Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital.

OBJECTIVES: Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS: We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS: A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS: Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.

Epidemiology of abdominal wall and groin hernia repairs in children.

PURPOSE: We sought to estimate the prevalence, incidence, and timing of surgery for elective and non-elective hernia repairs. METHODS: We performed a retrospective cohort study, abstracting data on children < 18 years from the 2005-2014 DoD Military Health System Data Repository, which includes > 3 million dependents of U.S. Armed Services members. Our primary outcome was initial hernia repair (inguinal, umbilical, ventral, or femoral), stratified by elective versus non-elective repair and by age. We calculated prevalence, incidence rate, and time from diagnosis to repair. RESULTS: 19,398 children underwent hernia repair (12,220 inguinal, 5761 umbilical, 1373 ventral, 44 femoral). Prevalence of non-elective repairs ranged from 6% (umbilical) to 22% (ventral). Incidence rates of elective repairs ranged from 0.03 [95% CI: 0.02-0.04] (femoral) to 8.92 [95% CI: 8.76-9.09] (inguinal) per 10,000 person-years, while incidence rates of non-elective repairs ranged from 0.005 [95% CI: 0.002-0.01] (femoral) to 0.68 [95% CI: 0.64-0.73] (inguinal) per 10,000 person-years. Inguinal (median = 20, interquartile range [IQR] = 0-46 days), ventral (median = 23, IQR = 5-62 days), and femoral hernias (median = 0, IQR = 0-12 days) were repaired more promptly and with less variation than umbilical hernias (median = 66, IQR = 23-422 days). CONCLUSIONS: These data describe the burden of hernia repair in the U.S. The large variation in time between diagnosis and repair by hernia type identifies an important area of research to understand mechanisms underlying such heterogeneity and determine the ideal timing for repair. LEVEL OF EVIDENCE: Prognosis study II.

Opioid Prescription Patterns for Children Following Laparoscopic Appendectomy.

OBJECTIVE: To describe variability in and consequences of opioid prescriptions following pediatric laparoscopic appendectomy. SUMMARY BACKGROUND DATA: Postoperative opioid prescribing patterns may contribute to persistent opioid use in both adults and children. METHODS: We included children <18 years enrolled as dependents in the Military Health System Data Repository who underwent uncomplicated laparoscopic appendectomy (2006-2014). For the primary outcome of days of opioids prescribed, we evaluated associations with discharging service, standardized to the distribution of baseline covariates. Secondary outcomes included refill, Emergency Department (ED) visit for constipation, and ED visit for pain. RESULTS: Among 6732 children, 68% were prescribed opioids (range = 1-65 d, median = 4 d, IQR = 3-5 d). Patients discharged by general surgery services were prescribed 1.23 (95% CI = 1.06-1.42) excess days of opioids, compared with those discharged by pediatric surgery services. Risk of ED visit for constipation (n = 61, 1%) was increased with opioid prescription [1-3 d, risk ratio (RR) = 2.46, 95% CI = 1.31-5.78; 4-6 d, RR = 1.89, 95% CI = 0.83-4.67; 7-14 d, RR = 3.75, 95% CI = 1.38-9.44; >14 d, RR = 6.27, 95% CI = 1.23-19.68], compared with no opioid prescription. There was similar or increased risk of ED visit for pain (n = 319, 5%) with opioid prescription [1-3 d, RR = 1.00, 95% confidence interval (CI) = 0.74-1.32; 4-6 d, RR = 1.31, 95% CI = 0.99-1.73; 7-14 d, RR = 1.52, 95% CI = 1.00-2.18], compared with no opioid prescription. Likewise, need for refill (n = 157, 3%) was not associated with initial days of opioid prescribed (reference 1-3 d; 4-6 d, RR = 0.96, 95% CI = 0.68-1.35; 7-14 d, RR = 0.91, 95% CI = 0.49-1.46; and >14 d, RR = 1.22, 95% CI = 0.59-2.07). CONCLUSIONS: There was substantial variation in opioid prescribing patterns. Opioid prescription duration increased risk of ED visits for constipation, but not for pain or refill.

Comparison of Military Health System Data Repository and American College of Surgeons National Surgical Quality Improvement Program-Pediatric.

BACKGROUND: Given the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations. METHODS: We selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012-2014). RESULTS: Age, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets. CONCLUSION: For the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.

Incidence and risk factors for sepsis after childhood splenectomy.

