A mid diastolic murmur at the apex is a classical description of a mitral stenosis (MS) murmur.
MS a valvular anomaly of the mitral valve that leads to obstruction of blood flow into the left ventricle. The most common cause of MS is rheumatic fever. The clinical manifestations depend on the extent of stenosis: reduced mitral opening leads to progressive congestion behind the stenotic valve. Acute decompensation can cause pulmonary oedema. Echocardiography is the main diagnostic tool for evaluating the mitral valve apparatus, left atrial size, and pulmonary pressure. In the event of high grade and/or symptomatic stenosis, percutaneous valvuloplasty or surgical valve replacement is often required.

Types and causes of murmurs:
Ejection systolic: Aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan-systolic: Mitral regurgitation, tricuspid regurgitation, VSD
Late systolic: Mitral valve prolapse, coarctation of aorta
Early diastolic: Aortic regurgitation, Graham-Steel murmur (pulmonary regurgitation)
Mid diastolic: Mitral stenosis, Austin-Flint murmur (severe aortic regurgitation)

Subtotal colectomy is resection of the entire right, transverse, left and part of the sigmoid colon. The rectal stump is closed and an end ileostomy fashioned in the right iliac fossa.

This patient is likely to have paralytic ileus and the administration of antiemetic drugs, in this situation, will have no effect. It is, therefore, important to decompress the stomach with a wide bore nasogastric tube.

Paralytic ileus is the obstruction of the intestine due to paralysis of the intestinal muscles. It commonly occurs after an abdominal surgery. Irrespective of the cause, paralytic ileus causes constipation, abdominal distention, nausea, and vomiting. It is a severe condition because if left untreated, an ileus can cut off blood supply to the intestines and cause tissue death.

Hypertension in a young patient without any obvious cause should be investigated.

A pheochromocytoma is a catecholamine-secreting tumour typically located in the adrenal medulla. Pheochromocytomas are usually benign (∼ 90% of cases) but may also be malignant. Classic clinical features are due to excess sympathetic nervous system stimulation and involve episodic blood pressure crises with paroxysmal headaches, diaphoresis, heart palpitations, and pallor. However, a pheochromocytoma may also present asymptomatically or with persistent hypertension. Elevated catecholamine metabolites in the plasma or urine confirm the diagnosis, while imaging studies in patients with positive biochemistry are used to determine the location of the tumour. Surgical resection is the treatment of choice, but is only carried out once alpha blockade with phenoxybenzamine has become effective.

Pheochromocytoma is said to follow a 10% rule:

,10% are extra-adrenal
,10% are bilateral
,10% are malignant
,10% are found in children
,10% are familial
,10% are not associated with hypertension
,10% contain calcification

Goodsall’s rule can be used to clinically predict the course of an anorectal fistula tract. Imagine a line that bisects the anus in the coronal plane (transverse anal line). Any fistula that originates anterior to the line will course anteriorly in a direct route. Fistulae that originate posterior to the line will have a curved path. An exception to the rule are anterior fistulas lying more than 3 cm from the anus, which may open into the anterior midline of the anal canal.

In patients with ulcerative colitis (UC) where medical management is not successful, surgical resection (pan-proctocolectomy) may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.

Patients with inflammatory bowel disease (UC and Crohn’s disease) frequently present in surgical practice. Elective indications for surgery in UC include disease that requires maximal therapy or prolonged courses of steroids.

Long-standing UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. Restorative options in UC include an ileoanal pouch. Complications of such a pouch include anastomotic dehiscence, pouchitis, and poor physiological function with seepage and soiling.
.
Emergency presentation of poorly-controlled colitis that fails to respond to medical therapy should usually be managed with a subtotal colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting.

Containment of fistula output and skin protection should be instituted as soon as the diagnosis is made as it will decrease local skin excoriation and inflammation, pain and infection. While low output fistulas may be controlled with a simple absorbent dressing, complex fistulas often require advanced techniques including barrier creams, powders, and sealants to protect the skin from auto-digestion as well as bridging for fistula isolation, topographical enhancements, and complex pouching systems with or without sump drainage
Fistulas arising from the oesophagus, duodenal stump after gastric resection, pancreaticobiliary tract, and jejunum are more likely to close without operative intervention. Additionally, those with long tracts and small enteric wall defects are associated with higher spontaneous closure rates. Fistulas in the colon show favourable rates of spontaneous resolution.

Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture. The classic triad of findings is right upper quadrant (RUQ) pain, fever, and jaundice. A pentad may also be seen, in which mental status changes and sepsis are added to the triad.

A spectrum of cholangitis exists, ranging from mild symptoms to fulminant overwhelming sepsis. Thus, therapeutic options for patient management include broad-spectrum antibiotics and, potentially, emergency decompression of the biliary tree.
The main factors in the pathogenesis of acute cholangitis are biliary tract obstruction, elevated intraluminal pressure, and infection of bile. A biliary system that is colonized by bacteria but is unobstructed, typically does not result in cholangitis. It is believed that biliary obstruction diminishes host antibacterial defences, causes immune dysfunction, and subsequently increases small bowel bacterial colonization. Although the exact mechanism is unclear, it is believed that bacteria gain access to the biliary tree by retrograde ascent from the duodenum or from portal venous blood. As a result, infection ascends into the hepatic ducts, causing serious infection. Increased biliary pressure pushes the infection into the biliary canaliculi, hepatic veins, and perihepatic lymphatics, leading to bacteraemia (25-40%). The infection can be suppurative in the biliary tract.

In most cases, the treatment of choice for acute cholecystitis is cholecystectomy performed early in the illness. The procedure can be carried out laparoscopically even when acute inflammation is present. Delayed surgery particularly around five to seven days after presentation is much more technically challenging and is often best deferred.

Up to 24% of women and 12% of men may have gallstones. Of these, up to 30% may develop local infection and cholecystitis. The classical symptom of cholecystitis is colicky right upper quadrant pain that occurs postprandially. Others include swinging pyrexia, and general feeling of being unwell. They are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.

Murphy’s sign is positive on examination. The standard diagnostic work-up consists of abdominal ultrasound and liver function tests. For management, cholecystectomy should ideally be done within 48 hours of presentation. In patients unfit for surgery, percutaneous drainage may be considered.

Microscopic colitis is an inflammation of the large intestine (colon) that causes persistent watery diarrhoea. The disorder gets its name from the fact that it’s necessary to examine the colon tissue under a microscope to identify it, since the tissue may appear normal with a colonoscopy or flexible sigmoidoscopy. It is characterised by normal endoscopic appearances, microscopic features of colonic inflammation and thickening of the sub epithelial collagen layer. Features such as granulomas are absent. It is the normal endoscopic appearance that makes the other options less likely.

In patients with suspected gallstone complications, blood tests should include a complete blood cell (CBC) count with differential, liver function panel, and amylase and lipase. Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis.

Acute cholecystitis is associated with polymorphonuclear leucocytosis. However, up to one third of the patients with cholecystitis may not manifest leucocytosis. In severe cases, mild elevations of liver enzymes may be caused by inflammatory injury of the adjacent liver.

Patients with cholangitis and pancreatitis have abnormal laboratory test values. Importantly, a single abnormal laboratory value does not confirm the diagnosis of choledocholithiasis, cholangitis, or pancreatitis; rather, a coherent set of laboratory studies leads to the correct diagnosis.

Choledocholithiasis with acute common bile duct (CBD) obstruction initially produces an acute increase in the level of liver transaminases (alanine and aspartate aminotransferases), followed within hours by a rising serum bilirubin level. The higher the bilirubin level, the greater the predictive value for CBD obstruction. CBD stones are present in approximately 60% of patients with serum bilirubin levels greater than 3 mg/dL.

If obstruction persists, a progressive decline in the level of transaminases with rising alkaline phosphatase and bilirubin levels may be noted over several days. Prothrombin time may be elevated in patients with prolonged CBD obstruction, secondary to depletion of vitamin K (the absorption of which is bile-dependent). Concurrent obstruction of the pancreatic duct by a stone in the ampulla of Vater may be accompanied by increases in serum lipase and amylase levels.

Repeated testing over hours to days may be useful in evaluating patients with gallstone complications. Improvement of the levels of bilirubin and liver enzymes may indicate spontaneous passage of an obstructing stone. Conversely, rising levels of bilirubin and transaminases with progression of leucocytosis in the face of antibiotic therapy may indicate ascending cholangitis with the need for urgent intervention. Blood culture results are positive in 30%-60% of patients with cholangitis.

