1
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Kakish H, Ngendahimana DK, Shein SL, Miyasaka EA. Characteristics of and cost of care for children with impaired development and acute appendicitis: A study of two national databases. Surgery 2024; 176:899-905. [PMID: 38851901 DOI: 10.1016/j.surg.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/08/2024] [Accepted: 05/06/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Characteristics of children with impaired development who have acute appendicitis are not well described in the literature. METHODS We reviewed the National Surgical Quality Improvement Program-Pediatric and the multicenter Pediatric Health Information System for patients with acute appendicitis. Comparisons for demographics, clinical outcomes, and hospital charges between children with impaired development versus neurotypical children were made using independent t test or Wilcoxon rank sum tests. The multivariable logistic regression model estimated the odds of complicated acute appendicitis in impaired development patients. Based on correlation analyses, hierarchical linear modeling was used to examine the extent to which impaired development influenced resource use. RESULTS Patients with impaired development were younger, had higher comorbidities, and were more commonly male sex. In the National Surgical Quality Improvement Program-Pediatric database, impaired development was associated with higher rates of complicated acute appendicitis (33.6% vs 27.5, P < .001), particularly in older children, and higher usage of computed tomography at National Surgical Quality Improvement Program-Pediatric hospitals (23.1% vs 15.1%, P < .001). In the Pediatric Health Information System database, the adjusted odds of complicated acute appendicitis were significantly higher in patients with impaired development (1.20 [1.09-1.31]), low childhood opportunity level (1.39 [95% confidence interval: 1.31-1.47]), and Black race (1.25 [1.17-1.33]). Hierarchical adjusted linear modeling showed that impaired development was associated with significantly higher hospital charges (9% increase). CONCLUSION Management of acute appendicitis in children with impaired development remains a challenge to clinicians, as evidenced by the higher rate of perforated appendicitis in older children, diagnostic computed tomography use at National Surgical Quality Improvement Program-Pediatric hospitals, postoperative computed tomography use, and increased costs.
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Affiliation(s)
- Hanna Kakish
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH. https://twitter.com/HannaKakish
| | - David K Ngendahimana
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Eiichi A Miyasaka
- Division of Pediatric Surgery, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH.
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2
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Fikri E, Eyanoer PC. The Determination of Appendicitis from Folate Acid and Vascular Endothelial Growth Factor Level in Animal Model: A Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Appendicitis is one of the most common abdominal emergencies that require surgery in children. The morbidity and mortality rate in appendicitis is greatly affected by rupture or leakage of the appendix. In establishing the diagnosis of appendicitis, several modalities are acknowledged, namely, pediatric appendicitis score and ultrasound. Pathologically, severity and complications of appendicitis occur related to good vascularization and tissue healing process through process of angiogenesis influenced by folic acid (FA) and vascular endothelial growth factor (VEGF). This is clinically important as currently non-operative and non-invasive therapies were developing in stratification of mild appendicitis.
AIM: This study aimed to review the determination of appendicitis from FA and VEGF levels in animal model.
METHODS: This study was conducted in accordance with the PRISMA guidelines for reporting systematic reviews. Articles were reviewed for relation of FA and VEGF in determining appendicitis in PubMed and Science Direct. Articles on experimental animal model published from 1990 to 2020 were included, while articles in English were excluded from the study.
RESULTS: The articles we reviewed conduct an assessment of appendicitis by FA and VEGF level in animal model. Three articles were reviewed ranging from 1990 to 2020. One article presented a significant association of decreased level of FA in determining appendicitis while the other two mentioned trends of decreased level of FA and VEGF in appendicitis without statistically significance.
CONCLUSION: Reduction of folate acid levels could be a critical prescient factor for the weight of muddled an appendicitis in animal model, however, there was a pattern demonstrating low estimation of VEGF as an indicator of appendicitis and convoluted appendix with no measurable note worthiness appeared.
