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Chorozoglou M, Reading I, Eaton S, Naqvi S, Pardy C, Sloan K, Major C, Demellweek N, Hall NJ. Assessing micro- vs macro-costing approaches for treating appendicitis in children with appendicectomy or non-operatively. Qual Life Res 2023; 32:2987-2999. [PMID: 37286916 PMCID: PMC10473981 DOI: 10.1007/s11136-023-03442-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVES We conducted a health economic sub-study within a feasibility RCT comparing a non-operative treatment pathway as an alternative to appendicectomy for the treatment of uncomplicated acute appendicitis in children. The objectives were to understand and assess data collection tools and methods and to determine indicative costs and benefits assessing the feasibility of conducting a full economic evaluation within the definitive trial. METHODS We compared different methods of estimating treatment costs including micro-costing, hospital administrative data (PLICS) and health system (NHS) reference costs. We compared two different HRQoL instruments (CHU-9D and EQ-5D-5L) in terms of data completeness and sensitivity to change over time, including potential ceiling effects. We also explored how the timing of data collection and duration of the analysis could affect QALYs (Quality Adjusted Life Years) and the results of the cost-utility analysis (CUA) within the future RCT. RESULTS Using a micro-costing approach, the total per treatment costs were in alignment with hospital administrative data (PLICS). Average health system reference cost data (macro-costing using NHS costs) could potentially underestimate these treatment costs, particularly for non-operative treatment. Costs incurred following hospital discharge in the primary care setting were minimal, and limited family borne costs were reported by parents/carers. While both HRQoL instruments performed relatively well, our results highlight the problem of ceiling effect and the importance of the timing of data collection and the duration of the analysis in any future assessment using QALYs and CUA. CONCLUSIONS We highlighted the importance of obtaining accurate individual-patient cost data when conducting economic evaluations. Our results suggest that timing of data collection and duration of the assessment are important considerations when evaluating cost-effectiveness and reporting cost per QALY. CLINICAL TRIAL REGISTRATION Current Controlled Trials ISRCTN15830435.
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Affiliation(s)
| | - Isabel Reading
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Simon Eaton
- Department of Population Health Sciences, University College London Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Shehryer Naqvi
- St George’s University Hospital NHS Foundation Trust, London, UK
| | - Caroline Pardy
- St George’s University Hospital NHS Foundation Trust, London, UK
| | - Keren Sloan
- Southampton Children’s Hospital, Southampton, UK
| | | | | | - Nigel J. Hall
- Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton Children’s Hospital, Southampton, UK
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Selman AMR, Sogbodjor LA, Williams K, Davenport M, Ramani Moonesinghe S. Structural indicators of quality care for children undergoing emergency abdominal surgery. Br J Surg 2023; 110:1100-1103. [PMID: 37079729 DOI: 10.1093/bjs/znad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Andrew M R Selman
- Department of Paediatric Anaesthesia, Evelina London Children's Hospital, London, UK
| | - Lisa A Sogbodjor
- Department of Paediatric Anaesthesia, Great Ormond Street Hospital for Children, London, UK
| | - Karen Williams
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - S Ramani Moonesinghe
- Department of Anaesthetics and Critical Care Medicine, University College London, London, UK
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Kakembo N, Grabski DF, Situma M, Ajiko M, Kayima P, Nyeko D, Shikanda A, Okello I, Tumukunde J, Nabukenya M, Ogwang M, Kisa P, Muzira A, Ruzgar N, Fitzgerald TN, Sekabira J, Ozgediz D. Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis. J Surg Res 2023; 286:23-34. [PMID: 36738566 DOI: 10.1016/j.jss.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 12/05/2022] [Accepted: 12/24/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. MATERIALS AND METHODS Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. RESULTS A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. CONCLUSIONS This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.
