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IRIS
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.
Evaluation of appendicitis risk prediction models in adults with suspected appendicitis
Nepogodiev D.;Matthews J. H.;Morley G. L.;Naumann D. N.;Ball A.;Chauhan P.;Bhanderi S.;Mohamed I.;Glasbey J. C.;Wilkin R. J. W.;Drake T. M.;Clements J.;Blencowe N. S.;Herrod P. J. J.;Pata F.;Frasson M.;Blanco-Colino R.;Soares A. S.;Bhangu A. ): MA Ghazanfar (Aberdeen Royal Infirmary);L Sreedharan (Addenbrooke's Hospital);S Kabwama (Airedale General Hospital, Keighley);RT Gray (Altnagelvin Area Hospital);IW Kamande (Antrim Area Hospital);S Nazarian (Barnet Hospital);FA Dar (Barnsley District General Hospital);AT Misky (Basildon University Hospital);S Arunachalam (Basingstoke And North Hampshire Hospital);CS Twum-Barima (Bedford Hospital);IM Mohamed (Birmingham Heartlands Hospital);KL Connor (Borders General Hospital, Melrose);PO Coe (Bradford Royal Infirmary);A Kosti (Bristol Royal Infirmary);M Elshaer (Broomfield Hospital);DA Colvin (Causeway Hospital, Coleraine);MP Charalambous (Charing Cross Hospital);KTD Yeung (Chelsea And Westminster Hospital);LAG Merker (Cheltenham General Hospital);TEM Morrison (Colchester General Hospital);AJ Thaventhiran (Conquest Hospital, St Leonards On Sea);TM Gilbert (Countess Of Chester Hospital);JM Clements (Craigavon Area Hospital);G Hicks (Croydon University Hospital);S Afshar (Cumberland Infirmary, Carlisle);NC Mckinley (Daisy Hill Hospital, Newry);N Assaf (Darent Valley Hospital, Dartford);T Hanna (Derriford Hospital);EGEMacinnes (Doncaster Royal Infirmary);N Thavanesan (Dorset County Hospital, Dorchester);AS Dubois (Dr Gray's Hospital, Elgin);LK Palani-Velu (Forth Valley Royal Hospital, Larbert);S Tezas (Furness General Hospital, Barrow-In-Furness);LPS Yow (Glan Clwyd Hospital, Rhyl);RW Radwan (Glangwili General Hospital, Carmarthen);NB Jamieson (Glasgow Royal Infirmary);M Abdelrahman (Gloucestershire Royal Hospital);KA Lee (Good Hope District General Hospital);Z A Zarka (Great Western Hospital, Swindon);NA Mcdowall (Hairmyres Hospital);CY Tan (Hinchingbrooke Hospital, Huntingdon);ML Venn (Homerton University Hospital);DL Ashmore (Huddersfield Royal Infirmary);SE Whitehorn (Hull Royal Infirmary);AM Golder (Inverclyde Royal Hospital, Greenock);A Reddy (James Cook University Hospital, Middlesbrough);C Delimpalta (James Paget Hospital, Great Yarmouth);OH Kay (John Radcliffe Hospital);P Sarmah (Kettering General Hospital);SM Shah (King George Hospital, Ilford);I Eiben (King's College Hospital);C Doyle (King's Mill Hospital, Sutton In Ashfield);V Tudyka (Kingston Hospital);E Issa (Leicester General Hospital);H West (Leicester Royal Infirmary);HK Brewer (Lincoln County Hospital);EZ Farrow (Lister Hospital, Stevenage);NS Taylor (Luton &;Dunstable Hospital);CJ Smart (Macclesfield District General Hospital);NP Griffiths (Manchester Royal Infirmary);C Halkias (Medway Maritime Hospital, Gillingham);P Vitish-Sharma (Milton Keynes University Hospital);SR Knight (Monklands Hospital, Airdrie);NG Mowbray (Morriston Hospital, Swansea);JB Olivier (Musgrove Park Hospital, Taunton);KJ Lee (New Cross Hospital, Wolverhampton);KD Clement (Ninewells Hospital, Dundee);DRRChrastek (Norfolk And Norwich University Hospital);N Panda (North Manchester General Hospital);MJ Connor (North Middlesex University Hospital);SE Fahmy (Northampton General Hospital, Northampton);ES Bryan (Northern General Hospital, Sheffield);WSNgu (Northumbria Specialist Emergency Care Hospital);SO Adegbola (Northwick Park Hospital, Harrow);EM Vaughan (Perth Royal Infirmary);W Stupalkowska (Peterborough City Hospital);LFC Simmonds (Pilgrim Hospital, Boston);A Malik (Pinderfields Hospital);A Hussein (Princess Alexandra Hospital, Harlow);MJ Karim (Princess Of Wales Hospital, Grimsby);T Singhal (Princess Royal University Hospital, Orpington);R Ormiston (Queen Alexandra Hospital, Portsmouth);D Nepogodiev (Queen Elizabeth Hospital Birmingham);VWS Kung (Queen Elizabeth Hospital, Woolwich);MA