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Bonomo RA, Tamma PD, Abrahamian FM, Bessesen M, Chow AW, Dellinger EP, Edwards MS, Goldstein E, Hayden MK, Humphries R, Kaye KS, Potoski BA, Rodríguez-Baño J, Sawyer R, Skalweit M, Snydman DR, Donnelly K, Loveless J. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Diagnostic Imaging of Suspected Acute Appendicitis in Adults, Children, and Pregnant People. Clin Infect Dis 2024; 79:S94-S103. [PMID: 38963819 DOI: 10.1093/cid/ciae348] [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: 06/19/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024] Open
Abstract
This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America (IDSA). In this paper, the panel provides recommendations for diagnostic imaging of suspected acute appendicitis. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.
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Affiliation(s)
- Robert A Bonomo
- Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Clinician Scientist Investigator, Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES) Cleveland, Ohio, USA
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fredrick M Abrahamian
- Department of Emergency Medicine, Olive View-University of California, Los Angeles (UCLA) Medical Center, Sylmar, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mary Bessesen
- Department of Medicine, Veterans Affairs Eastern Colorado Health Care, Aurora, Colorado, USA
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anthony W Chow
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Morven S Edwards
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Mary K Hayden
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Romney Humphries
- Division of Laboratory Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith S Kaye
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Brian A Potoski
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Jesús Rodríguez-Baño
- Division of Infectious Diseases and Microbiology, Department of Medicine, Hospital Universitario Virgen Macarena, University of Seville, Biomedicines Institute of Seville-Consejo Superior de Investigaciones Científicas, Seville, Spain
| | - Robert Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Marion Skalweit
- Department of Medicine and Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Katelyn Donnelly
- Clinical Affairs and Practice Guidelines, Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Jennifer Loveless
- Clinical Affairs and Practice Guidelines, Infectious Diseases Society of America, Arlington, Virginia, USA
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Scaife JH, Iantorno SE, Bucher BT. Rates of Concurrent Computed Tomography Imaging Following Ultrasound for Pediatric Patients With Appendicitis. J Surg Res 2024; 302:134-143. [PMID: 39102772 DOI: 10.1016/j.jss.2024.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 05/24/2024] [Accepted: 06/23/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Imaging guidelines recommend an ultrasound (US)-first approach to evaluate appendicitis to minimize radiation. However, the association between US and computed tomography (CT) utilization remains unclear. We aimed to determine how increased US utilization correlated with the rate of CT evaluation of pediatric acute appendicitis. METHODS We conducted a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Eligible patients were aged less than 18 y with a diagnosis of appendicitis. Imaging was determined by Current Procedural Terminology codes. Concurrent imaging was defined as US and CT use during the same encounter. We calculated the hospital rate of concurrent imaging and categorized hospitals into tertiles: low (< 20%), medium (20%-40%), and high (> 40%). We developed generalized ordinal logistic regression models with inverse probability weighting to assess patient characteristics and hospital rates of concurrent imaging associations. RESULTS Our analysis included 485 hospitals and 23,976 patients. Thirty four percent were treated at hospitals in the lowest, 35% at the middle, and 31% at the highest tertile hospitals. We observed a negative correlation (-0.27, P < 0.001) between increasing US use and concurrent imaging use. The odds of presenting to a higher concurrent imaging rate hospital were significantly lower for Blacks (adjusted odds ratio [aOR] [95% confidence interval {CI}]: 0.6, [0.4-0.9]) and Hispanics (aOR [95% CI]: 0.7 [0.5-0.9]) in comparison to Whites. The odds of presenting to a higher concurrent imaging rate hospital were higher for patients in the second (aOR [95% CI]: 1.9 [1.2-3.2]) and lowest income quartile (aOR [95% CI]: 3.7 [1.1-13.1]) compared to the highest income quartile. CONCLUSIONS Increased US use correlated with decreased CT utilization for diagnosing appendicitis. White children and those in lower socioeconomic neighborhoods are more likely to visit hospitals with high concurrent imaging use.
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Affiliation(s)
- Jack H Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Stephanie E Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Brian T Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Pernía J, Cancho T, Segovia I, de Ponga P, Granda E, Velasco R. Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound. Emerg Med J 2024; 41:475-480. [PMID: 38729752 DOI: 10.1136/emermed-2023-213466] [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: 06/28/2023] [Accepted: 04/30/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND OBJECTIVES The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression. RESULTS We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8). CONCLUSIONS Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis.
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Affiliation(s)
- Juan Pernía
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Teresa Cancho
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Inés Segovia
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Elena Granda
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Roberto Velasco
- Pediatric Emergency Unit, Parc Taulí Hospital Universitari. Institut d'Investigacio i Innovacio Parc Tauli (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Catalunya, Spain
- Paediatrics & Child Health, University College Cork, Cork, Ireland
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Bravo M, Palnizky-Soffer G, Man C, Moineddin R, Singer-Harel D, Zani A, Doria AS, Schuh S. Identification of children with a nondiagnostic ultrasound at a low appendicitis risk using a pediatric Appendicitis Risk Calculator. Acad Emerg Med 2024. [PMID: 39034602 DOI: 10.1111/acem.14990] [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: 05/14/2024] [Revised: 06/19/2024] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES Up to 50% of ultrasounds (USs) for suspected pediatric appendicitis are nondiagnostic. While the validated low-risk clinical pediatric Appendicitis Risk Calculator (pARC) score < 15% and the low-risk US with nonvisualized appendix and no periappendiceal inflammation carry relatively low appendicitis risks, the contribution of the combination of both characteristics to this risk has never been assessed. The primary objective was to determine the proportion of children with the low-risk US-low-risk pARC combination with appendicitis. We hypothesized that this proportion would be 2.5% (upper 95% CI ≤ 5%). METHODS A retrospective cohort study of 448 previously healthy children 4-17 years old at a pediatric ED with suspected appendicitis, nondiagnostic US, and persistent clinical concern about appendicitis. Two investigators abstracted demographic, clinical, and imaging data. Based on published criteria, USs were classified as low-risk or high-risk. The pARC includes seven demographic, clinical, and laboratory variables and is quantified according to the published formula. The primary outcome was appendicitis, based on the histological evidence. All nonoperated patients underwent a 1-month-follow-up to exclude delayed appendicitis diagnoses. RESULTS Sixty of the 448 (13.4%) patients had appendicitis; 269 (60%) had low-risk US, 262 (58.4%) had low-risk pARC, and 163 (36.4%) had both characteristics. The appendicitis rates with low-risk pARC alone and low-risk US alone were 14/262 (5.4%) and 21/269 (7.8%), respectively. A total of 2/163 children (1.2%) with low-risk pARC and low-risk US had appendicitis (95% CI 0%-4.4%). Higher-risk US increased the appendicitis odds 5 (95% CI 1.54-20.55) to 11 times (95% CI 2.41-51.10) across pARC levels. The low-risk combination had sensitivity of 96.7% (95% CI 88.5%-99.6%), specificity of 41.5%, positive predictive value of 20.4%, and negative predictive value of 98.8% (95% CI 95.6%-99.9%). CONCLUSIONS The children with low-risk pARC and low-risk US combination are unlikely to have appendicitis and can be discharged home. The presence of higher-risk US-pARC score combinations substantially increases the appendicitis risk and warrants reassessment or interval imaging.
