Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 15485

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : PC08 - PC11 Full Version

Evaluation of Diagnostic Accuracy of Alvarado, Appendicitis Inflammatory Response and Adult Appendicitis Scoring System in Diagnosing Acute Appendicitis: A Prospective Cohort Study


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60480.17409
Reena Meena, Ashok Kumar Sharma, Dheer Singh Kalwaniya, Aditya Tolat, Garima Tyagi, Vakulabharanam Naga Rohith, Pawan Kumar Gurivelli

1. Postgraduate, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India. 2. Professor, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India. 3. Assistant Professor, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India. 4. Postgraduate, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India. 5. Postgraduate, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India. 6. Postgraduate, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India. 7. Postgraduate, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India.

Correspondence Address :
Dr. Dheer Singh Kalwaniya,
Assistant Professor, Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India.
E-mail: drdsk85@gmail.com

Abstract

Introduction: Appendicitis is one of the most common surgical emergencies, but its clinical diagnosis is still a big challenge for surgeons to decrease the negative appendectomy rate.

Aim: To validate and compare alvarado, Appendicitis Inflammatory Response (AIR) score and adult appendicitis scoring system in diagnosing acute appendicitis.

Materials and Methods: A prospective cohort study was conducted in the Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India, from December 2020 to May 2022 on 100 patients who were clinically suspected of acute appendicitis. All three scores {AIR, Adult Appendicitis Score (AAS), Alvarado} were calculated. Diagnostic tests were used to calculate sensitivity, specificity, Negative Predictive Value (NPV) and Positive Predictive Value (PPV). DeLong test were used to compare the area under the curve of three scores with each other for predicting acute appendicitis and the final result was compared with the histopathological report. The data was presented as numbersvand percentage and the p-value <0.05 was considered statistically significant.

Results: The mean age of study subjects was 30.28±10.9 years. It was found that the AIR score had more sensitivity (92.55%), followed by the AAS (84.04%) score and Alvarado (60.64%) score for diagnosing acute appendicitis but the specificity of the Alvarado score was highest (100%), followed by AAS (83.33%) and AIR (66.67%) score. AIR score had more NPV (36.40%) as compared to AAS (25%) and Alvarado score (14%). The diagnostic accuracy of AIR (91%) was higher than AAS and Alvarado’s score 84% and 63%, respectively.

Conclusion: Appendicitis Inflammatory Response (AIR) score and AAS can be used over Alvarado score for better diagnosis of acute appendicitis in emergency patients and to reduce the rate of negative appendectomy.

Keywords

Appendix, Negative appendectomy, Right iliac fossa

Acute Appendicitis (AA) is one of the most common surgical emergencies in the world, with 7-12% of the general population being affected at some point in their life (1). Its incidence is 1.5 to 1.9 per 1000 in the general population and men are around 1.4 times more likely than woman to experience it (2). It is associated with high morbidity and occasional mortality related to the failure to make an early diagnosis. Although the diagnosis of appendicitis is clinical, the varied presentations create an environment of confusion in the diagnosis and subsequent management of the condition. Only 20-33% of cases present typical findings (3). The treatment of choice remains surgical in both complicated and uncomplicated patients. Hence, overdiagnosis can lead to an increase in unnecessary surgeries, resultant morbidity and drainage of resources in a resource-improvised setting (4). Recent studies have shown the negative appendectomy rate as high as 17.2% (5). Chae MS et al., conducted a study in 2017 in which the negative appendectomy rate was 20.8% (6). Sammalkorpi HE et al., studied histologically confirmed reduced negative appendectomy rate from 18.2-8.7% (7). Statistics show that one out of five appendicitis is misdiagnosed (5). On the other hand, underdiagnosing appendicitis, especially in particular groups like women in the reproductive age group and the elderly can have severe complications, including perforation. An effective scoring system can be an excellent guiding tool for deciding on managing patients with acute appendicitis (8).

In emergency cases, the concept of scoring along with the clinical examination can increase the accuracy of diagnosis (8). Alvarado score is the most extensively used and studied scoring system (9). Still, its sensitivity and specificity are suitable only for ruling out cases of appendicitis but not so for making decisions on patients requiring surgery (9),(10),(11),(12). In patients with suspected AA, clinical scores alone appear sensitive enough to select low-risk patients and reduce the need for imaging and negative surgical exploration (such diagnostic laparoscopy (13).

