunction shown to be associated with increased cardiovascular mortality and morbidity.

PATIENTS AND METHODS

Patients with CAE detected during routine coronary angiogram (CAG) and individuals with normal CAG findings have been included in our study. Urine albumin levels were measured by immunoturbidimetric method from samples collected in the morning. Patients with an albumin/creatinine (A/C) ratio less than 0.03 were normal and the ones between values 0.03-0.3 were considered to be microalbuminuric. Patients whose A/C ratios > 0.3 had macroalbuminuria and were excluded.

RESULTS

A total of 105 patients (60 with CAE and 45 with normal CAG) were included in the study. Serum creatinine, low-density lipoprotein cholesterol and homocysteine levels were increased in the CAE group. Urine A/C ratio was 0.036 ± 0.040 in the CAE group and 0.018 ± 0.013 in the controls; the difference was statistically significant (p = 0.002).

CONCLUSIONS

Blood homocysteine levels and urinary albumin levels are significantly increased in patients with CAE when compared to individuals with normal CAG. Microalbuminuria and hyperhomocysteinemia, two markers of endothelial dysfunction might be associated with pathophysiologic processes leading to CAE.

[Signs of diabetic cardiomyopathy in patients with controlled arterial hypertension and early postprandial hyperglycemia]

AIM

To study signs of diabetic cardiomyopathy (DCM) in nondiabetic patients with controlled arterial hypertension (AH) and glycemic response during first hour of glucose tolerance test (GTT).

MATERIAL AND METHODS

Patients (n = 47) with controlled AH were divided into 2 groups according to results of GTT with 75 g of glucose: patients of group 1 (n = 22) had glucose level ≤ 200 mg/dl during 1-st hour of GTT; other patients (n = 25) composed group 2. Examination of all patients included transthoracic echocardiography, ultrasound Dopplerography, tissue Doppler (TD) and 24-hour Holter ECG monitoring. Using data of these methods we calculated left ventricular (LV) mass and the following characteristics of mitral ring: E/A, TD e', TD a', TD s', TD e'/a'/. The following characteristics of heart rate variability were obtained: standard deviation of normal RR intervals (SDNN), low and high frequency (LF, HF) power, LF/HF ratio.

RESULTS

Patients of group 2 had higher LV mass (229.5 ± 58.2 vs. 192.1 ± 50.6 g; p = 0.036), more pronounced changes of TD e'/a' (0.71 ± 0.25 vs. 1.06 ± 0.58; p = 0.011), lower SDNN both during day (85.4 ± 14.1 vs. 112.5 ± 31.3 ms, p = 0.007) and night (82.2 ± 22.1 vs. 105.9 ± 28.5 ms, p = 0,004) time, higher nocturnal LF/HF ratio (3.75 ± 4.02 vs. 1.72 ± 0.81, p = 0,029).

CONCLUSION

In patients with controlled arterial hypertension (AH) and glycemic response during first hour of GCT we revealed various pronounced manifestations of DCM. These data constitute a basis for further studies.

The relationship between neutrophil/lymphocyte ratio and the TIMI flow grade in patients with STEMI undergoing primary PCI

OBJECTIVES

ST segment elevation myocardial infarction (STEMI) is an important cause of the morbidity and mortality in coronary artery disease. The aim of this study is to investigate the relationship between hematologic parameters and post primary PCI coronary no-reflow.

PATIENTS AND METHODS

A total of 145 consecutive STEMI patients (mean age=58.2±12.3 years) and healthy volunteer admitted within 6 hours from symptom onset were enrolled to the study in the cardiology clinics. The STEMI patients were divided into 2 groups based on the Thrombolysis In Myocardial Infarction (TIMI) flow grade. No-reflow was defined as post-PCI TIMI Flow Grade 0, 1 or 2 and angiographic success was defined as TIMI Grade 3 Flow.

RESULTS

Diabetes mellitus hypertension and smoking status were similar between groups. With respect to baseline laboratory status, fasting glucose, blood urea nitrogen, creatinine levels were not significantly different between groups. The neutrophil/lymphocyte (N/L) ratio was also significantly higher in STEMI group (7.1±4.6 vs. 2.3±1.7, p < 0.001). Additionally, N/L ratio was also significantly higher in No-reflow group (TIMI Flow Grade 0, 1 or 2) group (13.1±4.5 vs. 5.3±2.7, p < 0.001).

