Background: The Coronavirus Disease 2019 (COVID-19) pandemic has impacted volume, management strategies and patient outcomes of acute appendicitis. The aim of this systematic review and meta-analysis was to evaluate whether the COVID-19 pandemic resulted in higher incidence of complicated appendicitis in children presenting with acute appendicitis compared to the pre-COVID-19 period. The secondary aim was to investigate the proportion of the patients treated by non-operative management (NOM). Methods: A systematic search of four scientific databases was performed. The search terms used were (coronavirus OR SARS-CoV-2 OR COVID-19 OR novel coronavirus) AND (appendicitis). The inclusion criteria were all patients aged <18 years and diagnosed with acute appendicitis during the COVID-19 and pre-COVID-19 periods. The proportion of children presenting with complicated appendicitis and the proportion of children managed by NOM was compared between the two groups. The Downs and Black scale was used for methodological quality assessment. Results: The present meta-analysis included thirteen studies (twelve retrospective studies and one cross-sectional study). A total of 2782 patients (1239 during the COVID-19 period) were included. A significantly higher incidence of complicated appendicitis (RR = 1.63, 95% CI 1.33–2.01, p < 0.00001) and a significantly higher proportion of children managed via the NOM (RR = 1.95, 95% CI 1.45–2.61, p < 0.00001) was observed in patients during the COVID-19 pandemic when compared to the pre-COVID-19 period. Conclusion: There is a significantly higher incidence of complicated appendicitis in children during the COVID-19 pandemic than in the pre-COVID-19 period. Additionally, a significantly higher proportion of children was managed via the NOM during the pandemic in comparison to the pre-pandemic period.

Background: Despite great advances in medicine, numerous available laboratory markers, and radiological imaging, the diagnosis of acute appendicitis (AA) in some cases still remains controversial and challenging for clinicians. Because of that, clinicians are still looking for an ideal marker that would be specific to AA. The red blood cell distribution width (RDW) has been recently investigated in several studies as a potential biomarker for AA. The aim of this systematic review and meta-analysis was to systematically summarize and compare all relevant data on RDW as a diagnostic biomarker for AA. Methods: This systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Scientific databases (PubMed, Scopus, Web of Science, and Excerpta Medica database—EMBASE) were systematically searched for relevant comparative studies by two independent researches using keywords ((red cell distribution width) OR rdw) AND (appendicitis). An independent assessment of the methodological quality was performed by two authors using the Downs and Black scale. RevMan 5.4 software was used to perform the meta-analysis. Results: Fifteen studies were included in the final meta-analysis; the majority of the studies was retrospective. Nine studies compared the RDW values between AA and non-AA; four studies compared the same between AA and healthy controls, while two studies compared the RDW values among all three groups. The estimated heterogeneity among the studies for all outcome was statistically significant (I2 = 92–99%, p < 0.00001). The pooling the data demonstrated no statistically significant difference in the RDW values (weighted mean difference (WMD) = 0.03, 95% CI = (−0.46, 0.52), p = 0.91) between AA and healthy controls as well as between AA and non-AA cases (WMD = 0.23, 95%CI = (–0.19, 0.65), p = 0.28). A separate subanalysis was performed to evaluate the utility of this biomarker for the pediatric age group. Pooling the data demonstrated no significant difference among the AA and non-AA groups in terms of the RDW values (WMD = 0.99, 95% CI = (–0.35, 2.33), p = 0.15). Conclusion: The RDW value difference demonstrated no statistically significant difference in AA versus healthy individuals and AA versus non-AA individuals. At the moment, there is no evidence of RDW utility in diagnostic testing of AA. Further research with prospective, multicenter studies and studies targeting special patient groups with a large sample size are needed in this field.

