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Arredondo Montero J, Ros Briones R, Fernández-Celis A, López-Andrés N, Martín-Calvo N. Diagnostic Performance of Serum Leucine-Rich Alpha-2-Glycoprotein 1 in Pediatric Acute Appendicitis: A Prospective Validation Study. Biomedicines 2024; 12:1821. [PMID: 39200285 PMCID: PMC11352011 DOI: 10.3390/biomedicines12081821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/04/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
Introduction: Leucine-rich alpha-2-glycoprotein 1(LRG-1) is a human protein that has shown potential usefulness as a biomarker for diagnosing pediatric acute appendicitis (PAA). This study aims to validate the diagnostic performance of serum LRG-1 in PAA. Material and Methods: This work is a subgroup analysis from BIDIAP (BIomarkers for DIagnosing Appendicitis in Pediatrics), a prospective single-center observational cohort, to validate serum LRG-1 as a diagnostic tool in PAA. This analysis included 200 patients, divided into three groups: (1) healthy patients undergoing major outpatient surgery (n = 56), (2) patients with non-surgical abdominal pain (n = 52), and (3) patients with a confirmed diagnosis of PAA (n = 92). Patients in group 3 were divided into complicated and uncomplicated PAA. In all patients, a serum sample was obtained during recruitment, and LRG-1 concentration was determined by Enzyme-Linked ImmunoSorbent Assay (ELISA). Comparative statistical analyses were performed using the Mann-Whitney U, Kruskal-Wallis, and Fisher's exact tests. The area under the receiver operating characteristic curves (AUC) was calculated for all pertinent analyses. Results: Serum LRG-1 values, expressed as median (interquartile range) were 23,145 (18,246-27,453) ng/mL in group 1, 27,655 (21,151-38,795) ng/mL in group 2 and 40,409 (32,631-53,655) ng/mL in group 3 (p < 0.0001). Concerning the type of appendicitis, the serum LRG-1 values obtained were 38,686 (31,804-48,816) ng/mL in the uncomplicated PAA group and 51,857 (34,013-64,202) ng/mL in the complicated PAA group (p = 0.02). The area under the curve (AUC) obtained (group 2 vs. 3) was 0.75 (95% CI 0.67-0.84). For the discrimination between complicated and uncomplicated PAA, the AUC obtained was 0.66 (95% CI 0.52-0.79). Conclusions: This work establishes normative health ranges for serum LRG-1 values in the pediatric population and shows that serum LRG-1 could be a potentially helpful tool for diagnosing PAA in the future. Future prospective multicenter studies, with the parallel evaluation of urinary and salivary LRG-1, are necessary to assess the implementability of this molecule in actual clinical practice.
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Affiliation(s)
| | - Raquel Ros Briones
- Pediatric Surgery Department, Hospital Universitario de Navarra, 31008 Pamplona, Spain
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, IdiSNA, Universidad Pública de Navarra (UPNA), 31008 Pamplona, Spain
| | - Natalia López-Andrés
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, IdiSNA, Universidad Pública de Navarra (UPNA), 31008 Pamplona, Spain
| | - Nerea Martín-Calvo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad de Navarra, 31008 Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain
- CIBER de Fisiopatología de la Obesidad y la Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain
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Andric M, Stockheim J, Rahimli M, Klös M, Esser T, Soldatovic I, Dölling M, Al-Madhi S, Acciuffi S, Croner R, Perrakis A. Management of acute appendicitis during COVID-19 pandemic. Single center data from a tertiary care hospital in Germany. Innov Surg Sci 2023; 8:39-48. [PMID: 38058775 PMCID: PMC10696938 DOI: 10.1515/iss-2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/03/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives The unexpected global overload of the health system during COVID-19 pandemic has caused changes in management of acute appendicitis worldwide. Whereas conservative treatment was widely recommended, the appendicectomy remained standard therapy in Germany. We aimed to investigate the impact of COVID-19 pandemic on treatment routine for acute appendicitis at University Hospital of Magdeburg. Methods Adult patients with clinical and/or radiological diagnosis of acute appendicitis were included in the single center retrospective study. Data was collected to patient demographics, treatment modality and outcomes including morbidity and length of stay. The patient data related to COVID-19 period from March 22, 2020 to December 31, 2021 (649 days) were compared to the Non-COVID-19 period from June 12, 2018 to March 21, 2020 (649 days). Subgroup analysis related to conservative or surgical treatment has been performed. Results A total of 385 patients was