Acute appendicitis in children: is preoperative hyponatremia a predictive factor of perforation/gangrene? A prospective study.

PURPOSE: Distinguishing between perforated/gangrenous from uncomplicated appendicitis in children helps management. We evaluated hyponatremia as a new diagnostic marker for perforated/gangrenous appendicitis in children. METHODS: A prospective study including all children with acute appendicitis who underwent appendectomy at our institution from May 2021 to May 2023. Medical history and clinical criteria were analyzed. All blood samples were taken upon admission including serum inflammatory markers and electrolytes. Patients were divided into two groups (Group I: uncomplicated and Group II: perforated/gangrenous), and data between both groups were compared. RESULTS: The study included 153 patients [Group I: 111 (73%), Group II: 42 (27%)]. Mean serum sodium concentration in children with perforated/gangrenous appendicitis was significantly lower compared to children with uncomplicated appendicitis (131.8 mmol/L vs. 138.7 mmol/L; p < 0.001). The ROC curve of preoperative sodium level to differentiate between perforated/gangrenous and uncomplicated appendicitis revealed an AUC of 0.981. The cut-off-value of sodium level < 135 mmol/L identified perforated/gangrenous appendicitis with a sensitivity of 94% and a specificity of 91% (p < 0.001). Predictive factors of perforated/gangrenous appendicitis were: age less than 5 years (12% vs. 3%; p = 0.02), experiencing symptoms for more than 24 h (100% vs. 58%; p < 0.001), body temperature more than 38.5 °C (52% vs. 13%; p < 0.001), a serum sodium level less than 135 mmol/L (90% vs. 6%; p < 0.001), and a CRP serum level more than 50 mg/L (71% vs. 17%; p < 0.001). CONCLUSIONS: Hyponatremia, upon admission, is a novel, objective biochemical marker that can identify perforated/gangrenous appendicitis in children. We advocate that the assessment of serum sodium level should be added to the diagnostic algorithm in children with suspected acute appendicitis. Surgical intervention in patients with hyponatremia should not be delayed, and non-operative management should be avoided.

Comparing presentations and outcomes of children with cancer: a study between a lower-middle-income country and a high-income country.

BACKGROUND: Substantial progress has been achieved in managing childhood cancers in many high-income countries (HICs). In contrast, survival rates in lower-middle-income countries (LMICs) are less favorable. Here, we aimed to compare outcomes and associated factors between two large institutions; Egypt (LMIC) and Germany (HIC). METHODS: A retrospective review was conducted on newly diagnosed children with cancer between 2006 and 2010 in the departments of pediatric oncology at the South Egypt Cancer Institute (SECI) (n = 502) and the University Hospital of Cologne-Uniklinik Köln (UKK) (n = 238). Characteristics including age, sex, diagnosis, travel time from home to the cancer center, the time interval from initial symptoms to the start of treatment, treatment-related complications, compliance, and outcome were analyzed. A Cox proportional hazards regression model was applied to investigate the influence of risk factors. RESULTS: The most common diagnoses in SECI were leukemia (48.8%), lymphomas (24.1%), brain tumors (1%), and other solid tumors (24.7%), compared to 22.3%, 19.3%, 28.6%, and 26.5% in UKK, respectively. Patients from SECI were younger (5.2 vs. 9.0 years, P < 0.001), needed longer travel time to reach the treatment center (1.44 ± 0.07 vs. 0.53 ± 0.03 h, P < 0.001), received therapy earlier (7.53 ± 0.59 vs. 12.09 ± 1.01 days, P = 0.034), showed less compliance (85.1% vs. 97.1%, P < 0.001), and relapsed earlier (7 vs. 12 months, P = 0.008). Deaths in SECI were more frequent (47.4% vs. 18.1%) and caused mainly by infection (60% in SECI, 7% in UKK), while in UKK, they were primarily disease-related (79% in UKK, 27.7% in SECI). Differences in overall and event-free survival were observed for leukemias but not for non-Hodgkin lymphoma. CONCLUSIONS: Outcome differences were associated with different causes of death and other less prominent factors.

Predictive factors of post-laparoscopic appendectomy peritoneal collection in children and adolescents with complicated appendicitis.

INTRODUCTION: Intra-peritoneal collection (IPC) following laparoscopic appendectomy (LA) of complicated appendicitis in children is a serious complication. This is associated with a longer duration of hospital stay, more costs, and psychological upsets of both children and their parents. The aim of this study is to evaluate different factors that may affect the development of IPC following LA of complicated appendicitis. PATIENTS AND METHODS: Seventy-five children were admitted with acute complicated appendicitis. All of them had LA between January 2016 and October 2020. The following variables were studied: patients' demographics, clinical findings, laboratory and imaging studies and operative parameters. Patients were divided according to their post-operative course into two groups; Group (A): patients with IPC (n = 19), Group (B): patients without IPC (n = 56). Potential risk factors for the development of post-operative IPC were identified by univariate and multivariate logistic regression analysis. RESULTS: Nineteen cases (25.3%), out of 75 patients, presented with post-operative collection. Forty-seven (62.7%) patients were males, the overall median age was 11 (inter-quartile range [IQR] 10-13). The most significant operative variable was the operative time, which was significantly longer in Group A, 78 min (IQR 75-88) versus 56 (50-66), P = 0.001. The following variables were associated with an elevated incidence of post-operative IPC; age, body mass index, total leucocytic count (TLC), duration of symptoms, pediatric appendicitis score, pre-operative morbidity, being on medications, operative time, suction and irrigation or suction only and drain duration. In the multivariate model, TLC (odds ratios [OR]: 1.358, P 0.006), symptoms duration (OR: 2.051, P 0.012), morbidity (OR: 2.064, P 0.041) and operative time (OR: 2.631, P 0.039) were statistically significant and confirmed as being predictors of IPC post-LA in complicated appendicitis. CONCLUSION: Post-operative IPC is quite common after LA for complicated appendicitis. Increased TLC, prolonged symptoms duration, associated co-morbidity and operative time could be predictors of its occurrence. Improving general condition, surgical technique and reducing operative time help to reduce its incidence.

