Paediatric Septic Arthritis of the Hip and the Efficacy of Kocher's Criteria: A Literature Review.

Pediatric septic arthritis (SA), an intra-articular infection in children, is considered a surgical emergency. The most commonly affected joints are the lower limb joints. It is more common in children below five years old and in males. Several scoring systems aid in the prediction of the disease and help differentiate it from similar differential diagnoses (such as transient synovitis (TS)). The first and most famous scoring system is Kocher's Criteria (KC), which utilizes a mixture of clinical signs, symptoms, and laboratory markers to predict the likelihood of the diagnosis. This review aims to assess the current literature to look at primary papers comparing the predicted probability of KC to the original probability described therefore evaluating its efficacy and usefulness in today's pediatric population. PubMed was searched using the terms "septic arthritis AND hip AND (Kocher OR Kocher's criteria)," 27 studies resulted, and each study was screened by reading the abstracts. Six studies were included in this review. Inclusion criteria were any study that looked at SA of the hip in the pediatric population prospectively or retrospectively, using KC to help make a diagnosis and looking at the predicted probability of KC. Exclusion criteria included studies looking at adults, joints other than the hip, and papers not assessing the predicted probability. The efficacy of KC for diagnosing SA is not well-supported by current literature. Studies indicate that KC have low specificity for SA, suggesting it should not replace arthrocentesis as the diagnostic gold standard. Clinicians should use this model cautiously, and more extensive, prospective studies are needed to validate its effectiveness.

Aspirin Compared to Other Thromboprophylactic Agents in Patients Following Total Hip Arthroplasty: A Literature Review.

Total hip arthroplasty (THA) is a common but major surgery performed in the United Kingdom and around the globe. THA is associated with several postoperative complications, with one of the most common being venous thromboembolism (VTE) in the form of deep venous thrombosis (DVT) or pulmonary embolism (PE). VTE following orthopaedic surgery can have major consequences in terms of patient morbidity and may even cause mortality. It carries a significant cost to the health service, and thromboprophylactic agents are used to decrease the risk. Several different options are available for chemical thromboprophylaxis, including aspirin, low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and warfarin. This study aims to review the literature to determine if aspirin is less superior to the other available chemical thromboprophylaxis in postoperative patients following THA. The primary outcome assessed in this review is rates of symptomatic 90-day VTE in the form of PE or DVT. A literature review was conducted using PubMed, Scopus, and Google Scholar using the following terms: 'Aspirin AND (low molecular weight heparin OR LMWH OR Enoxaparin OR Apixaban OR DOAC OR direct oral anticoagulant OR warfarin) AND (orthopaedic OR orthopedic) AND (Total hip replacement OR THR OR THA OR total hip arthroplasty) AND ('venous thromboembolism' OR VTE).' Aspirin appears to have promising results as thromboprophylaxis in cases of THA. However, it is still up for debate as to whether it is non-inferior to other forms of thromboprophylaxis.

Who should get a right colectomy in low-grade appendiceal adenocarcinomas? Association of lymphovascular invasion and nodal metastases.

BACKGROUND: There is variation in the probability of nodal metastases from low-grade appendiceal adenocarcinomas, and the role of right colectomy is unclear. We aimed to define the prevalence and utility of lymphovascular invasion in predicting the risk of nodal metastases to help stratify patients who may benefit from right hemicolectomy. METHODS: Patients with nonmetastatic low-grade appendiceal adenocarcinomas were identified from the National Cancer Database (2010-2017). The primary outcome was probability of nodal metastases. Logistic regression was used to identify independent predictors of nodal metastases. A 4-tier risk model-the COH Composite Score-was calculated by assigning 1 point each for a high-risk feature (lymphovascular invasion, T3/T4 T stage, or nonmucinous histology). Survival analysis was performed using the Kaplan-Meier method. Multivariate Cox regression analysis was used to identify independent predictors of survival. RESULTS: A total of 1,303 patients with nonmetastatic low-grade appendiceal adenocarcinomas (64.2% mucinous) were identified. Of the 1,133 patients with known lymphovascular invasion status, 78 (6.9%) were lymphovascular invasion positive. In multivariate analysis, lymphovascular invasion was independently associated with nodal metastases (odds ratio, 8.68; P < .001). Overall accuracy of lymphovascular invasion in predicting nodal metastases was 86%. The COH Composite Score stratified patients in 4 categories with increasing risk of nodal metastases and incrementally worse survival. For patients with the COH Composite Score of 0 (12%), the nodal metastasis rate was 3.1%, and a right hemicolectomy in this group did not improve survival. CONCLUSION: The presence of lymphovascular invasion is strongly predictive of nodal metastases. Lymphovascular invasion as part of the COH Composite Score may help guide the extent of surgery in low-grade appendiceal adenocarcinomas.

