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Seasonal Variation in Cases of Acute Appendicitis

Seasonal Variation in Cases of Acute Appendicitis Hindawi Surgery Research and Practice Volume 2021, Article ID 8811898, 5 pages https://doi.org/10.1155/2021/8811898 Research Article 1 2 1 1 Rawan A. Rahman AlHarmi , Sayed Ali Almahari, Jasim AlAradi, Asma Alqaseer, 3 3 Noof Sami AlJirdabi, and Fatema Ali Ahmed Department of Surgery, Salmaniya Medical Complex, Manama, Bahrain Department of Pathology, Salmaniya Medical Complex, Manama, Bahrain Medical Intern, Salmaniya Medical Complex, Manama, Bahrain Correspondence should be addressed to Rawan A. Rahman AlHarmi; rawan.alhermi@gmail.com Received 10 September 2020; Revised 14 January 2021; Accepted 23 February 2021; Published 2 March 2021 Academic Editor: Todd Pesavento Copyright © 2021 Rawan A. Rahman AlHarmi et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer. Methods. A single-center cross-sectional, retrospective study on 697 cases of appendicitis admitted in the year 2018. Inclusion criteria: patients admitted with acute appendicitis who underwent appendectomy of all ages. Exclusion criteria: conservative management. Analysis was performed using Microsoft Excel. Pearson correlation coefficient was calculated to assess the correlation between monthly incidence of appendicitis and mean temperature in that month. Results. Fifty-one patients who were managed conservatively were excluded. Accordingly, 646 patients were included. Ages ranged from three to 77 years. Males comprised the majority (500, 77.4%). Gangrenous, perforated, and purulent appendices were regarded as complicated ap- pendicitis. )e highest number of cases were admitted in summer (234), comprising 36.2% of cases. Complicated cases were equal to 65, of which 23 (35.4%) were admitted in summer and 30 (46.2%) in winter. )e highest number of cases was during the month of July (68), while the lowest (40) was during February. )is corresponded to the highest recorded mean temperature (36.2 C) and second lowest (19.8 C), respectively. Moderate positive correlation (Pearson’s R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted. Conclusion. More cases of appendicitis were noted during summer. Monthly incidence correlated positively with the temperature. Larger numbers over several years are needed to draw better conclusions and reach the possible causes behind such variation. 1.1. Purpose. We aim through this study to investigate whether 1. Introduction the incidence of acute appendicitis increases in summer season. Acute appendicitis is a common global acute abdominal Our secondary objective is to assess whether the incidence of surgical condition [1]. Its etiology is poorly understood. En- complicated appendicitis increases in summer season com- vironmental factors have been implicated, including summer pared to other seasons. season, air pollution, and dust/allergens. Incidence is increased in certain ethnic groups and complications are increased in 2. Methods minorities, likely due to lack of healthcare access. Cases are classified into simple (nonperforated) and complex (gangre- 2.1. Study Design. )is is a single-center cross-sectional, nous, perforated, and pelvic/abdominal abscess) [2–5]. retrospective study conducted by the Department of Surgery Bahrain is an archipelago in the Gulf with an arid cli- in Salmaniya Medical Complex (the largest hospital in mate. )e year is divided into two seasons: summer (June- Bahrain; a 1029-bed tertiary hospital in the capital Manama, September) and winter (December-March). )ese are sep- serving all citizens and residents of all ages) on 697 cases arated by two transitional periods: first (April, May) and admitted to our facility with a clinical diagnosis of acute second (October, November) [6]. appendicitis in the year 2018. Approval of the institutional 2 Surgery Research and Practice ethical review board was attained on 06/07/2020 (no number respectively. Pearson’s correlation coefficient was calculated assigned). and