Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BackgroundThe goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis.MethodsA multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016–2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles.Results100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm³; OR 5.31 [95% CI: 4.87–5.80]), followed by female sex (OR 1.55 [95% CI: 1.42–1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13–17 years with elevated WBC [1.1%] vs. females 3–4 years with normal WBC [15.8%]).ConclusionsContemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted.Level of EvidenceIII.     

Morphological spectrum of adenoid-cystic carcinoma of the breast: focus on diagnostic and prognostic features

Adenoid cystic carcinoma (AdCC) is a salivary gland-type of cancer that may also occur in the breast. Breast AdCC shows the same morphological spectrum as is observed in salivary glands, with recognition of individual subtypes that may differ in their clinical behaviour. AdCC classic variant (C-AdCC) is a slowly growing tumour, with a low rate of axillary node and distant metastases. Local recurrences may develop as a consequence of incomplete surgical excision. C-AdCC should be differentiated from the solid-basaloid variant of AdCC (SB-AdCC) that is characterized by nuclear atypia, frequent mitotic figures and necrosis, in addition to the solid architecture. SB-AdCC is a more aggressive tumour, with higher rates of axillary node and distant metastases. AdCC may also co-exist with more aggressive types of carcinoma including metaplastic and neuroendocrine carcinoma, referred to as AdCC with high grade transformation (HG-AdCC). This paper reviews the key diagnostic criteria of the different subtypes of breast AdCC with emphasis on differential diagnosis and prognostic parameters.     

妊娠晚期孕妇抑郁情绪对新生儿神经行为发育的影响

目的探讨妊娠晚期孕妇抑郁情绪对新生儿神经行为发育的影响。方法选取2017年1月—2018年12月,收治本院的160例妊娠晚期孕妇抑郁情绪患者一般临床资料,妊娠周期28周以上,对孕妇抑郁情绪进行统计采用爱丁堡抑郁自评量表、负性认知加工偏向量表,对新生儿神经行为进行评估时按照婴儿神经国际量表。结果160例妊娠晚期孕妇抑郁情绪患者中,阳性30例、阴性130例,与阴性妊娠妇女相比,抑郁阳性妊娠妇女负性沉思偏向、负性解释偏向、负性记忆偏向、负性注意偏向均显著较高,差异具有统计学意义(P<0.05)。160例新生儿中,婴儿神经国际量表评分处于临界值为60例,正常值为100例,神经行为异常发生率为37.50%,负性沉思偏向、负性注意偏向与婴儿神经国际临界值呈负相关关系(P<0.05);与抑郁自评量表无明显相关性(P>0.05)。结论妊娠晚期孕妇具有较高抑郁发生率,其中负性认知加工偏向中负性沉思偏向、负性注意偏向与新生儿神经行为发育具有明显相关性。     

Influence of coronary stenosis location on diagnostic performance of machine learning-based fractional flow reserve from CT angiography

BackgroundCompared with invasive fractional flow reserve (FFR), coronary CT angiography (cCTA) is limited in detecting hemodynamically relevant lesions. cCTA-based FFR (CT-FFR) is an approach to overcome this insufficiency by use of computational fluid dynamics. Applying recent innovations in computer science, a machine learning (ML) method for CT-FFR derivation was introduced and showed improved diagnostic performance compared to cCTA alone. We sought to investigate the influence of stenosis location in the coronary artery system on the performance of ML-CT-FFR in a large, multicenter cohort.MethodsThree hundred and thirty patients (75.2% male, median age 63 years) with 502 coronary artery stenoses were included in this substudy of the MACHINE (Machine Learning Based CT Angiography Derived FFR: A Multi-Center Registry) registry. Correlation of ML-CT-FFR with the invasive reference standard FFR was assessed and pooled diagnostic performance of ML-CT-FFR and cCTA was determined separately for the following stenosis locations: RCA, LAD, LCX, proximal, middle, and distal vessel segments.ResultsML-CT-FFR correlated well with invasive FFR across the different stenosis locations. Per-lesion analysis revealed improved diagnostic accuracy of ML-CT-FFR compared with conventional cCTA for stenoses in the RCA (71.8% [95% confidence interval, 63.0%–79.5%] vs. 54.8% [45.7%–63.8%]), LAD (79.3 [73.9–84.0] vs. 59.6 [53.5–65.6]), LCX (84.1 [76.0–90.3] vs. 63.7 [54.1–72.6]), proximal (81.5 [74.6–87.1] vs. 63.8 [55.9–71.2]), middle (81.2 [75.7–85.9] vs. 59.4 [53.0–65.6]) and distal stenosis location (67.4 [57.0–76.6] vs. 51.6 [41.1–62.0]).ConclusionIn a multicenter cohort with high disease prevalence, ML-CT-FFR offered improved diagnostic performance over cCTA for detecting hemodynamically relevant stenoses regardless of their location.     

