The Unacceptable Morbidity of Negative Laparoscopic Appendicectomy.

BACKGROUND: One of the most common acute conditions managed by general surgeons is acute appendicitis. Laparoscopic appendicectomy (LA) is the surgical technique used by many surgeons. The aims of this study were to define our unit's negative appendicectomy rate and compare the outcomes associated with removal of a normal appendix with those for acute appendicitis in patients having LA. METHODS: A single-centre retrospective case note review of patients undergoing LA for suspected acute appendicitis was performed. Patients were divided into positive and negative appendicectomy groups based on histology results. The positive group was subdivided into uncomplicated and complicated (perforated and/or gangrenous) appendicitis. Outcomes were compared between groups. RESULTS: There were 1413 patients who met inclusion criteria, 904 in the positive group and 509 in the negative group, an overall negative appendicectomy rate of 36.0%. Morbidity rates (6.3% vs. 6.9%; P = 0.48) and types of morbidity were the same for negative appendicectomy and uncomplicated appendicitis. There was no significant difference in complication severity (all P > 0.17) or length of stay (2.3 vs. 2.6 days; P = 0.06) between negative appendicectomy and uncomplicated appendicitis groups. Patients with complicated appendicitis had a significantly higher morbidity rate compared to negative and uncomplicated groups (20.1% vs. 6.3% and 20.1% vs. 6.9%; both P < 0.001). CONCLUSION: The morbidity of negative LA is the same as LA for uncomplicated appendicitis. The morbidity of LA for complicated appendicitis is significantly higher. The selection criteria for LA in our unit needs to be reviewed to address the high negative appendicectomy rate and avoid unnecessary surgery and its associated morbidity.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy.

BACKGROUND: Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA. METHODS: A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017. RESULTS: During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1 days vs. 10.1 and 9.0 days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0 days vs. 3.3 and 5.2 days, p <0.02). The morbidity and length of stay were similar. CONCLUSION: Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.

The Impact of the Project K Youth Development Program on Self-Efficacy: A Randomized Controlled Trial.

A key issue for youth development programs is whether the learning they provide is transferred to participants' daily lives. It is also important that they are effective for the diverse range of participants they attract. This study used a randomized controlled trial design to measure the impact of Project K, a New Zealand-based youth development program, on academic and social self-efficacy. Project K combines a 3-week wilderness adventure, a 10 day community service component, and 1 year of mentoring to promote positive growth in 14-15 year olds with low self-efficacy. At baseline, the evaluation included 600 Project K (46 % female) and 577 Control participants (48 % female) and revealed that Project K was effective in improving both social and academic self-efficacy from pre- to post-program with effects being sustained 1 year later. Parents' perceptions of changes in the participants' interpersonal skills supported these findings. Differential program effects were found across participant subgroups, particularly 1 year after program completion. The implications of these differences are discussed.

Engagement and Mentor Support as Drivers of Social Development in the Project K Youth Development Program.

Youth development programs can achieve positive social outcomes, however studies comparing the influence of different program components are rare. Structural equation modeling of longitudinal, multilevel data (N = 327) from Project K, a multi-component youth development program, assessed how experiences of engagement or support in each component affected social outcomes. Participants reported significant gains in social self-efficacy and sense of community after the program. Engagement in the outdoor adventure and support during the mentoring partnership components significantly contributed to observed social gains, while engagement in the community service component did not. Results confirm youth development programs can positively influence adolescent social development, while highlighting the importance of moving beyond "black box" investigations in order to maximize program impact and efficiency.

Changes in Manipulative Peak Force Modulation and Time to Peak Thrust among First-Year Chiropractic Students Following a 12-Week Detraining Period.

