Pancreatic ductal adenocarcinoma: exploring clinicopathological trends and racial disparities in a comprehensive U.S. population-based study.

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy about 50% of PDAC are metastatic at presentation. In this study, we evaluated PDAC demographics, annual trend analysis, racial disparities, survival rate, and the role of different treatment modalities in localized and metastatic disease. METHODS: A total of 144,824 cases of PDAC were obtained from the SEER database from 2000 to 2018. RESULTS: The median age was 69 years, with a slightly higher incidence in males (52%) and 80% of all cases were white. Among cases with available data, 43% were grade III tumors and 57% were metastatic. The most common site of metastasis was the liver (15.7%). The annual incidence has increased steadily from 2000 to 2018. The overall observed (OS) 5-year survival rate was 4.4% (95% CI 4.3-4.6%), and 5 years cause-specific survival (CSS) was 5% (95% CI 5.1-5.4%). The 5-year survival with multimodal therapy (chemotherapy, surgery, and radiation) was 22% (95% CI 20.5-22.8%). 5-year CSS for the blacks was lower at 4.7% (95% CI 4.2-5.1%) compared to the whites at 5.3% (95% CI 5.1-5.4%). Multivariate analysis found male gender and black race associated with worse prognosis. Kaplan-Meier survival analysis found multimodal therapy to have the best outcomes in all three stages. CONCLUSION: PDAC is an aggressive malignancy with male gender and black race are associated with a poor prognosis. Surgery with chemoradiation was associated with the best overall survival. With steadily increasing rates of PDAC, improved treatment modalities are paramount to improving survival in these patients.

Post-transplant Lymphoproliferative Disorder (PTLD) in the US Population: Demographics, Treatment Characteristics, and Survival Analysis.

BACKGROUND: Post-transplant lymphoproliferative disorder (PTLD) is a lymphoplasmacytic proliferative disorder in the setting of hematopoietic stem cells and solid organ transplants. PTLD is divided into nondestructive, polymorphic, monomorphic, and classical Hodgkin lymphoma subtypes. Most cases of PTLDs are Epstein-Barr virus (EBV) related (two third of the cases), and most are of B cell (80-85%) origin. The polymorphic PTLD subtype can be locally destructive and show malignant features. Treatment for PTLD includes a reduction in immunosuppression, surgery, cytotoxic chemotherapy and/or immunotherapy, anti-viral agents, and/or radiation. The aim of this study was to examine the demographic factors and treatment modalities that influence survival in patients with polymorphic PTLD. METHODS: About 332 cases of polymorphic PTLD were identified from 2000 to 2018 using the Surveillance, Epidemiology, and End Results (SEER) database. RESULTS: The median age of the patients was found to be 44 years. The most common age groups were between the ages of 1-19 years (n=100. 30.1%) and 60-69 years (n=70. 21.1%). The majority of cases in this cohort underwent systemic (cytotoxic chemo and/or immuno) therapy only (n=137, 41.3%), while 129 (38.9%) cases did not undergo any treatment. The overall five-year observed survival was 54.6% (95% confidence interval (CI), 51.1 - 58.1). One-year and five-year survival with systemic therapy was 63.8% (95% CI, 59.6 - 68.0) and 52.5% (95% CI, 47.7 - 57.3), respectively. The one-year and five-year survival with surgery was 87.3% (95% CI, 81.2-93.4) and 60.8% (95% CI., 42.2 - 79.4), respectively. The one-year and five-year without therapy were 67.6% (95% CI, 63.2-72.0) and 49.6% (95% CI, 43.5-55.7), respectively. Univariate analysis revealed that surgery alone (hazard ratio (HR) 0.386 (0.170-0.879), p = 0.023) was a positive predictor of survival. Race and sex were not predictors of survival, although age >55 years was a negative predictor for survival (HR 1.128 (1.139-1.346), p <0.001). CONCLUSION: Polymorphic PTLD is a destructive complication of organ transplantation that is usually associated with EBV positivity. We found that it most often presents in the pediatric age group, and its occurrence in those older than 55 years was associated with a worse prognosis. Treatment with surgery alone is associated with improved outcomes and should be considered in addition to a reduction in immunosuppression in cases of polymorphic PTLD.

