Understanding family-level decision-making when seeking access to acute surgical care for children: Protocol for a cross-sectional mixed methods study.

BACKGROUND: There is limited understanding of how social determinants of health (SDOH) impact family decision-making when seeking surgical care for children. Our objectives of this study are to identify key family experiences that contribute to decision-making when accessing surgical care for children, to confirm if family experiences impact delays in care, and to describe differences in family experiences across populations (race, ethnicity, socioeconomic status, rurality). METHODS: We will use a prospective, cross-sectional, mixed methods design to examine family experiences during access to care for children with appendicitis. Participants will include 242 parents of consecutive children (0-17 years) with acute appendicitis over a 15-month period at two academic health systems in North Carolina and Virginia. We will collect demographic and clinical data. Parents will be administered the Adult Responses to Children's Symptoms survey (ARCS), the child and parental forms of the Adverse Childhood Experiences (ACE) survey, the Accountable Health Communities Health-Related Social Needs Screening Tool, and Single Item Literacy Screener. Parallel ARCS data will be collected from child participants (8-17 years). We will use nested concurrent, purposive sampling to select a subset of families for semi-structured interviews. Qualitative data will be analyzed using thematic analysis and integrated with quantitative data to identify emerging themes that inform a conceptual model of family-level decision-making during access to surgical care. Multivariate linear regression will be used to determine association between the appendicitis perforation rate and ARCS responses (primary outcome). Secondary outcomes include comparison of health literacy, ACEs, and SDOH, clinical outcomes, and family experiences across populations. DISCUSSION: We expect to identify key family experiences when accessing care for appendicitis which may impact outcomes and differ across populations. Increased understanding of how SDOH and family experiences influence family decision-making may inform novel strategies to mitigate surgical disparities in children.

Burkitt-type lymphoma incidentally found as the cause of acute appendicitis: a case report and review of literature.

BACKGROUND: Appendectomy remains one of the most common emergency operations. Recent research supports the treatment of uncomplicated appendicitis with antibiotics alone. While nonoperative management of appendicitis may be safe in some patients, it may result in missed neoplasms. We present a case of acute appendicitis where the final pathology resulted in a diagnosis of a Burkitt-type lymphoma. CASE PRESENTATION: An 18-year-old male presented to the emergency department with 24 h of right lower quadrant pain with associated urinary retention, anorexia, and malaise. Past medical history was significant for intermittent diarrhea and anal fissure. He exhibited focal right lower quadrant tenderness. Workup revealed leukocytosis and CT uncovered acute appendicitis with periappendiceal abscess and no appendicolith. Laparoscopic appendectomy was performed and found acute appendicitis with associated abscess abutting the rectum and bladder. Pathology of the resected appendix reported acute appendicitis with evidence of Burkitt-type lymphoma. A PET scan did not reveal any residual disease. Hematology/oncology was consulted and chemotherapy was initiated with an excellent response. CONCLUSIONS: Appendiceal lymphomas constitute less than 0.1% of gastrointestinal lymphomas. Primary appendix neoplasms are found in 0.5-1.0% of appendectomy specimens following acute appendicitis. In this case, appendectomy allowed for prompt identification and treatment of an aggressive, rapidly fatal lymphoma resulting in complete remission.

Decline in health status of extremely premature neonates with patent ductus arteriosus after second course of medical therapy.

INTRODUCTION: Many neonatal centers offer surgical ligation of patent ductus arteriosus (PDA) after two failed courses of pharmacologic therapy. This study compares health status of extremely premature (< 28 weeks gestation) neonates who failed medical therapy at the time of their second course of medical treatment versus operation. MATERIALS AND METHODS: A retrospective chart review was performed on neonates born at less than 28 weeks gestation who underwent PDA ligation after two rounds of medical therapy over a 7.5-year period. Measurements of health status at the time of the second course of medical therapy and the time of operation were compared. RESULTS: Neonates (n = 34) required less fraction of inspired oxygen (33.5 ± 12.9% vs. 48.5 ± 24%, p < 0.0001), had lower mean airway pressure (7.5 ± 1.9 vs. 9.1 ± 2.4 mm Hg, p < 0.0001), and were less likely to require vasopressor support (16.7 vs. 60%, p = 0.0126) at the time of the start of second course than at surgery. CONCLUSION: Our study suggests that extremely premature neonates show a decline in cardiopulmonary reserve between a second course of medical therapy and surgical intervention.