Resource overutilization in the diagnosis of lymphedema praecox

© 2019 Elsevier Inc. Purpose: Primary lymphedema presenting in adolescence is known as lymphedema praecox. Older children presenting with leg swelling are often subjected to a myriad of diagnostic tests. The purpose of this study is to review a large-cohort of patients with lymphedema praecox to determine the fiscal impact of diagnostic testing on these patients. Methods: A 13-year review was performed of patients with lymphedema praecox. Information was obtained on demographic parameters, diagnostic studies performed, and clinical outcomes. Results: Forty-nine patients were identified. The median age was 14 (range: 7–21) years. Participants were predominantly female (n = 40, 81.6%). 19 patients had bilateral disease and 30 had unilateral disease. The diagnosis was made on clinical exam only in 14 patients. 35 patients had imaging which consisted of plain X rays, Doppler ultrasound (DUS), lymphoscintigraphy (LSG) or MRI as the sole imaging study (n = 28) or in combination with others (n = 7). The charges for plain X-rays, DUS, LSG, and MRI with contrast were $335,$1715, $1269, and$6006 respectively. Conclusion: We believe that in the adolescent female with physical findings consistent with lymphedema praecox, diagnostic imaging should be limited to a Doppler ultrasound to rule out a secondary cause of the swelling. Level of Evidence: IV Type of Evidence: Case series with no comparison group

Lipase hypersecretion syndrome: A rare cutaneous manifestation of advanced pancreatic acinar cell carcinoma

Careful recognition of cutaneous lesions in patients with malignancies may aid in avoiding additional morbidity during end of life care

National Estimates and Factors Influencing Trauma Recidivism in Children Leading to Hospital Readmission

© 2019 Elsevier Inc. Introduction: Trauma is the leading cause of mortality in children. Factors influencing recidivism after major trauma have not been well documented in children. The objective of this study is to determine the burden of pediatric trauma recidivism and to identify predisposing factors in the United States. Methods: The 2010–2015 National Readmissions Database was queried for pediatric patients (≤ 18 years) with a diagnosis of major traumatic injuries. Patients readmitted for major trauma were subsequently identified. Patients that did not survive their index-hospitalization were excluded. Information on mechanism, intent, nature and injury severity including Abbreviated Injury Scale (AIS) and Injury Severity Scores (ISS) was obtained. Multivariable-regression analyses were performed adjusting for demographic, hospital-level and injury characteristics. Results: Of 286,508 pediatric trauma records analyzed, trauma recidivists represented 2.9% of the total population. Recidivists had a higher proportion of severe (AIS ≥ 3) head injury (11.3%). Recidivists were more likely to have public-insurance (OR [95% CI]:1.30[1.25–1.37]), and belong to lower income families (OR [95% CI]:1.22[1.15–1.31]). Recidivism was more common amongst patients with penetrating injuries (OR [95% CI]:2.12[1.96–2.28]). The risk adjusted cost of readmission for trauma was $8401[95% CI: 6748-10,053] higher compared to the index hospitalization with a total increased cost of 11.5 million USD annually. Conclusion: Although not common, recidivism after major trauma remains a significant public-health concern. This study gauges the previously unquantified burden of recidivism amongst children and identifies factors predisposing to recurrent trauma. Level of Evidence: III Type of Evidence: Case control stud

National Estimates and Factors Influencing Trauma Recidivism in Children Leading to Hospital Readmission.

© 2019 Elsevier Inc. Introduction: Trauma is the leading cause of mortality in children. Factors influencing recidivism after major trauma have not been well documented in children. The objective of this study is to determine the burden of pediatric trauma recidivism and to identify predisposing factors in the United States. Methods: The 2010–2015 National Readmissions Database was queried for pediatric patients (≤ 18 years) with a diagnosis of major traumatic injuries. Patients readmitted for major trauma were subsequently identified. Patients that did not survive their index-hospitalization were excluded. Information on mechanism, intent, nature and injury severity including Abbreviated Injury Scale (AIS) and Injury Severity Scores (ISS) was obtained. Multivariable-regression analyses were performed adjusting for demographic, hospital-level and injury characteristics. Results: Of 286,508 pediatric trauma records analyzed, trauma recidivists represented 2.9% of the total population. Recidivists had a higher proportion of severe (AIS ≥ 3) head injury (11.3%). Recidivists were more likely to have public-insurance (OR [95% CI]:1.30[1.25–1.37]), and belong to lower income families (OR [95% CI]:1.22[1.15–1.31]). Recidivism was more common amongst patients with penetrating injuries (OR [95% CI]:2.12[1.96–2.28]). The risk adjusted cost of readmission for trauma was $8401[95% CI: 6748-10,053] higher compared to the index hospitalization with a total increased cost of 11.5 million USD annually. Conclusion: Although not common, recidivism after major trauma remains a significant public-health concern. This study gauges the previously unquantified burden of recidivism amongst children and identifies factors predisposing to recurrent trauma. Level of Evidence: III Type of Evidence: Case control stud

Gallstone Ileus with COVID-19 Infection: An Unintended Sequela of Non-Operative Management of Acute Cholecystitis During the COVID-19 Pandemic.