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Affiliation(s)
- Nasser Kakembo
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Hospital, Mbarara, Uganda
| | - Margaret Ajiko
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Peter Kayima
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - David Nyeko
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Anne Shikanda
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Innocent Okello
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Martin Ogwang
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Nensi Ruzgar
- Yale University School of Medicine, New Haven, Connecticut
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John Sekabira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University of California, San Francisco, California
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Narayanan H, Raistrick C, Tom Pierce JM, Shelton C. Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study. Br J Anaesth 2022; 129:231-243. [PMID: 35729012 DOI: 10.1016/j.bja.2022.04.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Tackling the climate emergency is now a key target for the healthcare sector. Avoiding inhalational anaesthesia is often cited as an important element of reducing anaesthesia-related emissions. However, evidence supporting this is based on adult practice. The aim of this study was to identify the difference in carbon footprint of inhalational and i.v. anaesthesia when used in children. METHODS We used mathematical simulation models to compare general anaesthetic techniques in children weighing 5-50 kg for TIVA, i.v. induction then inhalational maintenance, inhalational induction then i.v. maintenance, and inhalational induction and maintenance. We simulated inhalational induction with sevoflurane alone, and co-induction with sevoflurane and nitrous oxide, and both remifentanil-propofol and propofol-only i.v. anaesthesia. For each technique, we drew on previously published life-cycle data to calculate carbon dioxide equivalents for anaesthetic durations up to 480 min. RESULTS TIVA with propofol and remifentanil had a smaller carbon footprint over a typical anaesthetic duration of 60 min (1.26 kg carbon dioxide equivalents [CO2e] for a 20 kg child) than i.v. induction followed by inhalational maintenance (2.58 kg CO2e) or inhalational induction and maintenance (2.98 kg CO2e). Inhalational induction followed by i.v. maintenance only had a lower carbon footprint than inhalational induction and maintenance when used in longer procedures (>77 min for children 5-20 kg; >105 min for children 30-50 kg). CONCLUSIONS In a simulation study, i.v. anaesthesia had climate benefits in paediatric anaesthesia. However, when used after inhalational induction, benefits were only achieved in longer procedures. These findings provide evidence-based guidance for reducing the environmental impact of paediatric anaesthesia, but these will require confirmation using real-world data.
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Affiliation(s)
- Hrishi Narayanan
- North West School of Anaesthesia, Health Education England North West, Manchester, UK.
| | - Christopher Raistrick
- Department of Anaesthesia, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - J M Tom Pierce
- Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Clifford Shelton
- Department of Anaesthesia, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Lancaster Medical School, Lancaster University, Lancaster, UK
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Abstract
PURPOSE OF REVIEW Neonates have a high risk of perioperative morbidity and mortality. The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) investigated the anesthesia practice, complications and perioperative morbidity and mortality in neonates and infants <60 weeks post menstrual age requiring anesthesia across 165 European hospitals. The goal of this review is to highlight recent publications in the context of the NECTARINE findings and subsequent changes in clinical practice. RECENT FINDINGS A perioperative triad of hypoxia, anemia, and hypotension is associated with an increased overall mortality at 30 days. Hypoxia is frequent at induction and during maintenance of anesthesia and is commonly addressed once oxygen saturation fall below 85%.Blood transfusion practices vary widely variable among anesthesiologists and blood pressure is only a poor surrogate of tissue perfusion. Newer technologies, whereas acknowledging important limitations, may represent the currently best tools available to monitor tissue perfusion. Harmonization of pediatric anesthesia education and training, development of evidence-based practice guidelines, and provision of centralized care appear to be paramount as well as pediatric center referrals and international data collection networks. SUMMARY The NECTARINE provided new insights into European neonatal anesthesia practice and subsequent morbidity and mortality.Maintenance of physiological homeostasis, optimization of oxygen delivery by avoiding the triad of hypotension, hypoxia, and anemia are the main factors to reduce morbidity and mortality. Underlying and preexisting conditions such as prematurity, congenital abnormalities carry high risk of morbidity and mortality and require specialist care in pediatric referral centers.
