Acute appendicitis in children: the importance of family history

BACKGROUND/PURPOSE

Acute appendicitis is common, frequently atypical, challenging, and still associated with significant morbidity. Despite major technologic advances, appendicitis remains a primarily clinical diagnosis. Therefore, no relevant anamnestic information should be overlooked. Surprisingly, the relationship between heredity and appendicitis is seldom considered. Because of the potential clinical importance of the family history, the authors addressed this question prospectively over a 52-month period in a practice that includes the majority of pediatric patients with appendicitis in the region.

METHODS

Family histories were obtained in a standardized manner, focusing on first-degree relatives. Children with incomplete family information were excluded. Patients (ages 2(1/2) to 19 years) were divided into 3 groups: group A, children who underwent an appendectomy (n = 166); group B (first control), children who presented with an acute abdomen and suspected appendicitis but did not undergo an appendectomy (n = 117); group C (second control), children who were seen in the practice for unrelated conditions (n = 141).

RESULTS

A positive parental history was obtained from 59 patients (36%) in group A, 24 patients (21%) in group B, and 20 patients (14%) in group C, and the odds ratios (ORs) were 2.0 (P =.035) and 2.9 (P <.001) for groups A versus B and A versus C, respectively. Of the 13 patients whose sibling had had acute appendicitis, 9 were in group A versus 2 each in groups B and C, and the OR for any family history (siblings, parents) in groups A versus B was 1.9 (P =.028) and for groups A versus C was 2.9 (P < 0.001). Appendicitis was histologically confirmed in 93% of children in group A.

CONCLUSIONS

Heredity is a significant factor in pediatric patients who have appendicitis. Children who have appendicitis are twice as likely to have a positive family history than are those with right lower quadrant pain (but no appendicitis) and almost 3 times as likely to have a positive family history than are surgical controls (without abdominal pain). Because of its potential value in changing the threshold for intervention, a careful family history should be obtained for every child in whom acute appendicitis is suspected.

Abdominal compartment syndrome in children: experience with three cases

BACKGROUND/PURPOSE

Abdominal compartment syndrome (ACS) is defined as cardiopulmonary or renal dysfunction caused by an acute increase in intraabdominal pressure. Although the condition is well described in adults, particularly trauma patients, little is known about ACS in children.

METHODS

Three girls, ages 4, 5, and 5 years, were treated for ACS by silo decompression. Each child presented in profound shock, required massive fluid resuscitation, and had tremendous abdominal distension. The first child sustained a thoracoabdominal crush injury, underwent immediate celiotomy for splenic avulsion and a liver laceration, and required decompression 5 hours postoperatively. The second underwent ligation of her bluntly transected inferior vena cava; because of massive edema, her abdominal wall could not be closed, and prophylactic decompression had to be performed. The third presented with shock of unknown etiology, and ACS developed acutely with a bladder pressure of 26 mm Hg.

RESULTS

Respiratory, renal, and hemodynamic function improved immediately in all 3 patients after decompression. Subsequently, each child underwent abdominal wall reconstruction and recovered uneventfully.

CONCLUSIONS

ACS is a potentially lethal complication of severe trauma and shock in children. To prevent the development of renal or cardiopulmonary failure in these patients, decompression should be considered for acute, tense abdominal distension.

Life-threatening air rifle injuries to the heart in three boys

Air rifles, or BB guns, are generally thought of as childhood toys. Although most injuries are not serious, life-threatening events have been reported. Within a 1-year period, 3 boys presented after BB gun shots to the chest, all requiring surgical intervention for penetrating injuries to the heart. A 15-year-old underwent window pericardiotomy for hemopericardium with thrombus 24 hours after admission. Another, 5 years of age, underwent emergent exclusion of the cardiac apex for a traumatic ventricular septal defect. The third, 8 years old, had a right ventricular injury requiring an urgent subxiphoid pericardial window for tamponade. All recovered uneventfully. Increased public awareness, adult supervision, safety training, and appropriate legislation are needed to decrease the risks of these potentially lethal weapons.

