Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.

Smartphone usage is universal among healthcare professionals and their influence is growing in patient care.

radiological evidence of vertebral spondylodiscitis and a psoas collection that was presumed to be secondary to an infective process. These radiological findings were subsequently found to be due to a contained AAA rupture with no signs of sepsis intra-operatively.Fortunately, the delay in diagnosis did not alter the long-term outcome and the patient recovered well after appropriate surgical management. Case ReportWe report a case of a 63-year-old Caucasian male who is a chronic smoker, hypertensive, and dyslipidemic. He was presented with a 4-month history of low back pain and a 1-year history of limiting bilateral intermittent claudication. On examination, he had a pulsatile expansile abdominal mass with absent femoral and distal pulses. The anklebrachial index was 0.61 on the right and 0.46 on the left with no distal tissue loss. The rest of the examination was otherwise unremarkable with good cardiac and respiratory status. Further lab workup including a complete blood count, renal function, liver function, coagulation profile, and erythrocyte sedimentation rate (ESR) were normal except for an elevated C-reactive protein (CRP) of 26.The initial CT aortogram showed a 4 cm infra-renal AAA (Fig. 1). Visualization of the common iliac arteries revealed tight stenosis and focal occlusion on the right and left side respectively. In addition, a right-sided 5 cm × 2.8 cm psoas muscle collection was evident along with erosion of the L4 vertebrae (Fig. 2). A lumbar spine MRI confirmed this collection and showed evidence of spondylodiscitis at L4-L5 manifested by erosive vertebral changes.Our provisional diagnosis was therefore spondylodiscitis at L4-L5 complicated by vertebral erosion and a psoas abscess. Although it was suspected, whether or not the aorta was involved in the infective process or even ruptured with a contained hematoma was a question yet to be answered.With these findings in mind, the patient was immediately referred to our infectious disease and neurosurgery service that opted to treat the spine infection non-operatively and obtain a CT-guided aspirate of the psoas collection.A 63-year-old Caucasian male presented with a 4-month history of low back pain associated with bilateral intermittent claudication. A contrast enhanced CT scan demonstrated a 4 cm abdominal aortic aneurysm (AAA), along with severe bilateral aorto-iliac disease, a right psoas collection, and extensive vertebral erosion. An MRI of the lumbar spine suggested spondylodiscitis at L4-L5. After an unsuccessful and prolonged course of antibiotics, a decision was ultimately made to repair the aneurysm and bypass the aorto-iliac disease. Intra-operatively, a chronic contained rupture (CCR) involving the posterior aortic wall was encountered and repaired with an aorto-bifemoral bypass graft.

Treatment protocols should be individualised based on the underlying condition and outcomes. Decision-making must be cognisant of the physical, social, psychological, and developmental needs of the child and family. A partnership approach is advocated, which includes child and parent/carer preferences allowing them to make an informed decision.

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Aim:The aim of this study is to identify the risk factors for a persistent gastrocutaneous fistula (GCF) after gastrostomy device (GD) removal in children.Materials and Methods:A retrospective analysis of 59 patients that underwent GD insertion and removal over an 11-year period (2005–2015). Patients were divided into two Groups (A and B) according to persistence or closure of the gastrocutaneous tract. Data included patient demographics, comorbidities, age at insertion, gastrostomy site infections, size and type of device, duration of placement, and method of insertion and removal. Statistical analysis was done using Chi-square test and ANOVA test where P < 0.05 was considered statistically significant.Results:A total of 34 patients (Group A) developed a GCF post-GD removal. The gastrostomy tract closed spontaneously in 25 patients (Group B). Underlying comorbidities did not influence spontaneous closure. Younger age at insertion (<2 years), longer duration of device placement, open gastrostomy insertion, upsizing the GD, changing a gastrostomy tube to a button, and site infections were significant risk factors for a persistent GCF.Conclusions:Risk analysis of persistent GCF is important for patient counseling before removal or replacement of the GD. We have identified a number of potentially reversible risk factors for a persistent GCF and have made recommendations accordingly.

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