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Ghani R, O’Connor A, Sajid I, Johnson G, Ullah S. Diagnostic accuracy of ultrasound in the paediatric population with acute right iliac fossa pain, our District General Hospital experience. THE ULSTER MEDICAL JOURNAL 2022; 91:26-29. [PMID: 35169335 PMCID: PMC8835414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/05/2021] [Indexed: 10/31/2022]
Abstract
AIM This project aimed to evaluate the role of ultrasound scan (USS) in children presenting with acute onset right iliac fossa (RIF) pain and suspected appendicitis. METHODS We retrospectively studied 100 consecutive children undergoing USS for RIF pain. Children with low to moderate clinical probability of appendicitis were seen by the surgical team and subsequently underwent USS by a radiologist or a sonographer with a special interest in paediatric USS. The clinical findings, blood tests, and radiological diagnosis led to a decision to operate, observe or discharge. USS findings were subsequently verified with the final histology. The six-month follow-up data of these patients were also analysed. RESULTS 35 males, median age of 11 years (range 4-17), and 65 females, median age of 14 years (range 6-18) were included. A total of 23 appendicectomies were performed. On histology appendicitis was confirmed in 20, including 16 pre-operatively diagnosed on USS. 6 of these appendicectomies were performed on clinical suspicion with normal USS. 1 patient was diagnosed with neuroendocrine tumour of the appendix. Only 2 negative appendicectomies were performed. 62 patients were discharged without intervention. USS sensitivity was 74%, and specificity was 92% for appendicitis. An additional 16 patients were identified with alternate pathology including 5 ovarian cysts. CONCLUSION Appendicitis was more common in male patients; however, there was no difference in overall disease prevalence in male or female paediatric patients. Thus, USS is a valuable tool to exclude appendicitis in children with low to moderate probability.
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Management of Gastroschisis: Results From the NETS2G Study, a Joint British, Irish, and Canadian Prospective Cohort Study of 1268 Infants. Ann Surg 2021; 273:1207-1214. [PMID: 33201118 DOI: 10.1097/sla.0000000000004217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In infants with gastroschisis, outcomes were compared between those where operative reduction and fascial closure were attempted ≤24 hours of age (PC), and those who underwent planned closure of their defect >24 hours of age following reduction with a pre-formed silo (SR). SUMMARY OF BACKGROUND DATA Inadequate evidence exists to determine how best to treat infants with gastroschisis. METHODS A secondary analysis was conducted of data collected 2006-2008 using the British Association of Pediatric Surgeons Congenital Anomalies Surveillance System, and 2005-2016 using the Canadian Pediatric Surgery Network.28-day outcomes were compared between infants undergoing PC and SR. Primary outcome was number of gastrointestinal complications. Interactions were investigated between infant characteristics and treatment to determine whether intervention effect varied in sub-groups of infants. RESULTS Data from 341 British and Irish infants (27%) and 927 Canadian infants (73%) were used. 671 infants (42%) underwent PC and 597 (37%) underwent SR. The effect of SR on outcome varied according to the presence/absence of intestinal perforation, intestinal matting and intestinal necrosis. In infants without these features, SR was associated with fewer gastrointestinal complications [aIRR 0.25 (95% CI 0.09-0.67, P = 0.006)], more operations [aIRR 1.40 (95% CI 1.22-1.60, P < 0.001)], more days PN [aIRR 1.08 (95% CI 1.03-1.13, P < 0.001)], and a higher infection risk [aOR 2.06 (95% CI 1.10-3.87, P = 0.025)]. In infants with these features, SR was associated with a greater number of operations [aIRR 1.30 (95% CI 1.17-1.45, P < 0.001)], and more days PN [aIRR 1.06 (95% CI 1.02-1.10, P = 0.003)]. CONCLUSIONS In infants without intestinal perforation, matting, or necrosis, the benefits of SR outweigh its drawbacks. In infants with these features, the opposite is true. Treatment choice should be based upon these features.
