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Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access
Kathleen A Jablonski, Mark F Guagliardo
Population Health Metrics , 2005, DOI: 10.1186/1478-7954-3-4
Abstract: We analyzed the KID Inpatient Database, a nationally representative sample of pediatric hospitalization, to compare rates of appendicitis rupture between white, African American, Hispanic and Asian children. We ran weighted logistic regression models to obtain national estimates of relative odds of rupture rate for the four groups, adjusted for developmental, biological, socioeconomic, health services and hospital factors that might influence disease outcome.Rupture was a much more burdensome outcome than timely surgery and rupture avoidance. Rupture cases had 97% higher hospital charges and 175% longer hospital stays than non-rupture cases on average. These burdens disproportionately affected minority children, who had 24% – 38% higher odds of appendicitis rupture than white children, adjusting for age and gender. These differences were reduced, but remained significant after adjusting for other factors.The racial/ethnic disparities in pediatric appendicitis outcome are large and are preventable with timely diagnosis and surgery for all children. Furthermore, estimating this disparity using the KID survey is a relatively straightforward process. Therefore pediatric appendicitis rupture rate is a good candidate for inclusion in the National Healthcare Disparities Report. As with most other health and healthcare disparities, efforts to reduce disparities in income, wealth and access to care will most likely improve the odds of favorable outcome for this condition as well.The persistence of racial and ethnic disparities in health and healthcare is a major theme in American healthcare policy. The Institute of Medicine report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" [1], describes and underscores the problem, and Healthy People 2010 [2] has made disparity elimination one of its two overarching goals. In response to these concerns Congress directed the Agency for Healthcare Research and Quality (AHRQ) to prepare a National Healthcare
Appendicitis in Children: Evaluation of the Pediatric Appendicitis Score in Younger and Older Children  [PDF]
Martin Sal?,Gustav Friman,Pernilla Stenstr?m,Bodil Ohlsson,Einar Arnbj?rnsson
Surgery Research and Practice , 2014, DOI: 10.1155/2014/438076
Abstract: Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years () and <4 years (). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; ), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; ). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis. 1. Introduction Appendicitis is the most common abdominal disease requiring surgery in children [1]. The risk of developing appendicitis during a lifetime is reported to be 8.7% for boys and 6.7% for girls [2]. Despite its high incidence, there are still diagnostic difficulties. The overall negative appendectomy rate among all children is suggested to be 8.4%, but in children under 6 years of age, the rate has been reported to be as high as 56.7% [3]. The diagnosis of acute appendicitis is considered to be especially challenging in children due to difficulties in communication and examination [4]. There are several studies reporting difficulties in diagnosing appendicitis in younger children [3, 5–9]. The diagnostic difficulties result in increased risks of both negative appendectomies and a delayed diagnosis, both leading to increased morbidity, more complications, longer hospital stay, and higher costs [3, 5–9]. These risks are further increased in the younger children [3, 8, 9]. The doctor delay is a known cause contributing to late diagnosis in young children [5, 6]. Other studies, with patients under 3 years and 4 years of age, have found parent delay to contribute as well to the late diagnosis [7, 10]. Our clinical experience, confirmed by the literature, shows that the younger children with acute appendicitis deviate from the typical
The role of parasites in acute appendicitis of pediatric patients
Dorfman,Saul; Cardozo,José; Dorfman,Denny; Del Villar,Alonso;
Investigación Clínica , 2003,
Abstract: abstract. there is little evidence regarding the relationship between parasites and acute appendicitis. in order to determine such a relationship, if any, 830 appendectomy specimens were studied. age, sex, pathological findings and the presence and type of parasites and the type of parasite were analyzed. parasites were present in 62 cases (7.46%). ascaris lumbricoides and trichuris trichiura were the most frequently encountered parasites. these were observed, alone or in combination, in 45 cases (72.5%). appendix perforation, peritonitis, necrosis and flegmonous appearance, were more frequent in the cases of acute appendicitis without parasitic infestation (p < 0.05). there were no differences between the cases with or without parasitic infestation (p > 0.05) in cases of peritonitis. the low incidence of parasites among the appendectomy specimens and the failure to demonstrate its relationship with all events derived of appendicitis, do not support the hypothesis that parasites are a major cause of appendicitis in pediatric patients.
