Evaluation of the diagnostic accuracy of plasma markers for early diagnosis in patients suspected for acute appendicitis

A Prospective Comparative Study on the Clinical Diagnostic Performance of Blood Inflammatory Markers in Acute Appendicitis

Objective

Despite the substantial advancements in imaging techniques for the diagnosis and differential diagnosis of acute appendicitis (AA) over recent decades, the specificity and sensitivity of widely utilized laboratory biomarkers in clinical practice remain inadequate.This study aimed to investigate the diagnostic utility of commonly employed blood inflammatory markers for AA.

Methods

A total of 399 participants who either sought medical care or underwent health examinations were enrolled in this prospective study. The cohort comprised 200 patients diagnosed with AA (AA group), 100 patients presenting with abdominal pain but without AA (AP group), and 99 healthy individuals undergoing routine health check-ups (HC group). For all subjects, the following biomarkers were measured: plasma neutrophil gelatinase-associated lipocalin (NGAL), white blood cell count (WBC), neutrophil count (NEU), percentage of neutrophils (NEU%), neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP). The diagnostic performance of the observed indicators, both individually and in combination, was assessed for the diagnosis of AA using Receiver Operating Characteristic (ROC) curves analysis and Delong's test.

Results

The laboratory indicators demonstrated a progressive increase from the HC group to the AP group, and further to the AA group (all p<0.05). Multifactorial logistic regression analysis identified NEU% and plasma NGAL as significant risk factors for the occurrence of AA. ROC curve analysis and Delong's test indicated that, in distinguishing the AA group from the HC group, the diagnostic performance of plasma NGAL, CRP, and NLR was equally substantial and superior to that of NEU and WBC. Within the AP group, plasma NGAL and CRP exhibited comparable diagnostic efficacy, outperforming NEU, WBC, and NLR. When differentiating AA in the non-appendicitis group (ie HC group + AP group), NGAL and CRP demonstrated comparable diagnostic efficacy, surpassing that of NEU, white WBC, and NLR. While the integration of multiple diagnostic tests can potentially improve overall diagnostic accuracy, the observed enhancement in the AUC is not statistically significant.

Conclusion

NGAL, CRP, WBC, NEU% and NLR were significantly increased in patients with acute abdomen. NGAL and NEU% may function as independent risk factors for predicting the incidence of AA, with NGAL and CRP demonstrating similar and favorable diagnostic performance. While the combined evaluation of these biomarkers may enhance the diagnostic value for AA, the improvement in the area under the curve (AUC) is not substantial.

Exploring S100A8/A9, neopterin, and MMP3 in familial Mediterranean fever

Familial Mediterranean fever (FMF) is characterized by inflammatory attacks due to overactivation of pyrin inflammasome. This study aimed to investigate the reliability of S100A8/A9, neopterin, and matrix metalloproteinase 3 (MMP3) at monitoring subclinical inflammation and disease activity, and at differentiating FMF attacks from appendicitis, the most common misdiagnosis among FMF patients. Blood samples (n = 75), comprising from FMF patients during an attack (n = 20), the same FMF patients during the attack-free period (n = 14), patients with appendicitis (n = 24), and healthy volunteers (n = 17) were obtained. Duplicate determinations of S100A8/A9, neopterin, and MMP-3 levels were conducted using the enzyme-linked immunosorbent assay (ELISA). FMF patients with and without attack and patients with appendicitis had significantly elevated S100A8/A9 levels compared to healthy volunteers (P-values: < 0.001, 0.036, 0.002, respectively). Patients with appendicitis and FMF patients with and without attack had significantly increased serum neopterin levels compared to healthy volunteers (P-value: < 0.001). MMP3 levels were significantly higher among patients with appendicitis and FMF patients during attack compared to healthy controls (P-values: < 0.001, 0.001). Serum levels of S100A8/A9, neopterin, and MMP3 were increased significantly during attacks compared to attack-free periods among FMF patients (P-values: 0.03, 0.047, 0.007). S100A8/A9 emerges as a valuable marker for monitoring disease activity. Neopterin and S100A8/A9 might help physicians to monitor subclinical inflammation during the attack-free periods of FMF patients. MMP3 might aid in diagnosing FMF attacks when distinguishing between attack and attack-free periods is challenging.

Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review

Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.

Apoptosis-associated speck-like protein containing a CARD (ASC), TNF Like Factor 1a(TL-1a) and B Cell Chemoattractant Chemokine Ligand 13(CXCL-13) expression profiles in familial Mediterranean fever (FMF) patients

Objectives: This study was carried out to compare the expression levels of ASC(Apoptosis Associated Speck Like Protein Containing a CARD), TL-1a(TNF Like Factor 1a) and CXCL 13(B Cell Chemoattractant Chemokine Ligand 13) genes in FMF patients According to Tell-Hashomer Criteria and Genetic analysis result in Düzce University Research and Application Hospital with healthy controls and to determine their clinical significance in FMF. Method: 36 patients (20 girls, 16 boys) and 12 healthy controls (7 girls, 5 boys) were included in the study. RNA was isolated from the peripheral blood of each individual and expression levels of ASC, TL-1a and CXCL 13 genes were determined. Routine biochemical parameters were also determined. Result: CXCL 13 and TL-1a gene expression levels were significantly increased in patients with FMF, the expression level of the ASC gene was found to be increased in FMF patients, but not significantly. Conclusion: The expression levels of these genes may be related to the pathogenesis of the disease and these genes could be used as a marker in the early diagnosis of the disease.

Assessment of the Diagnostic Value of Novel Biomarkers in Adult Patients With Acute Appendicitis: A Cross-Sectional Study

Background Acute appendicitis (AA) is one of the most frequent causes of abdominal pain requiring emergency intervention in adults. Approximately one-third of cases present with atypical clinical symptoms. This study aims to compare the monocyte-to-lymphocyte ratio (MLR), red cell distribution width (RDW) to lymphocyte ratio (RLR), and systemic immune inflammation index (SII) with other biomarkers in distinguishing patients with and without AA. Methodology A total of 347 patients (AA 125, nonspecific abdominal pain 90, and control group 132) were enrolled in the study according to the cross-sectional study design. Receiver operating characteristic (ROC) analysis was used to determine the cutoff in diagnostic value measurements. Statistical significance was determined by the statistics of sensitivity, specificity, positive predictive value, and negative predictive value. Comparison of ROC curves of C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), neutrophil-to-lymphocyte ratio (NLR), MLR, and SII was evaluated with the pairwise comparison of ROC curves and 95% confidence interval. Results In detecting AA, CRP, WBC, NEU, NLR, MLR, and SII have excellent diagnostic power (area under the curve [AUC] 0.80-0.88), while RDW, lymphocyte count, monocyte (MON) count, and RLR had acceptable diagnostic power (AUC 0.70-0.77). When the power in the diagnosis of AA was compared, a significant difference was found between CRP and NEU, CRP and SII, WBC and NEU, and WBC and SII. Conclusions The diagnosis of AA remains dependent on many factors. Inflammatory biomarkers assist this process. MLR and SII may be recommended to use in diagnosing AA in adults, along with other clinical findings. RLR is adequate but not superior.

