Bleeding Meckel's diverticulum diagnosis: an unusual indication for computed tomography

Despite the wide use of modern investigation techniques, the diagnosis of complications related to Meckel's diverticulum (MD) remains difficult. Arteriography is commonly indicated for acute bleeding, and radionuclide scans may help in identifying the site of intestinal hemorrhage. In contrast, computed tomography (CT) is usually considered little use in the diagnosis of bleeding MD. We present the case of a young patient with massive gastrointestinal hemorrhage, in whom the diagnosis of MD bleeding was preoperatively made with contrast-enhanced CT after two negatives arteriographie

Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan

Background: Percutaneous abscess drainage guided by computed tomography scan is considered the initial step in the management of patients presenting with Hinchey II diverticulitis. The rationale behind this approach is to manage the septic complication conservatively and to follow this later using elective sigmoidectomy with primary anastomosis. Methods: The clinical outcomes for Hinchey II patients who underwent percutaneous abscess drainage in our institution were reviewed. Drainage was considered a failure when signs of continuing sepsis developed, abscess or fistula recurred within 4 weeks of drainage, and emergency surgical resection with or without a colostomy had to be performed. Results: A total of 34 patients (17 men and 17 women; median age, 71 years; range, 34-90 years) were considered for analysis. The median abscess size was 6 cm (range, 3-18 cm), and the median duration of drainage was 8 days (range, 1-18 days). Drainage was considered successful for 23 patients (67%). The causes of failure for the remaining 11 patients included continuing sepsis (n = 5), abscess recurrence (n = 5), and fistula formation (n = 1). Ten patients who failed percutaneous abscess drainage underwent an emergency Hartmann procedure, with a median delay of 14 days (range, 1-65 days) between drainage and surgery. Three patients in this group (33%) died in the immediate postoperative period. Among the 23 patients successfully drained, 12 underwent elective sigmoid resection with a primary anastomosis. The median delay between drainage and surgery was 101 days (range, 40-420 days). In this group, there were no anastomotic leaks and no mortality. Conclusion: Drainage of Hinchey II diverticulitis guided by computed scan was successful in two-thirds of the cases, and 35% of the patients eventually underwent a safe elective sigmoid resection with primary anastomosis. By contrast, failure of percutaneous abscess drainage to control sepsis is associated with a high mortality rate when an emergency resection is performed. The current results demonstrate that percutaneous abscess drainage is an effective initial therapeutic approach for patients with Hinchey II diverticulitis, and that emergency surgery should be avoided whenever possibl

Aphrati and Kato Syme: Pottery, Continuity, and Cult in Late Archaic and Classical Crete

The analysis of ceramics from Aphrati sheds valuable new light on the history of this Cretan settlement and on its relationship with a nearby rural sanctuary at Kato Syme in the Late Archaic and Classical periods. It has long been held that Aphrati was deserted from ca. 600 to 400 B.C. A pottery deposit from the domestic quarter, however, now supports occupation of the city during this period. A ceramic classification system is presented and the morphological development and absolute chronology of several key shapes at Aphrati and Kato Syme are plotted. Historical implications of the ceramic evidence are also explored

Case Report: Don’t chew the fufu: a case report of suspected drug body stuffing

Background: Intrabody concealment of illicit substances is a common practice in the trafficking chain. Body packing is a technique used in drug trafficking that consists of deliberately ingesting many drug pellets. Body stuffing consists of precipitously swallowing packets of substances, which are smaller and more fragile than body-packing pellets, for concealment from law-enforcement officers in anticipation of impending search or arrest. Therefore, body stuffing is particularly dangerous due to the rupture risk of the loosely wrapped drug packets, which could lead to substance intoxication or even death. Case presentation:  This article reports the case of a young man who was taken by law enforcement authorities to our Emergency Department for investigation of suspected body stuffing. Although the patient denied the facts, the initial reading of the computed tomography (CT) scan confirmed the presence of multiple images compatible with drug pellets, which were mostly in the stomach. The pellet findings were more consistent with body packing than body stuffing as initially suspected by the police. However, upon admission to our secured inpatient ward for clinical surveillance of pellet evacuation, the patient denied again having ingested such pellets, and declared that he only ate ‘fufu’. Fufu is a traditional food of central and western Africa consisting of a starchy preparation compacted by hand into small balls. Fufu balls are usually swallowed without chewing to allow a sensation of stomach fullness throughout the day. Considering the fufu intake history, a careful reassessment of the imaging confirmed the presence of food content. Conclusions: This case study offers an example of suspected intrabody concealment of illicit substances, which turned out to be false positive due to fufu. It illustrates the importance of a history of food intake that could bias the interpretation of CT scan images.</ns3:p

Managing risks to drivers in road transport

This report presents a number of case studies in managing risks to road transport drivers. The cases feature a variety of initiatives and interventions to protect drivers.In the road transport sector, as with any other, it is important to pay attention to working conditions in order to ensure a skilled and motivated workforce. Certain characteristics of the sector make it more difficult to practice risk management than in other sectors. But by taking account of how the sector operates in practice, and the characteristics of drivers themselves and the way they work, risks can be successfully manage