Pediatric appendicitis score: A retrospective analysis  [cached]
Goulder F,Simpson T
Journal of Indian Association of Pediatric Surgeons , 2008,
Abstract: Aims: Evaluation of the pediatric appendicitis score (PAS), in all patients who had an appendicectomy over a one-year period. Methods: Retrospective study of 56 patients aged 4-15 years, who underwent an emergency appendicectomy. PAS was applied and patients were divided according to the PAS protocol into high probability and low probability groups. These results were then correlated with histology. Results: The PAS had sensitivity 0.87, specificity 0.59, positive predictive value 0.83, and negative predictive value 0.67. The negative appendicectomy rate would have been reduced to 17%, but five patients with appendicitis would have been denied early surgical treatment and may have been discharged. Conclusions: The PAS cannot be recommended as it would lead to an unacceptable risk of wrongly discharging or delaying necessary surgery in 13% of patients with appendicitis.
The value of preoperative diagnostic tests in acute appendicitis, retrospective analysis of 196 patients
Kemal Memisoglu, Bora Karip, Metin Mestan, Ender Onur
World Journal of Emergency Surgery , 2010, DOI: 10.1186/1749-7922-5-5
Abstract: The clinical data of 196 patients who have undergone conventional appendectomy between March 2007 and April 2008 were collected retrospectively. Patients were examined for age, sex, white blood cell count, ultrasonography results, histopathological diagnosis and hospital stay.Negative appendectomy rate was 17.3% (27% for female, 11.5% for male). White blood cell counts were found to be high in 83% for acute appendicitis group and %61 for negative appendectomy group. There were 66 (34%) patients who had negative USG findings for acute appendicitis. Of these patients, histopathological examination revealed acute appendicitis in 46 patients whereas 20 patients had normal appendix. Hospital stays were 2.79 +/- 1.9 and 2.66 +/- 1.7 days for negative and positive appendicectomies respectively.Besides the improvement of diagnostic tests for acute appendicitis, we could not sufficiently reduce the negative appendectomy rate.Appendicectomy is still the most common procedure in general surgery practice but diagnostic failure may still occur and this leads to delay in treatment or negative (non-therapeutic) appendectomies. We aimed to analyze retrospectively the diagnostic efficiency of the preoperative tests in relation with histopathologic results.Data of the 277 conventional appendectomies performed for acute appendicitis (AA) between March 2007 and April 2008 were collected. Fifteen patients with perforated appendicitis, 23 patients whose preoperative laboratory tests performed at another centre and 43 patients operated on without preoperative ultrasonography (USG) were excluded. In the remaining 196 patients, all had clinical findings such as, history of anorexia, pain followed by nausea, right lower quadrant pain, vomiting, rebound tenderness, guarding, rigidity and conventional appendectomies were carried out. A radiologist performed a graded compression USG (Siemens Sonoline G50) with a 3.5 MHz convex and 7.5 MHz linear probe. Data for age, sex, white blood cell count,
The role of parasites in acute appendicitis of pediatric patients
Saul Dorfman,José Cardozo,Denny Dorfman,Alonso Del Villar
Investigación Clínica , 2003,
Abstract: . There is little evidence regarding the relationship between parasites and acute appendicitis. In order to determine such a relationship, if any, 830 appendectomy specimens were studied. Age, sex, pathological findings and the presence and type of parasites and the type of parasite were analyzed. Parasites were present in 62 cases (7.46%). Ascaris lumbricoides and Trichuris trichiura were the most frequently encountered parasites. These were observed, alone or in combination, in 45 cases (72.5%). Appendix perforation, peritonitis, necrosis and flegmonous appearance, were more frequent in the cases of acute appendicitis without parasitic infestation (p < 0.05). There were no differences between the cases with or without parasitic infestation (p > 0.05) In cases of peritonitis. The low incidence of parasites among the appendectomy specimens and the failure to demonstrate its relationship with all events derived of appendicitis, do not support the hypothesis that parasites are a major cause of appendicitis in pediatric patients. Resumen. Existe poca evidencia con respecto a la relación entre parásitos y apendicitis aguda. Con el objeto de clarificar dudas, se estudiaron 830 muestras de especimenes apendiculares. Se analizaron la edad, el sexo, los hallazgos histopatológicos, la presencia o no de parásitos y el tipo de parásito presente. Se observaron parásitos en 62 casos (7,46%). Ascaris lumbricoides y Trichuris trichiura fueron los parásitos mas frecuentemente visualizados, solos o en combinación en 45 casos (72,5%). La perforación apendicular, la peritonitis, la necrosis apendicular y las características flegmonosas del apéndice, fueron observados con mayor frecuencia en los casos sin infestación parasitaria (p < 0,05). En los casos de peritonitis, no se observó diferencia significativa entre los casos con o sin infestación parasitaria. La baja frecuencia de la presencia parasitaria en las biopsias estudiadas y la imposibilidad de demostrar una relación entre los parásitos y todas las manifestaciones histopatológicas de la apendicitis aguda, impiden afirmar que los parásitos constituyen una causa importante en la etiopatogénia de la apendicitis aguda en pacientes pediátricos.