Comparison of Thiol-Disulfide Hemostasis With Inflammatory Markers in the Inflammatory Process of Acute Appendicitis

Background

Acute appendicitis is one of the events most frequently encountered by general surgeons. Despite the high incidence, serious problems are experienced in the diagnosis and clinical follow-up. In the pathogenesis of the disease, oxidative stress and impaired antioxidant defense mechanisms created in the body by this stress play an important role. As dynamic thiol-disulfide hemostasis is closely related to oxidative stress and is known to have a crucial role in the pathogenesis of oxidative stress, this study aimed to compare its value with other inflammatory markers in the diagnosis and follow-up of acute appendicitis.

Methodology

This study included cases admitted for surgery with a diagnosis of acute abdomen at Keçiören Research and Training Hospital General Surgery Clinic between April 2015 and July 2015 who were intraoperatively diagnosed with acute appendicitis and underwent routine appendectomy. In the preoperative period and after clinical healing before discharge, blood samples were obtained to examine white blood cell (WBC), mean platelet volume (MPV), total bilirubin, C-reactive protein (CRP), and thiol-disulfide balance, and the results were recorded.

Results

A total of 68 cases were operated on for acute appendicitis, and 59 were evaluated comprising 23 (39%) females and 36 (61%) males with a mean age of 35.6 years (range = 19-65 years). The mean duration of hospital stay was two days (range = 1-8 days). The results of the tests performed preoperatively and before discharge and their p-values were as follows: native thiol (-SH) 393.5 ± 9.4 µmol/L and 369.3 ± 9.5 µmol/L (p = 0.04), total thiol 434 ± 9.7 µmol/L and 396.7 ± 10.2 µmol/L (p = 0.03), disulfide (-S-S) 16.8 ± 0.7 µmol/L and 15.7 ± 0.9 µmol/L (p = 0.3), WBC 13.2 ± 0.5 × 10³/mL and 9.2 ± 0.4 × 10³/mL (p = 0.0), CRP 8.17 ± 1.24 mg/L and 7.84 ± 0.82 mg/L (p = 0.17), MPV 7.4 ± 0.37 fL and 7.97 ± 0.19 fL (p = 1.0), and total bilirubin 0.86 ± 0.08 mg/dL and 0.69 ± 0.06 mg/dL (p = 0.08).

Conclusions

In the clinical follow-up of acute appendicitis patients, the decrease in WBC, total thiol, and native thiol values can be helpful to clinicians as markers of clinical healing. However, CRP may not be a useful marker of clinical healing in acute appendicitis patients who are discharged early.

Hyperbilirubinemia and Hyponatremia as Predictors of Complicated Appendicitis

Several studies have reported elevated serum bilirubin or reduced serum sodium levels in patients with complicated appendicitis (CA). This study examined the efficacy of hyperbilirubinemia, hyponatremia, and both combined in the preoperative diagnosis of CA. Patients who underwent surgery for acute appendicitis were included in this retrospective review. In total, 247 patients were included in the final analysis. Of these, 36 (14.2%) had early appendicitis, 177 (72.0%) had acute suppurative appendicitis, 32 (13.0%) had necrotizing/gangrenous acute appendicitis, and 2 (0.8%) had other types of appendicitis. The mean total bilirubin (TBIL) level was significantly higher in patients with CA than in those with uncomplicated appendicitis. Conversely, the mean serum sodium level was significantly lower in patients with CA than in those with uncomplicated appendicitis. The levels of TBIL (odds ratio: 1.098, 95% CI: 1.052–1.147) and serum sodium (odds ratio: 0.743, 95% CI: 0.646–0.855) were associated with CA. Hyponatremia combined with hyperbilirubinemia yielded significant discriminatory value for the diagnosis of CA. TBIL and serum sodium levels can be considered as adjuvant parameters in the diagnosis of perforated/necrotizing appendicitis. Although hyperbilirubinemia and hyponatremia together were better able to determine the risk of CA than either marker alone, other markers are required to definitively predict CA. Furthermore, large-scale studies are needed to confirm these findings.

Diagnostic Accuracy of Serum Amyloid A in Acute Appendicitis: A Systematic Review and Meta-Analysis

Background: Serum amyloid A has been widely reported as a useful biochemical marker in the diagnoses of acute appendicitis. The aim of this study was to appraise the diagnostic accuracy of serum amyloid A in the diagnosis of acute appendicitis. Methods: A systematic search of several databases was conducted. The search time was from the beginning of the databases creation to March 1, 2021, and the languages were restricted to English and Chinese. Clinical studies using serum amyloid A for the diagnosis of acute appendicitis were included. The overall sensitivity and specificity were calculated by using a bivariable mixed effects model. Heterogeneity was tested using I² statistics. This study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; no. CRD42021241343). Results: Five studies comprising 668 participants were eligible for inclusion. The overall sensitivity and specificity of serum amyloid A in diagnosing acute appendicitis were 0.87 (95% confidence interval [CI], 0.79-0.92) and 0.74 (95% CI, 0.59-0.85), respectively. The positive and negative likelihood were 3.3 (95% CI, 2.1-5.4) and 0.18 (95% CI, 0.11-0.28), respectively. The area under the summary receiver operating characteristic curves was 0.89 (95% CI, 0.86-0.91). The heterogeneity was significant (I² = 82%; 95% CI [63%-100%]). Conclusions: Serum amyloid A has good diagnostic accuracy for acute appendicitis. It is expected that serum amyloid A could be helpful in the early clinical diagnosis of acute appendicitis.

The role of neutrophil-to-lymphocyte ratio as an outcome predictor factor in acute appendicitis: a single medical center’s experience

Introduction: Acute abdominal pain persists in defying modern diagnostic procedures. Inflammatory response variables in urine and blood tests can help rule out other disorders and support a clinical diagnosis of acute appendicitis (AA), but there is no specific blood test that can diagnose AA. In order to address this, our study sought to establish the value of (NLR) as a prognostic and severity predictor in patients with AA.

Material and method: We conducted an observational retrospective study of 356 patients who had undergone surgery for AA, assessing NLR as an outcome metric. The NLR was estimated using the differential WBC (white blood count) reported on admission; the data obtained were then recorded in a database and statistically analyzed.

Results: The NLR medians correlated (p<0.001) in uncomplicated AA, AA with localized peritonitis, and AA with generalized peritonitis (Kruskal-Wallis test). The ROC curve identified 81.4 % sensitivity, 62.5 % specificity, and a 73 % AUC in localized peritonitis. The NLR value was associated with generalized peritonitis with a sensitivity of 63.7 %, specificity of 64.3 %, and AUC of 68.2%. The NLR-patient death association had 100% sensitivity, 80.3% specificity, and 93.5 AUC.

Conclusion: NLR determination in individuals with acute appendicitis may be useful in predicting complications. NLR values greater than 7.86 are usually related with generalized peritonitis, while values larger than 12.9 may predict an increased risk of patient death. Calculating NLR from a complete blood count is a straightforward and cost-effective method of analyzing complicated AA in resource-constrained settings.

Diagnostic accuracy of combining C-Reactive protein and Alvarado Score among 2-to-20-year-old patients with acute appendicitis suspected presenting to Emergency Departments

OBJECTIVE

Main objective was whether the combination of C-Reactive Protein (CRP) and Alvarado Score (AS) increase the diagnosis accuracy of AS among 2-to-20-year-old patients with suspected acute appendicitis presenting to Emergency Departments.

