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Bravo M, Palnizky-Soffer G, Man C, Moineddin R, Singer-Harel D, Zani A, Doria AS, Schuh S. Identification of children with a nondiagnostic ultrasound at a low appendicitis risk using a pediatric Appendicitis Risk Calculator. Acad Emerg Med 2024; 31:1256-1263. [PMID: 39034602 DOI: 10.1111/acem.14990] [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: 05/14/2024] [Revised: 06/19/2024] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES Up to 50% of ultrasounds (USs) for suspected pediatric appendicitis are nondiagnostic. While the validated low-risk clinical pediatric Appendicitis Risk Calculator (pARC) score < 15% and the low-risk US with nonvisualized appendix and no periappendiceal inflammation carry relatively low appendicitis risks, the contribution of the combination of both characteristics to this risk has never been assessed. The primary objective was to determine the proportion of children with the low-risk US-low-risk pARC combination with appendicitis. We hypothesized that this proportion would be 2.5% (upper 95% CI ≤ 5%). METHODS A retrospective cohort study of 448 previously healthy children 4-17 years old at a pediatric ED with suspected appendicitis, nondiagnostic US, and persistent clinical concern about appendicitis. Two investigators abstracted demographic, clinical, and imaging data. Based on published criteria, USs were classified as low-risk or high-risk. The pARC includes seven demographic, clinical, and laboratory variables and is quantified according to the published formula. The primary outcome was appendicitis, based on the histological evidence. All nonoperated patients underwent a 1-month-follow-up to exclude delayed appendicitis diagnoses. RESULTS Sixty of the 448 (13.4%) patients had appendicitis; 269 (60%) had low-risk US, 262 (58.4%) had low-risk pARC, and 163 (36.4%) had both characteristics. The appendicitis rates with low-risk pARC alone and low-risk US alone were 14/262 (5.4%) and 21/269 (7.8%), respectively. A total of 2/163 children (1.2%) with low-risk pARC and low-risk US had appendicitis (95% CI 0%-4.4%). Higher-risk US increased the appendicitis odds 5 (95% CI 1.54-20.55) to 11 times (95% CI 2.41-51.10) across pARC levels. The low-risk combination had sensitivity of 96.7% (95% CI 88.5%-99.6%), specificity of 41.5%, positive predictive value of 20.4%, and negative predictive value of 98.8% (95% CI 95.6%-99.9%). CONCLUSIONS The children with low-risk pARC and low-risk US combination are unlikely to have appendicitis and can be discharged home. The presence of higher-risk US-pARC score combinations substantially increases the appendicitis risk and warrants reassessment or interval imaging.
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Affiliation(s)
- Michael Bravo
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gili Palnizky-Soffer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carina Man
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Augusto Zani
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
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Vig A, Sinha A, Yadav T, Krishnamurthy S, Bhatt S, Rathod KJ, Pathak M, Saxena R, Khera PS. Can Ultrasound Spot the Culprit - Evaluating the Effectiveness of Ultrasonography in Precisely Diagnosing Acute Appendicitis in Children. J Indian Assoc Pediatr Surg 2024; 29:479-483. [PMID: 39479427 PMCID: PMC11521236 DOI: 10.4103/jiaps.jiaps_89_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 11/02/2024] Open
Abstract
Introduction Acute appendicitis is a common surgical emergency in children, often requiring imaging for confirmation due to diverse presentations. While computed tomography scan is favored in many centers for its sensitivity, it comes with radiation exposure and higher costs. Ultrasonography, being radiation-free and cost-effective, is gaining popularity, especially in pediatric cases. However, its reported accuracy varies in the literature. This study aims to evaluate the diagnostic accuracy of ultrasonography in pediatric appendicitis cases and to determine its precision in distinguishing between simple and complicated cases of appendicitis. Materials and Methods A retrospective analysis was conducted on children with suspected appendicitis who presented to the department of pediatric surgery. All patients underwent ultrasonography followed by appendicectomy based on considered clinical decision. Ultrasonography findings were compared with intraoperative observations categorized as uncomplicated or complicated appendicitis. Results Among 152 patients, ultrasonography accurately diagnosed appendicitis in 94.6% of cases, with 5.38% having nonvisualized appendices. In our group, the sensitivity and specificity of ultrasound to detect appendicitis were 94.62% and 95.65%, respectively. The diagnostic accuracy of the test is 95.63%. However, in our study, the sensitivity of the ultrasonography to correctly identify if it is a simple or complicated appendicitis was only 54.9% but had a specificity of 98.7%. Thus, ultrasonography showed a much lower sensitivity (54.9%) in distinguishing between simple and complicated appendicitis. Conclusion Ultrasonography demonstrates high sensitivity and specificity in diagnosing pediatric appendicitis, making it a promising preoperative investigation. However, it may not accurately differentiate between simple and complicated cases. A comprehensive approach involving clinical and laboratory parameters alongside secondary imaging may be necessary for accurate diagnosis, especially in cases of perforated appendicitis.
