Case report: Incarcerated obturator hernia, initially presenting as right hip pain!

INTRODUCTION

An incarcerated Obturator herniation is a rare external abdominal hernia. Abdominal CT-scanning is the first choice for the diagnosis of such an incarcerated Obturator hernia. Since intestinal incarceration leads to acute necrosis. Therefore emergency surgical treatment is required. However, due to the lack of specificity of the clinical manifestations of incarcerated Obturator hernia, a delay in adequate diagnostics may be higher than expected.

PRESENTATION OF CASE

An 82 year woman was admitted to the hospital because of right hip joint pain. She was initially evaluated and admitted by orthopedics team for suspected arthritis. A CT-scan with contrast was ordered, which showed an intestinal ischemic obstruction in a right sided obturator hernia, an acute laparotomy was carried out.

DISCUSSION

This case is important and differs from the well-known similar cases through the emergency admission at the orthopedic department because of the clear right hip pain and clinical history from the patient. An Obturator herniation (OH) is a rare external abdominal hernia accounting for only 0.07 %-1 % of all hernia cases. Because the female pelvis is wider which can lead to herniation of abdominal contents. The Howship-Romberg sign should be checked during physical examination.

CONCLUSION

Obturator hernia is very rare and difficult to diagnose. Moreover when elderly women suffer from long-term chronic diseases, a very thin body, or a history of multiple deliveries. Howship-Romberg sign should be checked in these situations during physical examination. Early diagnosis and treatment significantly reduces the occurrence of intestinal perforation, necrosis, sepsis and/or other severe adverse events, thereby, a significant prognostic improvement of patients.

Impact of contouring variability on oncological PET radiomics features in the lung

Radiomics features extracted from oncological PET images are currently under intense scrutiny within the context of risk stratification for a variety of cancers. However, the lack of robustness assessment poses problems for their application across institutions and for broader patient populations. The objective of the current study was to examine the extent to which radiomics parameters from oncological PET vary in response to manual contouring variability in lung cancer. Imaging data employed in the study consisted of 26 PET scans with lesions in the lung being created through the use of an anthropomorphic phantom in conjunction with Monte Carlo simulations. From each of the simulated lesions, 25 radiomics features related to the gray-level co-occurrence matrices (GLCOM), gray-level size zone matrices (GLSZM), and gray-level neighborhood difference matrices (GLNDM) were extracted from ground truth contour and from manual contours provided by 10 raters in regard to four intensity discretization schemes with number of gray levels of 32, 64, 128, and 256, respectively. The impact of interrater variability in tumor delineation upon the agreement between raters on radiomics features was examined via interclass correlation and leave-p-out assessment. Only weak and moderate correlations were found between segmentation accuracy as measured by the Dice coefficient and percent feature error from ground truth for the vast majority of the features being examined. GLNDM-based texture parameters emerged as the top performing category of radiomcs features in terms of robustness against contouring variability for discretization schemes engaging number of gray levels of 32, 64, and 128 while GLCOM-based parameters stood out for discretization scheme engaging 256 gray levels. How and to what extent interrater reliability of radiomics features vary in response to the number of raters were largely feature-dependent. It was concluded that impact of contouring variability on PET-based radiomics features is present to varying degrees and could be experienced as a barrier to convey PET-based radiomics research to clinical relevance.

Effects of Oenothera biennis L. and Hypericum perforatum L. extracts on some central nervous system myelin proteins, brain histopathology and oxidative stress in mice with experimental autoimmune encephalomyelitis

