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We commend Mori et al’s prospective cohort study in Emergency Medicine Journal on the diagnostic accuracy of the Tongue Coating Index (TCI) for acute appendicitis. This work addresses a key gap in non-invasive abdominal emergency diagnostics—especially valuable in resource-limited settings—and its rigorous comparison with the Alvarado Score offers important clinical insights. We appreciate their validation of a simple, low-burden assessment tool. While the study is methodologically sound, we have several observations to contribute to its clinical translation and future refinement.1