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Affiliation(s)
- Michael Bravo
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gili Palnizky-Soffer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carina Man
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Augusto Zani
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
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Stiegler C, Kapitza C, Weber F, Patalakh W, Schäfer C. Case report: A rare cause of intestinal perforation in a third-trimester pregnant woman. Front Med (Lausanne) 2024; 11:1387043. [PMID: 39021822 PMCID: PMC11251912 DOI: 10.3389/fmed.2024.1387043] [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] [Received: 02/29/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Background An acute abdomen is a medical emergency that requires early diagnosis and treatment. In pregnancy, this process is significantly more challenging, and radiological findings are sometimes unclear due to the enlarged uterus displacing other structures. Moreover, endometriosis-related complications are rare, and the disease is often undiagnosed. Case presentation We report a case of acute perforation of the cecum and appendix during pregnancy (35 weeks of gestation) caused by a previously unknown, deep infiltrating endometriosis with focal ulceration of the affected bowel wall, which sonographically seemed to be acute appendicitis. Conclusion Despite the relatively low risk, clinicians should be aware of possible endometriosis-associated complications in pregnancy with potentially life-threatening events, even in previously unknown endometriosis. Further studies should evaluate intestinal complications during pregnancy in relation to previous treatment of intestinal endometriosis (conservative vs. surgical).
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Affiliation(s)
- Clemens Stiegler
- Medical Department II, Klinikum Neumarkt, Neumarkt in der Oberpfalz, Germany
| | - Christopher Kapitza
- Medical Department II, Klinikum Neumarkt, Neumarkt in der Oberpfalz, Germany
| | - Florian Weber
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Wladimir Patalakh
- Department for Surgery, Klinikum Neumarkt, Neumarkt in der Oberpfalz, Germany
| | - Claus Schäfer
- Medical Department II, Klinikum Neumarkt, Neumarkt in der Oberpfalz, Germany
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Luksaite-Lukste R, Gecaite I, Marcinkeviciute K, Dumskis E, Samuilis A, Zvirblis T, Jasiunas E, Bausys A, Drungilas M, Luksta M, Kryzauskas M, Petrulionis M, Beisa A, Uselis S, Valeikaite-Taugininene G, Rackauskas R, Strupas K, Poskus T. Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial. J Clin Med 2024; 13:3363. [PMID: 38929896 PMCID: PMC11203661 DOI: 10.3390/jcm13123363] [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: 04/18/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods-Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results-A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions-Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.
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Affiliation(s)
- Raminta Luksaite-Lukste
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Igne Gecaite
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | | | - Eimantas Dumskis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Arturas Samuilis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Tadas Zvirblis
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (K.M.); (T.Z.); (A.B.)
- Department of Mechanical and Material Engineering, Vilnius Gediminas Technical University, LT-03224 Vilnius, Lithuania
| | - Eugenijus Jasiunas
- Vilnius University Hospital Santaros Klinikos, LT-08406 Vilnius, Lithuania; (E.J.); (M.D.)
| | - Augustinas Bausys
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (K.M.); (T.Z.); (A.B.)
| | - Mantas Drungilas
- Vilnius University Hospital Santaros Klinikos, LT-08406 Vilnius, Lithuania; (E.J.); (M.D.)
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Marius Petrulionis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Augustas Beisa
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Simonas Uselis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Gintare Valeikaite-Taugininene
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Rokas Rackauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
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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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10
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Schuh S, Man C, Marie E, Alhashmi GHA, Halevy D, Wales PW, Singer-Harel D, Finkelstein A, Sweeney J, Doria AS. Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis-A prospective cohort study. Am J Emerg Med 2023; 71:217-224. [PMID: 37453161 DOI: 10.1016/j.ajem.2023.06.026] [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: 02/14/2023] [Revised: 05/29/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED). STUDY DESIGN prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway. RESULTS 150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT. CONCLUSION this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.
| | - Carina Man
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Eman Marie
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | | | - Dan Halevy
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Paul W Wales
- Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada
| | - Aya Finkelstein
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Judith Sweeney
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Andrea S Doria
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
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11
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Diercks DB, Adkins EJ, Harrison N, Sokolove PE, Kwok H, Wolf SJ, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: Approved by ACEP Board of Directors February 1, 2023. Ann Emerg Med 2023; 81:e115-e152. [PMID: 37210169 DOI: 10.1016/j.annemergmed.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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12
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Eltorki M, Busse JW, Freedman SB, Thompson G, Beattie K, Serbanescu C, Carciumaru R, Thabane L, Ali S. Intravenous ketorolac versus morphine in children presenting with suspected appendicitis: a pilot single-centre non-inferiority randomised controlled trial. BMJ Open 2022; 12:e056499. [PMID: 35383071 PMCID: PMC8984007 DOI: 10.1136/bmjopen-2021-056499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite a lack of evidence demonstrating superiority to non-steroidal anti-inflammatory drugs, like ketorolac, that are associated with lower risk of harms, opioids remain the most prescribed analgesic for acute abdominal pain. In this pilot trial, we will assess the feasibility of a definitive trial comparing ketorolac with morphine in children with suspected appendicitis. We hypothesise that our study will be feasible based on a 40% consent rate. METHODS AND ANALYSIS A single-centre, non-inferiority, blinded (participant, clinician, investigators and outcome assessors), double-dummy randomised controlled trial of children aged 6-17 years presenting to a paediatric emergency department with ≤5 days of moderate to severe abdominal pain (≥5 on a Verbal Numerical Rating Scale) and are investigated for appendicitis. We will use variable randomised blocks of 4-6 and allocate participants in 1:1 ratio to receive either intravenous (IV) ketorolac 0.5 mg/kg+IV morphine placebo or IV morphine 0.1 mg/kg+IV ketorolac placebo. Analgesic co-intervention will be limited to acetaminophen (commonly used as first-line therapy). Participants in both groups will be allowed rescue therapy (morphine 0.5 mg/kg) within 60 min of our intervention. Our primary feasibility outcome is the proportion of eligible patients approached who provide informed consent and are enrolled in our trial. Our threshold for feasibility will be to achieve a ≥40% consent rate, and we will enrol 100 participants into our pilot trial. ETHICS AND DISSEMINATION Our study has received full approval by the Hamilton integrated Research Ethics Board. We will disseminate our study findings at national and international paediatric research conferences to garner interest and engage sites for a future multicentre definitive trial. TRIAL REGISTRATION NCT04528563, Pre-results.
