Outcomes of transforaminal epidural injection of amniotic membrane/umbilical cord particulate for lumbar radiculopathy: a case series.

Background: Radiculopathy can be a debilitating condition. Amniotic membrane/umbilical cord (AM/UC) particulate is a relatively new injectable treatment modality. Herein we report the outcomes of epidural injection of AM/UC particulate in managing lumbar radiculopathy. Methods: Consecutive patients with lumbar radiculopathy who received epidural injection of AM/UC particulate for lumbar radiculopathy were included. Primary outcome was change in pain as measured by the 11-point numerical rating scale. Safety was assessed by AM/UC- and procedure-related complications. Paired t-tests were used to determine statistical significance. Results: A total of 12 patients with a mean age of 56.7 ± 21.0 years were included in the analysis. The patients were previously treated with physical therapy (91.7%), chiropractic corrective measures (16.7%), epidural steroid injection (83.3%), and radiofrequency ablation (8.3%). Two patients (16.7%) were taking opioids for chronic pain syndrome. After AM/UC injection, the average pain score decreased from 6.6 ± 1.5 to 5.2 ± 1.9 at 1-3 months, 2.0 ± 1.4 at 6 months, and 2.9 ± 1.4 at last mean follow-up of 21.3 ± 11.1 months (p < 0.001). No patients required subsequent treatment or surgery. There were also no complications. Conclusion: This case series supports the preliminary safety and shows potential benefit of epidural AM/UC particulate injection in this cohort of patients with lumbar radiculopathy pain.

Student Reflections on Learning in a Doctoral-Level Writing Course.

BACKGROUND: Programs to improve student writing have been deployed widely in nursing graduate education, but few operational indicators exist for measuring their value. PROBLEM: The challenge of measuring outcomes reflects the complexity of what transpires when graduate students write. Better understanding is needed of what it means to students to "learn" from writing support. APPROACH: A full-semester writing course was implemented in a nursing science PhD program. In formative course assessment activities, students identified problems in early drafts of their work, which they subsequently learned to detect and resolve. In this article, students report what was learned. CONCLUSION: Writing skills, like clinical skills, are intertwined with intellectual maturation and sense of professional identity. Writing, like clinical learning, requires an investment of time and labor far beyond what is typical in didactic approaches to classroom-based graduate education. Our experience suggests a need to reconceptualize writing pedagogy in nursing.

The Impact of a 1-Year COVID-19 Extension on Undergraduate Dentistry in Dundee: Final Year Students' Perspectives of Their Training in Oral Surgery.

BACKGROUND: The detrimental impact of the COVID-19 pandemic on dental education prompted the Scottish Government to fund an additional year to the dental course to ensure that the students had the necessary clinical experience. The aim of the study was to better understand the final year student perceptions of this extension on their oral surgery experience at the University of Dundee. METHODS: This mixed methods study consisted of an anonymous online questionnaire and a focus group. RESULTS: Forty-one students (69.3%) completed the questionnaire and ten students participated in the focus group. Thirty-six (88.8%) students agreed that the oral surgery teaching provided sufficient knowledge to undertake independent practice. All of the students felt confident to carry out an extraction, and the majority of them (n = 40, 95%) felt confident to remove a retained root, however, their confidence with surgery was lower. CONCLUSION: The extension gave the students sufficient experience in oral surgery to gain confidence in clinical skills and an appropriate level of knowledge in preparation for the next phase of their career. Most of the students agreed that the extension was necessary and beneficial. This cohort graduated with more oral surgery experience than any of the students did in the previous 4 years from Dundee and with experience that was comparable with the students at other schools in the pre-COVID-19 era.

An Educational Evaluation of Thiel Cadavers as a Model for Teaching Suturing Skills to Dental Students during the COVID-19 Pandemic.

Suturing is an essential skill in dentistry and not one easily acquired. The COVID-19 pandemic prompted a change to the use of Thiel cadavers and online resources with the aim of improving skill acquisition using the best model available. This study investigated the utility of the Thiel cadaver for teaching suturing skills and the potential impact of the lockdown. Fifty-seven year 4 students attended a teaching session. Student views on this teaching were explored via a questionnaire survey and qualitative data collected from a focus group. Data were analysed using an inductive approach. The response rate was 53% (30 students) for the questionnaire with 9 students participating in the focus group. Independent feedback was provided by two members of the teaching staff. Online video resources were very well received by the students with 97% agreeing that it was useful preparation. Ninety percent (90%) thought that the cadaveric model was suitable for this teaching and realistic. Positive emergent themes from the focus group centred on the use of the cadaveric model and the positive and relaxed teaching and learning environment. Staff perceived this model as superior to previously used models. There were no reported negative pandemic impacts and the cadaver model was well received.

