RIFT Study Group on behalf of the West Midlands Research Collaborative. Appendicitis risk prediction models in children presenting with right iliac fossa pain (RIFT study): a prospective, multicentre validation study

Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study

OBJECTIVE

The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED).

METHODS

A literature search was conducted to identify potential CPSs and a single-center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5-15 years presenting with acute right-sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician-collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low-risk or high-risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow-up for those discharged directly from ED.

RESULTS

Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86-0.94) and specificity 99.0% (95% CI 96.4%-99.7%) in diagnosing high-risk cases and a misclassification rate of 4.5% for low-risk cases.

CONCLUSIONS

The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC-ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings.

Systematic Review and Meta-analysis to Compare the Short- and Long-term Outcomes of Non-operative Management With Early Operative Management of Simple Appendicitis in Children After the COVID-19 Pandemic

BACKGROUND

Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and long-term failure rates of NOM and the complication rate of appendicectomy in children with simple appendicitis.

METHODS

The systematic review was registered a priori (CRD42022322149). Study inclusion criteria are: participants aged ≤ 18 years of age; groups undergoing both NOM and appendicectomy for simple appendicitis; outcomes including one or more of: NOM failure rate at 30 days or 1 year and beyond; study design: RCT or case control study. Four databases were searched and 3 reviewers determined study eligibility and data extraction. Risk of bias was assessed and meta-analysis was performed using Stata.

RESULTS

The database search identified 2731 articles, 14 studies met the inclusion criteria; 4 RCTs and 10 case controlled studies. All studies had moderate-serious risk of bias. There were no deaths in either group in any study. Meta-analysis demonstrated a 30 day failure rate of 20 % (95 % CI 11-29 %) and 11 studies reported failure rate at 1 year or beyond at 32 % (95 % CI 25-38 %). Rates of significant complications of appendicectomy was 1 % (95 % CI 0-1 %).

CONCLUSIONS

Non-operative management of simple appendicitis in children is safe, with moderate early success. The failure rate increases over time, resulting in eventual appendicectomy in a third of the children diagnosed with appendicitis. These data will enable clinicians to have an informed discussion with children and their parents about their treatment options for simple appendicitis.

LEVEL OF EVIDENCE

II.

Interpretable and intervenable ultrasonography-based machine learning models for pediatric appendicitis

Appendicitis is among the most frequent reasons for pediatric abdominal surgeries. Previous decision support systems for appendicitis have focused on clinical, laboratory, scoring, and computed tomography data and have ignored abdominal ultrasound, despite its noninvasive nature and widespread availability. In this work, we present interpretable machine learning models for predicting the diagnosis, management and severity of suspected appendicitis using ultrasound images. Our approach utilizes concept bottleneck models (CBM) that facilitate interpretation and interaction with high-level concepts understandable to clinicians. Furthermore, we extend CBMs to prediction problems with multiple views and incomplete concept sets. Our models were trained on a dataset comprising 579 pediatric patients with 1709 ultrasound images accompanied by clinical and laboratory data. Results show that our proposed method enables clinicians to utilize a human-understandable and intervenable predictive model without compromising performance or requiring time-consuming image annotation when deployed. For predicting the diagnosis, the extended multiview CBM attained an AUROC of 0.80 and an AUPR of 0.92, performing comparably to similar black-box neural networks trained and tested on the same dataset.

Development and validation of a clinical prediction rule for acute appendicitis in children in primary care

BACKGROUND

Recognising acute appendicitis in children presenting with acute abdominal pain in primary care is challenging. General practitioners (GPs) may benefit from a clinical prediction rule.

OBJECTIVES

To develop and validate a clinical prediction rule for acute appendicitis in children presenting with acute abdominal pain in primary care.

METHODS

In a historical cohort study data was retrieved from GP electronic health records included in the Integrated Primary Care Information database. We assigned children aged 4-18 years presenting with acute abdominal pain (≤ 7 days) to development (2010-2012) and validation (2013-2016) cohorts, using acute appendicitis within six weeks as the outcome. Multiple logistic regression was used to develop a prediction model based on predictors with > 50% data availability derived from existing rules for secondary care. We performed internal and external temporal validation and derived a point score to stratify risk of appendicitis into three groups, i.e. low-risk, medium-risk and high-risk.

