Appendicitis Score Research Articles

RIPASA Score versus Pediatric Appendicitis Score in Diagnosis of Acute Appendicitis in Pediatric Patients

RIPASA Score versus Pediatric Appendicitis Score in Diagnosis of Acute Appendicitis in Pediatric Patients

Efficacy of automated machine learning models and feature engineering for diagnosis of equivocal appendicitis using clinical and computed tomography findings

This study evaluates the diagnostic efficacy of automated machine learning (AutoGluon) with automated feature engineering and selection (autofeat), focusing on clinical manifestations, and a model integrating both clinical manifestations and CT findings in adult patients with ambiguous computed tomography (CT) results for acute appendicitis (AA). This evaluation was compared with conventional single machine learning models such as logistic regression(LR) and established scoring systems such as the Adult Appendicitis Score(AAS) to address the gap in diagnostic approaches for uncertain AA cases. In this retrospective analysis of 303 adult patients with indeterminate CT findings, the cohort was divided into appendicitis (n = 115) and non-appendicitis (n = 188) groups. AutoGluon and autofeat were used for AA prediction. The AutoGluon-clinical model relied solely on clinical data, whereas the AutoGluon-clinical-CT model included both clinical and CT data. The area under the receiver operating characteristic curve (AUROC) and other metrics for the test dataset, namely accuracy, sensitivity, specificity, PPV, NPV, and F1 score, were used to compare AutoGluon models with single machine learning models and the AAS. The single ML models in this study were LR, LASSO regression, ridge regression, support vector machine, decision tree, random forest, and extreme gradient boosting. Feature importance values were extracted using the “feature_importance” attribute from AutoGluon. The AutoGluon-clinical model demonstrated an AUROC of 0.785 (95% CI 0.691–0.890), and the ridge regression model with only clinical data revealed an AUROC of 0.755 (95% CI 0.649–0.861). The AutoGluon-clinical-CT model (AUROC 0.886 with 95% CI 0.820–0.951) performed better than the ridge model using clinical and CT data (AUROC 0.852 with 95% CI 0.774–0.930, p = 0.029). A new feature, exp(-(duration from pain to CT)3 + rebound tenderness), was identified (importance = 0.049, p = 0.001). AutoML (AutoGluon) and autoFE (autofeat) enhanced the diagnosis of uncertain AA cases, particularly when combining CT and clinical findings. This study suggests the potential of integrating AutoML and autoFE in clinical settings to improve diagnostic strategies and patient outcomes and make more efficient use of healthcare resources. Moreover, this research supports further exploration of machine learning in diagnostic processes.

Predictors of appendicectomy one year after antibiotic treatment for acute appendicitis: Insights from a prospective, multicentre, observational study.

Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis. One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment. A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management. At 1year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management.

Appendicitis in Children: Does Age Really Matter?

Acute appendicitis (AA) is a frequent and emergent surgical abdominal condition that presents some particularities and challenges in young children. Data of 402 children aged <16 years with a confirmed diagnosis of AA were retrospectively reviewed. Included patients were divided into two groups: Group A (preschool children aged ≤5 years, n = 44) and Group B (school children aged >5 years, n = 358). Clinical presentation, biological findings, calculated diagnosis scores (paediatric appendicitis score [PAS] and Alvarado score), intraoperative findings and outcomes were comparatively analysed between the two groups. Children of Group A had more likely fever, bowel disorders, diffuse abdominal pain and diffuse tenderness than those of Group B (P = 0.001, P = 0.005, P = 0.006 and P = 0.001, respectively). Regarding biomarkers, the mean of white blood cell count and C-reactive protein levels was higher in Group A than in Group B (18,849 cell/mm3 and 162.8 mg/L in Group A versus 15,938 cell/mm3 and 86.7 mg/L in Group B, P = 0.003 and < 0.001, respectively). The mean of calculated PAS and Alvarado scores was higher in Group A than in Group B (8.2 ± 1.1 and 8.2 ± 1 vs. 7.5 ± 1.4 and 7.4 ± 1.5, P = 0.003 and P = 0.001, respectively). Most children with a calculated PAS and Alvarado score equal to or higher than 8 belonged to Group A (PAS: 84.1% vs. 58.4%, P = 0.001, Alvarado score: 84.1% vs. 55.6%, P < 0.001). The perforation of the appendix was seen in 77.3% of Group A patients and only in 41.5% of children in Group B (P < 0.0001). The mean length of stay was 5.1 ± 1.9 days in Group A and 4.3 ± 2.8 days in Group B but without any statistical difference between the two groups (P = 0.094). AA in preschool children is associated with atypical presentation and rapid progression of the disease making the early diagnosis mostly challenging in our settings.

