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Objective: The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED). Methods: A literature search was conducted to identify potential CPSs and a single‐center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5–15 years presenting with acute right‐sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician‐collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low‐risk or high‐risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow‐up for those discharged directly from ED. Results: Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC‐ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86–0.94) and specificity 99.0% (95% CI 96.4%–99.7%) in diagnosing high‐risk cases and a misclassification rate of 4.5% for low‐risk cases. Conclusions: The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC‐ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings. [ABSTRACT FROM AUTHOR]

Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer. Aims: describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity). Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy. There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes. Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy. [ABSTRACT FROM AUTHOR]

Background: In contrast to many countries, the prevalence of COVID‐19 in Australia and New Zealand has been low. We hypothesised, however, that a potential secondary effect of the COVID‐19 pandemic would be delayed presentation of paediatric appendicitis, with resultant higher rates of complicated appendicitis. This study was an initiative of the Australian and New Zealand Surgery in Children Registrars' Association for Trials collaborative, a trainee‐led research group based in Australia and New Zealand. Methods: A binational multicentre, retrospective review was undertaken of paediatric patients with appendicitis early in the COVID‐19 pandemic (20 March–30 April 2020), compared with previous years (2018, 2019). Primary outcomes were the duration of symptoms prior to presentation and the severity of disease. Results: A total of 400 patients from six centres were included. Duration of symptoms prior to presentation, sepsis at presentation, complicated disease and presence of complications did not differ significantly between time periods. Duration of intravenous antibiotic treatment and overall antibiotic treatment were both significantly shorter during 2020 (2.4 days versus 3.5 in 2018 and 3.0 in 2019 [P = 0.0038] and 3.7 days versus 5.2 in 2018 and 4.6 in 2019 [P = 0.04], respectively). Management approach did not differ, with the majority of patients managed operatively. Conclusions: We did not demonstrate any difference in duration of symptoms prior to presentation or other markers of disease severity early in the pandemic. Duration of antibiotic treatment was shorter during this period compared with previous years. Management of children with appendicitis, both simple and complicated, did not appear to change as a result of COVID‐19. [ABSTRACT FROM AUTHOR]

Background: Appendicitis is a leading cause of surgical hospital admission. To date, there have been no published epidemiological studies describing appendicitis in tropical and remote Australia and none specifically documenting appendicitis in Indigenous Australians. This descriptive study used available state data to investigate appendicitis across Far North Queensland (FNQ). Methods: Queensland Health hospital admission data for FNQ was analysed to explore appendicitis epidemiology and outcomes in FNQ, 2012–2018. Population data for the same time period provided rates. Results: Over the study period, 3458 hospital presentations for appendicitis were available for analysis. Mean incidence was 178 per 100 000/yr. Median age was 27 years with 50.1% female patients. The annual rate of appendicitis was higher in the Indigenous population. Most patients had a laparoscopic procedure with a low rate of conversion to open surgery (2.6%). More than 80% of patients were discharged from hospital in less than 3 days. Intensive care (ICU) admission rate was low overall (1.1%) although higher for Indigenous people (2.4%). Following discharge, the hospital re‐admission rate was 3.8% and all‐cause mortality was 0.03%. Conclusion: The incidence of appendicitis in FNQ is higher than that reported in the rest of Australia in both Indigenous and non‐Indigenous populations. Despite logistical challenges of health care, clinical outcomes are in line with best practice across the country. Clinicians in FNQ should maintain a high index of suspicion for diagnosing appendicitis in rural and remote settings. [ABSTRACT FROM AUTHOR]

