Nuevo sistema de calificación diagnóstica para apendicitis pediátrica basado en parámetros hematológicos ajustados por edad y sexo / A novel diagnostic scoring system for pediatric appendicitis based on age and sex-adjusted hematological parameters

Resumen Antecedentes: El diagnóstico de apendicitis aguda representa un reto en pacientes pediátricos. Objetivo: Establecer la importancia del índice neutrófilos-linfocitos (INL), índice plaquetas-linfocitos (IPL) y otros parámetros hematológicos ajustados por edad y sexo en la predicción de apendicitis aguda, así como describir un nuevo sistema de calificación. Material y métodos: Se analizaron retrospectivamente expedientes clínicos de 946 niños hospitalizados por apendicitis aguda. Se desarrolló un sistema de calificación basado en INL, IPL, ILM y proteína C reactiva (PCR) ajustados por edad y sexo. Resultados: Los pacientes se dividieron en grupo I de exploración negativa y grupo II de apendicitis aguda; las medias de edad correspondientes fueron 12.20 ± 2.31 y 11.56 ± 3.11. El recuento leucocitario, porcentaje de neutrófilos, INL, IPL, ILM y PCR fueron superiores en el grupo II. La calificación osciló entre 0 y 8 puntos; se determinó que 4.5 fue el mejor punto de corte para apendicitis aguda con mayor área bajo la curva (0.96), sensibilidad (94 %), especificidad (86 %), valor predictivo positivo (97.5 %), valor predictivo negativo (65 %), precisión (92.6 %) y tasa de clasificación errónea (7.4 %). Conclusión: El sistema de calificación que se propone, calculado por edad y sexo de los pacientes, se puede utilizar para evitar cirugías innecesarias.

Abstract Background: Acute appendicitis diagnosis can sometimes be a real challenge in pediatric patients. Objective: To establish the importance of neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and other hematological parameters adjusted for age and sex in the prediction of acute appendicitis, as well as to describe a new scoring system. Material and methods: Medical records of 946 children hospitalized for acute appendicitis were retrospectively analyzed. A scoring system based on NLR, PLR, lymphocyte/monocyte ratio (LMR), and C-reactive protein (CRP) adjusted for age and sex was developed. Results: Patients were divided into group I, with negative examination, and group II, with acute appendicitis; mean ages were 12.20 ± 2.31 and 11.56 ± 3.11, respectively. Leukocyte count, neutrophil percentage, NLR, PLR, LMR and PCR were higher in group II. The scores ranged from 0 to 8 points; 4.5 was determined to be the best cut-off point for acute appendicitis with the highest area under the curve (0.96), sensitivity (94%), specificity (86%), positive predictive value (97.5%), negative predictive value (65%), accuracy (92.6%) and misclassification rate (7.4%). Conclusion: The proposed scoring system, calculated based on patient age and gender, can be used for unnecessary surgeries to be avoided.

Construction and application of a decision tree model for children with complicated appendicitis / 中国医师杂志

Objective:To establish a decision tree model of pediatric complicated appendicitis (CA) based on Pediatric Appendicitis Score (PAS) combined with inflammatory indicators, and to evaluate its clinical application efficacy in pediatrics.Methods:The clinical data of 544 children diagnosed with appendicitis in Children′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2018 to December 2021 was retrospectively analyzed. According to postoperative pathology, the children were divided into uncomplicated appendicitis group and CA group. The independent risk factors of CA were screened by univariate and multivariate logistic regression analysis, and these parameters were included to establish the decision tree model. The accuracy of the decision tree model was verified by receiver operating characteristic (ROC) curve.Results:Binary logistic regression analysis indicated that the PAS, C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) were identified as independent risk factors for complicated appendicitis in children (all P<0.05). PAS, CRP and NLR were included as covariables to construct the decision tree model and binary logistic regression model for predicting CA. The decision tree demonstrated an overall accuracy of 79.2% with a sensitivity of 86.7% and specificity of 71.9%, and achieved an area under curve (AUC) of 0.821(95% CI: 0.786-0.857). The binary logistic regression model had a sensitivity of 79.6% and specificity of 69.1%, with an overall accuracy of 75.1% and achieved an AUC of 0.808(95% CI: 0.770-0.845). Conclusions:The decision tree model based on PAS score combined with CRP, NLR is a simple, intuitive and effective tool , which can provide pediatric emergency physicians a reliable basis for diagnosis of pediatric CA.