CONCLUSIONS

The N/L ratio, which is cheaply and easily measurable laboratory data is independently associated with post primary PCI coronary no-reflow.

[Prediction of severe cardiac complications with the help of myocardial perfusion scintigraphy in patients with residual chronic total occlusion after percutaneous coronary interventions]

Aim of the study was assessment of prognostic value of exercise myocardial perfusion scintigraphy in patients with stable and unstable angina in whom revascularization by percutaneous coronary intervention (PCI) was incomplete and at least one chronic total coronary artery occlusion (CTO) remained after PCI. Between March 2002 and December 2007 569 consecutive patients with multivessel lesions were subjected to SPECT imaging of myocardial perfusion after incomplete revascularization of the myocardium by PCI. At least 1 residual CTO was found in 129 patients (79% men, mean age 64+/-8 years). Primary outcomes were defined as cardiac death or myocardial infarction. Secondary outcomes were registered in 10 (7.9%) and 15 (11.9%) patients, respectively, with moderate and large transitory disturbances of perfusion. Logarithimic range criterion was statistically significant in patients distributed to groups by total estimation of rest in relation to cardiac complications. Univariate and multivariate Cox proportional hazards regression analysis gave additional important information for prediction of severe and nonsignificant cardiac complications when scintigraphic data were added to angiographic and clinical data, left ventricular ejection fraction, and results of treadmill test. Early monitoring with the use of myocardial scintigraphy by SPECT method is associated with increasing prognostic value relative to severe cardiac complications in patients subjected to incomplete revascularization by PCI, and having at least one residual chronic total occlusion.

[Effect of intracoronary and intravenous administration of tirofiban loading dose in patients underwent percutaneous coronary interventions because of acute coronary syndrome]

Aim of this multicenter retrospective study was assessment of effect of intracoronary administration of tirofiban loading dose in troponin positive patients with acute coronary syndrome (ACS). We analyzed multicenter data base of patients subjected to percutaneous coronary interventions (PCI) because of ST-elevation or non-ST elevation ACS from October 2010 to October 2011. Patients who received loading doses of aspirin (300 mg) and clopidogrel (600 mg) before PCI and tirofiban (10 mg/kg bolus with subsequent infusion 0.15 mg/kg/min for 24 h) were selected for the study (n=133, 89 with intravenous and 44 - intracoronary administration of tirofiban loading dose). We assessed hospital mortality, myocardial reinfarctions (reMI), necessity of target vessel revascularization (TVR) and pronounced bleedings. There were no significant differences in mortality, reMI, and TVR between two groups. However major adverse cardiac events was significantly less in patients who received intracoronary tirofiban (6.8 vs. 21.3% in i.v. group; p=0.046). Hospital stay was significantly shorter in intracoronary compared with i.v. group (3.84+/-0.96 vs. 4.55+/-1.11 days; p=0.001). Rates of bleedings did not differ significantly between groups. Thus compared with i.v. intracoronary administration of tirofiban loading dose allows lower rate of major adverse cardiac events as well as to shorten length of hospital stay of patients with ACS.

Surgery for hilar cholangiocarcinoma; a 10 year experience of a tertiary referral centre in the UK

OBJECTIVE

To review the outcome of patients operated for hilar cholangiocarcinoma and analyse prognostic variables.

PATIENTS AND METHODS

A prospectively collected database on patients with hilar cholangiocarcinoma, between 1992 and 2003, and relevant clinical notes were reviewed retrospectively. A total of 174 patients, 96 male, median age 63 years (27-86), were referred. Jaundice was the initial presentation in 167.