Outcomes of rectal cancer patients who refuse surgery after incomplete clinical response to neoadjuvant therapy.

BACKGROUND AND OBJECTIVES: Total mesorectal excision (TME) remains the standard of care for patients with rectal cancer who have an incomplete response to total neoadjuvant therapy (TNT). A minority of patients will refuse curative intent resection. The aim of this study is to examine the outcomes for these patients. METHODS: A retrospective cohort study of stage 1-3 rectal adenocarcinoma patients who underwent neoadjuvant chemoradiation therapy or TNT at a single institution. Patients either underwent TME, watch-and-wait protocol, or if they refused TME, were counseled and watched (RCW). Clinical outcomes and resource utilization were examined in each group. RESULTS: One hundred seventy-one patients (Male 59%) were included with a median surveillance of 43 months. Twenty-nine patients (17%) refused TME and had shortened overall survival (OS). Twelve patients who refused TME converted to a complete clinical response (cCR) on subsequent staging with a prolonged OS. 92% of these patients had a near cCR at initial staging endoscopy. Increased physician visits and testing was utilized in RCW and WW groups. CONCLUSION: A significant portion of patients convert to cCR and have prolonged OS. Lengthening the time to declare cCR may be considered in select patients, such as those with a near cCR at initial endoscopic staging.

Efficacy of embolotherapy for the treatment of pelvic congestion syndrome: A systematic review.

Pelvic congestion syndrome (PCS) poses a significant health, diagnostic, and economic challenges. Transcatheter embolisation has emerged as a promising treatment for PCS. A systematic review was performed in order to assess the safety and efficacy of transcatheter embolisation in the treatment of PCS. A systematic search of electronic databases was performed using 'PubMed', 'Embase', 'Medline (OVID)', and 'Web of Science', for articles pertaining to efficacy of embolotherapy for the treatment of pelvic congestion syndrome. A total of 25 studies were included in this systematic review with a combined total of 2038 patients. All patients included were female with a mean average age of 37.65 (31-51). Of the 25 studies, 18/25 studies reported pre- and post-procedural pelvic pain outcomes using a visual analogue scale (VAS). All studies showed a reduction in VAS post-procedure. Transcatheter embolisation had a high technical success rate (94%) and an overall complication rate of 9.0%, of which 10.4% were major and 89.6% were minor. Fifteen out of 19 (78.9%) major complications required a subsequent intervention. Transcatheter embolisation using various techniques is effective and safe in treating PCS. A low quality of evidence limits the currently available literature; however, embolisation has shown to improve symptoms in the majority of patients with low complication rates and recurrence rates.

Colorectal cancer in young adults.

The incidence of colorectal cancer in young adults (CRCYAs) is increasing globally, and it is now the third leading cause of cancer death among young adults under 50 years old. The rising incidence is attributed to various emerging risk factors such as genetics, lifestyle factors, and microbiome profiles. Delayed diagnosis and more advanced disease presentation contribute to worse outcomes. A multidisciplinary approach to care is crucial to ensure comprehensive and personalized treatment plans for CRCYA.

The effect of a sexual abuse history on symptoms and anorectal physiology findings in patients presenting to a colorectal pelvic floor service.

BACKGROUND: Studies report that 12%-23% of patients with functional anorectal disorders have a history of sexual abuse (SA). This article aims to assess whether there is a difference in symptom severity, quality of life or anorectal physiology findings in female patients presenting to a colorectal pelvic floor service with and without a history of sexual abuse. METHODS: A retrospective analysis of all female patients attending a single tertiary pelvic floor unit for faecal incontinence or constipation between 2017 and 2019 was performed. Patients were divided into two groups depending on the presence or absence of a volunteered history of sexual abuse. Validated quality of life and symptom severity scores, along with anorectal physiology studies were analysed and compared between the two groups. RESULTS: There were 148 patients included in the study period and 17% reported a history of SA. There was no statistically significant difference in symptom severity, quality of life scores or anorectal physiology studies between those with and without a history of SA. CONCLUSION: In female patients seeking management for defaecatory symptoms, those who have reported a history of SA did not demonstrate any significant difference in symptom severity, quality of life or physiological measures when compared to those without a history of SA.

