Appendix A – STROBE reporting checklist
Appendix A: STROBE Statement—Checklist of items that should be included in reports of cross- sectional studies
Item
No Recommendation
Page No Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title
or the abstract
1
(b) Provide in the abstract an informative and balanced summary of what was done and what was found
5-6
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported
7-8
Objectives 3 State specific objectives, including any prespecified hypotheses 8
Methods
Study design 4 Present key elements of study design early in the paper 8 Setting 5 Describe the setting, locations, and relevant dates, including periods
of recruitment, exposure, follow-up, and data collection
8
Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of participants
9-10
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable
9-11
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group
9
Bias 9 Describe any efforts to address potential sources of bias 9-11
Study size 10 Explain how the study size was arrived at n/a
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why
9-11
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding
11- 12 (b) Describe any methods used to examine subgroups and
interactions
12
(c) Explain how missing data were addressed n/a (d) If applicable, describe analytical methods taking account of
sampling strategy
n/a
(e) Describe any sensitivity analyses 12
Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed
12- 15
(b) Give reasons for non-participation at each stage n/a
(c) Consider use of a flow diagram n/a
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders
12- 15 (b) Indicate number of participants with missing data for each
variable of interest
n/a
Outcome data 15* Report numbers of outcome events or summary measures 12- 15 Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted
estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included
12- 15
(b) Report category boundaries when continuous variables were categorized
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses
15
Discussion
Key results 18 Summarise key results with reference to study objectives 15- 18 Limitations 19 Discuss limitations of the study, taking into account sources of
potential bias or imprecision. Discuss both direction and magnitude of any potential bias
18- 19
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence
15- 19
Generalisability 21 Discuss the generalisability (external validity) of the study results 15- 19
Other information
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based
2
*Give information separately for exposed and unexposed groups.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at
www.strobe-statement.org
.Appendix B – ICD-10 coded EGS conditions
Urgent/emergent visit to emergency department or admission to Ontario hospital after visit to the ED with an emergency general surgical condition (main diagnosis in DAD of any of the following):
1. Cholecystitis