RESULTS

The development and validation cohorts included 2,041 and 3,650 children, of whom 95 (4.6%) and 195 (5.3%) had acute appendicitis. The model included male sex, pain duration (<24, 24-48, > 48 h), nausea/vomiting, elevated temperature (≥ 37.3 °C), abnormal bowel sounds, right lower quadrant tenderness, and peritoneal irritation. Internal and temporal validation showed good discrimination (C-statistics: 0.93 and 0.90, respectively) and excellent calibration. In the three groups, the risks of acute appendicitis were 0.5%, 7.5%, and 41%.

CONCLUSION

Combined with further testing in the medium-risk group, the prediction rule could improve clinical decision making and outcomes.

What is important to the GP in recognizing acute appendicitis in children: a delphi study

BACKGROUND

For diagnostic research on appendicitis in registration data, insight is needed in the way GPs generate medical records. We aimed to reach a consensus on the features that GPs consider important in the consultation and medical records when evaluating a child with suspected appendicitis.

METHODS

We performed a three-round Delphi study among Dutch GPs selected by purposive sampling. An initial feature list was created based on a literature search and features in the relevant Dutch guideline. Finally, using a vignette describing a child who needed later reassessment, we asked participants to complete an online questionnaire about which consultation features should be addressed and recorded.

RESULTS

A literature review and Dutch guideline yielded 95 consultation features. All three rounds were completed by 22 GPs, with the final consensus list containing 26 symptoms, 29 physical assessments and signs, 2 additional tests, and 8 further actions (including safety-netting, i.e., informing the patient about when to contact the GP again). Of these, participants reached consensus that 37 should be actively addressed and that 20 need to be recorded if findings are negative.

CONCLUSIONS

GPs agreed that negative findings do not need to be recorded for most features and that records should include the prognostic and safety-netting advice given. The results have implications in three main domains: for research, that negative findings are likely to be missing; for medicolegal purposes, that documentation cannot be expected to be complete; and for clinical practice, that safety-netting advice should be given and documented.

Parental Knowledge of Appendicitis and Its Management Options Among Children of Makkah Region, Saudi Arabia

BACKGROUND

Despite decades of studies, appendicitis in children still presents several uncertainties regarding optimal treatment.

OBJECTIVES

To assess parental understanding of appendicitis, along with its risks and treatment, and to determine attitudes to operative and non-operative treatment of uncomplicated appendicitis.

METHODS

This is a cross-sectional study. The current study has targeted all parents who visited the pediatric outpatient departments or clinics at three different hospitals in Makkah and Jeddah City, including Maternity and Children Hospital (MCH) in Makkah, King Fahad Armed Force Hospital (KFAFH), and Saudi German Private Hospital (SGH) in Jeddah. Data was collected via an online Google form and was analyzed by using SPSS.

RESULTS

A total of 408 subjects were involved in this study. The majority of them were females (74.5%); 25.5% were males. Most of the study participants aged between 25 and 34 years. Our results found that the average knowledge score of the study population was 4.1±1.81 out of 11. Only 23.5% of them had good knowledge about appendicitis. More than half of the respondents identified the appendix as a part of the digestive system and most of the study population were aware of the current treatment for appendicitis, which is surgery (80.9%). Female participants and respondents who knew someone that has been treated for appendicitis were significantly associated with a better level of knowledge about appendicitis (P-values: 0.011 and 0.033, respectively). Moreover, we found that educational level significantly influenced preference for treatment with antibiotics and surgery if appendicitis happened again (P-value: 0.049).

CONCLUSION

The study population had poor knowledge of appendicitis and its management options. The highlighted criteria of self-reported relevance to parents should be addressed in all appendicitis counseling and consent. We advocate for the establishment of national public awareness campaigns, as well as increased research and clinical trials. Understanding lay views of treatment alternatives and efficacy will influence future approaches to appendicitis therapy by analyzing the community's preference for emerging treatment modalities and identifying future directions for patient-centered clinical trials.