included in the study, 203 (52.73 %) during Non-COVID-19 period and 182 (47.27 %) during COVID-19 period. Mean age of entire collective was 43.28 years, containing 43.9 % female patients (p=0.095). Conservative treatment was accomplished in 49 patients (12.7 % of entire collective), increasing from 9.9 % to 15.9 % during COVID-19 period (p=0.074). Laparoscopic appendicectomy was performed in 99.3 % (n=152) of operated patients during COVID-19 period (p=0.013), followed by less postoperative complications compared to reference period (23.5 % vs. 13.1 %, p=0.015). The initiation of antibiotic therapy after the diagnosis increased from 37.9 % to 53.3 % (p=0.002) during COVID-19 period regardless the following treatment modality. Antibiotic treatment showed shorter duration during pandemic period (5.57 days vs. 3.16 days, p<0.001) and it was given longer in the conservative treatment group (5.63 days vs. 4.26 days, p=0.02). The overall length of stay was shorter during COVID-19 period (4.67 days vs. 4.12 days, p=0.052) and in the conservative treatment group (3.08 days vs. 4.47 days, p<0.001). However, the overall morbidity was lower during the COVID-19 period than before (17.2 % vs. 7.7 %, p=0.005) and for conservative therapy compared to appendicectomy (2 % vs. 14.3 %, p=0.016). There was no mortality documented. Conclusions According to our findings the COVID-19 pandemic had a relevant impact on treatment of acute appendicitis, but it was possible to maintain the traditional diagnostic and treatment pathway. Although laparoscopic appendicectomy remains a recommended procedure, the conservative treatment of uncomplicated appendicitis with excellent short-term outcome can be a safe alternative to surgery during potential new wave of COVID-19 pandemic and in the daily routine.
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Affiliation(s)
- Mihailo Andric
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Jessica Stockheim
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Mirhasan Rahimli
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Michael Klös
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Torben Esser
- Institute of Microbiology and Hospital Hygiene, University Hospital Magdeburg, Magdeburg, Germany
| | - Ivan Soldatovic
- Institute for Medical statistics, Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | - Maximilian Dölling
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Sara Al-Madhi
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Sara Acciuffi
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Roland Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
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Yang HB, Song HB, Han JW, Youn JK, Ko D, Ryu YJ, Kim JY, Kim HY. Clinical course in children with equivocal appendicitis on computed tomography: a retrospective cohort study. Ann Surg Treat Res 2023; 104:51-59. [PMID: 36685769 PMCID: PMC9830045 DOI: 10.4174/astr.2023.104.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose Appendectomy is one of the most common surgeries in children. Although various radiological examinations are performed, they do not always reveal a definitive diagnosis of appendicitis. This study aimed to investigate the clinical course of equivocal appendicitis, identify the factors associated with appendectomy, and suggest appropriate management for these patients. Methods Patients younger than 19 years who visited Seoul National University Bundang Hospital with a differential diagnosis of appendicitis from January 2013 to December 2017 were included. All participants conducted 'appendiceal CT' with a scoring scale of 1-5. The higher the score, the higher the likelihood of a radiologic diagnosis of appendicitis. We defined the appendicitis CT score of 2-4 as equivocal appendicitis (n = 143). Medical records were reviewed retrospectively for demographics, further examination as abdominal ultrasonography, and appendectomy status (yes or no). The mean follow-up period was 15.6 ± 71 days. Results Equivocal appendicitis accounted for 16.7%. Additional ultrasonography test was performed in 24.5% (35 of 143). In total, 34 patients (23.8%) underwent appendectomy. Among the patients with appendiceal CT scores 2, 3, and 4, 4.9%, 50.0%, and 87.5% underwent appendectomy, respectively. Higher WBC count, higher appendicitis CT score, and readmission were significantly associated with appendectomy in patients with equivocal appendicitis. Conclusion Higher appendicitis CT score and WBC level were positively associated with appendectomy. Careful observation can be a treatment option in appendicitis CT score 2 or 3 groups. Appendectomy is the first-line treatment for patients with appendicitis score 4. Additional ultrasonography test is advisable to determine treatment modality for equivocal appendicitis.
