The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa

BACKGROUND

Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis.

METHODS

The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay).

RESULTS

Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]).

CONCLUSION

HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

Surgical management of appendicitis in patients with human immunodeficiency virus (HIV) positivity: a propensity score-matched analysis in a base hospital for HIV treatment in Japan

PURPOSE

To investigate the impact of human immunodeficiency virus (HIV) infection on surgical outcomes after appendectomy.

METHODS

Data on patients who underwent appendectomy for acute appendicitis between 2010 and 2020 at our hospital were investigated retrospectively. The patients were classified into HIV-positive and HIV-negative groups using propensity score-matching (PSM) analysis, adjusting for the five reported risk factors for postoperative complications: age, sex, Blumberg's sign, C-reactive protein level, and white blood cell count. We compared the postoperative outcomes of the two groups. HIV infection parameters, including the number and proportion of CD4 + lymphocytes and the HIV-RNA levels were also compared before and after appendectomy in the HIV-positive patients.

RESULTS

Among 636 patients enrolled, 42 were HIV-positive and 594 were HIV-negative. Postoperative complications occurred in five HIV-positive patients and eight HIV-negative patients, with no significant difference in the incidence (p = 0.405) or severity of any complication (p = 0.655) between the groups. HIV infection was well-controlled preoperatively using antiretroviral therapy (83.3%). There was no deterioration in parameters and no changes in the postoperative treatment in any of the HIV-positive patients.

CONCLUSION

Advances in antiviral drugs have made appendectomy a safe and feasible procedure for HIV-positive patients, with similar postoperative complication risks to HIV-negative patients.

Appendiceal disease in hematopoietic cell transplantation

Appendiceal diseases are rare reported complications during hematopoietic stem cell transplantation with no guidance on management in the published literature. Medical therapy may be considered in selected patients prior to surgical solutions.

Acute appendicitis in people living with HIV: What does the emergency surgeon needs to know?

Acute appendicitis is among the commonest surgical emergencies seen in an acute setting. Individuals living with the Human Immunodeficiency Virus (HIV) and/or the Acquired Immunodeficiency Syndrome (AIDS) have an increased risk of encountering complications with acute appendicitis. We conducted a literature search using the words appendicitis and HIV in google scholar, Medline, Scopus and PubMed. The search also extended to cover HIV presented with acute appendicitis, their outcome during and following the management of acute appendicitis. Several studies showed that HIV is associated with a higher rate of acute appendicitis than the general population. HIV can directly affect the appendix, through opportunistic infections, immune reconstitution inflammatory syndrome associated with start of antiretroviral medication. High index of suspicion is needed to exclude conditions that mimic acute appendicitis (abdominal tuberculosis, pyelonephritis, cytomegalovirus, cryptosporidium, pneumococcus, Amoebic appendicitis and pill impaction). The clinical presentation may not be typical of acute appendicitis and can be associated with low white cell count and variable fever. The Alvarado score for predicting acute appendicitis can be used and more research is needed to establish cut-off point value. Computed tomography scan and ultrasound are widely used in clinical diagnosis. Importantly, acute appendicitis with HIV/AIDS can be associated with high rate of post-surgical complications like infections, delay of healing, perforation, peritonitis, intra-abdominal abscess and longer hospital stay. HIV/AIDS with acute appendicitis is complex condition. Therefore, we conclude that patients with known HIV and acute appendicitis should also be managed in close liaison with HIV physicians during, before and after surgical treatment.

The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis

BACKGROUND

The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status.

METHODS

This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days.

RESULTS

A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days.

CONCLUSIONS

Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.

A retrospective evaluation of the Modified Alvarado Score for the diagnosis of acute appendicitis in HIV-infected patients

BACKGROUND

The aim of this study was to evaluate and compare the diagnostic value of a Modified Alvarado Score (MAS) ≥7 for acute appendicitis in both Human Immunodeficiency Virus (HIV)-negative (HIVneg) and positive (HIVpos) patientcohorts.

METHODS

This retrospective study included all HIV-tested patients undergoing appendectomy at a regional hospital from March 2010 to March 2011. The MAS was calculated for all patients, as well as for the HIVneg and HIVpos groups separately. Two subgroups were considered for each of these: MAS ≥7 (high likelihood of appendicitis) and MAS <7 (low likelihood of appendicitis). These subgroups were then analysed against histopathological findings of the resected appendix. MAS specificities and sensitivities were determined by comparing Receiver Operator Characteristic (ROC) curves for the various scores.

