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Worrall JC, Al-Dujaili H, Macdonald DB. Just the facts: radiation from CT scanning. CAN J EMERG MED 2024; 26:619-621. [PMID: 38802559 DOI: 10.1007/s43678-024-00714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 04/27/2024] [Indexed: 05/29/2024]
Affiliation(s)
- J C Worrall
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - H Al-Dujaili
- Department of Radiology, Stanford University School of Medicine, Stanford, USA
| | - D B Macdonald
- Department of Medical Imaging, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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2
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Chawla T, Gopee-Ramanan P, Green CR, Hartery A, Kassam Z, Murray N, Vu KN, Kirkpatrick IDC. CAR/CETARS/CSAR Practice Guideline on Imaging the Adult Patient With Right Lower Quadrant Pain. Can Assoc Radiol J 2024:8465371241266568. [PMID: 39066632 DOI: 10.1177/08465371241266568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
In 2023, the Canadian Society of Abdominal Radiology (CSAR) and Canadian Emergency, Trauma, and Acute Care Radiology Society (CETARS) received Canadian Association of Radiologists (CAR) member feedback that there was an unmet educational need for guidance in the imaging investigation of right lower quadrant (RLQ) pain. Members requested specific guidance on how to handle controversial scenarios including which test to order when, specifics of imaging protocols, and managing pregnant patients who have RLQ pain-all from a Canadian perspective. After conducting an exhaustive literature review, the working group agreed that a Canadian-specific set of guidelines was warranted. The management recommendations presented in this guideline were discussed as a group to achieve expert consensus. As the workup for RLQ pain can vary considerably in the paediatric population, the scope of this paper was restricted to adults (18 years of age or older). Whenever possible, the best evidence was used to inform the clinical guidance, and where gaps existed, the guidelines reflect consensus among experts in the field. The result is a framework to aid in this process of managing patients with RLQ pain across various clinical scenarios while addressing current questions and controversies, particularly those most relevant to the Canadian healthcare system.
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Affiliation(s)
- Tanya Chawla
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Prasaanthan Gopee-Ramanan
- Department of Radiology, McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Angus Hartery
- Discipline of Radiology, Faculty of Medicine, Memorial University of Newfoundland, Health Sciences Centre, St John's, NL, Canada
| | - Zahra Kassam
- Department of Medical Imaging, Western University, London, ON, Canada
- St. Joseph's Health Care London, London, ON, Canada
| | - Nicolas Murray
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Kim-Nhien Vu
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Université de Montréal, Montréal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
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3
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Brook OR, Dadour JR, Robbins JB, Wasnik AP, Akin EA, Borloz MP, Dawkins AA, Feldman MK, Jones LP, Learman LA, Melamud K, Patel-Lippmann KK, Saphier CJ, Shampain K, Uyeda JW, VanBuren W, Kang SK. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update. J Am Coll Radiol 2024; 21:S3-S20. [PMID: 38823952 DOI: 10.1016/j.jacr.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Joseph R Dadour
- Research Author, Centre Hospitalier de l'Université de Montréal, Montréal, Montreal, Quebec, Canada
| | | | - Ashish P Wasnik
- Panel Vice Chair, University of Michigan, Ann Arbor, Michigan
| | - Esma A Akin
- The George Washington University Medical Center, Washington, District of Columbia; Commission on Nuclear Medicine and Molecular Imaging
| | - Matthew P Borloz
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Emergency Physicians
| | | | | | - Lisa P Jones
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Learman
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Kira Melamud
- New York University Langone Health, New York, New York
| | | | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | | | - Jennifer W Uyeda
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
| | | | - Stella K Kang
- Specialty Chair, New York University Medical Center, New York, New York
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4
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Choi HU, Cho J, Hwang J, Lee S, Chang W, Park JH, Lee KH. Diagnostic performance and image quality of an image-based denoising algorithm applied to radiation dose-reduced CT in diagnosing acute appendicitis. Abdom Radiol (NY) 2024; 49:1839-1849. [PMID: 38411690 PMCID: PMC11213764 DOI: 10.1007/s00261-024-04246-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE To evaluate diagnostic performance and image quality of ultralow-dose CT (ULDCT) in diagnosing acute appendicitis with an image-based deep-learning denoising algorithm (IDLDA). METHODS This retrospective multicenter study included 180 patients (mean ± standard deviation, 29 ± 9 years; 91 female) who underwent contrast-enhanced 2-mSv CT for suspected appendicitis from February 2014 to August 2016. We simulated ULDCT from 2-mSv CT, reducing the dose by at least 50%. Then we applied an IDLDA on ULDCT to produce denoised ULDCT (D-ULDCT). Six radiologists with different experience levels (three board-certified radiologists and three residents) independently reviewed the ULDCT and D-ULDCT. They rated the likelihood of appendicitis and subjective image qualities (subjective image noise, diagnostic acceptability, and artificial sensation). One radiologist measured image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). We used the receiver operating characteristic (ROC) analyses, Wilcoxon's signed-rank tests, and paired t-tests. RESULTS The area under the ROC curves (AUC) for diagnosing appendicitis ranged 0.90-0.97 for ULDCT and 0.94-0.97 for D-ULDCT. The AUCs of two residents were significantly higher on D-ULDCT (AUC difference = 0.06 [95% confidence interval, 0.01-0.11; p = .022] and 0.05 [0.00-0.10; p = .046], respectively). D-ULDCT provided better subjective image noise and diagnostic acceptability to all six readers. However, the response of board-certified radiologists and residents differed in artificial sensation (all p ≤ .003). D-ULDCT showed significantly lower image noise, higher SNR, and higher CNR (all p < .001). CONCLUSION An IDLDA can provide better ULDCT image quality and enhance diagnostic performance for less-experienced radiologists.
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Affiliation(s)
- Hyeon Ui Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea.
| | - Jinhee Hwang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Seungjae Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Won Chang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Korea
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5
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Han JW, Son J, Oh C. Features of colonic diverticulitis in children and adolescents: A multicenter study. Asian J Surg 2024; 47:2195-2199. [PMID: 38388263 DOI: 10.1016/j.asjsur.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/21/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Colonic diverticulitis (CD), typically seen in the elderly of Western countries, is increasingly prevalent worldwide, yet data on CD in children and adolescents are scarce. This study explores the characteristics of CD in this younger demographic. METHODS In a multicenter, retrospective review, 104 patients under 20 years diagnosed with CD at four Korean tertiary hospitals from June 2003 to December 2020 were analyzed. Abdominal CT scans were used for diagnosis, with the modified Hinchey classification assessing the severity of CD. RESULTS CD was found in the cecum or ascending colon in 103 (99%) of cases. The mean patient age was 17.24 ± 2.4 years, with males constituting 59.6% of cases. Solitary lesions were noted in 93 (89.4%) of patients. Severity was classified as modified Hinchey stage 0 in 58.7%, stage Ia in 29.8%, and stage Ib in 11.5%, with no cases of stage II or higher. Misdiagnosis as acute appendicitis occurred in six instances. IV antibiotics were administered to 68.3%, and oral antibiotics were sufficient for 24%. Surgical treatment was necessary for two patients. A 7.8% recurrence rate was noted among first-time CD patients, yet all cases were amenable to conservative management. CONCLUSION While uncommon, CD in children and adolescents is a growing concern, with most cases presenting as solitary lesions in the cecum or ascending colon. The severity is typically less than that in adults, and conservative treatment is generally effective. These findings underscore the need for specific management guidelines for pediatric CD, advocating for non-surgical initial approaches.
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Affiliation(s)
- Ji-Won Han
- Department of Surgery, Ewha Womans University Seoul Hospital, Seoul, South Korea
| | - Joonhyuk Son
- Department of Pediatric Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Chaeyoun Oh
- Department of Surgery, Korea University College of Medicine, Ansan, South Korea.
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6
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Wang K, Nyandoro MG, Teoh M, Naunton-Morgan R. Emphasizing the Clinical Diagnosis of Acute Appendicitis Amidst Technological Advancements. Cureus 2024; 16:e60555. [PMID: 38957595 PMCID: PMC11218429 DOI: 10.7759/cureus.60555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2024] [Indexed: 07/04/2024] Open
Abstract
Background The clinical diagnosis of acute appendicitis (AA) can be challenging. This study aimed to evaluate the significance of this diagnosis amidst technological progress. It compared clinical diagnosis to radiology-aided diagnostic outcomes and negative appendicectomy rates (NAR). Methodology This study conducted a single-center retrospective and prospective cohort observational study on all adult patients presenting with suspected AA in 2018 at a major tertiary teaching hospital in Perth, Western Australia. Key demographics, clinicopathological, radiology, and operative reports were reviewed. Data were analyzed using SPSS v.27. Results Of 418 patients with suspected AA, 234 (56%) were in the retrospective group. The median age was 35 (IQR=26), and 224 (54%) were female. The overall NAR was 18.6% (95% CI (14.8-22.4)) and 20.8% for clinical diagnosis. Notably, the NAR for ultrasound (USS)-reported AA (false positive) was 17.6% (95% CI (10.6-27.4)). Three-quarters of the patients, 298 (71.3%), had radiological imaging. The most common modality was CT 176 (59.1%), and 33 (7.9%) had both CT and USS imaging performed. Compared with final histopathology, no significant difference was found in the accuracy of clinically diagnosed and USS-diagnosed cases, with rates of 83.5% and 82.5%, respectively (p=0.230). CT had the best positive predictive value at 82.1%. Single-modality imaging did not cause a significant surgical delay (p=0.914), but multi-modal imaging showed a non-significant trend toward delay (p=0.065). When surgeons assessed an appendix as normal, 54 (12.9%), the histopathological assessment revealed pathology in 28 (51.9%). The inter-observer agreement was only fair to moderate, Kappa=0.46 (95% CI (0.33-0.58); p<0.001). The intraoperative identification of a normal appendix inversely correlated to the grade of the primary surgeon, which was likely related to the number of surgical personnel in the theater (p<0.001). Conclusion This study showed that clinical diagnosis matches the diagnostic accuracy of imaging technologies. Utilizing diagnostic imaging methods promptly and appropriately did not lead to considerable delays in surgery. Surgeons' capability to diagnose appendicitis during surgery is moderately accurate. Most patients underwent imaging, with CT scans being the most common. Moving forward, practitioners must minimize excessive reliance on imaging techniques as this can be resource-intensive, especially in developing countries. Future clinical practice should balance embracing technological advancements and preserving essential clinical diagnostic expertise, for medicine is both a science and an art.