Pancreatic Diffuse Large B-cell Lymphoma in the US Population.

BACKGROUND: Pancreatic lymphomas (PLs) represent <2% of all lymphomas and <0.5% of all pancreatic neoplasms. An accurate histologic diagnosis of PL is needed to predict prognosis and adequately treat the patient. This study aims to investigate the demographic, clinical, and pathological factors affecting the prognosis and survival of pancreatic diffuse large B-cell lymphoma (DLBCL). METHODS: Demographic and clinical data from 493 cases of DLBCL of the pancreas were identified between 2000 and 2018 using the Surveillance, Epidemiology, and End Results (SEER) database. RESULTS: The most common age group was between the ages of 70 and 79 years (27.0%). While 44% of cases involved distant sites (a proxy for secondary pancreatic DLBCL), regional and localized involvement was seen in 33%, with the most common cause of death being a primary pancreatic DLBCL. Most patients (71%) received only chemotherapy (systemic therapy). The overall five-year observed survival was 46% (95% CI, 43.5-48.3). The one-year and five-year survival with chemotherapy only was 68% (95% CI, 65.3-70.3) and 48% (95% CI, 44.7-50.5), respectively. The one-year and five-year survival with surgery and chemotherapy was 96% (95% CI, 91.3-99.9) and 80% (95% CI, 71.4-89.2), respectively. Surgery with chemotherapy (HR: 0.397 (95% CI, 0.197-0.803), p = 0.010) were both positive predictors in survival prognosis. Multivariable analysis identified age >55 years (HR: 2.475 (95% CI, 1.770-3.461), p < 0.001), distant stage (HR: 6.894 (95% CI, 4.121-11.535), p < 0.001), and undergoing no surgery (HR: 2.610 (95% CI, 1.307-5.215), p = 0.007) as negative predictors for survival. CONCLUSION: PLs are rare malignant pancreatic neoplasms with DLBCL being the most common histological subtype. An accurate and timely diagnosis of pancreatic DLBCL is necessary to implement effective treatments and reduce mortality. Systemic therapy (chemotherapy) with or without surgical therapy improved survival. Increased age and regional and distant spread negatively impacted survival.

Papillary Renal Cell Carcinoma: Demographics, Survival Analysis, Racial Disparities, and Genomic Landscape.

Papillary renal cell carcinoma (PRCC) is the second most common histological subtype of renal cell cancer. This research aims to present a large database study highlighting the demographic, clinical, and pathological factors, racial disparities, prognosis, and survival of PRCC. The clinical and demographic data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database, and molecular data was cured from the Catalogue Of Somatic Mutations in Cancer (COSMIC) database. PRCC had a median age of diagnosis at 64 years, with a higher incidence in men (77%), and Whites (68%). 70.3% of cases were Grades I-IV (13, 53, 31, and 3%, respectively). In patients with known data, 85% were localized to the kidney, and 84% of cases were 7 cm in size. No metastasis occurred in 97% of the known data. The most common treatment offered was surgical resection (9%). The 5-year overall survival was 79%, with patients undergoing surgery having a 90.6% 5-year survival. Multivariable analysis revealed age > 60 years, Black race, poor histologic differentiation, distant metastases, and tumor size > 10 cm as independent risk factors for mortality. The most common mutations identified from the COSMIC database were MET, KMT2D, KMT2C, ARID1A, and SPEN. PRCC affects male individuals in the sixth decade of life. Increased age, Black race, distant metastases, and tumors > 10 cm are associated with a worse prognosis. Surgical resection offers a favorable survival outcome. Next-generation sequencing (NGS) could identify potentially targetable alterations and future personalized therapeutic approaches.

Gastrointestinal Stromal Tumors (GIST): A Population-Based Study Using the SEER Database, including Management and Recent Advances in Targeted Therapy.

Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal (GI) system. Most GISTs originate from the interstitial cells of Cajal (ICC), the pacemaker cell situated between the circular and longitudinal layers of the muscularis propria along the GI tract. In this population-based study using the SEER database, we sought to identify demographic, clinical, and pathologic factors that affect the prognosis and survival of patients with this neoplasm. Molecular genetic advances, current management guidelines, and advances in targeted therapy are discussed. Methods: Demographic and clinical data from GIST patients were retrieved from the SEER research plus database for the period 2000−2018. Statistical analysis was performed with IBM SPSS® v20.2 software using the Chi-square test, paired t-test, multivariate analysis, and Kaplan−Meier functions. Results: A total of 10,833 patients with GIST were identified. Most patients were between 60−74 years of age: 40%, Caucasian: 68%, and the male to female ratio was 1.1:1. The most common primary tumor sites were stomach: 63%, small intestine: 30%, rectum: 3%, and esophagus: 0.7%. When reported, the grade of differentiation was well: 38%, moderately: 32%, undifferentiated: 19%, poorly: 12%. The size of most tumors ranged between 6−10 cm: 36% and they were treated by surgical intervention: 82% and/or chemotherapy/targeted therapy: 39%. The stage was localized: 66%, advanced: 19%, and regional: 15%. The 5-year survival was 74% (95% confidence interval (95% CI) = 72.6−74.7), and the 5-year cause-specific survival 82% (95% CI = 80.7−82.6). The 5-year cause-specific survival by treatment included surgery at 86% (95% CI = 85.4−87.3), chemotherapy/targeted therapy with or without surgery at 77% (95% CI = 75.7−78.9), and radiation at 75% (95% CI = 74.5−80). On multivariable analysis tumor size > 5 cm, poorly and undifferentiated grade, age > 60, and distant metastases at presentation were associated with worse overall survival. Conclusion: GISTs comprise 1−2% of malignancies of the GI tract, usually affect male Caucasians between the ages of 60 and 74 years, most tumors occur in the stomach and small intestine, and are usually >5 cm, but still localized, at the time of diagnosis. Most tumors receive multimodality surgical and chemotherapy/targeted therapy treatment, with a 5-year overall survival of 74% and cause-specific survival of 82%. GIST patients would benefit from enrollment in large clinical trials to establish better therapy guidelines for unresectable, treatment-refractory, and recurrent tumors.

Letter to the Editor: Case of Appendix Incarcerated in an Umbilical Hernia.

Umbilical hernias and acute appendicitis are common general surgical problems, but an appendix incarcerated in an umbilical hernia is quite rare. We present a case of such and briefly review the available literature on the topic. We conclude that future authors should include a minimum set of information in such case reports or case series so that readers can gain as much as possible from our collective experience with this uncommon problem.

Socially Responsible Surgery: Building Recognition and Coalition.

IMPORTANCE: Socially responsible surgery (SRS) integrates surgery and public health, providing a framework for research, advocacy, education, and clinical practice to address the social barriers of health that decrease surgical access and worsen surgical outcomes in underserved patient populations. These patients face disparities in both health and in health care, which can be effectively addressed by surgeons in collaboration with allied health professionals. OBJECTIVE: We reviewed the current state of surgical access and outcomes of underserved populations in American rural communities, American urban communities, and in low- and middle-income countries. EVIDENCE REVIEW: We searched PubMed using standardized search terms and reviewed the reference lists of highly relevant articles. We reviewed the reports of two recent global surgery commissions. CONCLUSION: There is an opportunity for scholarship in rural surgery, urban surgery, and global surgery to be unified under the concept of SRS. The burden of surgical disease and the challenges to management demonstrate that achieving optimal health outcomes requires more than excellent perioperative care. Surgeons can and should regularly address the social determinants of health experienced by their patients. Formalized research and training opportunities are needed to meet the growing enthusiasm among surgeons and trainees to develop their practice as socially responsible surgeons.

Diagnosis and Treatment of the Extraesophageal Manifestations of Gastroesophageal Reflux Disease.

