Diagnosis of acute appendicitis in children using a clinical practice guideline

Exploring the role of an artificial intelligence chatbot on appendicitis management: an experimental study on ChatGPT

BACKGROUND

Appendicitis is a common surgical condition that requires urgent medical attention. Recent advancements in artificial intelligence and large language processing, such as ChatGPT, have demonstrated potential in supporting healthcare management and scientific research. This study aims to evaluate the accuracy and comprehensiveness of ChatGPT's knowledge on appendicitis management.

METHODS

Six questions related to appendicitis management were created by experienced RACS qualified general surgeons to assess ChatGPT's ability to provide accurate information. The criteria of ChatGPT answers' accuracy were compared with current healthcare guidelines for appendicitis and subjective evaluation by two RACS qualified General Surgeons. Additionally, ChatGPT was then asked to provide five high level evidence references to support its responses.

RESULTS

ChatGPT provided clinically relevant information on appendicitis management, however, was inconsistent in doing so and often provided superficial information. Further to this, ChatGPT encountered difficulties in generating relevant references, with some being either non-existent or incorrect.

CONCLUSION

ChatGPT has the potential to provide timely and comprehensible medical information on appendicitis management to laypersons. However, its issue of inaccuracy in information and production of non-existent or erroneous references presents a challenge for researchers and clinicians who may inadvertently employ such information in their research or healthcare. Therefore, clinicians should exercise caution when using ChatGPT for these purposes.

Pediatric Appendicitis Score or Ultrasonography? In Search of a Better Diagnostic Tool in Indian Children with Lower Abdominal Pain

OBJECTIVES

To prospectively assess the performance of pediatric appendicitis score (PAS) in diagnosing acute appendicitis in the children with lower abdominal pain and correlated with ultrasound findings; and to assess the impact of the PAS on clinical outcome and its efficacy in differentiating between complicated and uncomplicated appendicitis.

METHODS

A prospective study was done which included cases of lower abdominal pain. Appendectomy was done for PAS ≥ 6, and diagnosis was confirmed on histopathology. A receiver operator characteristic (ROC) curve was created to assess the PAS performance. The sensitivity, specificity, and accuracy of ultrasonography in diagnosing appendicitis were assessed, and analysis of agreement between ultrasonography and PAS score was done by kappa statistics.

RESULTS

Of 260 cases with lower abdominal pain, 205 were suspected of having appendicitis. One hundred fifty-nine had PAS ≥ 6. There were 2/159 (1.26%) cases of negative appendectomies and 2/46 (4.34%) cases of missed appendicitis. The mean PAS was significantly higher in patients with appendicitis than in those without appendicitis. The area under the ROC curve was 0.9925. Sensitivity, specificity, and positive and negative predictive value of PAS were 98.74%, 95.65%, 95.7% and 95.65%, respectively. Complicated appendicitis had significantly more PAS, fever, and cough tenderness than uncomplicated appendicitis. The sensitivity and specificity of ultrasonography were 86.79% and 17.39%, respectively. Agreement between ultrasonography-proven appendicitis and PAS-dependent appendicitis was weak.

CONCLUSION

PAS has high efficacy in diagnosing acute appendicitis. Clinical outcome was more favorable with the use of PAS. Ultrasonography should be used judiciously and in combination with clinical judgment.

Contrast-enhanced ultrasound in pediatric interventional radiology

There is growing interest in the use of contrast-enhanced ultrasound (CEUS) in diagnostic and interventional radiology. CEUS applications in interventional radiology are performed with intravascular or intracavitary administration of microbubble-based US contrast agents to allow for real-time evaluation of their distribution within the vascular bed or in body cavities, respectively, providing additional information beyond gray-scale US alone. The most common interventional-radiology-related CEUS applications in children have been extrapolated from those in adults, and they include the use of CEUS to guide lesion biopsy and to confirm drain placement in pleural effusions and intra-abdominal fluid collections. Other applications are emerging in interventional radiology for use in adults and children, including CEUS to optimize sclerotherapy of vascular malformations, to guide arthrography, and for lymphatic interventions. In this review article we present a wide range of interventional-radiology-related CEUS applications, emphasizing the current and potential uses in children. We highlight the technical parameters of the CEUS examination and discuss the main imaging findings.