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Affiliation(s)
- Katie Wang
- General Surgery, Sir Charles Gairdner Hospital, Perth, AUS
| | | | - Mary Teoh
- General and Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, AUS
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7
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Mostafa R, El-Atawi K. Misdiagnosis of Acute Appendicitis Cases in the Emergency Room. Cureus 2024; 16:e57141. [PMID: 38681367 PMCID: PMC11055627 DOI: 10.7759/cureus.57141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Acute appendicitis (AA) is one of the most frequent surgical emergencies, especially in pediatric populations, with its misdiagnosis in emergency settings presenting significant health risks. This misdiagnosis leads to various complications, such as delayed treatment or unnecessary surgeries. Factors such as age, gender, and comorbidities contribute to diagnostic errors, leading to complications such as peritonitis and increased negative appendectomy rates. This underscores the importance of accurate clinical assessment and awareness of common pitfalls, such as cognitive biases and over-reliance on laboratory tests. This review delves into the prevalence of AA misdiagnosis, its health burden, and the challenges inherent in the diagnostic process. It scrutinizes the effectiveness of different diagnostic approaches, including clinical assessment and imaging techniques. The treatment paradigms for AA are also explored, focusing on surgical interventions and the potential of conservative treatments using antibiotics. The review underscores the criticality of precise diagnosis in preventing adverse outcomes and ensuring effective treatment.
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Affiliation(s)
- Reham Mostafa
- Department of Emergency Medicine, Al Zahra Hospital Dubai (AZHD), Dubai, ARE
| | - Khaled El-Atawi
- Pediatrics/Neonatal Intensive Care Unit, Latifa Women and Children Hospital, Dubai, ARE
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8
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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9
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Zhu C, Dev H, Sharbatdaran A, He X, Shimonov D, Chevalier JM, Blumenfeld JD, Wang Y, Teichman K, Shih G, Goel A, Prince MR. Clinical Quality Control of MRI Total Kidney Volume Measurements in Autosomal Dominant Polycystic Kidney Disease. Tomography 2023; 9:1341-1355. [PMID: 37489475 PMCID: PMC10366880 DOI: 10.3390/tomography9040107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023] Open
Abstract
Total kidney volume measured on MRI is an important biomarker for assessing the progression of autosomal dominant polycystic kidney disease and response to treatment. However, we have noticed that there can be substantial differences in the kidney volume measurements obtained from the various pulse sequences commonly included in an MRI exam. Here we examine kidney volume measurement variability among five commonly acquired MRI pulse sequences in abdominal MRI exams in 105 patients with ADPKD. Right and left kidney volumes were independently measured by three expert observers using model-assisted segmentation for axial T2, coronal T2, axial single-shot fast spin echo (SSFP), coronal SSFP, and axial 3D T1 images obtained on a single MRI from ADPKD patients. Outlier measurements were analyzed for data acquisition errors. Most of the outlier values (88%) were due to breathing during scanning causing slice misregistration with gaps or duplication of imaging slices (n = 35), slice misregistration from using multiple breath holds during acquisition (n = 25), composing of two overlapping acquisitions (n = 17), or kidneys not entirely within the field of view (n = 4). After excluding outlier measurements, the coefficient of variation among the five measurements decreased from 4.6% pre to 3.2%. Compared to the average of all sequences without errors, TKV measured on axial and coronal T2 weighted imaging were 1.2% and 1.8% greater, axial SSFP was 0.4% greater, coronal SSFP was 1.7% lower and axial T1 was 1.5% lower than the mean, indicating intrinsic measurement biases related to the different MRI contrast mechanisms. In conclusion, MRI data acquisition errors are common but can be identified using outlier analysis and excluded to improve organ volume measurement consistency. Bias toward larger volume measurements on T2 sequences and smaller volumes on axial T1 sequences can also be mitigated by averaging data from all error-free sequences acquired.
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Affiliation(s)
- Chenglin Zhu
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY 14850, USA
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Hreedi Dev
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Arman Sharbatdaran
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Xinzi He
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY 14850, USA
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Daniil Shimonov
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
- The Rogosin Institute, New York, NY 10021, USA
| | - James M. Chevalier
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
- The Rogosin Institute, New York, NY 10021, USA
| | - Jon D. Blumenfeld
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
- The Rogosin Institute, New York, NY 10021, USA
| | - Yi Wang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY 14850, USA
| | - Kurt Teichman
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - George Shih
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Akshay Goel
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Martin R. Prince
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
- Columbia College of Physicians and Surgeons, New York, NY 10032, USA
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10
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Cho J, Kim HY, Lee S, Park JH, Lee KH. Radiology Residents' Independent Diagnosis of Appendicitis Using 2-mSv Computed Tomography: A Secondary Analysis of a Large Pragmatic Randomized Trial. Korean J Radiol 2023; 24:529-540. [PMID: 37271207 DOI: 10.3348/kjr.2023.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/28/2023] [Accepted: 04/04/2023] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVE To compare the diagnostic performance and clinical outcomes of 2-mSv computed tomography (CT) and conventional-dose CT (CDCT), following radiology residents' interpretation of CT examinations for suspected appendicitis. MATERIALS AND METHODS Altogether, 3074 patients with suspected appendicitis aged 15-44 years (28 ± 9 years, 1672 females) from 20 hospitals were randomly assigned to the 2-mSv CT (n = 1535) or CDCT (n = 1539) groups in a pragmatic trial from December 2013 and August 2016. Overall, 107 radiology residents participated in the trial as readers in the form of daily practice after online training for 2-mSv CT. They made preliminary CT reports, which were later finalized by attending radiologists via addendum reports, for 640 and 657 patients in the 2-mSv CT and CDCT groups, respectively. We compared the diagnostic performance of the residents, discrepancies between preliminary and addendum reports, and clinical outcomes between the two groups. RESULTS Patient characteristics were similar between the 640 and 657 patients. Residents' diagnostic performance was not significantly different between the 2-mSv CT and CDCT groups, with a sensitivity of 96.0% and 97.1%, respectively (difference [95% confidence interval {CI}], -1.1% [-4.9%, 2.6%]; P = 0.69) and specificity of 93.2% and 93.1%, respectively (0.1% [-3.6%, 3.7%]; P > 0.99). The 2-mSv CT and CDCT groups did not significantly differ in discrepancies between the preliminary and addendum reports regarding the presence of appendicitis (3.3% vs. 5.2%; -1.9% [-4.2%, 0.4%]; P = 0.12) and alternative diagnosis (5.5% vs. 6.4%; -0.9% [-3.6%, 1.8%]; P = 0.56). The rates of perforated appendicitis (12.0% vs. 12.6%; -0.6% [-4.3%, 3.1%]; P = 0.81) and negative appendectomies (1.9% vs. 1.1%; 0.8% [-0.7%, 2.3%]; P = 0.33) were not significantly different between the two groups. CONCLUSION Diagnostic performance and clinical outcomes were not significantly different between the 2-mSv CT and CDCT groups following radiology residents' CT readings for suspected appendicitis.
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Affiliation(s)
- Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hae Young Kim
- Department of Radiology, Asan Medical Center, Seoul, Korea.
| | - Seungjae Lee
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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Zhang R, Zhao ZM, Zhang CD. Laboratory biomarker as an alternative to low-dose computed tomography for the diagnosis of suspected appendicitis? Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study. Int J Surg 2023; 109:1524-1525. [PMID: 37010153 PMCID: PMC10389477 DOI: 10.1097/js9.0000000000000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Rui Zhang
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute
| | - Zhe-Ming Zhao
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
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Choi K, Choi JY, Kim HJ, Kim HJ, Jang SK. Added Value of Structured Reporting for US of the Pediatric Appendix: Additional CT Examinations and Negative Appendectomy. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:653-662. [PMID: 37324982 PMCID: PMC10265224 DOI: 10.3348/jksr.2022.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/06/2022] [Accepted: 09/02/2022] [Indexed: 06/17/2023]
Abstract
Purpose This study aimed to determine the incremental value of using a structured report (SR) for US examinations of the pediatric appendix. Materials and Methods Between January 2009 and June 2016, 1150 pediatric patients with suspected appendicitis who underwent US examinations of the appendix were included retrospectively. In November 2012, we developed a five-point scale SR for appendix US examinations. The patients were divided into two groups according to the form of the US report: free-text or SR. The primary clinical outcomes were compared between the two groups, including the rate of CT imaging following US examinations, the negative appendectomy rate (NAR), and the appendiceal perforation rate (PR). Results In total, 550 patients were included in the free-text group and 600 patients in the SR group. The rate of additional CT examinations decreased by 5.3% in the SR group (8.2%, p = 0.003), and the NAR decreased by 8.4% in the SR group (7.8%, p = 0.028). There was no statistical difference in the appendiceal PR (37.6% vs. 48.0%, p = 0.078). Conclusion The use of an SR to evaluate US examinations for suspected pediatric appendicitis results in lower CT use and fewer negative appendectomies without an increase in appendiceal PR.
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Borruel Nacenta S, Ibáñez Sanz L, Sanz Lucas R, Depetris M, Martínez Chamorro E. Update on acute appendicitis: Typical and untypical findings. RADIOLOGÍA (ENGLISH EDITION) 2023; 65 Suppl 1:S81-S91. [PMID: 37024234 DOI: 10.1016/j.rxeng.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/08/2022] [Indexed: 04/08/2023]
Abstract
Acute appendicitis is the most common indication for emergency abdominal surgery throughout the world and a common reason for consultation in emergency departments. In recent decades, diagnostic imaging has played a fundamental role in identifying acute appendicitis, helping to reduce the rate of blind laparotomies and hospital costs. Given the results of clinical trials supporting the use of antibiotic therapy over surgical treatment, radiologists need to know the diagnostic criteria for complicated acute appendicitis to be able to recommend the best treatment option. This review aims not only to define the diagnostic criteria for appendicitis in different imaging modalities (ultrasonography, computed tomography, and magnetic resonance imaging), but also to explain the diagnostic protocols, atypical presentations, and other conditions that can mimic appendicitis.