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Kotwica A, Shija P, Hampton T, Howard D. The introduction of a paediatric ENT and anaesthesia skills course in Kilimanjaro Christian Medical Centre hospital, (KCMC), Moshi, Tanzania. Trop Doct 2021; 51:375-378. [PMID: 34018887 DOI: 10.1177/00494755211016612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Human factors and a safe operating theatre environment are of paramount importance, wherever surgery is undertaken. The majority of patients in sub-Saharan Africa do not yet have access to safe surgery. The Paediatric ENT Skills and Airway Course introduced and evaluated here was designed to improve outcomes and safety in a typical East African environment. The lectures, tutorials and practicals covered technical and non-technical skills. Responses from pre- and post-course questionnaires were evaluated as an initial surrogate for effectiveness of this course. The latter showed improvement in all taught skills and found universal recommendation. The course had been established to try to minimise morbidity and mortality after paediatric surgery at our institution, KCMC. We encouraged team co-operation in the care of patients, and recommend other centres consider similar courses building on human factors for safer operating theatre working practices.
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Affiliation(s)
- Aleksandra Kotwica
- Research fellow, Rhinology and Laryngology Research Fund, Royal National Ear, Nose and Throat Hospital, London, UK
| | - Peter Shija
- ENT Surgical Consultant, Department of ENT, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tom Hampton
- Research fellow, Rhinology and Laryngology Research Fund, Royal National Ear, Nose and Throat Hospital, London, UK.,Research fellow, Department of ENT, Alder Hey Children's Hospital, Liverpool, UK.,Trustee, Institute of Life Course and Medical Sciences, University of Liverpool, University of Liverpool, Merseyside, UK
| | - David Howard
- Research fellow, Rhinology and Laryngology Research Fund, Royal National Ear, Nose and Throat Hospital, London, UK
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Hinton L, Armstrong N. 'They don't know themselves, so how can they tell us?': parents navigating uncertainty at the frontiers of neonatal surgery. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42 Suppl 1:51-68. [PMID: 32275334 DOI: 10.1111/1467-9566.13073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
When a baby is diagnosed with a condition needing surgery they, and their family, start down an uncertain and unknown path. Living with uncertainty underpins every stage of the journey from hospital to home. These journeys span the highly technical to the mundane. They are likely to involve, at crucial points, medicalised and specialised neonatal and surgical care in paediatric centres of excellence where parents are mere spectators. Yet ultimately parents are able to take their baby home, confident experts in their daily care. Drawing on narrative interviews with 42 UK parents whose baby underwent neonatal surgery, this paper explores how parents navigate this uncertainty through acquiring experiential and lay knowledge and developing expertise in their baby's condition and treatment options. These conditions are rare. Building on sociological understandings of the work of chronic illness, as well as more recent work on newborn screening, sharing information online and examinations of experiential knowledge, we explore lay knowledge and expertise as it intersects with biomedical and surgical frontiers. We demonstrate how the development of expertise is an emergent, three-stage process supported by both biomedical and lay knowledge and elucidate this process of knowledge-building as a scaffold through which to manage uncertainty.
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Affiliation(s)
- Lisa Hinton
- Department of Public Health and Primary Care, THIS Institute, University of Cambridge, Cambridge, UK
| | - Natalie Armstrong
- Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester, Leicester, UK
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Tiboni SG, Stewart RJ. Trends in the delivery of elective general paediatric surgery. Ann R Coll Surg Engl 2020; 102:271-276. [PMID: 31918560 DOI: 10.1308/rcsann.2019.0178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION There has been regular dialogue regarding the importance of developing clinical networks to compensate for the steady decline in general paediatric surgery performed by adult surgeons. Despite this dialogue, there are no contemporary published data to quantify the issue. This report documents patterns in delivery of general paediatric surgery in England and shows what is being performed where and by whom. MATERIALS AND METHODS Using the Surgical Workload Outcome Database, we compared hospital-level data between 2009 and 2017. Inclusion criteria were children under 18 years admitted to NHS hospitals in England for elective general paediatric surgery. Data were analysed with an online statistical package performing paired t-tests. RESULTS There was no real change in the overall number of elective general paediatric surgical marker cases, but the type mix has changed. The number of marker cases performed by adult surgeons fell by 34% (4699 vs 3090 p < 0.05). The number of marker cases performed by specialist paediatric surgeons increased by 21% (8184 vs 9862 p < 0.05). This increase in workload occurred in both tertiary (21% increase) and peripheral (18% increase) centres. When analysing data by operation type it was apparent that 78% of the increased workload was attributable to an increase in orchidopexy rate. CONCLUSION Best practice is to treat children close to home by staff with the right skills. This study shows significant shifts in the general paediatric surgical workload. It is important to monitor these trends for successful succession planning as well as configuration of services.