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Affiliation(s)
- Ayushi Vig
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Arvind Sinha
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shreyas Krishnamurthy
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Somya Bhatt
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Kirtikumar J. Rathod
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Manish Pathak
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rahul Saxena
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pushpinder Singh Khera
- Department of Pediatric Surgery and Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Becker CR, Bergmann KR, Vazquez‐Benitez G, Bretscher BM, Kharbanda AB. Resource utilization and outcomes among children risk stratified by pediatric appendicitis risk calculator at a tertiary pediatric center. Acad Emerg Med 2022; 29:415-422. [PMID: 34942048 DOI: 10.1111/acem.14433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/08/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Appendicitis is a common pediatric condition requiring surgery. The pediatric appendicitis risk calculator (pARC) was recently developed to guide clinical care. The objective of this study is to describe resource utilization and clinical outcomes among children with appendix ultrasound (US) scans risk stratified by pARC score. METHODS Prospective enrolled observational cohort single-center study of children aged 5-18, who had an US for suspected appendicitis. We estimated the rate of appendicitis, rate of equivocal US scans, and resource utilization by pARC score strata. Total adjusted charges were determined for low-risk pARC patients compared to discharged emergency department (ED) patients with abdominal pain and complete blood count (CBC) obtained without advanced abdominal imaging. RESULTS Over the 13-month study period, 407 children were enrolled. The overall rate of appendicitis was 33.4%, and 199 (49%) were male. The observed rate of appendicitis was 3.3% in those with a pARC score of <15% and 96.8% in those with a pARC score of ≥85%. Of enrolled patients, 152 (37.3%) had a pARC score <15%. Of those with a pARC score of <15%, the negative appendectomy rate was 28.6%, and the rate of equivocal US was 49.3%. The rate of CT scans and hospitalizations was 19% and 23%, respectively. Median total charges for patients with pARC <15% with usual care were $3756. Median total charges for patients presenting to the ED with abdominal pain who had a CBC but no advanced abdominal imaging performed was $2484, indicating a potential savings of $1272 per patient. CONCLUSIONS There is a high rate of resource utilization among patients who are low appendicitis risk by pARC score. Outcome variation by pARC scores presents future opportunity to selectively reduce resource utilization in pediatric patients.
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Affiliation(s)
- Callie R. Becker
- Division of Pediatric Emergency Medicine Department of Pediatrics M Health Fairview Masonic Children’s Hospital Minneapolis Minnesota USA
| | - Kelly R. Bergmann
- Department of Emergency Medicine Children’s Minnesota Minneapolis Minnesota USA
| | | | | | - Anupam B. Kharbanda
- Department of Emergency Medicine Children’s Minnesota Minneapolis Minnesota USA
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Predictors for Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e962-e968. [PMID: 31136455 DOI: 10.1097/pec.0000000000001840] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.