OBJECTIVE: To review the clinical presentation, diagnosis, and treatment options available for management of extraesophageal manifestations of gastroesophageal reflux disease (GERD) and to compare the most recent technological advances to the existing guidelines. SUMMARY BACKGROUND DATA: Extraesophageal manifestations of GERD include cough, laryngopharyngeal reflux (LPR), and asthma. Recent advances in diagnostic modalities may have outpaced the existing diagnostic and therapeutic clinical guidelines. METHODS: We searched the MEDLINE, Cochrane, and Embase databases for articles pertaining to the presentation, diagnosis, and treatment of extraesophageal manifestations of reflux, specifically cough due to reflux, LPR, and asthma due to reflux. Search terms applied to 3 thematic topics: diagnosis, medical treatment, and surgical treatment. We had searched the bibliographies of included studies, yielding a total of 271 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines. RESULTS: One hundred twenty-eight articles met criteria for analysis. Our findings show that the diagnosis of cough, LPR, or asthma due to gastroesophageal reflux is difficult, as no criterion standard test exits. Also, patients often present without heartburn or regurgitation typical of GERD. Combined multichannel intraluminal impedance, the pH (MII-pH) monitoring system, and the symptom association probability (SAP) test might distinguish extraesophageal manifestations of reflux from idiopathic chronic cough, laryngitis due to other causes, and atopic asthma. In addition, extraesophageal manifestations of reflux are most effectively diagnosed with a stepwise approach incorporating empiric treatment and antisecretory therapy, combined MII-pH monitoring, and surgical intervention in few selected cases. CONCLUSIONS: Recent studies demonstrate the potential diagnostic role of MII-pH monitoring. Surgical intervention provides resolution of extraesophageal symptoms less reliably than typical symptoms when the patient has GERD.

Quantifying the Burden of Interhospital Cost Variation in Pediatric Surgery: Implications for the Prioritization of Comparative Effectiveness Research.

Importance: Practice variation is believed to be a driver of excess health care spending, although few objective data exist to guide the prioritization of comparative effectiveness research (CER) in pediatric surgery. Objective: To identify high-priority general pediatric surgical procedures for CER on the basis of the following 2 complementary measures: the magnitude of interhospital cost variation as a surrogate for the need for and potential effect of CER at the patient level and the cumulative fiscal burden of this cost variation when considering the case volume from all hospitals as a surrogate for public health relevance. Design, Setting, and Participants: This was a cohort study of patients undergoing 1 of the 30 most costly pediatric surgical operations at 45 children's hospitals between January 1, 2014, and September 30, 2015. Cost data were extracted from the Pediatric Health Information System database and adjusted for differences in unit-based costing at the hospital level and for differences in case mix and disease severity at the patient level. Main Outcomes and Measures: First, the width of the interquartile range (WIQR) of the adjusted procedure-specific median cost across hospitals. Second, the procedure-specific cost variation burden, which was calculated as the aggregate sum of absolute cost differences between the overall adjusted median cost derived from all patients treated at all hospitals and the adjusted cost of each individual patient treated at all hospitals. Results: A total of 92 535 encounters were analyzed. The median number of encounters per hospital was 2011 (interquartile range [IQR], 1224-2619), and the median number of encounters per procedure was 610 (IQR, 442-2610). In the final cohort, 66.9% (n = 61 933) of the patients were male, and the median age was 7 years (IQR, 1.9-12.3 years). Cost variation at the hospital level was greatest for gastroschisis (WIQR, $48 471; median, $111 566 [IQR, $91 195-$139 936]), congenital diaphragmatic hernia (WIQR, $43 948; median, $154 730 [IQR, $129 764-$173 712]), tracheoesophageal fistula/esophageal atresia (WIQR, $39 206; median, $105 259 [IQR, $87 335-$126 541]), and total colectomy for ulcerative colitis (WIQR, $24 497; median, $34 910 [IQR, $28 815-$53 312]). The following 5 diagnoses accounted for 52.5% of the cumulative cost variation burden from all 30 conditions: uncomplicated appendicitis (18.0% [$66 205 117]), complicated appendicitis (14.1% [$51 702 402]), gastroschisis (9.5% [$34 940 331]), gastrostomy (5.8% [$21 227 436]), and small-intestinal atresia (5.1% [$18 840 546]). Neonatal cases contributed 3.6% of the case volume and accounted for 26.8% of the cumulative cost variation burden from all 30 conditions. Conclusions and Relevance: A small number of procedures account for most of the cost variation burden in pediatric surgery, with some demonstrating wide cost variation among hospitals. Gastroschisis and small-intestinal atresia may be particularly high-yield targets for multidisciplinary CER efforts, while the management of appendicitis and gastrostomy should be considered high-priority conditions among pediatric surgeons.

