LETTERS TO THE EDITOR
Stump Appendicitis A Challenging Clinical Problem
2. Lupinacci RM, Bouchet-Doumenq C, Salepcioglu H, et al. Stump appendicitis. A diagnostic trap [published online ahead of print]. Clin Res Hepatol Gastroenterol. 2013. 3. Tang XB, Qu RB, Bai YQ, et al. Stump appendicitis in children. J Pediatr Surg. 2011;46:233Y236.
To the Editor: e read with great interest the article by Schreiner et al,1 ‘‘A Warning: Don’t Be Stumped by Stump Appendicitis.’’ We recognize the authors for their very important article, because all physicians must be aware of this clinical entity as any delay in diagnosis may lead to high rates of morbidity and even mortality. According to our experience, stump appendicitis may also happen after open appendectomy, especially when the base of the appendix is in the retrocecal subserosal position. Unfortunately, it may also happen when the operation is done by an inexperienced surgeon such as general surgery residents in a teaching hospital without adequate supervision, a situation that must never happen. Stump appendicitis is an underestimated condition and a diagnostic trap that few surgeons think about when faced with localized pain in the right side of the lower abdomen. Misdiagnosis and therefore delay of the appropriate treatment result in increased complications.2 So, we agree with the authors that diagnosis of stump appendicitis should be considered if, after appendectomy, the patient continues to have right-sided lower-quadrant pain or peritonitis without a known cause or has recurrent similar symptoms.1,3 Computed tomography scan seems to be the best imaging modality, and if the diagnosis is confirmed, prompt surgical or laparoscopic intervention should be done. Hamed Ghoddusi Johari, MD Shima Eskandari, MD
W
Trauma Research Center, General Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran [email protected]
DISCLOSURE The authors declare no conflict of interest. REFERENCES 1. Schreiner C, Hartin CW Jr, Yamout SZ, et al. A warning: don’t be stumped by stump appendicitis. Pediatr Emerg Care. 2013;29:76Y77.
Pediatric Emergency Care
&
Organization of Pediatric Emergencies To the Editors: he organization of pediatric emergency rooms (PERs) is a vital component of health care systems. Pediatric emergency room overcrowding is widespread and has reached crisis proportions worldwide.1 Overcrowding threatens public health by compromising patient safety: one of the most relevant problems in the functioning of PER is represented by the progressive increase in nonurgent consultations. This leads to an increased frequency of medication errors as well as of increased mortality and delayed treatment for patients with time-sensitive conditions. Furthermore, inadequate inpatient capacity for a population with an increasing severity of illness (eg, chronic diseases, partly due to the increased quality of care of premature babies) is observed in developed countries. Potential solutions for overcrowding require multidisciplinary system-wide support.2 To date, no definitive solutions have been identified. One possibility is to let nonurgent consultants wait for many hours at the PER and discourage them from coming again without being referred by their general practitioner (GP). Although self-referred children are less severely ill than GP-referred children, many parents properly judge the severity of their child’s illness.3 Thus, recommendations regarding interventions that would discourage self-referral to the PER should be carefully considered. Another possible way to reduce consultations at PER is to oblige parents to pay for the consultation if an urgent intervention is not justified, that is, in about 50% of cases. In the United States, the Medicaid reform already raised some questions.4 Indeed, in response to copays and premiums, parents would defer needed preventive and sick care for children and increase use of the emergency room. Another difficulty is that the ultimate declaration of nonurgent consultation at the PER can be made only after the consultation and is physician-
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Volume 29, Number 11, November 2013
dependent. Unfortunately, the degree of emergency felt by the parents is not always the same scored by the physicians. Most often, parents of children who are ill utilize the emergency department because they truly feel their child is quite ill. This represents a well-known source of conflict with the physicians. Application of such 2-tiered system may have unintended consequences, including preventing parents from bringing children to the PER when they are not ‘‘sick enough,’’ resulting in delays in seeking care. Allowing parents to make decisions around the triage of their child may lead to unrecognized severity of illness and presentation to a PER at a time when morbidity and mortality associated with their condition are higher. Furthermore, this system potentially discriminates against those who are unable to afford medical care for their children. Overall, these interventions on payment of consultation should be studied on efficacy and safety before they can be suggested as a real solution for overcrowding. Modifying our current approach to PER overcrowding could be fruitful and useful. First, to reduce the number of nonurgent consultants to come to the PER, teaching hospitals could increase the quality of care in the surrounding local hospitals and GP’s offices. CME programs do help, for sure. However, parents sometimes think that waiting for hours at a tertiary care PER is worth the cause, because their child will benefit from the highest quality of care. If a quality label for local hospitals and GPs’ offices could be created by funding teaching hospitals for the development of local educational programs and Web-based protocols sharing, a part of the overcrowding would be probably solved. Another key point is the triage. Research in this field is ongoing, but it mainly focuses on the identification of severely ill patients.5 Clinical research should probably focus on the reliability of triage systems in identifying children who can wait and eventually refer them to the GP.6 Patients who are severely ill are easily identified by the nurse’s quick look. The problem nowadays is to appropriately identify children who can reasonably wait for a physician to visit them. Another interesting option is to visit nonurgent consultant in separate areas of the PER, once triaged. When registered as nonurgent, these children can be medically examined following their order of arrival at the PER. This has 2 main advantages: parents will not be stressed by other children being called before their child, and allocated medical resources for this www.pec-online.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Stump Appendicitis A Challenging Clinical Problem
2. Lupinacci RM, Bouchet-Doumenq C, Salepcioglu H, et al. Stump appendicitis. A diagnostic trap [published online ahead of print]. Clin Res Hepatol Gastroenterol. 2013. 3. Tang XB, Qu RB, Bai YQ, et al. Stump appendicitis in children. J Pediatr Surg. 2011;46:233Y236.
