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

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Dr Bhanu K Bhakhri

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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On Sep 2018




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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
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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."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Best regards,
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On Aug 2018




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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.
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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

Important Notice

Original article / research
Year : 2009 | Month : October | Volume : 3 | Issue : 5 | Page : 1731 - 1736

Ultrasonography Is Still A Useful Diagnostic Tool In Acute Appendicitis

TAURO LF*, PREMANAND T S** , AITHALA P S***, GEORGE C****, SURESH H B*****, ACHARYA D******, JOHN P*******

*,**,***,****Department of General Surgery,Fr. Muller Medical College,Kankanady,Mangalore – 575002,(INDIA) *****,******,*******Department of Radio-diagnosis, Fr. Muller Medical College, Kankanady, Mangalore – 575002, (INDIA)

Correspondence Address :
Dr. Leo Francis Tauro (MS)Department
of Surgery, Fr. Muller Medical College
Kankanady, Mangalore – 575002.
Ph No: Hosp: (0824) 436301,Res: (0824) 2224911
E-mail:drlftauro@rediffmail.com

Abstract

Aim: The aim of the study was to evaluate the role of ultrasonography in the diagnosis of acute appendicitis and to study the correlation between clinical signs, laboratory investigations and ultrasonographic findings in the evaluation of the diagnosis of acute appendicitis.
Methods: A total number of 100 patients (52 men and 48 women) over a period of 2 years, with the clinical suspicion of appendicitis, were subjected to abdominal ultrasonographic examination. Ultrasound positive cases were subjected to surgery. The accuracy of ultrasonography in the diagnosis of appendicitis was compared with clinical diagnosis, laparotomy findings and histopathological examination reports.
Results: Out of 100 cases that underwent ultrasonography, 58 cases were sonographically positive for appendicitis and 3 cases were appendicular masses. Right iliac fossa tenderness, rebound tenderness and Rovsing’s sign were the cardinal signs. The Murphy’s triad of symptoms holds good in the diagnosis of appendicitis in the present study. The overall specificity of ultrasound was 88.09% and the sensitivity was 91.37% in the diagnosis of acute appendicitis.
Conclusion:Acute appendicitis is a common indication for emergency abdominal surgery. Ultrasonography is still a useful tool in the diagnosis of acute appendicitis in spite of sophisticated investigations like CT abdomen and laparoscopy; thus, reducing the cost of treatment and preventing negative laparotomies.

Keywords

Appendix, Appendicitis, Ultrasound in appendicitis, Sensitivity, Specificity.

How to cite this article :

TAURO LF, PREMANAND T S, AITHALA P S, GEORGE C, SURESH H B, ACHARYA D, et al.. ULTRASONOGRAPHY IS STILL A USEFUL DIAGNOSTIC TOOL IN ACUTE APPENDICITIS. Journal of Clinical and Diagnostic Research [serial online] 2009 October [cited: 2018 Sep 23 ]; 3:1731-1736. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2009&month=October&volume=3&issue=5&page=1731-1736&id=567

Introduction
Acute appendicitis is still the most common indication for emergency abdominal surgery. The clinical diagnosis of appendicitis is difficult in a few cases. Approximately 20-33% of patients will present atypically (1),(2). Delay in the diagnosis and surgery in these atypical cases of appendicitis result in perforation. This occurs in 17-39% of patients with appendicitis. The elderly and very young patients are at a higher risk (1),(3). To prevent high morbidity and mortality, most of the surgical authorities have advocated timely surgical intervention (early appendicectomy), accepting that a significant number of normal appendices will be removed (1), (4). The diagnosis of appendicial inflammation cannot be accurately made, based on a single symptom, sign or diagnostic test in all cases. The diagnosis of acute appendicitis can be established accurately in over 80% of the cases by some experienced senior surgeons (5), (6).

Abdominal ultrasonography (USG) has a definitive role in the diagnosis of acute appendicitis, establishes an alternative diagnosis in patients with acute right lower abdominal pain and reduces the number of negative laparotomies (7),(8),(9).