METHODS

This is a secondary analysis of prospective cohort study consecutively including all patients from 2 to 20 years of age attended for suspected acute appendicitis in 4 Spanish Emergency Departments during 6-month period. We collected demographic, clinical, analytic and radiographic, and surgical data. AS categories were retrospectively calculated as low (0-4 points), intermediate (5-6 points) or high (7-10 points). The cut-off levels were >0.5 mg/dl for CRP. The outcome was diagnosis of acute appendicitis within 14 days of the index visit.

RESULTS

A total of 331 patients with suspected of acute appendicitis (mean age 11.8 (SD 3.8) years; 52.9% males) were recruited. According to AS, 108 (32.6%) were at low risk, 76 at (23.0%) intermediate risk and 147 (44.4%) at high risk of acute appendicitis. One hundred and sixteen (35.0%) cases had confirmed histopathological diagnosis of acute appendicitis. The AUCs of ROC were 0.76 (0.70-0.81) for AS and 0.79 (95% CI 0.75-0.84) for CRP-AS being the difference statistically significant (p=0.003). The CRP for diagnosis acute appendicitis in low risk AS group had negative predictive value of 95.8% (95%CI 87.3-98.9) and likelihood ratio negative of 0.4 (95%CI 0.2-1.0)..

CONCLUSIONS

CRP-AS has shown to increase the diagnostic accuracy of AS for acute appendicitis. This approach may be useful to rule out the diagnosis of acute appendicitis in paediatric patients attended for abdominal pain suggestive of acute appendicitis.

Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children

Background: For children with acute appendicitis (AA), a clear diagnosis is a challenge. The purpose of this study is to explore whether inflammatory markers in the blood combined with symptom duration are helpful in the diagnosis of acute appendicitis and in predicting the severity of acute appendicitis. Methods: All the selected patients underwent appendectomy between November 10, 2011 and November 15, 2019, in whom preoperative WBCC, CRP, and NE% had been measured in a short time. All patients were divided into two groups: uncomplicated AA and complicated AA, postoperatively. Results: For our standards, 813 patients were selected, 442 of them had complicated AA. The mean [standard deviation (SD)] age for the uncomplicated AA group was 9.78 ± 2.02 years and for the complicated AA group was 9.69 ± 2.16 years (P = 0.55). Elevated WBCC, CRP, and NE% had a higher relatively sensitivity in complicated AA than uncomplicated AA especially when WBCC, CRP, and NE% were at normal levels, which had a sensitivity of 100% in uncomplicated AA, but this only applied to nine patients. CRP values were significantly different in three time groups, whether uncomplicated or complicated AA. Conclusion: The combination of WBCC, CRP, and NE% values is very sensitive for the diagnosis of acute appendicitis, and when we predict complicated AA using the CRP value, we also need to consider the time of symptom onset.

Diagnostic Value of Serum Urokinase-Type Plasminogen Activator Receptor in Children With Acute Appendicitis

OBJECTIVES

Acute appendicitis (AA) is the most common surgical emergency in children. The accurate and timely diagnosis of AA in children can be challenging, and delayed diagnosis rates have been reported to range from 5.9% to 27.6%. Although combining clinical history and repeated physical examination with laboratory tests and radiographic imaging modalities help reach the diagnosis, novel biomarkers can support the surgeons' decision as well. The aims of this study were to evaluate a new plasma marker, urokinase-type plasminogen activator receptor (uPAR), to improve diagnostic accuracy in AA patients, and to determine a cutoff value of uPAR, which can safely include/exclude the diagnosis of AA.

METHODS

We conducted a prospective study of children who underwent surgery for AA. Patients were categorized into the following 3 groups: group 1, controls consisted of 32 healthy volunteers; group 2, patients underwent surgery for nonperforated AA (n = 35); and group 3, patients underwent surgery for perforated AA (n = 21). Blood was sampled from group 1 at the admission and from group 2 and 3 before appendectomy. Serum uPAR, white blood cell count, absolute neutrophil count (ANC), and C-reactive protein concentrations were measured.

RESULTS

Urokinase-type plasminogen activator receptor, ANC, and white blood cell count values were significantly higher in group 2 and 3 than group 1, but there was no significant difference between group 2 and 3. C-reactive protein values were significantly higher only in group 3 than other groups. The cutoff value for uPAR is 2.2 ng/mL with sensitivity of 85.7% and specificity of 84.3% and ANC is 5900 cells/mm with sensitivity of 91.1% and specificity of 96.9% to diagnose appendicitis. The specificity was 81.3% and sensitivity was raised to 98.2% when evaluated together.

CONCLUSIONS

The incorporation of uPAR count and ANC could be a strong predictor of AA in children.

Body Mass Index and Calprotectin Blood Level Correlation in Healthy Children: An Individual Patient Data Meta-Analysis

Background: Calprotectin (CP) is a protein complex involved in many inflammatory diseases. Obesity is characterized by low-grade inflammation and elevated circulating levels of calprotectin. However, associations between body mass index (BMI) and calprotectin levels have not been explored in otherwise healthy children. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched PubMed and Cochrane Library database up to July 2019. Healthy children’s blood calprotectin values were extracted, and potential correlations were explored. Results: A total of six studies that included data on 593 healthy children were identified. Median calprotectin value was 900.0 (482.0; 1700) ng·mL⁻¹. Multivariable analysis showed no significant associations with age, sample type (serum vs. plasma), or sex. In contrast, a significant effect of BMI z-score (p < 0.001) emerged. Indeed, a positive correlation between BMI z-score and CP, was detected in girls (R: 0.48; p < 0.001) and boys (R: 0.39; p < 0.001). Conclusion: Calprotectin blood levels correlate with the degree of adiposity in healthy children, but are not affected by age, sex, or sample type (serum or plasma).

Calprotectin is superior to procalcitonin as a sepsis marker and predictor of 30-day mortality in intensive care patients

Sepsis is the most frequent cause of death in the intensive care unit (ICU). A rapid and correct diagnosis and initiation of therapy is crucial for improving patient outcomes. The aim of this study was to compare the performance of calprotectin with the more widely used sepsis biomarker procalcitonin (PCT) in ICU patients. The performance of calprotectin and PCT as sepsis and prognostic markers for 30-d mortality was compared in a prospective, observational study in an eight-bed ICU. We investigated concentrations of the biomarkers in plasma collected at admission from all ICU patients admitted during a year (2012-2013, n = 271) together with simplified acute physiology 3 scores (SAPS3) and sequential organ failure assessment (SOFA) scores. The receiver operating characteristic (ROC) analysis showed a higher area under the curve (AUC) value for calprotectin (0.79) than for PCT (0.49) when used as a sepsis marker. The calprotectin concentrations at admission were higher in non-survivors than in survivors at day 30. In our study, calprotectin was superior to PCT for distinguishing between ICU patients with sepsis and non-sepsis patients. Calprotectin also had higher predictive ability regarding 30-d mortality.

The diagnostic value of ischaemia-modified albumin in acute abdominal pain

AIM

The differential diagnosis of paediatric patients admitted to the emergency department presenting with acute abdominal pain may be difficult. This study aims to investigate the diagnostic value of ischaemia-modified albumin (IMA) in the differential diagnosis of acute abdominal pain in children and in distinguishing surgical from non-surgical cases.

METHODS

The study was conducted with a total of 152 subjects who provided informed consent, including 112 patients admitted to the paediatric emergency department and paediatric surgical clinic and 40 healthy control subjects. Blood samples were collected after initial examination to determine IMA, white blood cell (WBC) and C-reactive protein (CRP) values.