Development and Validation of Pediatric Opioid Analgesia Self-Instruction System (PedOASIS): An Opioid Knowledge Tool for Pediatric Clinicians.

BACKGROUND: Acute pain is common in children and young adults with cancer and sickle cell disease. Current training curricula fail to adequately impart skills for pain management. We sought to develop and validate an education and assessment tool to address the safe effective use of opioids for pain management by pediatrics trainees. METHODS: The first version of the tool contained 10 case-based, multiple-choice questions. It was pilot tested within a medium-sized pediatric residency program using preintervention and postintervention surveys to assess residents' knowledge and comfort related to prescribing opioids. Content validation was performed through an expert panel of physicians. Internal reliability was tested by administering the tool to learners and practitioners with varying levels of training. RESULTS: Comfort with choosing and converting between opioids increased significantly in pilot testing (P=0.005). Mean objective knowledge scores increased from 51% to 85.9% (P<0.001). The revised tool showed internal reliability within each group (Cronbach alpha 0.71 to 0.78) and significant differences in mean scores between groups (F ratio=9.45, P=0.0002). CONCLUSIONS: This tool demonstrates validity and internal reliability. Its use was associated with short-term educational gains and it garnered overall favorable feedback from users. Further testing is needed to assess the duration of these gains.

Self-perceptions of critical thinking skills in university students are associated with BMI and exercise.

Objective: To assess the role of body mass index (BMI) and exercise levels in self-perception of critical thinking skills. Participants: Three hundred forty-seven students from an upper-division nutrition class over two consecutive years. Methods: A pre/post survey with a 15-week intervention assessed perceived critical thinking skills in a blended classroom. Results: Students gained in perceived critical thinking skills in six areas over the semester. A higher BMI was associated with decreased perception of one's ability to think logically, along with increased perception that memorization was the key to success. Those that exercised reported that they had strong critical thinking skills compared to those that exercised less frequently. Conclusions: A blended classroom approach was effective in increasing multiple areas of perceptions of critical thinking. However, some perceptions of critical thinking are viewed differently for those of different BMIs and exercise frequency. Consequently, designing interventions specifically targeting those with higher BMIs, could work to erase these inequities.

Elucidating Waterborne Pathogen Presence and Aiding Source Apportionment in an Impaired Stream.

Fecal indicator bacteria (FIB) are the basis for water quality regulations and are considered proxies for waterborne pathogens when conducting human health risk assessments. The direct detection of pathogens in water and simultaneous identification of the source of fecal contamination are possible with microarrays, circumventing the drawbacks to FIB approaches. A multigene target microarray was used to assess the prevalence of waterborne pathogens in a fecally impaired mixed-use watershed. The results indicate that fecal coliforms have improved substantially in the watershed since its listing as a 303(d) impaired stream in 2002 and are now near United States recreational water criterion standards. However, waterborne pathogens are still prevalent in the watershed, as viruses (bocavirus, hepatitis E and A viruses, norovirus, and enterovirus G), bacteria (Campylobacter spp., Clostridium spp., enterohemorrhagic and enterotoxigenic Escherichia coli, uropathogenic E. coli, Enterococcus faecalis, Helicobacter spp., Salmonella spp., and Vibrio spp.), and eukaryotes (Acanthamoeba spp., Entamoeba histolytica, and Naegleria fowleri) were detected. A comparison of the stream microbial ecology with that of sewage, cattle, and swine fecal samples revealed that human sources of fecal contamination dominate in the watershed. The methodology presented is applicable to a wide range of impaired streams for the identification of human health risk due to waterborne pathogens and for the identification of areas for remediation efforts.IMPORTANCE The direct detection of waterborne pathogens in water overcomes many of the limitations of the fecal indicator paradigm. Furthermore, the identification of the source of fecal impairment aids in identifying areas for remediation efforts. Multitarget gene microarrays are shown to simultaneously identify waterborne pathogens and aid in determining the sources of impairment, enabling further focused investigations. This study shows the use of this methodology in a historically impaired watershed in which total maximum daily load reductions have been successfully implemented to reduce risk. The results suggest that while the fecal indicators have been reduced more than 96% and are nearing recreational water criterion levels, pathogens are still detectable in the watershed. Microbial source tracking results show that additional remediation efforts are needed to reduce the impact of human sewage in the watershed.

