BackgroundHernias of the posterior rectus sheath are very rare abdominal wall hernias with only a handful of cases reported in the literature to date. As an uncommon disease, it is important to recognize and report this case in order to enhance scientific knowledge of this disease.Case presentationThis case report presents a spontaneous posterior rectus sheath herniation in a 79-year-old white man with previous abdominal surgery for appendicitis. His herniation was discovered incidentally during an examination for his chief complaints of lower abdominal pain and diarrhea which were later diagnosed as Salmonella-related gastroenteritis. A computed tomography scan of his abdomen and pelvis showed abdominal wall hernia with loops of small bowel extending into his rectus abdominis muscle. In this case, it was decided to leave the situation alone for now due to no evidence of bowel obstruction and the low risk of this hernia getting strangulated, which otherwise would have warranted urgent surgery.ConclusionsThis report adds to the limited stock of available literature on this unusual issue and strengthens the evidence base on the best approach to support informed clinical decision making. The significant clinical implication of such case reports is increased identification rate of rare clinical conditions which otherwise often go unnoticed.
Background: The incidence of colorectal cancer (CRC) in younger adults (<50 years old) is rising worldwide, at a rate of 1% per annum since mid-1980s. The clinical concern is that younger adults may have more advanced disease leading to poorer prognosis compared to their older cohort due to lack of screening. Therefore, the aim of this study is to assess the incidence and short-term outcomes of colorectal cancer in younger adults. Methods: This is a retrospective study from a prospectively maintained bi-national database from 2007 to 2018. Results: There were 1540 younger adults diagnosed with CRC, with a rise from 5.8% in 2007 to 8.4% in 2018. Majority had lower American Society of Anaesthesiologists (ASA) scores (89%), rectal cancers (46.1%) and higher tumour stage (65.4%). As a consequence, they were likely to have higher circumferential resection margin positivity (6%, P = 0.02) and to receive adjuvant chemotherapy (57.1%, P < 0.001) compared to their older cohort. Multivariate analysis showed disadvantaged socioeconomic status (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.37-7.94, P < 0.001) and increasing tumour stage (OR 14.9, 95% CI 1.89-116.9, P < 0.001) were independent predictors for circumferential resection margin positivity whereas being female (OR 0.71, 95% CI 0.53-0.95, P = 0.02), higher ASA score (OR 175.3, 95% CI 26.7-1035.5, P < 0.001), urgent surgery (OR 2.75, 95% CI 1.84-4.11, P < 0.001) and anastomotic leak (OR 5.02, 95% CI 3.32-7.58, P < 0.001) were predictors of inpatient mortality. Conclusion: There is a steady rise in the incidence of colorectal cancer in younger adults. Both physicians and younger adults should be aware of the potential risk of colorectal cancer (CRC) and appropriate investigations performed so not to delay the diagnosis.
and 3 positive oral challenge results. This resulted in 81 patients being delabelled. Women were more likely than men to have a true penicillin allergy OR 4.0 (95% CI 1.23-13.2). There were no serious adverse events. Conclusion:Patients presenting to ED with a self-reported label of penicillin allergy can be safely tested in the ED setting using skin testing followed by an out of hospital graded oral challenge. The majority (81%) are able to be de-labelled as penicillin allergic. This de-labelling process should result in better patient outcomes, reduced costs to the health system and reduced antibiotic resistance. P24 DUAL EFFECT OF PHENYLEPHRINE TO IMPROVE CORONARY PERFUSION DURING ANAPHYLAXIS MANAGEMENTJoseph S Tobias, Elizabeth Richards and Chu Woon Ng Bundaberg Base Hospital, Queensland, Australia Introduction: Adrenaline, the drug of choice in anaphylaxis may produce side effects like tachycardia resulting in impaired coronary perfusion in the setting of severe hypotension. In this situation, Phenylephrine was used to improve coronary perfusion by Increasing coronary flow time from reflex bradycardia and an increase in coronary perfusion pressure resulting from an overall increase in systemic blood pressure.Description: We describe a situation where at the end of an elective high anterior resection for colovesical fistula, immediately after administering reversal agents (Neostigmine and glycopyrrolate), there was severe hypotension with systolic blood pressure of 40m mmHg unresponsive to Ephedrine and Metaraminol. Adrenaline boluses resulted in tachycardia with marked ST segment elevation and slight increase in blood pressure. Intravenous Phenylephrine 100 mcg bolus was given and repeated twice over a period of 15 minutes which reduced the heart rate from 130 to 100 beats/ minute as well as increased the blood pressure with ST segment returning to baseline. ANZAAG guidelines were followed to maximise management and team efficiency during and after the crisis and resulted in an uneventful recovery. A 10 fold increase in serum Tryptase confirmed anaphylaxis.Discussion: Anaphylaxis to reversal agents (Neostigmine and Glycopyrrolate) is rare 1 and in this situation it was complicated by ECG evidence of tachycardia induced ST segment elevation after administration of 2 doses of 100 mcg increments of adrenaline with only small increase in blood pressure. Phenylephrine improved the myocardial perfusion and blood pressure. We recommend that Phenylephrine should be considered in the presence of Adrenaline induced tachycardia to improve myocardial perfusion during anaphylaxis management. Background: Antibiotic-associated severe cutaneous adverse reactions (AA-SCAR) are frequently associated with difficult causality assessments and compounded by the absence of reliable clinical diagnostics.
Pneumoperitoneum, or the accumulation of free air in the peritoneal cavity, is commonly associated with visceral perforation, mandating emergent surgical intervention. Non-surgical pneumoperitoneum, where visceral perforation is not the cause, does not commonly require surgical management. Chronic pneumoperitoneum secondary to small bowel diverticulosis is rare. Of all gastrointestinal diverticular diseases, jejunoileal diverticulosis is the rarest form. We describe a case of chronic pneumoperitoneum in an 83-year-old male presenting with intermittent abdominal distension and constipation over five years resulting in many presentations to his rural hospital. There were never any associated signs of sepsis such as fever or tachycardia. A computed tomography scan revealed large volume pneumoperitoneum without evidence of perforated viscera or free fluid. An elective diagnostic laparoscopy revealed extensive small bowel diverticular disease. One of the diverticuli exhibited pneumotosis intestinalis where bubbles of gas were noted within the diverticulum wall and mesentery in the local vicinity. Given the extent of the small bowel diverticular disease, the patient's advanced age, and relative lack of symptoms, bowel resection was not undertaken and the patient was managed conservatively. This article illustrates a case of chronic pneumoperitoneum due to small bowel diverticulosis. It highlights the differential diagnoses for chronic pneumoperitoneum, increases awareness of this rare and challenging condition, and portrays the utility of conservative management avoiding major surgery and its potential complications.
This paper presents a multiple linear curve fitting method for finding how the change of manipulated variables affect the final result using productivity prediction of garment employees data set. To perform fitting, a function is defined, which depends on the parameters that measures the closeness between the data and model. The simplest form of modelling is linear regression, which is the prediction of one variable from another. When the relationship between a few variables are assumed to be linear, then multiple linear regression will be used to model the relationship between a continuous response variable and continuous or categorical explanatory variables.
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