Ostéo-arthrite à Yersinia enterocolitica : à propos d'un cas affectant la hanche

We report a case of bacteriologically documented hip infection caused by Yersinia enterocolitica. A 67-year-old male with a history of valvular disease was admitted for pain and motion range limitation in the left hip with a fever. No organisms were recovered by needle aspiration, but Yersinia enterocolitica grew in joint fluid obtained by surgical arthrotomy. Investigations of the gastrointestinal tract were normal, and there was no evidence of endocarditis. After 6 weeks of appropriate antibiotic therapy and immobilization with transtibial traction, the clinical and laboratory test abnormalities improved. However, the patient died from an intercurrent condition. Y. enterocolitica, a well-known cause of reactive arthritis, can cause septic arthritis.     

Ostéo-arthrite à Yersinia enterocolitica : à propos d'un cas affectant la hancheSeptic arthritis of the hip caused by Yersinia enterocolitica: a case report.

We report a case of bacteriologically documented hip infection caused by Yersinia enterocolitica. A 67-year-old male with a history of valvular disease was admitted for pain and motion range limitation in the left hip with a fever. No organisms were recovered by needle aspiration, but Yersinia enterocolitica grew in joint fluid obtained by surgical arthrotomy. Investigations of the gastrointestinal tract were normal, and there was no evidence of endocarditis. After 6 weeks of appropriate antibiotic therapy and immobilization with transtibial traction, the clinical and laboratory test abnormalities improved. However, the patient died from an intercurrent condition. Y. enterocolitica, a well-known cause of reactive arthritis, can cause septic arthritis.     

The role of Yersinia enterocolitica and Yersinia pseudotuberculosis in granulomatous appendicitis: a histologic and molecular study

Granulomatous appendicitis is an enigmatic entity. Purported causes include Crohn's disease, foreign body reactions, sarcoidosis, and infectious agents; however, most cases remain idiopathic. Yersinia enterocolitica (YE) and Y. pseudotuberculosis (YP) have been implicated as causes of appendicitis, ileocolitis, and mesenteric adenitis. The authors examined the potential role of YE and YP in granulomatous appendicitis using histologic and molecular methods. Forty cases of granulomatous appendicitis were evaluated for histologic features including transmural inflammation, number and character of granulomas, and mucosal changes. Twort Gram, Grocott methenamine-silver (GMS), and Ziehl-Neelsen stains were evaluated, and polymerase chain reaction (PCR) analysis was performed to identify pathogenic YP and YE. Twenty-five percent (10 of 40) of the cases were positive for pathogenic Yersinia by PCR (four YE, four YP, and two with both species). Prominent histologic features included epithelioid granulomas with lymphoid cuffing, transmural inflammation with lymphoid aggregates, mucosal ulceration, and cryptitis. One Yersinia-positive case contained mural Gram-negative bacilli; fungal and acid-fast bacilli stains were all negative. Except for one culture-negative case, serologies and cultures were not done or results were unavailable. Two Yersinia-positive patients were diagnosed subsequently with Crohn's disease, suggesting a possible relationship between the two entities. No other patients developed significant sequelae. YE and YP are important causes of granulomatous appendicitis, and Yersinia infection may mimic Crohn's disease. No histologic features distinguish reliably between Yersinia species, or between Yersinia-positive and Yersinia-negative cases. Because special stains and cultures are often not diagnostic, PCR analysis is an excellent technique for the diagnosis of Yersinia.     

Slipped capital femoral epiphysis and Blount disease as indicators for early metabolic surgical intervention