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O'Connell RM, Elwahab SA, Mealy K. Should all paediatric appendicectomies be performed in a specialist or high-volume setting? Ir J Med Sci 2020; 189:1015-1021. [PMID: 31898162 DOI: 10.1007/s11845-019-02156-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Acute appendicitis is a common surgical emergency in children. The majority of appendicectomies in children are performed by general surgeons, rather than specialist paediatric surgeons. AIM To assess the impact of hospital specialization, hospital volume, and surgeon volume on outcomes for children undergoing appendicectomy in Ireland. METHODS NQAIS (National Quality Assurance and Improvement System) data for all appendicectomies performed on children in Ireland between January 2014 and November 2017 was examined. Hospitals were categorized as specialist paediatric centres (SPCs), high-volume general (HVGHs), moderate-volume general (MVGHs), or low-volume general (LVGHs) by annual case volume. Similarly, surgeons were categorized as high-volume (HVSs), moderate-volume (MVSs), or low-volume (LVSs) by annual volume. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care, and readmission rates were collected and analysed. RESULTS About 9593 appendicectomies were performed in 21 hospitals by 134 surgeons. Patients in SPCs had lowest overall rates of laparoscopic surgery (48% v 66% (HVGHs) v 70% (MVGHs) v 57%(LVGHs), p < 0.001). In SPCs 30-day readmission rates were lower for younger children (5.3% for 5-8-year olds v 6.7% (HVGHs) v 7.3%(MVGHs) v 10.5% (LVGHs), p = 0.023). HVSs performed more laparoscopic appendicectomies on younger patients (0-4 years: 40% v 6% (MVSs) v 17%(LVSs), p < 0.001) but performed the least on older children (13-16 years: 76% v 82%(MVSs) v 82%(LVSs), p < 0.001). CONCLUSION Children younger than 8 years undergoing appendicectomy in HVGHs or SPCs, or by HVSs, have marginally better outcomes. In older children, marginally shorter in-hospital stays and higher laparoscopic rates are seen in those looked after outside of high-volume or specialist units. Our results show that nonspecialist centres provide an essential, and safe, service to paediatric patients with acute appendicitis.
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Affiliation(s)
| | - Sami Abd Elwahab
- Department of Surgery, Wexford General Hospital, Wexford, Ireland
| | - Kenneth Mealy
- Department of Surgery, Wexford General Hospital, Wexford, Ireland
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Dell A, Numanoglu A, Arnold M, Rode H. Pediatric surgeon density in South Africa. J Pediatr Surg 2018; 53:2065-2071. [PMID: 29366506 DOI: 10.1016/j.jpedsurg.2017.11.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/07/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are limited data regarding the available pediatric surgical workforce in South Africa and their employment prospects on completion of their specialist training. METHODS This aim of this study was to quantify and analyze the pediatric surgical workforce in South Africa as well as to determine their geographic and sector distribution. This involved a quantitative descriptive analysis of all registered specialist as well as training pediatric surgeons in South Africa. RESULTS The results showed 2.6 pediatric surgeons per one million population under 14 years. More than half (69%) were male and the median age was 46.8 years. There were however, more female surgical registrars currently in training. The majority of the pediatric surgical practitioners were found in Gauteng, followed by the Western Cape and Kwa-Zulu Natal. The majority of specialists reportedly worked in the public sector, however the number of public sector pediatric surgeons available to those without health insurance fell below those available to private patients. CONCLUSION Interprovincial differences as well as intersectoral differences were marked indicating geographic and socioeconomic maldistribution of pediatric surgeons. Addressing this maldistribution requires concerted efforts to expand public sector specialist posts. STUDY TYPE Descriptive audit LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Angela Dell
- Department of Surgery, University of Cape Town Health Sciences Faculty, Groote Schuur Hospital, Observatory, Cape Town, South Africa.
