Question

Find an article in the newspaper or other media that uses components of the evidence-based public health approach e.g. presents the burden of disease, draws conclusions about causation, and presents evidence-based recommendations, and/or discussed implementation and evaluation. Briefly explain which element(s) of the PERIE (Problem, Etiology, Recommendation, Implementation, Evaluation) approach are utilized in the article.  

Answer 1

Evidence-based public health approach is the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of behavioral science theory and program.An evidence-based approach to public health could potentially have numerous direct and indirect benefits, including access to more and higher-quality information on best practice, a higher likelihood of successful prevention programs and policies, greater workforce productivity, and more efficient use of public. Biomedical research is the first step in implementation of evidence based public health.

Article:

Acute appendicitis is the most common abdominal emergency, with a lifetime risk of 7% to 8%. Clinical features vary but typically include right lower-quadrant abdominal pain, anorexia, nausea, and vomiting. Although there are many theorized etiologies, appendicitis is thought to occur primarily as a result of luminal obstruction that has progressed to inflammation, ischemia, and possibly perforation. Treatment is usually by appendectomy after appropriate fluid resuscitation, analgesia, and antibiotics. Emerging evidence suggests an antibiotic-treatment approach may be an alternative to surgery.

Acute appendicitis is one of the most common causes of acute abdominal pain requiring emergent surgery. The overall estimated lifetime risk is 7% to 8% with a slight predominance in Caucasian males. While no age is exempt, acute appendicitis commonly affects those aged 10 to 20 years.It is characterized by a wide range of symptoms that overlap with other gastroenterological, gynecologic, or urologic conditions, such as peptic ulcer disease, Meckel’s diverticulum, Crohn’s disease, gastroenteritis, irritable bowel disease, ectopic pregnancy, endometriosis, testicular or ovarian torsion, pelvic inflammatory disease, urinary tract infection, and renal stones.

Most patients suffering from acute appendicitis will experience a typical migratory periumbilical pain, which intensifies in the first 24 hours. This eventually localizes to right lower quadrant abdominal pain, anorexia, nausea, and vomiting. Other nonspecific symptoms include general malaise, indigestion, diarrhea, and flatulence. A mild leukocytosis (white blood cell count >10,000 cells/microL), a slight hyperbilirubinemia (total bilirubin >1.0 mg/dL), and a low-grade fever (101.0°F) are additional findings that may be observed during acute appendicitis. Signs and symptoms usually correlate with the timing of disease onset. Since symptoms may vary, imaging studies with CT (preferred), US, and MRI may be performed to increase the specificity of the diagnosis and help rule out perforation.

For some with uncomplicated appendicitis, evidence suggests antibiotic therapy alone may be sufficient instead of proceeding to surgery. The single-cohort, prospective, observational NOTA Study (Non Operative Treatment for Acute Appendicitis) evaluated the outcomes of patients (n = 159) with suspected appendicitis (mean AIR score 4.9) treated nonoperatively with a 7-day course of amoxicillin/clavulanic acid.22 The follow-up period was 2 years. Results showed that for patients who successfully completed antibiotic therapy, the 2-year efficacy was 83% (118 patients recurrence-free and 14 patients with recurrence nonoperatively managed), and the recurrence rate was 13.8%.22

Most recently, the Appendicitis Acuta (APPAC) trial (Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis) randomized more than 500 patients with uncomplicated appendicitis to early appendectomy or antibiotic treatment alone.Patients in the antibiotic arm of the study received IV ertapenem (1 g daily) for 3 days followed by 7 days of oral levofloxacin (500 mg, once daily) and metronidazole (500 mg, 3 times daily).23 The primary outcome was resolution of appendicitis without the need for surgical intervention and no recurrence for one year. At study end, 99.6% of those in the appendectomy group had a successful appendectomy with an overall complication rate of 20.5%; 27.3% of those in the antibiotic group needed an appendectomy, with an overall complication rate of 7%.Thus, the study did not meet noninferiority criteria when compared with appendectomy. Limitations acknowledged by the authors included small sample size, thereby underpowering the study, and a short follow-up period. The investigators also completed a 5-year follow-up of patients included in the APPAC trial.24 At the 5-year mark, late recurrent appendicitis and complication rates were assessed. Appendicitis had recurred in 39% of patients in the antibiotic group, and the overall complication rate was 24% in the appendectomy group compared with 7% for those randomized to antibiotics.24 The authors concluded that for some a nonoperative treatment approach might be reasonable.24

The appropriate duration of antibiotic therapy has been debated, and it is dependent on the clinical scenerio. Results from the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial determined there was no difference between 3 to 5 days of antibiotic therapy compared with 5 to 10 days.Current guidelines suggest postoperative antibiotic therapy continue for 24 to 72 hours.20 In patients who do not undergo source control, 5 to 7 days of therapy are recommended.20 If the patient has no response after 5 to 7 days, the patient should be reassessed for another source-control procedure.20 For patients who have bacteremia, antibiotics may be stopped after 7 days if there is adequate source control and the bacteremia has resolved.

PERIE (Problem, Etiology, Recommendation, Implementation, Evaluation)

Problem:

Acute appendicitis

Etiology:

Peptic ulcer disease, Meckel’s diverticulum, Crohn’s disease, gastroenteritis, irritable bowel disease, ectopic pregnancy, endometriosis, testicular or ovarian torsion, pelvic inflammatory disease, urinary tract infection, and renal stones.

Recommendation :

Appendectomy after appropriate fluid resuscitation, analgesia, and antibiotics

Implementation:

Antibiotic therapy in acute appendicitis as an alternative for surgery.

Evaluation:

Treatment for Acute Appendicitis) evaluated the outcomes of patients (n = 159) with suspected appendicitis (mean AIR score 4.9) treated nonoperatively with a 7-day course of amoxicillin/clavulanic acid.22 The follow-up period was 2 years. Results showed that for patients who successfully completed antibiotic therapy, the 2-year efficacy was 83% (118 patients recurrence-free and 14 patients with recurrence nonoperatively managed), and the recurrence rate was 13.8%

Through this PERIE in the acute appendicitis condition it is found that early management using antibiotic therapy found to be more effective and alternative to prevent appendectomy surgery. This evidenced based practice approach will open the eyes of public to select the non invasive method of treatment.