Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis.

Importance: Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown. Objective: To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs. Design, Setting, and Participants: This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023. Exposures: Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter. Main Outcomes and Measures: The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state. Results: There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients. Conclusions and Relevance: In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.

Achieving global surgical excellence: an evidence-based framework to guide surgical quality improvement programs in low and middle income countries.

Objectives: There is a lack of evidence-based guidelines for enhancing global surgical care delivery. We propose a set of recommendations to serve as a framework to guide surgical quality improvement and scale-up initiatives in low and middle income countries (LMICs). Methods: From January-December 2019, we reviewed the available literature and their application toward LMIC settings. The first initiative was the establishment of Best Practices Recommendations intended to summarize best-level evidence around quality improvement processes that have shown to decrease morbidity and mortality in LMICs. The GRADE level of evidence and strength of the recommendation were assigned in accordance with the WHO handbook for guidelines development. The second initiative was the scale-up of principles and practices by establishing international expert consensus on the optimal organization of surgical services in LMICs using a modified Delphi methodology. Results: Recommendations for three topic areas were established: reducing surgical site infections, improving quality of trauma systems, and interventions to reduce maternal and perinatal mortality. 27 studies were included in a quantitative synthesis and meta-analysis for interventions reducing surgical site infections, 27 studies for interventions improving the quality of trauma systems, and 14 studies for interventions reducing maternal and perinatal mortality. Using Delphi methodology, an international expert panel established consensus that district hospitals should place the highest priority on developing surgical services for low complexity, high volume conditions. At the national level, emergency and essential surgical care should be integrated within national Universal Health Coverage frameworks. Conclusions: This project fills a critical cap in the rapidly developing field of global surgery: gathering evidence-based, practical, and cost-effective solutions that will serve as a guide for the efficient planning and allocation of resources necessary to promote quality and safe essential surgical services in LMICs.

Mean platelet volume and mortality in patients with alcohol use disorder.

Several recent studies have pointed out the relationship of platelet size with increased mortality or adverse clinical course. Most studies show that increased mean platelet volume (MPV) may be associated with a deleterious outcome in different settings such as sepsis or neoplasia, whereas other researchers have found the opposite. In inflammatory conditions there is an altered secretion of several cytokines, some of them exerting a marked influence on platelet biogenesis and/or on platelet activation and aggregation. Alcohol use disorder is a chronic situation characterized by a protracted low-grade inflammation. In this study we analyze the relationship between proinflammatory cytokines and MPV and their relationships with mortality in patients with alcohol abuse. We determined serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6 and IL-8 and routine laboratory variables among 184 patients with alcohol use disorder admitted to our hospital and followed-up for a median of 42 months. We found that MPV was inversely related to TNF-α (ρ=-0.34), and directly to IL-8 (ρ=0.32, p<0.001 in both cases) and to IL-6 (ρ=0.15; p = 0.046). Reduced MPV was related both with short-term (<6 months) and long-term mortality. Conclusion: These results suggest that inflammatory cytokines are strongly related to MPV. A low MPV is associated with a poor prognosis among patients with alcohol use disorder.

Patient and Hospital Characteristics Associated With Delayed Diagnosis of Appendicitis.

