Secondary Defects Research Articles

Effect of added Ag on plasticity enhancement of Au80Sn20 eutectic alloys

Abstract Inherent brittleness greatly limits machining and applications of Au80Sn20 eutectic solder alloys. To overcome the frangibility of Au80Sn20 eutectic alloys, Ag was added to form novel Au78.44Sn19.6Ag1.96 alloy. The effects of 2 wt% Ag addition on the solidification microstructure and plastic deformation of Au80Sn20 eutectic alloys were then studied. The as-obtained Au78.44Sn19.6Ag1.96 exhibited excellent plastic deformation at room temperature. Ag was well-solubilized in Au5Sn phase to yield (Au,Ag)5Sn, eliminating secondary phase defects in Au5Sn. The point defects introduced by Ag reduced its stacking fault energy and enabled (Au,Ag)5Sn to initiate stacking faults and twinning. Moreover, the typical eutectic growth state of Au80Sn20 alloy was changed. AuSn phase in Au78.44Sn19.6Ag1.96 alloys showed preferential orientation in basal direction, leading to formation of basal-prismatic facets and providing basal slip at room temperature. The ability to coordinate deformation between both phases improved and room temperature plastic deformation reached above 60%. These findings can help steer possible future research regarding the deformation mechanism of fragile metals and provide practical guidance to increase the plasticity of fragile metals for solder manufacturing.

Dry mechanical-electrochemical polishing of selective laser melted 316L stainless steel

This paper aims to improve the surface quality of 316L stainless steel parts manufactured by selective laser melting (SLM) using dry mechanical-electrochemical polishing (DMECP). DMECP is an advanced surface finishing method combining the advantages of both mechanical and electrochemical polishing techniques in a more environmentally friendly manner. In this paper, the SLM process-related defects causing poor surface quality are analysed first. The material removal mechanism of DMECP is investigated to continuously remove the oxide layers formed during polishing. Surface morphology and roughness evolution under different polishing conditions are characterised. The top surface roughness can be reduced by over 91% from 8.72 μm to 0.75 μm compared to side surface by over 93% from 12.10 to 0.80 μm. The material removal on the top surface is more efficient than that on the side surface under the same polishing condition. The secondary defects formed during polishing can be removed using mechanical polishing mode. The chemical element composition of the polished surface exhibits almost identical content to the initial 316L powders. Compared with the initial dark and rough surfaces, the results validate the capability of DMECP as an effective tool to improve the SLM surface quality and achieve a mirror finish.

A first-principles study of damage induced by gaseous species He, Kr, and Xe on the structure of nuclear fuel, U3Si

A first-principles approach is employed to study the damage caused by gaseous species, He, Kr, and Xe atoms, on the structures of nuclear fuel U3Si. Formation energies suggest that a U vacancy is more readily generated than is an Si vacancy, and that gaseous atoms, He, Kr, and Xe, favor residing in vacancies compared with interstitial sites. By combining the trapping energies and formation energies of secondary vacancy defects, it can be determined that the number capacity of one U or Si vacancy to trap He atoms in U3Si is two or three, while it is only one with respect to Kr and Xe. When the number of trapped He (Kr and Xe) atoms is increased to four (two), the production of a secondary U vacancy is energetically favorable, and the formation of He (Kr and Xe) bubbles can be initiated. Additionally, when an Xe atom is trapped in an Si vacancy of β-U3Si, Xe bubble evolution is predominantly controlled by diffusion. From this work, one may gain new insight into the mechanism behind bubble formation in uranium silicide fuels.

Bowen's Disease in the Thenar Eminence: A Case Report

Bowen's disease is a squamous cell carcinoma in situ that can degenerate into an invasive squamous cell carcinoma. Early diagnosis and treatment are crucial. There are several therapeutic options available but the most successful is surgical excision with a safety margin. We present a case report of an atypical Bowen's disease in an uncommon location, for which was performed surgical excision with 1cm of safety margin and then the secondary defect was covered by a skin graft. No complications were registered. An acceptable functional and aesthetic outcome was obtained without evidence of relapse.

