Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs.

BACKGROUND: Ultrasound is preferred over computed tomography (CT) for diagnosing appendicitis in children to avoid undue radiation exposure. We previously reported our experience in instituting a standardized appendicitis ultrasound template, which decreased CT rates by 67.3%. In this analysis, we demonstrate the ongoing cost savings associated with using this template. METHODS: Retrospective chart review for the time period preceding template implementation (June 2012-September 2012) was combined with prospective review through December 2015 for all patients in the emergency department receiving diagnostic imaging for appendicitis. The type of imaging was recorded, and imaging rates and ultrasound test statistics were calculated. Estimated annual imaging costs based on pretemplate ultrasound and CT utilization rates were compared with post-template annual costs to calculate annual and cumulative savings. RESULTS: In the pretemplate period, ultrasound and CT rates were 80.2% and 44.3%, respectively, resulting in a combined annual cost of $300,527.70. Similar calculations were performed for each succeeding year, accounting for changes in patient volume. Using pretemplate rates, our projected 2015 imaging cost was $371,402.86; however, our ultrasound rate had increased to 98.3%, whereas the CT rate declined to 9.6%, yielding an annual estimated cost of $224,853.00 and a savings of $146,549.86. Since implementation, annual savings have steadily increased for a cumulative cost savings of $336,683.83. CONCLUSIONS: Standardizing ultrasound reports for appendicitis not only reduces the use of CT scans and the associated radiation exposure but also decreases annual imaging costs despite increased numbers of imaging studies. Continued cost reduction may be possible by using diagnostic algorithms.

Streptococcal Pharyngitis and Appendicitis in Children.

BACKGROUND: Several pathologies, including pharyngitis, are associated with abdominal pain that can mimic appendicitis. We sought to further understand the link between appendicitis-like symptoms and streptococcal (strep) pharyngitis. METHODS: All patients undergoing ultrasound imaging for appendicitis in our emergency department during 2013 were reviewed (n = 1572). A total of 207 patients were identified who underwent both ultrasound for appendicitis and testing for strep pharyngitis. Demographic and outcomes data between rule out appendicitis patients who underwent strep testing and those who did not were compared. RESULTS: Strep testing was more common in younger patients (mean age = 8.26 vs 10.26 years P < .001) and evenly matched by gender (104 male, 103 female). Of the 207 patients tested for strep pharyngitis, 8 (3.9%) patients had appendicitis and 35 (16.9%) patients tested positive for strep pharyngitis. No cases of concurrent strep pharyngitis and appendicitis were identified. The negative appendectomy rate in the strep pharyngitis tested group was 38.5% (5/13), compared with 7.7% (23/296) ( P = .003) in the nontested group. The appendicitis rate among the strep tested group was 3.8% (8/207) compared with 20% (273/1365) in the nontested group ( P < .001). CONCLUSIONS: Patients undergoing testing for strep pharyngitis were younger, had lower rates of appendicitis, and had a higher rate of negative appendectomy. A diagnosis of concurrent appendicitis and strep pharyngitis is rare. In cases of patients with sufficient symptoms to warrant testing for strep pharyngitis a diagnosis of appendicitis is less likely and surgical intervention leads to higher negative appendectomy rates.

Resource use in pediatric blunt and penetrating trauma.

BACKGROUND: Trauma is one of the leading causes of pediatric morbidity and mortality with significant patient and economic impacts that necessitate constant study. Significant differences in outcomes and resource use exist between blunt and penetrating mechanisms. METHODS: The National Trauma Data Bank was analyzed for patients aged 0-18 y with International Classification of Diseases, 9th Revision injury codes for blunt and penetrating trauma from 2007-2012. Demographic information, causes, treatments, complications, and outcomes were assessed. RESULTS: A total of 748,347 pediatric trauma patients were assessed. Blunt trauma was identified as the cause in 601,898 (80.43%) patients compared with 55,597 (7.4%) patients with penetrating trauma. Blunt trauma patients were younger on average and more likely to be female. Despite having a slightly higher mean injury severity scores, blunt trauma patients had shorter length of stay in the hospital (2.9 versus 4.3 d, P < 0.001), fewer complications (34.8% versus 38.6%, P < 0.001), and a much lower mortality rate (1.3% versus 7.1%, P < 0.001). Blunt trauma patients were more likely to undergo computed tomography scanning but less likely to receive transfusions (1.79% versus 5.5%, P < 0.001) and to undergo exploratory laparotomy (0.9% versus 9.4%, P < 0.001) and thoracotomy (0.07% versus 1.7%, P < 0.001). Variations in outcome and resource use were also noted by age. CONCLUSIONS: Compared with penetrating trauma, blunt trauma is more common and patients have shorter length of stay, less complications, lower mortality, and are less likely to need operative intervention or blood transfusion. Resource use also varied by age.

Postoperative timing of computed tomography scans for abscess in pediatric appendicitis.