Madasi V concluded that the Alvarado score was surpassed in validity and reliability by the newly designed AIR score (14). Karki OB and Hazra NK found that AIR scoring performed well and was more accurate than the Alvarado scoring system, with high specificity and high NPV preventing negative appendectomies (15). Pogorelic Z et al., found that the AIR score can detect acute appendicitis with a high level of sensitivity and specificity. The results of this study have also demonstrated the high significance of the AIR score in differentiating between perforated and non perforated appendicitis, which can have a major impact on treatment choices (16).

All the existing scoring system has been crafted for the western population. Therefore, studies are needed to validate the scoring system of the Indian population. Hence, the present study was conducted with the aim to assess the predictive accuracy of Alvarado, AIR and AAS scoring systems in diagnosis of acute appendicitis.

Material and Methods

This prospective cohort study was conducted in the Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India, from December 2020 to May 2022. The ethical clearance from the Institutional Ethics Committee. (IEC/VMMC/SJH/Thesis/2020-11/CC-140).

Inclusion criteria: All clinically suspected patients of acute appendicitis in the Emergency Department between the age of 18 to 60 years were included in the study.

Exclusion criteria: Pregnant women, patients who were not fit for surgery, patients with appendicular perforation or abscess, appendicular mass and patients who were not willing for surgery were excluded from the study.

Sample size calculation: The study of Sammalkorpi HE et al., observed that the sensitivity and specificity of AAS was 49% and 93.3%, respectively (7). The study of Madasi V observed that the sensitivity and specificity of the Alvarado score was 87.3% and 52.4%, respectively and of AIR score was 95.7% and 90.5%, respectively (14). Taking these values as a reference, the minimum required sample size with desired precision of 15%, 80% power of study, and 5% level of significance is 86 patients. To reduce the margin of error, the total sample size taken was 100.

Study Procedure

All patients were scored using AAS, Alvarado and AIR scoring system (13),(17),(18),(19). Alvarado is a 10 points scoring system introduced in 1986, it is based on pain migration to Right Iliac Fossa (RIF), anorexia, nausea and vomiting, RIF tenderness, rebound tenderness, fever, raised White Blood Cells (WBC), shift of WBC to left. AIR score includes vomiting, pain in Right Lower Quadrant (RLQ), abdominal guarding, raised temperature, WBC, serum CRP and segmented neutrophils. The new diagnostic scoring system known as AAS evaluates pain in RLQ, abdominal guarding, WBC, neutrophils proportion and CRP levels. The operative decision was made and the patient underwent an emergency appendectomy. Resected appendix specimen was sent for a histopathology examination. A postoperative histopathological report was collected and compared with the preoperative diagnosis. The calculated score was considered positive if it showed the probability of appendicitis and a comparison was made with the gold standard histopathological diagnosis. Based on the data collected, sensitivity and specificity were calculated for each scoring system separately and the receiver operator curve was plotted for further analysis.

Statistical Analysis

The presentation of the categorical variables was done in the form of numbers and percentages (%). On the other hand, the qualitative data were presented as the means±Standard Deviation (SD) and as median with 25th and 75th percentiles (interquartile range). Receiver operating characteristic curve was used to find cut-off point of the total Alvarado score, total AIR and total AAS for predicting appendicitis. For statistical significance, p-value <0.05 was considered statistically significant.

Results

The mean age of study subjects was 30.28±10.9 years (Table/Fig 1). Out of 100 patients, 96 (96%) were males and 4 (4%) were females.

In the present study, while calculating the Alvarado component, anorexia was the most common symptom (99%), followed by nausea (88%) and pain migration (32%) (Table/Fig 2). For the AIR scoring system, pain in Right Iliac Fossa (RIF) was present in all the patients (100%), followed by vomiting (94%), fever (88%) and mild abdominal guarding (61%) (Table/Fig 3).

A total of 100% of patients had pain in the right lower quadrant. Pain relocation was seen in 60% of patients. Mild abdominal guarding was elicited in 72% of patients, while moderate and severe abdominal guarding was present in 28% of patients (Table/Fig 4).

In the present study, 94 out of 100 patients diagnosed with acute appendicitis without perforation presented within 24 hours of onset symptoms. And in 66 (70.21%) patients, the C-reactive Protein (CRP) level was elevated. Six patients presented to the emergency after 24 hours, and their CRP level was lower than those who presented early (Table/Fig 4).

For Alvarado's score, most patients scored >7 i.e., 57, out of which none patients had a negative appendectomy. Forty-three patients were having ≤7 and out of which the negative appendectomy was found in six patients (Table/Fig 5).

