Understanding Evidence-Based Practice Effect of PET vs. CT SCAN in Diagnosing Appendicitis - Term Paper Example

 Understanding Evidence-Based Practice Effect of PET vs. CT SCAN in Diagnosing Appendicitis Abstract The essay aims to address a two-fold objective to wit: (1) to analyze the research articles presented; and (2) to conduct an evidence-based practice research using the propose PICO question. In Children Suffering from Appendicitis, is a PET More Effective in Confirming the Diagnosis Versus the CT Scan? Name of the Study Study 1 Dearing, D.D., Recabaren, J.A. & Alexander, M. (2008). Can Computed Tomography Scan be Performed Effectively in the Diagnosis of Acute Appendicitis without the Added Morbidity of Rectal Contrast? The American Surgeon, 74(10): 917-920. Study 2 Garcia-Peña, B.M., Cook, E.F. & Mandl, K.D. (2004). Selective Imaging Strategies for the Diagnosis of Appendicitis in Children. PEDIATRICS, 113(1): 24-28. Study 3 Hossain, A.K., Shulkin, B.L., Gelfand, M.J., Bashir, H., Daw, N.C., Sharp, S.E., Nadel, H.R. &Dome, J.S. (2010). FDG Positron Emission Tomography/Computed Tomography Studies of Wilm’s Tumor. European Journal of Nuclear Medicine and Molecular Imaging, 37: 1300-1308. Study 4 Neff, L.P., Ladd, M.R., Becher, R.D., Jordanhazy, R.A., Gallaher, J.R. & Pranikoff, T. (2011). Computerized Tomography Utilization in Children with Appendicitis – Differences in Referring and Children’s Hospitals. The American Surgeon, 77(8): 1061-1065. Introduction The PICO question developed is, “In children suffering from appendicitis, is a PET more effective in confirming the diagnosis versus the CT scan?” The PICO question is a relevant question as it intends to address the challenge to most of the physicians in diagnosing acute appendicitis. Garcia-Peña, Cook & Mandl (2004) stated that diagnosing appendicitis in children is quite difficult as it pose similarities of initial presentation to other childhood diseases (p. 24). There are a lot of diagnostic tools developed to early confirm suspected diagnosis but these diagnostic tools differ in accuracy and effectivity, such as the PET and the CT scan. I came up with this PICO question because I noticed that physicians are ordering CT scan first to be followed by PET if CT scan is negative. Therefore, the proposed PICO question will seek to determine the most confirmative diagnostic tool of appendicitis among children by determining the number of incorrect/missed diagnosis. Methods Typing words such as “PET Imaging,” “CT scan,” and “appendicitis were the searching techniques that I used in searching for the evidences in my propose PICO question. Cochrane, Medline, and PubMed databases were utilized in the study. Search is narrowed by typing “imaging appendicitis.” The articles that I chose were: Can Computed Tomography Scan be Performed Effectively in the Diagnosis of Acute Appendicitis without the Added Morbidity of Rectal Contrast? (2008); Selective Imaging Strategies for the Diagnosis of Appendicitis in Children (2004); FDG Positron Emission Tomography/Computed Tomography Studies of Wilm’s Tumor (2010); andComputerized Tomography Utilization in Children with Appendicitis – Differences in Referring and Children’s Hospitals (2011). I chose these articles and considered them as the best evidences because of emphasis given on the use of PET and CT scan among children with appendicitis and the involvement of a larger sample. Evidences matched what my PICO question look for as these evidences studied children, PET and CT scan, and appendicitis. Research Name of Study Target Population Study Design Outcome measured Statistical outcome (p- value) Side effects Study Limitations Study 1 245 patients undergoing appendectomy Retrospective review Effective diagnosis of acute appendicitis and reduced attendant morbidity using CT Scanning without rectal contrast. ≤ 0. 05 Failure to visualize the appendix and pericecal fat stranding. The study did not reach statistical significance and patients with unequivocal signs of appendicitis were not studied because they are presented directly to the operating room. Study 2 958 children ages 3-21 years old with suspected appendicitis Retrospective cohort Reduced of unnecessary testing of children with suspected appendicitis and increased diagnostic accuracy. -not stated- Potential long-term risks of ionizing radiation. Hypothetical nature of guidelines 2 & 3. Chosen management strategies were not ideal in case of suspected appendicitis. Unavailability of the second data set to validate the risk groups. Study 3 27 patients ages 1.9-23 years with Wilm’s tumor Review of imaging studies Increased utility of FDG PET/CT Scanning among patients with Wilm’s tumor. -not stated- Increased incidence of missed/delayed diagnosis PET limitations of visualizing lung nodules and lesions < 10 mm, short clinical course, and unclear difference of patients with favorable and unfavorable histologies. Study 4 546 children ages 0-17 who underwent appendectomy Retrospective chart review Decreased use of CT Scan as a diagnostic tool of appendicitis in referring hospitals and increased use of Alvarado scores. < 0. 