OBJECTIVE: The purpose of this study was to analyze differences in peak force modulation and time-to-peak thrust in posterior-to-anterior (PA) high-velocity-low-amplitude (HVLA) manipulations in first-year chiropractic students prior to and following a 12-week detraining period. METHODS: Chiropractic students (n=125) performed 2 thrusts prior to and following a 12-week detraining period: total peak force targets were 400 and 600 N, on a force-sensing table using a PA hand contact of the participant's choice (bilateral hypothenar, bilateral thenar, or cross bilateral). Force modulation was compared to defined target total peak force values of 600 and 400 N, and time-to-peak thrust was compared between data sets using 2-tailed paired t-tests. RESULTS: Total peak force for the 600 N intensity varied by 124.11 + 65.77 N during the pre-test and 123.29 + 61.43 N during the post-test compared to the defined target of 600 N (P = .90); total peak force for the 400 N intensity varied by 44.91 + 34.67 N during the pre-test and 44.60 + 32.63 N during the post-test compared to the defined target of 400 N (P = .57). Time-to-peak thrust for the 400 N total peak force was 137.094 + 42.47 milliseconds during the pre-test and 125.385 + 37.46 milliseconds during the post-test (P = .0004); time-to-peak thrust for the 600 N total peak force was 136.835 + 40.48 milliseconds during the pre-test and 125.385 + 33.78 milliseconds during the post-test (P = .03). CONCLUSIONS: The results indicate no drop-off in the ability to modulate force for either thrust intensity, but did indicate a statistically significant change in time-to-peak thrust for the 400 N total peak force thrust intensity in first-year chiropractic students following a 12-week detraining period.

Failure to rescue following oesophagectomy in Australia: a multi-site retrospective study using American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Failure to rescue (FTR), defined as death after a major complication, is increasingly being used as a surrogate for assessing quality of care following major cancer resection. The aim of this paper is to determine the failure to rescue (FTR) rate after oesophagectomy and explore factors that may contribute to FTR within Australia. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2023 at five Australian hospitals was conducted to identify patients who underwent an oesophagectomy. The primary outcome was FTR rate. Perioperative parameters were examined to evaluate predictive factors for FTR. Secondary outcomes include major complications, overall morbidity, mortality, length of stay and 30-day readmissions. RESULTS: A total of 155 patients were included with a median age of 65.2 years, 74.8% being male. The FTR rate was 6.3%. In total, 50.3% of patients (n = 78) developed at least one postoperative complication with the most common complication being pneumonia (20.6%) followed by prolonged intubation (12.9%) and organ space SSI/anastomotic leak (11.0%). Multivariate logistic regression analysis was performed to determine any factors that were predictive for FTR however none reached statistical significance. CONCLUSION: This study is the first to evaluate the FTR rates following oesophagectomy within Australia, with FTR rates and complication profile comparable to international benchmarks. Integration of multi-institutional national databases such as ACS NSQIP into units is essential to monitor and compare patient outcomes following major cancer surgery, especially in low to moderate volume centres.

Gastric diverticulum: a contemporary review and update in management.

BACKGROUND: Gastric diverticula (GD) are the rarest form of gastrointestinal tract diverticulum, with an estimated incidence of 0.013-2.6%. GD are poorly understood and there are no established management guidelines. Only sparse updates have been published since the mid-20th century. This paper reviews the current literature and provides some suggested guidelines for the management of GD. METHODS: A search of Medline via OvidSP and Google Scholar for 'gastric diverticulum' and associated synonyms from the year 1950 onwards was performed. We included randomized controlled trials (RCTs), cohort and case-control studies, and case series. Full text, English language manuscripts on adult populations were included. RESULTS: A total of 103 manuscripts were included in the final selection - 77 individual case studies, 23 case series and three reviews. No RCTs, cohort or case-control studies were found. The case studies represent 305 patients, 50.8% female with average age 49.2 years (range 18-80). The most common symptom was abdominal pain (48.2%). The average maximum diameter was 3.97 cm (range 0.5-9). One hundred and four patients were managed operatively. Despite persistent recommendations in the literature that GD > 4 cm should be considered for resection, there are no data supporting this approach. CONCLUSION: The evidence pertaining to the management of GD is sparse. The decision for operative management should be individualized and based primarily on the presence of symptoms or complications which may be directly attributable to the GD. Where surgery is indicated, a laparoscopic approach, potentially with intra-operative gastroscopy, is appropriate.

A protocol for analyzing repeated measures of online group behavior.

