Diagnosing Acute Appendicitis in Children with Neutrophil-Lymphocyte Ratio: A Cross-Sectional Study Running title: Diagnosing AA in Children with NLR

Diagnosing Acute Appendicitis in Children with Neutrophil-Lymphocyte Ratio: A Cross-Sectional Study Running title: Diagnosing AA in Children with NLR | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Diagnosing Acute Appendicitis in Children with Neutrophil-Lymphocyte Ratio: A Cross-Sectional Study Running title: Diagnosing AA in Children with NLR Ahmed Alawi, Bayan Fatani, Ameen Alsaggaf, Alaa Ghallab, Mohammed Awad, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5779845/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aimed to evaluate the value of neutrophil-to-lymphocyte ratio (NLR) in diagnosing AA in the pediatric population. Methods This retrospective cross-sectional study involved 200 pediatric patients aged between 0–14 years of both sexes, admitted as a case of acute appendicitis (AA). Data of patients retrieved from the hospital's patient administration system database. Normal appendex group (n = 100) included patients with abdominal pain without appendicitis. Uncomplicated AA group (n = 165) included patients with abdominal pain diagnosed with simple AA and treated with medical treatment or simple appendectomy. Complicated AA group (n = 35) included patients with recurrent or complicated appendicitis. Results White blood cells (WBCs), neutrophils and NLR were significantly higher in the uncomplicated and complicated appendicitis groups than the normal appendix group and in the complicated appendicitis group than the uncomplicated appendicitis group. In multivariate regression, WBCs and NLR were independent predictors for AA (P ≤ 0.001). NLR was an independent predictor for complicated appendicitis (P = 0.012). NLR can significantly predict AA and complicated appendicitis repectively at cut-off > 1.7 and > 10.1 with 74% and 68.57% sensitivity, and 69% and 56.98% specificity. Conclusions NLR is a valuable and cost-effective diagnostic marker for AA and complicated appendicitis in the pediatric population. Acute Appendicitis Complicated Pediatric Neutrophil-to-Lymphocyte Ratio White Blood Cell Count Figures Figure 1 1. Introduction Acute appendicitis (AA) is one of the most common causes of abdominal pain in children that necessitates emergency surgery [ 1 ]. Children often exhibit symptoms for an extended period and have a higher rate of perforation (31.8–45.8%), which may be more pronounced in preschoolers [ 2 ]. The diagnosis of AA in children under the age of five can be particularly challenging due to atypical symptoms and difficulties in obtaining a comprehensive medical history [ 3 ]. Timely diagnosis is crucial in AA, as delays can lead to an increased risk of perforation and subsequent complications [ 4 ]. Despite the use of clinical assessments and imaging techniques such as ultrasound (US) and computerized tomography (CT), there is a need for clear decision aids to aid in early AA detection [ 5 ]. Most patients have uncomplicated appendicitis, while those admitted with complicated appendicitis have higher morbidity rates and poorer surgical outcomes [ 6 ]. The utility of conventional inflammatory biomarkers, including the white blood cell count (WBC) and the neutrophil-to-lymphocyte ratio (NLR) from routine complete blood count (CBC) tests, has been investigated in the diagnosis of AA [ 7 ]. NLR has recently gained attention as a potential diagnostic marker for AA due to its simplicity, cost-effectiveness, and ease of calculation from CBC tests. NLR reflects the balance between neutrophil-mediated inflammation and lymphocyte response, which may be altered in inflammatory conditions like appendicitis [ 8 ]. To date, no study has been conducted in Jeddah city to examine the relationship between these biomarkers and AA. Thus, this study aimed to evaluate the diagnostic value of NLR in AA in the pediatric population. 2. Patients and Methods 2.1. Patients: This retrospective cross-sectional study involved 200 pediatric patients aged between 0–14 years of both sexes, diagnosed by AA. Data collected between January 2018 and January 2024 following ethical approval from the King Fahad Armed Forces Hospital ethical committee in Jeddah, Saudi Arabia (approval code ID: 481191) Patients with large missing data were excluded. The diagnosis with AA was based on clinical presentation, physical examination, laboratory results, and/or abdominal ultrasound. The definitive diagnosis was confirmed through histopathological evaluation. Normal appendex group (N = 100) included patients with abdominal pain without appendicitis. Uncomplicated AA group (N = 165) included included patients with abdominal pain diagnosed with simple AA and treated with medical treatment or simple appendectomy. Complicated AA group (N = 35) included patients with recurrent or complicated appendicitis. Data on demographics, laboratory investigations (WBCs, neutrophils, lymphocytes, NLR, and sodium level), histopathological results, diagnosis, treatment, antibiotics that have been taken and other medication, were extracted from the hospital’s patient administration system database. 2.2. Statistical analysis Statistical analysis was performed using SPSS v27 (IBM©, Chicago, IL, USA). The Shapiro-Wilks test and histograms were employed to evaluate the normality of the data distribution. Quantitative parametric data were presented as mean and standard deviation (SD) and were analyzed using the ANOVA (F) test with a post hoc Tukey test. Qualitative variables were presented as frequency and percentage (%) and were analyzed using the Chi-square test. The overall diagnostic performance of each test was assessed using ROC curve analysis. Multivariate regression was also utilized to estimate the relationship between a dependent variable and multiple independent variables. A two-tailed p-value of < 0.05 was considered statistically significant. 3. Results Age and sex were insignificantly different among the three groups. Table 1 Table 1: Demographic data of the studied groups Normal appendix group (n=100) Uncomplicated appendicitis group (n=165) Complicated appendicitis group (n=35) P Age (years) 9.6 ± 2.49 9.2 ± 1.96 9.7 ± 2.08 0.095 Sex Male 49 (49%) 94 (56.97%) 14 (40%) 0.135 Female 51 (51%) 71 (43.03%) 21 (60%) Data are presented as mean ± SD or frequency (%). WBC, neutrophil and NLR were significantly higher in the uncomplicated appendicitis and complicated appendicitis groups than normal appendix group and were significantly higher in the complicated appendicitis group than the uncomplicated appendicitis group (P < 0.05). Lymphocyte was insignificantly different among the three groups. Sodium level was significantly higher in thw normal appendix than in uncomplicated appendicitis groups and complicated appendicitis groups (P < 0.001) and was insignificantly different between the uncomplicated appendicitis and complicated appendicitis groups. Table 2 Table 2: Laboratory investigation of the studied groups Normal appendix group (n=100) Uncomplicated appendicitis group (n=165) Complicated appendicitis group (n=35) P Post hoc WBC (× 10 3 /µL) 8 ± 1.83 12 ± 4.4 14.4 ± 6.22 <0.001* P1<0.001* P2<0.001* P3=0.003* Neutrophil (× 10 3 /µL) 4.9 ± 1.59 8.8 ± 4.24 11.2 ± 5.48 <0.001* P1<0.001* P2<0.001* P3=0.002* Lymphocyte (× 10 3 /µL) 2.7 ± 1.09 2.5 ± 2.47 2.2 ± 2.5 0.086 Neutrophil to lymphocyte ratio 1.5 ± 0.32 4.9 ± 5 8.2 ± 5.94 <0.001* P1<0.001* P2<0.001* P3<0.001* Sodium level (mEq/L) 140.4 ± 2.98 138.1 ± 2.61 138 ± 1.92 <0.001* P1<0.001* P2<0.001* P3=0.985 Data is presented as mean ± SD, P1: P between group normal appendix and group uncomplicated appendicitis, P2: P between group normal appendix and group complicated appendicitis, P3: P between group uncomplicated appendicitis and group complicated appendicitis. The way of confirming diagnosis was insignificantly different between uncomplicated appendicitis and complicated appendicitis groups. Antibiotics and treatment were significantly different between uncomplicated appendicitis and complicated appendicitis groups. Table 3 Table 3: Confirm diagnosis, treatment and antibiotics of the studied groups Uncomplicated appendicitis group (n=165) Complicated appendicitis group (n=35) P Way of confirming diagnosis Clinical 55 (33.33%) 8 (22.86%) 0.097 US 96 (58.18%) 20 (57.14%) CT 14 (8.48%) 7 (20%) Treatment Simple appendectomy 71 (43.03%) 0 (0%) <0.001* Antibiotic 94 (56.97%) 0 (0%) Complicated perforated Appendectomy 0 (0%) 22 (62.86%) Complicated Abscess Appendicitis 0 (0%) 6 (17.14%) Recurrent attack with antibiotics 0 (0%) 7 (20%) Antibiotics Piperacillin/ tazobactam 107 (68.15%) 23 (65.71%) 0.006* Cefuroxime 48 (30.57%) 11 (31.43%) Metronidazole 40 (25.48%) 11 (31.43%) Amoxicillin 2 (1.27%) 1 (2.86%) Vancomycin 1 (0.64%) 0 (0%) Trimethoprim / Sulfamethoxazole 1 (0.64%) 0 (0%) Ciprofloxacin 1 (0.64%) 0 (0%) Gentamicin 0 (0%) 4 (11.43%) Amoxicillin / Clavulanic acid 0 (0%) 1 (2.86%) Histopathology No significant pathology abnormality 1 (1.45%) 0 (0%) 1 Normal appendix with fecal impaction 1 (1.45%) 0 (0%) 1 Acute simple appendicitis 59 (85.51%) 1 (4.35%) <0.001* Acute suppurative appendicitis with serositis 1 (1.45%) 0 (0%) 1 Acute gangrenous appendicitis 0 (0%) 1 (4.35%) 1 Chronic appendicitis 1 (1.45%) 0 (0%) 1 Lymphoid hyperplasia 4 (5.8%) 0 (0%) 0.568 Lymphoid follicular hyperplasia 1 (1.45%) 0 (0%) 1 Appendix measuring 10*2cm 0 (0%) 1 (4.35%) 1 Perforated appendicitis 1 (1.45%) 18 (78.26%) <0.001* Perforated appendicitis with fecal impaction 0 (0%) 1 (4.35%) 1 Caseating granulomatous appendicitis with mycobacterial tuberculosis 0 (0%) 1 (4.35%) 1 Data are presented as frequency (%). US: ultrasound, CT: computerized tomography. Regarding histopathology in uncomplicated appendicitis group, there were 1 (1.45%) patient had normal appendix with fecal impaction, 59 (85.51%) patients had acute simple appendicitis, 1 (1.45%) patient had acute suppurative appendicitis with serositis, 1 (1.45%) patient had chronic appendicitis, 4 (5.8%) patients had lymphoid hyperplasia, 1 (1.45%) patient had lymphoid follicular hyperplasia, 1 (1.45%) patient had perforated appendicitis. 1 (1.45%) patient had no significant pathology abnormality. Appendix measuring 10*2cm, acute gangrenous appendicitis, perforated appendicitis with fecal impaction and caseating granulomatous appendicitis with mycobacterial tuberculosis were not present in any patients. Table 3 Regarding histopathology in complicated appendicitis, there were 1 (1.45%) patient had acute simple appendicitis, 1 (1.45%) patient had acute gangrenous appendicitis, 1 (1.45%) patient had appendix measuring 10*2cm, 18 (78.26%) patient had perforated appendicitis, 1 (1.45%) patient had perforated appendicitis with fecal impaction. Normal appendix with fecal impaction, acute suppurative appendicitis with serositis, chronic appendicitis, lymphoid hyperplasia and lymphoid follicular hyperplasia) were not present in any patients. Table 3 Acute simple appendicitis was significantly higher in uncomplicated appendicitis than in complicated appendicitis while perforated appendicitis was significantly lower in uncomplicated appendicitis than in complicated appendicitis (P < 0.001). Table 3 In multivariate regression, WBC and NLR were independent predictor for AA (OR (95%CI): 1.251(1.088–1.44), and 2.171 (1.584–2.976), P < 0.001) while neutrophil was not. NLR was independent predictor for complicated appendicitis (OR (95% CI): 1.098 (1.02–1.181) P = 0.012) while WBC and neutrophil were not. Table 4 Table 4: Logistic regression of variant markers for prediction of acute and complicated appendicitis Multivariate Odds ratio 95% CI P Acute appendicitis WBC (× 10 3 /µL) 1.251 1.088 - 1.44 0.001* Neutrophil (× 10 3 /µL) 1.078 0.917 - 1.266 0.359 Neutrophil to lymphocyte ratio 2.171 1.584 - 2.976 <0.001* Complicated appendicitis WBC (× 10 3 /µL) 1.123 0.928 -1.357 0.231 Neutrophil (× 10 3 /µL) 1.012 0.816 - 1.255 0.91 NLR 1.098 1.02 - 1.181 0.012* *Significant as P ≤0.05, CI: Confidence interval, NLR: Neutrophil to lymphocyte ratio. WBC can significantly predict acute appendicitis (P 9.2 with 75% sensitivity, 69% specificity, 82.9% PPV and 58%NPV. Neutrophil can significantly predict acute appendicitis (P 6.2 with 73% sensitivity, 72% specificity, 83.9% PPV and 57.1%NPV. NLR can significantly predict acute appendicitis (P 1.7 with 74% sensitivity, 69% specificity, 82.7% PPV and 57%NPV. Figure 1A WBC can significantly predict complicated appendicitis (P 10.1 with 68.57% sensitivity, 56.98% specificity, 17.4% PPV and 93.2%NPV. Neutrophil can significantly predict complicated appendicitis (P 7.8 with 68.57% sensitivity, 64.91% specificity, 20.5% PPV and 94%NPV. NLR can significantly predict complicated appendicitis (P 3.5 with 74.29% sensitivity, 69.81% specificity, 24.5% PPV and 95.4% NPV. Figure 1B 4. Discussion AA is a condition characterized by appendix inflammation typically caused by a blockage in the appendix, leading to an infection [ 9 ]. The higher levels of WBCs and in AA can be explained by the body's natural immune response to the infection [ 10 ]. Neutrophils are the first type of WBCs to respond to an infection and are responsible for killing and digesting bacteria. Neutrophilia is a common indicator of an acute bacterial infection, such as appendicitis [ 11 ]. A higher NLR is associated with a more severe inflammatory response [ 12 ], and studies have shown that an elevated NLR is a useful marker for the diagnosis and prognosis of AA [ 13 – 15 ]. To date, no study has been conducted in Jeddah city to examine the relationship between these biomarkers and AA. Thus, we condicted the first study to evaluate the diagnostic value of NLR in AA in the pediatric population in Jeddah city. WBC count, neutrophil count, and NLR were found to be significantly elevated in both uncomplicated and complicated appendicitis groups compared to the normal appendix group. This finding is consistent with previous studies that have demonstrated the utility of these inflammatory markers in diagnosing AA [ 16 , 17 ]. The study also found that the normal appendix group had significantly higher sodium levels compared to both appendicitis groups. This observation aligns with Lindestam et al. [ 18 ] who suggested that hyponatremia may be associated with AA. In the present study, WBC can significantly predict AA (AUC = 0.794) at cut-off > 9.2 with 75% sensitivity, and 