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Affiliation(s)
- Mohamed Eltorki
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence & Impact, McMaster, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Graham Thompson
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Karen Beattie
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Redjana Carciumaru
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- St Joseph's Research Institute, St Joseph's Health Care, Hamilton, Ontario, Canada
| | - Samina Ali
- Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
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13
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Ahmad T, Khdair Ahmad F, Manson D. Diagnostic Performance of a Staged Pathway for Imaging Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e1197-e1201. [PMID: 31913249 DOI: 10.1097/pec.0000000000001964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The objective of this work is to assess the performance of our staged diagnostic pathway in the evaluation of suspected appendicitis cases in children. The pathway consisted of clinical assessment by the emergency physician, performing initial ultrasound (US), consultation, and clinical reevaluation by the surgery team followed by a repeat focused US scan in inconclusive cases. Computed tomography (CT) was limited to cases where the repeat US remained inconclusive and the clinical reassessment indicated persistent concerns for appendicitis. METHOD Retrospective review of the electronic medical records of 206 consecutive children who presented to our emergency department with acute abdominal pain and underwent US examination for suspected appendicitis. The imaging findings, management plan, and surgical outcome (in those who underwent surgery) were reviewed. The diagnostic performance of the initial US, repeat US, and the full imaging protocol were evaluated including the negative appendectomy rate (NAR) and the number of CT scans performed. RESULTS Of the 206 cases, 73 (35.4%) had appendicitis. Computed tomography was performed in 9 (4.3%) of 206 cases. The US/CT ratio was 23:1. Our approach showed a diagnostic accuracy of 95.6% (197/206), sensitivity of 97.3% (73/75), specificity of 93.7% (124/133), positive predictive value of 89.0% (73/82), and negative predictive value of 98.7% (82/95). The NAR was 2.7% (2/72). The accuracy of the protocol is higher than that of the initial US alone (61.2%; 126/206) and that of the repeat US (84.2%; 16/19). CONCLUSION The strategy of repeating limited focused US followed by CT scan in cases that remain inconclusive has good diagnostic accuracy and reasonable NAR and decreases the number of CT scans.
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Affiliation(s)
- Tahani Ahmad
- From the Department of Radiology, Dalhousie University, Department of Diagnostic Imaging, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Fareed Khdair Ahmad
- Section of Pediatric Gastroenterology, Department of Pediatrics, The University of Jordan, Amman, Jordan
| | - David Manson
- Department of Medical Imaging, University of Toronto, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
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14
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Determining the impact of body mass index on ultrasound accuracy for diagnosing appendicitis: Is it less useful in obese children? J Pediatr Surg 2021; 56:2010-2015. [PMID: 33573804 DOI: 10.1016/j.jpedsurg.2021.01.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasonography (US) is the preferred imaging for suspected pediatric appendicitis. We hypothesize that children with elevated Body-Mass-Index-for-age percentile (BMIP) may be more likely to have an inaccurate or equivocal (IE) US. METHODS After IRB approval, a four-year review was performed on pediatric patients evaluated for appendicitis by US. The CDC BMIP Calculator was used. IE subgroups were analyzed together for comparison against the accurate group. RESULTS 1059 patients were included: median age 11.3 years (IQR: 8.2, 14.6), 506 (47.8%) males. Median BMIP was 65.9 (IQR: 33.9, 89.6). US accurately diagnosed 857 (80.9%), incorrectly diagnosed 76 (7.2%), 126 (11.9%) were equivocal. Overall sensitivity was 0.85, specificity 0.96, PPV 0.93 and NPV 0.91. Obese children (BMIP ≥95%), had higher odds of IE US (OR: 1.86, 95% CI: 1.28, 2.70; p = 0.001). When analyzed by sex, risk increased in obese males (OR: 2.55, 95% CI:1.53, 4.24; p = 0.0003) but normalized in obese females (OR: 1.30, 95% CI:0.74, 2.28; p = 0.35). CONCLUSIONS An elevated BMIP may increase difficulty in visualizing the appendix, resulting in inaccurate or equivocal findings. This risk is seen specifically in obese males. If US findings do not correlate with clinical assessment in obese children with abdominal pain, further evaluation may be warranted.
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15
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Liu T, Wang L. Acute appendicitis in a child with nonspecific signs and symptoms and nondiagnostic sonography: Necessity of computed tomography. Radiol Case Rep 2021; 16:2496-2498. [PMID: 34257787 PMCID: PMC8259221 DOI: 10.1016/j.radcr.2021.05.078] [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: 05/06/2021] [Revised: 05/29/2021] [Accepted: 05/29/2021] [Indexed: 11/27/2022] Open
Abstract
Acute appendicitis is a common acute abdomen in children, especially in children over 5 years old. Although the incidence rate is lower than that of adults, the disease is more serious than adults. The rate of complication of peritonitis and perforation of appendix is even high. Generally, abdominal pain is still the main symptom of acute appendicitis in children, but children cannot express it, parents and doctors are easy to neglect. Ultrasound is the most commonly used imaging examination in the diagnosis of acute appendicitis in children. High fever can appear earlier, up to 39°C, at the same time can have mental atrophy, chills, convulsions and toxic shock. However, when the clinical symptoms of patients are not typical, and no obvious abnormality is found by ultrasound, it is easy to cause misdiagnosis to clinicians. Here we report a case of 9-years-old Chinese female with intermittent abdominal pain and vomiting. Initially she was diagnosed with acute gastroenteritis and was treated with antibiotics. However, there was nothing found by ultrasound, and her abdominal pain symptoms still did not relieve. Finally, abdominal CT examination confirmed acute appendicitis after 48 hours. The lesson is that ultrasound scanning should not be limited to the right lower abdomen, due to the great variation of appendix position in children with appendicitis. In addition, if there is no abnormality found by ultrasound and the infection index is increased, we suggest that abdominal CT should be examined immediately.
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Affiliation(s)
- Tieshan Liu
- Department of Pediatrics, PKU Care Zibo Hospital, Zibo, Shandong, 255069, P.R. China author
| | - Lina Wang
- Department of Pediatrics, PKU Care Zibo Hospital, Zibo, Shandong, 255069, P.R. China author
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16
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Affiliation(s)
- Katherine He
- Department of General Surgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street CA-034, Boston, MA 02115, USA
| | - Shawn J Rangel
- Department of Pediatric & Thoracic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue - Fegan 3, Boston, MA 02115, USA.
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17
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Kharbanda AB, Vazquez-Benitez G, Ballard DW, Vinson DR, Chettipally UK, Dehmer SP, Ekstrom H, Rauchwerger AS, McMichael B, Cotton DM, Kene MV, Simon LE, Zhu J, Warton EM, O’Connor PJ, Kharbanda EO. Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial. JAMA Netw Open 2021; 4:e2036344. [PMID: 33560426 PMCID: PMC7873779 DOI: 10.1001/jamanetworkopen.2020.36344] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis. OBJECTIVE To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis. DESIGN, SETTING, AND PARTICIPANTS In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019. INTERVENTIONS AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care. MAIN OUTCOMES AND MEASURES Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool. RESULTS We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group. CONCLUSIONS AND RELEVANCE In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02633735.