The Role of Ultrasound and Laboratory Findings for Diagnosis of Appendicitis in Pediatric Patients  [cached]
Gurcan Erbay,Elif Karadeli,Zafer Koc
Cukurova Medical Journal , 2012,
Abstract: Purpose: Acute appendicitis is one of the most common reasons of abdominal surgery in children. The aim of this study was to compare findings of abdomen ultrasonography and laboratory results on the diagnosis of appendicitis in pediatric patients. Materials-Methods: Preopperative ultrasonography and laboratory findings of 114 children (53 girls and 61 boys; mean age: 132 months) who clinically suspected acute appendicitis and undergone appendectomy between January 2007- January 2009 were evaluated retrospectively. If appendix was visualize on US, outer diameter was measured. Six mm or more of outer appendiceal diameter was accepted as a sign of acute appendisicitis. Also periappendicular fluid, lymph node, C-reactive protein (CRP) values, white blood cells and neutrophil percentage were compared with pathologic results. The pathologic diagnosis was the gold standart. Results: Six mm or more of appendiceal diamater was accepted as a sign of acute appendicitis, the corresponding sensitivity, specificity, positive and negative predictive values and accuracy were found 76.40%, 80%, 93.15%, 87.35% and 71.19 % respectively. If 7mm or more of appendiceal diamater accepted as a sign of acute appendicitis, the sensitivity, specificity, positive and negative predictive values and accuracy were found 66.29%, 88% , 95.12%, 42.31% and 71.05% respectively. In patients with acute appendicitis, white blood cells, neutrophil percentage and CRP values were found higher than other patients. There was a significant difference in the white blood cells, neutrophil percentage and CRP values between normal patients and patients with acute appendicitis. There was no significant difference in the presence of periappendicular fluid and lymph node on ultrasonography examination between normal patients and patients with acute appendicitis. Conclusion: Ultrasonography is a cheap, practical and noninvasive method, and does not require ionizing radiation and oral or intravenous contrast material. Therefore, ultrasonography should be used the primary imaging modality for pediatric patients. If ultrasonography is non-diagnostic for appendicitis, computed tomography can be prefered as a second imaging modality [Cukurova Med J 2012; 37(2.000): 84-89]
Single Incision Laparoscopic Surgery for Acute Appendicitis: Feasibility in Pediatric Patients  [PDF]
Andre Chow,Omer Aziz,Sanjay Purkayastha,Ara Darzi,Paraskevas Paraskeva
Diagnostic and Therapeutic Endoscopy , 2010, DOI: 10.1155/2010/294958
Abstract: Background. Laparoscopic appendicectomy is accepted by many as the gold standard approach for the treatment of acute appendicitis. The use of Single Incision Laparoscopic Surgery (SILS) has the potential of further reducing postoperative port site complications as well as improving cosmesis and patient satisfaction. Method. In this paper we report our experience and assess the feasibility of SILS appendicectomy in the pediatric setting. Results. Five pediatric patients with uncomplicated appendicitis underwent SILS appendicectomy. There were no significant intraoperative or postoperative complications. All patients were discharged within 24 hours. Conclusions. The use of Single Incision Laparoscopic Surgery appears to be a feasible and safe technique for the treatment of uncomplicated appendicitis in the pediatric setting. Further studies are warranted to fully investigate the potential advantages of this new technique. 