Rate of Pediatric Appendiceal Perforation at a Children’s Hospital During the COVID-19 Pandemic Compared With the Previous Year | Emergency Medicine | JAMA Network Open | JAMA Network
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Table.  Demographic Characteristics and Outcomes of Patients With Appendicitis in a 10-Week Period, 2019 vs 2020
Demographic Characteristics and Outcomes of Patients With Appendicitis in a 10-Week Period, 2019 vs 2020
1.
Saad  L. Americans worry doctor visits raise COVID-19 risk. Gallup. Published April 6, 2020. Accessed June 18, 2020. https://news.gallup.com/poll/307640/americans-worry-doctor-visits-raise-covid-risk.aspx
2.
Masroor  S.  Collateral damage of COVID-19 pandemic: delayed medical care.   J Card Surg. 2020;35(6):1345-1347. doi:10.1111/jocs.14638 PubMedGoogle ScholarCrossref
3.
Garcia  S, Albaghdadi  MS, Meraj  PM,  et al.  Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic.   J Am Coll Cardiol. 2020;75(22):2871-2872. doi:10.1016/j.jacc.2020.04.011 PubMedGoogle ScholarCrossref
4.
Teo  KC, Leung  WCY, Wong  YK,  et al.  Delays in stroke onset to hospital arrival time during Covid-19.   Stroke. 2020;51(7):2228-2231. doi:10.1161/STROKEAHA.120.030105PubMedGoogle ScholarCrossref
5.
Lazzerini  M, Barbi  E, Apicella  A, Marchetti  F, Cardinale  F, Trobia  G.  Delayed access or provision of care in Italy resulting from fear of COVID-19.   Lancet Child Adolesc Health. 2020;4(5):e10-e11. doi:10.1016/S2352-4642(20)30108-5 PubMedGoogle ScholarCrossref
6.
Metzler  B, Siostrzonek  P, Binder  RK, Bauer  A, Reinstadler  SJ.  Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage.   Eur Heart J. 2020;41(19):1852-1853. doi:10.1093/eurheartj/ehaa314 PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    Ethnographic Accessibility
    Paul Nelson, MS, MD | Family Health Care, P.C. retired
    As an avocational student of healthcare reform, it has been helpful for me to view its essential attributes as equitably available, ethnographically accessible, justly efficient, and reliably effective with values of altruism, trust, cooperation, reciprocity, and excellence. The world-wide market-place arenas of each nation's resources, knowledge, and human dignity add a high level of uncertainty to understanding each nation's population health  that is encountered by its healthcare industry.

    My own view of ethnography for health is its study of human suffering and how variously defined clusters of a community's families will manage their Well-Being. Specifically, when the
    level of human suffering changes within a family, such as a person's steadily worsening abdominal pain, what options are available to a family that are trustworthy as a means to encounter caring relationships for controlling that pain.

    Unlike nearly all of the other 36 nations that belong to the Organisation for Economic Co-operation and Development (OECD), our nation is alone for its lack of a nationally mandated commitment to arrange equitably available and ethnographically accessible Primary Healthcare that is justly efficient and reliably effective for each of its resident persons. This report by Doctors Place, Lee, and Howell represents a prominent social dilemma within the paradigm paralysis of our nation's population health and its healthcare. The attributes of timely healthcare should be a daily carillon reminder to us all as a basis for improving every community's primary healthcare.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    Emergency Medicine
    December 4, 2020

    Rate of Pediatric Appendiceal Perforation at a Children’s Hospital During the COVID-19 Pandemic Compared With the Previous Year

    Author Affiliations
    • 1Department of Emergency Medicine, Inova Fairfax Medical Campus, Virginia Commonwealth University School of Medicine, Falls Church
    • 2Department of Pediatrics, Inova Fairfax Medical Campus, Virginia Commonwealth University School of Medicine, Falls Church
    JAMA Netw Open. 2020;3(12):e2027948. doi:10.1001/jamanetworkopen.2020.27948
    Introduction

    Clinicians have witnessed a dramatic shift in health care consumption during the coronavirus disease 2019 (COVID-19) pandemic as patients fear exposure to coronavirus from visiting health care facilities.1,2 Among the many concerning patterns emerging is that of delayed medical care. Garcia et al3 reported a 38% decline in cardiac ST-segment elevation myocardial infarction activations, and Teo et al4 noted fewer patients with ischemic stroke presenting within the therapeutic window. Lazzerini et al5 described 12 children who presented in severe condition because of delays in accessing care; 4 of these children died.

    We noted an increased incidence of perforated appendicitis coinciding with the closure of Virginia public schools on March 16, 2020, and sought to determine whether a true difference existed.

    Methods

    As part of a quality improvement initiative to alert our community to the dangers of delayed medical care, we assessed the percentage of acute and perforated appendicitis in children younger than 18 years. The study period covered 10 weeks between March 16 and June 7, 2020, at the pediatric emergency department in Inova Children’s Hospital in Northern Virginia. We compared this rate with the same period 1 year earlier. The final diagnosis of appendicitis and the presence of perforation was determined by the operative report. Data were collected using the electronic medical record (Epic; Epic Systems Corporation). We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. The office of research at INOVA Health System determined this review to be exempt from the need for study approval or patient informed consent because it was conducted as an institutional quality improvement project.