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Affiliation(s)
- Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Han-Byol Song
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji-Won Han
- Department of Surgery, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Young Jin Ryu
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea.,Department of Surgery, College of Medicine, Seoul National University, Seoul, Korea
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Simmering JE, Polgreen LA, Talan DA, Cavanaugh JE, Polgreen PM. Association of Appendicitis Incidence With Warmer Weather Independent of Season. JAMA Netw Open 2022; 5:e2234269. [PMID: 36190731 PMCID: PMC9530968 DOI: 10.1001/jamanetworkopen.2022.34269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Acute appendicitis is a common cause of abdominal pain and the most common reason for emergency surgery in several countries. Increased cases during summer months have been reported. OBJECTIVE To investigate the incidence of acute appendicitis by considering local temperature patterns in geographic regions with different climate over several years. DESIGN, SETTING, AND PARTICIPANTS This cohort study used insurance claims data from the MarketScan Commercial Claims and Encounters Database and the Medicare Supplemental and Coordination of Benefits Database from January 1, 2001, to December 31, 2017. The cohort included individuals at risk for appendicitis who were enrolled in US insurance plans that contribute data to the MarketScan databases. Cases of appendicitis in the inpatient, outpatient, and emergency department settings were identified using International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. Local weather data were obtained for individuals living in a metropolitan statistical area (MSA) from the Integrated Surface Database. Associations were characterized using a fixed-effects generalized linear model based on a negative binomial distribution. The model was adjusted for age, sex, and day of week and included fixed effects for year and MSA. The generalized linear model was fit with a piecewise linear model by searching each 0.56 °C in temperature for change points. To further isolate the role of temperature, observed temperature was replaced with the expected temperature and the deviation of the observed temperature from the expected temperature for a given city on a given day of year. Data were analyzed from October 1, 2021, to July 31, 2022. MAIN OUTCOMES AND MEASURES The primary outcome was the daily number of appendicitis cases in a given city stratified by age and sex, with mean temperature in the MSA over the previous 7 days as the independent variable. RESULTS A total of 450 723 744 person-years at risk and 689 917 patients with appendicitis (mean [SD] age, 35 [18] years; 347 473 male [50.4%] individuals) were included. Every 5.56 °C increase in temperature was associated with a 1.3% increase in the incidence of appendicitis (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) when temperatures were 10.56 °C or lower and a 2.9% increase in incidence (IRR, 1.03; 95% CI, 1.03-1.03) for temperatures higher than 10.56 °C. In terms of temperature deviations, a higher-than-expected temperature increase greater than 5.56 °C was associated with a 3.3% (95% CI, 1.0%-5.7%) increase in the incidence of appendicitis compared with days with near-0 deviations. CONCLUSIONS AND RELEVANCE Results of this cohort study observed seasonality in the incidence of appendicitis and found an association between increased incidence and warmer weather. These results could help elucidate the mechanism of appendicitis.
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Affiliation(s)
| | - Linnea A. Polgreen
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City
| | - David A. Talan
- Ronald Reagan UCLA (University of California, Los Angeles) Medical Center, Department of Emergency Medicine, UCLA
| | | | - Philip M. Polgreen
- Department of Internal Medicine, University of Iowa, Iowa City
- Department of Epidemiology, University of Iowa, Iowa City
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Low-Dose Abdominal CT for Evaluating Suspected Appendicitis: Recommendations for CT Imaging Techniques and Practical Issues. Diagnostics (Basel) 2022; 12:diagnostics12071585. [PMID: 35885490 PMCID: PMC9320604 DOI: 10.3390/diagnostics12071585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 12/04/2022] Open
Abstract
A vast disparity exists between science and practice for CT radiation dose. Despite high-level evidence supporting the use of low-dose CT (LDCT) in diagnosing appendicitis, a recent survey showed that many care providers were still concerned that the low image quality of LDCT may lead to incorrect diagnoses. For successful implementation of LDCT practice, it is important to inform and educate the care providers not only of the scientific discoveries but also of concrete guidelines on how to overcome more practical matters. Here, we discuss CT imaging techniques and other practical issues for implementing LDCT practice.
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Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
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Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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Javanmard-Emamghissi H, Hollyman M, Boyd-Carson H, Doleman B, Adiamah A, Lund JN, Moler-Zapata S, Grieve R, Moug SJ, Tierney GM. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg 2021; 108:1351-1359. [PMID: 34476484 PMCID: PMC8499866 DOI: 10.1093/bjs/znab287] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.
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Affiliation(s)
- H Javanmard-Emamghissi
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - M Hollyman
- Upper Gastrointestinal Surgery Department, Musgrove Park Hospital, Taunton, UK
| | - H Boyd-Carson
- Colorectal Department, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - A Adiamah
- Department of Gastrointestinal Surgery, NIHR Nottingham Digestive Disease Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J N Lund
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - S Moler-Zapata
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - R Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S J Moug
- Colorectal Department, Royal Alexandra Hospital, Paisley, UK
| | - G M Tierney
- Colorectal Department, Royal Derby Hospital, Derby, UK
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Luksaite-Lukste R, Kliokyte R, Samuilis A, Jasiunas E, Luksta M, Strupas K, Poskus T. Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT. J Clin Med 2021; 10:jcm10112456. [PMID: 34206008 PMCID: PMC8198775 DOI: 10.3390/jcm10112456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.
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Affiliation(s)
- Raminta Luksaite-Lukste
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
- Correspondence: ; Tel.: +37-068-9606-11
| | - Ruta Kliokyte
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, LT-08661 Vilnius, Lithuania; (R.K.); (A.S.)
| | - Arturas Samuilis
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, LT-08661 Vilnius, Lithuania; (R.K.); (A.S.)
| | - Eugenijus Jasiunas
- Centre of Informatics and Development, Vilnius University Hospital, Santara Clinics, LT-08661 Vilnius, Lithuania;
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
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Cho J, Lee S, Min HD, Kim HY, Ko Y, Park JH, Park SB, Lee KH. Final diagnosis and patient disposition following equivocal results on 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: a post hoc analysis of large pragmatic randomized trial data. Eur Radiol 2021; 31:9176-9187. [PMID: 33993331 DOI: 10.1007/s00330-021-08020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/08/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare 2-mSv CT and conventional-dose CT (CDCT, typically 7-8 mSv) regarding final diagnosis and patient disposition following equivocal CT results in adolescents and young adults with suspected appendicitis. METHODS In total, 3074 patients of 15-44 years (28 ± 9 years, 1672 women) from 20 hospitals were randomized to undergo contrast-enhanced 2-mSv CT (n = 1535) or CDCT (n = 1539) from December 2013 through August 2016. One hundred sixty-one radiologists prospectively rated the likelihood of appendicitis in a Likert scale (i.e., grades 1-5). The final diagnosis was based on CT image, surgical, pathologic, and clinical findings. Post hoc analysis was performed for final diagnosis, surgical procedure, and delay in patient management following equivocal results (i.e., grade 3). RESULTS The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal results, including confirmed appendicitis (1.2% [18 patients] vs. 1.2% [19], p > 0.99), negative appendectomy (0.1% [2] vs. 0.3% [4], p = 0.53), and perforated appendicitis (0.1% [1] vs. 0.2% [3], p = 0.53). More patients were confirmed as not having appendicitis following equivocal results in the CDCT group than in the 2-mSv CT group (2.2% [34] vs. 1.0% [16], p = 0.016). The two groups were comparable for the need of appendectomy (1.4% [22] vs. 1.5% [23], p > 0.99), need of additional imaging tests (0.7% [11] vs. 1.1% [17], p = 0.35), and delay in patient management following equivocal results. CONCLUSION 2-mSv CT is comparable to CDCT regarding final diagnosis and patient disposition following equivocal CT results. KEY POINTS • Our results strengthen evidence justifying the use of low-dose CT instead of conventional-dose CT (CDCT) in adolescents and young adults with suspected appendicitis. • The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal CT results, including confirmed appendicitis (1.2% vs. 1.2%, p > 0.99), negative appendectomy (0.1% vs. 0.3%, p = 0.53), and perforated appendicitis (0.1% vs. 0.2%, p = 0.53). • The two groups were comparable for the need for appendectomy (1.4% vs. 1.5%, p > 0.99), need for additional imaging tests (0.7% vs. 1.1%, p = 0.35), and delay in patient management, following equivocal CT results.
