Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience.

BACKGROUND: We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment. METHODS: We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay. RESULTS: A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US. CONCLUSIONS: Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.

Does Multisystem Inflammatory Syndrome Only Mimic Acute Appendicitis in Children or Can It Coexist: When Should We Suspect MIS-C?

Background and Objectives: Acute abdominal pain in children has been noticed to be a primary reason to seek medical attention in multisystem inflammatory disorder (MIS-C), which can prevail separately or together with acute appendicitis. Our aim was to distinguish regular appendicitis cases from MIS-C and to suggest the best clinical and laboratory criteria for it. Materials and methods: Cases of patients, admitted to the Pediatric Surgery Department over a six-month period in 2021, were retrospectively analyzed. Confirmed MIS-C or acute appendicitis cases were selected. MIS-C cases were either separate/with no found inflammation in the appendix or together with acute appendicitis. Acute appendicitis cases were either regular cases or with a positive COVID-19 test. Four groups were formed and compared: A-acute appendicitis, B-MIS-C with acute appendicitis, C-MIS-C only and D-acute appendicitis with COVID-19. Results: A total of 76 cases were overall analyzed: A-36, B-6, C-29 and D-5. The most significant differences were found in duration of disease A­1.4 days, B­4.5 days, C­4 days, D­4 days (p < 0.0001), C reactive protein (CRP) values A-19.3 mg/L B-112.5 m/L, C-143.8 mg/L and D-141 mg/L (p < 0.0001), presence of febrile fever A-13.9%, B-66.7%, C-96.6% and D-40% (p < 0.0001) and other system involvement: A 0%, B 100%, C 100% and D 20%. A combination of these factors was entered into a ROC curve and was found to have a possibility to predict MIS-C in our analyzed cases (with or without acute appendicitis) with an AUC = 0.983, p < 0.0001, sensitivity of 94.3% and specificity of 92.7% when at least three criteria were met. Conclusions: MIS-C could be suspected even when clinical data and performed tests suggest acute appendicitis especially when at least three out of four signs are present: CRP > 55.8 mg, symptoms last 3 days or longer, febrile fever is present, and any kind of other system involvement is noticed, especially with a known prior recent COVID-19 contact, infection or a positive COVID-19 antibody IgG test.

Challenging diagnosis of abdominal tuberculosis in children: case report.

Tuberculosis (TB) remains a significant cause of morbidity and mortality in the modern world. Abdominal TB is a rare form of extrapulmonary TB that has been found to affect children without comorbidities in particular, although exact numbers are unavailable because of lack of data and its rarity. The diagnosis of abdominal TB remains a challenge because of its unspecific clinical features and unclear recommendations regarding the best diagnostic tools. We report 4 cases of children with abdominal TB diagnosed at The Hospital of Lithuanian University of Health Sciences Kaunas clinics from 2008 to 2018 at the Department of Paediatric Surgery. All these cases are exceptional. The final diagnosis of abdominal TB was confirmed only after diagnostic laparoscopy and biopsy. Moreover, we suggest that QuantiFERON test and ascitic fluid analysis with serum ascites albumin gradient and adenosine deaminase tests should be performed before more invasive interventions. Laparoscopy with biopsy should be performed only in unclear cases.

Did the COVID-19 Pandemic Prolong the Time Till Diagnosis and Worsen Outcomes for Children with Acute Appendicitis?

Background and Objectives: Our aim was to see if the COVID-19 pandemic led to an increase of time until diagnosis, operation, and time spent in Emergency room (ER), and if it resulted in more cases of complicated appendicitis and complication rates in children. Materials and Methods: We conducted a retrospective analysis of patients admitted to the Pediatric Surgery Department with acute appendicitis during a 4-month period of the first COVID-19 pandemic and compared it to the previous year data-the same 4-month period in 2019. Results: During the pandemic, the time spent in the ER until arriving at the department increased significantly 2.85 vs. 0.98 h p < 0.001, and the time spent in the department until the operation 5.31 vs. 2.66 h, p = 0.03. However, the time from the beginning of symptoms till ER, operation time and the length of stay at the hospital, as well as the overall time until operation did not differ and did not result in an increase of complicated appendicitis cases or postoperative complications. Conclusions: The COVID-19-implemented quarantine led to an increase of the time from the emergency room to the operating room by 4 h. This delay did not result in a higher rate of complicated appendicitis and complication rates, allowing for surgery to be postponed to daytime hours if needed.

Epigenetic Regulation of APAF-1 Through DNA Methylation in Pancreatic Cancer.

BACKGROUND/AIM: Apoptotic peptidase activating factor 1 (APAF-1) is essential regulator of apoptosis and inactivation by DNA methylation is common event in numerous cancer types. We investigated the regulation of APAF-1 through DNA methylation in pancreatic cancer. MATERIALS AND METHODS: Datasets from 44 patients after pancreatoduodenectomy and the pancreatic adenocarcinoma (PDAC) cell lines Capan-2 and MIA PaCa-2 treated with decitabine were analyzed by RT-PCR, immunoblotting, methylation-specific PCR analysis, apoptosis and viability assays to identify effects of APAF-1 regulation. RESULTS: APAF-1 mRNA and protein levels were significantly down-regulated, and APAF-1 methylation status was associated with perineural invasion in PDAC. Decitabine inhibited cell viability and increased apoptosis rates, however failed to restore APAF-1 mRNA and protein levels in cells. CONCLUSION: APAF-1 gene hypermethylation may contribute to the progression of PDAC through perineural invasion. Decitabine could sensitize pancreatic cancer cells to apoptosis and growth retardation, however, not directly through the APAF-1 demethylation process.

Human antigen R mediated post-transcriptional regulation of inhibitors of apoptosis proteins in pancreatic cancer.

AIM: To determine the association of human antigen R (HuR) and inhibitors of apoptosis proteins (IAP1, IAP2) and prognosis in pancreatic cancer. METHODS: Protein and mRNA expression levels of IAP1, IAP2 and HuR in pancreatic ductal adenocarcinoma (PDAC) were compared with normal pancreatic tissue. The correlations among IAP1/IAP2 and HuR as well as their respective correlations with clinicopathological parameters were analyzed. The Kaplan-Meier method and log-rank tests were used for survival analysis. Immunoprecipitation assay was performed to demonstrate HuR binding to IAP1, IAP2 mRNA. PANC1 cells were transfected with either anti-HuR siRNA or control siRNA for 72 h and quantitative reverse transcription polymerase chain reaction (RT-PCR), western blot analysis was carried out. RESULTS: RT-PCR analysis revealed that HuR, IAP1, IAP2 mRNA expression were accordingly 3.3-fold, 5.5-fold and 8.4 higher in the PDAC when compared to normal pancreas (P < 0.05). Expression of IAP1 was positively strongly correlated with HuR expression (P < 0.05, r = 0.783). Western blot analysis confirmed RT-PCR results. High IAP1 expression, tumor resection status, T stage, lymph-node metastases, tumor differentiation grade, perineural and lymphatic invasion were identified as significant factors for shorter survival in PDAC patients (P < 0.05). Immunohistological analysis showed that HuR was mainly expressed in the ductal cancer cell's nucleus and less so in cytoplasm. RNA immunoprecipitation analysis confirmed IAP1 and IAP2 post-transcriptional regulation by HuR protein. Following siHuR transfection, IAP1 mRNA and protein levels were decreased, however IAP2 expression levels were increased. CONCLUSION: HuR mediated overexpression of IAP1 significantly correlates with poor outcomes and early progression of pancreatic cancer. Further studies are needed to assess the underlying mechanisms.