| | - Alp Numanoglu
- Department of Paediatric Surgery, University of Cape Town Health Sciences Faculty, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
| | - Marion Arnold
- Department of Paediatric Surgery, University of Cape Town Health Sciences Faculty, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
| | - Heinz Rode
- Department of Paediatric Surgery, University of Cape Town Health Sciences Faculty, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
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Lansdale N, Al-Khafaji N, Green P, Kenny SE. Population-level surgical outcomes for infantile hypertrophic pyloric stenosis. J Pediatr Surg 2018; 53:540-544. [PMID: 28576429 DOI: 10.1016/j.jpedsurg.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/12/2017] [Accepted: 05/14/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Determine national outcomes for pyloromyotomy; how these are affected by: (i) surgical approach (open/laparoscopic), or (ii) centre type/volume and establish potential benchmarks of quality. METHODS Hospital Episode Statistics data were analysed for admissions 2002-2011. Data presented as median (IQR). RESULTS 9686 infants underwent pyloromyotomy (83% male). Surgery was performed in 22 specialist (SpCen) and 39 nonspecialist centres (NonSpCen). The proportion treated in SpCen increased linearly by 0.4%/year (r=0.76, p=0.01). Annual case volume in SpCen vs. NonSpCen was 40 (24-53) vs. 1 (0-3). Time to surgery was shorter in SpCen (1day [1, 2] vs. 2 [1-3]), but total stay equal (4days [3-6]). 137 (1.4%) had complications requiring reoperation (wound problem 0.6%; repeat pyloromyotomy 0.5% and perforation, bleeding or obstruction 0.2%): pooled rates were similar between SpCen and NonSpCen (1.4% vs. 1.6%, p=0.52). Three NonSpCen had >5% reoperations (within 99.8% C.I. as small denominators). There was no relationship between reoperation and centre volume. Laparoscopic pyloromyotomy had increased risk of repeat pyloromyotomy (OR 2.28 [1.14-4.57], p=0.029). CONCLUSIONS Pyloric stenosis surgery shifted from centres local to patients, but outcomes were unaffected by centre type/volume. Modest reported benefits of laparoscopy appear offset by increased reoperations. Quality benchmarks could be set for reoperation <4%. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level III.
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Khadra C, Le May S, Ballard A, Théroux J, Charette S, Villeneuve E, Parent S, Tsimicalis A, MacLaren Chorney J. Validation of the scale on Satisfaction of Adolescents with Postoperative pain management - idiopathic Scoliosis (SAP-S). J Pain Res 2017; 10:137-143. [PMID: 28138264 PMCID: PMC5238766 DOI: 10.2147/jpr.s124365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Spinal fusion is a common orthopedic surgery in children and adolescents and is associated with high pain levels postoperatively. If the pain is not well managed, negative outcomes may ensue. To our knowledge, there is no measure in English that assesses patient’s satisfaction with postoperative pain management following idiopathic scoliosis surgery. The aim of the present study was to assess the psychometric properties of the satisfaction subscale of the English version of the Satisfaction of Adolescents with Postoperative pain management – idiopathic Scoliosis (SAP-S) scale. Methods Eighty-two participants aged 10–18 years, who had undergone spinal fusion surgery, fully completed the SAP-S scale at 10–14 days postdischarge. Construct validity was assessed through a principal component analysis using varimax rotation. Results Principal component analysis indicated a three-factor structure of the 13-item satisfaction subscale of the SAP-S scale. Factors referred to satisfaction regarding current medication received (Factor 1), actions taken by nurses and doctors to manage pain (Factor 2) and information received after surgery (Factor 3). Cronbach’s alpha was 0.91, showing very good internal consistency. Data on satisfaction and clinical outcomes were also reported. Conclusion The SAP-S is a valid and reliable measure of satisfaction with postoperative pain management that can be used in both research and clinical settings to improve pain management practices. Although it was developed and validated with adolescents who had undergone spinal fusion surgery, it can be used, with further validation, to assess adolescents’ satisfaction with pain management in other postoperative contexts.
