1.

1.               Garfield JL, Birkhahn RH, Gaeta TJ, Briggs WM. Diagnostic pathways and delays on route to operative intervention in acute appendicitis. Am Surg. 2004 Nov; 70(11):1010-3. 

Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, New York 11215, USA.

The purpose of this study was to determine the elements associated with delay in the evaluation of acute appendicitis at a community teaching hospital. We performed a retrospective chart review of patients undergoing operative exploration for presumed appendicitis in a 12-month period. Cases were categorized by the presence or absence of advanced radiographic imaging. Demographic information and time intervals from triage to operative incision were compared. One hundred twenty-four patients underwent operative exploration for presumed appendicitis. Forty-one patients had no advanced imaging, 67 had a CT scan, 8 had a sonogram, and 8 had both CT/sonogram. Patients using advanced radiographic imaging prior to operative exploration were no less likely to have a normal appendix at surgery. Diagnostic imaging significantly increased the preoperative emergency department length of stay. Two-thirds of patients with presumed acute appendicitis were imaged before operative exploration. The use of abdominal CT and sonogram resulted in significantly increased preoperative emergency department length of stay with no apparent improvement in diagnostic accuracy.

2.

Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol. 2004 Nov;104(5 Pt 1):1051-7. Review.

Department of Obstetrics and Gynaecology, University of Leicester, United Kingdom.

OBJECTIVE: We sought to evaluate the administration of antibiotics to pregnant women with preterm rupture of membranes (PROM). DATA SOURCES: We collected data by using the Cochrane Controlled Trials Register and MEDLINE. METHODS OF STUDY SELECTION: We included randomized controlled comparisons of antibiotic versus placebo (14 trials, 6,559 women). TABULATION, INTEGRATION, AND RESULTS: Antibiotics were associated with a statistically significant reduction in maternal infection and chorioamnionitis. There also was a reduction in the number of infants born within 48 hours and 7 days and with the following morbidities: neonatal infection (relative risk [RR] 0.67, 95% confidence interval [CI] 0.52-0.85), positive blood culture (RR 0.75, 95% CI 0.60-0.93), use of surfactant (RR 0.83 95% CI 0.72-0.96), oxygen therapy (RR 0.88, 95% CI 0.81-0.96), and abnormal cerebral ultrasound scan before discharge from hospital (RR 0.82, 95% CI 0.68-0.99). Perinatal mortality was not significantly reduced (RR 0.91, 95% CI 0.75-1.11). A benefit was present both in trials where penicillins and erythromycin were used. Amoxicillin/clavulanate was associated with a highly significant increase in the risk of necrotizing enterocolitis (RR 4.60, 95% CI 1.98-10.72). CONCLUSION: The administration of antibiotics after PROM is associated with a delay in delivery and a reduction in maternal and neonatal morbidity. These data support the routine use of antibiotics for women with PROM. Penicillins and erythromycin were associated with similar benefits, but erythromycin was used in larger trials and, thus, the results are more robust. Amoxicillin/clavulanate should be avoided in women at risk of preterm delivery because of the increased risk of neonatal necrotizing enterocolitis. Antibiotic administration after PROM is beneficial for both women and neonates.

3.

Shmuely H, Samra Z, Ashkenazi S, Dinari G, Chodick G, Yahav J. Association of Helicobacter pylori infection with Shigella gastroenteritis in young children. Am J Gastroenterol. 2004 Oct;99(10):2041-5. 

Helicobacter Research Institute and Microbiology Laboratory, Rabin Medical Center, Beilinson Campus, Petah Tiqvl 49100, Israel.

