Geographic barriers to children's surgical care: A systematic review of existing evidence.

BACKGROUND: Ensuring that children have access to timely and appropriate surgical care is a vital component of comprehensive pediatric care. This study systematically reviews the existing evidence related to geographic barriers in children's surgery. METHODS: Medline and Scopus databases were searched for any English language studies that examined associations between geographic burden (rural residence or distance to care) and a quantifiable outcome within pediatric surgical subspecialties. Two independent reviewers extracted data from each study. RESULTS: From 6331 studies screened, 22 studies met inclusion criteria. Most studies were retrospective analyses and conducted in the U.S. or Canada (14 and three studies, respectively); five were conducted outside North America. In transplant surgery (seven studies), greater distance from a transplant center was associated with higher waitlist mortality prior to kidney and liver transplantation, although graft outcomes were generally similar. In congenital cardiac surgery (five studies), greater travel was associated with higher neonatal mortality and older age at surgery but not with post-operative outcomes. In general surgery (eight studies), rural residence was associated with increased rates of perforated appendicitis, higher frequency of negative appendectomy, and increased length of stay after appendectomy. In orthopedic surgery (one study), rurality was associated with decreased post-operative satisfaction. No evidence for disparate outcomes based upon distance or rurality was identified in neurosurgery (one study). CONCLUSIONS: Substantial evidence suggests that geographic barriers impact the receipt of surgical care among children, particularly with regard to transplantation, congenital cardiac surgery, and appendicitis.

Fibroepithelial papillomatosis ("skin tags") in Rabson-Mendenhall syndrome.

Rabson-Mendenhall syndrome is a rare autosomal recessive syndrome in children involving a defective insulin receptor gene. Several phenotypic features are common to this syndrome, including severe hyperinsulinemia, growth retardation, acanthosis nigricans, dental dysplasia, hirsutism, coarse facial features, and pineal hyperplasia. The authors evaluated and treated a patient with Rabson-Mendenhall syndrome who presented with additional notable syndromic sequelae including extensive fibroepithelial papillomatosis ("skin tags"), not previously described to this extent.

Does minimal access mean minimal relationship? Defining the physician-patient relationship in postmodern culture.

Minimal access surgery is a good example of medicine in the postmodern era. It embodies the problems we see in both medicine and society that affect the way physicians and patients interact. The purpose of this article is to evaluate and assess the impact of these factors on the focused relationship between the physician and patient. We will discuss how minimal access surgery may be the start of a "new medicine" to benefit both patient and physician.