The 'penny pincher': a new technique for fast and safe removal of esophageal coins

BACKGROUND/PURPOSE

Considerable debate surrounds the choice of technique for the removal of esophageal coins: endoscopic extraction versus dislodgement with a Foley balloon versus dislodgement using bougienage. The "penny-pincher" (PP) technique was developed as an alternative, incorporating the main advantages of these various approaches.

METHOD

The PP technique is based on the insertion of a fluoroscopically guided device that consists of a grasping endoscopic forceps covered by a soft rubber catheter. The forceps provides a firm hold on the coin. The catheter protects the oropharynx and aligns the device with the coin. Once the tip of the catheter is close to the upper edge of the coin, the previously retracted radiopaque prongs of the grasping forceps are deployed and the edge of the coin firmly grasped and extracted. The procedure is done without anesthesia or sedation.

RESULTS

Twenty coins were removed from 19 consecutive children with a mean age of 34 months. Average lip-to-lip removal (including fluoroscopy) time was 41 seconds. There were no complications, and all patients were discharged shortly after coin removal.

CONCLUSION

The penny-pincher method for the removal of upper esophageal coins combines the simplicity, speed, and cost effectiveness of balloon catheter or bougie coin dislodgement with the safety and secure grasping of endoscopic or forceps removal.

Seat-belt transection of the pararenal vena cava in a 5-year-old child: survival with caval ligation

Blunt traumatic disruption of the inferior vena cava is associated with high mortality and is rare in children. A seat-belted 5-year-old girl sustained, in a motor vehicle accident, pararenal caval transection, right renal vein transection, laceration of the right kidney, duodenal injury, and a second lumbar vertebral fracture. Damage-control surgery consisted of inferior vena caval and right renal vein ligation and temporary abdominal wall silo closure. She is alive and well 10 months after the accident, with no sequelae of caval ligation and with normal right renal function.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures

BACKGROUND/PURPOSE

Delivery of local anesthesia for surgical office procedures for pediatric patients can be difficult. Injections are painful and often lead to patient anxiety, and topical anesthetics frequently provide incomplete anesthesia. The authors prospectively studied the efficacy of iontophoresis, a needle-free technique in which positively charged lidocaine and epinephrine molecules are drawn into the tissue by an electrical current as an anesthetic for pediatric surgical office procedures.

METHODS

Children undergoing an office procedure were offered local anesthesia via iontophoresis. Prospectively collected data included patient characteristics, procedure, iontophoresis dose and time, need for additional injected anesthetic, pain during the procedure as determined by a 0 to 5 faces scale, and complications. A satisfaction questionnaire was completed at the follow-up visit or by telephone.

RESULTS

Over an 8-month period, 34 patients with a mean age of 6.8 years (range, 3 months to 15 years) underwent 38 office procedures with anesthesia supplied through iontophoresis. Skin lesion excision (n = 14) and abscess drainage (n = 12) were the most common procedures. Seven patients required unplanned injected anesthetic. A small, superficial burn was the only complication. Sixty percent of patients and 84% of parents rated pain as 0 to 2 (zero to mild). Overall, 88% were satisfied with the anesthetic.

CONCLUSION

Iontophoresis appears to be an effective and safe alternative method of local anesthesia delivery for pediatric surgical office procedures.

Is thoracoscopically aided pleural debridement advantageous in children?

Thoracic empyema encompasses a spectrum of inflammatory manifestations ranging from thin parapneumonic pleural effusion to the formation of a thick, constricting rind. The aim of this study is to determine the applicability of thoracoscopically aided pleural debridement (TAPD) in children with complicated empyema and to assess its possible advantages. In the last 6 years, 26 children (ages 2 months-16 years; median, 7 years; mean, 7 years) were diagnosed with empyema (right, n = 15; left, n = 11). Their charts, radiographs, and follow-up courses were reviewed. All children had typical clinical and radiological findings of empyema; one also had necrotizing pneumonitis. Treatment modalities included antibiotics only (n = 3), antibiotics with tube thoracostomy (n = 11), open thoracotomy (n = 5), and TAPD (n = 7). Children treated with antibiotics alone had an average (avg) length of stay (LOS) of 31 days. Those managed with tube thoracostomy had an avg LOS of 13 days, and those who underwent thoracotomy had an avg LOS of 16 days. The seven children treated with TAPD had an avg LOS of 12 days, and their avg postoperative chest tube use was 6 days. Children with TAPD had considerable less pain and recovered faster. TAPD of empyema is promising for children whose lungs do not expand promptly after tube thoracostomy or who have a persistent loculated empyema.