WP4.4 - Is it appendicitis? Keeping it SIMPLE

Abstract Aims Several appendicitis scoring systems have been described, criteria used for these are subjective leading to interobserver-bias. Existence of many scores instead of one suggests most of them are not clinically useful. We describe a SIMPLE score that is based on objective parameters as listed in Table 1. Methods A sample size for prospective evaluation was performed based on analysis of 118 patients of all ages with suspected appendicitis assessed at a University Hospital (area under ROC-curve of 0.7, null AUC 0.5, alpha 0.05, power 0.95). Each variable point weightage was calculated using multivariate analysis. ROC-analysis was used to define cut-offs for Leukocytes and CRP (GraphPad Prism-V9) as listed in Table -1. A SIMPLE-score was devised and prospectively validated. Results Table-1 SIMPLE-score Variable Odds ratio (95% CI) P-value Points Shift of abdominal pain 3.8 (1.3 – 12.1) 0.02 1 Impaired Oral intake 6.0 (1.5 – 31.5) 0.02 2 Mid-cycle 0.3 (0.0 – 2.1) 0.27 -1 Pyrexia of ≥37.5°C 2.5 (1.0 – 6.1) 0.04 1 Leukocytosis ≥10 5.5 (2.1 – 16.1) 0.00 2 Elevated CRP ≥9 4.0 (1.5 – 11.2) 0.01 2 SIMPLE score was calculated prospectively for 128 patients. Median age was 26.5 (range 4-85 years). Of these 62.5% (80) were females 37.5% (48) were males. A SIMPLE score of 2 or less was unlikely to be appendicitis (93.5% Negative Predictive Value), while a score of 3-6 was possibly appendicitis and a score of 7 or more was strongly associated with appendicitis (85% Positive Predictive Value). Conclusions SIMPLE score is objective, reliable, reproducible and indeed SIMPLE to use.

Nationwide prospective audit for the evaluation of appendicitis risk prediction models in adults: right iliac fossa treatment (RIFT)-Turkey.

Appendicitis is the most prevalent surgical emergency. The negative appendicectomy rate and diagnostic uncertainty are important concerns. This study aimed to assess the effectiveness of current appendicitis risk prediction models in patients with acute right iliac fossa pain. A nationwide prospective observational study was conducted, including all consecutive adult patients who presented with right iliac fossa pain. Diagnostic, clinical and negative appendicectomy rate data were recorded. The Alvarado score, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Adult Appendicitis Score systems were calculated with collected data to classify patients into risk categories. Diagnostic value and categorization performance were evaluated, with use of risk category-based metrics including 'true positive rate' (percentage of appendicitis patients in the highest risk category), 'failure rate' (percentage of patients with appendicitis in the lowest risk category) and 'categorization resolution' (true positive rate/failure rate). A total of 3358 patients from 84 centres were included. Female patients were less likely to undergo surgery than men (71.5% versus 82.5% respectively; relative risk 0.866, 95% c.i. 0.834 to 0.901, P < 0.001); with a three-fold higher negative appendicectomy rate (11.3% versus 4.1% respectively; relative risk 2.744, 95% c.i. 2.047 to 3.677, P < 0.001). Ultrasonography was utilized in 56.8% and computed tomography in 75.2% of all patients. The Adult Appendicitis Score had the best diagnostic performance for the whole population; however, only RIPASA was significant in men. All scoring systems were successful in females patients, but Adult Appendicitis Score had the highest area under the receiver operating characteristic curve value. The RIPASA and the Adult Appendicitis Score had the best categorization resolution values, complemented by their exceedingly low failure rates in both male and female patients. Alvarado and AIR had extremely high failure rates in men. The negative appendicectomy rate was low overall, but women had an almost three-fold higher negative appendicectomy rate despite lower likelihood to undergo surgery. The overuse of imaging tests, best exemplified by the 75.2% frequency of patients undergoing computed tomography, may lead to increased costs. Risk-scoring systems such as RIPASA and Adult Appendicitis Score appear to be superior to Alvarado and AIR.

