Risk factors for the development of complicated appendicitis in adults

Impacts of short-term air pollution exposure on appendicitis admissions: Evidence from one of the most polluted cities in mainland China

Background

Emerging evidence indicates that air pollutants contribute to the development and progression of gastrointestinal diseases. However, there is scarce evidence of an association with appendicitis in mainland China.

Methods

In this study, Linfen city, one of the most polluted cities in mainland China, was selected as the study site to explore whether air pollutants could affect appendicitis admissions and to identify susceptible populations. Daily data on appendicitis admissions and three principal air pollutants, including inhalable particulate matter (PM10), nitrogen dioxide (NO2), and sulfur dioxide (SO2) were collected in Linfen, China. The impacts of air pollutants on appendicitis were studied by using a generalized additive model (GAM) combined with the quasi-Poisson function. Stratified analyses were also performed by sex, age, and season.

Results

We observed a positive association between air pollution and appendicitis admissions. For a 10 μg/m3 increase in pollutants at lag01, the corresponding relative risks (RRs) and 95% confidence intervals (95% CIs) were 1.0179 (1.0129–1.0230) for PM10, 1.0236 (1.0184–1.0288) for SO2, and 1.0979 (1.0704–1.1262) for NO2. Males and people aged 21–39 years were more susceptible to air pollutants. Regarding seasons, the effects seemed to be stronger during the cold season, but there was no statistically significant difference between the seasonal groups.

Conclusions

Our findings indicated that short-term air pollution exposure was significantly correlated with appendicitis admissions, and active air pollution interventions should be implemented to reduce appendicitis hospitalizations, especially for males and people aged 21–39 years.

Does the length matter in acute appendicitis for the perforation risk?: A retrospective cohort study

It has been hypothesized that short appendices increase intraluminal pressure more rapidly and perforate more frequently than long appendices. Two hundred seventy-seven adult patients were retrospectively analyzed and underwent an appendectomy between January 2015 and August 2021. Data extracted from patient records included sex, age, time from admission to operation (hospital interval), weekday or weekend operation time, and operative and pathological findings. Operation was performed on 273 patients, of whom 178 (65.2%) were male and 95 (34.8%) female. The mean age of the male patients was 31.7 ± 08 (range 18-67), and that of the female patients was 38.9 ± 1.4 (range 18-78). Perforation was observed in 57 (20.9%) patients. Sex was not a factor in the development of perforation (P = .95). The mean age of the patients with and without perforation was 40.1 ± 2.2 and 32.7 ± 0.7, respectively. The perforation rate increased with age (P = .003). Appendix lengths were similar in both groups, and length was not a factor in the development of perforation (P = .83). This study found that the development of perforated appendicitis is not related to the length of the appendix. The risk of perforation increased with age.

Characteristics of Patients Presented with Complicated Appendicitis in Adama, Ethiopia: A Cross-Sectional Study

BACKGROUND

Complicated appendicitis (CA) is defined as perforated appendicitis, peritonitis, peri-appendicular abscess, or appendicular mass. One-third of patients who develop appendicitis are diagnosed with CA at presentation. Studies regarding the prevalence of CA are lacking in low-income countries, and the characteristics of patients presented with CA are incoherently identified.

OBJECTIVE

To assess the prevalence and the significant characteristics associated with CA among patients admitted with the diagnosis of acute appendicitis at Adama Hospital Medical College.

METHODS

A cross-sectional study was conducted from January 1, 2018, up to December 31, 2019. From a total of 1043 patients during the study period, the charts of 431 patients were selected using a systematic random sampling technique. Data were collected by a structured checklist. Bivariate and multivariable binary logistic regression analyses were employed to assess the association of patients' characteristics with CA.

RESULTS

Out of 431 patients, 157 (36.4%) had CA. Characteristics of patients having a significant association with CA were found to be generalized abdominal tenderness (AOR: 27.48, 95% CI: 4.03, 187.24), diagnosis with peritonitis (AOR: 14.87, 95% CI: 4.05, 54.54), right lower quadrant (RLQ) abdominal mass (AOR: 7.79, 95% CI: 2.02, 29.99), shock (10.37, 95% CI: 3.18, 33.76), white blood cell (WBC) count >11,000 (AOR: 2.16, 95% CI: 1.02, 4.61), onset to visit interval of 8-14 days (AOR: 10.45, 95% CI: 2.4, 45.52) and ultrasound report of acute appendicitis (AOR: 0.33, 95% CI: 0.13, 0.85), appendiceal abscess (AOR: 5.05, 95% CI: 1.48, 17.31), and appendiceal mass (AOR: 6.04, 95% CI: 1.45, 25.14).

CONCLUSION

The prevalence of CA was very high. Generalized abdominal tenderness, RLQ abdominal mass, shock, WBC count, onset to visit interval, abdominopelvic ultrasound report, and clinical diagnosis of peritonitis were significantly associated with CA.

