Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis.

BACKGROUND: Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES: The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA: We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS: We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS: We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS: MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

Using the faecal immunochemical test in patients with rectal bleeding: evidence from the NICE FIT study.

AIM: The aim of this work was to investigate whether the faecal immunochemical test (FIT) could safely rule out colorectal cancer (CRC) in patients with rectal bleeding (RB). METHOD: This was a multicentre, double-blinded diagnostic accuracy study in 50 National Health Service hospitals. Patients referred from primary care with suspected CRC on an urgent 2-week-wait pathway were asked to perform a FIT prior to colonoscopy. The primary outcome measure was the sensitivity of the FIT for CRC in patients with RB versus nonrectal bleeding symptoms (NRB). The secondary outcome measures included the diagnostic accuracy of the FIT for CRC and other serious bowel disease. RESULTS: Of 9822 patients included in the study, 3143 (32.0%) were referred with RB. CRC was present in 4.7% of patients with RB versus 2.7% of patients with NRB (p < 0.05). Faecal haemoglobin (f-Hb) was detectable (>2 µg/g) in 44.1% of patients with RB and 33.9% with NRB (p < 0.05). In RB patients, CRC was present in 10.4% when f-Hb was >2 µg/g compared with 0.1% when f-Hb was not detected. Flexible sigmoidoscopy in this group would further reduce the risk of CRC to 0.03%. The sensitivity of the FIT for CRC in RB versus NRB groups was 98.6% (95% CI 95.2%-99.8%) vs 95.6% (91.5%-98.1%) for f-Hb >2 µg/g and 96.6% (92.2%-98.9%) vs 86.3 (80.4%-90.9%) for f-Hb >10 µg/g. CONCLUSION: Faecal haemoglobin is not always detectable in patients with RB; 56% of patients had undetectable f-Hb (<2 µg/g) and CRC was present in 0.1%. The high sensitivity of the FIT can be used to rule out CRC in patients with RB and triage them more appropriately for investigation.

Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis.

Background: Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Methods: Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Results: Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Conclusion: Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.

Six weeks' notice of the on-call roster: fact or fantasy? An audit study.

INTRODUCTION:: Work-life balance is directly linked to morale, job satisfaction and staff retention - all of which are linked to high quality patient care. Receiving the duty roster in advance is the first step towards achieving any work-life balance, but anecdotally doctors frequently receive very little notice of this. This audit assessed NHS trusts' compliance with the Code of Practice, with specific reference to advance notification of duty rosters. METHOD:: The duty roster should be made available 6 weeks before commencement of post. The initial audit comprised a survey sent to all London surgical CT1s starting in October 2016. The interventions introduced following this were creation of a shared spreadsheet containing roster coordinator contact details, reminder emails sent to roster coordinators and distribution of results to NHS Improvement. A repeat survey was sent to all London surgical CT1s and CT2s starting in October 2017. RESULTS:: In the initial audit 48/88 (55%) responded, of whom 4/48 (8%) received their duty roster in accordance with the standard and 9/48 (19%) did not receive the roster at all before starting. A total of 40/48 (83%) of trainees had to make specific contact with their future NHS trust in order to obtain their roster. In this initial audit 12/48 (25%) of trainees were satisfied or very satisfied with the amount of notice given. In the reaudit 133/178 (75%) responded, of whom 23/133 (17%) had received their roster in accordance with the standard and 25/133 (19%) did not receive the roster at all before starting. A total of 97/133 (73%) of trainees had to make specific contact with their future NHS trust in order to obtain their roster. In the reaudit 56/133 (42%) of trainees were satisfied or very satisfied with the amount of notice given. CONCLUSIONS:: This closed loop audit led to a doubling in the proportion of trainees receiving their rosters in accordance with the standard, and this was associated with an increase in trainee satisfaction levels. However, adherence to the standard remained low in both phases of the audit, and a significant proportion of trainees continue to commence jobs without any knowledge of their on-call roster. A range of measures is proposed to address this.

Gastric necrosis and perforation in a patient with Asperger's syndrome.

Acute gastric necrosis is a very rare but potentially fatal condition which has been reported in patients with abnormal eating behaviours.We describe the case of a 24-year-old female with a background of Asperger's syndrome, who presented with abdominal pain and gross distension. She underwent an emergency exploratory laparotomy and was found to have a massively distended, necrotic stomach. A total gastrectomy was performed with interval reconstruction planned. This case reports the surgical management of a rarely seen condition and highlights the importance of recognising gastric necrosis and its causes, which include patients with abnormal eating behaviours, the majority of whom are young females. This is the first report highlighting gastric necrosis in a patient with Asperger's syndrome and coincides with a growing recognition of the association between eating disorders and the autistic spectrum. It is also a rare example of patient survival following total gastric necrosis with perforation.

Bacterial contamination of fabric and metal-bead identity card lanyards: a cross-sectional study.

In healthcare, fabric or metal-bead lanyards are universally used for carrying identity cards. However there is little information on microbial contamination with potential pathogens that may readily re-contaminate disinfected hands. We examined 108 lanyards from hospital staff. Most grew skin flora but 7/108 (6%) had potentially pathogenic bacteria: four grew methicillin-susceptible Staphylococcus aureus, and four grew probable fecal flora: 3 Clostridium perfringens and 1 Clostridium bifermentans (one lanyard grew both S. aureus and C. bifermentans). Unused (control) lanyards had little or no such contamination. The median duration of lanyard wear was 12 months (interquartile range 3-36 months). 17/108 (16%) of the lanyards had reportedly undergone decontamination including wiping with alcohol, chlorhexidine or chlorine dioxide; and washing with soap and water or by washing machine. Metal-bead lanyards had significantly lower median bacterial counts than those from fabric lanyards (1 vs. 4 CFU/cm(2); Mann-Whitney U=300.5; P<0.001). 12/32 (38%) of the metal-bead lanyards grew no bacteria, compared with 2/76 (3%) of fabric lanyards. We recommend that an effective decontamination regimen be instituted by those who use fabric lanyards, or that fabric lanyards be discarded altogether in preference for metal-bead lanyards or clip-on identity cards.