Creating diagnostic criteria for perforated appendicitis using cross-sectional imaging

Introduction

Preoperative determination of perforated versus acute appendicitis can be difficult. We compared CT and MRI performance in diagnosing perforated appendicitis, and created diagnostic criteria.

Methods

We retrospectively reviewed all pediatric patients who underwent appendectomy within one day of CT or MRI between 1/1/2013 and 1/16/2016. True diagnosis was determined by pathology report. Findings on CT/MRI were grouped into “hard” findings (abscess, pneumoperitoneum, extruded fecalith, appendiceal wall with visible hole) and “soft” findings (extensive/diffuse inflammation/free fluid, phlegmon). Correlation of white blood cell count (WBC), temperature, peritoneal signs, and symptom duration >72 h with perforation was assessed using logistic regression. Significant correlates were incorporated in clinical criteria.

Results

135 patients underwent appendectomy after CT/MRI. Fifty patients underwent MRI and 85 CT. Using hard and/or soft findings, MRI was 86.7% sensitive and 74.3% specific, compared to 68.4% (p = 0.19) and 92.4% (p = 0.025) for CT. WBC > 15, temperature >38.0 °C, and peritoneal signs predicted perforation. Diagnostic accuracy of MRI was highest using imaging findings alone. Accuracy of CT was improved by mandating at least one of the previous three clinical correlates, resulting in 68.4% sensitivity and 93.9% specificity.

Conclusions

MRI trended toward more sensitive and CT was more specific for complicated appendicitis. CT specificity is improved by our algorithm.

     

Can common serum biomarkers predict complicated appendicitis in children?

Purpose

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

Methods

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal–Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

Results

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5–12, 38% 13–17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5–12- (p < 0.0001) and 13–17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

Conclusions

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

     

Urinary biomarkers in pediatric appendicitis

Purpose

The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis.

Methods

A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis.

Results

Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79–0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value.

Conclusion

LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.

     

Effectiveness of gabapentin as a postoperative analgesic in children undergoing appendectomy

Purpose

Though gabapentin is increasingly used as a perioperative analgesic, data regarding effectiveness in children are limited. The purpose of this study was to evaluate gabapentin as a postoperative analgesic in children undergoing appendectomy.

Methods

A 12-month retrospective review of children undergoing appendectomy was performed at a two-hospital children’s institution. Patients receiving gabapentin (GP) were matched (1:2) with patients who did not receive gabapentin (NG) based on age, sex and appendicitis severity. Outcome measures included postoperative opioid use, pain scores, and revisits/readmissions.

Results

We matched 29 (33.3%) GP patients with 58 (66.6%) NG patients (n?=?87). The GP group required significantly less postoperative opioids than the NG group (0.034 mg morphine equivalents/kg (ME/kg) vs. 0.106 ME/kg, p?<?0.01). Groups had similar lengths of time from operation to pain scores?≤?3 (GP 12.21 vs. NG 17.01 h, p?=?0.23). GP and NG had similar rates of revisit to the emergency department (13.8 vs. 10.3%, p?=?0.73), readmission (6.9 vs. 1.7%, p?=?0.26), and revisits secondary to surgical pain (3.4 vs. 3.4%, p?=?1.00).

Conclusion

In this single-center, retrospective cohort study, gabapentin is associated with a reduction in total postoperative opioid use in children with appendicitis. While promising, further prospective validation of clinical effectiveness is needed.

     

Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation

Background

Appendicolith can cause appendiceal obstruction and acute appendicitis. Its high prevalence may be related to the high perforation rate in pediatric appendicitis. This study assessed the characteristics of appendicolith and its clinical significance in pediatric appendicitis.

Methods

A retrospective study was performed among children and adolescents younger than 17 years who were preoperatively diagnosed with appendicitis in the pediatric emergency department (ED). A total of 269 patients with a mean age of 9.98 ± 3.37 years were enrolled. Clinical features and contrast-enhanced computed tomography findings were analyzed.