BackgroundSlipped capital femoral epiphysis (SCFE) and Blount disease are strongly associated with pediatric obesity, yet they have only recently been identified as indications for consideration of metabolic and bariatric surgery (MBS).ObjectivesTo describe the relationships between pediatric obesity, MBS, SCFE, and Blount disease.SettingNationwide database.MethodsThe national inpatient sample was used to identify patients ≤20 years old with obesity who underwent MBS from 2007 to 2016. Presence of SCFE and Blount disease was similarly extracted.ResultsThe overall prevalence of SCFE and Blount disease among patients ≤20 years old is .02% for both (14,976, 11,238 patients, respectively) with no statistically significant change over the study period (P = .68, .07, respectively). The rates of SCFE and Blount disease in children with and without obesity are .46% versus .02% and .36% versus .01%, respectively (P < .001 for both). The mean age of patients with SCFE and obesity was 12 years old, while the mean age of those without obesity was 12.2 years old (P = .03). None of the children with obesity and SCFE underwent MBS. Similarly, the mean age of patients with Blount disease and obesity was 12.6 years old, while the mean age of those without obesity was 13.1 years old. Moreover, the mean age of children with Blount disease and obesity who underwent MBS was 16 years old (P < .001).ConclusionsOrthopedic complications remain a persistent problem in the pediatric population who suffer from obesity. Despite being diagnosed at a young age, patients with SCFE and/or Blount disease are not undergoing MBS until their later adolescent years, potentially leading to unnecessary disease progression or recurrence of disease after orthopedic interventions. Therefore, SCFE and Blount disease should be considered indications for early consideration of MBS in this pediatric population.     

Enterobius vermicularis-associated appendicitis: A 22-year case series and comprehensive review of the literature

IntroductionEnterobius vermicularis is known to be associated with appendicitis, however a causal relationship between Enterobius and appendicitis has not been established. The aim of this study was to explore the relationship between appendiceal Enterobius and histologic appendicitis.MethodsA retrospective review was performed of all pediatric appendectomies between 1997 and 2019. Patients with diagnosed with Enterobius were included for analysis. Patient demographics, operative findings, and pathologic reports were queried. Data were entered into an encrypted database and subsequently analyzed. A comprehensive review of the literature was also conducted.ResultsThirty-eight cases of Enterobius-associated appendicitis were identified out of 3541 (1.07%). Grossly normal appendices at operation were seen in 27% of patients. Inflammatory infiltrate was noted on histopathology in 78.3%, and Enterobius was considered to be the cause of that inflammation in 68.4%. The comprehensive literature review revealed 19 articles (1.87% incidence) that noted 35% of patients with appendiceal Enterobius had appendicitis on either histopathology or gross evaluation.ConclusionThe high rate of inflammation on pathology found among our patients with pinworm appendicitis suggests an association with presentation as acute appendicitis. Our comprehensive review revealed a higher proportion of Enterobius appendicitis. Treatment with antihelminthic therapy is recommended.Level of evidence (LOE)Level IV(4)-case series and comprehensive review.     

Yersinia enterocolitica coxitis after hip replacement: A case report

We report a case of hematogenous Yersinia enterocolitica coxitis 10 years after hip replacement. Despite extraction of the prosthesis and antibiotic treatment, the infection relapsed. Infections in replaced joints with Yersinia enterocolitica call for long-standing treatment with specific antibiotics.     

Discordance of the pediatric surgeon's intraoperative assessment of pediatric appendicitis with the pathologists report

Background/Purpose

The nature and duration of postoperative treatment in children with appendicitis is largely defined by the surgeon's intraoperative assessment of the degree of disease. Therefore, misclassification of patients could result in either inadequate or excessive duration of treatment.

Materials/Methods

During the execution of an institutional review board-approved multicenter, randomized, prospective, single-blinded trial of laparoscopic versus open appendectomy in children, we tracked the attending pediatric surgeon's determination of the degree of appendicitis and compared it to the pathologists report. Postoperative care was determined, per protocol, by the surgeon's intraoperative classification. “Interval” appendectomies were excluded from the analysis. Statistical significance was analyzed using χ² analyses.

Results

A total of 133 patients were randomized into the open group, whereas 122 randomized to laparoscopy during the first 2 years of the study. The attending pediatric surgeons and pathologists were concordant in the determination of acute appendicitis in 90% of open patients and 93% of laparoscopic patients (P = not significant). When children were classified by the attending surgeon as having complicated appendicitis (gangrenous or ruptured), the concordance rate dropped to 38% and 52%, respectively (P = not significant). When open and laparoscopic patients were combined, the length of postoperative stay (LOS) of concordantly classified acute appendicitis patients was 35 ± 16 hours. Concordantly classified complicated appendicitis LOS was 118 ± 61 hours, and discordantly classified complicated appendicitis (pathology = acute) LOS was 85 ± 41 hours (P = .01). Wound infection rates in the concordant and discordant “complicated” appendicitis groups were 23% and 7%, respectively (P = .05).When the surgeons are grouped as “junior”(n = 2) and “senior” (n = 3), there is a trend toward greater concordance in the latter group (P = .08).

