Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation

Background

Appendicolith can cause appendiceal obstruction and acute appendicitis. Its high prevalence may be related to the high perforation rate in pediatric appendicitis. This study assessed the characteristics of appendicolith and its clinical significance in pediatric appendicitis.

Methods

A retrospective study was performed among children and adolescents younger than 17 years who were preoperatively diagnosed with appendicitis in the pediatric emergency department (ED). A total of 269 patients with a mean age of 9.98 ± 3.37 years were enrolled. Clinical features and contrast-enhanced computed tomography findings were analyzed.

Results

Among the 269 patients, 147 (54.6%) had appendicoliths, with a mean maximal diameter of 5.21 ± 2.34 mm. Compared to the no appendicolith group, the appendicolith group demonstrated more prolonged abdominal pain (≥ 48 hours) before the ED visit (23.1% vs. 11.5%; P = 0.013), clinical features of severe appendicitis (presence of fever, vomiting, positive urine ketone, and increased C-reactive protein), and higher rate of perforation (43.5% vs. 9.8%; P < 0.001). Multivariate risk factor analysis for perforated appendicitis in the appendicolith group revealed that maximal diameter of 5 mm or more in the appendicolith (adjusted odds ratio [aOR] 2.919; 95% CI 1.325–6.428, P = 0.008) and proximal collapse adjacent to the appendicolith (aOR 2.943; 95% CI 1.344–6.443, P = 0.007) were significant.

Conclusions

Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and severe clinical conditions with a high risk of perforation.

     

MRI for clinically suspected pediatric appendicitis: an implemented program

Background

Emergent MRI is now a viable alternative to CT for evaluating appendicitis while avoiding the detrimental effects of ionizing radiation. However, primary employment of MRI in the setting of clinically suspected pediatric appendicitis has remained significantly underutilized.

Objective

To describe our institution’s development and the results of a fully implemented clinical program using MRI as the primary imaging evaluation for children with suspected appendicitis.

Materials and methods

A four-sequence MRI protocol consisting of coronal and axial single-shot turbo spin-echo (SS-TSE) T2, coronal spectral adiabatic inversion recovery (SPAIR), and axial SS-TSE T2 with fat saturation was performed on 208 children, ages 3 to 17?years, with clinically suspected appendicitis. No intravenous or oral contrast material was administered. No sedation was administered. Data collection includes two separate areas: time parameter analysis and MRI diagnostic results.

Results

Diagnostic accuracy of MRI for pediatric appendicitis indicated a sensitivity of 97.6% (CI: 87.1–99.9%), specificity 97.0% (CI: 93.2–99.0%), positive predictive value 88.9% (CI: 76.0–96.3%), and negative predictive value 99.4% (CI: 96.6–99.9%). Time parameter analysis indicated clinical feasibility, with time requested to first sequence obtained mean of 78.7 +/? 52.5?min, median 65?min; first-to-last sequence time stamp mean 14.2 +/? 8.8?min, median 12?min; last sequence to report mean 57.4 +/? 35.2?min, median 46?min. Mean age was 11.2 +/? 3.6?years old. Girls represented 57% of patients.

Conclusion

MRI is an effective and efficient method of imaging children with clinically suspected appendicitis. Using an expedited four-sequence protocol, sensitivity and specificity are comparable to CT while avoiding the detrimental effects of ionizing radiation.     

Seasonal and day of the week variations of perforated appendicitis in US children

Purpose

The present study aimed to determine whether children with perforated appendicitis were more likely to present during specific days of the week or seasons of the year.

Methods

After obtaining IRB exemption, a retrospective, population-based study of patients <18 with ICD9 codes of acute (540.9) or perforated (540.0, 540.1) appendicitis in the Kids’ Inpatient Database (KID) was performed. Univariate and multivariate analyses were performed analyzing patient and hospital factors.

Results

A total of 31,457 children were identified with acute appendicitis, of whom 10,524 (33.5%) were perforated. Mondays [odds ratio (OR): 1.16; 95% Confidence Interval (CI): 1.05?1.28] were significant for increased likelihood as day of presentation with perforation in US children more than any other day of the week. In seasonal analysis, fall (OR: 1.12; 95% CI: 1.04?1.21) and winter (OR: 1.11; 95% CI: 1.03?1.20) were at higher odds for perforation at presentation. Patients with Medicaid (OR: 1.22; 95% CI: 1.03?1.43) and those uninsured (OR: 1.50; 95% CI: 1.16?1.93) were more likely to present with perforation.