Rabie (Queen Elizabeth The Queen Mother Hospital);JH Park (Queen Elizabeth University Hospital, Glasgow);N Lal (Queen's Hospital);D Worku (Queen's Hospital, Romford);M D'Auria (Queen's Medical Centre, Nottingham);A Ang (Rotherham District General Hospital);M Orizu (Royal Alexandra Hospital, Paisley);E Gammeri (Royal Berkshire Hospital, Reading);ECS Clough (Royal Bolton Hospital);CH Choy (Royal Cornwall Hospital, Truro);PJJHerrod (Royal Derby Hospital);S Lawday (Royal Devon &;Exeter Hospital);AJ Hann (Royal Free Hospital);D Robinson (Royal Glamorgan Hospital, Ynysmaerdy);BG Wardle (Royal Gwent Hospital, Newport);D Mcdonnell (Royal Hampshire County Hospital, Winchester);DG Rutherford (Royal Infirmary Of Edinburgh);LM Hickey (Royal Lancaster Infirmary);AG Garg (Royal London Hospital);S Rezvani (Royal Oldham Hospital);CR Bell (Royal Preston Hospital);F Mahmood (Royal Stoke University Hospital);S Rehman (Royal Sussex County Hospital, Brighton);G Donaldson (Royal Victoria Hospital);A Peleki (Russells Hall Hospital);L Pearce (Salford Royal);OL Sharp (Salisbury District Hospital);S Jain (Sandwell General Hospital, West Bromwich);S Singh (Scarborough General Hospital);DB Thompson (Scunthorpe General Hospital);O El-Tayar (South West Acute, Enniskillen);M Hollyman (Southmead Hospital, Bristol);SN Rupasinghe (Southport And Formby District General Hospital);DB Toomey (St George's Hospital, London);MP Murray (St Helier Hospital, Carshalton);N Amtul (St James' University Hospital);RJ Mersh (St Mary's Hospital, London);RC Newton (St Peter's Hospital, Chertsey);W Al-Khyatt (St Richard'S Hospital, Chichester);GF Stephens (St Thomas' Hospital);SH Abbas (Stoke Mandeville Hospital, Aylesbury);MR Iqbal (Tunbridge Wells Hospital, Pembury);CE Brown (Ulster Hospital, Dundonald);S Renshaw (University College Hospital);KA Hureibi (University Hospital Coventry and Warwickshire);UP Pullabatla-Venkata (University Hospital Crosshouse, Kilmarnock);N O Donohoe (University Hospital Lewisham);A Myatt (University Hospital Of North Tees);RJ Egan (University Hospital Of Wales, Cardiff);K Rangarajan (University Hospital Southampton);M Trail (Victoria Hospital, Kirkcaldy);SC Mckay (Walsall Manor Hospital);NFTEngall (Warrington Hospital);E Jerome (Warwick Hospital);DC Townsend (Watford General Hospital);BY Patel (West Middlesex University Hospital);S Pronin (Western General Hospital, Edinburgh);N Chandratreya (Weston General Hospital, Weston-Super-Mare);JH Choong (Whipps Cross University Hospital);TM Mohamed (Whittington Hospital);NJ Hudson-Peacock (William Harvey Hospital);R Manson (Wishaw General Hospital);S Bhanderi (Worcestershire Royal Hospital);KRMHebbar (Worthing Hospital);BS Mothe (Wythenshawe Hospital, Manchester);CR Weegenaar (Yeovil District Hospital);M Saad (York Hospital);CR Bowman (Ysbyty Wrexham Maelor Hospital);Italy: F Serventi (Alghero OspedaleCivile);F Fleres (AOU G. Martino Policlinico di Messina / UniversitàdegliStudi di Messina);C Foppa (Aou-Careggi - Florence);G Pata (Asst SpedaliCivili di Brescia);G Baronio (Asst Valle Camonica-Esine);D Pertile (Ausl Piacenza);A Lucchi (Ausl Romagna - Ceccarini Hospital - Riccione);A Sagnotta (AziendaOspedaliera Santa Maria Terni);I Maretto (AziendaOspedalieraUniversitaria Di Padova);T Campagnaro (AziendaOspedalieraUniversitariaIntegrata Verona);M Gatti (Borgomanero Hospital);EGJGjoni (Busto Arsizio Hospital);F Roscio (Galmarini Hospital, Tradate);M Inama (Hospital Pederzoli);F Coccolini (Hpg XXIII Bergamo);A Sgrò (IrccsPoliclinico San Matteo - Pavia);F Colombo (L. Sacco University Hospital);A Avanzolini (Morgagni-Pierantoni Hospital, Forlì);S Aresu (Nostra Signora Della Mercedes Hospital);A De-Manzoni-Garberini (OspedaleCivileSpirito Santo di Pescara);DA Merlini (Ospedale Di Rho (Milano);- Asst Rhodense);A Chessa (OspedaleS. Giovanni di Dio-Orbetello);N Tamini (Ospedale San Gerardo);S Mulas (Ospedale Santissima Annunziata Aou Sassari UocChirurgiaGenerale E D'Urgenza);N Cillara (Po Santissima Trinità - Assl Cagliari);D Coletta (Policlinico Umberto