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Watanabe A, Guo M, Schweitzer C, Wiseman SM. Multiple positive imaging tests in diagnosing acute appendicitis: An analysis of more than 27,000 cases. Am J Surg 2024; 231:74-78. [PMID: 38490880 DOI: 10.1016/j.amjsurg.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/28/2024] [Accepted: 02/23/2024] [Indexed: 03/17/2024]
Affiliation(s)
- Akie Watanabe
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Michael Guo
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Christina Schweitzer
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.
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Mostafa R, El-Atawi K. Misdiagnosis of Acute Appendicitis Cases in the Emergency Room. Cureus 2024; 16:e57141. [PMID: 38681367 PMCID: PMC11055627 DOI: 10.7759/cureus.57141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Acute appendicitis (AA) is one of the most frequent surgical emergencies, especially in pediatric populations, with its misdiagnosis in emergency settings presenting significant health risks. This misdiagnosis leads to various complications, such as delayed treatment or unnecessary surgeries. Factors such as age, gender, and comorbidities contribute to diagnostic errors, leading to complications such as peritonitis and increased negative appendectomy rates. This underscores the importance of accurate clinical assessment and awareness of common pitfalls, such as cognitive biases and over-reliance on laboratory tests. This review delves into the prevalence of AA misdiagnosis, its health burden, and the challenges inherent in the diagnostic process. It scrutinizes the effectiveness of different diagnostic approaches, including clinical assessment and imaging techniques. The treatment paradigms for AA are also explored, focusing on surgical interventions and the potential of conservative treatments using antibiotics. The review underscores the criticality of precise diagnosis in preventing adverse outcomes and ensuring effective treatment.
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Affiliation(s)
- Reham Mostafa
- Department of Emergency Medicine, Al Zahra Hospital Dubai (AZHD), Dubai, ARE
| | - Khaled El-Atawi
- Pediatrics/Neonatal Intensive Care Unit, Latifa Women and Children Hospital, Dubai, ARE
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Wazzan M, Abduljabbar A, Khizindar H, Alzahrani A, Aljohani RM, Nahas R, Aman R, Tawfiq S, Aldajani A. Up-to-Date Diagnostic CT Standards for Acute Appendicitis: Wall Thickness and Intraluminal Fluid Thickness. Cureus 2023; 15:e48154. [PMID: 37965237 PMCID: PMC10643053 DOI: 10.7759/cureus.48154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 11/16/2023] Open
Abstract
Acute appendicitis is a prevalent condition that requires accurate and timely diagnosis and management to avoid potential complications. Classically, the diagnosis of appendicitis is made using the appendicular outer-to-outer wall diameter. In this study, we examined the sensitivity and specificity of computed tomography (CT) scans for diagnosing acute appendicitis using wall thickness and lumen thickness rather than diameter. This study included data from 350 patients who presented to the emergency department with clinically suspected acute appendicitis. All patients underwent a CT scan, and 62 radiologically positive patients underwent surgery. A radiological diagnosis was made using the conventional outer-to-outer wall diameter with a cut-off of 6 mm for a positive diagnosis. These 62 positive CT scans were reviewed and compared with surgical results. The study showed that a threshold of 2.25 mm for appendicular lumen thickness is an excellent diagnostic tool for acute appendicitis, demonstrating a high sensitivity of 96.4% and a lower specificity of 67%. In contrast, 1.6 mm wall thickness indicates acute appendicitis, with 81.8% sensitivity and 84% specificity. However, the wall thickness remains inferior to the conventionally used measurement of 6.75 mm for appendicular diameter, with a sensitivity of 87.5% and a specificity of 100%.
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Affiliation(s)
- Mohammad Wazzan
- Department of Radiology, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Ahmed Abduljabbar
- Department of Radiology, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Huda Khizindar
- Department of Radiology, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Aghnar Alzahrani
- Department of Medicine and Surgery, Albaha University, Baha, SAU
| | - Renad M Aljohani
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Rana Nahas
- Department of Medicine, Faculty of Medicine, Ibn Sina National College, Jeddah, SAU
| | - Rahf Aman
- Department of Medicine and Surgery, Batterjee Medical College, Jeddah, SAU
| | - Shouq Tawfiq
- Department of Medicine and Surgery, King Faisal University, Jeddah, SAU
| | - Arwa Aldajani
- Department of Medicine and Surgery, Alfaisal University College of Medicine, Riyadh, SAU
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Harmantepe AT, Dikicier E, Gönüllü E, Ozdemir K, Kamburoğlu MB, Yigit M. A different way to diagnosis acute appendicitis: machine learning. POLISH JOURNAL OF SURGERY 2023; 96:38-43. [PMID: 38629278 DOI: 10.5604/01.3001.0053.5994] [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] [Indexed: 04/19/2024]
Abstract
<b><br>Indroduction:</b> Machine learning is a branch of artificial intelligence based on the idea that systems can learn from data, identify patterns, and make decisions with minimal human intervention.</br> <b><br>Aim:</b> Our aim is to predict acute appendicitis, which is the most common indication for emergency surgery, using machine learning algorithms with an easy and inexpensive method.</br> <b><br>Materials and methods:</b> Patients who were treated surgically with a prediagnosis of acute appendicitis in a single center between 2011 and 2021 were analyzed. Patients with right lower quadrant pain were selected. A total of 189 positive and 156 negative appendectomies were found. Gender and hemogram were used as features. Machine learning algorithms and data analysis were made in Python (3.7) programming language.</br> <b><br>Results:</b> Negative appendectomies were found in 62% (n = 97) of the women and in 38% (n = 59) of the men. Positive appendectomies were present in 38% (n = 72) of the women and 62% (n = 117) of the men. The accuracy in the test data was 82.7% in logistic regression, 68.9% in support vector machines, 78.1% in k-nearest neighbors, and 83.9% in neural networks. The accuracy in the voting classifier created with logistic regression, k-nearest neighbor, support vector machines, and artificial neural networks was 86.2%. In the voting classifier, the sensitivity was 83.7% and the specificity was 88.6%.</br> <b><br>Conclusions:</b> The results of our study show that machine learning is an effective method for diagnosing acute appendicitis. This study presents a practical, easy, fast, and inexpensive method to predict the diagnosis of acute appendicitis.</br>.
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Affiliation(s)
| | - Enis Dikicier
- Sakarya University Faculty of Medicine, Department of General Surgery
| | - Emre Gönüllü
- Sakarya University Education and Research Hospital, Department of General Surgery
| | | | | | - Merve Yigit
- Sakarya University Education and Research Hospital, Department of General Surgery
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Diagnostic accuracy of computed tomography in adults with suspected acute appendicitis at the emergency department in a private tertiary hospital in Tanzania. PLoS One 2022; 17:e0276720. [PMID: 36301963 PMCID: PMC9612457 DOI: 10.1371/journal.pone.0276720] [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: 04/30/2021] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The increasing incidence of acute appendicitis in sub-Saharan Africa emphasizes the need for accurate and reliable diagnostic tools. However, the variability in the diagnostic performance of computed tomography for suspected acute appendicitis coupled with comparatively higher negative appendectomy rates in this setting highlight a possible concern regarding the diagnostic accuracy. This study evaluated the diagnostic accuracy of a computed tomography scan for suspected acute appendicitis at the emergency department in Tanzania. METHODS A retrospective diagnostic accuracy study was conducted from July to October 2020. All patients above 14 years of age who presented at the emergency department with right iliac fossa abdominal pain of fewer than ten days and underwent computed tomography for suspected acute appendicitis were evaluated, and the Alvarado score was computed. Histological diagnosis and clinical follow-up of 14 days were considered the reference standard. Ethical clearance was sought from the Aga Khan University Ethical review committee. RESULTS 176 patients were included in this study. The sensitivity, specificity, and diagnostic accuracy were 100% (95% CI 91.8-100), 96.9% (95% CI 92.2-99.1), and 96.9% (95% CI 93.1-98.3), respectively. The mean Alvarado score in those without acute appendicitis was 4 (95% CI 3.7-4.3) compared to a mean score of 6.6 (95% CI 6.0-7.2) amongst those with acute appendicitis. The area under the receiver operator characteristics curve of computed tomography was 98.4%, and that of the Alvarado score was 84.1%. CONCLUSIONS The diagnostic performance of computed tomography in this study is similar to that established elsewhere. However, the Alvarado score is not routinely used for the initial screening of suspected acute appendicitis patients. A threshold of Alvarado score of 4 as a guide to conduct computed tomography for suspected acute appendicitis would have decreased computed tomography use by 50%, and missed 4 cases. Implementation studies that address Alvarado score use should be conducted.
