Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.

Primary malignant fibrous histiocytoma, now classified as pleomorphic undifferentiated sarcoma, is the most common soft-tissue sarcoma in adult life. Primary splenic pleomorphic undifferentiated sarcoma is extremely rare and aggressive, and is associated with a poor prognosis; only 14 cases of splenic pleomorphic undifferentiated sarcoma have been documented in the English literature. We discuss a case of a 56-year-old woman with iron-deficiency anaemia, early satiety and left upper-quadrant pain, who was preoperatively diagnosed with a large splenic cyst following thorough investigation. This was excised in an elective procedure. Unfortunately, histology confirmed splenic pleomorphic undifferentiated sarcoma. Following a review and summary of the literature, we discuss key differentials between splenic cysts and splenic pleomorphic undifferentiated sarcoma. This case highlights that iron-deficiency anaemia is unusual in splenic cysts and more sinister causes must be considered.

Surgical training in the United Kingdom (UK) is facing crucial challenges. Multiple fundamental changes in recent years have meant the same high-quality training needs to be delivered in a shorter duration. In this review, we consider the current training pathways for surgery in the UK, the impact of the European Working Time Directive (EWTD), the ongoing issue of service delivery versus training, and briefly the new Junior Doctor contract and the effects of Brexit on surgical training. The purpose of the review is to attempt to apply strategic thinking and strategy development to improve the current state of surgical training given the current climate new trainees find themselves in. Strategic thinking and wicked issues are defined, and three umbrella suggestions to improve surgical training are explored. Whether these suggestions can be implemented with reference to different models of strategic decision making is discussed. Finally, despite a new pilot scheme aimed at improving surgical house officer (SHO) surgical training, little change is offered to current trainees. The impact this has on surgical trainees is discussed and suggestions on how they can make the most of the current climate are made in this article.

Background: Emergency general surgical patients are inherently at high risk of malnutrition. Early decision-making with implementation is fundamental to patient recovery. For many patients, parenteral nutrition (PN) is the only feeding option available. The present study assessed the timing and outcomes of this decisionmaking process. Methods:A sample of at least 10 consecutive adult patients admitted as a general surgical emergency to eight UK hospitals over 1 year who had received PN was identified. Patient demographics, basic descriptors and nutritional data were captured.Process measures regarding dates decisions were made or activities completed were extracted from records, as were outcome measures including PN complications. Six time frames examining the process of PN delivery were analysed. Associations between categorical and binary variables were investigated with a chi-squared test with significance determined as p < 0.05. Results:In total, 125 patients were included. Intestinal obstruction was the most common diagnosis with 59% of all patients deemed high risk on nutritional assessment at admission. Median time to decision for PN was 5 days following admission (n = 122, interquartile range = 7). Patients received PN for a mean of 11 days.Eighty-five percent of patients developed a complication, with a phosphate abnormality being the most commonly reported (54%). Only altered blood glucose levels appeared to correlate with a delay in starting PN (p < 0.01). Conclusions:The present study shows there are delays in the decision to use PN in the acutely ill surgical patient. Once initiated, the pathway is relatively short. There are high rates of electrolyte abnormalities in this population.