- Email: [email protected]
Forgotten art
ARTICLE IN PRESS
Letter to the Editors Forgotten art
To the Editors: We read with interest the manuscript entitled “Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging?”1 Although the results of the study were impressive, we feel that there are some points that must be clarified. First, computed tomography (CT) is widely available and is the imaging test most commonly used to evaluate patients for suspected appendicitis. The sensitivity and specificity of CT are 91–98.5% and 90–98%, respectively. The use of ionizing radiation in CT is a particular concern when performing imaging for children or pregnant patients.2 In addition, an intravenous contrast medium is typically used to increase the diagnostic accuracy of CT, although it is associated with the added potential for allergic reactions and contrast-induced nephropathy. On the other hand, the sensitivity and specificity of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis are 96% and 96%, respectively, including if subgroup populations of children and pregnant patients. MRI may be considered as a first-line imaging test that avoids the potential risk for exposure to ionizing radiation and iodinated contrast medium.2 Second, in recent years, laboratory and medical imaging methods have been used more liberally by physicians. Medicine is an “art based on science.” Taking a history and physical examination are the most important parts of this art. Sometimes, taking a detailed history and thoughtful physical examination are more important than laboratory and medical imaging methods (CT or MRI) for diagnosis and management of the patients. Third, we recently read another paper by these authors entitled “Clinical and laboratory findings in
the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial.”3 They evaluated 1,321 patients with a clinical suspicion of acute appendicitis who underwent CT. Age, sex, body temperature, pain scores, the duration of symptoms, white blood cell count (WBC) and C-reactive protein (CRP) were recorded on admission, and they concluded that “If both WBC count and CRP are normal, acute appendicitis is very unlikely. The current results emphasize the role of CT imaging in patients with suspected acute appendicitis.”3 Are the aforementioned studies parts of the same cohort? If yes, then these 2 papers could be written as a single paper. Barısx Saylam, MD I_ brahim I_ bili, MD Mesut Tez, MD From the Department of General Surgery, Ankara Numune Hospital, Ankara, Turkey E-mail: [email protected]
References 1. Lietzen E, M€allinen J, Gr€ onroos JM, Rautio T, Paajanen H, Nordstr€ om P, et al. Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging? Surgery 2016;160:789-95. 2. Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim SM, et al. A systematic review and meta-analysis of diagnostic performance of MRI for evaluation of acute appendicitis. AJR Am J Roentgenol 2016;206:508-17. 3. Lietzen E, Ilves I, Salminen P, Paajanen H, Rautio T, Nordstr€ om P, et al. Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial. Clin Chem Lab Med 2016;54: 1691-7. http://dx.doi.org/10.1016/j.surg.2016.09.040
SURGERY 1
Letter to the Editors Forgotten art
To the Editors: We read with interest the manuscript entitled “Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging?”1 Although the results of the study were impressive, we feel that there are some points that must be clarified. First, computed tomography (CT) is widely available and is the imaging test most commonly used to evaluate patients for suspected appendicitis. The sensitivity and specificity of CT are 91–98.5% and 90–98%, respectively. The use of ionizing radiation in CT is a particular concern when performing imaging for children or pregnant patients.2 In addition, an intravenous contrast medium is typically used to increase the diagnostic accuracy of CT, although it is associated with the added potential for allergic reactions and contrast-induced nephropathy. On the other hand, the sensitivity and specificity of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis are 96% and 96%, respectively, including if subgroup populations of children and pregnant patients. MRI may be considered as a first-line imaging test that avoids the potential risk for exposure to ionizing radiation and iodinated contrast medium.2 Second, in recent years, laboratory and medical imaging methods have been used more liberally by physicians. Medicine is an “art based on science.” Taking a history and physical examination are the most important parts of this art. Sometimes, taking a detailed history and thoughtful physical examination are more important than laboratory and medical imaging methods (CT or MRI) for diagnosis and management of the patients. Third, we recently read another paper by these authors entitled “Clinical and laboratory findings in
the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial.”3 They evaluated 1,321 patients with a clinical suspicion of acute appendicitis who underwent CT. Age, sex, body temperature, pain scores, the duration of symptoms, white blood cell count (WBC) and C-reactive protein (CRP) were recorded on admission, and they concluded that “If both WBC count and CRP are normal, acute appendicitis is very unlikely. The current results emphasize the role of CT imaging in patients with suspected acute appendicitis.”3 Are the aforementioned studies parts of the same cohort? If yes, then these 2 papers could be written as a single paper. Barısx Saylam, MD I_ brahim I_ bili, MD Mesut Tez, MD From the Department of General Surgery, Ankara Numune Hospital, Ankara, Turkey E-mail: [email protected]
References 1. Lietzen E, M€allinen J, Gr€ onroos JM, Rautio T, Paajanen H, Nordstr€ om P, et al. Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging? Surgery 2016;160:789-95. 2. Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim SM, et al. A systematic review and meta-analysis of diagnostic performance of MRI for evaluation of acute appendicitis. AJR Am J Roentgenol 2016;206:508-17. 3. Lietzen E, Ilves I, Salminen P, Paajanen H, Rautio T, Nordstr€ om P, et al. Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial. Clin Chem Lab Med 2016;54: 1691-7. http://dx.doi.org/10.1016/j.surg.2016.09.040
SURGERY 1