 Good morning, my name is Dr. Shumun Saini. So, Merzman, Mahabhi Medical College, and Dr. Zain Hospital, New Delhi. The topic of my oral paper presentation is the Diagnostic Utility of Spectral Doppler in Acute Appendicitis. The aim of the study was to evaluate the diagnostic utility of spectral Doppler in Acute Appendicitis as an exam to grade scale ultrasoundography. The objective of the study was to measure the PSV and RI values of the Vascularity of Appendix in patients clinically suspected to have acute appendicitis and to find the cutoff values of PSV and RI which can differentiate appendicitis from normal abit. Another objective was to implement the cutoff values obtained to evaluate the diagnostic performance of spectral Doppler in Acute Appendicitis and its added advantage in the borderline category of diameter of 6 to 8 ml. Coming up is the introduction. Right is is one of the most common presentation in the emergency room of which a major cause is acute appendicitis and it remains the most common cause of abdominal pain that may require surgical intervention and hospitalization. The radiological evaluations for appendicitis have been constantly evolving over the recent years and now the graded compression ultrasoundography has emerged as the initial and the most commonly used immediate modality in diagnostic appendicitis and the conditions that may make appendicitis. USB is the preferred modality for appendicitis because of its easy availability, cause effectiveness and no radiation exposure. USB can diagnose appendicitis by calculating the maximum outer diameter of the appendicitis visualizes a blind ending non compressible k-peristaltic tubular structure in the right eyelid corsa along with other signs of inflammation. But a major problem of ultrasoundography is that diagnosing appendicitis in the equivocal category where the diameter is 6 to 8 ml various studies have found that in this category approximately half of the patients did not even have appendicitis. So this limitation has been partially resolved by the adjective use of color Doppler as it can also detect peripheral walls hyperemia in acute appendicitis. Similarly now spectral Doppler has emerged to provide an objective and quantitative data in the form of mean PSV that is peak systolic philosophy and RI resistive index values which provide a statistically significant differentiation between a patient with appendicitis and without appendicitis. So the objective of our study was to assess the potential utility of PSV and RI values by appendicitis to sectoral Doppler in diagnosing acute appendicitis. The study was a prospective observational analytical study at a tertiary care hospital on the study period of 18 months. Subjects of age between 12 to 15 years with acute abdominal pain and clinically suspected of acute appendicitis were taken only those patients were included in which the sectoral Doppler parameters were obtained. Patients with complicated appendicitis in which appendix not visualized color not obtained or no sectoral Doppler parameters were obtained were excluded from the study. So after obtaining informed written concerns pre-physically in examination finding ultrasound was performed on the subject using a linear ready transducer of her ultramachine logic E. The technique used was a created compression technique and the patients were scanned in supine, left posterior oblique and stretching supine positions and appendix was visualized as an aparystallic non-compressible tubular blindening structure. The maximum outer diameter of the appendix was noted along with other findings such as appendicolis, peri-appendixial fluid, ecogenic fat, etc. Colored opals were then attempted on the appendixial wall and after identification of the colors signal within the wall, sectoral Doppler was attempted in non-angle corrected interrogation which was used to provide spectral tracing indicating PSP and RI values. This is the study closure after we have obtained the sectoral Doppler parameters and then the patients were followed up and the patient undergoing surgery he put a biological report for the final diagnosis was traced and then patients not going undergoing surgery, clinical follow-up for resolution of symptoms or admission was done. Now sample size, coming on to the sample size the significance of sectoral Doppler parameters has been studied question and all. So keeping that study as a reference study the sample size obtained for our study was 32 patients and to eliminate error the proposed sample size of the study was 40 patients. Coming on to the rigorous, so out of a total of 150 patients who were initially came to us for the sample size of the patients, the patients were initially evaluated with grayscale, ultrasonography, then colored Doppler and then spectral Doppler or to call this patients sectoral Doppler waveforms were obtained in 40 patients. On performing grayscale ultrasound the appendixial diameters of the patients changed from 6 to 14 mm with a mean diameter of 9.16 mm. The mean diameter of appendix in the patients with appendixitis was 9.97 while it was 8.62 in patients without appendixitis. So in both the groups there was a significant difference. Along with grayscale ultrasound, anterior findings like periopendical phage, inflammation, fluid was also observed. However there were no significant differences between the groups of patients having appendixitis and those without appendixitis. On spectral Doppler evaluation, the mean PSV value obtained in the patients with and without appendixitis was 19.2 centimeter per second and 14.15 centimeter per second, showing significant difference between the two groups. The mean RI values were 0.62 and 0.52. However, there was no significant difference between the two groups in case of R. This is the ROC curve obtained and from for appendixial diameter, the cutoff value obtained for appendixitis was 8.7 mm. So at a cutoff of more than 8.7 mm, it predicted appendixitis with a sensitivity of 81 percent, sensitivity of 58 percent, positive predictive value of 56.5 percent, interview of 82.4 and a diagnostic accuracy of 67.5 percent. This is the ROC curve analysis of PSV values and the cutoff value obtained was 11.8 centimeter per second and it showed a sensitivity of 96.8 percent and a sensitivity of 54.2 percent. Now this is the third ROC curve of RI values. The cutoff obtained was 0.56 with a sensitivity of 81.2 percent and a specificity of 58.3 percent. We applied this cutoff value on 15 patients in the borderline category and we found that the PSV predicted appendixitis with a sensitivity of 50 percent, specificity of 58.3 percent, PSV of 16.7 percent and PV of 87.5 percent and added diagnostic accuracy of 57.1 percent. The cutoff value of RI predicted appendixitis with a sensitivity of 50 percent, specificity of 41.7 percent, PV of 12.5 percent and interview of 83.3 percent. RI had 42.9 