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Dhillon BK, Kortbeek S, Baghela A, Brindle M, Martin DA, Jenne CN, Vogel HJ, Lee AHY, Thompson GC, Hancock REW. Gene Expression Profiling in Pediatric Appendicitis. JAMA Pediatr 2024; 178:391-400. [PMID: 38372989 PMCID: PMC10877506 DOI: 10.1001/jamapediatrics.2023.6721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/13/2023] [Indexed: 02/20/2024]
Abstract
Importance Appendicitis is the most common indication for urgent surgery in the pediatric population, presenting across a range of severity and with variable complications. Differentiating simple appendicitis (SA) and perforated appendicitis (PA) on presentation may help direct further diagnostic workup and appropriate therapy selection, including antibiotic choice and timing of surgery. Objective To provide a mechanistic understanding of the differences in disease severity of appendicitis with the objective of developing improved diagnostics and treatments, specifically for the pediatric population. Design, Setting, and Participants The Gene Expression Profiling of Pediatric Appendicitis (GEPPA) study was a single-center prospective exploratory diagnostic study with transcriptomic profiling of peripheral blood collected from a cohort of children aged 5 to 17 years with abdominal pain and suspected appendicitis between November 2016 and April 2017 at the Alberta Children's Hospital in Calgary, Alberta, Canada, with data analysis reported in August 2023. There was no patient follow-up in this study. Exposure SA, PA, or nonappendicitis abdominal pain. Main Outcomes and Measures Blood transcriptomics was used to develop a hypothesis of underlying mechanistic differences between SA and PA to build mechanistic hypotheses and blood-based diagnostics. Results Seventy-one children (mean [SD] age, 11.8 [3.0] years; 48 [67.6%] male) presenting to the emergency department with abdominal pain and suspected appendicitis were investigated using whole-blood transcriptomics. A central role for immune system pathways was revealed in PA, including a dampening of major innate interferon responses. Gene expression changes in patients with PA were consistent with downregulation of immune response and inflammation pathways and shared similarities with gene expression signatures derived from patients with sepsis, including the most severe sepsis endotypes. Despite the challenges in identifying early biomarkers of severe appendicitis, a 4-gene signature that was predictive of PA compared to SA, with an accuracy of 85.7% (95% CI, 72.8-94.1) was identified. Conclusions This study found that PA was complicated by a dysregulated immune response. This finding should inform improved diagnostics of severity, early management strategies, and prevention of further postsurgical complications.
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Affiliation(s)
- Bhavjinder K. Dhillon
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Simone Kortbeek
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Arjun Baghela
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary Brindle
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dori-Ann Martin
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Craig N. Jenne
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Hans J. Vogel
- Department of Biological Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Amy H. Y. Lee
- Department of Molecular Biology & Biochemistry, Simon Fraser University, British Columbia, Canada
| | - Graham C. Thompson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Robert E. W. Hancock
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
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Reddy K, Ramteke H, Patel DJ, Deshpande SG, Patil M, Nayak K. Testicular Torsion and Irreversible Loss in an Adolescent Male: A Harrowing Case Report With Emphasis on Timely Intervention and Literature Review. Cureus 2023; 15:e42754. [PMID: 37654931 PMCID: PMC10468147 DOI: 10.7759/cureus.42754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023] Open
Abstract
Testicular torsion is a condition characterized by the twisting of the testis and spermatic cord within the scrotum, resulting in the obstruction of venous return and subsequent swelling. If left untreated, the torsion can progress to block the arterial blood supply, leading to ischemia. Prolonged ischemia can result in testicular necrosis and decreased fertility. Recognizing the urgency of this condition, timely diagnosis and management are crucial. In this clinical case, a 16-year-old male presented with left-sided scrotal pain following a minor trauma. Despite prompt medical attention, the delay in seeking treatment resulted in irreversible testicular necrosis. The case emphasizes the urgency of diagnosing and managing testicular torsion to prevent serious consequences such as testicular loss and reduced fertility. It serves as a poignant reminder for healthcare professionals to remain vigilant in recognizing this urological emergency and advocating for timely intervention to optimize patient outcomes.
