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Watanabe A, Guo M, Schweitzer C, Wiseman SM. Multiple positive imaging tests in diagnosing acute appendicitis: An analysis of more than 27,000 cases. Am J Surg 2024; 231:74-78. [PMID: 38490880 DOI: 10.1016/j.amjsurg.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/28/2024] [Accepted: 02/23/2024] [Indexed: 03/17/2024]
Affiliation(s)
- Akie Watanabe
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Michael Guo
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Christina Schweitzer
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.
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2
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Kim D, Woodham BL, Chen K, Kuganathan V, Edye MB. Rapid MRI Abdomen for Assessment of Clinically Suspected Acute Appendicitis in the General Adult Population: a Systematic Review. J Gastrointest Surg 2023; 27:1473-1485. [PMID: 37081221 PMCID: PMC10366263 DOI: 10.1007/s11605-023-05626-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/27/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. METHODS We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. RESULTS Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. CONCLUSIONS MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.
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Affiliation(s)
- Dongchan Kim
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Benjamin Luke Woodham
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
| | - Kathryn Chen
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Vinushan Kuganathan
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Michael Benjamin Edye
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
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3
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To Scan or Not to Scan: Development of a Clinical Decision Support Tool to Determine if Imaging Would Aid in the Diagnosis of Appendicitis. World J Surg 2021; 45:3056-3064. [PMID: 34370058 DOI: 10.1007/s00268-021-06246-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Appendicitis is one of the most common surgically treated diseases in the world. CT scans are often over-utilized and ordered before a surgeon has evaluated the patient. Our aim was to develop a tool using machine learning (ML) algorithms that would help determine if there would be benefit in obtaining a CT scan prior to surgeon consultation. METHODS Retrospective chart review of 100 randomly selected cases who underwent appendectomy and 100 randomly selected controls was completed. Variables included components of the patient's history, laboratory values, CT readings, and pathology. Pathology was used as the gold standard for appendicitis diagnosis. All variables were then used to build the ML algorithms. Random Forest (RF), Support Vector Machine (SVM), and Bayesian Network Classifiers (BNC) models with and without CT scan results were trained and compared to CT scan results alone and the Alvarado score using area under the Receiver Operator Curve (ROC), sensitivity, and specificity measures as well as calibration indices from 500 bootstrapped samples. RESULTS Among the cases that underwent appendectomy, 88% had pathology-confirmed appendicitis. All the ML algorithms had better sensitivity, specificity, and ROC than the Alvarado score. SVM with and without CT had the best indices and could predict if imaging would aid in appendicitis diagnosis. CONCLUSION This study demonstrated that SVM with and without CT results can be used for selective imaging in the diagnosis of appendicitis. This study serves as the initial step and proof-of-concept to externally validate these results with larger and more diverse patient population.
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4
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El-Gohary Y, Molina M, Chang J, Dodd A, Miller E, Harrell C, Wang F, Zhang H, Davidoff AM, Fernandez-Pineda I, Murphy AJ, Huang EY. The use of computed tomography versus clinical acumen in diagnosing appendicitis in children: A two-institution international study. J Pediatr Surg 2021; 56:1356-1361. [PMID: 33339568 DOI: 10.1016/j.jpedsurg.2020.09.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Appendicitis in children can be diagnosed utilizing clinical and laboratory findings, with the assistance of ultrasound (US) and/or computed tomography (CT). However, repeated exposure to ionizing radiation increases the lifetime risk of cancer. We compared the work-up of suspected appendicitis between a children's hospital in the United States (USA) and one in Spain to identify differences in imaging use and associated outcomes. METHODS A two-institution retrospective review was performed for surgical consultations of suspected appendicitis from 2015-2017. We compared imaging use, the utilization of overnight observation, and diagnostic accuracy rates between the two centers. RESULTS A total of 1,952 children were evaluated. Among the 1,288 in the USA center, 754(58.5%) underwent CT during their evaluation. The most common imaging modality was US only (39.9%), then CT only (39.3%), CT+US (19.3%), and no imaging (i.e. only clinical acumen) (1.6%). In Spain, only 19 (2.9%) of 664 children underwent CT compared to the USA (p < 0.0001). Only clinical acumen was the most common modality employed (48.6%), followed by US only (48.5%), US+CT (2.4%), and CT only (0.5%). In the USA, 16.8% were observed overnight, 2.3% of whom received no imaging. In Spain, 33.4% were observed overnight, 32.4% of whom had no imaging (p < 0.0001). The accuracy rates for diagnosing appendicitis in the USA and Spain centers were 94.7% and 95.1%, respectively. CONCLUSION Use of clinical acumen and/or US have similar clinical outcomes and similar accuracy rates compared to heavy reliance on CT imaging for diagnosing appendicitis, with associated decrease in radiation exposure. The disparate diagnostic approach of the two centers may reflect that physical examination is a dying art in North America. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yousef El-Gohary
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA.