Appendicitis Inflammatory Response score categorised 89 out of 100 cases as high risk, out of which only 2 (2.25%) patients had a negative appendectomy. Eleven patients were in the low-risk category, and the negative appendectomy was found in 4 patients (36.36%) (Table/Fig 6).

Adult Appendicitis Score score categorises the patients into three categories low, intermediate, and high risk. 70 patients came in high risk, out of which only 1 (1.43%) patient underwent a negative appendectomy. Twenty one patients came under intermediate risk out of which 19 (90.14%) patients' histopathological examination came as acute appendicitis. In the low-risk group, the negative appendectomy rate was high. Out of 9 patients 3 (33.33%) had a negative appendectomy (Table/Fig 7).

It was found that the AIR score had more sensitivity (92.55%), followed by the AAS (84.04%) score and Alvarado (60.64%) score but the specificity of the Alvarado score was more (100%), which was 83.33% for AAS and 66.67% for AIR score (Table/Fig 8).

Discussion

In this study, 100 patients were included with the age of the study population ranging from 18-60 years. A total of 43% of patients were between 21-30 years. Madasi V conducted a study in which the maximum number of patients were in the age group of 20-40 years 60.90% (14). Another study by Viniol A et al., concluded that acute appendicitis is peak in age from 10-30 years (20). The incidence of acute appendicitis is more in the younger age group, might be due to the larger amount of lymphoid tissue in young patients.

In the present study, all the patients presented with pain in the right iliac fossa (100%) followed by anorexia (99%) and vomiting (94%). On clinical examination, right iliac fossa tenderness was found in all patients, followed by fever (88%) and abdominal guarding. In 2017, a study conducted by Gopalam PR and Konidala MVSS anorexia was found in most (94%) of the patients, followed by vomiting and nausea, RLQ pain, rebound soreness and abdominal guarding in 78%, 72%, 71% and 70% of cases, respectively (21). In another study conducted by Von-Mühlen B et al., 95.3% patients came to the Emergency Department with pain in right iliac fossa, vomiting was reported in 51.7% and the temperature was raised in 27.9% (18). Presenting symptoms might be variable because of previous treatment taken by the patient before presenting to the tertiary care hospital, and clinical findings may vary accordingly.

Receiver Operating Curve (ROC) had a discriminating ability to predict appendicitis. The discriminatory power of the total Alvarado score {Area Under the Curve (AUC) 0.892}, comprehensive AIR (AUC 0.833) and total AAS (AUC 0.808) but in contrast to the present study, the study conducted by Macco S et al., reported an area under the ROC of 0.90 for AIR score and 0.87 for Alvarado score and AAS score was not included in their study (22).

It was found that the AIR score had more sensitivity (92.55%), followed by the AAS (84.04%) score and Alvarado (60.64%) score but the specificity of the Alvarado score was more (100%), which was 83.33% for AAS and 66.67% for AIR score. In a study conducted by Madasi V sensitivity of AIR score was 95.7% which was comparable to the current study, but the specificity of the AIR score, sensitivity, and specificity of the Alvarado score were not comparable to the present study (14).

In the present study, AIR score had more NPV (36.40%) than the other scores AAS (25%) and Alvarado scores (14%). Alvarado's score had more PPV (100%) than AAS (98.7%) and AIR (97.8%). In study conducted by Madasi V PPV and NPV for Alvarado score was 96% and 23%, PPV of AIR score was 99.2% which were comparable to the present study, but in contrast to the present study NPV for AIR score
was 61.3% (14).

In the present study the diagnostic accuracy of AIR (91%) was more than AAS (85%) and Alvarado's score (63%). In a study conducted by Madasi V diagnostic accuracy of AIR score was 95% which was comparable to the present study but the diagnostic accuracy of Alvarado score was 85% which was different from the present study. This might be due to the less number of the study population in more time period in our study compare to the Madasi V study. There is always a trade-off between sensitivity and specificity (any increase in sensitivity will be accompanied by a decrease in specificity) so we choose that variable as best in which combination of sensitivity and specificity gives the maximum predictive value i.e., maximum diagnostic accuracy so overall total AIR was a better predictor of uncomplicated acute appendicitis.

Limitation(s)

This study was conducted in a single tertiary care centre with a study population of 100 which was not sufficient to conclude. A multicentric study with large study population will be required to conclude AIR is a better predictor of uncomplicated acute appendicitis compared to AAS and Alvarado score.

Conclusion

Appendicitis Inflammatory Response can be used for better diagnosis of uncomplicated acute appendicitis in a tertiary health center as compared to AAS and Alvarado scores to decrease a negative appendectomy rate.