69% specificity, and complicated appendicitis (AUC = 0.704) at cut-off > 10.1 with 68.57% sensitivity, and 56.98% specificity. Prasetya et al. [ 19 ] agreed with our findings and noticed that WBC can predict complicated appendicitisin children (AUC = 0.644) at cut-off = 13.63 with 66.1% sensitivity, and 62.5% specificity. However, they reported that WBCs can also predict AA. This difference may be attributed to different cut-off points. In line with our results, Eun et al. [ 20 ] reported that WBC can significantly predict AA in pediatrics with 79% sensitivity, and 68% specificity. In this study, neutrophil can significantly predict AA (AUC = 0.804) at cut-off > 6.2 with 73% sensitivity, and 72% specificity, and complicated appendicitis (AUC = 0.715) at cut-off > 7.8 with 68.57% sensitivity, and 64.91% specificity. In agreement with our findings, a meta nalysis by Eun et al. [ 20 ] stated that the absolute neutrophil count can significantly predict AA in pediatrics with 75% sensitivity, and 78% specificity. Also, Prasetya et al. [ 19 ] demonstrated that neutrophil can significantly predict AA in children (AUC = 0.756) at cut-off = 64.2 with 83.1% sensitivity, and 59.2% specificity, and complicated appendicitis (AUC = 0.762) at cut-off = 80.05 with 74.5% sensitivity, and 66.7% specificity. Similarly, Beecher et al. [ 17 ] showed that neutrophils can distinguishing complicated appendicitis and uncomplicated appendicitis (AUC = 0.79, p 1.7 with 74% sensitivity, and 69% specificity, and complicated appendicitis (AUC = 0.755) at cut-off > 3.5 with 74.29% sensitivity, and 69.81% specificity. In agreement with our findings, Khan et al. [ 21 ] found that NLR can significantly predict AA (AUC = 0.906) at cut-off = 2.49 with 71.4% sensitivity, and 12.5% specificity. Also, Eun et al. [ 20 ] assessed NLR diagnostic utility e for AA in pediatric patients. They noticed that NLR can significantly predict AA with 82% sensitivity, and 76% specificity. Prasetya et al. [ 19 ] agreed with our findings and noticed that NLR can significantly predict AA at cut-off = 2.87 with 83.5% sensitivity, and 57.7 specificity and complicated appendicitis at cut-off = 6.59 with 84.6% sensitivity, and 56.5%% specificity. Additionally, Hajibandeh et al. [ 8 ] illustrated that NLR can significantly predict AA at cut-off > 4.7 and complicated appendicitis (AUC = 0.91) at cut-off = 8.8 with 76.92% sensitivity and 100% specificity. The findings of this study are limited by the study's retrospective nature, small sample size, and single center location. Conducting larger, multicenter, prospective studies to validate the findings and reduce the potential biases associated with retrospective data collection is recommended. The integration of NLR, along with WBC and neutrophil count into clinical decision-making processes is recommended to improve the accuracy and timeliness of AA diagnosis in the pediatric population. Conclusion NLR is a valuable and cost-effective diagnostic marker for AA and complicated appendicitis in the pediatric population. Declarations Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [AA], [BMF], [AA] and [AG]. The first draft of the manuscript was written by [MA] and [MMS] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data Materials and/or Code availability: Data is available upon reasonable request from corresponding author. Funding: No funding was received for conducting this study. Conflict of interest: The authors declare no competing interests. Ethical approval and consent to participate: The study done after approval from ethical approval from the King Fahad Armed Forces Hospital ethical committee in Jeddah, Saudi Arabia (approval code ID: 481191). Acknowledgments: Nil References Becker C, Kharbanda A.(2019) Acute appendicitis in pediatric patients: an evidence-based review.Pediatr Emerg Med Pract;16:1-20. 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Karatas T, Selcuk E, Karatas M, Yildirim A, Bitirim M, Orman I.(2023) Evaluation of the performance of simple laboratory parameters used in the diagnosis of acute appendicitis.Niger J Clin Pract;26:478-84. Hajibandeh S, Hajibandeh S, Hobbs N, Mansour M.(2020) Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis.Am J Surg;219:154-63. Borruel Nacenta S, Ibáñez Sanz L, Sanz Lucas R, Depetris MA, Martínez Chamorro E.(2023) Update on acute appendicitis: Typical and untypical findings.Radiología (English Edition);65:S81-S91. Gürünlüoglu K, Zararsiz G, Aslan M, Akbas S, Tekin M, Gürünlüoglu S, et al.(2023) Investigation of serum interleukin 6, high-sensitivity c-reactive protein and white blood cell levels during the diagnosis and treatment of paediatric appendicitis patients before and during the covid-19 pandemic. Afr J Paediatr Surg;20:130-7. Al Amri FS, Fihrah RS, Al Jabbar I, Alqahtani R, Alnujaymi B, Alshehri RM, et al.(2023) Accuracy of neutrophil-to-lymphocyte ratio in predicting the severity of acute appendicitis: A single-center retrospective study.Cureus;15:e45923. Telafarlı MA, Yeni M.(2023) The diagnostic value of the systemic immune-inflammatory index in acute appendicitis cases in the emergency department.Langenbecks Arch Surg;408:136. Şener K, Çakır A, Kılavuz H, Altuğ E, Güven R.(2023) Diagnostic value of systemic immune inflammation index in acute appendicitis.Rev Assoc Med Bras;69:291-6. Adir A, Braester A, Natalia P, Najib D, Akria L, Suriu C, et al.(2024) The role of blood inflammatory markers in the preoperative diagnosis of acute appendicitis.Int J Lab Hematol;46:58-62. Özkan A, Özdemir S, Akça H, Akça M.(2024) Can the neutrophil/lymphocyte*platelet ratio predict acute appendicitis? An analytical study.Namık Kemal Tıp Dergisi;12:45-51. Kahramanca S, Ozgehan G, Seker D, Gökce EI, Seker G, Tunç G, et al.(2014) Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis.Ulus Travma Acil Cerrahi Derg;20:19-22. Beecher SM, Hogan J, O''Leary DP, McLaughlin R.(2016) An appraisal of inflammatory markers in distinguishing acute uncomplicated and complicated appendicitis.Dig Surg;33:177-81. Lindestam U, Almström M, Jacks J, Malmquist P, Lönnqvist PA, Jensen BL, et al.(2020) Low plasma sodium concentration predicts perforated acute appendicitis in children: A prospective diagnostic accuracy study.Eur J Pediatr Surg;30:350-6. Prasetya D, Rochadi, Gunadi.(2019) Accuracy of neutrophil lymphocyte ratio for diagnosis of acute appendicitis in children: A diagnostic study.Ann Med Surg (Lond);48:35-8. Eun S, Ho IG, Bae GE, Kim H, Koo CM, Kim MK, et al.(2021) Neutrophil-to-lymphocyte ratio for the diagnosis of pediatric acute appendicitis: a systematic review and meta-analysis.Eur Rev Med Pharmacol Sci;25:7097-107. Khan SA, Ashraf R, Hassaan N, Naseer M, Azad MH, Javed H.(2023) The role of neutrophil-to-lymphocyte ratio in the diagnosis of acute appendicitis.Cureus;15:e51164. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5779845","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":399304636,"identity":"cd0dc7c9-0c4b-43eb-a1ee-96fd49dbb3fd","order_by":0,"name":"Ahmed Alawi","email":"","orcid":"","institution":"Consultant at King Fahd Armed Forces Hospital (KFAFH)","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Alawi","suffix":""},{"id":399304637,"identity":"b96f89ea-134a-437e-baa7-1e8c18140ae0","order_by":1,"name":"Bayan Fatani","email":"","orcid":"","institution":"King Faisal Specialist Hospital and Research Center","correspondingAuthor":false,"prefix":"","firstName":"Bayan","middleName":"","lastName":"Fatani","suffix":""},{"id":399304638,"identity":"3a4ead17-8291-45e6-9a9c-33b7bff100eb","order_by":2,"name":"Ameen Alsaggaf","email":"","orcid":"","institution":"Consultant at King Fahd Armed Forces Hospital (KFAFH)","correspondingAuthor":false,"prefix":"","firstName":"Ameen","middleName":"","lastName":"Alsaggaf","suffix":""},{"id":399304641,"identity":"cb60adc3-b30a-419f-833b-7a4ab694b998","order_by":3,"name":"Alaa Ghallab","email":"","orcid":"","institution":"Consultant at King Fahd Armed Forces Hospital (KFAFH)","correspondingAuthor":false,"prefix":"","firstName":"Alaa","middleName":"","lastName":"Ghallab","suffix":""},{"id":399304642,"identity":"c5dfc5a0-957b-4611-a623-40b3805081fe","order_by":4,"name":"Mohammed Awad","email":"","orcid":"","institution":"Tanta University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Awad","suffix":""},{"id":399304643,"identity":"ab3addc2-eb8b-454c-b565-67c513849e21","order_by":5,"name":"Mohamed Shalaby","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYBACgwM8IIqZgUGCgfEAYwODHIh74AEeLZZIWhhAWozBWhLwaLFH15LYAOLj02J2vPfgpxsV1tHys5sfHPi543D6/LDDD4G22MnpNuDQcuZcsnTOmfTcDXeOGRzsPXM4d+PtNAOglmRjswM4tNzIMZDObTucu0EiweAAL5CxcXYCSMuBxG04tBjcyDH+nfvvcO78GekfDv5tO5xuODv9AyEtZtK5DYdzG4DWHQbakiAvnUPAljNnzKxzjgH9ciOn4LDsmXTDDdI5BQcSDHD7xeB4j/HtnBprkMM2Pny7w1pefnb65g8fKuzkcGlBB83A9AA2ijjlIFDHIN9AvOpRMApGwSgYGQAARYN0QuKE1HEAAAAASUVORK5CYII=","orcid":"","institution":"Tanta University","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Shalaby","suffix":""}],"badges":[],"createdAt":"2025-01-07 09:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5779845/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5779845/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73672667,"identity":"a8faa9a0-afd5-48d6-8fd4-75295108f2bc","added_by":"auto","created_at":"2025-01-13 12:50:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":90725,"visible":true,"origin":"","legend":"\u003cp\u003eVariant markers (WBCs, neutrophil and NLR) for prediction (A) acute appendicitis and (B) complicated appendicitis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5779845/v1/e9ec804bff91718ea9cb2955.png"},{"id":76409924,"identity":"e6815149-64e0-4f40-9a3b-e1408bc31782","added_by":"auto","created_at":"2025-02-17 00:16:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1247849,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5779845/v1/63212e3b-15a8-4267-9f4b-d83edcaf8098.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnosing Acute Appendicitis in Children with Neutrophil-Lymphocyte Ratio: A Cross-Sectional Study Running title: Diagnosing AA in Children with NLR","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAcute appendicitis (AA) is one of the most common causes of abdominal pain in children that necessitates emergency surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Children often exhibit symptoms for an extended period and have a higher rate of perforation (31.8\u0026ndash;45.8%), which may be more pronounced in preschoolers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of AA in children under the age of five can be particularly challenging due to atypical symptoms and difficulties in obtaining a comprehensive medical history [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTimely diagnosis is crucial in AA, as delays can lead to an increased risk of perforation and subsequent complications [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the use of clinical assessments and imaging techniques such as ultrasound (US) and computerized tomography (CT), there is a need for clear decision aids to aid in early AA detection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost patients have uncomplicated appendicitis, while those admitted with complicated appendicitis have higher morbidity rates and poorer surgical outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The utility of conventional inflammatory biomarkers, including the white blood cell count (WBC) and the neutrophil-to-lymphocyte ratio (NLR) from routine complete blood count (CBC) tests, has been investigated in the diagnosis of AA [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNLR has recently gained attention as a potential diagnostic marker for AA due to its simplicity, cost-effectiveness, and ease of calculation from CBC tests. NLR reflects the balance between neutrophil-mediated inflammation and lymphocyte response, which may be altered in inflammatory conditions like appendicitis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, no study has been conducted in Jeddah city to examine the relationship between these biomarkers and AA. Thus, this study aimed to evaluate the diagnostic value of NLR in AA in the pediatric population.\u003c/p\u003e"},{"header":"2. Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Patients:\u003c/h2\u003e \u003cp\u003eThis retrospective cross-sectional study involved 200 pediatric patients aged between 0\u0026ndash;14 years of both sexes, diagnosed by AA. Data collected between January 2018 and January 2024 following ethical approval from the King Fahad Armed Forces Hospital ethical committee in Jeddah, Saudi Arabia (approval code ID: 481191) Patients with large missing data were excluded.\u003c/p\u003e \u003cp\u003eThe diagnosis with AA was based on clinical presentation, physical examination, laboratory results, and/or abdominal ultrasound. The definitive diagnosis was confirmed through histopathological evaluation.\u003c/p\u003e \u003cp\u003eNormal appendex group (N\u0026thinsp;=\u0026thinsp;100) included patients with abdominal pain without appendicitis. Uncomplicated AA group (N\u0026thinsp;=\u0026thinsp;165) included included patients with abdominal pain diagnosed with simple AA and treated with medical treatment or simple appendectomy. Complicated AA group (N\u0026thinsp;=\u0026thinsp;35) included patients with recurrent or complicated appendicitis.\u003c/p\u003e \u003cp\u003eData on demographics, laboratory investigations (WBCs, neutrophils, lymphocytes, NLR, and sodium level), histopathological results, diagnosis, treatment, antibiotics that have been taken and other medication, were extracted from the hospital\u0026rsquo;s patient administration system database.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS v27 (IBM\u0026copy;, Chicago, IL, USA). The Shapiro-Wilks test and histograms were employed to evaluate the normality of the data distribution. Quantitative parametric data were presented as mean and standard deviation (SD) and were analyzed using the ANOVA (F) test with a post hoc Tukey test. Qualitative variables were presented as frequency and percentage (%) and were analyzed using the Chi-square test. The overall diagnostic performance of each test was assessed using ROC curve analysis. Multivariate regression was also utilized to estimate the relationship between a dependent variable and multiple independent variables. A two-tailed p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eAge and sex were insignificantly different among the three groups. Table\u0026nbsp;1\u003c/p\u003e\n\u003cp\u003eTable 1: Demographic data of the studied groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"108%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNormal appendix\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003egroup\u003cbr\u003e\u0026nbsp; (n=100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eUncomplicated appendicitis group\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(n=165)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eComplicated appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e9.6 ± 2.