A Retrospective Analysis of Patients Undergoing Telemedicine Evaluation in the PreAnesthesia Testing Clinic at H. Lee Moffitt Cancer Center.

BACKGROUND: Telemedicine for preanesthesia evaluation can decrease access disparities by minimizing commuting, time off work, and lifestyle disruptions from frequent medical visits. We report our experience with the first 120 patients undergoing telemedicine preanesthesia evaluation at Moffitt Cancer Center. METHODS: This is a retrospective analysis of 120 patients seen via telemedicine for preanesthesia evaluation compared with an in-person cohort meeting telemedicine criteria had it been available. Telemedicine was conducted from our clinic to a patient's remote location using video conferencing. Clinic criteria were revised to create a tier of eligible patients based on published guidelines and anesthesiologist consensus. RESULTS: Day-of-surgery cancellation rate was 1.67% in the telemedicine versus 0% in the in-person cohort. The two telemedicine group cancellations were unrelated to medical workup, and cancellation rate between the groups was not statistically significant (P = .49). Median round trip distance and time saved by the telemedicine group was 80 miles [range 4; 1180] and 121 minutes [range 16; 1034]. Using the federal mileage rate, the median cost savings was $46 [range $2.30; 678.50] per patient. Patients were similar in gender and race in both groups (P = .23 and .75, respectively), but the in-person cohort was older and had higher American Society of Anesthesiologists physical status classification (P = .0003). CONCLUSIONS: Telemedicine preanesthesia evaluation results in time, distance, and financial savings without increased day-of-surgery cancellations. This is useful in cancer patients who travel significant distances to specialty centers and have a high frequency of health care visits. American Society of Anesthesiologists Physical Status classification and age differences between cohorts indicate possible patient or provider selection bias. Randomized controlled trials will aid in further exploring this technology.

Update on the management of sigmoid diverticulitis.

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

The impact of interpersonal support, supervisory support, and employee engagement on employee turnover intentions: Differences between financially distressed and highly financially distressed hospitals.

BACKGROUND: Critical access hospitals (CAHs) are small hospitals in rural communities in the United States. Because of changes in rural population demographics, legacy financial obligations, and/or structural issues in the U.S. health care system, many of these institutions are financially distressed. Indeed, many have closed due to their inability to maintain financial viability, resulting in a health care and economic crisis for their communities. Employee recruitment, retention, and turnover are critical to the performance of these hospitals. There is limited empirical study of the factors that influence turnover in such institutions. PURPOSE: The primary purpose of the study was to study relationships between interpersonal support, supervisory support, employee engagement, and employee turnover intentions in CAHs. A secondary purpose was to study how financial distress affects these relationships. METHODOLOGY: Based on a survey of CAH employees (n = 218), the article utilizes mediated moderation analysis of a structural equation model. RESULTS: Interpersonal support and supervisory support are positively associated with employee engagement, whereas employee engagement mediates the relationships between both interpersonal support and supervisory support and employee turnover intentions. Statistically significant differences are found between these relationships in financially distressed and highly financially distressed institutions. CONCLUSIONS: Our results are consistent with the social exchange theory upon which our hypotheses and model are built and demonstrate the value of using the degree of organizational financial distress as a contextual variable when studying motivational factors influencing employee turnover intentions. PRACTICAL IMPLICATIONS: In addition to advancing management theory as applied in the CAH context, our study presents the practical insight that employee perceptions of their employer's financial condition should be considered when organizations develop employee retention strategies. Specifically, employee engagement strategies appear to be of greater value in the case of highly financially distressed organizations, whereas supervisory support seems more effective in financially distressed organizations.

Impact of Neoadjuvant Systemic Therapy on Pancreatic Fistula Rates Following Pancreatectomy: a Population-Based Propensity-Matched Analysis.

