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.     

非职业因素与血铅水平的岭回归分析

调查１３３名城市居民的血铅水平。通过ＲｉｄｇｅＲｅｇｒｅｓｓｉｏｎ程序分析非职业因素对血铅水平的影响。结果表明，汽车尾气是影响城市居民的血铅水平的主要因素。     

Symptomatic compression of the optic nerve by the carotid artery: clinical profile of 18 patients with 24 affected eyes identified by magnetic resonance imaging.

OBJECTIVE: To characterize the clinical features and course of patients with magnetic resonance imaging (MRI)-defined optic nerve compression by the supraclinoid carotid artery. DESIGN: Retrospective, observational case series. PARTICIPANTS: Eighteen patients with 24 affected eyes were identified by reviewing case records from the author's referral-based neuro-ophthalmology practice. Predetermined inclusion and exclusion criteria were applied to potential participants. MAIN OUTCOME MEASURES: The following variables were abstracted from the medical record: age, gender, presenting symptoms, past medical problems, visual acuity, color vision, visual field, pupillary reactions, optic disc appearance, other neurologic signs, and previously documented and follow-up examinations. RESULTS: There were eight women and ten men ranging in age from 28 to 86 years (median age, 72 years) at the time of diagnosis. Ten (56%) of 18 patients had hypertension. Twelve patients had unilateral optic neuropathy, whereas 6 patients had bilateral optic neuropathy. One patient presented with subacute superior orbital fissure syndrome due to mass effect of a dolichoectatic carotid artery. Another patient had oculomotor nerve palsy with signs of aberrant regeneration due to intracavernous mass effect of a dolichoectatic carotid artery. One patient had a bitemporal hemianopia associated with bilateral compression of the immediate prechiasmatic optic nerves by dolichoectatic carotid arteries. The predominant pattern of visual field loss in most patients reflected nerve fiber bundle injury. A central scotoma or absolute central visual field loss was noted in only 6 (25%) of 24 affected eyes. Most patients demonstrated saucerlike excavation of the optic disc. Progression of visual acuity loss occurred at a relatively slow rate. CONCLUSIONS: Although uncommon, intracranial compression of the optic nerve by the carotid artery should be considered in a patient with unexplained or progressive unilateral or bilateral optic neuropathy. This entity can be diagnosed using clinical skills to exclude more common causes of optic nerve injury and coronal-oriented MRI to confirm anatomic compression of the symptomatic optic nerve. Although many affected patients have excavation of the optic disc and nerve fiber bundle visual field defects, most have additional signs atypical for glaucoma, minimizing the potential for diagnostic confusion between the two disorders.     

Improving oral rehabilitation through the preservation of the tissues through alveolar preservation

When performing a tooth extraction, imminent collapse of the tissue by resorption and remodeling of the socket is a natural occurrence. The procedure for the preservation of the alveolar ridge has been widely described in the dental literatures and aims to maintain hard and soft tissues in the extraction site for optimal rehabilitation either with conventional fixed or removable prosthetics or implant-supported prosthesis.     

3D-based full-guided ridge expansion osteotomy – A case report about a new method with successive use of different surgical guides,transfer of splitting vector and simultaneous implant insertion

For horizontal bone deficiency alveolar ridge osteotomy is considered an option for augmentation. Major advantages are the option for a one-stage approach and the absence of donor site morbidity. However, the conventional technique is associated with complications such as perforations and fractures of the cortical bone.A case using a 3D based modified, full-guided alveolar ridge expansion is described to explain the technique step by step. Main features of modified technique: successive application of surgical guides for ridge osteotomy and expansion – implementation of virtually determined splitting vector, which allows guided bone splitting along a guide surface of template in an ideal direction - osteotomy as deep as implant length. The example shows that the 3D based modified alveolar ridge osteotomy is a suitable alternative to the conventional technique as it has several advantages such as fewer fractures and perforations of the cortical vestibular bone.The individualized preoperative planning helps to minimize complications. However, long-term outcomes and a study, conducted on a study group, is needed to evaluate the benefits of our presented treatment protocol.     

Acute primary angle closure in an Asian population: long-term outcome of the fellow eye after prophylactic laser peripheral iridotomy

