OBJECTIVE:We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States.
SUMMARY ...BACKGROUND DATA:Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons.
METHODS:This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a “complicated” outcome variable and risk factors were assessed using multivariable logistic regression.
RESULTS:A total 3597 subjects were enrolled across 28 sitesmedian age was 37 (27–52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1–2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of “complicated” appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not.
CONCLUSION:In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for “complicated” appendicitis.
The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal ...malignancy.
Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit.
A total of 3,293 patients were included. The median age was 38 (27–53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma 60.4%, neuroendocrine 37.5%, and lymphoma 2.1%). Patients with malignancy were older (56 34.5–67 vs 37 27–52 years, P < .001), had longer duration of symptoms before presentation (36–41 vs 18–23 hours, P = .03), and were more likely to have a phlegmon on imaging (6.3% vs 1.3%, P = .03). Multivariable analyses showed that an enlarged appendiceal diameter was independently associated with malignancy (odds ratio = 1.06, 95% confidence interval = 1.01–1.12; P = .01). The incidence of malignancy in patients >40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients ≤40 years old with appendiceal diameter ≤10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24–7.42; P = .02).
The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.
Intramural hematoma (IMH) is considered a part of acute aortic syndromes (AAS), a group of life-threatening aortic diseases with a similar presentation that appears to have different clinical ...manifestations and pathological and survival characteristics. AAS comprises three major entities, namely, aortic dissection (AD), IMH, and PAU. IMH-like classic AD is classified using Stanford and DeBakey classification systems to indicate the aortic area involved. Early diagnosis and treatment of AAS are crucial for survival; however, diagnosis of IMH may be delayed and challenging due to atypical presentation, investigation findings, and case progression. In this report, we describe a case of delayed and challenging diagnosis of a Stanford type A IMH that was managed surgically with a good outcome.
A myxoma is a benign intramuscular gelatinous tumor that is rarely known to arise from the scrotum. It can be confused both clinically and radiologically with other more common scrotal wall lesions ...such as a sebaceous cyst or an abscess. We report a case of a 54-year-old patient who presented with a scrotal wall swelling that was initially suspected to be an infected cyst or cold abscess on imaging. The final diagnosis of a myxoma was made after surgical excision and histopathological examination.
To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18-45 years).
This was a post-hoc analysis of a prospectively collected ...database (January 2017-June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes.
Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 ± 8 years at a median gestational age of 15 (range 10-23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days.
Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.
Aims: Gender roles vary from society to society and are subject to change over time. Failure to be gender-sensitive in a physician's professional role and practice can result in negative consequences ...such as gender discrimination and influence various aspects of medical education, career opportunities, and specialization selection. Gender discrimination can lead to a division in selection of profession and lead to certain jobs being dominated by either men or women. The aim of this study is to reveal the perceptions of intern medical students at Marmara University Pendik Education and Research Hospital about gender inequality and how this issue affects their medical education. Methods: The present study is cross-sectional in nature. An eleven-item questionnaire adapted from a similar study was applied to determine the opinions of interns regarding gender inequality and discrimination and how this issue has affected their medical education. Out of the 245 interns reached, 150 (62%) agreed to participate in our study. Links to the questionnaire were sent to participants via WhatsApp. Participants remained anonymous throughout the study. Results: Forty six percent (n=69) of participants were male and 54.0% (n=81) were female. The majority of students wanted to specialize in a surgical field during the beginning of their medical training (53.3%), whereas the most desired branches to specialize in towards the end of medical school were internal branches (52.0%). Interns stated that they encountered sexist behaviors/expressions from their peers, members of faculty, as well as deans (54.67%, 66.0%, and 58.0% respectively) (p=0.169, 0.297 and 0.647 respectively). 39.3% of interns believe that gender equality is not given due importance in medical school (p=0.05). The majority of participants (56.7%) agreed that female interns are more exposed to sexism than male interns (p=0.016). Males are the preferred gender among interns for surgical branches (p=0.01) as well as specialties including invasive procedures (p=0.02). 56.0% of participants agree that a female physicians' profession/specialty plays a major role in her decision to have children later in life (p=0.063). Conclusion: Gender discrimination is an important issue that affects different aspects of life, including medicine. Gender equality must be promoted throughout medical school; this can be achieved by integrating gender awareness into the curriculum of medical education and providing positive role models and purposeful teaching during internships. Further efforts are needed to cultivate a culture of gender inclusivity throughout this transformative process. Keywords: Gender in medicine, gender discrimination, gender inequality, medical education, interns
A myxoma is a benign intramuscular gelatinous tumor that is rarely known to arise from the scrotum. It can be confused both clinically and radiologically with other more common scrotal wall lesions ...such as a sebaceous cyst or an abscess. We report a case of a 54-year-old patient who presented with a scrotal wall swelling that was initially suspected to be an infected cyst or cold abscess on imaging. The final diagnosis of a myxoma was made after surgical excision and histopathological examination.
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