RESULTS

Mean IMA values of patients with acute appendicitis (AA), perforated appendicitis (PA) and non-specific abdominal pain were significantly higher compared to the control group. Mean IMA values of the AA and PA cases were also significantly higher compared to the group with non-specific abdominal pain. No significant difference was determined in mean IMA between the AA and PA groups. WBC and CRP levels of the AA and PA groups were significantly higher compared to the group with non-specific abdominal pain.

CONCLUSION

Our study shows that IMA, together with WBC and CRP, may be a biomarker capable of assisting the differential diagnosis of acute abdominal pain in children and distinguishing surgical from non-surgical cases.

Comparison of Open Appendectomy and Laparoscopic Appendectomy in Perforated Appendicitis

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

Preoperative assessment of complicated appendicitis through stress reaction and clinical manifestations

This study assessed the severity of the disease through the preoperative clinical manifestations and inflammatory reaction indicators of acute appendicitis, and established a score table to predict complicated appendicitis (CA).The clinical data of 238 patients with acute appendicitis in our hospital were retrospectively analyzed, which included 18 patients with acute simple appendicitis (7.6%), 170 patients with acute purulent appendicitis (72.0%), and 48 patients with acute gangrene and perforation (20.3%). The clinical manifestations and inflammatory reaction indicators were analyzed by univariate logistic regression. Multivariate logistic regression analysis was performed to screen out the independent risk factors of CA. The β coefficients of independent risk factors entering the multivariate model were assigned by rounding, and the total score was the sum of values of all factors. Finally, verification and analysis were performed for the predictive model, and the operating characteristic curve (ROC) curve was drawn. Then, the area under the curve (AUC) was compared with the THRIVE scale, and the Hosmer-Lemeshow method was used to evaluate whether the model fitted well.The multivariate logistic regression analysis of independent risk factors was performed, and the values were rounded to the variable assignment based on the β coefficient values. The plotted ROC and AUC was calculated as 0.857 (P < .001). Using the Hosmer-Lemeshow method, the X-value was 12.430, suggesting that the prediction model fitted well.The scoring system can quickly determine whether this is a CA, allowing for an earlier and correct diagnosis and treatment. Furthermore, the scoring system was convenient, economical, and affordable. Moreover, it is easy to popularized and promote.

Role of Platelet to Lymphocyte Ratio as a Biomedical Marker for the Pre-Operative Diagnosis of Acute Appendicitis

Background: Recently, the possible use of laboratory parameters such as full blood count, neutrophil count, neutrophil to lymphocyte ratio (NLR), thrombocyte count (PLT), and mean thrombocyte volume (MPV) have been investigated in diagnosis of acute appendicitis and the prediction of complications. The aim of this study was to investigate the utility of the platelet to lymphocyte ratio (PLR) value as a biomedical marker in the prediction of acute appendicitis and perforated appendix. Patients and Methods: The data were retrieved from the hospital records related to age, gender, length of stay in hospital, MPV, leukocyte, neutrophil, lymphocyte, and thrombocyte counts measured in the peripheral venous blood sample on presentation, NLR and PLR values, and the pathology results. The patients were grouped according to the pathology results as follows: group 1 (normal appendix, n = 86); group 2 (acute appendicitis, n = 458); group 3 (perforated appendicitis, n = 14). Results: The study included a total of 558 patients (308 males; 250 females) with a mean age of 34.24 ± 14.27 years. The mean length of stay in hospital was 2.12 days. The leukocyte and neutrophil count values of group 1 were lower than group 2 and group 3 values (p < 0.001). The lymphocyte count values of group 1 were higher than those of the other groups (p < 0.001). The NLR and PLR values of group 1 were lower than group 2 and group 3 values (p < 0.001). The length of stay in hospital was shorter in group 1 than in group 2 and group 3 (p = 0.42). The receiver operating characteristic (ROC) curve test results showed that PLR and NLR values were sensitive and specific to differentiate normal appendix, acute appendicitis, and perforated appendicitis. Conclusion: The results of this study demonstrated that PLR value, such as NLR, could be evaluated as a new biomarker that could be valuable in the differentiation of normal appendix from acute appendicitis and in the differentiation of acute appendicitis from perforated appendicitis.

White blood cell count and eosinopenia as valuable tools for the diagnosis of bacterial infections in the ED

Identifying an infection may be difficult in the ED. Neutrophilic leukocytosis is often used in the diagnosis of infection despite its lack of specificity in situations of stress. Our objective was to study the value of each parameter of the WBC count, in particular eosinopenia, to diagnose bacterial infections in the ED. We conducted a retrospective and observational study over a period of 6 months. All patients with one of the following diagnoses were eligible: pneumonia (9.9%), pyelonephritis (26.2%), prostatitis (8.4%), appendicitis (26.2%), cholecystitis (8.4%), and diverticular sigmoiditis (5%). A total of 466 infected patients were included for statistical analysis, and a control group of 466 uninfected patients was randomly selected in the same period of time. All leukocyte count parameters were significantly modified (p < 0.001) in the infected group compared with the control group. Neutrophils and total leukocytes remain the two most suitable parameters for the diagnosis of infections in the ED. Eosinopenia represented the most efficient parameter of the WBC count for the diagnosis of urinary and biliary tract infections. Deep eosinopenia presented a specificity of 94% for the diagnosis of infection. Any modification of the WBC count associated with an elevation of CRP (> 40 mg/L) or fever (> 38.5 °C) showed a high specificity for the diagnosis of infection. A careful analysis of the WBC count remains a valuable tool for the diagnosis of infection in the ED.

Diagnosis of acute pediatric appendicitis from children with inflammatory diseases by combination of metabolic markers and inflammatory response variables

BACKGROUND

The discovery of new metabolic markers may be helpful for early diagnosis of acute pediatric appendicitis (APA). However, no studies have been reported regarding identification of potential metabolic markers for the APA diagnosis by metabonomics.

METHODS

Serum samples of APA (n=32), non-appendicitis inflammation (NAI, n=32) and healthy children (HS, n=65) were analyzed by the 1H NMR-based metabonomics. A logistic regression model was established to screen the most efficient markers combinations for classification. Forty double-blind samples were further validated the model.

RESULTS

Nine blood metabolites that were different in the APA group from other groups were identified. To differentiate APA from HS, single variable of acetate, formate, white blood cell (WBC) and C-reactive protein (CRP) showed a high diagnostic value (area under the receiver operating characteristic [AUROC]<0.92), while they had a weak diagnostic value (AUROC<0.77) for identifying the APA and NAI. By contrast, the AUROC values of leucine (0.799) were higher than that of WBC and CRP. A combination of five variables, i.e. leucine, lactate, betaine, WBC and CRP, showed a high diagnostic value (AUROC=0.973) for the APA discriminating from the NAI, and the sensitivity and specificity were 93.8% and 93.7%, respectively. Further double-blind sample prediction showed that the accuracy of the model was 85% for 40 unknown samples.

CONCLUSIONS

The current study provides useful information in our understanding of the metabolic alterations associated with APA and indicates that measurement of these metabolites in serum effectively aids in the clinical identification of APA.