RESULTS

ERCP was the initial interventional investigation at the referring centre in 150, of which only 30 were stented successfully. PTC and decompression was carried out on 120. In 17, combined PTC and ERCP were required for placement of stents. Seventy-two underwent laparotomy at which 27 had locally advanced disease. Forty-five had potentially curative resections. Extra hepatic bile duct resection was done in 14 patients of which four were R0 resections. Thirty-one had bile duct resection including partial hepatectomy with 19 R0 resections (P=0.042). Post-operative complications developed in 19 patients, and there were 4 30 day mortalities [hepatic insufficiency:/sepsis (n=3), thrombosis of the reconstructed portal vein (n=1)]. Among the patients with R0 resections, the cumulative survival rates at 1, 3, and 5 year; was 83, 58, 41%, respectively, and in those with R1 resections were 71, 24, 24%, respectively, (P=0.021). Overall survival was shorter in patients with positive perineural invasion (P=0.066: NS). There was no significant difference in survival between the node positive and negative group. Median survival of patients who underwent liver resection was longer than those with bile duct resection only (30 vs 24 months P=0.43: NS).

CONCLUSIONS

ERCP was associated with a high failure rate in achieving pre-operative biliary decompression which was subsequently achieved by PTC. Clear histological margins were associated with improved survival and were better achieved by liver resection as compared to extra hepatic bile duct resection. Positive level I lymph nodes did not adversely impact survival.

Surgical treatment of metastases to the pancreas

BACKGROUND AND AIMS

Metastases to the pancreas are rare and their surgical treatment is not well reported. We present a considerable experience from a single centre analysing various prognostic factors.

METHODS

Data were collected on 13 cases who underwent surgery between 1988 and 2002. Since 1997, data have been recorded prospectively on a dedicated database. Clinical and histopathological factors were reviewed.

RESULTS

There were two women and 11 men with a median age of 62 years (range 40-73). There were seven cases of renal cell carcinomas, three colorectal carcinomas, two sarcomas and one lung carcinoma. A prolonged disease-free interval from primary surgery was characteristic for renal cell carcinoma cases (median = 10.8 years). The operative procedures performed included seven pancreatoduodenectomies, four total and two distal pancreatectomies. The operative mortality and morbidity was 7.7% and 46.1% respectively. The overall one- and two-year survival was 78.8% and 54% respectively. Median survival for renal cell carcinoma was 30.5 months and for non-renal cell carcinoma was 26.4 months (p = 0.76).

CONCLUSIONS

Pancreatectomy should be considered for metastases to the pancreas in the absence of generalised metastatic disease. However, decision making and experience should be concentrated in centres with significant familiarity of this approach.

Role of surgical portosystemic shunts in the era of interventional radiology and liver transplantation

Background

In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension was reviewed.

Methods

This retrospective study analysed the management of patients with portal hypertension in a tertiary liver transplant unit between June 1993 and May 2002. During this 9-year interval, 394 patients underwent endoscopic control of varices, 235 transjugular intrahepatic portosystemic shunts were inserted, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt.

Results

Twenty-nine shunt operations were performed in nine patients with cirrhosis, one patient with congenital hepatic fibrosis and 19 without parenchymal liver disease. There were 12 side-to-side lienorenal, nine mesocaval, three proximal lienorenal, two distal lienorenal, two portacaval and one mesoportal shunts. Encephalopathy was seen in five of 11 patients with a non-selective shunt, but did not occur after side-to-side or selective lienorenal shunt procedures. At a median follow-up of 42·5 months, one mesocaval shunt had thrombosed and one portacaval shunt had stenosed; both were successfully managed by percutaneous intervention. To date, six patients have died; two succumbed to postoperative complications, one of which was related to the shunt.

Conclusion

Patients with Budd–Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in patients with cirrhosis, a side-to-side lienorenal shunt is a good option.

[Acute appendicitis after blunt abdominal trauma]

Acute appendicitis is the most common acute surgical condition of the abdomen. The concept of lumen obstruction as the cause has been widely accepted in the pathogenesis of acute appendicitis. In the literature, we have found a few case reports and a retrospective clinical study related to abdominal trauma as a possible factor in etiology of acute appendicitis. Whether blunt abdominal trauma can be the inciting event leading to acute appendicitis or only is a coincidence is not clear. We represent a case of perforated acute appendicitis after blunt abdominal trauma. Although a causative relationship between trauma and appendicitis cannot be proved in our case, we suggest that appendicitis should be considered in the patients with blunt abdominal trauma for not only medical but also its potential legal implications.