SUMMARY
BackgroundObesity is increasingly being recognized as a risk factor for a number of benign and malignant gastrointestinal conditions. However, literature on the underlying pathophysiological mechanisms is sparse and ambiguous. Insulin resistance is the most widely accepted link between obesity and disease, particularly colorectal cancer. The recognition that intra-abdominal fat is immunologically active sheds new light not only on the pathogenesis of obesity-related gastrointestinal conditions, but also on inflammatory conditions such as Crohn's disease.
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.
INTRODUCTION The UK has a higher mortality for colon cancer than the European average. The UK Government introduced a 2-week referral target for patients with colorectal symptoms meeting certain criteria and 62-day target for the delivery of treatment from the date of referral for those patients diagnosed with cancer. Hospitals are expected to meet 100% and 95% of these targets, respectively; therefore, an efficient and effective patient pathway is required to deliver diagnosis and treatment within this period. It is suggested that 'straight-to-test' will help this process and we have examined our implementation of 'straight-to-colonoscopy' as a method of achieving this aim. PATIENTS AND METHODS We carried out a retrospective audit of 317 patients referred under the 2-week rule over a 1-year period between October 2004 and September 2005 and were eligible for 'straight-to-colonoscopy'. Demographic data, appropriateness of referral and colonoscopy findings were obtained. The cost effectiveness and impact on waiting period were also analysed. RESULTS A total of 317 patients were seen within 2 weeks. Cancer was found in 23 patients and all were treated within 62 days. Forty-four patients were determined by the specialist to have been referred inappropriately because they did not meet NICE referral guidelines. No cancer was found in any of the inappropriate referrals. The use of straight-to-test colonoscopy lead to cost savings of £26,176 (£82.57/patient) in this group compared to standard practice. There was no increase in waiting times. CONCLUSIONS Straight-to-colonoscopy for urgent suspected cancer referrals is a safe, feasible and cost-effective method for delivery of the 62-day target and did not lead to increase in the endoscopy waiting list.
Most non-branded multivitamins are lower cost alternatives to branded multivitamins, with similar compositions. The AACE recommendation for two-tablet doses of multivitamins is not being met by most English centres. Calcium and iron supplementation is also inadequate.
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