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Affiliation(s)
- Laurie Malia
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Jesse J Sturm
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Sharon R Smith
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | | | - Brendan Campbell
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Henry Chicaiza
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
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Lentz B, Fong T, Rhyne R, Risko N. A systematic review of the cost-effectiveness of ultrasound in emergency care settings. Ultrasound J 2021; 13:16. [PMID: 33687607 PMCID: PMC7943664 DOI: 10.1186/s13089-021-00216-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/19/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The use of ultrasound (US) in emergency departments (ED) has become widespread. This includes both traditional US scans performed by radiology departments as well as point-of-care US (POCUS) performed by bedside clinicians. There has been significant interest in better understanding the appropriate use of imaging and where opportunities to enhance cost-effectiveness may exist. The purpose of this systematic review is to identify published evidence surrounding the cost-effectiveness of US in the ED and to grade the quality of that evidence. METHODS We performed a systematic review of the literature following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies were considered for inclusion if they were: (1) economic evaluations, (2) studied the clinical use of ultrasound, and (3) took place in an emergency care setting. Included studies were critically appraised using the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS We identified 631 potentially relevant articles. Of these, 35 studies met all inclusion criteria and were eligible for data abstraction. In general, studies were supportive of the use of US. In particular, 11 studies formed a strong consensus that US enhanced cost-effectiveness in the investigation of pediatric appendicitis and 6 studies supported enhancements in the evaluation of abdominal trauma. Across the studies, weaknesses in methodology and reporting were common, such as lack of sensitivity analyses and inconsistent reporting of incremental cost-effectiveness ratios. CONCLUSIONS The body of existing evidence, though limited, generally demonstrates that the inclusion of US in emergency care settings allows for more cost-effective care. The most definitive evidence for improvements in cost-effectiveness surround the evaluation of pediatric appendicitis, followed by the evaluation of abdominal trauma. POCUS outside of trauma has had mixed results.
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Affiliation(s)
- Brian Lentz
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, 1411 E. 31st Street, QIC 22123, Oakland, CA, 94602, USA
| | - Tiffany Fong
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Randall Rhyne
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA.
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Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, Tsao K. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019; 54:723-727. [PMID: 29925468 DOI: 10.1016/j.jpedsurg.2018.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Kathryn Tinsley Anderson
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX.
| | - Marisa A Bartz-Kurycki
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Mary T Austin
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Akemi L Kawaguchi
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Lillian S Kao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kevin P Lally
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kuojen Tsao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
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Abstract
OBJECTIVES This study aims to investigate the optimal outer appendiceal diameter via ultrasound for the diagnosis of acute appendicitis. METHODS A retrospective chart review was conducted on patients (ages, 2-18 years) presenting to an urban pediatric emergency department between January 1, 2009 and December 31, 2010 with suspected acute appendicitis. Children were considered as having "suspected acute appendicitis" if they (1) presented with acute abdominal pain and had either a surgical consult or an abdominal ultrasound, or (2) presented or transferred with the stated suspicion of acute appendicitis. Pathology reports were used to confirm the diagnosis of appendicitis. The appendiceal diameters were determined by board-certified pediatric radiologists. RESULTS A total of 320 patient charts were reviewed (females, 57%; mean age, 10.9; SD, 3.9). Seventy-two percent (N = 230) of the patients screened positive for acute appendicitis via ultrasound, 69% (N = 222) had confirmed acute appendicitis, 75% (N = 239) of the ultrasound reports included an outer appendiceal diameter. Overall, ultrasound was found to be highly sensitive (91%) and moderately specific (74%). With an outer appendiceal diameter of 6 mm as a cutoff, ultrasound had an excellent sensitivity (100%) but poor specificity (43%). With an outer diameter of 7 mm as a cutoff, sensitivity decreased to 94% but specificity increased to 71%. With increasing cutoff size, the sensitivity decreased and specificity increased. CONCLUSIONS Our data suggest that the optimal outer appendiceal diameter for the diagnosis of acute appendicitis should be 7 mm instead of the currently used 6 mm.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix. Am J Emerg Med 2018; 37:879-883. [PMID: 30097276 DOI: 10.1016/j.ajem.2018.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/28/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.