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Affiliation(s)
- Anupam B. Kharbanda
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - David R. Vinson
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | | | - Steven P. Dehmer
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Heidi Ekstrom
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Adina S. Rauchwerger
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Brianna McMichael
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | | | - Laura E. Simon
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Jingyi Zhu
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - E. Margaret Warton
- The Kaiser Permanente Northern California Division of Research, Oakland, California
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18
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Anandalwar SP, Graham DA, Kashtan MA, Bachur RG, Barnewolt CE, Callahan MJ, Rangel SJ. Leveraging the Combined Predictive Value of Ultrasound and Laboratory Data to Reduce Radiation Exposure and Resource Utilization in Children with Suspected Appendicitis. J Surg Res 2021; 257:529-536. [DOI: 10.1016/j.jss.2020.07.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/01/2020] [Accepted: 07/11/2020] [Indexed: 11/28/2022]
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19
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Piazza M, Baldeo R, Daniel R. Vomiting of unclear etiology in an autistic child-multiple possible diagnoses: A case report. J Am Coll Emerg Physicians Open 2020; 1:1009-1012. [PMID: 33145552 PMCID: PMC7593463 DOI: 10.1002/emp2.12097] [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: 01/11/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/04/2022] Open
Abstract
Appendicitis is a common complaint in the emergency department (ED) presenting with abdominal pain or vomiting and is often the foremost etiology the provider must rule out using history and physical examination. However, history and physical examination is limited in children and the developmentally delayed who are often non-cooperative. Less commonly, choledochal cysts are found that also require management, or rarer still, multiple possible radiologic or surgical diagnoses. This case report follows a delayed child presenting with vomiting found to have a large type 1 choledochal cyst, cholecystitis, and appendicitis on advanced imaging prompting surgical management of these etiologies. This report reviews the evaluation of children with vomiting and the need for thorough evaluation with advanced imaging when appropriate.
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Affiliation(s)
- Matthew Piazza
- Emergency Medicine, Good Samaritan Hospital Medical CenterWest IslipNew YorkUSA
| | - Rudolph Baldeo
- Emergency Medicine, Good Samaritan Hospital Medical CenterWest IslipNew YorkUSA
| | - Reethamma Daniel
- Emergency Medicine, Good Samaritan Hospital Medical CenterWest IslipNew YorkUSA
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20
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Koberlein GC, Trout AT, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Falcone RA, Garber MD, Joseph MM, Nguyen JC, Safdar NM, Karmazyn B. ACR Appropriateness Criteria ® Suspected Appendicitis-Child. J Am Coll Radiol 2020; 16:S252-S263. [PMID: 31054752 DOI: 10.1016/j.jacr.2019.02.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/08/2019] [Indexed: 12/29/2022]
Abstract
Acute appendicitis represents the most common abdominal surgical urgency/emergency in children. Imaging remains a central tool in the diagnosis of acute appendicitis and has been shown to facilitate management and decrease the rate of negative appendectomies. The initial consideration for imaging in a child with suspected acute appendicitis is based on clinical assessment, which can be facilitated with published scoring systems. The level of clinical risk (low, intermediate, high) and the clinical scenario (suspicion for complication) define the need for imaging and the optimal imaging modality. In some situations, no imaging is required, while in others ultrasound, CT, or MRI may be appropriate. This review frames the presentation of suspected acute appendicitis in terms of the clinical risk and also discusses the unique situations of the equivocal or nondiagnostic initial ultrasound examination and suspected appendicitis with suspicion for complication (eg, bowel obstruction). 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - George C Koberlein
- Research Author, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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21
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Evaluating Changes in Diagnostic Accuracy of Ultrasound for Appendicitis: Does Practice Make Perfect? J Emerg Med 2020; 59:563-572. [PMID: 32732135 DOI: 10.1016/j.jemermed.2020.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US. OBJECTIVES The primary objective was to demonstrate changes in diagnostic accuracy of US for appendicitis over time, after implementation of an US-first protocol. Secondary objectives included evaluating trends in utilization and factors associated with accuracy of US. METHODS We reviewed 5 years of pediatric emergency department encounters that included US evaluations for appendicitis. The primary outcome was conclusive US (fully visualized normal appendix or unequivocal appendicitis) vs. equivocal US (partially visualized or nonvisualized appendix). We also analyzed rates of conclusive US over time; accuracy, sensitivity, and specificity of US for appendicitis; and associations of US accuracy with patient gender, body mass index, and ultrasonographer's experience. RESULTS A conclusive US report was found in 267 of 1058 encounters (25.2%); overall accuracy rate was 24.5%. Over 5 years, the diagnostic accuracy of US for appendicitis improved significantly from 13.9% to 31.5% (p = 0.001). Overall sensitivity was 80.7% and specificity was 77.6%. Male gender and dedicated US of the appendix were significantly associated with conclusive US (ps < 0.001). Higher body mass index was significantly associated with equivocal US (p < 0.001). Ultrasonographer experience was not significantly associated with conclusive US (p = 0.22). CONCLUSIONS An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.
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Quality Assurance and Performance Improvement Project for Suspected Appendicitis. Pediatr Qual Saf 2020; 5:e290. [PMID: 32656463 PMCID: PMC7297388 DOI: 10.1097/pq9.0000000000000290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/20/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction: Considerable variability exists in the diagnosis and management of acute appendicitis, affecting both quality and costs of care. This prospective cohort study aimed to decrease unnecessary radiological investigations, standardize radiological imaging, avoid unnecessary hospital admissions, and decrease our institution rate of negative appendectomy. Methods: A multidisciplinary appendicitis care pathway was implemented. This pathway involved the use of the Pediatric Appendicitis Score, standardization of ultrasound reporting, and risk stratification to determine patient disposition. Patients were prospectively enrolled in the pathway and compared a preimplementation retrospective cohort. Results: We included 235 patients in this study that took place between February 2017 and January 2018. An 88.5% pathway adherence rate for appropriate referral for ultrasounds, an 84% compliance rate for correct risk stratification, and the need for a surgical consult were achieved. After implementation, standardization of ultrasound (U/S) reporting increased from 0% to 78%. The rate of computed tomography utilization decreased from 7.3% to 4.7%. An appendectomy was completed in 68 (29%) of patients. There was only 1 (1.5%) negative appendectomy, compared to the prepathway institutional negative appendectomy rate of 4%. Conclusion: The implementation of a standardized, evidence-based, appendicitis care pathway has the potential to improve quality of care by reducing negative appendectomies, unnecessary computed tomography scans, and unnecessary hospital admissions. The participation of the emergency and diagnostic imaging departments is critical to the successful implementation of this quality improvement measure. This simple, effective model can be easily implemented at other centers to improve the care of children.