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Ayeni A, Mahmood F, Mustafa A, Mcleish B, Kulkarni V, Singhal S, Akingboye A. Predicting the Severity of Acute Appendicitis in Children Using Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR). Cureus 2022; 14:e28619. [PMID: 36185898 PMCID: PMC9523736 DOI: 10.7759/cureus.28619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The ability to predict risk of perforation in acute appendicitis (AA) could direct timely management and reduce morbidity. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are surrogate severity markers in infections. This study investigates the use of PLR and NLR as a marker for distinguishing uncomplicated (UA) and complicated appendicitis (CA) in children. Materials and methods This retrospective single-center study collected data between January 1, 2014, and December 31, 2020. Children between five and 17 years of age with histologically confirmed appendicitis were included. Cut-off values for NLR and PLR were determined by employing the receiver operating characteristic (ROC) curve with sensitivity and specificity in addition to regression analysis. Results A total of 701 patients were included with a median age of 13 years. Out of which 52% of the cohort was female. The difference between the NLR and PLR ratios between UA and CA was significant (p=0.05, Kruskal-Wallis). For UA, the area under the ROC curve (AUC) and cut-off for NLR and PLR were 0.741, 3.80 with 95% CI of 0.701-0.781 and 0.660, 149.25 with 95% CI of 0.618-0.703, respectively. In CA, using NLR and PLR, AUC and cut-off were 0.776, 8.86 with 95%CI of 0.730-0.822 and 0.694, 193.67 with 95%CI of 0.634-0.755, respectively. All were significant with p<0.001. Conclusions NLR and PLR are reliable, synergistic markers predicting complicated appendicitis which can guide non-operative management in children.
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Diagnostic, Therapy and Complications in Acute Appendicitis of 19,749 Cases Based on Routine Data: A Retrospective Multicenter Observational Study. J Clin Med 2022; 11:jcm11154495. [PMID: 35956110 PMCID: PMC9369616 DOI: 10.3390/jcm11154495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/30/2022] [Accepted: 07/31/2022] [Indexed: 12/19/2022] Open
Abstract
Background: Acute appendicitis is one of the most common emergencies in general surgery. The gold standard treatment is surgery. Complications may occur during or after an appendectomy. In addition to age, clinically important factors for the outcome after appendicitis seems to be the comorbidities and the stage of the appendicitis at the time of the operation. Large observational data describing these facts are missing. Methods: In this retrospective multicenter observational study, all inpatients over the age of 17 years with a diagnosis of acute appendicitis in 47 hospitals of the Clinotel Hospital Group between 2010 and 2017 were included. Results: A total of 19,749 patients with acute appendicitis were operated on. The number of patients with more than five secondary diagnoses has increased from 8.4% (2010) to 14.5% (2017). The number of secondary diagnoses correlates with the ages of the patients and leads to a significantly longer hospital stay. Computer tomography (CT) has gained in importance in recent years in the diagnosis of acute appendicitis. A total of 19.9% of patients received a CT in 2017. Laparoscopic appendectomy increased from 88% in 2010 to 95% in 2017 (p < 0.001). The conversion rate did not change relevant in the study period (i.e., 2.3% in 2017). Appendicitis with perforation, abscess, or generalized peritonitis was observed in 24.8% of patients. Mortality was 0.6% during the observation period and was associated with age and the number of secondary diagnoses. The analysis is based on administrative data collected primarily for billing purposes, subject to the usual limitations of such data. This includes partially incomplete clinical data. Conclusions: Multimorbidity is increasingly present in patients with acute appendicitis. Mortality is still in an acceptably low range with no increase. A CT scan is necessary for a precise diagnosis in unclear clinical situations to avoid unnecessary operations and was performed more often at the end of the study than at the beginning.
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Low-Dose Abdominal CT for Evaluating Suspected Appendicitis: Recommendations for CT Imaging Techniques and Practical Issues. Diagnostics (Basel) 2022; 12:diagnostics12071585. [PMID: 35885490 PMCID: PMC9320604 DOI: 10.3390/diagnostics12071585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 12/04/2022] Open
Abstract
A vast disparity exists between science and practice for CT radiation dose. Despite high-level evidence supporting the use of low-dose CT (LDCT) in diagnosing appendicitis, a recent survey showed that many care providers were still concerned that the low image quality of LDCT may lead to incorrect diagnoses. For successful implementation of LDCT practice, it is important to inform and educate the care providers not only of the scientific discoveries but also of concrete guidelines on how to overcome more practical matters. Here, we discuss CT imaging techniques and other practical issues for implementing LDCT practice.
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Chatzikonstantinou M, Toeima M, Ding T, Qazi A, Aston N. De Garengeot hernias. Over a century of experience. A systematic review of the literature and presentation of two cases. Acta Chir Belg 2022; 122:15-22. [PMID: 33153415 DOI: 10.1080/00015458.2020.1841484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
De Garengeot hernia is a rare femoral hernia that contains the vermiform appendix. It has always been a subject of interest, mainly because of its uncommon entity, but also because of the diagnostic challenge it presents and the lack of consensus in its surgical management. It mainly presents as an emergency, with strangulation of the femoral hernia and acute inflammation of the appendix. The purpose of this study is to present two cases of De Garengeot hernias, the different surgical approach in each one and to perform a systematic literature review on all published accounts of De Garengeot hernias focusing on the surgical management of the hernias that contained an inflamed appendix. A literature search was performed using the keywords 'De Garengeot hernia' and 'appendicitis in femoral hernia'. All the published papers in the English language from 1898 to the end of 2019, as well as two patients from Lewisham and Greenwich NHS Trust, were included. There were 110 female vs 17 males. The majority of the described approaches were via either a Lockwood, or a transinguinal (Lothestein/McVay) incision. Most of the operations were done with an open incision. In the presence of an inflamed appendix, most hernias were repaired with sutures. Forty-one patients had their hernia repaired with non-absorbable sutures and four with absorbable. Most of the patients recovered without complications and were discharged after an average of 4.82 days.
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Affiliation(s)
| | - Mohamed Toeima
- Department of General Surgery, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
| | - Tao Ding
- Department of Statistical Sciences, UCL, London, UK
| | - Almas Qazi
- Department of General Surgery, University Hospital Lewisham, Lewisham and Greenwich NHS Trust, London, UK
| | - Niall Aston
- Department of General Surgery, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
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Tekin E, Tuncer K, Ozlu I, Sade R, Pirimoglu RB, Polat G. Ultra-low-dose computed tomography and its utility in wrist trauma in the emergency department. Acta Radiol 2022; 63:192-199. [PMID: 33508953 DOI: 10.1177/0284185121989958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use and frequency of computed tomography (CT) are increasing day by day in emergency departments (ED). This increases the amount of radiation exposed. PURPOSE To evaluate the image quality obtained by ultra-low-dose CT (ULDCT) in patients with suspected wrist fractures in the ED and to investigate whether it is an alternative to standard-dose CT (SDCT). MATERIAL AND METHODS This is a study prospectively examining 336 patients who consulted the ED for wrist trauma. After exclusion criteria were applied, the patients were divided into the study and control groups. Then, SDCT (120 kVp and 100 mAs) and ULDCT (80 kVp and 5 mAs) wrist protocols were applied simultaneously. The images obtained were evaluated for image quality and fracture independently by a radiologist and an emergency medical specialist using a 5-point scale. RESULTS The effective radiation dose calculated for the control group scans was 41.1 ± 2.1 µSv, whereas the effective radiation dose calculated for the study group scans was 0.5 ± 0.0 µSv. The effective radiation dose of the study group was significantly lower than that of the control group (P < 0.01). The CT images in the study group showed no significant differences in the mean image quality score between observer 1 and observer 2 (3.4 and 4.3, respectively; P = 0.58). Both observers could detect all fractures using the ULDCT images. CONCLUSION ULDCT provides high-quality images in wrist traumas while reducing the radiation dose by approximately 98% compared to SDCT without any changes in diagnostic accuracy.
