Chorng Kuang How

Diagnosis of appendicitis with left lower quadrant pain

Abdominal pain is one of the most common chief complaints of patients presenting to the emergency department and, among the diagnoses of abdominal pain, appendicitis is the most common surgical disorder. Traditionally, the diagnosis of appendicitis is based on well-established clinical criteria combined with physician experience. However, appendicitis presenting with rare and misleading left lower quadrant (LLQ) pain may result in an initial false-negative diagnosis by the physician and even result in failure to order the subsidiary examination of computed tomography (CT) or ultrasound, so increasing the risk of perforation/abscess formation and prolonged hospital stay. In this report, we present 2 cases of atypical appendicitis with LLQ pain where the correct diagnosis was not initially considered. One patient had right-sided appendicitis; the inflamed appendix was 12 cm in length and projected into the LLQ. Local peritonitis developed during observation. With the aid of CT, the diagnosis was established in time. The other patient had left-sided appendicitis with situs inversus totalis. Adverse outcomes with appendiceal rupture and abscess formation occurred due to inadvertent physical examinations and inadequate observation. Early clinical suspicion and adequate observation are indicated in patients with uncertain clinical features. However, in patients with unresolved clinical symptoms and/or local peritonitis that develop during observation, imaging studies play a significant role in preoperative diagnosis and determination of proper treatment.

Early changes of the anemia phenomenon in male 100-km ultramarathoners

Background Sports anemia is a widely observed phenomenon after prolonged running. There are various factors that contribute to sports anemia, including hemodilution, exercise‐induced oxidative stress, iron deficiency, gastrointestinal bleeding, hematuria, and hemolysis resulting from foot‐strike and/or from compression of contracting muscles on capillaries. Until now, there has been no published report that describes the overall hematological, urinary, and fecal consequences in Asian male ultramarathoners after a 100‐km (62.5‐mile) ultramarathon event. Methods A total of 25 male runners were recruited into our study. Blood was drawn 1 week before, immediately after, and then 24 hours subsequent to the race. Hematological samples were analyzed for the anemia phenomenon. Additionally, urinary and fecal samples were collected before and after the race for detection of occult blood. Results The blood hemoglobin and erythropoietin values of the recruited runners showed a statistically significant rise in the immediate post‐race values and a rapid drop in values at 24 hours post‐race. Blood concentrations of red blood cells and hematocrit were significantly lower at 24 hours post‐race compared with pre‐race. The white blood cell count, interleukin‐6, tumor necrosis factor‐alpha, high‐sensitivity C‐reactive protein, and ferritin all showed significant increases both immediately after and 24 hours post‐race compared with pre‐race hematological values. There were immediate decreases of both haptoglobin and iron, as well as an increase of total iron‐binding capacity levels in post‐race blood tests. For both urinary and fecal samples, there was a statistically significant difference between the pre‐ and post‐race results in occult blood. Conclusion Running a 100‐km ultramarathon will induce substantial sports anemia, and oxidative stress response, hemolysis, hematuria, and gastrointestinal bleeding are typical factors that contribute to its onset.

Whether intravenous contrast is necessary for CT diagnosis of acute appendicitis in adult ED patients

RATIONALE AND OBJECTIVESnTo assess the necessity of intravenous contrast medium for abdominopelvic computed tomography (CT) diagnosis of acute appendicitis (APP) among adult patients with right lower quadrant (RLQ) abdominal pain at emergency department (ED).nnnMATERIALS AND METHODSnED patients with clinical suspicion of APP from RLQ pain for a period of 8 months were enrolled retrospectively. Both pre- and postintravenous contrast-enhanced CT scans were performed for these patients. The visibility of vermiform appendix and specific CT findings of APP were recorded separately for noncontrast CT (NCT) and contrast-enhanced CT (CCT) images without knowledge of the patients identity and final diagnosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT diagnosis for APP were compared between the two groups. The ease of identifying appendix was also compared.nnnRESULTSnForty-two (42.0%) of the 100 patients (55 males, 45 females; age range, 16-90 years; mean age, 49.3 years) were APP. There was no significant difference for the visibility of appendix (94% vs. 91%; P = .589) and radiological characters between the CCT and NCT groups. There were significant differences between the two groups for sensitivity (100% vs. 90.5%; P = .036), specificity (94.8% vs. 100%; P = .038), PPV (93.3% vs. 100%; P = .021), NPV (100% vs. 93.5%; P = .021), but no significant difference for accuracy (97% vs. 96%; P = 1). The appendix was easier to detect on CCT than NCT images (P = .013).nnnCONCLUSIONnThe diagnostic sensitivity of CCT was significantly better than that of NCT. Intravenous contrast administration could also make doctors easier in indentifying appendixes.

Clinical Impact of Speed Variability to Identify Ultramarathon Runners at Risk for Acute Kidney Injury.

