| Objective Through the evaluation of possible clinical predictive indicators that affect the severity of acute appendicitis(AA),the use of indicators with diagnostic value after the evaluation is used to make stratified diagnosis of AA,and then choose the best treatment method to avoid possible surgery and postoperative complications can also reduce the risk of negative appendectomy.Methods Based on the inclusion and exclusion criteria of the study design,the clinical medical records of 1606 AA patients who underwent appendicectomy in The 940th Hospital of Joint Logistic Support Force of PLA HIS system from June 2012 to September 2020(including 45 indicators)were collected as research subjects and according to the pathological results,they were divided into simple appendicitis group(SA)and complicated appendicitis group(CA).To assess the clinical predictors of CA that were available before the availability of laboratory test results,we divided the collected measures into non-laboratory,laboratory and combined groups.To make the results of multivariate analysis more clinically significant,age at 60 years old and fever at 37.4℃ were transformed into dichotomous variables,and the remaining all continuous variables were transformed into dichotomous variables by medians for univariate analysis,and the statistically significant indicators were separately included into binary logistic multivariate regression analysis to derive independent risk factors for each group.Finally,receiver operating characteristic curve(ROC curve)was used to evaluate the diagnostic significance of each independent risk factor and the combined diagnostic tests,and the area under the curve(AUC),standard error(SE),95%confidence interval(95%CI),optimal cut-off point(cut-off value),sensitivity and specificity,to compare the diagnostic efficacy of each independent risk factor for predicting CA and finally to obtain the best clinical predictor.Results Among the 1606 study subjects,1373(85.5%)patients with SA and 233(14.5%)patients with CA,the data of basic characteristics and test results were analyzed as follows.The results of univariate analysis in the non-laboratory group showed that patients aged≥ 60 years were more common in the CA Group(χ2=10.43,P=0.001),in which the median age was 35 years[Interquartile Range(IR),24～51 years]in the SA group and 40 years[IR,25～59 years]in the CA Group;in the origin,482(82.7%)of 583(36.3%)rural patients with SA and 101(17.3%)with CA,there were 891(87.1%)SA patients and 132(12.9%)CA patients in 1023(63.7%)town patients,with significant differences between groups(χ2=5.85,P=0.016).The median onset to visit intervals were 24.0h(IR,19.0～48.0h)and 48.0h(IR,24.0～96.Oh)(χ2=41.35,P<0.001).Among the patients with fever,1022(86.8%)of 1178(73.3%)<37.4℃patients with SA and 156(13.2%)of 156(26.7%)patients with CA,351(82.0%)of 428(26.7%)of≥ 37.4℃ patients with SA and 77(18.0%)of 78(18.0%)patients with CA,there were differences between groups(χ2=5.71,P=0.017).Among the patients with anorexic nausea,362(22.5%)had no anorexia,322(89.0%)SA patients and 40(11.0%)CA patients among cardiac patients,1051(84.5%)SA patients and 193(15.5%)CA patients among 1244(77.5%)anorexic nausea patients,there were significant between groups(χ2=4.51,P=0.034).The results of univariate analysis in the laboratory group showed that the statistics in the SA and CA groups were as follows:white blood cell neutrophil count ratio(WNR)[1.2(1.1～1.2)× 109/L and 1.1(1.1～1.2)× 109/L,χ2=7.96,P=0.005],white blood cell lymphocyte count ratio(WLR)[11.8(7.8～17.8)× 109/L and 14.4(9.9～20.1)× 