INTRODUCTION: Postoperative pancreatic fistula (POPF) drives morbidity and mortality following pancreatectomy. Use of neoadjuvant chemotherapy (NAC) has recently increased in the treatment of potentially resectable pancreatic ductal adenocarcinoma (PDAC). This study examined the effect of NAC on POPF rates and postoperative outcomes in PDAC. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset was queried to identify PDAC patients who underwent curative-intent pancreatectomies. Propensity score matching was used to stratify patients by receipt of NAC. Postoperative outcomes were compared and logistic regression applied to identify POPF predictors. RESULTS: Six thousand eight hundred sixty-three patients met the inclusion criteria; of those, 1908 (27.8%) received NAC and 4955 (72.2%) did not (NNAC). Two thousand sixty-two patients were matched 1:1 from each group. NAC patients had significantly lower POPF rates (9.0% vs. 14.5%; P < 0.001); the majority were categorized as grade A (5.1% vs. 9.5%). Overall 30-day morbidity was lower with NAC (40.4% vs. 49.5%; P < 0.001). Specifically, pneumonia (2.3% vs. 4.1%), organ space infections (7.9% vs. 13.2%), sepsis (5.2% vs. 8.0%), and delayed gastric emptying (10.1% vs. 14.8%) occurred less frequently in the NAC group. Postoperative mortality and unplanned reoperations were similar. On multivariate analysis, receipt of NAC was an independent predictor of decreased POPF rates (HR, 0.73 [0.56-0.94]; P = 0.016). Other factors included gland texture, duct size, male gender, and lower BMI. CONCLUSIONS: In this propensity-matched, population-based cohort study of PDAC patients, NAC was associated with lower POPF rates and overall major complications. Those findings suggest a modest protective effect of NAC from POPF.

Nonsurgical Management of Acute Appendicitis in Sickle Cell Disease.

A 9-year-old child with sickle cell disease (sickle beta zero thalassemia) was diagnosed to have acute appendicitis during a hospitalization for pain, acute chest syndrome, and exacerbation of asthma. Because of his high surgical risk, his appendicitis was treated nonsurgically, successfully deferring his appendectomy. He remains well after 1 year. This approach should be considered at least in other sickle cell patients with appendicitis, and perhaps other high-risk populations, if not all children with appendicitis.

Small Bowel Diverticulosis As a Cause of Chronic Pneumoperitoneum.

Pneumoperitoneum, or the accumulation of free air in the peritoneal cavity, is commonly associated with visceral perforation, mandating emergent surgical intervention. Non-surgical pneumoperitoneum, where visceral perforation is not the cause, does not commonly require surgical management. Chronic pneumoperitoneum secondary to small bowel diverticulosis is rare. Of all gastrointestinal diverticular diseases, jejunoileal diverticulosis is the rarest form. We describe a case of chronic pneumoperitoneum in an 83-year-old male presenting with intermittent abdominal distension and constipation over five years resulting in many presentations to his rural hospital. There were never any associated signs of sepsis such as fever or tachycardia. A computed tomography scan revealed large volume pneumoperitoneum without evidence of perforated viscera or free fluid. An elective diagnostic laparoscopy revealed extensive small bowel diverticular disease. One of the diverticuli exhibited pneumotosis intestinalis where bubbles of gas were noted within the diverticulum wall and mesentery in the local vicinity. Given the extent of the small bowel diverticular disease, the patient's advanced age, and relative lack of symptoms, bowel resection was not undertaken and the patient was managed conservatively. This article illustrates a case of chronic pneumoperitoneum due to small bowel diverticulosis. It highlights the differential diagnoses for chronic pneumoperitoneum, increases awareness of this rare and challenging condition, and portrays the utility of conservative management avoiding major surgery and its potential complications.

Anesthetic and analgesic methods for gynecologic brachytherapy: A meta-analysis and systematic review.

Gynecologic brachytherapy procedures require targeted procedural and anesthetic needs including optimization of intra- and post-procedure analgesia, low rate of complications, and appropriate and timely transitions of care. It is uncertain whether neuraxial or general anesthesia is superior for these and other anesthetic outcomes. After a targeted search of the recent literature for anesthesia and analgesia studies for gynecologic brachytherapy, twenty studies were identified and appraised for potential review. Meta-analysis showed a decreased frequency in rescue analgesic administration in patients who underwent neuraxial anesthesia compared with general anesthesia for the procedure and literature review showed a comparable rate of anesthesia-related complications. Neuraxial anesthesia may be considered for gynecologic brachytherapy because of improved pain control, decreased opioid consumption, and similar rate of anesthesia complications.

