To the Editor.
—The meta-analysis presented by Dr Wagner and colleagues1 provides a good picture of the clinical signs and symptoms of acute appendicitis. Most of the studies on this subject indicate that the most reliable signs in the diagnosis of acute appendicitis are those with a high likelihood ratio, providing that these signs are present on each individual patient. I agree with the statement that the routine history and physical examination remain the most effective and practical tools to make the diagnosis. Nevertheless, we cannot ignore the fact that a white blood cell count with a differential cell count is also an important tool in the evaluation, but this is not mentioned by the authors in their article.I also agree with their assertion that "clinicians often do not collect enough clinical details for accurate and precise diagnosis." It is for this reason that I would like to emphasize that the
Alvarado A. Does This Patient Have Appendicitis?. JAMA. 1997;277(8):626. doi:10.1001/jama.1997.03540320028019
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