Impact of COVID-19 on acute appendicitis presentation, management and pathology findings in adult and paediatric populations.

BACKGROUND: We investigated the impact of the COVID-19 pandemic on trends of presentation, management and pathology findings in patients who underwent an appendicectomy for suspected acute appendicitis. METHOD: The retrospective study reviewed patients (n = 939 adults and n = 329 children) who had an appendicectomy performed for suspected acute appendicitis and histopathology assessment in the Belfast Health and Social Care Trust, Northern Ireland. Pre-COVID-19 (March 2019 to February 2020) and COVID-19 Year 1 (March 2020 to February 2021) data were compared. Chi-squared tests were applied to compare timeframes. RESULTS: 513 adult appendicectomies were performed in the immediate year pre-COVID-19, compared to 426 in COVID-19 Year 1, representing a 17% reduction. No such reduction was seen within the paediatric population, likely related to a change in regional paediatric referral criteria during the pandemic. When comparing COVID-19 Year 1 with pre-pandemic, fewer patients presented with <24 hours of symptoms (45% v 53%, p = 0.005), and there was greater use of pre-operative computed tomography imaging in adults (63.2% v 48.7%, p<0.001). Fewer adult and paediatric cases of simple acute appendicitis and non-diagnostic specimens, with relative increased proportions of perforated acute appendicitis, were observed in COVID-19 Year 1 compared with pre-pandemic. No absolute increase in perforated acute appendicitis cases was observed in adults. CONCLUSION: Year 1 of the COVID-19 pandemic was associated with delayed presentation of acute appendicitis in adults and children. In adults, an overall reduction in appendicectomy operations, increased use of pre-operative diagnostic imaging, and fewer specimens showing simple acute appendicitis or non-diagnostic features, collectively support appropriate restriction of surgery for those patients with a more certain acute appendicitis diagnosis.

Multidisciplinary, In Situ Simulation Improves Experienced Caregiver Confidence With High-Risk Pediatric Emergencies.

OBJECTIVES: Emergency department (ED) caregivers have reported feeling uncomfortable performing emergency pediatric procedures, likely because of either a lack of training or infrequent exposure to these events. To address these gaps, ongoing education for experienced ED caregivers must aim to improve caregiver confidence with high-risk, low-volume pediatric emergency care. This study used multidisciplinary, in situ simulations to facilitate improved caregiver confidence when treating pediatric emergencies in an ED setting. METHODS: Two-hour pediatric code blue simulations were held in 7 EDs throughout the Seattle, Washington, metropolitan area. Questionnaire data were collected from 353 simulation participants (60% nurses, 19.5% ED technicians, 14% ED physicians; median team size = 5) via pre simulation and post simulation surveys assessing confidence and understanding regarding interventions/treatments, standard protocols, culture of safety behavior, and team members' roles/responsibilities. Paired t tests were used to analyze changes in self-reported confidence. RESULTS: Confidence improved across all questions (37%-57% of participants reported good/complete confidence pre simulation, improving 94%-98% post simulation; P < 0.00001 for all). Participants cited learning equipment location/use (37%), hands-on practice (32%), and discussion (22%) as the most helpful aspects of the simulations. Identified changes to practice made post simulation included more effective communication (18%) and utilization of a pediatric emergency drug sheet (13%). CONCLUSIONS: Multidisciplinary, in situ simulation improves experienced ED caregivers' confidence with pediatric emergencies in an ED setting. These findings suggest that investment in simulation-based education may improve clinical care and quality and safety improvement plans for the treatment of pediatric emergencies in general EDs.

How to use perianal examination in children.

No examination of a child's abdomen or gastrointestinal system is complete without an examination of the 'backside' or perineum, however there is often reluctance among paediatricians to perform this examination routinely. This article aims to describe how to use perineal examination in infants and children. It discusses the indications and stepwise approach to performing a per-rectal examination and interpretation of the findings one could expect to encounter. We include four cases encompassing the major conditions, both congenital and acquired, that paediatricians should be aware of and how they were managed in our institution.

The ribosome biogenesis factor yUtp23/hUTP23 coordinates key interactions in the yeast and human pre-40S particle and hUTP23 contains an essential PIN domain.

Two proteins with PIN endonuclease domains, yUtp24(Fcf1)/hUTP24 and yUtp23/hUTP23 are essential for early pre-ribosomal (r)RNA cleavages at sites A0, A1/1 and A2/2a in yeast and humans. The yUtp24/hUTP24 PIN endonuclease is proposed to cleave at sites A1/1 and A2/2a, but the enzyme cleaving at site A0 is not known. Yeast yUtp23 contains a degenerate, non-essential PIN domain and functions together with the snR30 snoRNA, while human hUTP23 is associated with U17, the human snR30 counterpart. Using in vivo RNA-protein crosslinking and gel shift experiments, we reveal that yUtp23/hUTP23 makes direct contacts with expansion sequence 6 (ES6) in the 18S rRNA sequence and that yUtp23 interacts with the 3΄ half of the snR30 snoRNA. Protein-protein interaction studies further demonstrated that yeast yUtp23 and human hUTP23 directly interact with the H/ACA snoRNP protein yNhp2/hNHP2, the RNA helicase yRok1/hROK1(DDX52), the ribosome biogenesis factor yRrp7/hRRP7 and yUtp24/hUTP24. yUtp23/hUTP23 could therefore be central to the coordinated integration and release of ES6 binding factors and likely plays a pivotal role in remodeling this pre-rRNA region in both yeast and humans. Finally, studies using RNAi-rescue systems in human cells revealed that intact PIN domain and Zinc finger motifs in human hUTP23 are essential for 18S rRNA maturation.

The PIN domain endonuclease Utp24 cleaves pre-ribosomal RNA at two coupled sites in yeast and humans.

During ribosomal RNA (rRNA) maturation, cleavages at defined sites separate the mature rRNAs from spacer regions, but the identities of several enzymes required for 18S rRNA release remain unknown. PilT N-terminus (PIN) domain proteins are frequently endonucleases and the PIN domain protein Utp24 is essential for early cleavages at three pre-rRNA sites in yeast (A0, A1 and A2) and humans (A0, 1 and 2a). In yeast, A1 is cleaved prior to A2 and both cleavages require base-pairing by the U3 snoRNA to the central pseudoknot elements of the 18S rRNA. We found that yeast Utp24 UV-crosslinked in vivo to U3 and the pseudoknot, placing Utp24 close to cleavage at site A1. Yeast and human Utp24 proteins exhibited in vitro endonuclease activity on an RNA substrate containing yeast site A2. Moreover, an intact PIN domain in human UTP24 was required for accurate cleavages at sites 1 and 2a in vivo, whereas mutation of another potential site 2a endonuclease, RCL1, did not affect 18S production. We propose that Utp24 cleaves sites A1/1 and A2/2a in yeast and human cells.