We investigated the effects of Oenothera biennis L. and Hypericum perforatum L. extracts on brain tissue histopathology, myelin oligodendrocyte glycoprotein (MOG), myelin basic protein (MBP), total antioxidant status (TAS), total oxidant status (TOS) and oxidative stress index (OSI) in mice with experimental autoimmune encephalomyelitis (EAE). Forty-seven C57BL/6J mice were divided into the following groups: multiple sclerosis (MS), control (healthy mice), MS + H. perforatum treated (MS + HP), MS + O. biennis treated (MS + OB). All groups except the control group were immunized by EAE methods. Two weeks after the immunization, the mice in the MS + HP group were fed normal food containing 18 - 21 g/kg H. perforatum extract, the mice in MS + OB group were fed normal food containing 18 - 21 g/kg O. biennis extract, and the mice in control and MS groups were fed normal food for six weeks. Brain tissue samples were collected from all mice for histopathological and biochemical analysis. Clinical signs of the disease were scored using functional systems scores (FSS) daily. The H. perforatum and O. biennis extracts ameliorated the increased brain tissue MOG and MBP values for animals with MS. H. perforatum and O. biennis extract decreased the TOS and OSI values for brain tissue and increased TAS levels in brain tissue of animals with MS. In addition, H. perforatum and O. biennis extracts decreased the clinical signs at the end of the experiment compared to the beginning of extract administration. We found that myelin was lost in MS group vs. control group. H. perforatum and O. biennis extract treatments decreased the amount of myelin loss in the MS + HP and MS + OB groups. We also observed amyloid deposition on vascular walls, in the cytoplasm of the neurons and in the intercellular space in the MS group. O. biennis and H. perforatum treated groups exhibited neither abnormal amyloid deposition nor obvious cell infiltration. The beneficial effects of O. biennis and H. perforatum for attenuating myelin loss and amyloid deposition suggest their therapeutic utility for treatment of MS.

HELLP syndrome is still a serious, life-threatening complication of pregnancy: admission of 34 women to an eastern Turkish intensive care unit

OBJECTIVE

The transfer of the obstetric patient to the intensive care unit is considered as an indicator of maternal morbidity. The most important two indications for admittance of the obstetric patient to the intensive care unit are postpartum hemorrhage and hypertensive disorders. The purpose of this study was to determine maternal morbidity and mortality rates in patients diagnosed with hemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome who required intensive care.

MATERIALS AND METHODS

The charts of 34 patients who were diagnosed with HELLP syndrome and treated in intensive care unit between the years 2005 - 2013 were evaluated retrospectively.

RESULTS

During the study period, a total of 151 patients were diagnosed with HELLP syndrome and 34 patients were admitted to the intensive care unit. Mean age of the patients was 28.97 ± 7.26 years and there was no significant difference be- tween survivors and non-survivors (p = 0.442). There were no significant differences between survivors and non-survivors in terms of gestational age, parity, and multiparity rates (p > 0.05). There was 31.2% mortal cases and 77.8% of living cases had received regular antenatal follow-up and the difference was statistically significant (p = 0.006). 30 patients (88.2%) required invasive mechanical ven- tilation. The average Glasgow Coma Score (GCS) of patients was 6.47 ± 4.34. There were significant differences between patients who lived and who died in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) score, and duration of invasive mechanical ventilation (p < 0.05). Twenty-two patients (64.7%) required transfusion of blood and blood products. Maternal mortality occurred in 16 patients (47%). The causes of death were: intracerebral hemorrhage in six cases, acute respiratory distress syndrome (ARDS) in three cases, disseminated intravascular coagulation (DIC) in three\cases, sepsis/multi- ple organ dysfunction syndrome (MODS) in two cases, hepatic rupture in one case, and massive pulmonary embolism in one case. Con- clusion: HELLP syndrome is still one of the most serious and life-threatening complications of pregnancy. Mortality rate can be reduced by regular antenatal follow-up and transfer of pregnant women who carry risk to the intensive care unit without delay.

