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Basukala S, Gurung S, Tamang A, Shrestha O, Devkota M, Thapa N, Pathak BD, Mehta K, Bhattarai AM. Diagnostic value of biochemical markers in prediction of perforation in acute appendicitis: a cross-sectional study. Ann Med Surg (Lond) 2024; 86:6495-6501. [PMID: 39525771 PMCID: PMC11543151 DOI: 10.1097/ms9.0000000000002547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/25/2024] [Indexed: 11/16/2024] Open
Abstract
Background Acute appendicitis, despite being the most common surgery, can result in increased morbidity and mortality in the case of perforated appendicitis. Identifying a perforation early can reduce the impact on the patient. Bilirubin, C-reactive protein (CRP), and white blood cell (WBC) count have been shown to indicate perforation in appendicitis. Methods A cross-sectional analytical study was conducted to observe the association between preoperative bilirubin, CRP, and white cell count with the histological findings of either the presence or absence of perforation of the appendix. The eligibility criteria included all patients above 18 years with appendicitis who were managed surgically in the study hospital, Shree Birendra Hosptial, between 1 December 2021 to 30 May 2022. The study was conducted after the approval from the ethics committee. Results Out of 150 patients, 112 had open surgery and 38 underwent laparoscopic appendectomy. One hundred thirty-four had non-perforated appendix and 16 cases had perforated appendix. The older age group was associated with appendiceal perforation more than the younger age group. Patients with a duration of symptoms less than 24 h and more than 72 h developed perforated appendicitis less frequently. The odds of encountering perforated appendicitis increased by 2.644 times per 0.972 rise in total bilirubin (P= 0.004) and the odds of encountering perforated appendicitis increased by 6.474 times per 1.868 rise in conjugated bilirubin (P= 0.003). There was no significant difference in total leucocyte count and neutrophil percentage among perforated and non-perforated groups. Conclusion The diagnostic value of the CRP, total bilirubin, and conjugated bilirubin levels was strong and significant when used in combination rather than their individual performance in the diagnosis of perforated acute appendicitis.
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Affiliation(s)
- Sunil Basukala
- Department of Surgery, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Suman Gurung
- Department of Pathology, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Ayush Tamang
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Oshan Shrestha
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Manu Devkota
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Niranjan Thapa
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Bishnu Deep Pathak
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Kshitij Mehta
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
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Dölling M, Andric M, Rahimli M, Klös M, Pachmann J, Stockheim J, Al-Madhi S, Wex C, Kahlert UD, Herrmann M, Perrakis A, Croner RS. Inflammatory Signals Across the Spectrum: A Detailed Exploration of Acute Appendicitis Stages According to EAES 2015 Guidelines. Diagnostics (Basel) 2024; 14:2335. [PMID: 39451658 PMCID: PMC11506629 DOI: 10.3390/diagnostics14202335] [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: 09/10/2024] [Revised: 10/05/2024] [Accepted: 10/14/2024] [Indexed: 10/26/2024] Open
Abstract
Background: In this retrospective study, we evaluate the diagnostic utility of C-reactive protein (CRP) and leucocyte count within the EAES 2015 guidelines for acute appendicitis (AA) in differentiating uncomplicated (UAA) from complicated AA (CAA). Methods: Conducted at a tertiary care center in Germany, the study included 285 patients over 18 years who were diagnosed with AA from January 2019 to December 2021. Patient data included demographics, inflammatory markers, and postoperative outcomes. Results: CRP levels (Md: 60.2 mg/dL vs. 10.5 mg/dL; p < 0.001) and leucocyte count (Md: 14.4 Gpt/L vs. 13.1 Gpt/L; p = 0.016) were higher in CAA. CRP had a medium diagnostic value for detecting CAA (AUC = 0.79), with a cutoff at 44.3 mg/L, making it more likely to develop CAA. Leucocyte count showed low predictive value for CAA (AUC = 0.59). CRP ≥ 44.3 mg/L was associated with a higher risk of postoperative complications (OR: 2.9; p = 0.002) and prolonged hospitalization (OR: 3.5; p < 0.001). Conclusions: CRP, within the context of the EAES classification, presents as a valuable diagnostic marker to distinguish CAA from UAA, with a higher risk of postoperative complications and hospitalization. Leucocyte count showed low diagnostic value for the identification of CAA.
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Affiliation(s)
- Maximilian Dölling
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Mihailo Andric
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Mirhasan Rahimli
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Michael Klös
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Jonas Pachmann
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Jessica Stockheim
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Sara Al-Madhi
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Cora Wex
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
| | - Ulf D. Kahlert
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
- Molecular and Experimental Surgery, Department of General-, Visceral-, Vascular and Transplant Surgery, Faculty of Medicine and University Hospital Magdeburg, Otto-Von-Guericke University, 39120 Magdeburg, Germany
| | - Martin Herrmann
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany;
- Department of Internal Medicine 3—Rheumatology and Immunology, Uniklinikum Erlangen, Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Uniklinikum Erlangen, Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Aristotelis Perrakis
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
- Department of General, Minimally-Invasive Surgery and Surgical Oncology, Center for Hepatobiliary and Colorectal Surgery, Iatriko Medical Center, 15125 Athens, Greece
| | - Roland S. Croner
- University Clinic for General-, Visceral-, Vascular and Transplantation Surgery, Faculty of Medicine, Otto-Von-Guericke University, 39120 Magdeburg, Germany (U.D.K.); (A.P.); (R.S.C.)
- Molecular and Experimental Surgery, Department of General-, Visceral-, Vascular and Transplant Surgery, Faculty of Medicine and University Hospital Magdeburg, Otto-Von-Guericke University, 39120 Magdeburg, Germany
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Mohammadi Tofigh A, Samsami M, Haghbin Toutounchi A, Tavakoli S, Taabzadeh Z, Khoshnoudi H, Adinevand E. 5-Hydroxyindoleacetic acid as a biomarker for revealing perforation in acute appendicitis. BMC Gastroenterol 2024; 24:366. [PMID: 39402472 PMCID: PMC11472468 DOI: 10.1186/s12876-024-03451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 10/03/2024] [Indexed: 10/19/2024] Open
Abstract
BACKGROUND The present study investigated the level of 5-hydroxyindoleacetic acid (5-HIAA) in perforated and nonperforated appendicitis patients. This issue is important for timely diagnosis of acute appendicitis complications and making decision about the surgical plan and type of incision. METHODS This prospective study was conducted on patients with acute appendicitis. 5-HIAA levels were measured in urine spot sample of every patient before the surgery. The patients were finally included based on result of pathology for presence of appendicitis or not and sorted by direct surgical detection for exist of perforation or not. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 5-HIAA were investigated. The data were statistically analyzed by SPSS v.27. RESULTS A total of 150 patients were included in two groups as 40 patients in the perforated appendicitis group and 110 patients in the noncomplicated acute appendicitis group. The average age of patients in the perforated appendicitis group was 28.8 ± 6.07 years, and that of patients in the acute appendicitis group was 29.6 ± 6.96 years. 94 patients (63%) were male, and 56 (37%) were female. No significant difference was observed in terms of age or sex between the two groups. The difference in the 5-HIAA concentration between the acute appendicitis group (0.3 ± 0.04 mg/dl) and the perforated appendicitis group (0.5 ± 0.03 mg/dl) was significant (P < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 82%, 62%, 75%, 77%, and 88% respectively. CONCLUSION This study shows that the 5-HIAA concentration in patients with perforated appendicitis can potentially increased significantly more than that in patients in the early stages of acute appendicitis. further studies with larger sample sizes are needed to prove the present results.
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Affiliation(s)
- Arash Mohammadi Tofigh
- Department of General Surgery, Imam Hosein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Samsami
- Department of General Surgery, Imam Hosein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Haghbin Toutounchi
- Department of General Surgery, Imam Hosein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shervin Tavakoli
- Department of General Surgery, Guilan University of Medical Sciences, Rasht, Iran
| | - Zeinab Taabzadeh
- Department of Internal Medicine, Imam Hosein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hojatolah Khoshnoudi
- Department of General Surgery, Imam Hosein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ehsan Adinevand
- Department of General Surgery, Imam Hosein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Krishnan N, Pakkasjärvi N, Kainth D, Arredondo Montero J, Danielson J, Verma P, Verma A, Yadav DK, Anand S. Utility of thiol/disulphide homeostasis as a biomarker for acute appendicitis: a systematic review and meta-analysis. Pediatr Surg Int 2024; 40:152. [PMID: 38847871 DOI: 10.1007/s00383-024-05728-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/13/2024]
Abstract
The aim of this study was to analyze the role of thiol/disulfide homeostasis (TDH) parameters as an indicator of oxidative stress in acute appendicitis (AA). PubMed, EMBASE, Web of Science, and Scopus databases were systematically searched. Studies reporting on TDH in AA (both complicated and uncomplicated cases) were included. The comparator group were healthy controls. The TDH domain was compared between the groups using anti-oxidant parameters, namely native thiol and total thiol levels, and native thiol/total thiol ratio; and oxidant parameters, namely disulfide level, disulfide/native thiol ratio, and disulfide/total thiol ratio. The statistical analysis was performed using a random-effects model. The methodological quality of the studies was assessed utilizing the Newcastle-Ottawa scale. Eleven studies with a total of 926 subjects, comprising 457 patients with uncomplicated appendicitis, 147 with complicated appendicitis, and 322 healthy controls were included. Our study demonstrated significantly increased oxidative stress in AA as compared to healthy controls in all TDH parameters and significantly lower total thiol levels in complicated AA as compared to uncomplicated AA. Due to a poor methodological quality in five out of eleven studies, future prospective studies with adequate power are essential to validate these observations and refine the diagnostic approaches to AA.
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Affiliation(s)
- Nellai Krishnan
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi, 110029, Delhi, India
| | - Niklas Pakkasjärvi
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Deepika Kainth
- Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Johan Danielson
- Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Pulkit Verma
- Division of Biomedical Informatics, Indian Council of Medical Research, New Delhi, India
| | - Ajay Verma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi, 110029, Delhi, India
| | - Devendra Kumar Yadav
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi, 110029, Delhi, India
| | - Sachit Anand
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi, 110029, Delhi, India.
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Arredondo Montero J, Pérez Riveros BP, Bueso Asfura OE. Diagnostic performance of serum CA-125 for overall and complicated acute appendicitis: a systematic review and meta-analysis. Updates Surg 2024; 76:793-801. [PMID: 38637439 DOI: 10.1007/s13304-024-01842-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/27/2024] [Indexed: 04/20/2024]
Abstract
This study aimed to analyze the diagnostic performance of serum CA-125 in acute appendicitis (AA). This review was registered in PROSPERO (CRD42023450988). We included prospective and retrospective original clinical studies evaluating the diagnostic performance of serum CA-125 in AA. A search was conducted in PubMed, Web of Science, Scopus, and OVID. Search terms and keywords were: (appendicitis OR appendectomy) AND (CA-125 OR CA125). Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS-2 index. A synthesis of the results, standardization of the metrics, and three random-effect meta-analyses were performed. Five studies with data from 533 participants (including 219 patients with a confirmed diagnosis of AA and 107 controls) were included in this review. The random-effect meta-analysis of serum CA-125 (AA vs controls) included 3 articles (125 AA and 70 controls) and resulted in a non-significant mean difference [95% CI] of - 6.80 [- 20.51, 6.92] U/mL (p = 0.33). The meta-analysis by subgroups that included only male patients resulted in a significant mean difference [95% CI] of 3.48 [0.46, 6.49] U/mL (p = 0.02). Although serum CA-125 does not appear to be a good overall marker for the diagnosis of AA, our subgroup analyses show that this marker could be useful for diagnosing AA in males. It also appears to be a potentially useful tool for discriminating complicated and uncomplicated AA. However, the limited number of included studies precludes drawing generalizable conclusions. Future prospective studies focused on males and in its potential ability to discriminate between complicated and uncomplicated AA are required.Registration. PROSPERO (CRD42023450988).
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Affiliation(s)
- Javier Arredondo Montero
- Pediatric Surgery Department, Complejo Asistencial Universitario de León, C/Altos de Nava s/n, 24008, León, Castilla y León, Spain.
- School of Medicine, University of Navarra, Pamplona, Navarra, Spain.
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Pacilli M, Kamaleswaran R. New Genetic Biomarkers to Diagnose Pediatric Appendicitis. JAMA Pediatr 2024; 178:341-342. [PMID: 38372987 DOI: 10.1001/jamapediatrics.2023.6731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Affiliation(s)
- Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta
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Marcinkevičs R, Reis Wolfertstetter P, Klimiene U, Chin-Cheong K, Paschke A, Zerres J, Denzinger M, Niederberger D, Wellmann S, Ozkan E, Knorr C, Vogt JE. Interpretable and intervenable ultrasonography-based machine learning models for pediatric appendicitis. Med Image Anal 2024; 91:103042. [PMID: 38000257 DOI: 10.1016/j.media.2023.103042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 11/10/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023]
Abstract
Appendicitis is among the most frequent reasons for pediatric abdominal surgeries. Previous decision support systems for appendicitis have focused on clinical, laboratory, scoring, and computed tomography data and have ignored abdominal ultrasound, despite its noninvasive nature and widespread availability. In this work, we present interpretable machine learning models for predicting the diagnosis, management and severity of suspected appendicitis using ultrasound images. Our approach utilizes concept bottleneck models (CBM) that facilitate interpretation and interaction with high-level concepts understandable to clinicians. Furthermore, we extend CBMs to prediction problems with multiple views and incomplete concept sets. Our models were trained on a dataset comprising 579 pediatric patients with 1709 ultrasound images accompanied by clinical and laboratory data. Results show that our proposed method enables clinicians to utilize a human-understandable and intervenable predictive model without compromising performance or requiring time-consuming image annotation when deployed. For predicting the diagnosis, the extended multiview CBM attained an AUROC of 0.80 and an AUPR of 0.92, performing comparably to similar black-box neural networks trained and tested on the same dataset.