Conclusion

Perforated appendicitis was more likely to present on Mondays in US children. Although appendicitis is most common in summer months, rates of perforated appendicitis were highest in fall and winter.     

The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis

Purpose

Early ultrasound (US) evaluation of children with abdominal pain and suspected acute appendicitis (AA) is an important diagnostic tool. Since 2007, US has become part of routine emergency room (ER) work-up performed for suspected pediatric AA in our hospital.

Methods

We retrospectively compared hospital admissions from 2007 to 2008 with those from 2005 to 2006, when most ultrasounds were done after admission to Pediatric Surgery for observation.

Results

During the study (2005?C2008), 6,511 children came to the ER with acute abdominal pain. Although pediatric ER sonography increased from 28.1% (865/3,079) in 2005?C2006 to 51.7% (1,775/3,432) in 2007?C2008 (p?<?0.0001), hospitalizations decreased from 33 to 30.1% (p?=?0.011). Concurrently, ER US for AA increased from 20.8% (639/2,440) to 38.9% (1,336/2,096) (p?<?0.0001), admissions for suspected AA decreased from 51.8% (331/639) to 42% (561/1,336) (p?<?0.0001).

Conclusions

Sonography led to a significant decline in admissions and better selection of patients who required surgery for AA. Recurrent ER referrals for the same complaint within 2?weeks was very low (2.9%) with no difference between the two study periods (p?=?1); none had AA. These findings encourage us to continue early US in children with suspected AA. This effective tool decreases unnecessary hospital stays, investigative procedures, and surgery, while reducing costs.     

A comparison of non-contrast and contrast-enhanced MRI in the initial stage of Legg-Calvé-Perthes disease

Background

A prognostic indicator of outcome for Legg-Calvé-Perthes disease (LCP) is needed to guide treatment decisions during the initial stage of the disease (stage 1), before deformity occurs. Radiographic prognosticators are applicable only after fragmentation (stage II).

Objective

We investigated pre- and postcontrast MRI in depicting stage I femoral head involvement.

Materials and methods

Thirty children with stage I LCP underwent non-contrast coronal T1 fast spin-echo (FSE) and corresponding postcontrast fat-suppressed T1-weighted fast spin-echo (FSE) sequences to quantify the extent of femoral head involvement. Three pediatric radiologists and one pediatric orthopedic surgeon independently measured central head involvement.

Results

Interobserver reliability of percent head involvement using non-contrasted MR images had intraclass correlation coefficient (ICC) of 0.72. Postcontrast MRI improved interobserver reliability (ICC 0.82). Qualitatively, the area of involvement was more clearly visible on contrast-enhanced MRI. A comparison of results obtained by each observer using the two MRI techniques showed no correlation. ICC ranged from ?0.08 to 0.03 for each observer. Generally, greater head involvement was depicted by contrast compared with non-contrast MRI (Pearson r?=??0.37, P?=?0.04).

Conclusion

Pre- and postcontrast MRI assess two different components of stage I LCP. However, contrast-enhanced MRI more clearly depicts the area of involvement.     

Variation in the documentation of findings in pediatric voiding cystourethrogram

Background

Few standards exist for reporting results of voiding cystourethrogram (VCUG).

Objective

To assess the variation in reporting of VCUG findings from different facilities using a standardized assessment tool.

Materials and methods

VCUG reports were evaluated for demographic, technical, anatomical and functional information. Reports were categorized by age, gender, indication and vesicouretal reflux (VUR) status. Institutions were classified as a free-standing pediatric hospital (n?=?3), pediatric hospital within a hospital (n?=?11), or non-pediatric facility (n?=?24) and reports were classified as having been read by a pediatric radiologist or not. Each category of outside reports (n?=?152) was randomly matched with a twice-larger group of Hospital A reports from the same category (n?=?304). Multivariate linear regression was used to analyze the association between the primary outcome (percentage of items described in dictated VCUG report) and the type of radiologist and institution.