Chinese patient with neurofibromatosis-Noonan syndrome caused by novel heterozygous NF1 exons 1\u201358 deletion: a case report

BackgroundNeurofibromatosis-Noonan syndrome (NFNS) is a rare autosomal dominant hereditary disease. We present a case of NFNS due to the heterozygous deletion of exons 1–58 of the NF1 gene on chromosome 17 in a 15-month-old boy.Case presentationA 15-month-old boy was admitted for motor and language developmental delay, numerous café-au-lait spots, hypertelorism, left blepharoptosis, pectus excavatum, cryptorchidism, secondary atrial septal defect, and UBOs (undefined bright objects) revealed by cranial MRI T2FLAIR in basal ganglia and cerebellum. Using whole exome sequencing, we identified a de novo heterozygous deletion including exons 1–58 of the NF1 gene.ConclusionAlthough genetic tests are useful tools for diagnosis of NFNS, NF1, or NS, comprehensive analysis of genetic factors and phenotypes is indispensable in the clinical practice. To the best of our knowledge, this case presents the first Chinese NFNS case due to NF1 defects, and the NF1 exons 1–58 deletion-related phenotype is unlike any other reported case.

ОЦІНЮВАННЯ КІЛЬКОСТІ ВТОРИННИХ ДЕФЕКТІВ ПРОГРАМНИХ ЗАСОБІВ ШЛЯХОМ КОМПЛЕКСУВАННЯ МОДИФІКОВАНИХ МОДЕЛЕЙ РОСТУ НАДІЙНОСТІ ДЖЕЛІНСЬКІ-МОРАНДИ І ШИКА-ВОЛВЕРТОНА

Виконано аналіз множин моделей оцінювання надійності програмних засобів (МНПЗ) або за іноземною назвою моделей зростання надійності ПЗ (Software Reliability Growth Models – SRGM). Досліджено ймовірнісні МНПЗ з метою встановлення таких, що можуть бути використано для врахування фактору прояву вторинних дефектів. Під вторинними дефектами розуміються такі, що вносяться в ПЗ після усунення первинних, які проявляються та усуваються в процесі налагодження та тестування ПЗ. Проаналізовано припущення та аналітичні вирази моделей росту надійності програмних засобів Джелінські-Моранди, Шика-Волвертона, щодо питання їх застосування для врахування фактору внесення та прояву вторинних дефектів проектування програмних засобів. Запропоновано підхід щодо кількісної оцінки вторинних дефектів, що полягає в модифікації функцій ризику моделей внесенням до них параметра, який визначає число вторинних дефектів та комплексування модифікованих функцій ризику. Проаналізовані проблемні питання, що виникають при комплексуванні модифікованих простої експоненціальної моделі і моделі Джелінські-Моранди. Розглянуті підходи, при яких можливе комплексування модифікованих МНПЗ – узгодженість припущень, прийняття додаткових припущень, що узгоджують моделі, співставлення параметрів щодо умов здійснення аналітичних перетворень. Показані переваги комплексування модифікованих моделей росту надійності Джелінські-Моранди і Шика-Волвертона у порівнянні з комплексуванням модифікованої моделі росту надійності Джелінські-Моранди і модифікованої простої експоненціальної моделі. Проведено співставлення параметрів модифікованих моделей росту надійності Джелінські-Моранди і Шика-Волвертона, в результаті чого виявлено співпадання більшості з них. Додано припущення моделі росту надійності Шика-Волвертона про пропорційність функції ризику тривалості тестування, що не відповідає припущенню МНПЗ Джелінські-Моранди, оскільки відповідний параметр використовується в аналітичних перетвореннях при комплексуванні моделей. Обґрунтована можливість комплексування МНПЗ Джелінські-Моранди і Шика-Волвертона. Показана послідовність аналітичних перетворень об’єднаної моделі модифікованих моделей Джелінські-Моранди і Шика-Волвертона на основі яких одержана формула для оцінювання кількості вторинних дефектів програмних засобів. Одержаний вираз спрощує оцінювання кількості вторинних дефектів ПЗ, у порівнянні з їх оцінюванням на основі комплексування модифікованих моделей Джелінські-Моранди і простої експоненціальної моделі. Одержана формула у поєднанні з МНПЗ інших класифікаційних ознак дозволяє спрогнозувати значення функції ризику та далі використовувати її для комплексного оцінювання показників надійності та функціональної безпеки складних систем, у тому числі систем, які можливо віднести до класу критичних (наприклад, програмно-технічних комплексів інформаційно-керуючих систем АЕС)