Whole community transcriptome of a sequencing batch reactor transforming 2,4-dinitroanisole (DNAN) and 3-nitro-1,2,4-triazol-5-one (NTO).

Two sequencing batch reactors (SBRs) were run to bio-mineralize 2,4-dinitroanisole (DNAN) and 3-nitro-1,2,4-triazol-5-one (NTO) in lab scale settings. The reactors were shown to reproducibly biotransform these munitions under aerobic and anaerobic conditions during the operations of these SBRs. Complete removal (100% biotransformation) of DNAN (initially 17.7 ± 5.4 mg L-1) and NTO (initially 15.0 ± 7.1 mg L-1) was observed in an anaerobic SBR when Luria-Bertani (LB) broth was present. In contrast, an aerobic SBR degraded only 58 ± 22% of DNAN (initially 19.7 ± 6.2 mg L-1) and 45 ± 24% of NTO (initially 9.7 ± 6.3 mg L-1) when either LB or glucose was also added indicating that anaerobic conditions are more favorable for biotransformation of these munitions. Transcriptomic analysis of the DNAN and NTO degrading anaerobic SBR revealed upregulation of a putative nitroreductase, hydroxylaminophenol mutases, 4-hydroxylphenyl acetate associated genes, and quinone oxioreductases. Major Bacterial populations included Bacteroidales, Campylobacterales, Enterobacteriales, Pseudomonadales, Burkholderiales and Clostridiales. Results from this study can be used to inform investigation of munition degrading organisms and the functional genes responsible.

Transport and attenuation of Salmonella enterica, fecal indicator bacteria and a poultry litter marker gene are correlated in soil columns.

Millions of tons of fecal-contaminated poultry litter are applied to U.S. agricultural fields annually. Precipitation and irrigation facilitate transport of fecal-derived pathogens and fecal indicator bacteria (FIB) to groundwater. The goal of this study was to compare transport of pathogens, FIB, and a microbial source tracking marker gene for poultry litter (LA35) in a simulated soil-to-groundwater system. Nine laboratory soil columns containing four different soil types were used to evaluate microbial transport to groundwater via infiltration. Quantitative polymerase chain reaction was used to monitor Salmonella enterica Typhimurium, Escherichia coli, Enterococcus spp., Brevibacterium sp. LA35 and Bacteroidales leached from soil columns inoculated with poultry litter. S. enterica was correlated with LA35 poultry litter marker gene and FIB concentrations in column soils containing organic matter, but not in acid washed sands. In contrast, S. enterica was found to correlate with LA35 and FIB in the leachate from columns containing sand, but not with leachate from organic soil columns. The majority of recovered DNA was found in leachate of predominately sandy soil columns, and in the soil of loamy columns. At least 90% of the DNA retained in soils for each microbial target was found in the top 3cm of the column. These studies suggest that poultry litter associated pathogens and FIB are rapidly released from litter, but are influenced by complex attenuation mechanisms during infiltration, including soil type. This study advances our understanding of the potential for subsurface transport of poultry litter associated pathogens and FIB, and support the use of the LA35 marker gene for evaluating poultry litter impacts on groundwater.

Increased body weight affects academic performance in university students.

For K-12 students, obesity has been linked to student educational achievements. The study objective was to determine whether academic performance in university students is correlated with BMI. Students from two consecutive academic years (Jan-May 2013 and Jan-May 2014) were given an optional class survey in May, as extra credit. Of the 452 students that completed the survey, 204 females and 75 males (N = 279; 73% female and 27% male) consented to participate in the study. The number of correct answers to problem-solving questions (PSQs) and the overall final grade for the class were compared to the calculated BMI using linear regression with a Pearson's R correlation and unpaired t-tests. BMI was significantly negatively correlated with student's final grades (P = 0.001 Pearson's r = - 0.190) and PSQs were positively correlated with final grades (P < 0.001; Pearson's r = 0.357). Our findings show a correlation between healthy body weight and improved academic performance. Further, the data suggest that future research in the area of body weight, diet, and exercise and any correlations of these with academic performance in college students are warranted.

