Document Detail

Validation and refinement of a prediction rule to identify children at low risk for acute appendicitis.
MedLine Citation:
PMID:  22869405     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: To validate and refine a clinical prediction rule to identify which children with acute abdominal pain are at low risk for appendicitis (Low-Risk Appendicitis Rule).
DESIGN: Prospective, multicenter, cross-sectional study.
SETTING: Ten pediatric emergency departments.
PARTICIPANTS: Children and adolescents aged 3 to 18 years who presented with suspected appendicitis from March 1, 2009, through April 30, 2010.
MAIN OUTCOME MEASURES: The test performance of the Low-Risk Appendicitis Rule.
RESULTS: Among 2625 patients enrolled, 1018 (38.8% [95% CI, 36.9%-40.7%]) had appendicitis. Validation of the rule resulted in a sensitivity of 95.5% (95% CI, 93.9%-96.7%), specificity of 36.3% (33.9%-38.9%), and negative predictive value of 92.7% (90.1%-94.6%). Theoretical application would have identified 573 (24.0%) as being at low risk, misclassifying 42 patients (4.5% [95% CI, 3.4%-6.1%]) with appendicitis. We refined the prediction rule, resulting in a model that identified patients at low risk with (1) an absolute neutrophil count of 6.75 × 103/μL or less and no maximal tenderness in the right lower quadrant or (2) an absolute neutrophil count of 6.75 × 103/μL or less with maximal tenderness in the right lower quadrant but no abdominal pain with walking/jumping or coughing. This refined rule had a sensitivity of 98.1% (95% CI, 97.0%-98.9%), specificity of 23.7% (21.7%-25.9%), and negative predictive value of 95.3% (92.3%-97.0%).
CONCLUSIONS: We have validated and refined a simple clinical prediction rule for pediatric appendicitis. For patients identified as being at low risk, clinicians should consider alternative strategies, such as observation or ultrasonographic examination, rather than proceeding to immediate computed tomographic imaging.
Anupam B Kharbanda; Nanette C Dudley; Lalit Bajaj; Michelle D Stevenson; Charles G Macias; Manoj K Mittal; Richard G Bachur; Jonathan E Bennett; Kelly Sinclair; Craig Huang; Peter S Dayan;
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Publication Detail:
Type:  Journal Article; Multicenter Study; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't; Validation Studies    
Journal Detail:
Title:  Archives of pediatrics & adolescent medicine     Volume:  166     ISSN:  1538-3628     ISO Abbreviation:  Arch Pediatr Adolesc Med     Publication Date:  2012 Aug 
Date Detail:
Created Date:  2012-08-07     Completed Date:  2012-11-02     Revised Date:  2013-10-17    
Medline Journal Info:
Nlm Unique ID:  9422751     Medline TA:  Arch Pediatr Adolesc Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  738-44     Citation Subset:  AIM; IM    
Department of Pediatrics Columbia University College of Physicians and Surgeons, New York, New York, USA.
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MeSH Terms
Abdominal Pain / etiology*
Acute Disease
Appendicitis / complications,  diagnosis*
Child, Preschool
Cross-Sectional Studies
Decision Support Techniques*
Diagnosis, Differential
Emergency Service, Hospital
Prospective Studies
Reproducibility of Results
Sensitivity and Specificity
Grant Support
Marc Auerbach / ; Lei Chen / ; Todd Chang / ; Andrea Cruz / ; Charles G Macias / ; Denise Dowd / ; Stephen Freedman / ; Anupam B Kharbanda / ; Prashant Mahajan / ; Jared Muenzer / ; David Schnadower / ; Joe Zorc /
Comment In:
J Pediatr. 2013 Mar;162(3):654-5   [PMID:  23438925 ]
Erratum In:
Arch Pediatr Adolesc Med. 2012 Oct;166(10):901

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