Beyond perforation: Influence of peritoneal contamination on clinical severity and resource utilization in children with perforated appendicitis.

PURPOSE: The purpose of the study was to explore the relationship between the degree of peritoneal contamination and postoperative resource utilization in children with complicated appendicitis. METHODS: Intraoperative findings were collected prospectively at a single children's hospital from 2012 to 2014. The degree of peritoneal contamination was categorized as either "localized" (confined to the right lower quadrant and pelvis) or "extensive" (extending to the liver). Imaging utilization, postoperative length of stay (pLOS), hospital cost, and readmission rates were compared between groups. RESULTS: Of 88 patients with complicated appendicitis, 38% had extensive contamination. Preoperative characteristics were similar between groups. Patients with extensive contamination had higher rates of postoperative imaging (58.8% vs 27.7%, P<0.01), a 50% longer median pLOS (6days [IQR 4-9] vs 4days [IQR 2-5], P=0.003), a 30% higher median hospital cost ($17,663 [IQR $12,564-$23,697] vs $13,516 [IQR $10,546-$16,686], P=0.004), and a nearly four-fold higher readmission rate (20.6% vs 5.6%, P=0.04) compared to children with localized contamination. CONCLUSION: Extensive peritoneal contamination is associated with significantly higher resource utilization compared to localized contamination in children with complicated appendicitis. These findings may have important severity-adjustment implications for reimbursement and readmission rate reporting for hospitals that serve populations where late presentation is common.

Rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the National Surgery Quality Improvement Program.

PURPOSE: The purpose of this study was to characterize the rates of surgical site infections (SSI) associated with colorectal procedures in children and the relative burden of these events within the scope of pediatric surgical practice. METHODS: The NSQIP-Pediatric Public Use File was queried for all pediatric surgery procedures captured from 50 hospitals during 2012-2013. Rates of incisional and deep organ/space SSIs (ISSI and OSI, respectively) were calculated for all procedures, and the relative burden of SSIs from the entire dataset attributable to colorectal procedures was determined. RESULTS: Colorectal procedures accounted for 2.5% (2872/114,395) of the NSQIP-P caseload and contributed 7.1% of the SSI burden. The SSI rate for all colorectal procedures was 5.9% (ISSI:3.2%; OSI:2.7%), and the highest rates were associated with total abdominal colectomy (11.4%) partial colectomy (8.3%), and colostomy closure (5.0%). Inflammatory bowel disease contributed the greatest relative burden of SSIs among colorectal diagnoses (24.9%; ISSI:22%; OSI:28.6%), followed by Hirschsprung's Disease (14.2%; ISSI:15.4%; OSI:12.8%) and anorectal malformations (12.4%; ISSI:17.6%; OSI:6.4%). CONCLUSION: Colorectal procedures are responsible for a disproportionate burden of SSIs within pediatric surgery. The rate and relative burden of SSIs are particularly high for colostomy closure, partial colectomy, and procedures for inflammatory bowel disease. Efforts to reduce SSI burden may be best focused on this cohort of children.

Diagnostic imaging practices for children with suspected appendicitis evaluated at definitive care hospitals and their associated referral centers.

PURPOSE: The purpose of this study was to compare rates of ultrasound (US) and computed tomography (CT) for suspected appendicitis at hospitals able to provide definitive surgical care with those from their associated referral hospitals. METHODS: A retrospective cohort study of children undergoing appendectomy using the Pediatric NSQIP Appendectomy Pilot Database (1/1/2013-8/31/2014) was performed. Imaging rates at the initial hospital of presentation were compared between groups after adjusting for differences in demographic characteristics. RESULTS: We identified 4859 patients from 28 definitive care hospitals, of which 35% underwent diagnostic imaging at a referral hospital prior to transfer (range: 20.3-70.4%). The overall odds of receiving a CT scan was 10.9-times greater (95% CI: 9.4-12.5) at referring hospitals compared to definitive care hospitals, and the odds were significantly higher for referral hospitals in 96% (27/28) of the geographic regions represented. The overall odds of an initial attempt at US prior to CT was 11.1 times greater (95% CI: 9.09-14.28), and the odds of receiving any ultrasound was 6.25-times greater (95% CI: 5.26-7.14) at definitive care hospitals compared to referral hospitals. CONCLUSIONS: Children initially evaluated for suspected appendicitis at referring hospitals are much more likely to receive a diagnostic CT, and those imaged with CT are much less likely to receive an US as the initial diagnostic test.