| | - Maria Molina
- Department of Pediatric Surgery, Hospital Universitario Virgen Del Rocio, Sevilla, Spain
| | - Jeremy Chang
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Ashley Dodd
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Emily Miller
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Camden Harrell
- Department of Biostatistics, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Fang Wang
- Department of Biostatistics, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA
| | - Hui Zhang
- Department of Biostatistics, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA; Division of Biostatistics, Department of Biostatistics, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Chicago, IL 60611, USA
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA; Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | | | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA; Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Eunice Y Huang
- Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA..
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5
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Bracken RL, Harringa JB, Markhardt BK, Kim N, Park JK, Kitchin DR, Robbins JB, Ziemlewicz TJ, Birstler J, Ryan MJ, Hoang L, Pickhardt P, Reeder SB, Repplinger MD. Abdominal fellowship-trained versus generalist radiologist accuracy when interpreting MR and CT for the diagnosis of appendicitis. Eur Radiol 2021; 32:533-541. [PMID: 34268596 PMCID: PMC8665009 DOI: 10.1007/s00330-021-08163-7] [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: 12/13/2020] [Revised: 06/12/2021] [Accepted: 06/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To compare the diagnostic accuracy of generalist radiologists working in a community setting against abdominal radiologists working in an academic setting for the interpretation of MR when diagnosing acute appendicitis among emergency department patients. METHODS This observational study examined MR image interpretation (non-contrast MR with diffusion-weighted imaging and intravenous contrast-enhanced MR) from a prospectively enrolled cohort at an academic hospital over 18 months. Eligible patients had an abdominopelvic CT ordered to evaluate for appendicitis and were > 11 years old. The reference standard was a combination of surgery and pathology results, phone follow-up, and chart review. Six radiologists blinded to clinical information, three each from community and academic practices, independently interpreted MR and CT images in random order. We calculated test characteristics for both individual and group (consensus) diagnostic accuracy then performed Chi-square tests to identify any differences between the subgroups. RESULTS Analysis included 198 patients (114 women) with a mean age of 31.6 years and an appendicitis prevalence of 32.3%. For generalist radiologists, the sensitivity and specificity (95% confidence interval) were 93.8% (84.6-98.0%) and 88.8% (82.2-93.2%) for MR and 96.9% (88.7-99.8%) and 91.8% (85.8-95.5%) for CT. For fellowship-trained radiologists, the sensitivity and specificity were 96.9% (88.2-99.5%) and 89.6% (82.8-94%) for MR and 98.4% (90.5-99.9%) and 93.3% (87.3-96.7%) for CT. No statistically significant differences were detected between radiologist groups (p = 1.0, p = 0.53, respectively) or when comparing MR to CT (p = 0.21, p = 0.17, respectively). CONCLUSIONS MR is a reliable, radiation-free imaging alternative to CT for the evaluation of appendicitis in community-based generalist radiology practices. KEY POINTS • There was no significant difference in MR image interpretation accuracy between generalist and abdominal fellowship-trained radiologists when evaluating sensitivity (p = 1.0) and specificity (p = 0.53). • There was no significant difference in accuracy comparing MR to CT imaging for diagnosing appendicitis for either sensitivity (p = 0.21) or specificity (p = 0.17). • With experience, generalist radiologists enhanced their MR interpretation accuracy as demonstrated by improved interpretation sensitivity (OR 2.89 CI 1.44-5.77, p = 0.003) and decreased mean interpretation time (5 to 3.89 min).