A Comparison of the Alvarado Score and the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score in the Diagnosis of Acute Appendicitis: A Prospective Cohort Study.

Background Diagnosing acute appendicitis remains a problem, especially in teenagers with right lower quadrant pain.Imaging studies aid in accurate diagnosis but have limitations such as cost and availability. The Modified Alvarado Scoring System (MASS) is simple and cost-effective with fewer parameters. The Raja Isteri Pengiran Anak Saleha Appendicitisscoring system (RIPASA), designed for Asian populations, includes more parameters. This study compares the effectiveness of RIPASA and Alvarado scores in diagnosing acute appendicitis in a specific clinical setting. Objectives To compare the scoring systems of RIPASA and Alvarado in the diagnosis of acute appendicitis at a tertiary care hospital. Methods Data has been collected from all patients who attended the NRI general hospital emergency department and outpatient wing with acute appendicitis, admitted as inpatients based on clinical history and relevant investigations. Patients satisfying inclusion and exclusion criteria were selected and the basic investigations were done. Summary statistics were done using mean, standard deviation and proportions. Inferential statistics were done by using an independent t-test, kappa statistic, sensitivity and specificity with a 95% confidence interval (CI). All the measurements are done using the statistical package for the social sciences (SPSS) software version 21.0 (IBM Corp., Armonk, NY, USA) and open epidemiological (OpenEpi) software 3.01. A probability (p) <0.05 is considered as statistically significant. Results A total of 110 patients were analyzed for this study with a majority (39%) of them in the 21-30 age group. In our study, females (53%) outnumbered males (47%). Ultrasound findings in our cohort were acute appendicitis (93%), chronic appendicitis (2%) and normal appendix (5%). However, histopathology reported acute appendicitis (75%), chronic appendicitis (9%) and negative/non-specific (15%). The probability of appendicitis as predicted by Alvarado and RIPASA were 40% and 51% respectively. Definitive diagnosis of appendicitis was made in 16.4% with RIPASA whereas only 5.5% with Alvarado. When comparing the Alvarado and RIPASA scores, the sensitivity or true positive rate was higher for RIPASA (73.63%) than for Alvarado (50.55%). Conclusion There was a significant difference between the mean scores in Alvarado and RIPASA inpatients with scores suggestive of appendicitis and no appendicitis. Diagnostic accuracy was higher in RIPASA scoring compared to ALVARDO scoring. There was a significant statistical difference between the two scoring systems. When it comes to diagnosing in low-resource countries the study recommends a combination of Alvarado and RIPASA scoring systems.

Systemic immune-inflammation index combined with pediatric appendicitis score in assessing the severity and prognosis for paediatric appendicitis.

Pediatric appendicitis is a common cause of abdominal pain in children and is recognized as a significant surgical emergency. A prompt and accurate diagnosis is essential to prevent complications such as perforation and peritonitis. To investigate the predictive value of the systemic immune-inflammation index (SII) combined with the pediatric appendicitis score (PAS) for the assessment of disease severity and surgical outcomes in children aged 5 years and older with appendicitis. Clinical data of 104 children diagnosed with acute appendicitis were analyzed. The participants were categorized into the acute appendicitis group and chronic appendicitis group based on disease presentation and further stratified into the good prognosis group and poor prognosis group based on prognosis. The SII and PAS were measured, and a joint model using the combined SII and PAS was constructed to predict disease severity and surgical outcomes. Significant differences were observed in the SII and PAS parameters between the acute appendicitis group and chronic appendicitis group. Correlation analysis showed associations among the SII, PAS, and disease severity, with the combined SII and PAS model demonstrating significant predictive value for assessing disease severity [aera under the curve (AUC) = 0.914] and predicting surgical outcomes (AUC = 0.857) in children aged 5 years and older with appendicitis. The study findings support the potential of integrating the SII with the PAS for assessing disease severity and predicting surgical outcomes in pediatric appendicitis, indicating the clinical utility of the combined SII and PAS model in guiding clinical decision-making and optimizing surgical management strategies for pediatric patients with appendicitis.

Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study.

The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED). A literature search was conducted to identify potential CPSs and a single-center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5-15 years presenting with acute right-sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician-collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low-risk or high-risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow-up for those discharged directly from ED. Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86-0.94) and specificity 99.0% (95% CI 96.4%-99.7%) in diagnosing high-risk cases and a misclassification rate of 4.5% for low-risk cases. The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC-ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings.

Evaluating Pediatric Appendicitis Score and Alvarado Scoring System for Detecting Acute Appendicitis in Pediatric Population

Abstract Background Acute appendicitis is the most common surgical condition of children. About 1 to 10% of children presenting in surgical emergencies with acute abdomen fall within the domain of acute appendicitis. In few of these cases, clinical signs and symptoms at presentation are such that acute appendicitis is a clear diagnosis while more often it is challenging for a surgeon to make a clinical diagnosis of acute appendicitis. In these circumstances, explorations reveal negative appendectomies and an organ with potential functions can be lost. Objective To evaluate the Pediatric Appendicitis Score and Alvarado Scoring System in Detecting Acute Appendicitis in Pediatric Population in terms of applicability, safety, and specificity in the diagnosis of Acute Appendicitis among the study group and to suggest improvements and/or modifications to increase the predictive values of Pediatric Appendicitis Score and Alvarado Scoring System, decrease the rates of false diagnosis or reduce costs. Methods a prospective cohort study that was conducted on 50 patients aged under 14 years admitted to pediatric surgery department in Ain Shams University Hospital within a period of 6 months with an expected diagnosis of Acute appendicitis. Each patient was subjected to a detailed medical history taking (with emphasis on The age, gender, duration of pain, complaint complaints ofabdominal pain and duration, fever, nausea-vomiting, diarrhea or constipation), Clinical examination:(right lower quadrant sensitivity,defense, rebound tenderness, percussion/ cough/ right lower quadrant sensitivity with jumping). Laboratory investigations:(complete blood count, the total white blood cell (WBC) and total neutrophil counts c-reactive protein ) and Ultrasound examination. Alvarado score as well as PAS were calculated for each patient . the results were then compared to the intra operative findings confirming or excluding the diagnosis of acute appendicitis. Results in the study group that was 38% males and 62% females with ages ranging from 3 to 14 years .Pediatric appendicitis score (PAS) was found to significantly predict acute appendicitis in the studied patients at cutoff 5.0 with sensitivity, specificity, PPV and NPV was 60.5%, 100%, 100% and 71.9% respectively (p &amp;lt; 0.001). Alvarado score can significantly predict acute appendicitis in the studied patients at cutoff 4.0 with sensitivity, specificity, PPV and NPV was 79.1%, 85.7%, 84.7% and 80.4% respectively (p &amp;lt; 0.001). Conclusion The results of this study showed the higher sensitivity of Alvarado score and more specificity of the Pediatric Appendicitis score. However, the sensitivity, specificity, PPV, and NPV of these criteria were not considered enough to confirm the diagnosis of acute appendicitis alone. There is a need for new parameters in the scoring systems. Such as including ultrasonagraphic findings and additional laboratory investigations such as CRP.

Different Recent Scoring Systems for Better Diagnosis of Acute Appendicitis

Abstract Background Acute appendicitis is one of the most common surgical emergencies, with a lifetime prevalence rate of approximately one in seven. Aim of the Work to compare RIPASA score, (AIR) score and Modified Alvarado Score widely and easily used scoring systems, in order to identify which one is the best in sensitivity, specificity, positive predictive value, negative predictive value and accuracy, So which one leads to the most accurate diagnosis of acute Appendicitis. Patients and Methods A randomized prospective study that was conducted in Ain-Shams University Hospitals. The study started in February 2022 till the number of cases is fulfilled. 50 patients presented with RT iliac fossa tenderness. Each patient was scored by the three scoring systems using history, examination, clinical labs. Results 66.0% of cases were positive confirmed histology and (34.0%) cases were negative confirmed histology. There were highly statistically significant difference between Negative Confirmed histology and Positive Confirmed histology regarding RIPASA score, (AIR) score and Modified Alvarado Score. In this study, receiver operating characteristic curve (ROC) shows that the best cut off point of Modified Alvarado Score to detect Positive Modified Alvarado Score group was found &amp;gt;5 * with sensitivity of 87.88%, specificity of 64.71%, PPV of 82.9%, NPV of 73.3% and total accuracy of 77.0%. Conclusion the Appendicitis Inflammatory Response score and Raja Isteri Pengiran Anak Saleha Appendicitis score have high discriminating powers and outperform the Modified Alvarado score. They could aid in selecting patients who require timely surgery or those who require further evaluation. Both these scores have the potential to turn out into scoring systems of choice if future research can substantiate our study findings.

