Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Exploring the Relationship Between Patient Age and Cancer-Specific Survival in Papillary Thyroid Cancer: Rethinking Current Staging Systems

Purpose Patient age is considered to play a unique prognostic role in papillary thyroid cancer (PTC), with a distinct staging dichotomization at 45 years of age. This is based on older, limited data demonstrating a marked rise in mortality around the ages of 40 to 50 years. We hypothesized that age is associated with compromised survival from cancer, with no cutoff denoting survival difference. Patients and Methods Patients with PTC who had surgery were identified from the SEER database (1998 to 2012). Multivariable proportional hazards modeling utilizing several flexible smoothing approaches were used to examine the association between age and cancer-specific survival (CSS) and to determine whether there is an age cut point that is associated with CSS decrement. Results A total of 31,802 patients with PTC were included. Median age was 45 years (range, 2 to 105 years). Ten-year CSS according to age was as follows: 2 to 19 years, 99.8%; 20 to 29 years, 99.9%; 30 to 39 years, 99.8%; 40 to 49 years, 99.5%; 50 to 59 years, 98.1%; 60 to 69 years, 94.8%; 70 to 79 years, 91.5%; 80 to 89 years, 79.2%; and ≥ 90 years, 73.9%. After adjustment for patient demographic and clinicopathologic characteristics, increasing age was associated with increasing mortality from the disease in a dose-dependent fashion, without an apparent cut point. Each of the smoothing approaches demonstrated a similar linearity of risk over all ages and provided close measures of goodness of fit to the data. Conclusion Patient age is significantly associated with death from PTC in a linear fashion, without an apparent age cut point demarcating survival difference. These results challenge the appropriateness of a patient age cut point in current staging systems for PTC and argue for considering a revision in how we anticipate prognosis for patients with PTC

Assessing the role of robotic proctectomy in obese patients: a contemporary NSQIP analysis

Robotic proctectomy has become increasingly popular for both benign and malignant indications. The purpose of this study was to determine if the robotic approach has a distinct advantage over laparoscopy in obese patients, which has been suggested by previous subgroup analyses. We performed a retrospective review of 2016-2018 National Surgery Quality Improvement Program (NSQIP) data to compare outcomes between patients who underwent robotic versus laparoscopic proctectomy, stratified by Body Mass Index (BMI) subgroups. We also compared outcomes of converted minimally invasive proctectomy to planned open operations. Four thousand four hundred eighteen (69.3%) patients underwent laparoscopic proctectomy, and 1956 (30.7%) patients underwent robotic proctectomy. Robotic proctectomy was associated with a significantly lower conversion rate compared to laparoscopic proctectomy (5.1% vs 12.3%; p = 0.002), and this relationship was maintained on an adjusted model. Obese (BMI &gt; 30) patients were more likely to require conversion in both laparoscopic and robotic groups with the greatest difference in the conversion rate in the obese subgroup. Patients who underwent conversion had higher composite morbidity compared to patients who underwent planned open operations (50.8% vs 41.3%; p &lt; 0.001). And among patients with rectal cancer, robotic proctectomy was associated with a greater incidence of positive radial tumor margins compared to laparoscopic proctectomy (8.0% vs 6.4%; p = 0.039), driven primarily by the obese subgroup. Our study demonstrates that robotic proctectomy is associated with a 7% lower conversion rate compared to laparoscopy and that obese patients are more likely to require conversion than non-obese patients. Among obese patients with rectal cancer, we identified an increased risk of positive radial margins with robotic compared to laparoscopic proctectomy

Robotic Thyroidectomy for Cancer in the US: Patterns of Use and Short-Term Outcomes