K80.0 Calculus of gallbladder with acute cholecystitis, K80.1 Calculus of gallbladder with other cholecystitis, K81.0 Acute cholecystitis, K81.1 Chronic cholecystitis, K81.8 Other cholecystitis, K81.9 Cholecystitis, unspecified, K82.2 Perforation of gallbladder
2. Common bile duct stones
K80.30 Calculus of bile duct with cholangitis, K80.31 Calculus of bile duct with cholangitis with obstruction, K80.4 Calculus of bile duct with cholecystitis without obstruction, K80.41 Calculus of bile duct with cholecystitis with obstruction, K80.50 Calculus of bile duct without cholangitis or cholecystitis, K80.51 Calculus of bile duct without cholangitis or cholecystitis with obstruction
3. Acute appendicitis
K35.0 Acute appendicitis with generalized peritonitis, K35.1 Acute appendicitis with
peritoneal abscess, K35.2, K35.3 Acute appendicitis with localized peritonitis, K35.8
Acute appendicitis, other and unspecified, K35.9 Acute appendicitis unspecified, K36
Other appendicitis, K37 Unspecified appendicitis
4. Incarcerated or strangulated inguinal/femoral/umbilical/ventral hernia Inguinal with Obstruction no gangrene: K40.0 bilateral with obstruction without gangrene, K40.3 unilateral with obstruction without gangrene
Inguinal with Gangrene: K40.1 bilateral with gangrene, K40.4 unilateral with gangrene
Femoral without gangrene: K41.0 bilateral with obstruction without gangrene, K41.3 unilateral with obstruction without gangrene
Femoral with gangrene: K41.1 bilateral with gangrene, K41.4 unilateral with gangrene
Ventral with obstruction no gangrene: K43.0
Ventral with gangrene K43.1
Umbilical with obstruction no gangrene: K42.0
Umbilical with gangrene: K42.1
Parastomal hernia with obstruction no gangrene: K34.3
Parastomal hernia with gangrene K34.4
Other specified abdominal hernia with obstruction without gangrene K45.0
Other specified abdominal hernia without gangrene K45.1
Unspecified abdominal hernia with obstruction without gangrene K46.0
Unspecified abdominal hernia with gangrene K46.1
5. Adhesive small bowel obstruction
K56.5: Adhesive small bowel obstruction, K56.6: other or unspecified intestinal obstruction
6. Acute diverticulitis abscess or perforation
K57.2: Diverticular disease of large intestine with perforation and abscess, K57.8: Diverticular disease of intestine with perforation and abscess
7. Perforated peptic ulcer disease
Gastric with perforations: K25.1 perforation, K25.2 hemorrhage and perforation, K25.5 chronic or unspecified with perforation, K25.6 chronic or unspecified with hemorrhage and perforation
Duodenal with perforations: K26.1 perforation, K26.2 hemorrhage and perforation, K26.5 chronic or unspecified with perforation, K26.6 chronic or unspecified with hemorrhage and perforation
Peptic ulcer site unspecified with perforations: K27.1 perforation, K27.2
hemorrhage and perforation, K27.5 chronic or unspecified with perforation, K27.6
chronic or unspecified with hemorrhage and perforation
Appendix C - Previous surgical procedures that would make transplant and non- transplant patients ineligible for development of EGS conditions during the study period
