Laparoscopic Cholecystectomy for Severe Acute Cholecystitis in a Patient with Situs Inversus Totalis and Posterior Cystic Artery

Situs inversus totalis is an inherited condition characterized by a mirror-image transposition of thoracic and abdominal organs. It often coexists with other anatomical variations. Transposition of the organs imposes special demands on the diagnostic and surgical skills of the surgeon. We report a case of a 34-year-old female patient presented with left upper quadrant pain, signs of acute abdomen, and unknown situs inversus totalis. Severe acute cholecystitis was diagnosed, and an uneventful laparoscopic cholecystectomy was performed. A posterior cystic artery was identified and ligated. Laparoscopic cholecystectomy is feasible in patients with severe acute calculus cholecystitis and situs inversus totalis; however, the surgeon should be alert of possible anatomic variations

Automatic Gunn and Salus sign quantification in retinal images

Prolonged hypertension can lead to abnormal changes in the retinal vasculature, including sclerosis and thickening of the arteriole walls. These changes can cause compression (Gunn’s sign) and deflection (Salus’s sign) of the veins at arteriovenous crossings. In retinal images, Gunn’s sign appears as a tapering of the vein at a crossing point, while Salus’s sign presents as an S-shaped curving. This paper presents a method for the automatic quantification of these two signs once a crossover has been detected; combining segmentation, artery vein classification, and morphological feature extraction techniques to calculate vein widths and angles entering and exiting the crossover. The method was tested on a small set of crossings, graded by a set of 3 doctors who were in agreement as having or not having Gunn/Salus sign. Results show separation between the two classes and that we can reliably detect and quantify these sign under the right conditions

No-Reflow Phenomenon: A Major Issue Concerning Revascularization in Acute Coronary Syndromes

The no-reflow phenomenon (NRp), a dreaded complication of primary and also of any complex percutaneous coronary intervention (PCI), is characterized by insufficient myocardial perfusion in a territory of a coronary artery without evidence of mechanical obstruction. Microvascular injury is the underlying mechanism of NRp and its manifestation is not only impaired TIMI flow (<3), but also impaired TIMI myocardial perfusion grade (TMPG) which should be assessed in case of chest pain, persistent ST segment elevation or hemodynamic compromise despite the presence of TIMI III flow. The NRp mechanism is multifaceted, the evidence base for its treatment is inconsistent and limited, but its predictors are well known. The armamentarium against NRp consists of preventive and therapeutic strategies, both mechanical and pharmacological. A brief overview of all the above issues concerning NRp is attempted herein. Rhythmos 2019;14(2):27-30

An asymptomatic double aortic arch with separate right vertebral artery and left subclavian artery originating from Kommerell Diverticulum combined with congenital asplenia and absence of celiac trunk

This report describes the unique case of a completely patent Double Aortic Arch (DAA) combined with Kommerell Diverticulum (KD), absence of celiac trunk and congenital asplenia. The anatomical variants described were identified and assessed in a 51-year old female from a computed-tomography angiography (CTA) images with 3D-volume rendered reconstructions during her follow-up after hysterectomy. The reconstructed CTA images showed a DAA with the left common carotid artery stemming from the hypoplastic left aortic arch while  the left subclavian artery originated from a KD in the descending thoracic aorta. A symmetric arrangement of the aortic arch branches was demonstrated, comprising a full vascular ring. Since the patient had been completely asymptomatic and with no symptoms of compression of the esophagus or trachea, no surgical management was advised. The abdomen CTA imaging revealed absence of the celiac trunk with direct origin of the common hepatic and the left gastric artery from the superior mesenteric artery as well as asplenia. We presented a case of asymptomatic DAA of completely patent arches with  the right vertebral artery branching separately of and the left SCA originating from KD in the descending aorta. The term KD can be identified also in other arch anomalies than the one originally described. Since anatomical anomalies can be frequently combined, thorough imaging inspection with CTA of both thorax and abdomen is suggested

An Undersized Stent Does Not Forgive

Stent thrombosis is a rare complication of percutaneous coronary intervention (PCI) with potential devastating results. Stent undersizing and malapposition are major risk factors of stent thrombosis and have been strongly associated with early stent thrombosis. However, despite the continuous progress of interventional cardiology, there is no consensus regarding optimal management of this medical emergency. Herein, we present a case of subacute stent thrombosis that manifested as a severe inferior ST-elevation myocardial infarction four days after an initial PCI of the right coronary artery. A stepwise treatment approach was followed aiming initially to achieve flow TIMI III without stenting during primary PCI. During a revision procedure, stent undersizing and malapposition were identified as underlying mechanisms of stent thrombosis using intravascular imaging guidance and treated successfully with corrective PCI. Further evidence is needed to refine the optimal treatment strategy in the setting of stent thrombosis. Rhythmos 2019;14(2):31-34.

Comparative performance and external validation of three different scores in predicting inadequate bowel preparation among Greek inpatients undergoing colonoscopy

Background Predictive scores aim to predict bowel preparation adequacy among hospitalized patients undergoing colonoscopy. We evaluated the comparative efficacy of these scores in predicting inadequate bowel cleansing in a cohort of Greek inpatients. Methods We performed a post hoc analysis of data generated from a cohort of inpatients undergoing colonoscopy in 4 tertiary Greek centers to validate the 3 models currently available (models A, B and C). We used the Akaike information criterion to quantify the performance of each model, while Harrell's C-index, as the area under the receiver operating characteristics curve (AUC), verified the discriminative ability to predict inadequate bowel prep. Primary endpoint was the comparison of performance among models for predicting inadequate bowel cleansing. 70.7 +/- 15.4 years-were included in the analysis. Model B showed the highest performance (Harrell's C-index: AUC 77.2% vs. 72.6% and 57.5%, compared to models A and C, respectively). It also achieved higher performance for the subgroup of mobilized inpatients (Harrell's C-index: AUC 72.21% vs. 64.97% and 59.66%, compared to models A and C, respectively). Model B also performed better in predicting patients with incomplete colonoscopy due to inadequate bowel preparation (Harrell's C-index: AUC 74.23% vs. 69.07% and 52.76%, compared to models A and C, respectively).Conclusions Predictive model B outperforms its comparators in the prediction of inpatients with inadequate bowel preparation. This model is particularly advantageous when used to evaluate mobilized inpatients

Neurological and neurourological complications of electrical injuries

Electrical injury can affect any system and organ. Central nervous system (CNS) complications are especially well recognised, causing an increased risk of morbidity, while peripheral nervous system (PNS) complications, neurourological and cognitive and psychological abnormalities are less predictable after electrical injuries.PubMed was searched for English language clinical observational, retrospective, review and case studies published in the last 30 years using the key words: electrical injury, electrocution, complications, sequelae, neurological, cognitive, psychological, urological, neuropsychological, neurourological, neurogenic, and bladder.In this review, the broad spectrum of neurological, cognitive, psychological and neurourological consequences of electrical trauma are discussed, and clinical features characteristic of an underlying neurological, psychological or neurourological disorder are identified. The latest information about the most recently discovered forms of nervous system disorders secondary to electrical trauma, such as the presentation of neurological sequelae years after electrocution, in other words long-term sequelae, are presented. Unexpected central nervous system or muscular complications such as hydrocephalus, brain venous thrombosis, and amyotrophic lateral sclerosis are described. Common and uncommon neuropsychological syndromes after electrical trauma are defined. Neurourological sequelae secondary to spinal cord or brain trauma or as independent consequences of electrical shock are also highlighted