Appropriate risk stratification and careful follow‐up are mandated in elderly patients with comorbidities. Herein, we report a case presenting 5 months after the nonoperative management of acute cholecystitis during the height of the COVID‐19 pandemic

Assessing surgical care delivery at facilities caring for higher volumes of minority children utilizing the pediatric quality indicator for perforated appendicitis: a propensity-matched analysis

© 2019, Springer-Verlag GmbH Germany, part of Springer Nature. Introduction: The pediatric quality indicator (PDI) measures released by the Agency for Healthcare Research and Quality (AHRQ) provide an impetus for benchmarking quality of care in children. The PDI-17, aimed at studying perforation in appendicitis, is one such measure that this study aims to utilize to assess surgical care delivery and outcomes in children managed at majority–minority hospitals. Methods: The Kid Inpatient Database (2000–2012) was queried for pediatric patients (\u3c 18 years) with a diagnosis of appendicitis, with and without perforation. Facilities were categorized into tertiles based on rates of perforation (PDI-17). Similarly, tertiles were generated based on volume of minority patients (Black and Hispanic) treated at each facility. Multivariable regression analysis adjusted for demographic parameters, hospital-level characteristics, propensity score quintiles, clinically relevant outcomes, and tertiles of minority patients treated. Results: Of the 322,805 patients with appendicitis 28.7% had perforated appendicitis. Patients presenting to facilities caring for a higher volume of perforated appendicitis were younger with public insurance or no insurance and, however, these patients were less likely to belong to a minority group (p \u3c 0.05). Additionally, these patients were less likely to belong to the highest income quartile (OR [95% CI] 0.45 [0.39–0.52]). Hospitals treating the highest volume of minority patients [majority–minority hospitals (MMHs)] had an 87% (OR [95% CI] 1.87 [1.77–1.98]) increased likelihood of also treating the highest rates of perforated appendicitis. Conclusion: Hospitals treating a high volume of complicated appendicitis are less likely to care for minority groups. Additionally, MMHs lacking experience and volume in caring for complicated appendicitis have an increased likelihood of patients with perforations which is indicative of poor healthcare access

Gunshot Injuries in American Trauma Centers: Analysis of the Lethality of Multiple Gunshot Wounds

Introduction: Trauma center care and survival have been improving over the past several years. However, yearly firearm-related deaths have remained near constant at 33 000. One challenge to decreasing gunshot mortality is patients presenting with complex injury patterns from multiple gunshot wounds (GSWs) made possible by high-caliber automated weapons. Our study analyzes outcomes of trauma patients of firearms using the National Trauma Databank (NTDB). Methods: We conducted a retrospective review of the NTDB from the years 2003-2015 for patients with penetrating injuries. We separated patients into groups based on stab wounds, single GSW, and multiple GSW. We performed multivariate logistic regression analyses in which we adjusted for demographics and injury severity. Results: Overall, 382 376 patients presenting with penetrating injuries were analyzed. Of those 167 671 had stab, 106 538 single GSW, and 57 819 multiple GSW injuries. Crude mortality was 1.97% for stab wounds, 13.26% for single GSW, and 18.84% for multiple GSW. Adjusted odds ratio (OR) compared with 2003 demonstrates a trend toward decreased mortality for stab wounds (OR range of 0.48-0.69, P \u3c.05 for years 2010-2015). A similar trend was demonstrated in single GSW injuries (OR 0.31-0.83, P \u3c.01 for years 2005-2015). Conversely, multiple GSW injuries did not follow this trend (OR 0.91-1.36 with P \u3e 0.05 for each year). Conclusion: In contrast to significant improvement in survival in patients with a single GSW injury since 2003, multiple GSW injuries still pose a challenge to trauma care. This warrants further investigation into the efficacy of legislature, and the lack thereof, as well as future preventative measures to this type of injury

Assessing surgical care delivery at facilities caring for higher volumes of minority children utilizing the pediatric quality indicator for perforated appendicitis: a propensity-matched analysis.

© 2019, Springer-Verlag GmbH Germany, part of Springer Nature. Introduction: The pediatric quality indicator (PDI) measures released by the Agency for Healthcare Research and Quality (AHRQ) provide an impetus for benchmarking quality of care in children. The PDI-17, aimed at studying perforation in appendicitis, is one such measure that this study aims to utilize to assess surgical care delivery and outcomes in children managed at majority–minority hospitals. Methods: The Kid Inpatient Database (2000–2012) was queried for pediatric patients (\u3c 18 years) with a diagnosis of appendicitis, with and without perforation. Facilities were categorized into tertiles based on rates of perforation (PDI-17). Similarly, tertiles were generated based on volume of minority patients (Black and Hispanic) treated at each facility. Multivariable regression analysis adjusted for demographic parameters, hospital-level characteristics, propensity score quintiles, clinically relevant outcomes, and tertiles of minority patients treated. Results: Of the 322,805 patients with appendicitis 28.7% had perforated appendicitis. Patients presenting to facilities caring for a higher volume of perforated appendicitis were younger with public insurance or no insurance and, however, these patients were less likely to belong to a minority group (p \u3c 0.05). Additionally, these patients were less likely to belong to the highest income quartile (OR [95% CI] 0.45 [0.39–0.52]). Hospitals treating the highest volume of minority patients [majority–minority hospitals (MMHs)] had an 87% (OR [95% CI] 1.87 [1.77–1.98]) increased likelihood of also treating the highest rates of perforated appendicitis. Conclusion: Hospitals treating a high volume of complicated appendicitis are less likely to care for minority groups. Additionally, MMHs lacking experience and volume in caring for complicated appendicitis have an increased likelihood of patients with perforations which is indicative of poor healthcare access