IntroductionAcute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review.MethodsWe performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis.ResultsComputed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied.ConclusionWhile CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.

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Although the newer continuous-flow left ventricular assist devices (CF-LVADs) provide clinical advantages over the pulsatile pumps, the effects of low pulsatility on inflammation are incompletely understood. The objective of our study was to examine the levels of inflammatory mediators in CF-LVAD recipients compared with both healthy control subjects and heart failure patients who were candidates for CF-LVAD support. Plasma levels of chemokines, cytokines, and inflammatory markers were measured in 18 CF-LVAD recipients and compared with those of 14 healthy control subjects and 14 heart failure patients who were candidates for CF-LVADs. The levels of granulocyte macrophage-colony stimulating factor, macrophage inflammatory proteins-1β, and macrophage-derived chemokine were significantly higher in the CF-LVAD group compared with both the heart failure and the healthy control groups, whereas no significant differences were observed between the healthy control subjects and the heart failure groups. Compared with the healthy controls, C-reactive protein, interferon gamma-induced protein-10, monocyte chemotactic protein-1, and interleukin-8 levels were significantly higher in both the CF-LVAD and heart failure groups, but no significant differences were observed between the CF-LVAD recipients and the heart failure patients. Inflammatory markers were elevated in CF-LVAD recipients compared with healthy control subjects and the heart failure patients. Further studies should investigate the clinical implications of elevated levels of inflammation in CF-LVAD recipients.

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The number of studies evaluating RTI proportions and fatalities in SSA countries is increasing but without the exponential rise expected from World Health Organization calls for research during the Decade of Action for Road Traffic Injuries. Further research infrastructure including standardization of taxonomy, definitions, and data reporting measures, as well as funding, would allow for improved cross-country comparisons.

Background Some posit that any amount of myocardial ischemia can be detected by high-sensitivity cardiac troponin assays. We hypothesized that patients with myocardial ischemia induced by exercise stress would have significantly higher increases in high-sensitivity cardiac troponin T (hs-cTnT) concentrations than patients without ischemia. Methods We prospectively recruited for a biorepository 317 adult patients who presented to an academic hospital emergency department for evaluation possible ischemic symptoms and who were scheduled for exercise echocardiography. Blood samples were obtained before stress testing and 2-h post-testing. For this study, plasma hs-cTnT (Roche Diagnostics) concentrations were determined in a core laboratory blinded to clinical status. Absolute and relative changes between baseline and 2-h post-stress measurements were compared between patients with and without ischemia induced by stress testing. Results The median age was 51 (44.0, 60.0) years, 45.9% were male, and 37.8% were African American. In total, 26 patients (8.1%) had myocardial ischemia induced by exercise. Median baseline, 2-h post-stress, and absolute δ concentrations were, respectively, 6.0, 8.0, and 0.2 ng/L for patients with evidence of ischemia; 3.8, 4.6, and 0.0 ng/L for those without; and 3.9, 4.9, and 0.0 ng/L overall. Baseline and 2-h hs-cTnT concentrations were higher among patients with abnormal stress tests (all P ≤0.05), but absolute and relative changes in hs-cTnT concentrations were not significantly different between individuals with ischemia and individuals without. Conclusions There was no evidence of change in hs-cTnT values in response to exercise stress testing, regardless of the presence of myocardial ischemia.

Objectives. To study the relationship between nocturnal periodic breathing episodes and behavioral awakenings at high altitude. Methods. Observational study. It is 6-day ascent of 4 healthy subjects from Besisahar (760 meters) to Manang (3540 meters) in Nepal in March 2012. A recording pulse oximeter was worn by each subject to measure their oxygen saturation and the presence of periodic breathing continuously through the night. An actigraph was simultaneously worn in order to determine nocturnal behavioral awakenings. There were no interventions. Results. 187-hour sleep at high altitude was analyzed, and of this, 145 hours (78%) had at least one PB event. At high altitude, 10.5% (95% CI 6.5–14.6%) of total sleep time was spent in PB while 15 out of 50 awakenings (30%, 95% CI: 18–45%) occurring at high altitudes were associated with PB (P < 0.001). Conclusions. Our data reveals a higher than expected number of behavioral awakenings associated with PB compared to what would be expected by chance. This suggests that PB likely plays a role in behavioral awakenings at high altitude.