Results

Among the 269 patients, 147 (54.6%) had appendicoliths, with a mean maximal diameter of 5.21 ± 2.34 mm. Compared to the no appendicolith group, the appendicolith group demonstrated more prolonged abdominal pain (≥ 48 hours) before the ED visit (23.1% vs. 11.5%; P = 0.013), clinical features of severe appendicitis (presence of fever, vomiting, positive urine ketone, and increased C-reactive protein), and higher rate of perforation (43.5% vs. 9.8%; P < 0.001). Multivariate risk factor analysis for perforated appendicitis in the appendicolith group revealed that maximal diameter of 5 mm or more in the appendicolith (adjusted odds ratio [aOR] 2.919; 95% CI 1.325–6.428, P = 0.008) and proximal collapse adjacent to the appendicolith (aOR 2.943; 95% CI 1.344–6.443, P = 0.007) were significant.

Conclusions

Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and severe clinical conditions with a high risk of perforation.

     

Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation

Purpose

Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients.

Methods

An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children’s hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation.

Results

Survey response rate was 49% (n?=?93/190) pre-simulation, 22% (n?=?42/190) post-simulation, and 79% (n?=?150/190) at 2-year follow-up. These providers reported more anxiety (p?=?0.01) and less confidence (p?=?0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p?=?0.02) and greater confidence (p?=?0.01), compared to untrained providers.

Conclusions

Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence.

Level of evidence

II, Prospective cohort.

     

Quality improvement program reduces venous thromboembolism in infants and children with long-gap esophageal atresia (LGEA)

Purpose

Patients with long-gap esophageal atresia (LGEA) treated with the Foker process are at increased risk of venous thromboembolism (VTE). An institutional quality improvement program to decrease VTE risk factor exposure and utilize prophylactic anticoagulation was implemented. We aim to evaluate the efficacy and safety of a VTE risk-reduction program in patients with LGEA.

Methods

Implementation and evaluation of a VTE risk-reduction program in patients with LGEA from 2012 to 2015 was performed. Symptomatic VTE with radiographic confirmation were defined as events. Post-program characteristics were evaluated and compared to a historical cohort.

Results

Sixty-seven patients were identified. Two developed VTE (7 %) post-program implementation; compared to 13/40 (33 %) VTE incidence in the historical cohort (p = 0.018). Baseline demographics were similar, including age, esophageal atresia type and gap length. Post-protocol patients had fewer paralysis episodes (p = 0.004), paralysis days (p = 0.003), central venous catheters (p = 0.003), thoracotomies (p < 0.001), ventilator hours (p = 0.02), and decreased hospital (p < 0.001) and ICU stay (p < 0.001). All patients in the VTE risk-reduction program were exposed to prophylactic anticoagulation. No bleeding complications and/or thrombosis-related mortality occurred.

Conclusion

VTE risk-reduction program implementation decreased symptomatic VTE incidence with associated decreases in ICU and hospital length of stay. Prophylactic anticoagulation can be utilized safely in a complicated pediatric surgical population.

     

Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma

Purpose

Current guidelines for computed tomography (CT) after blunt trauma were developed to capture all intra-abdominal injuries (IAI). We hypothesize that current AST/ALT guidelines are too low leading to unnecessary CT scans for children after blunt abdominal trauma (BAT).

Methods

Patients who received CT of the abdomen after blunt trauma at our Level I Pediatric Trauma Center were stratified into a high risk (HR) (liver/spleen/kidney grade ≥III, hollow viscous, or pancreatic injuries) and low risk (LR) (liver/kidney/spleen injuries grade ≤II, or no IAI) groups.

Results

247 patients were included. Of the 18 patients in the HR group, two required surgery (splenectomy and sigmoidectomy). Transfusion was required in 30% of grade III and 50% of grade IV injuries. Eleven (5%) patients in LR group were transfused for indications other than IAI, and none were explored surgically. Both AST (r = 0.44, p < 0.001) and ALT (r = 0.43, p < 0.001) correlated with grade of liver injury. Using an increased threshold of AST/ALT, 400/200 had a negative predictive value of 96% in predicting the presence of HR liver injuries.

Conclusion

The current cutoff of liver enzymes leads to over-identification of LR injuries. Consideration should be given to an approach that aims to utilize CT in pediatric BAT that identifies clinically HR injury.