Initial experience with the changeable skin-level port-valve: a new concept for long-term gastrointestinal access

BACKGROUND/PURPOSE

Experience with a new multipurpose system for long-term enteral access is reported. At the core of the concept is a changeable, skin-level "port" (SL port) that incorporates a valve accessible through a locking, right-angle feeding adapter. The new system allows conversion of a previously-inserted, long gastrointestinal catheter into a "button-type" skin-level device without removal of the long catheter, thereby eliminating pain, tract damage, and the risk of separation of the viscus from the abdominal wall.

METHODS

Sixty-four SL ports were used in 44 children (ages 2 weeks to 19 years). Conversion from long tube to skin-level device was performed 33 times, either immediately after the catheter placement or some time thereafter (percutaneous endoscopic gastrostomy, 18; Stamm gastrostomy, 6; laparoscopic gastrostomy, 7; jejunostomy, 2). Insertion as an assembled button-type device in an established tract was performed seven times. Twenty SL ports showing signs of leakage were replaced with an identical device without catheter removal. SL ports remained in place from 1 week to 15 months.

Pyloric duplications: review and case study

Gastric duplications are unusual congenital anomalies that often require surgical treatment. Pyloric duplications are particularly rare; few are reported in the English literature. This article reviews the literature on pyloric duplications and describes a pyloric duplication associated with hypertrophic pyloric stenosis in a 5-week-old child and a duplication that recurred 7 years later.

A simple approach to physician entry of patient problem list

The patient's problem list is one of the key components of the electronic medical record. Besides the immediate benefits of using the patient problem list for medical records coding and creation of discharge documentation, a coded problem list is a prerequisite of patient management, clinical decision support and research. The ICD9 coding system that is the current standard for coding diagnoses and procedures is not conducive to physician usage. In this paper we describe a simple system that provides physicians with a quick and easy method to enter and maintain a patient's problem list. Physicians can use their own terminology. ICD9 codes are included where possible, but free text is allowed. The system strikes a balance between capturing a fully coded patient problem list and encouraging usage by a wide physician user group.

Vascular malformation: case report and literature review

The therapeutic outcome of congenital vascular malformations generally parallels the complexity of the lesion. The less extensive malformations that are prone to regression may be observed. Larger lesions that produce facial asymmetry or have diffuse extremity involvement require a more aggressive approach. Even with the limitations of current treatment methods these extensive malformations can usually be controlled thus affording the patient a better life.

Electrolyte changes caused by hydrotherapy in purpura fulminans

Purpura fulminans is a rare manifestation of meningococcemia that in its full-blown form has a predictive death value of 61%. Those patients who survive usually develop gangrenous lesions that involve skin and underlying structures, mostly of the extremities and sometimes of the cheeks. Experience with early excision and skin grafting of these lesions has generally been unsatisfactory since, due to the unique pathophysiology of the disease and involvement of the most distal branches of the cutaneous circulation, the lesions are not completely demarcated until well after complete recovery from the acute phase of the disease. Recently there was an outburst of purpura fulminans in Southern California and other parts of the country. During the months of January and February 1986 we were consulted on five cases. These ranged from two months to six years in age and consisted of two boys and three girls. One two-month-old died during the acute phase, another six-year-old remained in shock and in need of hemodynamic and respiratory support and succumbed three weeks after the onset of the disease, during which time all four extremities showed progressive necrosis. Of the three patients that survived, one three-year-old girl resolved her purpuric lesions except for small necrotic patches on the buttocks that did not require surgical intervention. The other two children were left with gangrenous lesions of the upper and lower extremities over 30% of total body surface area. One of these two patients demonstrated an electrolyte disturbance.(ABSTRACT TRUNCATED AT 250 WORDS)