Conclusions

In the 2 institutions studied, the 5 pediatric surgeon's intraoperative classification of appendicitis correlated with the pathologist's reading in a high percentage of those patients labeled “acute” but in only approximately one half of those defined as “complicated.” These phenomena are independent of the operative approach but may correlate with surgeon experience. Interventions to improve the timeliness of pathologic diagnosis may improve the accuracy and efficiency of care of pediatric appendicitis.     

Haemolytic uraemic syndrome associated withYersinia enterocolitica infection

Haemolytic uraemic syndrome (HUS) associated withYersinia enterocolitica gastroenteritis is reported in a 6-year-old girl.Y. enterocolitica of biotype 03 was isolated from the patient's initial stool sample and was subsequently identified as serotype 03 based on the rising agglutinin titres. This paper shows that yersiniosis should be suspected as a possible cause of HUS, and investigations should include the measurement of serum agglutinin titres against antigen preparations of the genusYersinia.     

Acute appendicitis in children is associated with an abundance of bacteria from the phylum Fusobacteria

Background

Although luminal obstruction has traditionally been viewed as the underlying cause of appendicitis, recent evidence has suggested that the disease may result directly from invasion by specific pathogens, e.g. Fusobacterium nucleatum. The purpose of this study was to survey microbial communities within pediatric appendectomy specimens using a culture-independent approach.

Methods

We performed 16S ribosomal gene sequence analysis to profile the microbiota present within luminal fluid obtained from 22 pediatric appendectomy specimens. These included 10 simple appendicitis cases, 5 perforated appendicitis cases, 2 interval appendectomies, and 5 incidental appendectomies.

Results

Samples could be divided into 2 distinct clusters based upon the composition of the appendiceal bacterial communities. Appendicitis samples contained an increased abundance of Fusobacterium spp. and a reduced abundance of Bacteroides spp. relative to non-appendicitis cases. Appendicitis samples also contained variable amounts of other oral taxa such as Porphyromonas, Parvimonas, and Gemella, whereas these taxa were generally absent from non-appendicitis samples.

Conclusions

Acute appendicitis is associated with an abundance of Fusobacterium spp. and other pathogens commonly found in the oral cavity. Further research is needed to determine whether these organisms directly cause appendicitis or rather proliferate in the appendix as a secondary consequence of inflammation.     

To CT or not to CT? The influence of computed tomography on the diagnosis of appendicitis in obese pediatric patients

Background

Appendicitis is a common pediatric query. However, obesity often results in nondiagnostic ultrasounds and increased likelihood of abdominal computed tomography (CT). Concern regarding radiation exposure led the Canadian Association of Radiologists to recommend foregoing CT when ultrasounds are nondiagnostic and clinical suspicion is high. We evaluated this recommendation by quantifying the influence of CT on the diagnosis of pediatric appendicitis.

Methods

We performed a 2-year retrospective case series of children presenting with suspected appendicitis. We stratified patients by weight (obese v. nonobese) and pediatric appendicitis score (PAS) and examined how often they received abdominal CT, why they received it, and its influence on diagnosis.

Results

Of 223 patients (84 obese, 139 nonobese), 54 received CT. Obese patients received CTs more frequently than nonobese patients (29% v. 22%). The most common reason for CT was a nondiagnostic ultrasound (75% in obese, 80% in nonobese patients). Sixty-five percent of CTs obtained after nondiagnostic ultrasounds confirmed the initial diagnosis, but the rates were 80% and 50%, respectively, when only obese and only nonobese patients were considered. Obese patients were 4 times more likely to have a CT confirming their initial appendicitis diagnosis.

Conclusion

Because obese patients are more likely than nonobese patients to have a CT that confirms appendicitis, when treating an obese pediatric patient with suspected appendicitis and a nondiagnostic ultrasound, surgeons with a high clinical suspicion should strongly consider foregoing CT and proceeding with treatment.     

Same day discharge after pediatric laparoscopic appendectomy in community hospitals

IntroductionSame-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units.MethodsPatients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units.ResultsThere were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference.ConclusionSame-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.     