The impact of a line probe assay based diagnostic algorithm on time to treatment initiation and treatment outcomes for multidrug resistant TB patients in Arkhangelsk region, Russia

BACKGROUND: In the Arkhangelsk region of Northern Russia, multidrug-resistant (MDR) tuberculosis (TB) rates in new cases are amongst the highest in the world. In 2014, MDR-TB rates reached 31.7% among new cases and 56.9% among retreatment cases. The development of new diagnostic tools allows for faster detection of both TB and MDR-TB and should lead to reduced transmission by earlier initiation of anti-TB therapy. STUDY AIM: The PROVE-IT (Policy Relevant Outcomes from Validating Evidence on Impact) Russia study aimed to assess the impact of the implementation of line probe assay (LPA) as part of an LPA-based diagnostic algorithm for patients with presumptive MDR-TB focusing on time to treatment initiation with time from first-care seeking visit to the initiation of MDR-TB treatment rather than diagnostic accuracy as the primary outcome, and to assess treatment outcomes. We hypothesized that the implementation of LPA would result in faster time to treatment initiation and better treatment outcomes. METHODS: A culture-based diagnostic algorithm used prior to LPA implementation was compared to an LPA-based algorithm that replaced BacTAlert and L&ouml;wenstein Jensen (LJ) for drug sensitivity testing. A total of 295 MDR-TB patients were included in the study, 163 diagnosed with the culture-based algorithm, 132 with the LPA-based algorithm. RESULTS: Among smear positive patients, the implementation of the LPA-based algorithm was associated with a median decrease in time to MDR-TB treatment initiation of 50 and 66 days compared to the culture-based algorithm (BacTAlert and LJ respectively, p&lt;0.001). In smear negative patients, the LPA-based algorithm was associated with a median decrease in time to MDR-TB treatment initiation of 78 days when compared to the culture-based algorithm (LJ, p&lt;0.001). However, several weeks were still needed for treatment initiation in LPA-based algorithm, 24 days in smear positive, and 62 days in smear negative patients. Overall treatment outcomes were better in LPA-based algorithm compared to culture-based algorithm (p = 0.003). Treatment success rates at 20 months of treatment were higher in patients diagnosed with the LPA-based algorithm (65.2%) as compared to those diagnosed with the culture-based algorithm (44.8%). Mortality was also lower in the LPA-based algorithm group (7.6%) compared to the culture-based algorithm group (15.9%). There was no statistically significant difference in smear and culture conversion rates between the two algorithms. CONCLUSION: The results of the study suggest that the introduction of LPA leads to faster time to MDR diagnosis and earlier treatment initiation as well as better treatment outcomes for patients with MDR-TB. These findings also highlight the need for further improvements within the health system to reduce both patient and diagnostic delays to truly optimize the impact of new, rapid diagnostics

Diagnostic accuracy of non-invasive tests to screen for at-risk MASH-An individual participant data meta-analysis

Background & Aims: There is a need to reduce the screen failure rate (SFR) in metabolic dysfunction-associated steatohepatitis (MASH) clinical trials (MASH+F2-3; MASH+F4) and identify people with high-risk MASH (MASH+F2-4) in clinical practice. We aimed to evaluate non-invasive tests (NITs) screening approaches for these target conditions. Methods: This was an individual participant data meta-analysis for the performance of NITs against liver biopsy for MASH+F2-4, MASH+F2-3 and MASH+F4. Index tests were the FibroScan-AST (FAST) score, liver stiffness measured using vibration-controlled transient elastography (LSM-VCTE), the fibrosis-4 score (FIB-4) and the NAFLD fibrosis score (NFS). Area under the receiver operating characteristics curve (AUROC) and thresholds including those that achieved 34% SFR were reported. Results: We included 2281 unique cases. The prevalence of MASH+F2-4, MASH+F2-3 and MASH+F4 was 31%, 24% and 7%, respectively. Area under the receiver operating characteristics curves for MASH+F2-4 were .78, .75, .68 and .57 for FAST, LSM-VCTE, FIB-4 and NFS. Area under the receiver operating characteristics curves for MASH+F2-3 were .73, .67, .60, .58 for FAST, LSM-VCTE, FIB-4 and NFS. Area under the receiver operating characteristics curves for MASH+F4 were .79, .84, .81, .76 for FAST, LSM-VCTE, FIB-4 and NFS. The sequential combination of FIB-4 and LSM-VCTE for the detection of MASH+F2-3 with threshold of .7 and 3.48, and 5.9 and 20 kPa achieved SFR of 67% and sensitivity of 60%, detecting 15 true positive cases from a theoretical group of 100 participants at the prevalence of 24%. Conclusions: Sequential combinations of NITs do not compromise diagnostic performance and may reduce resource utilisation through the need of fewer LSM-VCTE examinations