title: Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis.
abstract: BACKGROUND
  Appendicitis is the most common surgical emergency in children; yet, diagnosis of equivocal presentations continues to challenge clinicians.
  
  
  OBJECTIVE
  The objective of this study was to investigate the hypothesis that the use of a modified clinical practice and harmonic ultrasonographic grading scores (MCPGS) may improve the accuracy in diagnosing acute appendicitis in the pediatric population.
  
  
  METHODS
  
  
  
  METHODS
  Sensitivity, specificity, and accuracy of the modified scoring system. Five hundred and thirty patients presented with suspected diagnosis of acute appendicitis during the period from December 2000 to December 2009 were enrolled in this study. Children's data that have already been published of those who presented with suspected diagnosis of acute appendicitis- to whom a special clinical practice grading scores (CPGS) incorporating clinical judgment and results of gray scale ultrasonography (US) was applied- were reviewed and compared to the data of 265 pediatric patients with equivocal diagnosis of acute appendicitis (AA), to whom a modified clinical practice grading scores (MCPGS) was applied. Statistical analyses were carried out using Z test for comparing 2 sample proportions and student's t-test to compare the quantitative data in both groups. Sensitivity and specificity for the 2 scoring systems were calculated using Epi-Info software.
  
  
  RESULTS
  The Number of appendectomies declined from 200 (75.5%) in our previous CPGS to 187 (70.6%) in the MCPGS (P > 0.05).Specificity was significantly higher when applying MCPGS (90.7%) in this study compared to 70.47% in our previous work when CPGS was applied (P < 0.01). Furthermore, the positive predictive value (PPV) was significantly higher (95.72%) than in our previous study (82.88%), (P < 0.01). Overall agreement (accuracy) of MCPGS was 96.98%. Kappa = 0.929 (P < 0.001). Negative predictive power was 100%. And the Overall agreement (accuracy) was 96.98%.
  
  
  CONCLUSIONS
  MCPGS tends to help in reduce the numbers of avoidable and unnecessary appendectomies in suspected cases of pediatric acute appendicitis that may help in saving hospital resources.
authors.affiliation: Division of Pediatric Surgery, Departments of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt. ossamaz2004@yahoo.com.
authors.forename: Ossama
authors.initials: O
authors.lastname: Zakaria
authors.forename: Tamer A
authors.initials: TA
authors.lastname: Sultan
authors.forename: Tarek H
authors.initials: TH
authors.lastname: Khalil
authors.forename: Tamer
authors.initials: T
authors.lastname: Wahba
references.citation: J Pediatr Surg. 1998 Sep;33(9):1371-5
references.pmid: 9766356
references.citation: J Acoust Soc Am. 1997 Jan;101(1):143-54
references.pmid: 9000731
references.citation: Phys Med Biol. 1986 Dec;31(12):1401-9
references.pmid: 3809241
references.citation: J Pediatr Surg. 2003 Mar;38(3):367-71; discsussion 367-71
references.pmid: 12632351
references.citation: J Pediatr Surg. 2003 Feb;38(2):236-42
references.pmid: 12596112
references.citation: Am J Surg. 2003 Mar;185(3):194-7
references.pmid: 12620554
references.citation: J Pediatr Surg. 2001 May;36(5):780-3
references.pmid: 11329589
references.citation: J Pediatr Surg. 2002 Jun;37(6):877-81
references.pmid: 12037754
references.citation: J Pediatr Surg. 2003 May;38(5):659-62
references.pmid: 12720164
references.citation: JAMA. 1999 Oct 20;282(15):1458-65
references.pmid: 10535437
references.citation: Acad Emerg Med. 2009 Jul;16(7):591-6
references.pmid: 19549016
references.citation: Gastroenterol Clin Biol. 1991;15(11):794-9
references.pmid: 1769468
references.citation: Afr J Paediatr Surg. 2010 Sep-Dec;7(3):163-5
references.pmid: 20859021
references.citation: J Pediatr Surg. 2004 Mar;39(3):458-63; discussion 458-63
references.pmid: 15017570
references.citation: Indian J Pediatr. 2011 Mar;78(3):287-90
references.pmid: 21046287
references.citation: Ultrasound Obstet Gynecol. 1997 Apr;9(4):266-70
references.pmid: 9168579
references.citation: Surg Gynecol Obstet. 1990 Jun;170(6):527-32
references.pmid: 2343368
references.citation: Arch Surg. 2002 Jul;137(7):799-804; discussion 804
references.pmid: 12093335
references.citation: J Acoust Soc Am. 1985 Jan;77(1):302-6
references.pmid: 3973223
references.citation: Am Surg. 1999 Aug;65(8):769-73
references.pmid: 10432089
references.citation: J Pediatr Surg. 2000 Sep;35(9):1320-2
references.pmid: 10999688
references.citation: Arch Surg. 2011 Jan;146(1):64-7
references.pmid: 21242447
references.citation: J Pediatr. 2011 Jan;158(1):112-8
references.pmid: 20828717
references.citation: AJR Am J Roentgenol. 1998 Nov;171(5):1203-6
references.pmid: 9798848
references.citation: Pediatrics. 2002 Dec;110(6):1088-93
references.pmid: 12456904
references.citation: J Pediatr Surg. 1990 Nov;25(11):1113-6
references.pmid: 2273422
references.citation: J Pediatr Surg. 1995 Feb;30(2):173-8; discussion 178-81
references.pmid: 7738734
references.citation: World J Surg. 1997 Mar-Apr;21(3):313-7
references.pmid: 9015177
references.citation: World J Surg. 2001 May;25(5):578-84
references.pmid: 11369983
references.citation: J Acoust Soc Am. 1990 Dec;88(6):2852-8
references.pmid: 2283443
references.citation: Lancet. 1993 Nov 27;342(8883):1317-22
references.pmid: 7901634
references.citation: Pediatr Emerg Care. 2011 Mar;27(3):165-9
references.pmid: 21346681
references.citation: Radiographics. 2000 Jul-Aug;20(4):1127-35
references.pmid: 10903701