I Università 'La Sapienza');J Atzeni (Policlinico Universitario Di Monserrato);E Erdas (Policlinico Universitario 'Duilio Casula');G Gallo (Pugliese-Ciaccio' Hospital, Catanzaro / University;E Francone (S. Andrea Hospital Poll-Asl5);P Di Gioia (S. Maria DelleCroci Ravenna);A Birindelli (S. Orsola-Malpighi);CL Bianchi (San Bartolomeo Hospital Sarzana);F Ferrara (San Carlo Borromeo Hospital, Milan);A Biancafarina (San Donato Hospital, Arezzo);M Podda (San Francesco Hospital, Nuoro);S Scabini (San Martino Genova);L Marano (San Matteo degliInfermi Hospital - Ausl Umbria 2 - Spoleto);A Miegge (San Raffaele Hospital);D Sasia (Santa Croce And Carle Hospital, Cuneo);G Savino (Santa Maria Regina degliAngeliAulss 5 Polesana- Adria Hospital);F Pata (Sant'Antonio Abate Hospital, Gallarate);M Scatizzi (Santo Stefano Hospital);FE D'Amico (Treviso Hospital - Ca Foncello);GA Arcuri (U. S. L. Umbria 1 - Città Di Castello);L Gavagna (University of Ferrara);G Salamone (University of Palermo);F Tatulli (V. Emanuele II, Bisceglie);E Goldin (Vicenza Hospital);Portugal: ML Matos (Centro Hospitalar de Entre o Douro e VougaE. P. E. );AB Caldeira (Centro Hospitalar De São João);J Romano (Centro HospitalarLisboaOcidental);J Pereira (Centro HospitalarTondela-Viseu);JGM Azevedo (Centro Hospitalar Vila Nova De Gaia);JM Azevedo (Hospital Da Horta);JFFSimoes (Hospital Garcia De Orta);ACQ Silva (Hospital Pedro Hispano - Uls Matosinhos);AS Soares (Hospital Prof. Dr. Fernando Fonseca);Republic of Ireland: DP O'Leary (Beaumont Hospital);ND Kennedy (Blackrock Clinic);EM Quinn (Connolly Hospital, Blanchardstown);AY Zhang (Letterkenny University Hospital);PM Neary (Mater Misericordiae University Hospital);JA De-Marchi (Our Lady Of Lourdes Hospital);BR O'Connor (Our Lady's Children's Hospital, Dublin);K Wijesundera (Portiuncula Hospital);NM Foley (Sligo University Hospital);J Wong (St James' Hospital;Dublin Ireland);ND Kennedy (St Vincent's University Hospital);LA Tiedt (Tallaght Hospital);JC Bolger (University Hospital Limerick);TM Connelly (University Hospital Waterford);OS Ahmed (Wexford General Hospital);Spain: V Vigorita (Alvaro Cunqueiro Hospital);V García (ComplejoAsistencial De Segovia);J Arredondo (ComplejoAsistencial Universitario De León);E Redondo (ComplejoAsistencial Universitario De Palencia);B Sainz (ComplejoHospitalario De Navarra);I Aldrey (ComplexoHospitalario Universitario De Ourense);A Landaluce-Olavarria (Galdacano);A De Andrés Gómez (General University Hospital Of Valencia);E Cordoba (H Clinico Universitario Zaragoza);MN Sánchez-Fuentes (H. U. Miguel Servet. Zaragoza);C Cerdán-Santacruz (Hospital Arnau De Vilanova De Lleida);J Beltran-De-Heredia (Hospital Clinico De Valladolid);MTGM García (Hospital Comarcal De Valdeorras);T Veres (Hospital De Cerdanya);A García-Novoa (Hospital Do Salnés);A MeleroAbellán (Hospital General de Villarrobledo);L García-Catalá (Hospital General Universitario De Elche);M Ruiz-Marín (Hospital General Universitario Reina Sofía);P Menendez (Hospital Gutierrez Ortega);S Roldán-Ortiz (Hospital Puerta Del Mar);JA Navas-Cuéllar (Hospital Punta De Europa);D Sabia (Hospital Sant Joan Despi, Moises Broggi);JC Gomez-Rosado (Hospital Univ. Virgen Macarena);M Serrano Navidad (Hospital Universitari de Bellvitge);C Caula (Hospital Universitari De Girona Doctor JosepTrueta);ER Sanchez (Hospital Universitari Germans Trias I Pujol);E Espin-Basany (Hospital UniversitariVallD'Hebron);D Fernández-Martínez (Hospital Universitario Central De Asturias, Oviedo);AF Bravo-Gutiérrez (Hospital Universitario de Canarias);C Payá-Llorente (Hospital Universitario Doctor Peset, Valencia);P Dujovne (Hospital Universitario Fundación Alcorcon, Madrid);F Lima (Hospital Universitario Infanta Sofia);V Soria-Aledo (Hospital Universitario J. M. Morales Meseguer, Murcia);CJ Gomez (Hospital Universitario Joan XXIII, Tarragona);I Pascual-Miguelañez (Hospital universitario La Paz);M Muinelo (Hospital Universitario LucusAugusti);C Magadan Alvarez (Hospital Universitario Marques De Valdecilla);HJ Vargas-Pierola (Hospital Universitario Mutua Terrassa);M Vallve-Bernal (Hospital Universitario Nuestra Señora De Candelaria);JM Hidalgo-Rosas (Hospital Universitario Parc Tauli);JJ Arenal-Vera (Hospital Universitario Rio Hortega);F Sena-Ruiz (Hospital Universitario Son Espases);L Sanchez-Guillen (Hospital Universitario Y Politécnico La Fe);P Villarejo-Campos (Hospital Universitarios Ciudad Real);L Tallon-Aguilar (Hospital Virgen Del Rocío, Sevilla);A Garcea (Torrevieja Hospital). Supervising consultants(investigation;supervision;writing – review &;editing): United Kingdom: E Aly (Aberdeen Royal Infirmary);JM Bennett (Addenbrooke's Hospital);L Whittaker (Airedale General Hospital, Keighley);AL Gidwani (Altnagelvin Area Hospital);CK Byrnes (Antrim Area Hospital);SMF Saunders (Barnet Hospital);MH Shiwani (Barnsley District General Hospital);N Ashraf (Basildon University Hospital);AK Venkatasubramaniam (Basingstoke And North Hampshire Hospital);KE Bevan (Bedford Hospital);D Mcarthur (Birmingham Heartlands Hospital);AK Mustafa (Borders General Hospital, Melrose);JP Griffith (Bradford Royal Infirmary);JM Blazeby (Bristol Royal Infirmary);A Charalabopoulos (Broomfield Hospital);W Campbell (Causeway Hospital, Coleraine);G Reese (Charing Cross Hospital);OJ Warren (Chelsea And Westminster Hospital);M Peacock (Cheltenham General Hospital);D Menzies (Colchester General Hospital);D Jenner (Conquest Hospital, St Leonards On Sea);NJ Eardley (Countess Of Chester Hospital);S Yoong (Craigavon Area Hospital);M Abulafi (Croydon University Hospital);H Avalapati (Cumberland Infirmary, Carlisle);R Thompson (Daisy Hill Hospital, Newry);P Nastro (Darent Valley Hospital, Dartford);R Kochupapy (Derriford Hospital);D Beral (Doncaster Royal Infirmary);BM Stubbs (Dorset County Hospital, Dorchester);R McIntyre (Dr Gray's Hospital, Elgin);J Crozier (Forth Valley Royal Hospital, Larbert);PK Patel (Furness General Hospital, Barrow-In-Furness);V Pento (Glan Clwyd Hospital, Rhyl);WD Beasley (Glangwili General Hospital, Carmarthen);CSD Roxburgh (Glasgow Royal Infirmary);ST Hornby (Gloucestershire Royal Hospital);H Youssef (Good Hope District General Hospital);R Alexander (Great Western Hospital, Swindon);S Denley (Hairmyres Hospital);F Di Franco (Hinchingbrooke Hospital, Huntingdon);A Quddus (Homerton University Hospital);A Saha (Huddersfield Royal Infirmary);I Hunter (Hull Royal Infirmary);JAFHannay (Inverclyde Royal Hospital, Greenock);A Reddy (James Cook University Hospital, Middlesbrough);VR Velchuru (James Paget Hospital, Great Yarmouth);GEL Bond-Smith (John Radcliffe Hospital);Y Salama (Kettering General Hospital);A Bhargava (King George Hospital, Ilford);SP Panagiotopoulos (King's College Hospital);N Watson (King's Mill Hospital, Sutton In Ashfield);V Tudyka (Kingston Hospital);G Garcea (Leicester General Hospital);AP Boddy (Leicester Royal Infirmary);PG Dunning (Lincoln County Hospital);Geraint Lloyd (Lister Hospital, Stevenage);SV Gurjar (Luton &;Dunstable Hospital);CJ Smart (Macclesfield District General Hospital);J Hill (Manchester Royal Infirmary);B Andrews (Medway Maritime Hospital, Gillingham);A Singh (Milton Keynes University Hospital);F Ruzvidzo (Monklands Hospital, Airdrie);G Shingler (Morriston Hospital, Swansea);D Mahon (Musgrove Park Hospital, Taunton);S Elgaddal (New Cross Hospital, Wolverhampton);CJ Payne (Ninewells Hospital, Dundee);IA Shaikh (Norfolk And Norwich University Hospital);S Dalmia (North Manchester General Hospital);MS Nair (North Middlesex University Hospital);JG Finch (Northampton General Hospital, Northampton);KS Chapple (Northern General Hospital, Sheffield);S Bawa (Northumbria Specialist Emergency Care Hospital);J Watfah (Northwick Park Hospital, Harrow);CA Carden (Perth Royal Infirmary);R Makhija (Peterborough City Hospital);M Rao (Pilgrim Hospital, Boston);J Sarveswaran (Pinderfields Hospital);V Vijay (Princess Alexandra Hospital, Harlow);S Rekhraj (Princess Of Wales Hospital, Grimsby);T Singhal (Princess Royal University Hospital, Orpington);B Knight (Queen