Results

Of the 456 studies, 66% were in girls, 56% were in those <12 months old, and the indication was urinary tract infection (UTI) in 81%. The mean percentage of items reported was 67?±?14% (74?±?7% at free-standing pediatric hospitals, 61?±?10% at pediatric hospitals within a hospital, and 48?±?11% at non-pediatric facilities). In multivariate analysis, VCUG reports generated at non-pediatric facilities had 17% fewer items included (95% CI: 14.5–19.7%, P?P?P?Conclusion More complete VCUG reports were observed when generated at free-standing pediatric hospitals and when interpreted by a pediatric radiologist.     

Comparison of in-hospital morbidity and mortality in HIV-infected and uninfected children after surgery

Purpose

Increasingly HIV-infected children can be expected to require surgery. The aim of this study was to compare the outcome of HIV-infected and HIV-unexposed children undergoing surgery.

Patients and methods

A prospective study of children less than or equal to 60?months admitted to a tertiary pediatric surgical service from July 2004 to July 2008. Children underwent age-definitive HIV testing and were followed up postoperatively for complications, length of stay and mortality.

Results

Three hundred and twenty-seven children were enrolled: 82 (23?%) HIV-infected and 245 (67?%) were HIV-unexposed. Eighty-four (26?%) children were malnourished, which was higher in the HIV-infected group [41 (50.0?%) vs. 43 (17.5?%), relative risk (RR) 2.9; 95?% confidence interval (CI) 2.0–4.1; p?<?0.0001]. Three hundred and twenty-eight surgical procedures were performed. A similar number of major [28 (34.2?%) vs. 64 (26.1?%); p?=?0.2] and emergency procedures [37 (45.1?%) vs. 95 (38.8?%); p?=?0.34] were performed in each group. HIV-infected children had a higher rate of contamination at surgery [40 (48.7?%) vs. 49 (20?%); RR 2.43 (CI 1.7–3.4); p?<?0.0001]. There were more complications in the HIV-infected group [34 (41.5?%) vs. 14 (5.7?%); RR 7.3 (CI 4.1–12.8); p?<?0.0001]. The most common complications were surgical site complications 30 (55?%), followed by postoperative infections, 19 (34?%). Infections with drug-resistant organisms occurred more commonly in HIV-infected children [11/19 (58?%) vs. 2/13 (15?%); RR 3.8 (CI 1.3–14.2); p?=?0.02]. The median length of hospital stay was longer in the HIV-infected group [4 (IQR 2–14) vs. 2 (IQR 1–4) days; p?=?0.0001]. There was a higher mortality amongst the HIV-infected group [6 (7.3?%) vs. 0 (0?%); p?<?0.0001].

Conclusion

HIV-infected children have a higher rate of postoperative complications and mortality compared with HIV-unexposed children.     

Acute appendicitis in children: ultrasound and CT findings in negative appendectomy cases

Background

To decrease the negative appendectomy rate in children, knowledge of the misleading imaging findings on US and CT in negative appendicitis cases is important.

Objective

To evaluate the negative appendectomy rate and describe the imaging findings of US and CT that lead radiologists to misdiagnose acute appendicitis in children.

Materials and methods

From 2007 to 2013, 374 children operated for suspected appendicitis were proved to either have acute appendicitis (n?=?348) or to be negative for appendicitis (n?=?26) on pathological reports. Negative appendectomy rates were compared among imaging modalities, age groups and genders. We retrospectively reviewed US and CT findings from negative appendectomy cases.

Results

The overall negative appendectomy rate was 7.0% (26/374). There were no statistically significant differences among the subgroups. The most common misleading presentations on US were sonographic tenderness (9/16, 56%) and non-compressibility (9/16, 56%). The most common misleading finding on CT were the presence of an appendicolith or hyperdense feces (5/12, 42%). Periappendiceal fat inflammation was observed in only one case of negative appendicitis on US and on CT.

Conclusion

Radiologists can misdiagnose children with equivocal diameters of appendices as having acute appendicitis when sonographic tenderness or non-compressibility is present on US and when an appendicolith or hyperdense feces is noted on CT. The possibility of negative appendicitis should be borne in mind when periappendiceal fat inflammation is absent or minimal in indeterminate cases.     

Missed opportunities in the treatment of pediatric appendicitis

Introduction

This study sought to evaluate the outcomes of in-hospital delay and determine associated co-morbidities in the treatment of pediatric acute appendicitis.