Material and Methods

This prospective study was carried out in the department of Surgery, in collaboration with the department of Radio-diagnosis, at our Medical College Hospital, over a period of 2 years from March 2000 to February 2002. A total of 100 patients (52 men and 48 women; age range 8 years to 57 years) who presented with pain in the right lower abdomen, in whom acute appendicitis was suspected based on clinical features, were subjected to abdominal USG examination .

Inclusion Criteria
1. All patients who presented with pain in the right lower abdomen, in whom acute appendicitis was suspected, were included in this study.
2. Patients with appendicular masses who were managed conservatively and later underwent interval appendicectomy, were included.
3. Patients with a history suggestive of recurrent appendicitis were also included in the study.

Exclusion Criteria
1. Patients with chronic infectious diseases like ileo-caecal tuberculosis were not included in this study.
2. Patients with carcinoid tumours and other neoplastic lesions of the appendix were not included in the study.

Clinical diagnosis of acute appendicitis was done by consultants, based on the symptom of pain which was localized to the right lower quadrant, a history of migration of pain, vomiting, fever and peritoneal signs. Based on the sonological report, a definitive surgical management was instituted.

Graded compression USG was done using 3.5 - 7.5 MHz linear – array transducers according to the situation. The following accepted criteria were considered for the diagnosis of an inflamed appendix.

a. [Table/Fig 1] Visualization of non-compressible appendix as a blind ending tubular aperistaltic structure (10).
b. [Table/Fig 2] Target appearance of  6mm. (6 millimeters) in the total diameter on cross section
(81%) maximal mural wall thickness  2mm) (11).
c. [Table/Fig 3] Diffuse hypoechogenesity (associated with a higher incidence of
perforation).
d. Lumen may be distended with anechoic / hyper echoic material.
e. Loss of wall layers.
f. [Table/Fig 4] Visualization of appendicolith (6%). (Table/Fig 4a & Table/Fig 4b)
g. [Table/Fig 5] Localized peri-appendiceal fluid collection.
h. Prominent hyper echoic mesoappendix / pericaecal fat.
i. Free pelvic fluid.

Grebeldinger (12) has stated that the most relevant criteria for USG evaluation was non-compressibility (97.67%). The second criterion was thickened wall (86.04%).

It was kept in mind that a normal appendix is not visualized on USG examination and such a finding was taken as a negative test by USG in the diagnosis of appendicitis.

The accuracy of USG in diagnosing appendicitis was compared with clinical diagnosis, laparotomy findings and resulting histopathological examination (HPE).

Results

Before the analysis of the data, certain assumptions were done.

1. HPE diagnosis was accepted as the final confirmation of the diagnosis.
2. All cases which were treated conservatively were discharged and those cases of appendicectomies in which HPE was negative, were all considered as true negatives.
3. Though USG was done by 4 radiologists in our hospital, no significance was attached to the inter observer variation, as all the radiologists had equally good experience with USG.
4. Though many consultants were involved in clinical diagnosis, again no significance was attached to the inter observer variation.

The above observation shows that, out of 100 cases for whom USG abdomen was done, 58 cases (58%) were sonologically positive for appendicitis and 3 cases were appendicular masses [Table/Fig 6]. Among USG negative cases (42%), an alternative diagnosis could be attained in more than half the number of cases, such as right ureteric colic, pelvic inflammatory disease, ovarian cyst and intestinal ascariasis. 18% of cases were inconclusive [Table/Fig 7] .

The above observation shows that all the cases presented with pain in the right iliac fossa (RIF) and clinical suspicion of acute appendicitis which were the selection criteria for the present study. Tenderness in RIF was the most common sign elicited in all the cases (100%). Irrespective of the pathology, vomiting was found to be present in 91% of the cases. Murphy’s triad of symptoms i.e. pain in abdomen, vomiting and fever held good in the diagnosis of acute appendicitis in our study [Table/Fig 8]. Smith (13) studied 100 cases of acute appendicitis in which only 60 patients had a temperature of 37.2oC, which tallied with our study.

