Sohail R. Shah

Can the Diagnosis of Appendicitis Be Made Without a Computed Tomography Scan

Historically, management of appendicitis emphasized avoidance of perforation at the expense of negative appendectomies. Development of advanced imaging modalities led to an over-reliance on imaging to diagnose appendicitis, particularly computed tomography (CT) scans. Detrimental effects of radiation have led to efforts to minimize CT use in the diagnosis of appendicitis, especially in vulnerable populations such as children and pregnant patients. Clinical scoring systems offer a standardized method to risk stratify patients with suspected appendicitis. Diagnostic algorithms combine various diagnostic modalities into a standardized pathway for the diagnosis of appendicitis while limiting the necessity for CT scans.

Utility of pediatric female fertility preservation discussions following pelvic radiation

IntroductionWhile many childhood cancers are curable with therapy, adverse consequences in fertility exist. We sought to assess the number of female patients with pelvic tumors receiving radiation therapy, and the proportion that undergo measures for fertility preservation (FP).MethodsA total of 53 female patients treated with pelvic tumors from 2000 to 2016 were retrospectively identified.Results19 (34%) of these patients underwent pelvic radiation therapy (pXRT). Three of the patients received pXRT for palliative treatment. Of the 19 female patients receiving pXRT, six (31%) were prepubertal and 13 (68%) were postpubertal. Three patients (16%) had documentation of a discussion of FP measures prior to pXRT. One was prepubertal and the others were post-pubertal. Six patients (32%) were evaluated by endocrinology after radiation therapy, diagnosed with ovarian failure, and placed on hormone therapy. Current guidelines recommend discussion of FP in pre-and postpubertal patients with cancer. This 16-year retrospective review of female patients that underwent pXRT for pelvic tumors demonstratedu2009<u200917% of patients have documentation of a discussion of FP measures.ConclusionFemale pediatric patients who underwent chemotherapy and pXRT suffer a high rate of premature ovarian failure, high morbidity and mortality as well as low rates of documented FP discussions. Based on these findings we have established a multi-disciplinary fertility preservation team available for consultation and a protocol for discussing and documenting the impact of pXRT, along with other treatments, on fertility.Level of evidenceIII.

Standardized reporting of appendicitis-related findings improves reliability of ultrasound in diagnosing appendicitis in children

PURPOSEnOur objective was to increase ultrasound reliability for diagnosing appendicitis in an academic childrens hospital emergency department (ED) through a multidisciplinary quality improvement initiative.nnnMETHODSnA retrospective review of ultrasound use in patients diagnosed with appendicitis in our ED from 1/1/2011 to 6/30/2014 established a baseline cohort. From 8/1/2014 to 7/31/2015 a diagnostic algorithm that prioritized ultrasound over CT was used in our ED, and a standardized template was implemented for the reporting of appendicitis-related ultrasound findings by our radiologists.nnnRESULTSnOf 627 patients diagnosed with appendicitis in the ED during the retrospective review, 46.1% (n=289) had an ultrasound. After implementation of the diagnostic algorithm and standardized ultrasound report, 88.4% (n=236) of 267 patients diagnosed with appendicitis had an ultrasound (p<0.01). The frequency of indeterminate results decreased from 44.3% to 13.1%, and positive results increased from 46.4% to 66.1% in patients with appendicitis (p<0.01). The sensitivity of ultrasound (indeterminate counted as negative) increased from 50.6% to 69.2% (p<0.01).nnnCONCLUSIONSnUltrasound reliability for the diagnosis of appendicitis in children can be improved through standardized results reporting. However, these changes should be made as part of a multidisciplinary quality improvement initiative to account for the initial learning curve necessary to increase experience.nnnLEVEL OF EVIDENCEnLevel II, Study of Diagnostic Test.