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Salinas-Castro KJ, Mejía-Quiñones V, Zúñiga-Londoño NY. Acute appendicitis after closed abdominal trauma: A case report. Radiol Case Rep 2023; 18:631-634. [DOI: 10.1016/j.radcr.2022.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022] Open
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Lemmons J, Adindu E, Igwe M, Godfrey C, Booker A, Dongarwar D, Salihu HM. Racial and insurance status disparities in imaging modality among pediatric patients diagnosed with appendicitis. J Natl Med Assoc 2023; 115:66-72. [PMID: 36588062 DOI: 10.1016/j.jnma.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/05/2022] [Accepted: 11/28/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Studies have assessed the type of diagnostic imaging used in the treatment of appendicitis in children. Few studies investigated racial/ethnic and insurance disparities in imaging modalities used in pediatric patients diagnosed with appendicitis. Our study seeks to determine whether race/ethnicity and insurance status are associated with imaging modality chosen for pediatric patients diagnosed with appendicitis in the emergency department. METHODS This was a retrospective cohort study utilizing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2019. We included children <18 years old with a ICD-9-CM and ICD-10-CM diagnosis of appendicitis. Exposures were patient race/ethnicity and insurance status. Outcome of interest was imaging modality. We conducted adjusted survey logistic regression to evaluate the patient characteristics and receipt each of the imaging modalities among those with a diagnosis of appendicitis. RESULTS Of 308,140,115 emergency department (ED) visits, 1,126,865 (0.37%) had a diagnosis of appendicitis. Overall, male patients were more likely to receive CAT scan in comparison to female children (OR=2.52, 95% CI= 1.16-5.49). Additionally, Hispanic children who had significantly greater odds of obtaining ultrasound (OR= 4.56, 95% CI=1.09-19.12). Hispanic children were also less likely to receive x-ray (OR= 0.31, 95% CI=0.11-0.89) or computed tomography (CT) scans (OR= 0.23, 95% CI=0.07-0.76). Children diagnosed with appendicitis who had insurance other than private, Medicare, Medicaid, or self-pay were significantly more likely to receive x-ray studies (OR=4.39, 95% CI= 1.23-15.69). CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS This study demonstrated the presence of racial/ethnic and insurance status disparities in the imaging modality chosen to assist in diagnosing appendicitis in pediatric patients.
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Affiliation(s)
- Jasmine Lemmons
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA.
| | - Ebubechi Adindu
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA
| | - Michael Igwe
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA
| | - Chelsea Godfrey
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA
| | - Aleah Booker
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training, and Research, Baylor College o Medicine, Houston, TX, USA; Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
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Yang HB, Song HB, Han JW, Youn JK, Ko D, Ryu YJ, Kim JY, Kim HY. Clinical course in children with equivocal appendicitis on computed tomography: a retrospective cohort study. Ann Surg Treat Res 2023; 104:51-59. [PMID: 36685769 PMCID: PMC9830045 DOI: 10.4174/astr.2023.104.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose Appendectomy is one of the most common surgeries in children. Although various radiological examinations are performed, they do not always reveal a definitive diagnosis of appendicitis. This study aimed to investigate the clinical course of equivocal appendicitis, identify the factors associated with appendectomy, and suggest appropriate management for these patients. Methods Patients younger than 19 years who visited Seoul National University Bundang Hospital with a differential diagnosis of appendicitis from January 2013 to December 2017 were included. All participants conducted 'appendiceal CT' with a scoring scale of 1-5. The higher the score, the higher the likelihood of a radiologic diagnosis of appendicitis. We defined the appendicitis CT score of 2-4 as equivocal appendicitis (n = 143). Medical records were reviewed retrospectively for demographics, further examination as abdominal ultrasonography, and appendectomy status (yes or no). The mean follow-up period was 15.6 ± 71 days. Results Equivocal appendicitis accounted for 16.7%. Additional ultrasonography test was performed in 24.5% (35 of 143). In total, 34 patients (23.8%) underwent appendectomy. Among the patients with appendiceal CT scores 2, 3, and 4, 4.9%, 50.0%, and 87.5% underwent appendectomy, respectively. Higher WBC count, higher appendicitis CT score, and readmission were significantly associated with appendectomy in patients with equivocal appendicitis. Conclusion Higher appendicitis CT score and WBC level were positively associated with appendectomy. Careful observation can be a treatment option in appendicitis CT score 2 or 3 groups. Appendectomy is the first-line treatment for patients with appendicitis score 4. Additional ultrasonography test is advisable to determine treatment modality for equivocal appendicitis.
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Affiliation(s)
- Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Han-Byol Song
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji-Won Han
- Department of Surgery, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Young Jin Ryu
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea.,Department of Surgery, College of Medicine, Seoul National University, Seoul, Korea
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Daytime versus nighttime laparoscopic appendectomy in term of complications and clinical outcomes: A retrospective study of 1001 appendectomies. Heliyon 2022; 8:e11911. [PMID: 36478845 DOI: 10.1016/j.heliyon.2022.e11911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/25/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
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Kambadakone AR, Santillan CS, Kim DH, Fowler KJ, Birkholz JH, Camacho MA, Cash BD, Dane B, Felker RA, Grossman EJ, Korngold EK, Liu PS, Marin D, McCrary M, Pietryga JA, Weinstein S, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Right Lower Quadrant Pain: 2022 Update. J Am Coll Radiol 2022; 19:S445-S461. [PMID: 36436969 DOI: 10.1016/j.jacr.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
This document focuses on imaging in the adult and pregnant populations with right lower quadrant (RLQ) abdominal pain, including patients with fever and leukocytosis. Appendicitis remains the most common surgical pathology responsible for RLQ abdominal pain in the United States. Other causes of RLQ pain include right colonic diverticulitis, ureteral stone, and infectious enterocolitis. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of the experts. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Avinash R Kambadakone
- Division Chief, Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts; Medical Director, Martha's Vineyard Hospital Imaging.
| | - Cynthia S Santillan
- Vice Chair of Clinical Operations, University of California, San Diego, San Diego, California
| | - David H Kim
- Panel Chair; Vice Chair of Education, Department of Radiology, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California. ACR LI-RADS; Division Chief, SAR Portfolio Director; RSNA Radiology Senior DE
| | - James H Birkholz
- Divisional Director, Quality and Safety (Abdominal Imaging), Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Radiology Representative to the Interdisciplinary Dysmotility (GIMIG) Conference
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida; Committee on Emergency Radiology-GSER
| | - Brooks D Cash
- Chief of Gastroenterology, Hepatology, and Nutrition Division, University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Bari Dane
- Director of Body CT, Abdominal Imaging; Director of Quality and Safety Outpatient Imaging, NYU Grossman School of Medicine, New York, New York
| | - Robin A Felker
- Associate Clerkship Director for Internal Medicine, Georgetown University; Primary care physician, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Eric J Grossman
- Medical Director, Multi-Specialty Clinic, Santa Barbara Cottage Hospital, Santa Barbara, California; American College of Surgeons
| | - Elena K Korngold
- Section Chief, Body Imaging, Chair, Department of Radiology Promotion and Tenure Committee, Oregon Health and Science University, Portland, Oregon
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Marion McCrary
- Associate Director of Duke GME Coaching, Duke Signature Care, Durham, North Carolina; American College of Physicians; Governor-Elect, American College of Physicians North Carolina Chapter
| | | | | | - Katherine Zukotynski
- Co-Associate Chair for Research, Department of Radiology, McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair; Section Chief Abdominal Imaging, Director of MRI and CT, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Rafique U, Elfeky MA, Bhatti K, Siddique K. Does Diagnostic Laparoscopy Still Have a Role in the Evaluation of Right Iliac Fossa Pain Versus Imaging Techniques or Experience? Cureus 2022; 14:e30678. [PMID: 36439602 DOI: 10.7759/cureus.30678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
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Cai X, Bi J, Zheng Z, Liu Y. Decision-making changes for patients and medical personnel in the management of acute appendicitis during the COVID-19 pandemic. BMC Emerg Med 2022; 22:170. [PMID: 36280806 PMCID: PMC9590391 DOI: 10.1186/s12873-022-00727-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute appendicitis is the most common cause of acute abdomen. During the pandemic, to contain the spread of COVID-19, there were some integral changes in the medical processes based on the pandemic prevention policy, especially regarding emergency surgery. This study was conducted to investigate whether this pandemic also impacted the decision-making for both patients and medical personnel along with the treatment outcomes. METHODS Patients of age 18 years or older who were diagnosed clinically and radiologically with acute appendicitis between Jan 1, 2017, and Dec 31, 202,0 were reviewed. The data of 1991 cases were collected and used for this study. Two groups were formed, one group before and the other group after the outbreak. The gathered data included gender, age, appendiceal fecalith, outcomes of treatment, and long-term outcomes of non-operation (8 months follow-up). We also collected details of surgical cases from the above two groups. This data also included age, gender, appendiceal fecalith, fever, jaundice, length of onset before presenting to an emergency department (ED), anesthesia, surgery, white cell count, pathology, complications, and length of stay. We compared the above data respectively and analyzed the differences. RESULTS Compared to the period before the outbreak, patient visits for acute appendicitis remarkably dropped (19.8%), but surgical cases showed no change (dropped by roughly 5%). There were significant differences (P < 0.05) in failure of non-operation(after the pandemic 8.31% vs. before pandemic 3.22%), interval appendectomy(after pandemic 6.29% vs. before pandemic 12.84%), recurrence(after pandemic 23.27% vs. before pandemic 14.46%), and outcomes of recurrence. There was a significant difference (P < 0.05) in anesthesia method, surgery way, and complications( before pandemic 4.15% vs. after pandemic9.89% P < 0.05) in patients who underwent the surgery. There was no statistical difference (P > 0.05) concerning age, gender, fever, jaundice, appendiceal fecalith, white cell count, and length of onset before presenting to the ED. CONCLUSION The current pandemic prevention policy is very effective, but some decision-making processes of doctor-patient have changed in the context of COVID-19 pandemic, that further influenced some treatment outcomes and might lead to a potential economic burden. It is essential to address the undue concern of everyone and optimize the treatment process.