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Affiliation(s)
- Ričards Marcinkevičs
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, Zürich, 8092, Switzerland.
| | - Patricia Reis Wolfertstetter
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Steinmetzstrasse 1-3, Regensburg, 93049, Germany; Faculty of Medicine, University of Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany.
| | - Ugne Klimiene
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, Zürich, 8092, Switzerland
| | - Kieran Chin-Cheong
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, Zürich, 8092, Switzerland
| | - Alyssia Paschke
- Faculty of Medicine, University of Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany
| | - Julia Zerres
- Faculty of Medicine, University of Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany
| | - Markus Denzinger
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Steinmetzstrasse 1-3, Regensburg, 93049, Germany; Faculty of Medicine, University of Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany
| | - David Niederberger
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, Zürich, 8092, Switzerland
| | - Sven Wellmann
- Faculty of Medicine, University of Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany; Division of Neonatology, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Steinmetzstrasse 1-3, Regensburg, 93049, Germany
| | - Ece Ozkan
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 43 Vassar Street, Cambridge, 02139, USA
| | - Christian Knorr
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Steinmetzstrasse 1-3, Regensburg, 93049, Germany
| | - Julia E Vogt
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, Zürich, 8092, Switzerland.
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Tian BWCA, Agnoletti V, Ansaloni L, Coccolini F, Bravi F, Sartelli M, Vallicelli C, Catena F. Management of Intra-Abdominal Infections: The Role of Procalcitonin. Antibiotics (Basel) 2023; 12:1406. [PMID: 37760703 PMCID: PMC10525176 DOI: 10.3390/antibiotics12091406] [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] [Received: 08/01/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.
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Affiliation(s)
- Brian W. C. A. Tian
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore;
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, M. Bufalini Hospital, 47521 Cesena, Italy
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, 27100 Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, 56126 Pisa, Italy
| | | | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Carlo Vallicelli
- Department of Emergency and Trauma Surgery, M. Bufalini Hospital, 47521 Cesena, Italy
| | - Fausto Catena
- Department of Surgery, “Maurizio Bufalini” Hospital, 47521 Cesena, Italy
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Ghali MS, Hasan S, Al-Yahri O, Mansor S, Al-Tarakji M, Obaid M, Shah AA, Shehata MS, Singh R, Al-Zoubi RM, Zarour A. Adult appendicitis score versus Alvarado score: A comparative study in the diagnosis of acute appendicitis. Surg Open Sci 2023; 14:96-102. [PMID: 37577253 PMCID: PMC10413131 DOI: 10.1016/j.sopen.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/20/2023] [Accepted: 07/16/2023] [Indexed: 08/15/2023] Open
Abstract
Background Acute Appendicitis (AA) is the most common abdominal surgical emergency. It requires proper management to decrease mortality and morbidity. Clinical scoring systems for diagnosing AA aimed to decrease the use of radiological scans and the rate of negative appendectomies (NA). We aim to assess the adult appendicitis score (AAS) in the diagnosis prediction of AA. Method A retrospective study with 1303 cases of AA is performed. We compared the correlation of AAS and Alvarado scores to postoperative histopathology. Specificity, sensitivity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were assessed. ROC was used. Results AAS risk stratification was applied to the study population. Group I for a low probability, and groups II and III for an intermediate and high probability of AA. We found that 159 patients were matched in group I, 505, and 639 were in groups II and III of AAS, respectively. The correlation between Alvarado and AAS with HP was significant. AAS ≥ 16 presented sensitivity and specificity of 50 % and 75.47 %, respectively, with PPV of 97.96 % and NPV of 6.02 %, with an accuracy of 51.04 %. Regarding AAS ≥ 11, the sensitivity was 88.96 %, specificity was 39.62 %, PPV was 97.2 %, NPV was 13.21 %, and accuracy was 86.95 %. Conclusion AAS is relatively more accurate than Alvarado's score, especially in selecting a safe candidate for discharge from an emergency. In addition, AAS is found to decrease the need for radiological images and NA rate more than Alvarado.
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Affiliation(s)
- Mohamed Said Ghali
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of General Surgery, Ain Shams University, Cairo, Egypt
| | - Samer Hasan
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Omer Al-Yahri
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Salah Mansor
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohannad Al-Tarakji
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Munzir Obaid
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Amjad Ali Shah
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mona S. Shehata
- Department of Pharmacy, Women's Wellness and Research center, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Raed M. Al-Zoubi
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of Chemistry, Jordan University of Science and Technology, P.O.Box 3030, Irbid 22110, Jordan
- Department of Biomedical Sciences, QU-Health, College of Health Sciences, Qatar University, Doha 2713, Qatar
| | - Ahmad Zarour
- Department of Surgery, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell medical college, Doha, Qatar
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Sobczak J, Burzyńska M, Sikora A, Wysocka A, Karawani J, Sikora JP. Post-Traumatic Stress Response and Appendicitis in Children-Clinical Usefulness of Selected Biomarkers. Biomedicines 2023; 11:1880. [PMID: 37509519 PMCID: PMC10377452 DOI: 10.3390/biomedicines11071880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
Acute appendicitis is an inflammatory process which is one of the most frequent global causes of surgical interventions in children. The goal of the study was to determine whether acute phase proteins, that is, C-reactive protein (CRP), procalcitonin (PCT) and neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL-6), transforming growth factor-beta1 (TGF-β1) and cortisol (HC) play a role in the pathomechanism of post-trauma stress response of the organism and to establish the impact of the applied surgical procedure and/or of inflammation on their concentrations. An additional purpose was to establish the clinical usefulness of the studied biomarkers in the diagnostics of appendicitis. CRP concentrations were quantified via the immunoturbidimetric method, while the levels of IL-6 and PCT were assessed using a bead-based multiplexed immunoassay system in a microplate format (Luminex xMAP technology); NGAL, TGF-β1 and cortisol concentrations were determined via the enzyme-linked immunosorbent assay (ELISA) technique. All the investigated biomarkers were assayed twice, i.e., immediately before the surgery and 12-24 h after its completion. Significant increases in CRP, IL-6 and PCT concentrations were found in all children subjected to laparoscopic surgeries (p = 0.001, p = 0.006, and p = 0.009, respectively) and open (classic) surgeries (p = 0.001, p = 0.016, and p = 0.044, respectively) compared to the initial concentrations. The patients undergoing classical surgery moreover presented with significant (p = 0.002, and p = 0.022, respectively) increases in NGAL and TGF-β1 levels after the procedures. In a group of children undergoing laparoscopic surgery, the appendicitis induced an increase in cortisol concentration, whereas in patients undergoing classical surgery the increase in the levels of this biomarker was caused by the type of performed surgical procedure. Simultaneously assaying the levels of CRP, NGAL and IL-6 (p = 0.008, p = 0.022, and p = 0.000, respectively) may prove useful in clinical practice, enabling the diagnosis of appendicitis in paediatric patients reporting to a hospital with abdominal pains, in addition to data from anamnesis and from clinical or ultrasound examination. The performed study confirms the participation of examined biomarkers in the pathomechanism of post-injury stress reaction of the organism to surgical trauma.
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Affiliation(s)
- Jarosław Sobczak
- Department of Paediatric Emergency Medicine, 2nd Chair of Paediatrics, Central Clinical Hospital, Medical University of Łódź, ul. Sporna 36/50, 91-738 Łódź, Poland
- Department of Management and Logistics in Healthcare, Medical University of Łódź, ul. Lindleya 6, 90-131 Łódź, Poland
| | - Monika Burzyńska
- Department of Epidemiology and Biostatistics, Chair of Social and Preventive Medicine, Medical University of Łódź, ul. Żeligowskiego 7/9, 90-752 Łódź, Poland
| | - Anna Sikora
- Department of Intensive Care and Anaesthesiology, 2nd Chair of Paediatrics, Central Clinical Hospital, Medical University of Łódź, ul. Sporna 36/50, 91-738 Łódź, Poland
| | - Anna Wysocka
- Department of Paediatric Surgery and Oncology, Chair of Surgical Paediatrics, Central Clinical Hospital, Medical University of Łódź, ul. Sporna 36/50, 91-738 Łódź, Poland
| | - Jakub Karawani
- Faculty of Medicine, Lazarski University, ul. Świeradowska 43, 02-662 Warsaw, Poland
| | - Janusz P Sikora
- Department of Paediatric Emergency Medicine, 2nd Chair of Paediatrics, Central Clinical Hospital, Medical University of Łódź, ul. Sporna 36/50, 91-738 Łódź, Poland
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Mekrugsakit N, Tullavardhana T. The Value of Complete Blood Count Parameters in Predicting Complicated Acute Appendicitis; a Prognostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e42. [PMID: 37609538 PMCID: PMC10440749 DOI: 10.22037/aaem.v11i1.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Introduction Low accuracy of clinical variables can result in delayed diagnosis and increase the incidence of complicated appendicitis in some cases. This study aimed to determine the value of simple complete blood count (CBC) biomarkers in predicting complicated appendicitis. Methods This is a single-center retrospective cross-sectional study, which was conducted on cases referred to emergency department following acute appendicitis who underwent appendectomy, to evaluate the accuracy of some cell blood count variables (white blood cell count (WBC), neutrophil percent, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV)) in predicting complicated cases (gangrenous and ruptured appendicitis). Results There were 252 (68.3%) patients in the uncomplicated appendicitis group and 117 (31.7%) patients in the complicated appendicitis group. The mean age of patients was 34.1 ± 1.09 (Range: 18 -79) years (55.3% male). There were no differences between groups regarding the mean age (p = 0.053), gender distribution (p=0.07), Alvarado score (p = 0.055), platelet count (p =0.204), PLR (p = 0.115), and MPV (p = 0.205). The complicated appendicitis cases had longer onset of symptoms (p <0.001), higher WBC count (p = 0.011), higher neutrophil count (p < 0.001), and higher NLR (p < 0.001). Neutrophil count (area under the curve (AUC) = 0.61, 95% confidence interval (CI) = 0.56-0.66; p = 0.001) and NLR (AUC = 0.65, 95% CI = 0.60-0.69; p = 0.001) had higher level of accuracy in this regard. In contrast, the area under the curve of WBC count (AUC = 0.57, 95% CI = 0.52-0.63; p = 0.22), platelet count (AUC = 0.44, 95% CI = 0.38-0.49; p = 0.049), PLR (AUC = 0.57, 95% CI = 0.52-0.62; p = 0.026), and MPV (AUC = 0.54, 95% CI = 0.49-0.60; p = 0.193) showed low accuracy in predicting complicated acute appendicitis. Conclusion Based on the findings of present study it seems that WBC, neutrophil percent, NLR, PLR, and MPV have failed to poor accuracy in predicting cases with complicated appendicitis in emergency department.
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Affiliation(s)
- Natchanok Mekrugsakit
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak Nakhon-nayok, Thailand
| | - Thawatchai Tullavardhana
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak Nakhon-nayok, Thailand
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12
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Zülfikaroğlu B, Akkurt G, Akın M, İşman FK, Yastı AÇ, Özmen MM. Role of serum levels of tumour necrosis factor-like weak inducer of apoptosis (TWEAK) in predicting severity of acute appendicitis. Turk J Surg 2023; 39:121-127. [PMID: 38026909 PMCID: PMC10681112 DOI: 10.47717/turkjsurg.2023.5747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 03/23/2023] [Indexed: 12/01/2023]
Abstract
Objectives One of the most prevalent abdominal crises is acute appendicitis (AA). Clinical diagnosis, even for skilled surgeons, is frequently challenging, as indicated by the high proportion of negative investigations. The purpose of this study was to see if serum TWEAK levels might be used to diagnose acute appendicitis. Material and Methods Between June 2017 and May 2019, all patients who had surgery with the original diagnosis of AA were included in the study. TWEAK, WBC, CRP, and bilirubin levels were compared. Results The levels of WBC, CRP, and bilirubin were compared to pathology. All three blood indicators increased significantly in AA patients. However, no statistically significant difference in the levels of all three blood indicators was seen between individuals with simple AA and those with severe AA. TWEAK plasma concentrations were considerably greater in patients with severe AA than in the healthy control and NAA groups. TWEAK levels were significantly greater in individuals with severe AA compared to patients with simple AA. Conclusion Serum TWEAK levels that are elevated may be used to diagnose acute appendicitis as well as prognostic indicators for the severity of appendicitis.