Resistance exercise training and in vitro skeletal muscle oxidative capacity in older adults.

Whether resistance exercise training (RET) improves skeletal muscle substrate oxidative capacity and reduces mitochondrial production of reactive oxygen species in older adults remains unclear. To address this, 19 older males (≥60 years) were randomized to a RET (n = 11) or to a waitlist control group (n = 8) that remained sedentary for 12 weeks. RET was comprised of three upper body and four lower body movements on resistance machines. One set of 8-12 repetitions to failure of each movement was performed on three nonconsecutive days/week. Improvements in chest press and leg press strength were assessed using a three-repetition maximum (3 RM). Body composition was assessed via dual energy X-ray absorptiometry. Muscle biopsies were obtained from the vastus lateralis muscle at baseline and at both 3 weeks and 12 weeks. Palmitate and pyruvate oxidation rates were measured from the (14)CO2 produced from [1-(14)C] palmitic acid and [U-(14)C] pyruvate, respectively, during incubation of muscle homogenates. PGC-1α, TFAM, and PPARδ levels were quantified using qRT-PCR Citrate synthase (CS) and ß-HAD activities were determined spectrophotometrically. Mitochondrial production of reactive oxygen species (ROS) were assessed using the Amplex Red Hydrogen Peroxide/Peroxidase assay. There were no significant changes in body weight or body composition following the intervention. Chest press and leg press strength (3RM) increased ~34% (both P < 0.01) with RET There were no significant changes in pyruvate or fatty acid oxidation or in the expression of target genes with the intervention. There was a modest increase (P < 0.05) in ßHAD activity with RET at 12 weeks but the change in CS enzyme activity was not significant. In addition, there were no significant changes in ROS production in either group following RET Taken together, the findings of this study suggest that 12 weeks of low volume RET does not increase skeletal muscle oxidative capacity or reduce ROS production in older adults.

Management of acute pediatric pain in the emergency department.

PURPOSE OF REVIEW: This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic. RECENT FINDINGS: Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow. SUMMARY: The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.

Selective overexpression of Toll-like receptor-4 in skeletal muscle impairs metabolic adaptation to high-fat feeding.

Toll-like receptor-4 (TLR-4) is elevated in skeletal muscle of obese humans, and data from our laboratory have shown that activation of TLR-4 in skeletal muscle via LPS results in decreased fatty acid oxidation (FAO). The purpose of this study was to determine whether overexpression of TLR-4 in skeletal muscle alters mitochondrial function and whole body metabolism in the context of a chow and high-fat diet. C57BL/6J mice (males, 6-8 mo of age) with skeletal muscle-specific overexpression of the TLR-4 (mTLR-4) gene were created and used for this study. Isolated mitochondria and whole muscle homogenates from rodent skeletal muscle (gastrocnemius and quadriceps) were investigated. TLR-4 overexpression resulted in a significant reduction in FAO in muscle homogenates; however, mitochondrial respiration and reactive oxygen species (ROS) production did not appear to be affected on a standard chow diet. To determine the role of TLR-4 overexpression in skeletal muscle in response to high-fat feeding, mTLR-4 mice and WT control mice were fed low- and high-fat diets for 16 wk. The high-fat diet significantly decreased FAO in mTLR-4 mice, which was observed in concert with elevated body weight and fat, greater glucose intolerance, and increase in production of ROS and cellular oxidative damage compared with WT littermates. These findings suggest that TLR-4 plays an important role in the metabolic response in skeletal muscle to high-fat feeding.

Early skeletal muscle adaptations to short-term high-fat diet in humans before changes in insulin sensitivity.

OBJECTIVE: The purpose of this investigation was to understand the metabolic adaptations to a short-term (5 days), isocaloric, high-fat diet (HFD) in healthy, young males. METHODS: Two studies were undertaken with 12 subjects. Study 1 investigated the effect of the HFD on skeletal muscle substrate metabolism and insulin sensitivity. Study 2 assessed the metabolic and transcriptional responses in skeletal muscle to the transition from a fasted to fed state using a high-fat meal challenge before and after 5 days of the HFD. RESULTS: Study 1 showed no effect of a HFD on skeletal muscle metabolism or insulin sensitivity in fasting samples. Study 2 showed that a HFD elicits significant increases in fasting serum endotoxin and disrupts the normal postprandial excursions of serum endotoxin, as well as metabolic and transcriptional responses in skeletal muscle. These effects after 5 days of the HFD were accompanied by an altered fasting and postprandial response in the ratio of phosphorylated- to total-p38 protein. These changes all occurred in the absence of alterations in insulin sensitivity. CONCLUSIONS: Our findings provide evidence for early biological adaptations to high-fat feeding that proceed and possibly lead to insulin resistance.

