Host-guest peptide sets have been useful in evaluating the propensity of different amino acids to adopt an alpha-helical or beta-sheet form, and this concept is applied here to the triple-helical conformation. A set of host-guest peptides of the form acetyl-(Gly-Pro-Hyp)3-Gly-X-Y-(Gly-Pro-Hyp)4-Gly-GlyCONH2 was designed to evaluate the contribution of an isolated Gly-X-Y triplet to triple-helix stability in a defined environment. Peptides were synthesized to include guest triplets with the X and Y positions occupied by the most common nonpolar residues found in collagen: Pro (X position) and Hyp (Y position); Ala; Leu, the most frequent hydrophobic residue; and Phe, the only commonly occurring aromatic residue. The guest triplets of the 12 peptides synthesized represent 35% of the sequence found in the alpha 1 chain of type I collagen. All peptides formed stable triple-helical structures, and the peptides showed a range of thermal stabilities (Tm = 21-44 degrees C), depending on the identity of the guest triplet. Thermodynamic calculations indicate these peptides have a range of free energy values (delta delta G = 9 kcal/mol) and suggest that favorable entropy is the dominant factor in increased stability. Replacement of Ala by Leu in the X position did not affect the thermal stability, while an Ala to Leu change in the Y position was destabilizing. These data provide experimental evidence that hydrophobic residues do not stabilize the triple helical conformation. Although Leu and Phe are found almost exclusively in the X position in collagens, peptides with Leu and Phe in the Y position formed stable triple-helices. This supports the hypothesis that the X positional preference of these residues relates to their increased potential for intermolecular hydrophobic interactions rather than their destabilization of the triple-helical molecule. These studies establish the utility of host-guest peptides in defining a scale of triple-helix propensities and in clarifying the interactions stabilizing the triple-helical conformation.

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Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.