Pentraxin-3: A strong novel biochemical marker for appendicitis in children

Trends and Predictors of Pediatric Negative Appendectomy Rates: A Single-Centre Retrospective Study

BACKGROUND

Appendectomy is still the standard treatment for acute appendicitis in the majority of centers. Despite all available diagnostic tools, the rates of negative appendectomies are still relatively high. This study aimed to determine negative appendectomy rates and to analyze the demographic and clinical data of the patients whose histopathology report was negative.

METHODS

All patients younger than 18 years who underwent appendectomy for suspected acute appendicitis in the period from 1 January 2012 to 31 December 2021 were included in the single-center retrospective study. Electronic records and archives of histopathology reports were reviewed for patients with negative appendectomy. The primary outcome of this study was a negative appendectomy rate. Secondary outcomes comprehended the rate of appendectomies and the association of age, sex, body mass index (BMI), values of laboratory markers, scoring systems, and ultrasound reports with negative histopathology reports.

RESULTS

During the study period, a total of 1646 appendectomies for suspected acute appendicitis were performed. In 244 patients, negative appendectomy was reported regarding the patients' pathohistology. In 39 of 244 patients, other pathologies were found, of which ovarian pathology (torsion and cysts) torsion of greater omentum and Meckel's diverticulitis were the most frequent. Finally, the ten-year negative appendectomy rate was 12.4% (205/1646). The median age was 12 years (interquartile range, IQR 9, 15). A slight female predominance was noted (52.5%). A significantly higher incidence of negative appendectomies was noted in girls, with a peak incidence between the ages of 10 and 15 years (p < 0.0001). Male children whose appendectomy was negative had significantly higher BMI values compared to female patients (p = 0.0004). The median values of white blood cell count, neutrophil count, and CRP in the patients with negative appendectomy were 10.4 × 10⁹/L, 75.9%, and 11 mg/dL, respectively. The median of Alvarado's score was 6 (IQR 4; 7.5), while the median of the AIR score was 5 (IQR 4, 7). The rate of children with negative appendectomy who underwent ultrasound was 34.4% (84/244), among which 47 (55.95%) concluded negative reports. The rates of negative appendectomies were not homogenous in terms of distribution regarding the season. The incidence of negative appendectomies was more frequent during the cold period of the year (55.3% vs. 44.7%; p = 0.042).

CONCLUSIONS

The majority of negative appendectomies were performed in children older than 9 years and most frequently in female children aged 10 to 15 years. In addition, female children have significantly lower BMI values compared to male children with negative appendectomy. An increase in the utilization of auxiliary diagnostic methods such as computed tomography could affect the reduction in the pediatric negative appendectomy rate.

Clinical Outcomes of Daytime Versus Nighttime Laparoscopic Appendectomy in Children

Aim of the study: To evaluate the clinical outcomes and complication rate of laparoscopic appendectomy in children operated on during the daytime versus nighttime. Methods: A total of 303 children who underwent laparoscopic appendectomy for acute appendicitis between 1 January 2020 and 31 December 2022 were enrolled in this retrospective study. The patients were divided into two study groups. The first group consisted of the patients who underwent laparoscopic appendectomy during the day shift from 07:00-21:00 (n = 171), while the patients in the second group underwent laparoscopic appendectomy during the night shift from 21:00-07:00 (n = 132). The groups were compared for baseline clinical and laboratory data, treatment outcomes, and complications. The Mann-Whitney U test was used to compare continuous variables, while the Chi-square test was used to compare categorical variables. A two-sided Fisher's exact test was used when the frequency of events in a certain cell was low. All p values less than 0.05 were considered significant. Results: The proportion of complicated appendicitis was almost the same in both patient groups (n = 63, 36.8% vs. n = 49, 37.1%, p = 0.960). Out of the total number of patients presenting during the daytime and nighttime, 11 (6.4%) and 10 (7.6%) developed a postoperative complication, respectively (p = 0.697). Additionally, rates of readmission (n = 5 (2.9%) vs. n = 2 (1.5%); p = 0.703), redo-surgery (n = 3 (1.7%) vs. n = 0; p = 0.260), conversion to open surgery (n = 0 vs. n = 1 (0.8%); p = 0.435) and length of hospital stay (n = 3 (IQR 1, 5) vs. n = 3 (IQR 2, 5); p = 0.368) did not differ significantly between daytime and nighttime appendectomies. The duration of the surgery was significantly shorter in patients presenting during the day than in those presenting at night (26 min (IQR 22, 40) vs. 37 min (31, 46); p < 0.001). Conclusions: Different shift times did not affect the treatment outcomes or complication rates for children receiving laparoscopic appendectomy.

Serum pentraxin-3 in diagnosing acute appendicitis in patients with acute abdominal pain: A systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Acute appendicitis is one of many common reasons for acute abdominal pain, and its exact diagnosis is still debatable amongst clinicians. This systematic review and meta-analysis of diagnostic test accuracy aim to look at serum pentraxin-3 performance in diagnosing acute appendicitis in patients with acute abdominal pain.