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Affiliation(s)
- Christelle Khadra
- Faculty of Nursing, Université de Montréal; CHU Sainte-Justine Research Centre; Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Sylvie Le May
- Faculty of Nursing, Université de Montréal; CHU Sainte-Justine Research Centre
| | - Ariane Ballard
- Faculty of Nursing, Université de Montréal; CHU Sainte-Justine Research Centre
| | - Jean Théroux
- Faculty of Nursing, Université de Montréal; School of Health Professions, Murdoch University, Perth, WA, Australia
| | | | - Edith Villeneuve
- Department of Anesthesia, CHU Sainte-Justine; Department of Anesthesia
| | - Stefan Parent
- CHU Sainte-Justine Research Centre; Department of Surgery, Faculty of Medicine, Université de Montréal; Orthopaedic Service, Department of Surgery, CHU Sainte-Justine
| | - Argerie Tsimicalis
- Ingram School of Nursing, McGill University; Shriners Hospitals for Children, Montreal, QC
| | - Jill MacLaren Chorney
- Pediatric Complex Pain Team, IWK Health Centre; Department of Anesthesia, Pain Management, and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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15
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Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012. Ann Surg 2016; 263:184-90. [DOI: 10.1097/sla.0000000000001099] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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16
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Comparison of the immediate effects of surgical incision on dorsal horn neuronal receptive field size and responses during postnatal development. Anesthesiology 2008; 109:698-706. [PMID: 18813050 DOI: 10.1097/aln.0b013e3181870a32] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pain behavior in response to skin incision is developmentally regulated, but little is known about the underlying neuronal mechanisms. The authors hypothesize that the spatial activation and intensity of dorsal horn neuron responses to skin incision differ in immature and adult spinal cord. METHODS Single wide-dynamic-range dorsal horn cell spike activity was recorded for a minimum of 2 h from anesthetized rat pups aged 7 and 28 days. Cutaneous pinch and brush receptive fields were mapped and von Frey hair thresholds were determined on the plantar hind paw before and 1 h after a skin incision was made. RESULTS Baseline receptive field areas for brush and pinch were larger and von Frey thresholds lower in the younger animals. One hour after the incision, brush and pinch receptive field area, spontaneous firing, and evoked spike activity had significantly increased in the 7-day-old animals but not in the 28-day-old animals. Von Frey hair thresholds decreased at both ages. CONCLUSIONS Continuous recording from single dorsal horn cells both before and after injury shows that sensitization of receptive fields and of background and afferent-evoked spike activity at 1 h is greater in younger animals. This difference is not reflected in von Frey mechanical thresholds. These results highlight the importance of studying the effects of injury on sensory neuron physiology. Injury in young animals induces a marked and rapid increase in afferent-evoked activity in second-order sensory neurons, which may be important when considering long-term effects and analgesic interventions.
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Abstract
The importance of continuing medical education (CME) as a method of improving the quality of care of children undergoing anesthesia is universally recognized. This article, which is based on a presentation at the FEAPA European Conference on Paediatric Anaesthesia in September 2007 in Amsterdam, gives a theoretical overview of continuing education and introduces some generic educational concepts, such as the CRISIS-criteria and Kirkpatrick's evaluation model, which are as relevant to pediatric anesthesia as to other areas of medical practice. The terms CME and continuing professional develop are described. Some consideration is given to how anesthesiologists can assess the potential worth of an educational activity for their practice. No attempt will be made to judge particular educational activities, as the choice of the most appropriate activity rests primarily with the individual.
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Affiliation(s)
- Nigel McBeth Turner
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands.
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