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Affiliation(s)
- Xuan Cai
- grid.414360.40000 0004 0605 7104Department of General Surgery, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, 100035 Beijing, China
| | - Jingtao Bi
- grid.414360.40000 0004 0605 7104Department of General Surgery, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, 100035 Beijing, China
| | - Zhixue Zheng
- grid.414360.40000 0004 0605 7104Department of General Surgery, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, 100035 Beijing, China
| | - Yaqi Liu
- grid.414360.40000 0004 0605 7104Department of General Surgery, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, 100035 Beijing, China
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Actualización de la apendicitis aguda: hallazgos típicos y atípicos. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Diagnostic accuracy of computed tomography and ultrasound for the diagnosis of acute appendicitis: A systematic review and meta-analysis. Radiography (Lond) 2022; 28:1127-1141. [PMID: 36130469 DOI: 10.1016/j.radi.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/10/2022] [Accepted: 08/24/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The diagnosis of acute appendicitis remains challenging. This review determined the current diagnostic accuracy of CT and ultrasound for suspected acute appendicitis in adults. METHODS This systematic review adhered to the PRISMA for diagnostic test accuracy guidelines. A systematic search was undertaken in appropriate databases. Screening of potential titles and abstracts, full-text retrieval, methodological quality assessment using QUADAS, and data extraction was performed. Meta-analyses were performed for relevant subgroups, and sensitivity analysis was completed to account for outliers. GRADE was utilized to assess the certainty of findings. RESULTS 31 studies evaluating CT, 10 evaluating US, and six evaluating both were included. Pooled sensitivity and specificity for CT was 0.972 [0.958, 0.981] and 0.956 [0.941, 0.967] respectively, and 0.821 [0.738, 0.882] and 0.859 [0.727, 0.933] for US, respectively. When analyzing subgroups based on the use of contrast enhancement, sensitivity and specificity was highest for CT with intravenous and oral contrast (0.992 [0.965, 0.998], 0.974 [0.936, 0.99]), compared to CT with intravenous contrast (0.955 [0.922, 0.974], 0.942 [0.916, 0.960]). Low-Dose CT produced comparable values (0.934 [0.885,0.963], 0.937 [0.911, 0.955]) relative to these subgroups and standard dose non-contrast CT (0.877 [0.774,0.937], 0.914 [0.827, 0.959]). US studies which excluded equivocal findings demonstrated significantly greater values than the remainder of US studies (p < 0.0001). CONCLUSION The updated diagnostic test accuracies of CT, US and relevant subgroups should be implemented in light of factors such as dose, cost, and timing. IMPLICATIONS FOR PRACTICE For diagnosis of adult acute appendicitis: • CT with intravenous plus oral contrast enhancement yields statistically significantly greater diagnostic accuracy than CT with intravenous contrast alone. • Low-dose CT yields comparable sensitivity and specificity to standard-dose CT. • Ultrasound studies which exclude equivocal results may overinflate sensitivity and specificity.
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Yoon S, Yoo KH, Park SH, Kim H, Lee JH, Park J, Park SH, Kim HJ. Low-dose abdominopelvic computed tomography in patients with lymphoma: An image quality and radiation dose reduction study. PLoS One 2022; 17:e0272356. [PMID: 35951525 PMCID: PMC9371255 DOI: 10.1371/journal.pone.0272356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
Abstract
This study aimed to evaluate image quality, the detection rate of enlarged lymph nodes, and radiation dose exposure of ultralow-dose and low-dose abdominopelvic computed tomography (CT) in patients with lymphoma. Patients with lymphoma who underwent abdominopelvic CT using dual-source scanner were retrospectively recruited from a single center. CT images were obtained at 90 kVp dual-source mode reformatted in three data sets using the advanced modelled iterative reconstruction algorithm: 100% (standard-dose CT), 66.7% (low-dose CT), and 33.3% (ultralow-dose CT). Two radiologists analyzed subjective image quality and detection of abdominal enlarged lymph nodes on ultralow-dose, low-dose, and standard-dose CT blindly and independently. The results were compared with reference standards. Three readers (two radiologists and one hematologist) reviewed overall image quality and spleen size. In total, 128 consecutive CT scans (77 complete response, 44 partial response, 6 progressive disease, and 1 initial evaluation) from 86 patients (64 B-cell lymphoma, 14 T/NK-cell lymphoma, and 8 Hodgkin’s lymphoma cases) were assessed. The enlarged lymph node-based detection rates for two readers were 97.0% (96/99) and 94.0% (93/99) on standard-dose CT, 97.0% (96/99) and 94.0% (93/99) on low-dose CT, and 94.0% (93/99) and 89.9% (89/99) on ultralow-dose CT. Overall image quality was 3.8 ± 0.5, 3.9 ± 0.5, and 4.1 ± 0.5 on ultralow-dose CT; 4.7 ± 0.4, 4.6 ± 0.5, and 4.8 ± 0.3 on low-dose CT; and 4.8 ± 0.4, 4.7 ± 0.4, and 4.9 ± 0.2 on standard-dose CT, according to two radiologists and one hematologist, respectively. Intraclass correlation coefficients of spleen size were 0.90 (95% confidence interval [CI], 0.87–0.93), 0.91 (95% CI, 0.88–0.93), and 0.91 (95% CI, 0.88–0.93) on ultralow-dose, low-dose, and standard-dose CT, respectively. Mean effective radiation doses of standard-dose, low-dose, and ultralow-dose CT were 5.7 ±1.8 mSv, 3.8 ± 1.2 mSv, and 1.9 ± 0.6 mSv, respectively. Our findings suggest that ultralow-dose and low-dose CT, even with radiation doses reduced by 66.7% and 33.3%, respectively, maintained adequate image quality. These imaging modalities may be employed for follow-up lymphoma evaluation in consideration of the long surveillance periods.
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Affiliation(s)
- Sungjin Yoon
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kwai Han Yoo
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - So Hyun Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- * E-mail:
| | - Hawk Kim
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jae Hoon Lee
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jinny Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
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Low-Dose Abdominal CT for Evaluating Suspected Appendicitis: Recommendations for CT Imaging Techniques and Practical Issues. Diagnostics (Basel) 2022; 12:diagnostics12071585. [PMID: 35885490 PMCID: PMC9320604 DOI: 10.3390/diagnostics12071585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 12/04/2022] Open
Abstract
A vast disparity exists between science and practice for CT radiation dose. Despite high-level evidence supporting the use of low-dose CT (LDCT) in diagnosing appendicitis, a recent survey showed that many care providers were still concerned that the low image quality of LDCT may lead to incorrect diagnoses. For successful implementation of LDCT practice, it is important to inform and educate the care providers not only of the scientific discoveries but also of concrete guidelines on how to overcome more practical matters. Here, we discuss CT imaging techniques and other practical issues for implementing LDCT practice.
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Depetris M, Martínez Chamorro E, Ibáñez Sanz L, Albillos Merino J, Rodríguez Cuellar E, Borruel Nacenta S. The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: A retrospective study. RADIOLOGIA 2022; 64:506-515. [PMID: 36402536 DOI: 10.1016/j.rxeng.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/13/2020] [Indexed: 10/18/2022]
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Bolmers MDM, de Jonge J, Bom WJ, van Rossem CC, van Geloven AAW, Bemelman WA. In-hospital Delay of Appendectomy in Acute, Complicated Appendicitis. J Gastrointest Surg 2022; 26:1063-1069. [PMID: 35048258 DOI: 10.1007/s11605-021-05220-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Present theory is that uncomplicated and complicated appendicitis are different entities. Recent studies suggest it is safe to delay surgery in patients with uncomplicated appendicitis. We hypothesize that patients with complicated appendicitis are at higher risk for postoperative complications when surgery is delayed. METHODS Data was used from the multicenter, prospective SNAPSHOT appendicitis study of 1975 patients undergoing surgery for suspected appendicitis. Adult patients (≥ 18 years) who underwent appendectomy for appendicitis were included in this study. The primary outcome was the difference in postoperative complications between patients with complicated appendicitis who were operated within and after 8 h after hospital presentation. Secondary outcomes were the incidence of both uncomplicated and complicated appendicitis in relationship to delay of appendectomy. Follow-up was 30 days. A multivariable analysis was performed. RESULTS Of 1341 adult patients with appendicitis, 34.3% had complicated appendicitis. In patients with complicated appendicitis, 22.8% developed a postoperative complication compared to 8.2% for uncomplicated appendicitis (P < 0.001). Delay in surgery (> 8 h) increased the complication rate in patients with complicated appendicitis (28.1%) compared to surgery within 8 h (18.3%; P = 0.01). Multivariate analysis showed a delay in surgery as an independent predictor for a postoperative complication in patients with complicated appendicitis (OR 1.71; 95%CI 1.01-2.68, P = 0.02). CONCLUSION In-hospital delay of surgery (> 8 h) in patients with complicated appendicitis is associated with a higher risk of a postoperative complication. It is important that we recognize and treat these patients early.