Effect of COVID-19 on pediatric appendicitis presentations and complications

PurposeAppendicitis is the most common surgical emergency in children. This study aims to examine how the COVID-19 pandemic affected pediatric patients with acute appendicitis with regards to presentation and complications.MethodsAfter obtaining ethics approval, we performed a chart review of pediatric patients admitted with a diagnosis of appendicitis from March 1, 2019 to June 30, 2019 and March 1, 2020 to June 30, 2020. Data collection included a post-operative period of 30 days. The primary outcome of interest was complication rates post-appendectomy. Secondary outcomes included time to presentation, symptoms, time to surgery, and rate of perforation.ResultsOverall, 205 patients were included with 115 in the pre-pandemic group and 90 in the pandemic group. There was no significant difference in complication rates (16% pre-pandemic vs. 13.3% pandemic). In the pandemic group, time from symptom onset to presentation was significantly longer (1.87 days vs. 2.42 days, p = 0.01), more patients presented with emesis (70% vs. 55%, p<0.05), more patients had perforated appendicitis (47% vs. 32%, p<0.05), more patients were likely to be tachycardic (46% vs. 32%, p = 0.05)  and waited less time for surgery (5.75 h vs. 4.15 h, p = 0.05) which both approached significance.ConclusionSignificant delays in pediatric appendicitis presentation, and higher rates of tachycardia and perforation were seen during the pandemic. This did not result in increased complication rates but could suggest pandemic patients were more ill than their pre-pandemic counterparts.     

Cost effectiveness of the quality assurance and performance improvement project for suspected appendicitis study

IntroductionAppendicitis is the most common pediatric emergent surgical condition, with 77,000 American pediatric admissions costing $680 million US annually. Diagnosing appendicitis can be challenging. The prospective Quality Assurance and performance improvement project for suspected aPPEndicitis (QAPPE) study implemented a standardized appendicitis assessment pathway. This current study aims to assess the cost-effectiveness of the QAPPE pathway.MethodsQAPPE data (February 2018–January 2019) were compared to retrospective data from the year prior (January–December 2017). Patients aged < 18, presenting with suspicion of appendicitis were identified using the emergency department patient database. Patients were excluded if they were transferred from an outside center or if appendicitis was not suspected. Study arms were compared using Student’s t-test and assessed with standard costing techniques. The Incremental Cost-Effectiveness Ratio (ICER) was determined. Deterministic and probabilistic sensitivity analyses of the model were performed. Effectiveness was assessed by percent of negative appendectomies where alternate diagnosis was made intraoperatively or histologically. Significance was set at p < 0.05.ResultsQAPPE (n = 247) and traditional care (n = 234) patients were compared. Traditional care had higher admission frequency and lower pediatric appendicitis score. Demographics between all included patients and those admitted were similar overall. Patient costs were $3656.32 (95% CI $2407–$5250) Canadian (CAD) for QAPPE and $3823.56 (95% CI $2604–$5451) CAD for traditional care. QAPPE was the dominant strategy in the base model and probabilistic simulation found it favored in 64.7% of model iterations with a willingness to pay of $70,000 CAD.ConclusionUsing the QAPPE pathway to assess patients with suspected appendicitis reduced costs and improved effectiveness of patient care.Level of evidence2.     

Does the implementation of a pediatric appendicitis pathway promoting ultrasound work outside of a children's hospital?

Background

Efficacy of care pathways for pediatric appendicitis is well established in children's hospitals, but not in community Emergency Departments (EDs). Methods: A diagnostic pathway combining the Pediatric Appendicitis Score (PAS) with selective ultrasound was implemented. The charts of 2201 pediatric patients seen at four general EDs before and after implementation were retrospectively reviewed, identifying 611 children seriously considered for appendicitis.