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Affiliation(s)
- Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Seungjae Lee
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Hooney Daniel Min
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Yousun Ko
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea.
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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10
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Conwell NK, Kennedy NJ, Quinton AE. Diagnostic performance of ultrasound to differentiate perforated from non‐perforated paediatric appendicitis: A narrative review. SONOGRAPHY 2020. [DOI: 10.1002/sono.12232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Nancy K. Conwell
- Department of Medical Imaging Toowoomba Hospital South Toowoomba Queensland Australia
| | - Narelle J. Kennedy
- Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Nepean University of Sydney, Nepean Hospital Penrith New South Wales Australia
- Christopher Kohlenberg Department of Perinatal Ultrasound Nepean Hospital Penrith New South Wales Australia
| | - Ann E. Quinton
- Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Nepean University of Sydney, Nepean Hospital Penrith New South Wales Australia
- Medical Sonography, School of Health, Medical and Applied Science, Central Queensland University Sydney New South Wales Australia
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11
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Ko Y, Lee WJ, Park JH, Kim HY, Sim JY, Tannaphai P, Lee KH. Diagnostic sensitivity and specificity of 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: post hoc subgroup analysis of the LOCAT data. Eur Radiol 2020; 30:4573-4585. [PMID: 32240354 DOI: 10.1007/s00330-020-06811-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To test whether the difference in sensitivity or specificity between 2-mSv CT and conventional-dose CT (CDCT) for the diagnosis of appendicitis differs across subgroups of adolescents and young adults with suspected appendicitis. MATERIALS AND METHODS We used the per-protocol analysis data of a trial conducted between Dec 2013 and Aug 2016, including 2773 patients (median age [interquartile range], 28 [21-35] years) and 160 radiologists from 20 hospitals. We defined subgroups by sex, body size, clinical risk scores for appendicitis, time of CT examination (i.e., working vs. after hours), CT machines, radiologists' experience, previous site experience in 2-mSv CT, and site practice volume. We drew forest plots and tested for additive or multiplicative interaction between radiation dose and subgroup attributes. If any subgroup had fewer than 200 patients, we considered the results from that subgroup not meaningful. RESULTS For most subgroups, the 95% CIs for the differences in sensitivity and specificity were 4.0 percentage points or narrower and contained the minute overall between-group differences. There was no significant interaction on sensitivity or specificity. A few subgroups, including those of extreme body sizes, high appendicitis inflammatory response scores, and hospitals with small appendectomy volume, were regarded to have insufficient numbers of patients. CONCLUSIONS There was no notable subgroup heterogeneity, which implies that 2-mSv CT can replace CDCT in diverse populations. Further studies are needed for the subgroups for which we had only small data. KEY POINTS • The minute difference in sensitivity or specificity between the 2-mSv CT and conventional-dose CT (typically 7 mSv) groups were consistent across various patient or hospital characteristics. • These results indicate that 2-mSv CT can replace conventional-dose CT in diverse populations. • Further studies are needed to confirm whether 2-mSv CT can replace conventional-dose CT in patients of extreme body sizes, high appendicitis inflammatory response scores, or hospitals with small appendectomy volume, as those subgroups in our data included limited numbers of patients.
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Affiliation(s)
- Yousun Ko
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea.,Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Woo Joo Lee
- Department of Statistics, Inha University, Incheon, South Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Ji Ye Sim
- Department of Radiology, Hanil General Hospital, Seoul, South Korea
| | - Penampai Tannaphai
- Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea. .,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea.
