{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T18:08:25Z","timestamp":1788977305041,"version":"build-2803163510"},"reference-count":18,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Clinical, laboratory, and imaging correlates of complicated appendicitis are well studied, but routinely recorded gross-pathology morphometrics and pathology-confirmed evidence from Palestine are less well characterized. We evaluated correlates of histopathological severity and adjusted associations with complicated appendicitis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective cohort included appendectomy encounters at Al-Makassed Islamic Charitable Society Hospital from December 2015 to July 2025. Source reconciliation identified 1,287 unique encounters; 245 histologically normal appendices and 32 records without a classifiable severity category were excluded, leaving 1,010 patients. Complicated appendicitis was defined as gangrenous or perforated disease. Group comparisons used chi-square or Monte Carlo exact tests and Kruskal-Wallis tests. A prespecified logistic model included age, sex, appendicolith, white blood cell count (WBC), and C-reactive protein (CRP).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The cohort included 227 catarrhal\/simple, 458 suppurative, 262 gangrenous, and 63 perforated cases. Operative approach, nausea and\/or vomiting, other intraoperative findings, appendicolith, WBC, neutrophil percentage, operative duration, and hospital stay differed across severity categories. In the adjusted model (n\u2009=\u2009991), appendicolith was associated with higher odds of complicated appendicitis (adjusted odds ratio 2.20, 95% confidence interval 1.37\u20133.52; P\u2009=\u20090.001), whereas WBC showed an unexpected inverse association (adjusted odds ratio 0.938 per 1\u2009\u00d7\u200910\u2079\/L, 95% confidence interval 0.906\u20130.971; P\u2009&lt;\u20090.001). Age, sex, and CRP were not independently associated. Discrimination was weak (area under the receiver operating characteristic curve 0.594, 95% confidence interval 0.557\u20130.632). Maximum diameter, wall thickness, and appendix length showed no significant adjusted linear associations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Appendicolith was associated with complicated appendicitis, but weak discrimination and limited explained variation preclude use of the model as a clinical prediction tool. The inverse WBC association and negative linear morphometric findings require cautious interpretation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0357811","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T17:34:02Z","timestamp":1788975242000},"page":"e0357811","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Clinical, laboratory, operative, and appendiceal morphometric correlates of histopathological appendicitis severity: A retrospective cohort study from Palestine"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4138-8497","authenticated-orcid":true,"given":"Ali","family":"Shakhshir","sequence":"first","affiliation":[{"name":"Arab American University","place":["Jenin, Palestine"],"department":["Department of Clinical Medicine, Faculty of Medicine"]},{"name":"Arab American University","place":["Jenin, Palestine"],"department":["Scientific Research Committee, Faculty of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahdi","family":"Aljamal","sequence":"additional","affiliation":[{"name":"Arab American University","place":["Jenin, Palestine"],"department":["Department of Surgery, Faculty of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdallah","family":"Alem","sequence":"additional","affiliation":[{"name":"Arab American University","place":["Jenin, Palestine"],"department":["Department of Clinical Medicine, Faculty of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ibrahim","family":"Aljamal","sequence":"additional","affiliation":[{"name":"Al-Makassed Islamic Charitable Society Hospital","place":["Jerusalem, Palestine"],"department":["Department of Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zainah Amjad","family":"Issa","sequence":"additional","affiliation":[{"name":"Arab American University","place":["Jenin, Palestine"],"department":["Faculty of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,9]]},"reference":[{"issue":"1","key":"pone.0357811.ref001","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s13017-020-00306-3","article-title":"Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines","volume":"15","author":"S Di Saverio","year":"2020","journal-title":"World J Emerg Surg"},{"issue":"22","key":"pone.0357811.ref002","doi-asserted-by":"crossref","first-page":"2299","DOI":"10.1001\/jama.2021.20502","article-title":"Diagnosis and Management of Acute Appendicitis in Adults: A Review","volume":"326","author":"D Moris","year":"2021","journal-title":"JAMA"},{"issue":"7","key":"pone.0357811.ref003","doi-asserted-by":"crossref","first-page":"1724","DOI":"10.3390\/diagnostics12071724","article-title":"The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults","volume":"12","author":"B Skjold-\u00d8degaard","year":"2022","journal-title":"Diagnostics (Basel)"},{"issue":"2","key":"pone.0357811.ref004","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1177\/14574969211008330","article-title":"Diagnosis of Uncomplicated and Complicated Appendicitis in Adults","volume":"110","author":"WJ Bom","year":"2021","journal-title":"Scand J Surg"},{"issue":"1","key":"pone.0357811.ref005","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1148\/radiol.2017171260","article-title":"Systematic Review and Meta-Analysis of CT Features for Differentiating Complicated and Uncomplicated Appendicitis","volume":"287","author":"HY Kim","year":"2018","journal-title":"Radiology"},{"issue":"1","key":"pone.0357811.ref006","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1186\/s13244-021-01086-3","article-title":"Predictive ability of CT findings in the differentiation of complicated and uncomplicated appendicitis: a retrospective investigation of 201 patients undergone appendectomy at initial admission","volume":"12","author":"J Iamwat","year":"2021","journal-title":"Insights Imaging"},{"issue":"1","key":"pone.0357811.ref007","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1186\/s13017-021-00398-5","article-title":"Periappendiceal fat-stranding models for discriminating between complicated and uncomplicated acute appendicitis: a diagnostic and validation study","volume":"16","author":"H-A Lin","year":"2021","journal-title":"World J Emerg 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systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings","volume":"14","author":"R Kaewlai","year":"2023","journal-title":"Insights Imaging"},{"issue":"11","key":"pone.0357811.ref012","first-page":"1590","article-title":"Effectiveness of pre-operative routine blood tests in predicting complicated acute appendicitis","volume":"28","author":"SS Uluda\u011f","year":"2022","journal-title":"Ulus Travma Acil Cerrahi Derg"},{"issue":"8","key":"pone.0357811.ref013","doi-asserted-by":"crossref","first-page":"1393","DOI":"10.1007\/s00384-019-03332-z","article-title":"Appendicolith appendicitis is clinically complicated acute appendicitis-is it histopathologically different from uncomplicated acute appendicitis","volume":"34","author":"J M\u00e4llinen","year":"2019","journal-title":"Int J Colorectal Dis"},{"issue":"14","key":"pone.0357811.ref014","doi-asserted-by":"crossref","first-page":"4166","DOI":"10.3390\/jcm13144166","article-title":"Hidden Appendicoliths and Their Impact on the Severity and Treatment of Acute Appendicitis","volume":"13","author":"M D\u00f6lling","year":"2024","journal-title":"J Clin Med"},{"issue":"1","key":"pone.0357811.ref015","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgast-2024-001403","article-title":"Appendicolith classification: physical and chemical properties of appendicoliths in patients with CT diagnosed acute appendicitis - a prospective cohort study","volume":"11","author":"S Vanhatalo","year":"2024","journal-title":"BMJ Open Gastroenterol"},{"key":"pone.0357811.ref016","first-page":"524","article-title":"Does the length matter in acute appendicitis for the perforation risk?","volume":"56","author":"C Dibeko\u011flu","year":"2022","journal-title":"Sisli Etfal Hastan Tip 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