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Affiliation(s)
- Rebecca L Bracken
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - B Keegan Markhardt
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Department of Radiology, UnityPoint Health Meriter,
Madison, WI, USA
| | - Newrhee Kim
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Department of Radiology, UnityPoint Health Meriter,
Madison, WI, USA
| | - John K Park
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Department of Radiology, UnityPoint Health Meriter,
Madison, WI, USA
| | - Douglas R Kitchin
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Madison Radiologists, Madison, WI, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
| | | | - Jen Birstler
- Department of Biostatistics & Medical Informatics,
University of Wisconsin-Madison, Madison, WI, USA
| | - Michael J Ryan
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - Perry Pickhardt
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA.,Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA.,Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
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Greer D, Bennett P, Wagstaff B, Croaker D. Lymphopaenia in the diagnosis of paediatric appendicitis: a false sense of security? ANZ J Surg 2019; 89:1122-1125. [PMID: 31452301 DOI: 10.1111/ans.15394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Appendicitis is a common indication for emergent surgery in children; however, it is a small proportion of presentations with abdominal pain. As viral illness is a common differential diagnosis, lymphopaenia is used by some as a predictor against appendicitis. Furthermore, neutrophil-lymphocyte ratio (NLR) has been found to predict appendicitis. We aimed to verify if lymphopaenia predicted against appendicitis in children. METHODS Retrospective review was conducted for all patients aged 15 years and under presenting with abdominal pain to our institution in 2017, and data including age, white cell count, neutrophil and lymphocyte count, NLR, C-reactive protein and diagnosis of appendicitis were recorded. Statistical analysis was performed using Stata©. Receiver operating characteristic curves for various tests were formed and areas under curve (AUC) compared using regression, P < 0.05 was considered significant. RESULTS A total of 1263 patients were presented, of whom 546 had their blood performed and were included, 86 had appendicitis and 460 did not. Neutrophilia was the best predictor for appendicitis (AUC = 0.86), significantly higher than NLR (0.81), P < 0.05. Lymphopaenia was a poor negative predictor of appendicitis (AUC = 0.46), and while isolated lymphopaenia was more predictive (AUC = 0.23) this was inferior to the positive prediction of neutrophilia, P < 0.05. CONCLUSION The value of isolated lymphopaenia to predict against appendicitis is largely accounted for inherently normal neutrophils, independently lymphopaenia has little value. NLR, while predictive, is a weaker predictor than neutrophilia.
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Affiliation(s)
- Douglas Greer
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Peter Bennett
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Benjamin Wagstaff
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - David Croaker
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
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7
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Absolute neutrophil count as a diagnostic guide for the use of MRI in the workup of suspected appendicitis in children. J Pediatr Surg 2019; 54:1359-1364. [PMID: 30001891 DOI: 10.1016/j.jpedsurg.2018.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/24/2018] [Accepted: 06/13/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE To assess the additive value of magnetic resonance imaging (MRI) in the setting of an equivocal US (Eq-US) with or without an elevated absolute neutrophil count (ANC). METHODS Single-institution, retrospective review of children ages 5-18 years who presented to the ER with suspected appendicitis from 9/2015 to 8/2016. US, ANC, and MRI results were reviewed. Imaging was identified as positive/suspicious, normal, or equivocal and ANC <8000/mm3 was defined as normal. RESULTS 738 patients with a median age of 11 years (IQR 8-14) met inclusion criteria. US was equivocal in 61.4%. Among 304 (67.1%) patients with an Eq-US and normal ANC, only 5 (1.6%) had acute appendicitis. In contrast, 28 of 149 patients (18.8%) with Eq-US and elevated ANC had appendicitis. MRI was performed in 125 patients with Eq-US and was positive/suspicious in 2.9% (2/69) with normal ANC and 25.0% (14/56) with elevated ANC. MRI had 94.7% sensitivity and 100% specificity for acute appendicitis in patients with an Eq-US. CONCLUSIONS MRI has high sensitivity and specificity for diagnosing acute appendicitis in children. Patients with Eq-US plus a normal ANC have a very low likelihood of appendicitis and do not typically require further imaging. MRI may have utility for children with Eq-US and elevated ANC. LEVEL OF EVIDENCE Level III.
