Associations between Th1-related cytokines and complicated pediatric appendicitis.

The pathogenesis of appendicitis is not understood fully, and the diagnosis can be challenging. Previous research has suggested an association between a T helper (Th) 1-dependent immune response and complicated appendicitis. This prospective cohort study aimed to evaluate the association between serum concentrations of the Th1-associated cytokines interleukin (IL)-1α, IL-1ß, IL-2, IL-6, IL-10, IL-17A and tumor necrosis factor beta (TNF-ß) and the risk of complicated appendicitis in children. Appendicitis severity was determined through histopathological examination. A total of 137 children < 15 years with appendicitis were included with a median age of 10 years (IQR 8-12); 86 (63%) were boys, and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of serum IL-6 and IL-10, and lower of TNF-ß. After adjustment for age, symptom duration, and presence of appendicolith in a multivariable logistic regression, a higher concentration of IL-6 remained associated with an increased risk of complicated appendicitis (aOR 1.001 [95% CI 1.000-1.002], p = 0.02). Serum concentrations of IL-1α, IL-1ß, IL-2, IL-10, IL-17A and TNF-ß were not significantly associated with the risk of complicated appendicitis. In conclusion, our results suggests that the systemic inflammatory response in complicated appendicitis is complex and not solely Th1-dependent.

Supranormal differential renal function on MAG3 scan in children with ureteropelvic junction obstruction - Prevalence and pyeloplasty during follow-up.

BACKGROUND: Children with suspected ureteropelvic junction obstruction (UPJO) may present with a paradoxical ipsilateral supranormal differential renal function (snDRF) on 99mTechnetium mercaptoacetyltriglycine scintigraphy (MAG3 scan). OBJECTIVE: The aim was to investigate the prevalence of snDRF, the risk of pyeloplasty among children with UPJO and snDRF, and to explore the experience of snDRF among international pediatric urologists. METHODS: A retrospective cohort study of children with suspected unilateral UPJO who underwent MAG3 scan at four hospitals in Sweden between 2005 and 2020. SnDRF was defined as DRF ≥55%. Normal DRF was defined as DRF 45-54%. Primary outcome was risk of pyeloplasty. Indications for pyeloplasty were loss of >10%-points of differential renal function (DRF), ipsilateral DRF <40%, or symptomatic UPJO. Logistic and cox regressions were performed in univariate and multivariable analyses, adjusting for age, gender, year, laterality, antenatal hydronephrosis, anterior-posterior diameter (APD), and kidney size. An international questionnaire regarding the management of snDRF was developed and distributed to pediatric urologists. RESULTS: The prevalence of snDRF was 19%. SnDRF was more common in boys, children with antenatal hydronephrosis, children undergoing their first MAG3 scan at a younger age, and in the left kidney. After further exclusion of 70 children with DRF <45%, a total of 264 were included for longitudinal follow-up of median 6.6 (IQR 2.5-11.5) years. SnDRF was not associated with increased risk of pyeloplasty (adjusted OR 0.98 (95% CI 0.41-2.33), p = 0.96, and adjusted HR 1.00 (95% CI 0.53-1.91), p = 0.99) or time to pyeloplasty (1.1 years vs. 1.6 years, p = 0.40). Among the 79 surveyed pediatric urologists, a majority would not change clinical UPJO-management based on the presence or absence of ipsilateral snDRF. DISCUSSION: There are only a few studies considering the need of pyeloplasty based on the presence of snDRF and this is the first survey among pediatric urologists on its management. With more included patients than previous studies, this study showed a snDRF prevalence of 19%, congruent with the findings of others. The underlying cause of snDRF is debated, but it cannot solely be explained as an artifact of hydronephrotic kidneys. Further studies on the clinical implications of snDRF are warranted, since DRF influences the decision to operate. CONCLUSION: A fifth of all children with suspected UPJO presented with ipsilateral snDRF on initial MAG3 scan, and snDRF was not associated with a greater risk of pyeloplasty. Supported by a large group of international pediatric urology colleagues, this study concludes that the same clinical follow-up and management apply, regardless of presence of snDRF.

Surgical management of necrotising enterocolitis in Sweden: A national cohort study.

AIM: Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. METHODS: Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. RESULTS: In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. CONCLUSION: Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

South Africa and the Surgical Diaspora-A Hub for Surgical Migration and Training.