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3
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Lv X, Zhang Y. Comparative observation on the accuracy of ultrasonography and CT in preoperative diagnosis of acute appendicitis in children. Minerva Pediatr (Torino) 2021; 74:97-99. [PMID: 34128603 DOI: 10.23736/s2724-5276.21.06421-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Xuefei Lv
- Department of Radiology, Wuhan Red Cross (The 11th) Hospital, Wuhan, China
| | - Yu Zhang
- Department of Ultrasonic Imaging, Hubei NO. 3 People's Hospital of Jianghan University, Wuhan, China -
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4
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Ferguson DM, Ferrante AB, Orr HA, Arshad SA, Curbo ME, Parker TD, Chang ML, Tsao K. Clinical Practice Guideline Nonadherence and Patient Outcomes in Pediatric Appendicitis. J Surg Res 2020; 257:135-141. [PMID: 32828996 DOI: 10.1016/j.jss.2020.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 06/19/2020] [Accepted: 07/11/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) have been associated with improved patient outcomes. We aimed to evaluate institutional CPG adherence and hypothesized that adherence would be associated with fewer complications in pediatric appendicitis. METHODS A retrospective review was conducted of pediatric (<18 y) appendicitis patients who underwent appendectomy (6/1/2017-5/30/2018). Patients were managed using an institutional pediatric appendicitis CPG. The primary outcome was CPG adherence, defined as receipt of preoperative antibiotics at diagnosis, surgical prophylaxis before incision, and, in perforated/gangrenous appendicitis, continued postoperative antibiotics, and prescription for discharge antibiotics. Univariate and multivariate analyzes were performed. RESULTS Among 399 patients, the baseline characteristics were similar between CPG-adherent and nonadherent patients. Overall CPG adherence was low at 55% (n = 221). Only 58% of patients received preoperative antibiotics per protocol (n = 233). Patients with simple appendicitis were more likely to proceed to surgery without receiving any preoperative antibiotics (35% vs. 21%, P = 0.004). Surgical prophylaxis compliance was high at 97% (n = 389). CPG violation was associated with reoperation (n = 5 versus 0, P = 0.02). After adjusting for age and admission white blood cell count, the association between CPG adherence and postoperative surgical site infection or intra-abdominal abscess remained nonsignificant (OR: 1.2, 95% CI: 0.5-2.5). CONCLUSIONS Despite a long-standing pediatric appendicitis CPG, adherence with antibiotic components of the CPG was poor. CPG violation was significantly associated with reoperation, but was not associated with other postoperative complications. Regular audits of CPG adherence are necessary to ascertain reasons for noncompliance and identify ways to improve adherence.
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Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | | | - Hillary A Orr
- Children's Memorial Hermann Hospital, Houston, Texas
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Maile E Curbo
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Tayler D Parker
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Michael L Chang
- Children's Memorial Hermann Hospital, Houston, Texas; Division of Pediatric Infectious Diseases, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
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5
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Hartford EA, Woodward GA. Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children. Pediatr Emerg Care 2020; 36:347-352. [PMID: 32618901 DOI: 10.1097/pec.0000000000002157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.
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Affiliation(s)
| | - George A Woodward
- Professor, Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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6
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Liu Q, Hao F, Chen B, Li L, Liu Q, Guo C. Multi-Center Prospective Study of Restrictive Post-Operative Antibiotic Treatment of Children with Complicated Appendicitis. Surg Infect (Larchmt) 2020; 21:778-783. [PMID: 32150521 DOI: 10.1089/sur.2019.293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: No consensus has been reached regarding the most advantageous duration of antibiotic prophylaxis to decrease post-operative infection complications of appendectomy for acute complex appendicitis. This study aimed to determine the efficacy of short-term antibiotic treatment on post-operative complications in children with complex appendicitis. Methods: A multi-center, parallel group, randomized study was conducted in patients younger than 14 years of age with complicated appendicitis at three hospitals in China. The qualified patients were randomized prospectively to either the restrictive 72-hour short-term antibiotic strategy or the standard antibiotic usage. A comparison of the complications within 24 months, including infectious complications and long-term results, were conducted between the two groups. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR), number ChiCTR1900023941 and is complete. Results: A shorter duration of antibiotic treatment had no effect on intestinal function recovery, antibiotic-associated diarrhea, and health-care-associated Clostridium difficile infection and infectious complication, including intra-abdominal abscess development (17.9% vs. 18.0%, p = 0.52). Furthermore, no substantial difference for re-admission requirement and re-operation were found between the two treatment strategies. A sizeable decrease in total duration of hospitalization (p < 0.001) and average total antibiotic duration (p < 0.001) were observed for the restrictive antibiotic strategy group. Conclusion: In complicated appendicitis, the restrictive antibiotic usage was equivalent to standard antibiotic usage in terms of short- and long-term outcomes, but with shorter hospital stays and fewer antibiotic agents.