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e9.2 ± 1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e9.7 ± 2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e49 (49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e94 (56.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e14 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp dir=\"RTL\"\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e51 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e71 (43.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e21 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean ± SD or frequency (%).\u003c/p\u003e\n\u003cp\u003eWBC, neutrophil and NLR were significantly higher in the uncomplicated appendicitis and complicated appendicitis groups than normal appendix group and were significantly higher in the complicated appendicitis group than the uncomplicated appendicitis group (P \u0026lt; 0.05). Lymphocyte was insignificantly different among the three groups. Sodium level was significantly higher in thw normal appendix than in uncomplicated appendicitis groups and complicated appendicitis groups (P \u0026lt; 0.001) and was insignificantly different between the uncomplicated appendicitis and complicated appendicitis groups. Table\u0026nbsp;2\u003c/p\u003e\n\u003cp\u003eTable 2: Laboratory investigation of the studied groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"113%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNormal appendix\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003egroup \u0026nbsp;(n=100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eUncomplicated appendicitis group\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(n=165)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eComplicated appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003egroup (n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003ePost hoc\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eWBC (× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e8 ± 1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e12 ± 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e14.4 ± 6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP3=0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNeutrophil\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e4.9 ± 1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e8.8 ± 4.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e11.2 ± 5.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP3=0.002*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eLymphocyte\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e2.7 ± 1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e2.5 ± 2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e2.2 ± 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp dir=\"RTL\"\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNeutrophil to lymphocyte ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.5 ± 0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e4.9 ± 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e8.2 ± 5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP3\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eSodium level (mEq/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e140.4 ± 2.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e138.1 ± 2.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e138 ± 1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003eP3=0.985\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is presented as mean ± SD, P1: P between group normal appendix and group uncomplicated appendicitis, P2: P between group normal appendix and group complicated appendicitis, P3: P between group uncomplicated appendicitis and group complicated appendicitis.\u003c/p\u003e\n\u003cp\u003eThe way of confirming diagnosis was insignificantly different between uncomplicated appendicitis and complicated appendicitis groups. Antibiotics and treatment were significantly different between uncomplicated appendicitis and complicated appendicitis groups. Table\u0026nbsp;3\u003c/p\u003e\n\u003cp\u003eTable 3: Confirm diagnosis, treatment and antibiotics of the studied groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"106%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eUncomplicated appendicitis group\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(n=165)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eComplicated appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eWay of confirming diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eClinical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e55 (33.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e8 (22.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\"\u003e\n \u003cp dir=\"RTL\"\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eUS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e96 (58.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e20 (57.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e14 (8.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e7 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eSimple appendectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e71 (43.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"5\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAntibiotic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e94 (56.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eComplicated perforated Appendectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e22 (62.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eComplicated Abscess Appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e6 (17.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eRecurrent attack with antibiotics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e7 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAntibiotics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003ePiperacillin/\u003cbr\u003e\u0026nbsp;tazobactam\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e107 (68.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e23 (65.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"9\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e0.006*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eCefuroxime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e48 (30.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e11 (31.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eMetronidazole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e40 (25.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e11 (31.