Same-day discharge after appendectomy for uncomplicated appendicitis in children: Potential barriers to increased utilization.

BACKGROUND: Utilization of same-day discharge (SDD) after appendectomy for uncomplicated appendicitis (UA) was closely examined to explore potential barriers to greater use of SDD. METHODS: Children (≤18 years) who underwent appendectomy for UA between 2015 and 2019 at a tertiary care children's hospital were reviewed. Associations with SDD were evaluated using multivariable regression models. RESULTS: Among 973 children, SDD was less frequently utilized after appendectomy performed between 12pm and 5pm (aOR 0.14, p < 0.001) and after 5pm (aOR 0.01, p < 0.001) compared to before 12pm. SDD utilization was also less frequent in those from lower resource neighborhoods (adjusted odds ratio [aOR] 0.90 per decile increase in Area Deprivation Index, p = 0.04), females (aOR 0.53, p = 0.005), and patients residing 30-60 min away (aOR 0.56, p = 0.04) compared to <30 min away. CONCLUSIONS: SDD utilization was primarily impacted by operative timing and socioeconomic and travel factors, focuses for quality improvement efforts to further increase utilization of SDD.

Calvarial lytic lesions in neurosyphilis with ocular involvement.

We report a case of calvarial lytic lesions in neurosyphilis with ocular involvement. A 42-year-old woman with a past medical history of polysubstance abuse presented with recent bilateral vision loss. CT revealed numerous calvarial lytic lesions and multiple myeloma was initially suspected. Syphilis screening with RPR and confirmative CSF studies were positive for active infection. The patient was treated with Penicillin G and demonstrated clinical improvement. The objective of this study was to provide insight into a rare manifestation of syphilis with osseous involvement and encourage further discourse into establishment of standards of care for syphilitic osteomyelitis. There exist no evidence-based guidelines regarding optimal treatment route and duration, role of bone biopsy, determination of therapeutic impact, and threshold for surgical intervention in the management of syphilitic osteomyelitis.

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.

Association of Neighborhood Socioeconomic Disadvantage With Complicated Appendicitis in Children.

BACKGROUND: Lower socioeconomic status (SES) is linked to poorer outcomes for a variety of health conditions in children, potentially through delay in accessing care. The objective of this study was to measure the association between SES and delay in surgical care as marked by presentation with complicated appendicitis (CA). METHODS: Children treated for acute appendicitis between 2015-2019 at a large academic children's hospital were reviewed. Patient home addresses were used to calculate travel time to the children's hospital and to determine Area Deprivation Index (ADI), a neighborhood-level SES marker. Multivariable logistic regression models were used to compare the likelihood of CA across ADI while adjusting for confounders. RESULTS: Of 1,697 children with acute appendicitis, 38.8% had CA. Compared to those with uncomplicated disease, children with CA were younger, lived farther from the children's hospital, and were more likely to have Medicaid insurance and have ED visits in the 30 days preceding diagnosis. Children with CA disproportionately came from disadvantaged neighborhoods (P < 0.007), with 32% from the two most disadvantaged ADI deciles. The odds of CA rose 5% per ADI decile-increase (adjusted odds ratio [aOR] 1.05, 95%CI 1.01-1.09, P = 0.02). Younger age and >60-min travel time were also associated with CA. Association between ADI and CA remained among younger (<10 y) children (aOR 1.07, 95%CI 1.00-1.15, P = 0.048) and those living closer (<30 min) to the hospital (aOR 1.06, 95%CI 1.01-1.11, p=0.02). CONCLUSIONS: ADI is associated with CA among children, suggesting ADI may be a valuable marker of difficulty accessing surgical care among disadvantaged children.