PURPOSE: To study the long-term outcome of fellow eyes of Asian patients with acute primary angle closure (APAC) who underwent prophylactic laser peripheral iridotomy (LPI). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Ninety-six consecutive patients with APAC at presentation to one Singapore hospital from January 1990 through December 1994. METHODS: The presenting features of the fellow eye were recorded, and the subsequent long-term intraocular pressure (IOP) outcome after LPI was analyzed. All fellow eyes were initially treated with pilocarpine 2% eyedrops four times daily before LPI, which was performed within 1 week of presentation. For any eye, a rise in IOP during follow-up was defined as a rise in IOP requiring treatment by medication or surgery. MAIN OUTCOME MEASURES: Incidence of acute angle closure and IOP. RESULTS: The mean follow-up period was 50.8 months (range, 9-99 months). Of the 96 patients, 15 patients had bilateral APAC, and APAC developed in one fellow eye before LPI could be performed. The remaining 80 fellow eyes were studied. No cases of APAC developed after prophylactic LPI. Seventy-one fellow eyes (88.8%) were successfully treated with LPI alone without the need for additional glaucoma treatment in the long term. Seven eyes (8.8%) had IOPs of 21 mmHg or less on presentation, but a rise in IOP developed on follow-up despite the presence of a patent LPI. Two fellow eyes (2.5%) had signs of preexisting chronic angle closure glaucoma at presentation and required further glaucoma treatment even after LPI. There were no significant complications from the procedure in any of the fellow eyes studied. CONCLUSIONS: In this Asian population with APAC, prophylactic LPI is safe and effective in preventing acute angle closure in fellow eyes. In addition, prophylactic LPI prevents long-term rise in IOP in 88.8% of fellow eyes (with approximately 4 years of follow-up). However, because a small proportion of fellow eyes did experience a rise in IOP within the first year, despite the presence of a patent LPI, close monitoring is still advised in the follow-up of fellow eyes of patients with APAC.     

Low-dose fibrinolytic therapy in infants

We describe three pediatric patients in whom locally infused streptokinase at a dose of 50 U/kg/hr was used successfully to treat thrombosis in a major artery, a major vein, and a systemic-to-pulmonary arterial graft. Complications, including hemorrhage and distal embolization, were minimized by careful monitoring of the coagulation status of the blood and by avoiding rapid infusions. Selective thrombolytic therapy appears to be as effective in infants as in adults. Because the dose required is reduced, the incidence of complications is lower than with systemic infusions.     

Reduction of intraoperative myocardial infarction by means of exogenous anaerobic substrate enhancement: prospective randomized study.

In a prospective study, patients who had an ejection fraction of 40% or more and who were undergoing elective coronary artery operation were randomly divided into three groups that differed in the method of anaerobic substrate enhancement during cardiopulmonary bypass. Group 1, the controls (n = 157), received no additional glucose, insulin, and potassium solutions and experienced immediate spontaneous defibrillation (10%), transmural myocardial infarction (10.3%), malignant ventricular arrhythmias (26%), and severe atrial arrhythmias (20%). Group 2 (n = 120) received a bolus of hypertonic glucose, insulin, and potassium in the pump perfusate before aortic cross-clamping. In this group, the rate of spontaneous defibrillation was 41%, of transmural infarction, 8.3%, of malignant ventricular arrhythmias, 31%, and of severe atrial arrhythmias, 19%. Group 3 (n = 114) had the aortic root continuously infused with glucose, insulin, and potassium solution at 4 degrees C during aortic cross-clamping. This group was significantly improved; the rate of spontaneous defibrillation was 60%, there were no transmural myocardial infarctions and the incidence of severe atrial arrhythmias was 6% and that of malignant ventricular arrhythmias, 5%. It is proposed that the superior clinical results in Group 3 resulted from better myocardial preservation achieved by more efficient means of providing continuous anaerobic substrate, coronary washout, and elution of lactic acidosis, uniform global hypothermia, and direct supplemental myocardial potassium in addition to mere cardioplegic effects.     

Inducible sustained ventricular tachycardia refractory to individual class I drugs: effect of adding a second class I drug

As class I drugs often fail to control ventricular tachycardia when used individually, two such drugs may be combined in an attempt to increase efficacy. The effect of combinations of class I drugs was tested in nine patients undergoing electrophysiologic study for documented ventricular tachycardia or fibrillation, in whom single class I drugs failed to prevent the induction of sustained ventricular tachycardia. By study design, all patients had inducible ventricular tachycardia during the control study, after receiving intravenous procainamide, 1306 ± 243 mg alone, oral quinidine, 1600 ± 0 mg alone, and in five patients, oral disopyramide, 1200 ± 0 mg alone. After oral quinidine and (on a subsequent day) oral disopyramide were found to be ineffective, intravenous procainamide was added and the study was repeated. All patients continued to have inducible sustained ventricular tachycardia despite the addition of procainamide. All showed an increase in tachycardia cycle length; quinidine alone vs qunidine plus procainamide, 351 ± 61 vs 499 ± 65 msec, p < 0.0005; disopyramide alone vs disopyramide plus procainamide, 405 ± 41 vs 494 ± 31 msec, p < 0.005. Also, induction of tachycardia was easier on the combination in 9 of 13 tests where this could be assessed (five of eight patients on quinidine plus procainamide and four of five patients on disopyramide plus procainamide). In conclusion, although induced ventricular tachycardia was slower on two class I drugs and therefore might be better tolerated, in no patient did the combination prevent induction of sustained tachycardia. Easier induction suggests that spontaneous episodes might become more frequent. Therefore such combinations cannot be expected to provide effective prophylaxis in patients refractory to large doses of individual class I drugs.