Targeting hedgehog signaling reduces self-renewal in embryonal rhabdomyosarcoma

Current treatment regimens for rhabdomyosarcoma (RMS), the most common pediatric soft tissue cancer, rely on conventional chemotherapy, and although they show clinical benefit, there is a significant risk of adverse side effects and secondary tumors later in life. Therefore, identifying and targeting sub-populations with higher tumorigenic potential and self-renewing capacity would offer improved patient management strategies. Hedgehog signaling has been linked to the development of embryonal RMS (ERMS) through mouse genetics and rare human syndromes. However, activating mutations in this pathway in sporadic RMS are rare and therefore the contribution of hedgehog signaling to oncogenesis remains unclear. Here, we show by genetic loss- and gain-of-function experiments and the use of clinically relevant small molecule modulators that hedgehog signaling is important for controlling self-renewal of a subpopulation of RMS cells in vitro and tumor initiation in vivo. In addition, hedgehog activity altered chemoresistance, motility and differentiation status. The core stem cell gene NANOG was determined to be important for ERMS self-renewal, possibly acting downstream of hedgehog signaling. Crucially, evaluating the presence of a subpopulation of tumor-propagating cells in patient biopsies identified by GLI1 and NANOG expression had prognostic significance. Hence, this work identifies novel functional aspects of hedgehog signaling in ERMS, redefines the rationale for its targeting as means to control ERMS self-renewal and underscores the importance of studying functional tumor heterogeneity in pediatric cancers.

Anesthetic Management in Children with Congenital Lobar Emphysema

BACKGROUND

The cause of congenital lobar emphysema (CLE) is unknown and characterized by hyperinflation of one or more lobes of the lung. The purpose of this retrospective study was to present the anesthetic management of children with congenital lobar emphysema (CLE) receiving treatment in our center.

METHODS

Ten children underwent CLE-related surgical treatment in our center between March 1995 and August 2014. All cases were diagnosed on the basis of postero-anterior chest radiography and computerized tomography. Age, sex, preoperative clinical findings, location of lesions, surgical and anesthetic procedures, results of anesthesia and duration of hospitalization were evaluated.

RESULTS

Six patients were male (60%) and four female (40%). Their ages ranged from 40 days to 6 years. Dyspnea was present in all cases and severe in four of them. Four patients had emphysema in the left upper lobe, three in the right middle lobe, one in the right upper lobe and one in the left lower lobe. All patients were extubated in the operating room and none experienced post-operative respiratory distress. Post-operative analgesia was provided via the previously placed intrapleural catheter. All the patients were extubated in the operation room. There was no post-operative mortality or morbidity.

CONCLUSIONS

Anesthetic management of patients with CLE is challenging. In these patients the surgical team and -anesthetists should collaborate closely and the time between anesthesia induction and thoracotomy should be as short as possible.

In vitro motility changes in Roux limb after Roux-en-Y reconstruction

BACKGROUND

The aim of this study is to compare the motility of Roux limb with that of normal segment.

MATERIALS AND METHODS

Rats were divided into 3 equal groups as control, Roux-en-Y (Group A) and Roux-en-Y with vagotomy (Group B). Only midline incision and manipulations were applied in control group. Following distal gastrectomy, Roux-en-Y reconstruction was applied in Group A, while vagotomy Roux-en-Y gastrojejunostomy was applied in Group B. Rats were sacrificed 1 month later by cervical dislocations under anesthesia. The obtained jejunal segments were cut into four equal parts. The bath was 37 °C warm while 95 % O2 and 5 % CO2 gases were supplied in 10 ml bicarbonate Krebs' solution.

RESULTS

KCl responses were similar in all three groups. Acetylcholine contraction responses in the vagotomy and non-vagotomy Roux-en-Y groups was higher than in those in control group significantly (p < 0.05). This response in vagotomy Roux-en-Y group was also higher than that in non-vagotomy group (p < 0.05). The induced electrical field stimulation contraction response in the vagotomy + Roux-en-Y group was lower than those in control group and non-vagotomy group (p < 0.05).

CONCLUSIONS

These results show that muscarinic receptor density and/or function may increase after vagotomy and non-vagotomy group operation, and vagotomy may contribute to this increase. The decrease in electrical signal response in vagotomy Roux-en-Y group may depend on the decrease in acetylcholine oscillation from the cholinergic nerve ending (Tab. 1, Fig. 5, Ref. 25).