revealed a moderate positive correlation (Pearson’s R 0.5183; R Coefficient of Determination 0.2686; P value 0.084292) between the monthly incidence of appendicitis 2.2. Participants. )e patients were selected, as stated pre- and the corresponding recorded mean temperature in that viously, from those admitted with acute appendicitis (based month (Figure 1). on clinical and/or laboratory/imaging diagnosis) in the year We further investigated the variables related to com- 2018. Inclusion criteria: patients admitted with a diagnosis of plicated appendicitis, namely, the ethnic group. )e highest acute appendicitis who underwent appendectomy (open or groups presenting with complications were Bahrainis (23, laparoscopic) of all ages (including those admitted under 35.4%) and Southern Asians (27, 41.5%) (Table 4). Another pediatric surgery). Exclusion criteria: conservative man- studied variable was the duration of symptoms at the time of agement (e.g., appendiceal mass and other clinical diag- presentation. Two patients were excluded from T1 group, nosis). Patient data was collected from the National Health five from the summer group, and two from T2 group due to Information System (I-SEHA). )e study did not involve lack of documentation. For the rest, it was noted that the any patient intervention or contact. average time at presentation was 2.03, 2.2, 2.06, and 4.3 days Seasons were divided as previously mentioned into following the onset of symptoms in winter, T1, summer, and winter (January to March, December), first transitional T2 groups, respectively (Table 5). period, termed as T1 (April and May), summer (June to September), and second transitional period, termed as T2 4. Discussion (October and November). Data on the mean monthly temperature was obtained from the official website of the In concordance with many studies, the majority of our Ministry of Transportation and Telecommunications in patient population were males, accounting for 77.4% of the Bahrain (Civil Aviation Affairs) [7]. study population [1]. In our study, the highest number of cases were admitted in summer (234) compared to other seasons. )e month 2.3. Statistical Analysis. Biostatistical analysis was per- with the highest number of cases (68) was July, coinciding formed using Microsoft Excel software for Mac with with the year’s highest mean temperature of 36.2 C recorded Analysis ToolPak (Version 16.38). A Chi-Square P value of in this month. Moreover, our data suggested a moderate <0.05 was considered statistically significant with a corre- positive correlation between the mean temperature and sponding confidence level of 95%. Pearson correlation co- incidence. Our findings are in line with other studies which efficient was calculated to assess the correlation between the addressed this issue in Canada, the United States, South monthly incidence of acute appendicitis and corresponding Korea, Iran, Italy, Taiwan, Pakistan, Finland, China, and the mean temperature recorded in each month of the year 2018. United Kingdom [3,5,8–13]. On the other hand, a study conducted in northern Saudi 3. Results Arabia revealed an increased incidence in spring months, Out of 697 patients, 51 were managed conservatively and which coincide with the sandstorm season. )is might be thus excluded. A final total of 646 patients were included in attributed to dust and allergen burden to the lymphoid tissue the study. Patients were evaluated by history taking, physical [4]. In other areas like Nigeria, Turkey, certain parts of the assessment, laboratory investigations, and radiological United States and the United Kingdom, different results were obtained. For example, in Nigeria, appendicitis was studies (as indicated). Ages ranged from three to 77 years. Among these, males comprised the majority: 500 (77.4%) more common in the rainy season, which is known for compared to 146 (22.6%) females. About 47.4% of the pa- humidity, allergens, higher rates of bacterial, viral, and in- tients originated from Southern Asia countries (India, testinal parasitic infections [5,14,15]. Bangladesh, Pakistan, Nepal, Sri Lanka), while 40.9% were What is the reason behind the observed increase in Bahrainis. Other ethnic groups and demographic data are incidence of appendicitis in summer in many countries? demonstrated in Table 1. Kaplan et al. have suggested that the exposure to air pol- Final histopathological examination categories are dem- lution was noted to trigger the occurrence of appendicitis, onstrated in Table 2. Gangrenous, perforated, and purulent particularly in men during summer season [3]. In a study conducted on pediatric age group in Taiwan, it was noted appendices were regarded as complicated appendicitis. )e highest number of cases were registered in summer, that the percentage of appendicitis cases with fecoliths in 234 cases, comprising 36.2% of all cases, while 203 cases were summer was lower than other seasons. )is was attributed to admitted in winter months (31.4%), 106 (16.4%) in T1, and lymphoid hyperplasia which may be associated with the 103 (16%) in T2. Complicated cases were equal to 65, of outbreak of enterovirus during this time of the year [9]. which 23 (35.4%) were admitted in summer, 30 (46.2%) in Zhang et al. proposed that pediatric appendicitis cases were winter, seven (10.8%) in T1, and five (7.7%) in T2 (Table 3). associated with higher temperatures, lower humidity, and )e highest number of cases was during the month of less sunshine [12]. July (68), while the month with the lowest number was Dietary habits in summer might play a role. Studies February (40). )is corresponded to the highest recorded have suggested a role for dehydration and less bowel ° ° mean temperature (36.2 C) and the second lowest (19.8 C), movements in summer [11]. A review by Fares has stated Surgery Research and Practice 3 Table 1: Demographic data of participants. Ethnic group Number Percentage (%) Bahraini 264 40.9 Southern Asians 306 47.4 Other Asians 30 4.6 Gulf nationals 20 3 Other Arabs 9 1.4 African 12 1.9 Hispanic/latino 1 0.15 European 1 0.15 Others 3 0.5 Sex Male 500 77.4 Female 146 22.6 Minimum Maximum Age 3 years 77 years Table 2: Histopathologic classification. Histopathology Frequency Percentage (%) Acute appendicitis 464 71.8 Early acute appendicitis 62 9.6 Gangrenous appendix 59 9 Reactive lymphoid hyperplasia 37 5.7 Cicatrized/fibrosed appendix 11 1.7 Perforated appendix 5 0.8 Normal appendix 2 0.3 Inflamed appendix with helminth 2 0.3 Purulent with abscess formation 1 0.2 Inflamed appendix with carcinoid tumor 1 0.2 Granulomatous appendicitis 1 0.2 Inflamed appendix with sessile serrated adenoma (SSA) 1 0.2 Table 3: Distribution of cases by season. All cases Complicated cases Non-complicated cases Season Months (N � 646) (%) (N � 65, 10%) (%) (N � 581, 90%) (%) January February Winter 203 (31.4) 30 (46.2) 173 (53.8) March December April First transitional period (T1) 106 (16.4) 7 (10.8) 99 (89.2) May June July Summer 234 (36.2) 23 (35.4) 211 (64.6) August September October Second transitional period (T2) 103 (16) 5 (7.7) 98 (92.3) November that the increased consumption of low fiber diet and Another key factor suggested by Fares are the infectious sugar in summer, particularly when individuals are likely agents implicated in appendicitis through causing lymphoid to be out, can lead to constipation and subsequently to hyperplasia and resulting lumen obstruction. Summer peak appendicitis. Alcohol consumption is reportedly highest of infection caused by agents such as Campylobacter, Sal- monella, Escherichia coli, Entamoeba histolytica, Ascaris during summertime and has been linked to constipation [5]. )ough in our part of the world, alcohol con- lumbricoides, Trichuris trichiura, Taenia saginata, Enterobius sumption is forbidden and restricted for religious vermicularis, and Strongyloides stercoralis is noted in some reasons. countries [5]. In our study, only two cases were found on 4 Surgery Research and Practice 70 38 35 18 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Monthly incidence 