Methods

This was a retrospective analysis of the national inpatient sample from 2000 to 2008. Immediate treatment was defined as treatment in hospital day 0 or 1. Delay in treatment was defined as treatment in hospital day 2 and beyond.

Results

During the study period, 683,016 pediatric appendicitis were identified. 17,737 (2.6?%) experienced a delay in treatment. Multivariate analysis identified associated co-morbidities for delay in treatment: ALL (OR 12.84, CI 11.04–14.94), AML (OR 9.41, CI 7.58–11.68), neutropenia (OR 5.53, CI 4.60–6.65), and ovarian cyst without torsion (OR 3.17, CI 2.94–3.42). Surgical management included more than 13-fold increase in drainage procedures (5.5 vs. 0.4?%), sixfold increase in cecectomy (1.2 vs. 0.2?%), 14-fold increase in hemicolectomy (1.4 vs. 0.1?%), 11-fold increase in small bowel laceration suture repair (1.1 vs. 0.1?%), and 15-fold increase in small bowel resection (1.5 vs. 0.1?%).

Conclusions

In-hospital delay beyond 2?days is associated with significant negative outcomes with regard to complications, economic burden, and subsequent surgical management. Using the co-morbidity index, high-risk co-morbidities with associated delay in treatment were identified.     

The evaluation of the validity of Alvarado,Eskelinen, Lintula and Ohmann scoring systems in diagnosing acute appendicitis in children

Purpose

To show whether Alvarado, Eskelinen, Lintula and Ohmann scoring systems have predictive values in diagnosing acute appendicitis in children.

Methods

Sixty patients with suspected acute appendicitis were prospectively evaluated. Alvarado, Eskelinen, Lintula and Ohmann scores were calculated separately for each patient at the time of admission. The specificity, sensitivity, positive and negative predictive values of the scores were calculated. The predictive value of the scores was evaluated with the receiver operating characteristic (ROC) curve and the consistency among the scores by Kappa test.

Results

Twenty of the patients were female (33.3 %). The mean age of the patients was 9.9 years (3–16 years). Forty two patients were operated and appendectomies were performed with the diagnosis of acute appendicitis. The area under the ROC curve showed that the scores had no predictive value in diagnosing acute appendicitis. Kappa test showed that agreement between the scores was not good.

Conclusion

The sensitivity and specificity of the four scoring systems were not sufficient enough in diagnosing acute appendicitis in our patient group. We concluded that the most important factor affecting the decision for surgery in suspected acute appendicitis is the surgeon’s experience combined with physical findings of repeated clinical examinations.     

Accuracy of abdominal ultrasound and MRI for detection of Crohn disease and ulcerative colitis in children

Background

Endoscopy is currently the primary diagnostic technique for inflammatory bowel disease (IBD) in children.

Objective

To assess the accuracy of US and dynamic contrast-enhanced MRI for diagnosing inflammatory bowel disease and for distinguishing Crohn disease and ulcerative colitis in comparison to a reference standard.

Materials and methods

Consecutive children with suspected IBD underwent diagnostic workup including ileocolonoscopy and upper gastrointestinal endoscopy as the reference standard, abdominal US, and MR enterography and colonography at 3 T. The protocol included a dynamic contrast-enhanced 3-D sequence. Sensitivity, specificity and kappa values were calculated for one ultrasonographer and two MRI observers.

Results

We included 28 children (15 boys) with mean age 14 years (range 10–17 years). The diagnosis was IBD in 23 children (72%), including 12 with Crohn disease, 10 with ulcerative colitis and 1 with indeterminate colitis. For the diagnosis of inflammatory bowel disease the sensitivity was 55% for US and 57% (both observers) for MR entero- and colonography, and the specificity was 100% for US and 100% (observer 1) and 75% (observer 2) for MR entero- and colonography. Combined MRI and US had sensitivity and specificity of 70% and 100% (observer 1) and 74% and 80% (observer 2), respectively. With the addition of a dynamic contrast-enhanced MR sequence, the sensitivity increased to 83% and 87%. US and MRI could only distinguish between Crohn disease and ulcerative colitis when terminal ileum lesions were present.

Conclusion

US and MR entero- and colonography have a high accuracy for diagnosing inflammatory bowel disease in children but cannot be used to distinguish Crohn disease and ulcerative colitis.     