OBJECTIVE: Helicobacter pylori infection is acquired mainly in early childhood. Much is unknown about the mode of transmission. The organism can be cultivated from cathartic stools and vomitus and is potentially transmissible during episodes of gastrointestinal tract illness. Because Shigella and Salmonella are common pathogens in enteric infections in children, we examined the association of H. pylori with Shigella and Salmonella infections in pediatric patients. METHODS: The study population included consecutive children aged 2-72 months hospitalized with acute gastroenteritis who had culture-proven shigellosis (N = 78) or salmonellosis (N = 76). Sixty-five healthy similarly aged children with culture-negative stools served as controls. Parents of cases were queried for personal and family characteristics and socioeconomic indicators. The stool specimens from all participants were tested for H. pylori antigen. RESULTS: On univariate analysis, Shigella gastroenteritis was significantly associated with H. pylori positivity (odds ratio, OR: 3.5, 95% confidence interval (CI): 1.5-8.8, p= 0.004) compared to controls. This association remained significant even after adjusting for living conditions, father's occupation, and father's education (OR = 3.38, 95% CI: 1.39-8.22, p= 0.007). Salmonella gastroenteritis was not associated with H. pylori positivity (OR = 1.1; 95% CI: 0.4-3.0, p= 0.8). CONCLUSION: H. pylori infection in young children is associated with Shigella gastroenteritis. This association warrants further investigation.

Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:  

11422.   Daniels NH, Callen JP. Mycophenolate mofetil is an effective treatment for peristomal pyoderma gangrenosum. Arch Dermatol. 2004 Dec;140(12):1427-9.

11423.   Garfield JL, Birkhahn RH, Gaeta TJ, Briggs WM. Diagnostic pathways and delays on route to operative intervention in acute appendicitis.Am Surg. 2004 Nov;70(11):1010-3.

11424.   Gray HC, Foy TM, Becker BA, Knutsen AP. Rice-induced enterocolitis in an infant: TH1/TH2 cellular hypersensitivity and absent IgE reactivity. Ann Allergy Asthma Immunol. 2004 Dec;93(6):601-5.

11425.     in't Hof KH, van Lankeren W, Krestin GP, Bonjer HJ, Lange JF, Becking WB, Kazemier G. Surgical validation of unenhanced helical computed tomography in acute appendicitis.Br J Surg. 2004 Dec;91(12):1641-5.

11426.   Kenyon S, Boulvain M, Neilson J.Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol. 2004 Nov;104(5 Pt 1):1051-7. Review.

11427.   Lien WC, Lai TI, Lin GS, Wang HP, Chen WJ, Cheng TY. Epiploic appendagitis mimicking acute cholecystitis. Am J Emerg Med. 2004 Oct;22(6):507-8.

11428.   Moreno-Espinosa S, Farkas T, Jiang X.  Human caliciviruses and pediatric gastroenteritis. Semin Pediatr Infect Dis. 2004 Oct;15(4):237-45. Review.

11429.   Nielsen OH, Vainer B, Schaffalitzky de Muckadell OB. Microscopic colitis: a missed diagnosis? Lancet. 2004 Dec 4;364(9450):2055-7. Review.

11430.  Nikolaidis P, Hwang CM, Miller FH, Papanicolaou N. The nonvisualized appendix: incidence of acute appendicitis when secondary inflammatory changes are absent. AJR Am J Roentgenol. 2004 Oct;183(4):889-92.

11431. Sandborn WJ, Pardi DS. Clinical management of pouchitis. Gastroenterology. 2004 Dec;127(6):1809-14.

Pathogenesis:

11432.     Ashkenazi S.  Shigella infections in children: new insights. Semin Pediatr Infect Dis. 2004 Oct;15(4):246-52. Review.

11433. Shmuely H, Samra Z, Ashkenazi S, Dinari G, Chodick G, Yahav J.  Association of Helicobacter pylori infection with Shigella gastroenteritis in young children. Am J Gastroenterol. 2004 Oct;99(10):2041-5.

1.

Burton LK Jr, Murray JA, Thompson DM. Ear, nose, and throat manifestations of gastroesophageal reflux disease. Complaints can be telltale signs. Postgrad Med. 2005 Feb;117(2):39-45.