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Affiliation(s)
- Laurie Malia
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Jesse J Sturm
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Sharon R Smith
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | | | | | - Henry Chicaiza
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
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Anderson KT, Bartz-Kurycki M, Austin MT, Kawaguchi A, John SD, Kao LS, Tsao K. Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation. J Pediatr Surg 2017; 52:1909-1915. [PMID: 28927978 DOI: 10.1016/j.jpedsurg.2017.08.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis. METHODS A multidisciplinary group (emergency medicine, radiology, and surgery) at a children's hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time. RESULTS Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs ($88, IQR $52-$169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01). CONCLUSION Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Tinsley Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Marisa Bartz-Kurycki
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Mary T Austin
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Akemi Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Susan D John
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
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Church JT, Klein EJ, Carr BD, Bruch SW. Early appendectomy reduces costs in children with perforated appendicitis. J Surg Res 2017; 220:119-124. [PMID: 29180172 DOI: 10.1016/j.jss.2017.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Perforated appendicitis can be managed with early appendectomy, or nonoperative management followed by interval appendectomy. We aimed to identify the strategy with the lowest health care utilization and cost. METHODS We retrospectively reviewed the medical records of all children ≤18 years old with perforated appendicitis admitted to a single institution between January 2009 and March 2016. After excluding immunosuppressed patients and transfers from outside hospitals, we grouped the remaining patients by early or interval appendectomy. Cost accounting data were obtained from our institutional database. The primary outcome was total hospital cost over 2 y from initial admission for appendicitis. Other outcomes analyzed included initial admission costs, number of admissions, emergency room and clinic visits, percutaneous procedures, cross-sectional and overall imaging studies, and length of stay. RESULTS A total of 203 children with perforated appendicitis were identified. After exclusion of immunosuppressed patients and outside hospital transfers, 94 patients were included in the study. Thirty-nine underwent early appendectomy and 55 initial nonoperative management; of these, 54 underwent elective interval appendectomy. Five of 55 patients (9%) failed initial nonoperative management and required earlier-than-planned appendectomy. Total cost over 2 y was significantly lower with early appendectomy than initial nonoperative management ($19,300 ± 14,300 versus $26,000 ± 17,500; P = 0.05). Early appendectomy resulted in fewer hospital admissions, clinic visits, invasive procedures, and imaging studies. CONCLUSIONS Early appendectomy results in lower hospital costs and less health care utilization compared with initial nonoperative management with elective interval appendectomy. A prospective study will shed more light on this question and can assess the role of nonoperative management without interval appendectomy in children with perforated appendicitis.
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Affiliation(s)
- Joseph T Church
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.
| | - Edwin J Klein
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin D Carr
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven W Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg 2016; 51:1939-1943. [PMID: 27670963 DOI: 10.1016/j.jpedsurg.2016.09.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study appraises the diagnostic quality of ultrasound for acute appendicitis in children and consequently challenges the perception of inferior accuracy and suitability compared to computed tomography (CT). METHODS Radiologist reports for consecutive "query appendicitis" ultrasound studies were retrieved from a hospital database for the study period 2009-2014. Children who subsequently underwent appendicectomy were identified. Corresponding operative and histopathology findings were evaluated. Diagnostic accuracy of ultrasound was determined by analyzing overall accuracy, sensitivity, specificity, predictivity, and likelihood ratios. RESULTS A total of 3799 ultrasound examinations were evaluated. Mean age was 11.5±3.8years. The proportion of patients investigated with preoperative ultrasound was 59.9% (1103/1840). Appendix visualization rate was 91.7%. Overall diagnostic accuracy was 95.5%. Sensitivity and specificity values were 97.1% (95.9-98.1; 95% CI) and 94.8% (93.9-95.6; 95% CI), respectively. Separate analysis of only ultrasound positive and negative examinations (i.e., excluding nondiagnostic examinations) confirmed sensitivity and specificity values of 98.8% and 98.3%. CONCLUSION In this largest reported single institution series of ultrasound examinations for appendicitis, we report benchmark standard quality of diagnostic accuracy and visualization rates. Given the radiation and cost implications of CT, there is a strong argument to recommend ultrasound as the primary imaging modality. Diagnostic Study-Level II.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia; Discipline of Surgery, University of Adelaide, South Australia.
| | - Roger Gent
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Claire Frauenfelder
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia
| | - Laura Lukic
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Rebecca J Linke
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia; Discipline of Paediatrics, School of Medicine, University of Adelaide, South Australia
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12
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Appendiceal diameter: CT versus sonographic measurements. Pediatr Radiol 2016; 46:316-21. [PMID: 26573824 DOI: 10.1007/s00247-015-3491-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 08/20/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ultrasound and CT are the dominant imaging modalities for assessment of suspected pediatric appendicitis, and the most commonly applied diagnostic criterion for both modalities is appendiceal diameter. The classically described cut-off diameter for the diagnosis of appendicitis is 6 mm when using either imaging modality. OBJECTIVE To demonstrate the fallacy of using the same cut-off diameter for both CT and US in the diagnosis of appendicitis. MATERIALS AND METHODS We conducted a retrospective review of patients younger than 18 years who underwent both US and CT of the appendix within 24 h. The shortest transverse dimension of the appendix was measured at the level of the proximal, mid and distal appendix on US and CT images. We compared mean absolute difference in appendiceal diameter between US and CT, using the paired t-test. RESULTS We reviewed exams of 155 children (58.7% female) with a mean age of 11.3 ± 4.2 years; 38 of the children (24.5%) were diagnosed with appendicitis. The average time interval between US and CT was 7.0 ± 5.4 h. Mean appendiceal diameter measured by CT was significantly larger than that measured by US in cases without appendicitis (5.3 ± 1.0 mm vs. 4.7 ± 1.1 mm, P < 0.0001) and in cases with appendicitis (8.3 ± 2.2 mm vs. 7.0 ± 2.0 mm, P < 0.0001). Mean absolute diameter difference at any location along the appendix was 1.3-1.4 mm in normal appendices and 2 mm in cases of appendicitis. CONCLUSION Measured appendiceal diameter differs between US and CT by 1-2 mm, calling into question use of the same diameter cut-off (6 mm) for both modalities for the diagnosis of appendicitis.