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAmoxicillin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e2 (1.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (2.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eVancomycin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (0.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eTrimethoprim / Sulfamethoxazole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (0.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eCiprofloxacin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (0.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eGentamicin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e4 (11.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAmoxicillin / Clavulanic acid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (2.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"12\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eHistopathology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNo significant pathology abnormality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (1.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNormal appendix with fecal impaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (1.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAcute simple appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e59 (85.51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAcute suppurative appendicitis with serositis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (1.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAcute gangrenous appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eChronic appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (1.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eLymphoid hyperplasia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e4 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.568\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eLymphoid follicular hyperplasia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (1.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAppendix measuring 10*2cm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003ePerforated appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (1.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e18 (78.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003ePerforated appendicitis with fecal impaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eCaseating granulomatous appendicitis with mycobacterial tuberculosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (%). US: ultrasound, CT: computerized tomography.\u003c/p\u003e\n\u003cp\u003eRegarding histopathology in uncomplicated appendicitis group, there were 1 (1.45%) patient had normal appendix with fecal impaction, 59 (85.51%) patients had acute simple appendicitis, 1 (1.45%) patient had acute suppurative appendicitis with serositis, 1 (1.45%) patient had chronic appendicitis, 4 (5.8%) patients had lymphoid hyperplasia, 1 (1.45%) patient had lymphoid follicular hyperplasia, 1 (1.45%) patient had perforated appendicitis. 1 (1.45%) patient had no significant pathology abnormality. Appendix measuring 10*2cm, acute gangrenous appendicitis, perforated appendicitis with fecal impaction and caseating granulomatous appendicitis with mycobacterial tuberculosis were not present in any patients. Table\u0026nbsp;3\u003c/p\u003e\n\u003cp\u003eRegarding histopathology in complicated appendicitis, there were 1 (1.45%) patient had acute simple appendicitis, 1 (1.45%) patient had acute gangrenous appendicitis, 1 (1.45%) patient had appendix measuring 10*2cm, 18 (78.26%) patient had perforated appendicitis, 1 (1.45%) patient had perforated appendicitis with fecal impaction. Normal appendix with fecal impaction, acute suppurative appendicitis with serositis, chronic appendicitis, lymphoid hyperplasia and lymphoid follicular hyperplasia) were not present in any patients. Table\u0026nbsp;3\u003c/p\u003e\n\u003cp\u003eAcute simple appendicitis was significantly higher in uncomplicated appendicitis than in complicated appendicitis while perforated appendicitis was significantly lower in uncomplicated appendicitis than in complicated appendicitis (P \u0026lt; 0.001). Table\u0026nbsp;3\u003c/p\u003e\n\u003cp\u003eIn multivariate regression, WBC and NLR were independent predictor for AA (OR (95%CI): 1.251(1.088–1.44), and 2.171 (1.584–2.976), P \u0026lt; 0.001) while neutrophil was not. NLR was independent predictor for complicated appendicitis (OR (95% CI): 1.098 (1.02–1.181) P = 0.012) while WBC and neutrophil were not. Table\u0026nbsp;4\u003c/p\u003e\n\u003cp\u003eTable 4: Logistic regression of variant markers for prediction of acute and \u003cstrong\u003ecomplicated\u003c/strong\u003e appendicitis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eOdds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eAcute appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eWBC (× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.088 - 1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNeutrophil (× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.917 - 1.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNeutrophil to lymphocyte ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e2.171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.584 - 2.976\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eComplicated appendicitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eWBC (× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.928 -1.357\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNeutrophil (× 10\u003csup\u003e3\u003c/sup\u003e/µL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.816 - 1.255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003eNLR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e1.02 - 1.181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e0.012*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Significant as P ≤0.05, CI: Confidence interval, NLR: Neutrophil to lymphocyte ratio.\u003c/p\u003e\n\u003cp\u003eWBC can significantly predict acute appendicitis (P \u0026lt; 0.001 and AUC = 0.794) at cut-off \u0026gt; 9.2 with 75% sensitivity, 69% specificity, 82.9% PPV and 58%NPV. Neutrophil can significantly predict acute appendicitis (P \u0026lt; 0.001 and AUC = 0.804) at cut-off \u0026gt; 6.2 with 73% sensitivity, 72% specificity, 83.9% PPV and 57.1%NPV. NLR can significantly predict acute appendicitis (P \u0026lt; 0.001 and AUC = 0.776) at cut-off \u0026gt; 1.7 with 74% sensitivity, 69% specificity, 82.7% PPV and 57%NPV. Figure\u0026nbsp;1A\u003c/p\u003e\n\u003cp\u003eWBC can significantly predict complicated appendicitis (P \u0026lt; 0.001 and AUC = 0.704) at cut-off \u0026gt; 10.1 with 68.57% sensitivity, 56.98% specificity, 17.4% PPV and 93.2%NPV. Neutrophil can significantly predict complicated appendicitis (P \u0026lt; 0.001 and AUC = 0.715) at cut-off \u0026gt; 7.8 with 68.57% sensitivity, 64.91% specificity, 20.5% PPV and 94%NPV. NLR can significantly predict complicated appendicitis (P \u0026lt; 0.001 and AUC = 0.755) at cut-off \u0026gt; 3.5 with 74.29% sensitivity, 69.81% specificity, 24.5% PPV and 95.4% NPV. Figure\u0026nbsp;1B\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAA