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      More Severe Presentations of Acute Appendicitis During COVID-19

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          Abstract

          Introduction Coronavirus disease (COVID-19) has caused unprecedented changes to almost every aspect of society. On March 11, 2020, the World Health Organization declared COVID-19 a pandemic. In order to contain the spread, Argentinian government rapidly declared a mandatory stay-at-home order on March 20th.1 We aimed to evaluate differences in imaging findings and postoperative outcomes of acute appendicitis (AA) patients between the COVID-19 pandemic period and a non-pandemic period. Methods We prospectively collected data of all patients who underwent laparoscopic appendectomy (LA) for AA between April 1, 2020, and August 31, 2020, during COVID-19 quarantine (G1) and compared them to a control group of patients who underwent LA during the same period in 2018 and 2019 (G2). Abdominal ultrasound (US) and computed tomography (CT) findings were reviewed and classified according to a modified score based on a reported classification: 1 normal, 2 non-diagnostic study, 3 uncomplicated AA, and 4 complicated AA.2 Complicated appendicitis was defined intraoperatively as a gangrenous or perforated appendix and severe peritonitis as the presence of fecal peritonitis in any quadrant or purulent fluid in more than one quadrant. The Kruskal-Wallis test was used to compare continuous variables, whereas the χ 2 test was used for categorical variables. A p value < 0.05 was considered statistically significant. Results A total of 202 LA were included for the analysis: 60 during COVID-19 quarantine (G1) and 142 in the control group (G2). Clinical diagnosis of AA was supported by US in all cases, and the number of CT scans performed for AA diagnosis (G1: 30% vs. G2: 35%, p = 0.43) remained similar in both groups. US grade 4 AA (G1: 13% vs. G2: 4%, p = 0.02), periappendiceal fluid presence (G1: 63% vs. G2: 37%, p = 0.0005), and wider appendix diameter in US (G1: 11 mm vs. G2: 9 mm, p = 0.002) were more frequent in G1. CT grade 4 AA (G1: 67% vs. G2: 23%, p = 0.03) and higher appendix diameter in CT (G1: 14 mm vs G2: 11 mm, p = 0.008) were also found in G1 (Fig. 1). Significant delays in consultation (G1: 54 vs. G2: 34 h, p = 0.0008), higher rates of severe peritonitis (G1: 42% vs. G2: 15%, p < 0.0001), and more complicated appendicitis (G1: 38% vs. G2: 19%, p = 0.004) were noted in G1. Patients in G1 also had higher rates of postoperative intraabdominal abscess (G1: 17% vs. G2: 7% p = 0.04), readmissions (G1: 12% vs. G2: 4%, p = 0.03), reoperations (G1: 5% vs. G2: 1%, p < 0.0001), and longer total LOS (G1: 3 vs. G2: 2 days, p = 0.04) (Table 1). Fig. 1 Uncomplicated (grade 3) and complicated (grade 4) acute appendicitis by US and CT Table 1 Perioperative variables and outcomes after laparoscopic appendectomy Variable G1 (COVID-19 quarantine) G2 (control group) p n = 60 n = 142 Sex (n (%))   Male 30 (50) 75 (53) 0.71   Female 30 (50) 67 (47) Mean age (range) (years) 37 (16–80) 39 (16–85) 0.70 ASA (n (%))   I–II 137 (96) 60 (100) 0.14   III–IV 5 (4) 0 (0) Previous abdominal surgery (n (%)) 17 (28) 28 (20) 0.18 Arterial hypertension (n (%)) 4 (7) 12 (8) 0.67 Diabetes (n (%)) 3 (5) 3 (2) 0.27 Mean white blood cell count (/mm3) 13,264 (6000–24,000) 13,223 (4500–25,000) 0.90 Mean time to consultation (range) (hours) 54 (12–240) 34 (5–120) 0.0008 Ultrasound AA grade (n (%)) 60 (100) 142 (100) 1   1 1 (2) 3 (2) 0.84   2 15 (25) 31 (22) 0.62   3 36 (60) 102 (72) 0.10   4 8 (13) 6 (4) 0.02 Diameter by ultrasound (mm (range)) 11 (18) 9 (6) 0.002 Periappendiceal fluid (n (%)) 38 (63%) 53 (37%) 0.0005 Computed tomography AA grade (n (%)) 18 (30) 35 (25) 0.57   1–2 0 (0) 0 (0) 1   3 6 (33) 27 (77) 0.002   4 12 (67) 8 (23) 0.002 Diameter by computed tomography (mm (range)) 14 (23) 11(8) 0.008 Complicated appendicitis (n (%)) 23 (38) 27 (19) 0.03 Severe peritonitis (n (%)) 25 (42) 21 (15) 0.01 Mean operative time (range) (minutes) 52 (20–120) 49 (15–105) 0.87 Conversion rate (n (%)) 1 (2) 1 (0.70) 0.53 Mean LOS (range) (days) 2.42 (1–17) 1.96 (1–30) 0.16 LOS with readmissions 3 (1–17) 2 (1–30) 0.04 Readmissions (n (%)) 7 (12) 5 (4) 0.03 Intra- abdominal abscess (n (%)) 10 (17) 10 (7) 0.04 Reoperations, (n (%)) 3 (5) 2 (1) < 0.0001 p < 0.05 are denoted in italic Abbreviations: ASA American Society of Anesthesiologists, AA acute appendicitis, LOS length of stay Discussion Our study found that the use of abdominal ultrasound and CT scan for the diagnosis remained similar during the COVID-19 pandemic. However, we indeed found higher rates of complicated appendicitis by both imaging modalities. Contrary to our results, previous reports have shown a significant decrease in the overall number of radiological examinations for AA.3 An increased proportion of severe cases identified by CT scan have been also reported during the pandemic.3 Our findings could be partially explained by significant delays in consultation due to the “stay-at-home” order during the quarantine.4 Higher rates of complicated appendicitis and severe peritonitis were also detected intraoperatively, along with greater postoperative morbidity. Some authors have advocated for a shift in the management of AA during the pandemic towards the use of medical treatment with antibiotics.5 Although this treatment strategy seems reasonable in uncomplicated AA, it is likely to fail in patients with complicated appendicitis and/or peritonitis.6 Conclusion We objectively demonstrated through imaging and intraoperative findings that patients with AA during COVID-19 pandemic have a more severe disease at presentation. Further studies are needed to determine potential detrimental effects of quarantine and “stay home” policies during a pandemic.