Cytokines and Chemokines in Pediatric Appendicitis: A Multiplex Analysis of Inflammatory Protein Mediators

OBJECTIVES

We aimed to demonstrate the potential of precision medicine to describe the inflammatory landscape present in children with suspected appendicitis. Our primary objective was to determine levels of seven inflammatory protein mediators previously associated with intra-abdominal inflammation (C-reactive protein-CRP, procalcitonin-PCT, interleukin-6 (IL), IL-8, IL-10, monocyte chemoattractant protein-1-MCP-1, and serum amyloid A-SAA) in a cohort of children with suspected appendicitis. Subsequently, using a multiplex proteomics approach, we examined an expansive array of novel candidate cytokine and chemokines within this population.

METHODS

We performed a secondary analysis of targeted proteomics data from Alberta Sepsis Network studies. Plasma mediator levels, analyzed by Luminex multiplex assays, were evaluated in children aged 5-17 years with nonappendicitis abdominal pain (NAAP), acute appendicitis (AA), and nonappendicitis sepsis (NAS). We used multivariate regression analysis to evaluate the seven target proteins, followed by decision tree and heat mapping analyses for all proteins evaluated.

RESULTS

185 children were included: 83 with NAAP, 79 AA, and 23 NAS. Plasma levels of IL-6, CRP, MCP-1, PCT, and SAA were significantly different in children with AA compared to those with NAAP (p < 0.001). Expansive proteomic analysis demonstrated 6 patterns in inflammatory mediator profiles based on severity of illness. A decision tree incorporating the proteins CRP, ferritin, SAA, regulated on activation normal T-cell expressed and secreted (RANTES), monokine induced by gamma interferon (MIG), and PCT demonstrated excellent specificity (0.920) and negative predictive value (0.882) for children with appendicitis.

CONCLUSIONS

Multiplex proteomic analyses described the inflammatory landscape of children presenting to the ED with suspected appendicitis. We have demonstrated the feasibility of this approach to identify potential novel candidate cytokines/chemokine patterns associated with a specific illness (appendicitis) amongst those with a broad ED presentation (abdominal pain). This approach can be modelled for future research initiatives in pediatric emergency medicine.

Assessment of proadrenomedullin as diagnostic or prognostic biomarker of acute appendicitis in children with acute abdominal pain

BACKGROUND

Acute appendicitis (AA) is one of the most frequent surgical pathologies in pediatrics.

OBJECTIVES

To investigate the utility of proadrenomedullin (pro-ADM) for the diagnosis of AA.

METHODS

Prospective, analytical, observational, and multicenter study conducted in 6 pediatric emergency departments. Children up to 18 years of age with suspected AA were included. Clinical, epidemiological, and analytical data were collected.

RESULTS

We studied 285 children with an average age of 9.5 years (95% confidence interval [CI], 9.1-9.9). AA was diagnosed in 103 children (36.1%), with complications in 10 of them (9.7%). The mean concentration of pro-ADM (nmol/L) was higher in children with AA (0.51 nmol/L, SD 0.16) than in children with acute abdominal pain (AAP) of another etiology (0.44 nmol/L, SD 0.14; p < 0.001). This difference was greater in complicated cases compared with uncomplicated AA (0.64 nmol/L, SD 0.17 and 0.50 nmol/L, SD 0.15, respectively; p = 0.005). The areas under the receiver-operating characteristic curves were 0.66 (95% CI, 0.59-0.72) for pro-ADM, 0.70 (95% CI, 0.63-0.76) for C-reactive protein (CRP), 0.84 (95% CI, 0.79-0.89) for neutrophils, and 0.84 (95% CI, 0.79-0.89) for total leukocytes. The most reliable combination to rule out AA was CRP ≤1.25 mg/dL and pro-ADM ≤0.35 nmol/L with a sensitivity of 96% and a negative predictive value of 93%.

CONCLUSION

Children with AA presented higher pro-ADM values than children with AAP of other etiologies, especially in cases of complicated AA. The combination of low values of pro-ADM and CRP can help to select children with low risk of AA.

The Diagnostic Value of Irisin in Pediatric Patients with Acute Abdominal Pain

Objectives

Diagnosis of pediatric patients presenting to the Emergency Department with acute abdominal pain is not always easy. The purpose of this study was to investigate the effectiveness of irisin, a peptide hormone with reactivity shown in the appendix and neutrophils, in the differential diagnosis of pediatric patients with acute abdominal pain.

Methods

162 subjects consenting to participate, including 112 patients presenting to the Pediatric Emergency and Pediatric Surgery clinics with acute abdominal pain and 50 controls, were enrolled in the study. Blood was collected from all patients following initial examination for irisin, WBC, and CRP investigation.

Results

Mean irisin levels in cases of acute appendicitis (AA) and perforated appendicitis (PA) were statistically significantly higher compared to nonspecific abdominal pains and the control group. No statistically significant difference was observed in irisin levels between AA and PA cases. WBC and CRP levels were also significantly higher in cases of AA and PA compared to nonspecific abdominal pains.

Conclusions

Differential diagnosis of acute abdominal pains in children and deciding on surgery are a difficult and complex process. Our study shows that irisin can be a useful biomarker in differentiating AA and PA from other acute abdominal pains in children.

Diagnostic Accuracy of Serum and Urine S100A8/A9 and Serum Amyloid A in Probable Acute Abdominal Pain at Emergency Department

Study Design

This study was performed to investigate the diagnostic values of some inflammatory biomarkers in abdominal pain.

Methods

Patients over 18 years of age with acute recent abdominal pain who presented to the Emergency Department were evaluated. Serum and urinary samples were taken and evaluated for serum and urine S100A8/A9 and serum amyloid A. All patients were referred to a surgeon and were followed up until the final diagnosis. In the end, the final diagnosis was compared with the levels of biomarkers.

Results

Of a total of 181 patients, 71 underwent surgery and 110 patients did not need surgery after they were clinically diagnosed. Mean levels of serum and urine S100A8/A9 had a significant difference between two groups, but serum amyloid A did not show. The diagnostic accuracy of serum S100A8/A9, urine S100A8/A9, and serum amyloid A was 86%, 79%, and 50%, respectively, in anticipation of the need or no need for surgery in acute abdominal pain.

Conclusions

Our study showed that in acute abdominal pain, serum and urine S100A8/A9 can be useful indicators of the need for surgery, but serum amyloid A had a low and nonsignificant diagnostic accuracy.

Extraction, isolation, and concentration of calprotectin antigen (S100A8/S100A9) from granulocytes

BACKGROUND

Calprotectin is a promising biomarker for granulocyte activation. It is mainly measured in faeces as a marker for inflammatory bowel disease. A limitation is that there is no widely accepted calibrator.

AIM

To establish a method for purification of calprotectin from human granulocytes that is easily reproducible, reliable, and could contribute to a better agreement between different calprotectin methods.

METHODS AND RESULTS

Calprotectin was purified from granulocyte extracts using ion-exchange chromatography. The granulocytes were separated from blood bags. The purity was analysed by analysing pixel density of a picture of the sodium dodecyl sulfate polyacrylamide gel electrophoresis and by size exclusion chromatography. The calprotectin concentration of the pure antigen solution was determined using Biuret method. The purity was >95% for 3 preparations, and their concentrations were 1079, 1080, and 1813 mg/L.

CONCLUSION

It is possible to reproducibly prepare highly purified calprotectin antigen from human granulocytes. The preparations can be used for preparing calibrators, controls for immunological calprotectin assays, and immunisation for raising antibodies against human calprotectin in hens.

