Browsing by Subject "Pediatrics"
Now showing 1 - 20 of 29
- Results Per Page
- Sort Options
Item Accuracy in Diagnosing Pediatric Appendicitis: Discordance in Diagnosis and Masqueraders(2016-04-04) Farzal, Zehra; Fischer, Anne C.; Piper, Hannah; Schindel, DavidBACKGROUND: The classification of perforated versus nonperforated appendicitis remains poorly defined despite being clinically significant and requiring dramatically different therapeutic approaches. We hypothesized that there is substantial variability in the determination of perforated and nonperforated appendicitis across specialties due to the lack of standardized criteria. To identify and quantify the degree of variability in the diagnosis of acute versus perforated appendicitis, a comparative analysis of radiologic results, operative findings, and pathologic review was undertaken to identify the degree of discordance across specialties as the primary objective. Given the new suggested paradigm of non-operative management of acute appendicitis, a secondary objective was to identify the incidence of atypical diagnoses detected among appendectomy specimens to better elucidate those potentially missed in non-operative management. METHODS: An IRB-approved retrospective review of 1311 appendectomies over a 16-month period at an independent children's hospital allowed a comparison of the diagnostic classification of appendicitis as perforated (PA) or nonperforated (NPA) based on radiology (R), operative (O), and pathology (P) reports. Three groups, P+O (N=1241), P+R (N=516), O+R (N=512), were compared to identify inter-specialty discordance in classification. The length of stay (LOS) was analyzed as a proxy for clinical behavior to confirm that the diagnostic classification was consistent with the clinical behavior of being perforated or nonperforated (PA with LOS >48hours and NPA with LOS ≤48 hours). Given the numerous pathologic descriptives of appendicitis, a more extensive pathologic review of all appendectomies was done to identify an intra-specialty variance in diagnostic classification and to identify any other diagnosis in the setting of presumed appendicitis. This arm of the study involved an expanded IRB-approved retrospective review of pediatric patients (n=6816) who underwent appendectomies at an independent children's hospital over an 11-year period from January 2000 to December 2010. Inclusion criteria were age <17 and surgery for presumed appendicitis, thus excluding incidental appendectomies (n=269) with a final review of 6547 specimens. RESULTS: In the assessment of the degree of discordance, the subsets P+O, P+R, O+R revealed a discordance of 11%, 15.7% and 16.6% within the classification of appendicitis respectively. In the O+R group, 35% of the cases that were operatively designated as 'perforated' contradicted the radiologic diagnosis of being 'nonperforated' appendicitis. Cases designated as PA in all subsets (P+O, P+R, O+R) clinically behaved as perforated with a mean LOS>48 hours (97, 95, 95, respectively), whereas the cases designated as nonperforated appendicitis (NPA) exhibited greater variation from the expected LOS≤48 hours, with means 35, 83, and 62, respectively. The more exhaustive pathologic review identified 7 classifications for appendicitis in 91.6% patients, 5% false positives, and ~3% coincident other diagnoses. 5998 (91.6%) subjects showed true appendicitis including acute non-perforated, perforated, chronic, suppurative, gangrenous, necrotizing, and catarrhal appendicitis. In 224 subjects (3.4%), diagnoses other than appendicitis were identified: non-inflammatory obstruction (n=71), other infectious etiologies (n=58), non-specific inflammatory changes (n=58), extra-appendiceal pathology (n=31), tumors (n=10), and foreign body (n=2). Of the tumors, 6 patients with true appendicitis had co-existing carcinoid tumors. 325 specimens (5.0%) were documented as negative appendicitis. CONCLUSION: Variability in the classification of appendicitis between specialties suggests an error rate inherent in diagnosis. This error rate may explain why identifying best clinical guidelines for length of antibiotic therapy and treatment has been elusive. Standardizing classification criteria across specialties may help identify best practices for optimal use of hospital resources and improve diagnostic accuracy for meaningful clinical trials. This study represents the largest analysis of the incidence of pathologies that mimic appendicitis in the pediatric population, conveying a broad overlap of diagnoses that present in a similar fashion. Given how commonly appendicitis is diagnosed, follow-up for routine appendectomies has been streamlined and expedited in such a way that the review of pathology by the practitioner may be overlooked. The number of infectious etiologies and tumors detected reinforces the increasing importance of pathology review in post-operative follow-up to appropriately diagnose uncommon conditions that may necessitate further work-up and treatment. Additionally, the possibility of missing an alternative or co-incidental diagnosis such as a carcinoid tumor in the non-operative management of appendicitis merits some reflection in planning operative versus non-operative management. Given the recent popularity of non-operative therapy for appendicitis, this research gives the clinician a reliable incidence of other potential diagnoses if symptoms recur. Having percentages for conditions that present similarly also allows for proper counseling of patients who opt for non-operative management.Item Alexithymia in Adolescents with Inflammatory Bowel Disease(2012-12-20) Crowley, Jaime Dorian; Wetherington, Crista E.Adolescents with inflammatory bowel disease exhibit increased psychosocial problems, such