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Affiliation(s)
- Erdal Tekin
- Department of Emergency Medicine, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Kutsi Tuncer
- Department of Orthopedics and Traumatology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Ibrahim Ozlu
- Department of Emergency Medicine, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Recep Sade
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
- Clinical Research, Development and Design Application and Research Center, Ataturk University, Erzurum, Turkey
| | | | - Gokhan Polat
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
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Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
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Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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Impact of COVID-19 on the incidence of CT-diagnosed appendicitis and its complications in the UK and Sweden. Int J Colorectal Dis 2022; 37:1375-1383. [PMID: 35575916 PMCID: PMC9108134 DOI: 10.1007/s00384-022-04181-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 02/04/2023]
Abstract
AIM To compare the number of appendicitis cases and its complications, during the first months of the COVID-19 pandemic in Sweden and the UK and the corresponding time period in 2019. METHOD Reports of emergency abdominopelvic CT performed at 56 Swedish hospitals and 38 British hospitals between April and July 2020 and a corresponding control cohort from 2019 were reviewed. Two radiologists and two surgeons blinded to the date of cohorts analyzed all reports for diagnosis of appendicitis, perforation, and abscess. A random selection of cases was chosen for the measurement of inter-rater agreement. RESULT Both in Sweden (6111) and the UK (5591) fewer, abdominopelvic CT scans were done in 2020 compared to 2019 (6433 and 7223, respectively); p < 0.001. In the UK, the number of appendicitis was 36% lower in April-June 2020 compared to 2019 but not in Sweden. Among the appendicitis cases, there was a higher number of perforations and abscesses in 2020, in Sweden. In the UK, the number of perforations and abscesses were initially lower (April-June 2020) but increased in July 2020. There was a substantial inter-rater agreement for the diagnosis of perforations and abscess formations (K = 0.64 and 0.77). CONCLUSION In Sweden, the number of appendicitis was not different between 2019 and 2020; however, there was an increase of complications. In the UK, there was a significant decrease of cases in 2020. The prevalence of complications was lower initially but increased in July. These findings suggest variability in delay in diagnosis of appendicitis depending on the country and time frame studied.
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Lala B, Shah J, Salvador TM, Ricci JA. Expanding the Utilization of Low-Dose Computed Tomography in Plastic and Reconstructive Surgery Based on Validated Practices Among Surgical Specialties. Ann Plast Surg 2021; 87:e163-e170. [PMID: 33833174 DOI: 10.1097/sap.0000000000002815] [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: 11/25/2022]
Abstract
INTRODUCTION As computed tomography (CT) usage increases, so have concerns over radiation-induced malignancy. To mitigate these risks, low-dose CT (LDCT) has emerged as a versatile alternative by other specialties, although its use in plastic surgery remains sparse. This study aimed to investigate validated uses of LDCT across surgical specialties and extrapolate these insights to expand its application for plastic surgeons. METHODS A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using search terms "low dose CT" OR "low dose computed tomography" AND "surgery," where the name of each surgical specialty was substituted for word "surgery" and each specialty term was searched separately in combination with the 2 CT terms. Data on radiation dose, outcomes, and level of evidence were collected. Validated surgical applications were correlated with similar procedures and diagnostic tests performed routinely by plastic surgeons to extrapolate potential applications for plastic surgeons. RESULTS A total of 3505 articles were identified across surgical specialties, with 27 ultimately included. Depending on the application, use of LDCT led to a 25% to 97% reduction in radiation dose and all studies reported noninferior image quality and diagnostic capability compared with standard-dose CT. Potential identified uses included the following: evaluation of soft tissue infections, preoperative and postoperative management of facial and hand fractures, flap design, 3D modeling, and surgical planning. DISCUSSION Low-dose CT is a valid imaging alternative to standard-dose CT. Expanded utilization in plastic surgery should be considered to minimize the iatrogenic effects of radiation and to promote patient safety without compromising outcomes.
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Affiliation(s)
- Brittany Lala
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, NY
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14
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Haijanen J, Sippola S, Tammilehto V, Grönroos J, Mäntyoja S, Löyttyniemi E, Niiniviita H, Salminen P. Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study. Br J Surg 2021; 108:1483-1490. [PMID: 34761262 PMCID: PMC10364876 DOI: 10.1093/bjs/znab383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. METHODS This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. RESULTS Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001). CONCLUSION Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Ville Tammilehto
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Siiri Mäntyoja
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | | | - Hannele Niiniviita
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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15
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Luksaite-Lukste R, Kliokyte R, Samuilis A, Jasiunas E, Luksta M, Strupas K, Poskus T. Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT. J Clin Med 2021; 10:jcm10112456. [PMID: 34206008 PMCID: PMC8198775 DOI: 10.3390/jcm10112456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.
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Affiliation(s)
- Raminta Luksaite-Lukste
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
- Correspondence: ; Tel.: +37-068-9606-11
| | - Ruta Kliokyte
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, LT-08661 Vilnius, Lithuania; (R.K.); (A.S.)
| | - Arturas Samuilis
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, LT-08661 Vilnius, Lithuania; (R.K.); (A.S.)
| | - Eugenijus Jasiunas
- Centre of Informatics and Development, Vilnius University Hospital, Santara Clinics, LT-08661 Vilnius, Lithuania;
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
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16
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CT based Acute Appendicitis Severity Index for acute appendicitis and validate its effectiveness in predicting complicated appendicitis. Emerg Radiol 2021; 28:921-927. [PMID: 34032950 DOI: 10.1007/s10140-021-01950-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
AIM To propose a CT-based scoring system called Acute Appendicitis Severity Index (AASI) for diagnosis of acute appendicitis and validates its effectiveness in predicting complicated appendicitis. SUBJECTS AND METHODS Retrospective analyses of CT images of 120 adult patients with pathologically proven uncomplicated (n = 64) and complicated (n = 56) acute appendicitis were performed. All patients had undergone a CT scan of the abdomen and pelvis using 320 multi-detectors computed tomography with Adaptive Iterative Dose Reduction 3D (AIDR 3D). CT image parameters were identified and used to develop a CT-based scoring system (AASI) to predict the severity of acute appendicitis and its outcome. All image analysis was performed by 2 radiologists and the total score was assigned to each patient based on the proposed CT scoring system. Validation of the effectiveness of the proposed scoring system (AASI) was done using statistical models. RESULTS The mean and standard deviation of AASI was found to be significantly higher (P value = 0.001) in the complicated appendicitis group (observer 1 = 10.2 ± 1.6 and observer 2 = 9.63 ± 2.3) as compared to that in uncomplicated acute appendicitis group (observer 1 = 7.09 ± 2.2 and observer 2 = 6.38 ± 1.9). There was an excellent interobserver agreement of the Acute Appendicitis Severity Index for both the uncomplicated and complicated appendicitis groups (K = 0.89, 95% CI = 0.87-0.92, P = 0.001). The cutoff value for AASI used to predict complicated appendicitis was taken as 9.5 and 8.5. This resulted in an AUC of 0.877 and 0.848, accuracy of 83% and 81%, the sensitivity of 75% and 80%, the specificity of 90% and 81%, the positive predictive value of 87% and 78%, and a negative predictive value of 81% and 83% by both reviewers respectively. CONCLUSION The proposed CT-based AASI is a reliable parameter for the prediction of complicated appendicitis.
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17
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Feng H, Shi G, Liu H, Du Y, Zhang N, Wang Y. The Value of PETRA in Pulmonary Nodules of <3 cm Among Patients With Lung Cancer. Front Oncol 2021; 11:649625. [PMID: 34084745 PMCID: PMC8167054 DOI: 10.3389/fonc.2021.649625] [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: 01/05/2021] [Accepted: 04/15/2021] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to evaluate the visibility of different subgroups of lung nodules of <3 cm using the pointwise encoding time reduction with radial acquisition (PETRA) sequence on 3T magnetic resonance imaging (MRI) in comparison with that obtained using low-dose computed tomography (LDCT). Methods The appropriate detection rate was calculated for each of the different subgroups of lung nodules of <3 cm. The mean diameter of each detected nodule was determined. The detection rates and diameters of the lung nodules detected by MRI with the PETRA sequence were compared with those detected by computed tomography (CT). The sensitivity of detection for the different subgroups of pulmonary nodules was determined based on the location, size, type of nodules and morphologic characteristics. Agreement of nodule characteristics between CT and MRI were assessed by intraclass correlation coefficient (ICC) and Kappa test. Results The CT scans detected 256 lung nodules, comprising 99 solid nodules (SNs) and 157 subsolid nodules with a mean nodule diameter of 8.3 mm. For the SNs, the MRI detected 30/47 nodules of <6 mm in diameter and 52/52 nodules of ≥6 mm in diameter. For the subsolid nodules, the MRI detected 30/51 nodules of <6 mm in diameter and 102/106 nodules of ≥6 mm in diameter. The PETRA sequence returned a high detection rate (84%). The detection rates of SN, ground glass nodules, and PSN were 82%, 72%, and 94%, respectively. For nodules with a diameter of >6 mm, the sensitivity of the PETRA sequence reached 97%, with a higher rate for nodules located in the upper lung fields than those in the middle and lower lung fields. Strong agreement was found between the CT and PETRA results (correlation coefficients = 0.97). Conclusion The PETRA technique had high sensitivity for different type of nodule detection and enabled accurate assessment of their diameter and morphologic characteristics. It may be an effective alternative to CT as a tool for screening and follow up pulmonary nodules.