References

1.
Chalazonitis AN, Tzovara I, Sammouti E, Ptohis N, Sotiropoulou E, Protoppapa E. CT in appendicitis. Diagn Interv Radiol. 2008;14(1):19-25.
2.
Cuschieri A. Essential surgical practice. 3 rd ed. Oxford: Butterworth-Heinermann. 1995.
3.
Mohamed A, Bhat N. Acute appendicitis dilemma of diagnosis and management. The Internet J Surg. 2009;23(2):34-41. [crossref]
4.
Flum DR, Koepsell T. The clinical and Economic Correlates of misdiagnosed appendicitis. Nationwide Analysis. Arch Surg. 2002;137(7):799-804. [crossref] [PubMed]
5.
Joshi MK, Joshi R, Alam SE, Agarwal S, Kumar S. Negative appendectomy: an audit of resident-performed surgery. How can its incidence be minimized? Indian J Surg. 2015;77(3):913-17. [crossref] [PubMed]
6.
Chae MS, Hong CK, Ha YR, Chae MK, Kim YS, Shin TY, et al. Can clinical scoring systems improve the diagnostic accuracy in patients with suspected adult appendicitis and equivocal preoperative computed tomography findings? Clin Exp Emerg Med. 2017;4(4):214-21. [crossref] [PubMed]
7.
Sammalkorpi HE, Mentula P, Savolainen H, Leppäniemi A. The introduction of adult appendicitis score reduced negative appendectomy rate. Scand J Surg. 2017;106(3):196- 201. [crossref] [PubMed]
8.
Brigand C, Steinmetz JP, Rohr S. The usefulness of scores in the diagnosis of appendicitis. J Chir (Paris). 2009;146(1):02-07. [crossref] [PubMed]
9.
Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med. 2011;9(1):139-40. [crossref] [PubMed]
10.
Chong CF, Thien A, Mackie AJ, Tin AS, Tripathi S, Ahmad MA, et al. Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singapore Med J. 2011;52(5):340-45.
11.
Walczak DA, Pawelczak D, Z . óltaszek A, Jaguscik R, Falek W, Czerwińska M, et al. The value of scoring systems for the diagnosis of acute appendicitis. Pol Przegl Chir. 2015;87(2):65-70. [crossref] [PubMed]
12.
Nanjundaiah N, Mohammed A, Shanbhag V, Ashfaque K, Priya SA. A comparative study of RIPASA score and ALVARADO score in the diagnosis of acute appendicitis. J Clin Diagn Res. 2014;8(11):NC03-NC05.
13.
Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27-28. [crossref] [PubMed]
14.
Madasi V. Comparison of predictive validity of alvarado score and Appendicitis Inflammatory Response (AIR) Score, a hospital based observational study. Int J Sur Trauma and Orthopedics. 2016;2(3):30-36. [crossref]
15.
Karki OB, Hazra NK. Evaluation of the Appendicitis Inflammatory Response Score against Alvarado score in diagnosis of acute appendicitis. Kathmandu Univ Med J. 2019;5(3):68-72. [crossref]
16.
Pogorelic Z, Mihanovic J, Nincevic S, Luksic B, Elezovic Baloevic S, Polasek O, et al. Validity of appendicitis inflammatory response score in distinguishing perforated from non- perforated appendicitis in children. Pediatr Emerg Care. 2021;8(1):09-18. [crossref] [PubMed]
17.
Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg. 2008;31(1):37-42. [crossref] [PubMed]
18.
Von-Mühlen B, Franzon O, Beduschi MG, Kruel N, Lupselo D. AIR score assessment for acute appendicitis. Arq Bras Cir Dig. 2015;28(3):171-73. [crossref] [PubMed]
19.
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-64. [crossref] [PubMed]
20.
Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bosner S, et al. Studies of the symptom abdominal pain--a systematic review and meta-analysis. Fam Pract. 2014;31(1):517-29. [crossref] [PubMed]
21.
Gopalam PR, Konidala MVSS. Comparison of acute inflammatory score and Alvarado score in diagnosis of acute appendicitis at a tertiary care hospital. Int Surg J. 2017;4(1):4034-38. [crossref]
22.
Macco S, Vrouenraets BC, de Castro SM. Evaluation of scoring systems in predicting acute appendicitis in children. Surgery. 2016;160(6):1599-604. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/60480.17409

Date of Submission: Sep 27, 2022
Date of Peer Review: Oct 30, 2022
Date of Acceptance: Dec 20, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 28, 2022
• Manual Googling: Nov 18, 2022
• iThenticate Software: Dec 16, 2022 (12%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com