Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis

PurposeTo examine what proportion of caregivers, if given a choice, would choose medical versus surgical treatment of appendicitis and what factors would be important in their decision.MethodsA survey was devised and given to the caregivers of children presenting to the pediatrician for a routine visit in community and academic pediatric clinics. The survey presented a summary of outcomes after medical (non-operative) and surgical treatment of uncomplicated appendicitis. Participants were then asked to choose medical versus surgical treatment if their child were to develop appendicitis. They were also asked to rate the importance of certain factors in their decision ? 1 being “not important” and 5 being “very important”.ResultsFour hundred surveys were distributed with an 86.2% (345/400) response rate. Six percent (21/342) of respondents reported a history of appendicitis and 49.4% (168/340) reported having known someone who had appendicitis. The majority of respondents, 85.3% (284/333), were mothers. A minority of respondents, 41.7% (95% CI: 36.7, 47.0), chose medical treatment over surgery for appendicitis. There was no statistical difference in the proportion of mothers (41.6%) versus fathers who chose medical treatment (41.3%). Caregivers who chose medical treatment were more likely to rate time in hospital (p = .008) and time out of school (p = 05) as important in decision making when compared with those who chose surgery. Those who chose surgical treatment were more likely to rate risk of recurrent appendicitis (p < .001) as important to decision making. In the multivariate analysis, those who rated time in hospital as very important had more than twice the odds of choosing medical therapy (OR 2.20, p = 0.02) when compared with those who rated it as less important. Not knowing someone who has had appendicitis was significantly associated with choosing medical therapy when compared with those who do know someone who has had appendicitis, OR 2.3, p = .002. Rating pain as very important was also significantly associated with choosing medical therapy, when compared to those rating pain 1–3, OR 3.38, p = .03.ConclusionsIn this survey of caregivers of children presenting for routine care, 41.7% would choose medical, or non-operative, therapy for their children with acute appendicitis. The risk of recurrence, time in hospital, and time out of school, pain, and knowing someone who has had appendicitis were all important factors that families may consider when making a decision. These data may be useful for surgeons counseling patients on which treatment to pursue.     

AVIATION NURSING IN THE WESTERN AUSTRALIAN KIMBERLEY

ABSTRACT: This article provides a brief overview of the Western Australian (WA) Kimberley Royal Flying Doctor Service and the role of the flight nurse who accompanies patients requiring aerial medical evacuation from rural and remote WA. Two short case histories of head injured patients evacuated from the Kimberley region will be outlined and some of the potential concerns associated with transferring patients at altitude in a confined and altered working environment will be discussed.     

BENEFICENCE,TEMPERANCE AND MEDICAL SCIENCE

John Coakley Lettsom (1744–1815) founded the Medical Society of London and played a key role in the development of the Royal Humane Society. His Quaker background underpinned his interest in social reform. He established dispensaries and soup kitchens for the poor, recognized the need for public health measures in the control of disease, and advocated prison reform and education of the poor.     

Heparin effect on ionised calcium concentration

The effect of heparin on plasma ionised calcium was studied by adding it in increasing amounts to whole blood from 10 normal subjects. There was no significant change in ionised calcium from the addition of 1 U/ml but a significant fall of 0.02 mmol/1 when 2 U/ml were added and a progressive further fall with increasing concentrations. Heparin from three different manufacturers produced similar results. The effect of heparinisation in vivo was studied during regular haemodialysis on 10 patients with chronic renal failure. Following intravenous injection of 10000 U of heparin there was a consistent and significant fall averaging 0.03 mmol/l.     

The need for basic sciences in the understanding and practice of anaesthesia

We conducted a survey using an unstructured, then a structured, questionnaire to determine the attitudes of 78 postfellowship anaesthetists to the Basic Sciences component of the part I examination for the FRCA. Seventy-two per cent replied. These anaesthetists felt that about 65% of the basic science syllabus was essential to the understanding and practice of everyday anaesthesia, but there was varying opinion as to the importance of specific topics. Cardiovascular, respiratory, central nervous system and renal physiology were all regarded as essential, as was the pharmacology of anaesthetic drugs. Topics regarded as irrelevant included biochemistry, endocrinology, membrane theory and immunology. Paradoxically, there were many topics which anaesthetists regarded as essential but on which they were unable to give a tutorial. There was little difference between the responses of consultants and trainees. This survey may help to identify a core syllabus on which the majority of anaesthetists agree but also suggests that the current syllabus is overloaded with detail that has no place in clinical practice.     

