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Şenaylı A. Diagnosing granulomatous disease during appendectomy. Clin Case Rep 2021; 9:e05074. [PMID: 34815873 PMCID: PMC8593883 DOI: 10.1002/ccr3.5074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/12/2021] [Accepted: 10/26/2021] [Indexed: 12/29/2022] Open
Abstract
Difficulties during surgery are uncommon situations in appendectomy. For granulomatous appendicitis, literature is insufficient about surgical findings. The procedure of a 17-year-old male patient was a struggle due to adhesions. I thought a surgeon could expect granulomatous diseases by evaluating the macroscopic appearance of the appendix during surgical procedure.
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Affiliation(s)
- Atilla Şenaylı
- Faculty of MedicinePediatric Surgery DepartmentT.C. Yozgat Bozok UniversityYozgatTurkey
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2
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Harris J, Fleming CA, Stassen PN, Mullen D, Mohan H, Foley J, Heeney A, Nugent E, Schmidt K, Mealy K. A comparison of intra-operative diagnosis to histopathological diagnosis of acute appendicitis in paediatric and adult cohorts: an analysis of over 1000 patients. Ir J Med Sci 2021; 191:1809-1813. [PMID: 34515986 PMCID: PMC9308595 DOI: 10.1007/s11845-021-02770-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/28/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Appendicitis is a common general surgical emergency. The role of removing a normal appendix is debated. However, this relies on accurate intra-operative diagnosis of a normal appendix by the operating surgeon. This study aimed to compare surgeon's intra-operative assessment to final histological result acute appendicitis in paediatric and adult patients. METHODS All patients who underwent appendicectomy over a 14-year period in a general surgical department were identified using the prospective Lothian Surgical Audit system and pathology reports retrieved to identify final histological diagnosis. Open appendicectomy was selected to examine, as the routine practise at our institution is to remove a normal appendix at open appendicectomy. RESULTS A total of 1035 open appendicectomies were performed for clinically suspected appendicitis. Sensitivity of intra-operative diagnosis of appendicitis with operating surgeon was high at 95.13% with no difference between trainee and consultant surgeon or between adult and paediatric cases. Specificity of intra-operative diagnosis was lower in the paediatric group (32.58%) than in the adult group (40.58%). Women had a higher rate of negative appendicectomy than men. CONCLUSION The results of this study highlight some discordance between histological evidence of acute appendicitis and intra-operative impression. Therefore other clinical variables and not just macroscopic appearance alone should be used when deciding to perform appendicectomy.
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Affiliation(s)
- Johnathon Harris
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland.
| | | | - Paul N Stassen
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Daniel Mullen
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Helen Mohan
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - James Foley
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Anna Heeney
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Emmeline Nugent
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Karl Schmidt
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Ken Mealy
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
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3
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Bolmers MDM, de Jonge J, van Rossem CC, van Geloven AAW, Bemelman WA. Discrepancies between Intraoperative and Histological Evaluation of the Appendix in Acute Appendicitis. J Gastrointest Surg 2020; 24:2088-2095. [PMID: 31410818 DOI: 10.1007/s11605-019-04345-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/24/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE To identify discrepancies between intraoperative and histological evaluations of the appendix in acute appendicitis and to evaluate the effect on surgical outcome. METHODS Data was used from our previous multicentre, prospective, cohort study of patients with suspected acute appendicitis. Appendices were scored during intraoperative and histological evaluation as uncomplicated or complicated appendicitis. Primary outcome was percentage of concordance between intraoperative and histological evaluation. Secondary outcomes were (infectious) postoperative complications, length of hospital stay, hospital re-admission and re-intervention rate, all within 30 days of surgery. RESULTS A total of 1850 patients were included. In 65.7% (1215/1850) of the appendices, the intraoperative evaluation was uncomplicated and in 34.3% (635/1850), complicated appendicitis. Patients with uncomplicated appendicitis had a postoperative course with significantly less postoperative complications (7.2% vs 24.3%), a shorter length of hospital stay (2 vs 5 days) and a lower re-admission (4.2% vs 9.6%) and re-intervention rate (1.1% vs 4.3%) than intraoperative complicated appendicitis (p < 0.001). In 93.5% (1136/1215) of the intraoperative uncomplicated patients and in 46.6% (296/635) of the intraoperative complicated patients, there was an agreement with pathology (Kappa 0.45). In 23.9% (81/339) of patients with intraoperative complicated and histological uncomplicated appendicitis, a postoperative complication was observed, which was similar to the postoperative complication rate of complicated appendicitis both on intraoperative and histological evaluation (24.7% (73/296)). CONCLUSIONS There is a moderate agreement between a surgeon and pathologist in diagnosing patients with complicated appendicitis. However, the intraoperative diagnosis of complicated appendicitis was significantly associated with postoperative complications. Routine histological evaluation should be preserved for excluding malignancies in suspect appendices.
