The accuracy of the Alvarado score in predicting acute appendicitis in the black South African population needs to be validated

Background: The Alvarado score is the most widely used clinical prediction tool to facilitate decision-making in patients with acute appendicitis, but it has not been validated in the black South African population, which has much wider differential diagnosis than developed world populations. We investigated the applicability of this score to our local population and sought to introduce a checklist for rural doctors to facilitate early referral. Methods: We analyzed patients with proven appendicitis for the period January 2008 to December 2012. Alvarado scores were retrospectively assigned based on patients' admission charts. We generated a clinical probability score (1-4 = low, 5-6 = intermediate, 7-10 = high). Results: We studied 1000 patients (54% male, median age 21 yr). Forty percent had inflamed, nonperforated appendices and 60% had perforated appendices. Alvarado scores were 1-4 in 20.9%, 5-6 in 35.7% and 7-10 in 43.4%, indicating low, intermediate and high clincial probability, respectively. In our subgroup analysis of 510 patients without generalized peritonitis, Alvarado scores were 1-4 in 5.5%, 5-6 in 18.1% and 7-10 in 76.4%, indicating low, intermediate and high clinical probability, respectively. Conclusion: The widespread use of the Alvarado score has its merits, but its applicability in the black South African population is unclear, with a significant proportion of patients with the disease being potentially missed. Further prospective validation of the Alvarado score and possible modification is needed to increase its relevance in our setting. Contexte: Le score d'Alvarado est l'outil de prediction clinique le plus couramment utilise pour faciliter la prise de decision chez les patients presentant une appendicite aigue, mais il n'a pas ete valide dans la population noire sud-africaine chez qui le diagnostic differentiel est beaucoup plus vaste que dans les populations des pays industrialises. Nous avons explore l'applicabilite de ce score a notre population locale et tente de presenter une liste de verification aux medecins ruraux pour accelerer les demandes de consultation. Methodes: Nous avons analyse les dossiers de patients atteints d'une appendicite averee pendant la periode allant de janvier 2008 a decembre 2012. Les scores d'Alvarado ont ete assignes retrospectivement selon les dossiers d'admission des patients. Nous avons genere un score de probabilite clinique (1-4 = faible, 5-6 = intermediate, 7-10 = eleve). Resultats: Nous avons ainsi etudie 1000 patients (54 % de sexe masculin, age median 21 ans). Quarante pour cent presentaient des appendices enflammes non perfores et 60 % des appendices perfores. Les scores d'Alvarado se situaient a 1-4 chez 20,9 %, a 5-6 chez 35,7 % et a 7-10 chez 43,4 %, correspondant a une probabilite clinique faible, intermediate et elevee, respectivement. Dans notre analyse de sousgroupes sur 510 patients indemnes de peritonite generalisee, les scores d'Alvarado se situaient a 1-4 chez 5,5 %, a 5-6 chez 18,1 % et a 7-10 chez 76,4 %, correspondant a une probabilite clinique faible, intermediaire et elevee, respectivement. Conclusion: L'utilisation repandue du score d'Alvarado a ses merites, mais son applicabilite dans la population noire d'Afrique du Sud est indeterminee, la maladie risquant de passer inaperque chez une proportion significative de patients. Il faudra proceder a une validation prospective plus approfondie du score d'Alvarado et le modifier peut-etre si l'on veut en accroitre la pertinence dans notre contexte.
It is increasingly accepted that the omission of surgical care from the Millennium Development Goals was a serious oversight, and over the last decade there has been an increased awareness [...]