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Affiliation(s)
- Barış Zülfikaroğlu
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Gökhan Akkurt
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Merve Akın
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Ferruh Kemal İşman
- Clinic of Clinical Chemistry, Göztepe Training and Research Hospital, İstanbul, Türkiye
| | - Ahmet Çınar Yastı
- Clinic of General Surgery, Ankara Numune Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Mahir Özmen
- Department of Surgery, İstinye University Faculty of Medicine, İstanbul, Türkiye
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Sikander B, Rosenberg J, Fonnes S. Individual biomarkers in the blood are not yet applicable in diagnosing complicated appendicitis: A scoping review. Am J Emerg Med 2023; 67:100-107. [PMID: 36842426 DOI: 10.1016/j.ajem.2023.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Appendicitis is one of the most common surgical emergencies globally and it can both be difficult to diagnose but also to differentiate complicated from uncomplicated appendicitis preoperatively. The objective of this scoping review was to develop an overview of biomarkers in blood discriminating complicated from uncomplicated appendicitis and characterize their applicability in an acute setting including time, cost, and analysis technique required as well as their individual precision. METHOD This scoping review was reported in accordance with PRISMA-ScR. The included studies had to report on biomarkers measured in the blood for at least ten patients with suspected appendicitis. A systematic literature search was conducted on August 28, 2022, in PubMed and Embase but restricted to articles published in January 2000 and onwards. A protocol was uploaded to Open Science Framework prior to data extraction. RESULTS A total of 65 biomarkers were included from 52 studies, covering 14,312 patients. There was 60% routine- and 40% novel biomarkers based on the reported analysis technique. The most frequently investigated biomarkers within each group were white blood cell count and procalcitonin. The routine biomarkers were of low financial cost but poor diagnostic accuracy with sensitivity ranging between 15 and 100% and specificity between 27 and 100%. Novel markers were costly ranging from 275 to 800$, and their diagnostic accuracy was based on limited population sizes (median 34 patients) and reported for only 5% of the novel markers. CONCLUSION Routine biomarkers were applicable in an acute setting but had poor diagnostic accuracy. Novel biomarkers are being investigated for potential, but the concept is still premature due to lack of diagnostic accuracy studies reporting cost-benefit for individual markers and whether they can be applied in an acute setting.
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Affiliation(s)
- Binyamin Sikander
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark.
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark
| | - Siv Fonnes
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark
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Gürünlüoglu K, Zararsiz G, Aslan M, Akbas S, Tekin M, Gürünlüoglu S, Bag HG, Cin ES, Macit B, Demircan M. Investigation of Serum Interleukin 6, High-Sensitivity C-Reactive Protein and White Blood Cell Levels during the Diagnosis and Treatment of Paediatric Appendicitis Patients Before and during the COVID-19 Pandemic. Afr J Paediatr Surg 2023; 20:130-137. [PMID: 36960509 DOI: 10.4103/ajps.ajps_128_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction In this study, we prospectively investigated changes in serum interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP) and full white blood cell (WBC) counts during the diagnosis and treatment of paediatric patients with appendicitis. We also investigated the effects of the COVID-19 pandemic on the diagnosis and treatment processes of paediatric appendicitis patients. Materials and Methods A non-perforated appendicitis group (n = 110), a perforated appendicitis group (n = 35) and an appendicitis + COVID-19 group (n = 8) were formed. Blood samples were taken upon admission and every day until the three studied parameters returned to normal values. To investigate the effects of the COVID-19 pandemic on paediatric appendicitis patients, the perforated appendicitis rates and the times from the onset of the first symptoms to the operation before and during the pandemic were compared. Results WBC, IL-6, and hsCRP dropped below the upper limits on the second postoperative day in the non-perforated appendicitis group, four to six days postoperatively in the perforated appendicitis group, and three to six days postoperatively in the appendicitis + COVID-19 group. These parameters were not within normal range in patients who developed complications during follow-up. The time from the onset of abdominal pain to the surgery was significantly longer during than before the pandemic in both the non-perforated appendicitis group and the perforated appendicitis group. Conclusions Our results show that WBC, IL-6, and hsCRP are useful laboratory parameters that can complete clinical examinations in the diagnosis of appendicitis in paediatric patients and the identification of complications that may develop postoperatively.
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Affiliation(s)
- Kubilay Gürünlüoglu
- Department of Paediatric Surgery, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Gökmen Zararsiz
- Department of Bioistatistics, Faculty of Medicine, Erciyes University, Kayseri, Turkiye
| | - Mehmet Aslan
- Department of Paediatrics, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Sedat Akbas
- Department of Anaesthesiology, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Mehmet Tekin
- Department of Paediatrics, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Semra Gürünlüoglu
- Department of Pathology, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Harika Gözükara Bag
- Department of Biostatics and Medical Informatics, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Ecem Serbest Cin
- Department of Paediatric Surgery, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Bengü Macit
- Department of Paediatrics, Faculty of Medicine, Inonu University, Malatya, Turkiye
| | - Mehmet Demircan
- Department of Paediatric Surgery, Faculty of Medicine, Inonu University, Malatya, Turkiye
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Afzal Z, Bukhari I, Kumar S, Deeknah A, Lei W, Mitrasinovic S, Chan O, Francis FE, Satheesan KS. Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Cohort Study. Cureus 2023; 15:e37193. [PMID: 37159762 PMCID: PMC10163560 DOI: 10.7759/cureus.37193] [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: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND During the coronavirus disease 2019 (COVID-19) pandemic, the management of acute appendicitis shifted towards non-operative management in the United Kingdom (UK). The open approach was recommended over the laparoscopic approach due to the risk of aerosol generation and subsequent contamination. The aim of this study was to compare the overall management and surgical outcomes of the patients treated for acute appendicitis before and during the COVID-19 pandemic. MATERIALS AND METHODS We performed a retrospective cohort study at a single district general hospital in the UK. We compared the management and outcome of the patients diagnosed with acute appendicitis before the pandemic, from March to August 2019, and during the pandemic, from March to August 2020. We looked at the patient demographics, methods of diagnosis, management, and surgical outcomes for these patients. The primary outcome of the study was the 30-day readmission rate. Secondary outcomes included length of stay and post-operative complications. RESULTS Over the period of six months, a total of 179 patients were diagnosed with acute appendicitis in 2019 (Pre-COVID-19 pandemic, from March 1, 2019, to August 31, 2019) versus 152 in 2020 (during the COVID-19 pandemic, from March 1, 2020, to August 31, 2020). For the 2019 cohort, the mean age of the patients was 33 (range 6-86 years), 52% (n=93) were female, and the mean BMI was 26 (range 14-58). For the 2020 cohort, the mean age was 37 (range 4-93 years), 48% (n=73) of the patients were female, and the mean BMI was 27 (range 16-53). At the first presentation, in 2019, 97.2% of the patients (174 out of 179) received surgical treatment compared to 70.4% (107 out of 152) in 2020. Three per cent of the patients (n=5) were managed conservatively in 2019 (two out these failed conservative management) as compared to 29.6% (n=45) in 2020 (21 of these failed conservative management). Pre-pandemic, only 32.4% (n= 57, ultrasound (US) scan: 11, computer tomography (CT) scan): 45, both US and CT: 1) of the patients received imaging to confirm the diagnosis as compared to 53.3% during pandemic (n=81, US scan: 12, CT scan: 63, both US and CT: 6). Overall, the CT to US ratio increased. We found that during 2019, 91.5% (n=161/176) of the patients who received surgical treatment went through laparoscopic surgery as compared to only 74.2% (n=95/128) in 2020 (p<0.0001). Postoperative complications occurred in 5.1% (n=9/176) of the surgical patients in 2019 as compared to 12.5% (n=16/128) in 2020 (p<0.033). The mean length of hospital stay in 2019 was 2.9 days (range 1-11) versus 4.5 days in 2020 (range 1-57) (p<0.0001). The 30-day readmission rate was 4.5% (8/179) versus 19.1% (29/152) (p<0.0001). The 90-day mortality rate was zero for both cohorts. CONCLUSION Our study shows that the management of acute appendicitis changed due to the COVID-19 pandemic. More patients went through imaging, especially CT scans for diagnosis and received non-operative management with antibiotics only. The open surgical approach became more common during the pandemic. This was associated with longer lengths of hospital stay, more readmissions, and an increase in postoperative complications.
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Affiliation(s)
- Zeeshan Afzal
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS (National Health Service) Foundation Trust, Cambridge, GBR
- Department of Surgery, Peterborough City Hospital, Peterborough, GBR
| | - Ishtiyaq Bukhari
- Department of Surgery, Peterborough City Hospital, Peterborough, GBR
| | - Sumit Kumar
- Department of Surgery, Peterborough City Hospital, Peterborough, GBR
| | | | - Winnie Lei
- Department of Surgery, University of Cambridge, Cambridge, GBR
- Milner Therapeutics Institute, University of Cambridge, Cambridge, GBR
| | | | - Onton Chan
- Department of Surgery, Peterborough City Hospital, Peterborough, GBR
| | | | - Kanagasingham S Satheesan
- Department of Surgery, Peterborough City Hospital, Peterborough, GBR
- Leicester Medical School, University of Leicester, Leicester, GBR
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Tintor G, Jukić M, Šupe-Domić D, Jerončić A, Pogorelić Z. Diagnostic Utility of Serum Leucine-Rich α-2-Glycoprotein 1 for Acute Appendicitis in Children. J Clin Med 2023; 12:2455. [PMID: 37048540 PMCID: PMC10094962 DOI: 10.3390/jcm12072455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
PURPOSE The aim of this study is to assess the diagnostic utility of serum leucine-rich α-2-glycoprotein 1 (LRG1) in pediatric patients with acute abdominal pain, admitted to the emergency surgical unit, in order to make a prompt and accurate diagnosis of acute appendicitis. PATIENTS AND METHODS Pediatric patients older than 5 years of age who presented to the emergency department from 15 October 2021 to 30 June 2022 with acute abdominal pain and suspected acute appendicitis were prospectively recruited in the study. Demographic and clinical data, as well as operative and postoperative data, were recorded. A total of 92 patients were equally distributed into two groups: children with acute appendicitis who underwent laparoscopic appendectomy and non-appendicitis patients, presenting with non-specific abdominal pain. LRG1 levels were determined using a commercially available LRG1 enzyme-linked immunosorbent assay (ELISA) kit. Serum LRG1 levels, as well as other inflammatory markers (white blood cell count (WBC), C-reactive protein (CRP) and absolute neutrophil count) were compared between groups. RESULTS The median level of LRG1 in serum was significantly higher in the group of children with pathohistologically confirmed acute appendicitis than in the control group, at 350.3 µg/mL (interquartile range (IQR) 165.2-560.3) and 25.7 µg/mL (IQR 14.7-36.8) (p < 0.001), respectively. Receiver operating characteristic area under the curve for LRG1 from serum was 1.0 (95% CI 0.96-1.00; p < 0.001) and the value of >69.1 µg/mL was found to perfectly separate acute appendicitis cases from controls. Additionally, as expected, each of the examined laboratory inflammatory markers provided a significantly higher values in the acute appendicitis group compared to the control group: WBC 14.6 × 109/L (IQR 12.7, 18.7) vs. 7.0 × 109/L (IQR 5.4, 9.0) (p < 0.001), CRP 16.3 mg/dL (IQR 6.9, 50.4) vs. 2.2 mg/dL (IQR 2, 2) (p < 0.001) and absolute neutrophil count 84.6% (IQR 79.5, 89.0) vs. 59.5% (IQR 51.5, 68.6) (p < 0.001). CONCLUSIONS LRG1 in the serum was found to be a promising novel biomarker, with excellent differentiation of acute appendicitis from non-appendicitis cases in children presenting with non-specific abdominal pain.
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Affiliation(s)
- Goran Tintor
- Department of Plastic Reconstructive and Aesthetic Surgery, University Hospital of Split, 21000 Split, Croatia;
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia;
| | - Miro Jukić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia;
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Daniela Šupe-Domić
- Department of Medical Laboratory Diagnostics, University Hospital of Split, 21000 Split, Croatia;
- Department of Health Studies, University of Split, 21000 Split, Croatia
| | - Ana Jerončić
- Department of Research in Biomedicine and Health, School of Medicine, University of Split, 21000 Split, Croatia;
| | - Zenon Pogorelić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia;
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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Applicability of American College of Radiology Appropriateness Criteria Decision-Making Model for Acute Appendicitis Diagnosis in Children. Diagnostics (Basel) 2022; 12:diagnostics12122915. [PMID: 36552924 PMCID: PMC9776694 DOI: 10.3390/diagnostics12122915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/13/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Acute appendicitis is one of the most common causes of abdominal pain in the emergency department and the most common surgical emergency reason for children younger than 15 years of age, which could be enormously dangerous when ruptured. The choice of radiological approach is very important for the diagnosis. In this way, unnecessary surgery is avoided. The aim of this study was to examine the validity of the American College of Radiology appropriateness criteria for radiological imaging in diagnosing acute appendicitis with multivariate decision criteria. In our study, pediatric patients who presented to the emergency department with abdominal pain were grouped according to the Appendicitis Inflammatory Response (AIR) score and the choice of radiological examinations was evaluated with fuzzy-based Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE) and with the fuzzy-based Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) model for the validation of the results. As a result of this study, non-contrast computed tomography (CT) was recommended as the first choice for patients with low AIR score (where Φnet=0.0733) and with high AIR scores (where Φnet=0.0702) while ultrasound (US) examination was ranked third in patients with high scores. While computed tomography is at the forefront with many criteria used in the study, it is still a remarkable practice that US examination is in the first place in daily routine. Even though there are studies showing the strengths of these tools, this study is unique in that it provides analytical ranking results for this complex decision-making issue and shows the strengths and weaknesses of each alternative for different scenarios, even considering vague information for the acute appendicitis diagnosis in children for different scenarios.