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Affiliation(s)
- Kavyanjali Reddy
- Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshal Ramteke
- Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Dharmesh J Patel
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swati G Deshpande
- Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mihir Patil
- Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Krushank Nayak
- Department of Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Schuh S, Man C, Marie E, Alhashmi GHA, Halevy D, Wales PW, Singer-Harel D, Finkelstein A, Sweeney J, Doria AS. Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis-A prospective cohort study. Am J Emerg Med 2023; 71:217-224. [PMID: 37453161 DOI: 10.1016/j.ajem.2023.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/29/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED). STUDY DESIGN prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway. RESULTS 150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT. CONCLUSION this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.
| | - Carina Man
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Eman Marie
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | | | - Dan Halevy
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Paul W Wales
- Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada
| | - Aya Finkelstein
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Judith Sweeney
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Andrea S Doria
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
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Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam versus Ceftriaxone with Metronidazole. J Pediatr Surg 2023; 58:1128-1132. [PMID: 36931937 DOI: 10.1016/j.jpedsurg.2023.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database. METHODS We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated. RESULTS We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant. CONCLUSION Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns. LEVEL OF EVIDENCE Level III. STUDY TYPE Retrospective Comparative Study.
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Fawkner-Corbett D, Hayward G, Alkhmees M, Van Den Bruel A, Ordóñez-Mena JM, Holtman GA. Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis. BMJ Open 2022; 12:e056854. [PMID: 36328382 PMCID: PMC9639107 DOI: 10.1136/bmjopen-2021-056854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. DESIGN A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. RESULTS 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). CONCLUSIONS The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO REGISTRATION NUMBER CRD42017080036.
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Affiliation(s)
- David Fawkner-Corbett
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Academic Paediatric Surgery Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Gail Hayward
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Mohammed Alkhmees
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ann Van Den Bruel
- EPI-Centre, Academic Centre for Primary Care, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Jose M Ordóñez-Mena
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Gea A Holtman
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Sogbodjor LA, Singleton G, Davenport M, Walker S, Moonesinghe SR. Quality metrics for emergency abdominal surgery in children: a systematic review. Br J Anaesth 2021; 128:522-534. [PMID: 34895715 DOI: 10.1016/j.bja.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children. METHODS We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications. RESULTS We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways. CONCLUSIONS This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis. CLINICAL TRIAL REGISTRATION PROSPERO CRD42017055285.
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Affiliation(s)
- Lisa A Sogbodjor
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Georgina Singleton
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Suellen Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond St Institute of Child Health, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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7
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Chaudhari H, Schneeweiss M, Rebinsky R, Rullo E, Eltorki M. An Advanced Nursing Directive for Children With Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study. JMIR Res Protoc 2021; 10:e33158. [PMID: 34668867 PMCID: PMC8567150 DOI: 10.2196/33158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background Pediatric appendicitis accounts for an estimated 7% to 10% of abdominal pain cases in the emergency department (ED). The diagnosis is time-consuming, and the investigative process depends on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive (AND) to expedite this process is unclear and needs further exploration. Objective This study aims to describe key components of ED flow in patients with suspected appendicitis seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order set that includes blood work, urine tests, analgesics, fluids, and an abdominal-pelvis ultrasound prior to physician assessment. Methods This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after AND implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, blood work results, and time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a chi-square test will be used. The Student t test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and 7 days afterward. Results There are currently 3900 patients who have been screened, 344 patients who have been enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. Conclusions This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based AND. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies. International Registered Report Identifier (IRRID) RR1-10.2196/33158
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Affiliation(s)
- Hanu Chaudhari
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Reid Rebinsky
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Enrico Rullo
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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Hodge SV, Mickiewicz B, Lau M, Jenne CN, Thompson GC. Novel molecular biomarkers and diagnosis of acute appendicitis in children. Biomark Med 2021; 15:1055-1065. [PMID: 34284638 DOI: 10.2217/bmm-2021-0108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Reliable and efficient diagnosis of pediatric appendicitis is essential for the establishment of a clinical management plan and improvement of patient outcomes. Current strategies used to diagnose a child presenting with a suspected appendicitis include laboratory studies, clinical scores and diagnostic imaging. Although these modalities work in conjunction with each other, one optimal diagnostic strategy has yet to be agreed upon. The recent introduction of precision medicine techniques such as genomics, transcriptomics, proteomics and metabolomics has increased both the diagnostic sensitivity and specificity of appendicitis. Using these novel strategies, the integration of precision medicine into clinical practice via point-of-care technologies is a plausible future. These technologies would assist in the screening, diagnosis and prognosis of pediatric appendicitis.