To the Editor: e read with great interest the article by Schreiner et al,1 ‘‘A Warning: Don’t Be Stumped by Stump Appendicitis.’’ We recognize the authors for their very important article, because all physicians must be aware of this clinical entity as any delay in diagnosis may lead to high rates of morbidity and even mortality. According to our experience, stump appendicitis may also happen after open appendectomy, especially when the base of the appendix is in the retrocecal subserosal position. Unfortunately, it may also happen when the operation is done by an inexperienced surgeon such as general surgery residents in a teaching hospital without adequate supervision, a situation that must never happen. Stump appendicitis is an underestimated condition and a diagnostic trap that few surgeons think about when faced with localized pain in the right side of the lower abdomen. Misdiagnosis and therefore delay of the appropriate treatment result in increased complications.2 So, we agree with the authors that diagnosis of stump appendicitis should be considered if, after appendectomy, the patient continues to have right-sided lower-quadrant pain or peritonitis without a known cause or has recurrent similar symptoms.1,3 Computed tomography scan seems to be the best imaging modality, and if the diagnosis is confirmed, prompt surgical or laparoscopic intervention should be done. Hamed Ghoddusi Johari, MD Shima Eskandari, MD
W
Trauma Research Center, General Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran [email protected]
DISCLOSURE The authors declare no conflict of interest. REFERENCES 1. Schreiner C, Hartin CW Jr, Yamout SZ, et al. A warning: don’t be stumped by stump appendicitis. Pediatr Emerg Care. 2013;29:76Y77.
Pediatric Emergency Care
&
Organization of Pediatric Emergencies To the Editors: he organization of pediatric emergency rooms (PERs) is a vital component of health care systems. Pediatric emergency room overcrowding is widespread and has reached crisis proportions worldwide.1 Overcrowding threatens public health by compromising patient safety: one of the most relevant problems in the functioning of PER is represented by the progressive increase in nonurgent consultations. This leads to an increased frequency of medication errors as well as of increased mortality and delayed treatment for patients with time-sensitive conditions. Furthermore, inadequate inpatient capacity for a population with an increasing severity of illness (eg, chronic diseases, partly due to the increased quality of care of premature babies) is observed in developed countries. Potential solutions for overcrowding require multidisciplinary system-wide support.2 To date, no definitive solutions have been identified. One possibility is to let nonurgent consultants wait for many hours at the PER and discourage them from coming again without being referred by their general practitioner (GP). Although self-referred children are less severely ill than GP-referred children, many parents properly judge the severity of their child’s illness.3 Thus, recommendations regarding interventions that would discourage self-referral to the PER should be carefully considered. Another possible way to reduce consultations at PER is to oblige parents to pay for the consultation if an urgent intervention is not justified, that is, in about 50% of cases. In the United States, the Medicaid reform already raised some questions.4 Indeed, in response to copays and premiums, parents would defer needed preventive and sick care for children and increase use of the emergency room. Another difficulty is that the ultimate declaration of nonurgent consultation at the PER can be made only after the consultation and is physician-
T
Volume 29, Number 11, November 2013
dependent. Unfortunately, the degree of emergency felt by the parents is not always the same scored by the physicians. Most often, parents of children who are ill utilize the emergency department because they truly feel their child is quite ill. This represents a well-known source of conflict with the physicians. Application of such 2-tiered system may have unintended consequences, including preventing parents from bringing children to the PER when they are not ‘‘sick enough,’’ resulting in delays in seeking care. Allowing parents to make decisions around the triage of their child may lead to unrecognized severity of illness and presentation to a PER at a time when morbidity and mortality associated with their condition are higher. Furthermore, this system potentially discriminates against those who are unable to afford medical care for their children. Overall, these interventions on payment of consultation should be studied on efficacy and safety before they can be suggested as a real solution for overcrowding. Modifying our current approach to PER overcrowding could be fruitful and useful. First, to reduce the number of nonurgent consultants to come to the PER, teaching hospitals could increase the quality of care in the surrounding local hospitals and GP’s offices. CME programs do help, for sure. However, parents sometimes think that waiting for hours at a tertiary care PER is worth the cause, because their child will benefit from the highest quality of care. If a quality label for local hospitals and GPs’ offices could be created by funding teaching hospitals for the development of local educational programs and Web-based protocols sharing, a part of the overcrowding would be probably solved. Another key point is the triage. Research in this field is ongoing, but it mainly focuses on the identification of severely ill patients.5 Clinical research should probably focus on the reliability of triage systems in identifying children who can wait and eventually refer them to the GP.6 Patients who are severely ill are easily identified by the nurse’s quick look. The problem nowadays is to appropriately identify children who can reasonably wait for a physician to visit them. Another interesting option is to visit nonurgent consultant in separate areas of the PER, once triaged. When registered as nonurgent, these children can be medically examined following their order of arrival at the PER. This has 2 main advantages: parents will not be stressed by other children being called before their child, and allocated medical resources for this www.pec-online.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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