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Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol 2015; 45:1945-52. [PMID: 26280638 DOI: 10.1007/s00247-015-3443-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/28/2015] [Accepted: 07/15/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND To facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis. OBJECTIVE The purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis. MATERIALS AND METHODS In this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates. RESULTS We identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation - only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8). CONCLUSION A scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children's hospital and stratifies risk for children based on their likelihood of appendicitis.
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Improvement in diagnostic accuracy of ultrasound of the pediatric appendix through the use of equivocal interpretive categories. AJR Am J Roentgenol 2015; 204:849-56. [PMID: 25794076 DOI: 10.2214/ajr.14.13026] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The purpose of this article is to evaluate the diagnostic performance of ultrasound of the pediatric appendix using standardized structured reports that incorporate equivocal interpretive categories. MATERIALS AND METHODS Standardized structured appendix ultrasound reports using a five-category interpretive scheme were reviewed. Interpretive categories were positive, intermediate likelihood, or negative when the appendix was visualized, and secondary signs or no secondary signs when the appendix was not visualized. Interpretations were compared with clinical and pathologic follow-up. Diagnostic accuracy was compared with the accuracy of a simulated binary interpretive scheme based on the same data. RESULTS One thousand three hundred fifty-seven examinations were included, with appendicitis present in 16.9% (230/1357) of cases. The appendix was visualized in 47.2% (641/1357) of cases, with interpretations as follows: positive, 27.5% (176/641); intermediate likelihood, 9.7% (62/641); and normal, 62.9% (403/641). The appendicitis rate in each group was 92.6% (163/176), 25.8% (16/62), and 0.5% (2/403), respectively. The appendix was not visualized in 52.8% (716/1357) of cases, with secondary findings identified in 8.5% (61/716) and no secondary findings in 91.5% (655/716) of cases. The appendicitis rate was 39.3% (24/61) and 3.8% (25/655) in these groups, respectively. Appendicitis was present in 32.5% of equivocal (intermediate likelihood and not visualized, secondary findings) cases and 2.6% of negative (normal and not visualized, no secondary findings) cases. Diagnostic accuracy of a five-category scheme was 96.8% versus 94.1% for a binary scheme. CONCLUSION Appendix ultrasound examinations interpreted according to a scheme that incorporates equivocal categories better convey diagnostic certainty and increase diagnostic accuracy compared with a binary interpretive scheme.
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Prendergast PM, Poonai N, Lynch T, McKillop S, Lim R. Acute appendicitis: investigating an optimal outer appendiceal diameter cut-point in a pediatric population. J Emerg Med 2013; 46:157-64. [PMID: 24113477 DOI: 10.1016/j.jemermed.2013.08.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 04/25/2013] [Accepted: 08/14/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute appendicitis is the most common cause of abdominal pain in children requiring operative intervention. Among a number of sonographic criteria to aid in the diagnosis of appendicitis, an outer diameter >6 mm is the most objective and widely accepted. However, there is a lack of evidence-based standards governing this consensus. STUDY OBJECTIVES The aim of this study was to determine the outer appendiceal diameter that maximizes sensitivity and specificity in a pediatric population. METHODS A retrospective review of all urgent diagnostic ultrasounds (US) was performed over 2 years in children aged <18 years. The diagnostic accuracy of various cut-points was assessed by calculating the sensitivity and specificity and plotting a receiver operating characteristic (ROC) curve. RESULTS The study sample consisted of 398 patients in whom the appendix was visualized on US. The median outer appendiceal diameter was significantly higher in the surgical group compared to the nonsurgical group (9.4 mm; range = 8.1-12.0 vs. 5.5 mm; range = 4.4-6.5, p < 0.01). The optimal cut-point with the greatest area under the ROC curve was determined to be an outer appendiceal diameter of 7.0 mm. CONCLUSIONS In our patients, adopting a 7-mm rather than a 6-mm appendiceal diameter threshold would balance a greater number of missed cases of acute appendicitis for a reduction in the number of unnecessary surgeries.