Assessing Clinical Acumen in Predicting Acute Appendicitis in Emergency Surgery: A Prospective Study

BACKGROUND

Clinical acumen and experience are critical in the diagnosis of the commonest surgical emergency, acute appendicitis. However, there is an increasing focus on haematological and radiological parameters in reaching the diagnosis of appendicitis, which can negate the importance of clinical findings. The aim was to assess the accuracy of each grade of the surgical team in diagnosing acute appendicitis using clinical acuity alone and compare them to each other as well as validated predictive scores.

METHODS

A prospective single-centre study was performed over a six-month period (Dec 2020-May 2021). All patients presenting to the emergency department with right iliac fossa pain were included.

RESULTS

A total of 180 patients were included of whom 35% were male. Mean age was 36.2 years (range 16-91). 51.1% had a final diagnosis of appendicitis, of which 91.3% were managed surgically and 8.7% were treated conservatively with antibiotics. Consultants were correct in their prediction of appendicitis in 84.6% of cases (females-83.4%, males-86.6%). Registrars accurately predicted appendicitis in 82.2% of patients (females-80.3%, males-85.7%), whilst house officers (SHOs) and interns were right in 73.8% (females-69.2%, males-82.5%) and 72.7% (females-66.6%, males-83.9%) of cases, respectively. In patients with a histological or radiological diagnosis of appendicitis, the mean Acute Inflammatory Response Score and Acute Appendicitis Score were 7.0 (high risk ≥ 9) and 12.5 (high risk ≥ 16), respectively. Clinicians had superior diagnostic accuracy when compared with both the clinical scores used.

CONCLUSION

Seniority was associated with improved diagnostic accuracy in clinically predicting acute appendicitis. This study showed that the clinical judgement of experienced surgeons is more reliable than clinical scores in the diagnosis of appendicitis.

Routine ultrasound for suspected appendicitis in children: a single-centre retrospective cohort study

INTRODUCTION

Appendicitis continues to be a common surgical emergency in children, but its diagnosis remains challenging. Use of diagnostic imaging to confirm appendicitis has gained popularity in some countries because it is associated with lower negative appendicectomy rates. This study reports our centre's experience of adopting routine ultrasound for the investigation of suspected appendicitis in children.

METHODS

A single-centre retrospective cohort study was performed investigating all children aged 5-16 years admitted under surgeons with suspected appendicitis, in January-December 2019. Primary outcomes were the rate of ultrasound use, its accuracy in diagnosing/excluding appendicitis and negative appendicectomy rate. Other outcomes were treatment received, length of stay and complications.

RESULTS

The majority of the 193 children with suspected appendicitis underwent a diagnostic ultrasound (87.5%). Ultrasound was highly sensitive (0.90, 95% confidence interval (CI) 0.81-0.96) and specific (1.0, 95% CI 0.96-1.0) for appendicitis in this study. Negative appendicectomy rate was extremely low (1.4%). Laparoscopic appendicectomy was the preferred management (75/86), with one case started open and no conversions to open. A minority of cases of simple appendicitis (10/86) were treated primarily with antibiotics. Rates of complex appendicitis and postoperative complications were similar to other studies.

CONCLUSION

Ultrasound can be highly sensitive and specific for appendicitis. Its routine use to confirm appendicitis prior to surgery is associated with a low negative appendicectomy rate. This is a major change in practice for a general surgical unit in the United Kingdom.

Added value of CRP to clinical features when assessing appendicitis in children

BACKGROUND

The diagnostic value of C-reactive protein (CRP) for appendicitis in children has not been evaluated in primary care. As biochemical responses and differential diagnoses vary with age, separate evaluation in children and adults is needed.

OBJECTIVES

To determine whether adding CRP to symptoms and signs improves the diagnosis of appendicitis in children with acute abdominal pain in primary care.

METHODS

A retrospective cohort study in Dutch general practice. Data was collected from the Integrated Primary Care Information database between 2010 and 2016. We included children aged 4-18 years, with no history of appendicitis, presenting with acute abdominal pain, and having a CRP test. Initial CRP levels were related to the specialist's diagnosis of appendicitis, and the test's characteristics were calculated for multiple cut-offs. The value of adding CRP to signs and symptoms was analysed by logistic regression.

