Abstract Objectives The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. Methods This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. 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The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. Results Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). Jan 12, 2018 - Automatic Mouse and Keyboard 5.2.9.2 + Crack [3MB] ~ Cybi Crack. 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Advanced Web Ranking 9.2 Serial NumbersStudy Setting and Population The study took place at a Canadian pediatric hospital with about 250 trauma team activations in our ED annually, of which 125 have an Injury Severity Score of >12. We chose a consecutive sample of previously healthy children 4 to 17 years old with abdominal pain and right lower quadrant abdominal tenderness, as defined by an initial PAS ≥ 2 points, who in the opinion of the ED staff physician/fellow required imaging (US represents the initial imaging at our institution) for suspected appendicitis. This PAS cutoff reflects a conservative imaging practice of some physicians to ensure that appendicitis is not missed. Table 1. Characteristics of Patients With and Without Appendicitis Characteristic Appendicitis ( n = 111) No Appendicitis ( n = 183) p-value • BMI = body mass index; IQR = interquartile range; PAS = pediatric appendicitis score. Age (yr), mean ± SD 10 ± 3.2 10.6 ± 3.8 0.14 Sex (% male) 72 (64.9%) 71 (38.8%). Table 2. Diagnostic Performance of Initial and Interval Ultrasound Ultrasound Appendicitis No Appendicitis Total Initial Positive 89 10 99 Equivocal 21 102 123 Negative 1 71 72 Total 111 183 294 Interval Positive 12 1 13 Equivocal 5 12 17 Negative 0 10 10 Total 17 23 40 Interval US The interval US confirmed or ruled out appendicitis in 22 of the 40 (55.0%) children who had equivocal initial US interpretation, with one false-positive interval US. The sensitivity of the interval US was 71% (12 of 17), the specificity was 44% (10of 23), and the equivocal rate was 45.0% (18 of 40). Discussion To the best of our knowledge, this is the first study to demonstrate that the serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in very few CTs. This approach appears to be most useful in children with equivocal initial US in whom appendicitis was diagnosed or ruled out by the combination of the clinical reassessment and interval US/surgical consultation in virtually all study patients.
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