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          WHO Declares COVID-19 a Pandemic

          The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing, WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is “deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction,” and he called on countries to take action now to contain the virus. “We should double down,” he said. “We should be more aggressive.” Among the WHO’s current recommendations, people with mild respiratory symptoms should be encouraged to isolate themselves, and social distancing is emphasized and these recommendations apply even to countries with no reported cases (2). Separately, in JAMA, researchers report that SARS-CoV-2, the virus that causes COVID-19, was most often detected in respiratory samples from patients in China. However, live virus was also found in feces. They conclude: “Transmission of the virus by respiratory and extrarespiratory routes may help explain the rapid spread of disease.”(3). COVID-19 is a novel disease with an incompletely described clinical course, especially for children. In a recente report W. Liu et al described that the virus causing Covid-19 was detected early in the epidemic in 6 (1.6%) out of 366 children (≤16 years of age) hospitalized because of respiratory infections at Tongji Hospital, around Wuhan. All these six children had previously been completely healthy and their clinical characteristics at admission included high fever (>39°C) cough and vomiting (only in four). Four of the six patients had pneumonia, and only one required intensive care. All patients were treated with antiviral agents, antibiotic agents, and supportive therapies, and recovered after a median 7.5 days of hospitalization. (4). Risk factors for severe illness remain uncertain (although older age and comorbidity have emerged as likely important factors), the safety of supportive care strategies such as oxygen by high-flow nasal cannula and noninvasive ventilation are unclear, and the risk of mortality, even among critically ill patients, is uncertain. There are no proven effective specific treatment strategies, and the risk-benefit ratio for commonly used treatments such as corticosteroids is unclear (3,5). Septic shock and specific organ dysfunction such as acute kidney injury appear to occur in a significant proportion of patients with COVID-19–related critical illness and are associated with increasing mortality, with management recommendations following available evidence-based guidelines (3). Novel COVID-19 “can often present as a common cold-like illness,” wrote Roman Wöelfel et al. (6). They report data from a study concerning nine young- to middle-aged adults in Germany who developed COVID-19 after close contact with a known case. All had generally mild clinical courses; seven had upper respiratory tract disease, and two had limited involvement of the lower respiratory tract. Pharyngeal virus shedding was high during the first week of symptoms, peaking on day 4. Additionally, sputum viral shedding persisted after symptom resolution. The German researchers say the current case definition for COVID-19, which emphasizes lower respiratory tract disease, may need to be adjusted(6). But they considered only young and “normal” subjecta whereas the story is different in frail comorbid older patients, in whom COVID 19 may precipitate an insterstitial pneumonia, with severe respiratory failure and death (3). High level of attention should be paid to comorbidities in the treatment of COVID-19. In the literature, COVID-19 is characterised by the symptoms of viral pneumonia such as fever, fatigue, dry cough, and lymphopenia. Many of the older patients who become severely ill have evidence of underlying illness such as cardiovascular disease, liver disease, kidney disease, or malignant tumours. These patients often die of their original comorbidities. They die “with COVID”, but were extremely frail and we therefore need to accurately evaluate all original comorbidities. In addition to the risk of group transmission of an infectious disease, we should pay full attention to the treatment of the original comorbidities of the individual while treating pneumonia, especially in older patients with serious comorbid conditions and polipharmacy. Not only capable of causing pneumonia, COVID-19 may also cause damage to other organs such as the heart, the liver, and the kidneys, as well as to organ systems such as the blood and the immune system. Patients die of multiple organ failure, shock, acute respiratory distress syndrome, heart failure, arrhythmias, and renal failure (5,6). What we know about COVID 19? In December 2019, a cluster of severe pneumonia cases of unknown cause was reported in Wuhan, Hubei province, China. The initial cluster was epidemiologically linked to a