Transposition flaps: a valid option for reconstruction of soft tissue defects of scalp

Background: The scalp wounds are becoming increasingly common as a result of high-speed automobile accidents, fall from heights and others. Scalp reconstruction is a challenge for plastic surgeons. Minor wounds heal of themselves, but some wounds need some type of intervention in the form of reconstruction. Authors have raised flaps in unconventional measurements.Methods: Authors have incorporated 19 patients in this study over a period of one year. Extensive surgical procedures like burring of the skull bones and patients with comorbid conditions were not included. Authors simply rely on local flaps preferably transposition flaps to cover mainly the exposed skull bones. All the flaps were raised leaving the galea intact. The secondary defects were always skin grafted with split skin graft taken from thigh. Authors have raised random flaps in unconventional dimensions showing that a large random flap can be raised on a single vessel with good results.Results: All the wounds healed well without significant complications. So, this method of reconstruction can be applied to even large defects where very sophisticated services are not available.Conclusions: This method of reconstruction can be applied to even very large defects where very sophisticated microvascular services and expertise are not available with appreciably good results.

Cranioplasty for bone defects after craniosynostosis surgery. Case series with literature review

IntroductionSurgical treatment of craniosynostosis in children may generate secondary cranial vault defects by incomplete ossification process. The incidence of cranial defects after craniosynostosis surgery is poorly reported in the literature with a variable incidence of 0.5% to 18.2%. To better understand the impact and management of the cranial defects after craniosynostosis surgery, we selected and reviewed al cranioplasties that met this criterion between 2002 and 2019. Patients and methodWe found 41 patients (28 M and 13 F) operated between January 2002 to January 2019 who underwent cranioplasty for cranial defects secondary to craniosynostosis surgery in the infancy. All patient were at least 5 years old (range 5 to 17 years, median 11). The indication was aesthetic in 28 patients and for headaches, learning difficulties or changes in the cerebral blood flow in 13 patients. The material used in cranioplasty was the poly-methyl-methacrylate (PMMA) in 40 patients and customized porous hydroxyapatite (CPHA) in 1 patient. ResultsThe mean follow-up period after cranioplasty was of 37 months (range 2 to 125 months, median of 27 months). In the postoperative period there were no mortality nor neurological complications. There were 3 cases (7%) of superficial local postoperative wound infection but with no evidence of long-term infection. The long-term CT scan follow-up showed no material migration, dislocation or fractures. ConclusionConsidering the characteristics of the cranial vault after craniosynostosis surgery the treatment by cranioplasty with heterologous materials appears to be feasible thus avoiding donor site morbidity. For selected cases with small defects, our experience shows that the use of PMMA may be a safe alternative for the cranial vault repair in children older than 5 years.

Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb – a case series

IntroductionPropeller flaps have gained great popularity among reconstructive surgeons; however, the inability to directly close the donor site of large propeller flaps constitutes a well-known limitation of this technique. Skin grafting of the donor area is not always feasible nor desirable. To address large propeller flaps secondary defects, we investigated the use of a second propeller flap harvested from a nearby region of relative skin redundancy to assist the donor site closure generated by the first. Since the donor defect of the second flap is closed by direct suture, the aim of this “sequential” propeller flaps technique is to achieve complete, like-with-like, soft tissue restoration while avoiding skin grafting. MethodsFrom April 2018 to September 2019, eight patients presenting post-traumatic soft tissue defects were planned to be reconstructed by means of the sequential propeller flaps technique, for a total of 16 propeller flaps. The locations of the defects included the distal leg in four cases, the heel in two cases, the proximal lateral thigh in one case and proximal posterior thigh in the remaining one. All the flaps but one were harvested as a perforator-based propeller type and rotated by different degrees around the skeletonized perforator. In one patient, due to an intraoperative complication following the first flap harvest, the harvest of the second flap was abandoned. ResultsIn all but one patient, a complete, tension free primary closure of all wounds was achieved without complications, the functional recovery as well the esthetic outcome were excellent. One patient showed intraoperative signs of vascular insufficiency involving 15% of the first flap. The plan of harvesting the second flap was intraoperatively abandoned and the definitive wound closure with a free muscle gracilis was carried out the following week. ConclusionIn some selected cases, the use of multiple propeller flaps performed in sequence allows the surgeon to obtain complete, like-with-like wound closure with vascularized tissue avoiding a free tissue transfer procedure, however, it requires a vast experience with propeller flaps and meticulous preoperative planning.

Understanding the role of OXPHOS dysfunction in the pathogenesis of ECHS1 deficiency.

Mitochondria provide the main source of energy for eukaryotic cells, oxidizing fatty acids and sugars to generate ATP. Mitochondrial fatty acid β-oxidation (FAO) and oxidative phosphorylation (OXPHOS) are two key pathways involved in this process. Disruption of FAO can cause human disease, with patients commonly presenting with liver failure, hypoketotic glycaemia and rhabdomyolysis. However, patients with deficiencies in the FAO enzyme short-chain enoyl-CoA hydratase 1 (ECHS1) are typically diagnosed with Leigh syndrome, a lethal form of subacute necrotizing encephalomyelopathy that is normally associated with OXPHOS dysfunction. Furthermore, some ECHS1-deficient patients also exhibit secondary OXPHOS defects. This sequela of FAO disorders has long been thought to be caused by the accumulation of inhibitory fatty acid intermediates. However, new evidence suggests that the mechanisms involved are more complex, and that disruption of OXPHOS protein complex biogenesis and/or stability is also involved. In this review, we examine the clinical, biochemical and genetic features of all ECHS1-deficient patients described to date. In particular, we consider the secondary OXPHOS defects associated with ECHS1 deficiency and discuss their possible contribution to disease pathogenesis.

Tongue flap: a "workhorse flap" in repair of recurrent palatal fistulae.

A prospective study done to evaluate the efficacy of tongue flaps in secondary palatal defects, in terms of functionality, esthetics, and donor site morbidity, and to clarify the technique of elevating and insetting of tongue flap. Twenty patients having recurrent secondary palatal fistula, post cleft treatment were treated with anteriorly and posteriorly based dorsal tongue flaps. Patients were evaluated for outcome in terms of flap uptake and effectiveness, correction of oronasal regurgitation, speech and articulation, donor site morbidity, and esthetics. Twenty patients in age range of 11-24years, with secondary palatal fistulae, were treated with anteriorly/posteriorly based tongue flap. There were two recurrences as the flap got detached in one patient and necrosis of flap in another. In other patients, healing was uneventful. The flap showed good success rate in terms of uptake and correction of oronasal regurgitation, with imperceptible donor site morbidity. With speech therapy assistance and periodic evaluation by a therapist, significant improvement in speech and articulation was noted over time in all successfully healed patients. Use of tongue flap for repair of palatal fistulae is a successful technique as it provides appreciable quality and quantity of well-vascularized tissue for fistula closure with negligible functional and esthetic morbidity associated with donor site. As per our study, it is a reliable technique for palatal fistula closure. It even provides good speech improvement over time.

The "Snail Flap": A Rotation Flap in Scalp Reconstruction.