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Fawkner-Corbett D, Hayward G, Alkhmees M, Van Den Bruel A, Ordóñez-Mena JM, Holtman GA. Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis. BMJ Open 2022; 12:e056854. [PMID: 36328382 PMCID: PMC9639107 DOI: 10.1136/bmjopen-2021-056854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. DESIGN A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. RESULTS 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). CONCLUSIONS The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO REGISTRATION NUMBER CRD42017080036.
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Affiliation(s)
- David Fawkner-Corbett
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Academic Paediatric Surgery Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Gail Hayward
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Mohammed Alkhmees
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ann Van Den Bruel
- EPI-Centre, Academic Centre for Primary Care, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Jose M Ordóñez-Mena
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Gea A Holtman
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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20
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Çocuklarda Akut Apandisit Tanısında Yeni Bir Belirteç Olarak Sistemik İmmün-İnflamasyon İndeksin Değerlendirilmesi. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1106843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim: The aim of this study was to determine the usefulness of systemic immune-inflammation index (SII) in the diagnosis of acute appendicitis (AA) in children
Material and Method: This study was done retrospectively, and two groups were formed as AA and control group. AA group was divided into two subgroups as nonperforated appendicitis and perforated appendicitis. The groups were compared for age, sex, WBC, neutrophil, lymphocyte and platelet count, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), C-reactive protein (CRP).
Results: The study included a total of 162 children. There were 81 children in the AA group and 81 in the control group. Of 81 patients included in the AA group, 31 were girls (38.3%) and 50 were boys (61.7%), and the median age of the patients was 11 (5) years. When the AA group and the control group were compared in terms of laboratory values. It was found that WBC count, neutrophil count, platelet count, NLR, PLR and SII in the AA group were significantly higher and lymphocyte count was significantly lower (p
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21
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Richards CB, Pendower LK, Kotecha PD, Elmqvist K, Chinaka FN, Tomasi I. Identifying Recurrence Risk Factors in CT-Confirmed Acute Appendicitis in Adults Managed Non-operatively During the COVID-19 Pandemic. Cureus 2022; 14:e28794. [PMID: 36225457 PMCID: PMC9533956 DOI: 10.7759/cureus.28794] [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] [Accepted: 09/05/2022] [Indexed: 12/04/2022] Open
Abstract
Background/Objective: Acute appendicitis (AA) is predominantly managed with appendectomy, but can be treated non-operatively, leading to a high risk of recurrence. Non-operative management has been more common since the COVID-19 pandemic affected the feasibility of performing surgery. This case-control study analyzed non-operatively managed patients in order to identify clinical and radiological factors associated with recurrence risk. Methods: Over 12 months, 48 adults with CT-proven AA managed non-operatively were identified, and followed up for at least six further months to assess them for recurrence (readmission to hospital more than 14 days after discharge and after symptom resolution, requiring treatment for appendicitis). Clinical and CT data were collected and a Cox regression survival analysis was performed to produce hazards ratios (HRs). Results: Of the 48 patients, 12 (25%) experienced a recurrence up until the end of the follow-up period, eight of whom were then treated operatively, and four treated non-operatively. On the univariate analysis, greater recurrence risk was observed in patients with diabetes mellitus, higher heart rate (on admission and maximum value during admission), lower white cell count and neutrophils and appendiceal wall thinning on CT. On the multivariate analysis, diabetes mellitus (HR=7.72, p=0.021) and higher heart rate (HR=1.08, p=0.018) were associated with statistically significant greater recurrence risk. Conclusions: Diabetes mellitus and higher heart rate on admission are associated with greater recurrence risk of AA managed non-operatively. No CT findings were associated with statistically significant greater risk. Clinicians should, therefore, consider DM and heart rate when making decisions on appendicitis management, especially during the COVID-19 pandemic but also beyond it.
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22
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The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults. Diagnostics (Basel) 2022; 12:diagnostics12071724. [PMID: 35885627 PMCID: PMC9322371 DOI: 10.3390/diagnostics12071724] [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: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: How to best define, diagnose and differentiate uncomplicated from complicated acute appendicitis remains debated. Hence, the aim of this review was to present an overview of the current knowledge and emerging field of acute appendicitis with a focus on the diagnostic differentiation of severity currently subject to ongoing investigations. (2) Methods: We conducted a PubMed search using the MeSH terms “appendicitis AND severity” and “appendicitis AND classification”, with a focus on studies calling appendicitis as ‘uncomplicated’ or ‘complicated’. An emphasis on the last 5 years was stressed, with further studies selected for their contribution to the theme. Further studies were retrieved from identified full-text articles and included per the authors’ discretion. (3) Results: The assumption that appendicitis invariably will proceed to perforation has been outdated. Both uncomplicated and complicated appendicitis exist with likely different pathophysiology. Hence, this makes it important to differentiate disease severity. Clinicians must diagnose appendicitis, but, in the next step, also differentiate between uncomplicated and complicated appendicitis in order to allow for management decisions. Diagnostic accuracy without supportive imaging is around 75–80% and, based on clinical judgement and blood tests alone, the negative appendectomy rate has been described as high as 36%. More research is needed on available biomarkers, and the routine use of imaging still remains debated. Scoring systems have the potential to improve diagnostic accuracy, but no scoring system has yet been validated for differentiating disease severity. Currently, no universally agreed definition exists on what constitutes a complicated appendicitis. (4) Conclusions: Uncomplicated and complicated appendicitis appear to have different pathophysiology and should be treated differently. The differentiation between uncomplicated and complicated appendicitis remains a diagnostic challenge.
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Binboga S, Isiksacan N, Binboga E, Kasapoglu P, Surek A, Karabulut M. Diagnostic Value of Serum Cytokines in Predicting a Complicated Acute Appendicitis. AN ACAD BRAS CIENC 2022; 94:e20201947. [PMID: 35507979 DOI: 10.1590/0001-3765202220201947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/27/2021] [Indexed: 11/22/2022] Open
Abstract
The diagnostic role of serum cytokines depends on the etiology and pathogenesis of acute appendicitis but the clinical significance of these cytokines in the differential diagnosis of complicated acute appendicitis remains unclear. To investigate the prediction of progression and diagnostic values of interleukin-6, interleukin-1 beta, and tumor necrosis factor-alpha in complicated acute appendicitis. This study was conducted in 100 patients with a definitive diagnosis of acute appendicitis and 20 individuals assigned for the control group. Venous blood was collected to assess biochemical tests, as well as interleukin-6, interleukin-1β, and tumor necrosis factor-α levels. Serum levels of all parameters were dramatically higher in the complicated group compared with uncomplicated. Duration of hospitalization, rates of postoperative infection, intraabdominal abscess, and re-hospitalization were higher in complicated group. Cut-off points of WBC, CRP, NLR, interleukin-6, interleukin-1β and tumor necrosis factor-α were 13.5x103/µL, 1.92 mg/dL, 6.09, 23.4 pg/mL, 5.6 pg/mL and 24 pg/mL (p=0.0014, p<0.001, p=0.009, respectively and p<0.001 for the rest). AUC of interleukin-6 was larger than AUCs of all other parameters, suggesting the highest predicting power of interleukin-6 among other parameters. Serum interleukin-6, interleukin-1β, and tumor necrosis factor-α levels are valuable diagnostic parameters to predict a complicated acute appendicitis.
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Affiliation(s)
- Sinan Binboga
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Zuhuratbaba Neighborhood, Tevfik Saglam Road, Number 11, 34147, Bakirkoy, Istanbul, Turkey
| | - Nilgun Isiksacan
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Biochemistry, Zuhuratbaba Neighborhood, Tevfik Saglam Road, Number 11, 34147, Bakirkoy, Istanbul, Turkey
| | - Elif Binboga
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Intensive Care Unit, Zuhuratbaba Neighborhood, Tevfik Saglam Road, Number 11, 34147, Bakirkoy, Istanbul, Turkey
| | - Pinar Kasapoglu
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Biochemistry, Zuhuratbaba Neighborhood, Tevfik Saglam Road, Number 11, 34147, Bakirkoy, Istanbul, Turkey
| | - Ahmet Surek
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Zuhuratbaba Neighborhood, Tevfik Saglam Road, Number 11, 34147, Bakirkoy, Istanbul, Turkey
| | - Mehmet Karabulut
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Zuhuratbaba Neighborhood, Tevfik Saglam Road, Number 11, 34147, Bakirkoy, Istanbul, Turkey
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Xia J, Wang Z, Yang D, Li R, Liang G, Chen H, Heidari AA, Turabieh H, Mafarja M, Pan Z. Performance optimization of support vector machine with oppositional grasshopper optimization for acute appendicitis diagnosis. Comput Biol Med 2022; 143:105206. [PMID: 35101730 DOI: 10.1016/j.compbiomed.2021.105206] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/27/2021] [Accepted: 12/30/2021] [Indexed: 12/13/2022]
Abstract
Preoperative differentiation of complicated and uncomplicated appendicitis is challenging. The research goal was to construct a new intelligent diagnostic rule that is accurate, fast, noninvasive, and cost-effective, distinguishing between complicated and uncomplicated appendicitis. Overall, 298 patients with acute appendicitis from the Wenzhou Central Hospital were recruited, and information on their demographic characteristics, clinical findings, and laboratory data was retrospectively reviewed and applied in this study. First, the most significant variables, including C-reactive protein (CRP), heart rate, body temperature, and neutrophils discriminating complicated from uncomplicated appendicitis, were identified using random forest analysis. Second, an improved grasshopper optimization algorithm-based support vector machine was used to construct the diagnostic model to discriminate complicated appendicitis (CAP) from uncomplicated appendicitis (UAP). The resultant optimal model can produce an average of 83.56% accuracy, 81.71% sensitivity, 85.33% specificity, and 0.6732 Matthews correlation coefficients. Based on existing routinely available markers, the proposed intelligent diagnosis model is highly reliable. Thus, the model can potentially be used to assist doctors in making correct clinical decisions.
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Affiliation(s)
- Jianfu Xia
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Zhifei Wang
- Department of Hepatobiliary, Pancreatic and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Hangzhou, 310014, China.
| | - Daqing Yang
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Rizeng Li
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Guoxi Liang
- Department of Information Technology, Wenzhou Polytechnic, Wenzhou, 325035, China.
| | - Huiling Chen
- Department of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, 325035, China.
| | - Ali Asghar Heidari
- Department of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, 325035, China.
| | - Hamza Turabieh
- Department of Information Technology, College of Computers and Information Technology, Taif University, P.O. Box 11099, Taif, 21944, Taif, Saudi Arabia.
| | - Majdi Mafarja
- Department of Computer Science, Birzeit University, Birzeit, 72439, Palestine.
| | - Zhifang Pan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, PR China.
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25
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Kaya A, Karaman K, Aziret M, Ercan M, Köse E, Kahraman YS, Karacaer C. The role of hematological parameters in distinguishing acute appendicitis from lymphoid hyperplasia. ULUS TRAVMA ACIL CER 2022; 28:434-439. [PMID: 35485518 PMCID: PMC10443127 DOI: 10.14744/tjtes.2020.69027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND One of the most misdiagnosed appendicular pathologies is lymphoid hyperplasia (LH) that can be managed con-servatively when identified early and is self-limiting. The aim of this retrospective study was to compare acute appendicitis (AA) with LH in terms of hematological parameters to determine whether there is a hematological predictor to distinguish the two diseases. METHODS Complete blood cell counts of patients with AA were compared with those having LH. RESULTS One-hundred-ninety-five patients (118 male/77 female) underwent appendectomy. Histopathological examination re-vealed acute AA in 161 patients (82.6%), and negative appendectomy (NA) in 19 patients (9.7%). Of the NA specimens, 16 were LH (8.2%). Thirteen patients (6.7%) had AA with simultaneous LH. White blood cell count (p=0.030, neutrophil (p=0.009), neutrophil per-centage (p=0.009), and neutrophil/lymphocyte ratio (p=0.007) were significantly higher in AA whereas lymphocyte count (p=0.027), lymphocyte percentage (p=0.006) were significantly higher in LH. Multi logistic regression analysis revealed white blood cell count as the only independent predictor in distinguishing AA from LH with a 69.1% sensitivity, 80.0% specificity, 77.5% positive predictive value, and 72.1% negative predictive value. The cut-off value for white blood cell count was 11.3 Ku/L, and every one unit (1000/mm3) increase in white blood cell count raises the risk of AA by 1.24 times, while values below this value will increase the likelihood of LH. CONCLUSION The most predictive complete blood count parameter in distinguishing LH from AA appears to be as white blood cell count.