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Affiliation(s)
- Hui Feng
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Gaofeng Shi
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hui Liu
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu Du
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ning Zhang
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yaning Wang
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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18
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Mellnick VM. Clinical Appendicitis Scores May Lower CT Utilization and Diagnostic Accuracy. Radiology 2021; 300:359-360. [PMID: 34003062 DOI: 10.1148/radiol.2021210632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vincent M Mellnick
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
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19
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Cho J, Lee S, Min HD, Kim HY, Ko Y, Park JH, Park SB, Lee KH. Final diagnosis and patient disposition following equivocal results on 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: a post hoc analysis of large pragmatic randomized trial data. Eur Radiol 2021; 31:9176-9187. [PMID: 33993331 DOI: 10.1007/s00330-021-08020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/08/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare 2-mSv CT and conventional-dose CT (CDCT, typically 7-8 mSv) regarding final diagnosis and patient disposition following equivocal CT results in adolescents and young adults with suspected appendicitis. METHODS In total, 3074 patients of 15-44 years (28 ± 9 years, 1672 women) from 20 hospitals were randomized to undergo contrast-enhanced 2-mSv CT (n = 1535) or CDCT (n = 1539) from December 2013 through August 2016. One hundred sixty-one radiologists prospectively rated the likelihood of appendicitis in a Likert scale (i.e., grades 1-5). The final diagnosis was based on CT image, surgical, pathologic, and clinical findings. Post hoc analysis was performed for final diagnosis, surgical procedure, and delay in patient management following equivocal results (i.e., grade 3). RESULTS The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal results, including confirmed appendicitis (1.2% [18 patients] vs. 1.2% [19], p > 0.99), negative appendectomy (0.1% [2] vs. 0.3% [4], p = 0.53), and perforated appendicitis (0.1% [1] vs. 0.2% [3], p = 0.53). More patients were confirmed as not having appendicitis following equivocal results in the CDCT group than in the 2-mSv CT group (2.2% [34] vs. 1.0% [16], p = 0.016). The two groups were comparable for the need of appendectomy (1.4% [22] vs. 1.5% [23], p > 0.99), need of additional imaging tests (0.7% [11] vs. 1.1% [17], p = 0.35), and delay in patient management following equivocal results. CONCLUSION 2-mSv CT is comparable to CDCT regarding final diagnosis and patient disposition following equivocal CT results. KEY POINTS • Our results strengthen evidence justifying the use of low-dose CT instead of conventional-dose CT (CDCT) in adolescents and young adults with suspected appendicitis. • The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal CT results, including confirmed appendicitis (1.2% vs. 1.2%, p > 0.99), negative appendectomy (0.1% vs. 0.3%, p = 0.53), and perforated appendicitis (0.1% vs. 0.2%, p = 0.53). • The two groups were comparable for the need for appendectomy (1.4% vs. 1.5%, p > 0.99), need for additional imaging tests (0.7% vs. 1.1%, p = 0.35), and delay in patient management, following equivocal CT results.
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Affiliation(s)
- Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Seungjae Lee
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Hooney Daniel Min
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Yousun Ko
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea.
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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20
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Larsen NE, Mikkelsen E, Knudsen AR, Larsen LP. Low-dose CT for diagnosing intestinal obstruction and pneumoperitoneum; need for retakes and diagnostic accuracy. Acta Radiol Open 2021; 10:2058460121989313. [PMID: 33786202 PMCID: PMC7958640 DOI: 10.1177/2058460121989313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background One of the main concerns using low-dose (LD) CT for evaluation of patients with suspected intestinal obstruction or pneumoperitoneum is the potential need to make an additional standard-dose (SD) CT scan (retake) due to insufficient diagnostic accuracy of the LD CT. Purpose To determine the frequency of retakes and evaluate the diagnostic accuracy of LD CT for the assessment of intestinal obstruction and pneumoperitoneum. Material and Methods This retrospective study registered all LD CT scans over a one-year period at Aarhus University Hospital, Denmark in patients with suspected intestinal obstruction or perforation, comprising a total of 643 LD CT scans. A retake was defined as a SD CT scan of the abdomen and pelvis performed with or without intravenous contrast within 72 h after the initial LD CT due to either continued suspicion of intestinal obstruction or perforation or due to unclarified secondary findings. The sensitivity and specificity of LD CT for diagnosing intestinal obstruction and pneumoperitoneum compared to the discharge diagnoses of the scanned patients were determined. Results The frequency of retakes was 3%. The overall LD CT sensitivity and specificity for assessment of patients with suspected intestinal obstruction and pneumoperitoneum was 83% and 99%, respectively, but higher in certain subgroups. Conclusions LD CT led to few retakes and had a high diagnostic accuracy for diagnosing intestinal obstruction and pneumoperitoneum. Thus, LD CT can be recommended as the examination of choice in patients with suspected intestinal obstruction or perforation in order to reduce radiation dose.
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Affiliation(s)
- Nis E Larsen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Eva Mikkelsen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anders R Knudsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Lars P Larsen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
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21
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Téoule P, Laffolie JD, Rolle U, Reissfelder C. Acute Appendicitis in Childhood and Adulthood. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:764-774. [PMID: 33533331 DOI: 10.3238/arztebl.2020.0764] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/05/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions. METHODS This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases. RESULTS In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment. CONCLUSION Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.
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Affiliation(s)
- Patrick Téoule
- Department of Surgery, Universitäts -medizin Mannheim, Medical Faculty Mannheim, Heidelberg UniversityDepartment of General Pediatrics and Neonatology, Pediatric Gastroenterology, University of Giessen, GermanyDepartment of Pediatric Surgery, University Hospital Frankfurt, Goethe-University Frankfurt am Main, Frankfurt, Germany
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22
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Yang B, Vali Y, Dehmoobad Sharifabadi A, Harris IM, Beese S, Davenport C, Hyde C, Takwoingi Y, Whiting P, Langendam MW, Leeflang MM. Risk of bias assessment of test comparisons was uncommon in comparative accuracy systematic reviews: an overview of reviews. J Clin Epidemiol 2020; 127:167-174. [DOI: 10.1016/j.jclinepi.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 07/21/2020] [Accepted: 08/10/2020] [Indexed: 01/04/2023]
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23
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Establishment of Submillisievert Abdominal CT Protocols With an In Vivo Swine Model and an Anthropomorphic Phantom. AJR Am J Roentgenol 2020; 215:685-694. [DOI: 10.2214/ajr.19.22053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Li RF, Hou CL, Zhou H, Dai YS, Jin LQ, Xi Q, Zhang JH. Comparison on radiation effective dose and image quality of right coronary artery on prospective ECG-gated method between 320 row CT and 2nd generation (128-slice) dual source CT. J Appl Clin Med Phys 2020; 21:256-262. [PMID: 32510768 PMCID: PMC7484880 DOI: 10.1002/acm2.12911] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/09/2020] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
This retrospective study was to compare the image quality of right coronary artery (RCA) and effective radiation dose on prospective ECG‐gated method between 320 row computed tomography (CT) and 2nd generation (128‐slice) dual source CT. A total of 215 candidates underwent CT coronary angiography using prospective ECG‐gated method, 120 patients enrolled in 320 row CT group, and 95 patients in dual source CT group. We divided RCA image quality scores as 1/2/3/4, which means excellent/good/adequate/not assessable and heart rates were considered, as well as the radiation dose. There is no statistically significant difference of RCA image quality of Score 1/2 between 320 row CT and 2nd generation dual source CT, but lower heart rate (<70/min) improved RCA image quality. Meanwhile, the 2nd generation dual source CT scan have significant lower radiation dose. For patients with high level heart rate variation, both prospective ECG‐gated method of 320 row CT scan (Toshiba) and 2nd generation dual source CT scan (Siemens) basically provided good image quality on RCA. There is an advantage of effective radiation dose reduction in prospective ECG‐gated method using the 2nd generation dual source CT scan. After the iodine contrast agent was injected into elbow vein, the threshold triggering method was used to carry out prospective gated scanning, and the acquired fault image was reconstructed by the standard post‐processing software of each manufacturer. The radiation dose value is obtained through the dose report automatically generated after each scan.