1. Introduction The rapid uptake of minimally invasive techniques has affected many areas of surgery, including the management of acute appendicitis. Laparoscopic appendicectomy is also a standard and recognised technique in the paediatric setting, with some surgeons advocating a primarily laparoscopic approach to all paediatric patients presenting with appendicitis [1]. Initial fears regarding the possibility of increased rates of postoperative complications seem to have been dispelled with improved instrumentation, technique, and growing experience both from the surgeon and ancillary staff [2]. In fact, although operating times and cost may be increased with the laparoscopic approach, this may be offset by a reduced postoperative stay compared to the standard open approach [3]. Single Incision Laparoscopic Surgery (SILS) is a new technique through which laparoscopic surgery takes place through a single umbilical incision, without the need for additional laparoscopic ports. This new method has been used for a variety of laparoscopic operations including tubal ligation [4], hysterectomy [5], appendicectomy [6, 7], cholecystectomy [8], sleeve gastrectomy [9], colectomy [10], and nephrectomy [11]. The single incision technique has the possible advantages of reduced postoperative pain, faster return to normal function, reduced port site complications, and improved cosmesis and patient satisfaction. In this paper we present our first experiences and assess the feasibility of using SILS to treat appendicitis in the pediatric population. 2. Patients SILS appendicectomy was carried out in 5 children in a teaching hospital in central London. All
The value of unenhanced CT in the diagnosis of acute appendicitis
D'Ippolito, Giuseppe;Mello, Giselle Guedes Netto de;Szejnfeld, Jacob;
Sao Paulo Medical Journal , 1998, DOI: 10.1590/S1516-31801998000600003
Abstract: objective: to establish the accuracy of unenhanced ct in the preoperative diagnosis of acute appendicitis. design: accuracy study, prospective and blinded. setting: the university hospital. participants: 52 patients with clinical and laboratorial manifestations of acute appendicitis. ct diagnosis was made by: presence of an abnormal appendix, appendiceal calculi with pericecal phlegmon or alterations in the pericecal appendicular site and absence of signs that may lead to other diagnosis. main outcome measures: overall accuracy, comparing the tomographic aspects with the intra-operative findings and pathological reports ("gold standard"). results: acute appendicitis was confirmed in 44 cases. efficacy was 92%, sensitivity was 91%, specificity was 100%, positive predictive value was 100% and negative predictive value was 67%. conclusions: unenhanced ct presents a similar overall accuracy to that reported by other authors who studied enhanced ct diagnosis of acute appendicitis.
Outcome of pediatric hypospadias repair in adulthood
Boris Chertin,Dan Prat,Ofer Z Shenfeld
Open Access Journal of Urology , 2010,
Abstract: Boris Chertin1, Dan Prat1, Ofer Z Shenfeld21Division of Pediatric Urology, 2Department of Urology, Shaare Zedek Medical Center, Jerusalem, Faculty of Medical Science, Hebrew University, Jerusalem, IsraelPurpose: To review the evolution of the technique of hypospadias repair.Methods: A search of Pubmed, Medline and the Journal of Pediatric Urology was performed, and papers dealing with surgical techniques for hypospadias repair were critally reviewed. Special emphasis was given to papers on the effects in the long term of hypospadias repair on voiding and sexual dysfunction.Results: The techniques for hypospadias repair have evolved over the years. The most popular technique now is tubularized incised plate urethroplasty. Long-term results with the use of the new techniques of the hypospadias repair in terms of voiding and sexual problems should be addressed.Conclusion: There is a need for valid studies on the outcomes of hypospadias repair in adults that were performed in childhood in terms of cosmetic appearance, voiding and sexual performance.Keywords: hypospadias, hypospadias surgery, adult, later outcome
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