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Affiliation(s)
- Sarah Vl Hodge
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Beata Mickiewicz
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Matthew Lau
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Craig N Jenne
- Department of Microbiology, Immunology & Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Graham C Thompson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada.,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
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9
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IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy. Ann Surg 2021; 274:406-410. [PMID: 34132703 DOI: 10.1097/sla.0000000000005006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. METHODS A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. RESULTS One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. CONCLUSIONS In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.
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10
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Komanchuk J, Martin DA, Killam R, Eccles R, Brindle ME, Khanafer I, Joffe AR, Blackwood J, Yu W, Gupta P, Sethi S, Moorjani V, Thompson G. Magnetic Resonance Imaging Provides Useful Diagnostic Information Following Equivocal Ultrasound in Children With Suspected Appendicitis. Can Assoc Radiol J 2021; 72:797-805. [PMID: 33648355 DOI: 10.1177/0846537121993797] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE In Canada, ultrasonography is the primary imaging modality for children with suspected appendicitis, yet equivocal studies are common. Magnetic resonance imaging provides promise as an adjunct imaging strategy. The primary objective of this study was to determine the proportion of children with suspected appendicitis and equivocal ultrasound where magnetic resonance imaging determined a diagnosis. METHODS A prospective consecutive cohort of children aged 5-17 years presenting to a tertiary pediatric Emergency Department with suspected appendicitis were enrolled. Participants underwent diagnostic and management strategies according to our local suspected appendicitis pathway, followed by magnetic resonance (Siemens Avanto 1.5 Tesla) imaging. Sub-specialty pediatric radiologists reported all images. RESULTS Magnetic resonance imaging was performed in 101 children with suspected appendicitis. The mean age was 11.9 (SD 3.4) years and median Pediatric Appendicitis Score was 6 [IQR 4,8]. Ultrasonography was completed in 98/101 (97.0%). Of 53/98 (54.1%) with equivocal ultrasound, magnetic resonance imaging provided further diagnostic information in 41 (77.4%; 10 positive, 31 negative; 12 remained equivocal). Secondary findings of appendicitis on magnetic resonance imaging in children with equivocal ultrasound included abdominal free fluid (24, 45.3%), peri-appendiceal fluid (12, 22.6%), intraluminal appendiceal fluid (9, 17.0%), fat stranding (8, 15.1%), appendicolith (2, 3.8%), and peri-appendiceal abscess (1, 1.9%). The observed agreement between magnetic resonance imaging results and final diagnosis was 94.9% (kappa = 0.89).
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Affiliation(s)
- Jelena Komanchuk
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Dori-Ann Martin
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Rory Killam
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Robin Eccles
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Mary E Brindle
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ijab Khanafer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jaime Blackwood
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Weiming Yu
- Department of Pathology, University of Calgary, Alberta, Canada
| | - Priya Gupta
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay Sethi
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Vijay Moorjani
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Graham Thompson
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
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11
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Yu D, Gu C, Zhang S, Yang H, Yao T. Ultrasound features and the diagnostic strategy of subhepatic appendicitis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1083. [PMID: 33145302 PMCID: PMC7575950 DOI: 10.21037/atm-20-5265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background This study aimed to compare the differences of ultrasound findings between subhepatic appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the accuracy of diagnosis. Methods A retrospective analysis was performed in our hospital. One thousand five hundred ninety-one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as the control group. The difference in ultrasound features between the two groups was studied. Comparisons between the two groups showed statistically significant differences in the frequencies of the fishbone sign, enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05). Results Statistical significance was not observed with the difference in the frequency of whether there was lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn to look for the main factors associated. The results of interpretation on the critical points of diagnosis for subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right upper abdomen. Conclusions An abnormally dilated ileum in the right lower abdomen – the fishbone sign, is a vital sign leading to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen + whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.