109/L,χ2=18.33,P<0.001],neutrophil count ratio(NLR)[10.2(6.3～16.1)and 12.5(8.3～18.5),χ2=12.91,P<0.001],neutrophil percentage(NEU%)[86.3(80.9～90.2)%and 88.2(83.8～91.2)%,χ2=9.65,P=0.002],platelet lymphocyte count ratio(PLR)[177.3(125.8～262.3)and 202.6(150.0～304.3),χ2=9.28,P=0.002],serum albumin(ALB)[45.4(42.1～48.5)g/L and 43.3(38.8～46.2)g/L,χ2=29.77,P<0.001],total bilirubin(TBIL)[17.4(12.5～24.1)μmol/L and 20.5(13.6～29.0)μmol/L,χ2=11.21,P=0.001],natrium(NA)[138.8(136.5～140.7)mmol/L and 137.7(135.2～140.0)mmol/L,χ2=15.04,P<0.001],international normalized ratio(INR)[1.1(1.0～1.1)and 1.1(1.0～1.2),χ2=38.98,P<0.001],fibrinogen(FIB)[3.6(2.6～4.8)g/L and 4.7(3.7～6.2)g/L,χ2=54.74,P<0.001].The statistically significant indicators in the univariate analysis results were included in the binary logistic multivariate regression analysis.The non-laboratory group showed:age(OR=1.623,95%CI:1.148～2.294,P=0.006),origin(OR=1.342,95%CI:1.006～1.790,P=0.045),onset to visit interval(OR=4.146,95%CI:2.519～6.825,P<0.001),fever(OR=1.465,95%CI:1.079～1.988,P=0.014),anorexia and nausea(OR=1.495,95%CI:1.033～2.163,P=0.033)were independent risk factors for CA;the laboratory group showed:WLR(OR=8.438,95%CI:2.302～30.930,P=0.001),NLR(OR=6.453,95%CI:1.640σ25.400,P=0.008),ALB(OR=0.614,95%CI:0.449～0.839,P=0.002),INR(OR=1.725,95%Cl:1.241～2.397,P=0.001),FIB(OR=2.239,95%CI:1.608～3.118,P<0.001)are independent risk factors for CA;combined group display:the time between onset and visit(OR=2.750,95%CI:1.603～4.718,P<0.001),anorexia and nausea(OR=1.465,95%CI:1.006～2.134,P=0.046),WLR(OR=10.988,95%CI:2.573～46.931,P=0.001),NLR(OR=8.196,95%CI:1.804～37.237,P=0.006),ALB(OR=0.716,95%CI:0.516～0.992,P=0.045),INR(OR=1.585,95%CI:1.134～2.215,P=0.007),FIB(OR=1.848,95%CI:1.314～2.598,P<0.001)were independent risk factors for CA.The independent risk factors in the results of the multivariate regression analysis of each group were used for ROC diagnostic tests.The non-laboratory group showed that the onset to visit interval was the maximum AUC=0.678,SE:0.018,95%CI:0.655～0.701,when the onset to visit interval is>42H,the sensitivity is 69.10%,the specificity is 60.45%,P<0.001;in the laboratory group and the combination group:FIB is the maximum AUC=0.688,SE:0.017,95%CI:0.665～0.710,when FIB>3.61g/L,the sensitivity is 78.97%,the specificity is 49.96%,P<0.001.The combined diagnosis of the indicators of each group showed that the non-laboratory group AUC=0.667,SE:0.019,95%CI:0.643～0.690,sensitivity 70.82%,specificity 57.90%,P<0.001;laboratory group AUC=0.720,SE:0.017,95%CI:0.697～0.741,sensitivity of 77.25%,specificity of 56.23%,P<0.001;combination group AUC=0.730,SE:0.016,95%CI:0.707～0.752,sensitivity of 75.54%,specificity is 59.07%,P<0.001.Conclusions 1.In the non-laboratory group,advanced age,origin,extended onset to visit interval,fever,anorexia and nausea are the clinical predictive risk factors for the severity of AA,and the combined diagnosis efficiency is low;2.In the laboratory group,the increase in WLR,NLR,INR,FIB levels and the decrease in ALB levels are clinical predictive risk factors for the severity of AA,and the combined diagnostic efficiency is moderate;3.In the combined group,extended onset to visit interval,anorexia nausea,the increase of WLR,NLR,INR,FIB level and the decrease of ALB level are clinical predictive risk factors for the severity of AA,and the combined diagnostic efficiency is moderate;4.On the clinical predictive assessment CA,the laboratory group indicators had better diagnostic efficacy than the non-laboratory group indicators. |
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