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Affiliation(s)
- M D M Bolmers
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands. .,Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands.
| | - J de Jonge
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - W J Bom
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - C C van Rossem
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - A A W van Geloven
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Seghers VJ, Kan JH, Somcio R, Sher AC, Paul Guillerman R, Sammer MBK. CT imaging of esophageal foreign bodies in children: a pictorial essay. Jpn J Radiol 2022; 40:262-270. [PMID: 34661860 DOI: 10.1007/s11604-021-01201-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
Foreign body (FB) ingestion is common in children, particularly from 6 months to 3 years of age. As young children may be unable to provide a clinical history and the ingestion is often unwitnessed, imaging plays an important role in diagnosis, predicting outcomes and detecting complications that require surgical intervention. Since 2015, our institution's diagnostic algorithm for suspected airway foreign bodies has included a noncontrast airway FB CT (FB-CT) with the z-axis coverage spanning from the larynx to the proximal segmental bronchi of the lower lung zones. The effective dose of radiation from this FB-CT airway protocol is typically less than 1 mSv, compared to an effective dose of just under 1 mSv to up to 3 mSv for a fluoroscopic esophagram in children under 10 years of age and 1-3 mSv for a routine pediatric CT chest. In using the FB-CT airway protocol at our institution, we observed that esophageal rather than airway FBs were sometimes encountered on these exams. However, the confidence among radiologists for definitively diagnosing an esophageal foreign body on noncontrast CT was variable. Consequently, we created a teaching module of positive cases for our group of 21 pediatric body radiologists to increase their diagnostic confidence. This pictorial essay illustrates our institutional experience and can help others to confidently diagnose esophageal foreign bodies using a dedicated CT foreign body imaging protocol. At a similar radiation dose to a fluoroscopic esophagram, CT provides the additional advantage of an expedited diagnosis without the need for a radiologist on site.
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Affiliation(s)
- Victor J Seghers
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA.
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA.
| | - J Herman Kan
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Ray Somcio
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Andrew C Sher
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - R Paul Guillerman
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Marla B K Sammer
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
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28
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Mahajan PS, Abdulmajeed H, Aljafari A, Kolleri JJ, Dawdi SA, Mohammed H. A Cautionary Tale: Unveiling Valentino’s Syndrome. Cureus 2022; 14:e22667. [PMID: 35371708 PMCID: PMC8965196 DOI: 10.7759/cureus.22667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/05/2022] Open
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Cho J, Kim Y, Lee S, Min HD, Ko Y, Chee CG, Kim HY, Park JH, Lee KH. Appendiceal Visualization on 2-mSv CT vs. Conventional-Dose CT in Adolescents and Young Adults with Suspected Appendicitis: An Analysis of Large Pragmatic Randomized Trial Data. Korean J Radiol 2022; 23:413-425. [PMID: 35289144 PMCID: PMC8961010 DOI: 10.3348/kjr.2021.0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/29/2021] [Accepted: 11/10/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Youngjune Kim
- Aerospace Medical Group, Air Force Education and Training Command, Jinju, Korea
| | - Seungjae Lee
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Hooney Daniel Min
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yousun Ko
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | | | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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Bolmers MDM, Bom WJ, Scheijmans JCG, van Geloven AAW, Boermeester MA, Bemelman WA, van Rossem CC. Accuracy of imaging in discriminating complicated from uncomplicated appendicitis in daily clinical practice. Int J Colorectal Dis 2022; 37:1385-1391. [PMID: 35583564 PMCID: PMC9167165 DOI: 10.1007/s00384-022-04173-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Radiologic imaging can accurately diagnose acute appendicitis, but little is known about its discriminatory capacity between complicated and uncomplicated appendicitis. OBJECTIVE This study aims to investigate the accuracy of imaging in discriminating complicated from uncomplicated appendicitis. METHODS Data was used from the prospective, nationwide, observational SNAPSHOT appendicitis database, including patients with suspected acute appendicitis who were planned for an appendectomy. Usage of ultrasound (US), CT, MRI or a combination was recorded. Radiological reports were used to group for complicated or uncomplicated appendicitis. The reference standard was based on operative and pathological findings. Primary outcomes were sensitivity and specificity in discriminating complicated from uncomplicated appendicitis. Secondary outcomes were diagnostic accuracy results per imaging modality and for the subgroups age, BMI, and sex. RESULTS Preoperative imaging was performed in 1964 patients. In 1434 patients (73%), only US was used; in 109 (6%) patients, only CT was used; and 421 (21%) patients underwent US followed by CT or MRI. Overall, imaging workup as practiced, following the national guideline, had a poor sensitivity for complicated appendicitis of only 35%, although specificity was as high as 93%. For US, accuracy for complicated appendicitis was higher in children than in adults; sensitivity 41.2% vs. 26.4% and specificity 94.6% vs. 93.4%, respectively, p = 0.003. For relevant subgroups such as age, sex and BMI, no other differences in the discriminatory performance were found. CONCLUSION A diagnostic workup with stepwise imaging, using a conditional CT or MRI strategy, poorly discriminates between complicated and uncomplicated appendicitis in daily practice.
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Affiliation(s)
| | - Wouter J. Bom
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, Tergooi MC, Hilversum, The Netherlands
| | - Jochem C. G. Scheijmans
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marja. A. Boermeester
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A. Bemelman
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
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Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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32
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Schmidt FN, Hahn M, Stockhausen KE, Rolvien T, Schmidt C, Knopp T, Schulze C, Püschel K, Amling M, Busse B. Influence of X-rays and gamma-rays on the mechanical performance of human bone factoring out intraindividual bone structure and composition indices. Mater Today Bio 2021; 13:100169. [PMID: 34927043 PMCID: PMC8649390 DOI: 10.1016/j.mtbio.2021.100169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/01/2022] Open
Abstract
Doses of irradiation above 25 kGy are known to cause irreversible mechanical decay in bone tissue. However, the impact of irradiation doses absorbed in a clinical setting on the mechanical properties of bone remains unclear. In daily clinical practice and research, patients and specimens are exposed to irradiation due to diagnostic imaging tools, with doses ranging from milligray to Gray. The aim of this study was to investigate the influence of irradiation at these doses ranges on the mechanical performance of bone independent of inter-individual bone quality indices. Therefore, cortical bone specimens (n = 10 per group) from a selected organ donor were irradiated at doses of milligray, Gray and kilogray (graft tissue sterilization) at five different irradiation doses. Three-point bending was performed to assess mechanical properties in the study groups. Our results show a severe reduction in mechanical performance (work to fracture: 50.29 ± 11.49 Nmm in control, 14.73 ± 1.84 Nmm at 31.2 kGy p ≤ 0.05) at high irradiation doses of 31.2 kGy, which correspond to graft tissue sterilization or synchrotron imaging. In contrast, no reduction in mechanical properties were detected for doses below 30 Gy. These findings are further supported by fracture surface texture imaging (i.e. more brittle fracture textures above 31.2 kGy). Our findings show that high radiation doses (≥31.2 kGy) severely alter the mechanical properties of bone. Thus, irradiation of this order of magnitude should be taken into account when mechanical analyses are planned after irradiation. However, doses of 30 Gy and below, which are common for clinical and experimental imaging (e.g., radiation therapy, DVT imaging, CT imaging, HR-pQCT imaging, DXA measurements, etc.), do not alter the mechanical bending-behavior of bone.
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Affiliation(s)
- Felix N. Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Interdisciplinary Competence Center for Interface Research (ICCIR), Forum Medical Technology Health Hamburg (FMTHH), Martinistrasse 52, 20246, Hamburg, Germany
| | - Michael Hahn
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Kilian E. Stockhausen
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Constantin Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias Knopp
- Interdisciplinary Competence Center for Interface Research (ICCIR), Forum Medical Technology Health Hamburg (FMTHH), Martinistrasse 52, 20246, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Section for Biomedical Imaging, University Medical Center Hamburg-Eppendorf, Lottestrasse 55, 22529, Hamburg, Germany
| | - Christian Schulze
- Institute for Synaptic Physiology, Center for Molecular Neurobiology Hamburg, Falkenried 94, 20251, Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Interdisciplinary Competence Center for Interface Research (ICCIR), Forum Medical Technology Health Hamburg (FMTHH), Martinistrasse 52, 20246, Hamburg, Germany
- Corresponding author. Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany.
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D'Souza N, Hicks G, Beable R, Higginson A, Rud B. Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane Database Syst Rev 2021; 12:CD012028. [PMID: 34905621 PMCID: PMC8670723 DOI: 10.1002/14651858.cd012028.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
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Affiliation(s)
| | | | | | | | - Bo Rud
- Gastrounit, Copenhagen University Hospital Hvidovre , Hvidovre, Denmark
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Haijanen J, Sippola S, Tammilehto V, Grönroos J, Mäntyoja S, Löyttyniemi E, Niiniviita H, Salminen P. Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study. Br J Surg 2021; 108:1483-1490. [PMID: 34761262 PMCID: PMC10364876 DOI: 10.1093/bjs/znab383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. METHODS This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. RESULTS Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001). CONCLUSION Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Ville Tammilehto
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Siiri Mäntyoja
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | | | - Hannele Niiniviita
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Lin HA, Tsai HW, Chao CC, Lin SF. Periappendiceal fat-stranding models for discriminating between complicated and uncomplicated acute appendicitis: a diagnostic and validation study. World J Emerg Surg 2021; 16:52. [PMID: 34645500 PMCID: PMC8511616 DOI: 10.1186/s13017-021-00398-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/03/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Recent studies have reported promising outcomes of non-operative treatment for uncomplicated appendicitis; however, the preoperative prediction of complicated appendicitis is challenging. We developed models by incorporating fat stranding (FS), which is commonly observed in perforated appendicitis. MATERIAL AND METHODS We reviewed the data of 402 consecutive patients with confirmed acute appendicitis from our prospective registry. Multivariate logistic regression was performed to select clinical and radiographic factors predicting complicated acute appendicitis in our model 1 (involving backward elimination) and model 2 (involving stepwise selection). We compared c statistics among scoring systems developed by Bröker et al. (in J Surg Res 176(1):79-83. https://doi.org/10.1016/j.jss.2011.09.049 , 2012), Imaoka et al. (in World J Emerg Surg 11(1):1-5, 2016), Khan et al. (in Cureus. https://doi.org/1010.7759/cureus.4765 , 2019), Kim et al. (in Ann Coloproctol 31(5):192, 2015), Kang et al. (in Medicine 98(23): e15768, 2019), Atema et al. (in Br J Surg 102(8):979-990. https://doi.org/10.1002/bjs.9835 , 2015), Avanesov et al. (in Eur Radiol 28(9):3601-3610, 2018), and Kim et al. (in Abdom Radiol 46:1-12, 2020). Finally, we examined our models by performing the integrated discrimination improvement (IDI) test. RESULTS Among enrolled patients, 64 (15.9%) had complicated acute appendicitis. We developed new 10-point scoring models by including the following variables: C-reactive protein, neutrophil to lymphocyte ratio, and computed tomography features of FS, ascites, and appendicolith. A cutoff score of ≥ 6 exhibited a high sensitivity of 82.8% and a specificity of 82.8% for model 1 and 81.3% and 82.3% for model 2, respectively, with c statistics of 0.878 (model 1) and 0.879 (model 2). Compared with the model developed by Bröker et al. which included C-reactive protein and the abdominal pain duration (c statistic: 0.778), the models developed by Atema et al. (c statistic: 0.826, IDI: 5.92%, P = 0.0248), H.Y Kim et al. (c statistics: 0.838, IDI: 13.82%, P = 0.0248), and our two models (IDI: 18.29%, P < 0.0001) demonstrated a significantly higher diagnostic accuracy. CONCLUSION Our models and the scoring systems developed by Atema et al. and Kim et al. were validated to have a high diagnostic accuracy; moreover, our models included the lowest number of variables.
