Alistair Lock

Introduction: Definitive and accurate diagnosis of acute appendicitis is essential to reduce morbidity, yet ultrasound demonstrates variable performance which has generally improved over time with advancing technology and user expertise. This study aimed to evaluate the diagnostic accuracy of ultrasound for appendicitis in adults in our institution and document alternative diagnoses detected. Methods: We conducted a retrospective review of all abdominal ultrasound examinations performed between January 2021 and December 2021 for patients ≥ 16 years where appendicitis was a clinical query. Reports were categorised as positive or negative based on standardised interpretive phrases. Clinical records, operative findings, histology and follow‐up determined true outcomes. Inconclusive examinations (non‐visualised appendix) were classified as negative for analysis. Results: The cohort comprised 331 patients (92% female; mean age 28 years). Appendicitis prevalence was 16% (53/331). For the detection of appendicitis, ultrasound demonstrated sensitivity of 60%, specificity 98%, PPV 82% and NPV 93%. Alternative diagnoses ( n = 108) were more frequent than appendicitis by 2:1 and included haemorrhagic ovarian events, hydrosalpinx, mesenteric adenitis and other gynaecological or abdominal pathologies. Conclusions: Ultrasound demonstrated modest sensitivity but high specificity for diagnosing appendicitis in adults, consistent with international data when inconclusive cases are included. This shows that in the absence of any ultrasound features, appendicitis is unlikely. Alternative findings were twice as common as appendicitis, highlighting the value of ultrasound as a primary imaging modality for the assessment of patients with right lower quadrant pain.

Background: The role of patient educational materials for paediatric patients is increasing. A reading grade level of eighth‐grade (USA) or year nine (Australia and New Zealand) is recommended as acceptable. The aim of this paper was to assess the reading grade levels of paediatric online patient educational materials, within Australasia.Methods: The online Google® search engine was used with a variety of keyword combinations, filtered to the location of Australia and New Zealand. Suitable websites were explored for webpages related to slipped upper femoral epiphysis, septic arthritis, osteomyelitis, talipes equinovarus and developmental dysplasia of the hip. Readability was assessed using the online readability software WEB FX®.Results: Seventy‐six patient educational webpages were analysed: 66 from Australia and 10 from New Zealand. Only eight of the 76 webpages (10.5%) had reading grade levels below the recommended eighth‐grade (US)/year nine (AUS/NZ) level. Webpages from private healthcare providers and pages related to septic arthritis had the significantly highest reading grades.Conclusions: Australasian families have limited online patient educational materials available to them, which are mostly set at reading grade levels above recommended standards. Healthcare providers should be incentivized to improve the readability of their patient educational materials to reduce health disparities and improve health literacy moving forward.

YouTube is an increasingly accessible platform for families to obtain health information from; however, it is unregulated. The aim of this article was to assess the quality, reliability and accuracy of YouTube videos related to three common pediatric hip conditions: development dysplasia of the hip (DDH), slipped capital femoral epiphysis (SCFE) and Legg-Calve-Perthes disease. YouTube was searched using a variety of keyword combinations. Videos were analysed using Journal of the American Medical Association, Global Quality Score and condition-specific scores created specifically for this study. Video duration and the number of views were also recorded. In total 120 videos were analysed, 40 for each of DDH, SCFE and Perthes disease. YouTube videos from physicians and academic institutions/hospitals are of significantly higher quality, reliability and accuracy than videos from patients, nonphysicians and commercial outlets. The higher quality for physician videos is associated with significantly longer video. Differences between the three pediatric orthopaedic conditions were not statistically significant. Videos of higher quality may be used as an adjunctive tool to strengthen clinical consultation. Parents and caregivers should be guided to videos from academic institutions or hospitals as a way of improving health literacy.

Grafts are required to restore tissue integrity and function. However, current gold standard autografting techniques yield limited harvest, with high rates of complication. In the search for viable substitutes, the number of biomaterials being developed and studied has increased rapidly. To date, low clinical uptake has accompanied inherently high failure rates, with immune rejection a specific and common end result. The objective of this review article was to evaluate published immune assays evaluating biomaterials, and to stress the value that incorporating immune assessment into evaluations carries. Immunogenicity assays have had three areas of focus: cell viability, maturation and activation, with the latter being the focus in the majority of the literature due to its relevance to functional outcomes. With recent studies suggesting poor correlation between current in vitro and in vivo testing of biomaterials, in vitro immune response assays may be more relevant and enhance ability in predicting acceptance prior to in vivo application. Uptake of in vitro immune response assessment will allow for substantial reductions in experimental time and resources, including unnecessary and unethical animal use, with a simultaneous decrease in inappropriate biomaterials reaching clinic. This improvement in bench to bedside safety is paramount to reduce patient harm.

