Is procalcitonin able to help in pediatric appendicitis diagnosis?

BACKGROUND: Appendicitis clinical diagnosis in children is difficult and the acute inflammatory markers hyperleucocytis and CRP do not contribute to it. OBJECTIVE: To study the predictive value of procalcitonin (PCT) and to assess variations of its serum level according to inflammatory lesions in paediatric appendicitis. PATIENTS AND METHOD: Among 101 children aged two and 15, hospitalized for painful abdominal syndromes, 70 underwent operation for acute appendicitis and appendiceal peritonitis, 31 had no operation. PCT was evaluated in all children, normal serum concentration was <0,5 microg/L. Every appendicectomy part has been examined through histological analysis to confirm the diagnosis and the histological lesions have been classified into three categories according to their severity. RESULTS: Out of 70 appendix analysed at histology, 68 (97%) were healthy and 2 (3%)were unhealthy. Among the 68 cases of healthy appendix, 19 had a PCT higher than 0,5 microg/L and among 33 cases of unhealthy appendix 4 had a PCT higher than 0,5 microg/L. The PCT mean of healthy children was not significantly different from unhealthy appendix population, appendicitis prevalence was 0,67, PCT sensitivity 28%: IC 95% [18-40], specificity 88%: IC 95% [72-97], positive predictive value 83%: IC 95% [61-95], and negative predictive value 37%: IC 95% [26-49]. PCT mean increases with the severity of inflammatory lesions of the appendix (P=0,0051). CONCLUSION: PCT has not a good predictive value in acute paediatric appendicitis but remains a good indicator of severity in paediatric appendicitis.     

Can computed tomography scan be performed effectively in the diagnosis of acute appendicitis without the added morbidity of rectal contrast?

The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. We performed a retrospective review of radiology, operative, and pathology reports of consecutive patients undergoing appendectomy or CT examination for appendicitis during 2006. CT scans were performed without rectal contrast. The accuracy of each type of inpatient CT examination and negative appendectomy rates were determined. Two hundred and thirty-eight patients underwent appendectomy. One hundred and thirty-four appendectomy patients (56%) received a preoperative CT scan. The negative appendectomy rates were 6.3 per cent overall, 8.7 per cent without CT examination and 4.5 per cent with CT (P = 0.3). Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning.     

Computerized tomography in the workup of pediatric appendicitis: why are children scanned?

Physicians increasingly use computerized tomography (CT) for the evaluation of suspected acute appendicitis (AA) in children despite increasing awareness of the potential dangers of CT-associated radiation exposure. Many studies demonstrate the value of CT in the diagnosis of AA, but none have determined what factors influence the decision to perform a CT. We investigated factors associated with the use of CT during initial workup of children who subsequently underwent appendectomy. This is a retrospective review of all patients aged 0 to 17 years who underwent appendectomy for AA by pediatric surgeons over 11 years. Both univariate and multivariable logistic regression models were created to predict use of CT. A total of 546 children underwent appendectomy for AA, of which 293 (53%) underwent CT. In univariate analysis, seven variables were significantly associated with the use of CT: female gender, Hispanic ethnicity, initial presentation to referring hospitals, lower Alvarado scores, delays from onset of symptoms to hospital presentation, migration, and rebound tenderness. In multivariable analysis, four variables significantly independently predicted the use of CT: initial presentation to a referring hospital [odds ratio (OR) 3.50), female gender (OR 1.49), increased latency from symptom onset to presentation (OR 1.34), and the presence of rebound tenderness (OR 0.23), which had a protective effect; the overall model was statistically significant (P < 0.0001). This model is the first to define variables that significantly predict CT utilization in the pediatric population. Continued investigation will be necessary to develop effective algorithms for judicious use of CT for suspected AA.     

Is computed tomography necessary to determine liver injury in pediatric trauma patients with negative ultrasonography?

Purpose

Abdominal trauma is the third most common cause of all trauma-related deaths in children. Liver injury is the second most common, but the most fatal injury associated with abdomen trauma. Because the liver enzymes have high sensitivity and specificity, the use of tomography has been discussed for accurate diagnosis of liver injury.

Methods

Our study was based on retrospective analyses of hemodynamically stabil patients under the age of 18 who were admitted to the emergency department with blunt abdominal trauma.