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Affiliation(s)
- Ahmet Kaya
- Department, of Surgical Oncology, Sakarya University Faculty of Medicine, Sakarya-Turkey
| | - Kerem Karaman
- Department of Gastroenterological Surgery, Sakarya University Faculty of Medicine, Sakarya-Turkey
| | - Mehmet Aziret
- Department of Gastroenterological Surgery, Sakarya University Faculty of Medicine, Sakarya-Turkey
| | - Metin Ercan
- Department of Gastroenterological Surgery, Sakarya University Faculty of Medicine, Sakarya-Turkey
| | - Elif Köse
- Department of Public Health, Sakarya University Faculty of Medicine, Sakarya-Turkey
| | - Yavuz Selim Kahraman
- Department, of Surgical Oncology, Sakarya University Faculty of Medicine, Sakarya-Turkey
| | - Cengiz Karacaer
- Department of Internal Medicine, Sakarya University Faculty of Medicine, Sakarya-Turkey
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26
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Shi W, Wu Y, Zhong L, Huang Z, Zhong M, Wang J, Huang W, Yi X, Lu X, Yuan J, Huang W, Zhou X. Diagnostic Accuracy of Serum Amyloid A in Acute Appendicitis: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:380-387. [PMID: 35319305 DOI: 10.1089/sur.2021.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Serum amyloid A has been widely reported as a useful biochemical marker in the diagnoses of acute appendicitis. The aim of this study was to appraise the diagnostic accuracy of serum amyloid A in the diagnosis of acute appendicitis. Methods: A systematic search of several databases was conducted. The search time was from the beginning of the databases creation to March 1, 2021, and the languages were restricted to English and Chinese. Clinical studies using serum amyloid A for the diagnosis of acute appendicitis were included. The overall sensitivity and specificity were calculated by using a bivariable mixed effects model. Heterogeneity was tested using I2 statistics. This study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; no. CRD42021241343). Results: Five studies comprising 668 participants were eligible for inclusion. The overall sensitivity and specificity of serum amyloid A in diagnosing acute appendicitis were 0.87 (95% confidence interval [CI], 0.79-0.92) and 0.74 (95% CI, 0.59-0.85), respectively. The positive and negative likelihood were 3.3 (95% CI, 2.1-5.4) and 0.18 (95% CI, 0.11-0.28), respectively. The area under the summary receiver operating characteristic curves was 0.89 (95% CI, 0.86-0.91). The heterogeneity was significant (I2 = 82%; 95% CI [63%-100%]). Conclusions: Serum amyloid A has good diagnostic accuracy for acute appendicitis. It is expected that serum amyloid A could be helpful in the early clinical diagnosis of acute appendicitis.
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Affiliation(s)
- Wenhua Shi
- The Second Clinical College of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, China
| | - Yizhe Wu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, China
| | - Linyu Zhong
- The Second Clinical College of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, China
| | - Zhibin Huang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, China
| | - Minlin Zhong
- The Second Clinical College of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, China
| | - Jin Wang
- Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China
| | - Wujiao Huang
- Laboratory Department, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China
| | - Xiaojiang Yi
- Department of Colorectal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China
| | - Xinquan Lu
- Department of Colorectal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China
| | - Jingjing Yuan
- Anesthesiology Department, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China
| | - Wei Huang
- Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China
| | - Xianshi Zhou
- Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, Yuexiu District, Guangzhou, China.,Guangdong Provincial Key Laboratory of Research on Emergency in TCM, Yuexiu District, Guangzhou, China.,Guangzhou Key Laboratory of Traditional Chinese Medicine for Prevention and Treatment of Emerging Infectious Diseases, Yuexiu District, Guangzhou, China
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27
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Evaluation of plasma level of fibrinogen as a diagnostic criterion in acute appendicitis; cohort study. Ann Med Surg (Lond) 2022; 75:103393. [PMID: 35251602 PMCID: PMC8888974 DOI: 10.1016/j.amsu.2022.103393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/07/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute appendicitis (AA) is the most common etiology of abdominal operation worldwide. Despite advances in diagnostic guidelines there are still missed patients. This study evaluates assumption of plasma fibrinogen as a diagnostic criterion in AA. Method All patients over 12 years who were referred to emergency department and underwent index open appendectomy were enrolled in this cohort study. Histopathologically confirmed positive reports for presence of AA were allocated in a group. Controls experienced open appendectomy although pathological study was negative for AA. In addition to registering demographic data, plasma sample was examined for fibrinogen, quantitative C-reactive protein (CRP), and complete blood count preoperatively. Variables were compared. The ROC curve was customized and correlation coefficient for study markers was measured. Results Total 168 patients were enrolled. From all, 96 (57.1%) had confirmed AA, histopathologically. Gender, age, race, and body mass index had no difference between study groups (p > 0.05). In almost all patients increasing in white cell counts and left cellular shift was observed (p > 0.05). However, plasma level of fibrinogen and CRP reached to 389.2 ± 229.99 mg/dL (p = 0.001) and 33.06 ± 16.29 mg/L (p = 0.03) respectively, which both were significantly elevated in positive AA. Analysis showed area under the curve of serum fibrinogen was 0.892 (p < 0.001) with a cut-off point of 272 mg/dL had about 66.7% (95% CI:58.2–73.3) sensitivity, 92.8% (95% CI: 89.5–96.1) specificity, and 0.698 (p = 0.04) correlation coefficient for diagnosis of AA. Conclusion Amounts of elevated serum fibrinogen could imply on the diagnosis of AA specifically when concordance of clinical findings except for increasing CRP is unremarkable.
Despite advances in diagnostic guides for acute appendicitis (AA), discordance between clinical and laboratory findings leads to doubtful diagnosis. Plasma fibrinogen elevates concurrently with C-reactive protein (CRP) in AA while has further specificity. Measurement of serum fibrinogen could when CRP is elevated and diagnosis of AA is in doubt.
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28
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Arredondo Montero J, Bardají Pascual C, Bronte Anaut M, López-Andrés N, Antona G, Martín-Calvo N. Diagnostic performance of serum interleukin-6 in pediatric acute appendicitis: a systematic review. World J Pediatr 2022; 18:91-99. [PMID: 34978051 DOI: 10.1007/s12519-021-00488-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite the radiological and analytical advances of the last decades, there is still a significant rate of diagnostic error in pediatric acute appendicitis. In recent years, multiple biomarkers have emerged as potential diagnostic tools. This study aimed to examine the diagnostic performance of serum interleukin-6 in pediatric acute appendicitis. METHODS We conducted a systematic review of the literature that involved an extensive search in the main databases of medical bibliography (Medline, PubMed, Web of Science and SciELO). Two independent reviewers selected the relevant articles based on the previously defined inclusion and exclusion criteria. Methodological quality of the selected article was rated using the QUADAS2 index. Data extraction was performed by two independent reviewers. RESULTS The research in the medical bibliography databases resulted in 68 articles. We removed 26 duplicates. Among the remaining 42 articles, we excluded 33 following the inclusion and exclusion criteria. Of the final 9 studies included in this review, 8 provided measured serum interleukin-6 values, and all of them reported significant differences between groups, but inconsistent results regarding sensitivity and specificity. CONCLUSIONS The diagnostic performance of interleukine-6 alone for the diagnosis of acute appendicitis in children is limited. The sensitivity and specificity of interleukine-6 for the diagnosis of non-complicated acute appendicitis in the pediatric population are moderate but increased in complicated appendicitis. There seems to be a direct relationship between serum level of interleukin-6 and the hours of evolution of abdominal pain in children with acute appendicitis. The increasingly widespread use of non-operative management of acute appendicitis warrants further exploration of the classificatory potential of this marker between complicated and uncomplicated appendicitis. We consider that this may be an avenue of research to explore in the future.
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Affiliation(s)
- Javier Arredondo Montero
- Pediatric Surgery Department, Complejo Hospitalario de Navarra, Calle Irunlarrea 3, 31008, Pamplona, Navarra, Spain.
| | - Carlos Bardají Pascual
- Pediatric Surgery Department, Complejo Hospitalario de Navarra, Calle Irunlarrea 3, 31008, Pamplona, Navarra, Spain
| | | | - Natalia López-Andrés
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Giuseppa Antona
- Pediatric Surgery Department, Complejo Hospitalario de Navarra, Calle Irunlarrea 3, 31008, Pamplona, Navarra, Spain
| | - Nerea Martín-Calvo
- Department of Preventive Medicine and Public Health, Instituto de Investigación Sanitaria de Navarra (IdiSNA), University of Navarra, Pamplona, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Health Institute Carlos III, Madrid, Spain
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Arredondo Montero J, Antona G, Rivero Marcotegui A, Bardají Pascual C, Bronte Anaut M, Ros Briones R, Fernández-Celis A, López-Andrés N, Martín-Calvo N. Discriminatory capacity of serum interleukin-6 between complicated and uncomplicated acute appendicitis in children: a prospective validation study. World J Pediatr 2022; 18:810-817. [PMID: 36114365 PMCID: PMC9617836 DOI: 10.1007/s12519-022-00598-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Serum interleukin-6 (IL-6) has a moderate diagnostic performance in pediatric acute appendicitis (PAA). The evidence regarding its capacity to discern between complicated and uncomplicated PAA is scarce. METHODS We designed a prospective observational study to validate serum IL-6 as a marker for diagnostic classification between complicated and uncomplicated PAA. This study included 205 patients divided into three groups: (1) patients who underwent major outpatient surgery (n = 57); (2) patients with non-surgical abdominal pain (NSAP) in whom the diagnosis of PAA was excluded (n = 53), and (3) patients with a confirmed diagnosis of PAA (n = 95). The PAA patients were further classified as uncomplicated or complicated PAA. IL-6 concentration was determined in all patients at diagnosis. Comparative statistical analysis was performed using the Mann-Whitney U test, the Fisher exact test and the Kruskall Wallis test. The area under the receiver operating characteristic curves (AUC) were calculated. RESULTS Median (interquartile range, IQR) serum IL-6 values were 2 pg/mL (2.0-3.4) in group 1, 3.9 pg/mL (2.4-11.9) in group 2, and 23.9 pg/mL (11.1-61.0) in group 3 (P < 0.001). Among the participants in group 3, those with uncomplicated PAA had median (IQR) serum IL-6 values of 17.2 pg/mL (8.5-36.8), and those with complicated PAA had 60.25 pg/mL (27.1-169) serum IL-6 (P < 0.001). At the cut-off point of 19.55 pg/mL, the AUC for the discrimination between patients in group 2 vs. 3 was 0.83 [95% confidence interval (CI) 0.76-0.90], with a sensitivity of 61.3% and a specificity of 86.8. The AUC for the discrimination between patients with uncomplicated and complicated PAA was 0.77 (95% CI 0.68-0.86) and the cut-off point was 25.90 pg/mL, with a sensitivity and specificity of 84.6% and 65.6%, respectively. CONCLUSIONS Serum IL-6 has a good performance in discerning between complicated and uncomplicated PAA. A score including clinical and radiological variables may increase the diagnostic performance of this molecule.
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Affiliation(s)
- Javier Arredondo Montero
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain.
- School of Medicine, Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain.
| | - Giuseppa Antona
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain
| | | | - Carlos Bardají Pascual
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain
| | | | - Raquel Ros Briones
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Natalia López-Andrés
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Nerea Martín-Calvo
- School of Medicine, Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Health Institute Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Navarra, Spain
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The potential role of interleukin-6, endotoxin and C-reactive protein as standard biomarkers for acute appendicitis in adults. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh200723026d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction/Objective. Acute appendicitis (AA) is by far the most frequent
urgent condition in abdominal surgery and numerous biomarkers may help the
physician to diagnose and even predict the severity of the disease. The
objective of the paper was to determine the accuracy of C-reactive protein
(CRP), interleukin-6 (IL-6) and endotoxin and compare it with the diagnostic
value of Alvarado score (AS) in adults surgically treated for AA. Methods.
Sixty-seven patients were diagnosed with AA using AS. Prior to surgery serum
levels of inflammatory biomarkers were determined and together with AS were
respectively compared to the results of histopathological analysis of
specimens. The patients were divided into three group according to the
histopathological assessment. Results. The univariate analysis revealed
that the increase of CRP level by one unit increases the probability of
complicated AA (CoAA) occurence by 1% (1.00 to 1.02, p < 0.05). ROC curve
analysis has revealed that CRP has better capacity to predict supurative AA
(SAAs)/CoAAs than catarrhal AA (CAA), with the cut-of value 19.45. Increase
of AS value by one unit produced 2.98 fold increase of the probability of
CoAA occurrence (1.60 to 5.57, p < 0.001), while positive AS value increases
the probability of CoAA occurrence 24.67 times (4.94 to 123.12; p < 0.001).
ROC curve analysis was demonstrated that AS may better predict CoAAs than
CAAs/SAAs, with the cut-off value 8.50. Conclusion. AS and CRP should be
routinely used combined as powerful tools for diagnosis and prediction of
complicated AA.