Clinical Scoring Systems to Diagnose Complicated Acute Appendicitis in a Rural Hospital: Are They Good Enough?

Introduction Acute appendicitis (AA) is the most common surgical emergency in developed countries, whose incidence peaks in the second and third decades. The risk of mortality in uncomplicated AA is very low. There are many scoring systems to predict AA. Prediction scores are used less frequently to predict complicated AA. Rural hospitals are often constrained by a lack of round-the-clock imaging or special laboratory services, which may enable accurate diagnosis. Materials and methods This study aimed to determine whether prediction scores without imaging or C-reactive protein (CRP) levels could predict complicated AA in a rural setting. All cases of AA for the previous 13 months were recruited for the study. Demographic data, clinical signs and symptoms, complete blood counts, intraoperative findings, and the corresponding histopathological results were collated. The scoring systems (Alvarado, RIPASA, Tzanakis, and Ohmann) were calculated from the clinical and laboratory data.Demographic variables, clinical features, and histopathological findings are described as frequencies/proportions. Chi-squared and Student's t-tests were used to analyze differences between patients with complicated and uncomplicated AA. A receiver operating curve (ROC) analysis was performed to calculate the area under the curve (AUC) and determine whether appendicitis scores could predict complicated AA. Results There were 76 patients with a mean age of 29.1±13.0 years.Serositis was observed in 65% of the patients; mucosal ulceration was the most common microscopic finding, with a pathological diagnosis of AA in 58 (76.3%) patients. Rovsing's sign and the presence of phlegmon and granuloma were significantly different between those with and without complicated AA. The clinical prediction scores were not significantly different between the two groups.The Tzanakis and Ohmann scores were significant (cutoff: 6.5 and 7.25, p=0.001 and 0.01, respectively) in diagnosing AA (sensitivity/specificity of 98.3/66.7 and 98.3/94.4, respectively). With a cutoff of 5.75, the RIPASA score, with an AUC of 0.663 (p=0.09), showed the highest sensitivity (90.7) and specificity (76.6) for diagnosing complicated AA. Conclusion Diagnosing AA based solely on clinical presentation remains a challenge. This study showed that clinical scores such as those of Alvarado, RIPASA, Tzanakis, and Ohmann could not accurately predict complicated AA. Scoring systems without imaging and intraoperative diagnoses are not infallible; therefore, histopathological examination of the resected appendix is mandatory.

Reliability of Diagnosis of Acute Appendicitis by Clinical Assessment Through Modified ALVARADO Vs RIPASA Scoring System at Combined Military Hospital, Rawalpindi

