Mandatory imaging in the work-up of children suspected of having appendicitis reduces the rate of unnecessary surgeries.

OBJECTIVE: In children, the diagnosis "acute appendicitis" is difficult. In 2010, a new Dutch appendicitis guideline was published with the goal to reduce the negative appendectomy rate. The guideline recommended mandatory imaging (ultrasound first and CT or MRI when inconclusive) before surgery. This study examines whether the negative appendectomy rate in children has declined after the implementation of the guideline and if the number of ionising imaging procedures increased. METHODS: In this cohort study, all consecutive patients aged 17 or younger, with the suspicion of appendicitis were included. Patients were divided into two groups. Those who presented between 2006 and 2010 (before the implementation) and those between 2011 and 2016 (after implementation). RESULTS: In total, 748 children were enrolled, of which 363 children were seen before and 385 children after implementation of the guideline. Before implementation, 46% of the children with acute appendicitis underwent preoperative ultrasound compared with 95% in the post implementation group, p < 0.001. Any imaging was performed in 51% and 100%, respectively, p < 0.001. The percentage of negative appendectomy before implementation was 13% and 2.7% after implementation, p < 0.001. There was no significant increase in the number of CT scans before and after the implementation of the guideline, 3.6% versus 6.0%, respectively, p = 0.126. There was no increase in direct medical costs. CONCLUSIONS: Mandatory preoperative imaging in children with the suspicion of acute appendicitis results in a significant decrease in negative appendectomies with no increase in the number of CT scans and without a substantial increase in costs.

Evaluation of scoring systems in predicting acute appendicitis in children.

BACKGROUND: Acute appendicitis can be difficult to diagnose, especially in children. Appendicitis scoring systems have been developed as a diagnostic tool to improve the decision-making process in patients with suspected acute appendicitis. This study evaluates the Appendicitis Inflammatory Response score, Alvarado score, and Pediatric Appendicitis Score in children suspected of acute appendicitis. METHODS: Data were collected retrospectively. All children younger than 18 years suspected of acute appendicitis who presented to the emergency department between January 2006 and June 2014 were included in this study. Variables were registered to evaluate 3 different appendicitis scoring systems. The diagnostic performance of the 3 scores was analyzed using the area under the receiver-operating curve and by calculating the diagnostic performances at different cut-off points. RESULTS: The present study included 747 consecutive children. There were 399 boys (53%) and 348 girls (47%) with a mean age of 11 years (range, 1-17 years). In total, 269 children (36%) were diagnosed with acute appendicitis. The area under the receiver-operating curve of the Appendicitis Inflammatory Response score was 0.90, the Alvarado score was 0.87, and the Pediatric Appendicitis Score was 0.82 (P < .05, respectively). The specificity and positive predictive value of the Appendicitis Inflammatory Response score were better at predicting an acute appendicitis than that of the Alvarado score and Pediatric Appendicitis Score. In children with a low-risk acute appendicitis, false negative rates of 14% for the Appendicitis Inflammatory Response, 7% for the Alvarado, and 18% for the Pediatric Appendicitis Score were measured. CONCLUSION: In this study, the Appendicitis Inflammatory Response score had the highest discriminating power and outperformed the Alvarado score and Pediatric Appendicitis Score in predicting acute appendicitis in children. Excluding acute appendicitis safely in children with the scoring systems still remains uncertain.

Prognostic value of continued smoking on survival and recurrence rates in patients with head and neck cancer: A systematic review.

BACKGROUND: The purpose of this systematic review was to determine the prognostic value of continued smoking after diagnosis on survival and recurrence rates in head and neck cancer. METHODS: A systematic search was performed and predefined inclusion and exclusion criteria were used to screen and select the articles. The remaining articles were critically appraised. RESULTS: Six articles were used for data extraction. The survival rate of patients who continued to smoke was 21% to 35% lower compared with patients who quit smoking. The recurrence rate for continued smoking was 23% and 30% higher. In 1 study, there was no difference between continuation and cessation of smoking, and 1 study showed a higher recurrence rate for patients who continued to smoke, which was not statistically significant. CONCLUSION: There is consistent evidence that survival rates are lower and recurrence rates are higher for patients who continue to smoke after being diagnosed with head and neck cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2214-E2220, 2016.

[A splenic arteriovenous fistula]. / Een arterioveneuze fistel van de miltvaten.

BACKGROUND: Splenic arteriovenous fistula is a rare entity which can present as portal hypertension and related symptoms. CASE DESCRIPTION: A 60-year-old female attended the emergency department with haematemesis. She had microcytic anaemia and was admitted to the Gastroenterology and Hepatology Department. Gastroduodenoscopy revealed three grade II-III varices in the distal oesophagus. The ultrasound image was suggestive of liver cirrhosis and showed signs of portal hypertension such as ascites, splenomegaly and dilated vessels near the splenic hilum. CT angiography showed an enlarged splenic vein in the arterial phase suggestive of arteriovenous fistula. This was confirmed by selective angiography of the splenic artery. The splenic arteriovenous fistula was treated with percutaneous transarterial embolization. CONCLUSION: Patients with an arteriovenous fistula in the spleen are generally treated by splenectomy. However, in our patient embolization treatment was effective.