59 40 53 44 62 64 68 52 50 57 46 51 Mean temperature 18.4 19.8 24.6 26.9 31.5 35.7 36.2 35.5 34.5 30.9 24.9 21.6 Monthly incidence Mean temperature Figure 1: Correlation between monthly incidence and mean recorded temperature. Table 4: Complicated cases by ethnic group. Ethnic group Number Percentage (%) Percentage from ethnic group overall (%) Bahraini 23 35.4 8.7 Southern asians 27 41.5 8.8 Other asians 8 12.3 26.7 Gulf nationals 2 3.1 10 Other arabs 2 3.1 22.2 African 2 3.1 16.7 Hispanic/latino 0 0 0 European 1 1.5 100 Others 0 0 0 5. Conclusion Table 5: Duration of symptoms (in days) at presentation by season In line with other studies, more cases of appendicitis were for complicated cases. noted during summer months. )e monthly incidence correlated positively with the mean temperature. Larger Season Average Maximum Minimum numbers over several years might be needed to be studied to Winter 2.03 7 1 draw better conclusions on our patient population and even T1 2.2 4 1 reach to possible causes behind such variation. Summer 2.06 4 1 T2 4.3 10 1 Data Availability histopathological analysis to have helminths, presented and )e data are available in the supplementary information operated in the months of January and May. Both were files. found to have nematodes. We note that 47.4% of our patient population originates Conflicts of Interest from South Asia. )ey tend to work as labors in industries and might be exposed to air pollution and spend many )e authors certify that they have no affiliations with or working hours outdoor in the sun. We believe this might involvement in any organization or entity with any financial play a role in the disease. or nonfinancial interest in the subject matter or materials )rough our study, we also aimed to investigate whether discussed in this manuscript. complicated cases presented more in summer months. However, out of 65 complicated cases, we found that only 23 Supplementary Materials cases (35.4%) were admitted in summer, 30 (46.2%) in winter, seven (10.8%) in T1, and five (7.7%) in T2. Raw data are provided. (Supplementary Materials) Surgery Research and Practice 5 References [1] M. Ferris, S. Quan, B. S. Kaplan et al., “)e global incidence of appendicitis,” Annals of Surgery, vol. 266, no. 2, pp. 237–241, [2] A. Bhangu, K. Søreide, S. Di Saverio, J. H. Assarsson, and F. T. Drake, “Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management,” *e Lancet, vol. 386, no. 10000, pp. 1278–1287, 2015. [3] G. G. Kaplan, E. Dixon, R. Panaccione et al., “Effect of ambient air pollution on the incidence of appendicitis,” Canadian Medical Association Journal, vol. 181, no. 9, pp. 591–597, 2009. [4] R. Sanda, M. Zalloum, M. El-Hossary et al., “Seasonal vari- ation of appendicitis in northern Saudi Arabia,” Annals of Saudi Medicine, vol. 28, no. 2, pp. 140-141, 2008. [5] A. Fares, “Summer appendicitis,” Annals of Medical and Health Sciences Research, vol. 4, no. 1, pp. 18–21, 2014. [6] Bahrain Weather Services, “Bahrain climate,” 2020, http:// www.bahrainweather.gov.bh/web/guest/climate. [7] Bahrain’s Ministry of Transportation and Telecommunica- tions, “Civil aviation affairs: monthly weather summary,” 2020, http://mtt.gov.bh/directorates/civil-aviation. [8] P.-L. Wei, C.-S. Chen, J. J. Keller, and H.-C. Lin, “Monthly variation in acute appendicitis incidence: a 10-year nation- wide population-based study,” Journal of Surgical Research, vol. 178, no. 2, pp. 670–676, 2012. [9] Y. J. Hsu, Y. W. Fu, and T. Chin, “Seasonal variations in the occurrence of acute appendicitis and their relationship with the presence of fecaliths in children,” BMC Pediatrics, vol. 19, no. 1, p. 443, 2019. [10] W. Ahmed, M. S. Akhtar, and S. Khan, “Seasonal variation of acute appendicitis,” Pakistan Journal of Medical Sciences, vol. 34, no. 3, pp. 564–567, 2018. [11] I. Ilves, A. Fagerstrom, ¨ K. H. Herzig, P. Juvonen, P. Miettinen, and H. Paajanen, “Seasonal variations of acute appendicitis and nonspecific abdominal pain in Finland,” World Journal of Gastroenterology, vol. 