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Affiliation(s)
- Ren-Feng Li
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chang-Long Hou
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huang Zhou
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yan-Shan Dai
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li-Qin Jin
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qian Xi
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian-Hua Zhang
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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25
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The Accuracy of Low-dose Computed Tomography Protocol in Patients With Suspected Acute Appendicitis: The OPTICAP Study. Ann Surg 2020; 271:332-338. [PMID: 30048324 DOI: 10.1097/sla.0000000000002976] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare diagnostic accuracy of contrast enhanced low-dose computed tomography (CT) accomplished in the OPTICAP trial phantom phase to standard CT in patients with suspected acute appendicitis. BACKGROUND Increasing use of CT as the gold standard in diagnosing acute appendicitis has raised concerns regarding radiation exposure. Unenhanced low-dose CT protocols have shown similar diagnostic accuracy with standard CT for diagnosing appendicitis. To our knowledge, there are no other trials in which the same patient with suspected acute appendicitis underwent both standard and low-dose CT allowing interpatient comparison. METHODS OPTICAP is an interpatient protocol sequence randomized noninferiority single-center trial performed at Turku University Hospital between November, 2015 and August, 2016. Sixty patients with suspected acute appendicitis and body mass index <30 kg/m were enrolled to undergo both standard and low-dose contrast enhanced CT scans, which were categorized as normal, uncomplicated or complicated appendicitis by 2 radiologists in blinded manner. All patients with CT confirmed appendicitis underwent appendectomy to obtain histopathology. RESULTS The low-dose protocol was not inferior to standard protocol in terms of diagnostic accuracy; 79% [95% confidence interval (CI) 66%-89%) accurate diagnosis in low-dose and 80% (95% CI 67%-90%) in standard CT by primary radiologist. Accuracy to categorize appendicitis severity was 79% for both protocols. The mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44 mSv, respectively). CONCLUSION Diagnostic accuracy of contrast enhanced low-dose CT was not inferior to standard CT in diagnosing acute appendicitis or distinguishing between uncomplicated and complicated acute appendicitis in patients with a high likelihood of acute appendicitis. Low-dose CT enabled significant radiation dose reduction.
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26
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Bord S, El Khuri C. High-Risk Chief Complaints III. Emerg Med Clin North Am 2020; 38:499-522. [DOI: 10.1016/j.emc.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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27
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Tan WJ, Acharyya S, Chew MH, Foo FJ, Chan WH, Wong WK, Ooi LL, Ng JCF, Ong HS. Randomized control trial comparing an Alvarado Score-based management algorithm and current best practice in the evaluation of suspected appendicitis. World J Emerg Surg 2020; 15:30. [PMID: 32357897 PMCID: PMC7193351 DOI: 10.1186/s13017-020-00309-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An objective algorithm for the management of suspected appendicitis guided by the Alvarado Score had previously been proposed. This algorithm was expected to reduce computed tomography (CT) utilization without compromising the negative appendectomy rate. This study attempts to validate the proposed algorithm in a randomized control trial. METHODS A randomized control trial comparing the management of suspected acute appendicitis using the proposed algorithm compared to current best practice, with the rate of CT utilization as the primary outcome of interest. Secondary outcomes included the percentage of missed diagnosis, negative appendectomies, length of stay in days, and overall cost of stay in dollars. RESULTS One hundred sixty patients were randomized. Characteristics such as age, ethnic group, American Society of Anesthesiologist score, white cell count, and symptom duration were similar between the two groups. The overall CT utilization rate of the intervention arm and the usual care arm were similar (93.7% vs 92.5%, p = 0.999). There were no differences in terms of negative appendectomy rate, length of stay, and cost of stay between the intervention arm as compared to the usual care arm (p = 0.926, p = 0.705, and p = 0.886, respectively). Among patients evaluated with CT, 75% (112 out of 149) revealed diagnoses for the presenting symptoms. CONCLUSION The proposed AS-based management algorithm did not reduce the CT utilization rate. Outcomes such as missed diagnoses, negative appendectomy rates, length of stay, and cost of stay were also largely similar. CT utilization was prevalent as 93% of the study cohort was evaluated by CT scan. TRIAL REGISTRATION The study has been registered at ClinicalTrials.gov (NCT03324165, Registered October 27 2017).
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Affiliation(s)
- Winson Jianhong Tan
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore. .,Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore.
| | - Sanchalika Acharyya
- Clinical Research & Innovation Office, Tan Tock Seng Hospital Singapore, Singapore, Singapore
| | - Min Hoe Chew
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore.,Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Fung Joon Foo
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore.,Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Weng Hoong Chan
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Wai Keong Wong
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore.,Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - London Lucien Ooi
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Chung Fai Ng
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hock Soo Ong
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
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Collard M, Lakkis Z, Loriau J, Mege D, Sabbagh C, Lefevre JH, Maggiori L. [Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis]. ACTA ACUST UNITED AC 2020; 157:S33-S43. [PMID: 32355509 PMCID: PMC7190476 DOI: 10.1016/j.jchirv.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
La saturation intrahospitalière liée à l’arrivée massive de patients atteints du COVID-19 nécessitant une prise en charge urgente conduit à reconsidérer la prise en charge des autres patients. Différer au maximum les hospitalisations et les opérations chirurgicales non urgentes est un des objectifs des chirurgiens afin de désengorger autant que possible le système de soins. Alors que la majorité des opérations programmées sont annulées, la réduction de la chirurgie d’urgence est évidemment compliquée à proposer sans altérer la qualité de la prise en charge et conduire à une perte de chance pour le patient. Cependant, l’appendicite aiguë constitue une situation spécifique bien particulière et la fréquence de cette pathologie conduit à considérer ce cas particulier. En effet, tandis que le traitement recommandé de l’appendicite aiguë non compliquée est chirurgical, l’alternative non chirurgicale par antibiothérapie seule a été largement évaluée dans la littérature au cours de travaux de qualité. Dans la mesure où la limite principale du traitement médical exclusif de l’appendicite aiguë non compliquée est le risque de récidive à distance, cette option thérapeutique représente une alternative de choix pour réduire la surcharge intrahospitalière dans ce contexte de crise sanitaire. L’objectif de ce travail est donc de mettre à disposition des médecins et des chirurgiens un guide pratique issu d’une analyse de la littérature sur le traitement médical de l’appendicite aiguë non compliquée de l’adulte afin de pouvoir proposer ce traitement alternatif aux bons patients et dans des bonnes conditions, notamment lorsque l’accès au bloc opératoire est impossible.
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Affiliation(s)
- M Collard
- Service de chirurgie digestive, Sorbonne université, hôpital Saint-Antoine, AP-HP, 75012, Paris, France
| | - Z Lakkis
- Service de chirurgie digestive et oncologique , et de transplantation hépatique, CHU de Besançon, 2, boulevard Alexander-Fleming, 25000, Besançon, France
| | - J Loriau
- Service de chirurgie viscérale, groupe hospitalier Paris Saint-Joseph, 75014, Paris, France
| | - D Mege
- Service de chirurgie digestive, assistance publique hôpitaux de Marseille, hôpital de la Timone, CHU de Marseille, France
| | - C Sabbagh
- Service de chirurgie digestive, CHU Amiens-Picardie, 8000 Amiens, France.,Unité de recherche SSPC (simplification des soins des patients chirurgicaux complexes), université de Picardie Jules-Verne, 80025 Amiens, France
| | - J H Lefevre
- Service de chirurgie digestive, Sorbonne université, hôpital Saint-Antoine, AP-HP, 75012, Paris, France
| | - L Maggiori
- Service de chirurgie colorectale, hôpital Beaujon, université de Paris, AP-HP, 92110 Clichy, France
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Collard M, Lakkis Z, Loriau J, Mege D, Sabbagh C, Lefevre JH, Maggiori L. Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis. J Visc Surg 2020; 157:S33-S42. [PMID: 32362368 PMCID: PMC7181971 DOI: 10.1016/j.jviscsurg.2020.04.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.
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Affiliation(s)
- M Collard
- Digestive Surgery Department, Sorbonne University, Saint-Antoine Hospital, AP-HP, 75012 Paris, France
| | - Z Lakkis
- Department of Digestive Surgical Oncology, Liver Transplantation Unit, University Hospital of Besançon, 2, boulevard Alexander Fleming, 25000, Besançon, France
| | - J Loriau
- Department of Visceral Surgery, Groupe Hospitalier Paris Saint Joseph, 75014, Paris, France
| | - D Mege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - C Sabbagh
- Digestive surgery department, CHU Amiens-Picardie, 80000 Amiens, France; Research Unit SSPC (simplification des soins des patients chirurgicaux complexes), université de Picardie Jules Verne, 80025 Amiens, France
| | - J H Lefevre
- Digestive Surgery Department, Sorbonne University, Saint-Antoine Hospital, AP-HP, 75012 Paris, France
| | - L Maggiori
- Department of Colorectal surgery, Beaujon Hospital, Paris University, AP-HP, 92110, Clichy, France.
