Factors Contributing to Nonvisualization of the Appendix on Ultrasound in Children With Suspected Appendicitis.

OBJECTIVE: This study aimed to identify the patient characteristics, history factors, physical examination findings, and sonographic findings, which contribute to a higher risk of the appendix not being visualized on ultrasound evaluation (ie, nondiagnostic or equivocal study) in patients being evaluated for appendicitis. Secondarily, this study assessed the utility of an equivocal ultrasound, specifically in the ability to predict the absence of appendicitis. METHODS: A retrospective case review was performed, of children (age, 0-18 years) presenting to a pediatric emergency department with clinical suspicion for appendicitis, who underwent sonographic studies during the 12-month study period. RESULTS: Five hundred forty-three cases were reviewed, of which 75 (14%) were diagnosed with appendicitis. The sensitivity of ultrasound diagnosis of appendicitis was 62.7% and specificity was 79.1%. The appendix was not visualized in 398 (73%) cases. Of the cases where the appendix was not visualized, 370 did not have appendicitis (negative predictive value, 93%). In cases where the appendix was not visualized and the white blood cell count was less than 10,000, the negative predictive value rose to 97%. The patient's age (odds ratio [OR], 1.049), weight (OR, 1.015), presence of appendicolith (OR, 0.426), presence of right lower quadrant fat stranding on sonography (OR, 0.081), and presence of hyperemia on sonography (OR, 0.094) were found to be significant in affecting the visualization of the appendix on ultrasound. CONCLUSIONS: Increasing patient's age and weight leads to increased likelihood that the appendix will not be visualized on ultrasound, whereas the presence of an appendicolith, right lower quadrant fat stranding or hyperemia will increase the likelihood of visualization. The sensitivity and specificity of ultrasound for the diagnosis of appendicitis are moderate but the negative predictive value of an equivocal study is high. Clinicians can use supporting clinical examination and laboratory findings, in conjunction with a nondiagnostic ultrasound evaluation of the appendix to exclude the diagnosis of appendicitis, without the need for further imaging.

Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation.

Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodysplastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, inpatient healthcare utilization of this population is unknown. Here we describe survival, intensity of healthcare utilization, and characteristics associated with high resource use at the end of life (EOL). Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We compared the distribution of demographic and clinical characteristics of patients as well as healthcare utilization over 2 years postrelapse and at EOL by postrelapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity by summing the presence of any of the following criteria: death in the hospital, use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense healthcare use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, postrelapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. One hundred fifty-four patients were included; median age at relapse was 56 years (interquartile range [IQR], 39 to 63), 55% were men, 79% had AL, and median time from HCT to relapse was 6 months (IQR, 3 to 10). After relapse, 28% received supportive care only, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion, second HCT, or donor lymphocyte infusion plus second HCT). With the exception of time until relapse and Karnofsky Performance Status, baseline characteristics (gender, age, race, graft-versus-host disease, year of treatment) did not significantly differ by postrelapse treatment group. One hundred thirty-six patients (88%) died within 2 years of relapse; survival differed significantly by postrelapse treatment group, with those receiving disease-directed treatment showing lower risk of death. Healthcare use in AL/MDS patients after post-HCT relapse was high overall, with 44% visiting the emergency department at least once (22% at least 2 times), 93% hospitalized (55% at least 2 times, 16% at least 5 times), and 38% using the intensive care unit (median length of stay 5, days; IQR, 3 to 10). Use was high even among those receiving only supportive care. For those patients who died, the mean intensity score for EOL healthcare use was 1.8 (standard deviation, 1.8). Most patients (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, an increase in age (estimate -.03 (95% CI, -.06 to -.003) and having AL versus MDS were significantly associated with a decreased EOL healthcare intensity score; no other variables were associated with intensity of EOL healthcare use. Healthcare utilization after post-HCT relapse is associated with receipt of disease-directed therapy but remains high across all groups despite known poor prognosis. Interventions are needed to minimize nonbeneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.

Opportunities for Palliative Care in Patients With Burn Injury-A Systematic Review.

CONTEXT: Patients with significant burn injuries likely have palliative care needs. OBJECTIVES: We performed a systematic review of existing evidence concerning the palliative care needs of burn patients. METHODS: Through November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains. RESULTS: Our searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains-processes of care, psychologic symptoms, social aspects, and end of life-were addressed by studies but three domains-spiritual, cultural, or ethics-were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments. CONCLUSION: Most existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.

Postural responses exhibit multisensory dependencies with discordant visual and support surface motion.

The purpose of this study was to identify how the postural system weights coincident yet discordant disturbances of the visual and proprioceptive/vestibular systems. Eleven healthy subjects (25-38 yrs) received either fore-aft translations of an immersive, wide field-of-view visual environment (0.1 Hz, +/- 3.7 m/sec), or anterior-posterior translations of the support surface (0.25 Hz, +/- 15 cm/sec), or both concurrently. Kinematics of the head, trunk, and shank were collected with an Optotrak system and angular motion of each segment plotted across time. With only support surface translation, segmental responses were small (1 degrees -2 degrees ) and mostly opposed the direction of sled translation. When only the visual scene was moving, segmental responses increased as the trial progressed. When the inputs were presented coincidentally, response amplitudes were large even at the onset of the trial. Mean RMS values across subjects were significantly greater with combined stimuli than for either stimulus presented alone and areas under the power curve across subjects were significantly increased at the frequency of the visual input when both inputs were presented. Thus, intra-modality dependencies were observed, such that responses to the visual inputs significantly increased and responses to the somatosensory signals reflected the stimulus amplitude only when the two inputs were combined. We believe it unlikely that the role of any single pathway contributing to postural control can be accurately characterized in a static environment if the function of that pathway is context dependent.