20, no. 14, pp. 4037–4042, 2014. [12] Y. Zhang, F. X. Lyu, Q. Kang et al., “Association of meteo- rological factors with pediatric acute appendicitis in China: a 7-year retrospective analysis,” Medicine (Baltimore), vol. 97, no. 42, Article ID e12913, 2018. [13] T. J. York, “Seasonal and climatic variation in the incidence of adult acute appendicitis: a seven year longitudinal analysis,” BMC Emergency Medicine, vol. 20, no. 1, p. 24, 2020. [14] A. Oguntola, M. Adeoti, and T. Oyemolade, “Appendicitis: trends in incidence, age, sex, and seasonal variations in South- Western Nigeria,” Annals of African Medicine, vol. 9, no. 4, pp. 213–217, 2010. [15] A. Bal, Z. T. Ozkececi, O. Turkoglu et al., “Demographic characteristics and seasonal variations of acute appendicitis,” Annali Italiani di Chirurgia, vol. 86, pp. 539–544, 2015. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Surgery Research and Practice Hindawi Publishing Corporation

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Copyright © 2021 Rawan A. Rahman AlHarmi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Surgery Research and Practice Volume 2021, Article ID 8811898, 5 pages https://doi.org/10.1155/2021/8811898 Research Article 1 2 1 1 Rawan A. Rahman AlHarmi , Sayed Ali Almahari, Jasim AlAradi, Asma Alqaseer, 3 3 Noof Sami AlJirdabi, and Fatema Ali Ahmed Department of Surgery, Salmaniya Medical Complex, Manama, Bahrain Department of Pathology, Salmaniya Medical Complex, Manama, Bahrain Medical Intern, Salmaniya Medical Complex, Manama, Bahrain Correspondence should be addressed to Rawan A. Rahman AlHarmi; rawan.alhermi@gmail.com Received 10 September 2020; Revised 14 January 2021; Accepted 23 February 2021; Published 2 March 2021 Academic Editor: Todd Pesavento Copyright © 2021 Rawan A. Rahman AlHarmi et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer. Methods. A single-center cross-sectional, retrospective study on 697 cases of appendicitis admitted in the year 2018. Inclusion criteria: patients admitted with acute appendicitis who underwent appendectomy of all ages. Exclusion criteria: conservative management. Analysis was performed using Microsoft Excel. Pearson correlation coefficient was calculated to assess the correlation between monthly incidence of appendicitis and mean temperature in that month. Results. Fifty-one patients who were managed conservatively were excluded. Accordingly, 646 patients were included. Ages ranged from three to 77 years. Males comprised the majority (500, 77.4%). Gangrenous, perforated, and purulent appendices were regarded as complicated ap- pendicitis. )e highest number of cases were admitted in summer (234), comprising 36.2% of cases. Complicated cases were equal to 65, of which 23 (35.4%) were admitted in summer and 30 (46.2%) in winter. )e highest number of cases was during the month of July (68), while the lowest (40) was during February. )is corresponded to the highest recorded mean temperature (36.2 C) and second lowest (19.8 C), respectively. Moderate positive correlation (Pearson’s R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted. Conclusion. More cases of appendicitis were noted during summer. Monthly incidence correlated positively with the temperature. Larger numbers over several years are needed to draw better conclusions and reach the possible causes behind such variation. 1.1. Purpose. We aim through this study to investigate whether 1. Introduction the incidence of acute appendicitis increases in summer season. Acute appendicitis is a common global acute abdominal Our secondary objective is to assess whether the incidence of surgical condition [1]. Its etiology is poorly understood. En- complicated appendicitis increases in summer season com- vironmental factors have been implicated, including summer pared to other seasons. season, air pollution, and dust/allergens. Incidence is increased in certain ethnic groups and complications are increased in 2. Methods minorities, likely due to lack of healthcare access. Cases are classified into simple (nonperforated) and complex (gangre- 2.1. Study Design. )is is a single-center cross-sectional, nous, perforated, and pelvic/abdominal abscess) [2–5]. retrospective study conducted by the Department of Surgery Bahrain is an archipelago in the Gulf with an arid cli- in Salmaniya Medical Complex (the largest hospital in mate. )e year is divided into two seasons: summer (June- Bahrain; a 1029-bed tertiary hospital in the capital Manama, September) and winter (December-March). )ese are sep- serving all citizens and residents of all ages) on 697 cases arated by two transitional periods: first (April, May) and admitted to our facility with a clinical diagnosis of acute second (October, November) [6]. appendicitis in the year 2018. Approval of the institutional 2 Surgery Research and Practice ethical review board was attained on 06/07/2020 (no number respectively. Pearson’s correlation coefficient was calculated assigned). and revealed a moderate positive correlation (Pearson’s R 0.5183; R Coefficient of Determination 0.2686; P value 0.084292) between the monthly incidence of appendicitis 2.2. Participants. )e patients were selected, as stated pre- and the corresponding recorded mean temperature in that viously, from those admitted with acute appendicitis (based month (Figure 1). on clinical and/or laboratory/imaging diagnosis) in the year We further investigated the variables related to com- 2018. Inclusion criteria: patients admitted with a diagnosis of plicated appendicitis, namely, the ethnic group. )e highest acute appendicitis who underwent appendectomy (open or groups presenting with complications were Bahrainis (23, laparoscopic) of all ages (including those admitted under 35.4%) and Southern Asians (27, 41.5%) (Table 4). Another pediatric surgery). Exclusion criteria: conservative man- studied variable was the duration of symptoms at the time of agement (e.g., appendiceal mass and other clinical diag- presentation. Two patients were excluded from T1 group, nosis). Patient data was collected from the National Health five from the summer group, and two from T2 group due to Information System (I-SEHA). )e study did not involve lack of documentation. For the rest, it was noted that the any patient intervention or contact. average time at presentation was 2.03, 2.2, 2.06, and 4.3 days Seasons were divided as previously mentioned into following the onset of symptoms in winter, T1, summer, and winter (January to March, December), first transitional T2 groups, respectively (Table 5). period, termed as T1 (April and May), summer (June to September), and second transitional period, termed as T2 4. Discussion (October and November). Data on the mean monthly temperature was obtained from the official website of the In concordance with many studies, the majority of our Ministry of Transportation and Telecommunications in patient population were males, accounting for 77.4% of the Bahrain (Civil Aviation Affairs) [7]. study population [1]. In our study, the highest number of cases were admitted in summer (234) compared to other seasons. )e month 2.3. Statistical Analysis. Biostatistical analysis was per- with the highest number of cases (68) was July, coinciding formed using Microsoft Excel software for Mac with with the year’s highest mean temperature of 36.2 C recorded Analysis ToolPak (Version 16.38). A Chi-Square P value of in this month. Moreover, our data suggested a moderate <0.05 was considered statistically significant with a corre- positive correlation between the mean temperature and sponding confidence level of 95%. Pearson correlation co- incidence. Our findings are in line with other studies which efficient was calculated to assess the correlation between the addressed this issue in Canada, the United States, South monthly incidence of acute appendicitis and corresponding Korea, Iran, Italy, Taiwan, Pakistan, Finland, China, and the mean temperature recorded in each month of the year 2018. United Kingdom [3,5,8–13]. On the other hand, a study conducted in northern Saudi 3. Results