Association of Neighborhood Socioeconomic Disadvantage With Complicated Appendicitis in Children.

BACKGROUND: Lower socioeconomic status (SES) is linked to poorer outcomes for a variety of health conditions in children, potentially through delay in accessing care. The objective of this study was to measure the association between SES and delay in surgical care as marked by presentation with complicated appendicitis (CA). METHODS: Children treated for acute appendicitis between 2015-2019 at a large academic children's hospital were reviewed. Patient home addresses were used to calculate travel time to the children's hospital and to determine Area Deprivation Index (ADI), a neighborhood-level SES marker. Multivariable logistic regression models were used to compare the likelihood of CA across ADI while adjusting for confounders. RESULTS: Of 1,697 children with acute appendicitis, 38.8% had CA. Compared to those with uncomplicated disease, children with CA were younger, lived farther from the children's hospital, and were more likely to have Medicaid insurance and have ED visits in the 30 days preceding diagnosis. Children with CA disproportionately came from disadvantaged neighborhoods (P < 0.007), with 32% from the two most disadvantaged ADI deciles. The odds of CA rose 5% per ADI decile-increase (adjusted odds ratio [aOR] 1.05, 95%CI 1.01-1.09, P = 0.02). Younger age and >60-min travel time were also associated with CA. Association between ADI and CA remained among younger (<10 y) children (aOR 1.07, 95%CI 1.00-1.15, P = 0.048) and those living closer (<30 min) to the hospital (aOR 1.06, 95%CI 1.01-1.11, p=0.02). CONCLUSIONS: ADI is associated with CA among children, suggesting ADI may be a valuable marker of difficulty accessing surgical care among disadvantaged children.

Acute Effects of Gastrocnemius/Soleus Self-Myofascial Release Versus Dynamic Stretching on Closed-Chain Dorsiflexion.

CONTEXT: Limited ankle dorsiflexion (DF) range of motion has been correlated with decreased flexibility of the gastrocnemius/soleus complex. Decreased ankle DF range of motion can lead to an increase in lower-extremity injuries, for example, acute ankle sprains, Achilles tendinopathy. OBJECTIVE: The purpose of this study was to determine whether a single application of the intervention to the gastrocnemius/soleus complex via multidirectional self-myofascial release using a foam roller, multiplanar dynamic stretch performed in downward dog, or a combination of both techniques acutely improved ankle DF. DESIGN: Subjects were assigned to groups via random card selection. Investigators provided verbal cues as needed to yield correct performance of interventions. Both interventions were performed twice for 1 minute using a dynamic walking rest of 30.48 m at a self-selected pace between interventions. Statistical analyses were completed using a 1-way analysis of variance, at α level ≤ .05. SETTING: A convenience sample study. PARTICIPANTS: A total of 42 asymptomatic physical therapy students (18 females and 24 males) with mean age of 26.12 (4.03) years volunteered to participate. INTERVENTIONS: Multidirectional self-myofascial release using a foam roller, multiplanar dynamic stretch performed in downward dog, or a combination of both techniques. MAIN OUTCOME MEASURES: Weight-bearing right ankle DF measurements were recorded in centimeters using a forward lunge technique (intraclass correlation coefficient = .98, .97, and .96). RESULTS: Data analysis revealed no significant difference between the 3 groups in all pre-post measurements (P = .82). Mean (SD) measurements from pretest to posttest for myofascial release, dynamic stretching, and combination interventions were 0.479 (0.7) cm, 0.700 (0.7) cm, and 0.907 (1.4) cm, respectively. CONCLUSION: Until further studies are conducted, the selection of technique to increase ankle DF range of motion should be based on each individual patient's ability, preference, and response to treatment.

Negative pressure wound therapy in infants and children: a single-institution experience.