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The Dynamics of Inflammatory Markers in Patients with Suspected Acute Appendicitis. Medicina (B Aires) 2021; 57:medicina57121384. [PMID: 34946329 PMCID: PMC8709480 DOI: 10.3390/medicina57121384] [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: 11/16/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Laboratory tests of inflammatory mediators are routinely used in the diagnosis of acute appendicitis (AA). The aim of this study was to evaluate the differences of dynamics of inflammatory markers of the blood in patients with suspected acute appendicitis between complicated AA (CAA), non-complicated AA (NAA), and when AA was excluded (No-AA). Methods: This was a retrospective analysis of prospectively collected data of patients presented to the Emergency Department (ER) of a tertiary hospital center during a three-year period. All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. The dynamics of inflammatory markers of the blood between different types of AA (No-AA, NAA or CAA) during different periods of time are presented. Results: A total of 453 patients were included in the study, with 297 patients in the No-AA group, 99 in the NAA group, and 57 in the CAA group. White blood cell (WBC) count in the No-AA decreased with time, with a statistically significant difference between the <8 h and 25–72 h group. The neutrophils (NEU) percentage decreased in the No-AA group and was statistically significantly different between the <8 h and 25–72 h and <8 h and >72 h groups. C-reactive protein (CRP) increased significantly in the No-AA group throughout all time intervals, and from the first 24 h to the 25–72 h in the NAA and CAA groups. There was a statistically significant difference between the WBC count between No-AA, NAA, and No-AA and CAA groups during the first 24 and 24–48 h. There was a statistically significant difference between NEU percentage and LYMP percentage and in the NEU/LYMP ratio between No-AA and CAA groups through all time periods. CRP was significantly higher in the first 24 h in the CAA than in the No-AA group, and in the 24–48 h in the CAA group than in the No-AA and NAA groups. The linear logistic regression model, involving inflammatory mediators and clinical characteristics, showed mediocre diagnostic accuracy for diagnosing AA with an AUC of 0.737 (0.671–0.802). Conclusions: Increasing concentrations of inflammatory markers are more characteristic in CAA patients than in No-AA during the first 48 h after onset of the disease. A combination of laboratory tests with clinical signs and symptoms has a mediocre diagnostic accuracy in suspecting AA.
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Akgül F, Er A, Ulusoy E, Çağlar A, Çitlenbik H, Keskinoğlu P, Şişman AR, Karakuş OZ, Özer E, Duman M, Yılmaz D. Integration of Physical Examination, Old and New Biomarkers, and Ultrasonography by Using Neural Networks for Pediatric Appendicitis. Pediatr Emerg Care 2021; 37:e1075-e1081. [PMID: 31503129 DOI: 10.1097/pec.0000000000001904] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate physical examinations, imaging, and laboratory analyses individually and combined using innovative statistical analysis methods for the accurate diagnosis of pediatric appendicitis. METHODS Patients admitted to hospital with symptoms of abdominal pain whose pediatric appendicitis scores greater than 3 were included in the study. Clinical, radiologic, and laboratory findings and as a new biomarker calprotectin (CPT) concentrations were evaluated individually and combined using artificial neural networks (ANNs), which revealed latent relationships for a definitive diagnosis. RESULTS Three hundred twenty patients were evaluated (190 appendicitis [43 perforated] vs 130 no appendicitis). The mean ± SD age was 11.3 ± 3.6 years and 63% were male. Pediatric appendicitis scores, white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin (PCT) and CPT concentrations were higher in the appendicitis group; however, only WBC and ANC were higher in first 24 hours of pain. White blood cells and CRP were diagnostic markers in patients whose appendix could not be visualized using ultrasonography (US). On classic receiver operating characteristic (ROC) analysis, the areas under the curve (AUCs) were not strong enough for differential diagnosis (WBC, 0.73; ANC, 0.72; CRP, 0.65; PCT and CPT, 0.61). However, when the physical examination, US, and laboratory findings were analyzed in a multivariate model and the ROC analysis obtained from the variables with ANN, an ROC curve could be obtained with 0.91 AUC, 89.8% sensitivity, and 81.2% specificity. C-reactive protein and PCT were diagnostic for perforated appendicitis with 0.83 and 0.75 AUC on ROC. CONCLUSIONS Although none of the biomarkers were sufficient for an accurate diagnosis of appendicitis individually, a combination of physical examination and laboratory and US was a good diagnostic tool for pediatric appendicitis.
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Affiliation(s)
- Fatma Akgül
- From the Department of Pediatric Emergency Care
| | - Anıl Er
- From the Department of Pediatric Emergency Care
| | - Emel Ulusoy
- From the Department of Pediatric Emergency Care
| | | | | | | | | | | | - Erdener Özer
- Department of Pathology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Murat Duman
- From the Department of Pediatric Emergency Care
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Güngör A, Göktuğ A, Güneylioğlu MM, Yaradılmış RM, Bodur I, Öztürk B, Karaman İ, Karacan CD, Tuygun N. Utility of biomarkers in predicting complicated appendicitis: can immature granulocyte percentage and C-reactive protein be used? Postgrad Med 2021; 133:817-821. [PMID: 34165049 DOI: 10.1080/00325481.2021.1948306] [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] [Indexed: 10/21/2022]
Abstract
BACKGROUND Acute appendicitis is the most common reason for abdominal surgery in children. The aim of this study was to evaluate the utility of biomarkers in predicting complicated appendicitis (CA). METHODS Patients having a diagnosis of acute appendicitis who underwent operations were retrospectively determined, and the utility of biomarkers in predicting CA was evaluated. RESULTS A total of 251 patients were included in the study. The mean age was 130.9 ± 48.8 months, 148 of the cases (59%) were simple appendicitis, and 103 (41%) were CA. The C-reactive protein (CRP) levels, immature granulocyte (IG) percentage, white blood cell counts, and absolute neutrophil counts were significantly higher in the CA patients. The bilirubin levels and neutrophil to lymphocyte ratios were not useful for predicting CA. The best area under the curve (AUC) values to predict CA were with the IG percentage and CRP level (0.82), the IG percentage [odds ratio (OR) 9.36, 95% CI (4.94-17.75), p < 0.001] and CRP [OR 8.42, 95% CI (4.72-15.02), p < 0.001] were the best marker in predicting CA. The sensitivity of the IG percentage and CRP level were higher than other markers. CONCLUSION To predict CA, the best AUC values were associated with the IG percentage and the CRP level. Because it is easy, fast to measure, does not require taking extra blood, and does not lead to additional costs, IG percentage may be preferred in the diagnosis of patients with CA.
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Affiliation(s)
- Ali Güngör
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Aytaç Göktuğ
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Muhammed Mustafa Güneylioğlu
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Raziye Merve Yaradılmış
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Ilknur Bodur
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Betül Öztürk
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - İbrahim Karaman
- Department of Pediatric Surgery, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Can Demir Karacan
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Nilden Tuygun
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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Lenski M, Tonn JC, Siller S. Interleukin-6 as inflammatory marker of surgical site infection following spinal surgery. Acta Neurochir (Wien) 2021; 163:1583-1592. [PMID: 33118112 DOI: 10.1007/s00701-020-04628-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND In order to elucidate whether serum inflammatory markers identify patients with local surgical site infection(SSI) as underlying disease for recurrent or new symptomatology following spine surgery, we evaluated the diagnostic potential of interleukin-6(IL-6) as a marker of SSI. The diagnostic significance of IL-6 was compared to the standard serum inflammatory markers C-reactive protein(CRP) and white blood cell count (WBCC). METHOD Ninety-eight consecutive patients with readmission due to recurrent or new symptomology after spinal surgery of degenerative spine disorders entered the study. Baseline patients' characteristics and the abovementioned inflammatory markers were collected, and arithmetical means with standard deviation, area under the curve (AUC), thresholds, sensitivity, specificity, positive(+)likelihood ratio (LR), and negative(-)LR with corresponding 95% confidence interval(95%CI) were calculated and correlated with presence or absence of SSI. RESULTS Nine patients suffered from a SSI, whereas the remaining 89 patients had a recurrent/adjacent-segment degenerative disorder without evidence of infection. The most significant parameter for diagnosing a SSI was serum IL-6 (cut-off value > 15.3 pg/ml, AUC = 0.954, SE = 85.7%, SP = 97.3%), followed by CRP (cut-off value = 0.8 mg/dl, AUC = 0.916, SE = 88.9%, SP = 84.5%) CONCLUSIONS: In the case of recurrent or new symptomatology following spinal surgery, serum IL-6 has the highest diagnostic potential for diagnosing spinal SSI.
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Diagnosis of acute appendicitis in children using urinary 5-hydroxy indol acetic acid and pediatric appendicitis score: A randomized control trial. Ann Med Surg (Lond) 2021; 65:102274. [PMID: 33898036 PMCID: PMC8058523 DOI: 10.1016/j.amsu.2021.102274] [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: 02/17/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Acute appendicitis in children represents a common problem. Diagnosis may be difficult due to lack of clinical data. Several scoring systems and laboratory investigations are used for diagnosis. This study aimed to build a model for diagnosis of acute appendicitis in children using urinary 5-hydroxyindoleacetic acid (5-HIAA) and pediatric appendicitis score. Methods This study was conducted on 191 children with suspicion of acute appendicitis. They were divided into two groups A and B. Children were evaluated in group A with pediatric appendicitis score, ultrasound, and CRP. In group B children were evaluated in the same manner of group A plus measuring of 5-HIAA. Results mean age was 13.3 ± 5.2 years. The mean duration of symptoms was 2.2 ± 1.4 days. The mean level of urinary 5-HIAA was 43.53 ± 24.05 in appendicitis patients in group B. In group A there were 65 cases who had appendectomy. Seventy-five children were operated in group B. Negative appendectomies were found in 13 and 7 cases in groups A and B respectively. Thirteen cases were readmitted in group A with diagnosis of acute appendicitis while seven cases were readmitted in group B. Conclusion This combination of urinary 5-HIAA and pediatric appendicitis score builds a model for diagnosis of acute appendicitis in children. This model improves the accuracy of diagnosis of acute appendicitis, reduces both the incidence of negative appendectomies and the incidence of readmission or missed cases in children.
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Klein TT, Kohn E, Klin B, Ziv-Baran T, Kozer E, Berkovitch M, Abu Kishk I. sTREM-1 as a diagnostic biomarker for acute appendicitis in children. Asian J Surg 2021; 44:1172-1178. [PMID: 33766532 DOI: 10.1016/j.asjsur.2021.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/13/2021] [Accepted: 02/08/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The typical history of acute appendicitis is observed in less than 60% of cases. Therefore, searching for a surrogate marker is mandatory. Our goal was to determine whether the soluble triggering receptor expressed on myeloid cells (sTREM-1) is an efficient biomarker for acute appendicitis. METHODS sTREM-1 serum levels were measured in addition to carrying out routine diagnostic tests (urine dipstick, complete blood count and CRP) in children admitted to the Emergency Department with suspected appendicitis. Statistical analysis was performed in order to examine whether sTREM-1 was a significant predictor of appendicitis. RESULTS Fifty three of 134 children enrolled in the study were diagnosed with appendicitis. There was no significant difference in serum sTREM-1 levels (p = 0.111) between children with or without appendicitis (n = 81). Leukocytes, neutrophils and CRP were significantly elevated in the appendicitis group (p < 0.001). The appendix diameter was significantly larger and the Alvarado score significantly higher in the appendicitis group (p < 0.001). CONCLUSION serum sTREM-1 is not a good marker for acute appendicitis. Customary tests in addition to a proper patient history and physical examination are still the most effective methods to diagnose acute appendicitis.
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Affiliation(s)
- Tal Taraboulos Klein
- Pediatric Division, Shamir Medical Center (Assaf Harofeh), Zerifin, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elkana Kohn
- Clinical Pharmacology Unit, Shamir Medical Center (Assaf Harofeh), Zerifin, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Baruch Klin
- Pediatric Division, Shamir Medical Center (Assaf Harofeh), Zerifin, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Affiliated to the Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Eran Kozer
- Pediatric Division, Shamir Medical Center (Assaf Harofeh), Zerifin, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Matityahu Berkovitch
- Clinical Pharmacology Unit, Shamir Medical Center (Assaf Harofeh), Zerifin, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ibrahim Abu Kishk
- Pediatric Division, Shamir Medical Center (Assaf Harofeh), Zerifin, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Lontra MB, Savaris RF, Cavazzola LT, Maissiat J. Comparison of leucine-rich alpha-2-glycoprotein-1 (LRG-1) plasma levels between patients with and without appendicitis, a case-controlled study. Sci Rep 2021; 11:5574. [PMID: 33692371 PMCID: PMC7946883 DOI: 10.1038/s41598-021-84013-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/08/2021] [Indexed: 01/07/2023] Open
Abstract
Acute appendicitis (AA) is the first cause of emergency surgery. Leucine-Rich Alpha-2-Glycoprotein 1 (LRG1) has been shown to be a potential biomarker in cases of AA in children, but there are conflicting results for its use in adults. The objective of this study is to compare the median plasma values of LRG1 in patients with acute abdomen with and without appendicitis. This case–control study was conducted prospectively at the emergency room (ER) of a tertiary teaching hospital, between March 1st, 2011 and December 31st, 2012. Patients with recent abdominal pain, aged 18–70 years who attended at the ER were included in the study. Blood samples were drawn at the first presentation. Those who were submitted to surgery and had a pathology report of AA were considered as cases. Those without a need for surgery and treated for other conditions, e.g., pelvic inflammatory disease, were considered as controls. Follow-up in controls was made up to 30 days. LRG1 plasma median values were measured using an ELISA kit and compared between groups. A total of 28 participants, 14 cases with acute appendicitis and 14 controls, were included. The median (range) values of leucine-rich alpha-2-glycoprotein-1 level in the group with appendicitis and control group were 8.8 ng/ml (5.5–31) and 11 (4.6–108) ng/ml, respectively (Mann–Whitney test P = 0.26). Median plasma leucine-rich alpha-2-glycoprotein-1 levels were not useful in diagnosing Acute Appendicitis in patients with acute abdominal pain.