Importance: Racial disparities in timely diagnosis and treatment of surgical conditions exist; however, it is poorly understood whether there are hospital structural measures or patient-level characteristics that modify this phenomenon. Objective: To assess whether patient race and ethnicity are associated with delayed appendicitis diagnosis and postoperative 30-day hospital use and whether there are patient- or systems-level factors that modify this association. Design, Setting, and Participants: This population-based, retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient and emergency department (ED) databases from 4 states (Florida, Maryland, New York, and Wisconsin) for patients aged 18 to 64 years who underwent appendectomy from January 7, 2016, to December 1, 2017. Data were analyzed from January 1, 2016, to December 31, 2017. Exposure: Delayed diagnosis of appendicitis, defined as an initial ED presentation with an abdominal diagnosis other than appendicitis followed by re-presentation within a week for appendectomy. Main Outcomes and Measures: A mixed-effects multivariable Poisson regression model was used to estimate the association of delayed diagnosis of appendicitis with race and ethnicity while controlling for patient and hospital variables. A second mixed-effects multivariable Poisson regression model quantified the association of delayed diagnosis of appendicitis with postoperative 30-day hospital use. Results: Of 80 312 patients who received an appendectomy during the study period (median age, 38 years [IQR, 27-50 years]; 50.8% female), 2013 (2.5%) experienced delayed diagnosis. In the entire cohort, 2.9% of patients were Asian or Pacific Islander, 18.8% were Hispanic, 10.9% were non-Hispanic Black, 60.8% were non-Hispanic White, and 6.6% were other race and ethnicity; most were privately insured (60.2%). Non-Hispanic Black patients had a 1.41 (95% CI, 1.21-1.63) times higher adjusted rate of delayed diagnosis compared with non-Hispanic White patients. Patients at hospitals with a more than 50% Black or Hispanic population had a 0.73 (95% CI, 0.59-0.91) decreased adjusted rate of delayed appendicitis diagnosis compared with hospitals with a less than 25% Black or Hispanic population. Conversely, patients at hospitals with more than 50% of discharges of Medicaid patients had a 3.51 (95% CI, 1.69-7.28) higher adjusted rate of delayed diagnosis compared with hospitals with less than 10% of discharges of Medicaid patients. Additional factors associated with delayed diagnosis included female sex, higher levels of patient comorbidity, and living in a low-income zip code. Delayed diagnosis was associated with a 1.38 (95% CI, 1.36-1.61) increased adjusted rate of postoperative 30-day hospital use. Conclusions and Relevance: In this cohort study, non-Hispanic Black patients had higher rates of delayed appendicitis diagnosis and 30-day hospital use than White patients. Patients presenting to hospitals with a greater than 50% Black and Hispanic population were less likely to experience delayed diagnosis, suggesting that seeking care at a hospital that serves a diverse patient population may help mitigate the increased rate of delayed diagnosis observed for non-Hispanic Black patients.

International consensus recommendations for the optimal prioritisation and distribution of surgical services in low-income and middle-income countries: a modified Delphi process.

OBJECTIVES: To develop consensus statements regarding the regional-level or district-level distribution of surgical services in low and middle-income countries (LMICs) and prioritisation of service scale-up. DESIGN: This work was conducted using a modified Delphi consensus process. Initial statements were developed by the International Standards and Guidelines for Quality Safe Surgery and Anesthesia Working Group of the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) and the International Society of Surgery based on previously published literature and clinical expertise. The Guidance on Conducting and REporting DElphi Studies framework was applied. SETTING: The Working Group convened in Suva, Fiji for a meeting hosted by the Ministry of Health and Medical Services to develop the initial statements. Local experts were invited to participate. The modified Delphi process was conducted through an electronically administered anonymised survey. PARTICIPANTS: Expert LMIC surgeons were nominated for participation in the modified Delphi process based on criteria developed by the Working Group. PRIMARY OUTCOME MEASURES: The consensus panel voted on statements regarding the organisation of surgical services, principles for scale-up and prioritisation of scale-up. Statements reached consensus if there was ≥80% agreement among participants. RESULTS: Fifty-three nominated experts from 27 LMICs voted on 27 statements in two rounds. Ultimately, 26 statements reached consensus and comprise the current recommendations. The statements covered three major themes: which surgical services should be decentralised or regionalised; how the implementation of these services should be prioritised; and principles to guide LMIC governments and international visiting teams in scaling up safe, accessible and affordable surgical care. CONCLUSIONS: These recommendations represent the first step towards the development of international guidelines for the scaling up of surgical services in LMICs. They constitute the best available basis for policymaking, planning and allocation of resources for strengthening surgical systems.

Interventions Addressing Social Needs in Perinatal Care: A Systematic Review.

Introduction: Health is impacted by a wide range of nonmedical factors, collectively termed the social determinants of health (SDoH). As the mechanisms by which these factors influence wellness and disease continue to be uncovered, health systems are beginning to assess their roles in addressing patient's social needs. This study seeks to identify and analyze clinic-based interventions aimed at addressing patients' social needs in perinatal care, including prenatal, antepartum, and postpartum care. Methods: We conducted a search of six databases through May 2020 for articles describing screening or intervention activities addressing social needs in at least one SDoH domain as defined by Healthy People 2020. We required that studies include pregnant or postpartum women and be based in a clinical setting. Results: Thirty-one publications describing 26 unique studies were identified. Most studies were either randomized-controlled trials (n=10) or observational studies (n=7) and study settings were both public and private. The mean age of women ranged from 17.4 to 34.1 years. Most studies addressed intimate partner violence (n=19). The next most common need addressed was social support (n=5), followed by food insecurity (n=3), and housing (n=2). Types of interventions varied from simple screening to ongoing counseling and case management. There was wide heterogeneity in outcomes investigated. Most IPV interventions that included counseling or ongoing support resulted in reduced IPV recurrence and severity. No intervention with only screening showed a reduction in rate of IPV. Conclusion: This systematic review shines light on several avenues to support pregnant and postpartum women through interventions that embed acknowledgment of social needs and actions addressing these needs into the clinical environment. The results of this review suggest that interventions with counseling or ongoing support may show promise in alleviating social risk factors and improving some clinical outcomes. However, the strength of this evidence is limited by the paucity of studies. More rigorous research is imperative to augment the knowledge of social needs interventions, especially in domains outside of IPV.