Rebound tenderness was present in 65% of the cases and Rovsing’s sign was positive in 43% of cases. A total of 58 cases were diagnosed to have appendicular pathology by USG and all these patients were operated upon. Out of the 58 operated cases, 53 were HPE positive and 5 were found to be negative on HPE [Table/Fig 9] . The sonologically negative cases were managed conservatively. In the conservative group of 42 cases, appendicectomy was done for 10 cases due to the persistence of symptoms and due to the surgeon’s suspicion. Out of these 10 operated cases, 5 were reported to be acute appendicitis on HPE [Table/Fig 10] . 3 cases of appendicular masses were treated conservatively and were subjected to interval appendectomy after 3 months of interval.

The overall specificity (88.09%) and sensitivity (91.37%) of USG in diagnosing appendicular pathology were high, indicating accurate diagnosis by USG in almost all patients with pain in RIF (For Table/Fig 11 refer to ) [Table/Fig 10] .

Discussion

USG is a valued tool for clinically suspected appendicitis and it enhances the diagnostic accuracy in cases with pain in the RIF and reduces the number of negative appendicectomies.

Of the 58 cases of appendicitis, pain in abdomen and vomiting were the predominant clinical symptoms, but they are not specific for acute appendicitis. Tenderness in RIF was present in almost all cases. Rebound tenderness, guarding and Rovsing’s sign if present, are more specific for acute appendicitis. These findings tallied with the findings of the study by Rosemary Kozar et al (14) . Leucocytosis was present in 75% of the cases and Neutrophilia in 86% of the cases. A study of 225 patients by Doraiswamy (1982) (15) showed leucocytosis in 42% and neutrophilia in 96% of the cases.

Abdominal USG could diagnose 58 cases as appendicitis out of a total of 100 cases who presented with clinical features similar to appendicitis, from which true positive cases of appendicitis were found after surgery and HPE. John et al (16) reviewed a total 140 cases of appendicitis in which they could diagnose 70 cases as appendicitis by USG.

The overall specificity and sensitivity were found to be 88.09% and 91.37% respectively, which showed that USG has a high specificity and sensitivity in diagnosing appendicitis. The overall specificity and sensitivity rates were at par with the values drawn by Skanne et al (17), Hahn et al (18), Tarzan Z et al (19) and Puylaert et al (20), whose specificity values varied from 90-100% and sensitivity ranges varied from 70-95%.

Limitations And Drawbacks Of The Study
This study does not include diagnostic laparoscopy, which is the recent modality of diagnosis and treatment of acute appendicitis. We have not included contrast CT abdomen for the accurate diagnosis of doubtful cases due to the cost factor. This study would have been more accurate if we would have included all cases with right iliac fossa pain. USG is operator dependant; though USG was done by 4 radiologists in our hospital, no significance was attached to the inter observer variation as all the radiologists had equally good experience with USG.

Conclusion

Acute appendicitis is the most common acute abdominal condition, necessitating emergency surgery. When the clinical signs and the symptoms are combined with USG findings, the diagnostic accuracy is significantly high. USG helps in diagnosing other causes of RIF pain which helps in excluding appendicular pathology. The overall specificity of abdominal USG in the diagnosis of acute appendicitis was 88.09% and sensitivity was 91.37%. It should be emphasized that USG does not replace clinical diagnosis, but is a useful adjunct in the diagnosis of acute appendicitis. We recommend USG as a valuable tool in diagnosing acute appendicitis in spite of sophisticated investigations like CT abdomen and laparoscopy; thus, reducing the cost of treatment and preventing negative laparotomies.

References

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Grebeldinger S. Ultrasonographic diagnosis of acute appendicitis. Med. Pregl. 1996; 49:487-91.
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Seymor I Schwartz, G.Tom Shires, Frank C. Spenner. Appendix ; Schwartz Principles of Surgery, international edition, Mc. Graw –Hill INC, Health Professions division, 7th edn. 1999; 1383-94.
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Doraiswamy N.V. Leucocyte counts in the diagnosis and prognosis of acute appendicitis in children. Br. J. Surg. 1979; 66:782.
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George MJ, Siba PP, Charan PK, Rao RRM. Evaluation of Ultrasonography as a useful Diagnostic Aid in Appendicitis. Indian J Surg. 2002; 64: 436 – 9.
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Skanne P, Amland P.F., Nordshus T. et al. Ultrasonography in patients with suspected acute appendicitis. A prospective study. Br. Jr. Radiol, 1990; 63:787-93.
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