In this article, we feature a novel protocol that enables the analysis of repeated measures of online group behavior. The protocol accounts for (1) the nested hierarchy of the data with weeks nested in persons, and persons nested in weeks, and (2) the temporal nature of the behavior at the early, mid, and late periods of each week. To manage and analyze such data in a general way, we first give an illustration of the data structure. Thereafter, we propose a five-step Courtney-Fanguy-Costley protocol that (1) considers the data structure, (2) defines the levels of data, (3) considers variable variation, timing, and necessary aggregation, (4) ensures necessary variation, and (5) specifies null and mixed-effects models. We also provide exemplary R code for readers to replicate our approach.•A general five-step protocol for analyzing repeated measures of online group behavior is offered.•A description of the complex nested data structure is offered.•Users can simulate data in R to run through the protocol.

Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit.

OBJECTIVES: Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention. METHODS: A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group. RESULTS: There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001). CONCLUSIONS: There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.

autopsych: An R Shiny tool for the reproducible Rasch analysis, differential item functioning, equating, and examination of group effects.

In this paper, we present autopsych, a novel online tool that allows school assessment experts, test developers, and researchers to perform routine psychometric analyses and equating of student test data and to examine the effect of student demographic and group conditions on student test performance. The app extends current open-source software by providing (1) extensive embedded result narration and summaries for written reports, (2) improved handling of partial credit data via customizable item-person Wright maps, (3) customizable item- and person-flagging systems, (4) item-response theory model constraints and controls, (5) many-facets Rasch analysis to examine item bias, (6) Rasch fixed item equating for mapping student ability across test forms, (7) tabbed spreadsheet outputs and immediate options for secondary data analysis, (8) customizable graphical color schemes, (9) extended ANOVA analysis for examining group differences, and (10) inter-rater reliability analyses for the verifying the consistency of rater scoring systems. We present the app's architecture and functionalities and test its performance with simulated and real-world small-, medium-, and large-scale assessment data. Implications and planned future developments are also discussed.

Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature.

BACKGROUND: Boerhaave syndrome is a rare and life-threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non-operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature. METHODS: A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed. RESULTS: In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%. CONCLUSIONS: We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.

Non-operative management of small post-appendicectomy intra-abdominal abscess is safe and effective.

BACKGROUND: Intra-abdominal abscess (IAA) post-appendicectomy occurs in 1.4-4.4% of cases. Non-operative management of small (<4 cm) post-appendicectomy IAA in children is well established, but minimal evidence exists in adults. Percutaneous catheter drainage is considered standard treatment for IAA, yet outcome data for post-appendicectomy IAA are sparse. The aims of this study were to assess the effectiveness of non-operative management of small (<4 cm diameter) IAA and the outcomes of percutaneous drainage for larger (>4 cm) IAA post-appendicectomy. METHODS: A retrospective case note review of a series of patients with a post-appendicectomy IAA between 2006 and 2017 was conducted. IAAs were treated selectively; small (<4 cm) IAAs were managed non-operatively and larger IAAs were managed with percutaneous drainage . RESULTS: A total of 4901 patients had an appendicectomy. Forty-two (0.9%) developed a post-operative IAA. Sixteen (38%) had a percutaneous drainage and 26 (62%) had non-operative management. The percutaneous drainage group had a higher proportion of complicated appendicitis (75%) compared to the non-operative group (42%, P = 0.04). The percutaneous drainage group had a significantly higher leucocytosis (P = 0.01) and C-reactive protein (P = 0.02). All patients managed non-operatively resolved without the need for invasive procedures. In the percutaneous drainage group, six had aspiration alone, nine had a percutaneous drain and one was abandoned. Three required repeat percutaneous drainage and four (25%) required operative drainage. Seven patients (34%) of the percutaneous drainage group had grade II or III complications. CONCLUSION: This case series study provides support that small (<4 cm) IAA post-appendicectomy can be safely and effectively managed non-operatively.

A national risk assessment for intersex in fish arising from steroid estrogens.