BACKGROUND: Children who have undergone splenectomy may develop impaired immunologic function and heightened risk of overwhelming postsplenectomy infection. We sought to define the long-term rate of and risk factors for postsplenectomy sepsis. METHODS: We leveraged the Military Health System Data Repository, a nationally representative claims database including >3 million children registered as dependents of members of the United States Armed Services (2005-2014). Inclusion criterion was splenectomy at age 18 years or prior. The primary outcome was hospitalization for sepsis. RESULTS: Among 195 children who underwent splenectomy, 7% (n = 13) were hospitalized with sepsis, with an incidence of 1.8 (95% CI = 1.0-3.1) events per 100 person-years. The median time to sepsis was 224 days (IQR = 109-606) and 38% (5/13) of events occurred within the first postsplenectomy year. The postsplenectomy mortality rate was 1% (n = 3). After adjusting for underlying diagnosis, older age at splenectomy (HR = 0.90 per year, 95% CI = 0.81-0.99) was associated with decreased hazard of sepsis. CONCLUSIONS: In a contemporary national cohort, the prevalence of postsplenectomy sepsis was 7% (1.8 events per 100 person-years). Although most presented during the first year after splenectomy, many (62%) sepsis events occurred later, suggesting that postsplenectomy immunologic dysfunction persists beyond one year. The immunologic consequences of asplenia must continue to be acknowledged, as postsplenectomy sepsis remains a serious concern. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level III.

Management of Reducible Ventral Hernias: Clinical Outcomes and Cost-effectiveness of Repair at Diagnosis Versus Watchful Waiting.

OBJECTIVE: To compare long-term clinical and economic outcomes associated with 3 management strategies for reducible ventral hernia: repair at diagnosis (open or laparoscopic) and watchful waiting. BACKGROUND: There is variability in ventral hernia management. Recent data suggest watchful waiting is safe; however, long-term clinical and economic outcomes for different management strategies remain unknown. METHODS: We built a state-transition microsimulation model to forecast outcomes for individuals with reducible ventral hernia, simulating a cohort of 1 million individuals for each strategy. We derived cohort characteristics (mean age 58 years, 63% female), hospital costs, and perioperative mortality from the Nationwide Inpatient Sample (2003-2011), and additional probabilities, costs, and utilities from the literature. Outcomes included prevalence of any repair, emergent repair, and recurrence; lifetime costs; quality-adjusted life years (QALYs); and incremental cost-effectiveness ratios. We performed stochastic and probabilistic sensitivity analyses to identify parameter thresholds that affect optimal management, using a willingness-to-pay threshold of $50,000/QALY. RESULTS: With watchful waiting, 39% ultimately required repair (14% emergent) and 24% recurred. Seventy per cent recurred with repair at diagnosis. Laparoscopic repair at diagnosis was cost-effective compared with open repair at diagnosis (incremental cost-effectiveness ratio $27,700/QALY). The choice of operative strategy (open vs laparoscopic) was sensitive to cost and postoperative quality of life. When perioperative mortality exceeded 5.2% or yearly recurrence exceeded 19.2%, watchful waiting became preferred. CONCLUSIONS: Ventral hernia repair at diagnosis is very cost-effective. The choice between open and laparoscopic repair depends on surgical costs and postoperative quality of life. In patients with high risk of perioperative mortality or recurrence, watchful waiting is preferred.

Contemporary Factors Associated with the Use of Laparoscopy for Inguinal Hernia Repair Among Department of Defense Beneficiaries.

INTRODUCTION: The factors that contribute to variation in utilization of laparoscopic inguinal hernia repair are unknown. We sought to determine the current usage patterns of laparoscopic and open surgery in the elective repair of uncomplicated unilateral inguinal hernia in a large population with universal health care coverage comprised of Department of Defense (DoD) beneficiaries. MATERIALS AND METHODS: The DoD Military Health System Data Repository (MDR) tracks health care delivered to a universally insured population of active/reserve/retired members of the U.S. Armed Services and their dependents. The MDR was queried for elective unilateral inguinal hernia repair among adult patients between 2008 and 2014. The primary outcome was laparoscopic (vs. open) approach to hernia repair. We conducted univariable and multivariable analyses of patient- and systems-level factors associated with approach to inguinal hernia repair. This research was approved by our institutional review board prior to commencement of the study and need for informed consent was waived given the design of this study. RESULTS: Among 37,742 elective uncomplicated unilateral inguinal hernia repairs, 35% (n = 13,114) were performed laparoscopically. In 2014, 40% of inguinal hernia repairs were performed laparoscopically, compared with 27% of repairs in 2008 (P < 0.01). In multivariable analysis, laparoscopic hernia repair was more likely for male patients (OR = 1.38, 95% CI = 1.23-1.54, P < 0.01), military (vs. civilian) institutions (OR = 1.34, 95% CI = 1.28-1.41, P < 0.01), active-duty officers (vs. active-duty enlisted; OR = 1.21, 95% CI = 1.12-1.30, P < 0.01), and more recent year of surgery (P < 0.01). Laparoscopic repair was significantly less likely among patients with greater than one comorbidity (vs. none; OR = 0.68, 95% CI = 0.61-0.76, P < 0.01). CONCLUSION: In a large, universally insured population of military service members and their dependents, laparoscopic inguinal repair is increasingly used and was preferred over open repair for younger, healthier, active-duty patients and those treated within the military (vs. non-military) care system.