Alexandra Hospital, Portsmouth);TD Pinkney (Queen Elizabeth Hospital Birmingham);MN Siddiqui (Queen Elizabeth Hospital, Woolwich);JF Sebastian (Queen Elizabeth The Queen Mother Hospital);P Glen (Queen Elizabeth University Hospital, Glasgow);S Vakis (Queen's Hospital);H Ebied (Queen's Hospital, Romford);R Vohra (Queen's Medical Centre, Nottingham);R Rajaram (Rotherham District General Hospital);J Gray (Royal Alexandra Hospital, Paisley);D Mcgrath (Royal Berkshire Hospital, Reading);G Faulkner (Royal Bolton Hospital);S Gopalswamy (Royal Cornwall Hospital, Truro);JN Lund (Royal Derby Hospital);NJ Smart (Royal Devon &;Exeter Hospital);M Varcada (Royal Free Hospital);A Woodward (Royal Glamorgan Hospital, Ynysmaerdy);GL Williams (Royal Gwent Hospital, Newport);K Szentpali (Royal Hampshire County Hospital, Winchester);R Ravindran (Royal Infirmary Of Edinburgh);C Bronder (Royal Lancaster Infirmary);MA Thaha (Royal London Hospital);A Rate (Royal Oldham Hospital);V Daya Shetty (Royal Preston Hospital);VSR Rao (Royal Stoke University Hospital);MS Sajid (Royal Sussex County Hospital, Brighton);B Clements (Royal Victoria Hospital);RT Patel (Russells Hall Hospital);C Mason (Salford Royal);G Branagan (Salisbury District Hospital);A Torrance (Sandwell General Hospital, West Bromwich);K Maude (Scarborough General Hospital);G Kaur (Scunthorpe General Hospital);A Lyons (Southmead Hospital, Bristol);P Ainsworth (Southport And Formby District General Hospital);R Hagger (St George's Hospital, London);AZ Zadi (St Helier Hospital, Carshalton);SUMaslekar (St James' University Hospital);J Kinross (St Mary's Hospital, London);S Irukulla (St Peter's Hospital, Chertsey);W Hawkins (St Richard'S Hospital, Chichester);S Wheatstone (St Thomas' Hospital);T Magro (Stoke Mandeville Hospital, Aylesbury);STR Bailey (Tunbridge Wells Hospital, Pembury);G Marshall (Ulster Hospital, Dundonald);J Mccullough (University College Hospital);G Marangoni (University Hospital Coventry and Warwickshire);EL Leung (University Hospital Crosshouse, Kilmarnock);CM Borg (University Hospital Lewisham);S Gopinath (University Hospital Of North Tees);J Torkington (University Hospital Of Wales, Cardiff);J Kirkby-Bott (University Hospital Southampton);S Yalamarthi (Victoria Hospital, Kirkcaldy);S Mirza (Walsall Manor Hospital);M Brett (Warrington Hospital);S Ramcharan (Warwick Hospital);V Pandey (Watford General Hospital);B Thava (West Middlesex University Hospital);D Speake (Western General Hospital, Edinburgh);N Chandratreya (Weston General Hospital, Weston-Super-Mare);SM Andreani (Whipps Cross University Hospital);SJ Sahay (Whittington Hospital);B Aravind (William Harvey Hospital);M Downey (Wishaw General Hospital);D Nicol (Worcestershire Royal Hospital);P Whitehouse (Worthing Hospital);A Sharma (Wythenshawe Hospital, Manchester);N Francis (Yeovil District Hospital);P Chitsabesan (York Hospital);DJ Stewart (Ysbyty Wrexham Maelor Hospital);Italy: GG Norcia (Alghero OspedaleCivile);Cucinotta E;F Cianchi (Aou-Careggi - Florence);U FumagalliRomario (Asst SpedaliCivili di Brescia);L Taglietti (Asst Valle Camonica-Esine);P Capelli (Ausl Piacenza);G Garulli (Ausl Romagna - Ceccarini Hospital - Riccione);A Parisi (AziendaOspedaliera Santa Maria Terni);D Nitti (AziendaOspedalieraUniversitaria Di Padova);A Guglielmi (AziendaOspedalieraUniversitariaIntegrata Verona);A Alonzo (Borgomanero Hospital);IS Scandroglio (Busto Arsizio Hospital);F Roscio (Galmarini Hospital, Tradate);G Moretto (Hospital Pederzoli);L Ansaloni (Hpg XXIII Bergamo);A Pietrabissa (IrccsPoliclinico San Matteo - Pavia);D Foschi (L. Sacco University Hospital);N Vettoretto (Montichiari Hospital);G Ercolani (Morgagni-Pierantoni Hospital, Forlì);M Coppola (Nostra Signora Della Mercedes Hospital);E Colangelo (OspedaleCivileSpirito Santo di Pescara);E Morandi (Ospedale Di Rho (Milano Asst Rhodense);A Chessa (OspedaleS. Giovanni di Dio-Orbetello);N Tamini(Ospedale San Gerardo);P Niolu (Ospedale Santissima Annunziata Aou Sassari UocChirurgiaGenerale E D'Urgenza);M Pala (Po Santissima Trinità - Assl Cagliari);M Coletti (Policlinico Umberto I Università 'La Sapienza');A Pisanu (Policlinico Universitario Di Monserrato);A Nicolosi (Policlinico Universitario 'Duilio Casula');G Sammarco (Pugliese-Ciaccio' Hospital, Catanzaro / University;S Berti (S. Andrea Hospital Poll-Asl5);P Soliani (S. Maria DelleCroci Ravenna);V Tonini (S. Orsola-Malpighi);CL Bianchi (San Bartolomeo Hospital Sarzana);M Stella (San Carlo Borromeo Hospital, Milan);G Ceccarelli (San Donato Hospital, Arezzo);C De Nisco (San Francesco Hospital, Nuoro);S Scabini (San Martino Genova);G Castagnoli (San Matteo degliInfermi Hospital - Ausl Umbria 2 - Spoleto);P De Nardi (San Raffaele Hospital);F Borghi (Santa Croce And Carle Hospital, Cuneo);F Agresta (Santa Maria Regina degliAngeliAulss 5 Polesana- Adria Hospital);A Benevento (Sant'Antonio Abate Hospital, Gallarate);S Cantafio (Santo Stefano Hospital);FE D'Amico (Treviso Hospital - Ca Foncello);MC Cesari (U. S. L. Umbria 1 - Città Di Castello);M Rubbini (University of Ferrara);G Salamone (University of Palermo);G Chetta (V. Emanuele II, Bisceglie);F De Marchi (Vicenza Hospital);Portugal: MF Nora (Centro Hospitalar de Entre o Douro e VougaE. P. E. );HS Sousa (Centro Hospitalar De São João);CA Nascimento (Centro HospitalarLisboaOcidental);CAO Casimiro (Centro HospitalarTondela-Viseu);SD Costa (Centro Hospitalar Vila Nova De Gaia);MJ Rosa (Hospital Da Horta);NMD Carvalho (Hospital Garcia De Orta);JCF Correia (Hospital Pedro Hispano - Uls Matosinhos);AP Gomes (Hospital Prof. Dr. Fernando Fonseca);Republic of Ireland: AD Hill (Beaumont Hospital);TN Walsh (Connolly Hospital, Blanchardstown);MA Aremu (Letterkenny University Hospital);J Mulsow (Mater Misericordiae University Hospital);S El-Masry (Our Lady Of Lourdes Hospital);J Gillick (Our Lady's Children's Hospital, Dublin);J Garvin (Portiuncula Hospital);M Caldwell (Sligo University Hospital);B Mehigan (St James' Hospital, Dublin);DC Winter (St Vincent's University Hospital);CB Peirce (University Hospital Limerick);F Cooke (University Hospital Waterford);K Mealy (Wexford General Hospital);Spain: A Ruano (Alvaro Cunqueiro Hospital);G Ais (ComplejoAsistencial De Segovia);J Fueyo (ComplejoAsistencial Universitario De León);E Redondo (ComplejoAsistencial Universitario De Palencia);B Sainz (ComplejoHospitalario De Navarra);AE Parajó (ComplexoHospitalario Universitario De Ourense);A Landaluce-Olavarria (Galdacano);JC Bernal-Sprekelsen (General University Hospital Of Valencia);E Cordoba (H Clinico Universitario Zaragoza);JA Monzón-Abad (H. U. Miguel Servet. Zaragoza);C Cerdán-Santacruz (Hospital Arnau De Vilanova De Lleida);F Blanco (Hospital Clinico De Valladolid);T Veres (Hospital De Cerdanya);A MeleroAbellán (Hospital General de Villarrobledo);A Arroyo (Hospital General Universitario De Elche);M Ruiz-Marín (Hospital General Universitario Reina Sofía);P Menendez (Hospital Gutierrez Ortega);MC Bazán-Hinojo (Hospital Puerta Del Mar);JA Navas-Cuéllar (Hospital Punta De Europa);MI Ramos-Bernado (Hospital Sant Joan Despi, Moises Broggi);JA Lopez-Ruiz (Hospital Univ. Virgen Macarena);T Golda (Hospital Universitari de Bellvitge);D Julià (Hospital Universitari De Girona Doctor JosepTrueta);MM Cuadrado (Hospital Universitari Germans Trias I Pujol);E Espin-Basany (Hospital UniversitariVallD'Hebron);D Fernández-Martínez (Hospital Universitario Central De Asturias, Oviedo);AF Bravo-Gutiérrez (Hospital Universitario de Canarias);SA Gómez-Abril (Hospital Universitario Doctor Peset, Valencia);P Dujovne (Hospital Universitario Fundación Alcorcon, Madrid);J Martinez (Hospital Universitario Infanta Sofia);JL Aguayo (Hospital Universitario J. M. Morales Meseguer, Murcia);M Millan (Hospital Universitario Joan XXIII, Tarragona);M Alvarez-Gallego (Hospital universitario La Paz);M Muinelo-Lorenzo (Hospital Universitario LucusAugusti);JI Martin Parra (Hospital Universitario Marques De Valdecilla);E Muñoz-Muñoz (Hospital Universitario Mutua Terrassa);PE González De Chaves-Rodríguez (Hospital Universitario