The primary mechanisms involved in this effect appear to include a decrease in hepatocyte nuclear factor 4α (HNF-4α) expression, probably leading to a down regulation of PEPCK, one of the KU-60019 order main rate-limiting enzymes of gluconeogenesis. These findings suggest an important role of Ang-(1-7) in hepatic glucose metabolism. This work was supported by a grant of CNPq (INCT-NanoBiofar), FAPEMIG, PRONEX (FAPEMIG/CNPq-Edital 17/2010) and CAPES. There are none competing of interests. “
“Acute appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, with a lifetime risk of 8.6% for males and 6.7% for females.1 and 2 Historically, negative appendectomy rates of

more than 20% were considered the norm. However, this is no longer acceptable because even though complication rates in the setting of negative appendectomy are low, conditions such as incisional hernias, intestinal obstruction secondary to adhesions, and stump leakages can result in significant morbidity. Computed tomography (CT) scan has emerged as the dominant imaging

modality for evaluation of suspected appendicitis in adults.3 It has decreased negative appendectomy rates to less than 10%.4, 5 and 6 However, the radiation exposure with CT poses a concern, particularly in appendicitis, which occurs predominantly in young patients most susceptible to the adverse effects of radiation.7 and 8 Available literature has estimated that at least 25% of CT Thiamine-diphosphate kinase scans are not clinically warranted learn more and may pose more harm than benefit.9 Rules for clinical decisions guiding CT use are therefore essential to minimize unnecessary CT scans.9 We previously proposed a management algorithm for suspected appendicitis with the Alvarado score (AS) (Table 1) guiding CT use.10 This algorithm was, however, developed based on retrospective data with its antecedent limitations. This study aimed to compare the performance statistics of the AS with CT scan in the evaluation of suspected appendicitis. Thereafter, we attempt to use the AS to stratify patients with suspected

appendicitis into subgroups that might benefit from CT evaluation. An objective algorithm for the management of suspected appendicitis guided by the AS is then proposed. We performed an analysis of prospectively collected data from 450 consecutive patients with suspected appendicitis, admitted to the General Surgery Department at Singapore General Hospital. The study ran from August 2013 to March 2014, and only patients who underwent CT evaluation were included in the final analysis. Decision for CT evaluation was left to the discretion of the attending surgeon during the initial assessment. Patient demographics, presenting signs and symptoms, and relevant laboratory values were prospectively collected and recorded in a standardized data collection sheet.