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

The musculoskeletal abnormalities of the Similaun Iceman (“ÖTZI”): clues to chronic pain and possible treatments

BACKGROUND AND INTRODUCTION: In 1991, a deceased human male was found frozen in a glacier pool in the Italian Alps in north west Italy, and is now carefully preserved in the South Tyrol Museum of Archaeology, in Bolzano, Italy. The bodily tissues of the 5,300 year old male (colloquially referred to as the Iceman or Ötzi) were well preserved despite damage related to freezing, and glacial movement. Associated articles of well-preserved clothing, tools, weapons and other devices were also present and have been studied in detail. Clinical examination and imaging investigations have also shown that the Icemen had experienced possible illnesses in his lifetime and had identifiable areas of arthritis and musculoskeletal injury. This report includes some key observations on the musculoskeletal state of Ötzi and reference to the involvement of tattoo markings. Some aspects about the aetiology of his abnormalities and inflammatory arthritis are considered along with possible treatments that he might have employed. METHODS AND RESULTS: We (WFK and MK) undertook a clinical musculoskeletal examination of the Iceman, details of which with available photographs and radiographic imaging pertaining to the musculoskeletal findings of the Iceman are reported here. The skin of the Iceman has numerous linear carbon tattoos, which are not of a decorative type. These have been presumed to possibly be "medicinal" tattoos administered for therapeutic reasons and may have been used in acupuncture-like treatment of pain. Spinal imaging identified areas of spinal damage and our observations have provided clues as to possible sites of spinal initiated pain and hence sites for administration of the "medicinal" tattoos. We observed body areas of the Iceman, in which imaging demonstrated arthritis and other forms of long-term musculoskeletal damage, but which do not have adjacent or corresponding "medicinal" tattoos. We contend that the back and leg "medicinal" tattoos correspond directly to sites of chronic right knee and right ankle pain, and left thoracolumbar pain. They also correspond to lower lumbar and sciatic referred radicular pain which may have a contributory cause related to the presence of a transitional lumbar 5 vertebra. Using recent published data (Keller et al. in Nature Commun 3:698, 2012. doi: 10.1038/ncomms1701 ) of the genome structure of the Iceman, we suggest some potential causes of the osteoarthritis or inflammatory joint injury may relate to presence of coronary heart disease (CHD) and Lyme disease (Borrelia burgdorferi) infection. We speculate on possible medical applications of natural products for self-medication. CONCLUSIONS: These observations highlight several diagnostic features of musculoskeletal conditions in the Iceman with the possibility that tattoos may have been used for diagnosis or location of his painful states. The origins of his musculoskeletal conditions are unclear but there are indications that Lyme disease and CHD may have been factors. The associations or use of natural products may give insights into their applications at the time of the life of the Iceman.</p

Reintroducing rewilding to restoration – Rejecting the search for novelty

Rewilding is emerging as a major issue in conservation. However, there are currently a dozen definitions of rewilding that include Pleistocene rewilding, island rewilding, trophic rewilding, functional rewilding and passive rewilding, and these remain fuzzy, lack clarity and, hence, hinder scientific discourse. Based on current definitions, it is unclear how the interventions described under the rewilding umbrella differ from those framed within the long-standing term ‘restoration’. Even projects held up as iconic rewilding endeavours invariably began as restoration projects (e.g., Oostvaaderplassen; Pleistocene Park; the return of wolves to Yellowstone, etc.). Similarly, rewilding organisations (e.g., Rewilding Europe) typically began with a restoration focus. Scientific discourse requires precise language. The fuzziness of existing definitions of rewilding and lack of distinction from restoration practices means that scientific messages cannot be transferred accurately to a policy or practice framework. We suggest that the utility of ‘rewilding’ as a term is obsolete, and hence recommend scientists and practitioners use ‘restoration’ instead

Foster children’s behavioral development and foster parent stress: testing a transactional model

The goal of this three-wave longitudinal study was to analyze foster parent stress and foster children’s internalizing and externalizing behaviors in a transactional framework. Participants in this study were 237 children in foster care in the Netherlands with, mostly, long placement durations (M = 56.86 months, SD = 49.10 months). We examined concurrent, prospective unidirectional and bidirectional relations between foster children’s behavior and foster parent stress by using cross-lagged structural equation modeling and examined whether the results were stable across different subgroups of foster children. In contrast to our hypothesis, we found no bidirectional relations. There were unidirectional prospective pathways from foster children’s internalizing and externalizing problems to foster parent stress, but no significant prospective pathways from foster parent stress to foster children’s internalizing and externalizing problems. The results were fairly stable across different subgroups of foster children. The lack of bidirectional relations was unexpected given the presence of transactional relations in biological parent-child dyads. Foster parents seem not to influence their foster children when it comes to regulating problem behavior. Therefore, the question is whether foster parents can, in more general terms, help their foster children benefit from their improved home environment.Development Psychopathology in context: familyDevelopment Psychopathology in context: clinical setting