Children with appendicitis on the US-Mexico border have socioeconomic challenges and are best served by a freestanding children's hospital.

INTRODUCTION: The US-Mexico border is medically underserved. Recent political changes may render this population even more vulnerable. We hypothesized that children on the border present with high rates of perforated appendicitis due to socioeconomic barriers. METHODS: A prospective survey was administered to children presenting with appendicitis in El Paso, Texas. Primary outcomes were rate of perforation and reason for diagnostic delay. We evaluated the association between demographics, potential barriers to care, risk of perforation and risk of misdiagnosis using logistic regression. p < 0.05 was considered significant. RESULTS: 98 patients participated from October 2016 to February 2017. 96 patients (98%) were Hispanic and 81 (82%) had Medicaid or were uninsured. 11 patients (11%) resided in Mexico or Guatemala. Patients were less likely to receive a CT and more likely to receive an ultrasound if they presented to a freestanding children's hospital (p = 0.01). 37 patients (38%) presented with perforation, of which 19 (52%) were the result of practitioner misdiagnosis. Patients who presented to a freestanding children's hospital were less likely to be misdiagnosed than patients presenting to other facilities (p = 0.05). Children who underwent surgery in a freestanding children's hospital had the shortest length of stay after adjusting for perforation status and potential confounders (p < 0.01). CONCLUSION: Children with low socioeconomic status did not have difficulty accessing care on the USA-Mexico border, but they were commonly misdiagnosed. Children were less likely to receive a CT, more likely to be correctly diagnosed and length of stay was shorter when patients presented to a freestanding children's hospital.

Penetrating trauma in children on the United States-Mexico border: Hispanic ethnicity is not a risk factor.

INTRODUCTION: The United States-Mexico border is perceived as dangerous by the media and current political leaders. Hispanic ethnicity, low socioeconomic status, male gender and adolescent age have previously been identified as risk factors for penetrating trauma (PT). METHODS: A retrospective review of PT was performed in a border region. Children 0-17 years old, admitted to the region's only level I trauma center between 2001 and 2016 were included. Standardized morbidity ratio was used to compare observed to expected morbidity. RESULTS: There were 417 PT admissions. 197 (47%) were non-accidental, 34 (8%) suicide attempts and 186 (45%) accidental. There were 12 homicides, 7 suicides and no accidental deaths. The region contains over 280,000 children, thus yielding a homicide rate of 0.26 per 100,000. The U.S. pediatric homicide rate was 2.6-4.0 over this period. Adolescents 13-17 years old accounted for 237 (57%) admissions, 152 (78%) of non-accidental admissions and 12 (63%) deaths. Most admissions (N = 321, 77%) and 15 of the deaths (79%) were males. Non-accidental injuries were more frequent in ZIP codes associated with low incomes. Hispanic patients accounted for 173 (88%) of non-accidental trauma. However, 40 (20%) non-accidental injuries occurred in Mexico and 157 (80%) injuries occurred in an 82% Hispanic region. Therefore, the standardized morbidity ratio for Hispanic ethnicity was 1.048 (CL 0.8-1.2, P = 0.6). CONCLUSION: On the United States-Mexico border, the pediatric homicide rate was less than 1/10 the national average. Male adolescents are at risk for non-accidental PT. In a Hispanic majority population, Hispanic ethnicity was not a risk factor for PT. It is possible that economic disparity, rather than race/ethnicity, is a risk factor for PT.

Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure.

BACKGROUND: Computed tomography (CT) for pediatric traumatic brain injury (TBI) is common. Evidence suggests that 1 in 1,200 children undergoing CT will die of malignancy from radiation exposure. Presently, there is no protocol for surveying children with mild TBI; repeat CT (rCT) is often performed. We hypothesized that rCT could be avoided. Outcomes of similar patients who underwent rCT were compared with those of patients followed by clinical examination alone. METHODS: An 8-year retrospective review was performed of patients admitted to a Level I pediatric trauma center with TBI, CT evidence of TBI, and Glasgow Coma Scale (GCS) score of 14 to 15. There were two groups, those who underwent rCT (rCT+) and those who did not (rCT-). Data included age, Injury Severity Score (ISS), mechanism of injury, type of TBI, and outcome. Patients with coagulopathies, ventriculoperitoneal shunts, developmental disabilities, nonaccidental trauma, concomitant injuries, or medical problems resulting in intubation or sedation not attributed to TBI were excluded. RESULTS: Of 391 patients admitted with TBI, 120 were included in the study. A total of 106 patients were rCT+, and 14 were rCT-. rCT+ children were older (mean, 98.7 ± 7.3 vs. 35.3 ± 11.5 months; p = 0.0025) and more likely to have epidural hematoma (EDH) (100% rCT with EDH vs. 76% rCT all other TBI, p = 0.044). Mechanism of injury and mean ISS (15.2 ± 0.6 vs. 13.0 ± 1.1, p = 0.195) were not different between the groups. There were no worsening neurologic symptoms or need for surgery in rCT- children. rCT identified seven patients (6.6%) with CT progression of their injury. Five had an EDH, and two had a subarachnoid hemorrhage. Two children with EDH underwent operation. CONCLUSION: Our study indicates that routine rCT without evidence of clinical deterioration is not indicated in children with admission GCS score of 14 to 15 and TBI on CT scan. Children with EDH seem to have a higher potential for progression, and rCT seems to be indicated in this subgroup. LEVEL OF EVIDENCE: Therapeutic study, level IV.