RESULTS

We identified 1076 eligible children, among whom 203 were referred for specialist evaluation and 70 had appendicitis. The sensitivity and specificity of a CRP cut-off ≥10 mg/L were 0.87 (95%CI, 0.77-0.94) and 0.77 (95%CI, 0.74-0.79), respectively. When symptoms lasted > 48 h, this sensitivity increased to 1.00. Positive predictive values for CRP alone were low (0.18-0.38) for all cut-off values (6-100 mg/L). Adding CRP increased the area under the curve from 0.82 (95%CI, 0.78-0.87) to 0.88 (95%CI, 0.84-0.91), and decision curve analysis confirmed that its addition provided the highest net benefit.

CONCLUSION

CRP adds value to history and physical examination when diagnosing appendicitis in children presenting acute abdominal pain in primary care. Appendicitis is least likely if the CRP value is < 10 mg/L and symptoms have been present for > 48 h.

Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.

Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis

OBJECTIVE

Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis.

DESIGN

A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort.

RESULTS

67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)).

CONCLUSIONS

The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application.

PROSPERO REGISTRATION NUMBER

CRD42017080036.

Impact of the COVID-19 pandemic on management and outcomes of children with appendicitis: The Children with AppendicitiS during the CoronAvirus panDEmic (CASCADE) study

AIM

To report the impact of the SARS-CoV-2 pandemic on management and outcomes of paediatric appendicitis in the UK and Ireland.

METHODS

Prospective, multicentre observational cohort study at general surgical and specialist paediatric surgical centres in the United Kingdom and Ireland from 1st April to 31st July 2020. Primary outcome was treatment strategy used for acute appendicitis.

RESULTS

This study includes 2002 children treated for acute appendicitis of a median age of 10 (range 1-15) years and 605 children from a similar data set pre pandemic from 2017. In the pandemic cohort 560/2002(28%) were initially treated non operatively of whom 125/560(22%) proceeded to appendicectomy within initial hospital admission. Non operative treatment wasn't used in the pre pandemic cohort. Diagnostic imaging use was greater during the pandemic compared to pre pandemic (54vs31%; p < 0.00001) but overall use of laparoscopy was similar during both time periods (62.4vs66.6%). Hospital readmission rate was lower (8.7vs13.9%; p = 0.0002) during the pandemic than pre pandemic and Re-intervention rate was similar (2.9vs2.6%;p = 0.42). In cases treated operatively negative appendicectomy rate was lower during the pandemic than pre pandemic (4.4vs15.4%; p =0.0001), and during the pandemic was amongst the lowest ever reported in the UK.

CONCLUSION

COVID-19 has had a significant impact on the management of children with appendicitis in the UK and Ireland. The rate of imaging and the use of non operative management increased, whilst the negative appendicectomy rate reduced. Overall, patient outcomes have not been adversely impacted by change in management during the pandemic.

CONCLUSION

Level I.

TYPE OF STUDY

Prognosis study.

Predicting the Severity of Acute Appendicitis in Children Using Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR)

Introduction

The ability to predict risk of perforation in acute appendicitis (AA) could direct timely management and reduce morbidity. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are surrogate severity markers in infections. This study investigates the use of PLR and NLR as a marker for distinguishing uncomplicated (UA) and complicated appendicitis (CA) in children.

Materials and methods

This retrospective single-center study collected data between January 1, 2014, and December 31, 2020. Children between five and 17 years of age with histologically confirmed appendicitis were included. Cut-off values for NLR and PLR were determined by employing the receiver operating characteristic (ROC) curve with sensitivity and specificity in addition to regression analysis.