Magnetic resonance imaging in children with sickle cell disease—detecting alterations in the apparent diffusion coefficient in hips with avascular necrosis

Background

Avascular necrosis (AVN) is a common morbidity in children with sickle cell disease (SCD) that leads to pain and joint immobility. However, the diagnosis is often uncertain or delayed.

Objective

To examine the ability of apparent diffusion coefficient (ADC) measurements on diffusion-weighted imaging to detect AVN in children with SCD.

Materials and methods

ADC values were calculated at the hips of normal children (n?=?19) and children with SCD who were either asymptomatic with no known previous hip disease (n?=?13) or presented for the first time with clinical symptoms of hip pathology (n?=?12). ADC values were compared for differences among groups with and without AVN using non-parametric statistical methods.

Results

The ADC values were elevated in the hips of children with AVN (median ADC?=?1.57?×?10^?3?mm²/s [95% confidence interval?=?0.86–2.10]) and differed significantly in pairwise comparisons (all P?Conclusion Children with sickle cell disease have elevated apparent diffusion coefficient values in their affected hips on initial diagnosis of avascular necrosis.     

Lactobacillus rhamnosus GG supplementation for preventing respiratory infections in children: A Meta-analysis of Randomized, Placebo-controlled Trials

Objective

To systematically review the effectiveness of administering Lactobacillus rhamnosus GG (LGG) for preventing respiratory infections in children.

Design

Systematic Review and Meta-analysis.

Data sources

Electronic databases and trial registries.

Results

Four RCTs involving 1805 participants met the inclusion criteria. Compared with placebo, LGG administration was associated with a reduced incidence of acute otitis media (four RCTs, n=1805, RR 0.76, 95% CI 0.64–0.91, fixed effects model, NNT 17, 95% CI 11–46), a reduced risk of upper respiratory infections (one RCT, n=281, RR 0.62, 95% CI 0.50–0.78, NNT 4, 95% CI 3–8) and antibiotic treatments (four RCTs, n=1805, RR 0.80, 95% CI 0.71–0.91, fixed effects model). There was no significant difference between the LGG and the control groups in the risk of overall respiratory infections and the incidence of lower respiratory infections. However, subgroup analysis of two studies on children older than 1 year showed significant reduction in the risk of overall respiratory infections (two RCTs, n=794, RR 0.73, 95% CI 0.57–0.92, random effects model, NNT 8, 95% CI 5–14). Adverse effects were similar in both groups. No serious adverse events were reported.

Conclusion

The administration of Lactobacillus rhamnosus GG compared with placebo has the potential to reduce the incidence of acute otitis media, the upper respiratory infections and antibiotic use in children.     

Predictors of mortality in neonates with meconium aspiration syndrome

Objective

To identify risk factors for mortality in neonates with meconium aspiration syndrome.

Methods

All neonates (2004–2010) with meconium aspiration syndrome, irrespective of gestation were included. Risk factors were compared between those who died and survived.

Results

Out of 172 included neonates, 44 (26%) died. Mean (SD) gestation and birth weight were 37.9 (2.3) weeks and 2545 (646g), respectively. Myocardial dysfunction [aOR 28.4; 95% CI (8.0–101); P<0.001] and higher initial oxygen requirement [aOR 1.04; 95% CI (1.02–1.07); P<0.001] increased odds of dying while a higher birth weight [aOR 0.998; 95% CI (0.997–1.00); P=0.005] reduced the odds of dying.

Conclusions

Meconium aspiration syndrome is associated with significant mortality. Myocardial dysfunction, birth weight, and initial oxygen requirement are independent predictors of mortality.     

Prevalence of Monosymptomatic Nocturnal Enuresis and its Correlates in School Going Children of Lucknow

Objectives

To determine the prevalence of primary monosymptomatic nocturnal enuresis (PMNE) and its correlates in school going children of Lucknow.

Methods

It is a cross-sectional school based study conducted in a random sample of 1212 school going children of Lucknow belonging to the middle socioeconomic strata. Data was collected via questionnaire designed for parents. Detailed urological history was obtained and physical examination done in the children whose parents answered the questionnaire. The chi-square test was used to compare the categorical/dichotomous indicators and backward logistic regression was used to find out the significant risk factors for monosymptomatic nocturnal enuresis.