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Ko Y, Lee WJ, Park JH, Kim HY, Sim JY, Tannaphai P, Lee KH. Diagnostic sensitivity and specificity of 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: post hoc subgroup analysis of the LOCAT data. Eur Radiol 2020; 30:4573-4585. [PMID: 32240354 DOI: 10.1007/s00330-020-06811-y] [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: 11/10/2019] [Revised: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To test whether the difference in sensitivity or specificity between 2-mSv CT and conventional-dose CT (CDCT) for the diagnosis of appendicitis differs across subgroups of adolescents and young adults with suspected appendicitis. MATERIALS AND METHODS We used the per-protocol analysis data of a trial conducted between Dec 2013 and Aug 2016, including 2773 patients (median age [interquartile range], 28 [21-35] years) and 160 radiologists from 20 hospitals. We defined subgroups by sex, body size, clinical risk scores for appendicitis, time of CT examination (i.e., working vs. after hours), CT machines, radiologists' experience, previous site experience in 2-mSv CT, and site practice volume. We drew forest plots and tested for additive or multiplicative interaction between radiation dose and subgroup attributes. If any subgroup had fewer than 200 patients, we considered the results from that subgroup not meaningful. RESULTS For most subgroups, the 95% CIs for the differences in sensitivity and specificity were 4.0 percentage points or narrower and contained the minute overall between-group differences. There was no significant interaction on sensitivity or specificity. A few subgroups, including those of extreme body sizes, high appendicitis inflammatory response scores, and hospitals with small appendectomy volume, were regarded to have insufficient numbers of patients. CONCLUSIONS There was no notable subgroup heterogeneity, which implies that 2-mSv CT can replace CDCT in diverse populations. Further studies are needed for the subgroups for which we had only small data. KEY POINTS • The minute difference in sensitivity or specificity between the 2-mSv CT and conventional-dose CT (typically 7 mSv) groups were consistent across various patient or hospital characteristics. • These results indicate that 2-mSv CT can replace conventional-dose CT in diverse populations. • Further studies are needed to confirm whether 2-mSv CT can replace conventional-dose CT in patients of extreme body sizes, high appendicitis inflammatory response scores, or hospitals with small appendectomy volume, as those subgroups in our data included limited numbers of patients.
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Affiliation(s)
- Yousun Ko
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea.,Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Woo Joo Lee
- Department of Statistics, Inha University, Incheon, South Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Ji Ye Sim
- Department of Radiology, Hanil General Hospital, Seoul, South Korea
| | - Penampai Tannaphai
- Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea. .,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea.
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Patel K, Zha N, Neumann S, Tembelis MN, Juliano M, Samreen N, Hussain J, Moshiri M, Patlas MN, Katz DS. Computed Tomography of Common Bowel Emergencies. Semin Roentgenol 2020; 55:150-169. [DOI: 10.1053/j.ro.2019.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Crellin AJ, Musbahi O, Onwu N, Singh S. Appendiceal Crohn's disease: a rare differential of right iliac fossa pain. BMJ Case Rep 2020; 13:13/2/e232549. [PMID: 32111706 DOI: 10.1136/bcr-2019-232549] [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] [Indexed: 11/03/2022] Open
Abstract
A 30-year-old man with a history of severe right iliac fossa pain was referred to the surgical emergency unit. His symptoms began 3 days prior as mild, non-specific abdominal pain which progressively localised to the right iliac fossa and worsened in severity. Investigations were suggestive of acute appendicitis, and therefore a laparoscopic appendicectomy was planned. Laparoscopy revealed a thickened, necrotic appendix with a mass at the base of the appendix, in keeping with the appearance of an appendiceal malignancy. Subsequently a right hemicolectomy was performed. Histology revealed active chronic inflammation and granulomas highly suggestive of appendiceal Crohn's disease. Since, the patient has made a good recovery and presently shows no further signs of Crohn's disease. This case is demonstrative of one of many rare findings on histological examination of the appendix. It emphasises the need for a wide differential when investigating right iliac fossa pain.
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Affiliation(s)
| | - Omar Musbahi
- Oxford University Clinical Academic Graduate School, Oxford University, Oxford, UK
| | - Natasha Onwu
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sandeep Singh
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Eurboonyanun K, Rungwiriyawanich P, Chamadol N, Promsorn J, Eurboonyanun C, Srimunta P. Accuracy of Nonenhanced CT vs Contrast-Enhanced CT for Diagnosis of Acute Appendicitis in Adults. Curr Probl Diagn Radiol 2020; 50:315-320. [PMID: 32037023 DOI: 10.1067/j.cpradiol.2020.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/09/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is one of the most common causes of acute abdominal pain requiring emergency intervention. It is often difficult for the clinician to make an accurate diagnosis due to nonspecific and overlapping clinical symptoms. Computed tomography (CT) has become the imaging modality of choice for the evaluation of suspected acute appendicitis. The main purpose of our study was to compare nonenhanced CT (NECT) with contrast-enhanced CT (CECT) for the diagnosis of acute appendicitis. MATERIAL AND METHODS A total of 140 patients were enrolled in the study. Two abdominal radiologists-masked to both the clinical information and the final diagnosis-retrospectively reviewed the computed tomographic findings and made an imaging diagnosis based on (1) NECT only, (2) CECT only, and (3) both NECT and CECT. With the final diagnosis as the reference standard, the accuracy of each CT technique was estimated. RESULTS The respective sensitivity, specificity, and accuracy for NECT, CECT, and NECT + CECT for the diagnosis of acute appendicitis were 80.7%, 86.7%, and 84.3%; 86.0%, 81.9%, and 83.6%; and, 87.7%, 80.7%, and 83.6%. There was no significant difference in the diagnosis of acute appendicitis among the 3 techniques. In order to make a correct diagnosis, the presence of at least 3 imaging findings for NECT or at least 4 for CECT had the best diagnostic accuracy. We also found that 9.25 mm was the optimal cut-off threshold for the detection of patients with acute appendicitis. CONCLUSION Our study allowed direct comparison between NECT, CECT, and NECT + CECT combined. There was no difference in the ability of each CT technique for diagnosing patients with acute appendicitis. For a patient whom iodinated contrast media is contraindicated or a patient who has an increased risk of severe adverse reaction, we would encourage the use of NECT because it provides comparable diagnostic accuracy without further exposing such patient to the contrast media.
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Affiliation(s)
- Kulyada Eurboonyanun
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
| | | | - Nittaya Chamadol
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Julaluck Promsorn
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chalerm Eurboonyanun
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Piyachat Srimunta
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Kim HJ, Lee KH, Kim MJ, Park SB, Ko Y. Using 2-mSv Appendiceal CT in Usual Practice for Adolescents and Young Adults: Willingness Survey of 579 Radiologists, Emergency Physicians, and Surgeons from 20 Hospitals. Korean J Radiol 2020; 21:68-76. [PMID: 31920030 PMCID: PMC6960317 DOI: 10.3348/kjr.2019.0010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 08/10/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To survey care providers' willingness to use 2-mSv computed tomography (CT) in their usual practice for adolescents and young adults with suspected appendicitis. MATERIALS AND METHODS An ethical committee approved this prospective study. We introduced 2-mSv CT in 20 hospitals through a pragmatic clinical trial. At the final phase of the trial, we invited 698 potentially-involved care providers in the survey regarding their willingness to use 2-mSv CT. Multivariable logistic regression analyses were performed to identify factors associated with willingness. Nine months after the completion of the trial patient recruitment, we surveyed whether the hospitals were using 2-mSv CT in usual practice. RESULTS The analyses included responses from 579 participants (203 attendings and 376 trainees; 221 radiologists, 196 emergency physicians, and 162 surgeons). Regarding the willingness to immediately change their standard practice to 2-mSv CT, 158 (27.3%), 375 (64.8%), and 46 (7.9%) participants responded as "yes" (consistently), "partly" (selectively), and "no", respectively. Willingness varied considerably across the hospitals, but only slightly across the participants' departments or job titles. Willingness was significantly associated with attendings (p = 0.004), intention to maintain the dedicated appendiceal CT protocol (p < 0.001), belief in compelling evidence on the carcinogenic risk of conventional-dose CT radiation (p = 0.028), and hospitals having more than 1000 beds (p = 0.031). Fourteen of the 20 hospitals kept using 2-mSv appendiceal CT in usual practice after the trial. CONCLUSION Despite the extensive efforts over the years of this clinical trial, many care providers were willing to use 2-mSv CT selectively or not willing to use.