Hernia recurrence following inguinal hernia repair in children.

PURPOSE: We aimed to describe the incidence, timing, and predictors of recurrence following inguinal hernia repair (IHR) in children. METHODS: We used the TRICARE claims database, a national cohort of >3 million child dependents of members of the U.S. Armed Forces. We abstracted data on children <12y who underwent IHR (2005-2014). Our primary outcome was recurrence (ICD9-CM diagnosis codes). We calculated incidence rates for the population and stratified by age, time from repair to recurrence, and multivariable logistic regression to determine predictors. RESULTS: Nine thousand nine hundred ninety-three children met inclusion criteria. Age at time of IHR was ≤1y in 37%, 2-3y in 23%, 4-5y in 16%, and 5-12y in 24%. Median follow-up time was 3.5y (IQR:1.6-6.1). 137 patients recurred (1.4%), with an incidence of 3.46 per 1000 person-years. Over half occurred in children 0-1y at repair (60%). The majority occurred within a year following repair (median 209 days [IQR:79-486]). Children 0-1y had 2.53 times greater odds of recurrence (compared to >5y). Children with multiple comorbidities had 5.45 times greater odds compared to those with no comorbidities. CONCLUSIONS: The incidence of recurrence following IHR is 3.46 per 1000 person-years. The majority occurred within a year of repair. Children ≤1y and those with multiple comorbidities were at increased risk. LEVEL OF EVIDENCE: Prognosis Study, Level II.

Testicular atrophy following inguinal hernia repair in children.

PURPOSE: We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children. METHODS: We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including > 3 million children. We abstracted data on male children < 12 years who underwent inguinal hernia repair (2005-2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis. RESULTS: 8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1-5). Median follow-up was 3.57 years (IQR 1.69-6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children [Formula: see text] 5 years, with 72% in children < 2 years. Median time to atrophy was 2.4 years (IQR 0.64-3), with 30% occurring within 1 year and 75% within 3 years. CONCLUSION: Testicular atrophy is a rare complication following inguinal hernia repair, with children < 2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later. LEVEL OF EVIDENCE: Prognosis Study, Level II.

The "mortality ascent": Hourly risk of death for hemodynamically unstable trauma patients at Level II versus Level I trauma centers.

BACKGROUND: Severely injured trauma patients have higher in-hospital mortality at Level II versus Level I trauma centers (TCs). To better understand these differences, we sought to determine if there were any periods during which hemodynamically unstable trauma patients are at higher risk of death at Level II versus Level I TCs within the first 24 hours postadmission. STUDY DESIGN: Trauma patients aged 18 years to 64 years, with Injury Severity Score of 15 or greater, systolic blood pressure less than 90 mm Hg at admission, and treated at Level II or Level I TCs, were identified using the 2007 to 2012 National Trauma Data Bank. Burn patients, transfers, and patients dead on arrival were excluded. Log-binomial regression models, adjusted for patient- and hospital-level confounders, were used to compare mortality at Level II versus Level I TCs over the first 24 hours postadmission. RESULTS: Of 13,846 hemodynamically unstable patients, 4,212 (30.4%) were treated at 149 Level II TCs, and 9,634 (69.6%) at 116 Level I TCs. Within the first 24 hours, 3,059 (22.1%) patients died. In risk-adjusted models, mortality risk was significantly elevated at Level II versus Level I TCs during the 24 hours postadmission (relative risk, 1.08; 95% confidence interval, 1.01-1.16). Hourly mortality risk was significantly different between Level II and Level I TCs during 4 hours to 7 hours postadmission, with a maximal difference at 7 hours (relative risk, 1.70; 95% confidence interval, 1.23-2.36) and comparable mortality risk beyond 7 hours postadmission. CONCLUSION: The 4-hour to 7-hour time window postadmission is critical for hemodynamically unstable trauma patients. Variations in available treatment modalities may account for higher relative mortality at Level II TCs during this time. Further investigation to elucidate specific risk factors for mortality during this period may lead to reductions in in-hospital mortality among hemodynamically unstable trauma patients. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Insurance status is associated with complex presentation among emergency general surgery patients.