Background Ultramarathon is a high endurance exercise associated with a wide range of exercise-related problems, such as acute kidney injury (AKI). Early recognition of individuals at risk of AKI during ultramarathon event is critical for implementing preventative strategies. Objectives To investigate the impact of speed variability to identify the exercise-related acute kidney injury anticipatively in ultramarathon event. Methods This is a prospective, observational study using data from a 100 km ultramarathon in Taipei, Taiwan. The distance of entire ultramarathon race was divided into 10 splits. The mean and variability of speed, which was determined by the coefficient of variation (CV) in each 10 km-split (25 laps of 400 m oval track) were calculated for enrolled runners. Baseline characteristics and biochemical data were collected completely 1 week before, immediately post-race, and one day after race. The main outcome was the development of AKI, defined as Stage II or III according to the Acute Kidney Injury Network (AKIN) criteria. Multivariate analysis was performed to determine the independent association between variables and AKI development. Results 26 ultramarathon runners were analyzed in the study. The overall incidence of AKI (in all Stages) was 84.6% (22 in 26 runners). Among these 22 runners, 18 runners were determined as Stage I, 4 runners (15.4%) were determined as Stage II, and none was in Stage III. The covariates of BMI (25.22 ± 2.02 vs. 22.55 ± 1.96, p = 0.02), uric acid (6.88 ± 1.47 vs. 5.62 ± 0.86, p = 0.024), and CV of speed in specific 10-km splits (from secondary 10 km-split (10th – 20th km-split) to 60th – 70th km-split) were significantly different between runners with or without AKI (Stage II) in univariate analysis and showed discrimination ability in ROC curve. In the following multivariate analysis, only CV of speed in 40th – 50th km-split continued to show a significant association to the development of AKI (Stage II) (p = 0.032). Conclusions The development of exercise-related AKI was not infrequent in the ultramarathon runners. Because not all runners can routinely receive laboratory studies after race, variability of running speed (CV of speed) may offer a timely and efficient tool to identify AKI early during the competition, and used as a surrogate screening tool, at-risk runners can be identified and enrolled into prevention trials, such as adequate fluid management and avoidance of further NSAID use.

The impact of hepatitis B carrier on cardiac troponin I in 100-km ultramarathon runners

Background Prolonged endurance exercise is known to cause elevation of cardiac troponin I (cTnI). Previous studies have reported the correlation of several factors with exercise‐induced cTnI release. However, the investigation of the predictors for elevated cTnI and postrace kinetics of cTnI after ultramarathon running is lacking, especially in an Oriental population. Methods Twenty‐six participants, including eight hepatitis B virus carrier (HBVc) runners, who finished a 100‐km ultramarathon in Taiwan were enrolled. For each participant, blood samples were collected 1 week before the race, as well as immediately and 24 hours after the finish. Results The results showed that 19 runners (73.1%) had postrace elevated cTnI levels and eight (30.8%) had elevated cTnI values lasting more than 24 hours after the run. A multiple linear regression analysis demonstrated that the HBV status was a factor related to the high level of cTnI after 24 hours of running (&bgr; = 0.03, p = 0.08). The recovery of plasma cTnI levels was delayed in ultramarathon runners with latent HBV infection. Among HBVc runners, multiple linear regression analyses showed age (&bgr; = −0.01), previous running experience (&bgr; = −0.06), training distance (&bgr; = 0.37), and 4 hours of running distance (&bgr; = −0.04) as significant predictors of higher postrace cTnI levels. Conclusion For most athletes, cTnI values significantly increased immediately following the race in the absence of adverse clinical sequelae, and HBVc runners had higher and prolonged cTnI levels. While several factors are identified for such HBV effects, the specific causes need further elucidation.

The changes of red blood cell viscoelasticity and sports anemia in male 24-hr ultra-marathoners

Background: In endurance sports, stress, dehydration and release of chemical factors have been associated with red blood cell (RBC) alterations of structure and function, which may contribute to sports anemia, a well‐observed phenomenon during long‐distance running. Until now, the investigation of the changes of viscoelastic properties of RBC membrane, a decisive factor of RBC deformability to avoid hemolysis, is lacking, especially in an Oriental population. Methods: nineteen runners were prospectively recruited into our study. Hematological parameters were analyzed before and immediately after the 2015 Taipei 24H Ultra‐Marathon Festival, Taiwan. Video particle tracking microrheology was used to determine viscoelastic properties of each RBC sample by calculating the dynamic elastic modulus G′(f) and the viscous modulus G″(f) at frequency f = 20 Hz. Results: Haptoglobin, RBC count, hemoglobin, hematocrit, mean cell hemoglobin, plasma free hemoglobin and unsaturated iron‐binding capacity values of the recruited runners showed a statistically significant drop in the post‐race values. Blood concentration of reticulocyte and ferritin were significantly higher at post‐race compared with pre‐race. 15 out of the 19 runners had a concurrent change in the elastic and the viscous moduli of their RBCs. Changes in the elastic and the viscous moduli were correlated with changes in the RBC count, hemoglobin and hematocrit. Conclusion: Viscoelasticity properties, the elastic modulus G′(f) and the viscous modulus G″(f) of RBCs are associated with endurance exercise‐induced anemia.

Aorto-left Renal Cyst Fistula: A Rare Complication of Abdominal Aortic Aneurysm Rupture

Abdominal aortic aneurysm (AAA) rupture can occur in different ways, such as closed rupture into the retroperitoneum, open rupture into the peritoneal cavity, rupture into surrounding hollow structures, and chronic contained or sealed rupture. Here, we report an unusual case of spontaneous rupture of AAA into a renal cyst that presented with hematuria, abdominal pain and shock, and which was diagnosed with multidetector computed tomography. We also review the literature on unusual patterns of AAA rupture.

Erratum: Clinical impact of speed variability to identify ultramarathon runners at risk for acute kidney injury (PLoS ONE (2015) 10:7 (e0133146) (DOI:10.1371/journal.pone.0133146))

[This corrects the article DOI: 10.1371/journal.pone.0133146.].