Desempeño comparativo de la escala de Alvarado y la escala de apendicitis pediátrica en escolares y adolescentes

RESUMEN Introducción: La escala de Alvarado y la escala de apendicitis pediátrica se utilizan para la estratificación de pacientes pediátricos con sospecha de apendicitis. Objetivo: Comparar el desempeño diagnóstico de estas escalas en escolares y adolescentes, en general y según edad y sexo. Métodos: Estudio observacional prospectivo de 452 pacientes entre 5 y 18 años de edad, ingresados en el Hospital Pediátrico Docente Centro Habana, por dolor abdominal o apendicitis aguda, entre 2016 y 2017. Resultados: La escala de Alvarado tuvo a los 7 puntos: especificidad 96,15 %, razón de verosimilitud positiva 10,3. La escala de apendicitis pediátrica presentó a los 8 puntos: especificidad 96,15 %, razón de verosimilitud positiva 5,60. Las áreas bajo la curva fueron similares en general (0,851-0,858), siendo más altas y similares entre sí en escolares masculinos (0,918-0,923). En adolescentes femeninas, el área bajo la curva para la escala de apendicitis pediátrica (0,841) fue mayor que para la de Alvarado (0,802). Conclusiones: La escala de Alvarado resulta más específica, mientras que la escala de apendicitis pediátrica es más sensible. Se deben considerar diferentes puntos de corte para cada escala al estratificar según probable apendicitis. El desempeño discriminativo se comporta similar en general para ambas escalas, y muy bien en escolares masculinos. La mayor diferencia en desempeño ocurre en adolescentes femeninas, a favor de la escala de apendicitis pediátrica.

ABSTRACT Introduction: Alvarado scale and the pediatric appendicitis scale are used for the stratification of pediatric patients with suspected appendicitis. Objective: Compare the diagnostic performance of these scales in schoolchildren and adolescents, in general and according to age and sex. Methods: Prospective observational study of 452 patients between 5 and 18 years of age, admitted to Centro Habana Pediatric Teaching Hospital due to abdominal pain or acute appendicitis in the period 2016-2017. Results: Alvarado scale had at 7 points: specificity 96.15 %, positive likelihood ratio 10.3. The paediatric appendicitis scale presented at 8 points: specificity 96.15 %, positive likelihood ratio 5.60. The areas under the curve had a similar overall (0.851 - 0.858), being higher and similar to each other in male schoolchildren (0.918 - 0.923). In female adolescents, the area under the curve for the pediatric appendicitis scale (0.841) was greater than for Alvarado's (0.802). Conclusions: Alvarado scale is more specific, while the pediatric appendicitis scale is more sensitive. Different cut-off points should be considered for each scale when stratifying according to probable appendicitis. Discriminative performance behaves similar in general for both scales, and very well in male schoolchildren. The biggest difference in performance occurs in female adolescents, in favor of the pediatric appendicitis scale.

Primary appendectomy in appendicular masses of children: an institutional experience

Background: Early appendectomy (EA) for appendicular mass (AM) has been found to be a safer alternative in various studies in adults, while very few studies report such advantages in pediatric population. The purpose of this study was to assess the safety, efficacy and practical implications of EA in pediatric patients with AM.Methods: All patients with acute appendicitis or its complications that underwent EA between January 2016 and December 2018 were retrospectively reviewed. AM was defined if any or combination of the following criteria were satisfied with other signs of appendicitis: palpable mass in right iliac fossa (RIF), sonologically identified mass in RIF, per-operatively confirmed as a mass by surgeon.Results: 37 patients (among a total of 642 patients) were determined to have AM per-operatively and were included in the analysis. 29.7% (n=11) had a contained appendicular abscess. Age group ranged from 4-12 years (mean 7.8 years). The key per-operative findings were fecolith (21.6%), gangrenous appendix (56.8%), difficult adhesiolysis (48.6%), and full thickness bowel injury (2.7%). Postoperatively, wound infection in 9 (24.3%), intra-abdominal abscess in 1 (2.7%), prolonged ileus in 2 (5.4%) and sepsis in 2 (5.4%) were managed medically.Conclusions: EA approach in AM is a safe option in children as it avoids misdiagnosis, treats complicated appendicitis early, avoids second admission, and has shorter hospital stay with better compliance. Failures of non-operative management and potentially lethal complications of complicated appendicitis are also eliminated.

