Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis.

Importance: In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs. Objective: To assess the use and safety of outpatient management of acute appendicitis. Design, Setting, and Participants: This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020. Exposures: Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively. Main Outcomes and Measures: Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared. Results: Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores. Conclusions and Relevance: These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Impact of Covid-19 pandemic on volume and surgeon professional fees generated by emergency general surgery procedures.

INTRODUCTION: The COVID-19 pandemic has changed the dynamics of healthcare in the USA. In early 2020, most states issued orders to stop non-emergent elective surgeries. This contracted the overall revenue generated by the hospital systems. The impact of COVID-19 pandemic on volume has not been well studied but effects on surgeon professional fees generated remains unexplored. The goal of this study was to assess if COVID-19 pandemic has affected surgeon professional fees and revenues generated from emergency general surgeries. METHODS: This is a retrospective review to compare surgical case volume in 2019 and 2020. We obtained our data from a tertiary care referral center database. Data were collected from February to April of 2019 and 2020, corresponding to the duration of statewide ban on non-emergent surgical cases. We used the most reported current procedural terminology (CPT) Code for each surgical procedure to calculate the surgeon professional fees generated. We calculated the percentage difference in surgeon professional fees between 2019 and 2020 for comparison. RESULTS: There was a statistically significant decrease in daily emergent operations between 2019 and 2020 time periods (6.13/day vs 4.64/day). There was a statistically significant decrease in hospital admissions for appendicitis, cholecystitis, diverticulitis, skin and soft tissue infections, small bowel obstruction and GI bleed. Additionally, a statistically significant decrease in number of appendectomy, cholecystectomy, sigmoid colectomy with anastomosis, small bowel resection, operation for incarcerated and reducible hernia procedures was observed. There is a decline in surgeon professional fees generated in 2020 compared to 2019 for all emergent surgeries. When compared to 2019, we observed an increase of 238 more inquests in February to April of 2020, which is the same time period when we noticed a significant decrease in hospital admissions and procedures for emergency general surgery. CONCLUSION: The COVID-19 pandemic has negatively impacted surgical case volumes in 2020 compared to 2019. This includes both emergent and non-emergent cases. There is a need for more broad cost analysis which considers hospital expenditures and cost benefit analysis.

Septic arthritis of the hip, an unreported complication of perforated appendicitis: A case report.

INTRODUCTION: Progression of inflammation in acute appendicitis can lead to appendiceal perforation, which is associated with higher morbidity and mortality. Bacteremia due to a perforated appendicitis can lead to distal bacterial seeding, resulting in further complications. PRESENTATION OF CASE: We present here a case of appendiceal perforation in a 32-year-old previously healthy male. Patient was conservatively managed with intravenous (IV) antibiotics and was discharged on hospitalization day-6. Prior to scheduled interval appendectomy, he developed right sided hip pain with decreased range of motion. Computed tomography (CT) scan with contrast showed right hip abscess and enlarged pelvic lymph nodes. Arthrocentesis yielded purulent fluid with leukocytosis (84.8 k/CMM) and neutrophilia (89%). Patient underwent emergent incision and drainage of the hip abscess followed with 42-days of IV antibiotics for septic arthritis. CONCLUSION: This case presents a unique occurrence of a complication from appendiceal perforation in patients who are initially managed non-operatively. Clinicians should be mindful of rare complications associated with non-operative management of appendicitis.

Tolerance induction by hematopoietic cell transplantation: combined use of stem cells and progenitor cells.

BACKGROUND: Donor-specific hematopoietic cell transplantation (HCT) in the form of bone marrow transplantation has been long recognized experimentally as a means of inducing tolerance for subsequently transplanted organs. Clinical translation has been limited, however, due to HCT-associated complications. Unrelated myeloid progenitors (MP) can be administered simultaneously with hematopoietic stem cells (HSC). This reduces susceptibility to bacterial and fungal infections in neutropenic mice in laboratory studies. It is not known, however, if the addition of third-party MP interferes with tolerance induction. METHODS: BALB/c (H-2d) mice were irradiated and reconstituted with 4,000 AKR (H-2k) HSC or with 4,000 AKR HSC combined with 10(5) FVB (H-2q) MP. After 2 months, the mice received skin grafts from these three strains or from an unrelated strain, C57BL/6 (H-2b). Composition and origin of hematopoietic cells was analyzed using flow cytometry. RESULTS: Mice in both groups accepted all the host-type- and HSC-donor-matched grafts, and rejected unrelated grafts. Surprisingly, recipients of both HSC and MP also accepted MP-matched skin grafts (14 of 14), even with very low levels of MP-derived cells in circulation. The analysis revealed that, although most hematopoietic cells were derived from HSC donors, regulatory T cells were derived from both donors as well as the recipient. CONCLUSION: The addition of third-party MP cells does not interfere with HCT-induced tolerance induction and, surprisingly, induces MP-specific tolerance.

Critical structural motif for the catalytic inhibition of human topoisomerase II by UK-1 and analogs.

Three new analogs of UK-1 have been synthesized and their efficacies as topoisomerase II inhibitors have been determined. Results show that UK-1 and two of these analogs are catalytic inhibitors of topo II and identifies a critical structure motif necessary for enzyme inhibition.