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8
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Agathis AZ, Miller M, Divino CM. National Trends in Diagnostic Imaging for Appendicitis: A Cross-Sectional Analysis Using NSQIP. Am Surg 2019. [DOI: 10.1177/000313481908500627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Prior studies elucidate a high predictive value of imaging to diagnose appendicitis in small, regional cohorts. This cross-sectional study uniquely analyzes diagnostic imaging in a national appendectomy population. Using the 2016 ACS NSQIP database, positive predictive values (PPVs) for CT, ultrasound (US), and MRI were evaluated using chi-squared tests. Univariate and multivariate analyses considered patient-specific factors. Imaging was performed in 94.63 per cent of 11,841 appendectomy cases; most frequently via CT (78.69%), then combination CT and US (7.52%), US (7.15%), and MRI (0.30%). CT PPV was higher in overweight (98.70%) versus underweight patients (94.85%) ( P = 0.01). Gender and age did not impact CT PPV. Imaging from a referral site did not change CTor US PPV. Our study describes imaging frequencies and confirms high PPV. We found imaging equally predictive in women of childbearing age and elderly individuals compared with the general population. Furthermore, repeat scanning is unnecessary with prior positive imaging at outside sites.
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Affiliation(s)
- Alexandra Z. Agathis
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael Miller
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Celia M. Divino
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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9
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Harringa JB, Bracken RL, Davis JC, Mao L, Kitchin DR, Robbins JB, Ziemlewicz TJ, Pickhardt PJ, Reeder SB, Repplinger MD. Prospective evaluation of MRI compared with CT for the etiology of abdominal pain in emergency department patients with concern for appendicitis. J Magn Reson Imaging 2019; 50:1651-1658. [PMID: 30892788 DOI: 10.1002/jmri.26728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Computed tomography (CT) is commonly used in the Emergency Department (ED) to evaluate patients with abdominal pain, but exposes them to ionizing radiation, a possible carcinogen. MRI does not utilize ionizing radiation and may be an alternative. PURPOSE To compare the sensitivity of MRI and CT for acute abdominopelvic ED diagnoses. STUDY TYPE Prospective, observational cohort. POPULATION ED patients ≥12 years old and undergoing CT for possible appendicitis. FIELD STRENGTH/SEQUENCE 1.5 T MRI, including T1 -weighted, T2 -weighted, and diffusion-weighted imaging sequences. ASSESSMENT Three radiologists independently interpreted each MRI and CT image set separately and blindly, using a standard case report form. Assessments included likelihood of appendicitis, presence of an alternative diagnosis, and likelihood that the alternative diagnosis was causing the patient's symptoms. An expert panel utilized chart review and follow-up phone interviews to determine all final diagnoses. Times to complete image acquisition and image interpretation were also calculated. STATISTICAL TESTS Sensitivity was calculated for each radiologist and by consensus (≥2 radiologists in agreement) and are reported as point estimates with 95% confidence intervals. Two-sided hypothesis tests comparing the sensitivities of the three image types were conducted using Pearson's chi-squared test with the traditional significance level of P = 0.05. RESULTS There were 15 different acute diagnoses identified on the CT/MR images of 113 patients. Using individual radiologist interpretations, the sensitivities of noncontrast-enhanced MRI (NCE-MR), contrast-enhanced MR (CE-MR), and CT for any acute diagnosis were 77.0% (72.6-81.4%), 84.2% (80.4-88.0%), and 88.7% (85.5-92.1%). Sensitivity of consensus reads was 82.0% (74.9-88.9%), 87.1% (81.0-93.2%), 92.2% (87.3-97.1%), respectively. There was no difference in sensitivities between CE-MR and CT by individual (P = 0.096) or consensus interpretations (P = 0.281), although NCE-MR was inferior to CT in both modes of analysis (P < 0.001, P = 0.031, respectively). DATA CONCLUSION The sensitivity of CE-MR was similar to CT when diagnosing acute, nontraumatic abdominopelvic pathology in our cohort. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1651-1658.