METHODS

This systematic review is registered on the International Prospective Register of Systematic Reviews (CRD42022338296). The primary outcome of this study is to examine the sensitivity, specificity, and post-test probability of serum pentraxin-3 (the index test) in patients with acute appendicitis. We searched various academic databases such as Pubmed, MEDLINE, Cochrane Library, Science Direct, Google Scholar, ScieLO, MedRxiv, BioRxiv, and Research Square. Two independent authors reviewed, selected the articles, and extracted the data. The analysis was done using STATA software using the "midas" and "metandi" commands.

RESULTS

Five articles fulfilled our inclusion criteria with 520 patients, and 27.5% of them were children. The combined sensitivity is 90.3% (95% confidence interval 78.6-95.9), and the combined specificity is 91.2% (95% confidence interval 22.1-99.7). The area under the curve is 0.94 (95% confidence interval 0.92-0.96). Fagan's Nomogram showed that the positive likelihood ratio is 10.38 (95% confidence interval 0.38-284.76) with an 87% post-test probability, while the negative likelihood ratio is 0.11 (95% confidence interval 0.04-0.27) with a 7% post-test probability. The combined negative predictive value is 0.89 (95% confidence interval 0.81-0.98), and the positive predictive value is 0.90 (95% confidence interval 0.81-0.98).

CONCLUSION

Serum pentraxin-3 could only be used as a confirmation test for acute appendicitis but not exclude it.

Diagnostic performance of serum pentraxin-3 in pediatric acute appendicitis: a prospective diagnostic validation study

INTRODUCTION

Pediatric acute appendicitis (PAA) is a pathology with a high rate of diagnostic error. The search for new diagnostic tools is justified by the high morbidity and healthcare costs associated with diagnostic error.

METHODS

We designed a prospective study to validate serum pentraxin-3 (PTX3) as a diagnostic tool in PAA. Participants were divided into three groups: (1) patients with no underlying pathology (2) patients with non-surgical abdominal pain and (3) patients with a confirmed diagnosis of PAA. For further analyses, patients in group 3 were divided into complicated or uncomplicated PAA. Quantitative variables were expressed as medians and interquartile ranges and categorical variables as percentages. Quantitative variables were compared using the Kruskal-Wallis test and the Mann-Whitney U test. Diagnostic performance was evaluated with ROC curves.

RESULTS

This study included 215 patients divided into group 1 (n = 63), group 2 (n = 53) and group 3 (n = 99). Median serum PTX3 values were 2.54 (1.70-2.95) ng/mL, 3.29 (2.19-7.64) ng/mL and 8.94 (6.16-14.05) in groups 1, 2 and 3, respectively (p = 0.001). Patients with complicated PAA showed significantly higher values than patients with uncomplicated PAA (p = 0.04). The AUC (group 2 vs. 3) was 0.77 (95% CI 0.69-0.85) and the best cut-off point was at 7.28 ng/mL, with a sensitivity of 61.3% and a specificity of 73.1%. The AUC (complicated vs. uncomplicated PAA) was 0.65 (95% CI 0.54-0.77) and the best cut-off point was 12.33 ng/mL, with a sensitivity of 51.72% and a specificity of 72.73%.

CONCLUSIONS

The diagnostic ability of serum PTX3 in PAA is only moderate and therefore it cannot be considered a definitive diagnostic test. The discriminatory ability of PTX3 between complicated and uncomplicated PAA is poor. These findings, which contrast with those reported to date, should be validated with future properly designed prospective studies.

Biomarkers and their Clinical Applications in Pediatrics

Biomarker studies are becoming increasingly interesting for many fields of medicine. The use of biomarkers in medicine is involved in detecting diseases and supporting diagnosis and treatment decisions. New research and new discoveries on the molecular basis of the disease show that there may be a number of promising new biomarkers for use in daily clinical practice. Clinical trials in children lag behind adult research both in quality and quantity. The number of biomarkers validated to optimize pediatric patient management is limited. In the pathogenesis of many diseases, it should not be extrapolated to the pediatric clinical setting, taking into account that biomarkers that are effective in adults are clearly different in children and that ontogeny directly affects disease development and therapeutic response in children. The search for ideal biomarkers or markers that can make an early and definitive diagnosis in neonatal sepsis is still ongoing. The ideal biomarker for pediatric diseases should be costeffective, noninvasive, applicable to pediatric specific diseases, and its results should correspond to age-related physiological changes. Lactate, troponin and B-type natriuretic peptide are valuable biomarkers in the evaluation and management of critically ill children with cardiac disease. Tumor markers in children are biochemical substances used in the clinical treatment of pediatric tumors and to detect the presence of cancer (regression or progression). In this chapter, current and brief information about biomarkers and their clinical applications used in the diagnosis and monitoring of pediatric diseases is presented.;

Postoperative kinetics of pentraxin 3 (PTX3) after congenital heart surgery with cardiopulmonary bypass in pediatric patients

Background

Pentraxins are inflammatory proteins and markers of acute-phase responses. They are divided into short and long subgroups based on the length of the N-terminal region. The most studied short pentraxin is the C-reactive protein (CRP), which is known to be expressed in various inflammatory conditions, including surgical procedures. On the other hand, much less is known about the kinetics of long pentraxin 3 (PTX3) in surgical patients, especially in the pediatric population.