Background: In Australia, there has been a shift from the traditional 'on‐call' surgical model to the 'acute surgical unit' (ASU) model to improve outcomes in acute general surgery. Using emergency appendicectomy as a standardized procedure, we aimed to identify the different patterns of care between these on‐call structures by comparing two metropolitan district hospitals; one that employs a traditional on‐call model and the other, which employ the ASU model. Methods: Data on consecutive patients undergoing emergency appendectomies at the two hospitals (traditional and ASU model) between July 2018 and December 2018 were retrieved for retrospective review. Patient factors, preoperative factors, operative factors and post‐operative outcomes were collected and tabulated for comparative analysis between the traditional versus ASU model of care. Results: Univariate analysis demonstrated that there were a greater proportion of consultant‐led cases (P < 0.001), a shorter time to theatre (P = 0.047) and a greater number of out‐of‐hours operations (P < 0.001) in the ASU model compared to the traditional model. A larger proportion of patients from the traditional model underwent a computed tomography scan as part of their diagnostic workup compared to the ASU model (P < 0.001). There was no difference in negative appendicectomy rates, intraoperative conversion rates, post‐operative complication rates or mean lengths of hospital stay between the two on‐call models. Conclusion: The ASU and traditional on‐call model appears to achieve equivalent care outcomes for patients with acute appendicitis. [ABSTRACT FROM AUTHOR]

Background: Acute Appendicitis is the most common surgical presentation within Australia. Despite the increasing use of radiological investigations to aid clinical diagnosis, many appendectomies result in a histologically normal appendix. This study examines the histological negative appendicectomy rate (NAR) in a metropolitan hospital and determine factors associated with a negative appendicectomy (NA). Methods: Patients who underwent emergency appendicectomy for suspected acute appendicitis at Logan Hospital, Australia, between February 2016 and March 2019 inclusive were included. Clinicopathologic and imaging variables were analysed for associations with NA. Results: A total of 1241 patients underwent emergency appendicectomy of which 121 patients (9.8%) had a NA. The NAR for clinical diagnosis alone (no imaging) was 9.9%, 14.5% for ultrasonography alone and computed tomography scan alone was 4.9%. Univariate analysis revealed age <27 years (P < 0.001), absence of hypertension (P = 0.008), symptoms >48 hours (P < 0.001), absence of leucocytosis (P < 0.001), undergoing ultrasonography only (P < 0.001), undergoing computed tomography scan only (P < 0.001), macroscopically normal appendix (P < 0.001) and time to operation >24 hours (P < 0.001) were associated with NA. Multivariate analysis identified symptoms >48 h at presentation (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.20–3.24; P = 0.007), absence of leucocytosis (OR 2.41, 95% CI 1.52–3.81; P < 0.001) and macroscopically normal appendix (OR 5.70, 95% CI 3.49–9.33; P < 0.001) to be associated with a NA. Conclusion: The NAR reported is lowest in an Australian institution. The identified predictors of NA will be useful in identifying patients who would truly benefit from an appendicectomy versus those would have a higher rate of NA who may be suitable to be treated non‐operatively to be spared the unnecessary morbidity of surgery. A low negative appendicectomy rate may be achieved by careful clinical assessment by elucidating a patients signs and symptom duration with blood test results assessing for leucocytosis. [ABSTRACT FROM AUTHOR]

Background: This study aims to establish compliance levels to prescription guidelines among Australian surgeons in the use of antibiotics in the surgical management of appendicitis. The secondary outcomes are predictors of post‐operative infective complications; surgical site infection (SSI) and intra‐abdominal abscess (IAA) at 30 days. Methods: A multi‐centre, prospective, observational study was conducted over a period of 2 months with a 30‐day follow‐up. Patients were eligible for recruitment if they underwent appendicectomy for suspected appendicitis. Antibiotics prescription practices were recorded and compared to national guidelines. Results: A total of 1189 patients were recruited across 27 centres; 1081 (92.1%) patients were given prophylactic antibiotics at the time of appendicectomy. Patients with gangrenous appendicitis were more likely to receive prophylactic antibiotics (98.9%); lower rates of use were seen in the non‐appendicitis group (85.7%). A total of 619 (53.3%) patients received antibiotics in the post‐operative period. Despite recommendations, 300 (44.3%) patients with simple appendicitis received post‐operative antibiotics. Only six (2.9%) patients with complicated appendicitis did not receive antibiotics. Overall, SSI and IAA rates were 1.9% and 2.7%, respectively. Aboriginal and Torres Strait Islanders (P = 0.02) and patients with converted operations (P = 0.001) were more likely to have a SSI. Patients with complicated appendicitis and those operated on by a consultant were more likely to increase the odds of IAA (odds ratio 3.8 and 5.1, respectively). Conclusion: This broad‐based study shows mixed compliance with antibiotic guidelines in the surgical management of appendicitis in Australia. The use of post‐operative antibiotics in patients with simple appendicitis should be a target for antimicrobial stewardship programmes to prevent antibiotic over‐utilization. [ABSTRACT FROM AUTHOR]