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Jennings R, Guo H, Goldin A, Wright DR. Cost-effectiveness of Imaging Protocols for Suspected Appendicitis. Pediatrics 2020; 145:peds.2019-1352. [PMID: 31964758 DOI: 10.1542/peds.2019-1352] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inaccurate diagnosis of appendicitis leads to increased costs and morbidity. Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and may not visualize the appendix. METHODS We conducted a cost-effectiveness analysis using a decision-analytic model of 10 imaging strategies for suspected appendicitis in a hypothetical cohort of patients: no imaging with discharge or surgery; CT only; MRI only; or staged approach with CT or MRI after 1) negative ultrasound result or ultrasound without appendix visualization, 2) ultrasound without appendix visualization, or 3) ultrasound without appendix visualization but with secondary signs of inflammation. Inputs were derived from published literature and secondary data (quality-of-life and cost data). Sensitivity analyses varied risk of appendicitis and proportion of visualized ultrasound. Outcomes were effectiveness (quality-adjusted life-years [QALYs]), total direct medical costs, and cost-effectiveness (cost per QALY gained). RESULTS The most cost-effective strategy for patients at moderate risk for appendicitis is initial ultrasound, followed by CT if the appendix is not visualized but secondary signs are present (cost of $4815.03; effectiveness of 0.99694 QALYs). Other strategies were well above standard willingness-to-pay thresholds or were more costly and less effective. Cost-effectiveness was sensitive to patients' risk of appendicitis but not the proportion of visualized appendices. CONCLUSIONS Tailored approaches to imaging based on patients' risk of appendicitis are the most cost-effective. Imaging is not cost-effective in patients with a probability <16% or >95%. For moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even without appendix visualization.
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Affiliation(s)
- Rebecca Jennings
- Departments of Pediatrics and .,Seattle Children's Research Institute, Seattle, Washington; and
| | - He Guo
- School of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington
| | - Adam Goldin
- Pediatric General and Thoracic Surgery, Unviersity of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Davene R Wright
- Departments of Pediatrics and.,Seattle Children's Research Institute, Seattle, Washington; and.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
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Raval N, Kumawat A, Kalyane D, Kalia K, Tekade RK. Understanding molecular upsets in diabetic nephropathy to identify novel targets and treatment opportunities. Drug Discov Today 2020; 25:862-878. [PMID: 31981791 DOI: 10.1016/j.drudis.2020.01.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/26/2019] [Accepted: 01/15/2020] [Indexed: 12/11/2022]
Abstract
Diabetes and related complications are becoming a global encumbrance. Diabetic nephropathy (DN) is a major cause of end-stage renal disease (ESRD). The available therapeutic modalities related to DN do not treat DN at the molecular level, proposing further amendments in the management of DN based on the pathogenesis of DN. This manuscript discusses the concept and applications of nanomedicine for the treatment of DN that can improve renal targeting, retention and localization. This review also highlights the current issues related to targeting DN, challenges and allied opportunities toward the development of next-generation drugs and treatments for the management of DN.
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Affiliation(s)
- Nidhi Raval
- National Institute of Pharmaceutical Education and Research (NIPER) Ahmedabad, An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air Force Station, Gandhinagar 382355, Gujarat, India
| | - Akshant Kumawat
- National Institute of Pharmaceutical Education and Research (NIPER) Ahmedabad, An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air Force Station, Gandhinagar 382355, Gujarat, India
| | - Dnyaneshwar Kalyane
- National Institute of Pharmaceutical Education and Research (NIPER) Ahmedabad, An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air Force Station, Gandhinagar 382355, Gujarat, India
| | - Kiran Kalia
- National Institute of Pharmaceutical Education and Research (NIPER) Ahmedabad, An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air Force Station, Gandhinagar 382355, Gujarat, India
| | - Rakesh K Tekade
- National Institute of Pharmaceutical Education and Research (NIPER) Ahmedabad, An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air Force Station, Gandhinagar 382355, Gujarat, India; Indian Institute of Technology-Jammu, Jagti, PO Nagrota, Jammu 181 221, J&K, India.
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Wijaya A, Maruf A, Wu W, Wang G. Recent advances in micro- and nano-bubbles for atherosclerosis applications. Biomater Sci 2020; 8:4920-4939. [DOI: 10.1039/d0bm00762e] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Micro- and nano-bubbles have been developed as powerful multimodal theranostic agents for atherosclerosis treatment.
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Affiliation(s)
- Andy Wijaya
- Key Laboratory for Biorheological Science and Technology of Ministry of Education
- State and Local Joint Engineering Laboratory for Vascular Implants
- Bioengineering College
- Faculty of Medicine
- Chongqing University
| | - Ali Maruf
- Key Laboratory for Biorheological Science and Technology of Ministry of Education
- State and Local Joint Engineering Laboratory for Vascular Implants
- Bioengineering College
- Faculty of Medicine
- Chongqing University
| | - Wei Wu
- Key Laboratory for Biorheological Science and Technology of Ministry of Education
- State and Local Joint Engineering Laboratory for Vascular Implants
- Bioengineering College
- Faculty of Medicine
- Chongqing University
| | - Guixue Wang
- Key Laboratory for Biorheological Science and Technology of Ministry of Education
- State and Local Joint Engineering Laboratory for Vascular Implants
- Bioengineering College
- Faculty of Medicine
- Chongqing University
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Abstract
The diagnosis of pediatric appendicitis can be difficult, with a substantial proportion misdiagnosed based on clinical features and laboratory tests alone. Accordingly, advanced imaging with ultrasound (US), computed tomography (CT), and/or magnetic resonance imaging has become routine for most children undergoing diagnostic evaluation for appendicitis. There is increasing interest in the use of US as the primary imaging modality and reserving CT as a secondary diagnostic modality in equivocal cases. Magnetic resonance imaging, using a rapid protocol, without contrast or sedation, has been found to be highly sensitive and specific in the evaluation of children with acute right lower quadrant pain in a number of studies. Because magnetic resonance imaging has the advantage over CT of not using contrast or ionizing radiation, it may replace CT in many instances, whether after US as part of a stepwise imaging algorithm or as a primary imaging modality. Accessibility and cost, however, limit its more widespread use currently.
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Martinez-Rios C, McKinney JR, Al-Aswad N, K Shergill A, Louffat AF, Sung L, Thomas KE, Schuh S, Tomlinson G, Moineddin R, Doria AS. Parental preferences on diagnostic imaging tests for paediatric appendicitis. Paediatr Child Health 2018; 24:234-239. [PMID: 31239812 DOI: 10.1093/pch/pxy154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/27/2018] [Indexed: 02/06/2023] Open
Abstract
Objectives To determine parental preferences for diagnostic imaging tests (DITs) for paediatric appendicitis, to rank the attributes impacting the DIT selection and to identify DIT attributes that would cause parents to switch their DIT. Methods Parents of children who had an abdominal ultrasound (US) for right lower quadrant pain were interviewed. Two DITs were compared at a time, parents were asked to indicate their preferred test and to rank its attributes according to the impact each attribute had on their selection. The strength of their preference for the chosen DIT was measured by systematically adjusting attributes of the chosen DIT until the parent changed their choice. Results Fifty parents were interviewed. For US versus CT, more parents preferred US (68%, P=0.02) with higher importance ranks for cancer risk (P<0.0001), test accuracy (P=0.04), pain during test (P=0.3), and scan length (P<0.0001); and lower ranks for sedation (P=0.02), intravenous (IV) (P<0.02), and oral contrast (P=0.06). For US versus MRI, parents preferred MRI (78%, P<0.0001) with higher importance ranks for accuracy (P=0.2), pain during test (P=0.06), and scan length (P=0.06); and lower for noise (P<0.0001), claustrophobia (P<0.0001), use of IV contrast (P=0.06), and sedation (P=0.2). Conclusion US and MRI were the DIT preferred by parents for the investigation of acute paediatric appendicitis.