     

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

Purpose

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

Methods

This was a randomized controlled trial of patients aged 4–17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I—contained perforation, II—localized contamination to right gutter/pelvis, and III—diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin–clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

Results

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3?±?3.6 versus 10.1?±?3.6, p?<?0.05) with higher BMI (20.9?±?5.8 versus 17.9?±?3.5, p?<?0.05). There were no differences in gender, comorbidities, or perforation grade (I—20.4% vs. 26.3%, II—36.4% vs. 34.2%, III—43.2% vs. 39.5%, all p?>?0.05). Comparing IV to oral, there was no difference in length of stay (4.4?±?1.5 versus 4.4?±?2.0 days, p?>?0.05), postoperative abscess rate (11.6% vs. 8.1%, p?>?0.05), or readmission rate (14.0% vs. 16.2%, p?>?0.05). Hospital and outpatient charges were higher in the IV group (p?<?0.0001).

Conclusion

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

     

ARSH 2: Reproductive and Sexual Health Knowledge,Attitude and Practices: Comparison Among Boys and Girls (10–24 y)

Objective

To compare the knowledge, attitude and practice of boys and girls on reproductive sexual health and their perspective on the needs of adolescents on this aspect.

Methods

This comparative study was conducted among boys and girls between 10 and 24 y in three districts of Kerala; through a cross sectional community survey using a pretested structured schedule with additional sexuality related questions for 15–24 y age group.

Results

Higher percentage of boys knew about condoms (95.1 %, p 0.001) whereas higher percentage of girls (56.5 %, p 0.001) knew about copper-T. Girls had a better knowledge on legal age of marriage (91 %, p 0.001), that both the partners are equally responsible for the problem of infertility (89.7 %, p 0.009) and that the gender of the baby is determined by male sperm (60.4 %, p 0.001). Above 90 % of boys and girls demanded adolescent care services and facilities for counseling.

Conclusions

This comparative study on knowledge, attitude and practice of boys and girls between 10 and 24 y has shown that greater proportion of girls had correct knowledge on the legal age of marriage, ideal age of pregnancy, preferred an arranged marriage and felt the need for premarital counseling.

     

Implications of non-accidental trauma on resource utilization and outcomes

Purpose

The purpose was to compare the resource utilization and outcomes between patients with suspected (SUSP) and confirmed (CONF) non-accidental trauma (NAT).

Methods

The institutional trauma registry was reviewed for patients aged 0–18 years presenting from 2007 to 2012 with a diagnosis of suspicion for NAT. Patients with suspected and confirmed NAT were compared.

Results

There were 281 patients included. CONF presented with a higher heart rate (142?±?27 vs 128?±?23 bpm, p?<?0.01), lower systolic blood pressure (100?±?18 vs 105?±?16 mm Hg, p?=?0.03), and higher Injury Severity Score (15?±?11 vs 9?±?5, p?<?0.01). SUSP received fewer consultations (1.6?±?0.7 vs 2.4?±?1.1, 95% CI ? 0.58 to ? 0.09, p?<?0.01) and had a shorter length of stay (1.6?±?1.3 vs 7.8?±?9.8 days, 95% CI ? 4.58 to ? 0.72, p?<?0.01). SUSP were more often discharged home (OR 94.22, 95% CI: 21.26–417.476, p?<?0.01). CONF had a higher mortality rate (8.2 vs 0%, p?<?0.01).

Conclusions

Patients with confirmed NAT present with more severe injuries and require more hospital resources compared to patients in whom NAT is suspected and ruled out.

     

Airway foreign bodies in pediatric patients: anatomic location of foreign body affects complications and outcomes

Background

Airway foreign bodies (FB) are a common medical emergency within the pediatric population. While deaths are not uncommon, the in-hospital mortality rates and correlation with anatomic location of the airway foreign body have not been previously reported.

Methods

The KID database was reviewed for 2003, 2006, 2009, and 2012 for pediatric patients with a discharge diagnosis of airway foreign body using ICD-9 codes (933.1, 934.x).

Results

11,793 patients, ages 0–17, were found to have an airway FB. Of patients admitted for airway FB 21.2 % required mechanical ventilation during their hospitalization, and the overall mortality rate was 2.5 %. Location of the airway FB was dependent on age (p < 0.01). Use of mechanical ventilation was dependent on the location of the airway FB (p < 0.01) and being transferred from another hospital (OR 2.59, p < 0.01). Univariate analysis demonstrated differences in in-hospital mortality based on location (p < 0.01), use of a ventilator during hospitalization (OR 24.4, p < 0.01), and transfer from another hospital (OR 2.11, p < 0.01).

Conclusions

The in-hospital mortality rate for airway foreign bodies is 2.5 %. The anatomic location of airway FB in pediatric patients varies by age, and affects the need for mechanical ventilation and in-hospital mortality.