RESULTS

The study comprised 133 patients. Eighty-six (65%) were men and the median age was 20 years (range 4-64); 18 patients (14%) were HIVpos. Appendicitis was confirmed histologically in 113 patients, 100 in the HIVneg group and 13 in the HIVpos group. Specificity and sensitivity of a MAS ≥7 for HIVneg patients was 73 and 85% respectively. Based on the ROC curves, HIVpos patients only showed similar sensitivities (69%) and specificities (80%) at a MAS ≥8.

CONCLUSION

A MAS ≥7 is a reliable predictor of acute appendicitis in HIVneg patients. In HIVpos patients, the MAS threshold required to accurately predict appendicitis is 8. The use of a MAS ≥7 in this group of patients will result in unnecessary surgical intervention.

Appendectomy in patients with human immunodeficiency virus: Not as bad as we once thought

BACKGROUND

The number of patients living with human immunodeficiency virus and acquired immunodeficiency syndrome is growing due to advances in antiretroviral therapy. Existing literature on appendectomy within this patient population has been limited by small sample sizes. Therefore, we used a large, multiyear, nationwide database to study this topic comprehensively.

METHODS

Using the Nationwide Inpatient Sample, we identified 338,805 patients between 2005 and 2012 who underwent laparoscopic or open appendectomy for acute appendicitis. Interval appendectomies were excluded. We used multivariable adjusted regression models to test differences between patients with human immunodeficiency virus without acquired immunodeficiency syndrome and a reference group, as well as human immunodeficiency virus with acquired immunodeficiency syndrome and a reference group, with regard to duration of stay, hospital charges, in-hospital complications, and in-hospital mortality. Models were adjusted for patient age, sex, race, insurance, socioeconomic status, Elixhauser comorbidity score, and appendix perforation.

RESULTS

There were 1,291 (0.38%) patients with human immunodeficiency virus, among which 497 (0.15%) patients had acquired immunodeficiency syndrome. In regression analysis, human immunodeficiency virus alone was not associated with adverse outcomes, while acquired immunodeficiency syndrome alone was associated with longer duration of stay (incidence rate ratio 1.40 [1.37-1.57 95% confidence interval], P < .0001), increased total charges (exponentiated coefficient 1.16 [1.10-1.23 95% confidence interval], P < .0001), and increased risk of postoperative infection (odds ratio 2.12 [1.44-3.13 95% confidence interval], P = .0002).

CONCLUSION

Patients with acquired immunodeficiency syndrome who undergo appendectomy for acute appendicitis are subject to longer and more expensive hospital admissions and have greater rates of postoperative infections while patients with human immunodeficiency virus alone are not at risk for adverse outcomes.

Comparison of in-hospital mortality from acute myocardial infarction in HIV sero-positive versus sero-negative individuals

Few studies have explored hospitalization outcome differences between patients who are seropositive for human immunodeficiency virus (HIV) compared to HIV-seronegative patients with acute myocardial infarctions (AMIs). The aim of this study was to explore in-hospital AMI mortality risk in seropositive and seronegative patients. A secondary analysis of the Nationwide Inpatient Sample from 1997 to 2006 was conducted. This sample allows the approximation of all United States hospitalizations. All AMI encounters with and without co-occurring HIV were identified using appropriate International Classification of Diseases and procedure codes. Descriptive and Cox proportional-hazards analyses were then conducted to estimate mortality differences between seropositive and seronegative patients while adjusting for demographic, clinical, hospital, and care factors. The results demonstrated higher AMI hospitalization mortality hazard in seropositive compared to seronegative patients after adjustment for age, gender, ethnicity, medical co-morbidities, hospital type, and number of in-hospital procedures (HR 1.38, 95% confidence interval 1.01 to 1.87, p = 0.04). Stratified analysis demonstrated greater although not statistically significant mortality hazard for non-ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction in seropositive compared to seronegative patients. Typical AMI care procedures occurred at significantly lower rates in seropositive versus seronegative patients, including thrombolytic and anticoagulant agents (18% vs 22%), coronary arteriography (48% vs 63%), left cardiac catheterization (52% vs 66%), and coronary artery bypass graft (6% vs 14%). In conclusion, additional mortality burden and lower procedure rates occur for HIV-seropositive patients receiving AMI care. Health care providers should be alert to the increased mortality burden when treating seropositive patients with AMI.