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Affiliation(s)
- Patrick M Prendergast
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Naveen Poonai
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Pediatrics and Medicine, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Tim Lynch
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Pediatrics and Medicine, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Scott McKillop
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Medical Imaging and Radiology, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Rodrick Lim
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Pediatrics and Medicine, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada.
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Thirumoorthi AS, Fefferman NR, Ginsburg HB, Kuenzler KA, Tomita SS. Managing radiation exposure in children--reexamining the role of ultrasound in the diagnosis of appendicitis. J Pediatr Surg 2012; 47:2268-72. [PMID: 23217887 DOI: 10.1016/j.jpedsurg.2012.09.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 09/01/2012] [Indexed: 01/03/2023]
Abstract
PURPOSE To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children. METHODS A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18 years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate. RESULTS Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%). CONCLUSIONS US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.
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Affiliation(s)
- Arul S Thirumoorthi
- Division of Pediatric Surgery, Department of Surgery, New York University Medical Center, New York, NY 10016, USA.
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A critical evaluation of US for the diagnosis of pediatric acute appendicitis in a real-life setting: how can we improve the diagnostic value of sonography? Pediatr Radiol 2012; 42:813-23. [PMID: 22402833 DOI: 10.1007/s00247-012-2358-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 12/15/2011] [Accepted: 12/22/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND We have observed that day-to-day use of US for acute appendicitis does not perform as well as described in the literature. OBJECTIVE Review the diagnostic performance of US in acute appendicitis with attention to factors that influence performance. MATERIALS AND METHODS Retrospective review of all sonograms for acute appendicitis in children from May 2005 to May 2010 with attention to the rate of identification of the appendix, training of personnel involved and diagnostic accuracy. RESULTS The appendix was identified in 246/1,009 cases (24.4%), with identification increasing over time. The accuracy of US was 85-91% with 35 false-positives and 54 false-negatives. Pediatric sonographers were significantly better at identifying the appendix than non-pediatric sonographers (P < 0.0001). Increased weight was the only patient factor that influenced identification of the appendix (P = 0.006). CT use was stable over the 5 years but declined in cases where the appendix was identified by US. CONCLUSION In day-to-day use, US does not perform as purported in the literature. We do not visualize the appendix as often as we should and false-negative and false-positive exams are too common. To improve the diagnostic performance of this modality, involvement by experienced personnel and/or additional training is needed.
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18
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Dennett KV, Tracy S, Fisher S, Charron G, Zurakowski D, Calvert CE, Chen C. Treatment of perforated appendicitis in children: what is the cost? J Pediatr Surg 2012; 47:1177-84. [PMID: 22703790 DOI: 10.1016/j.jpedsurg.2012.03.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 03/06/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE We compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children. METHODS From June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy. RESULTS Patients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies. CONCLUSIONS Patients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.
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Affiliation(s)
- Kate V Dennett
- Department of Surgery, Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
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19
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Yiğiter M, Kantarci M, Yalçin O, Yalçin A, Salman AB. Does obesity limit the sonographic diagnosis of appendicitis in children? JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:187-190. [PMID: 21480284 DOI: 10.1002/jcu.20782] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 10/15/2010] [Indexed: 05/30/2023]
Abstract
PURPOSE The purpose of this study is to evaluate whether obesity has a negative impact on the ultrasound (US) visualization of the appendix in children clinically diagnosed with appendicitis. METHODS The medical records and US examinations of 122 children who underwent surgery due to acute or perforated appendicitis between February 2007 and January 2010 were reviewed. The body mass index (BMI) of each child was calculated and children were placed in one of three categories: group 1, underweight (BMI <10th percentile); group 2, normal weight (BMI between 10th and 85th percentiles); and group 3, overweight (BMI >85th percentile). US findings were classified as nonvisualized, normal, or inflamed appendix. The visualization rates of the appendix were compared between the three groups and the diagnostic accuracy of the US examination was calculated based on the histopathological results for each group. RESULTS There was no statistical difference between the three groups with regard to the visualization of the appendix by US. Diagnostic accuracy of US was 90.4%, 80.5%, and 80% in group 1, group 2, and group 3, respectively. CONCLUSION The findings of our study, in contrast to the findings of other reported studies, demonstrate that obesity does not affect the success rate of US in the visualization of the inflamed appendix in children.