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Affiliation(s)
- Matthijs D M Bolmers
- Department of Surgery, Tergooi Hospital Hilversum, 10016, 1213 XZ, Hilversum, The Netherlands
| | - Joske de Jonge
- Department of Surgery, Tergooi Hospital Hilversum, 10016, 1213 XZ, Hilversum, The Netherlands.
| | - Charles C van Rossem
- Department of Surgery, Maasstad Hospital Rotterdam, 9100, 3007 AC, Rotterdam, The Netherlands
| | - Anna A W van Geloven
- Department of Surgery, Tergooi Hospital Hilversum, 10016, 1213 XZ, Hilversum, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 22660, 1105 AZ, Amsterdam, The Netherlands
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Mackay TG, Dissanayake B, Yuide PJ, Burstow MJ, Gundara JS, Chua TC. Cohort study of 1241 patients to identify predictors of negative appendicectomy. ANZ J Surg 2020; 90:1984-1990. [PMID: 32808480 DOI: 10.1111/ans.16203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acute Appendicitis is the most common surgical presentation within Australia. Despite the increasing use of radiological investigations to aid clinical diagnosis, many appendectomies result in a histologically normal appendix. This study examines the histological negative appendicectomy rate (NAR) in a metropolitan hospital and determine factors associated with a negative appendicectomy (NA). METHODS Patients who underwent emergency appendicectomy for suspected acute appendicitis at Logan Hospital, Australia, between February 2016 and March 2019 inclusive were included. Clinicopathologic and imaging variables were analysed for associations with NA. RESULTS A total of 1241 patients underwent emergency appendicectomy of which 121 patients (9.8%) had a NA. The NAR for clinical diagnosis alone (no imaging) was 9.9%, 14.5% for ultrasonography alone and computed tomography scan alone was 4.9%. Univariate analysis revealed age <27 years (P < 0.001), absence of hypertension (P = 0.008), symptoms >48 hours (P < 0.001), absence of leucocytosis (P < 0.001), undergoing ultrasonography only (P < 0.001), undergoing computed tomography scan only (P < 0.001), macroscopically normal appendix (P < 0.001) and time to operation >24 hours (P < 0.001) were associated with NA. Multivariate analysis identified symptoms >48 h at presentation (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.20-3.24; P = 0.007), absence of leucocytosis (OR 2.41, 95% CI 1.52-3.81; P < 0.001) and macroscopically normal appendix (OR 5.70, 95% CI 3.49-9.33; P < 0.001) to be associated with a NA. CONCLUSION The NAR reported is lowest in an Australian institution. The identified predictors of NA will be useful in identifying patients who would truly benefit from an appendicectomy versus those would have a higher rate of NA who may be suitable to be treated non-operatively to be spared the unnecessary morbidity of surgery.
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Affiliation(s)
- Thomas G Mackay
- Division of Surgery, Logan Hospital, Metro South Health, Logan, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Bhanuka Dissanayake
- Division of Surgery, Logan Hospital, Metro South Health, Logan, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Peter J Yuide
- Division of Surgery, Logan Hospital, Metro South Health, Logan, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Matthew J Burstow
- Division of Surgery, Logan Hospital, Metro South Health, Logan, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Justin S Gundara
- Division of Surgery, Logan Hospital, Metro South Health, Logan, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Terence C Chua
- Division of Surgery, Logan Hospital, Metro South Health, Logan, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Rodríguez E, Valero J, Jaramillo L, Vallejo-Ortega MT, Lagos L. Evaluation of concordance among surgeons and pathologists regarding the diagnosis and classification of acute appendicitis in children. J Pediatr Surg 2020; 55:1503-1506. [PMID: 31718870 DOI: 10.1016/j.jpedsurg.2019.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/27/2019] [Accepted: 09/25/2019] [Indexed: 11/17/2022]
Abstract
UNLABELLED Acute appendicitis is the most frequent urgent abdominal surgical pathology in children. Therapeutic decisions in patients who have undergone an appendectomy are made based on the macroscopic findings at the moment of surgery. There is high variability between surgical and histopathological findings. METHOD Concordance among surgeons and pathologists regarding the diagnosis and classification of acute appendicitis was assessed in children who have undergone an appendectomy. Surgical site infection (SSI) incidence was measured for both the surgical and pathological classification. RESULTS The statistical analysis included 1092 children. The pathologists confirmed the presence of appendicitis in 90.4% of the patients. Concordance in the diagnosis of appendicitis among surgeons and pathologists was weak (kappa 0.57), while concordance in the classification of perforated or non-perforated appendicitis was moderate (kappa 0.7). There were no significant differences in these findings determined by the surgeons' experience or the open or laparoscopic approach. In the discordant group of 70 patients in which the surgeon classified the appendicitis as non-perforated but the pathologist classified as perforated, just one patient developed an intra-abdominal abscess. CONCLUSIONS The classification of appendicitis as perforated or non-perforated shows moderate concordance between the surgical and histopathological diagnosis. This concordance is not determined by the surgeons' experience or the surgical approach. TYPE OF STUDY Diagnostic Test LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Eliana Rodríguez
- Resident of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Universidad Nacional de Colombia, Colombia.