Acute Omental Infarction Mimicking Acute Appendicitis

Acute abdominal pain is a common cause of visits to the emergency department. Acute appendicitis remains the most common indication for abdominal surgical intervention in the pediatric age group. However, several conditions may present with a clinical picture similar to that of acute appendicitis. We report the case of a 7-year-old girl with a history of right lower quadrant abdominal pain of two days in duration. The pain was associated with vomiting and was exacerbated by movement. Abdominal examination revealed a localized tenderness in the right iliac fossa with guarding, giving the impression of acute appendicitis. After a thorough investigation, the patient was diagnosed as having acute omental infarction given the radiological findings seen in the computed tomography scan. The patient was successfully managed conservatively with analgesics and anti-inflammatory drugs. Physicians should keep a high index of suspicion for this condition when encountering a patient presenting with an acute right lower quadrant abdominal pain. Imaging modalities play a pivotal role in making the diagnosis.

Comparison of Open Appendectomy and Laparoscopic Appendectomy in Perforated Appendicitis

Introduction Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes. This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Materials and methods This study was a prospective randomized study conducted at the Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan, from January 2016 to January 2017, by randomly allotting the laparoscopic or the open appendectomy technique to 130 patients by the lottery method. Patients having a perforated appendix were included after they provided informed consent. Data were entered and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, US). Results The frequency of wound site infection was significantly higher in open appendectomy (27.69%) than in the laparoscopic approach (10.77%; p=0.01). Mean hospital stay was slightly longer in the laparoscopic approach (4.38 ± 1.09 days) than in open appendectomy (4.18 ± 0.77 days; p=0.23). Mean operating time for laparoscopic appendectomy and open appendectomy was 46.98 ± 2.99 minutes and 53.02 ± 2.88 minutes, respectively (p<0.000). Conclusion Laparoscopic appendectomy was associated with fewer surgical site infections and shorter mean operating time than an open appendectomy.

Circulating human leucine-rich α-2-glycoprotein 1 mRNA and protein levels to detect acute appendicitis in patients with acute abdominal pain

BACKGROUND

Elevated levels of circulating plasma and urine leucine-rich-2-glycoprotein-1 (LRG1) protein has been found in patients with acute appendicitis (AA) and may be useful for diagnosis. This study aimed to investigate whether combined tests including circulating LRG1 mRNA levels improve the early diagnosis of AA.

METHODS

Between December 2011 and October 2012, a prospective study was conducted on patients aged 18years or older presenting to the ED with acute abdominal pain (<7days of symptom onset). Levels of whole blood LRG1 mRNA and plasma LRG1 protein taken from these patients within 24h of arrival (mean 12.4h) were analyzed. The primary outcome was AA.

RESULTS

Eighty-four patients (40 (47.6%) with AA and 44 (52.4%) without AA; mean age 35years; 41.6% males) were recruited. Median whole blood LRG1 mRNA and plasma LRG1 levels were higher in AA patients than in non-AA. Of 40 AA patients, 13 (32.5%) were diagnosed as complicated AA. In ROC analysis of LRG1 mRNA (normalized to GAPDH), LRG1 protein and Alvarado score for discriminating AA and non-AA, the areas under the curve (AUC) were 0.723, 0.742 and 0.805 respectively. The AUC of combination of normalized LRG1 mRNA, LRG1 protein and Alvarado score was 0.845.

CONCLUSION

A combination of modified whole blood LRG1 mRNA levels, plasma LRG1 protein and Alvarado score at the ED may be useful to diagnose simple and complicated AA from other causes of abdominal pain.

Diagnostic Value of High-Mobility Group Box 1 (HMGB1) Protein in Acute and Perforated Appendicitis

AIM

Acute appendicitis is the most common cause of abdominal surgical emergencies. Early diagnosis of appendicitis can reduce perforation and mortality rate. High-mobility group box 1 (HMGB1) protein has been identified as a pro-inflammatory factor and its elevated serum levels have been noted in different diseases. So, the aim of this study was to determine the serum levels of HMGB1 in patients with acute and perforated appendicitis in compare to normal appendix.

MATERIAL AND METHODS

For this purpose, serum samples were obtained from 81 patients with primary criteria-based appendicitis 6 hr before and 72 hr after appendectomy, in which serum levels of HMGB1 were analyzed by enzyme-linked immunosorbent assay.

RESULTS

The levels of HMGB1 in patients with perforated appendicitis were significantly (p =.045) higher than in patients with acute appendicitis and normal appendix (p =.001) before appendectomy. Serum levels of HMGB1 were increased 72 hr after appendectomy in all the groups (p =.03) compared with the serum levels before appendectomy.