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Affiliation(s)
- Hyuk Jung Kim
- Department of Radiology, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology Seoul National University, Seoul, Korea.
| | - Min Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yousun Ko
- Department of Radiology, Asan Medical Center, Seoul, Korea
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Mahankali SK, Abdel Razek AAK, Ahamed SA. Reliability of standardized reporting system of acute appendicitis in adults at low-dose 320-rows CT. Eur J Radiol Open 2019; 6:330-335. [PMID: 31768408 PMCID: PMC6872863 DOI: 10.1016/j.ejro.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/01/2019] [Accepted: 11/02/2019] [Indexed: 12/26/2022] Open
Abstract
Aim To assess the reliability of a standardized reporting system of acute appendicitis at low-dose 320-rows CT. Subjects and Methods Retrospective analysis CT of 78 patients with pathologically proven acute appendicitis. The study was performed at a low-dose 320-rows CT. The image analysis was performed by 2 radiologists according to a standardized reporting system of acute appendicitis. Results There was an excellent overall of the inter-observer agreement of both observers for the standardized reporting system of acute appendicitis (K = 0.89, 95 % CI = 0.87-0.92, P = 0.001). There was good inter-observer agreement for visualization of the appendix (K = 0.78, P = 0.001), the tip diameter (K = 0.75, P = 0.001), and a single wall thickness of appendix (K = 0.77, P = 0.001). There was excellent inter-observer agreement for outer to outer wall diameter (K = 0.82, P = 0.001), mucosal hyper-enhancement (K = 0.80, P = 0.001), appendicolith (K = 0.86, P = 0.001), gas in the appendix (K = 0.82, P = 0.001), surrounding fat stranding (K = 0.81, P = 0.001), focal cecal thickening (K = 0.85, P = 0.001), peri-appendiceal air (K = 0.87, P = 0.001), peri-appendicular fluid collection, phlegmon, or abscess (K = 0.82, P = 0.001), and right ovary cyst (K = 0.83, P = 0.001). Conclusion we concluded that excellent reliability of a standardized reporting system of acute appendicitis in the adults using low-dose 320-rows CT.
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Rud B, Vejborg TS, Rappeport ED, Reitsma JB, Wille‐Jørgensen P. Computed tomography for diagnosis of acute appendicitis in adults. Cochrane Database Syst Rev 2019; 2019:CD009977. [PMID: 31743429 PMCID: PMC6953397 DOI: 10.1002/14651858.cd009977.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not. OBJECTIVES Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy. SEARCH METHODS We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status. SELECTION CRITERIA We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity. MAIN RESULTS We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery. AUTHORS' CONCLUSIONS The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.
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Affiliation(s)
- Bo Rud
- Copenhagen University Hospital HvidovreGastrounit, Surgical DivisionKettegaards Alle 30HvidovreDenmark2650
| | - Thomas S Vejborg
- Bispebjerg Hospital, University of CopenhagenDepartment of Radiology R23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 NV
| | - Eli D Rappeport
- Bispebjerg Hospital, University of CopenhagenDepartment of Radiology R23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 NV
| | - Johannes B Reitsma
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA Utrecht
| | - Peer Wille‐Jørgensen
- Bispebjerg HospitalDepartment of Surgical Gastroenterology KBispebjerg Bakke 23Copenhagen NVDenmarkDK‐2400
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Bax T, Macha M, Mayberry J. The utility of CT scan for the diagnostic evaluation of acute abdominal pain. Am J Surg 2019; 217:959-966. [DOI: 10.1016/j.amjsurg.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/16/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
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Zinsser D, Maurer M, Do PL, Weiß J, Notohamiprodjo M, Bamberg F, Othman AE. Reduced scan range abdominopelvic CT in patients with suspected acute appendicitis - impact on diagnostic accuracy and effective radiation dose. BMC Med Imaging 2019; 19:4. [PMID: 30635023 PMCID: PMC6329115 DOI: 10.1186/s12880-019-0304-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/02/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To evaluate a reduced range CT protocol in patients with suspected acute appendicitis as compared to standard abdominal CT regarding diagnostic performance, effective radiation dose and organ doses. METHODS In this study, we retrospectively included 90 patients (43 female, mean age 56.7 ± 17 years) with suspected acute appendicitis who underwent CT of abdomen and pelvis. From those CTs, we reconstructed images with a reduced scan range from L1 to the the pubic symphysis. Full range and reduced range datasets were assessed by two radiologists for i) coverage of the Appendix, ii) presence/absence of appendicitis and iii) presence of differential diagnoses. Furthermore, effective radiation doses as well as organ doses were calculated using a commercially available dose management platform (Radimetrics, Bayer HealthCare). RESULTS The Appendix was covered by the reduced range CT in all cases. In 66 patients CT confirmed the presence of appendicitis. In 14 patients, other relevant differential diagnoses were identified by CT, whereas in 10 patients no relevant findings were detected. Both readers identified all patients with appendicitis on both full and reduced range CT. For reduced range CT, total effective dose was 39% lower than for full range CT (reduced range: 4.5 [1.9-11.2] vs. full range: 7.4 [3.3-18.8] mSv; p ≤ 0.001). Notably, a remarkable reduction of organ dose in the female breasts by 97% (0.1 [0.1-0.6] vs. 3.8 [0.5-18.8] mSv; p ≤ 0.001) and in the testicles in males by 81% (3.4 [0.7-32.7] vs. 17.6 [5.4-52.9] mSv; p ≤ 0.001) was observed for reduced range CT compared to full range CT. CONCLUSIONS In patients with suspected acute appendicitis, reduced range abdominopelvic CT results in a comparable diagnostic performance with a remarkable reduction of total effective radiation dose and organ doses (especially breast dose in female and testicle dose in male patients) as compared to full range CT.
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Affiliation(s)
- Dominik Zinsser
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany.
| | - Michael Maurer
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Phuong-Linh Do
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Jakob Weiß
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Mike Notohamiprodjo
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Ahmed E Othman
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
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Gu P, Jiang C, Ji M, Zhang Q, Ge Y, Liang D, Liu X, Yang Y, Zheng H, Hu Z. Low-Dose Computed Tomography Image Super-Resolution Reconstruction via Random Forests. SENSORS 2019; 19:s19010207. [PMID: 30626109 PMCID: PMC6339014 DOI: 10.3390/s19010207] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/05/2019] [Accepted: 01/06/2019] [Indexed: 12/17/2022]
Abstract
Aiming at reducing computed tomography (CT) scan radiation while ensuring CT image quality, a new low-dose CT super-resolution reconstruction method based on combining a random forest with coupled dictionary learning is proposed. The random forest classifier finds the optimal solution of the mapping relationship between low-dose CT (LDCT) images and high-dose CT (HDCT) images and then completes CT image reconstruction by coupled dictionary learning. An iterative method is developed to improve robustness, the important coefficients for the tree structure are discussed and the optimal solutions are reported. The proposed method is further compared with a traditional interpolation method. The results show that the proposed algorithm can obtain a higher peak signal-to-noise ratio (PSNR) and structural similarity index measurement (SSIM) and has better ability to reduce noise and artifacts. This method can be applied to many different medical imaging fields in the future and the addition of computer multithreaded computing can reduce time consumption.
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Affiliation(s)
- Peijian Gu
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
- School of Information Engineering, Wuhan University of Technology, Wuhan 430070, China.
| | - Changhui Jiang
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Min Ji
- Shanghai United Imaging Healthcare, Shanghai 201807, China.
| | - Qiyang Zhang
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Yongshuai Ge
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Dong Liang
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Xin Liu
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Yongfeng Yang
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Hairong Zheng
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
| | - Zhanli Hu
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.
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Haijanen J, Sippola S, Grönroos J, Rautio T, Nordström P, Rantanen T, Aarnio M, Ilves I, Hurme S, Marttila H, Virtanen J, Mattila A, Paajanen H, Salminen P. Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial). BMC Surg 2018; 18:117. [PMID: 30558607 PMCID: PMC6296129 DOI: 10.1186/s12893-018-0451-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/28/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70-80%) or complicated (20-30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis. METHODS APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin. DISCUSSION To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis. TRIAL REGISTRATION Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.
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Affiliation(s)
- J. Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
| | - S. Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - J. Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - T. Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - P. Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - T. Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - M. Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - I. Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - S. Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - H. Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - J. Virtanen
- Department of Radiology, Turku University Hospital, University of Turku, Turku, Finland
| | - A. Mattila
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - H. Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - P. Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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41
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Sippola S, Grönroos J, Sallinen V, Rautio T, Nordström P, Rantanen T, Hurme S, Leppäniemi A, Meriläinen S, Laukkarinen J, Savolainen H, Virtanen J, Salminen P. A randomised placebo-controlled double-blind multicentre trial comparing antibiotic therapy with placebo in the treatment of uncomplicated acute appendicitis: APPAC III trial study protocol. BMJ Open 2018; 8:e023623. [PMID: 30391919 PMCID: PMC6231590 DOI: 10.1136/bmjopen-2018-023623] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/19/2018] [Accepted: 09/04/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Recent studies show that antibiotic therapy is safe and feasible for CT-confirmed uncomplicated acute appendicitis. Spontaneous resolution of acute appendicitis has already been observed over a hundred years ago. In CT-confirmed uncomplicated acute diverticulitis (left-sided appendicitis), studies have shown no benefit from antibiotics compared with symptomatic treatment, but this shift from antibiotics to symptomatic treatment has not yet been widely implemented in clinical practice. Recently, symptomatic treatment of uncomplicated acute appendicitis has been demonstrated in a Korean open-label study. However, a double-blinded placebo-controlled study to illustrate the role of antibiotics and spontaneous resolution of uncomplicated acute appendicitis is still lacking. METHODS AND ANALYSIS The APPAC III (APPendicitis ACuta III) trial is a multicentre, double-blind, placebo-controlled, superiority randomised study comparing antibiotic therapy with placebo in the treatment CT scan-confirmed uncomplicated acute appendicitis aiming to evaluate the role of antibiotics in the resolution of uncomplicated acute appendicitis. Adult patients (18-60 years) with CT scan-confirmed uncomplicated acute appendicitis (the absence of appendicolith, abscess, perforation and tumour) will be enrolled in five Finnish university hospitals.Primary endpoint is success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without surgical intervention within 10 days after initiating randomised treatment (treatment efficacy). Secondary endpoints include postintervention complications, recurrent symptoms after treatment up to 1 year, late recurrence of acute appendicitis after 1 year, duration of hospital stay, sick leave, treatment costs and quality of life. A decrease of 15 percentage points in success rate is considered clinically important difference. The superiority of antibiotic treatment compared with placebo will be analysed using Fisher's one-sided test and CI will be calculated for proportion difference. ETHICS AND DISSEMINATION This protocol has been approved by the Ethics Committee of Turku University Hospital and the Finnish Medicines Agency (FIMEA). The findings will be disseminated in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER NCT03234296; Pre-results.