Objective: To determine the diagnostic accuracy of RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) andModified ALVARADO score in the diagnosis of acute appendicitis by using histopathology as a gold standard.Study Design: A comparative cross-sectional study.Place and Duration of Study: The study was carried out at the Department of Surgery, Combined MilitaryHospital (CMH) Rawalpindi, Pakistan from January 2020 to August 2020.Methods: A total of 126 patients suspected of having acute appendicitis were included. All patients who hadmet the inclusion criteria were chosen via the process of consecutive sampling. Patients who had presentedwith right iliac fossa pain, migration of pain, anorexia, nausea, and vomiting and were admitted to the hospitalwere assessed prospectively using RIPASA and Modified ALVARADO scores. RIPASA (Raja Isteri Pengiran AnakSaleha Appendicitis) score &gt; 7.5 and Modified ALVARADO score &gt; 7 were used to diagnose acute appendicitis.The diagnosis was confirmed postoperatively using a histopathological report. Every scoring system wasassessed for validity by calculating sensitivity, specificity, diagnostic accuracy, negative predictive value, andpositive predictive value.Result: The results obtained from individuals recruited in the study showthat out of 126 patients, 70(55.6%)were male and 56(44.4%) were female. The mean age was 33.25±8.19 years. 83.3% of patients having RIPASA(Raja Isteri Pengiran Anak Saleha Appendicitis) score (≥7.5) and 68.3% of patients having Modified ALVARADOscore (≥7) have met the criteria for acute appendicitis. The sensitivity and specificity of the RIPASA (Raja IsteriPengiran Anak Saleha Appendicitis) score were 90.9% and 73.3% compared with 73.8% and 73.3% of theModified Alvarado score.Conclusion: The RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) scoring system is a more convenient,accurate, and specific scoring system for our population than the Modified ALVARADO scoring system. How to cite this: Qamar R, Mahmood K, Javed R, Sher F, Tufail I.Reliability of Diagnosis of Acute Appendicitis by Clinical Assessment Through Modified Alvarado Vs Ripasa Scoring System. Life and Science.2024; 5(2): 193-198. doi: http://doi.org/10.37185/LnS.1.1.346

Evaluation of clinical examination and preoperative imaging in patients with right iliac fossa pain and a medium or high risk score for appendicitis (RIFT-2)

Introduction: Clinical risk models can be used to safely stratify UK patients with suspected appendicitis with low scores to ambulatory pathways, preventing admissions and unnecessary surgery. This study aimed to examine the diagnostic pathways in patients with medium or high risk scores.&#x0D; Methods: This prospective cohort study included patients admitted with suspected appendicitis in the UK. Patients aged ≥16 years were included if they had a medium or high risk score for appendicitis (Appendicitis Inflammatory Response score &gt;2 in men, Adult Appendicitis Score &gt;8 in women). The primary outcome measure was the normal appendicectomy rate (NAR). The AIRS and AAS risk prediction models were validated against pre-determined criteria.&#x0D; Results: This UK study included 2,231 women and 1,958 men. Overall, 57.7% of patients underwent surgery. The NAR was 18.4% in women aged 16-45 years, 9.5% in men aged 16-45 years, 4.5% in women aged ≥46 years, and 2.1% in men aged ≥46 years. Risk prediction models did not achieve the pre-determined threshold to be used to identify patients with appendicitis. Ultrasound was the most common imaging modality in women aged 16-45 years, whereas CT was most common in the other subgroups. CT was performed in 12.8% women aged 16-45 years, 21.1% in men aged 16-45 years, 69.3% in women aged ≥46 years, and 74.5% in men aged ≥46 years. The overall NAR in patients who had CT imaging alone (3.6%) was lower than in patients who had no imaging (12.4%) or ultrasound imaging alone (19.0%).&#x0D; Conclusion: Patients with right iliac fossa pain should be risk scored, with low-risk patients triaged to ambulatory management and medium and high-risk patients routinely CT scanned. Normal appendicectomy should become a specific therapeutic option rather than a chance finding.

State of the Art Review: Evidence based management of acute appendicitis

Introduction: Even though acute appendicitis is the world’s most common emergency general surgical operation, it remains under-researcher with wide variations in care. The aim of this review was to present current evidence on the management of acute appendicitis, focusing on risk assessment, diagnostic modalities, treatment strategies, and special considerations for specific patient populations.&#x0D; &#x0D; Methods: The writing group conducted a modified Delphi to prioritise topic areas for inclusion in this review. Consensus was achieved when each topic had &gt;70% for either important or strongly important. Scoping reviews of current and grey literature were conducted to identify relevant evidence, focussing on new publications in the last 5 years (2019-2024).&#x0D; &#x0D; Results: Validated risk scoring systems, such as the Adult Appendicitis Score and the AIRS score, aid in identifying low-risk patients suitable for ambulatory management, while imaging modalities, including CT scans and ultrasound, play a pivotal role in confirming diagnosis and guiding treatment decisions. The review highlights the efficacy of surgical intervention versus antibiotic therapy, emphasising the importance of shared decision-making and individualised treatment plans. Tailored care strategies are needed for elderly patients, pregnant women, and those with appendiceal neoplasms whilst strategies for optimising antibiotic stewardship, minimising negative appendectomy rates, and enhancing postoperative care will provide the best evidence-based care.&#x0D; &#x0D; Discussion: This review provides evidence-based practices can be integrated into routine clinical care and ongoing education for frontline clinicians. The practice recommendations are designed to be evidence based and can be tailored depending on local resources. These should form the basis of future educational packages and surgical training programmes.&#x0D;

