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Appendicitis risk prediction models in children presenting with right iliac fossa pain (RIFT study): a prospective,
Insights
The Shera score effectively identifies children at low risk for acute appendicitis, potentially reducing unnecessary surgeries. This risk prediction model aids in stratifying pediatric appendicitis cases for appropriate management.
Area of Science:
- Pediatric Surgery
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Acute appendicitis is a common pediatric surgical emergency.
- Differentiating appendicitis from non-surgical conditions in children presents a diagnostic challenge.
- Accurate risk stratification is crucial for optimal management of pediatric appendicitis.
Purpose of the Study:
- To identify the optimal risk prediction model for stratifying acute appendicitis risk in children.
- To evaluate the performance of identified risk prediction models in a pediatric cohort.
- To determine the best model for identifying low-risk children who may avoid surgery.
Main Methods:
- A rapid review identified potential risk prediction models for acute appendicitis.
- A prospective, multicenter cohort study evaluated these models in children aged 5-15 with right iliac fossa pain.
- Model performance was assessed by varying score cutoffs to maintain a failure rate below 5%.
Main Results:
- The Shera score demonstrated the best performance (AUC 0.84) among 15 assessed models.
- Specific cutoffs for the Shera score achieved a failure rate of 3.3% and a specificity of 44.3%.
- The Shera score's positive predictive value was comparable to ultrasound for identifying appendicitis.
Conclusions:
- The Shera score can identify a significant group of low-risk children with acute appendicitis, enabling consideration for early discharge.
- Risk scoring alone does not determine surgical necessity; further imaging is recommended for medium- and high-risk children.
- Ultrasound, MRI, or low-dose CT are recommended for higher-risk pediatric appendicitis cases when uncertainty persists.
Background:
Acute appendicitis is the most common surgical emergency in children. Differentiation of acute appendicitis from conditions that do not require operative management can be challenging in children. This study aimed to identify the optimum risk prediction model to stratify acute appendicitis risk in children.
Methods:
We did a rapid review to identify acute appendicitis risk prediction models. A prospective, multicentre cohort study was then done to evaluate performance of these models. Children (aged 5-15 years) presenting with acute right iliac fossa pain in the UK and Ireland were included. For each model, score cutoff thresholds were systematically varied to identify the best achievable specificity while maintaining a failure rate (ie, proportion of patients identified as low risk who had acute appendicitis) less than 5%. The normal appendicectomy rate was the proportion of resected appendixes found to be normal on histopathological examination.
Findings:
15 risk prediction models were identified that could be assessed. The cohort study enrolled 1827 children from 139 centres, of whom 630 (34·5%) underwent appendicectomy. The normal appendicectomy rate was 15·9% (100 of 630 patients). The Shera score was the best performing model, with an area under the curve of 0·84 (95% CI 0·82-0·86). Applying score cutoffs of 3 points or lower for children aged 5-10 years and girls aged 11-15 years, and 2 points or lower for boys aged 11-15 years, the failure rate was 3·3% (95% CI 2·0-5·2; 18 of 539 patients), specificity was 44·3% (95% CI 41·4-47·2; 521 of 1176), and positive predictive value was 41·4% (38·5-44·4; 463 of 1118). Positive predictive value for the Shera score with a cutoff of 6 points or lower (72·6%, 67·4-77·4) was similar to that of ultrasound scan (75·0%, 65·3-83·1).
Interpretation:
The Shera score has the potential to identify a large group of children at low risk of acute appendicitis who could be considered for early discharge. Risk scoring does not identify children who should proceed directly to surgery. Medium-risk and high-risk children should undergo routine preoperative ultrasound imaging by operators trained to assess for acute appendicitis, and MRI or low-dose CT if uncertainty remains.
Funding:
None.
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