Contemporary practice among pediatric surgeons in the use of bowel preparation for elective colorectal surgery: A survey of the American Pediatric Surgical Association.

PURPOSE: The goal of this study was to characterize contemporary practice among pediatric surgeons in the use of mechanical bowel preparation (MBP) and oral antibiotics (OA) for elective colorectal surgery. METHODS: A survey of the American Pediatric Surgical Association membership was conducted to characterize variation in the use of MBP and OA for commonly performed elective colorectal procedures in children. RESULTS: Three-hundred thirteen members completed the survey. The most common approach used was MBP alone (31.1%), followed by diet modification only (26.8%), MBP combined with OA (19.6%), no preparation or dietary modification (12.2%), and OA alone (5.4%). The most common MBP used was a polyethylene glycol-based solution (92.6%), and the most common OA approach was neomycin combined with erythromycin (55.9%). Although MBP alone was the preferred approach among pediatric surgeons, the greatest relative change reported over time was in the adoption of dietary modifications only or no preparation at all. CONCLUSIONS: Significant variation exists in the use of bowel preparation among pediatric surgeons. Although use of MBP alone remains the preferred approach for most procedures, an increasing number of surgeons report abandoning this approach in favor of dietary modification alone or no preparation at all.

Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence?

PURPOSE: Despite rigorous data from adult literature demonstrating that oral antibiotics (OA) reduce infectious complications and mechanical bowel preparation (MBP) alone does not, MBP alone remains the preferred approach among pediatric surgeons. We aimed to explore the nature of this discrepancy through a survey of the American Pediatric Surgical Association membership. METHODS: Surgeons were queried for their choice of bowel preparation, factors influencing their practice, and their impression of the strength and relevance of the adult literature to pediatric practice. RESULTS: Surgeons who used MBP alone (31%) cited a reduction in stool burden and infectious complications as important factors, whereas surgeons choosing not to use OA (70%) reported a lack of benefit in reducing infectious complications as the primary reason. Although 53% of surgeons reported that evidence from adult literature was the most important influence, 73% of surgeons reported there was poor evidence supporting the use of OA (±MBP), and only 25% used a preparation supported by adult randomized data. CONCLUSIONS: Wide variation exists among pediatric surgeons in the perceived utility of MBP and OA. Although the majority of pediatric surgeons cited the adult literature as the strongest influence on their practice, this is not consistent with stated perceptions or practice.

Skin preparation before surgery: options and evidence.

BACKGROUND: Despite many advances in surgical asepsis, surgical site infection (SSI) remains a challenging and costly problem. Decontamination of the skin with an antiseptic agent is standard practice before any trans-cutaneous invasive procedure, but the antiseptic agent of choice to best reduce the risk of SSI remains controversial. METHODS: Review of relevant literature. RESULTS: Many randomized controlled trials (RCTs) have evaluated chlorhexidine-based and iodine-based preparation solutions, with and without an alcohol component. Most of these trials are underpowered to detect differences in SSI rates. The largest modern RCT showed that a chlorhexidine-isopropyl alcohol preparation reduced the risk of SSI substantially compared with a povidone-iodine preparation without alcohol in clean-contaminated surgery. Many smaller RCTs have shown that chlorhexidine-isopropyl alcohol is superior to povidone-iodine plus isopropyl alcohol or iodine povacrylex plus isopropyl alcohol in pre-operative skin decontamination; whether or not this translates into lower SSI rates is unknown. A mixed treatment comparison of 10 RCTs concluded that alcohol-based preparations have a 98% probability of reducing the risk of SSI more effectively than aqueous-based preparations. Non-randomized observational studies have generally found no difference in SSI rates among various skin antiseptic preparations. CONCLUSIONS: Alcohol-based agents are likely superior to aqueous agents. Chlorhexidine may decrease SSI rates compared with povidone-iodine, and chlorhexidine-isopropyl alcohol likely offers better skin decontamination before clean surgery than povidone-iodine plus isopropyl alcohol or iodine povacrylex plus isopropyl alcohol. The quality of the available data is moderate. Rigorous, well-powered RCTs with appropriate treatment comparisons are needed to establish the optimal and most cost-effective pre-operative skin preparation in various operations and wound classifications.

Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children.

BACKGROUND: The objective of this study was to examine the use of WBC count and polymorphonuclear leukocyte differential (PMN%) for improving the predictive value of ultrasound (US) in children with suspected appendicitis. STUDY DESIGN: We conducted a retrospective cohort study of children undergoing US for suspected appendicitis between January 1, 2010 and December 31, 2012 at a single children's hospital (n=845). Negative (NPV) and positive predictive values (PPV) for appendicitis were calculated for common constellations of US findings and compared with and without the use of laboratory thresholds (WBC>9×10(3)/µL and PMN%>65% for PPV; WBC≤9×10(3)/µL and PMN%≤65% for NPV). RESULTS: Fifty-one percent of US were considered "equivocal" (ie, appendix incompletely visualized, no primary or secondary signs, or presence of fluid only) and NPV increased significantly for this cohort using laboratory thresholds (41.9% vs 95.8%; p<0.001). Primary signs of appendicitis, without secondary signs, were documented in 18% of examinations, and the PPV associated with this cohort increased from 79.1% to 91.3% (p<0.001) using laboratory thresholds. Secondary signs with or without primary signs were documented in 24% of examinations, and laboratory thresholds improved the PPV in this cohort from 89.1% to 96.8% (p<0.001). Guidelines recommending against the use of CT for very high-risk and low-risk categories (NPV>95% and PPV>95%) on the basis of combined US and laboratory data could have reduced the number of CTs by 27.1% (101 of 373) during the study period. CONCLUSIONS: The incorporation of WBC count and PMN% can substantially improve the predictive value of US in the diagnosis of suspected appendicitis in children.

Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials.

BACKGROUND: Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate. METHODS: A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion. RESULTS: Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226). CONCLUSIONS: The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.

High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns.

BACKGROUND: Severe burn injuries increase patients' metabolic needs. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing. OBJECTIVES: To examine the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds). SEARCH METHODS: We searched the Cochrane Injuries Group Specialised Register (searched 28 Nov 2011), Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4), MEDLINE (Ovid) 1950 to Nov (Week 3) 2011, EMBASE (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Nov 2011), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Nov 2011), PubMed (Searched 28 Nov 2011). Online trials registers and conference proceedings were also searched to April 2010. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) comparing high-carbohydrate enteral feeds to high-fat enteral feeds for treatment of patients with 10% or greater total body surface area (TBSA) burns in the immediate post-burn period, with data for at least one of the pre-specified outcomes. DATA COLLECTION AND ANALYSIS: Two authors collected and analysed the following data: mortality, incidence of pneumonia and days on ventilator. Meta-analysis could only be performed for the outcomes mortality and incidence of pneumonia. A random-effects model was used for all comparisons. MAIN RESULTS: Two RCTs, reporting results from 93 patients, were included in this review. Patients given a high-carbohydrate feeding formula had an odds ratio (OR) of 0.12 (95% confidence interval (CI) 0.04 to 0.39) for developing pneumonia compared to patients given a high-fat enteral formula (P value = 0.0004). Patients given a high-carbohydrate formula had an OR of 0.36 (95% CI 0.11 to 1.15) for risk of death compared to patients given a high-fat enteral formula; this difference did not reach statistical significance (P value = 0.08). Risk of bias in these studies was assessed as high and moderate. AUTHORS' CONCLUSIONS: The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% TBSA burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias. Further research is needed in this area before strong conclusions can be drawn.