Implications of policy and management decisions on access, quality, and the type of services for the elderly in the United States

America has no conscious overall health policy. What we have is a system which encourages doctors to perform medical procedures on people, especially in hospitals, and which places little or no emphasis on a person's responsibility for his or her own health. There is no incentive whatsoever for doctors, except in HMOs, to provide the elderly with primary care or consultations on preventative health care. there is no reimbursement under Medicare for this type of service, and a financial disincentive exists for the doctor in that a healthier patient is less likely to use a physician's services. In addition, because there is inadequate funding for home health care and supportive services for families of the elderly who are experiencing problems functioning in their daily living, many people who could be kept out of nursing homes with proper support go into nursing homes, where they generally, after depletion of their assets, have their nursing home care covered by the Medicaid program. Because of the lack of recognition by the Medicare program of the major role of social and mental health factors on the health of the elderly, and the lack of reimbursement or other funding for services which treat the social, mental, and spiritual aspects of the person, the elderly are often inappropriately and expensively treated for physical symptoms; their other needs and problems are ignored, even though in many cases the treatment of the underlying problem would remove or ameliorate the physical symptom and expedite the recovery. Recommended changes in the health care system which will be of particular benefit to the elderly are by providing primary and preventative health care, providing alternatives to hospitalization and nursing home care wherever possible, discouraging unnecessary surgery and medication, providing for contributions to Medicare based on income of the elderly so that the poor and the rich are treated more equitably, decreasing the complexity of the Medicare reimbursement process, mandating geriatric education for health care professionals, developing public awareness concerning the quality of extended life and promoting public information programs designed to promote a new and positive image of aging in America.

Nitrous oxide has multiple deleterious effects on cobalamin metabolism and causes decreases in activities of both mammalian cobalamin-dependent enzymes in rats

In man, use of the general anesthetic nitrous oxide, N2O, is associated with hematologic and neurologic abnormalities that mimic those seen in cobalamin (Cbl, vitamin B12) deficiency. We have measured a number of aspects of Cbl metabolism in rts exposed to various concentrations of N2O for various periods of time. As little as 2% N2O given for 15 h resulted in 30% inhibition of methionine synthetase (MS) in rat liver. With 50% N2O, inhibition of 70% occurred with 1 h and did not change during the next 48 h. Under these conditions, no inhibition of methylmalonyl-CoA mutase (MMCoAM) was observed. The recovery of MS activity was slow and was only 80% of control values 72 h after N2O was stopped. Studies employing rats previously injected with [57Co]Cbl showed that N2O displaced [57Co]Cbl from MS in a manner that temporally and quantitatively paralleled the loss of MS activity. Recovery of MS activity paralleled the reappearance of [57Co]Cbl on MS. N2O also caused the hepatic content of CH3-[57Co]Cbl to decrease by 20-60%. When [57Co]-Cbl was extracted from liver and analyzed by paper chromatography, [57Co]Cbl analogues were present (10-40% of total [57Co]Cbl) in rats exposed to N2O, but not in control animals. When rats were exposed to 50% N2O for 33 d, the total of endogenous Cbl and Cbl analogues in liver decreased to 35% of control values and endogenous Cbl decreased to 10% of control values. At this time, MS activity was 15% of control values and MMCoAM was only 26% of control values. We conclude that N2O causes multiple defects in Cbl metabolism that include the following: (a) rapid inhibition of MS activity with a slow recovery when N2O is stopped; (b) displacement of Cbl from MS; (c) decreased CH3-Cbl; (d) conversion of Cbl to Cbl analogues; (e) the gradual development of Cbl deficiency and (f) an eventual decrease in MMCoAM activity with a further decrease in MS activity.