Clinical Features and Preventability of Delayed Diagnosis of Pediatric Appendicitis

Michelson, Kenneth A.; Reeves, Scott D.; Grubenhoff, Joseph A.; Cruz, Andrea T.; Chaudhari, Pradip P.; Dart, Arianna H; Finkelstein, Jonathan A.; Bachur, Richard G.

doi:10.1001/jamanetworkopen.2021.22248

Cited by 38 publications

(35 citation statements)

References 34 publications

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“…It should be noted that the use of computed tomography (CT) in the setting of PAA is limited due to the significant radiation dose associated with this particularly vulnerable population. The overall diagnostic yield in relation to PAA varies according to series, with recent publications establishing a diagnostic error rate of 4% and a diagnostic delay rate of 63%, respectively [ 8 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a diagnostic tool in pediatric acute appendicitis: a prospective validation study

et al. 2022

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Introduction NGAL has recently been studied as a biomarker in the diagnostic context of pediatric acute appendicitis (PAA), although existing series are scarce and have limited sample sizes. Materials and methods A prospective observational study was designed to validate serum NGAL as a diagnostic tool in PAA. This study included 215 patients, divided into 3 groups: (1) patients undergoing major outpatient surgery (n = 63), (2) patients with non-surgical abdominal pain in whom a diagnosis of PAA was excluded (n = 53) and (3) patients with a confirmed diagnosis of PAA (n = 99). Patients in group 3 were divided into complicated or uncomplicated appendicitis. In 201 patients, a serum sample was obtained at the time of diagnosis and NGAL concentration was determined by ELISA. The Kolmogorov–Smirnov test was used to assess normality. Comparative statistical analyses were performed using the Mann–Whitney U test, the Kruskal-Wallis test and the Fisher’s exact test. To calculate the discriminative ability of the molecule, the area under the receiver-operating characteristic curves (AUC) was calculated. A p value < 0.05 established statistical significance. Results Median (interquartile range) of serum NGAL values were 38.88 (27.15–48.04) ng/mL (group 1), 51.84 (37.33–69.80) ng/mL (group 2) and 65.06 (50.50–86.60) ng/mL (group 3). The AUC (group 2 vs 3) was 0.642 (95% CI 0.542–0.741) (p < 0.001) and the best cutoff point was found to be at 40.97 ng/mL, with a sensitivity of 89% and a specificity of 34.6%. No statistically significant differences in serum NGAL values were found between patients with uncomplicated PAA and those with complicated PAA. Conclusions This prospective validation study with a large sample size confirms that the diagnostic yield of NGAL in the context of PAA is only moderate, and therefore, it should not be used as a unique diagnostic tool. Furthermore, NGAL is not a valid biomarker to discern between uncomplicated and complicated PAA.

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Section: Introductionmentioning

confidence: 99%

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a diagnostic tool in pediatric acute appendicitis: a prospective validation study

et al. 2022

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“…Hispanic and NH black children were more than twice as likely to experience a delayed diagnosis. Potential reasons include (1) bias in having a lower threshold to test among NH white children or higher threshold to test among Hispanic and NH black children; (2) earlier presentation in the course of illness among Hispanic and NH black children compared with their NH white counterparts, which is known to predispose to delays because presentations are subtler6; (3) variability in English proficiency, with limited proficiency increasing the likelihood a clinician will fail to elicit key findings8–10; (4) differences in access to outpatient care that could contribute to a timely diagnosis; and (5) differences in the characteristics of NH black children, such as insurance, that predispose to delays in diagnosis, as evidenced by the loss of association in the adjusted model. Similarly, different patterns of testing may exist for publicly insured children compared with privately insured children.…”

Section: Discussionmentioning

confidence: 99%

“…The earliest opportunity to diagnose the serious condition was termed the ‘index encounter’, which was defined as the earlier of two encounters for patients with possible delayed diagnosis and the diagnosis encounter for those with timely diagnosis. Patients with possible delayed diagnosis were rated based on the likelihood that the serious condition was present during the index encounter using a five-level ordinal scale6: ‘near-definitely not’, ‘probably not’, ‘possibly’, ‘probably’ or ‘near-definitely’ (table 1). The primary outcome was delayed diagnosis, defined as a ‘probable’ or ‘near-definite’ delayed diagnosis.…”

Section: Methodsmentioning

confidence: 99%

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments

et al. 2022

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ObjectiveTo evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.MethodsThis was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.ResultsAmong 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.ConclusionDelayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

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“…Delayed treatment often leads to a more serious condition, which makes the mucosal barrier of the appendix more vulnerable to bacterial invasion ( 14 ). The preoperative temperature mirrors the systemic inflammatory response, and although the primary lesion has been surgically removed, this impact does not disappear immediately ( 13 ).…”

Section: Discussionmentioning

confidence: 99%

Prediction nomogram for evaluating the probability of postoperative fever in children with acute appendicitis

et al. 2022

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ObjectiveThe purpose of this study was to establish a predictive model of postoperative fever in children with acute appendicitis through retrospective analysis, and the prediction ability of the model is demonstrated by model evaluation and external validation.MethodsMedical records information on children undergoing surgery for acute appendicitis within 2 years were retrospectively collected, prospective collection was performed for external validation in the next 3 months. The patients were divided into two groups according to whether the postoperative body temperature exceeded 38.5°C. Multivariate logistic regression analysis was used to determine independent risk factors and develop regression equations and nomogram. ROC curve, calibration curve and decision curve were made for model evaluation. Finally, the clinical implication of the prediction model was clarified by associating postoperative fever with prognosis.ResultsHigh risk factors of postoperative fever included in the prediction model were onset time (X1), preoperative temperature (X2), leukocyte count (X3), C-reactive protein (X4) and operation time (X5). The regression equation is logit (P) = 0.005X1+0.166X2+0.056X3+0.004X4+0.005X5-9.042. ROC curve showed that the area under the curve (AUC) of the training set was 0.660 (0.621, 0.699), and the AUC of the verification set was 0.712 (0.639, 0.784). The calibration curve suggested that the prediction probability was close to the actual probability. Decision curve analysis (DCA) showed that patients could benefit from clinician’s judgment. Furthermore, prognostic analysis showed children presenting with postoperative fever had the more duration of postoperative fever, hospitalization stays and cost, except for rehospitalization.ConclusionAll the results revealed that the model had good predictive ability. Pediatricians can calculate the probability of postoperative fever and make timely interventions to reduce pain for children and parents.

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Clinical Features and Preventability of Delayed Diagnosis of Pediatric Appendicitis

Cited by 38 publications

References 34 publications

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a diagnostic tool in pediatric acute appendicitis: a prospective validation study

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a diagnostic tool in pediatric acute appendicitis: a prospective validation study

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments

Prediction nomogram for evaluating the probability of postoperative fever in children with acute appendicitis

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