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Affiliation(s)
- John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Rebecca L Bracken
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - John C Davis
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Lu Mao
- Department of Biostatistics and Medical Informatics, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Douglas R Kitchin
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Timothy J Ziemlewicz
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
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10
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Martinez-Rios C, McKinney JR, Al-Aswad N, K Shergill A, Louffat AF, Sung L, Thomas KE, Schuh S, Tomlinson G, Moineddin R, Doria AS. Parental preferences on diagnostic imaging tests for paediatric appendicitis. Paediatr Child Health 2018; 24:234-239. [PMID: 31239812 DOI: 10.1093/pch/pxy154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/27/2018] [Indexed: 02/06/2023] Open
Abstract
Objectives To determine parental preferences for diagnostic imaging tests (DITs) for paediatric appendicitis, to rank the attributes impacting the DIT selection and to identify DIT attributes that would cause parents to switch their DIT. Methods Parents of children who had an abdominal ultrasound (US) for right lower quadrant pain were interviewed. Two DITs were compared at a time, parents were asked to indicate their preferred test and to rank its attributes according to the impact each attribute had on their selection. The strength of their preference for the chosen DIT was measured by systematically adjusting attributes of the chosen DIT until the parent changed their choice. Results Fifty parents were interviewed. For US versus CT, more parents preferred US (68%, P=0.02) with higher importance ranks for cancer risk (P<0.0001), test accuracy (P=0.04), pain during test (P=0.3), and scan length (P<0.0001); and lower ranks for sedation (P=0.02), intravenous (IV) (P<0.02), and oral contrast (P=0.06). For US versus MRI, parents preferred MRI (78%, P<0.0001) with higher importance ranks for accuracy (P=0.2), pain during test (P=0.06), and scan length (P=0.06); and lower for noise (P<0.0001), claustrophobia (P<0.0001), use of IV contrast (P=0.06), and sedation (P=0.2). Conclusion US and MRI were the DIT preferred by parents for the investigation of acute paediatric appendicitis.
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Affiliation(s)
- Claudia Martinez-Rios
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Imaging, CHEO, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer R McKinney
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Graduate Entry Medical School, The University of Limerick, Limerick, Ireland
| | - Nadine Al-Aswad
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arvind K Shergill
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ada F Louffat
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lillian Sung
- Department of Pediatrics, Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Karen E Thomas
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Repplinger MD, Pickhardt PJ, Robbins JB, Kitchin DR, Ziemlewicz TJ, Hetzel SJ, Golden SK, Harringa JB, Reeder SB. Prospective Comparison of the Diagnostic Accuracy of MR Imaging versus CT for Acute Appendicitis. Radiology 2018; 288:467-475. [PMID: 29688158 DOI: 10.1148/radiol.2018171838] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose To compare the accuracy of magnetic resonance (MR) imaging with that of computed tomography (CT) for the diagnosis of acute appendicitis in emergency department (ED) patients. Materials and Methods This was an institutional review board-approved, prospective, observational study of ED patients at an academic medical center (February 2012 to August 2014). Eligible patients were nonpregnant and 12- year-old or older patients in whom a CT study had been ordered for evaluation for appendicitis. After informed consent was obtained, CT and MR imaging (with non-contrast material-enhanced, diffusion-weighted, and intravenous contrast-enhanced sequences) were performed in tandem, and the images were subsequently retrospectively interpreted in random order by three abdominal radiologists who were blinded to the patients' clinical outcomes. Likelihood of appendicitis was rated on a five-point scale for both CT and MR imaging. A composite reference standard of surgical and histopathologic results and clinical follow-up was used, arbitrated by an expert panel of three investigators. Test characteristics were calculated and reported as point estimates with 95% confidence intervals (CIs). Results Analysis included images of 198 patients (114 women [58%]; mean age, 31.6 years ± 14.2 [range, 12-81 years]; prevalence of appendicitis, 32.3%). The sensitivity and specificity were 96.9% (95% CI: 88.2%, 99.5%) and 81.3% (95% CI: 73.5%, 87.3%) for MR imaging and 98.4% (95% CI: 90.5%, 99.9%) and 89.6% (95% CI: 82.8%, 94.0%) for CT, respectively, when a cutoff point of 3 or higher was used. The positive and negative likelihood ratios were 5.2 (95% CI: 3.7, 7.7) and 0.04 (95% CI: 0, 0.11) for MR imaging and 9.4 (95% CI: 5.9, 16.4) and 0.02 (95% CI: 0.00, 0.06) for CT, respectively. Receiver operating characteristic curve analysis demonstrated that the optimal cutoff point to maximize accuracy was 4 or higher, at which point there was no difference between MR imaging and CT. Conclusion The diagnostic accuracy of MR imaging was similar to that of CT for the diagnosis of acute appendicitis.