Association Between Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Scoring and Pathological Severity of Acute Appendicitis: A Cross-Sectional Study.

Background and objectives Appendicitis is a frequent cause of abdominal pain. Because of the limited availability of imaging services in many medical centers and an urge to reduce the substantial number of unnecessary appendectomies, several clinical diagnostic tools have been constructed.A novel diagnostic tool, referred to as the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score, has been created to assist in identifying acute appendicitis (AA) in Asian nations. The study aimed to assess the correlation between RIPASA scores and the severity of appendicitis as determined by pathological examination. Materials and methods The study was a prospective observational investigation undertaken in the Department of General Surgery at Muslim education society (MES) Medical College Perinthalmanna over12 months. The study included all patients who had been diagnosed with AA and underwent appendectomy, provided they satisfied both the inclusion and exclusion criteria. An analysis was conducted on a convenience sample of 225 individuals using a prestructured proforma. The RIPASA scores were estimated before their surgery, taking into account their age, gender, symptoms, physical examination findings, and laboratory findings. These scores were subsequently contrasted withthe histopathological results obtained after the appendectomy. The individuals were categorized into three groups according to their RIPASA scores. The lower-score category, scores between 4 and 7. The intermediate-score category consists of scores ranging from 7.5 to 11.5, while the higher-score category includes scores of 12 and above. These scores are correlated with the histopathology report (HPR) to determine the presence of appendicitis, perforated appendix, appendicular abscess, or the absence of pathology observed. Results The study population comprised of 137 (60.9%) males and 88 (39.1%) females. Among these, 177 individuals (78.7%) were younger than 40 years, while 48 individuals (21.3%) were older than 40 years. Out of 225 cases, 146 cases were AA (64.9%), 27 (12%) appendicular abscess cases, and 41 (18.2%) appendicular perforation cases. The normal appendix was noted in 11 out of 225 cases in the low-score group. The association between the histopathological report and RIPASA score was found to be statistically highly significant (p=0.000). In the low-score group, there were 14 cases of appendicitis (53.8%), one case of appendicular abscess (3.8%), a total of 11 cases without pathology observed (42.3%), and no reported instances of appendicular perforation. In the intermediate-score category, there were 121 cases of appendicitis (89.6%), 12 cases of appendicular abscess (8.9%), 2 cases of appendicular perforation (1.5%), and no reported cases in the non-pathology category. Among the high-score category, there were 11 cases of appendicitis (17.2%), 14 cases of appendicular abscess (21.9%), 39 cases of appendicular perforation (60.9%), and no reported instances of negative appendectomy. Conclusion The study has shown that the RIPASA scoring system had a high diagnostic efficacy in identifying AA. This scoring system is an effective, dependable, cost-effective, noninvasive, reproducible, and safe diagnostic technique that does not require additional expenses or concerns.

Suspected Simple Appendicitis in Children: Should We Use a Nonoperative, Antibiotic-Free Approach? An Observational Study.