Mayo Clinic, Rochester, Minnesota, USA.

GERD is one of the most common gastrointestinal conditions in the general US population. ENT become more commonly recognized or suspected by physicians, although the direct association between symptoms and acid reflux has been difficult to establish. Most patients with suspected supraesophageal GERD do not have the typical symptoms of heartburn and acid regurgitation. Possible mechanisms of GERD-mediated damage to extraesophageal structures include direct-contact damage of mucosal surfaces by acid-pepsin exposure and a vagal reflex arc between the esophagus and the upper aerodigestive tract, triggered by acid reflux. Dual-channel ambulatory pH monitoring is the most sensitive and specific diagnostic test for determining transient reflux episodes, although demonstrating the presence of acid reflux alone does not prove that it is the cause of suspected GERD-related signs or symptoms. Therefore, physicians must sometimes resort to an empirical treatment strategy for both diagnosis and treatment. High-dose PPI therapy for 9 to 12 weeks is the recognized first-line therapy; operative therapy is reserved for patients who have severe complications or whose condition incompletely responds to treatment. Complete lack of response should prompt reconsideration of alternative diagnoses. Controlled, well-designed clinical trials to assess treatment and more sophisticated techniques to quantify acid reflux are needed to help determine which patients with suspected extraesophageal complications actually have GERD as the primary cause.

2.

Dalal I, Somekh E, Bilker-Reich A, Boaz M, Gorenstein A, Serour F. Serum and peritoneal inflammatory mediators in children with suspected acute appendicitis. Arch Surg. 2005 Feb;140(2):169-73.

Pediatric Infectious/Allergy/Immunology Unit, The E. Wolfson Medical Center, Holon, Israel.

HYPOTHESIS: Inflammatory markers differ between subjects with appendicitis and controls. Markers of inflammation differ in serum compared with intraperitoneal fluid. Among subjects with appendicitis, inflammatory markers differ between subjects with and without perforation. DESIGN: Cross-sectional. SETTING: Hospitalized care. PATIENTS: Twenty-four children who underwent an appendectomy. Group A (n = 19) consisted of patients with appendicitis and group N (n = 5) of patients with normal appendixes. MAIN OUTCOME MEASURES: Serum and peritoneal levels of interleukin (IL)8, IL-10, granulocyte colony-stimulating factor, interferon gamma soluble intercellular adhesion molecule-1, matrix metalloproteinase-9, and tissue inhibitor of metalloproteinases-1 were measured by enzyme-linked immunosorbent assay. RESULTS: Age, sex, complete blood count, C-reactive protein level, and serum cytokines did not significantly differ by group. Peritoneal concentrations of interleukin-8 (mean +/- SD, 1416.8 +/- 1436 pg/mL vs 48 +/- 74.4 pg/mL, P = .001), IL-10 (mean +/- SD, 3085 +/- 5893 pg/mL vs 84 +/- 46 pg/mL, P = .02), matrix metalloproteinase-9 (mean +/- SD, 1784 +/- 1225.1 ng/mL vs 435 +/- 563 ng/mL, P = .03), and tissue inhibitor of metalloproteinases-1 (mean +/- SD, 8939.2 +/- 7312.2 ng/mL vs 602.1 +/- 345.6 ng/mL, P<.001) were significantly different in group A compared with group N. When compared by perforation (n = 8 with perforation vs n = 11 without perforation), peritoneal granulocyte colony-stimulating factor levels were elevated in subjects with perforation (mean +/- SD, 4.3 +/- 14.4 pg/mL vs 62.7 +/- 79.2 pg/mL, P = .02). Although serum tissue inhibitor of metalloproteinases-1 was not different between groups N and A, it was significantly different between group N and patients with a perforated appendicitis (mean +/- SD, 205.9 +/- 43.8 ng/mL vs 3068.9 +/- 5122.4 ng/mL, P = .04). CONCLUSION: Presently, it is not practical to differentiate appendicitis in a pediatric population from other causes of abdominal pain based on the detection of systemic inflammatory response markers.