The Use of Routine Blood Cultures in Pediatric Appendicitis

OBJECTIVES

To determine the proportion of true-positive blood culture results in children presenting to the ED with suspected appendicitis. To describe the current practice of obtaining blood cultures in children with suspected appendicitis.

METHODS

We performed a 2-year retrospective health record review of all children aged 2 through 17 years investigated for suspected appendicitis at a tertiary Pediatric Emergency Department. Subjects were identified by searching (a) institutional records for ICD-10-CA coding, (b) diagnostic imaging records of ultrasounds for appendicitis, and (c) surgical database records for nonincidental appendectomies. Abstracted demographic and clinical data were matched to regional laboratory services data to describe the performance and result of blood cultures.

RESULTS

Overall, 1315 children investigated for appendicitis were reviewed. Seven hundred fifty (57.0%) were girls, the average age was 11.7 years (SD, 4.0). Blood cultures were obtained in 288 (21.9%) of 1315 patients. Of the 11 (3.8%) cultures that were positive, only 1 (0.35%) was a true positive. Young age, high triage acuity, and presence of fever were associated with the acquisition of cultures (P < 0.001 for all). The proportion of children undergoing appendectomy and the negative appendectomy rate was similar between those with and without blood culture (P = 0.10 and P = 0.96, respectively).

CONCLUSIONS

True-positive blood cultures are very rare in children presenting to the ED with suspected appendicitis. Given the potential for false-positive cultures and the social/economic implications of initial testing/retesting of false positives, the use of routine blood cultures for children with suspected appendicitis is not supported.

Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AAwith ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm–7 am weekdays and on weekends, 70.7%) than during business hours (7 am–7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of non-diagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 x 103/μL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.

The diagnostic value of hepcidin to predict the presence and severity of appendicitis in children

BACKGROUND

The aim of this study was to determine the diagnostic capacity of hepcidin in pediatric acute appendicitis and its accuracy as a predictor of the severity of appendicitis.

MATERIALS AND METHODS

In children with appendicitis (n = 39), leukocytes, platelet count, and the serum levels of C-reactive protein (CRP) and hepcidin were compared to a control group (n = 25) of patients with unspecific abdominal pain. Additionally, parameters were compared between children with simple (n = 17) and complicated appendicitis (n = 22). Receiver operation characteristic analyses of the different parameters were performed and the areas under the curve (AUCs) calculated.

RESULTS

Leukocytes and serum hepcidin levels were significantly higher in children with acute appendicitis versus control group (13.7 ± 5.7 versus 9.8 ± 3.9 G/L, P = 0.005 and 31.3 ± 21.7 versus 20.4 ± 14 ng/mL, P = 0.039). AUCs for hepcidin, leukocytes, and CRP were 0.654, 0.711, and 0.619, respectively. Complicated appendicitis was associated with significantly higher hepcidin concentrations compared to simple appendicitis (38.5 ± 17.6 ng/mL versus 21.6 ± 23.4 ng/mL, P < 0.001). A combination of leukocytes, CRP, and hepcidin had the highest AUC (0.914) to predict complicated appendicitis.

CONCLUSIONS

Increased serum levels of hepcidin were found in children with appendicitis compared to controls. While hepcidin was useful to identify patients with complicated appendicitis as it does not seem appropriate to distinguish between simple appendicitis and other causes for acute abdominal pain.

Use of autoantibodies against tumor-associated antigens as serum biomarkers for primary screening of cervical cancer

Serum autoantibodies against tumor-associated antigens (TAAs) have received much attention as potential biomarkers for early detection of cancers, since they can be detected in the early stages of cancers. Autoantibodies against Cancer Antigen 15-3 (CA15-3), carcinoembryonic antigen (CEA), Cancer Antigen 19-9 (CA19-9), c-Myc, p53, heat shock protein (Hsp)27 and Hsp70 have been suggested as potential markers for detecting several types of cancer. In the present study, the seven types of antibody listed above were evaluated for detecting cervical lesions. Enzyme-linked immunosorbent assays (ELISAs) were used to measure IgG levels of the autoantibodies in women with normal cytology, cervical intraepithelial neoplasia (CIN) I, CIN II, CIN III and cervical cancer. The increases of anti-CA15-3 and anti-CEA IgG in cervical cancer were more pronounced than the increases of the other markers, and the level of anti-CA19-9 IgG in CIN III stage was higher than in normal CIN I, CIN II or cervical cancer. A combination of ELISAs detecting anti-CA15-3, anti-CEA and anti-CA19-9 IgGs was found to reliably discriminate CINs from normal and to strongly differentiate cancer from normal (90.3% of sensitivity and 82.1% of specificity). We suggest that the combination of three ELISA may be useful for detecting cervical lesions.

[Appendicitis versus non-specific acute abdominal pain: Paediatric Appendicitis Score evaluation]

INTRODUCTION

Non-specific acute abdominal pain is the most common process requiring differential diagnosis with appendicitis in clinical practice. The aim of this study was to assess the Paediatric Appendicitis Score in differentiating between these two entities.

MATERIAL AND METHODS

All patients admitted due to suspicion of appendicitis were prospectively evaluated in our hospital over a two-year period. Cases of non-specific acute abdominal pain and appendicitis were enrolled in the study. Several variables were collected, including Score variables and C-reactive protein levels. Descriptive, univariate and multivariate analyses and diagnostic accuracy studies (ROC curves) were performed.

RESULTS

A total of 275 patients were studied, in which there were 143 cases of non-specific acute abdominal pain and 132 cases of appendicitis. Temperature and right iliac fossa tenderness on palpation were the variables without statistically significant differences, and with no discrimination power between groups. Pain on coughing, hopping, and/or percussion tenderness in the right lower quadrant was the variable with greater association with appendicitis. The Score correctly stratified the patients into risk groups. Substitution of temperature for C-reactive protein in the Score increased diagnostic accuracy, although with no statistically significant differences.

CONCLUSIONS

The Paediatric Appendicitis Score helps in differential diagnosis between appendicitis and non-specific acute abdominal pain. It would be advisable to replace the temperature in the Score, since it has no discrimination power between these groups. C-reactive protein at a cut-off value of 25.5mg/L value could be used instead.

The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis

OBJECTIVE

White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted.

METHODS

This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5-11, and 12-18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut-points.

RESULTS

A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0-13.9 years) were studied. Forty-one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval [CI] = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5-11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12-18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut-point of 10,000/mm³ , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), and 64% (12-18 years).

CONCLUSION

WBC count and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.

Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial

BACKGROUND

The current research on acute appendicitis aims to improve the diagnostics and to clarify to whom antibiotic treatment might be the treatment of choice.

METHODS

The present study is a retrospective analysis of a prospectively collected data in our randomized multicenter trial comparing surgery and antibiotic treatment for acute uncomplicated appendicitis (APPAC trial, NCTO1022567). We evaluated 1321 patients with a clinical suspicion of acute appendicitis, who underwent computed tomography (CT). Age, gender, body temperature, pain scores, the duration of symptoms, white blood cell count (WBC) and C-reactive protein (CRP) were recorded on admission.

