Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

The Bohemo‐Iberian regional chronostratigraphical scale for the Ordovician System and palaeontological correlations within South Gondwana

The Bohemo‐Iberian regional scale for South Gondwana, involving the ‘Mediterranean Province’, comprises five regional stages (Arenigian, Oretanian, Dobrotivian, Berounian and Kralodvorian) plus the global Tremadocian and Hirnantian. The predominance of shallow‐water taxa in those high‐latitude faunas imposes serious difficulties for correlating the regional succession with the formal global chronostratigraphy because of the almost total absence of the key graptolites and conodonts defining the base of the standard series, stages and stage slices. Instead, the abundant benthic faunas (trilobites, brachiopods, molluscs, echinoderms) of South Gondwanan origin largely dominated in the area from the middle Darriwilian to the late Katian. The poleward faunal migration of originally Avalonian, Baltic, Laurentian and even Asiatic taxa during the Boda Event of global warming progressively ends with the endemicity in the region, where the ensuing benthic assemblages were severely affected by the Hirnantian glaciation. The regional scale significantly improves the precision of correlations between Ordovician strata from SW and central Europe, North Africa and a large part of the Middle East. An updated record of palaeontological data from areas where Mediterranean faunas remain practically unknown, or are still poorly investigated, is also included. Palaeobiogeographical relationships based on the distribution of faunas across South Gondwana are suggested as an improvement for positioning many territories in modern palaeogeographical reconstructions and offer a constructive approach to problems related to the pre‐Variscan and pre‐Alpine orogenic puzzles.This work has been supported by the IBEROR project (‘Iberian Ordovician chronostratigraphy and its correlation with the global scale’, ref. CGL2012‐39471/BTE) of the Spanish Ministry of Economy and Competitiveness.Peer reviewe