Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis.

PURPOSE: To examine what proportion of caregivers, if given a choice, would choose medical versus surgical treatment of appendicitis and what factors would be important in their decision. METHODS: A survey was devised and given to the caregivers of children presenting to the pediatrician for a routine visit in community and academic pediatric clinics. The survey presented a summary of outcomes after medical (non-operative) and surgical treatment of uncomplicated appendicitis. Participants were then asked to choose medical versus surgical treatment if their child were to develop appendicitis. They were also asked to rate the importance of certain factors in their decision -1 being "not important" and 5 being "very important". RESULTS: Four hundred surveys were distributed with an 86.2% (345/400) response rate. Six percent (21/342) of respondents reported a history of appendicitis and 49.4% (168/340) reported having known someone who had appendicitis. The majority of respondents, 85.3% (284/333), were mothers. A minority of respondents, 41.7% (95% CI: 36.7, 47.0), chose medical treatment over surgery for appendicitis. There was no statistical difference in the proportion of mothers (41.6%) versus fathers who chose medical treatment (41.3%). Caregivers who chose medical treatment were more likely to rate time in hospital (p = .008) and time out of school (p = 05) as important in decision making when compared with those who chose surgery. Those who chose surgical treatment were more likely to rate risk of recurrent appendicitis (p < .001) as important to decision making. In the multivariate analysis, those who rated time in hospital as very important had more than twice the odds of choosing medical therapy (OR 2.20, p = 0.02) when compared with those who rated it as less important. Not knowing someone who has had appendicitis was significantly associated with choosing medical therapy when compared with those who do know someone who has had appendicitis, OR 2.3, p = .002. Rating pain as very important was also significantly associated with choosing medical therapy, when compared to those rating pain 1-3, OR 3.38, p = .03. CONCLUSIONS: In this survey of caregivers of children presenting for routine care, 41.7% would choose medical, or non-operative, therapy for their children with acute appendicitis. The risk of recurrence, time in hospital, and time out of school, pain, and knowing someone who has had appendicitis were all important factors that families may consider when making a decision. These data may be useful for surgeons counseling patients on which treatment to pursue.

Hiperbilirrubinemia en el recién nacido y lactancia materna: una prueba controlada de cuatro intervenciones / Hyperbilirubinemia in the breast-fed newborn: a controlled trial of four interventions

Se realizó una prueba clínica controlada para comparar el efecto de cuatro intervenciones distintas sobre la hiperbilirrubinemia en 125 bebés nacidos a término y alimentados a pecho. De 1685 bebés que satisfacían los criterios de inclusión, 126 (7,4 por ciento) tenían una concentración de bilirrubina en suero ? 291 umol/l (17 mg/dl). Cuando la bilirrubina alcanzó este nivel, se utilizó un método al azar para asignar los bebés a una de las cuatro intervenciones: 1) continuar la lactancia materna y observar; 2) interrumpir la lactancia materna y reemplazarla por complemento; 3) interrumpir la lactancia materna, reemplazarla por complemento y administrar fototerapia; 4) continuar con la lactancia materna y administar fototerapia. La concentración de bilirrubina en suero alcanzó 342 µmol/l (20 mg/dl) en 24 por ciento de los bebés del grupo 1, 29 por ciento en el grupo 2, 3 por ciento en el grupo 3 y 14 por ciento en el grupo 4. Cuando se empleó fototerapia, la disminución de la bilirrubina en suero fue significativamente mayor y más rápida (en comparación con los casos en que se administró fototerapia). En la mayoría de los bebés alimentados a pecho cuyos niveles de bilirrubina en suero alcanzaron 291 µmol/l (17 mg/dl), la bilirrubina declinó en forma espontánea y no llegó a 342 µmol/l (20 mg/dl). Si la ictericia es significativa y se toma la decisión de intervenir, se les puede presentar a los padres una serie de alternativas para que ellos, una vez informados, puedan decidir cuál de las intervenciones prefieren