Use of Laryngeal Mask Airway to Preoxygenate and Ventilate Through a Laryngeal Stoma in a Patient Undergoing General Anesthesia: A Case Report.

The use of the laryngeal mask airways is well established in routine and emergency airway management. Due to its traditional use as a supraglottic airway, it is often overlooked in patients with abnormal airway anatomy such as tracheostomies and laryngeal stomas. We present the unique method of using the laryngeal mask airways externally to facilitate preoxygenation and ventilation in a patient with a laryngeal stoma.

An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses.

BACKGROUND: Anastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak. METHODS: From 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving <30% of either the colon or rectal mucosa. Grade 3 was defined as ischemia or congestion involving >30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line. RESULTS: From 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023). CONCLUSION: Endoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery.

BACKGROUND: The effectiveness of thoracic epidural analgesia (EA) vs conventional IV analgesia (IA) after minimally invasive surgery is still unproven. We designed a randomized controlled trial comparing EA with IA after minimally invasive colorectal surgery. STUDY DESIGN: A total of 87 patients who underwent minimally invasive colorectal procedures at a single institution between 2011 and 2014 were enrolled. Eight patients were excluded and 38 were randomized to EA and 41 to IA. Pain was assessed with the Visual Analogue Scale and quality of life with the Overall Benefit of Analgesia Score daily until discharge. RESULTS: Mean age was 57 ± 14 years, 43% of patients were female, and mean BMI was 28.6 ± 6 kg/m2. The 2 groups were similar in demographic characteristics and distribution of diagnoses and procedures. Epidural analgesia had a higher incidence of hypotensive systolic blood pressure (<90 mmHg) episodes (9 vs 2; p < 0.05) and a trend toward longer Foley catheter duration (3 ± 2 days vs 2 ± 4 days; p > 0.05). Epidural and IA had equivalent mean lengths of stay (4 ± 3 days vs 4 ± 3 days), daily Visual Analogue Scale scores (2.4 ± 2.0 vs 3.0 ± 2.0), and Overall Benefit of Analgesia Scores (3.2 ± 2.0 vs 3.2 ± 2.0), and similar time to start oral diet (2.8 ± 2 days vs 2.2 ± 1 days). Epidural analgesia patients used a higher total dose of narcotics (147.5 ± 192.0 mg vs 98.1 ± 112.0 mg; p > 0.05). Epidural and IV analgesia had equivalent total hospital charges ($144,991 ± $67,636 vs $141,339 ± $75,579; p > 0.05). CONCLUSIONS: This study indicates that EA has no added clinical benefit in patients undergoing minimally invasive colorectal surgery. A trend toward higher total narcotics use and complications with EA was demonstrated.

A Nationwide Analysis of Kidney Autotransplantation.

There are limited data regarding outcomes of patients underwent kidney autotransplantation. This study aims to investigate outcomes of such patients. The nationwide inpatient sample database was used to identify patients underwent kidney autotransplantation during 2002 to 2012. Multivariate analyses using logistic regression were performed to investigate morbidity predictors. A total of 817 patients underwent kidney autotransplantation from 2002 to 2012. The most common indication of surgery was renal artery pathology (22.7%) followed by ureter pathology (17%). Overall, 97.7 per cent of operations were performed in urban teaching hospitals. The number of procedures from 2008 to 2012 were significantly higher compared with the number of them from 2002 to 2007 (473 vs 345, P < 0.01). The overall mortality and morbidity of patients were 1.3 and 46.2 per cent, respectively. The most common postoperative complications were transplanted kidney failure (10.7%) followed by hemorrhagic complications (9.7%). Obesity [adjusted odds ratio (AOR): 9.62, P < 0.01], fluid and electrolyte disorders (AOR: 3.67, P < 0.01), and preoperative chronic kidney disease (AOR: 1.80, P = 0.03) were predictors of morbidity in patients. In conclusion, Kidney autotransplantation is associated with low mortality but a high morbidity rate. The most common indications of kidney autotransplantation are renal artery and ureter pathologies, respectively. A kidney transplant failure rate of 10.7 per cent was observed in patients with kidney autotransplantation. The most common postoperative complication was hemorrhagic in nature.