Results

A total of 701 patients were included with a median age of 13 years. Out of which 52% of the cohort was female. The difference between the NLR and PLR ratios between UA and CA was significant (p=0.05, Kruskal-Wallis). For UA, the area under the ROC curve (AUC) and cut-off for NLR and PLR were 0.741, 3.80 with 95% CI of 0.701-0.781 and 0.660, 149.25 with 95% CI of 0.618-0.703, respectively. In CA, using NLR and PLR, AUC and cut-off were 0.776, 8.86 with 95%CI of 0.730-0.822 and 0.694, 193.67 with 95%CI of 0.634-0.755, respectively. All were significant with p<0.001.

Conclusions

NLR and PLR are reliable, synergistic markers predicting complicated appendicitis which can guide non-operative management in children.

Parental Knowledge of Appendicitis and Preference for Operative or Non-Operative Treatment at a United Kingdom Children’s Hospital

Appendicitis is a common cause of abdominal pain in children, and is the most common reason for children to undergo emergency abdominal surgery. To guide our research program in this field, we aimed to determine parental understanding with regard to appendicitis and its treatment. We also wished to assess parental preference for non-operative or surgical treatment of children with uncomplicated appendicitis. We asked parents attending a children’s outpatient clinic to complete a brief questionnaire that was interspersed with educational content to rectify any knowledge gaps. A total of 396 parents (of 414 approached) agreed to participate. There were gaps in parental knowledge, including not knowing where the appendix is located (one-third of respondents), not knowing what appendicitis is (40% of respondents), and underestimating the incidence of appendicitis. Parents typically overestimated the risks of complications and dying from both uncomplicated and complicated appendicitis. There was no influence of gender, age, or previous experience of appendicitis on these findings. When presented with the scenario of equal effectiveness of non-operative treatment and surgery for uncomplicated appendicitis, 59% of respondents expressed a preference for non-operative treatment over surgery, while 21% expressed a preference for surgery (20% expressed no preference). These findings are important for clinicians and researchers when discussing appendicitis and treatment options with families, and justify ongoing research into the comparative effectiveness of non-operative treatment and surgery.

Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown.

OBJECTIVE

The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP.

METHODS

A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2.

RESULTS

Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting.

CONCLUSIONS

There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.

Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology

PURPOSE

Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm.

METHODS

Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database.

RESULTS

Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA.

CONCLUSION

Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.

We can reduce negative paediatric appendicectomy rate: A cohort study

BACKGROUND

Appendicitis accounts for the most frequent surgical emergencies in childhood. The guidance from the Royal College of Surgeons and poor post operative outcomes in surgical patients during the pandemic, it would be expected that only children who had clinical signs of appendicitis and were unwell, would have undergone surgery. Hence, the negative appendicectomy rate during the pandemic should have decreased.The aim of this retrospective study was to assess the rate of negative appendicectomy amongst children <16 years of age during the first wave of the pandemic, from the announcement of the lockdown and determine if there was a true difference by comparing the rate with the same time period in 2019.

MATERIAL AND METHODS

Data of all children aged<16 years who were operated for appendicitis between 23/3/2020 and 30/06/2020 was collected retrospectively and compared with that of children operated during the same time period in 2019 for the rate of negative appendicectomy.Data were analysed using the two-tailed t-test for continuous data and χ2 or Fishers exact tests for categorical data with p value of <0.05 considered significant.

RESULTS

Twenty three paediatric patients presenting with acute appendicitis underwent appendicectomy during the COVID-19 pandemic and 35 patients during 2019.Overall 17.39% patients underwent laparoscopic appendicectomy in 2020 while 54.29% in 2019. The negative appendicectomy rate was zero during the pandemic while it was 17.14% in 2019. There was no difference in the median length of hospital stay during the two time periods. There was no significant difference in complication or re-admission rate.

CONCLUSION

This study has the lowest reported incidence of negative appendicectomy rate during the pandemic following wider use of pre operative imaging and early senior involvement in decision making. The increased number of complicated appendicitis during the pandemic did not translate to worse clinical outcomes.

Management of Acute Appendicitis During the COVID-19 Pandemic is Significantly Different: A Retrospective Single UK Hospital Study

INTRODUCTION

The COVID-19 pandemic has led to a change in the delivery of acute and emergency surgical services. With emphasis on reducing unnecessary operative intervention and performing more CT scans, there has been a shift in managing acute appendicitis conservatively. We evaluate the impact of this shift on the management of acute appendicitis.