AIMS: Perform an audit which identifies the breadth and commonality of presenting complaints and diagnoses presenting to Middlemore Hospital over a one-week period in August 2016. METHODS: Two thousand and eleven patients attended Middlemore Hospital over one week in winter 2016, with 53 patients excluded. Information from the remaining 1,958 patient discharge summaries were obtained and made confidential for coding purposes. RESULTS: Of 1,958 patients, there were 78 different presenting complaints, with 444 individual final diagnoses. The five most common complaints were cough (n=158, 8.1%), chest pain (n=133, 6.8%), shortness of breath (n=92, 4.7%), finger pain (n=69, 3.5%) and collapse (n=59, 3.0%). Viral illness (n=84, 4.3%), pneumonia (n=83, 4.3%) and laceration/incised wound (n=75, 3.8%) were the three most common diagnoses. With hindsight, only 2 of the 25 most common diagnoses could be classified as severe conditions-often associated with high morbidity or mortality. CONCLUSIONS: Numerous patients are diagnosed with mild conditions after work-up in the emergency department, however a broad diagnostic approach is required by junior clinicians given the possibility of more worrying diagnoses. An analysis of specific markers used by junior clinicians to aid differential diagnosis shows that not all signs and symptoms are required to make common diagnoses. For example, the absence of a documented fever, raised CRP or both, does not rule out significant infection in the case of pneumonia, urinary tract infection and cellulitis. This audit contributes to understanding the case-mix within the emergency department at Middlemore Hospital and allows for tailoring of service delivery and education of junior clinicians.

The issue of employee fatigue is becoming increasingly prominent, particularly in safety-critical industries. To produce an in-depth review collating the known psychological and physiological health and work effects of fatigue to guide mitigation strategies in safety-critical industries. Literature searches were conducted via scientific databases using appropriate filters and keywords. The available results were collated into a review and commentary. Decreased sleep duration and chronodisruption have been shown to cause both significant morbidity and mortality. There is a large body of evidence showing strong associations between fatigue, reduced cognition and occupational accidents, as well as increased metabolic and reproductive health sequelae, some forms of cancer and mortality. Additional evidence links fatigue with mental, gastrointestinal, neurological and chronic pain sequelae. Fatigue risk mitigation strategies should be implemented, not only to reduce these short- and long-term health risks in employees of safety-critical industries, but also to create more efficient, productive and effective workplace personnel with longer and more fulfilling careers. This requires improved acute fatigue mitigation, as well as the prevention of cumulative fatigue build-up and the formation of acute-on-chronic fatigue. The health recommendations for fatigue mitigation outlined in this paper are pertinent to all professions where employees have high rates of both acute and chronic fatigue.

Study Design.: In vitroStudy.Objective.: To evaluate the effect that factors released from human posterior spinal bone dust have on primary human osteoblast growth and maturation.Summary of Background Data.: Bone dust, created during spinal fusion surgeries, has the potential to be used as an autologous bone graft by providing a source of viable autologous osteoblasts and mesenchymal stem cells with osteogenic potential. Till date, no information is available on whether bone dust also provides a source of anabolic factors with the potential to enhance osteoblast proliferation and maturation, which would enhance its therapeutic potential.Methods.: Bone dust was collected from consenting patients undergoing elective posterior spinal fusion surgeries, and primary human osteoblasts were cultured from patients undergoing elective hip or knee arthroplasty. Growth factors and cytokines released by bone dust were quantified using enzyme-linked immunosorbent assay. Primary human osteoblast proliferation and gene expression in response to bone dust were assessed using³H-thymidine incorporation and real-time polymerase chain reaction, respectively.Results.: Human bone dust released anabolic cytokines (IL-1β and IL-6) and growth factors (TGF-β, VEGF, FGF-Basic, and PDGF-BB) in increasing concentrations over a 7-day period.In vitro, the anabolic factors released by bone dust increased osteoblast proliferation by 7-fold, compared with osteoblasts cultured alone. In addition, the factors released from bone dust up-regulated a number of osteoblastic genes integral to osteoblast differentiation, maturation, and angiogenesis.Conclusion.: This study is the first to demonstrate that human posterior spinal bone dust released anabolic factors that potently enhance osteoblast proliferation and the expression of genes that favor bone healing and bone union. As bone dust is anabolic and its harvest is fast, simple, and safe to perform, spinal surgeons should be encouraged to ‘recycle’ bone dust and harness the regenerative potential of this free autologous bone graft.Level of Evidence:N/A

Surgeons have a range of materials to choose from to complete wound closure, yet surprisingly very little is still known about the body’s immune response to the suture materials in current use. The growing literature of adverse suture material reactions provided the objective of this study, to use in vitro assays to quantify levels of inflammation produced by seven commonly used suture materials in surgical procedures. Human monocyte/macrophage THP-1 cells were exposed to suture materials for 1, 3 and 5 days. Gene expression and protein secretion of six inflammatory cytokines and two cell surface markers were assessed using qPCR and ELISA respectively, with LPS exposure providing a positive control. Furthermore, a IL-1β/IL-1RA marker ratio was assessed to determine the balance between pro-/anti-inflammatory expression. The findings from our in vitro study suggest that four commonly used suture materials cause upregulation of pro-inflammatory markers indicative of an early foreign body reaction, with no balance from anti-inflammatory markers. As prolonged early pro-inflammation is known to produce delayed wound healing responses, the knowledge produced from this study has potential to improve informed surgical decision making and patient safety. This work has the capability to reduce suture-related adverse immune reactions, and therefore positively affect patient outcomes.