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Affiliation(s)
- Dong Yu
- Department of Radiology, Jizhong Energy Fengfeng Group Hospital, Handan, China
| | - Chenyao Gu
- Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng, China
| | - Shuchen Zhang
- Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng, China
| | - Hui Yang
- Department of Orthopaedic, Jizhong Energy Fengfeng Group Hospital, Handan, China
| | - Taotao Yao
- Rehabilitation Center, the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
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An Administrative Data-based Surrogate Definition Identifies Children Evaluated Beyond Physical Examination for Suspected Appendicitis. Pediatr Qual Saf 2020; 5:e343. [PMID: 33575519 PMCID: PMC7870269 DOI: 10.1097/pq9.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 07/09/2020] [Indexed: 11/27/2022] Open
Abstract
Previous studies have reported on the evaluation of patients diagnosed with appendicitis. Very little is known about all patients evaluated for suspected appendicitis. Patients evaluated beyond physical examination with laboratory and imaging testing, then found not to have appendicitis, are more difficult to identify. Data readily available in administrative databases may be used to identify these patients.
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13
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Utilization and Performance Benchmarking for Postoperative Imaging in Children With Complicated Appendicitis. Ann Surg 2020; 275:816-823. [PMID: 32657938 DOI: 10.1097/sla.0000000000004250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Logie K, Robinson T, VanHouwelingen L. Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population. J Pediatr Surg 2020; 55:893-898. [PMID: 32081356 DOI: 10.1016/j.jpedsurg.2020.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE The widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter. METHODS An online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics. RESULTS A total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines. CONCLUSIONS The majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons. TYPE OF STUDY Survey LEVEL OF EVIDENCE: VII (Expert Opinion).
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Affiliation(s)
- Kathleen Logie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tessa Robinson
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada
| | - Lisa VanHouwelingen
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada.
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15
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Dhatt S, Sabhaney V, Bray H, Skarsgard ED. Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway. J Pediatr Surg 2020; 55:889-892. [PMID: 32067806 DOI: 10.1016/j.jpedsurg.2020.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department. METHODS We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy. RESULTS One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%). CONCLUSION Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- Saroop Dhatt
- University of British Columbia, Faculty of Medicine, British Columbia Children's Hospital, Vancouver, Canada
| | - Vikram Sabhaney
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Heather Bray
- Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Erik D Skarsgard
- Department of Surgery, University of British Columbia, Vancouver, Canada.
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16
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Naqvi SA, Thompson GC, Joffe AR, Blackwood J, Martin DA, Brindle M, Barkema HW, Jenne CN. Cytokines and Chemokines in Pediatric Appendicitis: A Multiplex Analysis of Inflammatory Protein Mediators. Mediators Inflamm 2019; 2019:2359681. [PMID: 30918467 PMCID: PMC6409077 DOI: 10.1155/2019/2359681] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/15/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We aimed to demonstrate the potential of precision medicine to describe the inflammatory landscape present in children with suspected appendicitis. Our primary objective was to determine levels of seven inflammatory protein mediators previously associated with intra-abdominal inflammation (C-reactive protein-CRP, procalcitonin-PCT, interleukin-6 (IL), IL-8, IL-10, monocyte chemoattractant protein-1-MCP-1, and serum amyloid A-SAA) in a cohort of children with suspected appendicitis. Subsequently, using a multiplex proteomics approach, we examined an expansive array of novel candidate cytokine and chemokines within this population. METHODS We performed a secondary analysis of targeted proteomics data from Alberta Sepsis Network studies. Plasma mediator levels, analyzed by Luminex multiplex assays, were evaluated in children aged 5-17 years with nonappendicitis abdominal pain (NAAP), acute appendicitis (AA), and nonappendicitis sepsis (NAS). We used multivariate regression analysis to evaluate the seven target proteins, followed by decision tree and heat mapping analyses for all proteins evaluated. RESULTS 185 children were included: 83 with NAAP, 79 AA, and 23 NAS. Plasma levels of IL-6, CRP, MCP-1, PCT, and SAA were significantly different in children with AA compared to those with NAAP (p < 0.001). Expansive proteomic analysis demonstrated 6 patterns in inflammatory mediator profiles based on severity of illness. A decision tree incorporating the proteins CRP, ferritin, SAA, regulated on activation normal T-cell expressed and secreted (RANTES), monokine induced by gamma interferon (MIG), and PCT demonstrated excellent specificity (0.920) and negative predictive value (0.882) for children with appendicitis. CONCLUSIONS Multiplex proteomic analyses described the inflammatory landscape of children presenting to the ED with suspected appendicitis. We have demonstrated the feasibility of this approach to identify potential novel candidate cytokines/chemokine patterns associated with a specific illness (appendicitis) amongst those with a broad ED presentation (abdominal pain). This approach can be modelled for future research initiatives in pediatric emergency medicine.