A look-back window evaluating the full extent of the OHIP database was used to identify previous surgical procedures that would make transplant and non-transplant patients ineligible for development of EGS conditions. Occurrence of other EGS conditions during the study period were still evaluated.
Not eligible to develop cholecystitis: previous cholecystectomy: S287; liver transplant
Not eligible to develop common bile duct stones: liver transplant; previous choledocojejunostomy: S285
Not eligible to develop appendicitis: previous appendectomy: S205, S206; previous right hemicolectomy: S166; previous total colectomy: S168, S169, S170
Not eligible to develop diverticulitis: previous total colectomy: S168, S169, S170
Appendix D. Median time and interquartile range in years from transplantation to emergency general surgical
condition overall, by solid organ transplant type, and by emergency general surgical condition
Appendix E. Logistic regression model of 30-day mortality following emergency general surgery conditions by transplant status
Unadjusted Odds Ratio (95% CI)
Adjusted Odds Ratio (95% CI) (No comorbidities)
Adjusted Odds Ratio (95% CI) All individual comorbidities
Adjusted Odds ratio (95% CI) AGD scores
C=0.881 c = 0.885
transplant (any) 1.52 (1.15, 1.99) 1.76 (1.32, 2.33) 1.44 (1.08, 1.91) 1.47 (1.11, 1.95) age 20 vs 40 0.06 (0.05, 0.08) 0.11 (0.09, 0.14) 0.10 (0.08, 0.13) 0.11 (0.09, 0.13) age 30 vs 40 0.29 (0.27, 0.31) 0.39 (0.36, 0.42) 0.39 (0.36, 0.42) 0.39 (0.36, 0.42) age 50 vs 40 2.67 (2.58, 2.77) 2.04 (1.97, 2.12) 1.93 (1.86, 2.00) 1.98 (1.91, 2.06) age 60 vs 40 5.96 (5.66, 6.27) 3.63 (3.45, 3.82) 3.10 (2.94, 3.28) 3.36 (3.19, 3.54) age 70 vs 40 11.86 (11.20, 12.55) 6.10 (5.75, 6.47) 4.60 (4.32, 4.89) 5.40 (5.09, 5.73) age 80 vs 40 22.48 (21.20, 23.83) 10.53 (9.91, 11.18) 6.94 (6.49, 7.41) 9.09 (8.55, 9.66) age 90 vs 40 43.35 (40.97, 45.87) 20.23 (19.08, 21.44) 11.77 (11.02, 12.58) 17.73 (16.71, 18.80) sex Male vs Female 1.02 (0.99, 1.04) 1.05 (1.02, 1.08) 1.00 (0.98, 1.03) 1.06 (1.03, 1.09) Income quintile
1 (lowest) vs 5 (highest) 1.24 (1.19, 1.29) 1.18 (1.13, 1.23) 1.10 (1.06, 1.15) 1.16 (1.11, 1.21)
2 vs 5 1.18 (1.14, 1.23) 1.13 (1.08, 1.18) 1.09 (1.04, 1.14) 1.14 (1.09, 1.19)
3 vs 5 1.09 (1.04, 1.13) 1.08 (1.04, 1.13) 1.05 (1.00, 1.10) 1.07 (1.02, 1.11)
4 vs 5 1.02 (0.97, 1.06) 1.07 (1.02, 1.12) 1.05 (1.00, 1.10) 1.09 (1.04, 1.14)
rural Y vs N 1.11 (1.07, 1.15) 1.02 (0.98, 1.05) 1.00 (0.96, 1.04) 1.05 (1.01, 1.09)
Asthma 0.94 (0.91, 0.98) 0.79 (0.76, 0.83)
HIV 0.87 (0.63, 1.20) 1.65 (1.17, 2.31)
Myocardial infarction in
past 2 years 3.60 (3.39, 3.82) 1.34 (1.26, 1.43)
COPD 4.37 (4.25, 4.50) 1.44 (1.39, 1.49)
Hypertension 4.85 (4.72, 4.99) 0.99 (0.96, 1.03)
Diabetes 2.50 (2.43, 2.57) 1.17 (1.14, 1.21)
Congestive heart failure 6.18 (6.01, 6.36) 1.73 (1.67, 1.78)
Dementia 6.55 (6.33, 6.78) 1.63 (1.57, 1.69)
Inflammatory bowel
disease 0.60 (0.55, 0.66) 0.53 (0.48, 0.58)
EGS condition Choledocolithiasis vs
appendicitis 7.63 (6.73, 8.64) 2.78 (2.45, 3.15) 2.68 (2.36, 3.04) Cholecystitis vs