    Nominal outcomes were analyzed using either Fisher exact or χ2 tests. Continuous outcomes were analyzed using a 2-tailed unpaired t test. The α level was set at 0.05 for all comparisons. Data were analyzed using online GraphPad, version 7.0 software (GraphPad Software).

    Results

    During the 10-week study period, 90 children were diagnosed with acute appendicitis; perforation had occurred in 35 cases (39%). The median patient age was 10 years (interquartile range [IQR], 7-13 years), 46 (51%) were boys, and 30 (33%) were White individuals (Table). During the same period in 2019, 70 children presented with acute appendicitis; perforation had occurred in 13 cases (19%). The median patient age in 2019 was 11 years (IQR, 9-14 years), 44 (63%) were boys, and 33 (47%) were White individuals. This change in the number of cases between 2020 and 2019 represents a 20% absolute increase in the incidence of perforated appendicitis (P = .009).

    During the COVID-19 study period, 8 children (9%) presented with a pelvic abscess that required initial medical management before delayed interval appendectomy. No patient required medical management in the 2019 control period (Table).

    Patient volumes in the emergency department were also decreased during the pandemic, from a mean of 144 patients per day (95% CI, 136%-152%) to 65 patients per day, reflecting a 55% decrease (95% CI, 39%-90%); P < .001). However, there was a nonsignificant increase in the admission rate of 16.4% over the 10-week study period compared with a baseline admission rate of 10.5% in 2019 (P = .07).

    Discussion

    Although studies in the adult literature and case series in the pediatric literature have reported delays in medical care attributable to COVID-19, we report a statistically significant increased rate of appendiceal perforation during this pandemic.2-6 Over the 3 months studied, parents displayed visible signs of anxiety when in the emergency department and openly expressed reluctance to visit the hospital for fear of contracting COVID-19.

    Unlike their adult counterparts, pediatric patients do not commonly experience medical conditions with a high risk of mortality. However, medical conditions do exist for which delayed diagnosis and management can lead to a significant increase in morbidity, prolonged hospitalization, and increased financial expense. In this cross-sectional study, appendiceal perforation also resulted in pelvic abscess, bowel obstruction, and sepsis.

    This was a single institutional cohort, and generalizability to other settings may be limited. Although the reduction in “unnecessary” emergency care may be welcomed by some, broad avoidance of the emergency department may lead to increased morbidity and mortality in both children and adults.

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    Article Information

    Accepted for Publication: September 24, 2020.

    Published: December 4, 2020. doi:10.1001/jamanetworkopen.2020.27948

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Place R et al. JAMA Network Open.

    Corresponding Author: Rick Place, MD, MHA, Department of Emergency Medicine, Inova Fairfax Medical Campus, 3300 Gallows Rd, Falls Church, VA 22042 (frederick.place@inova.org).

    Author Contributions: Dr Place had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Place, Howell.

    Acquisition, analysis, or interpretation of data: Place, Lee.

    Drafting of the manuscript: Place.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Howell.

    Supervision: Place.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Saad  L. Americans worry doctor visits raise COVID-19 risk. Gallup. Published April 6, 2020. Accessed June 18, 2020. https://news.gallup.com/poll/307640/americans-worry-doctor-visits-raise-covid-risk.aspx
    2.
    Masroor  S.  Collateral damage of COVID-19 pandemic: delayed medical care.   J Card Surg. 2020;35(6):1345-1347. doi:10.1111/jocs.14638 PubMedGoogle ScholarCrossref
    3.
    Garcia  S, Albaghdadi  MS, Meraj  PM,  et al.  Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic.   J Am Coll Cardiol. 2020;75(22):2871-2872. doi:10.1016/j.jacc.2020.04.011 PubMedGoogle ScholarCrossref
    4.
    Teo  KC, Leung  WCY, Wong  YK,  et al.  Delays in stroke onset to hospital arrival time during Covid-19.   Stroke. 2020;51(7):2228-2231. doi:10.1161/STROKEAHA.120.030105PubMedGoogle ScholarCrossref
    5.
    Lazzerini  M, Barbi  E, Apicella  A, Marchetti  F, Cardinale  F, Trobia  G.  Delayed access or provision of care in Italy resulting from fear of COVID-19.   Lancet Child Adolesc Health. 2020;4(5):e10-e11. doi:10.1016/S2352-4642(20)30108-5 PubMedGoogle ScholarCrossref
    6.
    Metzler  B, Siostrzonek  P, Binder  RK, Bauer  A, Reinstadler  SJ.  Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage.   Eur Heart J. 2020;41(19):1852-1853. doi:10.1093/eurheartj/ehaa314 PubMedGoogle ScholarCrossref
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