CONCLUSIONS

Since the serum levels of HMGB1 in patients with acute and perforated appendicitis were higher than in patients with normal appendix, these findings could be useful to develop a new biomarker along with other laboratory tests for accurate diagnosis of patients with appendicitis.

Trends in the Diagnosis and Management of Pediatric Appendicitis

• On the basis of class B evidence and consensus, acute appendicitis in children can often be diagnosed clinically with only selective use of imaging. (13)(14)(15)(16) • On the basis of class B evidence and consensus, ultrasonography is the test of choice when acute appendicitis is suspected but is unclear based on history, physical examination, and laboratory results. (17)(18)(19) • On the basis of class B evidence and consensus, the use of computed tomography scan should be limited to cases of suspected complex appendicitis with abscess or when there is clinical suspicion for acute appendicitis but ultrasonography results are not helpful. (16) • On the basis of class C evidence and consensus, children with possible appendicitis ideally should be treated in medical centers that have skilled sonographic personnel. (21) • On the basis of class B evidence and consensus, simple appendicitis should be treated by appendectomy during normal operating hours. Preoperative treatment with intravenous antibiotics and fluids during the overnight hours halts disease progression and allows for the safest surgery with the benefit of a full and rested staff. (24)(25)(26) • On the basis of class B evidence and consensus, complex appendicitis with a well-defined abscess can be treated nonoperatively initially, with the option of an interval appendectomy after recovery from the acute infection. (29)(30) (31)(32)(33)

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments

Objectives

Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation.

Methods

Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014.

Results

Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition.

Conclusions

Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.

Protocol for suspected pediatric appendicitis limits computed tomography utilization

BACKGROUND

Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study.

MATERIALS AND METHODS

An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation.

RESULTS

For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively.

CONCLUSIONS

Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance.

Sonography of acute appendicitis and its mimics in children

The diagnosis of acute right lower quadrant pain in a pediatric population is challenging. Acute appendicitis is the most common cause of an acute surgical abdomen. The common mimics of acute appendicitis are acute gastrointestinal and gynecologic diseases. This article reviews the sonographic findings of the spectrum of common acute abdominal emergencies in children with a focus on imaging clues to a specific diagnosis. This awareness can impact on diagnostic accuracy and impact patient management.

Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol

To improve diagnosis of pediatric appendicitis, many institutions have implemented a staged imaging protocol utilizing ultrasonography (US) first and then computed tomography (CT). A substantial number of children with suspected appendicitis undergo CT after US, and the efficient and accurate diagnosis of pediatric appendicitis continues to be challenging. The objective of the study is to characterize the utility of CT following US for diagnosis of pediatric appendicitis, in conjunction with a clinical appendicitis score (AS). Imaging studies of children with suspected appendicitis who underwent CT after US in an imaging protocol were retrospectively reviewed by three radiologists in consensus. Chart review derived the AS (range 0-10) and obtained the patient diagnosis and disposition, and an AS was applied to each patient. Clinical and radiologic data were analyzed to assess the yield of CT after US. Studies of 211 children (mean age 11.3 years) were included. The positive threshold for AS was determined to be 6 out of 10. When AS and US were concordant (N = 140), the sensitivity and specificity of US were similar to CT. When AS and US were discordant (N = 71) and also when AS ≥ 6 (N = 84), subsequent CT showed superior sensitivity and specificity to US alone. In the subset where US showed neither the appendix nor inflammatory change in the right lower quadrant (126/211, 60 % of scans), when AS < 6 (N = 83), the negative predictive value (NPV) of US was 0.98. However, when AS ≥ 6 (N = 43), NPV of US was 0.58, and the positive predictive value of subsequent CT was 1. There was a significant decrease in depiction of the appendix on US with patient weight-to-age ratio of >6 (kg/year, P < 0.001) and after-hours (1700 -0730 hours) performance of US (P < 0.001). Results suggest that the appendicitis score has utility in guiding an imaging protocol and support the contention that non-visualization of the appendix on US is not intrinsically non-diagnostic. There was little benefit to additional CT when AS < 6 and US did not show the appendix or evidence of inflammation; this would have avoided CT in 140/211 (66 %) patients. CT demonstrated benefit when AS ≥ 6, suggesting that cases with AS ≥ 6 and features that limit depiction of the appendix on US may be triaged to CT.

Alvarado score: a guide to computed tomography utilization in appendicitis

BACKGROUND

Although useful in evaluation of suspected appendicitis, not all patients require computed tomography (CT) evaluation. Clinical stratification of patients who benefit from CT evaluation is essential. We utilize the Alvarado score (AS) to stratify patients with suspected appendicitis into subgroups who benefit from CT evaluation and propose an objective algorithm with AS guiding CT utilization.