BACKGROUND: One-quarter to one half of pediatric appendicitis patients present with ruptured appendicitis and about 3%-25% go on to form postoperative intra-abdominal abscesses. The optimal timing of postoperative imaging for suspected abscess formation has been a subject of debate. METHODS: All patients who underwent appendectomy for complex appendicitis and were not discharged before postoperative day (POD) #5 from April 2012-October 2014 were identified. Patients were stratified into groups for comparison as follows: group 1 had postoperative computed tomography (CT) scans before POD#7 (n = 26) and group 2 did not (n = 169). Group 2 was further divided into those who were afebrile (group 2a, n = 106) or febrile (group 2b, n = 63) at POD#5. RESULTS: A total of 195 patients met criteria. Early use of CT scans resulted in more drainage procedures (group 1, 73.1% versus group 2b, 28.6%, P < 0.001) and a higher recurrent CT scan rate (38.5% versus 9.5%). The groups had equivalent lengths of stay (11.9 versus 9.8 d, P = 0.10) and readmission rates due to abscesses (19.2% group 1 versus 6.3%, group 2b, P = 0.12) with no septic events. In total, 130 of the 169 patients (76.9%) in group 2 had resolution of symptoms before discharge without intervention with readmission for abscess in only 5.9%. CONCLUSIONS: Waiting until POD#7 before scanning led to fewer drainage procedures and recurrent CT scans without increasing length of stay or readmission rates. Most complex appendicitis patients still admitted at POD#5 had resolution of symptoms without need for intervention.

Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template.

PURPOSE: Computed tomography (CT) for the diagnosis of appendicitis is associated with radiation exposure and increased cost. In an effort to reduce the diagnostic use of CT scans, we implemented a standardized ultrasound report template based on validated secondary signs of appendicitis. METHODS: In September 2012, as part of a quality improvement project, we developed and introduced a four category standardized ultrasound report template for limited right lower quadrant abdominal ultrasounds. Outcomes for patients undergoing ultrasound or CT scan for appendicitis between 9/10/2012 and 12/31/2013 (Period 2, n=2033) were compared to the three months prior to implementation (Period 1, n=304). RESULTS: In Period 1, 78 of 304 (25.7%) patients had appendicitis versus 385 of 2033 (18.9%) in Period 2 (p=0.006). Non-diagnostic exams decreased from 48% to 0.1% (p<0.001). Ultrasound sensitivity improved from 66.67% to 92.2% (p<0.001). Specificity did not significantly change (96.9% to 97.69%, p=0.46). CT utilization for appendicitis decreased from 44.3% in Period 1 to 14.5% at the end of Period 2 (p<0.001). CONCLUSIONS: Implementation of a standardized ultrasound report template based on validated secondary signs of appendicitis nearly eliminated non-diagnostic exams, improved diagnostic accuracy, and resulted in a striking decrease in CT utilization.

Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later.

PURPOSE: Beginning in 2003, the pediatric emergency medicine (PEM) physician replaced the surgeon as the team leader for all level II trauma resuscitations at a busy pediatric trauma center. The purpose was to review the outcomes 10 years after implementing this practice change. METHODS: Trauma registry data for all level II activations requiring admission were extracted for the 21 months (April 1, 2001-December 31, 2002) prior to policy change (period 1, **n=627) and compared to the admitted patients from the 10 subsequent years (2003-2013; period 2, n=2694). Data included demographics, length of stay (LOS), injury severity score (ISS), readmissions, complications, and mortality. RESULTS: Mean ISS scores for admitted patients during period 1 (8.5) were higher than during period 2 (7.8). During period 1, 53.6% of patients underwent abdominal CT versus 41.8% in period 2 (p<.001), and the median ED LOS was 135 versus 191 minutes in period 2. From 2000 to 2003, 91% of patients seen as level II trauma alerts were admitted compared to 56.6% of patients in period 2 (p<0.001). There were no missed abdominal injuries identified, and readmission rate was low. CONCLUSIONS: We conclude that level II trauma resuscitations can be safely evaluated and managed without immediate surgeon presence. Although ED LOS increased, admission rate and CT scan usage decreased significantly without an increase in missed injuries.

Increased cytokine production in interleukin-18 receptor alpha-deficient cells is associated with dysregulation of suppressors of cytokine signaling.

Since interleukin (IL)-18 is a proinflammatory cytokine, mice lacking IL-18 or its ligand-binding receptor (IL-18R) should exhibit decreased cytokine and chemokine production. Indeed, production of IL-1alpha, IL-6, and MIP-1alpha was reduced in IL-18 knock-out (ko) mouse embryonic fibroblast (MEF)-like cells. Unexpectedly, we observed a paradoxical 10-fold increase in IL-1beta-induced IL-6 production in MEF cells from mice deficient in the IL-18R alpha-chain (IL-18Ralpha) compared with wild type MEF. Similar increases were observed for IL-1alpha, MIP-1alpha, and prostaglandin E2. Likewise, coincubation with a specific IL-18Ralpha-blocking antibody augmented IL-1beta-induced cytokines in wild type and IL-18 ko MEF. Stable lines of IL-18Ralpha-depleted human A549 cells were generated using shRNA, resulting in an increase of IL-1beta-induced IL-1alpha, IL-6, and IL-8 compared to scrambled small hairpin RNA. In addition, we silenced IL-18Ralpha with small interfering RNA in primary human blood cells and observed up to 4-fold increases in the secretion of lipopolysaccharide- and IL-12/IL-18-induced IL-1beta, IL-6, interferon-gamma, and CD40L. Mechanistically, despite increases in Stat1 and IL-6, induction of SOCS1 and -3 (suppressor of cytokine signaling 1 and 3) was markedly reduced in the absence of IL-18Ralpha. Consistent with these observations, activation of the p38alpha/beta and ERK1/2 MAPKs and of protein kinase B/Akt increased in IL-18Ralpha ko MEF, whereas the negative feedback kinase MSK2 was more active in IL-18 ko cells. These data reveal a role for SOCS1 and -3 in the seemingly paradoxical hyperresponsive state in cells deficient in IL-18Ralpha, supporting the concept that IL-18Ralpha participates in both pro- and anti-inflammatory responses and that an endogenous ligand engages IL-18Ralpha to deliver an inhibitory signal.