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

Lack of agreement between different observers and methods in the measurement of capillary refill time in healthy volunteers: an observational study

Objetivo: As anomalias da perfus&#227;o perif&#233;rica s&#227;o manifesta&#231;&#245;es importantes do choque, sendo o tempo de reenchimento capilar comumente utilizado em sua avalia&#231;&#227;o. Entretanto, a reprodutibilidade das mensura&#231;&#245;es do tempo de reenchimento capilar e sua correla&#231;&#227;o com outras vari&#225;veis da perfus&#227;o perif&#233;rica n&#227;o foram avaliadas de forma abrangente. Nosso objetivo foi determinar, em volunt&#225;rios saud&#225;veis, a concord&#226;ncia entre diferentes m&#233;todos e diferentes observadores na quantifica&#231;&#227;o do tempo de reenchimento capilar, assim como sua correla&#231;&#227;o com outros marcadores da perfus&#227;o perif&#233;rica. M&#233;todos: Estudamos 63 volunt&#225;rios saud&#225;veis. Dois observadores mediram o tempo de reenchimento capilar por meio de dois m&#233;todos distintos: vis&#227;o direta (TRCcron&#244;metro) e v&#237;deo-an&#225;lise (TRCv&#237;deo). Medimos tamb&#233;m o &#237;ndice de perfus&#227;o derivado de pletismografia de pulso e a temperatura da polpa digital (T&#186;perif&#233;rica). A concord&#226;ncia entre os observadores e os m&#233;todos foi avaliada utilizando o m&#233;todo de Bland-Altman. As correla&#231;&#245;es foram calculadas utilizando a correla&#231;&#227;o de Pearson. Valor de p<0,05 foi considerado significante. Resultados: Os limites de concord&#226;ncia de 95% entre ambos os observadores foram de 1,9 segundo para TRCcron&#244;metro e 1,7 segundo para TRCv&#237;deo. Os limites de concord&#226;ncia de 95% entre TRCcron&#244;metro e TRCv&#237;deo foram de 1,7 segundo para o Observador 1 e 2,3 segundos para o Observador 2. As mensura&#231;&#245;es do TRCcron&#244;metro realizadas pelos dois observadores se correlacionaram com a T&#186;perif&#233;rica. As mensura&#231;&#245;es do TRCv&#237;deo realizadas pelos dois observadores se correlacionaram com a T&#186;perif&#233;rica e o &#237;ndice de perfus&#227;o. Conclus&#227;o: As mensura&#231;&#245;es do tempo de reenchimento capilar realizadas por diferentes observadores ou diferentes m&#233;todos em volunt&#225;rios saud&#225;veis mostraram baixa concord&#226;ncia. Apesar disso, o tempo de reenchimento capilar ainda refletiu a perfus&#227;o perif&#233;rica, conforme mostrado por sua correla&#231;&#227;o com vari&#225;veis objetivas da perfus&#227;o perif&#233;rica

Similar Microcirculatory Alterations in Patients with Normodynamic and Hyperdynamic Septic Shock

Rationale: In normodynamic septic shock, the quantitative assessment of sublingual microcirculation has shown decreases in perfused vascular density and red blood cell velocity. However, no studies have been performed in hyperdynamic septic shock. Objectives: To characterize the microcirculatory patterns and rule out the presence of fast red blood cell velocity in patients with hyperdynamic septic shock. Methods: We prospectively evaluated the sublingual microcirculation in healthy volunteers (n = 20) and in patients with hyperdynamic (n = 20) and normodynamic (n = 20) septic shock. Hyperdynamic septic shock was defined by a cardiac index >4.0 L/min/m(2). The microcirculation was assessed with sidestream dark field imaging and AVA 3.0 software. Measurements and Main Results: There were no differences in perfused vascular density, proportion of perfused vessels, or microvascular flow index between patients with hyperdynamic and normodynamic septic shock, but these variables were reduced compared with those of healthy volunteers, A similar pattern was observed in red blood cell velocity (9126291, 9686204, and 13036 120 mm/s, respectively; P <0.0001) and its coefficient of variation. In both types of septic shock, no microvessel had a red blood cell velocity higher than the 100th percentile value for healthy volunteers. Conclusions: Patients with hyperdynamic septic shock showed microcirculatory alterations similar to those of patients with normal cardiac output. Both groups of patients had reduced perfused vascular density and red blood cell velocity and increased flow heterogeneity compared with that of healthy subjects. Fast red blood cell velocity was not found, even in patients with high cardiac output. These results support the conclusion that microcirculatory function is frequently dissociated from systemic hemodynamic derangements in septic shoc

Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock

RESUMO Objetivo: Avaliar a prevalência de disfunção miocárdica e seu valor prognóstico em pacientes com sepse grave e choque séptico. Métodos: Pacientes sépticos adultos, admitidos em uma unidade de terapia intensiva, foram estudados de forma prospectiva por meio de ecocardiografia transtorácica dentro das primeiras 48 horas após sua admissão e, então, entre o sétimo e o décimo dias. As variáveis ecográficas de função biventricular, inclusive a relação E/e', foram comparadas entre sobreviventes e não sobreviventes. Resultados: Foi realizado um total de 99 ecocardiogramas (53 na admissão e 46 entre os dias 7 e 10) em 53 pacientes com média de idade de 74 anos (desvio padrão de 13 anos). Estava presente disfunção sistólica em 14 (26%); disfunção diastólica foi observada em 42 (83%) pacientes; e ambos os tipos de disfunção estavam presentes em 12 (23%) pacientes. A relação E/e', ou índice de disfunção diastólica, foi o melhor preditor de mortalidade hospitalar segundo a área sob a curva ROC (0,71) e se constituiu em um preditor independente do desfecho, conforme determinado pela análise multivariada (odds ratio - OR = 1,36 [1,05 - 1,76]; p = 0,02). Conclusão: Em pacientes sépticos admitidos em uma unidade de terapia intensiva, a disfunção sistólica determinada ecograficamente não se associa com aumento da mortalidade. Em contraste, a disfunção diastólica foi um preditor independente do desfecho

CAG repeat expansion in Huntington disease determines age at onset in a fully dominant fashion

Objective: Age at onset of diagnostic motor manifestations in Huntington disease (HD) is strongly correlated with an expanded CAG trinucleotide repeat. The length of the normal CAG repeat allele has been reported also to influence age at onset, in interaction with the expanded allele. Due to profound implications for disease mechanism and modification, we tested whether the normal allele, interaction between the expanded and normal alleles, or presence of a second expanded allele affects age at onset of HD motor signs. Methods: We modeled natural log-transformed age at onset as a function of CAG repeat lengths of expanded and normal alleles and their interaction by linear regression. Results: An apparently significant effect of interaction on age at motor onset among 4,068 subjects was dependent on a single outlier data point. A rigorous statistical analysis with a wellbehaved dataset that conformed to the fundamental assumptions of linear regression (e.g., constant variance and normally distributed error) revealed significance only for the expanded CAG repeat, with no effect of the normal CAG repeat. Ten subjects with 2 expanded alleles showed an age at motor onset consistent with the length of the larger expanded allele. Conclusions: Normal allele CAG length, interaction between expanded and normal alleles, and presence of a second expanded allele do not influence age at onset of motor manifestations, indicating that the rate of HD pathogenesis leading to motor diagnosis is determined by a completely dominant action of the longest expanded allele and as yet unidentified genetic or environmental factors. Copyright © 2012 by AAN Enterprises, Inc