BACKGROUND: The Affordable Care Act has the potential to significantly affect access to care for previously uninsured patients in need of emergency general surgical care. Our objective was to determine the relationship between insurance status and disease complexity at presentation among a national sample of emergency general surgical patients. METHODS: Data from the National Emergency Department Sample from 2006-2009 were queried to identify all patients aged 18-64 years old admitted through the emergency department with a primary diagnosis of appendicitis, diverticulitis, inguinal hernia, or bowel obstruction. Primary outcome of complex presentation was defined as also presenting with generalized peritonitis, intra-abdominal abscess, perforated bowel, intestinal gangrene, or other disease-specific measures of complexity. We used multivariable logistic regression to determine the independent association between insurance status and complex presentation. Models accounted for patient- and hospital-level covariates. Counterfactual models were used to estimate the risk of complex presentation attributable to lack of insurance. RESULTS: A total of 1,373,659 patients were included, with an overall uninsured rate of 12.3%. Uninsured patients had significantly higher, unadjusted rates of complex presentation, and uninsured payer status was independently associated with complex presentation (odds ratio 1.38, 95% confidence interval: 1.34-1.42). Counterfactual models suggest that having insurance would result in a 22.37% (95% confidence interval: 22.35-22.39%) relative decline in risk of complex emergency general surgical presentation among the uninsured population. CONCLUSION: Insurance status is independently associated with severity of disease at presentation among emergency general surgical conditions nationally. In light of recently reaffirmed Affordable Care Act insurance expansion provisions, these results anticipate increased timely access to operative care for newly insured patients and a corresponding decline in complex, emergency general surgical presentations.

Subtyping sub-Saharan esophageal squamous cell carcinoma by comprehensive molecular analysis.

Esophageal squamous cell carcinoma (ESCC) is endemic in regions of sub-Saharan Africa (SSA), where it is the third most common cancer. Here, we describe whole-exome tumor/normal sequencing and RNA transcriptomic analysis of 59 patients with ESCC in Malawi. We observed similar genetic aberrations as reported in Asian and North American cohorts, including mutations of TP53, CDKN2A, NFE2L2, CHEK2, NOTCH1, FAT1, and FBXW7. Analyses for nonhuman sequences did not reveal evidence for infection with HPV or other occult pathogens. Mutational signature analysis revealed common signatures associated with aging, cytidine deaminase activity (APOBEC), and a third signature of unknown origin, but signatures of inhaled tobacco use, aflatoxin and mismatch repair were notably absent. Based on RNA expression analysis, ESCC could be divided into 3 distinct subtypes, which were distinguished by their expression of cell cycle and neural transcripts. This study demonstrates discrete subtypes of ESCC in SSA, and suggests that the endemic nature of this disease reflects exposure to a carcinogen other than tobacco and oncogenic viruses.

Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients.

Importance: Trauma is the leading cause of death and disability among young adults, who are also among the most likely to be uninsured. Efforts to increase insurance coverage, including passage of the Patient Protection and Affordable Care Act (ACA), were intended to improve access to care and promote improvements in outcomes. However, despite reported gains in coverage, the ACA's success in promoting use of high-quality care and enacting changes in clinical end points remains unclear. Objectives: To assess for observed changes in insurance coverage and rehabilitation use among young adult trauma patients associated with the ACA, including the Dependent Coverage Provision (DCP) and Medicaid expansion/open enrollment, and to consider possible insurance and rehabilitation differences between DCP-eligible vs -ineligible patients and among stratified demographic and community subgroups. Design, Setting, and Participants: A longitudinal assessment of DCP implementation and Medicaid expansion/open enrollment using risk-adjusted before-and-after, difference-in-difference, and interrupted time-series analyses was conducted. Eleven years (January 1, 2005, to September 31, 2015) of Maryland Health Services Cost Review Commission data, representing complete patient records from all payers within the state, were used to identify all hospitalized young adult (aged 18-34 years) trauma patients in Maryland during the study period. Results: Of the 69 507 hospitalized patients included, 50 548 (72.7%) were male, and the mean (SD) age was 25 (5) years. Before implementation of the DCP, 1 of 4 patients was uninsured. After ACA implementation, the number fell to less than 1 of 10, with similar patterns emerging in emergency department and outpatient settings. The change was primarily driven by Medicaid expansion/open enrollment, which corresponded to a 20.1 percentage-point increase in Medicaid (95% CI, 18.9-21.3) and an 18.2 percentage-point decrease in uninsured (95% CI, -19.3 to -17.2). No changes were detected among privately insured patients. Rehabilitation use increased by 5.4 percentage points (95% CI, 4.5-6.2)-a 60% relative increase from a baseline of 9%. Mortality (-0.5; 95% CI, -0.9 to -0.1) and failure-to-rescue rates (-4.5; 95% CI, -7.4 to -1.6) also significantly declined. Stratified changes point to significant differences in the percentage of uninsured patients and rehabilitation access across the board, mitigating or even eradicating disparities in certain cases. Conclusions and Relevance: For patients who are injured, young, and uninsured, Medicaid expansion/open enrollment in Maryland changed insurance coverage and altered patient outcomes in ways that the DCP alone was never intended to do. Implementation of Medicaid expansion/open enrollment transformed the landscape of trauma coverage, directly affecting the health of one of the country's most vulnerable at-risk groups.