The occurrence of intersex fish is widespread in the rivers of England and Wales. The extent of intersex in fish populations is believed to be strongly linked to their exposure to steroid estrogens. The present study presents, to our knowledge, the first national, catchment-based risk assessment for steroid estrogens in the world. A graphical information system-based model predicted the concentrations of estradiol (E2), estrone, and ethinylestradiol, which were combined and compared with known biological effect levels to predict the risk of endocrine disruption for 10,313 individual river reaches (21,452 km) receiving effluent from more than 2000 sewage treatment plants serving more than 29 million people. The large scale of this assessment underlines the usefulness of computer-based risk assessment methods. Overall, 61% [corrected] of the modeled reaches (all percentages are in terms of the total river length modeled) in England and Wales were predicted to be not at risk from endocrine disruption (mean concentrations, <1 ng/L E2 equivalents). A large range existed in the percentage of river reaches at risk in the various regions, from 5% in Wales to 67% in the Thames catchment. Important factors influencing this proportion are the population density, particularly their location, and the available dilution. A very small proportion of reaches (approximately 1-3%) were predicted to be at high risk (>10 ng/L E2 equivalents). Many of these high-risk reaches, however, were ditches, which were composed almost entirely of sewage effluent. The model could be applied equally well to any other chemical of concern emanating from the human population that would be impractical to assess by measurement.

The Established Acute Surgical Unit: A reduction in nighttime appendicectomy without increased morbidity.

INTRODUCTION: Nighttime surgery for non-life threatening disease has been associated with poorer outcomes, but delaying surgery for acute appendicitis may also be detrimental. The aim was to assess the effect of the Acute Surgical Unit [ASU] model on nighttime surgery rates and outcomes for patients undergoing appendicectomy. METHOD: A retrospective review of medical records of patients having an appendicectomy. Primary outcomes were nighttime surgery rate, time from presentation to surgery, perforation rate, complication rate and length of stay. RESULTS: There was a large increase in workload: Pre ASU 278, Early ASU 553 and Est. ASU 923. There was a significant decrease in nighttime surgery rates: Pre ASU 46.9%, Early ASU 30.2% and Established ASU 28.3% (Pre vs. Early p < 0.001; Pre vs. Est. p < 0.001; Early vs. Est p = 0.004). When comparing the Pre ASU and Established ASU groups there was an increase in mean time from presentation to surgery (Pre 14.43 Hrs, Est. 18.65 Hrs; p = 0.001), an increase in perforation rate that was not significant (Pre 9.8%, Est. 14.2%; p = 0.05) and similar complication rates (Pre 8.66%, Est. 7.04%; p = 0.37). There was a significant decrease in length of stay between the Early and Established ASU groups (Pre 3.1 D, Est. 2.8D, p = 0.01). At our institution there was no statistically significant increase in complications for patients undergoing nighttime appendicectomy (Night 10.0%, Day 8.2%; p = 0.16). CONCLUSION: There was a significant decrease in nighttime surgery, without any difference in morbidity or length of stay for patients treated within the Established ASU (compared to Pre ASU group). LEVEL OF EVIDENCE: IIb.

Pulmonary hemorrhage in systemic lupus erythematosus.

The clinicopathological features of four patients with systemic lupus erythematosus and pulmonary hemorrhage are described. Our study confirms that pulmonary hemorrhage may be a dominant clinical expression of lung involvement in this disease. Its clinical manifestations are usually quite characteristic. However, hemoptysis may be absent. Radiographically, bilateral alveolar infiltrates resembling pulmonary edema or infection may be seen. Pulmonary hemorrhage was a major contributing factor to the death of three of our patients. The possible pathogenetic mechanisms responsible for pulmonary hemorrhage in our patients and other patients previously recorded in the literature are reviewed. Evidence supporting an immune complex pathogenesis is presented. Our immunopathological and ultrastructural studies demonstrate deposition of immune aggregates in the lungs in the alveolar septa, large blood vessels, and bronchioles in a manner similar to that which has been observed in the experimental serum sickness model of immune complex mediated pulmonary injury. The histological abnormalities, although nonspecific, are consistent with this interpretation, and collectively show diffuse alveolar lining cell and endothelial cell injury. However, an immune complex pathogenesis may not completely explain the occurrence of pulmonary hemorrhage in SLE. Other factors, including bleeding disorders, pulmonary infection, oxygen toxicity, and the "shock lung" syndrome, may also have contributed to lung hemorrhage in some of these patients.