Results

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly higher as a result of liver injury. In the patients whose AST and ALT levels were lower than 40 IU/L, no liver injury was observed in the contrast-enhanced computed tomography (CT). No liver injury was detected in the patients with AST levels lower than 100 IU/L. Liver injury was detected with contrast-enhanced CT in only one patient whose ALT level was lower than 100 IU/L, but ultrasonography initially detected liver injury in this patient.

Conclusions

According to our findings, abdominal CT may not be necessary to detect liver injury if the patient has ALT and AST levels below 100 IU/L with a negative abdominal USG at admission and during follow-up.     

Suspected acute appendicitis: is ultrasonography or computed tomography the preferred imaging technique?

OBJECTIVE: To compare the sensitivity and specificity of unenhanced spiral computed tomography (CT) and ultrasonography (US) in patients with suspected acute appendicitis. DESIGN: Prospective study. SETTING: University hospital, Germany. SUBJECTS: 120 consecutive patients with acute appendicitis as a differential diagnosis, whose clinical findings were not enough to make operation essential, but were too severe to send home. INTERVENTIONS: CT and US of the appendix. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive value. RESULTS: The results were correlated with surgical and histopathological findings at appendicectomy or clinical follow-up. 93 patients had acute appendicitis, 27 patients did not. The sensitivity of CT was 95% and of US 87%. The corresponding specificities were 89% and 74%, positive predictive values 97% and 92%, negative predictive values 83% and 63%. In the 27 patients who did not have acute appendicitis, the correct diagnosis was established with CT in 14 patients and with US in eight. CONCLUSION: CT is more sensitive and specific than US in patients suspected of having acute appendicitis, but in whom the presentation is equivocal. The use of unenhanced spiral CT led to a significant improvement in the accuracy of preoperative diagnosis and a lower negative appendicectomy rate.     

Are there any metastases to the chest in non-muscle-invasive bladder cancer patients on follow-up computed tomography?

Purpose

The purpose of the study was to retrospectively determine whether there are metastases to the chest in patients with primary non-muscle-invasive urothelial carcinoma in the bladder on the follow-up computed tomography (CT).

Methods

We analyzed 328 patients with follow-up chest CT for urothelial carcinoma of the bladder diagnosed between January 2004 and September 2013. We divided patients into four groups: Ta (n?=?74), T1 (n?=?78), carcinoma in situ (CIS, n?=?25), and ≥?T2 (n?=?151). We used the chest CT to determine whether there were positive findings of metastasis. Univariate and multivariate analyses were achieved using categories of T stage, histological grade, multifocal lesions, and recurrence.

Results

On univariate analysis, there were significant differences on T stage (p?<?0.001) and histological grade (p?=?0.001), and there was no significant difference on multifocal lesions (p?=?0.11) and recurrence (p?=?0.34). Positive findings of metastases were observed in 1.4% (1/74) of the Ta patients, 0% (0/78) of the T1 patients, 8.0% (2/25) of the patients with carcinoma in situ (CIS), and 27.2% (41/151) of the ≥?T2 patients (p?<?0.001). On multivariate analysis, T staging was independent variable for positive findings of metastasis (Odds ratio; 2.84, 95% Confidence Interval; 1.65–4.89). In contrast, histological grade, multifocal lesions, and recurrence were not independent variables.

Conclusions

T stage would affect to metastasis to the chest. It might be appropriate to omit chest CT in patients with Ta or T1 without upstaging in the course of follow-up. We may suggest that the follow-up chest CT in patients with CIS.

     

Does adding computed tomography change the diagnosis and treatment of Tillaux and triplane pediatric ankle fractures?

Computed tomography (CT) has been deemed a necessary part of management for Tillaux and triplane pediatric ankle fractures. However, no previously published study has attempted to quantify its usefulness in changing management. Six third-party, blinded orthopedic surgeons (F.A.L., E.N.K., D.M.P., K.J.K., D.S.F., K.A.E.) were randomly assigned to evaluate 24 pediatric Tillaux or triplane fractures with plain radiographs; after 6 months, they were again randomly assigned to evaluate the 24 radiographs plus CT scans, totaling 144 third-party, blinded evaluations. Intra- and interobserver agreements were assessed via correlation coefficient analysis. Evaluation of CT scans changed the original diagnosis of fracture type from Tillaux to triplane fracture in 7 (4.9%) of 144 evaluations. Inter- and intraobserver agreements regarding primary treatment plans did not significantly differ between radiographs and radiographs plus CT scans (0.5 vs 0.4, respectively; P>.05). The addition of CT did not significantly change the impression of the amount of displacement per case. By adding CT, more patients who were assigned nonoperative management were reassigned to operative treatment (P=.033). Adding CT, although it may influence the decision to operate on Tillaux and triplane fractures, may not be as useful as previously thought.     