01 Medically-related radiation exposure. Cohort was limited only to children who eventually underwent an appendectomy. Inability to quantify the number of children who were spared an NA. Capturing all the clinical variables that factored into the decision to CT scan each individual patient is impossible. Target Population Study 1 involved 245 patients undergoing appendectomy and patients are selected based on the result of the radiology reports confirming suspecting clinical appendicitis; Study 2 targeted 1401 children ages 3-21 years old with suspected appendicitis but only reached 958 children who completed the data despite selection that all children with equivocal presentation of appendicitis were to be included; Study 3 included 27 patients ages 1.9-23 years with Wilm’s tumor; and Study 4 involved 546 children ages 0-17 who underwent appendectomy and selection of the participants were based on the clinical variables of appendicitis and the Alvarado scores. Study Design The four (4) research articles have retrospective cohort/study design. According to Polit and Beck (2008), retrospective designs collect data-outcomes at present and then link it to antecedents or determinants in the past (p. 210). Retrospective designs are cross-sectional in nature in that data from present outcome, past events, and occurrences are collected at a single point in time. The four articles proposed as evidence serve as past events and occurrences and the proposed study from PICO question will be the present data to be measured. Outcome Measured Outcomes of Study 1 are measured if the researcher will observe effective diagnosis of acute appendicitis and will reduce attendant morbidity using CT Scanning without rectal contrast; Study 2 will measure outcome in terms of reduced unnecessary testing of children with suspected appendicitis and increased diagnostic accuracy; outcome measured in Study 3 is increased utility of FDG PET/CT Scanning among patients with Wilm’s tumor; outcomes measured in Study 4 are decreased use of CT Scan as a diagnostic tool of appendicitis in referring hospitals and increased use of Alvarado scores. Side Effects Among of the predicted side-effects of the treatment are: failure to visualize the appendix and pericecal fat stranding, potential long-term risks of ionizing radiation, increased incidence of missed/delayed diagnosis, and medically-related radiation exposure. Limitations of the Study Analyzing all the strengths and limitations of the study, the following limitations were noted in each research article: Study 1 did not reach statistical significance and patients with unequivocal signs of appendicitis were not studied because they are presented directly to the operating room; the hypothetical nature of guidelines 2 & 3, not ideal to suspected appendicitis of the chosen management strategies, and unavailability of the second data set to validate the risk groups were the limitations of Study 2; Study 3 has PET limitations of visualizing lung nodules and lesions < 10 mm, has short clinical course, and has unclear difference of patients with favorable and unfavorable histologies; and Study 4’s cohort was limited only to children who eventually underwent an appendectomy, has inability to quantify the number of children who were spared an NA, and seems impossible to capture all the clinical variables that factored into the decision to CT scan each individual patient. Results Results from Garcia-Peña, Cook & Mandl (2004) stated that the increased use of ultrasonography and CT Scan have provided increased in accuracy in diagnosing acute appendicitis. Likewise, the stratification system developed by the researchers reduced the number of radiographic studies performed for diagnosing appendicitis; however, there is minimal increase in the negative appendectomy and missed diagnosis of appendicitis rates (p. 26). Dearing, Recabaren & Alexander (2008) discussed in the result of their study that the used of oral and IV contrast enhancement in CT Scanning appendicitis is as effective as CT Scanning with rectal contrast. The authors also found out that the negative appendectomy rates in surgical practice were lower compared to the acceptable negative appendectomy rate (p. 919). The result of the study of Hossain, Shulkin, Gelfand, Bashir, Daw, Sharp, Nadel & Dome (2010) stated that PET may be a useful adjunction to conventional imaging studies. Likewise, PET has greater accuracy of staging than any other conventional studies and can detect metastases in bone, extra-abdominal lymph nodes, chest wall, and pancreas – parts that were not detectable in normal CT scan. However, PET cannot detect lung nodules which have Read More