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Affiliation(s)
- Qianyang Liu
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Fabao Hao
- Department of Pediatric General Surgery, Qingdao Maternity and Child Care Hospital, Qingdao, P.R. China
| | - Bailin Chen
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Lei Li
- Department of Neonatology, Jinan Maternity and Child Care Hospital, Jinan, P.R. China
| | - Qingshuang Liu
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
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7
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Akpede GO, Adetunji AE, Udefiagbon EO, Eluehike SO, Odike AI, Ewah-Odiase RO, Omosofe FO, Akerele JM, Atafo RO, Okonofua MO, Onyeke I, Oyedeji OA, Mbanefo K, Ogbaini-Emovon E, Okokhere PO, Günther S, Dongo AE. Acute Abdomen in Pediatric Patients With Lassa Fever: Prevalence and Response to Nonoperative Management. J Pediatric Infect Dis Soc 2019; 8:519-524. [PMID: 30272215 DOI: 10.1093/jpids/piy093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 09/04/2018] [Indexed: 02/01/2023]
Abstract
Few reports on the prevalence of acute abdomen (AAbd) in pediatric patients with Lassa fever (LF) are available, and no firm policy on its management exists. Here, we report on its prevalence in and the response to treatment among a cohort of children with confirmed LF. Six (10.3%) of 58 children with LF had AAbd, whereas 6 (2.8%) of 215 children with AAbd had LF. Nonoperative treatment was successful in 5 of the 6 children with both AAbd and LF. We conclude that AAbd is not uncommon in pediatric patients with LF, and it could be responsive to nonoperative treatment. Testing for LF in all children with febrile AAbd might be justified in areas in which LF is endemic.
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Affiliation(s)
- George O Akpede
- Departments of Paediatrics, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Adewale E Adetunji
- Departments of Paediatrics, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Ernest O Udefiagbon
- Departments of Surgery, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Sylvester O Eluehike
- Departments of Radiology, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Angela I Odike
- Departments of Paediatrics, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | | | - Folorunso O Omosofe
- Departments of Anaesthesia, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Johnbull M Akerele
- Departments of Surgery, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Rebecca O Atafo
- Departments of Nursing Services Unit, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Martha O Okonofua
- Departments of Nursing Services Unit, Irrua Specialist Teaching Hospital, Edo State, Nigeria.,Departments of Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Imonifome Onyeke
- Departments of Paediatrics, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Omobolaji A Oyedeji
- Departments of Paediatrics, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Kaine Mbanefo
- Departments of Paediatrics, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Ephraim Ogbaini-Emovon
- Departments of Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Peter O Okokhere
- Departments of Medicine, Irrua Specialist Teaching Hospital, Edo State, Nigeria
| | - Stephan Günther
- Bernhard-Nocht Institute for Tropical Medicine, WHO Collaborating Centre for Arboviruses and Hemorrhagic Fever Reference and Research, Department of Virology, Hamburg, Germany
| | - Andrew E Dongo
- Departments of Surgery, Irrua Specialist Teaching Hospital, Edo State, Nigeria
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8
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Alvarado Scores Predict Additive Value of Magnetic Resonance Imaging in Workup of Suspected Appendicitis in Children. J Surg Res 2019; 244:42-49. [PMID: 31279262 DOI: 10.1016/j.jss.2019.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/03/2019] [Accepted: 06/07/2019] [Indexed: 11/17/2022]
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9
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Jones RE, Gee KM, Preston SC, Babb JL, Beres AL. Diagnostic Utilization and Accuracy of Pediatric Appendicitis Imaging at Adult and Pediatric Centers. J Surg Res 2019; 240:97-103. [DOI: 10.1016/j.jss.2019.02.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 12/29/2022]
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10
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Gee KM, Jones RE, Babb JL, Preston SC, Beres AL. Clinical and Imaging Correlates of Pediatric Mucosal Appendicitis. J Surg Res 2019; 242:111-117. [PMID: 31075655 DOI: 10.1016/j.jss.2019.04.039] [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: 12/06/2018] [Revised: 03/20/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. MATERIALS AND METHODS After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. RESULTS Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). CONCLUSIONS Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.