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Affiliation(s)
- Claudia Martinez-Rios
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Imaging, CHEO, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer R McKinney
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Graduate Entry Medical School, The University of Limerick, Limerick, Ireland
| | - Nadine Al-Aswad
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arvind K Shergill
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ada F Louffat
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lillian Sung
- Department of Pediatrics, Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Karen E Thomas
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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de Castro SMM, Geerdink TH, Macco S, van Veen RN, Jensch S, Vrouenraets BC. Mandatory imaging in the work-up of children suspected of having appendicitis reduces the rate of unnecessary surgeries. J Pediatr Surg 2018. [PMID: 29540260 DOI: 10.1016/j.jpedsurg.2018.02.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In children, the diagnosis “acute appendicitis” is difficult. In 2010, a new Dutch appendicitis guideline was published with the goal to reduce the negative appendectomy rate. The guideline recommended mandatory imaging (ultrasound first and CT or MRI when inconclusive) before surgery. This study examines whether the negative appendectomy rate in children has declined after the implementation of the guideline and if the number of ionising imaging procedures increased. METHODS In this cohort study, all consecutive patients aged 17 or younger, with the suspicion of appendicitis were included. Patients were divided into two groups. Those who presented between 2006 and 2010 (before the implementation) and those between 2011 and 2016 (after implementation). RESULTS In total, 748 children were enrolled, of which 363 children were seen before and 385 children after implementation of the guideline. Before implementation, 46% of the children with acute appendicitis underwent preoperative ultrasound compared with 95% in the post implementation group, p < 0.001. Any imaging was performed in 51% and 100%, respectively, p < 0.001. The percentage of negative appendectomy before implementation was 13% and 2.7% after implementation, p < 0.001. There was no significant increase in the number of CT scans before and after the implementation of the guideline, 3.6% versus 6.0%, respectively, p = 0.126. There was no increase in direct medical costs. CONCLUSIONS Mandatory preoperative imaging in children with the suspicion of acute appendicitis results in a significant decrease in negative appendectomies with no increase in the number of CT scans and without a substantial increase in costs.
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Affiliation(s)
| | | | - Sven Macco
- Department of Surgery, OLVG, Amsterdam, The Netherlands
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Laghi A. Acute Appendicitis and Negative or Inconclusive Results at Initial US in Adult, Pediatric, and Pregnant Patients: What to Do Next? Radiology 2018; 288:728-729. [DOI: 10.1148/radiol.2018180922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Laghi
- From the Department of Radiological Sciences, Oncology and Pathology, Sapienza–University of Rome, Sant’Andrea University Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
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Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology 2018; 288:717-727. [DOI: 10.1148/radiol.2018180318] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
OBJECTIVE Diagnosing pediatric appendicitis is difficult because clinical findings are nonspecific. Improved accuracy can be obtained with ultrasound (US), CT, or MRI, despite considerable variation in their use at different institutions. This article reviews the evidence for best practices in imaging pediatric appendicitis. CONCLUSION When each modality is optimally used, a stepwise imaging approach that begins with graded compression US and proceeds to CT or MRI in select cases is currently best practice.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix. Am J Emerg Med 2018; 37:879-883. [PMID: 30097276 DOI: 10.1016/j.ajem.2018.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/28/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.
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Affiliation(s)
- Laurie Malia
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Jesse J Sturm
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Sharon R Smith
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | | | | | - Henry Chicaiza
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
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Kobayashi E, Johnson B, Goetz K, Scanlan J, Weinsheimer R. Does the implementation of a pediatric appendicitis pathway promoting ultrasound work outside of a children's hospital? Am J Surg 2018; 215:917-920. [PMID: 29615193 DOI: 10.1016/j.amjsurg.2018.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Efficacy of care pathways for pediatric appendicitis is well established in children's hospitals, but not in community Emergency Departments (EDs). METHODS A diagnostic pathway combining the Pediatric Appendicitis Score (PAS) with selective ultrasound was implemented. The charts of 2201 pediatric patients seen at four general EDs before and after implementation were retrospectively reviewed, identifying 611 children seriously considered for appendicitis. RESULTS There were no cases of missed appendicitis within the pathway cohort (0/72). Low-PAS children on pathway had fewer computed tomography (CT) scans (0% vs. 21%; p < 0.02). Moderate-PAS patients also had a reduced CT-first rate (2.4% vs. 23%; p < 0.01). However, pathway adoption in 2016 was only 24%. Correct pathway application would have avoided 58 ultrasounds and 17 CTs over three months (annual savings $281,276). CONCLUSION A pediatric appendicitis pathway is safe, rules out low suspicion patients without imaging, and is cost effective in a general hospital setting.
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Affiliation(s)
- Emily Kobayashi
- Swedish Medical Center, Swedish Pediatric Specialty Care, Seattle, WA, USA
| | - Bennett Johnson
- Swedish Medical Center, Swedish Pediatric Specialty Care, Seattle, WA, USA
| | - Kathleen Goetz
- Swedish Medical Center, Swedish Pediatric Specialty Care, Seattle, WA, USA
| | - James Scanlan
- Swedish Medical Center, Swedish Pediatric Specialty Care, Seattle, WA, USA
| | - Robert Weinsheimer
- Swedish Medical Center, Swedish Pediatric Specialty Care, Seattle, WA, USA.
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Corson-Knowles D, Russell FM. Clinical Ultrasound Is Safe and Highly Specific for Acute Appendicitis in Moderate to High Pre-test Probability Patients. West J Emerg Med 2018; 19:460-464. [PMID: 29760840 PMCID: PMC5942008 DOI: 10.5811/westjem.2018.1.36891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/04/2018] [Accepted: 01/23/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The goal of this study was to determine if a heterogeneous group of emergency physicians (EP) could diagnose acute appendicitis on CUS in patients with a moderate to high pre-test probability. Methods This was a prospective, observational study of a convenience sample of adult and pediatric patients with suspected appendicitis. Sonographers received a structured, 20-minute CUS training on appendicitis prior to patient enrollment. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure was considered a positive study. Non-visualization or indeterminate studies were considered negative. We collected pre-test probability of acute appendicitis based on a 10-point visual analog scale (moderate to high was defined as >3), and confidence in CUS interpretation. The primary objective was measured by comparing CUS findings to surgical pathology and one week follow-up. Results We enrolled 105 patients; 76 had moderate to high pre-test probability. Of these, 24 were children. The rate of appendicitis was 36.8% in those with moderate to high pre-test probability. CUS were recorded by 33 different EPs. The sensitivity, specificity, and positive and negative likelihood ratios of EP-performed CUS in patients with moderate to high pre-test probability were 42.8% (95% confidence interval [CI] [25–62.5%]), 97.9% (95% CI [87.5–99.8%]), 20.7 (95% CI [2.8–149.9]) and 0.58 (95% CI [0.42–0.8]), respectively. The 16 false negative scans were all interpreted as indeterminate. There was one false positive CUS diagnosis; however, the sonographer reported low confidence of 2/10. Conclusion A heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. This data adds support for surgical consultation without further imaging beyond CUS in the appropriate clinical setting.