Spatial–temporal clusters of pediatric perforated appendicitis in California

BackgroundPerforated appendicitis is a well-documented child health disparity. Geographic patterns in perforated appendicitis exist in several United States regions, but such patterns have not been described in California. We aimed to analyze spatial–temporal patterns of pediatric perforated appendicitis and identify population characteristics contributing to these cluster patterns.MethodsWe geocoded risk-adjusted perforated appendicitis rates per 1000 appendicitis cases in patients 1–17 years from 2005–2015 in California. We performed a space-time cube analysis to identify hot spot trends. We performed logistic regression to estimate rural classification associated with spatial–temporal hot spots and multivariate analysis to assess effects of socioeconomic factors.ResultsIn 2005–2015, 43,888 cases of pediatric perforated appendicitis occurred in California. Median risk-adjusted perforated appendicitis rate was 312 per 1000 appendicitis cases. We identified 11 spatial–temporal hot spots of perforated appendicitis. Rural micropolitan counties had 14 times higher odds of being classified as a hot spot (p<0.05, 95% CI 1–185). Poverty was a significant predictor of high perforated appendicitis median risk-adjusted rate (p<0.004).ConclusionsWe identified 11 California hot spots of perforated appendicitis that persisted across a ten-year time span. Incorporating geography alongside our understanding of socioeconomic factors is a critical step in addressing this important child health disparity.     

Routine Histopathologic Examination of Appendectomy Specimens: Retrospective Analysis of 1255 Patients

The objective of this study was to analyze the clinical benefit of histopathologic analysis of appendectomy specimens from patients with an initial diagnosis of acute appendicitis. We retrospectively analyzed the demographic and histopathologic data of 1255 patients (712 males, 543 females; age range, 17–85 years) who underwent appendectomy to treat an initial diagnosis of acute appendicitis. Patients who underwent incidental appendectomy during other surgeries were excluded from the study. Histopathologic findings of the appendectomy specimens were used to confirm the initial diagnosis. Ninety-four percent of the appendectomy specimens were positive for appendicitis. Of those, 880 were phlegmonous appendicitis, 148 were gangrenous appendicitis with perforation, and the remaining 88 showed unusual histopathologic findings. In the 88 specimens with unusual pathology, fibrous obliteration was observed in 57 specimens, carcinoid tumor in 11, Encheliophis vermicularis parasite infection in 8, granulatomous inflammation in 6, appendiceal endometriosis in 2, and 1 specimen each showed mucocele, eosinophilic infiltration, Taenia saginata parasite infection, and appendicular diverticulitis. All carcinoid tumors were located in the distal appendix. Six of the 11 carcinoid tumors were defined by histopathology as involving tubular cells, and the other 5 as involving enterochromaffin cells. Six patients had muscularis propria invasion, 2 patients had submucosa invasion, 2 patients had mesoappendix invasion, and 1 patient had serosal invasion. All patients with tumors remained disease free during the follow-up (range, 1–27 months). We conclude that when the ratio of unusual pathologic findings for appendectomy specimens is considered, it is evident that all surgical specimens should be subjected to careful histologic examination.     

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

BackgroundIn early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period.MethodsAll presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison.ResultsThere was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR).DiscussionThe 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.     

Diagnosing acute appendicitis: are we overusing radiologic investigations?

Purpose

Acute appendicitis is the most common emergency presenting to pediatric surgeons. With proper history and thorough physical examination, the diagnosis of the condition clinically should approach 90%. With the increasing ease of performing radiologic investigations because of technological advances, more ultrasound and computed tomography (CT) are used to help diagnosing appendicitis. The aim of this study is to review the trend of diagnosing appendicitis in a single center and discuss the implications.

Methods

A retrospective analysis was carried out for all patients who were admitted with acute appendicitis between 1997 and 2007. The methods of diagnosis were divided into 3 groups as follows: clinical, ultrasound, and CT. The demographics and operative findings were noted. Statistical analysis was done using Fisher's Exact test and paired t test when appropriate. A value of P < .05 was considered to be statistically significant.

Results

During this period, a total of 254 patients (167 boys and 87 girls) were admitted with appendicitis. The average age at presentation was 12 years, and the mean duration of symptoms before presentation was 2 days. For 11 years, there was an initial rise of the use of ultrasound (10% in 1997 to a peak of 60% in 2005). This percentage decreased with a corresponding rise of the use of CT scan (0% in 1997 to 35% in 2007). There was no correlation found between the use of adjunct investigations and the severity of appendicitis found at operation, suggesting an overreliance of CT.

Conclusion

It appears that there is an increasing trend in using radiologic investigations for the diagnosis of appendicitis for the past 11 years. With the association of cancer in later life and early radiation exposure well documented, it would be advisable to avoid the use of CT if possible.     

A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children

Background

With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse.