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Young adults presenting with lower abdominal pain are commonly diagnosed with inflammatory conditions arising from appendix, bowel, urinary tract, or female genital tract. Appendiceal intussusception is rarely considered as the primary diagnosis.2 The presentation of intussusception ranges from acute or chronic abdominal pain and rectal bleeding to an incidental radiological or intraoperative finding.2,3 Pain due to uncomplicated endometriosis-induced appendiceal intussusceptions might be cyclical but can also mimic acute appendicitis, caecal polyp, and malignancy.1,4 The inability to diagnose the condition preoperatively has resulted in overzealous surgical resection for suspected malignancy.4 The misdiagnosis of appendiceal intussusception for caecal polyps has also led to caecal perforation because of misguided attempts at endoscopic resection.5 Efforts should be made to reach a diagnosis preoperatively.

IntroductionCurrent assessment of carotid artery disease involves measurement of the degree of stenosis caused by the atherosclerotic plaque. For many reasons this is merely a surrogate marker of disease and the propensity to cause stroke. The area of unmet need is in asymptomatic carotid disease (ACD), where current imaging methods do not predict those at high stroke risk. Novel 3D ultrasound imaging biomarkers such as carotid plaque volume (CPV) and Grey scale median (GSM) are emerging as additional methods to assess the biological processes occurring within the atherosclerotic disease and will be explored as a means of assessing stroke risk.MethodsPatients with symptomatic and asymptomatic carotid disease were studied. Novel 3D ultrasound biomarkers; CPV and GSM were further explored. The relationship between CPV and arterial diameter was investigated. A more rapid method of measuring CPV and GSM utilising artificial intelligence (AI) assisted software was analysed. Multi-variate regression analysis explored the utility of combining CPV and GSM to determine who had suffered a neurological event. Finally, an abbreviated method of identifying individuals with ACD was conceptualised and tested.ResultsHigher CPV correlated with increasing vessel diameter in the common carotid artery (CCA) and proximal internal carotid artery (ICA) in both genders, p<0.01 for all. Utilising AI to aid measurement of CPV lead to substantial time saving and excellent accuracy; mean difference (±s.d.)[95%CI], -0.06 (0.24) [-0.53-0.41] cm3 and intra-class correlation (ICC) of 0.91; 95%CI 0.86-0.94. CPV reproducibility measured by inter-observer variability gave a mean difference (±s.d.)[95%CI] of just 0.01 (0.26) [-0.5-0.5] cm3 with excellent ICC and narrow confidence intervals, ICC=0.90; 95% CI (0.85-0.94). The second imaging biomarker, GSM was measured by 3D ultrasound with an interobserver mean difference (s.d.) [95% CI] of 6.4 (12.5) [95%CI -18.1 – 30.9] and ICC of 0.72 (0.48-0.85). Comparison of 3D GSM to histology score for each studied plaque (n=11) gave a correlation coefficient of 0.077, p=0.82. GSM was statistically different between the symptomatic (n=60) and asymptomatic (n=50) groups; median (IQR) 57 (21) v 64.5 (11.8), p=0.001. In univariate regression analysis GSM fared better at predicting symptomatic status independent of CPV; Odds Ratio (OR) (95% CI) 0.95 (0.91-0.98), p<0.001. Using CPV and GSM in multi-variable logistic regression gave an AUC of 0.71 which improved to 0.8 when demographics and risk factors were added but variance explained by the each of the biomarkers (pseudo R2) was low.Finally, an abbreviated carotid quick scan (CQS) was developed and tested in 100 asymptomatic patients and reduced scan time by around 6 minutes. The CQS delivered excellent agreement in predicting >50% stenosis when compared to full duplex; Cohen’s ƙ= 0.88, (95%CI 0.79-0.97; p<0.001), sensitivity 91.4%, specificity 97.6%, PPV 88.9%, NPV 98.2% and accuracy 96.5%. Twenty-four percent of peripheral artery disease patients and 50% of cardiac surgery patients had ACD.ConclusionUltimately, the area of unmet need is to determine how best to treat patients with asymptomatic carotid disease (ACD). A rapid means of identifying individuals with ACD has been tested along with two novel imaging biomarkers assessed by 3D ultrasound. The next steps are further validation of the AI algorithm to enhance CPV and GSM assessment and testing of additional markers of plaque vulnerability.

To review the incidence of respiratory conditions and their effect on mortality in HIV-infected and uninfected individuals prior to and during the era of highly active antiretroviral therapy (HAART). Two large observational cohorts of HIV-infected and HIV-uninfected men (Multicenter AIDS Cohort Study [MACS]) and women (Women's Interagency HIV Study [WIHS]), followed since 1984 and 1994, respectively. Adjusted odds or hazards ratios for incident respiratory infections or non-infectious respiratory diagnoses, respectively, in HIV-infected compared to HIV-uninfected individuals in both the pre-HAART (MACS only) and HAART eras; and adjusted Cox proportional hazard ratios for mortality in HIV-infected persons with lung disease during the HAART era. Compared to HIV-uninfected participants, HIV-infected individuals had more incident respiratory infections both pre-HAART (MACS, odds ratio [adjusted-OR], 2.4; 95% confidence interval [CI], 2.2-2.7; p<0.001) and after HAART availability (MACS, adjusted-OR, 1.5; 95%CI 1.3-1.7; p<0.001; WIHS adjusted-OR, 2.2; 95%CI 1.8-2.7; p<0.001). Chronic obstructive pulmonary disease was more common in MACS HIV-infected vs. HIV-uninfected participants pre-HAART (hazard ratio [adjusted-HR] 2.9; 95%CI, 1.02-8.4; p = 0.046). After HAART availability, non-infectious lung diseases were not significantly more common in HIV-infected participants in either MACS or WIHS participants. HIV-infected participants in the HAART era with respiratory infections had an increased risk of death compared to those without infections (MACS adjusted-HR, 1.5; 95%CI, 1.3-1.7; p<0.001; WIHS adjusted-HR, 1.9; 95%CI, 1.5-2.4; p<0.001). HIV infection remained a significant risk for infectious respiratory diseases after the introduction of HAART, and infectious respiratory diseases were associated with an increased risk of mortality.