METHODS

This study is a retrospective review of medical records of all patients admitted for suspected appendicitis over a 6-month duration. Relevant data were recorded. The AS for each patient was determined retrospectively and correlated with histological and CT findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined for various ASs and for CT.

RESULTS

Three hundred fifty-eight patients were studied, with 167 males (46.6%) and 191 females (53.4%). Prevalence of appendicitis was 50% (179 patients). Two hundred fourteen patients (59.8%) had CT performed. Surgery was performed for 206 patients (57.5%). Overall negative appendicectomy rate was 13.1%. Patients who underwent CT evaluation had a negative appendicectomy rate of 5.7% compared to 17.9% in those without CT evaluation (P = 0.009). CT scan had a sensitivity and specificity of 92.6% and 96.9%, respectively. An AS greater than 3 had a sensitivity superior to CT (95.5%), while an AS of 9 or greater had a specificity superior to CT (100%).

CONCLUSIONS

In suspected appendicitis, patients who benefit from CT evaluation are those with the AS ranging from 4 to 8. We propose a management algorithm with the AS guiding the necessity for CT evaluation.

Minimising medically unwarranted computed tomography scans

As computed tomography (CT) is such a superb diagnostic tool and individual CT risks are small, whenever a CT scan is clinically warranted, the CT benefit/risk balance is by far in the patient's favour. However, if a CT scan is not clinically warranted, this balance shifts dramatically. It is likely that at least 25% of CT scans fall into this latter category, in that they could either be replaced with alternative imaging modalities or could be avoided entirely. Use of clinical decision rules for CT usage represents a powerful approach for slowing down the increase in CT usage, because they have the potential to overcome some of the major factors that result in some CT scans being undertaken when they may not be clinically helpful.

Prospective evaluation of a clinical practice guideline for diagnosis of appendicitis in children

OBJECTIVES

The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases.

METHODS

The authors prospectively evaluated the clinical guideline in one pediatric emergency department (ED) in a general teaching hospital. Patients were risk-stratified based on history, physical examination findings, and laboratory results. Imaging was ordered selectively based on risk category, with ultrasound (US) as the initial imaging modality. Computed tomography (CT) was ordered if the US was negative or indeterminate. Surgery was consulted before imaging in high-risk patients.

RESULTS

A total of 475 patients were enrolled. Of those, 193 (41%) had appendicitis. No low-risk patient had appendicitis. Medium-risk patients had a 19% rate of appendicitis, and 83% of high-risk patients had appendicitis. Factors associated with an increased likelihood of appendicitis included decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsing's signs. Of the 475 patients, 276 (58%) were managed without a CT scan. Seventy-one of the 193 (37%) patients with appendicitis went to the operating room without any imaging. The rate of missed appendicitis was 2%, and the rate of negative appendectomy was 1%.

CONCLUSIONS

The clinical practice guideline performed well in a general teaching hospital. Rates of negative appendectomy and missed appendicitis were low and 58% of patients were managed without a CT scan.

Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis

Background

Appendicitis is the most common surgical emergency in children; yet, diagnosis of equivocal presentations continues to challenge clinicians.

Aim

The objective of this study was to investigate the hypothesis that the use of a modified clinical practice and harmonic ultrasonographic grading scores (MCPGS) may improve the accuracy in diagnosing acute appendicitis in the pediatric population.

Patients & Methods

Results

The Number of appendectomies declined from 200 (75.5%) in our previous CPGS to 187 (70.6%) in the MCPGS (P > 0.05).

Specificity was significantly higher when applying MCPGS (90.7%) in this study compared to 70.47% in our previous work when CPGS was applied (P < 0.01). Furthermore, the positive predictive value (PPV) was significantly higher (95.72%) than in our previous study (82.88%), (P < 0.01). Overall agreement (accuracy) of MCPGS was 96.98%. Kappa = 0.929 (P < 0.001). Negative predictive power was 100%. And the Overall agreement (accuracy) was 96.98%.

Conclusions

MCPGS tends to help in reduce the numbers of avoidable and unnecessary appendectomies in suspected cases of pediatric acute appendicitis that may help in saving hospital resources.

