Diagnostic Ultrasound for Acute Appendicitis: The Gold Standard.

BACKGROUND: Acute appendicitis may present a diagnostic dilemma. The aim of this study was to review the accuracy of ultrasound in the diagnosis of paediatric acute appendicitis. METHOD: Ultrasound studies performed for investigation of appendicitis during 2015-2021 were retrieved from a tertiary paediatric hospital database and reviewed. Medical records were reviewed to determine operative intervention, further imaging, and final diagnosis. Diagnostic accuracy was assessed by sensitivity, specificity, predictivity, and overall accuracy. All appendicectomy specimens underwent histopathological confirmation. This study was approved by the local Human Research Ethics Committee. RESULTS: A total of 8555 consecutive ultrasound examinations were performed during the study period. Mean patient age was 10.8 years ( ± 3.7). Overall diagnostic accuracy was 96.1% (8221/8555) with a visualisation rate of 91.0%. Sensitivity and specificity were 96.2% (CI 95.3-97.0%) and 96.1% (CI 95.6-96.5%), respectively. When limited to positive/negative scans, sensitivity was 99.6% (CI 99.2-99.8%) and specificity 99.0% (CI 98.7-99.3%). Positive and negative predictive values were 96.9% and 99.9%, respectively. Repeat ultrasound following a non-diagnostic scan led to a definitive diagnosis in 76.1%. Negative appendicectomy rate was 5.5% overall in children who had undergone pre-operative ultrasound (107/1938), and 4.4% when other surgical pathologies were excluded. CONCLUSION: Ultrasound examination provides gold-standard accuracy in the diagnosis of paediatric appendicitis and reduces rates of negative appendicectomy. Given the disadvantages of computed tomography and magnetic resonance imaging, ultrasound should be considered the first-line investigation of choice in the diagnosis of acute appendicitis in children. LEVEL OF EVIDENCE: III.

Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out?

BACKGROUND: Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma. METHODS: A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA. RESULTS: During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR] = 10.59, 95% confidence interval [CI] 1.98-56.69, P = 0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR = 30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR = 14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA. CONCLUSION: Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.

Epidemiology and outcomes of gastroschisis in Tasmania.

AIM: To describe the epidemiology and outcomes of gastroschisis in Tasmania. METHODS: A retrospective analysis of all pregnancies complicated by gastroschisis in Tasmania from 1996 to 2015 was undertaken (epidemiology cohort), and the presentation, surgical management and outcomes (surgery cohort) were reviewed for the period between September 1990 and July 2015. RESULTS: Gastroschisis was detected in 58 pregnancies during the 20-year epidemiology cohort period, giving an incidence of 4.4 per 10 000 live births for the 20-year period. Two of the four stillbirths occurred after 36 weeks' gestation. Of the 65 babies with gastroschisis treated at the Royal Hobart Hospital, 51 had a staged surgical repair (silo in 47, stoma formation in 4), and 14 had a primary closure. Staged repair was associated with a significantly longer duration of ventilation and stay in the neonatal intensive care unit. There were six post-natal deaths, all born in the first epoch. Death was significantly associated with the condition of the intestine at delivery (P = 0.02). There were no deaths in babies with simple gastroschisis. Complex gastroschisis was significantly associated with longer duration of total parenteral nutrition (P = 0.0002) and longer stay in hospital (P = 0.03). CONCLUSIONS: The incidence of gastroschisis in Tasmania is similar to that reported in other Australian regions and has not increased over the 20-year period of study. The high risk of stillbirth, and the significant association between mortality and the condition of the intestine at birth necessitates close fetal surveillance. Complex gastroschisis imposes a significant burden on hospital resources.

Chest x-ray as a screening tool for blunt thoracic trauma in children.

BACKGROUND: With the increasing use of thoracic computed tomography (CT) to screen for injuries in pediatric blunt thoracic trauma (BTT), we determined whether chest x-ray (CXR) and other clinical and epidemiologic variables could be used to predict significant thoracic injuries, to inform the selective use of CT in pediatric BTT. We further queried if these were discrepant from factors associated with the decision to obtain a thoracic CT. METHODS: This retrospective cohort study included cases of BTT from three Level I pediatric trauma centers between April 1999 and March 2008. Pre-CT epidemiologic, clinical, and radiologic variables associated with CT findings of any thoracic injury or a significant thoracic injury as well as the decision to obtain a thoracic CT were determined using logistic regression. RESULTS: Of 425 patients, 40% patients had a significant thoracic injury, 49% had nonsignificant thoracic injury, and 11% had no thoracic injury at all. Presence of hydrothorax and/or pneumothorax on CXR significantly increased the likelihood of significant chest injury visualized by CT (adjusted odds ratio 10.8; 95% confidence interval, 6.5-18), as did the presence of isolated subcutaneous emphysema (adjusted odds ratio, 19.8; 95% confidence interval, 2.3-168). Although a normal CXR finding was not statistically associated with a reduced risk of significant thoracic injury, 8 of the 9 cases with normal CXR findings and significant injuries involved occult pneumothoraces or hemothoraces not requiring intervention. Converse to features suggesting increased risk of significant injury, the decision to obtain a thoracic CT was only associated with later period in the study and obtaining a CT scan of another body region. CONCLUSION: CXR can be used to screen for significant thoracic injuries and direct the selective use of thoracic CT in pediatric BTT. Prospective studies are needed to validate these findings and develop guidelines that include CXR to define indications for thoracic CT in pediatric BTT. LEVEL OF EVIDENCE: Prognostic study, level III.

Insertion/deletion polymorphisms in the ΔNp63 promoter are a risk factor for bladder exstrophy epispadias complex.

Bladder exstrophy epispadias complex (BEEC) is a severe congenital anomaly; however, the genetic and molecular mechanisms underlying the formation of BEEC remain unclear. TP63, a member of TP53 tumor suppressor gene family, is expressed in bladder urothelium and skin over the external genitalia during mammalian development. It plays a role in bladder development. We have previously shown that p63(-/-) mouse embryos developed a bladder exstrophy phenotype identical to human BEEC. We hypothesised that TP63 is involved in human BEEC pathogenesis. RNA was extracted from BEEC foreskin specimens and, as in mice, ΔNp63 was the predominant p63 isoform. ΔNp63 expression in the foreskin and bladder epithelium of BEEC patients was reduced. DNA was sequenced from 163 BEEC patients and 285 ethnicity-matched controls. No exon mutations were detected. Sequencing of the ΔNp63 promoter showed 7 single nucleotide polymorphisms and 4 insertion/deletion (indel) polymorphisms. Indel polymorphisms were associated with an increased risk of BEEC. Significantly the sites of indel polymorphisms differed between Caucasian and non-Caucasian populations. A 12-base-pair deletion was associated with an increased risk with only Caucasian patients (p = 0.0052 Odds Ratio (OR) = 18.33), whereas a 4-base-pair insertion was only associated with non-Caucasian patients (p = 0.0259 OR = 4.583). We found a consistent and statistically significant reduction in transcriptional efficiencies of the promoter sequences containing indel polymorphisms in luciferase assays. These findings suggest that indel polymorphisms of the ΔNp63 promoter lead to a reduction in p63 expression, which could lead to BEEC.