The scalp rotation flap is still the flap of choice for scalp defects as it provides hair-bearing skin, replacing “like with like,” and can be designed to respect hairlines and patterns.1 Conventionally, these flaps are planned to be up to 8 times the diameter of the defect to allow for sufficient recruitment of scalp laxity and allow for primary closure of the secondary defect. Nevertheless, its use is limited by large flap to defect ratios (See Video [online], which displays the surgical technique of the “snail flap”). Video 1. This video displays the snail flap technique demonstrated in the article. From “The Snail Flap: A Rotation Flap in Scalp Reconstruction” Following the creation of the scalp defect, the thickness of the scalp is measured. If it is less than 5 mm, a snail flap is raised, as shown in the video, with a “flap:defect” ratio of 2:1. The tip of the flap is folded onto itself and advanced into the primary defect first. The secondary defect is then closed by spreading the tension across the entire arc. In younger patients, where the scalp thickness tends to be greater than 5 mm and there is increased scalp laxity, a “flap:defect” ratio of 1.5:1 may be chosen as the greater scalp laxity accords ease of closure (Fig. 1).

Riboflavin metabolism: role in mitochondrial function

Riboflavin, known as vitamin B2, a water-soluble vitamin, is an essential nutrient in vertebrates, hence adequate dietary intake is imperative. Riboflavin plays a role in a variety of metabolic pathways, serving primarily as an integral component of its crucial biologically active forms, the flavocoenzymes flavin adenine dinucleotide and flavin mononucleotide. These flavocoenzymes ensure the functionality of numerous flavoproteins including dehydrogenases, oxidases, monooxygenases, and reductases, which play pivotal roles in mitochondrial electron transport chain, β-oxidation of fatty acids, redox homeostasis, citric acid cycle, branched-chain amino acid catabolism, chromatin remodeling, DNA repair, protein folding, and apoptosis. Unsurprisingly, impairment of flavin homeostasis in humans has been linked to various diseases including neuromuscular and neurological disorders, abnormal fetal development, and cardiovascular diseases. This review presents an overview of riboflavin metabolism, its role in mitochondrial function, primary and secondary flavocoenzyme defects associated with mitochondrial dysfunction, and the role of riboflavin supplementation in these conditions.

Особенности эндоваскулярного закрытия вторичного дефекта межпредсердной перегородки у больных старшего возраста

Aim. Secondary atrial septal defect (ASD II) is one of the most common congenital heart defects. While all the issues of endovascular correction of this disease in children and young patients have been practically resolved, many issues still remain debatable regarding the treatment of adult patients. In the proposed work, the author analyzes the main information’s discussed in the literature concerning this issue, such as the expediency and tactics of treatment of adult patients with ASD II, depending on its anatomical forms, the status of intracardiac and pulmonary-arterial hemodynamics, the presence of concomitant diseases. Materials and methods. The article presents a literature review based on the results of searching of publications in Russian and international bibliographic da-tabases (PubMed, eLIBRARY, Medscape, etc.). Results. Analysis of the literature data in most cases indicates the feasibility and high efficiency of endovascular closure of hemodynamically significant ASD II in elderly patients. The analysis of dynamic observations in the long term after endovascular treatment, reveals a decrease in MPAP as well as the size of the right heart. At the same time, compliance with certain rules makes the intervention quite safe, regardless of the age of patients and, to a certain extent, the severity of symptoms. In the literature, it is particularly emphasized that when determining the management tactics of adult patients with ASD II in order to prevent possible complications, should be objectively evaluated and taken into account such factors that determine their initial state as: the presence of high MPAP, volume overload of the right heart, and vice versa, underloading of the left heart, the conditions of the heart valves, the presence of arterial hypertension, existence of heart rhythm disorders, ischemic heart disease and left ventricle dysfunction. Conclusion. Modern medical literature convincingly proves that with the right selection of patients, transcatheter closure is a safe, highly effective method of correction of ASD II, accompanied by real economic effect and it should be considered a standard in the treatment of middle-aged and elderly patients. At the same time, studies on long-term results show that the positive functional effect does not have age restrictions.