Malignant hyperthermia (MH) is a rare hypermetabolic state that may be triggered by both anaesthesia and non-anaesthesia triggers. The main anaesthesia triggers for MH are the depolarising muscle relaxant suxamethonium and volatile anaesthetic gases. MH presents in several ways with not all clinical symptoms being required to make a diagnosis. Safe and efficient patient management of MH requires knowledge and understanding of this inherited disorder. The perioperative team need to be aware of the tasks that are required to manage this emergency. This case study will discuss a suspected episode of MH presenting in a patient late on Christmas Eve 2018 in a regional facility. Access to the reversal drug dantrolene provided an additional challenge. The increase in knowledge gained by nursing staff involved in the management of this crisis proved to be a significant learning curve for all involved. It is hoped that this paper will enable other perioperative nurses to benefit from this experience. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this paper was to describe the characteristics of paediatric patients who underwent an aeromedical retrieval within Australia (gender and Indigenous status) for suspected appendicitis between 1 July 2014 and 30 June 2018 (4 years). By understanding these trends, we hope to further justify the need for point‐of‐care ultrasound training for clinicians working in rural and remote Australia. Method: Participants included Royal Flying Doctor Service (RFDS) patients aged 0–18 years (inclusive) who underwent an aeromedical retrieval for suspected appendicitis within Australia. Data were collected and coded on each patient's inflight working diagnosis, using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‐10‐AM) coding method. A combination of descriptive statistics and chi‐square analyses was used in data analysis, with significance considered at <0.05. Results: There were 384 children with a working diagnosis of suspected appendicitis, including 191 (49.7%) males and 193 (50.3%) females, with 133 (34.6%) patients identifying as Aboriginal and/or Torres Strait Islander (hereafter referred to as Indigenous) Australians. The aeromedical retrievals were from rural and remote locations to inner‐regional or metropolitan hospitals, with an average distance flown of 339.0 (SD = 206.4) kilometres. The RFDS most frequently retrieved for acute appendicitis (n = 159; 41.4%), acute abdominal pain (n = 127; 33.1%), and unspecified appendicitis (n = 84; 21.9%). There were non‐significant (P = 0.9) diagnostic differences between genders. Non‐Indigenous patients were overrepresented, compared with Indigenous patients, in relation to a transfer with a diagnosis of acute appendicitis (P = <0.01), whereas Indigenous patients were overrepresented, compared with non‐Indigenous patients, in relation to transfers with diagnoses of acute abdomen pain and unspecified appendicitis (P = <0.01). Conclusion: A significant number of paediatric patients are aeromedically retrieved from rural and remote locations with a diagnosis of appendicitis or acute abdominal pain. Future research should consider whether training in abdominal point‐of‐care ultrasound reduces retrievals. [ABSTRACT FROM AUTHOR]

Despite the prevalence of schistosomiasis across the world, appendicitis secondary to schistosomiasis is a rarely encountered presentation even in endemic areas, let alone in developed Western countries. We report a case of a 34-year-old male in Australia with acute appendicitis and subsequent histopathology, demonstrating the presence of schistosome ova. The case highlights the difficulties in pre-operative diagnosis of this entity and the importance of its recognition for the practising surgeon, especially in the developed world, where this rare condition may be encountered because of changing global travel and migration patterns. [ABSTRACT FROM AUTHOR]