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Affiliation(s)
- Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hung-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Chieh Chao
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Feng Lin
- School of Public Health, College of Public Health, Taipei Medical University, 250 Wu-Hsing Street, Taipei City, 110, Taiwan.
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Department of Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan.
- Department of Clinical Pathology, Taipei Medical University Hospital, Taipei, Taiwan.
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Conventional-Dose CT Versus 2-mSv CT for Right Colonic Diverticulitis as an Alternate Diagnosis of Appendicitis: Secondary Analysis of Large Pragmatic Randomized Trial Data. AJR Am J Roentgenol 2021; 217:1113-1121. [PMID: 33825498 DOI: 10.2214/ajr.21.25584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND. Adoption of low-dose CT for the diagnosis of appendicitis has been slow in children and in adults, partly because of concern about missing alternative diagnoses including right colonic diverticulitis. OBJECTIVE. The purpose of our study was to retrospectively compare the diagnostic performance of IV contrast-enhanced 2-mSv and conventional-dose CT (CDCT) for the diagnosis of right colonic diverticulitis in adolescents and young adults with suspected appendicitis. METHODS. This posthoc analysis of a prospective randomized controlled trial included 3074 patients (1672 female patients and 1402 male patients) ranging in age from 15 to 44 years old (mean ± SD, 28 ± 9 years) from 20 hospitals. From December 2013 to August 2016, patients were randomized to either the 2-mSv CT group (n = 1535 patients) or the CDCT (median, 7 mSv) group (n = 1539 patients). A total of 161 radiologists prospectively issued CT reports in which they suggested alternative diagnoses for 976 (2-mSV CT) and 924 (CDCT) patients. Seven independent assessors adjudicated final diagnoses on the basis of clinical and CT findings. Endpoints of test-positives, test-negatives, sensitivity, and specificity for right colonic diverticulitis were compared using chi-square and Mann-Whitney U tests. Characteristics and disposition of patients with test-positive results were assessed. Four readers retrospectively reviewed CT images of 400 patients selected from the trial (113 and 108 patients with diverticulitis from 2-mSv CT and CDCT groups, respectively) to evaluate interobserver agreement for right colonic diverticulitis in terms of Gwet coefficients. RESULTS. Between-group differences were minute for most endpoints related to right colonic diverticulitis: test-positives (difference, 0.2% [95% CI, -1.8% to 2.1%]; 7.8% [119/1535 patients] vs 7.6% [117/1539 patients]; p = .93), test-negatives (0.5% [95% CI, -1.5% to 2.5%]; 91.7% [1407/1535] vs 91.2% [1403/1539]; p = .67), sensitivity (0% [95% CI, -6% to 6%]; 95% [110/116] vs 95% [105/111]; p > .99), and specificity (0.3% [95% CI, -0.5% to 0.9%]; 99.4% [1401/1410] vs 99.1% [1397/1409]; p = .66). The characteristics and disposition of test-positive patients were similar between the two groups. Gwet coefficients were high and comparable between the two groups (2-mSv CT vs CDCT, 0.849 vs 0.889; p = .20). CONCLUSION. Two-millisievert CT is comparable to conventional-dose CT for the diagnosis of right colonic diverticulitis. CLINICAL IMPACT. By mitigating concern about a missed diagnosis of right colonic diverticulitis, the results further support the use of low-dose CT in patients with suspected appendicitis. TRIAL REGISTRATION. ClinicalTrials.gov NCT01925014.
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Podda M, Pisanu A, Sartelli M, Coccolini F, Damaskos D, Augustin G, Khan M, Pata F, De Simone B, Ansaloni L, Catena F, Di Saverio S. Diagnosis of acute appendicitis based on clinical scores: is it a myth or reality? ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021231. [PMID: 34487066 PMCID: PMC8477120 DOI: 10.23750/abm.v92i4.11666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "Duilio Casula", Cagliari (Italy).
| | - Adolfo Pisanu
- Department of Emergency Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University Hospital Policlinico "Duilio Casula", Cagliari, Italy.
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy.
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia.
| | - Mansoor Khan
- Department of General and Trauma Surgery, Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom.
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano.
| | - Belinda De Simone
- Department of Visceral Surgery, Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, Poissy, France.
| | - Luca Ansaloni
- Department of Surgery, "San Matteo" University Hospital, Pavia, Italy.
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy.
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy..
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Choi H, Chang W, Kim JH, Ahn C, Lee H, Kim HY, Cho J, Lee YJ, Kim YH. Dose reduction potential of vendor-agnostic deep learning model in comparison with deep learning-based image reconstruction algorithm on CT: a phantom study. Eur Radiol 2021; 32:1247-1255. [PMID: 34390372 PMCID: PMC8364308 DOI: 10.1007/s00330-021-08199-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/11/2021] [Accepted: 07/02/2021] [Indexed: 12/25/2022]
Abstract
Objectives To compare the dose reduction potential (DRP) of a vendor-agnostic deep learning model (DLM, ClariCT.AI) with that of a vendor-specific deep learning–based image reconstruction algorithm (DLR, TrueFidelity™). Methods Computed tomography (CT) images of a multi-sized image quality phantom (Mercury v4.0) were acquired under six radiation dose levels (0.48/0.97/1.93/3.87/7.74/15.47 mGy) and were reconstructed using filtered back projection (FBP) and three strength levels of the DLR (low/medium/high). The FBP images were denoised using the DLM. For all DLM and DLR images, the detectability index (d′) (a task-based detection performance metric) was obtained, under various combinations of three target sizes (10/5/1 mm), five inlets (CT value difference with the background; −895/50/90/335/1000 HU), five phantom diameters (36/31/26/21/16 cm), and six radiation dose levels. Dose reduction potential (DRP) measures the dose reduction made by using DLM or DLR, while yielding d′ equivalent to that of FBP at full dose. Results The DRPs of the DLM, DLR-low, DLR-medium, and DLR-high were 86% (81–88%), 60% (46–67%), 76% (60–81%), and 87% (78–92%), respectively. For 10-mm targets, the DRP of the DLM (87%) was higher than that of all DLR algorithms (58–86%). However, for smaller targets (5 mm/1 mm), the DRPs of the DLR-high (89/88%) were greater than those of the DLM (87/84%). Conclusion The dose reduction potential of the vendor-agnostic DLM was shown to be comparable to that of the vendor-specific DLR at high strength and superior to those of the DLRs at medium and low strengths. Key Points • DRP of the vendor-agnostic model was comparable to that of high-strength vendor-specific model and superior to those of medium- and low-strength models. • Under various radiation dose levels, the deep learning model shows higher detectability indexes compared to FBP. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08199-9.
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Affiliation(s)
- Hyunsu Choi
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro-173-beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Won Chang
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro-173-beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
| | - Jong Hyo Kim
- Department of Radiology, Seoul National University College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
- Department of Transdisciplinary Studies, Program in Biomedical Radiation Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Chulkyun Ahn
- Department of Transdisciplinary Studies, Program in Biomedical Radiation Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Heejin Lee
- Department of Applied bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro-173-beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro-173-beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro-173-beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Young Hoon Kim
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro-173-beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
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Song H, Lee S, Park JH, Kim HY, Min HD, Jeon JJ, Lee KH. Can Patient Triaging with Clinical Scoring Systems Reduce CT Use in Adolescents and Young Adults Suspected of Having Appendicitis? Radiology 2021; 300:350-358. [PMID: 34003054 DOI: 10.1148/radiol.2021203884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background There are ongoing efforts to reduce CT radiation exposure for the diagnosis of appendicitis. Recent guidelines recommend using clinical scoring systems to triage patients who need imaging examinations. Purpose To determine whether patient triaging with scoring systems can reduce CT use without a loss of diagnostic accuracy in adolescents and young adults suspected of having appendicitis. Materials and Methods This retrospective study used data from a previous multicenter randomized controlled trial conducted between December 2013 and August 2016. Five scoring systems (adult appendicitis, appendicitis inflammatory response, modified Alvarado, Broek, and Christian scores) were used to categorize patients into low-, intermediate-, or high-probability groups. CT use was simulated for only the intermediate-probability group. The primary outcomes were CT reduction rate, sensitivity, and specificity. The CT reduction rate was defined as the proportion of patients in low- and high-probability groups who would not have to undergo CT among all patients. Sensitivity and specificity were calculated in the overall diagnostic pathway using each scoring system and subsequent CT. As a secondary analysis, to maintain the diagnostic accuracy to a level of when CT was used for all patients with suspected appendicitis, new cutoff values for probability group stratification targeting 97.6% sensitivity and 94.9% specificity were applied for each of the scoring systems. Results A total of 2888 patients (mean age ± standard deviation, 28 years ± 9; 1580 women and 1308 men) with suspected appendicitis were evaluated, of whom 1088 had and 1800 did not have appendicitis. The CT reduction rates of the five scoring systems ranged from 55.6% (1606 of 2888 patients) to 71.1% (2053 of 2888), but at the cost of sensitivity (range, 48.7% [530 of 1088] to 81.2% [883 of 1088]) and specificity (range, 79.0% [1422 of 1800] to 97.8% [1761 of 1800]). Targeting 97.6% sensitivity and 94.9% specificity, the CT reduction rates of all five scoring systems were 0% (0 of 2888). Conclusion Using clinical scoring systems in triaging patients for selective CT use led to a considerable loss of diagnostic accuracy. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mellnick in this issue.