BACKGROUND: The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries. METHODS: We performed a cross-sectional observational study, combining individual-level data of 43,621 physicians from the Health Professions Council of South Africa with data from the registers of 14 high-income countries, and international statistics on surgical workforce, in order to quantify migration to and from South Africa in both absolute and relative terms. RESULTS: Of 6670 surgeons, anesthesiologists, and obstetricians in South Africa, a total of 713 (11%) were foreign medical graduates, and 396 (6%) were from a low- or middle-income country. South Africa was an important destination primarily for physicians originating from low-income countries; 2% of all surgeons, anesthesiologists, and obstetricians from low- and middle-income countries were registered in South Africa, and 6% in the other 14 recipient countries. A total of 1295 (16%) South African surgeons, anesthesiologists, and obstetricians worked in any of the 14 studied high-income countries. CONCLUSION: South Africa is an important regional hub for surgical migration and training. A notable proportion of surgical specialists in South Africa were medical graduates from other low- or middle-income countries, whereas migration out of South Africa to high-income countries was even larger.

Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings.

BACKGROUND: A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner. METHODS: We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000. RESULTS: The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics. CONCLUSIONS: While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

Acute burn care and outcomes at the Hospital Nacional Guido Valadares (HNGV), Timor-Leste: A 7-year retrospective study.

The purpose of this study was to describe the epidemiology of patients presenting with acute burns and undergoing admission at Hospital Nacional Guido Valadares (HNGV) in Dili, Timor-Leste in the period 2013 to 2019. HNGV is the only tertiary referral hospital in Timor-Leste. This was a retrospective study involving all acute burn patients admitted to the surgical wards of HNGV from 2013 to 2019. The data was collected from patient charts and hospital medical archives. Data were reviewed and analyzed statistically in terms of age, gender, residence, cause, total body surface area (TBSA), burns depth, length of stay (LOS), and mortality. The outcomes were analyzed using logistic regression. Over the 7-year period, there were 288 acute burn patients admitted to the surgical wards of HNGV. Most patients were children (55%), male (65%) and from the capital city of Dili or surrounding areas (59%). The most common cause of burns in children was scalds and the most common cause among adults was flames. Of the admitted patients 59% had burns affecting >10% of the TBSA and 41% had full thickness burns. The median LOS was 17 days (1-143) and the average mortality for admitted burn patients in HNGV was 5.6% (annual mortality 0-17%). The odds ratio for extended LOS was 1.9 (95% confidence interval 1.1-3.2) in female compared with male patients. The odds ratio for mortality was 14.6 (95% confidence interval 2.7-80.6) in the older adults when compared with younger adults. Higher TBSA, full thickness burns, and flame burns were also significantly associated with longer LOS and higher mortality. Children and male patients were disproportionately overrepresented among patients admitted to HNGV, while female patients had longer LOS and older adults had more severe injury and a higher risk of mortality. Establishment of a national program for the prevention of burns is essential.

An Evaluation of Serum IgE and Th2-Associated Interleukins in Children With Uncomplicated and Complicated Appendicitis.

Background: The pathogenesis of appendicitis is not understood completely and establishing a correct diagnosis can be clinically challenging. Previous investigations have shown an association between a T helper cell (Th)2-mediated inflammatory response, for example immunoglobulin E (IgE)-mediated allergy, and a decreased risk of complicated appendicitis. The present study aimed to evaluate differences in serum concentrations of IgE and Th2-associated interleukins (IL) in children with uncomplicated and complicated appendicitis. Method: A prospective study including children <15 years with appendicitis. Blood samples were collected preoperatively at the time of clinical assessment at the Pediatric Emergency Department and analyzed for concentrations of serum total IgE and IL-4, IL-9, and IL-13. Associations with complicated appendicitis were evaluated through logistic regression adjusting for age, appendicolith, and symptom duration. Results: 138 children with confirmed appendicitis were included. The median age was 10 (IQR 8-12) years, 87 (63%) were boys and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of IL-9 and IL-13 compared to children with uncomplicated appendicitis. In the univariate logistic regression, high concentrations of IL-13 were associated with an increased risk of complicated appendicitis [OR 1.02 (95% CI 1.01-1.04) p = 0.005], which remained in the multivariate analysis [aOR 1.02 (95% CI 1.01-1.04), p = 0.01]. Serum concentrations of IgE, IL-4, and IL-9 did not significantly affect the risk of complicated appendicitis. Conclusion: High levels of IL-13 seem to be associated with an increased risk of complicated appendicitis. This is incongruent with the hypothesis of an Th1/Th17-driven inflammation in this type of appendicitis.

Systematic review of low-income and middle-income country perceptions of visiting surgical teams from high-income countries.

BACKGROUND: The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders' perceptions of visiting surgical teams from high-income countries. METHOD: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach. RESULTS: Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers. CONCLUSION: Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.

Differential Activation of Immune Effector Processes in Mature Compared to Immature Sacrococcygeal Teratomas.