Due to this patient having a relapse after using carbimazole following orbital radiotherapy for severe proptosis., total thyroidectomy is the treatment of choice.
Thyroidectomy is the definitive surgical management for Graves thyrotoxicosis and usually requires a short course of pre-treatment with thionamides or inorganic iodine to achieve euthyroid state; this reduces operative complications and thyroid vascularity. Although subtotal thyroidectomy was once practiced, most surgeons now recommend complete thyroidectomy to minimize chances of relapse.

Radioactive iodine (I-131) is widely used to treat the thyrotoxicosis of Graves’ disease, but, despite its demonstrable efficacy and safety, there have long been concerns about its possible adverse effect on thyroid eye disease. A study showed that after radioiodine treatment 15% of patients developed new or worsened ophthalmopathy, whereas this occurred in only 3% of patients treated with methimazole and in none treated with radioiodine plus prednisone. In the radioiodine group 24% of those with pre-existing ophthalmopathy suffered an exacerbation, whereas only 8% of patients without eye disease at baseline developed it.

Antibody-mediated rejection (AMR) is defined as allograft rejection caused by antibodies of the recipient directed against donor-specific HLA molecules and blood group antigens. Although the mechanism by which HLA I antibodies promote inflammation and proliferation has been revealed by experimental models, the pathogenesis of HLA II antibodies is less defined. Antibodies to HLA II frequently accompany chronic rejection in renal transplants. AMR has been recognized as the leading cause of graft loss after kidney transplant if there is a donor-host antigenic disparity. Antibodies can be produced against epitopes of the antigen that differ from self by as little as one amino acid. Pre-existing antibodies or the development of de novo antibodies after transplantation has become a biomarker for AMR graft loss. HLA antibodies are risk factors for hyperacute, acute, and chronic allograft rejections.

The specificity of HLA antibodies can be determined using single-antigen luminex beads that consist of fluorescent microbeads conjugated to single recombinant HLA class I and class II molecules. Complement-fixing ability would be assessed by the binding of C1q to HLA antibodies present in the serum. In several studies, C1q-positive DSA had associated with antibody-mediated rejection in renal transplantation compared with antibodies identified only by IgG. Complement-fixing ability is relevant to hyperacute and acute rejections. Hyperacute rejection is predominantly complement-mediated severe allograft injury occurring within hours of transplantation. It is caused by high titre of pre-existing HLA or non-HLA antibodies in presensitized patients. But the incidence of hyperacute rejection is reduced due to improved DSA detection methods and desensitization protocols.

The College of Emergency Medicine states that the patient should be discharged with no follow-up required if the patient presents with anatomical snuffbox tenderness and plain radiographs show no fracture when done initially and after when wrist splint has been used.

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.

Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.

Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and are characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapse

Only ,30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:
Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both

Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction

Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction

Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

The scaphoid bone is the most commonly fractured carpal bone. Fractures are most often localized in the middle third of the scaphoid bone.
Generally, scaphoid bone fractures result from indirect trauma when an individual falls onto the outstretched hand with a hyperextended and radially deviated wrist. Pain when applying pressure to the anatomical snuffbox is highly suggestive of a scaphoid bone fracture.
X-ray is the initial test of choice for diagnosis. Computer tomography and magnetic resonance imaging may be indicated, if x-ray findings are negative but clinical suspicion is high.
Treatment can be conservative (e.g., wrist immobilization) or in certain cases surgical (e.g., proximal pole fracture). Complications include non-union and avascular necrosis.

Oesophageal dysphagia occurs when there is a difficulty with the passage of solid or liquid material through the oesophagus, specifically the region between the upper and lower oesophageal sphincter. It results from either abnormal motility of this segment of the oesophagus or obstruction.
Common causes of dysphagia:
Gastro-oesophageal reflux—waterbrash, regurgitation, due to dysmotility or stricture
Achalasia—classically hold-up relieved by carbonated beverages
Motility disorders—may be associated with central chest pain, systemic disease (scleroderma, dermatomyositis)
Oesophageal cancer—progressive, weight loss
Head and neck cancer—pain, dysphagia, otalgia, >90% smokers, often excess alcohol consumption
Pharyngeal pouch—slowly progressive, regurgitation, gurgling
Web—able to swallow only small amounts, “can’t swallow tablets”
Stroke
Neurodegenerative disorders—parkinsonism, motor neurone disease, multiple sclerosis, myasthenia gravis
Presbyphagia