percent diagnostic accuracy. Coming on to the discussion part. In our studies, the mean maximum output diameter of patients with appendixitis is 9.97 while the mean diameter of patients without appendixitis was 8.62. I have already described because there was a significant difference between these two groups whereas in the borderline group appendixitis was resulting in 12.5 cases. Then comparing to previous study in a study by a tender staff at all in 2014, a significant difference was seen in the diameter between the surgical and the nonsurgical groups of appendixitis. Similar results were also obtained by a study by G et al. So both the studies demonstrated that appendix diameter is an important grayscale criteria and differs significantly in the positions of appendicitis and those without appendicitis. And now our cutoff value that we obtained was 8.7 mm after plotting ROC curve and the sensitivity, specificity and PPV of power cutoff value were significantly lesser than a previous study by Kessler where the cutoff value of 6 mm obtained a sensitivity of 98 percent. So in our study the cutoff value of 6 mm had a sensitivity of 100 percent by specificity a little poor at 4.2 percent. Now if we consider the cutoff value at 7 mm the sensitivity was 93.8 percent, the specificity of 16.7 percent, PPV of 42.9 percent and MVV of 80 percent. Another study where our study had different results from J et al was that 5.7 mm was found to be a reliable cutoff criteria in the study by G et al. But our results were comparable to the results obtained in the study by Rittenbacker and the Kaiser where it was demonstrated that the cutoff values of 6 and 7 mm were highly sensitivity but they lacked specificity. The study by Rendez-Gas also concluded that adopting a 7 mm cutoff could actually maximize the sensitivity in specificity. Our study drew the same conclusion where it was concluded that appendicitis diameter was more useful in actually excluding appendicitis than in confirming its presence. In the borderline category only 14.2 percent of our patients had appendicitis which was fairly low when compared to previous studies by Tau et al or Oppenheimer where the number was more than 50 percent. The results of our study regarding the mean PSV of 19.2 centimeter and 14.5 centimeter patients with and without appendicitis were similar to our reference study by Sineadol. The cutoff value obtained from the ROC curve was 10 centimeters per second in Sineadol and we obtained the value of 11.8 centimeters per second which were very close. And in another similar study by Bakshandri, a cutoff value of 9.6 centimeters per second was obtained. Among those two studies we have actually obtained higher sensitivity as compared to Sineadol. However, the specificity in PPV was significantly lower. The sensitivity of our set of PSV in our study was similar to that by Bakshandri. The mean RA value in our study was also comparable to that obtained in the study by Insesu et al. Our study also closely replicated the results obtained in the study by Sineadol where the RA values of were 0.69 and 0.5. The cutoff value of RA that we obtained from our ROC curve was 0.56 and it has good sensitivity and specificity and good NPV also. But then compared with the study by Sineadol, the results obtained in our study were better than case of sensitivity comparable in terms of NPV but significantly lower in specificity and PPV. Our study also demonstrated lower sensitivity and specificity when compared to the study by Bakshandri. In our study, a total of 19 patients were operated and 24 patients were not operated. Out of the 24 patients that were not operated who had a recurrence of the symptoms and were subsequently operated and we found that if we had applied the if we apply the criteria of our PSV and RA values in those patients, we would have correctly predicting the presence of appendicitis. Among the patients that were operated, 16 were found to have appendicitis while 3 did not have appendicitis. All 3 of these patients had appendicitis between 6 to 8 m. If we apply the criteria value from our study in this patient, our cut-off PSV actually correctly predicted the absence of appendicitis in all these patients while RA correctly predicted absence of appendicitis in 1 out of 3 patients. The findings of our study were similar to those conducted by Sineadol which they found that on applying the criteria of cut-off PSV to 5 patients, they would have provided correct diagnosis in 4 of the 5 patients. When it comes to the borderline category, we had 14 patients in which 5 were operated. However, appendicitis was found only in 2 of them, all in the pathology. On applying our cut-off values of PSV and RA, we found that the PSV predicted appendicitis with a sensitivity of 50%, specificity of 58.3%, P2B of 16.7% and in review of 87.5%. The cut-off values of RA predicted appendicitis with a sensitivity of 50%, specificity of 41.7%, P2B of 12.5% and in review of 83.3%. So, our results for the borderline category were considerably different from the study by Sineadol and had lower sensitivity, specificity and BVG. Only the negative relative value was comparable between the 2 studies. So, this difference was likely due to a lower number of patients we had in the borderline category and the shorter time span of the study. In conclusion, spectral doctor parameters, especially PSV can prove to be a useful jump to great scale using correctly predicting appendicitis, even performing better than the criteria of maximum diameter. In the borderline category, however, spectral parameters in our study did not perform as well as those in previous studies. However, the cut-off values of PSV correctly predicted the absence of appendicitis in 3 patients who were operated but were performed to not have appendicitis. So, an additional study with the largest sample size and a longer time span are recommended to collaborate this findings that could define the utility of spectral doctor criteria in the context of borderline appendicitis of 6 to 8. These are my representative cases. The first case shows grade scale appendicitial diameter in the value of 8.7 mm. This is the image showing colored Doppler images and this is the spectral doctor parameters. The patient was operated and this is the findings. This is the second case in which the patient had a diameter of 7.1 mm and was subsequently operated. The patient had a diameter of 10 mm. However, the PSV and RE values were lower. The patient was not operated and was managed conservatively. This is another patient in the borderline category of 6 to 8 mm. This patient had low spectral doctor values and the patient was not operated and was valid conservatively. This patient actually had a data diameter, had data spectral doctor parameters, but the patient was clinically well and was not operated and was managed conservatively. These are the results.