November 2024 Pick of the Month

In With the New and In With the Old 

Academic Emergency Medicine receives many article submissions that purport new diagnostic tools for various conditions. These tools are usually derived retrospectively, and seldom tested in an independent sample. For these reasons, most of these papers are rejected by the journal.

Uniquely, in this month’s POTM, Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study, Lee et al. prospectively compare the overall diagnostic accuracy of 30 published decision rules identified through a systematic review of the literature. Importantly, and rarely seen in the literature, they also prospectively compared these relatively objective rules to the more subjective “physician gestalt.” 

Many of these decision rules may be unfamiliar to readers, but all clinicians know about good old gestalt – the intuitive judgment they employ on every shift to make diagnostic decisions for many conditions. Among the decision rules, the authors found that the pediatric Appendicitis Risk Calculator for pediatric ED (pARC-ED) had the highest overall area under the receiver operating characteristic curve, 0.90 (0.86–0.94), a diagnostic performance essentially matched by physician gestalt 0.88 (0.81–0.94).

In real practice, when ED clinicians judiciously try to avoid low-value radiation exposure, the findings by Lee and colleagues suggest the evidence-based utility of documenting both the pARC and the perception of low clinical gestalt (with or without blood biomarkers) in medical decision making in children and young persons with undifferentiated abdominal pain.

Jeffrey A. Kline, MD
Wayne State University School of Medicine
Editor-in-Chief

Source: Kirsty Challen, BSc, MBChB, MRes, PhD, Lancashire Teaching Hospitals | AEM Editor of Infographics