PubMed · 7382030
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J J James. 1980-06-27. Appendectomies during physicians' boycott.. https://pubmed.ncbi.nlm.nih.gov/7382030/
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BACKGROUND: Appendixes removed from patients with suspected appendicitis often appear normal on histological examination. We examined appendix specimens for expression of abnormal amounts of cytokines, an indicator of an inflammatory response. METHODS: Tumour necrosis factor alpha (TNFalpha) and interleukin-2 (IL-2) expression was measured by in-situ hybridisation in ten specimens from patients with acute appendicitis, 12 normal appendix specimens removed from patients undergoing elective abdominal surgery, and 31 appendix specimens from patients with a clinical diagnosis of appendicitis but an appendix histologically classified as normal. Cytokine-specific RNA antisense probes were prepared by in-vitro transcription and digoxigenin (DIG) labelled. In-situ hybridisation was done on 5 micrometer paraffin sections. Tissue sections hybridised by sense probes acted as negative control for each cytokine. Following hybridisation, the probes were detected by alkaline phosphatase labelled anti-DIG monoclonal antibody and visualised by nitroblue tetrazolium staining. FINDINGS: All histologically proven acute appendicitis specimens demonstrated intense cellular TNFalpha mRNA expression in germinal centres and moderate levels of expression throughout the mucosa. IL-2 mRNA was strongly expressed in the lamina propria and only moderately expressed in germinal centres. Normal appendixes all showed almost complete absence of TNFalpha and IL-2 mRNA expression. Seven of the 31 histologically classified normal appendix specimens from patients with a clinical diagnosis of appendicitis demonstrated TNFalpha and IL-2 mRNA expression similar to acute appendicitis specimens in germinal centres, submucosa, and lamina propria layers. INTERPRETATION: TNFalpha and IL-2 mRNA expression is a sensitive marker of inflammation in appendicitis. A substantial proportion of histologically normal appendixes showed clear evidence of an inflammatory response in the form of increased cytokine expression.
OBJECTIVE: To assess the role of the primary care provider (PCP) in the diagnosis and treatment of acute appendicitis in children by determining whether there were differences in the treatment and outcome of children whose parents contacted the PCP before taking the child to the hospital compared with those who did not. DESIGN: Retrospective review of medical records of pediatric patients discharged from the hospital with the diagnosis of acute appendicitis. SETTING: An urban children's hospital. METHODS: The medical records of children treated for acute appendicitis from July 1, 1990, through June 30, 1994, were identified through review of hospital discharge data and divided into 2 groups based on whether the children's parents had contacted the PCP before their arrival at the hospital. Contact with the PCP was determined by record review or telephone interview with the parent. The 2 groups were then studied for differences in treatment and outcome. Statistical analysis was by the X2 test and the Student t test, as appropriate, with the level of significance determined at P < .05. RESULTS: During the 4-year period, 343 children underwent appendectomy. Medical records were available for review for 321 children (94%). After review, records of 38 children were excluded because the primary problem was not acute appendicitis. Of the 283 children whose records were included in the study, the parents of 160 had contacted the PCP before arrival at the hospital (group 1, those who called) and the parents of 99 had not called (group 2, those who did not call). It could not be determined whether a call had been made for 24 children. The mean age of the children in group 1 was 124 months and in group 2 was 126 months (P = .74). Of group 1, 24% arrived at the hospital on a Saturday or Sunday, compared with 40% of group 2 (P = .007). Children in group 1 who arrived at the hospital during the weekend were operated on a mean (SD) of 4.7 hours (3.7 hours) after arrival at the hospital, compared with 10.6 hours (17.1 hours) for children in group 2 (P = .04). The mean (SD) interval between arrival at the hospital and operation on weekdays (Monday through Friday) was similar in both groups: 12 hours (20.6 hours) in group 1 and 13.7 hours (25.6 hours) in group 2 (P = .63). Appendiceal perforation was less likely in children in group 1 (62/160 [39%]) than in those in group 2 (53/99 [54%]; P = .03). Parents of 50 (89%) of 56 children who belonged to a health maintenance organization called the PCP compared with 96 (62%) of the 156 with fee-for-service insurance and 10 (26%) of the 38 with Medicaid (P < .001). No difference was noted in the interval between arrival at the hospital and operation or incidence of appendiceal perforation according to type of insurance. CONCLUSIONS: Children with appendicitis whose parents contacted the PCP before arrival at the hospital were less likely to have appendiceal perforation than those whose parents did not call the PCP, irrespective of insurance status. Children whose parents called the PCP before arrival at the hospital during the weekend were operated on more promptly than were children whose parents did not call the PCP. Contact with the PCP was associated with more expeditious care of children with acute appendicitis.