Predictors of emergency ventral hernia repair: Targets to improve patient access and guide patient selection for elective repair.

BACKGROUND: Emergency operations are associated with worse outcomes than elective operations. If not repaired electively, ventral hernias are at risk of strangulating and requiring emergency repair. We sought to identify patient- and hospital-level factors associated with emergency ventral hernia repair in a nationally representative, United States sample. METHODS: We abstracted data from the 2003-2011 Nationwide Inpatient Sample for adults (≥18 years) who underwent inpatient ventral hernia repair. Our primary outcome was emergency repair. We assessed differences in patient- and hospital-level factors as possible predictors of emergency repair using multivariable logistic regression. We examined secondary outcomes (mortality, total hospital cost, duration of stay) using multivariable logistic and generalized linear (family gamma; link log) regression. RESULTS: After weighting to the United States population, we included 453,161 adults (39.5% emergency). Independent predictors of emergency repair included payer status (uninsured: odds ratio 3.50, [3.10, 3.96]; Medicaid: 1.29 [1.20, 1.39] compared with private insurance), race/ethnicity (black: 1.77 [1.64, 1.92]; Hispanic: 1.44 [1.28, 1.61] compared with white), age (≥85 years: 2.23 [2.00, 2.47] compared with <45 years), and comorbidities (Charlson Comorbidity Index ≥3: 1.68 [1.56, 1.80] compared with 0). After risk-adjustment, emergency repair was associated with greater odds of in-hospital death, greater costs, and longer hospital stay. CONCLUSION: Inpatient ventral hernia repairs are frequently performed emergently, with worse outcomes in this group. Independent predictors of emergency repair include factors that may limit access to and/or selection for an elective operation. These predictors provide targets for interventions to improve access to elective care and inform patient selection with the goal of improving patient outcomes.

Differential access to care: The role of age, insurance, and income on race/ethnicity-related disparities in adult perforated appendix admission rates.

BACKGROUND: Differences in perforated appendix admission rates (PAAR) are an ambulatory-sensitive measure of access to care. While pediatric studies report disparities in PAAR, initial adult investigations suggest a lack of racial/ethnic inequity. The objectives of this study were to (1) assess for risk-adjusted, racial/ethnic differences in PAAR among adults on a national scale, (2) consider the extent to which variations (or lack thereof) are explained by age, insurance, and income, and (3) compare results within the United States population to a national segment of the population who are completely insured. METHODS: According to the Agency for Healthcare Research and Quality definition of PAAR, adults (aged 18-64 years) in the 2006-2010 Nationwide Inpatient Sample were queried for the occurrence and perforation of acute appendicitis. Risk-adjusted differences were compared by race/ethnicity over 5-year age increments using logistic regression with reweighted estimating equations. Noting disparate outcomes between younger (aged 18-34 years) versus older (aged 35-64 years) adults, age-stratified variations were further considered. Results were compared relative to differences among national military/civilian-dependent patients with universal insurance and were assessed for the extent to which disparities could be explained by variations in insurance and income. RESULTS: A total of 129,257 (weighted: 638,452) patients were included. Despite a lack of differences overall, significantly worse outcomes among younger (odds ratio point-estimates ranged from 1.11-1.32) and better outcomes among older (0.78-0.93) minority patients were found. This observation contrasted a lack of differences among completely insured military/civilian-dependent patients (n = 12,154). A total of 22.4% (non-Hispanic black versus non-Hispanic white) and 39.0% (Hispanic versus non-Hispanic white) of younger adult differences were explained by insurance-12.2% and 13.6% by income, 29.8% and 44.0% combined. CONCLUSION: This national assessment of differences in access to care among adults with acute appendicitis demonstrated the existence of racial/ethnic disparities in PAAR that varied with age and were partially, although incompletely, explained by variations in insurance and income.