Arabia revealed an increased incidence in spring months, Out of 697 patients, 51 were managed conservatively and which coincide with the sandstorm season. )is might be thus excluded. A final total of 646 patients were included in attributed to dust and allergen burden to the lymphoid tissue the study. Patients were evaluated by history taking, physical [4]. In other areas like Nigeria, Turkey, certain parts of the assessment, laboratory investigations, and radiological United States and the United Kingdom, different results were obtained. For example, in Nigeria, appendicitis was studies (as indicated). Ages ranged from three to 77 years. Among these, males comprised the majority: 500 (77.4%) more common in the rainy season, which is known for compared to 146 (22.6%) females. About 47.4% of the pa- humidity, allergens, higher rates of bacterial, viral, and in- tients originated from Southern Asia countries (India, testinal parasitic infections [5,14,15]. Bangladesh, Pakistan, Nepal, Sri Lanka), while 40.9% were What is the reason behind the observed increase in Bahrainis. Other ethnic groups and demographic data are incidence of appendicitis in summer in many countries? demonstrated in Table 1. Kaplan et al. have suggested that the exposure to air pol- Final histopathological examination categories are dem- lution was noted to trigger the occurrence of appendicitis, onstrated in Table 2. Gangrenous, perforated, and purulent particularly in men during summer season [3]. In a study conducted on pediatric age group in Taiwan, it was noted appendices were regarded as complicated appendicitis. )e highest number of cases were registered in summer, that the percentage of appendicitis cases with fecoliths in 234 cases, comprising 36.2% of all cases, while 203 cases were summer was lower than other seasons. )is was attributed to admitted in winter months (31.4%), 106 (16.4%) in T1, and lymphoid hyperplasia which may be associated with the 103 (16%) in T2. Complicated cases were equal to 65, of outbreak of enterovirus during this time of the year [9]. which 23 (35.4%) were admitted in summer, 30 (46.2%) in Zhang et al. proposed that pediatric appendicitis cases were winter, seven (10.8%) in T1, and five (7.7%) in T2 (Table 3). associated with higher temperatures, lower humidity, and )e highest number of cases was during the month of less sunshine [12]. July (68), while the month with the lowest number was Dietary habits in summer might play a role. Studies February (40). )is corresponded to the highest recorded have suggested a role for dehydration and less bowel ° ° mean temperature (36.2 C) and the second lowest (19.8 C), movements in summer [11]. A review by Fares has stated Surgery Research and Practice 3 Table 1: Demographic data of participants. Ethnic group Number Percentage (%) Bahraini 264 40.9 Southern Asians 306 47.4 Other Asians 30 4.6 Gulf nationals 20 3 Other Arabs 9 1.4 African 12 1.9 Hispanic/latino 1 0.15 European 1 0.15 Others 3 0.5 Sex Male 500 77.4 Female 146 22.6 Minimum Maximum Age 3 years 77 years Table 2: Histopathologic classification. Histopathology Frequency Percentage (%) Acute appendicitis 464 71.8 Early acute appendicitis 62 9.6 Gangrenous appendix 59 9 Reactive lymphoid hyperplasia 37 5.7 Cicatrized/fibrosed appendix 11 1.7 Perforated appendix 5 0.8 Normal appendix 2 0.3 Inflamed appendix with helminth 2 0.3 Purulent with abscess formation 1 0.2 Inflamed appendix with carcinoid tumor 1 0.2 Granulomatous appendicitis 1 0.2 Inflamed appendix with sessile serrated adenoma (SSA) 1 0.2 Table 3: Distribution of cases by season. All cases Complicated cases Non-complicated cases Season Months (N � 646) (%) (N � 65, 10%) (%) (N � 581, 90%) (%) January February Winter 203 (31.4) 30 (46.2) 173 (53.8) March December April First transitional period (T1) 106 (16.4) 7 (10.8) 99 (89.2) May June July Summer 234 (36.2) 23 (35.4) 211 (64.6) August September October Second transitional period (T2) 103 (16) 5 (7.7) 98 (92.3) November that the increased consumption of low fiber