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Affiliation(s)
- Daniel Corson-Knowles
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
| | - Frances M Russell
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
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Sola R, Wormer BA, Anderson WE, Schmelzer TM, Cosper GH. Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children. Am Surg 2017. [DOI: 10.1177/000313481708301218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Richard Sola
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Blair A. Wormer
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | | | - Graham H. Cosper
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Abstract
RATIONALE Neonatal appendicitis is extremely rare, and preoperative diagnosis is challenging. This study aimed to investigate the utility of ultrasound for the diagnosis of neonatal appendicitis. PATIENT CONCERNS Four cases of neonatal appendicitis were included in this case series. One was a female infant and the other 3 were male infants; they were aged from 10 to 17 days. DIAGNOSES Neonatal appendicitis. INTERVENTIONS Four newborns in our hospital were diagnosed with neonatal appendicitis by abdominal ultrasound. Their sonographic features were summarized and compared with surgical and pathological findings. OUTCOMES In these infants, abdominal ultrasound demonstrated ileocecal bowel dilatation, intestinal and bowel wall thickening, and localized encapsulated effusion in the right lower quadrant and the abscess area, which was assumed to surround the appendix. LESSONS Ultrasound is helpful for the diagnosis of neonatal appendicitis.
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Kaymakci A, Guven S, Erdogan S, Ciftci I, Gokcan R. Evaluation of Clinical and Imaging Findings in Children with Diagnosis of Acute Appendicitis. IRANIAN JOURNAL OF PEDIATRICS 2017; 27. [DOI: 10.5812/ijp.10095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
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Lee H, Kim H, Han H, Lee M, Lee S, Yoo H, Chang JH, Kim H. Microbubbles used for contrast enhanced ultrasound and theragnosis: a review of principles to applications. Biomed Eng Lett 2017; 7:59-69. [PMID: 30603152 PMCID: PMC6208473 DOI: 10.1007/s13534-017-0016-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 12/26/2016] [Accepted: 01/18/2017] [Indexed: 12/31/2022] Open
Abstract
Ultrasound was developed several decades ago as a useful imaging modality, and it became the second most popular diagnostic tool due to its non-invasiveness, real-time capabilities, and safety. Additionally, ultrasound has been used as a therapeutic tool with several therapeutic agents and in nanomedicine. Ultrasound imaging is often used to diagnose many types of cancers, including breast, stomach, and thyroid cancers. In addition, ultrasound-mediated therapy is used in cases of joint inflammation, rheumatoid arthritis, and osteoarthritis. Microbubbles, when used as ultrasound contrast agents, can act as echo-enhancers and therapeutic agents, and they can play an essential role in ultrasound imaging and ultrasound-mediated therapy. Recently, various types of ultrasound contrast agents made of lipid, polymer, and protein shells have been used. Air, nitrogen, and perfluorocarbon are usually included in the core of the microbubbles to enhance ultrasound imaging, and therapeutic drugs are conjugated and loaded onto the surface or into the core of the microbubbles, depending on the purpose and properties of the substance. Many research groups have utilized ultrasound contrast agents to enhance the imaging signal in blood vessels or tissues and to overcome the blood-brain barrier or blood-retina barrier. These agents are also used to help treat diseases in various regions or systems of the body, such as the cardiovascular system, or as a cancer treatment. In addition, with the introduction of targeted moiety and multiple functional groups, ultrasound contrast agents are expected to have a potential future in ultrasound imaging and therapy. In this paper, we briefly review the principles of ultrasound and introduce the underlying theory, applications, limitations, and future perspectives of ultrasound contrast agents.
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Affiliation(s)
- Hohyeon Lee
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Haemin Kim
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Hyounkoo Han
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Minji Lee
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Sunho Lee
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Hongkeun Yoo
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Jin Ho Chang
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
- Sogang Institute of Advanced Technology, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Hyuncheol Kim
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
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Abstract
Concerns about radiation exposure have led to a decrease in the use of computed tomography in suspected appendicitis, with increased reliance on ultrasound. Children with suspected appendicitis should be risk stratified using a combination of clinical signs and symptoms, white blood cell count, and ultrasound in order to guide further evaluation and management. Magnetic resonance imaging is a promising imaging modality but remains costly. Ongoing research is evaluating the role of nonoperative management in children with confirmed appendicitis.
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Otero HJ, Crowder L. Imaging Utilization for the Diagnosis of Appendicitis in Stand-Alone Children's Hospitals in the United States: Trends and Costs. J Am Coll Radiol 2017; 14:603-608. [PMID: 28223114 DOI: 10.1016/j.jacr.2016.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the imaging utilization patterns for the diagnosis of appendicitis among children's hospitals in the United States over the last 10 years (2005-2014). METHODS All patients with a primary discharge diagnosis of appendicitis included in a large administrative database of 45 pediatric institutions in the United States between 2005 and 2014 were selected. Demographics, imaging utilization, and costs were described. RESULTS In all, 96,786 children with appendicitis (59% boys, 41% girls; mean age: 9.9 years) were studied. The average length of stay decreased from 5.0 days in 2005 to 3.4 days in 2014 (P < .01). The percentage of patients undergoing CT increased between 2005 and 2007 from 59.1% to 62.6%, respectively, followed by a decrease from 62.6% to 32.7% in 2014 (r2 = 0.93). Radiograph utilization decreased from 14.2% in 2005 to 3.6% in 2014 (r2 = 0.93), and ultrasound and MRI increased from 25% and 0.03% in 2005 to 61% and 1.0% in 2014 (r2 = 0.97 and 0.64), respectively. The mean total hospital costs increased from $11,700 in 2005 to $16,500 in 2014; imaging costs increased only slightly from $3,205 to $3,259. The imaging fraction of hospital costs decreased from 27.5% to 19.8%. CONCLUSION There has been a significant decrease in utilization of CT and radiographs for the management of appendicitis in children, and ultrasound has continued to increase. Imaging costs have remained stable in comparison to rising hospital costs, generating a drop in the fraction of costs related to imaging.
