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.
The ef®cacy of acupuncture as a mono-therapy was evaluated in a pilot study of 16 patients suffering from erectile dysfunction (ED). In nine patients no organic co-morbidity was encountered. In a period of four weeks, acupuncture treatment was performed twice a week for a total of eight sessions. Each treatment session consisted of puncture of the same eight acupoints, four of which were connected to a Swiss made constant current Doltron ESA 600 stimulator. Low frequency electrical stimulation (5 Hz and 10 mA) was applied to these four acupoints, whereas no stimulation was applied to the other four points. After 30 min, the electrical stimulation was terminated and all needles removed. Blood samples were drawn according to a ®xed time schedule, to study the pro®le of a number of stress hormones, for example, adrenocorticotropic hormone, antidiuretic hormone and cortisol, the gonadotrophines follicle stimulating hormone and leutinizing hormone, and the sex steroid testosterone and its binding globulin, within the treatment period. Based on a diary of both patient and partner, and an interview one month after the end of treatment, the changes of sexual activity were evaluated over a period of 12 weeks, starting from the four weeks prior to the treatment, the four weeks during the treatment period and the four weeks after the treatment. An improvement of the quality of erection was experienced by 15% of patients, while 31% reported an increase in their sexual activity. No changes in the pro®les of hormones were detected. The use of acupuncture as a mono-therapeutic modality in ED, did not in¯uence the pro®le of the stress and sex hormones, but did improve the quality of erection and restored the sexual activity with an overall effect of 39%. No de®nite conclusions can be drawn from this pilot study. A controlled and blinded study including more patients will be needed before any de®nitive conclusion can be reached.
SummaryThe ejicacy of acupuncture and transcutaneous stimulation analgesia, supplemented by small doses of fentanyl (mean I .2 pg/kg, SD 1.7) was compared with moderate-dose fentanyl anaesthesia (mean 22.9 pg/kg, SD 2.8) in 29 patients who underwent surgery for retroperitoneal lymph node dissection. The present study describes the anaesthetic techniques and comparison of haemodynamics, demand for analgesics after surgery, recovery and blood gases, restoration of urinary and bowel functions, convalescence in terms of self-reliance and the postoperative course in respect of fatigue and morbidity. A more rapid return of consciousness, an absence of hypercapnia and a smaller decrease in p H were observed in patients who received acupuncture and transcutaneous stimulation ( p < 0.05). No clinically relevant disadvantages attributable to the method were demonstrated.
Introduction Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short‐term outcomes of TaTME, open, laparoscopic, and robotic TME internationally. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02–2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10–7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non‐transanal laparoscopic TME. However this association was lost in the mixed‐effects model controlling for patient and disease factors (OR 1.23, 0.77–1.97, P = 0.39 and OR 2.11, 0.79–5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55–4.77, P < 0.001) and male gender (OR 2.29, 1.52–3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%. Conclusion This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.
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