Objective: This study aims to characterize the molecular signatures of sacrococcygeal teratomas (SCTs). Methods: Three SCTs were analyzed with whole genome genotyping. RNA sequencing of 10 SCTs dominated by mature, immature and neuroglial elements was analyzed. Expression in SCT-samples with different elements were compared to each other and to a reference group of malignant pediatric tumors. Macrophages, T- and B-lymphocytes were detected by immunohistochemistry. Results: No chromosomal imbalances were detected. SCTs showed overexpression of genes involved in neurosignaling, DNA-binding molecules and pathways of early germ cells. Genes associated with immune effector processes were overexpressed in mature compared to immature SCTs, and immune cell infiltration was found predominantly around mature epithelial elements. Conclusion: The broad repertoire of histological elements in SCTs reflects differences in transcriptional regulation rather than differences in gene copy numbers. A paucity of immune response in immature SCTs may be a factor contributing to their uninhibited growth.

The Development and Inclusion of Questions on Surgery in the 2018 Zambia Demographic and Health Survey.

BACKGROUND: While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia. METHOD: Questions regarding surgical conditions were developed through an iterative consultative process and integrated into the rollout of the DHS survey in Zambia in 2018 and administered to a nationwide sample survey of eligible women aged 15-49 years and men aged 15-59 years. RESULTS: In total, 7 questions covering 4 themes of service delivery, diagnosed burden of surgical disease, access to care, and quality of care were added. The questions were administered across 12,831 households (13,683 women aged 15-49 years and 12,132 men aged 15-59 years). Results showed that approximately 5% of women and 2% of men had undergone an operation in the past 5 years. Among women, cesarean delivery was the most common surgery; circumcision was the most common procedure among men. In the past 5 years, an estimated 0.61% of the population had been told by a health care worker that they might need surgery, and of this group, 35% had undergone the relevant procedure. CONCLUSION: For the first time, questions on surgery have been included in a nationwide DHS. We have shown that it is feasible to integrate these questions into a large-scale survey to provide insight into surgical needs at a national level. Based on the DHS design and implementation mechanisms, a country interested in including a set of questions like the one included in Zambia, could replicate this data collection in other settings, which provides an opportunity for systematic collection of comparable surgical data, a vital role in surgical health care system strengthening.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

BACKGROUND: Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. RESULTS: For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. CONCLUSION: Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

The Effect of Botulinum Toxin Type A Injections on Stricture Formation, Leakage Rates, Esophageal Elongation, and Anastomotic Healing Following Primary Anastomosis in a Long- and Short-Gap Esophageal Atresia Model - A Protocol for a Randomized, Controlled, Blinded Trial in Pigs.

BACKGROUND: Esophageal atresia (EA) is a congenital malformation affecting 1:3000-4500 newborns. Approximately 15% have a long-gap EA (LGEA), in which case a primary anastomosis is often impossible to achieve. To create continuity of the esophagus patients instead have to undergo lengthening procedures or organ interpositions; methods associated with high morbidity and poor functional outcomes. Esophageal injections of Botulinum Toxin Type A (BTX-A) could enable primary anastomosis and mitigate stricture formation through decreased tissue tension. METHODS AND ANALYSIS: In this randomized controlled blinded animal trial, 24 pigs are divided into a long- or short-gap EA group (LGEA and SGEA, respectively) and randomized to receive BTX-A or isotonic saline injections. In the LGEA group, injections are given endoscopically in the esophageal musculature. After seven days, a 3 cm esophageal resection and primary anastomosis is performed. In the SGEA group, a 1 cm esophageal resection and primary anastomosis is performed, followed by intraoperative injections of BTX-A or isotonic saline. After 14 days, stricture formation, presence of leakage, and esophageal compliance is assessed using endoscopic and manometric techniques, and in vivo and ex vivo contrast radiography. Tissue elongation is evaluated in a stretch-tension test, and the esophagus is assessed histologically to evaluate anastomotic healing. ETHICS AND DISSEMINATION: The study complies with the ARRIVE guidelines for animal studies and has been approved by the Danish Animal Experimentation Council. Results will be published in peer-reviewed journals and presented at national and international conferences. HIGHLIGHTS: The optimal management of long-gap esophageal atresia remains controversialPrimary anastomosis could improve functional outcomes and reduce complicationsBotulinum Toxin Type A decreases tissue tension and could facilitate anastomosisReduced tension could further abate the risk for anastomotic stricture and leakageWe present a model to evaluate the method in long- and short-gap esophageal atresia.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report.

BACKGROUND: Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS: The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS: To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Associations of hair cortisol concentrations with paediatric appendicitis.