appendicitis 13.76 (12.21, 15.50) 4.48 (3.97, 5.06) 4.28 (3.79, 4.83) Diverticulitis vs
appendicitis 40.96 (36.09, 46.50) 11.54 (10.14, 13.13) 11.24 (9.88, 12.79) Hernia vs appendicitis 26.17 (23.10, 29.65) 6.09 (5.36, 6.91) 5.79 (5.09, 6.57) Small bowel obstruction
vs appendicitis 84.75 (75.59, 95.01) 17.70 (15.76, 19.88) 17.32 (15.41, 19.46) Perforated peptic ulcer
vs appendicitis
109.67 (96.34,
124.84) 26.90 (23.56, 30.71) 26.23 (22.96, 29.96)
Year 0.98 (0.98, 0.98) 0.97 (0.96, 0.97) 0.97 (0.97, 0.97)
ADG None (0) vs Low (1-5) 1.16 (1.01, 1.34)
AGD Moderate (6-9) vs
Low (1-5) 1.16 (1.11, 1.21)
AGD High (10 or more) vs
Low (1-5) 1.85 (1.78, 1.93)
Appendix F. Regression models of 30-day mortality following emergency general surgery conditions by transplanted organ
Unadjusted Odds Ratio (95% CI)
Adjusted Odds Ratio (95% CI) No comorbidities
Adjusted Odds Ratio (95% CI) All individual comorbidities
c = 0.885 age 20 vs 40 0.06 (0.05, 0.08) 0.11 (0.09, 0.14) 0.10 (0.08, 0.13) age 30 vs 40 0.29 (0.27, 0.31) 0.39 (0.36, 0.42) 0.39 (0.36, 0.42) age 50 vs 40 2.67 (2.58, 2.77) 2.04 (1.97, 2.12) 1.93 (1.86, 2.00) age 60 vs 40 5.96 (5.66, 6.27) 3.63 (3.45, 3.83) 3.10 (2.94, 3.28) age 70 vs 40 11.86 (11.20, 12.55) 6.10 (5.76, 6.47) 4.60 (4.32, 4.90) age 80 vs 40 22.48 (21.20, 23.83) 10.53 (9.91, 11.18) 6.94 (6.49, 7.41) age 90 vs 40 43.35 (40.97, 45.87) 20.23 (19.08, 21.45) 11.78 (11.02, 12.58) Transplant type Heart vs
None 0.65 (0.09, 4.73) 1.00 (0.13, 7.56) 0.54 (0.07, 4.11)
Transplant type Kidney vs
None 1.44 (1.01, 2.05) 1.50 (1.05, 2.16) 1.26 (0.87, 1.81)
Transplant type Liver vs
None 1.00 (0.49, 2.03) 1.37 (0.66, 2.81) 1.22 (0.59, 2.51)
Transplant type Lung vs
None 3.30 (1.84, 5.92) 5.12 (2.73, 9.60) 3.60 (1.90, 6.82)
sex M vs F 1.02 (0.99, 1.04) 1.05 (1.02, 1.08) 1.00 (0.98, 1.03)
Income quintile
1 vs 5 1.24 (1.19, 1.29) 1.18 (1.13, 1.23) 1.10 (1.06, 1.15)
2 vs 5 1.18 (1.14, 1.23) 1.13 (1.08, 1.18) 1.09 (1.04, 1.14)
3 vs 5 1.09 (1.04, 1.13) 1.08 (1.04, 1.13) 1.05 (1.00, 1.10)
4 vs 5 1.02 (0.97, 1.06) 1.07 (1.02, 1.12) 1.05 (1.00, 1.10)
rural Y vs N 1.11 (1.07, 1.15) 1.02 (0.98, 1.05) 1.00 (0.96, 1.04)
Asthma 0.94 (0.91, 0.98) 0.79 (0.76, 0.83)
HIV 0.87 (0.63, 1.20) 1.65 (1.18, 2.31)
Myocardial infarction in
past 2 years 3.60 (3.39, 3.82) 1.34 (1.26, 1.43)
COPD 4.37 (4.25, 4.50) 1.43 (1.39, 1.49)
Hypertension 4.85 (4.72, 4.99) 0.99 (0.96, 1.03)
Diabetes 2.50 (2.43, 2.57) 1.17 (1.14, 1.21)
Congestive heart failure 6.18 (6.01, 6.36) 1.73 (1.67, 1.78)
Dementia 6.55 (6.33, 6.78) 1.63 (1.57, 1.69)
Inflammatory bowel
disease 0.60 (0.55, 0.66) 0.53 (0.48, 0.58)
EGS condition Choledocolithiasis vs
appendicitis 7.63 (6.73, 8.64) 2.78 (2.45, 3.15) 2.68 (2.36, 3.03) Cholecystitis vs
appendicitis 13.76 (12.21, 15.50) 4.48 (3.97, 5.06) 4.28 (3.79, 4.83) Diverticulitis vs
appendicitis 40.96 (36.09, 46.50) 11.53 (10.13, 13.11) 11.23 (9.87, 12.78) Hernia vs appendicitis 26.17 (23.10, 29.65) 6.09 (5.36, 6.91) 5.79 (5.10, 6.57) Small bowel obstruction