diet and Another key factor suggested by Fares are the infectious sugar in summer, particularly when individuals are likely agents implicated in appendicitis through causing lymphoid to be out, can lead to constipation and subsequently to hyperplasia and resulting lumen obstruction. Summer peak appendicitis. Alcohol consumption is reportedly highest of infection caused by agents such as Campylobacter, Sal- monella, Escherichia coli, Entamoeba histolytica, Ascaris during summertime and has been linked to constipation [5]. )ough in our part of the world, alcohol con- lumbricoides, Trichuris trichiura, Taenia saginata, Enterobius sumption is forbidden and restricted for religious vermicularis, and Strongyloides stercoralis is noted in some reasons. countries [5]. In our study, only two cases were found on 4 Surgery Research and Practice 70 38 35 18 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Monthly incidence 59 40 53 44 62 64 68 52 50 57 46 51 Mean temperature 18.4 19.8 24.6 26.9 31.5 35.7 36.2 35.5 34.5 30.9 24.9 21.6 Monthly incidence Mean temperature Figure 1: Correlation between monthly incidence and mean recorded temperature. Table 4: Complicated cases by ethnic group. Ethnic group Number Percentage (%) Percentage from ethnic group overall (%) Bahraini 23 35.4 8.7 Southern asians 27 41.5 8.8 Other asians 8 12.3 26.7 Gulf nationals 2 3.1 10 Other arabs 2 3.1 22.2 African 2 3.1 16.7 Hispanic/latino 0 0 0 European 1 1.5 100 Others 0 0 0 5. Conclusion Table 5: Duration of symptoms (in days) at presentation by season In line with other studies, more cases of appendicitis were for complicated cases. noted during summer months. )e monthly incidence correlated positively with the mean temperature. Larger Season Average Maximum Minimum numbers over several years might be needed to be studied to Winter 2.03 7 1 draw better conclusions on our patient population and even T1 2.2 4 1 reach to possible causes behind such variation. Summer 2.06 4 1 T2 4.3 10 1 Data Availability histopathological analysis to have helminths, presented and )e data are available in the supplementary information operated in the months of January and May. Both were files. found to have nematodes. We note that 47.4% of our patient population originates Conflicts of Interest from South Asia. )ey tend to work as labors in industries and might be exposed to air pollution and spend many )e authors certify that they have no affiliations with or working hours outdoor in the sun. We believe this might involvement in any organization or entity with any financial play a role in the disease. or nonfinancial interest in the subject matter or materials )rough our study, we also aimed to investigate whether discussed in this manuscript. complicated cases presented more in summer months. However, out of 65 complicated cases, we found that only 23 Supplementary Materials cases (35.4%) were admitted in summer, 30 (46.2%) in winter, seven (10.8%) in T1, and five (7.7%) in T2. Raw data are provided. (Supplementary Materials) Surgery Research and Practice 5 References [1] M. Ferris, S. Quan, B. S. Kaplan et al., “)e global incidence of appendicitis,” Annals of Surgery, vol. 266, no. 2, pp. 237–241, [2] A. Bhangu, K. Søreide, S. Di Saverio, J. H. Assarsson, and F. T. Drake, “Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management,” *e Lancet, vol. 386, no. 10000, pp. 1278–1287, 2015. [3] G. G. Kaplan, E. Dixon, R. Panaccione et al., “Effect of ambient air pollution on the incidence of appendicitis,” Canadian Medical Association Journal, vol. 181, no. 9, pp. 591–597, 2009. [4] R. Sanda, M. Zalloum, M. El-Hossary et al., “Seasonal vari- ation of appendicitis in northern Saudi Arabia,” Annals of Saudi Medicine, vol. 28, no. 2, pp. 140-141, 2008. [5] A. Fares, “Summer appendicitis,” Annals of Medical and Health Sciences Research, vol. 4, no. 1, pp. 18–21, 2014. [6] Bahrain Weather Services, “Bahrain climate,” 2020, http:// www.bahrainweather.gov.bh/web/guest/climate. 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