The pathogenesis of paediatric appendicitis is still an enigma. In recent years, it has become more evident that our inherent immunological responses affect the trajectory of the disease course. Long-term stress has an impact on our immune system; however, it is practically and ethically challenging to prospectively track blood measurements of cortisol-levels in asymptomatic children should an acute appendicitis episode develop. The aim of this case-control study was therefore to evaluate the effect of increased stress measured as historical imprints in hair (hair cortisol concentrations [HCC]), on the risk of developing appendicitis and complicated appendicitis. 51 children (aged < 15 years) with appendicitis (34 with complicated appendicitis), were compared to 86 healthy controls. HCC reflecting the activity of the HPA-axis 0-3 and 4-6 months prior to sampling was evaluated and compared between groups as well as between the two measurements of each study subject. In the univariate analysis with both cases and controls, an increase in HCC between the measurement timepoints was associated with a substantial increase in risk of appendicitis (OR 7.52 [95% CI 2.49-22.67], p = 0.001). This increased risk remained in the multivariate analysis after adjustment for age, sex and season (aOR OR 10.76 [95%CI 2.50-46.28], p = 0.001). When comparing the cases of uncomplicated and complicated appendicitis through a multivariate analysis, adjusted for age and sex, the children with an increased HCC prior to appendicitis had a substantial and statistically significant increase in risk of complicated appendicitis (aOR 7.86 [95% CI 1.20-51.63], p = 0.03). Biological stress, measured as an increase in HCC, seems to be associated with an increased risk of paediatric appendicitis and a more complicated disease course.

Association of transport time with adverse outcome in paediatric trauma.

BACKGROUND: It is unclear how the length of prehospital transport time affects outcome in paediatric trauma. This study evaluated the association of transport time from alarm to arrival at hospital with adverse outcome in paediatric trauma patients in Sweden. METHODS: This was a retrospective study based on prospectively collected data from the Swedish trauma registry between 2012 and 2019 of children less than 18 years with major trauma (New Injury Severity Score (NISS) greater than 15). The primary outcome was 30-day mortality, and secondary outcomes were emergency interventions (e.g., chest tube or laparotomy) and low functional outcome (Glasgow Outcome Scale 2-3). Primary exposure was transport time from alarm to arrival at hospital. Co-variables in multivariable regressions were gender, age, ASA score before injury, injury intention, dominant injury type, NISS, Glasgow Coma Scale score, prehospital competence and hospital level. RESULTS: Among 597 patients, 30-day mortality was 9.8 per cent, emergency interventions were performed in 34.7 per cent and low functional outcome was registered in 15.9 per cent. Median transport time was 51 (i.q.r. 37-68) minutes. After adjustment for patient, injury and hospital characteristics, no association between longer transport time and 30-day mortality, frequency of emergency interventions or lower functional outcome could be found. Treatment at a university hospital was associated with a lower risk for 30-day mortality (odds ratio 0.23 (95 per cent c.i. 0.08 to 0.68), P = 0.008). CONCLUSION: Longer transport time after major paediatric trauma was not associated with adverse outcome. Hence, it seems that longer transport distances should not be an obstacle against centralization of paediatric trauma care. Further studies should focus on the role of prehospital competence and other transport-associated parameters and their association with adverse outcome.

Clinical Prediction Scores for Pediatric Appendicitis.

INTRODUCTION: The rate of misdiagnosis of appendicitis in children is a challenge and clinical prediction scores could be part of the solution. However, the pediatric appendicitis score (PAS) and the Alvarado score have shown disappointing diagnostic accuracy in pediatric validation studies, while the appendicitis inflammatory response (AIR) score and the novel pediatric appendicitis risk calculator (pARC) have not yet been validated thoroughly. Therefore, the aim of the present study was to evaluate these four prediction scores prospectively in children with suspected appendicitis. MATERIALS AND METHODS: A prospective study was conducted over a 2-year period. All patients <15 years with suspected appendicitis were eligible for inclusion. The four prediction scores were compared regarding predictive values, receiver operating characteristics (ROC) curves, decision curve analysis, and clinical outcome. RESULTS: Of the 318 patients included, 151 (47 %) patients had appendicitis. The AIR score and the pARC had substantially higher specificity and positive predictive value, and lower rate of false positives (7% and 2%), than the PAS and Alvarado score (36 and 28%, p < 0.001). Across the different gender and age groups, the AIR score and the pARC generally had fewer false positives than the PAS and Alvarado score. There were no significant differences in sensitivity, negative predictive values, rates of missed appendicitis, or ROC curve analysis. In decision curve analysis, the AIR score and the pARC outperformed the PAS and Alvarado score at most threshold probabilities. CONCLUSION: The AIR score and the pARC are superior to the PAS and Alvarado score in diagnosing children with suspected appendicitis.

A Nationwide Cohort Study of Outcome after Pediatric Appendicitis.

INTRODUCTION: Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome. MATERIALS AND METHODS: A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time. RESULTS: Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p = 0.002). CONCLUSION: Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.

Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe.

BACKGROUND: Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay. METHODS: This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed. RESULTS: Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin. CONCLUSION: A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children. LEVELS OF EVIDENCE: Level II treatment study.

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone.

INTRODUCTION: Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS: The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION: The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.