seafood wholesale market in Wuhan, although many of the initial 41 cases were later reported to have no known exposure to the market (7). A novel strain of coronavirus belonging to the same family of viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), as well as the 4 human coronaviruses associated with the common cold, was subsequently isolated from lower respiratory tract samples of 4 cases on 7 January 2020. On 30 January 2020, the WHO declared that the SARS-CoV-2 outbreak constituted a Public Health Emergency of International Concern, and more than 80, 000 confirmed cases had been reported worldwide as of 28 February 2020 (8). On 31 January 2020, the U.S. Centers for Disease Control and Prevention announced that all citizens returning from Hubei province, China, would be subject to mandatory quarantine for up to 14 days. But from China COVID 19 arrived to many other countries. Rothe C et al reported a case of a 33-year-old otherwise healthy German businessman :she became ill with a sore throat, chills, and myalgias on January 24, 2020 (9). The following day, a fever of 39.1°C developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Before the onset of symptoms, he had attended meetings with a Chinese business partner at his company near Munich on January 20 and 21. The business partner, a Shanghai resident, had visited Germany between January 19 and 22. During her stay, she had been well with no signs or symptoms of infection but had become ill on her flight back to China, where she tested positive for 2019-nCoV on January 26. This case of 2019-nCoV infection was diagnosed in Germany and transmitted outside Asia. However, it is notable that the infection appears to have been transmitted during the incubation period of the index patient, in whom the illness was brief and nonspecific. The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak (9). Our current understanding of the incubation period for COVID-19 is limited. An early analysis based on 88 confirmed cases in Chinese provinces outside Wuhan, using data on known travel to and from Wuhan to estimate the exposure interval, indicated a mean incubation period of 6.4 days (95% CI, 5.6 to 7.7 days), with a range of 2.1 to 11.1 days. Another analysis based on 158 confirmed cases outside Wuhan estimated a median incubation period of 5.0 days (CI, 4.4 to 5.6 days), with a range of 2 to 14 days. These estimates are generally consistent with estimates from 10 confirmed cases in China (mean incubation period, 5.2 days [CI, 4.1 to 7.0 days] and from clinical reports of a familial cluster of COVID-19 in which symptom onset occurred 3 to 6 days after assumed exposure in Wuhan (10-12). The incubation period can inform several important public health activities for infectious diseases, including active monitoring, surveillance, control, and modeling. Active monitoring requires potentially exposed persons to contact local health authorities to report their health status every day. Understanding the length of active monitoring needed to limit the risk for missing infections is necessary for health departments to effectively use resources. A recent paper provides additional evidence for a median incubation period for COVID-19 of approximately 5 days (13). Lauer et al suggest that 101 out of every 10 000 cases will develop symptoms after 14 days of active monitoring or quarantinen (13). Whether this rate is acceptable depends on the expected risk for infection in the population being monitored and considered judgment about the cost of missing cases. Combining these judgments with the estimates presented here can help public health officials to set rational and evidence-based COVID-19 control policies. Note that the proportion of mild cases detected has increased as surveillance and monitoring systems have been strengthened. The incubation period for these severe cases may differ from that of less severe or subclinical infections and is not typically an applicable measure for those with asymptomatic infections In conclusion, in a very short period health care systems and society have been severely challenged by yet another emerging virus. Preventing transmission and slowing the rate of new infections are the primary goals; however, the concern of COVID-19 causing critical illness and death is at the core of public anxiety. The critical care community has enormous experience in treating severe acute respiratory infections every year, often from uncertain causes. The care of severely ill patients, in particular older persons with COVID-19 must be grounded in this evidence base and, in parallel, ensure that learning from each patient could be of great importance to care all population,
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            Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial

            Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis, but long-term outcomes are not known.
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              Acute Appendicitis During Coronavirus Disease 2019 (COVID-19): Changes in Clinical Presentation and CT Findings

              Background Quarantine and stay-at-home orders are strategies that many countries used during the acute pandemic period of coronavirus disease 2019 (COVID-19) to prevent disease dissemination, health system overload, and mortality. However, there are concerns that patients did not seek necessary health care due to these mandates. Purpose To evaluate the differences in the clinical presentation of acute appendicitis and CT findings related to these cases between the COVID-19 acute pandemic period and nonpandemic period. Materials and Methods A retrospective observational study was performed to compare the acute pandemic period (March 23, 2020, to May 4, 2020) versus the same period the year before (March 23, 2019, to May 4, 2019). The proportion of appendicitis diagnosed by CT and level of severity of the disease were reviewed in each case. Univariate and bivariate analyses were performed to identify significant differences between the two groups. Results A total of 196 abdominal CT scans performed due to suspected acute appendicitis were evaluated: 55 from the acute pandemic period and 141 from the nonpandemic period. The proportion of acute appendicitis diagnosed by abdominal CT was higher in the acute pandemic period versus the nonpandemic period: 45.5% versus 29.8% (P = .038). The severity of the diagnosed appendicitis was higher during the acute pandemic period: 92% versus 57.1% (P = .003). Conclusion During the acute COVID-19 pandemic period, fewer patients presented with acute appendicitis to the emergency room, and those who did presented at a more severe stage of the disease.
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                Author and article information

                Contributors
                angeramoagustin@gmail.com
                Journal
                J Gastrointest Surg
                J Gastrointest Surg
                Journal of Gastrointestinal Surgery
                Springer US (New York )
                1091-255X
                1873-4626
                19 January 2021
                : 1-3
                Affiliations
                GRID grid.414357.0, ISNI 0000 0004 0637 5049, Department of Surgery, , Hospital Aleman of Buenos Aires, ; 1640 Pueyrredon Ave, Capital Federal, Buenos Aires, Argentina
                Article
                4892
                10.1007/s11605-020-04892-0
                7815199
                33469887
                © The Society for Surgery of the Alimentary Tract 2021

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                Categories
                Research Communication

                Surgery

                covid-19, acute appendicitis, imaging findings, computed tomography, abdominal ultrasound

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