     

Formula feeding and systemic hypoxia synergistically induce intestinal hypoxia in experimental necrotizing enterocolitis

Purpose

Feeding and systemic hypoxia are major stresses inducing necrotizing enterocolitis (NEC). This study aims to investigate the role of systemic hypoxia in NEC and its effect before and after feeding.

Methods

Neonatal mice were studied in three groups. Control (N = 9): breast feeding; NEC A (N = 8), gavage feeding + lipopolysaccharide (LPS) + preprandial hypoxia; and NEC B (N = 9), feeding + LPS + postprandial hypoxia. Pimonidazole, a hypoxia marker, was injected intraperitoneally before ileum was harvested for histology and quantitative RT-PCR studies. Statistical analysis was done using the ANOVA and Chi-square test.

Results

NEC incidence was 62.5% in NEC A and 88.9% in NEC B. The mortality in NEC B (55.6%) but not A (25%) is significantly higher than control (0%, p < 0.05). Pimonidazole staining elevated in both NEC A and B with higher pimonidazole grade in NEC B (p < 0.01). Both NEC groups had increased the expression of hypoxia-related genes: HIF-1α, GLUT-1, and PHD-3 with GLUT-1 expressed more in NEC B compared with NEC A (p < 0.01). The inflammation marker, IL6, was similarly raised in both NEC A and B.

Conclusion

Feeding and postprandial hypoxia synergistically induce intestinal hypoxia in NEC. As feeding increases intestinal oxygen demand, maintaining a balance between intestinal oxygen supply and demand is important to prevent NEC.

     

Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias

Purpose

To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique.

Methods

We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra.

Results

There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture.

Conclusions

Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.

     

Enhancing recovery after minimally invasive repair of pectus excavatum

Purpose

There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway.

Methods

A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010–2012) and after (2014–2015) implementation.

Results

There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased.

Conclusion

The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

     

The effect of the broad-spectrum antibiotics for prevention of postoperative intra-abdominal abscess in pediatric acute appendicitis

Background

We investigated the efficacy of broad-spectrum antibiotics for prevention of postoperative intra-abdominal abscess in pediatric acute appendicitis with our 3 risk factors:—WBC?>?16.5 (×?10³/µl), CRP?>?3.1 (mg/dl) and appendix maximum short diameter on diagnostic imaging?>?11.4 mm.

Methods

Four hundred twenty-two patients were reviewed. Patients with 0–1 risk factors were assessed as low-risk and those with 2–3 were high-risk. In the low-risk group, Group A (n?=?66) patients received broad-spectrum antibiotics and Group B patients (n?=?265) received narrow-spectrum monotherapy. In the high-risk group, Group C patients (n?=?63) received broad-spectrum antibiotics and Group D patients (n?=?28), narrow-spectrum antibiotics. The outcomes were the incidence of postoperative abscess and the total duration of intravenous (IV) antibiotics.

Results

The incidence of intra-abdominal abscess was 6.06% in Group A versus 1.89% in Group B (p?=?0.08), and 19.05% in Group C versus 3.57% in Group D (p?=?0.06). Total IV antibiotic duration (days) were 6.12?±?2.87 in Group A versus 3.83?±?0.69 in Group B (p?<?0.01), and 7.84?±?4.57 in Group C versus 4.00?±?0.82 in Group D (p?<?0.01).

Conclusion

Broad-spectrum antibiotics did not prevent postoperative intra-abdominal abscess in either low or high-risk groups.

     

Predictors of Microbiologically Confirmed Intrathoracic Tuberculosis

Objective

To identify risk factors for microbiologically confirmed intrathoracic tuberculosis in children.

Methods

Children, 6 mo to 15 y of age, attending the out-patient department of a tertiary care centre in India, with probable intrathoracic tuberculosis were enrolled. Microbiological confirmation of tuberculosis was defined as positivity on smear (Ziehl-Neelsen staining) and/or Xpert MTB/RIF and/or MGIT-960 culture. Association of various factors with microbiological confirmation were assessed by univariate and multivariate analysis.