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Affiliation(s)
- Hansel J Otero
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC.
| | - Lauren Crowder
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC
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Almaramhy HH. Acute appendicitis in young children less than 5 years: review article. Ital J Pediatr 2017; 43:15. [PMID: 28257658 PMCID: PMC5347837 DOI: 10.1186/s13052-017-0335-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/19/2017] [Indexed: 12/29/2022] Open
Abstract
Despite wide spread availability of sophisticated diagnostic imaging, acute appendicitis in pre-school children remains a diagnostic challenge. Most of these children present late, often with complications e.g. appendicular perforation, abscess formation and peritonitis and as result hospital stay is prolonged and is associated with increased morbidity and mortality.The purpose of this article is to review peculiar features of acute appendicitis in preschool children.
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Affiliation(s)
- Hamdi Hameed Almaramhy
- Department of Surgery, College of Medicine, Taibah University, AL-Madinah Al-Munawarah, Kingdom of Saudi Arabia.
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Ultrasound for Appendicitis: Performance and Integration with Clinical Parameters. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5697692. [PMID: 28044133 PMCID: PMC5156797 DOI: 10.1155/2016/5697692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/17/2022]
Abstract
Objective. To evaluate the performance of ultrasound in pediatric appendicitis and the integration of US with the pediatric appendicitis score (PAS) and C-reactive protein (CRP). Method. An institution-based, retrospective study of children who underwent abdominal US for suspected appendicitis between 2012 and 2015 at a tertiary pediatric surgery center. US results were dichotomized, with a nonvisualized appendix considered as a negative examination. Results. In total, 438 children were included (mean 8.5 years, 54% boys), with an appendicitis rate of 29%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for US were 82%, 97%, 92%, and 93%, respectively, without significant age or gender differences. Pediatric radiologists had significantly higher sensitivity compared to general radiologists, 88% and 71%, respectively (p < 0.01), but no differences were seen for specificity, PPV, and NPV. The sensitivity, NPV, and negative likelihood ratio for the combination of negative US, PAS < 5, and CRP < 5 mg/L were 98%, 98%, and 0.05 (95% CI 0.03–0.15). Conclusion. US may be a useful tool for evaluating children with suspected appendicitis, regardless of age or gender, and should be the first choice of imaging modalities. Combining US with PAS and CRP may reduce several unnecessary admissions for in-hospital observation.
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Bachur RG, Dayan PS, Dudley NC, Bajaj L, Stevenson MD, Macias CG, Mittal MK, Bennett J, Sinclair K, Monuteaux MC, Kharbanda AB. The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis. Acad Emerg Med 2016; 23:1235-1242. [PMID: 27251399 DOI: 10.1111/acem.13018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/22/2016] [Accepted: 05/31/2016] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Richard G. Bachur
- Division of Emergency Medicine; Children's Hospital Boston and Harvard Medical School; Boston MA
| | - Peter S. Dayan
- Department of Pediatrics; Columbia University College of Physicians and Surgeons; New York NY
| | - Nanette C. Dudley
- Department of Pediatrics; University of Utah School of Medicine; Salt Lake City UT
| | - Lalit Bajaj
- Department of Pediatrics; University of Colorado School of Medicine; Denver CO
| | | | | | - Manoj K. Mittal
- Department of Pediatrics; Children's Hospital of Philadelphia and Perelman School of Medicine; University of Pennsylvania; Philadelphia PA
| | - Jonathan Bennett
- Department of Pediatrics; Alfred I. DuPont Hospital for Children; Wilmington DE
| | - Kelly Sinclair
- Division of Emergency Medicine; Children's Mercy Hospitals and Clinics; Kansas City MO
| | - Michael C. Monuteaux
- Division of Emergency Medicine; Children's Hospital Boston and Harvard Medical School; Boston MA
| | - Anupam B. Kharbanda
- Department of Pediatric Emergency Medicine; Children's Hospital and Clinics of Minnesota; Minneapolis MN
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44
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Abstract
Ultrasound is the initial diagnostic modality of choice for evaluation of pediatric appendicitis. We report a case that highlights the importance of pain control, distraction, focusing on the appearance of the appendix and the surrounding structures, the value of size cutoff points for appendicitis, and repeating ultrasound examinations to optimize yield.
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45
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Abstract
Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.
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Affiliation(s)
- Charity C Glass
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115
| | - Shawn J Rangel
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115.
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Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE, Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R, Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ, Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016; 11:34. [PMID: 27437029 PMCID: PMC4949879 DOI: 10.1186/s13017-016-0090-5] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023] Open
Abstract
Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.
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Affiliation(s)
| | - Arianna Birindelli
- S. Orsola Malpighi University Hospital - University of Bologna, Bologna, Italy
| | - Micheal D Kelly
- Locum Surgeon, Acute Surgical Unit, Canberra Hospital, Canberra, ACT Australia
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | | | | | - Mark De Moya
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | - Aneel Bhangu
- Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Edgabaston, Birmingham, UK
| | | | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen Griffiths
- University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital, Birmingham, UK
| | | | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppaniemi
- Abdominal Center, University of Helsinki, Helsinki, Finland
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Manne Andersson
- Department of Surgery, Linkoping University, Linkoping, Sweden
| | | | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | | | | | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI USA
| | | | | | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP Brazil
| | | | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA USA
| | | | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Roberto Cirocchi
- Department of Surgery, Terni Hospital, University of Perugia, Terni, Italy
| | - Valeria Tonini
- S. Orsola Malpighi University Hospital - University of Bologna, Bologna, Italy
| | - Alice Piccinini
- Trauma Surgery Unit - Maggiore Hospital AUSL, Bologna, Italy
| | | | - Elio Jovine
- Department of Surgery, Maggiore Hospital AUSL, Bologna, Italy
| | - Roberto Persiani
- Catholic University, A. Gemelli University Hospital, Rome, Italy
| | - Antonio Biondi
- Department of Surgery, University of Catania, Catania, Italy
| | | | - Philip Stahel
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA USA
| | - George Velmahos
- Harvard Medical School - Chief of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
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How to diagnose acute appendicitis: ultrasound first. Insights Imaging 2016; 7:255-63. [PMID: 26883138 PMCID: PMC4805616 DOI: 10.1007/s13244-016-0469-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/18/2016] [Accepted: 01/25/2016] [Indexed: 12/24/2022] Open
Abstract
Acute appendicitis (AA) is a common abdominal emergency with a lifetime prevalence of about 7 %. As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging modalities have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low. Introduced in 1986, graded-compression ultrasound (US) has well-established direct and indirect signs for diagnosing AA. In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent specificity both in the paediatric and adult patient populations. As US sensitivity is limited, and non-diagnostic US examinations with non-visualization of the appendix are more a rule than an exception, diagnostic strategies and algorithms after non-diagnostic US should focus on clinical reassessment and complementary imaging with MRI/CT if indicated. Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates. Main Messages • Ultrasound (US) should be the first imaging modality for diagnosing acute appendicitis (AA). • Primary US for AA diagnosis will decrease ionizing radiation and cost. • Sensitivity of US to diagnose AA is lower than of CT/MRI. • Non-visualization of the appendix should lead to clinical reassessment. • Complementary MRI or CT may be performed if diagnosis remains unclear.
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