ABSTRACT
Background: Appendectomy has been the standard of care for treatment of appendicitis for decades. Nonoperative management (NOM) of appendicitis is an alternative treatment strategy and had a resurgence of interest owing to the COVID-19 pandemic and the need for alternate care delivery models. One of the concerns for treatment of appendicitis with NOM is the recurrence rate. Despite this, there are few data examining the predictors of recurrence to tailor patient selection for NOM of appendicitis. The objective of this study was to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively. Methods: We conducted a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital between May 1, 2019, and Apr. 30, 2021. Patients with appendicitis who were treated nonoperatively were identified. Patient demographics, radiographic information, management, and clinical outcomes were recorded. Results: The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a univariate and multivariate time-toevent competing-risk analysis was performed with Cox regression. Of the 74 patients, 35 (47.3%) were women (median age 48 [interquartile range (IQR) 33-64] yr) with appendicitis treated successfully nonoperatively, 21 patients (29.2%) had recurrent appendicitis and 20 (27.8%) underwent an interval appendectomy. Median time to recurrence was 17 days (IQR 7-66). Presence of an appendicolith on imaging was associated with a higher cause-specific hazard of recurrent appendicitis. Age, sex and history of diabetes were not found to be associated with recurrence of appendicitis. The adjusted cause-specific hazard ratio of recurrent appendicitis for presence of appendicolith was 2.67 (95% confidence interval 1.09-6.56, p = 0.032). Conclusion: Our study found that presence of appendicolith was associated with a 2.67 increase in cause-specific hazard of developing recurrent appendicitis within 6 months. This information can help tailor patient selection for nonoperative management.
ABSTRACT
BACKGROUND AND OBJECTIVES: Older adults with multiple comorbidities experience high rates of hospitalization and poor outcomes from Coronavirus Disease 2019 (COVID-19). Changes in care utilization by persons in advanced illness management (AIM) programs during the COVID-19 pandemic are not well known. The purpose of this study was to describe changes in care utilization by homebound AIM patients in an epicenter of the COVID-19 pandemic before and during the pandemic. RESEARCH DESIGN AND METHODS: Descriptive statistics and tests of differences were used to compare care utilization rates, including emergency department (ED) and inpatient admissions, acute and subacute rehabilitation, and AIM program utilization during the pandemic with rates 1 year prior. RESULTS: Acute and post-acute utilization for enrollees (n = 1,468) decreased March-May 2020 compared to 1 year prior (n = 1,452), while utilization of AIM program resources remained high. Comparing 2019 and 2020, ED visits/1,000 enrollees were 109 versus 44 (p < .001), inpatient admissions 213 versus 113 (p < .001), and rehabilitation facility admissions 56 versus 31 (p = .014); AIM program home visits were 1,935 versus 276 (p < .001), remote visits (telehealth/telephonic) 0 versus 1,079 (p < .001), and all other phone touches 3,032 versus 5,062 (p < .001). Home hospice admissions/1,000 increased: 16-31 (p = .011). DISCUSSION AND IMPLICATIONS: Our results demonstrate decreased acute and post-acute utilization, while maintaining high levels of connectedness to the AIM program, among a cohort of homebound older adults during the COVID-19 pandemic compared with 1 year prior. While further study is needed, our results suggest that AIM programs can provide support to this population in the home setting during a pandemic.
Subject(s)
COVID-19 , Home Care Services , Aged , Humans , Pandemics , Primary Health Care , SARS-CoV-2ABSTRACT
BACKGROUND: The recent global pandemic has placed a high priority on identifying drugs to prevent or lessen clinical infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused by Coronavirus disease-2019 (COVID-19). METHODS: We applied two computational approaches to identify potential therapeutics. First, we sought to identify existing FDA approved drugs that could block coronaviruses from entering cells by binding to ACE2 or TMPRSS2 using a high-throughput AI-based binding affinity prediction platform. Second, we sought to identify FDA approved drugs that could attenuate the gene expression patterns induced by coronaviruses, using our Disease Cancelling Technology (DCT) platform. RESULTS: Top results for ACE2 binding iincluded several ACE inhibitors, a beta-lactam antibiotic, two antiviral agents (Fosamprenavir and Emricasan) and glutathione. The platform also assessed specificity for ACE2 over ACE1, important for avoiding counterregulatory effects. Further studies are needed to weigh the benefit of blocking virus entry against potential counterregulatory effects and possible protective effects of ACE2. However, the data herein suggest readily available drugs that warrant experimental evaluation to assess potential benefit. DCT was run on an animal model of SARS-CoV, and ranked compounds by their ability to induce gene expression signals that counteract disease-associated signals. Top hits included Vitamin E, ruxolitinib, and glutamine. Glutathione and its precursor glutamine were highly ranked by two independent methods, suggesting both warrant further investigation for potential benefit against SARS-CoV-2. CONCLUSIONS: While these findings are not yet ready for clinical translation, this report highlights the potential use of two bioinformatics technologies to rapidly discover existing therapeutic agents that warrant further investigation for established and emerging disease processes.