Incidental Findings on Computed Tomography Scans for Acute Appendicitis: Prevalence, Costs, and Outcome

CT scan is increasingly being used to diagnose appendicitis due to its specificity and literature suggesting its cost-effectiveness. CT scans are associated with incidental findings. We sought to investigate the rates of incidental findings identified on CT scans, the follow-up of these findings, and the added cost associated with this follow-up. A retrospective review of patients who underwent appendectomies for acute appendicitis between 2003 and 2005 was completed at Elmhurst Hospital Center (Elmhurst, NY). Incidental findings were grouped into low and high significance, based on workup or follow-up needed. The diagnostic workup and cost of each incidental finding was ascertained. For patients who did not receive a workup due to lack of follow-up, an estimate of the minimum workup was calculated. Of 1142 patients with acute appendicitis, 876 (77%) had a CT scan. This rate increased over time (from 66% in 2003 to 85% in 2005, P < 0.01) and with age (70% in patients under 20 and 98% in patients over 50, P < 0.001). Incidental findings were common and increased with age (23% in the youngest group vs 78% in patients older than 50, P < 0.001). The cost associated with workup of these incidental findings increased with age as well. The increased use of CT scans is associated with a high rate of incidental findings. These findings are usually of low clinical significance but may require further workup and follow-up. Physicians need to be aware of the high rate of incidental findings, the need for further workup, and the associated costs.

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

PURPOSE

The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.

METHODS

Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.

RESULTS

One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).

CONCLUSIONS

Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Radiologic procedures, policies and protocols for pediatric emergency medicine

Protocol development between radiology and pediatric emergency medicine requires a multidisciplinary approach to manage straightforward as well as complex and time-sensitive needs for emergency department patients. Imaging evaluation requires coordination of radiologic technologists, radiologists, transporters, nurses and coordinators, among others, and might require accelerated routines or occur at sub-optimal times. Standardized protocol development enables providers to design a best practice in all of these situations and should be predicated on evidence, mission, and service expectations. As in any new process, constructive feedback channels are imperative for evaluation and modification.

Imaging utilization commentary: a radiology perspective

To adhere to the ALARA concept, imaging should be limited to studies that actually contribute to the management of the patient. For example, by applying the Ottawa Ankle Rule and the Ottawa Knee Rule, fewer radiographs are required to evaluate ankle and knee trauma in children. Chest radiographs usually do not contribute to the management of children presenting with typical acute bronchiolitis or asthma, and they can be detrimental because consolidation resulting from retained secretions is interpreted as pneumonia and the child is started on antibiotics unnecessarily. Moreover, a radiograph of the abdomen has poor validity and reproducibility for the diagnosis of constipation. The Pediatric Emergency Care Applied Research Network (PECARN) and the Pediatric Emergency Research in Canada (PERC) are currently developing decision rules for the use of CT in the assessment of minor head injuries in children, which should reduce its utilization in this condition. PECARN is also developing a decision rule for the use of CT in the assessment of abdominal trauma in children. CT is frequently used for the diagnosis of appendicitis in children, but appendicitis can be diagnosed clinically. If imaging is required, appendicitis can often be diagnosed with US, and CT need only be used in the minority of cases where the diagnosis is still in doubt. Utilization guidelines for pediatric imaging studies obtained in children in the emergency setting can improve yield and help in the more efficient management of often scarce health care resources.

Cancer risks from diagnostic radiology

In recent years, there has been a rapid increase in the number of CT scans performed, both in the US and the UK, which has fuelled concern about the long-term consequences of these exposures, particularly in terms of cancer induction. Statistics from the US and the UK indicate a 20-fold and 12-fold increase, respectively, in CT usage over the past two decades, with per caput CT usage in the US being about five times that in the UK. In both countries, most of the collective dose from diagnostic radiology comes from high-dose (in the radiological context) procedures such as CT, interventional radiology and barium enemas; for these procedures, the relevant organ doses are in the range for which there is now direct credible epidemiological evidence of an excess risk of cancer, without the need to extrapolate risks from higher doses. Even for high-dose radiological procedures, the risk to the individual patient is small, so that the benefit/risk balance is generally in the patients' favour. Concerns arise when CT examinations are used without a proven clinical rationale, when alternative modalities could be used with equal efficacy, or when CT scans are repeated unnecessarily. It has been estimated, at least in the US, that these scenarios account for up to one-third of all CT scans. A further issue is the increasing use of CT scans as a screening procedure in asymptomatic patients; at this time, the benefit/risk balance for any of the commonly suggested CT screening techniques has yet to be established.

ALARA: is there a cause for alarm? Reducing radiation risks from computed tomography scanning in children

PURPOSE OF REVIEW

Radiation exposure from computed tomography is associated with a small but significant increase in risk for fatal cancer over a child's lifetime. This review aims to heighten awareness and spearhead efforts to reduce unnecessary computed tomography scans in children.