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Affiliation(s)
- S. Ali Naqvi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary AB, Canada
| | - Graham C. Thompson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Ari R. Joffe
- Department of Pediatrics, Division of Critical Care, University of Alberta, Edmonton AB, Canada
| | - Jaime Blackwood
- Department of Pediatrics, Division of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Dori-Ann Martin
- Department of Pediatrics, Division of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Mary Brindle
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Herman W. Barkema
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary AB, Canada
| | - Craig N. Jenne
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
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17
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Shommu NS, Jenne CN, Blackwood J, Joffe AR, Martin DA, Thompson GC, Vogel HJ. Metabolomic and inflammatory mediator based biomarker profiling as a potential novel method to aid pediatric appendicitis identification. PLoS One 2018; 13:e0193563. [PMID: 29529041 PMCID: PMC5846776 DOI: 10.1371/journal.pone.0193563] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/14/2018] [Indexed: 11/18/2022] Open
Abstract
Various limitations hinder the timely and accurate diagnosis of appendicitis in pediatric patients. The present study aims to investigate the potential of metabolomics and cytokine profiling for improving the diagnosis of pediatric appendicitis. Serum and plasma samples were collected from pediatric patients for metabolic and inflammatory mediator analyses respectively. Targeted metabolic profiling was performed using Proton Nuclear Magnetic Resonance Spectroscopy and Flow Injection Analysis Mass Spectrometry/Mass Spectrometry and targeted cytokine/chemokine profiling was completed using a multiplex platform to compare children with and without appendicitis. Twenty-three children with appendicitis and 35 control children without appendicitis from the Alberta Sepsis Network pediatric cohorts were included. Metabolomic profiling revealed clear separation between the two groups with very good sensitivity (80%), specificity (97%), and AUROC (0.93 ± 0.05) values. Inflammatory mediator analysis also distinguished the two groups with high sensitivity (82%), specificity (100%), and AUROC (0.97 ± 0.02) values. A biopattern comprised of 9 metabolites and 7 inflammatory compounds was detected to be significant for the separation between appendicitis and control groups. Integration of these 16 significant compounds resulted in a combined metabolic and cytokine profile that also demonstrated strong separation between the two groups with 81% sensitivity, 100% specificity and AUROC value of 0.96 ± 0.03. The study demonstrated that metabolomics and cytokine mediator profiling is capable of distinguishing children with appendicitis from those without. These results suggest a potential new approach for improving the identification of appendicitis in children.