| | - Juan Valero
- Pediatric Surgeon, Fundación Hospital Pediátrico la Misericordia. Assistant Professor, Department of Surgery, Faculty of Medicine, Universidad Nacional de Colombia, Colombia
| | - Lina Jaramillo
- Pathologist, Fundación Hospital Pediátrico la Misericordia. Tenur Proffessor, Department of Pathology, Faculty of Medicine, Universidad Nacional de Colombia, Colombia
| | | | - Luisa Lagos
- Resident of Pediatrics, Department of Pediatrics, Faculty of Medicine, Universidad Nacional de Colombia, Colombia
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Labricciosa FM, Sartelli M, Barbadoro P, Abbo LM, Ansaloni L, Coccolini F, Catena F. Epidemiology and Risk Factors for Superficial Surgical Site Infections after Appendectomy for Acute Appendicitis: A Secondary Data Analysis. Surg Infect (Larchmt) 2020; 22:227-233. [PMID: 33202156 DOI: 10.1089/sur.2020.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The identification of risk factors for superficial surgical site infections (SSSIs) associated with appendectomy is paramount in the management of patients with acute appendicitis (AA). Methods: This study was a secondary data analysis from a prospective multi-center observational study. It included all consecutive hospitalized patients with AA who underwent appendectomy and were monitored for complications at 30 days after the intervention. A case-control approach was used to evaluate risk factors associated with the occurrence of SSSI. Results: Among 2,667 patients, 156 (5.8%) developed an SSSI. The series included 1,449 males (54.3%) and 1,218 females with a median age of 29 years (interquartile range [IQR] 20-45 years). Antimicrobial therapy within the previous 30 days was reported by 170 patients (6.4%), and a C-reactive protein concentration (CRP) >50 mg/L was observed in 609 (22.8%). A total of 960 patients (36.0%) underwent open surgery, 1,699 (63.7%) laparoscopic surgery, and 8 (0.3%) another surgical intervention. In 2,575 patients (95.6%), a pathological appendix was detected during the operation. In 776 patients (29.1%), an intra-operative abdominal drain (IAD) was placed; 125 patients (4.7%) were admitted to the intensive care unit. The median hospital length of stay was 3 days (IQR 2-5 days). The overall mortality rate was 0.11%. Multinomial logistic regression analysis of risk factors demonstrated that statistically significant risk factors independently associated with the occurrence of SSSIs were antimicrobial therapy within the previous 30 days, CRP >50 mg/L, open surgical procedures, presence of IAD, and intra-operative findings of complex appendicitis. Conclusions: Knowledge of five easily recognizable variables, assessable at hospital admission or as soon as the surgical intervention is concluded, might identify patients with a greater risk of developing an SSSI.
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Affiliation(s)
| | | | - Pamela Barbadoro
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lilian M Abbo
- Infectious Disease University, Miami Miller School of Medicine and Jackson Health System, Miami, Florida, USA
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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Gelpke K, Hamminga JTH, van Bastelaar JJ, de Vos B, Bodegom ME, Heineman E, Hofker HS, El Moumni M, Haveman JW. Reducing the negative appendectomy rate with the laparoscopic appendicitis score; a multicenter prospective cohort and validation study. Int J Surg 2020; 79:257-264. [PMID: 32387211 DOI: 10.1016/j.ijsu.2020.04.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/05/2020] [Accepted: 04/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Approximately nine percent of all acute appendectomies are unintentionally performed on a normal appendix. Failure of treatment (negative appendectomy or missed appendicitis) is associated with higher morbidity and mortality when compared to appendectomy for uncomplicated appendicitis. The Laparoscopic APPendicitis (LAPP) score was developed in order to systematically evaluate the appendix for the presence of inflammation. This study aims to determine whether the LAPP score reduces the negative appendectomy rate without missing appendicitis. METHODS From September 2013 through May 2016, 322 adult patients presenting with a clinical suspicion of acute appendicitis and an indication for diagnostic laparoscopy were included and analyzed in this multicenter prospective validation study. Depending on the LAPP score, the appendix was either removed (n = 300) or left in situ (n = 22). These patients were compared to a historical control group of 584 patients treated at the same hospitals. The appendix was examined by a pathologist and the negative appendectomy rate was calculated. RESULTS The negative appendectomy rate was significantly lower when the LAPP score was used (4,7% vs. 8,4%; P = 0,034). None of the patients with a negative LAPP score, in which the appendix remained in situ, developed acute appendicitis within three months. There were no significant differences in operation time, complications, or readmissions. Using the LAPP score was associated with significantly higher rates of preoperative radiological imaging (98% vs. 70%; P < 0,001). After adjusting for covariables, including radiological imaging, use of the LAPP score led to fewer treatment failures when compared to not using the LAPP score (OR: 0,48, 95% C.I. 0,251 to 0,914; P = 0,025). CONCLUSION The LAPP score is a safe and simple tool to reduce the negative appendectomy rate during laparoscopic surgery without missing cases of acute appendicitis.