RECENT FINDINGS

The use of pediatric computed tomography continues to grow despite evidence on known risks of computed tomography-related radiation and induction of fatal cancers in children. More than 60 million computed tomography scans are estimated to be performed annually in the USA, with 7 million in children. Pediatric radiologists apply the practice of ALARA ('as low as reasonably achievable') to reduce radiation exposure. Education and advocacy directed to the referring clinician reinforce these principles. Radiation exposure may be further reduced by developing clinical pathways limiting computed tomography scanning and encourage alternate, nonradiation imaging modalities, such as ultrasound and magnetic resonance imaging. Although individual risk estimates are small, widespread use of computed tomography in the population may implicate a future public health issue.

SUMMARY

Advocacy by pediatric healthcare providers to promote intelligent dose reduction based on the principles of ALARA and the judicious use of computed tomography scanning is essential to foster the safest possible care of children.

Comparison of pediatric emergency physicians' and surgeons' evaluation and diagnosis of appendicitis

OBJECTIVES

To compare the interexaminer reliability and ability to predict appendicitis between pediatric emergency physicians (EPs) and senior surgical residents.

METHODS

The authors conducted a prospective cohort study of children aged 3 to 18 years of age with signs and symptoms suspicious for appendicitis. Patients were initially examined by a pediatric EP attending and then by a consulting senior surgical resident. Physicians reported the presence or absence of specific historical and physical exam findings and predicted the likelihood the patient had appendicitis. Interexaminer reliability of historical and physical exam findings was compared (kappa statistic). Distributions and median probabilities of appendicitis were calculated for pediatric EP and surgeon predictions.

RESULTS

The authors evaluated 350 patients with acute abdominal pain. Historical questions revealed slight to very good agreement (kappa statistic range 0.33-0.82) between physician types, whereas physical examination findings exhibited poor to fair agreement (range 0.14-0.48). Physicians predicted similar median probabilities of appendicitis for patients who were ultimately diagnosed with appendicitis (75% vs. 70%; p = 0.73) and patients without appendicitis (25% vs. 30%; p = 0.59). For a subset of patients given a > or = 90% predicted probability of appendicitis, pediatric EPs and senior surgical residents had similar accuracy (80% vs. 79%; p = 0.92). Similarly, among patients with < or = 10% predicted probability, pediatric EPs were correct in 95% and senior surgical residents correct in 94% of patients (p = 0.63).

CONCLUSIONS

Pediatric EPs and senior surgical residents elicit historical findings from patients with suspected appendicitis with a greater degree of similarity than physical examination findings, which exhibit a wide degree of variability. Pediatric EPs and senior surgical residents do not differ in their ability to clinically predict appendicitis. These findings may be helpful in developing institutional management protocols.

The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED

STUDY OBJECTIVE

Appendicitis is part of the differential of an acute abdomen and can be a difficult diagnosis to make. Strategies to suggest which patients presenting to the emergency department (ED) should undergo computed tomography (CT) scan to confirm appendicitis have not been addressed. We develop guidelines for CT scanning based on Alvarado clinical scores for patients with suspected and confirmed cases of appendicitis.

METHODS

A retrospective review of 150 charts of patients aged 7 and older who presented with abdominal pain to the ED of a 392-bed acute care facility over a 6-month period were evaluated by ED physicians and underwent CT to rule out appendicitis. Patient demographics, presenting signs, and symptoms were documented. Using the scoring system for appendicitis, developed by Alvarado, each chart was retrospectively scored. The Alvarado scores were correlated with positive pathology findings, as well as Alvarado scores with a negative CT scan. Equivocal scores, having neither high sensitivity nor specificity for appendicitis were calculated.

RESULTS

Computed tomography scans with Alvarado scores of 3 or lower were performed in 37% (55/150) of patients to rule out appendicitis. The sensitivity of Alvarado scores 3 or lower for not having appendicitis was 96.2% (53/55), and the specificity 67% (2/3). Patients with Alvarado scores 7 or higher had an incidence of acute appendicitis of 77.7% (28/36). The sensitivity of Alvarado scores 7 or higher for appendicitis was 77% (28/36), and the specificity 100% (8/8). The sensitivity of equivocal Alvarado scores, defined as scores of 4 to 6, for acute appendicitis was 35.6% (21/59), and the specificity 94% (36/38). The sensitivity and specificity of CT scans in patients with equivocal Alvarado scores remained high, at 90.4% and 95%, respectively.