METHODS

A single UK centre retrospective study evaluating patients with suspected acute appendicitis pre-COVID-19 rota (18 March 2020) and post-COVID rota implementation. Data including demographics, inflammatory markers, imaging, mode of management and operative findings were collected. Logistic regression with SPSS was used to determine which factors were associated with conservative management and treated with antibiotics.

RESULTS

A total of 161 patients were analysed, 82 pre-COVID19 and 79 post-COVID19. Of the pre-COVID-19 patients, 67.07% underwent appendicectomy while the rest were conservatively managed; 24.3% of these patients underwent a CT scan only. Post-COVID-19, 22.78% of patients underwent appendicectomy with a higher percentage of diagnostic CT scans performed, 43/79 (54.4%, p <0.001). The proportion of histologically normal appendicectomies was significantly reduced in the post-COVID-19 era (12.78% vs 0.00%; p-value 0.001). Logistic regression analysis showed a normal WCC to be associated with greater likelihood of conservative management. No conservatively managed patients returned to theatre in the 30-day follow-up period.

CONCLUSION

Due to the restrictions imposed by the post-COVID-19 rota, a greater proportion of patients were managed conservatively with comparable patient outcomes. The approach also led to fewer negative appendicectomies owing to greater reliance on imaging.

CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT)

OBJECTIVE

To establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.

DESIGN

Feasibility randomised controlled trial with embedded qualitative study to inform recruiter training to optimise recruitment and the design of a future definitive trial.

SETTING

Three specialist paediatric surgery centres in the UK.

PATIENTS

Children (aged 4-15 years) with a clinical diagnosis of uncomplicated acute appendicitis.

INTERVENTIONS

Appendicectomy or a non-operative treatment pathway (comprising broad-spectrum antibiotics and active observation).

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of eligible patients recruited. Secondary outcomes evaluated adherence to interventions, data collection during follow-up, safety of treatment pathways and clinical course.

RESULTS

Fifty per cent of eligible participants (95% CI 40 to 59) approached about the trial agreed to participate and were randomised. Repeated bespoke recruiter training was associated with an increase in recruitment rate over the course of the trial from 38% to 72%. There was high acceptance of randomisation, good patient and surgeon adherence to trial procedures and satisfactory completion of follow-up. Although more participants had perforated appendicitis than had been anticipated, treatment pathways were found to be safe and adverse event profiles acceptable.

CONCLUSION

Recruitment to a randomised controlled trial examining the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy for the treatment of uncomplicated acute appendicitis in children is feasible.

TRIAL REGISTRATION NUMBER

ISRCTN15830435.

Using Machine Learning to Predict the Diagnosis, Management and Severity of Pediatric Appendicitis

Background: Given the absence of consolidated and standardized international guidelines for managing pediatric appendicitis and the few strictly data-driven studies in this specific, we investigated the use of machine learning (ML) classifiers for predicting the diagnosis, management and severity of appendicitis in children. Materials and Methods: Predictive models were developed and validated on a dataset acquired from 430 children and adolescents aged 0-18 years, based on a range of information encompassing history, clinical examination, laboratory parameters, and abdominal ultrasonography. Logistic regression, random forests, and gradient boosting machines were used for predicting the three target variables. Results: A random forest classifier achieved areas under the precision-recall curve of 0.94, 0.92, and 0.70, respectively, for the diagnosis, management, and severity of appendicitis. We identified smaller subsets of 6, 17, and 18 predictors for each of targets that sufficed to achieve the same performance as the model based on the full set of 38 variables. We used these findings to develop the user-friendly online Appendicitis Prediction Tool for children with suspected appendicitis. Discussion: This pilot study considered the most extensive set of predictor and target variables to date and is the first to simultaneously predict all three targets in children: diagnosis, management, and severity. Moreover, this study presents the first ML model for appendicitis that was deployed as an open access easy-to-use online tool. Conclusion: ML algorithms help to overcome the diagnostic and management challenges posed by appendicitis in children and pave the way toward a more personalized approach to medical decision-making. Further validation studies are needed to develop a finished clinical decision support system.