Late-onset hypertrophic pyloric stenosis with gastric outlet obstruction: case report and review of the literature.

We report late-onset hypertrophic pyloric stenosis in a 17-year-old female. She presented with abdominal pain and an episode of upper gastrointestinal hemorrhage and subsequently developed gastric outlet obstruction. Work-up revealed circumferential pyloric thickening, delayed gastric emptying, and a stenotic, elongated pyloric channel. Biopsies showed benign gastropathy, negative for Helicobacter pylori, without eosinophilic infiltrates. Botulinum toxin injection provided limited relief. Diagnostic laparoscopy confirmed the hypertrophic pylorus and we performed laparoscopic pyloromyotomy. The patient tolerated the procedure well and had complete symptom resolution at 1-year follow-up. Hypertrophic pyloric stenosis is a rare cause of gastric outlet obstruction in adolescents and may be managed successfully with laparoscopic pyloromyotomy.

Esophagogastroduodenoscopy in a public referral hospital in Lilongwe, Malawi: spectrum of disease and associated risk factors.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is a valuable tool for diagnosing and treating upper gastrointestinal disease. Prioritizing the use of EGD in resource-limited settings must be customized to local populations to maximize population benefit from the examination. METHODS: Cross-sectional, retrospective review of EGD reports was conducted at Kamuzu Central Hospital (KCH), Lilongwe, Malawi. Esophageal tumors were defined as obstructive or nonobstructive and esophageal varices were graded on a scale of I to IV. Descriptive statistics were calculated and logistic regression performed for each disease state compared with all other reports. RESULTS: A total of 1,034 cases were reviewed (56% male; mean age (standard deviation), 44 (17) years). The most common indications were dysphagia (37%), hematemesis (21%), and epigastric pain (16%). The most common diagnoses were normal (36%), esophageal cancer (27%), and esophageal varices (17%). Eighty-six percent of esophageal tumors were obstructive and 45% of esophageal varices were grade III or IV. Normal examinations were more likely to be female, younger, and present with dyspepsia. Esophageal cancers were more likely to be male, older, present with dysphagia, and present from districts outside Lilongwe. Esophageal varices were more likely to present with hematemesis. CONCLUSIONS: EGD is a limited resource at KCH; patient selection should be guided by patient age and indication. The high burden of esophageal cancer and varices in Malawi suggests that therapeutic endoscopy would be beneficial.

Visual screening for malignant melanoma: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of various melanoma screening strategies proposed in the United States. DESIGN: We developed a computer simulation Markov model to evaluate alternative melanoma screening strategies. PARTICIPANTS: Hypothetical cohort of the general population and siblings of patients with melanoma. Intervention We considered the following 4 strategies: background screening only, and screening 1 time, every 2 years, and annually, all beginning at age 50 years. Prevalence, incidence, and mortality data were taken from the Surveillance, Epidemiology, and End Results Program. Sibling risk, recurrence rates, and treatment costs were taken from the literature. MAIN OUTCOME MEASURES: Outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. Cost-effectiveness ratios were in dollars per quality-adjusted life year (US dollars/QALY) gained. RESULTS: In the general population, screening 1 time, every 2 years, and annually saved 1.6, 4.4, and 5.2 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 10,100/QALY, US dollars 80,700/QALY, and US dollars 586,800/QALY, respectively. In siblings of patients with melanoma (relative risk, 2.24 compared with the general population), 1-time, every-2-years, and annual screenings saved 3.6, 9.8, and 11.4 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 4000/QALY, US dollars 35,500/QALY, and US dollars 257,800/QALY, respectively. In higher risk siblings of patients with melanoma (relative risk, 5.56), screening was more cost-effective. Results were most sensitive to screening cost, melanoma progression rate, and specificity of visual screening. CONCLUSIONS: One-time melanoma screening of the general population older than 50 years is very cost-effective compared with other cancer screening programs in the United States. Screening every 2 years in siblings of patients with melanoma is also cost-effective.