Results

Study reports the prevalence of PMNE to be 12.6 % (95 % CI?=?10.9–14.3 %) and significant association of enuresis with the presence of home conflicts(adjusted OR?=?38.37, 95 % CI?=?20.04–73.47), stress in children due to enuresis(adjusted OR?=?10.86, 95%CI?=?5.73–20.57), scolding(adjusted OR?=?6.78,95%CI?=?3.69–12.44), parental history of enuresis(adjusted OR?=?3.57, 95%CI?=?1.96–6.50), poor scholastic performance(adjusted OR?=?2.88,95 %?=?1.49–5.56), age 6–8 y (adjusted OR?=?13.80,95%CI?=?4.38–43.45) and living with single parent (adjusted OR?=?0.34, 95%CI?=?0.17–0.68). Prevalence of monosymptmatic nocturnal enuresis MNE was 17.9 % (p?=?0.001) among children who were not exclusively breastfed till 6 mo of age in the index study.

Conclusions

Enuresis is a pediatric health problem with high prevalence . Parental awareness needs to be created about this condition.     

What is the impact of the use of transanastomotic feeding tube on patients with esophageal atresia: a systematic review and meta-analysis

Background

The transanastomotic feeding tube (TAFT) is widely used around the world in patients with esophageal atresia (EA). However, the safety of the use of TAFT is still unknown and remains to be clarified.

Methods

The following electronic databases were searched: PubMed, EMBASE and Cochrane. Studies comparing outcomes in patients with the use of TAFT (TAFT+) and patients without the use of TAFT (TAFT-) were scrutinized. The quality of included studies was evaluated with the Newcastle–Ottawa scale score. Statistical heterogeneity was assessed using the I² value. A fixed or random-effect model was applied.

Results

Four retrospective controlled studies involving 455 patients were included. The pooled estimates showed that the use of TAFT significantly increased the risk of stricture, with a risk ratio (RR) of 1.83 (95% CI 1.30–2.58; P?=?0.0005). The meta-analyses of other postoperative complications did not show significant differences between TAFT+ and TAFT- group, with a RR of 1.65 (95% CI 0.93–2.93; P?=?0.09) for anastomotic leakage, 0.91 (95% CI 0.34–2.44; P?=?0.85) for sepsis, 1.89 (95% CI 0.22–16.20; P?=?0.56) for tracheomalacia, 0.50 (95% CI 0.13–1.93; P?=?0.31) for gastroesophageal reflux, 1.29 (95% CI 0.28–5.92; P?=?0.74) for wound infection, and 0.97 (95% CI 0.03–36.75; p?=?0.99) for pneumonia.

Conclusions

This study demonstrates that the use of TAFT in patients with EA significantly increases the risk of stricture. However, TAFT is not associated with other complications, including anastomotic leakage, sepsis, tracheomalacia, gastroesophageal reflux, wound infection and pneumonia.

     

Needle core biopsy in the diagnosis of pediatric thyroid neoplasms: a single institution retrospective review

Purpose

Our institution routinely utilizes needle core biopsy (NCB), instead of fine needle aspiration, in the evaluation of pediatric thyroid nodules. This practice initially arose from limited cytopathology services in our hospital. Given the lack of information regarding the utility of NCB in diagnosing pediatric thyroid neoplasms, we set out to review our institution’s experience with this technique.

Methods

We performed a single institution retrospective chart review of all children who underwent thyroidectomy for primary thyroid pathology.

Results

Seventy-four patients, with a mean age of 12.9 ± 4.5 (SD) years, underwent partial or total thyroidectomy between 2002 and 2010. Seven of these patients had medically refractive hyperthyroidism. The remaining 67 patients had one or more thyroid nodules as identified by ultrasound. 24 (36 %) of these cases were malignant on final pathology. 14 (58 %) of the malignant cases were papillary thyroid carcinoma. 46 of the thyroid nodule cases underwent pre-operative NCB. Biopsy results for these patients were non-diagnostic in 6 (13 %), benign in 11 (24 %), atypical in 17 (37 %), and malignant in 12 (26 %). There were no complications arising from NCB. Sensitivity of NCB for diagnosing papillary carcinoma (PC) and follicular neoplasm was calculated at 0.88 (0.47–1.0, 95 % CI) and 0.84 (0.60–0.97, 95 % CI), respectively. Of the 28 patients not undergoing preoperative NCB, 12 underwent hemithyroidectomy, with one patient (8 %) requiring completion thyroidectomy for PC. Overall, the sensitivity of NCB in diagnosing PC and follicular thyroid neoplasms was 0.85 (0.55–0.99, 95 % CI), while the specificity was 0.63 (0.42–0.82, 95 % CI).