Endoscopy has the advantage of potentially yielding a histological diagnosis. The overall rate of oesophageal perforation after flexible endoscopy involving oesophageal instrumentation, biopsy, or dilatation is 2.6%

Oesophageal manometry remains the investigation of choice in suspected motility disorders. Manometry can classify oesophageal dysmotility into rare specific disorders such as achalasia and diffuse oesophageal spasm or more common non-specific motility disorders that do not respond directly to drug treatment but may improve if related reflux or psychiatric disturbances are treated. The symptoms of non-specific motility disorders may have an uncertain relation to the manometric abnormalities

Management is based on the history, findings of the clinical investigations, and prognosis for the individual patient. The underlying disorder is treated, but the impact of dysphagia on nutrition and hydration will compromise any intervention unless managed effectively. Poor physical condition from malnutrition or dehydration will lead to a suboptimal rehabilitation process, in both duration and completeness of recovery and inadequate management of dysphagia contributes to this. A malnourished person is at risk of decompensation of the swallow, leading to dysphagia. The clinical swallow assessment is used to determine safely modified diets that reduce malnutrition and dehydration. This may range from nil by mouth with total enteral support to full oral route or a balance of the two. Enteral feeding is essential to maintain nutritional status when oral feeding is suspended, even if only for a short time. Prompt involvement of a dietitian is thus essential.

Answer: Torsion of a testicular hydatid

The appendix testis (or hydatid of Morgagni) is a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time. The appendix of testis can, occasionally, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief. One third of patients present with a palpable blue dot discoloration on the scrotum. This is nearly diagnostic of this condition. If clinical suspicion is high for the serious differential diagnosis of testicular torsion, a surgical exploration of the scrotum is warranted. Torsion of the appendix of testis occurs at ages 0-15 years, with a mean at 10 years, which is similar to that of testicular torsion.

Occasionally a torsion of the hydatid of Morgagni can produce symptoms mimicking those created by a testicular torsion; a torsion of the hydatid, however, does not lead to any impairment of testicular function.
Absence of the cremasteric reflex is a sign of testicular torsion. This therefore confirms that the diagnosis is Torsion of a testicular hydatid.

Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
PID is initiated by an infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Of all acute PID cases, less than 50% test positive for the sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoea.
Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
The most common presenting complaint is lower abdominal pain. Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. Temperature is higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients.
Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh−Curtis syndrome.

The Frykman classification of distal radial fractures is based on the AP appearance and encompasses the eponymous entities of Colles fracture, Smith fracture, Barton fracture, chauffeur fracture.

Colles fractures are very common extra-articular fractures of the distal radius that occur as the result of a fall onto an outstretched hand. They consist of a fracture of the distal radial metaphyseal region with dorsal angulation and impaction, but without the involvement of the articular surface.
Colles fractures are the most common type of distal radial fracture and are seen in all adult age groups and demographics. They are particularly common in patients with osteoporosis, and as such, they are most frequently seen in elderly women.

Smith fractures, also known as Goyrand fractures in the French literature 3, are fractures of the distal radius with associated volar angulation of the distal fracture fragment(s). Classically, these fractures are extra-articular transverse fractures and can be thought of like a reverse Colles fracture.
The term is sometimes used to describe intra-articular fractures with volar displacement (reverse Barton fracture) or juxta-articular fractures

Barton fractures are fractures of the distal radius. It is also sometimes termed the dorsal type Barton fracture to distinguish it from the volar type or reverse Barton fracture.
Barton fractures extend through the dorsal aspect to the articular surface but not to the volar aspect. Therefore, it is similar to a Colles fracture. There is usually associated with dorsal subluxation/dislocation of the radiocarpal joint.

Chauffeur fractures (also known as Hutchinson fractures or backfire fractures) are intra-articular fractures of the radial styloid process. The radial styloid is within the fracture fragment, although the fragment can vary markedly in size.

The combination of a crush injury, limb swelling, and inability to move digits raises suspicion of compartment syndrome that would require a fasciotomy.

Compartment syndrome is a particular complication that may occur following fractures, especially supracondylar fractures and tibial shaft injuries. It is characterised by raised pressure within a closed anatomical space which may, eventually, compromise tissue perfusion, resulting in necrosis.