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Affiliation(s)
- Michael D Repplinger
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Perry J Pickhardt
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Jessica B Robbins
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Douglas R Kitchin
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Tim J Ziemlewicz
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Scott J Hetzel
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Sean K Golden
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - John B Harringa
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Scott B Reeder
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
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Kim JR, Suh CH, Yoon HM, Jung AY, Lee JS, Kim JH, Lee JY, Cho YA. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: A systematic review and meta-analysis. J Magn Reson Imaging 2017; 47:767-778. [PMID: 28815859 DOI: 10.1002/jmri.25825] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/10/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To evaluate in pediatric patients the diagnostic performance of magnetic resonance imaging (MRI) for suspected appendicitis and its negative appendectomy rate. MATERIALS AND METHODS The study involved diagnostic accuracy studies that used MRI for pediatric patients with suspected appendicitis. Various field strengths and sequences were used in each included study. The diagnostic accuracy of MRI in pediatric patients with suspected appendicitis and negative appendectomy rate were assessed. A search of MEDLINE and EMBASE databases was performed until January 10, 2017. Two reviewers assessed the methodological quality of the articles using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Pooled sensitivity and specificity for appendicitis diagnosis were calculated using hierarchical logistic regression modeling. Meta-regression was performed to explore factors affecting study heterogeneity. The pooled negative appendectomy rate was analyzed. RESULTS Thirteen original articles with 1946 patients were included. The summary sensitivity and specificity were 97% (95% confidence interval [CI], 95-98%) and 97% (95% CI, 93-98%), respectively; the area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.98 (95% CI, 0.97-0.99). In meta-regression, use of diffusion-weighted imaging (P < 0.01) and age (P < 0.01) affected heterogeneity, but there was no difference according to intravenous contrast agent use (P = 0.95). The pooled negative appendectomy rate of MRI was 4.5% (95% CI, 1.9-7.1%). CONCLUSION MRI shows excellent diagnostic performance for appendicitis in pediatric patients regardless of the use of intravenous contrast media. Therefore, nonenhanced-only MRI protocols might be appropriate for pediatric patients with suspected appendicitis. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:767-778.
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Affiliation(s)
- Jeong Rye Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology, Namwon Medical Center, Jeollabuk-do, Republic of Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Kutanzi KR, Lumen A, Koturbash I, Miousse IR. Pediatric Exposures to Ionizing Radiation: Carcinogenic Considerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13111057. [PMID: 27801855 PMCID: PMC5129267 DOI: 10.3390/ijerph13111057] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 12/13/2022]
Abstract
Children are at a greater risk than adults of developing cancer after being exposed to ionizing radiation. Because of their developing bodies and long life expectancy post-exposure, children require specific attention in the aftermath of nuclear accidents and when radiation is used for diagnosis or treatment purposes. In this review, we discuss the carcinogenic potential of pediatric exposures to ionizing radiation from accidental, diagnostic, and therapeutic modalities. Particular emphasis is given to leukemia and thyroid cancers as consequences of accidental exposures. We further discuss the evidence of cancers that arise as a result of radiotherapy and conclude the review with a summary on the available literature on the links between computer tomography (CT) and carcinogenesis. Appropriate actions taken to mitigate or minimize the negative health effects of pediatric exposures to ionizing radiation and future considerations are discussed.
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Affiliation(s)
- Kristy R Kutanzi
- Department of Environmental and Occupational Health, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Annie Lumen
- Division of Biochemical Toxicology, National Center for Toxicological Research, Jefferson, AR 72079, USA.
| | - Igor Koturbash
- Department of Environmental and Occupational Health, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Isabelle R Miousse
- Department of Environmental and Occupational Health, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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