Background: Suspected appendicitis is a common non‐obstetric indication for emergency abdominal surgery during pregnancy. Aims: Assess the risk of preterm birth and other maternal and neonatal adverse birth outcomes following appendicectomy during pregnancy. Materials and Methods: Population‐based data linkage study of women with singleton births in New South Wales, Australia, 2002–2014. Pregnancies with appendicitis and appendicectomy were compared to pregnancies without appendicitis. Crude and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for preterm birth were estimated. Modified Poisson regression with robust variance was used to estimate crude and adjusted risk ratios (aRR) with 99% CI for other outcomes. Results: Of 1 124 551 eligible pregnancies, 1024 (0.9/1000 pregnancies) had appendicitis and appendicectomy. Of these, 566 (55.3%) had laparoscopic and 458 (44.7%) had open appendicectomy. Appendicectomy at later gestational ages was associated with increasing rates of preterm birth. After adjustment for maternal and pregnancy factors, appendicectomy was associated with increased risk of preterm birth (overall aHR 1.73, 95% CI 1.42–2.09; planned aHR 2.08, 95% CI 1.60–2.72), maternal morbidity (aRR 2.68, 99% CI 1.88–3.83) and neonatal morbidity (aRR 1.42, 99% CI 1.03–1.94). However, there was no difference in perinatal mortality rates. Conclusion: Appendicectomy during pregnancy is associated with increased risk of spontaneous and planned preterm birth, maternal and neonatal morbidity. Availability of resources to prevent or manage preterm labour should be considered when appendicectomy is performed at gestational ages of 20 weeks or more. [ABSTRACT FROM AUTHOR]

The article discusses the Tranexamic acid (TXA) which reduces surgical bleeding and is beneficial in traumatic and postpartum haemorrhage. It mentions that the research had suggested benefit with GI haemorrhage as well; and the objectives of this trial were to determine the effect of TXA on death and complications in patients with acute GI bleeding.

Background: The provision of emergency general surgical services is undergoing a paradigm shift towards a consultant led, patient centered model in order to improve patient outcomes. The aim of this current study is to use meta-analytical techniques to assess the efficacy of acute surgical unit (ASU) in appendectomy.Methods: A meta-analysis was conducted according to the PRISMA guidelines. A comprehensive literature search of PubMed, Embase and Scopus for published studies comparing ASU and traditional (TRAD) model on appendectomy outcomes was performed. Random-effects methods were used to analyze key outcomes with data presented as odds ratio (OR) with 95% confidence interval (CI).Results: Fourteen comparative studies describing outcomes in 7980 patients were identified, 4258 patients were included in the ASU model (53.4%). ASU model had a shorter time to theatre (WMD: -0.40, 95% CI: -0.65 to 0.15, p: 0.002), length of hospital stay (WMD: -0.25, 95% CI: -0.46 to -0.05, p: 0.02) and complication rate (OR: 0.76, 95% CI: 0.59 to 0.99, p: 0.04) for appendectomy patients. ASU model did not significantly affect night time operating (OR: 1.04, 95% CI: 0.66 to 1.65, p: 0.86) negative appendectomy rates (OR: 0.98, 95% CI: 0.77-1.27, p: 0.91) or conversion rate (OR: 1.45, 95% CI: 0.70 to 2.98, p: 0.32).Conclusion: ASU model improves outcomes and quality of care in patients undergoing emergency appendectomy without any adverse implications. [ABSTRACT FROM AUTHOR]