Evolution of Recent Updates Regarding Diagnosis and Management of Inflamed Appendix in Children

Background: Acute appendicitis is the most common abdominal surgical emergency in adults as well as children.Due to the peculiar anatomy of the appendix in children and the unique characteristics of this age group, acuteappendicitis frequently presents atypically, more frequently misdiagnosed, and thus should be differentlyapproached. Objective: Our aim was discussing the unique features of the appendix and acute appendicitis inchildren, and how it’s approached and managed. Methods: We searched Pubmed for acute appendicitis, children,anatomy, manifestation, diagnosis, and management. Conclusion: Acute appendicitis in the pediatric age grouphas several peculiarities when compared to adults. It frequently presents atypically, and therefore more commonlymisdiagnosed. An algorithmic approach that integrates a clinical scoring system, such as the PediatricAppendicitis Score and diagnostic studies should be followed. Moreover, when surgery is decided, thelaparoscopic approach is the standard of treatment and should be always used unless contraindicated. In brief,acute appendicitis in children is not just a smaller appendix inflamed.

La puntuación de apendicitis pediátrica en la atención primaria de salud / Pediatric Appendicitis Score in Primary Healthcare

Introducción: La apendicitis aguda es la enfermedad que mayores cirugías de urgencia demanda en el mundo y su diagnóstico adolece de uniformidad de criterios. Objetivo: Evaluar la efectividad de la puntuación de apendicitis pediátrica en la atención primaria de salud. Método: Se realizó un estudio cuantitativo, transversal de evaluación de prueba diagnóstica, con enmascaramiento doble ciego. El universo estuvo constituido 31 pacientes, de hasta quince años de edad, con diagnóstico clínico de apendicitis aguda tratados en la Policlínica Universitaria René Vallejo Ortiz, Manzanillo, Granma. A todo paciente con sospecha diagnóstica de apendicitis aguda se le aplicó la puntuación de apendicitis pediátrica antes de su remisión y evaluación por el cirujano pediatra y se determinó la capacidad diagnóstica de la puntuación. Resultados: La edad media fue 12,41 años. Predominó el sexo masculino (61,29 por ciento). El 100 por ciento, 93,55 por ciento y el 87,1 por ciento de los pacientes tuvieron un diagnóstico clínico, operatorio e histopatológico de apendicitis aguda, respectivamente en el nivel secundario de salud. La puntuación de apendicitis pediátrica tuvo una sensibilidad de 96,96 por ciento, una especificidad de 50 por ciento, un valor predictivo positivo de 92,86 por ciento y un valor predictivo negativo de 66,67 por ciento. Conclusiones: La puntuación de apendicitis pediátrica presentó patrones de sensibilidad y especificidad que la hacen recomendable para su uso en la atención primaria de salud(AU)

Introduction: Acute appendicitis is the disease demanding the biggest emergency surgeries worldwide and its diagnosis lacks criteria uniformity. Objective: To evaluate the effectiveness of the Pediatric Appendicitis Score in primary healthcare. Method: A quantitative, cross-sectional and double-masked study of diagnostic test evaluation was performed. The study population consisted of 31 patients, up to the age of fifteen years, with clinical diagnosis of acute appendicitis treated in René Vallejo Ortiz University Polyclinic of Manzanillo, Granma. All patients with suspected acute appendicitis were applied the Pediatric Appendicitis Score before referral and evaluation by the pediatric surgeon, and the diagnostic capacity of the score was determined. Results: The average age was 12.41 years. The male sex predominated (61.29 percent). 100 percent, 93.55 percent and 87.1 percent of the patients had a clinical, operative and histopathological diagnosis of acute appendicitis, respectively, at the secondary level of healthcare. The pediatric appendicitis score had sensitivity of 96.96 percent, specificity of 50 percent, a positive predictive value of 92.86 percent, and a negative predictive value of 66.67 percent. Conclusions: The Pediatric Appendicitis Score presented patterns of sensitivity and specificity that make it recommendable for usage in primary health care(AU)