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Affiliation(s)
- Koen Gelpke
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jenneke T H Hamminga
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - James J van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Sittard-Geleen & Heerlen, the Netherlands
| | - Bart de Vos
- Department of Surgery, Wilhelmina Hospital, Assen, the Netherlands
| | - Maarten E Bodegom
- Department of Surgery, Bethesda Hospital, Hoogeveen, the Netherlands
| | - Erik Heineman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H Sijbrand Hofker
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mostafa El Moumni
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Can Surgeons Identify Appendicitis Macroscopically? Results From a Multicentre Prospective Study. Surg Laparosc Endosc Percutan Tech 2019; 29:344-348. [PMID: 31166292 DOI: 10.1097/sle.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The primary outcome was to investigate the accuracy of intraoperative macroscopic diagnosis by the operating surgeon with the results of the subsequent histopathologic examination. The secondary outcome was to identify the predictors of discrepancies between these 2 groups. MATERIALS AND METHODS A multicentre, prospective, observational study was conducted over a period of 2 months with a 30-day follow-up period. Patients who underwent surgery with the intention of appendicectomy were recruited in the study. RESULTS A total of 1169 patients were recruited. False negatives (FNs) were defined as a normal macroscopic diagnosis but histopathologically appendicitis, whereas false positive otherwise. Overall, FN rates were 22.4%, whereas false positive rates were 8.2%. The seniority of the operating surgeons did not affect the ability to accurately diagnose appendicitis macroscopically (P=0.069). However, consultant surgeons had the lowest FN rate of 15.6%. Females and preoperative ultrasound scan increased odds of FN, whereas preoperative computed tomography decreased the odds of FN appendicectomy. CONCLUSION Macroscopic identification intraoperatively is inaccurate with a FN rate of 22%.
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Imran JB, Madni TD, Minshall CT, Mokdad AA, Subramanian M, Clark AT, Phelan HA, Cripps MW. Predictors of a histopathologic diagnosis of complicated appendicitis. J Surg Res 2017. [PMID: 28624044 DOI: 10.1016/j.jss.2017.02.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite its utilization, the intraoperative (IO) assessment of complicated appendicitis (CA) is subjective. The histopathologic (HP) diagnosis should be the gold standard in identifying patients with CA; however, it is not immediately available to guide postoperative management. The objective of this study was to identify predictors of an HP diagnosis of CA. MATERIALS AND METHODS A retrospective review of all patients who underwent appendectomy at our institution from 2011-2013 was conducted. CA was defined by perforation or abscess on pathology report. Predictors of an HP diagnosis of CA were evaluated using a multivariable regression model. RESULTS A total of 239 of 1066 patients had CA based on IO assessment, whereas 143 of 239 patients (60%) had CA on HP and IO assessment. On multivariable analysis, an IO diagnosis of CA was associated with an HP diagnosis of CA (odds ratio [OR]: 10.92; 95% confidence interval [CI]: 7.19-16.58). Other risk factors were age (OR: 1.28; 95% CI: 1.09-1.49), number of days of pain (OR: 1.20; 95% CI: 1.07-1.37), increased heart rate (OR: 1.14; 95% CI: 1.02-1.26), appendix size (OR: 1.09; 95% CI: 1.03-1.16), and an appendicolith (OR: 1.74; 95% CI: 1.12-2.71) on preoperative CT imaging. CONCLUSIONS In addition to age, increased heart rate, pain duration, appendix size and appendicolith, the IO assessment is also associated with an HP diagnosis of CA; however, 40% of patients were incorrectly classified. Using these predictors with improved IO grading may achieve more accurate diagnosis of CA.
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Affiliation(s)
- Jonathan B Imran
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tarik D Madni
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christian T Minshall
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ali A Mokdad
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Madhu Subramanian
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Audra T Clark
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Herb A Phelan
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael W Cripps
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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