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The next presentation is by maria thomas talking about common inflammatory markers in directing therapy and pediatric acute appendicitis. Thank you um good morning greetings from live bianna india, so we will be presenting a study on common inflammatory markets directing therapy in pediatric acute appendicitis, done in two general hospitals in India and Oman. We have, we have no disclosures. We classified at acute appendicitis in the complicated and uncomplicated based on inter operative findings, supported by histopathological reports. Our objective was to um study if common inflammatory markers alone or in combination can help in distinguishing complicated and uncomplicated appendicitis. Our primary outcome was to identify distinguishing biomarkers the complicated appendicitis. We further try to establish cutoffs for these biomarkers individually and in combination, this was a five year retrospective study in two hospitals in 22 countries where the authors were working. All patient's with confirmed appendicitis who had undergone appendectomy were included in the study. These were the statistical methods used. In addition, we you used uh r. O. C. Analysis of the regression uh logistic regression model that we obtained and we we formulated a regression equation, which yielded a cut off as shown here, so the right side of the cut off um uh The right side of the uh inequality represented the cut off, whereas if the left side of the inequality exceeded the cut off, it predicted complicated appendicitis. 247 children were recruited into the study were included in the study, of which 40% were complicated. All laboratory parameters are significantly higher and complicated as compared to uncomplicated appendicitis. Uh We established cut off values for individual inflammatory markers in order to improve the diagnosis of complicated appendicitis, and as we see here, the AUC was highest for CRP, which also had the highest specificity and diagnostic accuracy. Um So then we combined uh we made a combination of various parameters and we established the, we tried to find out the AUC for a combination of all the inflammatory markers, which was found to be higher than the parameters individually, but it was comparable to CRP alone. The sensitivity to detect complicated appendicitis increased to over 70% when a combination of parameters were used now uh the combination of variables which showed a high a. U. C. Was then used in a regression multiple regression, and we found in order to find the significant predictors of complicated appendicitis, we found that neutrophils, lymphocytes, and platelets emerged as significant variables. The combination of these inflammatory parameters had an a. U. C. Which is comparable to Crp alone. The cut off, this combination of parameters been imputed in our specifically formulated regression equation gave the following uh formula and substituting the cut off values of neutrophils, lymphocytes, and platelets in this regression regression equation, and defining a cut off of greater than or equal to 1.2 increase the predicted value for complicated appendicitis, with the sensitivity of 78.4. So to conclude, CRP had the diagnostic highest diagnostic accuracy for complicated appendicitis. Are formulated regression equation with a value greater than or equal to 1.2 increase the predicted value for complicated appendicitis, and the combination was comparable to crp common biomarkers along with clinical findings may be used to try uh complicated and uncomplicated appendicitis, especially in areas where others diagnostic modalities may not be readily available like l. M. I. C. S. A combination of common by markers, especially with our regression equation has a potential to direct non operative management in areas of surgical resource scarcity. Thank you for your time and patient listening. Thank you very much, we've got some comments from Shalin nursing, which I'll rephrase as a question which is whether you use ct scans to help work out whether someone has complicated or uncomplicated appendicitis or other imaging uh. In, india, we don't use ct scan very commonly in patient's uh so most of the diagnosis was based on clinical uh criteria and findings and has this paper changed of these findings changed your management in your hospitals. Uh This was uh we just completed the paper and we need to uh uh we have uh it has decreased the number of non operative management's, decrease the number of operations uh yeah um have you looked at the specificity and sensitivity of these markers in the presence or absence of individual clinical variables. No we have not uh this is a retrospective study, so um we will be looking at it, sir, and you've talked about a number of different blood tests was monocyte count. One of the blood tests you looked at, no, we did not look at the monocyte count. We uh we looked at lymphocytes, neutrophils, and uh did not look at the monocytes. Thank you thank you very much for your presentation.