Simple appendicitis may be self-limiting or require antibiotic treatment or appendectomy. The aim of this study was to assess the feasibility and safety of a nonoperative, antibiotic-free approach for suspected simple appendicitis in children. This single-center, retrospective study included patients (0-17 years old) who were hospitalized at the pediatric surgery department due to suspected appendicitis between 2011 and 2012. Data from patients who primarily underwent appendectomy were used as controls. The follow-up of nonoperatively managed patients was conducted in 2014. The main outcome of interest was appendicitis recurrence. A total of 365 patients were included: 226 were treated conservatively and 139 underwent appendectomy. Fourteen (6.2% of 226) of the primarily nonoperatively treated patients required secondary appendectomy during follow-up, and histology confirmed simple, uncomplicated appendicitis in 10 (4.4% of 226) patients. Among a subset of 53 patients managed nonoperatively with available Alvarado and/or Pediatric Appendicitis Scores and sonographic appendix diameters in clinical reports, 29 met the criteria for a high probability of appendicitis. Three of these patients (10.3% of 29) underwent secondary appendectomy. No complications were reported during follow-up. A conservative, antibiotic-free approach may be considered for pediatric patients with suspected uncomplicated appendicitis in a hospital setting. Only between 6 and 10% of these patients required secondary appendectomy. Nevertheless, the cohort of patients treated nonoperatively was likely to have also included individuals with further abdominal conditions other than appendicitis. Active observation and clinical support during the disease course may help patients avoid unnecessary procedures and contribute to spontaneous resolution of appendicitis or other pediatric conditions as the cause of abdominal pain. However, further studies are needed to define validated diagnostic and management criteria.

AI in the ED: Assessing the efficacy of GPT models vs. physicians in medical score calculation

Background and aimsArtificial Intelligence (AI) models like GPT-3.5 and GPT-4 have shown promise across various domains but remain underexplored in healthcare. Emergency Departments (ED) rely on established scoring systems, such as NIHSS and HEART score, to guide clinical decision-making. This study aims to evaluate the proficiency of GPT-3.5 and GPT-4 against experienced ED physicians in calculating five commonly used medical scores. MethodsThis retrospective study analyzed data from 150 patients who visited the ED over one week. Both AI models and two human physicians were tasked with calculating scores for NIH Stroke Scale, Canadian Syncope Risk Score, Alvarado Score for Acute Appendicitis, Canadian CT Head Rule, and HEART Score. Cohen's Kappa statistic and AUC values were used to assess inter-rater agreement and predictive performance, respectively. ResultsThe highest level of agreement was observed between the human physicians (Kappa = 0.681), while GPT-4 also showed moderate to substantial agreement with them (Kappa values of 0.473 and 0.576). GPT-3.5 had the lowest agreement with human scorers. These results highlight the superior predictive performance of human expertise over the currently available automated systems for this specific medical outcome. Human physicians achieved a higher ROC-AUC on 3 of the 5 scores, but none of the differences were statistically significant. ConclusionsWhile AI models demonstrated some level of concordance with human expertise, they fell short in emulating the complex clinical judgments that physicians make. The study suggests that current AI models may serve as supplementary tools but are not ready to replace human expertise in high-stakes settings like the ED. Further research is needed to explore the capabilities and limitations of AI in emergency medicine.

A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process.

The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history. Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses. 124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4. There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration. Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021). ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).

A COMPARATIVE STUDY TO EVALUATE THE POSITIVE PREDICTIVE VALUE OF BIOCHEMICAL MARKERS WITH CLINICAL RIPASA SCORE IN ACUTE APPENDICITIS: AN IN VIVO STUDY

Objective: We evaluated the positive predictive value of biochemical markers with clinical Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score and the sensitivity and diagnostic accuracy. Methods: 75 patients who presented to the Emergency/General Surgery Department of Pacific Medical College and Hospital, Udaipur, with right iliac fossa (RIF) pain and who were suspected of acute appendicitis. A detailed history, clinical examination, and laboratory investigations were done which included a routine RIPASA score calculated. Results: RIF pain was present in all the patients, followed by vomiting (98.67%), and fever in 92%. Twenty-one patients had raised white blood cell (WBC) counts, out of them 15 patients had both raised WBC counts and raised C-reactive protein (CRP) and 6 had normal CRP. 52 patients had raised CRP levels, out of them 15 patients had both raised WBC counts and raised CRP and 37 had normal WBC counts. 17 patients had both CRP and WBC counts in normal range, but were diagnosed to have appendicitis according to RIPASA score. Our results show that raised CRP and WBC counts had a sensitivity of 28.85% and specificity of 73.91% with a diagnostic accuracy of 42.67%. Conclusion: When combined with WBC, CRP has good discriminatory power for appendicitis despite its inability to reliably predict acute appendicitis when used alone. However, a cutoff point for CRP that predicted perforated appendicitis could not be determined.