is a condition characterized by appendix inflammation typically caused by a blockage in the appendix, leading to an infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The higher levels of WBCs and in AA can be explained by the body's natural immune response to the infection [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Neutrophils are the first type of WBCs to respond to an infection and are responsible for killing and digesting bacteria. Neutrophilia is a common indicator of an acute bacterial infection, such as appendicitis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA higher NLR is associated with a more severe inflammatory response [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and studies have shown that an elevated NLR is a useful marker for the diagnosis and prognosis of AA [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, no study has been conducted in Jeddah city to examine the relationship between these biomarkers and AA. Thus, we condicted the first study to evaluate the diagnostic value of NLR in AA in the pediatric population in Jeddah city.\u003c/p\u003e \u003cp\u003eWBC count, neutrophil count, and NLR were found to be significantly elevated in both uncomplicated and complicated appendicitis groups compared to the normal appendix group. This finding is consistent with previous studies that have demonstrated the utility of these inflammatory markers in diagnosing AA [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study also found that the normal appendix group had significantly higher sodium levels compared to both appendicitis groups. This observation aligns with Lindestam et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] who suggested that hyponatremia may be associated with AA.\u003c/p\u003e \u003cp\u003eIn the present study, WBC can significantly predict AA (AUC\u0026thinsp;=\u0026thinsp;0.794) at cut-off \u0026gt;\u0026thinsp;9.2 with 75% sensitivity, and 69% specificity, and complicated appendicitis (AUC\u0026thinsp;=\u0026thinsp;0.704) at cut-off \u0026gt;\u0026thinsp;10.1 with 68.57% sensitivity, and 56.98% specificity.\u003c/p\u003e \u003cp\u003ePrasetya et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] agreed with our findings and noticed that WBC can predict complicated appendicitisin children (AUC\u0026thinsp;=\u0026thinsp;0.644) at cut-off =\u0026thinsp;13.63 with 66.1% sensitivity, and 62.5% specificity. However, they reported that WBCs can also predict AA. This difference may be attributed to different cut-off points. In line with our results, Eun et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported that WBC can significantly predict AA in pediatrics with 79% sensitivity, and 68% specificity.\u003c/p\u003e \u003cp\u003eIn this study, neutrophil can significantly predict AA (AUC\u0026thinsp;=\u0026thinsp;0.804) at cut-off \u0026gt;\u0026thinsp;6.2 with 73% sensitivity, and 72% specificity, and complicated appendicitis (AUC\u0026thinsp;=\u0026thinsp;0.715) at cut-off \u0026gt;\u0026thinsp;7.8 with 68.57% sensitivity, and 64.91% specificity.\u003c/p\u003e \u003cp\u003eIn agreement with our findings, a meta nalysis by Eun et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] stated that the absolute neutrophil count can significantly predict AA in pediatrics with 75% sensitivity, and 78% specificity. Also, Prasetya et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] demonstrated that neutrophil can significantly predict AA in children (AUC\u0026thinsp;=\u0026thinsp;0.756) at cut-off =\u0026thinsp;64.2 with 83.1% sensitivity, and 59.2% specificity, and complicated appendicitis (AUC\u0026thinsp;=\u0026thinsp;0.762) at cut-off =\u0026thinsp;80.05 with 74.5% sensitivity, and 66.7% specificity. Similarly, Beecher et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] showed that neutrophils can distinguishing complicated appendicitis and uncomplicated appendicitis (AUC\u0026thinsp;=\u0026thinsp;0.79, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003eOur results showed that NLR can significantly predict AA (AUC\u0026thinsp;=\u0026thinsp;0.776) at cut-off \u0026gt;\u0026thinsp;1.7 with 74% sensitivity, and 69% specificity, and complicated appendicitis (AUC\u0026thinsp;=\u0026thinsp;0.755) at cut-off \u0026gt;\u0026thinsp;3.5 with 74.29% sensitivity, and 69.81% specificity.\u003c/p\u003e \u003cp\u003eIn agreement with our findings, Khan et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] found that NLR can significantly predict AA (AUC\u0026thinsp;=\u0026thinsp;0.906) at cut-off =\u0026thinsp;2.49 with 71.4% sensitivity, and 12.5% specificity. Also, Eun et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] assessed NLR diagnostic utility e for AA in pediatric patients. They noticed that NLR can significantly predict AA with 82% sensitivity, and 76% specificity. Prasetya et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] agreed with our findings and noticed that NLR can significantly predict AA at cut-off =\u0026thinsp;2.87 with 83.5% sensitivity, and 57.7 specificity and complicated appendicitis at cut-off =\u0026thinsp;6.59 with 84.6% sensitivity, and 56.5%% specificity. Additionally, Hajibandeh et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] illustrated that NLR can significantly predict AA at cut-off \u0026gt;\u0026thinsp;4.7 and complicated appendicitis (AUC\u0026thinsp;=\u0026thinsp;0.91) at cut-off =\u0026thinsp;8.8 with 76.92% sensitivity and 100% specificity.\u003c/p\u003e \u003cp\u003eThe findings of this study are limited by the study's retrospective nature, small sample size, and single center location. Conducting larger, multicenter, prospective studies to validate the findings and reduce the potential biases associated with retrospective data collection is recommended. The integration of NLR, along with WBC and neutrophil count into clinical decision-making processes is recommended to improve the accuracy and timeliness of AA diagnosis in the pediatric population.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eNLR is a valuable and cost-effective diagnostic marker for AA and complicated appendicitis in the pediatric population.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eAuthor contributions:\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [AA], [BMF], [AA] and [AG]. The first draft of the manuscript was written by [MA] and [MMS] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Materials and/or Code availability:\u003c/p\u003e\n\u003cp\u003eData is available upon reasonable request from corresponding author.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003eConflict of interest:\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eEthical approval and consent to participate: The study done after approval from ethical approval from the King Fahad Armed Forces Hospital ethical committee in Jeddah, Saudi Arabia (approval code ID: 481191).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNil\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBecker C, Kharbanda A.(2019) Acute appendicitis in pediatric patients: an evidence-based review.Pediatr Emerg Med Pract;16:1-20.\u003c/li\u003e\n\u003cli\u003eAnand S, Krishnan N, Birley JR, Tintor G, Bajpai M, Pogorelić Z.