Objectives To describe current practice in managing children with possible acute appendicitis in EDs in Australia and New Zealand as the basis for a clinical practice guideline ( CPG). Methods An anonymous survey was distributed to consultant emergency physicians working at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand in April 2013. A second, site-based survey was distributed to the PREDICT representatives at each of the 13 sites. Results The response rate was 100% (13/13) for the site-based survey and 82% (145/176) for the physician survey. Most respondents agreed that right lower quadrant ( RLQ) tenderness (94%), anorexia (92%), migration of abdominal pain to the RLQ (86%), rebound tenderness in the RLQ (60%) and RLQ tenderness produced on coughing, hopping or percussion (63%) were valuable symptoms and signs in diagnosing appendicitis. The responses regarding nausea and vomiting and fever were less consistent. Less than 50% regarded blood tests (C-reactive protein, white cell count) as relevant for the diagnosis of appendicitis. Most physicians (61%) agreed there was a role for a validated CPG for possible appendicitis in children, although only 3/13 sites reported use of such a CPG. Conclusions This survey of senior emergency physicians across Australia and New Zealand demonstrated congruence in several clinical markers and disagreements in others in the approach to diagnosing children with possible appendicitis. Whereas emergency physicians would like a validated CPG, this survey has highlighted some critical issues. Particularly, the low regard for blood tests, integral to published diagnostic scoring systems, will be a challenge for the development and introduction of such a CPG in Australia and New Zealand. [ABSTRACT FROM AUTHOR]

Objectives To describe the burden of disease and hospitalisation costs in children with common infections using statewide administrative data. Methods We analysed hospitalisation prevalence and costs for 10 infections: appendicitis, cellulitis, cervical lymphadenitis, meningitis, osteomyelitis, pneumonia, pyelonephritis, sepsis, septic arthritis, and urinary tract infections in children aged <18 years admitted to hospital within New South Wales, Australia, using an activity-based management administrative dataset over three financial years (1 July 2016-30 June 2019). Results Among 339 077 admissions, 28 748 (8.48%) were coded with one of the 10 infections, associated with a total hospitalisation cost of AUD230 905 190 and a per episode median length-of-stay of 3 bed-days. Pneumonia was the most prevalent coded infection (3.1% [n  = 10 524] of all admissions), followed by appendicitis (1.61%; n  = 5460), cellulitis (1.22%; n  = 4126) and urinary tract infections (0.94%; n  = 3193). Eighty per cent of children (n  = 22 529) were admitted to a non-paediatric hospital. Mean costs were increased 1.18-fold per additional bed-day, 2.14-fold with paediatric hospital admissions, and 5.49-fold with intensive care unit admissions, which were both also associated with greater total bed-day occupancy. Indigenous children comprised 9.7% of children admitted with these infections, and mean per episode costs, and median bed-days were reduced compared with non-Indigenous children (0.84 [95% CI 0.78, 0.89] and 3 (IQR: 2,5) vs 2 (IQR: 2,4), respectively. Conclusions Infections in children requiring hospitalisation contributea substantial burden of disease and cost to the community. This varies by infection, facility type, and patient demographics, and this information should be used to inform and prioritise programs to improve care for children.

Objective: There is a growing body of evidence suggesting that administration of analgesia in paediatric ED is inadequate. The present study was designed to assess pain score documentation and provision of opioid analgesia to children and adults with confirmed appendicitis in a mixed Australian ED. Method: A retrospective chart review of all adults and children with histologically confirmed appendicitis diagnosed in the Townsville ED during 2006 was performed. Data collected included pain score documentation, weight, opioid dose, oral analgesia, time of presentation, level of doctor and prehospital analgesia. Results: Data were collected for 106 adults and 39 children. Among them, 13 (33%) children compared with 79 (75%) adults had a pain score documented (OR 0.16, 95% CI 0.07–0.37, P < 0.001). And 11 (28%) children compared with 79 (75%) adults received i.v. morphine (OR 0.13, 95% CI 0.06–0.31, P < 0.001). Administration of oral analgesia lowered the likelihood and pain score documentation increased the likelihood of receiving morphine in both children and adults. Conclusion: Documentation of pain scores and provision of i.v. morphine is generally poor. Children are less likely than adults to have a pain score documented, or receive i.v. morphine when presenting with appendicitis. [ABSTRACT FROM AUTHOR]