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Affiliation(s)
- Marcelo Bentancor Lontra
- Postgraduate Program in Medicine: Surgical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, 90035-002, Brazil. .,Surgical Oncologist and General Surgeon, Military Hospital of Porto Alegre, Porto Alegre, RS, 90440-191, Brazil. .,Surgical Oncologist and General Surgeon, Moinhos de Vento Hospital, Porto Alegre, RS, 90035-000, Brazil.
| | - Ricardo F Savaris
- Postgraduate Program in Medicine: Surgical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, 90035-002, Brazil. .,Department of Obstetrics and Gynecology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-002, Brazil.
| | - Leandro Totti Cavazzola
- Postgraduate Program in Medicine: Surgical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, 90035-002, Brazil.,Associate Professor of Surgery, Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-002, Brazil
| | - Jackson Maissiat
- Department of Obstetrics and Gynecology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-002, Brazil
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Antakia R, Xanthis A, Georgiades F, Hudson V, Ashcroft J, Rooney S, Singh AA, O'Neill JR, Fearnhead N, Hardwick RH, Davies R, Bennett JM. Acute appendicitis management during the COVID-19 pandemic: A prospective cohort study from a large UK centre. Int J Surg 2021; 86:32-37. [PMID: 33465496 PMCID: PMC7985094 DOI: 10.1016/j.ijsu.2020.12.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/13/2020] [Accepted: 12/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND During the Covid-19 pandemic, non-operative management for acute appendicitis (AA) was implemented in the UK. The aim of this study was to determine the efficacy and outcomes of conservative versus surgical management of AA during the pandemic. MATERIALS & METHODS We conducted an observational study in a tertiary referral centre. Data was collected from all patients (≥16 years) with a diagnosis of AA between November 1, 2019 to March 10, 2020 (pre-COVID period) and March 10, 2020 to July 5, 2020 (COVID period). RESULTS A total of 116 patients in the pre-COVID period were included versus 91 in the COVID period. 43.1% (n = 50) of patients pre-COVID were classified as ASA 2 compared to 26.4% (n = 24) during the COVID period (p-value = 0.042). 72.5% (n = 66) of the patients during the COVID period scored as high risk using the Alvarado score compared to 24.1% (n = 28) in the pre-COVID period (p-value<0.001). We observed a significant increase in radiological evaluation, 69.8% versus 87.5% of patients had a CT in the pre-COVID and COVID periods respectively (p-value = 0.008). 94.9% of patients were managed operatively in the pre-COVID period compared to 60.4% in the COVID period (p-value<0.001). We observed more open appendicectomies (37.3% versus 0.9%; p-value<0.001) during the COVID period compared to the pre-COVID period. More abscess formation and free fluid were found intraoperatively in the COVID period (p-value = 0.021 and 0.023 respectively). Re-attendance rate due to appendicitis-related issues was significantly higher in the COVID period (p = 0.027). CONCLUSION Radiological diagnosis of AA was more frequent during the COVID period. More conservative management for AA was employed during the COVID-19 pandemic, and for those managed operatively an open approach was preferred. Intra-operative findings were suggestive of delayed presentation during the COVID period without this affecting the length of hospital stay.
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Affiliation(s)
- Ramez Antakia
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK,Corresponding author. Division of Digestive Diseases, level E7 Addenbrooke's Hospital, Hills Road, CB2 0QQ, United Kingdom
| | | | | | - Victoria Hudson
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - James Ashcroft
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Siobhan Rooney
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - Aminder A. Singh
- Division of Digestive Diseases, Addenbrooke's Hospital, Cambridge, UK
| | - John R. O'Neill
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Nicola Fearnhead
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | | | - R.Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - John M.H. Bennett
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
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Marcinkevics R, Reis Wolfertstetter P, Wellmann S, Knorr C, Vogt JE. Using Machine Learning to Predict the Diagnosis, Management and Severity of Pediatric Appendicitis. Front Pediatr 2021; 9:662183. [PMID: 33996697 PMCID: PMC8116489 DOI: 10.3389/fped.2021.662183] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/01/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Given the absence of consolidated and standardized international guidelines for managing pediatric appendicitis and the few strictly data-driven studies in this specific, we investigated the use of machine learning (ML) classifiers for predicting the diagnosis, management and severity of appendicitis in children. Materials and Methods: Predictive models were developed and validated on a dataset acquired from 430 children and adolescents aged 0-18 years, based on a range of information encompassing history, clinical examination, laboratory parameters, and abdominal ultrasonography. Logistic regression, random forests, and gradient boosting machines were used for predicting the three target variables. Results: A random forest classifier achieved areas under the precision-recall curve of 0.94, 0.92, and 0.70, respectively, for the diagnosis, management, and severity of appendicitis. We identified smaller subsets of 6, 17, and 18 predictors for each of targets that sufficed to achieve the same performance as the model based on the full set of 38 variables. We used these findings to develop the user-friendly online Appendicitis Prediction Tool for children with suspected appendicitis. Discussion: This pilot study considered the most extensive set of predictor and target variables to date and is the first to simultaneously predict all three targets in children: diagnosis, management, and severity. Moreover, this study presents the first ML model for appendicitis that was deployed as an open access easy-to-use online tool. Conclusion: ML algorithms help to overcome the diagnostic and management challenges posed by appendicitis in children and pave the way toward a more personalized approach to medical decision-making. Further validation studies are needed to develop a finished clinical decision support system.
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Affiliation(s)
| | - Patricia Reis Wolfertstetter
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Sven Wellmann
- Division of Neonatology, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
| | - Christian Knorr
- Department of Pediatric Surgery and Pediatric Orthopedics, Hospital St. Hedwig of the Order of St. John of God, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Julia E Vogt
- Department of Computer Science, ETH Zurich, Zurich, Switzerland
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An observational study of innate immune responses in patients with acute appendicitis. Sci Rep 2020; 10:17352. [PMID: 33060696 PMCID: PMC7562899 DOI: 10.1038/s41598-020-73798-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/17/2020] [Indexed: 12/11/2022] Open
Abstract
Acute appendicitis is a common surgical emergency worldwide. Exaggerated immune responses could be associated with appendicitis. This study aimed at characterizing immune responses towards a large variety of gut commensals and pathogens, and pattern recognition receptor (PRR) ligands, and investigating the course of systemic inflammation in a prospective cohort of acute appendicitis patients. PBMC responses of 23 patients of the cohort and 23 healthy controls were characterized more than 8 months post-surgery. Serum cytokine levels were measured in 23 patients at the time of appendicitis and after one month. CRP, WBC and percentage of neutrophils were analyzed in the total cohort of 325 patients. No differences in PBMC responses were found between patients and controls. Stronger IL-10 responses were found following complicated appendicitis. A trend towards lower IL-8 responses was shown following gangrenous appendicitis. Serum IL-10 and IL-6 were significantly elevated at presentation, and IL-6, IL-8 and TNF-α levels were higher in complicated appendicitis. Routine biomarkers could predict severity of appendicitis with high specificities, but low sensitivities. Cytokine responses in patients following acute appendicitis did not differ from healthy controls. Higher serum cytokine levels were found in acute complicated and gangrenous cases. Further research into discriminative biomarkers is warranted.
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Zarog MA, O'Leary DP, Kiernan MG, Bolger J, Tibbitts P, Coffey SN, Lowery A, Byrnes GJ, Peirce C, Dunne CP, Coffey JC. Role of circulating fibrocytes in the diagnosis of acute appendicitis. BJS Open 2020; 4:1256-1265. [PMID: 33047514 PMCID: PMC7709380 DOI: 10.1002/bjs5.50350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/21/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023] Open
Abstract
Background Improved diagnostic biomarkers are required for acute appendicitis. The circulating fibrocyte percentage (CFP) is increased in inflammatory states, but has not been studied in acute appendicitis. This study aimed to determine CFP in acute appendicitis and compare diagnostic accuracy with standard serological biomarkers. Methods A prospective cohort study was carried out between June 2015 and February 2016 at University Hospital Limerick. The CFP was determined by dual‐staining peripheral venous samples for CD45 and collagen I using fluorescence‐activated cell sorting, and correlated with histopathological diagnoses. The accuracy of CFP in determining histological acute appendicitis was characterized and compared with the white cell count, C‐reactive protein concentration, neutrophil count, lymphocyte count and neutrophil : lymphocyte ratio. Results Of 95 adults recruited, 15 were healthy individuals and 80 had suspected appendicitis at presentation. Forty‐six of these 80 patients had an appendicectomy, of whom 34 had histologically confirmed appendicitis. The CFP was statistically higher in patients with pathologically proven acute appendicitis than in healthy controls (median 6·1 (i.q.r. 1·6–11·6) versus 2·3 (0·9–3·4) per cent respectively; P = 0·008). The diagnostic accuracy of CFP, as determined using the area under the receiver operating characteristic (ROC) curve, was similar to that of standard biomarkers. In multinomial regression analysis, only raised CFP was retained as an independent prognostic determinant of acute appendicitis (odds ratio 1·57, 95 per cent c.i. 1·05 to 2·33; P = 0·027). Conclusion The CFP is increased in histologically confirmed acute appendicitis and is as accurate as standard serological biomarkers in terms of diagnosis.
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Affiliation(s)
- M A Zarog
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland
| | - D P O'Leary
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - M G Kiernan
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland
| | - J Bolger
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - P Tibbitts
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland
| | - S N Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - A Lowery
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland
| | - G J Byrnes
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland
| | - C Peirce
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland
| | - C P Dunne
- Graduate Entry Medical School, Limerick, Ireland.,Centre for Interventions in Infection, Inflammation and Immunity, University of Limerick, Limerick, Ireland
| | - J C Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, Limerick, Ireland.,Centre for Interventions in Infection, Inflammation and Immunity, University of Limerick, Limerick, Ireland
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sB7H3 in Children with Acute Appendicitis: Its Diagnostic Value and Association with Histological Findings. J Immunol Res 2020; 2020:2670527. [PMID: 32953890 PMCID: PMC7482032 DOI: 10.1155/2020/2670527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
Background Several efforts have been made to find out a valuable marker to assist the diagnosis and differentiation of gangrenous/perforated appendicitis. We aimed to determine the diagnostic capacity of soluble B7H3 (sB7H3) in acute appendicitis (AA) and its accuracy as a predictor of the severity of appendicitis. Methods 182 children were allocated into four groups as follows: control group (CG, 90), simple appendicitis (SA, 12), purulent appendicitis (PA, 49), and gangrenous appendicitis (GA, 31). Prior to appendectomy, blood was collected and sent for analysis of routine examination and cytokines (sB7H3 and TNF-α). We compared values of all measured parameters according to histological findings. Furthermore, we assigned AA patients into the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic effects of significant markers were assessed by ROC curves. Results Only the levels of CRP, FIB, and sB7H3 had a remarkable rising trend in AA-based groups, while differences in the levels of CRP and FIB between simple appendicitis and purulent appendicitis were not statistically significant. In addition, sB7H3 was found as the only marker in children with AA, which was markedly associated with the degree of histological findings of the appendix. Furthermore, sB7H3 had a high diagnostic value in predicting AA and complex appendicitis (PA+GA) in children. However, the diagnostic performance of sB7H3 for distinguishing PA from GA was not remarkable. Additionally, only the levels of CRP and sB7H3 were statistically different between the nonperforated appendicitis group and the perforated appendicitis group. The diagnostic performance of CRP and sB7H3 could not merely predict perforation of AA in children; however, the diagnostic performance was improved after combination. Conclusions sB7H3 could be used as a valuable marker to predict the presence of AA and complex AA in children. However, the diagnostic value of sB7H3 to predict gangrenous/perforated appendicitis was not found to be remarkable. The combination of sB7H3 and CRP might improve the prediction of perforated appendicitis.
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Aydin E, Türkmen İU, Namli G, Öztürk Ç, Esen AB, Eray YN, Eroğlu E, Akova F. A novel and simple machine learning algorithm for preoperative diagnosis of acute appendicitis in children. Pediatr Surg Int 2020; 36:735-742. [PMID: 32314055 DOI: 10.1007/s00383-020-04655-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION There is a tendency toward nonoperative management of appendicitis resulting in an increasing need for preoperative diagnosis and classification. For medical purposes, simple conceptual decision-making models that can learn are widely used. Decision trees are reliable and effective techniques which provide high classification accuracy. We tested if we could detect appendicitis and differentiate uncomplicated from complicated cases using machine learning algorithms. MATERIALS AND METHODS We analyzed all cases admitted between 2010 and 2016 that fell into the following categories: healthy controls (Group 1); sham controls (Group 2); sham disease (Group 3), and acute abdomen (Group 4). The latter group was further divided into four groups: false laparotomy; uncomplicated appendicitis; complicated appendicitis without abscess, and complicated appendicitis with abscess. Patients with comorbidities and whose complete blood count and/or pathology results were lacking were excluded. Data were collected for demographics, preoperative blood analysis, and postoperative diagnosis. Various machine learning algorithms were applied to detect appendicitis patients. RESULTS There were 7244 patients with a mean age of 6.84 ± 5.31 years, of whom 82.3% (5960/7244) were male. Most algorithms tested, especially linear methods, provided similar performance measures. We preferred the decision tree model due to its easier interpretability. With this algorithm, we detected appendicitis patients with 93.97% area under the curve (AUC), 94.69% accuracy, 93.55% sensitivity, and 96.55% specificity, and uncomplicated appendicitis with 79.47% AUC, 70.83% accuracy, 66.81% sensitivity, and 81.88% specificity. CONCLUSIONS Machine learning is a novel approach to prevent unnecessary operations and decrease the burden of appendicitis both for patients and health systems. LEVELS OF EVIDENCE III.