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12
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Appendicitis risk prediction models in children presenting with right iliac fossa pain (RIFT study): a prospective, multicentre validation study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:271-280. [PMID: 32200936 DOI: 10.1016/s2352-4642(20)30006-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute appendicitis is the most common surgical emergency in children. Differentiation of acute appendicitis from conditions that do not require operative management can be challenging in children. This study aimed to identify the optimum risk prediction model to stratify acute appendicitis risk in children. METHODS We did a rapid review to identify acute appendicitis risk prediction models. A prospective, multicentre cohort study was then done to evaluate performance of these models. Children (aged 5-15 years) presenting with acute right iliac fossa pain in the UK and Ireland were included. For each model, score cutoff thresholds were systematically varied to identify the best achievable specificity while maintaining a failure rate (ie, proportion of patients identified as low risk who had acute appendicitis) less than 5%. The normal appendicectomy rate was the proportion of resected appendixes found to be normal on histopathological examination. FINDINGS 15 risk prediction models were identified that could be assessed. The cohort study enrolled 1827 children from 139 centres, of whom 630 (34·5%) underwent appendicectomy. The normal appendicectomy rate was 15·9% (100 of 630 patients). The Shera score was the best performing model, with an area under the curve of 0·84 (95% CI 0·82-0·86). Applying score cutoffs of 3 points or lower for children aged 5-10 years and girls aged 11-15 years, and 2 points or lower for boys aged 11-15 years, the failure rate was 3·3% (95% CI 2·0-5·2; 18 of 539 patients), specificity was 44·3% (95% CI 41·4-47·2; 521 of 1176), and positive predictive value was 41·4% (38·5-44·4; 463 of 1118). Positive predictive value for the Shera score with a cutoff of 6 points or lower (72·6%, 67·4-77·4) was similar to that of ultrasound scan (75·0%, 65·3-83·1). INTERPRETATION The Shera score has the potential to identify a large group of children at low risk of acute appendicitis who could be considered for early discharge. Risk scoring does not identify children who should proceed directly to surgery. Medium-risk and high-risk children should undergo routine preoperative ultrasound imaging by operators trained to assess for acute appendicitis, and MRI or low-dose CT if uncertainty remains. FUNDING None.
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13
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Bhangu A. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg 2020; 107:73-86. [PMID: 31797357 PMCID: PMC6972511 DOI: 10.1002/bjs.11440] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/12/2019] [Accepted: 10/29/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. METHODS A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16-45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). RESULTS Some 5345 patients across 154 UK hospitals were identified, of which two-thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut-off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut-off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). CONCLUSION Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision-making by identifying adults in the UK at low risk of appendicitis were identified.
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Kim HJ, Lee KH, Kim MJ, Park SB, Ko Y. Using 2-mSv Appendiceal CT in Usual Practice for Adolescents and Young Adults: Willingness Survey of 579 Radiologists, Emergency Physicians, and Surgeons from 20 Hospitals. Korean J Radiol 2020; 21:68-76. [PMID: 31920030 PMCID: PMC6960317 DOI: 10.3348/kjr.2019.0010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 08/10/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To survey care providers' willingness to use 2-mSv computed tomography (CT) in their usual practice for adolescents and young adults with suspected appendicitis. MATERIALS AND METHODS An ethical committee approved this prospective study. We introduced 2-mSv CT in 20 hospitals through a pragmatic clinical trial. At the final phase of the trial, we invited 698 potentially-involved care providers in the survey regarding their willingness to use 2-mSv CT. Multivariable logistic regression analyses were performed to identify factors associated with willingness. Nine months after the completion of the trial patient recruitment, we surveyed whether the hospitals were using 2-mSv CT in usual practice. RESULTS The analyses included responses from 579 participants (203 attendings and 376 trainees; 221 radiologists, 196 emergency physicians, and 162 surgeons). Regarding the willingness to immediately change their standard practice to 2-mSv CT, 158 (27.3%), 375 (64.8%), and 46 (7.9%) participants responded as "yes" (consistently), "partly" (selectively), and "no", respectively. Willingness varied considerably across the hospitals, but only slightly across the participants' departments or job titles. Willingness was significantly associated with attendings (p = 0.004), intention to maintain the dedicated appendiceal CT protocol (p < 0.001), belief in compelling evidence on the carcinogenic risk of conventional-dose CT radiation (p = 0.028), and hospitals having more than 1000 beds (p = 0.031). Fourteen of the 20 hospitals kept using 2-mSv appendiceal CT in usual practice after the trial. CONCLUSION Despite the extensive efforts over the years of this clinical trial, many care providers were willing to use 2-mSv CT selectively or not willing to use.
