Retrospective Multivariate Analysis of Data from Children with Suspected Appendicitis: A New Tool for Diagnosis

The Alvarado Score Is the Most Impactful Diagnostic Tool for Appendicitis: A Bibliometric Analysis

INTRODUCTION

The objective of this bibliometric analysis was to investigate the citation pattern of studies that have developed a diagnostic tool to diagnose appendicitis.

METHODS

We investigated characteristics of citations, publication frequency, evolution of citations, and fluctuation of previously highly cited studies. We analyzed which studies had been cited in the method section and identified impactful studies in this research field by a network visualization. We analyzed the differences in citations between diagnostic tools requiring a doctor to be present against the diagnostic tools not requiring doctors to be present, English language studies against non-English studies, and identified diagnostic tools targeting children.

RESULTS

There was an upward trend in publications in this research field, and between 1999-2021 the Alvarado score has been cited the most. In general, there was a high fluctuation, and 40 studies had been cited in the methods sections. There were significant differences in studies regarding diagnostic tools written in English compared to non-English studies, with more citations in the English-language studies. Furthermore, 22 studies had children as the target population.

CONCLUSIONS

The Alvarado score was the highest cited study since 1999, with 1086 citations, making it the most impactful study in this research field of diagnostic tools to diagnose appendicitis. Due to the diversity of target populations and settings for which diagnostic tools are developed, there is a need to expand research on diagnostic tools for appendicitis.

Differentiating abdominal pain due to COVID-19 associated multisystem inflammatory syndrome from children with acute appendicitis: a score system

PURPOSE

Differentiating abdominal pain due to coronavirus disease (COVID-19)-associated multisystem inflammatory syndrome (MIS-C) in children with acute appendicitis (AA) can cause diagnostic dilemmas. This study aimed to evaluate the efficacy of a previously described scoring system and improve its diagnostic ability in differentiating between these diseases.

METHODS

This study was conducted between March 2020 and January 2022. Patients who had MIS-C with gastrointestinal system (GIS) involvement and patients who underwent surgery for appendicitis were included. First, all patients were evaluated using the new scoring system (NSS). The groups were compared by adding new MISC-specific parameters to NSS. The scoring system was evaluated using propensity score matching (PSM).

RESULTS

A total of 35 patients with abdominal pain due to GIS involvement in MIS-C (group A) and 37 patients with AA who had ALT, PRC, and D-dimer results at their first admission (group B) were included in the study. The mean age of patients in group A was lower than that of patients in group B (p < 0.001). False NSS positivity was found in 45.7% of the patients with MIS-C. Lymphocyte (p = 0.021) and platelet counts (p = 0.036) were significantly lower in the blood count and serum D-dimer (p = 0.034), C-reactive protein (CRP) (p < 0.001), and procalcitonin (p < 0.001) were significantly higher in the MIS-C group. We created a scoring system called the Appendicitis-MISC Score (AMS) using the NSS and new parameters. The sensitivity and specificity of AMS diagnostic scores were 91.9% and 80%, respectively.

CONCLUSION

MIS-C with GIS involvement may present as acute abdomen. It is difficult to differentiate this condition from acute appendicitis. AMS has been shown to be useful for this differentiation.

Many diagnostic tools for appendicitis: a scoping review

BACKGROUND

We aimed to provide an overview of all diagnostic tools developed to diagnose appendicitis with their reported accuracy and to further characterize these including their need for diagnostic equipment.

METHODS

This scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews and a protocol was registered at Open Science Framework. We performed a systematic literature search in PubMed, Embase, China National Knowledge Infrastructure, Índice Bibliográfico Espanhol de Ciências da Saúde, and Latin American and Caribbean Health Sciences Literature. We included original articles of all languages with the purpose to derive an accessible diagnostic tool. We extracted data regarding study- and diagnostic tool characteristics, and the accuracy of each diagnostic tool.

RESULTS

The search led to 6419 records, where 74 studies were included, yielding 82 diagnostic tools reported in seven different languages. Among these tools, 35% included patient characteristics, 85% symptoms, 93% physical examinations, 37% vital signs, 78% laboratory values, and 16% imaging. Among the diagnostic tools, 35% relied on a medical doctor/surgeon with access to a laboratory, and six diagnostic tools did not require a bedside medical doctor/surgeon. The median positive predictive value, negative predictive value, sensitivity, and specificity across diagnostic tools were 91%, 94%, 89%, and 86%, respectively.

CONCLUSIONS

We identified 82 diagnostic tools that most frequently were based on symptoms and physical examinations. Most diagnostic tools relied on a medical doctor/surgeon with access to laboratory values. The accuracy was high across the diagnostic tools.

Comparison of the appendicitis inflammatory response and Alvarado scoring systems in the diagnosis of acute appendicitis in children

Our objective was to compare the diagnostic accuracy of Alvarado and appendicitis inflammatory response (AIR) scoring systems among children suspected of acute appendicitis concerning their postoperative outcomes. During a two-year period, a prospective multicentric study was carried in the selected hospitals of Iran. All children who were admitted with the diagnosis of acute appendicitis were enrolled in the study. However, patients suffering from generalized peritonitis or those who had a history of abdominal surgery were excluded. Before decision-making, each patient’s score according to two appendicitis scoring systems was calculated. The clinical outcomes and diagnosis of patients were then compared to the results of each scoring system. For those patients who were a candidate for surgery, the final diagnosis of acute appendicitis was made by histopathology. Patients were divided into a high- and low-risk group according to scoring systems outcomes. Among the patients with a low score for appendicitis, the AIR scoring system had a sensitivity and specificity of 95% and 74%, respectively, which was more promising in comparison to that of the Alvarado system (90% and 70%, respectively). Regarding the patients at higher risk of acute appendicitis, none of the scoring systems provided reliable results since both systems showed sensitivity and specificity of less than 50%, which was not sufficient to distinguish patients who are a candidate for surgery. AIR and Alvarado scoring systems are not accurate models to predict the risk of acute appendicitis among children; however, the AIR system could be used as a reliable material to rule out the acute appendicitis diagnosis.

Ultrasonographic findings of child acute appendicitis incorporated into a scoring system

INTRODUCTION

This study aimed to investigate the ultrasonographic features of child acute appendicitis and incorporate them into a scoring algorithm that will quantify the risk of complications and the strength of recommendation for surgical intervention.

METHODS

179 patients with suspected appendicitis and who had undergone ultrasonographic examination were included in this study. Based on their medical evaluation and post-surgical histopathological results, patients were categorised into the confirmed appendicitis (n = 101); and non-appendicitis (n = 78) groups.

RESULTS

In the appendicitis group, the appendix was visualised in 66 (65.3%) patients. In cases where the appendix was not visualised, we looked out for secondary inflammatory signs, which were present in 32 (31.7%) patients. Using stepwise logistic regression, Blumberg's sign, free fluid or collection, hyperaemia, non-compressible appendix and an appendix diameter > 7 mm were found to be significant predictive factors for appendicitis. A new scoring system called POPs was developed, combining inflammatory predictors and ultrasonography findings, with an area under the receiving operating characteristic curve of 0.958 (95% confidence interval 0.929-0.986).

CONCLUSION

The newly developed POPs-based diagnosis scheme proved a promising alternative to existing scoring systems, such as the Alvarado score. Although further calibration would be beneficial, the proposed scoring scheme is simple and easy to understand, memorise and apply in the emergency room.