3.

Horton KK. Pathophysiology and current management of necrotizing enterocolitis.  Neonatal Netw. 2005 Jan-Feb;24(1):37-46.

Rapides Regional Medical Center, Alexandria, Louisiana, USA.

Necrotizing enterocolitis continues to be a common and life-threatening gastrointestinal emergency in the low birth weight infant. Prematurity, ischemia, enteral feeding, and infectious disease have been identified as common risk factors, however the exact cause of NEC other than prematurity is yet to be identified. Good assessment skills by the nurse are imperative, because clinical signs of NEC can be both subtle and catastrophic. Frequent radiographs are essential for the diagnosis of NEC and ongoing assessment of neonates diagnosed with NEC. Radiographs including an abdominal flat plate examination and a left lateral decubitus film to evaluate for free air should be obtained every 6-8 hours in the neonates with Stages II and III NEC.

4.

Laitinen K, Arvola T, Moilanen E, Lampi AM, Ruuska T, Isolauri E. Characterization of breast milk received by infants with gross blood in stools. Biol Neonate. 2005;87(1):66-72.

Department of Paediatrics, Turku University Central Hospital, Turku, Finland. kirsi.laitinen@utu.fi

OBJECTIVE: The aim of this study was to ascertain factors that might be protective of the appearance of gross blood in the stools of breast-fed infants. METHODS: Logistic regression models were formed to search for variables possibly explaining the condition. In addition to the analyzed breast milk factors, mother's allergic disease was introduced into the models to control for its possible confounding effect. The breast milk samples, collected from mothers of infants with gross blood in stools (n = 23) and from mothers of healthy age-matched infants (n = 71), were analyzed for concentrations of transforming growth factor-beta2, tumor necrosis factor-alpha, interleukin (IL)-4, IL-10, prostaglandin (PG)E2, cysteinyl leukotrienes (Cys-LTs) and fatty acid composition. RESULTS AND CONCLUSIONS: Increase in the concentrations of PGE2 and Cys-LTs in the breast milk together with mother's allergic disease reduced the likelihood of gross blood in stools in the breast-fed infant. The results suggest that no single factor, but a combination of immunomodulatory factors may protect the child from gross blood in the stools of breast-fed infants. Allergic disease was not a risk factor as mother's allergic disease appeared to counterbalance the gross blood in stools. Due to the preliminary nature of the study, the results need to be verified in a larger setting. The challenge for the future lies in identifying of such active compounds for dietary modification to enforce particularly the properties of the breast milk which are immunoprotective for the infant and to reduce the likelihood of intestinal disorders in at risk infants.

5.

Levine CD, Aizenstein O, Lehavi O, Blachar A. Why we miss the diagnosis of appendicitis on abdominal CT: evaluation of imaging features of appendicitis incorrectly diagnosed on CT. AJR Am J Roentgenol. 2005 Mar;184(3):855-9.

Department of Radiology, University of Medicine and Dentistry in New Jersey, 150 Bergen St., Newark, NJ 07103, USA.

OBJECTIVE: Our purpose was to retrospectively evaluate the cases of patients with surgically proven appendicitis that was misdiagnosed on abdominal CT to determine the causes of the missed diagnosis. CONCLUSION: Increased awareness of the underlying factors common to most cases of the missed diagnosis of appendicitis on CT and increased radiologic vigilance in cases of atypical abdominal pain may enable us to further improve our diagnostic accuracy.

6.

Mancini GJ, Mancini ML, Nelson HS Jr. Efficacy of laparoscopic appendectomy in appendicitis with peritonitis. Am Surg. 2005 Jan;71(1):1-4; discussion 4-5.

Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee 37920, USA.

