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Objectives. To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer. Methods. A single-center cross-sectional, retrospective study on 697 cases of appendicitis admitted in the year 2018. Inclusion criteria: patients admitted with acute appendicitis who underwent appendectomy of all ages. Exclusion criteria: conservative management. Analysis was performed using Microsoft Excel. Pearson correlation coefficient was calculated to assess the correlation between monthly incidence of appendicitis and mean temperature in that month. Results. Fifty-one patients who were managed conservatively were excluded. Accordingly, 646 patients were included. Ages ranged from three to 77 years. Males comprised the majority (500, 77.4%). Gangrenous, perforated, and purulent appendices were regarded as complicated appendicitis. The highest number of cases were admitted in summer (234), comprising 36.2% of cases. Complicated cases were equal to 65, of which 23 (35.4%) were admitted in summer and 30 (46.2%) in winter. The highest number of cases was during the month of July (68), while the lowest (40) was during February. This corresponded to the highest recorded mean temperature (36.2°C) and second lowest (19.8°C), respectively. Moderate positive correlation (Pearson’s R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted. Conclusion. More cases of appendicitis were noted during summer. Monthly incidence correlated positively with the temperature. Larger numbers over several years are needed to draw better conclusions and reach the possible causes behind such variation.

This is a case of a 14-year-old woman diagnosed with acute pancreatitis based on history and laboratory investigations. CT scan confirmed the diagnosis of acute pancreatitis along with the presence of two bezoars in the stomach and proximal jejunum. Gastroscopy showed a large trichobezoar with difficult endoscopic extraction. Accordingly, the patient underwent laparotomy, gastrostomy and enterotomy with successful removal of the large gastric and jejunal daughter bezoars. Following surgery, pancreatitis resolved and investigations returned to normal. Child psychiatry consultation was sought, and she was diagnosed with trichotillomania and trichophagia.

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries.

Chronic renal failure patients need renal replacement therapy to sustain their lives. Renal replacement therapy could be either hemodialysis (HD) or peritoneal dialysis (PD). In hemodialysis, a vascular access is created to connect the patient to the dialysis machine; the access could be a central line, a native arterio-venous fistula (AVF) or a synthetic arteriovenous graft (AVG) 1 . AVF provides the best functional patency and the least complications 1 . AVF is the recommended vascular access in patients who need dialysis treatment 2 . Nevertheless, complications, such as AVF aneurysms, steal syndrome, venous hypertension and infections are not uncommon 3 .A recent study on regular hemodialysis patients revealed that AVF aneurysm formation is the most common complication 3 . Background: Arterio-venous fistula (AVF) provides the best functional patency for patients onregular hemodialysis (HD). Nevertheless, complications such as AVF aneurysms, steal syndrome, venous hypertension and infections are not uncommon. Objective: To evaluate the trends in AVF aneurysm formations, prophylaxis and treatment options. Design: A Retrospective, Descriptive Study. Setting: Hemodialysis Centers, Ministry of Health, Kingdom of Bahrain. Method: Two hundred and eleven patients on hemodialysis via arterio-venous fistula and arteriovenous graft were included in the study. Result: Two hundred and eleven patients were on hemodialysis via arterio-venous fistula and arterio-venous graft. Thirty (14.22%) patients developed arterio-venous fistula aneurysm. Sixteen (53.33%) were males, and the mean age was 57 years. Eleven (36.66%) patients had excision of the aneurysms with interposition graft. Six (20%) patients had excision of the aneurysms with new fistula formation. Six (20%) patients required a change of the cannula insertion site while the remaining 7 (23.33%) patients were waiting for their scheduled date of surgery. Conclusion: Aneurysm formation is the most common complication in post AVF patients on regular HD. AVF aneurysms are at high risk of rupture and fatal hemorrhage. Surgical treatments could safely be performed for high risk aneurysms. The most common cause of aneurysm formation is repeated punctures at the same site.

Acute appendicitis is one of the most common reasons for presentation to the emergency department that requires an emergency appendectomy. Clinical presentation with abdominal pain in the left lower quadrant is very uncommon but can occur with a congenital left-sided appendix or right-sided long appendix. We report a rare case of a 65-year-old man with incidental finding of situs inversus totalis who presented with left lower quadrant abdominal pain. A CT scan of the abdomen confirmed the diagnosis of left-sided acute appendicitis, and the patient underwent laparoscopic appendectomy with an uneventful postoperative course.

Fibroadenoma is a common benign lesion of the breast that usually occurs in young females. Giant fibroadenoma of the breast is a rare benign pathology, which is defined as fibroadenoma greater than 5 cm in size and/or weighs more than 500 g. It is usually found in adolescent women. A 37-year-old woman undergoing treatment for infertility was referred to the breast clinic with an ulcerating left breast lump that had progressively increased in size. Examination showed a fungating left breast mass that obliterated the nipple-areola complex. Ultrasound showed a large soft tissue mass in the left breast with enlarged left axillary lymph nodes. Computed tomographic (CT) scan showed a 13×17 cm left breast mass. Core biopsy of this mass reported possibility of phyllodes tumor, while axillary fine-needle aspiration cytology (FNAC) showed no evidence of malignancy. Total mastectomy with immediate reconstruction using silicone implant was performed. Final histopathology reported giant fibroadenoma. Most cases on giant fibroadenoma reported in literature are limited to adolescent or young females, however, our patient was relatively old, which makes this a rare case.

Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract. Complications involving Meckel’s diverticulum include bleeding, bowel obstruction and inflammation. We present a rare case of small bowel obstruction caused by Meckel’s diverticulum. A 50-year-old male presented to the emergency department with abdominal pain and vomiting. Computed tomography (CT) abdomen showed dilated small bowel loops with transition zone at the mid ileum, consistent with small bowel obstruction. The patient was taken to the operating theatre for exploratory laparotomy and was found to have a Meckel’s diverticulum causing mechanical small bowel obstruction, which was resected with primary anastomosis. The patient recovered with no postoperative complications and was discharged home. Meckel’s diverticulum is difficult to diagnose preoperatively since most patients are asymptomatic and requires a high index of suspicion. In patients presenting with an acute abdomen, it may be overlooked because of nonspecific symptoms. In the case of small bowel obstruction, Meckel’s diverticulum should be kept in mind as part of the differential diagnosis.