Background: In cases with solid tumors, preoperative radiological investigations provide valuable information on the anatomy of the tumor and the adjoining structures, thus helping in operative planning. However, due to a two-dimensional view in these investigations, a detailed spatial relationship is difficult to decipher. In contrast, three-dimensional (3D) printing technology provides a precise topographic view to perform safe surgical resections of these tumors. This systematic review aimed to summarize and analyze current evidence on the utility of 3D printing in pediatric extra-cranial solid tumors. Methods: The present study was registered on PROSPERO—international prospective register of systematic reviews (registration number: CRD42020206022). PubMed, Embase, SCOPUS, and Google Scholar databases were explored with appropriate search criteria to select the relevant studies. Data were extracted to study the bibliographic information of each article, the number of patients in each study, age of the patient(s), type of tumor, organ of involvement, application of 3D printing (surgical planning, training, and/or parental education). The details of 3D printing, such as type of imaging used, software details, printing technique, printing material, and cost were also synthesized. Results: Eight studies were finally included in the systematic review. Three-dimensional printing technology was used in thirty children with Wilms tumor (n = 13), neuroblastoma (n = 7), hepatic tumors (n = 8), retroperitoneal tumor (n = 1), and synovial sarcoma (n = 1). Among the included studies, the technology was utilized for preoperative surgical planning (five studies), improved understanding of the surgical anatomy of solid organs (two studies), and improving the parental understanding of the tumor and its management (one study). Computed tomography and magnetic resonance imaging were either performed alone or in combination for radiological evaluation in these children. Different types of printers and printing materials were used in the included studies. The cost of the 3D printed models and time involved (range 10 h to 4–5 days) were reported by two studies each. Conclusions: 3D printed models can be of great assistance to pediatric surgeons in understanding the spatial relationships of tumors with the adjacent anatomic structures. They also facilitate the understanding of families, improving doctor–patient communication.

Background Prone positioning is known to reduce mortality in intubated non-COVID-19 patients suffering from moderate to severe acute respiratory distress syndrome (ARDS). However, studies highlighting the effect of awake proning in COVID-19 patients are lacking. We aim to conduct a systematic review of the available literature to highlight the effect of awake proning on the need for intubation, improvement in oxygenation and mortality rates in COVID-19 patients with ARDS. Method – A systematic search of 2 medical databases (PubMed, Google Scholar) was performed until July 5, 2020. Thirteen studies fulfilled the inclusion criteria, and 210 patients were included for the final analysis. Result –Majority of the patients were above 50 years of age with a male gender predominance (69%). Face mask (26%) was the most common interface used for oxygen therapy. The intubation and mortality rates were 23.80% (50/210) and 5.41% (5/203) respectively. Awake proning resulted in improvement in oxygenation (reported by 11/13 studies): improvement in SpO 2 , P/F ratio, PO 2 and SaO 2 reported by 7/13 (54%), 5/13 (38%), 2/13 (15%) and 1/13 (8%) of the studies. No major complications associated with prone positioning were reported by the included studies. Conclusion Awake prone positioning demonstrated an improvement in oxygenation of the patients suffering from COVID-19 related respiratory disease. Need for intubation was observed in less than 30% of the patients. Thus, we recommend early and frequent proning in patients suffering from COVID-19 associated ARDS, however, randomized controlled trials are needed before any definite conclusions are drawn.

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Background: Acute appendicitis in the pediatric population remains a diagnostic challenge for clinicians. Despite many biochemical markers, imaging modalities and scoring systems, initial misdiagnosis and complication rates are high in children. This suggests the need for investigations directed towards new diagnostic tools to aid in the diagnosis. Recent studies have shown a correlation between serum sodium levels and complicated appendicitis. Although the exact reasons for hyponatremia in patients with complicated appendicitis are not known, there is persuasive data to support the role of pro-inflammatory cytokines such as IL-6 in the non-osmotic release of antidiuretic hormone. This meta-analysis aims to investigate all available data on hyponatremia as a diagnostic marker of complicated appendicitis in the pediatric population. Methods: The literature search was conducted by two independent investigators according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The scientific databases (PubMed, EMBASE, Web of Science, and Scopus) were systematically searched for relevant studies using the keywords (hyponatremia) AND (appendicitis) AND (children). The methodological quality was assessed using a validated scale, and RevMan 5.4 software was utilized for pooled analysis. Results: Seven studies were included in the final meta-analysis, five of which were retrospective. A total of 1615 and 2808 cases were distributed into two groups: group A with complicated appendicitis and group B with uncomplicated acute appendicitis, respectively. The studies compared serum sodium levels of patients among the groups. Pooling the data demonstrated significantly lower serum sodium levels in children with complicated appendicitis vs. the non-complicated appendicitis (WMD: −3.29, 95% CI = −4.52 to −2.07, p < 0.00001). The estimated heterogeneity among the included studies was substantial and statistically significant (I2 = 98%, p < 0.00001). Conclusion: The results of the present meta-analysis indicate that hyponatremia has potential to be utilized as a biochemical marker in the diagnosis of complicated appendicitis in the pediatric population. However, well designed prospective diagnostic efficiency studies are essential to consolidate the association between hyponatremia and complicated acute appendicitis.

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