BACKGROUND: Information regarding the use of negative pressure wound therapy (NPWT) in the pediatric population is limited. Because of adverse outcomes in adult patients, the Food and Drug Administration issued a warning in 2011 about the use of NPWT in infants and children. METHODS: We performed an institutional review board-approved, single-institution, retrospective review of pediatric patients who had undergone NPWT from 2007-2011. We collected the types of wounds for which NPWT was initiated, the NPWT outcomes, and the complications encountered. RESULTS: The data from 290 consecutive patients were reviewed. Their average age was 9.3 y (range 12 d to 18 y), and their average weight was 46.5 kg (range 1.1-177). Of the wounds, 66% were classified as acute, 10% as chronic, and 24% as traumatic. The two most common indications were surgical wound dehiscence (n = 47) and skin grafting (n = 41). NPWT was used in 15 wounds containing surgical hardware, with 2 devices requiring eventual removal. NPWT was used for a median of 9 d per patient (two dressing changes). Complications occurred in 5 patients (1.7%). Documentation problems were noted in 44 patients. After NPWT, about one-third of the patients (n = 95 patients) were able to undergo delayed primary closure. CONCLUSIONS: NPWT is an effective adjunct in wound healing and closure in the pediatric population, with no mortality ascribed to NPWT. Also, the complication rates were low.

The Time Is Now: Leveraging the Affective Domain in PT Education and Clinical Practice.

BACKGROUND AND PURPOSE: The traditional domains of learning are cognitive, psychomotor, and affective. These parallel the habits of head, hand, and heart as the foundations for knowing, doing, and being in health professions education. Physical therapy education is deeply rooted in a cognitive (head) and psychomotor (hand) taxonomy despite the mission, vision, and values of the profession that embody the knowledge, skills, and attitudes (KSAs) requiring competence in the affective (heart) domain. Recently, the Model for Excellence and Innovation in Physical Therapy Education and the American Council of Academic Physical Therapy excellence framework in academic physical therapy identified pedagogical variables grounded in the affective domain (AD), including shared beliefs and values, partnerships and collaborations, leadership and innovation, social responsibility and inclusion, and a drive for excellence with high expectations. POSITION AND RATIONALE: Fully integrating the AD into physical therapy education equips the future of the profession with the KSAs to achieve the mission and vision, meet stakeholder needs, and endure the demands of clinical practice. DISCUSSION AND CONCLUSION: Explicitly using the AD in physical therapy education is imperative to the success and sustainability of the profession and in meeting critical societal needs. Engaging all learners in the AD does not require monumental curricular change. Intentional activities and strategies can develop the humanistic values of the learner across a curriculum and can shift the culture of academia from primarily cognitive and psychomotor to one that is comprehensive across all domains. The AD informs the cognitive and psychomotor aspects of learning and has direct implications for clinical practice in meeting stakeholder needs.

Same-day discharge after appendectomy for uncomplicated appendicitis in children: Potential barriers to increased utilization.

BACKGROUND: Utilization of same-day discharge (SDD) after appendectomy for uncomplicated appendicitis (UA) was closely examined to explore potential barriers to greater use of SDD. METHODS: Children (≤18 years) who underwent appendectomy for UA between 2015 and 2019 at a tertiary care children's hospital were reviewed. Associations with SDD were evaluated using multivariable regression models. RESULTS: Among 973 children, SDD was less frequently utilized after appendectomy performed between 12pm and 5pm (aOR 0.14, p < 0.001) and after 5pm (aOR 0.01, p < 0.001) compared to before 12pm. SDD utilization was also less frequent in those from lower resource neighborhoods (adjusted odds ratio [aOR] 0.90 per decile increase in Area Deprivation Index, p = 0.04), females (aOR 0.53, p = 0.005), and patients residing 30-60 min away (aOR 0.56, p = 0.04) compared to <30 min away. CONCLUSIONS: SDD utilization was primarily impacted by operative timing and socioeconomic and travel factors, focuses for quality improvement efforts to further increase utilization of SDD.

Splitting hairs and challenging guidelines: Defining the role of perioperative antibiotics in pediatric appendicitis patients.

