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A clinical decision rule to identify children at low risk for appendicitis
Anupam B Kharbanda1, George A Taylor, Steven J Fishman
1Division of Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA. ak493@columbia.edu
Insights
New clinical decision rules accurately identify children with low risk of appendicitis, potentially reducing the need for computed tomography (CT) scans. These rules aid in safely observing children who do not require CT examination for suspected appendicitis.
Area of Science:
- Pediatric Emergency Medicine
- Diagnostic Imaging
- Clinical Decision Support
Background:
- Computed tomography (CT) is widely used for diagnosing appendicitis in children but raises concerns about ionizing radiation exposure.
- Existing clinical scores for appendicitis lack sufficient accuracy in pediatric populations.
- There is a need for reliable methods to identify children who do not have appendicitis, avoiding unnecessary CT scans.
Purpose of the Study:
- To develop and validate clinical decision rules for predicting which children with acute abdominal pain are at low risk for appendicitis.
- To reduce the reliance on CT scans in pediatric appendicitis evaluation.
Main Methods:
- A prospective cohort study enrolled 601 children and adolescents (aged 3-18) presenting with symptoms suspicious for appendicitis.
- Two low-risk clinical decision rules were developed using logistic regression and recursive partitioning.
- The sensitivity, negative predictive value (NPV), and negative likelihood ratio of each rule were assessed.
Main Results:
- A 6-part logistic regression score (including nausea, pain migration, difficulty walking, rebound tenderness, and neutrophil count) achieved a 96.3% sensitivity and 95.6% NPV for appendicitis.
- A recursive partitioning rule (based on neutrophil count, absence of nausea, and maximal tenderness location) demonstrated 98.1% sensitivity and 97.5% NPV.
- Application of these rules could theoretically decrease CT utilization by 20%.
Conclusions:
- The developed low-risk clinical decision rules accurately identify children with a low probability of appendicitis.
- These rules support the safe management of children through careful observation, potentially avoiding CT examinations.
- Implementation of these decision rules can help mitigate radiation exposure in pediatric patients.
Objective:
Computed tomography (CT) has gained widespread acceptance in the evaluation of children with suspected appendicitis. Concern has been raised regarding the long-term effects of ionizing radiation. Other means of diagnosing appendicitis, such as clinical scores, are lacking in children. We sought to develop a clinical decision rule to predict which children with acute abdominal pain do not have appendicitis.
Methods:
Prospective cohort study was conducted of children and adolescents who aged 3 to 18 years, had signs and symptoms suspicious for appendicitis, and presented to the emergency department between April 2003 and July 2004. Standardized data-collection forms were completed on eligible patients. Two low-risk clinical decision rules were created and validated using logistic regression and recursive partitioning. The sensitivity, negative predictive value (NPV), and negative likelihood ratio of each clinical rule were compared.
Results:
A total of 601 patients were enrolled. Using logistic regression, we created a 6-part score that consisted of nausea (2 points), history of focal right lower quadrant pain (2 points), migration of pain (1 point), difficulty walking (1 point), rebound tenderness/pain with percussion (2 points), and absolute neutrophil count of >6.75 x 10(3)/microL (6 points). A score < or =5 had a sensitivity of 96.3% (95% confidence interval [CI]: 87.5-99.0), NPV of 95.6% (95% CI: 90.8-99.0), and negative likelihood ratio of .102 (95% CI: 0.026-0.405) in the validation set. Using recursive partitioning, a second low-risk decision rule was developed consisting of absolute neutrophil count of <6.75 x 10(3)/microL, absence of nausea, and absence of maximal tenderness in the right lower quadrant. This rule had a sensitivity of 98.1% (95% CI: 90.1-99.9), NPV of 97.5% (95% CI: 86.8-99.9), and negative likelihood ratio of 0.058 (95% CI: 0.008-0.411) in the validation set. Theoretical application of the low-risk rules would have resulted in a 20% reduction in CT.
Conclusions:
Our low-risk decision rules can predict accurately which children are at low risk for appendicitis and could be treated safely with careful observation rather than CT examination.
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