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Affiliation(s)
- Hyunjoo Song
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Seungjae Lee
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Ji Hoon Park
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Hae Young Kim
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Hooney Daniel Min
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Jong-June Jeon
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Kyoung Ho Lee
- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
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- From the School of Computer Science and Engineering, Soongsil University, Seoul, Korea (H.S.); Department of Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L., J.H.P., K.H.L.) and Interdisciplinary Program in Bioengineering (K.H.L.), Seoul National University, Seoul, Korea; Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (J.H.P., H.Y.K., H.D.M., K.H.L.); Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
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Cho J, Lee S, Min HD, Kim HY, Ko Y, Park JH, Park SB, Lee KH. Final diagnosis and patient disposition following equivocal results on 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: a post hoc analysis of large pragmatic randomized trial data. Eur Radiol 2021; 31:9176-9187. [PMID: 33993331 DOI: 10.1007/s00330-021-08020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/08/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare 2-mSv CT and conventional-dose CT (CDCT, typically 7-8 mSv) regarding final diagnosis and patient disposition following equivocal CT results in adolescents and young adults with suspected appendicitis. METHODS In total, 3074 patients of 15-44 years (28 ± 9 years, 1672 women) from 20 hospitals were randomized to undergo contrast-enhanced 2-mSv CT (n = 1535) or CDCT (n = 1539) from December 2013 through August 2016. One hundred sixty-one radiologists prospectively rated the likelihood of appendicitis in a Likert scale (i.e., grades 1-5). The final diagnosis was based on CT image, surgical, pathologic, and clinical findings. Post hoc analysis was performed for final diagnosis, surgical procedure, and delay in patient management following equivocal results (i.e., grade 3). RESULTS The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal results, including confirmed appendicitis (1.2% [18 patients] vs. 1.2% [19], p > 0.99), negative appendectomy (0.1% [2] vs. 0.3% [4], p = 0.53), and perforated appendicitis (0.1% [1] vs. 0.2% [3], p = 0.53). More patients were confirmed as not having appendicitis following equivocal results in the CDCT group than in the 2-mSv CT group (2.2% [34] vs. 1.0% [16], p = 0.016). The two groups were comparable for the need of appendectomy (1.4% [22] vs. 1.5% [23], p > 0.99), need of additional imaging tests (0.7% [11] vs. 1.1% [17], p = 0.35), and delay in patient management following equivocal results. CONCLUSION 2-mSv CT is comparable to CDCT regarding final diagnosis and patient disposition following equivocal CT results. KEY POINTS • Our results strengthen evidence justifying the use of low-dose CT instead of conventional-dose CT (CDCT) in adolescents and young adults with suspected appendicitis. • The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal CT results, including confirmed appendicitis (1.2% vs. 1.2%, p > 0.99), negative appendectomy (0.1% vs. 0.3%, p = 0.53), and perforated appendicitis (0.1% vs. 0.2%, p = 0.53). • The two groups were comparable for the need for appendectomy (1.4% vs. 1.5%, p > 0.99), need for additional imaging tests (0.7% vs. 1.1%, p = 0.35), and delay in patient management, following equivocal CT results.
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Affiliation(s)
- Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Seungjae Lee
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Hooney Daniel Min
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Yousun Ko
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea.
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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Pringle HCM, Donigiewicz U, Bennett MR, Walker E, Fowler GE, Narang S, Ball S, Bethune RM. Appendicitis during the COVID-19 pandemic: lessons learnt from a district general hospital. BMC Surg 2021; 21:242. [PMID: 33980191 PMCID: PMC8114653 DOI: 10.1186/s12893-021-01231-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic dramatically influenced the delivery of healthcare. In line with the UK Royal Colleges' advice the management of acute appendicitis (AA) changed with greater consideration for non-operative management (NOM) or open appendicectomy when operative management (OM) was sought. We describe our experience of the presentation, management and outcomes for these patients to inform care for future viral pandemics. METHODS This retrospective, cohort study compared patients diagnosed with AA between March and July 2019 with those during the pandemic period of March to July 2020. Medical records were reviewed to obtain demographics, inflammatory markers, imaging, severity, management, histology, length of stay (LOS) and 90-day outcomes. RESULTS There were 149 and 125 patients in the 2019 and 2020 cohorts respectively. 14 patients (9.4%) had NOM in 2019 versus 31 (24.8%) in 2020 (p = 0.001). In the 2019 operative management (OM) group 125 patients (92.6%) had laparoscopic appendicectomy versus 65 (69.1%) in 2020. 59 patients (39.6%) had a CT in 2019 versus 70 (56%) in 2020. The median LOS was 4 days in 2019 and 3 days in 2020 (p = 0.03). Two patients in each year who received NOM had treatment failure (14.3% in 2019 and 6.5% in 2020). Three patients in 2019 who received OM had treatment failure (2.2%). Of 95 patients tested for COVID-19 all but one tested negative. CONCLUSION During the COVID-19 pandemic there was no observed increase in severity of AA, patients had a shorter LOS and were more likely to have imaging. NOM proportionally increased with no observed change in outcomes.
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Affiliation(s)
| | | | - Melissa-Rose Bennett
- Royal Devon & Exeter Hospital, Exeter, EX2 5DW Devon UK
- University of Exeter Medical School, St. Luke’s Campus, Heavitree Road, Exeter, EX1 2LU Devon UK
| | | | | | - Sunil Narang
- Royal Devon & Exeter Hospital, Exeter, EX2 5DW Devon UK
| | - Susan Ball
- NIHR Applied Research Collaboration, South West Peninsula (PenARC), University of Exeter Medical School, Exeter, EX1 2LU Devon UK
| | - Robert M. Bethune
- Royal Devon & Exeter Hospital, Exeter, EX2 5DW Devon UK
- University of Exeter Medical School, St. Luke’s Campus, Heavitree Road, Exeter, EX1 2LU Devon UK
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Podda M, Andersson R, Boermeester M, Coccolini F, Sartelli M, Moore EE, Sugrue M, Abu-Zidan F, Tolonen M, Damaskos D, Kluger Y, Soreide K, Pisanu A, Augustin G, Latifi R, Kelly M, Leppaniemi A, Fraga GP, Ten Broek R, Tan E, Van Goor H, Chiara O, Maier RV, Pata F, De Simone B, Ordoñez CA, Ansaloni L, Catena F, Di Saverio S. Do young patients with high clinical suspicion of appendicitis really need cross-sectional imaging? Proceedings from a highly controversial debate among the experts' panel of 2020 WSES Jerusalem guidelines. J Trauma Acute Care Surg 2021; 90:e101-e107. [PMID: 33496553 DOI: 10.1097/ta.0000000000003097] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Mauro Podda
- From the Department of Emergency Surgery (M.P., A.P.), Azienda Ospedaliero-Universitaria di Cagliari, University Hospital Policlinico Duilio Casula, Cagliari, Italy; Department of Surgery (R.A.), Linkoping University, Linkoping, Sweden; Department of Surgery (M.B.), University of Amsterdam, Amsterdam, The Netherlands; General, Emergency and Trauma Surgery (F.C.), Pisa University Hospital, Pisa, Italy; Department of Surgery (M.S.), Macerata Hospital, Macerata, Italy; Denver Health System-Denver Health Medical Center (E.E.M.), Denver, Colorado; Department of Surgery (M.S.), Letterkenny Hospital, Donegal, Ireland; Department of Surgery (F.A.-Z.), College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates; Department of Abdominal Surgery (M.T., A.L.), Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; Department of Upper GI Surgery (D.D.), Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom; Division of General Surgery (Y.K.), Rambam Health Care Campus, Haifa, Israel; Department of Gastrointestinal Surgery (K.S.), Stavanger University Hospital, Stavanger, Norway; Department of Surgery (G.A.), University Hospital Centre of Zagreb, Zagreb, Croatia; Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery (R.L.), New York Medical College, Valhalla, New York; Acute Surgical Unit (M.K.), Canberra Hospital, ACT, Canberra, Australia; Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas (G.P.F.), SP, Brazil; Department of Surgery (R.T.B., E.T., H.V.G.), Radboud University Medical Center, Nijmegen, The Netherlands; Niguarda Hospital Trauma Center (O.C.), Milan, Italy; Department of Surgery (R.V.M.), University of Washington, Harborview Medical Center, Seattle, Washington; Department of Surgery (F.P.), Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University o Rome, Rome, Italy; Department of Visceral Surgery (B.D.S.), Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, Poissy, France; Division of Trauma and Acute Care Surgery, Department of General Surgery (C.A.O.), Fundación Valle del Lili, Cali, Colombia; Department of General Surgery and Trauma (L.A.), Bufalini Hospital, Cesena, Italy; Emergency and Trauma Surgery Department (F.C.), Maggiore Hospital of Parma, Parma, Italy; and Department of General Surgery (S.D.S.), University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
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Bom WJ, Scheijmans JCG, Salminen P, Boermeester MA. Diagnosis of Uncomplicated and Complicated Appendicitis in Adults. Scand J Surg 2021; 110:170-179. [PMID: 33851877 PMCID: PMC8258714 DOI: 10.1177/14574969211008330] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis. Methods: A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed. Results: For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes. Conclusion: Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.