御制平安丹治疗晕动病的临床和实验研究

用御制平安丹(下称平安丹)治疗晕动病(运动病)343例,观察结果表明,平安丹服后有效率为92.8%,优于乘晕宁和人丹组(P<0.05～0.01)。平安丹可影响猫前庭感受器,抑制旋转后眼震,起到调节前庭—植物性神经功能的作用;它还能改善动物软脑膜微循环,有助于调整椎基底动脉、前庭通路等区域微循环障碍。以上效果与治疗剂量东莨菪碱(Scopolamine)相似。     

Study of the HLA system in Burkitt's lymphoma

Seventy-eight patients with Burkitt's lymphoma and seventy controls from Ghana were typed for HLA-A, B, C and DR antigens, to determine whether there is an association between the HLA system and Burkitt's lymphoma. Increased relative risk was observed in Burkitt's lymphoma patients with DR7, HLA-A1 and B12 (BW44).     

Circulating immune complexes during immunotherapy.

Chronic immunization may lead to the production of circulating immune complexes (CICs). This study was undertaken to determine the presence of circulating IgG immune complexes in 95 subjects with allergic rhinitis/asthma receiving immunotherapy, 46 individuals with similar diagnosis but not on immunotherapy, and 64 healthy controls. Modified Raji cell and murine leukemia cell (L-1210) assays, selected for a high density of Fc receptors and devoid of Epstein-Barr virus membrane antigen, were used. Other immunological parameters such as immunologlobulins G, A, M, E, and rheumatoid factor activity were also studied. The CIC concentrations in the treated group did not differ significantly from the untreated group, although both groups did have a significantly higher concentration than the healthy controls. The presence of CICs has no relationship with age or sex of patients, dosage of allergen administered, number and nature of allergens received, period between the time of last injection and the blood sampling, and the duration of immunotherapy. Serum IgG, IgA, IgM, and rheumatoid factor activity did not differ between the treated and untreated groups. IgE was significantly higher in the treated group when compared with the untreated, and IgE levels in treated patients with elevated CICs were significantly increased compared with CIC-negative treated patients. These data suggest that CICs are present in serum of atopic diseases such as allergic rhinitis/asthma. Significantly, an association of elevation of CICs with immunotherapy could not be demonstrated.     

HLA-DR7 association with African Burkitt's lymphoma

Association between HLA-DR7 and Burkitt's lymphoma previously reported has been confirmed by a second study. Analysis of additional data from a second study of 33 Ghanaian patients with African Burkitt's lymphoma and 54 Ghanaian controls matched for age and ethnic origin showed that 39.4% of cases, but only 14.8% of controls, had HLA-DR7 (p less than 0.01). The relative risk of 3.7 is similar to that observed in the earlier study (3.3). Combining the earlier and present studies, analysis of clinical data from 94 patients with Burkitt's lymphoma and 116 controls shows the relative risk of Burkitt's lymphoma among individuals with HLA-DR7 was 3.4 (p less than 0.001). There was an increased relative risk of the disease associated with HLA-DR7 in: patients under 10 years of age; and patients with advanced stages of disease (Stage III or IV). However, comparison of relative risks by sequential analysis of 2 X 2 tables showed that these differences by age and stage were not statistically significant.     

The use of detergents and immunoperoxidase reagents for the ultrastructural demonstration of internal immunoglobulin in lymph cells.

Lymph-borne immunoblasts were fixed in dilute glutaraldehyde and then treated with saponin. This treatment made most parts of the cells permeable to ferritin, so that anti-immunoglobulin (Ig) antibodies which had been conjugated to horse radish peroxidase (HRP) had no difficulty in gaining access to Ig which thus could be demonstrated at an ultrastructural level. Best results were obtained by fixing the cells in 0.1% glutaraldehyde for 7 min and then treating them with a 1% solution of saponin for 100 min at 55 degrees C before exposing them to the Ig-HRP conjugate. The method yielded reproducible results and although it causes a small amount of ultrastructural damage, it may be of value in detecting a variety of intracellular antigens.