Nuestra Señora De Candelaria);G Cánovas-Moreno (Hospital Universitario Parc Tauli);M Rodriguez-Lopez (Hospital Universitario Rio Hortega);JJ Segura-Sampedro (Hospital Universitario Son Espases);A García-Granero (Hospital Universitario Y Politécnico La Fe);FJ Redondo-Calvo (Hospital Universitarios Ciudad Real);L Tallon-Aguilar (Hospital Virgen Del Rocío, Sevilla);A Garcea (Torrevieja Hospital). Collaborators (investigation;writing – review &;editing): V Quan;G Ramsay;P Mekhail;C Richards;M Ghazanfar;JM Wohlgemut (Aberdeen Royal Infirmary);S Dyson;D Thakur;L Sreedharan;C Swords;O Siaw;M Zelazek;R Woo;A Badran (Addenbrooke's Hospital);N Aruparayil;P Christopoulos;B Chambers (Airedale General Hospital;Keighley);N O'Neill;RH Long;RT Gray;P Mccaughey;MJ Lynch Wong;RS Mccain;HC Lennox-Warburton;C Moore;KM Manektella (Altnagelvin Area Hospital);IW Kamande;S Mcilwaine;S Rupani;DJ Simpson;J Wauchope;M Ng;L Christian;A Crone (Antrim Area Hospital);JB Haddow;R Sacks;S Nazarian;NRA Symons;A Lazzaro (Barnet Hospital);SD Patil;FA Dar;S Roomi (Barnsley District General Hospital);I Silva;JM Hodgson;C Ly;AT Misky;H Froud;H Patel (Basildon University Hospital);S Arunachalam;P Cay;RS Karwal;S Arunachalam;D Danquah-Boateng (Basingstoke And North Hampshire Hospital);BJM Berry;HD Esmail;CS Twum-Barima;H Maripi;D Bilku;MA McKelvie;K Miller;A Maina (Bedford Hospital);R Velho;R Hasan;R Clingan;SMH Jah;K Waite;A Jones (Birmingham Heartlands Hospital);S Buckley-Jones;L Lecky-Thompson;KL Connor (Borders General Hospital;Melrose);N Saghir;S Mansoor;D Mistry;R Brown;A Wong;S Gurung (Bradford Royal Infirmary);F Wensley;TA Fleming;RKL Griggs;A Kosti;S Haines;S Bedoya;A Beverstock;J Johnson (Bristol Royal Infirmary);M Elshaer;G Govind;O Niaz (Broomfield Hospital);DA Colvin;ARS Dyal (Causeway Hospital;Coleraine);E Tokidis;S Punj;A Leusink (Charing Cross Hospital);KTD Yeung;I Rudland;M Kelly;R Morgan;S Al-Musawi;C Lek (Chelsea And Westminster Hospital);A Gilbert;A Gosal;R Mahoney;I Parwaiz (Cheltenham General Hospital);TEM Morrison;MJ Mitchard;B Ribeiro;H Merai;EA Dean;S Khan (Colchester General Hospital);A Baginski;C Mann;W Foers;L Jones;B Woodward (Conquest Hospital;St Leonards On Sea);DM Mcwhirter;AT Thomas;TG Gilbert;LWWeatherburn;JP Pilkington;FC Cameron;TM Gilbert;CS Chean (Countess Of Chester Hospital);JM Clements;JD Clements;C Mccann;S Davidson;L Hackney;JS Clements (Craigavon Area Hospital);A Martin;G Hicks;DT Du (Croydon University Hospital);Z Shakoor;SK Yen;M Adnan;S Ranathunga;S Sana;YH Tay;MY Chin;M Gillespie (Cumberland Infirmary;Carlisle);AG Brown;U Campbell (Daisy Hill Hospital;Newry);N Assaf;M Chatzikonstantinou (Darent Valley Hospital;Dartford);B Mahendran, T Flack (Derriford Hospital);M Chowdhary;JM Lim;EGEMacinnes;E Whiteman;JA Shepherd;A Pedder (Doncaster Royal Infirmary);N Thavanesan;KL Siggens;CW Lai;V Morrison-Jones;Z Hayat (Dorset County Hospital;Dorchester);AS Dubois;I Nehikhare;C Macleod;HC Quinn (Dr Gray's Hospital;Elgin);A Brown;G Neagle;LK Palani-Velu (Forth Valley Royal Hospital;Larbert);SM Chok;FM Carrano;OA Abbassi;GA Divekar;S Halmer (Furness General Hospital;Barrow-In-Furness);LPS Yow;V Pento;RE Adams;PL Davies;SY Wong;R Amarasinghe;LE Tague;E Jones (Glan Clwyd Hospital;Rhyl);RW Radwan;A Martin;E Jones (Glangwili General Hospital;Carmarthen);NB Jamieson;J Singh;K Boza;SD Kelly;F Morrison;W Hei Chan (Glasgow Royal Infirmary);NS Blencowe;M Abdelrahman;EJ Wilson;OOAwokoya;SN Griffiths;EN Kirkham;AE Cotton;A Adimonye;PA Leighton (Gloucestershire Royal Hospital);KA Lee;A Abdelrahman;H Cartwright;Z Gates;M Miguras (Good Hope District General Hospital);ZA Zarka;K Khan;C Louw;T Grove;T Badenoch;J Mckeon (Great Western Hospital;Swindon);NA Mcdowall;CS Wood;RP Leitch (Hairmyres Hospital);P Sgardelis;MI Perera;D Nagarajan;Y Malam (Hinchingbrooke Hospital;Huntingdon);K Theodoropoulou;ML Venn;S Rajagopal;S Kaptanis;D Popova;O Olagbaiye;S Tayeh;S Rigby (Homerton University Hospital);DL Ashmore, MP Harris (Huddersfield Royal Infirmary);SE Whitehorn;KZ Ren;G Liaw;S Zhou;F White (Hull Royal Infirmary);AM Golder;CM Marshall;JH Mitchell;DJ Anderson (Inverclyde Royal Hospital;Greenock);V Kanakala;A Hollingsworth;KR Paramasevon;J Milward;S Ahmed (James Cook University Hospital;Middlesbrough);C Delimpalta;BF Fanibi;N Ferguson (James Paget Hospital;Great Yarmouth);EA Dickson;AV Shaw;OH Kay;F Dixon;S Morrish;R Dandy;P Fooks (John Radcliffe Hospital);P Sharma;N Islam;V Tabain;R Keegan;P Sarmah;J Ahel;T Alhammali (Kettering General Hospital);J Graveston;EJBalai;J Graveston;SM Shah;K Rothnie (King George Hospital;Ilford);GP Pankin;IE Eiben;NJ Jackson;M Dhar;D Nash (King's College Hospital);C Doyle;S Dharamavaram;M Seth;F Chowdhury (King's Mill Hospital;Sutton In Ashfield);M Rezacova;N Seneviratne;EJ Turner (Kingston Hospital);C Currow;E Issa;JD Isherwood (Leicester General Hospital);BM Hobson;H West;DH Lui (Leicester Royal Infirmary);GR Nana;V Rodger;N Ting;HK Brewer;D Photiou (Lincoln County Hospital);EZ Farrow;D Taze;S Lodhia;L Earnshaw;K Kumar;A Neale;J Bastianpillai;M Cipparrone;A Barrie (Lister Hospital;Stevenage);NS Taylor;Z Nash;L Anandan;K Tailor;Z Vinnicombe;S Krivan;R Kuo;A Giorga;H Habib (Luton &;Dunstable Hospital);K Malik, M Bogdan (Macclesfield District General Hospital);FP Mahon-Daly;MJ Athersmith;JA Strange;NP Griffiths;C Wheeler;L Summerfield;RA Khaw (Manchester Royal Infirmary);O Ashour;E Iosif;M Fadel;K Gopalakrishnan;N Orme;S Williams;M Rashid (Medway Maritime Hospital;Gillingham);A Sultana, N Patel (Milton Keynes University Hospital);SR Knight;R Pearson (Monklands Hospital;Airdrie);T Yasin;V Bevan;NG Mowbray;B Al-Sarireh (Morriston Hospital;Swansea);JB Olivier;M Brown;N Mohd;EE Howie;M Poudevigne;C Paget (Musgrove Park Hospital;Taunton);H Rallage;K Chui;F Fawzi;S Layman;E Okorocha;GM Jama (New Cross Hospital;Wolverhampton);P Orawiec;O Kouli;A Hassane;KD Clement;J Kilkenny;AA Devine (Ninewells Hospital;Dundee);M Laurenson;I Slezak;T Barker;EYL Lau;M Limbada;J O'Brien;J Weaver;T Barker (Norfolk And Norwich University Hospital);N Panda;S Hajibandeh;J Shah;MM Mansour;SN Malik;S Davis;F Trew;SK Bandyopadhyay;K Dart (North Manchester General Hospital);MJ Connor;S Guru-Naidu;R Callan;MK Nair (North Middlesex University Hospital);M Alani;E Sezen;S Salim;SE Fahmy (Northampton General Hospital;Northampton);J Shurlock;K Siddique;A Forouzanfar;R Brews (Northern General Hospital;Sheffield);WSNgu (Northumbria Specialist Emergency Care Hospital);A Acharya;A Jain;SO Adegbola;K Sahnan;PJ Tozer;J Warusavitarne (Northwick Park Hospital;Harrow);KM Emslie;O Collier-Wakefield;P Sivaloganathan;C Dobson;M Elseedawy;EM Vaughan (Perth Royal Infirmary);W Stupalkowska;L McNally;M Williams;FH Motiwala;S Choi;A Ahmad Asmadi;D Burnside;A Everden;S Suriyakumar;LSandu (Peterborough City Hospital);DA Kent;J Bowen;LFC Simmonds;P Long;A Khair (Pilgrim Hospital;Boston);A Malik;K Shah;L Phelan (Pinderfields Hospital);R Pierre;AA Dhari;A Hussein;M Hoff (Princess Alexandra Hospital;Harlow);MJ Karim;S Nickson;T Setshwaelo;A Chalk;MJ Parkola;A Harlinska (Princess Of Wales Hospital;Grimsby);TCW Chan;JG Dudek;R Rolph (Princess Royal University Hospital;Orpington);M Allen;H Pollard;R Ormiston;R Gormely;H Finlayson;G Ljungqvist (Queen Alexandra Hospital;Portsmouth);C Peponis;JC Glasbey;R Tyler;MMA Rahman;S Dhesi;MS Noor Mohamed;F Arshad;RJW Wilkin;AR Faris;TSooriyamoorthy (Queen Elizabeth Hospital Birmingham);VWS Kung;EL Springate;W Barnieh;AS Patel;ZA Siddiqui;IA Chishti;J Ayube-Brown (Queen Elizabeth Hospital;Woolwich);MR Rabie;L Blake;E Yardimci;S Nagendram (Queen Elizabeth The Queen Mother Hospital);JH Park;GI Neophytou;L Henderson;MMH Farhan-Alanie;CY Kong;R Ghazala (Queen Elizabeth University Hospital;Glasgow);N Lal;J Evans;N Hussain (Queen's Hospital);M Kabir;D Worku (Queen's Hospital;Romford);I Hraishawi;M D'Auria;M Cox;JA Bailey;N Muhibullah;F Yanni (Queen's Medical Centre;Nottingham);A Ang (Rotherham District General Hospital);M Orizu;R Stevenson;A Nair;C Murphy;O Mcgucken (Royal Alexandra Hospital;Paisley);E Gammeri;R Pandya;H Bowerman;G Lafaurie;GI Van Boxel;