RESULTS

CT confirmed the diagnosis of acute appendicitis in 73% (n=970) and in 27% (n=351) it revealed no or other diagnosis. Acute appendicitis patients had significantly higher WBC levels than patients without appendicitis (median 12.2 and 10.0, respectively, p<0.0001), whereas CRP levels did not differ between the two groups. Ideal cut-off points were assessed with receiver operating characteristic (ROC) curves, but neither these markers or neither their combination nor any clinical characteristic could accurately differentiate between patients with acute appendicitis and those without. The proportion of patients with normal WBC count and CRP was significantly (p=0.0007) lower in patients with acute appendicitis than in patients without appendicitis.

CONCLUSIONS

Both clinical findings and laboratory tests are unable to reliably distinguish between patients with acute appendicitis and those without. If both WBC count and CRP are normal, acute appendicitis is very unlikely. The current results emphasize the role of CT imaging in patients with suspected acute appendicitis.

A Novel Oxidative Stress Mediator in Acute Appendicitis: Thiol/Disulphide Homeostasis

Aim. To investigate the role of a novel oxidative stress marker, thiol/disulphide homeostasis, in patients diagnosed with acute appendicitis (AA). Methods. In this study, seventy-one (43 male and 28 female) patients diagnosed with AA and 71 (30 male and 41 female) healthy volunteers were included. Age, gender, body mass index (BMI), haemoglobin (Hb), white blood cell (WBC), c-reactive protein (CRP), and thiol/disulphide homeostasis parameters (native thiol, total thiol, disulphide, disulphide/native thiol, native thiol/total thiol, and disulphide/total thiol ratios) were compared between the groups. Thiol/disulphide homeostasis was determined by a newly developed method by Erel and Neselioglu. Results. The native thiol, total thiol, and the native thiol/total thiol ratio levels were statistically significantly decreased in the AA compared with the control group (p < 0.001). Disulphide level and the ratios of disulphide/native thiol and disulphide/total thiol were higher in the AA group than in the control group (p < 0.001). There was a negative correlation of CRP with native thiol, total thiol, and native thiol/total thiol ratio while there was a positive correlation of CRP with disulphide/native thiol and disulphide/total thiol in the AA group. In the stepwise regression model, risk factors as disulphide/native thiol (OR = 1.368; p = 0.018) and CRP (OR = 1.635; p = 0.003) were determined as predictors of perforated appendicitis compared to the nonperforated group. Conclusion. This is the first study examining the thiol/disulphide homeostasis as a diagnostic aid in AA and establishing thiol/disulphide homeostatis balance shifted towards the disulphide formation due to thiol oxidation. Further studies are needed to optimize the use of this novel oxidative stress marker in AA.

Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis

Background

Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies.

Methods

A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost–benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively.

Results

Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature.

Conclusion

When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-5109-1) contains supplementary material, which is available to authorized users.

The use of platelet indices, plateletcrit, mean platelet volume and platelet distribution width in emergency non-traumatic abdominal surgery: a systematic review

Platelet indices (PI) -- plateletcrit, mean platelet volume (MPV) and platelet distribution width (PDW) -- are a group of derived platelet parameters obtained as a part of the automatic complete blood count. Emerging evidence suggests that PIs may have diagnostic and prognostic value in certain diseases. This study aimed to summarize the current scientific knowledge on the potential role of PIs as a diagnostic and prognostic marker in patients having emergency, non-traumatic abdominal surgery. In December 2015, we searched Medline/PubMed, Scopus and Google Scholar to identify all articles on PIs. Overall, considerable evidence suggests that PIs are altered with acute appendicitis. Although the role of PI in the differential diagnosis of acute abdomen remains uncertain, low MPV might be useful in acute appendicitis and acute mesenteric ischemia, with high MPV predicting poor prognosis in acute mesenteric ischemia. The current lack of consistency and technical standards in studies involving PIs should be regarded as a serious limitation to comparing these studies. Further large, multicentre prospective studies concurrently collecting data from different ethnicities and genders are needed before they can be used in routine clinical practice.

Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging?

BACKGROUND

One of the main aims of appendicitis research is the differential diagnostics between complicated and uncomplicated acute appendicitis that enable provision of the optimal treatment for each patient.

METHODS

Data in the present study were collected prospectively in our randomized antibiotic treatment for uncomplicated acute appendicitis trial (APPAC) comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (NCT01022567). We evaluated 705 patients who had acute appendicitis on computed tomography. Patients with uncomplicated acute appendicitis (n = 368) were compared with all complicated acute appendicitis patients (n = 337), and subgroup analyses were performed between uncomplicated acute appendicitis and an appendicolith appendicitis (CA1; n = 256) and uncomplicated acute appendicitis and perforation and/or abscess (CA2; n = 78). Age, sex, body temperature (°C), duration of symptoms, white blood cell count (E9/L), and C-reactive protein (mg/L) were recorded on admission. Receiver operating characteristic curves were calculated for white blood cell count, C-reactive protein, and temperature.

RESULTS

CA2 patients had significantly greater C-reactive protein levels (mean 122 and 47, respectively, P < .001) and longer duration of symptoms than uncomplicated acute appendicitis patients; 81% of CA2 patients and 38% of uncomplicated acute appendicitis patients had symptoms >24 hours before admission (P < .001). In receiver operating characteristic analysis, C-reactive protein and temperature had clinically significant results only in comparison with uncomplicated acute appendicitis and CA2 (area under the curve >0.7), but no optimum cutoff points could be identified.

CONCLUSION

In clinical decision making, neither clinical findings nor laboratory markers are reliable enough to estimate the severity of the acute appendicitis accurately or to determine the presence of an appendicolith. The current results emphasize the role of computed tomography in the differential diagnosis of complicated and uncomplicated acute appendicitis.

Diagnostic accuracy and prognostic utility of D Dimer in acute appendicitis in children

The objective was to determine the uselfulness of D Dimer (DD) as a diagnostic or prognostic marker in acute appendicitis (AA) in children using a prospective observational study in the pediatric emergency department of a tertiary hospital. We enrolled 135 patients aged 1-16 years presenting with abdominal pain consistent with AA, who required laboratory studies. We analyzed clinical, analytical variables and histopathology findings (when they underwent surgery). Statistical analysis was conducted using SPSS. 38.5% of the children were clinically diagnosed with AA (n = 52), confirmed by pathology in 51 patients. 55.8% were gangrenous appendicitis. Leucocyte count, C-reactive protein (CRP), and DD were higher in the AA group and in the gangrenous appendicitis group (p < 0.05), with highest values of DD in the gangrenous group. The area under the receiving operating characteristics (ROC) curve for DD in the diagnosis of AA is 0.66 (95% CI 0.56-0.75). For DD cut-off point of 230 ng/mL, sensitivity (Se) was 0.40, specificity (Sp) 0.80, positive predictive value (PPV) 0.57, and negative predictive value (NPV) 0.66. The area under the ROC curve for DD in children with gangrenous appendicitis is 0.93 (95% CI 0.87-1). A DD cut-off point of 230 ng/mL exhibited: Se = 0.69, Sp = 1, PPV = 1 and NPV = 0.72.

CONCLUSION

DD levels increase in patients with AA. Although it does not constitute a useful diagnostic marker, it could be a good prognostic marker.

Plasma calprotectin level: usage in distinction of uncomplicated from complicated acute appendicitis

Background

The aim of this study was to identify the diagnostic role of plasma calprotectin value for a distinction of presence acute appendicitis and the indifference of uncomplicated from complicated acute appendicitis.

Methods

Plasma calprotectin, white blood cell and C-reactive protein values of 89 patients, who have undergone laparoscopic appendectomy between January 2013 and May 2013 were evaluated.

