{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T06:51:19Z","timestamp":1792047079529,"version":"4.4.0"},"reference-count":138,"publisher":"Wiley","issue":"5","license":[{"start":{"date-parts":[[2017,5,11]],"date-time":"2017-05-11T00:00:00Z","timestamp":1494460800000},"content-version":"vor","delay-in-days":10,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Academic Emergency Medicine"],"published-print":{"date-parts":[[2017,5]]},"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n \n Acute appendicitis (\n AA<\/jats:styled-content>\n ) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children.\n <\/jats:p>\n <\/jats:sec>\n \n Objectives<\/jats:title>\n \n The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (\n PAS<\/jats:styled-content>\n ) and Emergency Department Point\u2010of\u2010Care Ultrasound (\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n ) in the diagnosis of\n AA<\/jats:styled-content>\n in\n ED<\/jats:styled-content>\n pediatric patients. We performed a systematic review and meta\u2010analysis and used a test\u2013treatment threshold model to identify diagnostic findings that could rule in\/out\n AA<\/jats:styled-content>\n and obviate the need for further imaging studies, specifically computed tomography (\n CT<\/jats:styled-content>\n ) scan, magnetic resonance imaging (\n MRI<\/jats:styled-content>\n ), and radiology department ultrasound (\n RUS<\/jats:styled-content>\n ).\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n We searched PubMed,\n EMBASE<\/jats:styled-content>\n , and\n SCOPUS<\/jats:styled-content>\n up to October 2016 for studies on\n ED<\/jats:styled-content>\n pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (\n QUADAS<\/jats:styled-content>\n \u20102) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (\n LR<\/jats:styled-content>\n + and\n LR<\/jats:styled-content>\n \u2013) for diagnostic modalities were calculated and when appropriate data was pooled using Meta\u2010DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker\u2010Kassirer method we developed a test\u2013treatment threshold model.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Twenty\u2010one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the\n QUADAS<\/jats:styled-content>\n \u20102 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of \u201cundifferentiated abdominal pain\u201d and abdominal pain \u201csuspected of\n AA<\/jats:styled-content>\n .\u201d In patients with undifferentiated abdominal pain, history of \u201cpain migration to right lower quadrant (\n RLQ<\/jats:styled-content>\n )\u201d (\n LR<\/jats:styled-content>\n +\u00a0= 4.81, 95% confidence interval [\n CI<\/jats:styled-content>\n ]\u00a0= 3.59\u20136.44) and presence of \u201ccough\/hop pain\u201d in the physical examination (\n LR<\/jats:styled-content>\n +\u00a0= 7.64, 95%\n CI<\/jats:styled-content>\n \u00a0= 5.94\u20139.83) were most strongly associated with\n AA<\/jats:styled-content>\n . In patients suspected of\n AA<\/jats:styled-content>\n none of the history or laboratory findings were strongly associated with\n AA<\/jats:styled-content>\n . Rovsing's sign was the physical examination finding most strongly associated with\n AA<\/jats:styled-content>\n (\n LR<\/jats:styled-content>\n +\u00a0= 3.52, 95%\n CI<\/jats:styled-content>\n \u00a0= 2.65\u20134.68). Among different\n PAS<\/jats:styled-content>\n cutoff points,\n PAS<\/jats:styled-content>\n \u00a0\u2265 9 (\n LR<\/jats:styled-content>\n +\u00a0= 5.26, 95%\n CI<\/jats:styled-content>\n \u00a0= 3.34\u20138.29) was most associated with\n AA<\/jats:styled-content>\n . None of the history, physical examination, laboratory tests findings, or\n PAS<\/jats:styled-content>\n alone could rule in or rule out\n AA<\/jats:styled-content>\n in\u00a0patients with undifferentiated abdominal pain or those suspected of\n AA<\/jats:styled-content>\n .\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n had\n LR<\/jats:styled-content>\n + of 9.24 (95%\n CI<\/jats:styled-content>\n \u00a0= 6.24\u201313.28) and\n LR<\/jats:styled-content>\n \u2013 of 0.17 (95%\n CI<\/jats:styled-content>\n \u00a0= 0.09\u20130.30). Using our test\u2013treatment threshold model, positive\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n could rule in\n AA<\/jats:styled-content>\n without the use of\n CT<\/jats:styled-content>\n and\n MRI<\/jats:styled-content>\n , but negative\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n could not rule out\n AA<\/jats:styled-content>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n \n Presence of\n AA<\/jats:styled-content>\n is more likely in patients with undifferentiated abdominal pain migrating to the\n RLQ<\/jats:styled-content>\n or when cough\/hop pain is present in the physical examination. Once\n AA<\/jats:styled-content>\n is suspected, no single history, physical examination, laboratory finding, or score attained on\n PAS<\/jats:styled-content>\n can eliminate the need for imaging studies. Operating characteristics of\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n are similar to those reported for\n RUS<\/jats:styled-content>\n in literature for diagnosis of\n AA<\/jats:styled-content>\n . In\n ED<\/jats:styled-content>\n patients suspected of\n AA<\/jats:styled-content>\n , a positive\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n is diagnostic and obviates the need for\n CT<\/jats:styled-content>\n or\n MRI<\/jats:styled-content>\n while negative\n ED<\/jats:styled-content>\n \u2010\n POCUS<\/jats:styled-content>\n is not enough to rule out\n AA<\/jats:styled-content>\n .\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/acem.13181","type":"journal-article","created":{"date-parts":[[2017,2,18]],"date-time":"2017-02-18T15:12:47Z","timestamp":1487430767000},"page":"523-551","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":192,"title":["Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point\u2010of\u2010care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta\u2010analysis"],"prefix":"10.1111","volume":"24","author":[{"given":"Roshanak","family":"Benabbas","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine State University of New York\/SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Hanna","sequence":"additional","affiliation":[{"name":"Department of Pediatrics State University of New York\/SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Pediatrics Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jay","family":"Shah","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Sinert","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine State University of New York\/SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2017,5,11]]},"reference":[{"key":"e_1_2_9_2_1","unstructured":"National Hospital Ambulatory Medical Care Survey: 2013 Emergency Department Summary Tables. 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