Laparoscopic appendectomy (LA) is safe and effective in cases of peritonitis, perforation, and abscess. We investigated our conversion rate and clinical outcomes in this patient population, as well as preoperative factors that predict operative conversion. A retrospective nonrandomized cohort of 92 patients underwent LA for acute appendicitis with peritonitis, perforation, or abscess at our institution between 1997 and 2002. Thirty-six of the 92 were converted to open appendectomy (OA), yielding a conversion rate of 39 per cent. The presence of phlegmon (42%), nonvisualized appendix (44%), technical failures (8%), and bleeding (6%) were reasons for conversion. Preoperative data had no predictive value for conversion. CT scan findings of free fluid, phlegmon, and abscess did not correlate with findings at the time of surgery. Total complication rates were 8.9 per cent in the LA group as compared to 50 per cent in the converted cohort. Postoperative data showed LA patients stayed 3.2 days versus 6.9 days for converted patients (P = 0.01). LA patients had less pneumonia (P = 0.02), intra-abdominal abscess (P = 0.01), ileus (P = 0.01), and readmissions (P = 0.01). LA is safe and effective in patients with appendicitis with peritonitis, perforation, and abscess, resulting in shorter hospital stays and less complication.

1.

 Ahmed I, Deakin D, Parsons SL Appendix mass: do we know how to treat it? Ann R Coll Surg Engl. 2005 May;87(3):191-5.

INTRODUCTION: The traditional management of appendiceal mass has been an initial conservative approach followed by interval appendicectomy. More recently, the necessity of interval appendicectomy has been questioned by a growing amount of evidence in the surgical literature. The aim of this study was to review the available scientific evidence and to determine how appendiceal masses are currently being managed in the Mid-Trent region by general surgeons. PATIENTS & METHODS: A literature search using Medline, Embase, Cinahl, HMIC and Biosis was carried out. A personal or telephonic survey of all consultants and specialist registrars working in general surgery in the Mid-Trent region (n = 67) was conducted recording their management protocol of 3 different clinical scenarios--a 14-year-old boy, a 29-year-old female and a 68-year-old male. Responses of the questionnaire were entered to a database in Microsoft Access 2000 and analysed. RESULTS: The results showed that there was difference of opinion on the management of appendix mass in either scenario. Appendectomy (interval or emergency) is still practised by 75% of general surgeons in the Mid-Trent region and less that 25% manage asymptomatic appendix mass without interval appendectomy. Additionally, specialist registrars appear more likely not to offer patients interval appendicectomy after successful conservative management (P < 0.05). CONCLUSIONS: At present, there is no agreed consensus on the management of appendiceal mass. There is a need to develop a protocol for the management of this common problem.

2.

Voth DE, Ballard JD Clostridium difficile toxins: mechanism of action and role in disease. Clin Microbiol Rev. 2005 Apr;18(2):247-63.

Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.

As the leading cause of hospital-acquired diarrhea, Clostridium difficile colonizes the large bowel of patients undergoing antibiotic therapy and produces two toxins, which cause notable disease pathologies. These two toxins, TcdA and TcdB, are encoded on a pathogenicity locus along with negative and positive regulators of their expression. Following expression and release from the bacterium, TcdA and TcdB translocate to the cytosol of target cells and inactivate small GTP-binding proteins, which include Rho, Rac, and Cdc42. Inactivation of these substrates occurs through monoglucosylation of a single reactive threonine, which lies within the effector-binding loop and coordinates a divalent cation critical to binding GTP. By glucosylating small GTPases, TcdA and TcdB cause actin condensation and cell rounding, which is followed by death of the cell. TcdA elicits effects primarily within the intestinal epithelium, while TcdB has a broader cell tropism. Important advances in the study of these toxins have been made in the past 15 years, and these are detailed in this review. The domains, subdomains, and residues of these toxins important for receptor binding and enzymatic activity have been elegantly studied and are highlighted herein. Furthermore, there have been major advances in defining the role of these toxins in modulating the inflammatory events involving the disruption of cell junctions, neuronal activation, cytokine production, and infiltration by polymorphonuclear cells. Collectively, the present review provides a comprehensive update on TcdA and TcdB's mechanism of action as well as the role of these toxins in disease.

Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:  

12657.   Ahmed I, Deakin D, Parsons SL.  Appendix mass: do we know how to treat it? Ann R Coll Surg Engl. 2005 May;87(3):191-5. Review.

12658.  Allan K, Barriga J, Afshani M, Davila R, Tombazzi C. Emphysematous gastritis. Am J Med Sci. 2005 Apr;329(4):205-7.

12659.  Chan I, Bicknell SG, Graham M. Utility and diagnostic accuracy of sonography in detecting appendicitis in a community hospital. AJR Am J Roentgenol. 2005 Jun;184(6):1809-12.

12660.  Daly CP, Cohan RH, Francis IR, Caoili EM, Ellis JH, Nan B. Incidence of acute appendicitis in patients with equivocal CT findings. AJR Am J Roentgenol. 2005 Jun;184(6):1813-20. 

12661.  de Saussure P, Soravia C. Images in clinical medicine. Crohn's disease. N Engl J Med. 2005 May 26;352(21):2222.

12662.  Deckers-Kocken JM, Pasmans SG. Successful tacrolimus (FK506) therapy in a child with pyoderma gangrenosum. Arch Dis Child. 2005 May;90(5):531.

12663. Goto M. Computed tomography and ultrasonography to detect appendicitis. Ann Intern Med. 2005 May 3;142(9):799-800; author reply 800.

12664.  McQueen A. "I think she's just crazy". Lancet. 2005 Apr 23-29;365(9469):1513.

12665.  Park SH, Park DI, Kim SH, Kim HJ, Cho YK, Sung IK, Sohn CI, Jeon WK, KimBI, Keum DK.  Effect of high-dose aspirin on Helicobacter pylori eradication. Dig Dis Sci. 2005 Apr;50(4):626-9.

12666. Webb A, Starr M. Acute gastroenteritis in children. Aust Fam Physician. 2005 Apr;34(4):227-31. Review.

Pathogenesis:

12667.    Binder V. Clinical epidemiology--how important now? Gut. 2005 May;54(5):574-5.

12668.    Mayer L. A novel approach to the treatment of ulcerative colitis: is it kosher? Gastroenterology. 2005 Apr;128(4):1117-9. Review.

12669.    McColl KE, Gillen D. Prediction of malignant potential in reflux disease. Am J Gastroenterol. 2005 May;100(5):1019-20.

12670.    Voth DE, Ballard JD. Clostridium difficile toxins: mechanism of action and role in disease. Clin Microbiol Rev. 2005 Apr;18(2):247-63. Review. 

12671.   Xavier R, Podolsky DK. Commensal flora: wolf in sheep's clothing. Gastroenterology. 2005 Apr;128(4):1122-6. Review.

12672.    Ahmed I, Deakin D, Parsons SL. Appendix mass: do we know how to treat it? Ann R Coll Surg Engl. 2005 May;87(3):191-5. Review. 

12673.  de Hoog M, Mouton JW, van den Anker JN. New dosing strategies for antibacterial agents in the neonate. Semin Fetal Neonatal Med. 2005 Apr;10(2):185-94.

12674.  Haboubi NY, Jones S. Influence of dietary factors on the clinical course of inflammatory bowel disease. Gut. 2005 Apr;54(4):567.

12675.  Kliegman RM. Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants. J Pediatr. 2005 May;146(5):710.

12676.  Premji SS. Standardised feeding regimens: hope for reducing the risk of necrotizing enterocolitis. Arch Dis Child Fetal Neonatal Ed. 2005 May;90(3):F192-3. Review.