Conclusions

Needle core biopsy appears to have a low rate of associated complications, and its sensitivity for diagnosing PC and follicular neoplasm is comparable to what has been reported for fine needle aspiration biopsy in a similar patient population.     

Ovary-sparing surgery for teratomas in children

Aim

To share our experience in ovary-sparing surgery for teratomas in children.

Patients and methods

The medical records of nine patients (mean age of 11.2 years, r 6–15 years) who had undergone ovary-sparing surgery for teratoma were analyzed retrospectively. Mean duration for follow-up was 29.5 months (r 15–75 months).

Results

Five patients suffered from chronic abdominal pain; two had acute colicky abdominal pain. In two patients, there was no presenting clinical symptom. Two patients were operated on emergency basis due to symptoms related with acute abdomen. On the other hand, seven were operated electively. Ultrasonography was performed in all patients. Additionally, MRI and tumor markers were performed in all but two. Main radiologic findings consisted of heterogenous cystic and solid ovarian masses predictive of teratoma. The definitive diagnosis in emergency cases were as follows: perforated appendicitis plus teratoma [1]; torsion of the ovarian mass with teratoma [1]. The final diagnosis in electively treated seven patients were: unilateral ovarian teratoma [4], bilateral ovarian teratoma [1], bilateral teratoma plus appendiceal inflammatory mass [1], unilateral teratoma and contralateral corpus hemorrhagicum cyst [1]. The operations were performed by open conventional surgery in six and laparoscopy in three patients. The procedures were ovary-sparing surgery in 12 ovaries, appendectomy in 2 patients and detorsion of ovary in 1 patient. The main indication for ovary-sparing surgery was the “existence of a perfect dissection plane between the tumor margins and healthy ovarian tissue”. The remaining ovarian tissue was evaluated macroscopically for residual lesions. Frozen section was performed in three suspected patients and the ovarian margins were free of any tumor cell. The pathologic diagnosis was: mature cystic teratoma in 10, immature teratoma in 1 and corpus hemorrhagicum cyst in 1. The postoperative outcome and follow-up was uneventful.

Conclusion

Heterogenous ovary mass containing solid and cystic portions with echogenic areas on ultrasound imaging is highly suggestive of ovarian teratomas. Emergent surgical intervention is indicated if there is any suspicion of ovarian torsion. Otherwise, MRI is performed for further radiological evaluation. Based on radiologic findings, ovary-sparing surgery can be safely performed if the preoperative diagnosis is teratoma and there is always a plane of dissection between the normal ovary and cyst wall.     

Practice variation and clinical confusion regarding undescended testes and retractile testes among primary care respondents: a multi-regional survey study in the United States

Purpose

Although previous studies have looked at referral patterns and indications for orchiopexy, this is the first attempt at quantifying the primary care provider knowledge base of cryptorchidism and its implications in a large multi-state setting in the United States.

Methods

Primary care providers (PCPs) (n?=?3,000) were invited to complete a web-based survey regarding cryptorchidism. We evaluated: practice setting; training; knowledge of cryptorchidism; relationship to pediatric urologists and surgeons; understanding of the relationship between cryptorchidism, infertility and testis cancer.

Results

Seventeen percent (n?=?453) of PCPs responded to the survey. Fifty-three percent indicated that they had minimal to no exposure to pediatric urology during training. Two-thirds refer patients with retractile testes to surgical specialists. Practice setting was associated with the type of information families received about the impact of UDT on fertility and malignancy with rural practices being more likely to counsel that unilateral UDT imparted a high risk of malignancy (RR 1.5; 95?% CI 1.2, 1.9) and bilateral UDT resulted in likely infertility (RR 2.1; 95?% CI 1.5, 2.8).

Conclusions

This study underscores the need for increased evidence-based recommendations, as well as improved training and education of PCPs in the US who deal with disorders of testicular descent.     

Urinary biomarkers in pediatric appendicitis

Purpose

The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis.

Methods

A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis.

Results

Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79–0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value.

Conclusion

LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.