Piggyback or Cava Replacement: Which Implantation Technique Protects Liver Recipients From Acute Kidney Injury and Complications?

The cava-preserving piggyback (PB) technique requires only partial cava clamping during the anhepatic phase in liver transplantation (LT) and, therefore, maintains venous return and may hemodynamically stabilize the recipient. Hence, it is an ongoing debate whether PB implantation is more protective from acute kidney injury (AKI) after LT when compared with a classic cava replacement (CR) technique. The aim of this study was to assess the rate of AKI and other complications after LT comparing both transplant techniques without the use of venovenous bypass. We retrospectively analyzed the adult donation after brain death LT cohort between 2008 and 2016 at our center. Liver and kidney function and general outcomes including complications were assessed. Overall 378 transplantations were analyzed, of which 177 (46.8%) were performed as PB and 201 (53.2%) as CR technique. AKI occurred equally often in both groups. Transient renal replacement therapy was required in 22.6% and 22.4% comparing the PB and CR techniques (P = 0.81). Further outcome parameters including the complication rate were similar in both cohorts. Five-year graft and patient survival were comparable between the groups with 81% and 85%, respectively (P = 0.48; P = 0.58). In conclusion, both liver implantation techniques are equal in terms of kidney function and overall complications following LT.

Conventional versus piggyback techniques: do they have different outcomes?

BACKGROUND: Conventional orthotopic liver transplant includes resection of the recipient's native liver, together with the retrohepatic inferior vena cava, whereas with the piggyback technique, the recipient's vena cava is preserved and the donor's vena cava is anastomosed with the recipient's hepatic veins. So the caval flow is maintained during explantation, but on the other hand, the cava must be dissected completely from the liver, prolonging hepatic excision. OBJECTIVE: To compare outcomes of conventional versus piggyback techniques. Primary outcomes were serious adverse events or complications, and secondary outcomes were graft survival for 3 and 12 months, quality of life, days in the intensive care unit and in the hospital, and days spent receiving mechanical ventilation. MATERIALS AND METHODS: From January 3, 2007, to December 31, 2008, 120 liver transplant patients were divided into 2 groups: conventional (n = 93) and piggyback (n = 27). RESULTS: Intraoperative and postoperative complications, graft survival for 3 and 12 months, quality of life, and hospital stay did not differ significantly between the 2 groups. However, the stay in the intensive care unit (median, 2 vs 3 days; range, 1-101 vs 1-60 days) and the number of days on ventilatory support (median, 1 vs 2 days; range, 0-41 vs 1-60 days) were notably lower in the conventional group. CONCLUSION: The conventional liver transplant technique had significantly better results than the piggyback technique in terms of length of stay in the intensive care unit and duration of mechanical ventilation.

Venous Outflow Reconstruction in Adult Living Donor Liver Transplant: Outcome of a Policy for Right Lobe Grafts without the Middle Hepatic Vein.

Introduction. The difficulty and challenge of recovering a right lobe graft without MHV drainage is reconstructing the outflow tract of the hepatic veins. With the inclusion or the reconstruction of the MHV, early graft function is satisfactory. The inclusion of the MHV or not in the donor's right lobectomy should be based on sound criteria to provide adequate functional liver mass for recipient, while keeping risk to donor to the minimum. Objective. Reviewing the results of a policy for right lobe grafts transplant without MHV and analyzing methods of venous reconstruction related to outcome. Materials and Methods. We have two groups Group A (with more than one HV anast.) (n = 16) and Group B (single HV anast.) (n = 24). Both groups were compared regarding indications for reconstruction, complications, and operative details and outcomes, besides describing different modalities used for venous reconstruction. Results. Significant increase in operative details time in Group A. When comparison came to complications and outcomes in terms of laboratory findings and overall hospital stay, there were no significant differences. Three-month and one-year survival were better in Group A. Conclusion. Adult LDLT is safely achieved with better outcome to recipients and donors by recovering the right lobe without MHV, provided that significant MHV tributaries (segments V, VIII more than 5 mm) are reconstructed, and any accessory considerable inferior right hepatic veins (IRHVs) or superficial RHVs are anastomosed.

Absorption of schiff-base retinal chromophores in vacuo.

The absorption spectrum of the all-trans retinal chromophore in the protonated Schiff-base form, that is, the biologically relevant form, has been measured in vacuo, and a maximum is found at 610 nm. The absorption of retinal proteins has hitherto been compared to that of protonated retinal in methanol, where the absorption maximum is at 440 nm. In contrast, the new gas-phase absorption data constitute a well-defined reference for spectral tuning in rhodopsins in an environment devoid of charges and dipoles. They replace the misleading comparison with absorption properties in solvents and lay the basis for reconsidering the molecular mechanisms of color tuning in the large family of retinal proteins. Indeed, our measurement directly shows that protein environments in rhodopsins are blue- rather than red shifting the absorption. The absorption of a retinal model chromophore with a neutral Schiff base is also studied. The data explain the significant blue shift that occurs when metharhodopsin I becomes deprotonated as well as the purple-to-blue transition of bacteriorhodopsin upon acidification.