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Affiliation(s)
- Murat Yiğiter
- Department of Pediatric Surgery, Ataturk University Faculty of Medicine, Erzurum 25240, Turkey
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COBBEN LP, BAKKER OJ, PUYLAERT JB, KINGMA LM, BLICKMAN JG. Imaging of patients with clinically suspected appendicitis in the Netherlands: conclusions of a survey. Br J Radiol 2009; 82:482-5. [DOI: 10.1259/bjr/31522537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Cobben L, Groot I, Kingma L, Coerkamp E, Puylaert J, Blickman J. A simple MRI protocol in patients with clinically suspected appendicitis: results in 138 patients and effect on outcome of appendectomy. Eur Radiol 2009; 19:1175-83. [PMID: 19137303 DOI: 10.1007/s00330-008-1270-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2008] [Accepted: 10/26/2008] [Indexed: 02/07/2023]
Abstract
To establish the value of breathhold magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis. Over a 14-month period, 138 patients clinically suspected of having appendicitis were evaluated prospectively with MRI and comprised the study group. Fast turbo spin-echo breathhold T1, T2 and T2 fat suppression sequences were used in coronal and axial planes. The imaging results were recorded separately and subsequently correlated with clinical, radiological and histopathological follow-up. The effect of imaging strategies in patients suspected of appendicitis on hospital resources was calculated. Sixty-two of the 138 patients had a histopathologically proven appendicitis. MRI determined appendicitis in 63 patients, with one examination being false positive. The resulting sensitivity and specificity were 100% and 99%, respectively. MRI showed an alternative diagnosis in 41 of the 75 remaining patients. In 22 of the remaining 34 patients, a normal appendix was depicted with MRI. In two patients, where MRI showed no appendicitis, an alternative diagnosis or normal appendix, an unnecessary appendectomy was performed. The overall effect of using MRI in patients suspected of appendicitis on the use of hospital resources could have been a net saving between 55,746 euros and 72,534 euros. MRI has a high accuracy in detecting and excluding appendicitis, an alternative diagnosis or showing the normal appendix, and can be a valuable and cost-effective tool in the workup of patients clinically suspected of having appendicitis.
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Affiliation(s)
- Lodewijk Cobben
- Department of Radiology, Medisch Centrum Haaglanden, Burgemeester Banninglaan 1, 2262BA Leidschendam, The Netherlands.
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Costo-efectividad de la tomografía computarizada y la ecografía en el diagnóstico de apendicitis. BIOMEDICA 2008. [DOI: 10.7705/biomedica.v28i1.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Affiliation(s)
- G Chéron
- Département des urgences pédiatriques, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France.
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Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: a survey of North American Pediatric Surgeons. J Pediatr Surg 2004; 39:875-9; discussion 875-9. [PMID: 15185217 DOI: 10.1016/j.jpedsurg.2004.02.035] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND/PURPOSE Variation exists among pediatric surgeons in the management of pediatric appendicitis. The goal of this study was to determine current practice patterns and provide a foundation for evidence-based outcome studies that would standardize patient care. METHODS Members of the American Pediatric Surgical Association (APSA) were surveyed. Data included preference of imaging, timing of operation, and opinions on interval appendectomy. Intraoperative principles surveyed included use of cultures, antibiotic irrigation, transperitoneal drains, and method of wound closure. Spectrum and duration of antibiotic coverage were assessed, as were discharge criteria. RESULTS Survey response was 70%. A majority prefers computerized tomographic (CT) imaging and favors interval appendectomy in appropriate candidates. Seventy percent indicate a stable child with suspected appendicitis would be operated on in a semiurgent manner rather than emergently in their practice. Discrepancy exists in the type and duration of antibiotic coverage, impact of clinical parameters on antibiotic use, and utility of discharge criteria. CONCLUSIONS This study consolidates current opinions on appropriate management of pediatric appendicitis, providing a foundation for evidence-based outcome studies capable of bringing conformity to the management of this surgical disease. Such studies would establish clinical practice guidelines that optimize resource utilization while maintaining quality care.
