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Can New Inflammatory Markers Improve the Diagnosis of Acute Appendicitis?
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. County Hospital Ryhov, Jönköping, Sweden .
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Hälsouniversitetet.
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för inflammationsmedicin. Linköpings universitet, Hälsouniversitetet.ORCID-id: 0000-0002-3993-9985
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet.
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2014 (Engelska)Ingår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 38, nr 11, s. 2777-2783Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

The diagnosis of appendicitis is difficult and resource consuming. New inflammatory markers have been proposed for the diagnosis of appendicitis, but their utility in combination with traditional diagnostic variables has not been tested. Our objective is to explore the potential of new inflammatory markers for improving the diagnosis of appendicitis. The diagnostic properties of the six most promising out of 21 new inflammatory markers (interleukin [IL]-6, chemokine ligand [CXCL]-8, chemokine C-C motif ligand [CCL]-2, serum amyloid A [SAA], matrix metalloproteinase [MMP]-9, and myeloperoxidase [MPO]) were compared with traditional diagnostic variables included in the Appendicitis Inflammatory Response (AIR) score (right iliac fossa pain, vomiting, rebound tenderness, guarding, white blood cell [WBC] count, proportion neutrophils, C-reactive protein and body temperature) in 432 patients with suspected appendicitis by uni- and multivariable regression models. Of the new inflammatory variables, SAA, MPO, and MMP9 were the strongest discriminators for all appendicitis (receiver operating characteristics [ROC] 0.71) and SAA was the strongest discriminator for advanced appendicitis (ROC 0.80) compared with defence or rebound tenderness, which were the strongest traditional discriminators for all appendicitis (ROC 0.84) and the WBC count for advanced appendicitis (ROC 0.89). CCL2 was the strongest independent discriminator beside the AIR score variables in a multivariable model. The AIR score had an ROC area of 0.91 and could correctly classify 58.3 % of the patients, with an accuracy of 92.9 %. This was not improved by inclusion of the new inflammatory markers. The conventional diagnostic variables for appendicitis, as combined in the AIR score, is an efficient screening instrument for classifying patients as low-, indeterminate-, or high-risk for appendicitis. The addition of the new inflammatory variables did not improve diagnostic performance further.

Ort, förlag, år, upplaga, sidor
Springer, 2014. Vol. 38, nr 11, s. 2777-2783
Nationell ämneskategori
Klinisk medicin
Identifikatorer
URN: urn:nbn:se:liu:diva-112174DOI: 10.1007/s00268-014-2708-7ISI: 000343048900006PubMedID: 25099684OAI: oai:DiVA.org:liu-112174DiVA, id: diva2:764260
Anmärkning

Funding Agencies|Jonkoping County Research Council; Research Council of South-Eastern Sweden (FORSS); Futurum- Academy of Health Care, Jonkoping County Council, Jonkoping, Sweden

Tillgänglig från: 2014-11-18 Skapad: 2014-11-18 Senast uppdaterad: 2017-12-05Bibliografiskt granskad
Ingår i avhandling
1. Structured management of patients with suspected acute appendicitis
Öppna denna publikation i ny flik eller fönster >>Structured management of patients with suspected acute appendicitis
2015 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Background. Acute appendicitis (“appendicitis”) is one of the most common abdominal surgical emergencies worldwide. In spite of this, the diagnostic pathways are highly variable across countries, between centres and physicians. This has implications for the use of resources, exposure of patients to ionising radiation and patient outcome. The aim of this thesis is to construct and validate a diagnostic appendicitis score, to evaluate new inflammatory markers for inclusion in the score, and explore the effect of implementing a structured management algorithm for patients with suspected appendicitis. Also, we compare the outcome of management with routine diagnostic imaging versus observation and selective imaging in equivocal cases.

Methods. In study I, the Appendicitis Inflammatory Response (AIR) score was constructed from eight variables with independent diagnostic value (right lower quadrant pain, rebound tenderness or muscular defence, WBC count, proportion of polymorphonuclear granulocytes, CRP, body temperature and vomiting). Its diagnostic properties were evaluated and compared with the Alvarado score. In study II, we performed an external validation and evaluation of novel inflammatory markers for inclusion in the score on patients with suspected appendicitis at two Swedish hospitals. In study III we externally validated and evaluated the impact of an AIR-scorebased algorithm assigning patients to a low or high risk of having appendicitis in an interventional multicentre study involving 25 Swedish hospitals and 3791 patients. In study IV, we compared the efficiency of routine diagnostic imaging with repeated clinical assessment followed by selective imaging in a randomised trial of 1028 patients with equivocal signs of appendicitis, as indicated by an intermediate AIR score, from study III.

Main results. In study I we found that the AIR score could assign 63% of the patients to either a high- or low-risk group of appendicitis with an accuracy of 97%, which compared favourably with the Alvarado score. In study II, the diagnostic properties of the AIR score proved to be  reproducible, but the inclusion of novel inflammatory markers did not improve the diagnostic accuracy. In study III, the AIR-score-based algorithm led to a reduction in negative explorations, operations for nonperforated appendicitis and hospital admissions in the low-risk group and reduced use of imaging in both low- and high-risk groups. In study IV, routine imaging led to more operations for nonperforated appendicitis but had no effect on negative explorations or perforated appendicitis.

Conclusions. The AIR score was found to have promising diagnostic properties that were not improved further with the inclusion of novel inflammatory variables. Structured management of patients with suspected appendicitis according to an AIR-score-based algorithm may improve outcome while reducing hospital admissions and use of imaging. Patients with equivocal signs of appendicitis do not benefit from routine imaging which may lead to an increased detection of, and treatment for, uncomplicated cases of appendicitis that are otherwise allowed to resolve spontaneously.

Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronic Press, 2015. s. 110
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1442
Nationell ämneskategori
Klinisk medicin Kirurgi
Identifikatorer
urn:nbn:se:liu:diva-113766 (URN)10.3384/diss.diva-113766 (DOI)978-91-7519-137-9 (ISBN)
Disputation
2015-03-06, Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 13:00
Opponent
Handledare
Forskningsfinansiär
Futurum - Akademin för hälsa och vård, Jönköpings län Forskningsrådet i Sydöstra Sverige, FORSS
Tillgänglig från: 2015-01-30 Skapad: 2015-01-30 Senast uppdaterad: 2015-11-16Bibliografiskt granskad

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Andersson, ManneRubér, MarieEkerfelt, ChristinaBjörnsson, HannaAndersson, Roland

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