Lesions of the thoracic aorta and its arch branches simulating neoplasm.

Abnormal radiographic densities in the midportion of the chest are most commonly caused by neoplasms, cysts, or inflammatory disease. However, vascular lesions may present an identical x-ray appearance, with no distinguishing clinical history or physical findings. The cardiothoracic surgeon must be aware of this similarity in order to ensure the most appropriate diagnostic and therapeutic approach. In our experience, the most frequent problem in differential diagnosis is a lesion of the thoracic aorta or its arch branches simulating neoplasm. Nine such cases are presented, with pertinent conventional radiographs angiograms, and computed tomographic (CT) scans. These are considered in anatomic sequence: (1) ruptured sinus of Valsalva aneurysm; (2) ascending aortic aneurysm; (3) tortuosity or aneurysm of the innominate and subclavian arteries; (4) transverse arch aneurysm; (5) pseudocoarctation; and (6) descending aortic aneurysm. Such vascular lesions must be considered early in the evaluation of any juxta-aortic chest density, particularly if the patient is hypertensive and has other manifestations of atherosclerosis. Angiography and computed tomography establish the diagnosis in most instances, although both are less reliable when thrombus fills all or part of an aneurysm. If these methods fail to establish a vascular origin, the possibility of neoplasm is pursued. When neither a vascular nor neoplastic origin can be proved, surgical exploration is indicated in the otherwise good-risk patient.

Bronchial atresia.

Bronchial atresia is a rare congenital anomaly usually producing an extrahilar mass and associated distal hyperinflation on chest roentogenogram. Bronchography reveals nonfilling of the atretic bronchus and displacement of neighboring normal bronchi. Characteristically, the patient is young and asymptomatic but has an abnormal chest roentgenogram. The only physical finding may be decreased breath sounds over the affected parenchyma. Treatment is surgical excision to prevent recurrent or persistent infection and encroachment on normal tissues by the hyperinflated lung. A case report and a review of 34 patients are presented.

The temporal and spatial variability of sediment transport and yields within the Bradford Beck catchment, West Yorkshire.

Recent EU directives have emphasised the need to understand and limit potential water quality problems within urban river systems. Under certain conditions sediments and contaminants derived from industrial and domestic waste and the urban surface may be expelled into urban rivers via the sewer and drainage system. These discharges may lead to water quality problems within urban catchments. One aspect of water quality is the suspended sediment. This can be directly detrimental to water quality by affecting the habitat for fish and other biota but it is also closely associated with pollutants, such as heavy metals, which may be adsorbed onto the sediments surface. This paper presents a comparative analysis of sediment yields for a small mixed rural/urban catchment, the Bradford Beck in West Yorkshire, over a number of precipitation events. Flow and water quality parameters were monitored at a high temporal resolution at strategic sites within the urban watercourse over a 2-year period. Rainfall was measured at six locations within the catchment. Analysis of discrete rainfall events allowed an understanding of the temporal and spatial variability of sediment transport within the catchment to be developed. The results demonstrated that for individual storms the sediment yields from the urban sub-catchment were generally higher than those from the rural system although the annual yields were comparable. Sediment transport within the urban area, for large events, was dominated by the impact of the Combined Sewer Overflows discharging. Within these events peak suspended sediment concentration, SSC, were generally higher than the rural system. Within smaller events the main sediment source within the urban area was the surface runoff discharging directly to the urban river. Analysis of SSC and discharge relationships illustrated the different sources of sediment for contrasting events. Within the rural system clockwise hysteresis, indicating exhaustion of sediment supply, was noted for larger storms. The high temporal resolution monitoring has enabled a better understanding of sediment dynamics within the Bradford Beck system to be developed. The general conclusions drawn can provide guidance for addressing sediment related water quality issued in other urban systems.