The clinical features of compartment syndrome include:
1. Pain, especially on movement
2. Paraesthesia
3. Pallor
4. Paralysis of the muscle group may also occur

Diagnosis is made by measurement of intracompartmental pressure. Pressures >20mmHg are abnormal and >40mmHg are diagnostic.

Compartment syndrome requires prompt and extensive fasciotomy. Myoglobinuria may occur following fasciotomy, resulting in renal failure. Therefore, aggressive IV fluids are required. If muscle groups are frankly necrotic at fasciotomy, they should be debrided, and amputation may have to be considered.

This individual has acute cholecystitis. This is demonstrated by well-localized pain in the right upper quadrant, usually with rebound and guarding; frequent presence of fever and peritonism. Ultrasonography is the procedure of choice in suspected gallbladder or biliary disease. A bile duct measuring 4mm is usually normal.
Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated (typically, laparoscopic cholecystectomy is the first-line therapy at centres with experience in this procedure).

Prolonged cold ischemia time (CIT) may contribute to the perception of the graft as being suboptimal since donation after circulatory death (DCD) kidneys may be considered less tolerant of CIT. In fact, previous reports recommend restriction of CIT to 12 to 18 hours when transplanting DCD kidneys and a recent UK registry analysis identified increased risks of DCD graft failure with CIT longer than 12 hours.
The donated kidney in this case had a CIT of 26 hours and the patient presented with symptoms 10 days later which would lead to acute rejection.

Pancreatitis is inflammation of the pancreas with variable involvement of regional tissues or remote organ systems. Acute pancreatitis (AP) is characterized by severe pain in the upper abdomen and elevation of pancreatic enzymes in the blood. In the majority of patients,
Biliary pancreatitis should always be treated eventually with a cholecystectomy after the process has subsided.
Feeding should be introduced enterally as the patient’s anorexia and pain resolves.
The use of nasogastric aspiration offers no clear advantage in patients with mild AP, but is beneficial in patients with profound pain, severe disease, paralytic ileus, and intractable vomiting.
AP is a mild, self-limiting disease that resolves spontaneously without complications. Patients can be initiated on a low-fat diet initially and need not invariably start their dietary advancement using a clear liquid diet. Systematic reviews and meta-analyses have shown that administration of enteral nutrition may reduce mortality and infectious complications compared with parenteral nutrition. Although the ideal timing to initiate enteral feeding remains undetermined, administration within 48 hours appears to be safe and tolerated.

Painful, bright red rectal bleeding is usually due to a fissure. Presence of pain and the sentinel tag suggests a posterior fissure-in-ano.

Anal fissures are a common cause of painful, bright red, rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapse

Diagnosis:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated with colonoscopy and EUA with biopsies of the area.

Treatment:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms. The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste. Side effects of diltiazem are better tolerated.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases.

Answer: Transposition of the great arteries

Transposition of the great arteries (TGA) is the most common cyanotic congenital heart lesion that presents in neonates. The hallmark of transposition of the great arteries is ventriculoarterial discordance, in which the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle.

Infants with transposition of the great arteries (TGA) are usually born at term, with cyanosis apparent within hours of birth.

The clinical course and manifestations depend on the extent of intercirculatory mixing and the presence of associated anatomic lesions. Note the following:

Transposition of the great arteries with intact ventricular septum: Prominent and progressive cyanosis within the first 24 hours of life is the usual finding in infants if no significant mixing at the atrial level is evident.

Transposition of the great arteries with large ventricular septal defect: Infants may not initially manifest symptoms of heart disease, although mild cyanosis (particularly when crying) is often noted. Signs of congestive heart failure (tachypnoea, tachycardia, diaphoresis, and failure to gain weight) may become evident over the first 3-6 weeks as pulmonary blood flow increases.

Transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: Infants often present with extreme cyanosis at birth, proportional to the degree of left ventricular (pulmonary) outflow tract obstruction. The clinical history may be similar to that of an infant with tetralogy of Fallot.

Transposition of the great arteries with ventricular septal defect and pulmonary vascular obstructive disease: Progressively advancing pulmonary vascular obstructive disease can prevent this rare subgroup of patients from developing symptoms of congestive heart failure, despite a large ventricular septal defect. Most often, patients present with progressive cyanosis, despite an early successful palliative procedure.

