Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4%, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.

Confirmation of the role of diabetes in the local recurrence of surgically resected non-small cell lung cancer

PURPOSE

We recently demonstrated that diabetes mellitus was an independent risk factor for local recurrence (LR) for patients undergoing resection of non-small cell lung cancer (NSCLC). This investigation was performed to confirm or refute this finding in a different patient cohort.

MATERIALS AND METHODS

Patients were eligible if they did not have a second primary cancer within 5 years of the original diagnosis, had at least 3-month follow-up, and did not receive radiotherapy. There were 373 and 168 patients in the original (P1) and confirmatory (P2) cohorts, respectively, with 66 and 30 patients with diabetes.

RESULTS

The median follow-up was 33 months (range, 3-98 months). Diabetes was an independent risk factor for LR in a Cox model in both the P2 (p=0.05, hazard ratio [HR] 2.15) and P1 (p=0.008, HR 1.90) cohorts, separately from BMI, glucose control, and the presence of the metabolic syndrome. The rates of LR in the patients with diabetes after combining the cohorts at 2, 3, and 5 years were 23%, 33%, and 56%, respectively; these rates were 15%, 19%, and 26% in non-diabetics. In multivariate Cox regression and competing risk analysis of the combined cohorts, the HRs for LR in patients with diabetes exceeded those of more established risk factors for LR including a 1-cm increase in tumor size and lymphovascular invasion.

CONCLUSIONS

Diabetes was confirmed to be an independent predictor of the risk of LR following resection of NSCLC.

Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4%, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.

Acute neurological findings in a national cohort of neonates with severe neonatal hyperbilirubinemia

OBJECTIVE

To describe and compare infants with severe hyperbilirubinemia, who presented with and without abnormal neurological findings and to identify associated risk factors.

STUDY DESIGN

Data on infants with severe hyperbilirubinemia (>425 μmol l(-1) and/or received exchange transfusion) were collected prospectively through the Canadian Paediatric Surveillance Program (CPSP) from 2002 to 2004. Cases were categorized into two groups on the basis of information provided by the reporting physician: neurologically normal or abnormal. Demographic characteristics were compared and univariate logistic regression was performed to identify factors associated with acute neurological abnormalities in infants.

RESULT

Of the initial cohort of 258 infants, 32 (12.4%) were identified to have neurological abnormalities. Infants in the highest peak bilirubin level group (>550 μmol l(-1)) had the greatest risk of acute neurological abnormalities. The mid range (451 to 550 μmol l(-1)) and lowest level (450 μmol l(-1)) groups were less likely to have abnormalities (odds ratio (OR)=0.174; P=0.0013 and 0.402; P=0.0613, respectively). Exchange transfusion and presentation within the first 2 days of age were positively associated with abnormal neurological findings in infants (OR=3.332, P=0.003 and OR=2.572, P<0.0001, respectively).

CONCLUSION

In this national cohort of infants with severe hyperbilirubinemia, a significant percentage of infants developed acute bilirubin encephalopathy. Long-term neurodevelopmental follow-up is necessary to determine the incidence of permanent neurological sequelae.

Lower urinary tract symptoms and sexual dysfunction: an audit of sexual symptoms among patients attending a nurse-led prostate clinic

Significant numbers of men with lower urinary tract symptoms (LUTS) also report symptoms of sexual dysfunction (SD). The prevalence of SD in patients referred to a prostate assessment clinic, was assessed using a confidential questionnaire. Fifty-six percent of patients reported difficulties in maintaining an erection and 48% felt that improving their sexual function would benefit their quality of life. None of the referral letters from primary care mentioned symptoms of SD. Patients with LUTS seen in primary and secondary care should be assessed for SD and offered appropriate advice and management.

Unicondylar knee replacement with a new tensioner device: clinical results of a multicentre study on 168 cases

INTRODUCTION

Ligament balancing is an established surgical technique in total knee arthroplasty with good clinical results. A similar technique for unicondylar knee arthroplasty was developed. The aim of this study was to asses the outcomes of a unicondylar knee replacement implanted with a ligament tensor.

MATERIALS AND METHODS

A prospective multicentre study of 168 medial compartment unicondylar knee prosthesis with a minimum follow-up of 2 years. Clinically, the knee society score was recorded. For subjective assessment, the visual analogue scale (VAS) for pain and satisfaction was used. Radiographic analysis was performed to determine radiolucent lines. The surgical technique was based on a ligament-orientated procedure. With this technique, the femoral orientation, flexion/extension gaps and limb alignment is determined with a unique ligament tensor.

RESULTS

The total KSS increased from 110.9 +/- 27.5 points preoperative to 176.5 +/- 21.1 points after 24 months. VAS for pain decreased from 6.0 +/- 1.9 preoperative to 2.8 +/- 1.7 after 24 months. VAS for satisfaction increased in the same period from 4.3 +/- 1.9 to 8.9 +/- 1.7. Four tibia implants had thin continuous radiolucent lines. Nine adverse events are reported. One patient died of unrelated causes. Five polyethylene inlays dislocated, one of five dislocated due to a fall. Three unicondylar knee prostheses were revised to a total knee arthroplasty, one because of undiagnosed pain, one for infection and one for femoral component malalignment.

CONCLUSION

We have demonstrated the efficacy of a tension-controlled ligament-balanced surgical technique for unicompartmental knee prosthesis that gives satisfying and reproducible short-term results.