CONCLUSIONS

In the equivocal clinical presentation of appendicitis as defined by Alvarado scores of 4 to 6, adjunctive CT is recommended to confirm the diagnosis in the ED setting. If clinical presentation suggests acute appendicitis by an Alvarado score of 7 or higher, surgical consultation is recommended. Computed tomography is not indicated in patients with Alvarado scores of 3 or lower to diagnose acute appendicitis.

Suspected Appendicitis in Children: Rectal and Intravenous Contrast-enhanced versus Intravenous Contrast-enhanced CT

PURPOSE

To retrospectively compare the diagnostic performance of intravenous contrast material-enhanced computed tomography (CT) with that of intravenous and rectal contrast-enhanced CT in the evaluation of children suspected of having appendicitis by using pathologic findings, surgical findings, or a follow-up telephone call as the reference standard.

MATERIALS AND METHODS

This HIPAA-compliant study was approved by the committee on clinical investigations. As part of a larger study, informed consent was obtained from all parents and from all children older than 7 years. Consecutive patients aged 5-21 years who presented to the emergency department and were suspected of having appendicitis were studied with CT. From April 2003 until February 2004, patients underwent intravenous and rectal contrast-enhanced CT. From March 2004 until December 2004, patients underwent intravenous contrast-enhanced CT. Demographic data, clinical outcomes, and test performance characteristics--including sensitivity, specificity, accuracy, and negative and positive predictive values--were compared.

RESULTS

Of the 416 patients who met inclusion criteria, 223 underwent intravenous and rectal contrast-enhanced CT and 193 underwent intravenous contrast-enhanced CT. There were no differences in sex distribution (55% vs 52% male patients), frequency of appendicitis (36% vs 32%), or frequency of equivocal CT findings (4%) between the groups. Intravenous and rectal contrast-enhanced CT had a sensitivity of 92% (95% confidence interval [CI]: 85%, 97%), a specificity of 87% (95% CI: 79%, 92%), a negative predictive value of 94% (95% CI: 90%, 98%), and an accuracy of 89% (95% CI: 85%, 93%). Intravenous contrast-enhanced CT had a sensitivity of 93% (95% CI: 84%, 97%), a specificity of 92% (95% CI: 85%, 96%), a negative predictive value of 95% (95% CI: 90%, 99%), and an accuracy of 92% (95% CI: 88%, 96%) (P > .2 for all comparisons).

CONCLUSION

There was no significant difference between the performance of intravenous contrast-enhanced CT and that of rectal and intravenous contrast-enhanced CT in children suspected of having appendicitis.

Current Concepts in Imaging of Appendicitis

Appendicitis is the most common cause of acute abdominal pain requiring surgery. Early diagnosis is crucial to the success of therapy. CT and ultrasound are widely recognized as very useful in the timely diagnosis of appendicitis. MR imaging is emerging as an alternative to CT in pregnant patients and in patients who have an allergy to iodinated contrast material. This article reviews the current imaging methods and diagnostic features of appendicitis.

Current management of appendicitis

Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.

Clinical approach to a child with abdominal pain who might have appendicitis

Appendicitis can usually be diagnosed on completion of a history and physical examination (abdominal pain, vomiting, right lower quadrant tenderness and guarding), although laboratory evaluation with a urinalysis and white blood cell count can be of assistance. In the few cases where doubt remains, plain films of the chest and abdomen can be helpful. Whether and when further imaging is indicated remains controversial. We reviewed reports of studies published since 2003 in which the sensitivity and specificity of CT and sonography for diagnosing appendicitis were determined. Sonography had an average sensitivity of 87.1% and an average specificity of 89.2% in the nine studies reported during that period. The average sensitivity of CT was 90.8% in 11 studies during that period, and there was an average specificity of 94.2% in 10 studies. We also looked at data from 299 patients who underwent appendectomies at our hospital. Of the appendices removed, only 10.7% did not have appendicitis. In many cases, CT or US imaging data were available in the form of reports or images or both from outside institutions. CT and US images were also available from our institution when the diagnosis was in question. This is how patients present in the real world-with studies that might not be the best, might not have been indicated, and might not have images available for another interpretation. Among patients operated on with neither CT nor US images, 10.9% did not have appendicitis. Among those in whom US imaging had been performed, 11.1% were negative for appendicitis, and among those in whom CT had been performed, 9.7% were negative. Although these studies were necessary because they were performed in patients whose diagnosis was the most difficult, it is in every patient's best interest to have a thorough examination by a surgeon prior to having a CT scan.