BackgroundWe describe nationally representative patterns of utilization and short-term outcomes from robotic versus open thyroidectomy for thyroid cancer.MethodsDescriptive statistics and multivariable analysis were used to analyze patterns of use of robotic thyroidectomy from the National Cancer Database (2010-2011). Short-term outcomes were compared between patients undergoing robotic versus open thyroidectomy, while adjusting for confounders.ResultsA total of 68,393 patients with thyroid cancer underwent thyroidectomy; 225 had robotic surgery and 57,729 underwent open surgery. Robotic thyroid surgery use increased by 30&nbsp;% from 2010 to 2011 (p&nbsp;=&nbsp;0.08). Robotic cases were reported from 93 centers, with 89 centers performing &lt;10 robotic cases. Compared with the open group, the robotic group was younger (51 vs. 47&nbsp;years; p&nbsp;&lt;&nbsp;0.01) and included more Asian patients (4 vs. 8&nbsp;%; p&nbsp;=&nbsp;0.006) and privately-insured patients (68 vs. 77&nbsp;%; p&nbsp;=&nbsp;0.01). Tumor size was similar between patients undergoing robotic versus open surgery. Total thyroidectomy was performed less frequently in the robotic group (67 vs. 84&nbsp;% open; p&nbsp;&lt;&nbsp;0.0001). Patients were relatively more likely to undergo robotic surgery if they were female (odds ratio [OR] 1.6; p&nbsp;=&nbsp;0.04), younger (OR 0.8/10&nbsp;years; p&nbsp;&lt;&nbsp;0.0001), or underwent lobectomy (OR 2.4; p&nbsp;&lt;&nbsp;0.0001). In adjusted multivariable analysis, there were no differences in the number of lymph nodes removed or length of stay between groups; however, there was a non-significant increase in the incidence of positive margins with robotic thyroidectomy.ConclusionsUse of robotic thyroidectomy for thyroid cancer is limited to a few institutions, with short-term outcomes that are comparable to open surgery. Multi-institutional studies should be undertaken to compare thyroidectomy-specific complications and long-term outcomes

Severe Obesity Is Associated with Symptomatic Presentation, Higher Parathyroid Hormone Levels, and Increased Gland Weight in Primary Hyperparathyroidism

Context: A relationship between primary hyperparathyroidism (PHPT) and obesity has been observed but is incompletely understood. Furthermore, obesity has been associated with vitamin D deficiency, suggesting that the three conditions may be linked

Optimizing water relations, gas exchange parameters, biochemical attributes and yield of water-stressed maize plants through seed priming with iron oxide nanoparticles

Abstract Drought poses significant risks to maize cultivation by impairing plant growth, water uptake and yield; nano priming offers a promising avenue to mitigate these effects by enhancing plant water relations, stress tolerance and overall productivity. In the current experiment, we tested a hypothesis that seed priming with iron oxide nanoparticles (n-Fe2O3) can improve maize performance under water stress by improving its growth, water relations, yield and biochemical attributes. The experiment was conducted on a one main plot bisected into two subplots corresponding to the water and drought environments. Within each subplot, maize plants were raised from n-Fe2O3 primed seeds corresponding to 0 mg. L− 1 (as control treatment), 25, 50, 75, and 100 mg. L− 1 (as trial treatments). Seed priming with n-Fe2O3 at a concentration of 75 mg. L− 1 improved the leaf relative water content, water potential, photosynthetic water use efficiency, and leaf intrinsic water use efficiency of maize plants by 13%, 44%, 64% and 17%, respectively compared to control under drought stress. The same treatments improved plant biochemical attributes such as total chlorophyll content, total flavonoids and ascorbic acid by 37%, 22%, and 36%, respectively. Seed priming with n-Fe2O3 accelerated the functioning of antioxidant enzymes such as SOD and POD and depressed the levels of leaf malondialdehyde and hydrogen peroxide significantly. Seed priming with n-Fe2O3 at a concentration of 75 mg. L− 1 improved cob length, number of kernel rows per cob, and 100 kernel weight by 59%, 27% and 33%, respectively, under drought stress. Seed priming with n-Fe2O3 can be used to increase maize production under limited water scenarios