Analysis of appendicitis management during COVID-19 pandemic: A study of Chinese adult cohorts

BACKGROUND

Healthcare seeking behavior has been widely impacted due to the restricted movements of individuals during the Coronavirus disease-19 (COVID-19) pandemic. This study aims to perform risk stratification in patients requiring timely intervention during the recovery periods.

METHODS

Operation notes of acute appendicitis (AA) patients within a hospital were analyzed during three six-month periods (23 January-23 July in 2019, 2020, and 2021, respectively). Patient data were collected retrospectively including demographics, pre-emergency status, perioperative information, postoperative outcomes, and follow-up results.

RESULTS

321 patients were included in this study, with 111, 86, and 124 patients in 2019, 2020, and 2021 groups, respectively. The median age of patients decreased by 4 years in 2020 as compared to that in 2019. The proportion of pre-hospitalization symptoms duration of more than 48 h in the 2020 group was higher (36.05% in 2020 vs. 22.52% in 2019). Length of hospital stay (LOS) in 2020 was shorter than it was during the same period in 2019 (4.77 vs. 5.64) and LOS in 2021 was shorter than in 2019 (4.13 vs. 5.64). Compared to the lockdown period, the proportion of patients with recurrent AA was higher in the post-lockdown period (15.1% vs. 27.4%). The median age was 34 years (vaccinated) vs. 37 years (unvaccinated). Logistic regression suggests that elevated C-reactive protein (CRP) (OR = 1.018, CI = 1.010-1.028), white cell count (WBC) (OR = 1.207, CI = 1.079-1.350), female (OR = 2.958, CI = 1.286-6.802), recurrent (OR = 3.865, CI = 1.149-12.997), and fecalith (OR = 2.308, CI = 1.007-5.289) were associated with complicated appendicitis (CA).

CONCLUSION

The lockdown measures during the COVID-19 epidemic are shown to be correlated with a reduction in the proportion of AA patients who underwent surgery, particularly in older adults. Risk factors for CA include elevated CRP, WBC, female, recurrent, and fecalith.

Suspected and Confirmed Acute Appendicitis During the COVID-19 Pandemic: First and Second Quarantines-a Prospective Study

Purpose

COVID-19 posed an unprecedented modern global healthcare crisis affecting both elective and urgent surgeries. The aim of this study is to evaluate the difference in the presentation of acute appendicitis (AA) before and during the COVID-19 era, the first and second quarantines.

Methods

We performed a prospective study from December 2018 to May 2021. Two cohorts were analysed, one with patients who presented to the emergency department (ED) with suspected AA and the second with confirmed AA. Both cohorts were divided into four groups: before COVID-19, during the first quarantine, between the first and second quarantine, and during the second quarantine. Data such as demographics, the time to first contact with the healthcare provider and time to operation, laboratory tests, clinical stage of AA, length of stay, and COVID-19 status were collected. A total of 469 patients were enrolled.

Results

A total of 209 patients were male (45%) and 260 were female (55%), with the median age being 33 years (24-45). In the first cohort of suspected AA, there was no difference in sex; however, more older patients presented to the ED during the first quarantine (41 years) compared with other groups (28.5, 36, and 32.5 years), p < 0.000. Before the pandemic, there was a shorter duration of symptoms to first contact with the healthcare provider (13 h) compared with other groups, p = 0.001. In the second cohort of confirmed AA, there was a shorter period of time to operation from first symptoms before the pandemic (22 h) compared with other groups (30, 35, 30.5 h), p < 0.000. There were more complicated gangrenous, perforated appendicitis or periappendicular abscess in Group 2 and 3 (26, 22 and 10%, and 26, 22 and 2%, respectively) compared with Group 1 (20, 4 and 3%) and Group 4 (22, 12, and 2%), p = 0.009. Hospital stay was longer during the first quarantine (3 days) compared with other groups (2 days), p = 0.009. Six patients were COVID-19 positive: one from Group 3 and five from Group 4 (p > 0.05).

Conclusions

Our study suggests that during the first quarantine of the COVID-19 pandemic, there was delayed presentation to the ED with suspected AA and there was a greater proportion of complicated appendicitis and longer hospitalization in confirmed cases as well.

The impact of COVID-19 pandemic lockdown on the incidence and outcome of complicated appendicitis

BACKGROUND

Patient attendance at emergency departments (EDs) during the COVID-19 pandemic outbreak has decreased dramatically under the "stay at home" and "lockdown" restrictions. By contrast, a notable rise in severity of various surgical conditions was observed, suggesting that the restrictions coupled with fear from medical facilities might negatively impact non-COVID-19 diseases. This study aims to assess the incidence and outcome of complicated appendicitis (CA) cases during that period.

