Eur J Pediatr Surg 2023; 33(02): 176-177
DOI: 10.1055/a-1932-8468
Letter to the Editor

Validation of Clinical Prediction Scores for Pediatric Appendicitis: Update with New Cutoff Values for the AIR Score

1   Department of Pediatrics, Lund University Clinical Sciences, Lund, Sweden
,
2   Department of Biomedical and Clinical Sciences, Linköping University, Jönköping, Sweden
3   Department of Surgery, Länssjukhuset Ryhov, Jonkoping, Sweden
› Author Affiliations

Gudjonsdottir et al validated four clinical prediction scores for appendicitis in children.[1] The Appendicitis Inflammatory Response (AIR) score and Pediatric Appendicitis Risk Calculator (pARC) had the best performance. A recent validation of the AIR score (AIR2) recommended an adjustment of the low-risk interval to 0 to 3 points compared with 0 to 4 in the design study.[2] This new interval does not change the final conclusion in the study by Gudjonsdottir et al but gives a different result ([Table 1]) worth a comment.

Table 1

Distribution of patients according to the risk level of respective score, with revised intervals for the AIR2 score

PAS

AIR2

Alvarado

pARC

p-Value

Total cohort

318

318

318

200

 No appendicitis

167

167

167

92

 Appendicitis

151

151

151

108

 Complicated appendicitis

67

67

67

44

Low risk

93 (29)

102 (32)

61 (19)

41 (21)

< 0.001

 No appendicitis

86 (51)

91 (54)

56 (33.5)

38 (41)

< 0.001

 Appendicitis

7 (5)

11 (7)

5 (3)

3 (3)

0.33

 Complicated appendicitis

1 (1)

2 (3)

2 (3)

1 (2)

1

Intermediate risk

171 (53)

80 (25)

115 (57)

< 0.001

 No appendicitis

73 (44)

61 (36.5)

53 (58)

< 0.001

 Appendicitis

98 (65)

19 (13)

62 (57)

< 0.001

 Complicated appendicitis

32 (48)

4 (6)

22 (50)

< 0.001

High risk

225 (71)

45 (14)

177 (56)

44 (22)

< 0.001

 No appendicitis

81 (49)

3 (2)

50 (30)

1 (1)

< 0.001

 Appendicitis

144 (95)

42 (28)

127 (84)

43 (40)

< 0.001

 Complicated appendicitis

66 (99)

33 (49)

61 (91)

21 (48)

< 0.001

Abbreviations: AIR2, revised Appendicitis Inflammatory Response score; PAS, Pediatric Appendicitis Score; pARC, Pediatric Appendicitis Risk Calculator.


Note: Values presented as n (%). p-Values are according to exact test. Scoring intervals: PAS: low = 0–5 and high = 6–10; AIR2 score: low = 0–3 and high = 9–12; Alvarado score low = 0–4 and high = 7–10; pARC: low = 0–14% and high = 85–100%.


With the new risk interval the Pediatric Appendicitis Score (PAS) and AIR2 score assign about half of the no appendicitis patients to the low risk group (51 and 54%, respectively) which is significantly better than the Alvarado and pARC (33.5 and 41%, respectively). All scores have high sensitivity for advanced appendicitis at their low cutoff point (0.97–0.99). Expectant management with planned reexamination, can thus safely be considered for this group.

The revision has no impact for the high-risk group. The AIR2 score and pARC both assign a smaller proportion of patients to this risk group (14 and 22%, respectively) compared with PAS and Alvarado (71 and 56%, respectively) but with much better specificity (0.93 and 0.98 vs. 0.64 and 0.72, respectively). At such a high specificity a diagnostic laparoscopy should be considered before imaging, as a negative imaging study can probably not rule out appendicitis.[3] [4]



Publication History

Received: 23 August 2022

Accepted: 23 August 2022

Accepted Manuscript online:
29 August 2022

Article published online:
14 October 2022

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  • References

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  • 2 Andersson M, Kolodziej B, Andersson RE. Validation of the Appendicitis Inflammatory Response (AIR) Score. World J Surg 2021; 45 (07) 2081-2091
  • 3 Jennings R, Guo H, Goldin A, Wright DR. Cost-effectiveness of imaging protocols for suspected appendicitis. Pediatrics 2020; 145 (02) e20191352
  • 4 van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology 2008; 249 (01) 97-106