BackgroundThe Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score.MethodsA systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children.ResultsForty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata.ConclusionsThe Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk.
[reaction: see text] The base-promoted cyclization of optically pure N-(p-methoxybenzyl)-N-(2-chloro)propionyl amino acid derivatives resulted in a diastereo- and enantioselective approach to valuable 1,3,4,4-tetrasubstituted beta-lactams. The stereochemical outcome of the reaction is exclusively governed by the configuration of the N-(2-chloro)propionyl moiety.
SPECIAL EDUCATION AND TITLE 1 PROGRAMS COEXIST IN ABOUT 65% OF ALL PUBLIC ELEMENTARY SCHOOLS IN THE NATION. ALTHOUGH SOME OF THE SERVICES OFFERED BY THE TWO PROGRAMS ARE SIMILAR, THE LEGISLATIVE INTENT, FUNDING MECHANISMS, AND THE POPULATIONS TARGETED BY EACH PROGRAM DIFFER. THIS ARTICLE EXPLORES INTEGRATION OF THE TITLE 1 COMPENSATORY EDUCATION PROGRAM AND SPECIAL EDUCATION. THIS INTEGRATION IS OFTEN ACHIEVED EITHER THROUGH COOPERATIVE TEACHING OR THROUGH BLENDED FUNDING OF STAFF SALARIES. PROFILES OF LOCAL EFFORTS TO INTEGRATE TITLE 1 AND SPECIAL EDUCATION SERVICES ARE PROVIDED.
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