Angiotensin II receptor blockade and skeletal muscle metabolism in overweight and obese adults with elevated blood pressure.

OBJECTIVES: Whether angiotensin II receptor blockade improves skeletal muscle fatty acid oxidation in overweight and obese humans is unknown. The purpose of the study was to test the hypothesis that the angiotensin II receptor blocker, olmesartan, would increase fatty acid oxidation and the activity of enzymes associated with oxidative metabolism in skeletal muscle of overweight and obese humans. METHODS: A total of 12 individuals (6 men and 6 women) aged 18-75 and with a body mass index ⩾25 kg/m2 were assigned to olmesartan or placebo for 8 weeks in a crossover fashion. Fatty acid oxidation was measured before and after each intervention by counting the (14)CO2 produced from [1-(14)C] palmitic acid in skeletal muscle homogenates. RESULTS: Fatty acid oxidation was not significantly different between treatment periods at baseline and post intervention. In addition, the enzyme activities of citrate synthase and ß-hydroxyacyl-coenzyme A dehydrogenase in skeletal muscle homogenates did not differ between treatment periods at baseline or post intervention. CONCLUSIONS: Treatment with olmesartan for 8 weeks does not improve fatty acid oxidation or the activity of enzymes associated with oxidative metabolism in skeletal muscle from overweight and obese individuals. Taken together, our results indicate that improvements in skeletal muscle metabolism are not among the additional benefits of olmesartan that extend beyond blood pressure reduction.

Low levels of lipopolysaccharide modulate mitochondrial oxygen consumption in skeletal muscle.

OBJECTIVE: We have previously demonstrated that activation of toll-like receptor 4 (TLR4) in skeletal muscle results in an increased reliance on glucose as an energy source and a concomitant decrease in fatty acid oxidation under basal conditions. Herein, we examined the effects of lipopolysaccharide (LPS), the primary ligand for TLR4, on mitochondrial oxygen consumption in skeletal muscle cell culture and mitochondria isolated from rodent skeletal muscle. MATERIALS/METHODS: Skeletal muscle cell cultures were exposed to LPS and oxygen consumption was assessed using a Seahorse Bioscience extracellular flux analyzer. Mice were also exposed to LPS and oxygen consumption was assessed in mitochondria isolated from skeletal muscle. RESULTS: Acute LPS exposure resulted in significant reductions in Carbonyl cyanide 4-(trifluoromethoxy) phenylhydrazone (FCCP)-stimulated maximal respiration (state 3u) and increased oligomycin induced state 4 (state 4O) respiration in C2C12 and human primary myotubes. These findings were observed in conjunction with increased mRNA of uncoupling protein 3 (UCP3), superoxide dismutase 2 (SOD2), and pyruvate dehydrogenase activity. The LPS-mediated changes in substrate oxidation and maximal mitochondrial respiration were prevented in the presence of the antioxidants N-acetylcysteine and catalase, suggesting a potential role of reactive oxygen species in mediating these effects. Mitochondria isolated from red gastrocnemius and quadriceps femoris muscle from mice injected with LPS also demonstrated reduced respiratory control ratio (RCR), and ADP- and FCCP-stimulated respiration. CONCLUSION: LPS exposure in skeletal muscle alters mitochondrial oxygen consumption and substrate preference, which is absent when antioxidants are present.

Ovarian tumor-initiating cells display a flexible metabolism.