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Affiliation(s)
- Hyuk Jung Kim
- Department of Radiology, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology Seoul National University, Seoul, Korea.
| | - Min Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yousun Ko
- Department of Radiology, Asan Medical Center, Seoul, Korea
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15
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Abstract
PURPOSE OF REVIEW Concern regarding appendicitis is a common reason for presentation to the paediatric emergency department. We review recent progress in the use of biomarkers, imaging and clinical scoring systems in improving diagnostic accuracy in suspected appendicitis in children. RECENT FINDINGS Use of ultrasound, often performed at the bedside, is becoming more widespread with a parallel reduction in computed tomography (CT) use. Protocols for image acquisition and interpretation have been shown to improve diagnostic accuracy. Novel biomarkers have been explored and clinical diagnostic algorithms refined but none have achieved the level of diagnostic accuracy required. SUMMARY Appendicitis remains a clinical diagnosis. Point of care ultrasound is increasingly available and offers higher diagnostic accuracy than several routinely performed laboratory investigations. Recent publications provide support for increased use of clinician performed ultrasound, increased use of MRI, less use of CT, less emphasis on basic laboratory investigation and a renewed respect for the value of serial examination, particularly early in the course of illness.
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Bax T, Macha M, Mayberry J. The utility of CT scan for the diagnostic evaluation of acute abdominal pain. Am J Surg 2019; 217:959-966. [DOI: 10.1016/j.amjsurg.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/16/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
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Laghi A. Acute Appendicitis and Negative or Inconclusive Results at Initial US in Adult, Pediatric, and Pregnant Patients: What to Do Next? Radiology 2018; 288:728-729. [DOI: 10.1148/radiol.2018180922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Laghi
- From the Department of Radiological Sciences, Oncology and Pathology, Sapienza–University of Rome, Sant’Andrea University Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
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Kim DW, Yoon HM, Lee JY, Kim JH, Jung AY, Lee JS, Cho YA. Diagnostic performance of CT for pediatric patients with suspected appendicitis in various clinical settings: a systematic review and meta-analysis. Emerg Radiol 2018; 25:627-637. [PMID: 30003463 DOI: 10.1007/s10140-018-1624-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 06/28/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the diagnostic performance of CT for pediatric patients with suspected appendicitis in various clinical settings and the proportion of acute appendicitis on final diagnosis among equivocal CT findings. METHODS MEDLINE and EMBASE databases were searched until October 21, 2017, for studies investigating diagnostic performance of CT for acute appendicitis in pediatric patients confirmed by histopathologic findings and/or clinical follow-up. Pooled estimates of sensitivity and specificity were calculated using a hierarchical logistic regression modeling. The proportion of true appendicitis among patients with inconclusive CT results was obtained using fixed and random effects meta-analyses. RESULTS Twenty-two articles with 3396 patients were included. The pooled sensitivity and specificity were 95% (95% CI, 93-97%) and 94% (95% CI, 90-96%), respectively, and the area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.98 (95% CI, 0.96-0.99). Subgroup analyses revealed a comparable diagnostic performance in the low-dose CT group (sensitivity, 97%; specificity, 96%) and the unenhanced group (sensitivity, 95%; specificity, 95%). Other subgroups (publication year, study design, enrolled population, true appendicitis proportion, CT channel number, and slice thickness) also showed good diagnostic performance. Six studies reporting the true appendicitis proportion among patients with equivocal CT findings had pooled proportion of 17% (95% CI, 9-29%). CONCLUSIONS CT showed good performance for suspected appendicitis in pediatric patients under various clinical settings, including in cases with dose reduction or absence of IV contrast. The prevalence of true appendicitis among patients with equivocal appendicitis results on CTs was not low; therefore, clinical attention should not be disregarded in this population.
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Affiliation(s)
- Dong Wook Kim
- Department of Radiology, Taean-gun Health Center and County Hospital, 1952-16, Seohae-ro, Pyeongcheon-ri, Taean-eup, Taean-gun, Chungcheongnam-do, 32148, Republic of Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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