Non-diagnostic sonography may reduce negative appendicectomy rate in women when combined with abbreviated Alvarado score.

BACKGROUND: The diagnosis of acute appendicitis (AA) remains a clinical one, with selective use of adjunct imaging. Patients with equivocal clinical presentation often undergo a diagnostic laparoscopy. To help reduce negative appendicectomy rates in women, we aimed to develop a simple scoring system based on the Alvarado score (AS) and ultrasound scan (US), as a diagnostic aid for AA in females. METHODS: All patients who underwent appendicectomy for AA at The Alfred Hospital Melbourne between 1 July 2012 and 30 June 2017 were included for this case-control study. Logistic regression was used to identify pre-operative parameters predictive of AA. Histopathological identification of AA was interpreted as the gold standard. Statistical analysis was performed using IBM SPSS Statistics V26. RESULTS: A total of 1194 patients were included, with 26% negative appendicectomy rate in women. Of the 8 parameters in the AS, logistic regression identified migratory pain, leukocytosis and leukocyte left shift as most significant predictors for AA. These three parameters were used in a 3-point test which carried a sensitivity of 92.1% and specificity of 28.7%. In women, a negative or non-diagnostic US improved the negative predictive value of the 3-point test from 57% to 82%. CONCLUSION: The 3-point abbreviated AS in combination with US may be clinically useful in women to exclude appendicitis without diagnostic laparoscopy. Further large-scale prospective studies are required to validate the utility across different subgroups.

Caseload distribution of general surgeons in regional Australia: is there a role for a rural surgery sub-specialization?

BACKGROUND: Rural and regional Australia presents a unique challenge in the delivery of surgical services by virtue of its geographical vastness and low population density. While up to 33% of Australians live in rural or regional areas, only 14.8% of surgeons work in a rural or regional area. Data regarding the caseload distribution of general surgeons working in a regional setting in Australia remain scarce. In order to better examine the training needs of rural general surgeons, this study aims to examine the caseload distribution of general surgeons working in regional Australia. METHODS: A retrospective review of surgical procedures carried out by general surgeons at Albury Base Hospital between September 2006 and December 2014 was carried out. Surgical procedures were grouped according to the classifications of the Royal Australasian College of Surgeons Morbidity and Audit Logbook Tool. RESULTS: During the study period, 21 652 procedures were carried out by general surgeons. A total of 58.7% (12711) of these procedures consisted of general surgical procedures and 35.9% (7763) were endoscopic procedures. A total of 5.4% of procedures carried out by general surgeons fell outside the scope of traditional general surgery, including cardiothoracic, orthopaedic, ear, nose and throat, neurosurgical, vascular and urological procedures. All general surgeons performed operations in surgical specialities outside of general surgery. CONCLUSION: This study adds weight to the value of a broad skill set in provision of surgical services in a rural setting.

Postoperative atrial fibrillation after isolated aortic valve replacement: a cause for concern?

BACKGROUND: Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short-term and long-term outcomes after general cardiac operations. There is, however, a paucity of data on the impact of POAF on outcomes after isolated aortic valve replacement (AVR). METHODS: Data for all patients undergoing isolated first-time AVR between June 2001 and December 2009 was obtained from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) National Cardiac Surgery Database Program and a retrospective analysis was conducted. Preoperative characteristics, early postoperative outcome, and late survival were compared between patients in whom POAF developed and those in whom it did not. Propensity score matching was performed to correct for differences between the 2 groups. RESULTS: Excluding patients with preoperative arrhythmia, isolated first-time AVR was performed in 2,065 patients. POAF developed in 725 (35.1%) of them. Patients with POAF were significantly older (mean age, 72 versus 65 years; p < 0.001) and presented more often with comorbidities, including hypertension, respiratory disease, and hypercholesterolemia (all p < 0.05). From the initial study population, 592 propensity-matched patient pairs were derived; the overall matching rate was 81.7%. In the matched groups, 30-day mortality was not significantly different between the POAF and non-POAF groups (1.5% versus 1%; p = 0.48). Patients with POAF were, however, at an independently increased risk of perioperative complications, including new renal failure, gastrointestinal complications, and 30-day readmission (p < 0.05). Seven-year mortality was not significantly different between POAF and non-POAF groups (78% versus 83%; p = 0.63). CONCLUSIONS: POAF is a risk factor for short-term morbidity but is not associated with a higher rate of early or late mortality after isolated AVR.