vs appendicitis 84.75 (75.59, 95.01) 17.70 (15.75, 19.88) 17.31 (15.41, 19.46) Perforated peptic ulcer
vs appendicitis 109.67 (96.34, 124.84) 26.88 (23.54, 30.69) 26.21 (22.95, 29.94)
year 0.98 (0.98, 0.98) 0.97 (0.96, 0.97) 0.97 (0.97, 0.97)
Appendix G. Regression models of 30-day mortality following specific emergency general surgery conditions by transplant status adjusted for all comorbidities
Fully Adjusted Odds Ratio (95% CI)
Effect Choledocolithiasis Cholecystitis Diverticulitis Hernia
Small bowel obstruction
c = 0.885 c = 0.860 c = 0.844 c = 0.795 c = 0.707
transplant (any) 3.62 (1.55, 8.45) 2.39 (1.14, 5.00) 3.83 (1.70, 8.62) 2.06 (0.82, 5.21) 0.86 (0.57, 1.28) age 20 vs 40 0.20 (0.13, 0.32) 0.46 (0.38, 0.56) 0.24 (0.10, 0.56) 0.36 (0.23, 0.56) 0.53 (0.49, 0.58) age 30 vs 40 0.02 (0.01, 0.08) 0.17 (0.10, 0.30) 0.04 (0.00, 0.43) 0.09 (0.03, 0.30) 0.20 (0.16, 0.26) age 50 vs 40 3.21 (2.55, 4.03) 1.88 (1.69, 2.07) 3.33 (2.13, 5.20) 2.14 (1.72, 2.66) 1.51 (1.44, 1.58) age 60 vs 40 7.55 (5.49, 10.38) 3.26 (2.81, 3.79) 9.06 (4.91, 16.70) 3.82 (2.82, 5.18) 2.00 (1.88, 2.13) age 70 vs 40 14.68 (10.43, 20.66) 5.67 (4.76, 6.77) 20.78 (11.08, 38.96) 6.18 (4.46, 8.58) 2.58 (2.40, 2.78) age 80 vs 40 26.44 (18.80, 37.18) 10.58 (8.74, 12.80) 41.47 (22.79, 75.49) 9.84 (7.10, 13.64) 3.55 (3.28, 3.83) age 90 vs 40 49.57 (35.37, 69.46) 22.73 (18.81, 27.46) 74.30 (40.34, 136.87) 16.66 (12.03, 23.07) 5.74 (5.31, 6.20) Myocardial infarction
in past 2 years 1.28 (1.03, 1.60) 1.57 (1.35, 1.82) 1.63 (1.21, 2.20) 1.35 (1.05, 1.72) 1.22 (1.12, 1.33) Asthma 0.69 (0.57, 0.83) 0.93 (0.82, 1.06) 0.77 (0.64, 0.94) 0.83 (0.70, 0.98) 0.77 (0.73, 0.82) Congestive heart
failure 2.27 (2.01, 2.56) 2.70 (2.46, 2.95) 1.84 (1.59, 2.13) 1.77 (1.56, 2.00) 1.45 (1.39, 1.51)
COPD 1.63 (1.43, 1.86) 1.55 (1.40, 1.72) 1.73 (1.48, 2.03) 1.80 (1.58, 2.04) 1.35 (1.29, 1.41)
Dementia 1.51 (1.31, 1.74) 1.75 (1.57, 1.95) 1.59 (1.34, 1.89) 1.73 (1.49, 2.00) 1.61 (1.53, 1.69) Diabetes 1.31 (1.17, 1.47) 1.46 (1.34, 1.58) 1.18 (1.03, 1.36) 1.19 (1.06, 1.35) 1.07 (1.03, 1.11)
HIV 1.26 (0.17, 9.35) 0.96 (0.23, 3.93) 4.39 (0.98, 19.68) 2.01 (0.55, 7.32) 1.32 (0.87, 1.99)
Hypertension 1.01 (0.87, 1.17) 1.02 (0.91, 1.13) 1.22 (1.03, 1.43) 1.08 (0.94, 1.24) 0.96 (0.92, 1.00) Inflammatory bowel
disease 0.84 (0.46, 1.55) 1.55 (1.06, 2.28) 1.40 (0.88, 2.25) 1.37 (0.88, 2.13) 0.37 (0.33, 0.41) Income quintile
1 vs 5 1.16 (0.97, 1.38) 1.29 (1.14, 1.47) 1.24 (1.01, 1.51) 1.23 (1.03, 1.46) 1.04 (0.98, 1.09) 2 vs 5 1.24 (1.04, 1.48) 1.19 (1.04, 1.36) 1.32 (1.08, 1.60) 1.18 (0.99, 1.41) 1.03 (0.97, 1.08) 3 vs 5 1.26 (1.05, 1.51) 1.10 (0.96, 1.26) 1.06 (0.86, 1.31) 1.02 (0.85, 1.23) 1.03 (0.98, 1.09)
4 vs 5 1.02 (0.84, 1.23) 1.15 (1.00, 1.31) 1.21 (0.99, 1.49) 1.08 (0.89, 1.30) 1.02 (0.97, 1.08) rural Y vs N 0.99 (0.85, 1.15) 1.08 (0.97, 1.20) 1.14 (0.96, 1.36) 0.95 (0.81, 1.11) 1.00 (0.95, 1.04) sex M vs F 1.16 (1.04, 1.29) 1.06 (0.98, 1.15) 0.93 (0.82, 1.06) 0.94 (0.84, 1.05) 0.98 (0.95, 1.01)
year 0.98 (0.97, 0.99) 0.98 (0.97, 0.99) 0.95 (0.93, 0.96) 0.97 (0.96, 0.98) 0.97 (0.96, 0.97)