Нарушение движений в структуре разных видов психической деятельности у ребенка с опсоклонус-миоклонус синдромом

Opsoclonus-myoclonus syndrome (OMS) is a rare and often relapsing neurologic illness with onset in early childhood. Patients with OMS have longitudinal mental development disturbances and features of emotional and behavioral state. Interruption of the normative mental development is determined by movement disorders (primary defect), which establish new conditions for child's life for a long time. Case study of the child with OMS and the discussion of movement disorders in the structure of the different mental processes types in this disease are presented. Movement disorders (primary defect) and their effects (secondary and other defects) affecting mental development are discussed (based on the levels of movements coordination concept by N.A. Bernstein). The research detects mistmatch between levels of movements coordination (intactness of higher levels and disturbance of lower levels), which important for prospective analysis of the mental disorders mechanisms in children with OMS.

Mechanisms of Disease Progression and Resistance to Tyrosine Kinase Inhibitor Therapy in Chronic Myeloid Leukemia: An Update.

Chronic myeloid leukemia (CML) is characterized by the presence of the BCR-ABL1 fusion gene, which encodes a constitutive active tyrosine kinase considered to be the pathogenic driver capable of initiating and maintaining the disease. Despite the remarkable efficacy of tyrosine kinase inhibitors (TKIs) targeting BCR-ABL1, some patients may not respond (primary resistance) or may relapse after an initial response (secondary resistance). In a small proportion of cases, development of resistance is accompanied or shortly followed by progression from chronic to blastic phase (BP), characterized by a dismal prognosis. Evolution from CP into BP is a multifactorial and probably multistep phenomenon. Increase in BCR-ABL1 transcript levels is thought to promote the onset of secondary chromosomal or genetic defects, induce differentiation arrest, perturb RNA transcription, editing and translation that together with epigenetic and metabolic changes may ultimately lead to the expansion of highly proliferating, differentiation-arrested malignant cells. A multitude of studies over the past two decades have investigated the mechanisms underlying the closely intertwined phenomena of drug resistance and disease progression. Here, we provide an update on what is currently known on the mechanisms underlying progression and present the latest acquisitions on BCR-ABL1-independent resistance and leukemia stem cell persistence.

Perforator propeller flaps in lower limb reconstruction: a literature review and case reports

Perforator-pedicled propeller flaps, which base their blood supply on isolated perforators, have been gaining popularity among plastic surgeons over the past two decades. They have proven to be of great value in the reconstruction of soft tissue defects in different areas of the body but are, thanks to their maximal mobility, mostly used in the reconstruction of extremities. In this article, we focus on perforator-pedicled propeller flaps in lower limb reconstruction, where they can be implemented in the coverage of primary as well as secondary soft tissue defects. Firstly, a brief literature review on evolution of propeller flap use in lower extremity is provided. Moreover, we present our surgical technique including the use of indocyanine green real-time angiography for reliable flap transfer. In addition, we report 3 cases of patients in whom we used a local propeller flap for the closure of skin defects in different parts of the leg.

The modified bipedicled flap for reconstruction of oncological skin defects of the trunk and extremities

Oncological skin defects of the extremities and trunk can be challenging. Our modified bipedicled flap utilises the principle of the bipedicled advancement flap, but allows for direct closure of the donor site (as opposed to skin grafting). It does not rely on the preservation of perforators and it random pattern, making it extremely versatile. We aimed to assess the outcomes for patients reconstructed using the modified bipedicled flap technique including oncological safety and complications. Consecutive patients were retrospectively identified from July 2011 to January 2019 using operative records. Demographics, operative details, oncological data and complications were recorded from patient records and the institution's internal electronic patient records system. No cases, having a modified bipedicled flap, were excluded from this study. One hundred flaps in 98 patients were included. Mean defect dimensions were 61.7mm by 33.1mm. Median length of stay was 1 day, time to discharge from dressing clinic was 15 days, and the length of follow-up was 6.0 years. Eight patients required oral antibiotics for suspected localised wound infection, and 6 patients had minor wound healing problems. There were no cases of flap failure, partial flap loss, returns to theatre for flap-related complications, or local disease recurrence. To our knowledge, this is the largest series of bipedicled flaps published to date. Our technique is easy to execute, versatile, and allows for direct closure of the secondary defect with excellent cosmetic results. It is oncologically safe, with a low incidence of complications. We commend it for use in the reconstruction of oncological skin defects of the trunk and extremities.