METHODS

A retrospective study comparing the rate and severity of acute appendicitis (AA) cases during the COVID-19 initial outbreak in Israel during March and April of 2020 (P20) to the corresponding period in 2019 (P19) was conducted. Patient data included demographics, pre-ED status, surgical data, and postoperative outcomes.

RESULTS

Overall, 123 patients were diagnosed with acute appendicitis, 60 patients during P20 were compared to 63 patients in P19. The rate of complicated appendicitis cases was significantly higher during the COVID-19 Lockdown with 43.3% (26 patients) vs. 20.6% (13 patients), respectively (p < 0.01). The average delay in ED presentation between P20 and P19 was 3.4 vs. 2 days (p = 0.03). The length of stay was 2.6 days in P20 vs. 2.3 days in P19 (p = 0.4), and the readmission rate was 12% (7 patients) vs. 4.8% (3 patients), p = 0.17, respectively. Logistic regression demonstrated that a delay in ED presentation was a significant risk factor for complicated appendicitis (OR 1.139, CI 1.011-1.284).

CONCLUSION

The effect of the COVID-19 initial outbreak and Lockdown coupled with hesitation to come to medical facilities appears to have discouraged patients with acute appendicitis from presenting to the ED as complaints began, causing a delay in diagnosis and treatment, which might have led to a higher rate of complicated appendicitis cases and a heavier burden on health care systems.

Complicated Appendicitis Among Adults With and Without Disabilities: A Cross-Sectional Nationwide Study in South Korea

Objective

Appendicitis is usually diagnosed based on a reliable set of signs and symptoms, and can be effectively treated with surgery, with low morbidity and mortality rates. However, appendicitis is often overlooked in vulnerable populations, including people with disabilities. This study compared 10-year trends of complicated appendicitis between South Koreans with a disability, according to disability severity and type, and those without disabilities

Methods

To identify cases of appendicitis, we used the DRG codes in the National Health Information Database of South Korea. Patients with appendicitis were classified in terms of severity based on the DRG codes. Age-standardized incidence rates were calculated for each year during 2008–2017 according to the presence, type, and severity of the disability. Factors associated with complicated appendicitis were examined by multivariate logistic regression using the most recent data (i.e., 2016–2017).

Results

The incidence of complicated appendicitis was higher in people with disabilities, especially those with severe disabilities (26.9 vs. 11.6%). This difference was particularly marked when considering those with a severe disability (aOR = 1.868, 95% CI:1.511–2.309), internal organ problems (aOR = 10.000, 95% CI:5.365–18.638) or a mental disability (aOR = 2.779, 95% CI:1.563–4.939).

Conclusions

The incidence of complicated appendicitis was higher in people with disability than in those without disability in all years. There was a substantial difference in the incidence of complicated appendicitis between the severe disability and non-disabled groups. Among the various disability types, the incidence of complicated appendicitis was highest for major internal organ problems, followed by intellectual or psychological disabilities. Our findings may be explained by barriers to healthcare access among people with disabilities, particularly those with a severe disability, internal organ problem, or mental disability.

Clinical Prediction Score for Ruptured Appendicitis in ED

Background

Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population.

Methods

This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis.

Result

During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times.

Conclusion

Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Complicated appendicitis are common during the epidemic period of 2019 novel coronavirus (2019-nCoV)

Objectives

To assess the prevalence of complicated appendicitis (including gangrene, abscess and perforation) after the outbreak of the 2019-nCoV epidemic and to identify the risk factors associated with complicated appendicitis.

Methods

Two groups were established in the study consisting of: one group for cases of acute appendicitis before the 2019-nCoV epidemic (before January 1, 2020; pre-epidemic group) and another group for those after the epidemic outbreak (after January 1, 2020; epidemic group). These two groups were compared in terms of demographic and clinical characteristics, prevalence of complicated appendicitis, and treatment intention. A multivariate analysis model using binary logistic regression was constructed.

Results

A total of 163 patients were included in this study, with 105 in the pre-epidemic group and 58 in the epidemic group. In the epidemic group, the interval from the onset of symptoms to admission was 65.0 h, which is significantly longer than the 17.3 h interval noted in the pre-epidemic group (P < 0.001). The prevalence of complicated appendicitis after the epidemic outbreak was significantly higher than before the outbreak (51.7% vs. 12.4%, P < 0.001). In addition, the epidemic group had a lower score of patient’s intention to seek treatment than the pre-epidemic group (9.5 ± 2.7 vs. 3.4 ± 2.6, P < 0.001). Based on the multivariate analysis, the risk factors for complicated appendicitis included the time from symptoms onset to admission (OR = 1.075) and the patients’ intention to receive treatment (OR = 0.541).

Conclusion

Complicated appendicitis was more common in patients with acute appendicitis after the outbreak of the 2019-nCoV epidemic.