The aim of this prospective study was to determine the early postoperative kinetics of PTX3 in relation to procalcitonin (PCT) and CRP levels in children undergoing congenital heart surgery with cardiopulmonary bypass (CPB).

Methods

A total of 21 children (9 boys and 12 girls, mean age 12 months) were included in the study. Blood samples for determination of CRP, PCT, and PTX3 levels were collected before the surgery and then immediately after its completion (postoperative day 0, POD 0) and subsequently at POD 1, 2, and 3.

Results

Serum PTX3 concentrations increased significantly between POD 0 and POD 1 (mean values were 12.2 and 72.4 ng/ml, respectively, p<0.001), decreased between POD 1 and POD 2 (mean values were 72.4 and 23.6 ng/ml, respectively, p<0.001), and normalized on POD 3 (the mean value was 1.2 ng/ml).

Conclusions

PTX3 concentrations are markedly elevated during the first postoperative day. Under normal circumstances, PTX3 rises and falls quickly, and its second rise in the early postoperative period may be abnormal, however, further studies are necessary.

Utility of Pentraxin-3 as a biomarker for diagnosis of acute appendicitis: a systematic review and meta-analysis

PURPOSE

To systematically summarize all relevant data and to define the current evidence on the utility of Pentraxin-3 (PTX3) as a biomarker for acute appendicitis (AA) in children.

METHODS

This review was conducted in accordance with the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science databases were systematically searched for studies comparing the levels of PTX3 in patients with AA vs healthy controls or non-specific abdominal pain (NSAP). Mean differences were calculated for all outcomes and the inverse variance method was used for weighted mean difference. The methodological quality of the included studies was assessed using the Downs and Black scale.

RESULTS

Five comparative studies were included. Significantly elevated levels of PTX3 in cases with AA vs healthy controls (WMD: 9.56, 95% CI 7.24-11.88, p < 0.00001), and patients with AA vs NSAP (WMD: 8.05, 95% CI 6.81-9.29, p < 0.00001) were demonstrated. Similarly, in separate meta-analyses, the levels of PTX3 were significantly elevated in children with AA vs healthy controls (WMD: 11.18, 95% CI 10.03-12.34, p < 0.00001), and children with AA vs NSAP (WMD: 8.35, 95% CI 6.88-9.82, p < 0.00001).

CONCLUSIONS

PTX3-levels are elevated in AA, but differentiation between perforated and non-perforated appendicitis demands other methods.

Pentraxin 3 expression in lungs and neutrophils of calves

Bacterial lung disease caused by Mannheimia haemolytica inflict significant mortality and morbidity resulting in enormous economic losses to cattle industry. The use of antibiotics is becoming more challenging because of development of anti-microbial resistance. The innate immune system plays a critical role in the initiation of immune response in the lung. Pentraxin 3 (PTX3), a pattern-recognition receptor is produced at sites of inflammation by many cell types, recognizes and binds to many pathogens, activates the complement cascade, and has a role in the clearance of apoptotic and necrotic cells. Because there are very few data on the expression of PTX3 in the lungs, we examined PTX3 expression in lungs of normal and M. haemolytica-infected calves and normal and E. coli lipopolysaccharide-treated cattle neutrophils using light and electron microscopic immunochemistry and Western blots. Immunohistology showed the presence of PTX3 in airway epithelial cells, alveolar septa and macrophages in normal and inflamed lungs of calves and the blots showed a significant increase in the expression of PTX3 in lungs from infected calves. Immuno-gold electron microscopy showed PTX3 in the nuclei, cytoplasm, and vesicular organelles of alveolar macrophages, endothelial cells and pulmonary intravascular macrophages (PIMs). Immunohistochemical staining for PTX3 in peripheral blood neutrophils shows an altered staining pattern in neutrophils stimulated with lipopolysachharide (LPS). However, western blots no significant change in PTX3 amount in LPS-treated neutrophils compared to the controls. These are the first data on the expression of PTX3 in the lungs and the neutrophils of cattle which may add to our understanding of innate immunity in cattle lungs.

Pentraxin-3, Interleukin-6, and Acute Appendicitis: Biomarkers That Need Further Exploration

Acute appendicitis is one of the most common abdominal emergencies that present in the hospital. With acute appendicitis, there is always a possibility of complications of perforation and peritonitis. Even though medicine has advanced substantially in different investigational modalities, appendicitis is confirmed clinically with the aid of a clinical approach (i.e., Alvarado Score), laboratory, and investigational modalities. However, biomarkers such as pentraxin-3 and interleukin-6 have been recently researched to assess the possibility of confirming the diagnosis of acute appendicitis in both adults and the pediatric age group. This article breaks down the previous research on pentraxin-3 and interleukin-6 biomarkers in relation to appendicitis and proposes a new hypothetical way of confirming the diagnosis.