(2022) Hyponatremia-a new diagnostic marker for complicated acute appendicitis in children: A systematic review and meta-analysis.Children (Basel);9.\u003c/li\u003e\n\u003cli\u003eMostafa R, El-Atawi K.(2024) Misdiagnosis of acute appendicitis cases in the emergency room.Cureus;16:e57141.\u003c/li\u003e\n\u003cli\u003eTrinidad S, Parrado R, Gavulic A, Hoang M, Duan Q, Overmann KM, et al.(2024) Characterizing inequities in pediatric appendicitis delayed diagnosis and perforation.J Pediatr Clin Pract;11:200108.\u003c/li\u003e\n\u003cli\u003eManueli Laos EG, Ducas A, Huh N, Mangano A, Lopez P, Masrur MA.(2024) Challenges in management of acute appendicitis: A narrative review.Curr Prob Surg;61:101596.\u003c/li\u003e\n\u003cli\u003eFadhle MJ, Al-Mayoof AF.(2024) Acute appendicitis in children in the Era of Covid-19.Afr J Paediatr Surg:10.4103/ajps.ajps_72_23.\u003c/li\u003e\n\u003cli\u003eKaratas T, Selcuk E, Karatas M, Yildirim A, Bitirim M, Orman I.(2023) Evaluation of the performance of simple laboratory parameters used in the diagnosis of acute appendicitis.Niger J Clin Pract;26:478-84.\u003c/li\u003e\n\u003cli\u003eHajibandeh S, Hajibandeh S, Hobbs N, Mansour M.(2020) Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis.Am J Surg;219:154-63.\u003c/li\u003e\n\u003cli\u003eBorruel Nacenta S, Ib\u0026aacute;\u0026ntilde;ez Sanz L, Sanz Lucas R, Depetris MA, Mart\u0026iacute;nez Chamorro E.(2023) Update on acute appendicitis: Typical and untypical findings.Radiolog\u0026iacute;a (English Edition);65:S81-S91.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;r\u0026uuml;nl\u0026uuml;oglu K, Zararsiz G, Aslan M, Akbas S, Tekin M, G\u0026uuml;r\u0026uuml;nl\u0026uuml;oglu S, et al.(2023) Investigation of serum interleukin 6, high-sensitivity c-reactive protein and white blood cell levels during the diagnosis and treatment of paediatric appendicitis patients before and during the covid-19 pandemic. Afr J Paediatr Surg;20:130-7.\u003c/li\u003e\n\u003cli\u003eAl Amri FS, Fihrah RS, Al Jabbar I, Alqahtani R, Alnujaymi B, Alshehri RM, et al.(2023) Accuracy of neutrophil-to-lymphocyte ratio in predicting the severity of acute appendicitis: A single-center retrospective study.Cureus;15:e45923.\u003c/li\u003e\n\u003cli\u003eTelafarlı MA, Yeni M.(2023) The diagnostic value of the systemic immune-inflammatory index in acute appendicitis cases in the emergency department.Langenbecks Arch Surg;408:136.\u003c/li\u003e\n\u003cli\u003eŞener K, \u0026Ccedil;akır A, Kılavuz H, Altuğ E, G\u0026uuml;ven R.(2023) Diagnostic value of systemic immune inflammation index in acute appendicitis.Rev Assoc Med Bras;69:291-6.\u003c/li\u003e\n\u003cli\u003eAdir A, Braester A, Natalia P, Najib D, Akria L, Suriu C, et al.(2024) The role of blood inflammatory markers in the preoperative diagnosis of acute appendicitis.Int J Lab Hematol;46:58-62.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zkan A, \u0026Ouml;zdemir S, Ak\u0026ccedil;a H, Ak\u0026ccedil;a M.(2024) Can the neutrophil/lymphocyte*platelet ratio predict acute appendicitis? An analytical study.Namık Kemal Tıp Dergisi;12:45-51.\u003c/li\u003e\n\u003cli\u003eKahramanca S, Ozgehan G, Seker D, G\u0026ouml;kce EI, Seker G, Tun\u0026ccedil; G, et al.(2014) Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis.Ulus Travma Acil Cerrahi Derg;20:19-22.\u003c/li\u003e\n\u003cli\u003eBeecher SM, Hogan J, O\u0026apos;\u0026apos;Leary DP, McLaughlin R.(2016) An appraisal of inflammatory markers in distinguishing acute uncomplicated and complicated appendicitis.Dig Surg;33:177-81.\u003c/li\u003e\n\u003cli\u003eLindestam U, Almstr\u0026ouml;m M, Jacks J, Malmquist P, L\u0026ouml;nnqvist PA, Jensen BL, et al.(2020) Low plasma sodium concentration predicts perforated acute appendicitis in children: A prospective diagnostic accuracy study.Eur J Pediatr Surg;30:350-6.\u003c/li\u003e\n\u003cli\u003ePrasetya D, Rochadi, Gunadi.(2019) Accuracy of neutrophil lymphocyte ratio for diagnosis of acute appendicitis in children: A diagnostic study.Ann Med Surg (Lond);48:35-8.\u003c/li\u003e\n\u003cli\u003eEun S, Ho IG, Bae GE, Kim H, Koo CM, Kim MK, et al.(2021) Neutrophil-to-lymphocyte ratio for the diagnosis of pediatric acute appendicitis: a systematic review and meta-analysis.Eur Rev Med Pharmacol Sci;25:7097-107.\u003c/li\u003e\n\u003cli\u003eKhan SA, Ashraf R, Hassaan N, Naseer M, Azad MH, Javed H.(2023) The role of neutrophil-to-lymphocyte ratio in the diagnosis of acute appendicitis.Cureus;15:e51164.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute Appendicitis, Complicated, Pediatric, Neutrophil-to-Lymphocyte Ratio, White Blood Cell Count","lastPublishedDoi":"10.21203/rs.3.rs-5779845/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5779845/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the value of neutrophil-to-lymphocyte ratio (NLR) in diagnosing AA in the pediatric population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cross-sectional study involved 200 pediatric patients aged between 0\u0026ndash;14 years of both sexes, admitted as a case of acute appendicitis (AA). Data of patients retrieved from the hospital's patient administration system database. Normal appendex group (n\u0026thinsp;=\u0026thinsp;100) included patients with abdominal pain without appendicitis. Uncomplicated AA group (n\u0026thinsp;=\u0026thinsp;165) included patients with abdominal pain diagnosed with simple AA and treated with medical treatment or simple appendectomy. Complicated AA group (n\u0026thinsp;=\u0026thinsp;35) included patients with recurrent or complicated appendicitis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWhite blood cells (WBCs), neutrophils and NLR were significantly higher in the uncomplicated and complicated appendicitis groups than the normal appendix group and in the complicated appendicitis group than the uncomplicated appendicitis group. In multivariate regression, WBCs and NLR were independent predictors for AA (P\u0026thinsp;\u0026le;\u0026thinsp;0.001). NLR was an independent predictor for complicated appendicitis (P\u0026thinsp;=\u0026thinsp;0.012). NLR can significantly predict AA and complicated appendicitis repectively at cut-off \u0026gt;\u0026thinsp;1.7 and \u0026gt;\u0026thinsp;10.1 with 74% and 68.57% sensitivity, and 69% and 56.98% specificity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eNLR is a valuable and cost-effective diagnostic marker for AA and complicated appendicitis in the pediatric population.\u003c/p\u003e","manuscriptTitle":"Diagnosing Acute Appendicitis in Children with Neutrophil-Lymphocyte Ratio: A Cross-Sectional Study Running title: Diagnosing AA in Children with NLR","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-13 12:50:18","doi":"10.21203/rs.3.rs-5779845/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67a715a6-d42a-44c0-b43d-065a20b69b47","owner":[],"postedDate":"January 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T00:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-13 12:50:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5779845","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5779845","identity":"rs-5779845","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}