J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 11, Number 3, March 2019, pages 171-178

Hyperbilirubinemia as a Predictor of Appendiceal Perforation: A Systematic Review and Diagnostic Test Meta-Analysis

Figure 2. Forest plot demonstrating sensitivity and specificity. coef: coefficient; SE: standard error; CI: confidence interval; Se: sensitivity; Sp: specificity; DOR: diagnostic odds ratio; LR⁺: positive likelihood ratio; LR^-: negative likelihood ratio; 1/LR^-: inverse negative likelihood ratio.

Figure 3. Plot showing the hierarchical summary receiver operating characteristic (HSROC) curve and summary operating point positioned towards the lower right angle. Obvious visual discrepancy of the covered areas of the confidence and prediction intervals indicating high between-studies heterogeneity.

Figure 4. Left panel: Cook’s distance showing one outlier (Khan’s study). Right panel: standardized residuals showing one outlier (Khan’s study). cooksd: Cook’s standard deviation; stid: study identity; Se:ustd = sensitivity standard deviation; Sp:ustd = specificity standard deviation.

**Table 1.** Study Characteristics
Author, study, country, and year	Age	Histologically confirmed appendicitis	Perforated appendicitis	Positive likelihood ratio (97.5% CI)	Negative likelihood ratio (97.5% CI)
CI: confidence interval; SE: standard error; RS: retrospective study; PNR: prospective non-randomized; NR: not reported.
Estrada, RS, USA, 2007	33 (5 - 66)	157	41	0.34 (0.23 - 0.51)	2.30 (1.57 - 3.38)
Khan, PNR, Nepal, 2008	29 (8 - 73)	118	18	5.73 (0.42 - 6.58)	0.05 (0.02 - 0.12)
Sand, RS, Germany, 2009	36 (6 - 91)	376	97	0.29 (0.22 - 0.38)	1.94 (1.55 - 2.43)
Kaser, RS, Switzerland, 2010	22 (5 - 92)	725	155	0.21 (0.16 - 0.27)	2.05 (1.75 - 2.39)
Atahan, RS, Turkey, 2011	31 (18 - 83)	302	45	0.15 (0.11 - 0.20)	5.44 (3.03 - 9.75)
Emmanuel, RS, Ireland, 2011	27 (5 - 82)	386	45	0.09 (0.06 - 0.13)	6.56 (4.30 - 10.02)
Hong, RS, Korea, 2012	31	732	245	0.13 (0.10 - 0.17)	1.96 (1.73 - 2.22)
McGowan, RS, UK, 2013	NR	1,271	154	0.13 (0.08 - 0.16)	2.35 (1.95 - 2.82)
Chaudary, PNR, India, 2013	27 (15 - 64)	45	5	0.41 (0.24 - 0.69)	3.69 (2.31 - 5.90)
D’Souza, PNR, UK, 2013	28 (5 - 85)	89	19	0.23 (0.13 - 0.39)	2.96 (1.53 - 5.72)
Nomura, RS, Japan, 2014	NR	279	131	0.44 (0.34 - 0.56)	1.72 (1.41 - 2.09)
Socea, RS, Romania, 2013	NR	274	51	0.26 (0.20 - 0.34)	15.10 (3.15 - 71.53)
Chambers, RS, UK, 2015	33 ± 17	797	122	0.50 (0.43 - 0.59)	1.83 (1.59 - 2.11)
Muller, RS, Germany, 2015	29 (16 - 91)	312	56	0.10 (0.07 - 0.14)	4.71 (3.40 - 6.52)
Saxena, PNR, India, 2015	NR	181	32	0.24 (0.14 - 0.42)	2.67 (0.95 - 7.48)
Shahabuddin, PNR, India, 2016	25 (10 - 65)	35	15	0.44 (0.27 - 0.71)	3.81 (1.20 - 12.13)
Eren, RS, Turkey, 2016	36 (18 - 90)	100	41	0.57 (0.31 - 1.03)	1.26 (0.93 - 1.70)
Abouzeid, PNR, Egypt, 2017	NR	74	7	0.17 (0.39 - 0.70)	3.91 (1.62 - 9.45)
Cheekuri, PNR India, 2017	27 (13 - 60)	65	35	0.52 (0.39 - 0.70)	3.91 (1.62 - 9.45)
Vineed, PNR, India, 2017	Below 13 excluded	71	29	0.50 (0.27 - 0.91)	1.45 (0.94 - 2.24)
Pooled estimates		6,235 (71%)	1,343(15%)	0.29 (0.17 - 0.48), SE (0.76)	2.88 (1.16 - 5.14), SE (0.85)

Table 1. Study Characteristics

Author, study, country, and year

Age

Histologically confirmed appendicitis

Perforated appendicitis

Positive likelihood ratio (97.5% CI)

Negative likelihood ratio (97.5% CI)

CI: confidence interval; SE: standard error; RS: retrospective study; PNR: prospective non-randomized; NR: not reported.

Estrada, RS, USA, 2007

33 (5 - 66)

157

0.34 (0.23 - 0.51)

2.30 (1.57 - 3.38)

Khan, PNR, Nepal, 2008

29 (8 - 73)

118

5.73 (0.42 - 6.58)

0.05 (0.02 - 0.12)

Sand, RS, Germany, 2009

36 (6 - 91)

376

0.29 (0.22 - 0.38)

1.94 (1.55 - 2.43)

Kaser, RS, Switzerland, 2010

22 (5 - 92)

725

155

0.21 (0.16 - 0.27)

2.05 (1.75 - 2.39)

Atahan, RS, Turkey, 2011

31 (18 - 83)

302

0.15 (0.11 - 0.20)

5.44 (3.03 - 9.75)

Emmanuel, RS, Ireland, 2011

27 (5 - 82)

386

0.09 (0.06 - 0.13)

6.56 (4.30 - 10.02)

Hong, RS, Korea, 2012

732

245

0.13 (0.10 - 0.17)

1.96 (1.73 - 2.22)

McGowan, RS, UK, 2013

1,271

154

0.13 (0.08 - 0.16)

2.35 (1.95 - 2.82)

Chaudary, PNR, India, 2013

27 (15 - 64)

0.41 (0.24 - 0.69)

3.69 (2.31 - 5.90)

D’Souza, PNR, UK, 2013

28 (5 - 85)

0.23 (0.13 - 0.39)

2.96 (1.53 - 5.72)

Nomura, RS, Japan, 2014

279

131

0.44 (0.34 - 0.56)

1.72 (1.41 - 2.09)

Socea, RS, Romania, 2013

274

0.26 (0.20 - 0.34)

15.10 (3.15 - 71.53)

Chambers, RS, UK, 2015

33 ± 17

797

122

0.50 (0.43 - 0.59)

1.83 (1.59 - 2.11)

Muller, RS, Germany, 2015

29 (16 - 91)

312

0.10 (0.07 - 0.14)

4.71 (3.40 - 6.52)

Saxena, PNR, India, 2015

181

0.24 (0.14 - 0.42)

2.67 (0.95 - 7.48)

Shahabuddin, PNR, India, 2016

25 (10 - 65)

0.44 (0.27 - 0.71)

3.81 (1.20 - 12.13)

Eren, RS, Turkey, 2016

36 (18 - 90)

100

0.57 (0.31 - 1.03)

1.26 (0.93 - 1.70)

Abouzeid, PNR, Egypt, 2017

0.17 (0.39 - 0.70)

3.91 (1.62 - 9.45)

Cheekuri, PNR India, 2017

27 (13 - 60)

0.52 (0.39 - 0.70)

3.91 (1.62 - 9.45)

Vineed, PNR, India, 2017

Below 13 excluded

0.50 (0.27 - 0.91)

1.45 (0.94 - 2.24)

Pooled estimates

6,235 (71%)

1,343(15%)

0.29 (0.17 - 0.48), SE (0.76)

2.88 (1.16 - 5.14), SE (0.85)