Estado atual do diagnóstico e tratamento da apendicite aguda na criança: avaliação de 300 casos

OBJETIVOS: Avaliar o estado atual do diagnóstico e tratamento da apendicite aguda em crianças operadas em dois grandes hospitais quaternários da cidade de São Paulo, no período de 30 meses. MÉTODO: Nossa casuística constou de 300 crianças operadas por apendicite aguda no período de 1998 a 2000 (65% do sexo masculino e 35% feminino). Foram analisadas as variáveis idade, sexo, manifestações clínicas, tempo gasto para o diagnóstico, achados de exame físico, laboratoriais e cirúrgicos, antimicrobianos administrados, complicações pós-operatórias e tempo de internação. Utilizou-se o teste t de Student para avaliar duas variantes e Análise de Variâncias quando mais de duas. RESULTADOS: Diagnosticou-se inicialmente apendicite aguda em apenas 63% dos casos, tendo os 35% restantes, diagnóstico de abdome agudo cirúrgico. O tempo decorrido na realização do diagnóstico foi superior a 24 horas em 57,4% dos casos, denotando retardo importante na sua elaboração. Dor abdominal (85,3%) e irritação peritoneal (82%) em fossa ilíaca direita foram os sinais e sintomas mais freqüentes. Identificou-se leucocitose em 83% dos pacientes e leucocitúria em 39,7 %. Em 92,4% das radiografias simples de abdome encontramos imagens sugestivas de apendicite aguda. A ultra-sonografia abdominal foi diagnóstica em 80,1% dos casos. Utilizaram-se esquemas antimicrobianos especialmente para agentes gram-negativos e anaeróbicos. A principal complicação foi infecção da ferida cirúrgica, não tendo sido observada mortalidade no grupo. A média de internação foi de 5.2 e 6,0 dias para meninos e meninas respectivamente. CONCLUSÃO: Mesmo com melhor conhecimento sobre apendicite aguda, refinamento técnico, laboratorial, radiológico e uso de antibioticoterapia adequada, o tempo de para diagnóstico e a morbidade ainda se mantém alta na idade pediátrica.

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis

PURPOSE

Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis.

METHODS

Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons.

RESULTS

Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively (P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were 11,791 dollars (imaged) and 9360 dollars (nonimaged) (P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups.

CONCLUSIONS

More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.

Guideline attribute and implementation preferences among physicians in multiple health systems

OBJECTIVES

Although practice guidelines are effective in assisting providers with clinical decision making, ineffective implementation strategies often prevent their use in practice. This study aimed to understand physician preferences for guideline format, placement, content, evidence, and learning strategies in different clinical environments.

SUBJECTS AND METHODS

Semistructured telephone interviews were conducted with 500 randomly selected physicians from 4 major US health systems who were involved in the treatment of patients with acute myocardial infarction or pediatric asthma. Paired sample t tests and Tukey's method of comparisons determined the relative ranking of physicians' guideline implementation preferences.

RESULTS

Physicians preferred guidelines located on the front of the patient chart, in palm pilots, or in progress notes and presented as flow charts/flow diagrams, algorithms, or preprinted orders that contain strategies to minimize readmits/encourage self-management and immediate treatment flows. Discussions with colleagues and continuing medical education are the most effective strategies for encouraging guideline use, and randomized controlled trials remain the most persuasive medical evidence.

CONCLUSIONS

Health care organizations must align guideline implementation efforts with physician preferences to encourage utilization. The results of this study reveal systematic physician preferences for guideline implementation that can be applied to clinical settings to encourage guideline use by physicians.

Procalcitonin as a predictor of severe appendicitis in children

The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in 212 children with appendicitis and compare it with that of the standard diagnostic modalities, C-reactive protein (CRP) level, leukocyte count, and abdominal ultrasound findings, in relation to the surgical and histological findings of the appendix. A PCT value of >0.5 ng/ml was found to be indicative of perforation or gangrene with 73.4% sensitivity and 94.6% specificity, a CRP level of >50 mg/l and a leukocyte count of >10(4)/mm3 were useful diagnostic markers for perforation, while abdominal ultrasonography had a sensitivity of 82.8% and a specificity of 91.2% for detecting appendicitis with imaging findings. PCT measurement seems to be a useful adjunctive tool for diagnosing acute necrotizing appendicitis or perforation, and surgical exploration will probably be required in patients with PCT values >0.5 ng/ml.