Outcomes for Children With a Nonvisualized Appendix on Ultrasound.

OBJECTIVES: Oftentimes while pursing the diagnosis of appendicitis, an ultrasound cannot visualize the appendix, and physicians must utilize other resources for evaluation. The primary objective of this study was to determine if there was a lower rate of appendicitis when the appendix was not visualized on ultrasound. Furthermore, we assessed the importance of specific clinical predictors in this population. METHODS: We conducted a retrospective chart review of all children who presented to our pediatric emergency department from 2011 to 2013 and had an abdominal ultrasound. We identified total numbers of ultrasounds with a nonvisualized appendix and then assessed follow-up for a randomly selected group of patients. We performed logistic regression to assess the predictive value of different clinical factors. RESULTS: A total of 3245 ultrasounds were analyzed, and in 54% of these, the appendix was nonvisualized. In total, 28% of the total patients and 11.9% of patients who received a nonvisualized ultrasound had appendicitis (95% confidence interval [CI], 8.3%-16.2%). Among those patients who had follow-up studies performed during the same visit, 21.2% had appendicitis (95% CI, 14.9%-28.8%), and of those discharged without a diagnosis, 1.5% had appendicitis (95% CI, 0.2%-5.4%). Male sex, leukocytosis, and an elevated absolute neutrophil count were each significantly associated with appendicitis after a nonvisualized appendix on ultrasound. CONCLUSIONS: A significant proportion of patients with suspected appendicitis who had an initial nonvisualized appendix on ultrasound were ultimately diagnosed with appendicitis. Clinicians must be vigilant about pursuing a definitive diagnosis if an initial ultrasound is nondiagnostic.

Novel Assessment of Accessory Pathway Function in Patients with Wolff-Parkinson-White Syndrome.

Surrogates for the shortest pre-excited R-R interval in atrial fibrillation (SPERRI) such as the accessory pathway effective refractory period (APERP) and shortest pre-excited paced cycle length (SPPCL) are flawed assessments of accessory pathway function in patients with WPW. Multi-extrastimulus pacing may have the theoretical advantage of more accurately mimicking the clinical reality of atrial fibrillation and thus may serve to better assess accessory pathway function. This cross-sectional study included 25 consecutive patients, aged ≤ 18 years, undergoing electrophysiology study for WPW. The longest S1S2, S2S3, S3S4 coupling intervals at which the antegrade AP refractoriness occurred, SPERRI, and SPPCL were recorded. Induction of atrial fibrillation was attempted in all patients and induced in 8 (32%, 4 SPERRIbaseline (265 ms ± 61 ms), 4 SPERRIIsuprel (258 ms ± 41 ms)). At baseline, the lower value of the S3ERP or S4ERP (274 ms ± 52 ms) was lower than the SPPCL (296 ms ± 54 ms, p < 0.0001) and APERP (296 ms ± 41 ms, p < 0.0001). More patients had S3ERP or S4ERP ≤ 250 ms (12/25, 48%) compared to those with APERP ≤ 250 ms (2/25 8%), p = 0.0016), SPPCL 5/24, 20%), p = 0.008 or either (6/25, 24%), p = 0.0143). With Isuprel, the lower value of the S3ERP or S4ERP (221 ms ± 36 ms) trended to be lower than the APERP (252 ms ± 36 ms, p = 0.0001) and the SPPCL (266 ms ± 57 ms, p = 0.001). With Isuprel, there was no statistical difference in the proportion of patients with S3ERP or S4ERP < 250 ms (12/16, 75%) compared to those with APERP ≤ 250 ms ((9/16, 56%), p = 0.08), SPPCL ≤ 250 ms ((9/16, 56%), p = 0.08), or either ((10/16, 63%), p = 0.16). Multi-extrastimulus pacing protocols demonstrate that accessory pathways are less refractory than as defined by single extrastimulus pacing and straight decremental pacing.

Pretreatment nutritional status and response to checkpoint inhibitors in lung cancer.

BACKGROUND: Checkpoint inhibitors are integral to non-small-cell lung cancer treatment. Existing data suggests that nutritional status may play a role in antitumor immunity. MATERIALS & METHODS: This retrospective study of 106 non-small-cell lung cancer patients who started checkpoint inhibitors between 2014 and 2017 at our institution assessed relationship of nutritional parameters to overall survival (OS) and progression-free survival. RESULTS: Mean age was 68.7 ± 9.2 years and 59.4% patients were male. On multivariate analysis for OS, hypoalbuminemia and significant weight loss were prognostic at p-values of 0.0005 and 0.0052, respectively. We noted a parabolic association between age and OS (p = 0.026, 0.0025). CONCLUSION: In our study, some malnutrition parameters were associated with decreased OS. U-shape relationship between age and OS noted here warrants further evaluation.