Background: There is evidence that antibiotics can be used as primary treatment for appendicitis, however, delayed surgical treatment might still be associated with perforation. Most patients at risk of perforation have high Alvarado scores. We designed a protocol-based approach to suspected appendicitis, in which the Alvarado score was used to select patients for early treatment with surgery or outpatient antibiotics. Methods: Patients included in the present study were adults and children referred to the surgical service at John Hunter Hospital (Newcastle, Australia) with suspected appendicitis in the 12 months from July 2000. Treatment groups: no treatment (Alvarado score 1-4); antibiotics alone (Alvarado 5-7); early surgery (Alvarado 8-10). Outcome measures: time to operation; duration of hospital stay; non-therapeutic operations; delayed treatment in association with perforation; recurrent appendicitis (for those treated with anti- biotics). Comparison group: 142 patients managed with `best clinical practice' as part of an earlier trial. Results: One hundred and twenty-two patients were enrolled. Median time to operation was 3.9 h (comparison group 7.3 h, P = 0.014). Median length of stay was 38.5 h (comparison group 44.2 h, P = 0.041). There were two cases of delayed treatment in association with perforation (2/122 = 1.6%, comparison group 2/142 = 1.4%, P = 0.88) and 10 non-therapeutic operations (10/122 = 8.1%, comparison group 15/142 = 10.6%, P = 0.51). Of those whose initial illness was treated successfully with antibiotics, 2/42 (4.8%) subsequently required appendicectomy. Conclusions: This protocol-based approach to suspected appendicitis is feasible. A prospective controlled study would be required to confirm potential benefits (in terms of short hospital stay) and to confirm that there is not an increase in adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: Omental infarction is a rare cause of an acute abdomen with nonspecific signs that can be easily mistaken with other more common intra-abdominal pathologies. The increased use of radiological imaging has brought this diagnosis to attention with respect to management plan. We present the experience of an Australian hospital network with the diagnosis and management of omental infarction to raise awareness of this uncommon pathology., Methods: A retrospective review of medical records of adult patients diagnosed with omental infarction from 2010 to 2020 was conducted across four major hospitals in South Western Sydney. Data relating to clinical presentation, investigations, management and outcomes were obtained., Results: Omental infarction was diagnosed in 61 patients (mean 51.1 years, range: 19-76 years old). All patients presented with nonspecific abdominal pain with the most common sites being the right iliac fossa followed by the right upper quadrant, respectively, over an average period of 2.7 days. Computed tomography and/or diagnostic laparoscopy identified omental infarction in all cases. Forty-two patients (68.9%) had successful conservative management, six failed conservative management and 19 patients had emergency laparoscopic omentectomy. The average hospital length of stay was 3.4 days with no significant morbidity or mortality., Conclusion: Omental infarction generally presents with nonspecific clinical signs often masquerading as other more common abdominal diagnosis like cholecystitis or appendicitis. A trial of conservative management initially coupled with appropriate imaging should be recommended within the first 24-48 h before considering surgical treatment in refractory cases.