The tectonic stress–driving alteration and evolution of chemical structure for low- to medium-rank coals—by molecular simulation method

Coal organic macromolecular structure can be significantly altered by tectonic stress, but such macromolecular models are seldom reported. Here, based on the ultimate analysis, FT-IR, XPS, and 13C NMR results, three molecular models of primary coal (P1) and TDCs (the brittle coal model B2 and ductile coal model D3) within periodic boundary conditions were constructed through the molecular mechanics (MM) and molecular dynamics (MD) calculation methods. By comparing the morphology characteristics of the above three models, the crystal parameters decrease with the increasing deformation intensity, which leads to a tighter configuration. Bridge bonds are easier to be stretched and even broken up within deformed coal, which can furtherly crack the coal molecules into several smaller segments. Oxygen functional groups and methyl can be lost by the deformation on coal, which leads to an increase of the disorder units within coal molecules. On the one hand, the ductile deformation increases the condensation degree of the aromatic layers through promoting the small disorder units (viz. CO) embed into the secondary structural defects. On the other hand, it can also improve the order degree and the stacking degree of aromatic layers. By comparative analysis, the evolution path of tectonically deformed coal molecules is furtherly proposed. The ultra micropore volumes of three models are several orders of magnitude larger than the pore volume within the range of 2–50 nm, indicating that ultra micropores are important storage spaces for excess methane resulting in coal and gas outburst.

2750 Acute Neck Pain Masquerading as Acute Gastric Volvulus

INTRODUCTION: Gastric volvulus is a rare cause of gastric outlet obstruction that if not recognized early can lead to ischemia, necrosis and death. Organoaxial is the most common type and is seen with secondary anatomic defects i.e. paraesophageal hernias, diaphragmatic hernias and diaphragm eventrations. It occurs in 60% of cases with 30% risk of strangulation. Risk factors include age >50 years, secondary anatomic defects, phrenic nerve paralysis and structural abnormalities of the stomach/spleen. Symptoms include abdominal pain, chest pain, retching and/or vomiting. Misdiagnosis occurs because of its nonspecific presentation. We describe a case of a patient who was admitted for suspect acute coronary syndrome and found to have an acute gastric volvulus. CASE DESCRIPTION/METHODS: 75 yo m with pmh of HTN, who p/w sudden onset neck pain radiating to L arm, with N/V during activity. He denied chest pain, SOB or diaphoresis. Vitals were T 98 F, HR 85, BP 156/69, and RR 18. On exam pt had decreased breath sounds LLL, NT abdomen, and left paraspinal neck tenderness. Pertinent labs: WBC: 11. Chemistry with hypokalemia. Normal troponins. CXR showed L hemidiaphragm elevation and hiatal hernia. Neck imaging was normal. EKG was normal without st changes. Overnight the pt became altered with intractable neck pain, nausea and vomiting. Repeat cxr showed widened mediastinum. A stat CTA chest/abd/pelvis showed organoaxial gastric volvulus with fluid filled esophagus. EGD abnormalities lead to an ex-lap with gastrostomy, gastropexy and volvulus reduction. Pt did well and went to a rehab facility. DISCUSSION: Gastric volvulus often manifests with abdominal pain in addition to nausea and vomiting rather than neck or chest pain. There have been reports of cases mimicking acute coronary syndrome. Intractable neck pain without abdominal pain is an extremely rare phenomenon in patients with acute gastric volvulus. In order to establish a diagnosis in our patient, a high index of suspicion was imperative for identifying an atypical presentation of acute gastric volvulus. This was illustrated by ordering a CT chest as soon as he became more ill-appearing. In retrospect, the intractable neck pain could have been considered as referred pain from the elevated left hemidiaphragm in the setting of a known hiatal hernia. Literature search was heterogeneous and scarce. Thus, we recommend high index of suspicion for acute gastric volvulus in the setting of intractable neck pain in order to intervene earlier and avoid worse outcomes.