A Study on the Clinical Factors Associated with Acute Appendicitis and Perforated Appendicitis among Children in a Secondary Medical Centre in Malaysia

Background

Appendicitis complicated with appendiceal perforation is common among children. The delay in diagnosis of appendicitis is due to children’s varied presentations and their difficulty in communicating symptoms. We aimed to identify clinical factors that aid in predicting acute appendicitis (AA) and perforated appendicitis (PA) among children.

Methods

This retrospective study involved 215 children aged 12 years and below with the initial diagnosis of AA and PA. Clinical factors studied were demographics, presenting symptoms, body temperature on admission (BTOA), white cell count (WCC), absolute neutrophil count (ANC), platelet count and urinalysis. Simple and multiple logistic regressions were used to determine the odds ratio of the statistically significant clinical factors. Results: The mean age of the included children was 7.98 ± 2.37 years. The odds of AA increased by 2.177 times when the age was ≥ 8 years (P = 0.022), 2.380 times when duration of symptoms ≥ 2 days (P = 0.011), 2.447 times with right iliac fossa (RIF) pain (P = 0.007), 2.268 times when BTOA ≥ 38 °C (P = 0.020) and 2.382 times when neutrophil percentage was ≥ 76% (P = 0.045). It decreased by 0.409 times with non-RIF pain (P = 0.007). The odds of PA was increased by 4.672 times when duration of symptoms ≥ 2 days (P = 0.005), 3.611 times when BTOA ≥ 38 °C (P = 0.015) and 3.678 times when neutrophil percentage ≥ 76% (P = 0.016). There was no significant correlation between WCC and ANC with AA and PA.

Conclusion

Older children with longer duration of symptoms, RIF pain and higher BTOA are more likely to have appendicitis. The risk of appendiceal perforation increases with longer duration of symptoms and higher BTOA.

Management and early outcomes of children with appendicitis in the UK and Ireland during the COVID-19 pandemic: a survey of surgeons and observational study

OBJECTIVES

Acute appendicitis is the most common surgical condition in children. In the UK, appendicectomy is the most common treatment with non-operative management unusual. Due to concerns about the risk of SARS-CoV-2 transmission during surgical procedures, surgeons were advised to consider non-operative treatment and avoid laparoscopy where possible. This study aims to report management and outcomes, to date, of children with appendicitis in the UK and Ireland during the COVID-19 pandemic.

DESIGN

Survey of consultant surgeons who treat children with appendicitis that informed a prospective multicentre observational cohort study.

SETTING

Data were collected from centres in the UK and Ireland for cases admitted between 1 April and 31 May 2020 (first 2 months of the COVID-19 pandemic) at both general surgical and specialist paediatric surgical centres.

PARTICIPANTS

The study cohort includes 838 children with a clinical and/or radiological diagnosis of acute appendicitis of which 527 (63%) were male.

MAIN OUTCOMES MEASURED

Primary outcome was treatment strategy used for acute appendicitis. Other outcomes reported include change in treatment strategy over time, use of diagnostic imaging and important patient outcomes to 30 days following hospital admission.

RESULTS

From very early in the pandemic surgeons experienced a change in their management of children with appendicitis and almost all surgeons who responded to the survey anticipated further changes during the pandemic. Overall, 326/838 (39%) were initially treated non-operatively of whom 81/326 (25%) proceeded to appendicectomy within the initial hospital admission. Of cases treated initially surgically 243/512 (48%) were performed laparoscopically. Diagnostic imaging was used in 445/838 (53%) children. Cases treated non-operatively had a shorter hospital stay than those treated surgically but hospital readmissions within 30 days were similar between groups. In cases treated surgically the negative appendicectomy rate was 4.5%. There was a trend towards increased use of surgical treatment and from open to laparoscopic appendicectomy as the pandemic progressed.

CONCLUSION

Non-operative treatment of appendicitis has been widely used for the first time in children in the UK and Ireland and is safe and effective in selected patients. Overall patient outcomes do not appear to have been adversely impacted by change in management during the pandemic thus far.