Magnet foreign body ingestion: rare occurrence but big consequences

PURPOSEnTo review the outcomes of magnet ingestions from two childrens hospitals and develop a clinical management pathway.nnnMETHODSnChildren <18years old who ingested a magnet were reviewed from 1/2011 to 6/2016 from two tertiary center childrens hospitals. Demographics, symptoms, management and outcomes were analyzed.nnnRESULTSnFrom 2011 to 2016, there were 89 magnet ingestions (50 from hospital 1 and 39 from hospital 2); 50 (56%) were males. Median age was 7.9 (4.0-12.0) years; 60 (67%) presented with multiple magnets or a magnet and a second metallic co-ingestion. Suspected locations found on imaging were: stomach (53%), small bowel (38%), colon (23%) and esophagus (3%). Only 35 patients (39%) presented with symptoms and the most common symptom was abdominal pain (33%). 42 (47%) patients underwent an intervention, in which 20 (23%) had an abdominal operation. For those undergoing abdominal surgery, an exact logistic regression model identified multiple magnets or a magnet and a second metallic object co-ingestion (OR 12.9; 95% CI, 2.4 - Infinity) and abdominal pain (OR 13.0; 95% CI, 3.2-67.8) as independent risk factors.nnnCONCLUSIONnMagnets have a high risk of requiring surgical intervention for removal. Therefore, we developed a management algorithm for magnet ingestion.nnnLEVEL OF EVIDENCEnLevel III.

A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition

PURPOSEnStandardized clinical pathways for simple appendicitis decrease length of stay and result in cost savings. We performed a prospective cohort study to assess a same day discharge (SDD) protocol for children with simple appendicitis.nnnMETHODSnAll children undergoing laparoscopic appendectomy for simple appendicitis after protocol implementation (February 2016 to January 2017) were assessed. Length of stay (LOS), 30-day resource utilization (ED visits and hospital readmissions), patient satisfaction, and hospital accounting costs for SDD were compared to non-SDD patients.nnnRESULTSnOf 602 children treated at our institution, 185 (31%) were successfully discharged per protocol. SDD patients had longer median PACU duration (3.0 vs. 1.0h, p<0.001), but postoperative LOS (4.4 vs. 17.4h, p<0.001) and overall LOS (17.1 vs. 31.2h, p<0.001) were significantly shorter. Complication rates (1.6% vs. 3.1%), ED visits (4.3% vs. 6.0%), and readmissions (0.5% vs. 2.4%) were not significantly different for SDD compared to non-SDD patients. However, SDD decreases total cost of an appendectomy episode (

Are Foley catheters needed after minimally invasive repair of pectus excavatum

8073 vs

Telemedicine in the perioperative experience

8424, p=0.002), and patients report high satisfaction with their hospital experience (mean 9.4 out of 10).nnnCONCLUSIONSnSafe and satisfactory outpatient management of pediatric simple appendicitis is achievable with appropriate patient selection. An SDD protocol can lead to significant generation of value to the healthcare system.nnnLEVEL OF EVIDENCEnPrognosis study, Level II.

Ambulatory pediatric surgery

Background. High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice. Materials and Methods. We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic childrens hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI). Results. Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient‐controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter. Conclusion. Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement.

Single-Visit Surgery offers added convenience and excellent family satisfaction

Telemedicine, the remote diagnosis and treatment of patients by means of technology, provides an alternative means for patients to gain access to health care services. Telemedicine is a general term that includes the use of various communication technologies, including telephone, email, or videoconferencing. Telemedicine has the potential to reduce inefficiencies in the delivery of healthcare, diminish patient travel and wait times, and increase access to specialists for patients in rural settings. We review the use of telemedicine in the perioperative phase of care for pediatric surgical patients, their caregivers, and surgical providers, including pre-operative assessments, and post-operative follow-up. We also discuss physician billing compliance with remote telemedicine consultation and explore the barriers to adoption among the caregivers of pediatric surgery patients.

Battery ingestions in children: Variations in care and development of a clinical algorithm

Ambulatory pediatric surgery has become increasingly common in recent years, with greater numbers of procedures being performed on an outpatient basis. This practice has clear benefits for hospitals and healthcare providers, but patients and families also often prefer outpatient surgery for a variety of reasons. However, maximizing the potential opportunities requires critical attention to patient and procedure selection, as well as anesthetic choice. A subset of outpatient procedures can be performed as single visit procedures, further simplifying the process for families and providers.