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Affiliation(s)
- Nusrat S. Shommu
- Bio-NMR Center, Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | - Craig N. Jenne
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Jaime Blackwood
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Ari R. Joffe
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Dori-Ann Martin
- Department of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Graham C. Thompson
- Department of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Hans J. Vogel
- Bio-NMR Center, Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
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18
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Shommu NS, Jenne CN, Blackwood J, Martin DA, Joffe AR, Eccles R, Brindle M, Khanafer I, Vogel HJ, Thompson GC. The Use of Metabolomics and Inflammatory Mediator Profiling Provides a Novel Approach to Identifying Pediatric Appendicitis in the Emergency Department. Sci Rep 2018; 8:4083. [PMID: 29511263 PMCID: PMC5840182 DOI: 10.1038/s41598-018-22338-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/21/2018] [Indexed: 01/18/2023] Open
Abstract
Multiplexed profiling approaches including various ‘omics’ platforms are becoming a new standard of biomarker development for disease diagnosis and prognosis. The present study applied an integrated metabolomics and cytokine profiling approach as a potential aid to the identification of pediatric appendicitis. Metabolic analysis using serum (n = 121) and urine (n = 102) samples, and cytokine analysis using plasma (n = 121) samples from children presenting to the Emergency Department with abdominal pain were performed. Comparisons between children with appendicitis vs. non-appendicitis abdominal pain, and with perforated vs. non-perforated appendicitis were made using multivariate statistics. Serum and urine biomarker patterns were statistically significantly different between groups. The combined serum metabolomics and inflammatory mediator model revealed clear separation between appendicitis and non-appendicitis abdominal pain (AUROC: 0.92 ± 0.03) as well as for perforated and non-perforated appendicitis (AUROC: 0.88 ± 0.05). Urine metabolic analysis also demonstrated distinction between the groups appendicitis and non-appendicitis abdominal pain (AUROC: 0.85 ± 0.04), and perforated and non-perforated appendicitis (AUROC: 0.98 ± 0.02). In children presenting to the Emergency Department with abdominal pain, metabolomics and inflammatory mediator profiling are capable of distinguishing children with appendicitis from those without. The approach also differentiates between severities of disease. These results provide an important first step towards a potential aid for improving appendicitis identification.
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Affiliation(s)
- Nusrat S Shommu
- Bio-NMR Center, Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | - Craig N Jenne
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Jaime Blackwood
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Dori-Ann Martin
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Ari R Joffe
- Division of Pediatric Critical Care, University of Alberta, Edmonton, AB, Canada
| | - Robin Eccles
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Mary Brindle
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ijab Khanafer
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Hans J Vogel
- Bio-NMR Center, Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | - Graham C Thompson
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada. .,Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada.
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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20
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Arthur T, Gartrell R, Manoharan B, Parker D. Emergency appendicectomy in Australia: findings from a multicentre, prospective study. ANZ J Surg 2017; 87:656-660. [PMID: 28687027 DOI: 10.1111/ans.14088] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/03/2017] [Accepted: 04/10/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations. METHODS A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates. RESULTS A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection. CONCLUSION The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.
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Affiliation(s)
- Thomas Arthur
- Department of Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Richard Gartrell
- Department of Surgery, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Bavahuna Manoharan
- Department of Surgery, Redcliffe Hospital, Brisbane, Queensland, Australia
| | - David Parker
- Department of Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Fullerton K, Depinet H, Iyer S, Hall M, Herr S, Morton I, Lee T, Melzer-Lange M. Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments. Acad Emerg Med 2017; 24:400-409. [PMID: 28039951 DOI: 10.1111/acem.13156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/22/2016] [Accepted: 12/19/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. METHODS This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. RESULTS In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). CONCLUSION Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.
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Affiliation(s)
| | - Holly Depinet
- Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Sujit Iyer
- Dell Children's Medical Center; Austin TX
| | - Matt Hall
- Children's Hospital Association; Overland Park KS
| | | | - Inge Morton
- Children's Hospital Los Angeles; Los Angeles CA
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Abstract
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
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Abstract
OBJECTIVES Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs). METHODS A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision. RESULTS A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed. CONCLUSIONS Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.