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Affiliation(s)
- Suvi Sippola
- Division of Digestive Surgery and
Urology, Turku University Hospital, Turku, Finland
- Department of Surgery,
University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and
Urology, Turku University Hospital, Turku, Finland
- Department of Surgery,
University of Turku, Turku, Finland
| | - Ville Sallinen
- Department of Surgery,
Helsinki University Central Hospital, Helsinki, Finland
| | - Tero Rautio
- Department of Surgery,
Oulu University Hospital, Oulu, Finland
| | - Pia Nordström
- Division of Surgery, Gastroenterology and
Oncology, Tampere University Hospital, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery,
Kuopio University Hospital, Kuopio, Finland
| | - Saija Hurme
- Department of Biostatistics,
University of Turku, Turku, Finland
| | - Ari Leppäniemi
- Department of Surgery,
Helsinki University Central Hospital, Helsinki, Finland
| | | | - Johanna Laukkarinen
- Division of Surgery, Gastroenterology and
Oncology, Tampere University Hospital, Tampere, Finland
| | - Heini Savolainen
- Department of Surgery,
Kuopio University Hospital, Kuopio, Finland
| | - Johanna Virtanen
- Department of Radiology,
Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and
Urology, Turku University Hospital, Turku, Finland
- Department of Surgery,
University of Turku, Turku, Finland
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Quadri R, Vasan V, Hester C, Porembka M, Fielding J. Comprehensive review of typical and atypical pathology of the appendix on CT: cases with clinical implications. Clin Imaging 2018; 53:65-77. [PMID: 30316106 DOI: 10.1016/j.clinimag.2018.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/13/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022]
Abstract
Acute appendicitis is the most common abdominal surgical emergency in the United States with approximately 250,000 cases annually. Computed Tomography (CT) has emerged as the most accurate diagnostic test to triage these patients for emergent surgery. Although the radiology search pattern is prioritized to detect an inflamed appendix, not all appearances equate to a typical surgical appendicitis. There are a select set of atypical pathologies involving the appendix that have subtle differences on CT, but can have catastrophic complications if treated with emergent appendectomy. This paper will review the spectrum of CT appearances and clinical management for typical and atypical appendiceal pathologies.
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Affiliation(s)
- Rehan Quadri
- University of Texas Southwestern Department of Radiology, United States of America.
| | - Vasantha Vasan
- University of Texas Southwestern Department of Radiology, United States of America
| | - Caitlin Hester
- University of Texas Southwestern Department of Surgery, United States of America
| | - Matthew Porembka
- University of Texas Southwestern Department of Surgery, United States of America
| | - Julia Fielding
- University of Texas Southwestern Department of Radiology, United States of America
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Lee SH, Yun SJ. Diagnostic performance of emergency physician-performed point-of-care ultrasonography for acute appendicitis: A meta-analysis. Am J Emerg Med 2018; 37:696-705. [PMID: 30017693 DOI: 10.1016/j.ajem.2018.07.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/11/2018] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To assess the sensitivity and specificity of emergency physician-performed point-of-care ultrasonography (EP-POCUS) for diagnosing acute appendicitis (AA). MATERIAL AND METHODS The PubMed and EMBASE databases were searched, and the diagnostic performance of EP-POCUS was evaluated using bivariate modeling and hierarchical summary receiver operating characteristic curves. Subgroup analysis was performed for pediatric patients to compare EP-POCUS and radiologist-performed ultrasonography (RADUS). Meta-regression analyses were performed according to patient and study characteristics. RESULTS In 17 studies (2385 patients), EP-POCUS for diagnosing AA exhibited a pooled sensitivity of 84% (95% confidence interval [CI]: 72%-92%) and a pooled specificity of 91% (95% CI: 85%-95%), with even better diagnostic performance for pediatric AA (sensitivity: 95%, 95% CI: 75%-99%; specificity: 95%, 95% CI: 85%-98%). A direct comparison revealed no significant differences (p = 0.18-0.85) between the diagnostic performances of EP-POCUS (sensitivity: 81%, 95% CI: 61%-90%; specificity: 89%, 95% CI: 77%-95%) and RADUS (sensitivity: 74%, 95% CI: 65%-81%; specificity: 97%, 95% CI: 93%-98%). The meta-regression analyses revealed that study location, AA proportion, and mean age were sources of heterogeneity. Higher sensitivity and specificity tended to be associated with an appendix diameter cut-off value of 7 mm and the EP as the initial operator. CONCLUSION The diagnostic performances of EP-POCUS and RADUS were excellent for AA, with EP-POCUS having even better performance for pediatric AA. Accurate diagnoses may be achieved when the attending EP is the initial POCUS operator and uses a 7-mm cut-off value.
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Affiliation(s)
- Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul, 01757, Republic of Korea
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, Republic of Korea.
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44
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Jiang C, Zhang Q, Fan R, Hu Z. Super-resolution CT Image Reconstruction Based on Dictionary Learning and Sparse Representation. Sci Rep 2018; 8:8799. [PMID: 29892023 PMCID: PMC5996061 DOI: 10.1038/s41598-018-27261-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Abstract
In this paper, a single-computed tomography (CT) image super-resolution (SR) reconstruction scheme is proposed. This SR reconstruction scheme is based on sparse representation theory and dictionary learning of low- and high-resolution image patch pairs to improve the poor quality of low-resolution CT images obtained in clinical practice using low-dose CT technology. The proposed strategy is based on the idea that image patches can be well represented by sparse coding of elements from an overcomplete dictionary. To obtain similarity of the sparse representations, two dictionaries of low- and high-resolution image patches are jointly trained. Then, sparse representation coefficients extracted from the low-resolution input patches are used to reconstruct the high-resolution output. Sparse representation is used such that the trained dictionary pair can reduce computational costs. Combined with several appropriate iteration operations, the reconstructed high-resolution image can attain better image quality. The effectiveness of the proposed method is demonstrated using both clinical CT data and simulation image data. Image quality evaluation indexes (root mean squared error (RMSE) and peak signal-to-noise ratio (PSNR)) indicate that the proposed method can effectively improve the resolution of a single CT image.
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Affiliation(s)
- Changhui Jiang
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.,Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Qiyang Zhang
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.,Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Rui Fan
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Zhanli Hu
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
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Foley WD. CT Features for Complicated versus Uncomplicated Appendicitis: What Is the Evidence? Radiology 2018; 287:116-118. [PMID: 29558303 DOI: 10.1148/radiol.2018180022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- W Dennis Foley
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, Wis 53226
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46
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Park JH, Jeon JJ, Lee SS, Dhanantwari AC, Sim JY, Kim HY, Lee KH. Can We Perform CT of the Appendix with Less Than 1 mSv? A De-escalating Dose-simulation Study. Eur Radiol 2017; 28:1826-1834. [DOI: 10.1007/s00330-017-5159-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/13/2017] [Accepted: 10/27/2017] [Indexed: 12/19/2022]
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47
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Low-dose CT for the diagnosis of appendicitis in adolescents and young adults (LOCAT): a pragmatic, multicentre, randomised controlled non-inferiority trial. Lancet Gastroenterol Hepatol 2017; 2:793-804. [PMID: 28919126 DOI: 10.1016/s2468-1253(17)30247-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 01/04/2023]
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48
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Weiner BC. Re: Gungor F, Kilic T, Akyol KC, et al. Diagnostic value and effect of bedside ultrasound in acute appendicitis in the emergency department. Acad Emerg Med 2017; 24:1295-1296. [PMID: 28695643 DOI: 10.1111/acem.13254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Brian C Weiner
- Gastroenterology/Hepatology/Nutrition, University of Florida College of Medicine, Gainesville, FL
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