as higher rates of depressive symptoms; however, the relationship between psychological factors and health outcomes remains relatively unstudied in this pediatric population. Both depression and stress have been linked to health outcomes in adults with inflammatory bowel disease. Alexithymia, defined as a personality trait and affective deficit disorder, may represent another psychological variable influencing health outcomes in inflammatory bowel disease populations. While no prior studies have investigated alexithymia in adolescents with inflammatory bowel disease, higher rates of alexithymia have been documented and associated with poorer quality of life in adults with inflammatory bowel disease. This study investigated the prevalence of alexithymia in adolescents with inflammatory bowel disease and examined the relationship between alexithymia and other psychological variables (i.e., depressive symptoms and perceived stress). An additional aim was to determine whether these psychological variables predicted adolescent inflammatory bowel disease patients’ health outcomes. An investigation of 63 participants with inflammatory bowel disease between the ages of 13 to 17 years revealed a significant prevalence of alexithymia compared to a previously reported rate in a normal adolescent population. Higher alexithymia scores were associated with greater depressive symptoms, perceived stress of major life events, perceived stress of daily hassles, and perceived recent stress. None of the psychological variables were significantly related to illness course, and only perceived stress of major life events was significantly correlated with disease severity. In contrast, all of the psychological variables showed significant inverse correlations with disease-specific quality of life. Notably, alexithymia emerged as the strongest predictor of disease-specific quality of life and consistently accounted for more unique variance than depressive symptoms and perceived stress. Taken together, the present results implicate alexithymia as a risk factor for poor illness perception and adjustment in adolescents with inflammatory bowel disease. The potential lifelong repercussions of alexithymia make it an important topic for health outcome research, which may guide the development of psychological interventions for this pediatric chronic illness population.Item A Four-Year Experience at a Level I Pediatric Trauma Center: 2009-2012(2015-01-26) Stevens, Audrey; Renkes, Rachel; Burkhalter, Lorrie; Foglia, RobertBACKGROUND: In the United States, trauma is the leading cause of death and disability in children. Annually 140,000 children are seen in the Emergency Department(ED) at our single Level-I verified pediatric trauma center. 12,000 -13,000 are due to trauma, with approximately 1,400 admissions. We reviewed the trauma experience at our hospital to assess its impact based upon the management, outcome, and hospital charges for these patients. METHODS: With IRB approval, the hospital Trauma Registry was accessed to identify the severity of injury, management and outcomes for patients admitted from Jan. 2009 - Dec. 2012. Data points included age, gender, Trauma Activation (TA), Injury Severity Score (ISS), admit service, ICU admission, length of stay (LOS), operative need, mortality, and hospital charges. ED deaths were excluded. RESULTS: There were 5,514 trauma admissions, 8.18% of all of the 67,429 hospital admissions; 60% were boys and 40% girls. Age was 6.82±4.41 years, and ISS was 8.21±7.54. 54% had a minor ISS (0-7), 32% moderate (8-15), 9.5% severe (16-24), and 5.2% very severe (>24). TAs were called in 1346(24.4%) patients, 1014(75.3%) ALERTs and 332(24.7%) STATs. 2607 (47.3%) patients required an operation. The majority of patients were assigned to Pediatric Surgery (44%) and Orthopedic Surgery (41%). Trauma ICU admissions were 14.2% of all trauma admissions, comparable to all hospital ICU admissions at 17.4%. The trauma ICU LOS was 3.59±5.64 days; this doubled to 7.02±15.96 days for all hospital ICU admissions. The trauma LOS was 2.48±4.57 days; again, this doubled to 5.17±10.31 days for all hospital patients. There were 64 trauma deaths (1.16%). The trauma cohort accounted for $188,472,675 of hospital charges, which was 4.3% of all hospital charges ($4,375,099,917) for four years. The average charge per trauma patient was $36,746 vs. $65,324 for all admits. CONCLUSION: If trauma were a single disease, it would be the third most frequent admission diagnosis. The trauma population is heterogeneous; 24% of the trauma patients required TA, 14% ICU admission, 47% needed surgery, and 46% had a moderate or higher ISS. The mortality rate of 1.16% is less than the national average of 2.26%. Hospital charges and the LOS (total and ICU) for trauma patients were half that of all patients. The lower cost may be due to an efficient use of resources, management, and care of trauma patients. Our patient management and hospital charges for these trauma patients, coupled with good outcomes, may be a model for other hospital admissions and other trauma programs.Item [News Release](1968-05-23) Chappell, Frank W., Jr.Item [News Release](1968-08-22) Chappell, Frank W., Jr.Item [News](1988-03-08) Harrell, AnnItem [News](1979-09-10) Harrell, AnnItem [News](1989-09-15) Quinn, JohnItem [News](1983-01-03) Harrell, AnnItem [News](1988-09-12) Harrell, AnnItem [News](1975-03-25) Taylor, SilviItem [News](1979-02-12) Harrell, AnnItem [News](1971-10-28) Fenley, Bob; Weeks, JohnItem [News](1980-05-08) Spiegel, RichardItem [News](1978-05-16) Land, ChrisItem [News](1979-11-06) Rutherford, SusanItem [News](1976-12-14) UnknownItem [News](1989-12-18) Dick, AmyItem [News](1983-11-16) Willding, LizItem [News](1970-06-24) Fenley, Bob; Weeks, John