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

Background

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

Materials and methods

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n = 26) comprised patients who had their fibula fixed while Group II (n = 34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

Results

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

Conclusion

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.     

Computed tomography and ultrasonography in the diagnosis of appendicitis: when are they indicated?

HYPOTHESIS: Relative merits and indications exist for ultrasonography (US) and computed tomography (CT) in the diagnosis of appendicitis. DESIGN: Prospective study. SETTING: General community and tertiary care hospital. METHODS: Ninety-nine patients (50 males and 49 females) were studied. Following consent, the initial disposition was recorded, designating the patient for operation, observation, or discharge from the hospital. Each patient was studied by CT and US. Studies were independently evaluated by 2 radiologists, and the results were designated as positive, negative, or equivocal. The surgeon reevaluated patients before and after learning the results of US and CT, recording whether the CT scan, US, or reexamination influenced the final disposition. RESULTS: Fifty patients had appendicitis; 6 appendixes were perforated. The initial clinical impression called for 44 operations, 49 observations, and 6 discharges. Thirty-four patients had their treatment plan changed from the initial disposition. Ultrasonography did not affect the initial impression. In contrast, 18 patients were rediagnosed solely on CT scan findings. Seven patients were rediagnosed by reexamination. Of 44 patients initially designated for operation, the CT scan and reexamination spared 6 females from surgery; the negative appendectomy rate potentially decreased from 50% to 17% (P =.03). The CT scan, US, or reexamination failed to spare 2 males from exploration with negative results. Of the 49 patients initially designated for observation, 23 were rediagnosed after reevaluation, 13 were discharged from the hospital, and 10 underwent expedient operation. One patient was spared from inappropriate discharge from the hospital. The reliability of the CT scan was good, with high sensitivities and specificities. Equivocal scan results lowered the diagnostic value. CONCLUSIONS: Selective use of a CT scan with a second examination can improve the diagnostic accuracy and management of suspected cases of appendicitis by (a) reducing the negative appendectomy rate in females, (b) moving patients from observation to earlier operation or discharge from the hospital, and (c) preventing inappropriate discharge of patients with appendicitis.     

To bridge or not to bridge?

Objective

Ventricular assist devices (VAD) are an important therapy that saves the lives of candidates a waiting heart transplantation (HTx). However, there are questions about posttransplantation effects of VADs.

Methods

Seventy-four patients with end-stage heart failure who underwent HTx in our clinic between February 2007 and July 2011 were divided into two groups; a bridge cohort (n = 28) and a nonbridge group comprising 46 who underwent HTx without mechanical circulatory support. There mean ages were 39.89 ± 15.66 and 38.33 ± 16.23 years respectively. Significantly more patients in the bridge group, were man displayed anemia, were treated with anticoagulation therapy, and underwent a resternotomy. In the nonbridge group, more patients needed preoperative inotropic support.

Results

Multiple logistic regression analysis revealed preoperative renal failure (P = .007, odds ratio [OR] 27) and inotropic support (P = .006, OR: 10,222) as well as longer cardiopulmonary bypasses (≥130 minutes, P = .001, OR: 11,24) to be risk factors for in-hospital mortality, which was 15.2% in nonbridge and 10.7% in bridge subjects, P = .733). Major adverse events, such as renal failure, pulmonary failure, right ventricular failure, neurological event, and reoperation due to bleeding, shown similar incidences between the groups. The amount of blood transfusion was significantly higher in the bridge group (2.34 U versus 3.56 U, P = .037). The preoperative incidence of human leukocyte antigen sensitization (panel reactive antibody ≥ 10%) and grade 2R were rejection episodes in the early period were similar.

Conclusion

Early posttransplant results were not adversely or beneficially influenced by the use of VADs. Similar to other types of cardiac surgery, a patients preoperative condition seemed to be the major factor affecting mortality.