Results

Calprotectin was 91 ng/mL (range 45–538) for acute appendicitis and 47 ng/ml (range 28–205) for the control group. There was a positive, statistically significant relation between calprotectin and C-reactive protein values (r = 0. 292 p = 0. 001, respectively). There was no statistically significant difference was determined between calprotectin and white blood cell values (r = 0. 142 p = 0. 187, respectively). CRP and Cal values were significantly higher in patients with a complicated AA group than in those with uncomplicated AA (p = 0. 014, p = 0. 0001, respectively) whereas white blood cell counts did not differ significantly between two groups (p = 0. 164).

Conclusion

Plasma calprotectin levels were increased in patients with acute appendicitis and should use in a distinction of uncomplicated from complicated acute appendicitis patients.

The Place of Calprotectin, Lactoferrin, and High-Mobility Group Box 1 Protein on Diagnosis of Acute Appendicitis with Children

The purpose of this study is to investigate the role of serum calprotectin (CP), lactoferrin (LF), and high-mobility group protein B1 (HMGB-1) levels and fecal CP and LF levels in differential diagnosis of acute uncomplicated appendicitis from other causes of abdominal pain and further from complicated appendicitis. Totally, 120 children were included grouped into 4 as: healthy controls, patients with right lower quadrant pain with other than surgical causes, patients with uncomplicated appendicitis, and patients with complicated appendicitis. Serum CP, LF, HMGB-1, C-reactive protein (CRP) levels, and white blood cell (WBC) count were studied as well as the fecal CP and LF levels. There was a statistically significant difference between control group and both uncomplicated and complicated acute appendicitis groups, regarding all parameters. In diagnosis of complicated acute appendicitis, area under curve (AUC) for fecal LF, serum CP, and serum HMGB-1 were determined as 1.00 and the cutoff level was determined as 25 μg/g feces, 670 ng/mL, and 30 ng/mL, respectively. In differential diagnosis of uncomplicated and complicated AA, the most accurate parameter was fecal LF with an AUC of 0.977. At a 60 μg/g cutoff value for this variable, sensitivity, specificity, and accuracy were 96.7, 93.3, and 95.0 %, respectively. In conclusion, HMGB-1, calprotectin, and lactoferrin constitute novel markers in diagnosis of AA. Moreover, their levels may be helpful for the clinicians to judge about the severity of the condition. Larger studies are warranted to determine the diagnostic potential of HMGB-1, LF, and CP in AA diagnosis.

Admission levels of serum amyloid a and procalcitonin are more predictive of the diagnosis of acute appendicitis compared with C-reactive protein

BACKGROUND

Acute appendicitis is the commonest surgical emergency, but its diagnosis can be elusive with a negative appendicectomy rate of 20%. The aims of this study were to investigate the potential value of the markers of acute inflammation, serum amyloid A (SAA), and serum procalcitonin (ProCT), in the diagnosis of acute appendicitis in adults and to compare that with the commonly used serum C-reactive protein (CRP).

METHODS

Adult patients presenting with acute right lower abdominal pain and a clinical suspicion of acute appendicitis were included. Blood samples were obtained within 6 hours of admission for rapid serum CRP assay and for end-of-recruitment batch analysis of SAA and serum ProCT concentrations.

RESULTS

A total of 147 patients (81 males) with a mean (±SD) age of 36 (±17) years were recruited. Appendicitis was confirmed histologically in 61 of 72 patients (84.7%) who underwent appendicectomy. A post hoc analysis revealed a diagnostic sensitivity and specificity for SAA of 92% and 72%, ProCT of 85% and 74%, and CRP of 75% and 72%, respectively. The receiver operator characteristics for the area under the curves showed that SAA (P=0.011) and ProCT (P=0.037) significantly exceeded CRP in the prediction of acute appendicitis on admission.

CONCLUSIONS

The measurement of SAA and serum ProCT on admission in patients with clinically suspected acute appendicitis seems to outperform serum CRP in aiding that diagnosis.

A new turbidimetric immunoassay for serum calprotectin for fully automatized clinical analysers

Serum and plasma calprotectin concentration is shown to be elevated when neutrophils are activated, and may therefore be used as a marker for inflammatory diseases. A serum calprotectin immunoassay was developed based on calprotectin values observed in samples from the intensive care unit. The polyclonal avian antibodies were raised and affinity purified with calprotectin antigens. The performance was tested and it was observed that the assay was linear in the range 0.3-24.7 mg/L, the limit of quantitation was observed to be lower than 0.3 mg/L, no antigen excess was observed up to 54 mg/L, all CVs were lower than 1.8 % in the precision study, the calibration curve stability was longer than 6 weeks, and there was no significant interference detected for haemoglobin, intralipid or bilirubin. The serum calprotectin immunoassay presented in this paper performs well within the criteria carefully set from the limited clinical experience obtained in both serum and plasma. In addition it is commutable with Bühlmann MRP8/14 ELISA.

Diagnostic Accuracy of Noncontrast CT in Detecting Acute Appendicitis: A Meta-analysis of Prospective Studies

The aim of the study is to evaluate the diagnostic accuracy of noncontrast CT in detecting acute appendicitis. Prospective studies in which noncontrast CT was performed to evaluate acute appendicitis were found on PubMed, EMBASE, and Cochrane Library. Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were assessed. The summary receiver-operating characteristic curve was conducted and the area under the curve was calculated. Seven original studies investigating a total of 845 patients were included in this meta-analysis. The pooled sensitivity and specificity were 0.90 (95% CI: 0.86–0.92) and 0.94 (95% CI: 0.92–0.97), respectively. The pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio was 12.90 (95% CI: 4.80–34.67), 0.09 (95% CI: 0.04–0.20), and 162.76 (95% CI: 31.05–853.26), respectively. The summary receiver-operating characteristic curve was symmetrical and the area under the curve was 0.97 (95% CI: 0.95–0.99). In conclusion, noncontrast CT has high diagnostic accuracy in detecting acute appendicitis, which is adequate for clinical decision making.

The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study?

PURPOSE

The purpose of this retrospective study was to investigate outcomes in children who underwent a non-diagnostic ultrasound (US) evaluating for appendicitis and to identify predictors of a negative diagnosis.

METHODS

An IRB-approved retrospective chart review was performed on patients age 0-18, who underwent an abdominal US evaluating for acute appendicitis from 2004 through 2013. Clinical data and specified outcomes were recorded, and exams were categorized into non-diagnostic studies and further separated into studies where the appendix was non-visualized.

RESULTS

Of the 1383 studies included for analysis, 876 were non-diagnostic for acute appendicitis (63.34%) with 777 specifically because the appendix was non-visualized. Seven hundred forty of the 876 non-diagnostic studies and 671 of the 777 non-visualized studies were ultimately considered true negatives, corresponding to a negative predictive value (NPV) of 84.47 and 86.36%, respectively. In patients with WBC <7.5×10(9)/L, the NPV of non-diagnostic and non-visualized studies increased to 97.12 and 98.86%, respectively. Patients with WBC <11.0×10(9)/L have similarly high NPVs of 95.59 and 96.99% (non-diagnostic and non-visualized).

CONCLUSION

Based on the high NPV of a non-diagnostic US in children without leukocytosis, these patients may safely avoid further diagnostic imaging for the workup of suspected appendicitis.