Answer: Lanz

The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendectomy.

Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the anterior superior iliac spine). They involve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity.

The Lanz incision is a transverse incision, whilst the Gridiron incision is oblique (superolateral to inferomedial). Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.

Rejection is related primarily to activation of T cells, which, in turn, stimulate specific antibodies against the graft. Various clinical syndromes of rejection can be correlated with the length of time after transplantation.

Hyperacute rejection
Hyperacute rejection of the renal allograft happens in the operating room within hours of the transplant, when the graft becomes mottled and cyanotic. This type of rejection is due to unrecognized compatibility of blood groups A, AB, B, and O (ABO) or to a positive T-cell crossmatch (class I human leukocyte antigen [HLA] incompatibility).
It is thought that IgG antibodies from the host bind to HLA-1 antigen of the donated organ.
No treatment exists, and nephrectomy is indicated.

Acute rejection
Acute rejection appears within the first 6 months after transplantation and affects approximately 15% of transplanted kidneys. Rejection is secondary to prior sensitization to donor alloantigens (occult T-cell crossmatch) or a positive B-cell crossmatch.
Acute tubular interstitial cellular rejection is the most common type of rejection reaction, with an incidence of approximately 20-25%. Typically, it occurs between 1 and 3 months after transplantation. It is T-cell mediated, and injury is directed to the renal tubules. The standard for diagnosis is renal allograft biopsy. Mild rejections may be successfully reversed with corticosteroids alone, whereas moderate or severe rejections may require the use of anti–T-cell antibodies, either polyclonal or monoclonal.
Late acute rejection is strongly correlated with the scheduled withdrawal of immunosuppressive therapy 6 months after transplantation.

Chronic rejection
Chronic rejection occurs more than 1 year after transplantation and is a major cause of allograft loss. It is a slow and progressive deterioration in renal function characterized by histologic changes involving the renal tubules, capillaries, and interstitium. Its precise mechanism is poorly defined and is an area of intense study. Diagnosis is by renal biopsy, and treatment depends on the identified cause if any. Application of conventional antirejection agents (e.g., corticosteroids or anti–T-cell antibodies) does not appear to alter the progressive course.

Lesions bearing normal dermal appendages and regular borders are likely to be benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Incision biopsy should not be done.

Melanocytic naevi are pigmented moles. Some moles are present at birth or appear within the first two years of life. These are known as congenital melanocytic naevi. Most develop during childhood and early adult life and are, consequently, called acquired melanocytic naevi. The number of moles increase up to the age of 30–40. Thereafter, the number of naevi tend to decrease. New moles appearing in adulthood need to be monitored and checked if growing or changing. Moles can be found anywhere on the skin, including on the hands and feet, genitals, eyes, and scalp.

There are three main types of acquired melanocytic naevi:
1. Junctional melanocytic naevi: flat and usually circular.
2. Compound melanocytic naevi: raised brown bumps most of which are hairy, some have a slightly warty surface.
3. Intradermal melanocytic naevi: raised and often hairy bumps, similar to compound naevi but more pale coloured (often skin-coloured).

A small number of foreign body aspirations are incidentally found after chest radiography or bronchoscopic inspection. Patients may be asymptomatic or may be undergoing testing for other diagnoses. If present, physical findings may include stridor, fixed wheeze, localized wheeze, or diminished breath sounds. If obstruction is severe, cyanosis may occur. Signs of consolidation can accompany post obstructive pneumonia.

Bronchoscopy can be used diagnostically and therapeutically. Most aspirated foreign bodies are radiolucent. Radiologic procedures do not have extreme diagnostic accuracy, and aspiration events are not always detected. Rigid bronchoscopy usually requires heavy intravenous sedation or general anaesthesia. The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope. The paediatric flexible bronchoscope lacks a hollow working channel through which instruments may be inserted or blood and secretions may be aspirated.
Unlike the flexible bronchoscope, the patient can be ventilated through the rigid scope; therefore, ventilation of the patient can be maintained. Rigid bronchoscopy is the procedure of choice for removing foreign bodies in children and in most adults. Success rates for extracting foreign bodies are reportedly more than 98%. Large solid and semisolid objects are best managed emergently in the operating room with a rigid bronchoscope and appropriate grasping instruments.