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BackgroundThe purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).MethodsAfter IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012–2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.ResultsAmong 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028–3012] and 37 weeks (IQR 34–38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19–42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).ConclusionsIn this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.Level of EvidenceDiagnostic Study, Level III.     

Elective neck dissection in metastatic cutaneous squamous cell carcinoma to the parotid gland: A systematic review and meta‐analysis

Current management of metastatic cutaneous squamous cell carcinoma (CSCC) to the parotid is surgical excision and postoperative radiotherapy. In the node‐negative neck, there is debate about the role of elective neck dissection (END), irradiation or observation. This systematic review assesses the prevalence of occult cervical disease and the evidence for END. A literature search was performed using Medline and Embase. All papers describing management of the neck in metastatic CSCC to the parotid were assessed for inclusion. Eighty‐nine papers were identified and 17 met inclusion criteria. A total of 874 ENDs were performed in 874 patients with metastatic CSCC to the parotid with no clinically evident cervical disease. The overall prevalence of occult disease in a random effects model was 22.5% (95% confidence intervals 18.9‐26.0). The prevalence of occult cervical disease in metastatic CSCC to the parotid is high. END is recommended in this patient group.     

Impact of negative‐pressure wound therapy on bacterial behaviour and bioburden in a contaminated full‐thickness wound

The use of negative‐pressure wound therapy (NPWT) has displayed significant clinical benefits in the healing of infected wounds. However, the effects of NPWT on bacterial colonisation and infection of traumatic wounds has been controversial. The aim of this study is to evaluate the impact of NPWT treatment in rabbits with a contaminated full‐thickness wound on bacterial behaviour, including colony morphology, spatial distribution, fissional proliferation, and bacterial bioburden. Full‐thickness wounds were created on the back of rabbits, and were inoculated with bioluminescent Staphylococcus aureus. The wounds were treated with sterile gauze dressings and NPWT with continuous negative pressure (−125 mm Hg). Wound samples were harvested on days 0 (6 hours after bacterial inoculation), 2, 4, 6, and 8 at the centre of wound beds before irrigation. Scanning electron microscopy and transmission electron microscopy (TEM) analyses were performed to determine the characteristic bacteriology. Laser scanning confocal microscopy was performed to obtain bioluminescent images, which were used to observe spatial distribution of the GFP‐labelled S. aureus within the tissue and quantify the bacterial bioburden. NPWT resulted in sparse amounts of scattered bacteria on the wound surface or as sparsely spaced single colonies within the tissue. Wound bioburden on day 8 in the NPWT and gauze groups was 34.6 ± 5.5% and 141.9 ± 15.4% of the baseline values (N = 6), respectively (P < .0001). TEM showed a lack of S. aureus active fission within NPWT‐treated tissue. NPWT can impact S. aureus colony morphology and spatial distribution both on the surface and within wound tissue, and reduce S. aureus as early as 48 hours after therapy initiation. Additionally, NPWT inhibits bacterial fissional proliferation in microcolonies.