The impact of diagnostic delay on the course of acute appendicitis

BACKGROUND: The diagnosis of acute appendicitis is often delayed, which may complicate the further course of the disease. AIMS: To review appendectomy cases in order to determine the incidence of diagnostic delay, the underlying factors, and impact on the course of the disease. METHODS: Records of all children who underwent appendectomy from 1994 to 1997 were reviewed. The 129 cases were divided into group A (diagnostic period within 48 hours) and group B (diagnostic period 48 hours or more). RESULTS: In the group with diagnostic delay, significantly more children had first been referred to a paediatrician rather than to a surgeon. In almost half of the cases in this group initial diagnosis was not appendicitis but gastroenteritis. The perforation rate in group A was 24%, and in group B, 71%. Children under 5 years of age all presented in the delayed group B and had a perforation rate of 82%. The delayed group showed a higher number of postoperative complications and a longer hospitalisation period. CONCLUSIONS: Appendicitis is hard to diagnose when, because of a progressing disease process, the classical clinical picture is absent. The major factor in diagnostic delay is suspected gastroenteritis. Early surgical consultation in a child with deteriorating gastroenteritis is advised. Ultrasonographs can be of major help if abdominal signs and symptoms are non-specific for appendicitis

Congenital arterioportal fistula of the liver with reversal of flow in the superior mesenteric vein

We report on a newborn with a large arterioportal fistula of the liver complicated by a sudden reversal of flow in the portal and superior mesenteric vein, leading to congestion and ischemia of the small intestine. Ultrasound, duplex Doppler sonography and angiographic features are presented. Ligation of the hepatic artery led to a complete recovery

The treatment of cryptorchidism : why, how, when : clinical studies in prepuberal boys

The clinical studies were initiated in 1982 on the understanding that they would be concluded in three years. The studies would be mainly prospective with a few exceptions, e.g. when retrospective evaluation was required. For the doubleblind, placebo-controlled study the population would be limited to 252 patients. While a time limit (mid 1985) was set for the evaluation of the first year of life as well as the surgical studies, the follow-up would be extended to include up-todate information in this dissertation. No clinical study would be started before obtaining the approval of the medical-ethical commission of the University Hospital Rotterdam, Erasmus University School of Medicine. Before any procedure was initiated, every effort would be made to explain this procedure to the boy and his parents in as great a detail as possible, so that informed consent could be obtained from the parents. The children would always be examined by each one of us separately (to enable an unprejudiced opinion) following a standard diagnostic procedure (see 2.3.). ,The boys would always be confronted by these same two doctors only in order to create mutual trust, which would be beneficial to the proceedings

Spinal epidural abscess presenting with abdominal pain

We report a case of spinal epidural abscess presenting as abdominal pain. An 7-year-old boy presented with abdominal pain. He was operated on under suspicion of appendicitis. During operation, no abnormalities were found. Postoperatively, the abdominal pain did not subside. Subsequently, the boy developed neurological abnormalities. MR1 showed a spinal epidural abscess. A laminectomy was performed and the boy was treated with antibiotics; he recovered well. This case showed that it is important to consider a spinal epidural abscess as a cause of abdominal pain with fever in children

Glutamine supplementation of parenteral nutrition does not improve intestinal permeability, nitrogen balance, or outcome in newborns and infants undergoing digestive-tract surgery: results from a double-blind, randomized, controlled trial

OBJECTIVE: To assess the effect of isocaloric isonitrogenous parenteral glutamine supplementation on intestinal permeability and nitrogen loss in newborns and infants after major digestive-tract surgery. SUMMARY BACKGROUND DATA: Glutamine supplementation in critically ill and surgical adults may normalize intestinal permeability, attenuate nitrogen loss, improve survival, and lower the incidence of nosocomial infections. Previous studies in critically ill children were limited to very-low-birthweight infants and had equivocal results. METHODS: Eighty newborns and infants were included in a double-blind, randomized trial comparing standard parenteral nutrition (sPN; n = 39) to glutamine-supplemented parenteral nutrition (GlnPN; glutamine target intake, 0.4 g kg day; n = 41), starting on day 2 after major digestive-tract surgery. Primary endpoints were intestinal permeability, as assessed by the urinary excretion ratio of lactulose and rhamnose (weeks 1 through 4); nitrogen balance (days 4 through 6), and urinary 3-methylhistidine excretion (day 5). Secondary endpoints were mortality, length of stay in the ICU and the hospital, number of septic episodes, and usage of antibiotics and ICU resources. RESULTS: Glutamine intake plateaued at 90% of the target on day 4. No differences were found between patients assigned sPN and patients assigned GlnPN regarding any of the endpoints. Glutamine supplementation was not associated with adverse effects. CONCLUSIONS: In newborns and infants after major digestive-tract surgery, we did not identify beneficial effects of isonitrogenous, isocaloric glutamine supplementation of parenteral nutrition. Glutamine supplementation in these patients therefore is not warranted until further research proves otherwise

Staff attitudes towards continuation of life-support in newborns with major congenital anomalies

This study was conducted to gain insight into the attitudes of medical staff towards life-support of newborns with life-threatening problems, seen against the background of these children's expected morbidity and quality of life. The opinions about the mode of life-support were determined by questionnaires and the demographic characteristics of the respondents were noted. Each patient's risk of mortality was scored by means of the standardized Paediatric Risk of Mortality Score (PRISM). Attitudes towards support were unanimous for 39 of the 46 patients. For the other 7 patients at least one of the respondents preferred a different support mode than that given at the time, The attitudes were influenced by the patient's risk of mortality.Conclusion Decisions about life-support of newborns with life-threatening problems should include all the disciplines involved in patient care and should be made at an early stage.</p