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Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study. BMC Pediatr 2016; 16:147. [PMID: 27577252 PMCID: PMC5006246 DOI: 10.1186/s12887-016-0687-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 08/24/2016] [Indexed: 12/29/2022] Open
Abstract
Background Despite the poor independent test characteristics of the white blood cell count (WBC) and neutrophil count (NC) in identifying appendicitis, common clinical decision supports including the Pediatric Appendicitis Score (PAS) and Alvarado Score (AS), require the WBC and NC values. Moreover, blood tests cause discomfort/pain to children and require time for processing results. Scores based on clinical information alone may be of benefit in the pediatric population. The objective of our study was to determine the test characteristics of the PAS and the AS with and without laboratory investigations (mPAS, mAS respectively) as well as the Lintula Score. Methods A prospective cohort study of children aged 5–17 years presenting to a pediatric ED with suspected appendicitis. Clinical care of the patient was left to the managing physician. At risk for appendicitis was defined by PAS ≥6; AS ≥5; LS ≥16, as originally described; modified cutoffs were defined as mPAS ≥4; mAS ≥4. Appendicitis was defined as acute inflammation, rupture or abscess of the appendix on pathologic evaluation. Test characteristics for each of the 5 scores were calculated. Results Of the 180 eligible children, 102 (56.7 %) were female. The average age was 11.2 years (SD 3.1). Appendectomy was performed in 58 (32.2 %) of children, 55 (94.8 %) were positive. For the PAS and mPAS, sensitivity and negative predictive values were similar (80.0 %, 86.4 % vs 87.3 %, 85.1 % respectively). For the AS and mAS, sensitivity and negative predictive values were also similar (85.5 %, 87.1 % vs 83.6 %, 83.3 % respectively). Specificities in the PAS, mPAS, AS and mAS were low (56.0 %, 32.0 %, 43.2 %, 63.0 % respectively). Test characteristics of the LS were poor (59.3 %, 79.2 %, 55.2 %, 81.8 %). Conclusions A modified Alvarado and PAS can be used to screen for children at low risk of appendicitis who may be carefully observed at home without the need for laboratory investigation. Translation to primary care settings should evaluate generalizability and determine impact on referral patterns. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0687-6) contains supplementary material, which is available to authorized users.
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The Effect of a Full Bladder on Proportions of Diagnostic Ultrasound Studies in Children with Suspected Appendicitis. CAN J EMERG MED 2016; 18:414-419. [PMID: 27039941 DOI: 10.1017/cem.2016.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES We examined the effect of a full bladder on proportions of diagnostic ultrasound (US) studies in children with suspected appendicitis. We also examined the effect of a full bladder on proportions of fully visualized ovaries on US in children with suspected appendicitis. METHODS We conducted a retrospective health record review of children aged 2-17 years presenting to a tertiary pediatric emergency department (ED) with suspected appendicitis who had an ultrasound performed. We compared proportions of diagnostic US studies in children with full and sub-optimally filled bladders. We also compared proportions of ovarian visualization in females with full and sub-optimally filled bladders. RESULTS 678 children were included in our final analysis. The proportion of diagnostic US studies did not vary significantly between groups with a full (132/283, 47%, 95% confidence interval [CI] 38%-56%) or sub-optimally filled bladder (205/395, 52%, 95% CI 47%-57%)(p=0.17). Rates of ovarian visualization were higher in females with a full bladder (196/205, 96%, 95% CI 93%-99%) compared to those with a sub-optimally filled bladder (180/223, 81%, 95% CI 76%-86%) (p<0.01). CONCLUSIONS Administrators and clinical decision makers should consider removing routine bladder filling practice from current pediatric appendicitis protocols in males and in pre-pubertal females where ovarian pathology is not suspected. Selective bladder filling prior to US should be performed in females when ovarian pathology is suspected.
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Bruce BB, El-Kareh R, Ely JW, Kanter MH, Rao G, Schiff GD, ten Berg MJ, McDonald KM. Methodologies for evaluating strategies to reduce diagnostic error: report from the research summit at the 7th International Diagnostic Error in Medicine Conference. Diagnosis (Berl) 2016. [DOI: 10.1515/dx-2016-0002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractIn this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-post designs, in favor of stepped wedge and interrupted time series; (6) Leverage best practices for patient safety research and engage experts from relevant domains; and (7) Consider sources of bias and design studies and their analyses to minimize selection and information bias and control for confounding. Areas of diagnostic error mitigation research identified for further attention include: role of competing diagnoses, understanding the impacts of organizational culture, timing of diagnosis, and sequencing of research studies. Future research will likely require novel clinical, health services, and qualitative research methods to address the age-old problem of arriving at an accurate diagnosis.
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Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments. CAN J EMERG MED 2016; 18:323-30. [DOI: 10.1017/cem.2015.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractObjectivesEvidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation.MethodsPhysician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014.ResultsOverall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition.ConclusionsPediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.
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