Introduction: The objectives of this study were to identify knowledge gaps and/or perceived limitations in the performance of paediatric appendiceal ultrasound by Australasian sonographers. We hypothesised that: sonographers' confidence in visualising the appendix in children was poor, particularly outside predominantly paediatric practice; workplace support for prolonging examinations to improve visualisation was limited; and the sonographic criteria applied in diagnosis did not reflect contemporary literature., Methods: A cross-sectional survey of Australasian sonographers regarding paediatric appendicitis was conducted using a mixed methods approach (quantitative and qualitative data). Text responses were analysed for key themes, and quantitative data analysed using chi-square, Mann-Whitney U and Wilcoxon signed-rank tests., Results: Of the 124 respondents, 27 (21.8%) reported a visualisation rate of less than 10%. Workplace support for extending examination time was significantly related to a higher appendix visualisation rate (χ 2 (2) = 16.839, P < 0.001). Text responses reported frustration locating the appendix and a desire for more time and practice to improve visualisation. Sonographers suggested a significantly lower maximum diameter cut-off in a 5-year-old compared to a 13-year-old (Z = -6.07, P < 0.001), and considered the presence of inflamed peri-appendiceal mesentery as the most useful sonographic criterion in diagnosing acute appendicitis., Conclusions: Respondents had a low opinion of their ability to confidently identify the appendix. Confidence was greater in those centres where extending scanning time was encouraged. Application of echogenic mesentery as the most significant secondary sonographic criterion is supported by recent studies. Opinions of diameter cut-offs varied, indicating potential for improved awareness of recent research., (© 2018 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

Background: Normal C-reactive protein (CRP) and white cell count (WCC) are often used to exclude a diagnosis of acute appendicitis in the Emergency Department (ED). Retrospective review of 281 adult patients with acute appendicitis was performed to study the incidence of normal CRP and WCC on admission and examine any possible predisposing factors., Method: Retrospective analysis of patient clinical records yielded CRP, WCC, operative diagnosis, time of symptom onset, imaging results and history and examination features. Case-control analysis was performed with patients with normal CRP and WCC considered the case group and those with raised CRP or WCC considered controls. Groups were compared using Mann-Whitney U-test and chi-squared analysis., Results: Of 281 consecutive patients with histologically proven appendicitis, 24 (8.54%) had normal CRP and WCC on presentation to ED. There were no significant differences in age, sex or time to blood collection between groups. Three patients had normal WCC and CRP and an Alvarado score of 4 or less on presentation. Three patients had persistently normal CRP and WCC on repeated testing. There was a trend towards earlier presentation in patients with normal CRP and WCC with 75.0% versus 58.4% presenting within 24 h of symptom onset (OR 2.14, P = 0.112)., Conclusion: Acute appendicitis remains diagnostically challenging and cannot be excluded on the basis of normal CRP and WCC. Serial clinical and biochemical assessment is warranted in patients with acute abdominal pain, particularly in those presenting early after symptom onset., (© 2016 Royal Australasian College of Surgeons.)

Background: In public hospitals, the work-up and surgery for patients with appendicitis is predominantly performed by surgical registrars, whereas in private hospitals, it is performed by consultants. This study aims to demonstrate the difference, if any, in the demographics, work-up, management and complication rate of patients in these two groups., Methods: This was a retrospective review of all patients who underwent laparoscopic appendicectomy at a major public hospital and major private hospital over the same 13 months. Data included demographics, admission details, work-up, length of stay, time to surgery, histology and complications. Fisher's exact test and the unpaired t-test were performed to look at the statistical difference between these two groups., Results: Total laparoscopic appendicectomies were 164 (public) and 105 (private). Median waiting times to operation were 13 and 9.5 h, respectively. Histological findings of appendicitis/neoplasia/normal appendix were 83.5/3.0/13.4% and 81.9/1.9/16.2%. Histological findings of gangrene or perforation were 26.2% and 11.6% (P = 0.0081). The proportion of those who had surgery more than 24 h after admission was 12.2% and 4.8% (P = 0.0517). Rates of pelvic collection were 1.2% and 1.9% (P = 0.6448), wound infection rates were 2.4% and 1.9% (P = 1) and overall complication rates were 7.3% and 8.6% (P = 0.8165). Mean operative time was 49.79 min for consultants and 67.98 min for registrars (P < 0.0001)., Conclusion: Consultants are faster at laparoscopic appendicectomies than registrars. A consultant lead service in a private hospital has earlier operation times and less patients ending up with gangrenous or perforated appendicitis but does not alter complication rates., (© 2014 Royal Australasian College of Surgeons.)

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