An altered metabolism during ovarian cancer progression allows for increased macromolecular synthesis and unrestrained growth. However, the metabolic phenotype of cancer stem or tumor-initiating cells, small tumor cell populations that are able to recapitulate the original tumor, has not been well characterized. In the present study, we compared the metabolic phenotype of the stem cell enriched cell variant, MOSE-LFFLv (TIC), derived from mouse ovarian surface epithelial (MOSE) cells, to their parental (MOSE-L) and benign precursor (MOSE-E) cells. TICs exhibit a decrease in glucose and fatty acid oxidation with a concomitant increase in lactate secretion. In contrast to MOSE-L cells, TICs can increase their rate of glycolysis to overcome the inhibition of ATP synthase by oligomycin and can increase their oxygen consumption rate to maintain proton motive force when uncoupled, similar to the benign MOSE-E cells. TICs have an increased survival rate under limiting conditions as well as an increased survival rate when treated with AICAR, but exhibit a higher sensitivity to metformin than MOSE-E and MOSE-L cells. Together, our data show that TICs have a distinct metabolic profile that may render them flexible to adapt to the specific conditions of their microenvironment. By better understanding their metabolic phenotype and external environmental conditions that support their survival, treatment interventions can be designed to extend current therapy regimens to eradicate TICs.

Metabolic changes during ovarian cancer progression as targets for sphingosine treatment.

Tumor cells often exhibit an altered metabolic phenotype. However, it is unclear as to when this switch takes place in ovarian cancer, and the potential for these changes to serve as therapeutic targets in clinical prevention and intervention trials. We used our recently developed and characterized mouse ovarian surface epithelial (MOSE) cancer progression model to study metabolic changes in distinct disease stages. As ovarian cancer progresses, complete oxidation of glucose and fatty acids were significantly decreased, concurrent with increases in lactate excretion and (3)H-deoxyglucose uptake by the late-stage cancer cells, shifting the cells towards a more glycolytic phenotype. These changes were accompanied by decreases in TCA flux but an increase in citrate synthase activity, providing substrates for de novo fatty acid and cholesterol synthesis. Also, uncoupled maximal respiration rates in mitochondria decreased as cancer progressed. Treatment of the MOSE cells with 1.5 µM sphingosine, a bioactive sphingolipid metabolite, decreased citrate synthase activity, increased TCA flux, decreased cholesterol synthesis and glycolysis. Together, our data confirm metabolic changes during ovarian cancer progression, indicate a stage specificity of these changes, and suggest that multiple events in cellular metabolism are targeted by exogenous sphingosine which may be critical for future prevention trials.

Sense of place among Atlanta public housing residents.

For almost two decades now, cities around the country have been demolishing traditional public housing and relocating residents to subsidized private market rental housing. In this paper, we examine sense of place, consisting of both community and place attachment, among a sample of Atlanta public housing residents prior to relocation (N = 290). We find that 41% of the residents express place attachment, and a large percentage express some level of community attachment, though residents of senior public housing are far more attached than residents of family public housing. Positive neighborhood characteristics, such as collective efficacy and social support, are associated with community attachment, and social support is also associated with place attachment. Negative neighborhood characteristics, such as social disorder and fear of crime, are not consistently associated with sense of place. We argue that embodied in current public housing relocation initiatives is a real sense of loss among the residents. Policy makers may also want to consider the possibilities of drawing upon residents' sense of place as a resource for renovating and revitalizing public housing communities rather than continuing to demolish them and relocating residents to other neighborhoods.

Effect of delay in presentation on rate of perforation in children with appendicitis.

INTRODUCTION: Appendicitis is the most common emergency operation in children. The rate of perforation may be related to duration from symptom onset to treatment. A recent adult study suggests that the perforation risk is minimal in the first 36 hours and remains at 5% thereafter. We studied a pediatric population to assess symptom duration as a risk factor for perforation. METHODS: We prospectively studied all children older than 3 years who underwent an appendectomy over a 22-month period. RESULTS: Of 202 patients undergoing appendectomies, 197 had appendicitis. Median age was significantly lower in the perforated group, but temperature and leukocytosis were not. As expected, length of hospital stay was longer in the perforated group (4-13 vs 2-6 days). The incidence of perforation was 10% if symptoms were present for less than 18 hours. This incidence rose in a linear fashion to 44% by 36 hours. Prehospital delays were greater in patients with perforated appendicitis. However, in-hospital delay (from presentation to surgery) was less than 5 hours in the perforated group and 9 hours in the nonperforated group. DISCUSSION: Appendiceal perforation in children is more common than in adults and correlates directly with duration of symptoms before surgery. Perforation is more common in younger children. Unlike in adults, the risk of perforation within 24 hours of onset is substantial (7.7%), and it increases in a linear fashion with duration of symptoms. In our experience, however, perforation correlates more with prehospital delay than with in-hospital delay.