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Affiliation(s)
- Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacqueline L Babb
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie C Preston
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, Children's Health, Dallas, Texas.
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11
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Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, Tsao K. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019; 54:723-727. [PMID: 29925468 DOI: 10.1016/j.jpedsurg.2018.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Kathryn Tinsley Anderson
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX.
| | - Marisa A Bartz-Kurycki
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Mary T Austin
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Akemi L Kawaguchi
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Lillian S Kao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kevin P Lally
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kuojen Tsao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
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12
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Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
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13
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Utility of standardized discharge criteria after appendectomy to identify pediatric patients requiring intervention after postoperative imaging. Surgery 2018; 164:1204-1208. [PMID: 30115455 DOI: 10.1016/j.surg.2018.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/14/2018] [Accepted: 05/18/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purposes of this study were to evaluate the efficacy of failure-of-discharge criteria and identify the cohort of pediatric patients after appendectomy in whom postoperative imaging would impact management. METHODS Pediatric patients who underwent an appendectomy from July 2009 to May 2017 were included. Complicated appendicitis was defined based on the intraoperative diagnosis. Postoperative imaging was recommended at postoperative days 5-7 for patients who met at least one criterion of failure of standard management: fever (>38°C), leukocytosis (white blood cell count >12,000/mm3), diet intolerance, or uncontrolled pain by oral analgesics at postoperative day 5. Primary outcomes included any intervention (reoperation, drainage procedures, or change in antibiotics). RESULTS In all, 3,276 pediatric patients undergoing appendectomy were identified. Of these patients, 12% met at least 1 discharge criterion of failure Most discharge failures (79%) underwent postoperative imaging, such as computed tomography (68%), ultrasonography then computed tomography (20%), or ultrasonography only (12%); 39% of imaging patients required intervention. On multiple logistic regression, 3 criteria (diet intolerance, fever, and leukocytosis), complicated disease, and age were associated with the need for intervention after imaging. The type of imaging modality did not discriminate need for intervention. CONCLUSION Standardized criteria identifying failure of ability to discharge the patient after appendectomy limits the need for unnecessary imaging. In the management of pediatric appendicitis, a selective approach resulted in a high yield of complications requiring intervention after obtaining postoperative imaging.
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14
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Anderson KT, Bartz-Kurycki M, Austin MT, Kawaguchi A, John SD, Kao LS, Tsao K. Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation. J Pediatr Surg 2017; 52:1909-1915. [PMID: 28927978 DOI: 10.1016/j.jpedsurg.2017.08.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis. METHODS A multidisciplinary group (emergency medicine, radiology, and surgery) at a children's hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time. RESULTS Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs ($88, IQR $52-$169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01). CONCLUSION Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Tinsley Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Marisa Bartz-Kurycki
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Mary T Austin
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Akemi Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Susan D John
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
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Ultrasound for Appendicitis: Performance and Integration with Clinical Parameters. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5697692. [PMID: 28044133 PMCID: PMC5156797 DOI: 10.1155/2016/5697692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/17/2022]
Abstract
Objective. To evaluate the performance of ultrasound in pediatric appendicitis and the integration of US with the pediatric appendicitis score (PAS) and C-reactive protein (CRP). Method. An institution-based, retrospective study of children who underwent abdominal US for suspected appendicitis between 2012 and 2015 at a tertiary pediatric surgery center. US results were dichotomized, with a nonvisualized appendix considered as a negative examination. Results. In total, 438 children were included (mean 8.5 years, 54% boys), with an appendicitis rate of 29%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for US were 82%, 97%, 92%, and 93%, respectively, without significant age or gender differences. Pediatric radiologists had significantly higher sensitivity compared to general radiologists, 88% and 71%, respectively (p < 0.01), but no differences were seen for specificity, PPV, and NPV. The sensitivity, NPV, and negative likelihood ratio for the combination of negative US, PAS < 5, and CRP < 5 mg/L were 98%, 98%, and 0.05 (95% CI 0.03–0.15). Conclusion. US may be a useful tool for evaluating children with suspected appendicitis, regardless of age or gender, and should be the first choice of imaging modalities. Combining US with PAS and CRP may reduce several unnecessary admissions for in-hospital observation.
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