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Affiliation(s)
- Steven G Muehlstedt
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
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Puig S, Hörmann M, Rebhandl W, Felder-Puig R, Prokop M, Paya K. US as a primary diagnostic tool in relation to negative appendectomy: six years experience. Radiology 2003; 226:101-4. [PMID: 12511675 DOI: 10.1148/radiol.2261011612] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate the effect of ultrasonography (US) on the rate of appendectomy after false-positive diagnosis of acute appendicitis (negative appendectomy). MATERIALS AND METHODS Data were analyzed in 736 pediatric patients (mean age, 13.2 years) who had undergone appendectomy between 1995 and 2000. Histologic data were compared in patients who underwent US with those who did not undergo imaging prior to surgery. US was performed by a radiologist or a pediatric surgeon or both. RESULTS A total of 643 (87.4%) of the 736 pediatric patients underwent preoperative US, and 93 (12.6%) of the 736 did not undergo preoperative US. Of the 736 patients, 97 (13.2%) underwent negative appendectomy. Thirty-four (36.6%) of the 93 patients who underwent appendectomy with no preoperative US and 63 (9.8%) of the 643 patients who underwent preoperative US underwent negative appendectomy. There was a significant association between US and positive appendectomy (P <.001). CONCLUSION US in pediatric patients suspected of having appendicitis can significantly lower the negative appendectomy rate.
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Affiliation(s)
- Stefan Puig
- Department of Radiology, University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Abstract
AIM: To re-evaluate the algorithm that has been used for over 40 years for diagnosis of acute abdominal pain among children.
METHODS: Among the 937 cases admitted to the surgical emergency ward in 2000, 656 cases of acute appendicitis were studied to evaluate the usefulness of the present algorithm for its calculated accuracy, false positive and false negative rates, the sensitivity and specificity in the instant diagnosis of various types of acute appendicitis in different age groups. The algorithm used was established in 1958 and revised for this study in 1999. It includes a 3-step analysis of clinical presentations, i.e.: firstly, a diagnosis of surgical pain by definite organic abdominal signs; then a diagnosis of the subgroup of surgical condition by special signs; and finally the diagnosis of the present disease by specific signs. A footnote describes a "comparative technique" of abdominal examination in non-cooperative children.
RESULTS: The general accuracy of diagnosis was 92.8%, overall mortality 0.1% among 973 cases of abdominal pain in 2000.373 attending surgeons and 241 residents including trainees joined the diagnosis and treatment with no remarkable difference in the results. The incidence of acute appendicitis, 656 in 973 cases, was 67.4% representing the majority of abdominal pain. In the series of 656 cases, the accuracy of diagnosis of acute appendicitis was 93.6%, false positive 6.4%, false negative 0.9%, sensitivity at first visit 82.7%, specificity for appendicitis 98.0%, no death or documentary complication.
CONCLUSION: The present algorithm used for diagnosis of acute abdominal pain is effective and preferable in reducing misdiagnosis and maltreatment at emergency. The use of some modern technology should be further explored.
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Affiliation(s)
- Hong Zhou
- Department of Pediatric Surgery, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing 100045, China.
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Guillerman RP, Brody AS, Kraus SJ. Evidence-based guidelines for pediatric imaging: the example of the child with possible appendicitis. Pediatr Ann 2002; 31:629-40. [PMID: 12389367 DOI: 10.3928/0090-4481-20021001-07] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- R Paul Guillerman
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
Decision making in medicine requires choosing the option that best maximizes benefit while minimizing risk and cost. Even though uncertainty is an inherent feature of any clinical issue, clinicians and policy makers frequently are required to evaluate the best evidence and make therapeutic or policy decisions based on that evidence. Decision analysis is a quantitative approach to decision making under conditions of uncertainty that can be applied to specific types of clinical problems. This method disaggregates a complex clinical problem into its most important components that then can be understood more easily and analyzed quantitatively. Decision analysis has many potential applications in medicine and can be applied to solve specific clinical problems, analyze health care costs, or develop health care policies. In this review, the basic methods for constructing and analyzing decision analyses will be presented, and specific applications of this method to pediatric surgery will be discussed.
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Affiliation(s)
- Randall S Burd
- Division of Pediatric Surgery, Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
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