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Affiliation(s)
- W J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - J C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - P Salminen
- Department of Surgery, University of Turku, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - M A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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44
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Lee KH, Lee S, Park JH, Lee SS, Kim HY, Lee WJ, Cha ES, Kim KP, Lee W, Lee JY, Lee KH. Risk of Hematologic Malignant Neoplasms From Abdominopelvic Computed Tomographic Radiation in Patients Who Underwent Appendectomy. JAMA Surg 2021; 156:343-351. [PMID: 33471110 DOI: 10.1001/jamasurg.2020.6357] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Importance Whether computed tomography (CT) radiation is truly carcinogenic remains controversial. Large epidemiological studies that purportedly showed an association between CT radiation and carcinogenesis were limited by confounding by indication and reverse causation, because the reasons for CT examination were unknown. Objective To measure the risk of hematologic malignant neoplasms associated with perioperative abdominopelvic CT radiation among patients who underwent appendectomy for acute appendicitis. Design, Setting, and Participants This nationwide population-based cohort study used the National Health Insurance Service claims database in South Korea to assess 825 820 patients who underwent appendectomy for appendicitis from January 1, 2005, to December 31, 2015, and had no underlying risk factors for cancer. Patients were divided into CT-exposed (n = 306 727) or CT-unexposed (n = 519 093) groups. The study was terminated on December 31, 2017, and data were analyzed from October 30, 2018, to September 27, 2020. Exposures Perioperative abdominopelvic CT examination from 7 days before to 7 days after appendectomy. Main Outcomes and Measures The primary outcome was the incidence rate ratio (IRR) of hematologic malignant neoplasms for both groups. The secondary outcomes were IRR of abdominopelvic organ cancers and IRR of all cancers. The lag period was 2 years for the primary outcome and 5 years for secondary outcomes. The IRRs were calculated using Poisson regression models with adjustment for age and sex. Results Among the study population of 825 820 patients (52.9% male; median age, 28 [interquartile range, 15-41] years), hematologic malignant neoplasms developed in 323 patients in the CT-exposed group during 1 486 518 person-years and 500 patients in the CT-unexposed group during 3 422 059 person-years. For all hematologic malignant neoplasms, the IRR for the CT-exposed vs CT-unexposed group was 1.26 (95% CI, 1.09-1.45; P = .002). In terms of individual categories of hematologic malignant neoplasms, the CT-exposed group had an elevated risk only for leukemia (IRR, 1.40 [98.75% CI, 1.04-1.87, adjusted by Bonferroni correction]; P = .005). There was no between-group difference in incidence rate of abdominopelvic organ cancers (IRR, 1.07 [95% CI, 1.00-1.15]; P = .06) and that of all cancers (IRR, 1.04 [95% CI, 0.99-1.09]; P = .14). Conclusions and Relevance This study controlled for reverse causation bias by defining the reasons for CT scan, and findings suggest that abdominopelvic CT radiation is associated with a higher incidence of hematologic malignant neoplasms. Efforts should be continued for judicious use of CT examinations.
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Affiliation(s)
- Kyung Hee Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Korea.,Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, Korea
| | - Seungjae Lee
- Department of Applied Bioengineering, Seoul National University Graduate School of Convergence Science and Technology, Seoul, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Korea.,Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Seoul National University Graduate School of Convergence Science and Technology, Seoul, Korea
| | - Sung Soo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Won Jin Lee
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Eun Shil Cha
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Kwang Pyo Kim
- Department of Nuclear Engineering, Kyung Hee University, Gyeonggi-do, Korea
| | - Woojoo Lee
- Department of Public Health Science, Seoul National University Graduate School of Public Health, Seoul, Korea
| | - Ji Yun Lee
- Division of Hematology-Oncology, Department of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Korea.,Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Seoul National University Graduate School of Convergence Science and Technology, Seoul, Korea.,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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45
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Haijanen J, Sula S, Salminen P. Optimizing the Gold Standard-Low-Dose Computed Tomography Modalities as a Part of Clinical Practice in Acute Appendicitis Imaging. JAMA Surg 2021; 156:351-352. [PMID: 33471044 DOI: 10.1001/jamasurg.2020.6358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Sami Sula
- Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Satasairaala Central Hospital, Pori, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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46
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Javanmard-Emamghissi H, Boyd-Carson H, Hollyman M, Doleman B, Adiamah A, Lund JN, Clifford R, Dickerson L, Richards S, Pearce L, Cornish J, Hare S, Lockwood S, Moug SJ, Tierney GM. The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study. Tech Coloproctol 2021; 25:401-411. [PMID: 32671661 PMCID: PMC7362319 DOI: 10.1007/s10151-020-02297-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.
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Affiliation(s)
| | | | | | - B Doleman
- Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
| | - A Adiamah
- NIHR Nottingham Digestive Disease Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J N Lund
- Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
| | | | | | | | - L Pearce
- Salford Royal NHS Trust, Salford, UK
| | - J Cornish
- Cardiff Royal Infirmary, Cardiff, UK
| | - S Hare
- Medway Maritime Hospital, Kent, UK
| | | | - S J Moug
- Royal Alexandra Hospital, Paisley, UK
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47
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Ultra low dose CT for non-traumatic abdominal emergencies: Current challenges and opportunities. Diagn Interv Imaging 2021; 102:335-336. [PMID: 33773954 DOI: 10.1016/j.diii.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 01/05/2023]
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48
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Sammer MBK, Kan JH, Somcio R, Sher AC, Hansen CM, Pahlka RB, Guillerman RP, Seghers VJ. Chest CT for the Diagnosis of Pediatric Esophageal Foreign Bodies. Curr Probl Diagn Radiol 2021; 50:566-570. [PMID: 33745769 DOI: 10.1067/j.cpradiol.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/04/2021] [Indexed: 01/08/2023]
Abstract
Foreign body ingestion is a common problem in children. Radiography is the mainstay of imaging, but many radiolucent items go undetected without further imaging by fluoroscopic esophagram. While studies in adults support the use of computed tomography (CT) for esophageal foreign body ingestion, CT has historically not been used in children given the typically higher radiation doses on CT compared with fluoroscopy. In distinction to an esophagram, CT does not require oral contrast nor presence of an onsite radiologist and can be interpreted remotely. At our institution, a dedicated CT protocol has been used for airway foreign bodies since 2015. Given the advantages of CT over esophagram, we retrospectively reviewed institutional radiation dose data from 2017 to 2020 for esophagrams, airway foreign body CT (FB-CT), and routine CT Chest to compare effective doses for each modality. For ages 1+ years, effective dose was lowest using the FB-CT protocol; esophagram mean dose showed the most variability, and was over double the dose of FB-CT for ages 5+ years. Routine CT chest doses were uniformly highest across all age ranges. Given these findings, we instituted a CT foreign body imaging protocol as the first-line imaging modality for radiolucent esophageal foreign body at our institution.
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Affiliation(s)
- Marla B K Sammer
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - J Herman Kan
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Ray Somcio
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Andrew C Sher
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Carly M Hansen
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX
| | - R Benton Pahlka
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX
| | - R Paul Guillerman
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Victor J Seghers
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX..
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49
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Ashcroft J, Singh AA, Rooney S, Bennett J, Davies RJ. A single centre evaluation of risk prediction models and imaging modalities in acute appendicitis. Ann R Coll Surg Engl 2021; 103:203-207. [PMID: 33645277 DOI: 10.1308/rcsann.2020.7033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients with suspected appendicitis remain a diagnostic challenge. The aim of this study was to validate risk prediction models, and to investigate diagnostic accuracy of ultrasonography and computed tomography (CT) in adults undergoing appendicectomy. METHODS A retrospective case review was performed of patients aged 16-45 years having an appendicectomy between January 2019 and January 2020 at a tertiary referral centre. Primary outcomes were the accuracy of a high risk appendicitis risk score and ultrasonography and CT imaging modalities compared with histological reports following appendicectomy. RESULTS A total of 206 patients (52% female) were included in the study. Removal of a histologically normal appendix was equally likely in men and women (13.1% vs 11.2% respectively, relative risk: 1.17, 95% confidence interval: 0.56-2.44, p=0.674). A high risk appendicitis score correctly identified 84.0% (79/94) of cases in men and 85.9% (67/78) of cases in women. Ultrasonography was reported as equivocal in 85.7% (18/21) of low risk women and 59.0% (23/39) of high risk women. CT correctly detected or excluded appendicitis in 75.0% (6/8) of low risk women and 88.5% (23/26) of high risk women. CONCLUSIONS This study suggests that risk prediction models may be useful in both women and men to identify appendicitis. Ultrasonography gave high rates of equivocal results and should not be relied on for the diagnosis of appendicitis. CT is a highly accurate diagnostic tool and could be considered in those at low risk where clinical suspicion remains to reduce negative appendicectomy rates.
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Affiliation(s)
- J Ashcroft
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - A A Singh
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - S Rooney
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - J Bennett
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, UK
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50
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Larsen NE, Mikkelsen E, Knudsen AR, Larsen LP. Low-dose CT for diagnosing intestinal obstruction and pneumoperitoneum; need for retakes and diagnostic accuracy. Acta Radiol Open 2021; 10:2058460121989313. [PMID: 33786202 PMCID: PMC7958640 DOI: 10.1177/2058460121989313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background One of the main concerns using low-dose (LD) CT for evaluation of patients with suspected intestinal obstruction or pneumoperitoneum is the potential need to make an additional standard-dose (SD) CT scan (retake) due to insufficient diagnostic accuracy of the LD CT. Purpose To determine the frequency of retakes and evaluate the diagnostic accuracy of LD CT for the assessment of intestinal obstruction and pneumoperitoneum. Material and Methods This retrospective study registered all LD CT scans over a one-year period at Aarhus University Hospital, Denmark in patients with suspected intestinal obstruction or perforation, comprising a total of 643 LD CT scans. A retake was defined as a SD CT scan of the abdomen and pelvis performed with or without intravenous contrast within 72 h after the initial LD CT due to either continued suspicion of intestinal obstruction or perforation or due to unclarified secondary findings. The sensitivity and specificity of LD CT for diagnosing intestinal obstruction and pneumoperitoneum compared to the discharge diagnoses of the scanned patients were determined. Results The frequency of retakes was 3%. The overall LD CT sensitivity and specificity for assessment of patients with suspected intestinal obstruction and pneumoperitoneum was 83% and 99%, respectively, but higher in certain subgroups. Conclusions LD CT led to few retakes and had a high diagnostic accuracy for diagnosing intestinal obstruction and pneumoperitoneum. Thus, LD CT can be recommended as the examination of choice in patients with suspected intestinal obstruction or perforation in order to reduce radiation dose.
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Affiliation(s)
- Nis E Larsen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Eva Mikkelsen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anders R Knudsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Lars P Larsen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
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