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Affiliation(s)
- Emrah Aydin
- Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey. .,Department of Pediatric Surgery, Bahcelievler State Hospital, Istanbul, Turkey. .,Department of Pediatric Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey. .,Maltepe Mah Topkapi, Cad No:4, 34010, Zeytinburnu, Istanbul, Turkey.
| | | | - Gözde Namli
- Department of Pediatric Surgery, Bahcelievler State Hospital, Istanbul, Turkey
| | - Çiğdem Öztürk
- Department of Pathology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Ayşe B Esen
- Department of Microbiology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Y Nur Eray
- Department of Pediatric Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Egemen Eroğlu
- Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Fatih Akova
- Department of Pediatric Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey.,Department of Pediatric Surgery, Biruni University, Istanbul, Turkey
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Serum bilirubin concentration as a marker of severity of acute appendicitis. Wideochir Inne Tech Maloinwazyjne 2020; 15:117-122. [PMID: 32117494 PMCID: PMC7020712 DOI: 10.5114/wiitm.2019.87140] [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: 06/14/2019] [Accepted: 07/06/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction Acute appendicitis (AA) is one of the most common causes of urgent admission to the hospital. Clinically applicable classification distinguishes simple and complex inflammation. Among commonly used inflammation markers of AA, bilirubin concentration is not well studied and thus is rarely applied. Aim To examine the association between increased serum total bilirubin concentration and the severity of AA. Material and methods This retrospective study included 169 patients with a presumptive diagnosis of AA who were operated upon between 2015 and 2017. The determined study endpoints were simple complex inflammation and a different diagnosis after surgery. The Mann-Whitney U, Kruskal-Wallis, Fisher’s exact, Spearman correlation coefficient and logistic regression tests and receiver-operating characteristics (ROC) were used in analyses. The area under the curve (AUC) was presented with 95% confidence intervals (95% CIs). Statistical significance was set at 0.05. Results In total, 84 (49.7%) patients underwent laparotomy and 85 (50.3%) laparoscopy. After surgery, 45 (26.6%) patients had a diagnosis other than AA. Furthermore, 83 (49.1%) and 41 (24.3%) patients had simple and complex AA, respectively. The median bilirubin concentration was 0.56, 0.69, and 1.08 mg/dl in patients without AA, with simple, and complex AA, respectively (p < 0.01). The optimal cut-off for serum bilirubin concentration to predict AA severity was ≥ 0.94 mg/dl (AUC = 0.652; 95% CI: 0.543–0.761) with a 44.9% positive and 83.9% negative predictive value (p = 0.006). Conclusions The serum bilirubin concentration should be considered as one of the possible markers of AA. Moreover, it can be used to predict the severity of AA.
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Destek S, Gül VO, Menteş MÖ, Çiçek AF. Diagnostic efficacy of serum procalcitonin, IL-6, IL-2, and D-dimer levels in an experimental acute appendicitis model. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:641-647. [PMID: 31290753 DOI: 10.5152/tjg.2019.18534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIMS Acute appendicitis is the most frequent cause of acute abdomen emergency surgery. It continues to be a problem today due to delayed diagnosis and its high perforation rate. For this reason, diagnostic tests continue to be developed. In this experimental study, the diagnostic significance of blood procalcitonin (PCT), interleukin (IL)-6, IL-2, and D-dimer levels in an acute appendicitis model in rabbits was investigated. MATERIALS AND METHODS A total of five groups were included: control group, sham group, and three different acute appendicitis groups. In the appendicitis groups, the appendix was ligated by laparotomy, and the blood PCT, IL-6, IL-2, and D-dimer levels were measured at 12 (group 3), 24 (group 4), and 48 h (group 5). Then, an appendectomy was performed. RESULTS In the present study, PCT and IL-6 levels increased in parallel with the inflammation of the appendix in all groups and were found to be statistically significant. IL-2 and D-dimer values were higher in the groups diagnosed with appendicitis but were not statistically significant. CONCLUSION In our experimental study, PCT and IL-6 levels were determined to be important in the early diagnosis of acute appendicitis, especially IL-6, and that these two parameters are more important markers than IL-2 and D-dimer.
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Affiliation(s)
- Sabahattin Destek
- Department of General Surgery, Bezmialem Vakif University School of Medicine, İstanbul, Turkey
| | - Vahit Onur Gül
- Department of General Surgery, Gülhane Military Medical Academy, Ankara, Turkey
| | - Mustafa Öner Menteş
- Department of General Surgery, Gülhane Military Medical Academy, Ankara, Turkey
| | - Ali Fuat Çiçek
- Department of Pathology, Gülhane Military Medical Academy, Ankara, Turkey
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Abstract
Introduction Very different results have been reported regarding the relationship between bilirubin and perforated appendicitis. We observed this relationship with our own studies. Methods The patients, who underwent appendectomy, were retrospectively categorized as perforated and non-perforated based on their files. Those with a total bilirubin (TB) 1.20 mg/dL or less were considered normal whereas those with a 1.21 mg/dL or higher were considered having a high. Those with a direct bilirubin (DB) 0.50 mg/dL or less were considered normal whereas those with a 0.51 mg/dL or higher were considered having a high. The patients were assessed under two groups. Perforated appendicitis (PA) and non-perforated appendicitis (NPA) were analyzed according to the TB in Group 1 and the DB in Group 2. Results Group 1 included 269 patients whose TB were measured. Of those, 218 had NPA and 51 had PA. The rate of patients with high TB among the patients with PA was 1.37 times higher than those with NPA (p ˂ 0.01). Group 2 included 258 patients whose DB values were measured. Of those, 208 had NPA and 50 had PA. The rate of patients with high TB among the patients with PA was 1.71 times higher than those with NPA (p ˂ 0.001). Conclusion In the diagnosis of PA, both TB and DB show low diagnostic values. In the diagnosis, they can only be considered as a supportive factor to other parameters. However, in the case of a differential diagnosis, we recommend using DB since it has a higher sensitivity and specificity.
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Affiliation(s)
- Murat Kanlioz
- General Surgery, Beylikdüzü Kolan Hospital, Istanbul, TUR
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Wong DC, Relton SD, Lane V, Ismail M, Goss V, Bytheway J, West RM, Deuchars J, Sutcliffe J. Bedside breath tests in children with abdominal pain: a prospective pilot feasibility study. Pilot Feasibility Stud 2019; 5:121. [PMID: 31720000 PMCID: PMC6833160 DOI: 10.1186/s40814-019-0502-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 09/16/2019] [Indexed: 01/30/2023] Open
Abstract
Background There is no definitive method of accurately diagnosing appendicitis before surgery. We evaluated the feasibility of collecting breath samples in children with abdominal pain and gathered preliminary data on the accuracy of breath tests. Methods We conducted a prospective pilot study at a large tertiary referral paediatric hospital in the UK. We recruited 50 participants with suspected appendicitis, aged between 5 and 15 years. Five had primary diagnosis of appendicitis. The primary outcome was the number of breath samples collected. We also measured the number of samples processed within 2 h and had CO2 ≥ 3.5%. Usability was assessed by patient-reported pain pre- and post-sampling and user-reported sampling difficulty. Logistic regression analysis was used to predict appendicitis and evaluated using the area under the receiver operator characteristic curve (AUROC). Results Samples were collected from all participants. Of the 45 samples, 36 were processed within 2 h. Of the 49 samples, 19 had %CO2 ≥ 3.5%. No difference in patient-reported pain was observed (p = 0.24). Sampling difficulty was associated with patient age (p = 0.004). The logistic regression model had AUROC = 0.86. Conclusions Breath tests are feasible and acceptable to patients presenting with abdominal pain in clinical settings. We demonstrated adequate data collection with no evidence of harm to patients. The AUROC was better than a random classifier; more specific sensors are likely to improve diagnostic performance. Trial registration ClinicalTrials.gov, NCT03248102. Registered 14 Aug 2017.
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Affiliation(s)
- David C Wong
- 1Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Samuel D Relton
- 2Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Mohamed Ismail
- 2Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria Goss
- 4Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Robert M West
- 2Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jim Deuchars
- 6School of Biomedical Sciences, University of Leeds, Leeds, UK
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Cui W, Liu H, Ni H, Qin X, Zhu L. Diagnostic accuracy of procalcitonin for overall and complicated acute appendicitis in children: a meta-analysis. Ital J Pediatr 2019; 45:78. [PMID: 31288826 PMCID: PMC6617950 DOI: 10.1186/s13052-019-0673-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/03/2019] [Indexed: 12/29/2022] Open
Abstract
Background Diagnostic value of procalcitonin (PCT) for acute appendicitis (AA) has been evaluated in adult patients, but the application in children remains controversial. The aim of this study was to evaluate the diagnostic value of PCT for overall and complicated AA in children. Methods The PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Chinese National Knowledge Infrastructure, and Wanfang were searched along with reference lists of relevant articles up to January 2018 without language restrictions. Original articles that reported the performance of PCT in the diagnosis of pediatric AA and associated complications were selected. To assess the diagnostic value of PCT, sensitivity, specificity, diagnostic odds ratios (DORs), summary receiver operating characteristic (ROC) curves, area under the curve (AUC), and 95% confidence intervals (95% CIs) were estimated. Results Seven qualifying studies (504 confirmed AA and 368 controls) from 6 countries for overall AA and 4 studies (187 complicated AA and 185 uncomplicated AA) for complicated AA from 3 countries were identified. The pooled sensitivity and specificity of PCT for the diagnosis of pediatric AA were 0.62 (95% CI: 0.57–0.66) and 0.86 (95% CI: 0.82–0.89), respectively. The DOR was 21.4 (95% CI: 3.64–126.1) and the AUC was 0.955. PCT was more accurate in diagnosing complicated appendicitis, with a pooled sensitivity of 0.89 (95% CI: 0.84–0.93), specificity of 0.90 (95% CI: 0.86–0.94), and DOR of 76.73 (95% CI: 21.6–272.9). Conclusion This meta-analysis showed that PCT may have potential value in diagnosing pediatric AA. Moreover, PCT had greater diagnostic value in identifying pediatric complicated appendicitis.
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Affiliation(s)
- Wei Cui
- Department of Scientific Research and Education, Anhui Provincial Children's Hospital, Wangjiang Road, Hefei, 230051, Anhui, China.,Anhui Institute of Pediatric Research, Hefei, Anhui, China
| | - Haipeng Liu
- Department of Scientific Research and Education, Anhui Provincial Children's Hospital, Wangjiang Road, Hefei, 230051, Anhui, China. .,Anhui Institute of Pediatric Research, Hefei, Anhui, China.
| | - Hong Ni
- Department of Scientific Research and Education, Anhui Provincial Children's Hospital, Wangjiang Road, Hefei, 230051, Anhui, China.,Anhui Institute of Pediatric Research, Hefei, Anhui, China
| | - Xianhui Qin
- National Clinical Research Center for Kidney Disease; State Key Laboratory for Organ Failure Research; Renal Division, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liran Zhu
- Department of Scientific Research and Education, Anhui Provincial Children's Hospital, Wangjiang Road, Hefei, 230051, Anhui, China.,Anhui Institute of Pediatric Research, Hefei, Anhui, China
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Güzel M, Aktimur R, Yıldırım K, Aktimur SH, Taşkın MH, Demir MC, Demirağ MD. The evaluation of ENA-78 and fibrinogen levels for the differential diagnosis of familial Mediterranean fever and acute appendicitis. J LAB MED 2019. [DOI: 10.1515/labmed-2018-0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Familial Mediterranean fever (FMF) is a disorder mainly present in the Mediterranean region, characterized by abdominal attacks that mimic acute peritonitis. Therefore, FMF might be confused with other conditions presenting with acute abdominal pain, particularly acute appendicitis (AA). We aimed to evaluate whether epithelial-derived neutrophil-activating peptide-78 (ENA-78) and fibrinogen levels and white blood cell (WBC) counts could be used as potential markers in the differential diagnosis of acute FMF attacks and AA.
Methods
The study involved three groups: patients with AA who underwent surgery (group 1, n = 30), patients with FMF attacks (group 2, n = 30), and patients with FMF who were attack-free (n = 30, controls), which included patients who were diagnosed as having FMF previously but had no attacks for a month.
Results
Significant differences were detected in the ENA-78 and fibrinogen levels between group 1 and group 2. No significant difference was found in the WBC count between group 1 and group 2. It was concluded that the WBC count was more sensitive (66%) for group 1, and fibrinogen showed higher sensitivity (86%) and specificity (96%) for group 2 compared with the other parameters.
Conclusions
We suggest that AA can be distinguished in patients with signs of peritonitis who were diagnosed as having FMF previously with the use of ENA-78 and fibrinogen levels; fibrinogen and ENA-78 might be helpful in discriminating between FMF attacks and AA.
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50
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Li Y, Zhang Z, Cheang I, Li X. Procalcitonin as an excellent differential marker between uncomplicated and complicated acute appendicitis in adult patients. Eur J Trauma Emerg Surg 2019; 46:853-858. [PMID: 31087109 DOI: 10.1007/s00068-019-01116-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022]
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