Correspondence

Increased Incidence of Perforated Appendixes in Hmong Children in California

N Engl J Med 2001; 344:1023-1024March 29, 2001

Article

To the Editor:

Health care for Hmong immigrants from Southeast Asia to the United States has been associated with major social, cultural, and communication problems.1 To determine whether the health care received by Hmong patients differs from that received by other patients, I studied the incidence of appendiceal perforation among 118 Hmong children and an equal number of randomly selected white children who underwent primary appendectomy between January 1989 and December 1997. The research was conducted at Valley Children's Hospital in Fresno, California. The hospital serves central California, where many of the 120,000 Hmong immigrants in the United States live. The research was part of fieldwork conducted in central California between September 1996 and August 1998; it was supported by grants from the Agency for Health Care Policy and Research, the National Science Foundation, and Valley Children's Hospital.2

The two groups of children were similar with respect to age and sex (Table 1Table 1Characteristics of Hmong and White Children Who Underwent Primary Appendectomy between January 1989 and December 1997.). The incidence of appendiceal perforation was significantly higher among the Hmong children (66 percent, as compared with 37 percent among the white children; P<0.001). The mean time from the onset of symptoms to the child's arrival at the emergency room was 3.3 days for the Hmong children, as compared with 2.2 days for the white children (P=0.008). The interval between arrival at the hospital and arrival at the operating room for surgery was 8.6 hours for the Hmong children and 6.3 hours for the white children (P=0.003). The longer interval for the Hmong children was related to the wait for an interpreter and the longer time required for the Hmong parents to provide consent for surgery.

The Hmong children had a significantly longer mean hospital stay (6.7 days, as compared with 4.8 days for the white children; P<0.001). In the group with appendiceal perforation, the length of the hospital stay was the same for the Hmong children (7.4 days). In the group without perforation, however, the hospital stay was significantly longer for the Hmong children (4.9 days, as compared with 3.2 days for the white children; P=0.002). This difference was associated with the surgical methods used. A larger proportion of Hmong children underwent open abdominal appendectomies (39 percent, as compared with 13 percent of the white children; P<0.001). The surgeon who participated in two thirds of the operations explained that open abdominal appendectomies were more likely to be performed in the Hmong children because it was easier to explain the procedure to their parents and to obtain consent. The laparoscopic appendectomy was harder to explain because it involved four incisions and removal of the appendix under video guidance. The surgeon stated that perforation was not a factor in the choice of surgery, since the laparoscopic technique is effective in patients with perforation and the surgical approach can be converted to an open procedure if necessary.

My findings are consistent with previous reports that delayed treatment is the most important risk factor for appendiceal perforation3,4 and that laparoscopic appendectomy reduces the length of the hospital stay.5,6 The results of this study suggest that social and cultural barriers and communication difficulties substantially compromised the health care received by the Hmong children.

Jun Hu, M.D., Ph.D.
Qinghai Medical College Affiliated Hospital, Xining, Qinghai 810001, China

6 References

1. 1

   Fadiman A. The spirit catches you and you fall down: a Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus, and Giroux, 1997.
   

2. 2

   Hu J. Under the knife: medical “noncompliance” in Hmong immigrants. (Ph.D. dissertation. Atlanta: Emory University, 2000.)
   

3. 3

   Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults: a prospective study. Ann Surg 1995;221:278-281
   CrossRef | Web of Science | Medline

4. 4

   Brender JD, Marcuse EK, Koepsell TD, Hatch EI. Childhood appendicitis: factors associated with perforation. Pediatrics 1985;76:301-306
   Web of Science | Medline

5. 5

   Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Am J Surg 1995;169:208-213
   CrossRef | Web of Science | Medline

6. 6

   Frazee RC, Roberts JW, Symmonds RE, et al. A prospective randomized trial comparing open versus laparoscopic appendectomy. Ann Surg 1994;219:725-731
   CrossRef | Web of Science | Medline

Citing Articles (4)

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   Alex J. Hu. (2010) An overview of the history and culture of the Xianbei (‘Monguor’/‘Tu’). Asian Ethnicity 11:1, 95-164
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   Murizah M Zain, Robert J Norman. (2008) Impact of obesity on female fertility and fertility treatment. Women's Health 4:2, 183-194
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   Andrew J. Portis, Kate Hermans, Kathleen A. Culhane-Pera, Gary C. Curhan. (2004) Rapid Communication: Stone Disease in the Hmong of Minnesota: Initial Description of a High-Risk Population. Journal of Endourology 18:9, 853-857
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   Julie A. Ross, Yang Xie, William R. Kiffmeyer, Sally Bushhouse, Leslie L. Robison. (2003) Cancer in the Minnesota Hmong population. Cancer 97:12, 3076-3079
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