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.

Accelerated atherosclerosis and cardiovascular disease are major causes of morbidity and mortality in patients of end-stage renal disease. Carotid intima media thickness is taken as a useful surrogate marker of atherosclerosis. Thirty end-stage renal disease (ESRD) patients were subjected to ultrasonography to study CIMT before the initiation of dialysis. CIMT was found to be higher in ESRD patients than in controls. Levels of a serum marker of oxidative stress were also found to be higher in patients than in the controls. CIMT is an easy, noninvasive, reproducible, and cost-effective investigation in patients with chronic renal failure.

Background: Emergency peripartum hysterectomy (EPH) is a rare but a lifesaving procedure done as a last resort to save life of mother. We conducted this study to know the incidence, leading causes, risk factors and complications of EPH. Methods: We conducted a retrospective analysis of all the patients who underwent EPH from January 2008 to December 2015 at SDMCM and H. All patients who underwent EPH from 22 weeks of gestation to 6 weeks postpartum were included in the study. Results: There were 21 emergency peripartum hysterectomies, with deliveries during the same period being 27271 and the rate of EPH was 0.7 per 1000 deliveries. Most common indication for EPH was uterine atony (38%), followed by uterine rupture (23.8%) and morbidly adherent placenta (19%). Most of the patients (47.6%) had previous cesarean deliveries. EPH was done following cesarean in 66.6%. Subtotal hysterectomy was done in 61.9%. Intra-operative urinary bladder injury was seen in 14.2% of the patients. Conclusions: Uterine atony and uterine rupture continues to be the most common causes for EPH in our population. Multiparity is an important risk factor among patients with rupture uterus. Cesarean delivery and repeat cesarean deliveries are the likely risk factors for EPH.

(J Clin Anesth. 2017;37:21–24) Although spinal ultrasound can assist with identification of axial anatomical structures and intervertebral spaces, there are ergonomic challenges with needle angulation and depth. In fact, some studies with residents have suggested that there is no benefit to using ultrasound assistance for epidural placement. However, these studies were limited by small size or specificity to center. In the present study, the authors evaluated the impact of additional information provided by preprocedural ultrasound examination among trainee anesthesiologists performing spinal anesthesia in obstetric patients undergoing elective cesarean delivery in a blinded, randomized controlled trial.

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