BACKGROUND: Ambiguity regarding timing and duration of perioperative IV antibiotics in AA and CA exists. We wanted to determine if an association existed between surgical site infections (SSI) in children with acute (AA) or complicated appendicitis (CA) and timing and duration of perioperative antibiotics. METHODS: We performed a single institution, case control observational study of patients with (n = 988) and CA (n = 561) from 2013 to 2017. The exposure was the timing and/or duration of pre- and postoperative antibiotics. The outcome measure was SSI development within 60 days of surgery. RESULTS: SSI occurred in 2.5% AA and 19.1% CA patients. We identified 18-70 min before incision (MBI) as the best interval for preoperative antibiotic administration with regards to SSI occurrence with SSI OR = 3.0 (95% CI 1.35, 6.68) p = 0.0356 for antibiotics given 0-17 MBI and OR = 3.21 (95% CI 1.45, 7.09) p = 0.0108) for antibiotics given >70 MBI. Postoperative antibiotics did not confer protection from SSI in AA patients (p = 0.718). CA patients who achieved normal physiologic indices within ≤6 days (Early Responders, ER) had 8.8% SSI while the Late Responders (LR, normal by >6 days) had 49.3% SSI rate (p < 0.001). ER patients who received IV antibiotics for 1-2 postoperative days had higher SSI rates compared to 3, 4, 5, or 6 days, but higher odds of SSI were found only with 1 day. Additional oral antibiotics decreased SSI for ER (OR 0.36, 95% CI 0.159, 0.87; p = 0.0145), but not LR patients (OR 1.25, 95% CI 0.55, 2.85, p = 0.5951). CONCLUSIONS: Antibiotics given within 18-70 MBI for appendectomy may be associated with decreased SSI. Postoperative antibiotics should not be given for AA. In ER CA patients, additional oral antibiotics may decrease SSI. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective comparative study.

Reducing opioid utilization after appendectomy: A lesson in implementation of a multidisciplinary quality improvement project.

BACKGROUND: Perioperative care after appendectomy may be the first exposure to opioids for many children. A quality improvement project was implemented to assess current practice of prescribing pain medications after a laparoscopic appendectomy to decrease unnecessary opioid use via simple, targeted steps. METHODS: Three measures were implemented in patients undergoing laparoscopic appendectomy for acute appendicitis: (1) ice packs to incision in postanesthesia care unit, (2) standard pain scores within 30 minutes of admission to ward postoperatively, and (3) standardized postoperative order set minimizing opioid utilization and limited number of opioids prescribed at discharge. Pre- and postimplementation data were compared with the primary outcome variable: opioid utilization during the postoperative period. RESULTS: There were no statistically significant differences in age or gender between the 814 preimplementation and 263 postimplementation patients. Postimplementation compliance is 66.9% for icepacks, 88% for pain scores, and 94.7% for postoperative order set. There were statistically significant decreases in intravenous and enteral opioids administered, number of opioid doses prescribed at discharge, and patients discharged with an opioid prescription. CONCLUSION: By using a multidisciplinary assessment of current state, culture, and management of parental, patient, and nursing expectations, our institution was able to reduce overall opioid consumption.

A tiered approach to optimize pediatric laparoscopic appendectomy outcomes.

BACKGROUND/PURPOSE: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost. METHODS: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes. RESULTS: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes. CONCLUSIONS: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Use of vacuum-assisted closure system in the management of complex wounds in the neonate.

The vacuum-assisted closure (VAC) system has become an accepted treatment modality for acute and chronic wounds in adults. The use of negative-pressure dressing has been documented in adults and, to some extent, in children. However, its use in premature infants has not been reported in the literature. The results of using the VAC system were examined in two premature infants with complex wounds. The VAC system was found to be effective in facilitating the closure of large and complex wounds in these patients. Complete epithelialization of the wounds was achieved in both patients without skin grafting. In conclusion, in two premature neonates with extraordinary soft tissue defects, the VAC system was a safe and effective choice to assist in closing these wounds.