A hyperoxic lung injury model in premature rabbits: the influence of different gestational ages and oxygen concentrations.

BACKGROUND: Many animal models have been developed to study bronchopulmonary dysplasia (BPD). The preterm rabbit is a low-cost, easy-to-handle model, but it has a high mortality rate in response to the high oxygen concentrations used to induce lung injury. The aim of this study was to compare the mortality rates of two models of hyperoxia-induced lung injury in preterm rabbits. METHODS: Pregnant New Zealand white rabbits were subjected to caesarean section on gestational day 28 or 29 (full term  = 31 days). The premature rabbits in the 28-day gestation group were exposed to room air or FiO2 ≥95%, and the rabbits in the 29-day gestation group were exposed to room air or FiO2  = 80% for 11 days. The mean linear intercept (Lm), internal surface area (ISA), number of alveoli, septal thickness and proportion of elastic and collagen fibers were quantified. RESULTS: The survival rates in the 29-day groups were improved compared with the 28-day groups. Hyperoxia impaired the normal development of the lung, as demonstrated by an increase in the Lm, the septal thickness and the proportion of elastic fibers. Hyperoxia also decreased the ISA, the number of alveoli and the proportion of collagen fibers in the 28-day oxygen-exposed group compared with the control 28-day group. A reduced number of alveoli was found in the 29-day oxygen exposed animals compared with the control 29-day group. CONCLUSIONS: The 29-day preterm rabbits had a reduced mortality rate compared with the 28-day preterm rabbits and maintained a reduction in the alveoli number, which is comparable to BPD in humans.

Aislamiento de Candida albicans de hisopado nasal y faríngeo en alumnos de secundaria / Isolation of Candida albicans from high school students' nasal and throat samples

Introducción: Candida sp puede encontrarse como comensal en equilibrio en la cavidad bucal humana; pero, en la población pediátrica y adolescente con un sistema inmune inmaduro las condiciones de la levadura se tornarían favorables para su patogenia. Objetivo: Determinar la presencia de Candida albicans en secreción faríngea y nasal en alumnos de educación secundaria. Diseño: Estudio descriptivo transversal. Lugar: Instituto de Medicina Tropical, Universidad Nacional Mayor de San Marcos, Lima, Perú. Participantes: Alumnos del 4to (52) y 5to (50) años de secundaria. Intervenciones: En octubre del 2007, las muestras nasales y faríngeas de 102 estudiantes de 14 a 17 años fueron colectadas en medios de transporte y luego cultivadas en los laboratorios del Instituto de Medicina Tropical, en agar sabouraud y CHROMOagar Candida. Se identificó las colonias sospechosas de Candida sp mediante el estudio de clamiodoconidias, tubo germinativo y pruebas metabólicas. Principales medidas de resultados: Identificación de levaduras de Candida sp. Resultados: Se aisló levaduras del género Candida en 11 de los escolares (10,8 por ciento). El 36,4 por ciento de las levaduras presentó resistencia moderada al antimicótico fluconazol. Conclusiones: Es recomendable continuar con estudios de vigilancia epidemiológica sobre las levaduras de importancia médica en portadores nasofaríngeos, con el fin estar preparados ante eventuales cuadros infecciosos...

Objective: To determine the presence of Candida albicans in throat and nasal secretion in high school students. Design: Cross-sectional study. Setting: Institute of Tropical Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru. Participants: High school students from San Juan Macias School in Santa Anita, Lima, Peru. Interventions: Nasal and throat samples were collected from 102 14-17 year-old students. Samples were grown on sabouraud agar and Candida CHROMOagar and identified by chlamydospores study and metabolic tests. Main outcome measures: Identification of C. albicans yeast. Results: Candida yeast was isolated from 11 students (10.8 per cent). A significant percentage of yeast (36.4 per cent) developed moderate resistance to fluconazole. Conclusions: Continuous surveillance of medically important yeasts in nasopharyngeal carriers is suggested in order to be prepared for eventual infectious conditions...