Results

Microbiologic confirmation was documented in 39 (25%) of 153 patients enrolled. On univariate analysis, microbiological positivity was associated with female gender, higher mean (SD) age [136.6 (31.8) vs. 117.3 (41.4) mo], parenchymal lesion on chest radiograph, low body mass index for age, having symptoms of cough and weight loss, lower mean (SD) hemoglobin [10.4 (1.37) g/dl vs. 11(1.52) g/dl; p = 0.04], and higher mean (SD) monocyte: lymphocyte ratio [0.38 (0.30) vs. 0.24 (0.02); p = 0.37]. Higher proportion of microbiologically negative children were BCG vaccinated (95% vs. 79%; p = 0.002). On multivariate analysis, microbiological positivity showed significant association with low body mass index for age (p = 0.033) and higher monocyte: lymphocyte ratio (p = 0.037).

Conclusions

Low body mass index for age and higher monocyte: lymphocyte ratios were associated with microbiological confirmation in children with intrathoracic tuberculosis.

     

Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications

Purpose

We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone.

Methods

We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT.

Results

We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43–2.87, p ≤ 0.0001, I ² = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28–4.05, p = 0.005, I ² = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43–2.78, p < 0.0001, I ² = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62–3.11, p = 0.42, I ² = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35–1.68, p = 0.46, I ² = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean).

Conclusions

Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.

     

<Emphasis Type="Italic">Bordetella Pertussis</Emphasis> Infection in Hospitalized Infants with Acute Bronchiolitis

Objective

To assess the frequency of B. pertussis infection among young infants hospitalized with acute bronchiolitis and to determine whether B. pertussis infection affects the clinical course of acute bronchiolitis.

Methods

A total of 172 infants <6 months of age hospitalized with acute bronchiolitis were tested for B. pertussis and respiratory viruses with real-time PCR. Cases were divided into 2 groups according to B. pertussis positive or negative. Clinical parameters, clinical severity scores and laboratory characteristics of the pertussis-positive and pertussis-negative cases were compared.

Results

Bordetella pertussis infection was detected in 44 (25.6%) of the 172 infants hospitalized for acute bronchiolitis, and as co-infection with respiratory viral agents in 27 (61.4%) infants. Of the 44 pertussis-positive infants, only 17 (38.6%) experienced a paroxysmal cough, 13 (29.5%) had whooping and 15 (34.1%) had post-tussive vomiting. There was no significant difference between pertussis-positive and pertussis-negative infants according to Wang clinical score at admission (4.9 ± 1.5 vs. 5.2 ± 2.5; p = 0.689). The overall disease severity score was also similar between the two groups (6.5 ± 1.4 vs. 6.9 ± 1.6; p = 0.095).

Conclusions

Bordetella pertussis infection is common in young infants hospitalized for acute bronchiolitis, mostly as co-infection with respiratory viruses. The clinical features of pertussis in the infants are not characteristic. Viral bronchiolitis and pertussis cases could not be differentiated by clinical findings. Co-infection with pertussis did not affect the clinical outcome in infants hospitalized with acute bronchiolitis.

     

Focused CT using a height-adjusted metric and the umbilicus as a landmark for children undergoing evaluation for appendicitis

Background

Confirmation of appendicitis in children often requires CT. A focused CT scan that is limited to the lower abdomen/pelvis might help to reduce radiation exposure.

Objective

To determine the position of the appendix relative to the umbilicus and derive a height-adjusted threshold for a focused CT that would identify most appendices.

Materials and methods

We conducted a retrospective study of children younger than 18 years who underwent a CT scan for suspected appendicitis. A pediatric radiologist determined the distance from the most cephalad portion of the appendix to the center of the umbilicus. This distance was divided by the child’s height to create a ratio for each child. We then assessed the largest of these distance/height ratios (“height constants”) as potential height-adjusted thresholds that, when multiplied by any patient’s height, would yield the superior threshold for the focused CT scan. Radiation reduction was calculated as percentage decrease in scan length compared to a complete abdominopelvic CT.

Results

Of 270 patients whose entire appendix was identified on CT, all were identified within 10.5 cm above the umbilicus. A focused CT using a height constant of 0.07 identified 100% of the appendices visualized on the complete CT scan and resulted in an estimated mean percentage radiation reduction of 27% (standard deviation [SD] +/-4.7). If a height constant of 0.03 was used, 97% of appendices were identified and the estimated radiation reduction was 43% (SD +/-4.3).

Conclusion

A height-adjusted focused abdominopelvic CT scan might reduce radiation exposure without sacrificing the diagnostic accuracy of the complete CT scan.