How Reliable Is Alvarado Score and Its Subgroups in Ruling Out Acute Appendicitis and Suggesting the Opportunity of Nonoperative Management or Surgery?
We thanks Foell and colleagues for their words of appreciation on our Non Operative Treatment for Acute Appendicitis (NOTA) Study. 1
We agree that the patients must be well selected and accurately followed up to achieve the best and safest outcomes, including an eventual timely surgical treatment in those patients who will ultimately fail nonoperative management (NOM).
First of all, as already stated in our reply to Lubrano et al, 2 the best indication for NOM and the greater chances of success are exactly for those cases of uncomplicated or nonperforated appendicitis, most often falling into the “indeterminate” or “equivocal” score groups.
We really thank Foell for making us aware of the finding of some discrepancy in the article. We went back to the patient's database and the study forms filled by treating physicians, and found what follows. Regarding the first issue, the Alvarado score is shown in all patients but 2 because in these 2 patients, the physicians did not report in the form of the Alvarado score, only the appendicitis inflammatory response score (AIR) score, and we could not find within the study forms any information of the presence (or certain absence) in these 2 patients of anorexia, migration of pain, and if the exact body temperature was above or below 37.5 °C. By the protocol, the inclusion of patients was upon the clinical diagnosis/suspicion made by an Attending General Surgeon, of acute appendicitis, confirmed by at least 1 validated score (Alvarado and/or AIR score) and therefore in some patients, the evaluating physicians assessed and reported both scores, in some other patients only one of the 2 scores, and usually AIR scores, more recent and including CRP levels, has been the preferred score used in clinical setting. Whenever only 1 score was used for inclusion of the patient in the study, we were able to calculate the second score, if not already done so and reported in the form, based on the data reported in the charts. In these 2 patients, the abovementioned data (presence or absence of anorexia, migration of pain, and temperature >37.5 °C) were missing and therefore for these 2 patients, Alvarado score is missing data.
The second issue is an interesting one and in fact looking at the available data, we have detected a typo error in reporting the mean value of Alvarado and the range that has been carried forward throughout the article. The actual correct mean value of Alvarado is 6.2 (instead of the incorrectly reported 5.2) and its correct range is 3 to 9 (instead of 5–9). Besides the error in typing the mean value of Alvarado score throughout the article, this corrected value of 6.2 score stands to confirm and reinforce the conclusions of NOTA study that NOM with antibiotics is a feasible and effective strategy in treating possible (equivocal) or probable appendicitis cases. 1 Nonetheless, we went forward in the interpretation of this corrected value and found that there is still a discrepancy between this 6.2 and the calculated minimum possible mean Alvarado score of 6.4, and this was because within the group of lowest included Alvarado score patients (62 patients in total, 33 patients had a score of 5 and 4 had a score of 6, whereas 16 patients had an even lower Alvarado score of 4 and 8 had Alvarado score of 3).