A Case of Acute Appendicitis of Children which its Symptoms and Signs were Self-disappeared

Acute appendicitis is a disease resulting from inflammation of the appendix. The most common symptoms and physical examinations are the following: right lower abdomen pain, tenderness, rebound tenderness, nausea, vomiting, and fever. The clinician makes a diagnosis based on these symptoms and physicals along with ultrasonography or radiologic imaging, such as computed tomography (CT), forviewing of the inflamed appendix. In this case a seven-year-old-male visited the Emergency Room with abdominal pain and tendernessin in the right lower quadrant, whose symptoms disappeared spontaneously without treatment, although the bedside ultrasonography showed an inflamed appendix. The patient underwent surgery and the operation findings indicated a concordant diagnosis. We report this case as the cardinal symptom of acute appendicitis has been right lower quadrant pain for many years, which may lead to misdiagnosis.

Validation of clinical scoring system in the primary care of children with suspected acute appendicitis.

Objective: To establish a scoring system for the diagnosis of acute appendicitis in children in order to decrease the rate of negative and delayed appendectomies and delayed. Methods: Record charts of pediatric patients admitted with suspected appendicitis at the Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital during July 2000 - September 2001 were retrospectively reviewed. Clinical predictors were listed out and weighed as coefficients, which were later formed into a score equation. The score was then prospectively studied in the following year from October 2001-September 2002. The score was used to aid decision making in the management of cases suspected of appendicitis. The out come was compared to the conventional management based on histologically confirmed diagnosis. Results: The retrospectively collected data listed out 14 significant variables. Using logistic regression, the parameters were weighed as coefficients, which became scores to each parameter. The score was applied to a consecutive series in the following year. By using the score, the patients were categorized into three groups: discharged, observed and operated. The accuracy of the score is 85.83% with a positive predictive value of 96.55% and negative predictive value of 75.81%. From this study group, the negative appendectomy rate is 4.17% and the perforation rate is 6.67%. Compared to the previous year during which 133 children were treated under the conventional management, the negative appendectomy rate was 4.51% and the perforation rate was 21.8% Conclusion: The scoring system is an accurate diagnostic tool, which proves the importance of history taking, physical examination in coordination with laboratory investigations and close observation. Altogether these parameters can reduce the rate of misdiagnosis and delayed diagnosis of pediatric appendicitis.

A Clinical Score and Ultrasonography for the Diagnosis of Childhood Acute Appendicits

Diagnosis of acute appendicitis in children is sometimes difficult. The aim of this study is to validate a clinical scoring system and ultrasonography for the early diagnosis and treatment of appendicitis in childhood. This is a prospective study on 59 children admitted with abdominal pain at St. Mary's Hospital, the Catholic University of Korea from July 2002 to August 2003. We applied Madan Samuel's Pediatric Appendicitis Score (PAS) based on preoperative history, physical examination, laboratory finding and ultrasonography. This study was designed as follows: patients with score 5 or less were observed regardless of the positive ultrasonographic finding, patients with score 6 and 7 were decided according to the ultrasonogram and patients above score 8 were operated in spite of negative ultrasonographic finding. The patients were divided into two groups, appendicitis (group A) and non-appendicitis groups (group B). Group A consisted of 36 cases and Group B, 23 cases. Mean score of group A was 8.75 and group B was 6.13 (p<0.001). Comparing the diagnostic methods in acute appendicitis by surveying sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, PAS gave 1.0000, 0.3043, 0.6923, 1.0000, and 0.7288, and ultrasonography gave 0.7778, 0.9130, 0.9333, 0.7241, and 0.8300 while the combined test gave 1.0000, 0.8696, 0.9231, 1.0000, and 0.9490, respectively. Negative laparotomy rate was 3 %. In conclusion, the combination of PAS and ultrasonography is a more accurate diagnostic tool than either PAS or ultrasonography.