Incidence of Residual Neuromuscular Blockade in a Post-Anaesthetic Care Unit

We conducted a prospective observational study to assess the incidence of residual neuromuscular blockade (RNMB) in a post-anaesthetic care unit (PACU) of a tertiary hospital. The subjects were 102 patients undergoing general anaesthesia with neuromuscular blockade (NMB). The procedural anaesthetists were unaware of their patients’ inclusion in the study, and the choice of muscle relaxant and use of reversal agents were at the anaesthetists’ discretion. On arrival to the PACU, the train-of-four ratio was assessed using electromyography, repeated every five minutes until the train-of-four ratio exceeded 0.9. RNMB was defined as a train-of-four ratio < 0.9. The requirement for airway support, incidence of desaturation while in the PACU and time to eligibility for PACU discharge were recorded. The mean interval between the last dose of relaxant and arrival in the PACU for patients with RNMB was 81 minutes. An intermediate-acting muscle relaxant had been used for most patients. Despite this, RNMB was observed in 31% (95% confidence interval 25 to 47%) of patients. Our findings suggest that RNMB in the PACU is common. As RNMB may predispose to postoperative complications, anaesthetists should utilise quantitative monitoring to assess neuromuscular blockade and optimise reversal use. Anaesthetists should be aware that intervals between the last dose of relaxant of well over one hour do not exclude the possibility of RNMB, even when using intermediate-acting neuromuscular blockade agents.

Similarities and differences between excessive exercising anorexia nervosa patients compared with DSM-IV defined anorexia nervosa subtypes

This study describes anorexia nervosa (AN) patients who use excessive exercise for weight management and how this behaviour relates to the classical Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) sub-grouping of AN. The study compared 428 clinical AN patients with 119 age and gender-matched controls. The AN cases were initially dichotomised according to DSM-IV subtype criteria into restricting (RAN; N=198) and binge-purge (BPAN; N=230) anorexia. The psychometric instruments were chosen to reflect key features concerning the diagnosis of eating disorders and characteristics of eating and food behaviour and included the 26-item Eating Attitude Test (EAT-26), Three Factor Eating Questionnaire (TFEQ), Dutch Eating Behaviour Questionnaire (DEBQ), Eysenck Personality Inventory (EPI) and Rosenberg Self-Esteem scale (RSE). Structured clinical interviews (1) were carried out in order to identify the subgroup of patients who use excessive exercise in order to facilitate weight control (EAN). The three groups (RAN, BPAN, EAN) did not differ in measures of current age, current body mass index, age of onset of AN and measures of restrained eating. However, significant differences were observed on EAT-26, DEBQ emotional and external factors, TFEQ disinhibition and hunger factors, EPI extraversion and neuroticism, and self-esteem. The EAN were similar to the RAN on the majority of variables but showed significant differences on extraversion, neuroticism, self-esteem and disease pathology (EAT-26). Compared with BPAN, EAN had lower disease pathology (EAT-26 scores), scored higher on the EPI extraversion scale, lower on the neuroticism scale and had greater self-esteem. The EAN also displayed significantly lower emotional and external eating (DEBQ) than BPAN and significantly lower disinhibition and hunger scores (TFEQ). These data suggest that EAN group display a mixed profile of characteristics resembling both BPAN and RAN. When EAN are defined as a separate group they appear to be phenotypically more similar to RAN than BPAN on this particular profile of variables. However when DSM-IV criteria are applied they are almost exclusively classified as BPAN. This outcome suggests that EAN do constitute an identifiable group that can be distinguished from RAN and BPAN. Consequently it is likely that the behaviour of excessive exercising should be considered as clinically relevant on the outcome of treatment.

Strong association of socioeconomic status with genetic ancestry in Latinos: implications for admixture studies of type 2 diabetes

AIMS/HYPOTHESIS

Type 2 diabetes is more prevalent in US American minority populations of African or Native American descent than it is in European Americans. However, the proportion of this epidemiological difference that can be ascribed to genetic or environmental factors is unknown. To determine whether genetic ancestry is correlated with diabetes risk in Latinos, we estimated the proportion of European ancestry in case-control samples from Mexico and Colombia in whom socioeconomic status had been carefully ascertained.

METHODS

We genotyped 67 ancestry-informative markers in 499 participants with type 2 diabetes and 197 controls from Medellín (Colombia), as well as in 163 participants with type 2 diabetes and 72 controls from central Mexico. Each participant was assigned a socioeconomic status scale via various measures.

RESULTS

Although European ancestry was associated with lower diabetes risk in Mexicans (OR [95% CI] 0.06 [0.02-0.21], p = 2.0 x 10(-5)) and Colombians (OR 0.26 [0.08-0.78], p = 0.02), adjustment for socioeconomic status eliminated the association in the Colombian sample (OR 0.64 [0.19-2.12], p = 0.46) and significantly attenuated it in the Mexican sample (OR 0.17 [0.04-0.71], p = 0.02). Adjustment for BMI did not change the results.

CONCLUSIONS/INTERPRETATION

The proportion of non-European ancestry is associated with both type 2 diabetes and lower socioeconomic status in admixed Latino populations from North and South America. We conclude that ancestry-directed search for genetic markers associated with type 2 diabetes in Latinos may benefit from information involving social factors, as these factors have a quantitatively important effect on type 2 diabetes risk relative to ancestry effects.