Richard G Bachur1, Peter S Dayan2, Nanette C Dudley3, Lalit Bajaj4, Michelle D Stevenson5, Charles G Macias6, Manoj K Mittal7, Jonathan Bennett8, Kelly Sinclair9, Michael C Monuteaux1, Anupam B Kharbanda10. 1. Division of Emergency Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA. 2. Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY. 3. Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT. 4. Department of Pediatrics, University of Colorado School of Medicine, Denver, CO. 5. Department of Pediatrics, University of Louisville, Louisville, KY. 6. Department of Pediatrics, Baylor College of Medicine, Houston, TX. 7. Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 8. Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, DE. 9. Division of Emergency Medicine, Children's Mercy Hospitals and Clinics, Kansas City, MO. 10. Department of Pediatric Emergency Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, MN.
Abstract
OBJECTIVE: White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted. METHODS: This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5-11, and 12-18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut-points. RESULTS: A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0-13.9 years) were studied. Forty-one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval [CI] = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5-11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12-18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut-point of 10,000/mm3 , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), and 64% (12-18 years). CONCLUSION: WBC count and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.
OBJECTIVE: White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted. METHODS: This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5-11, and 12-18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut-points. RESULTS: A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0-13.9 years) were studied. Forty-one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval [CI] = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5-11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12-18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut-point of 10,000/mm3 , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), and 64% (12-18 years). CONCLUSION: WBC count and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.
Authors: Anupam B Kharbanda; Gabriela Vazquez-Benitez; Dustin W Ballard; David R Vinson; Uli K Chettipally; Mamata V Kene; Steven P Dehmer; Richard G Bachur; Peter S Dayan; Nathan Kuppermann; Patrick J O'Connor; Elyse O Kharbanda Journal: Pediatrics Date: 2018-03-13 Impact factor: 7.124