Hospitalization of children with acute immune thrombocytopenic purpura – is it necessary?

OBJECTIVE:

To identify a target group of children with acute immune thrombocytopenic purpura (ITP) that may not require hospitalization for management.

METHODS:

A retrospective chart review was conducted of all children admitted over a two-year period to a tertiary care paediatric hospital with the diagnosis of acute ITP. Patients were classified according to typical and atypical presentations. Typical patients were defined as those aged between one and 10 years, with no hepatomegaly or significant splenomegaly and who had typical laboratory features for ITP. Patients who did not meet these criteria were categorized as atypical. Outcome measures included length of stay (LOS) in hospital; frequency of bone marrow aspiration (BMA); type of treatment; incidence of intracranial hemorrhage (ICH) or severe bleeding; and admission and discharge platelet counts.

RESULTS:

There were 74 patients hospitalized for a mean of 3.6 days. No patients suffered an ICH or bleeding requiring transfusion. Patients with typical presentations (42) were compared with patients with atypical presentations (32) and were not significantly different for clinically important outcomes such as admission and discharge platelet counts, serious complications or type of therapy. Typical patients had significantly fewer BMAs than did atypical patients – 22 of 42 (52%) versus 25 of 32 (78%) (P=0.02), and a shorter LOS – 3.1 (±0.9) days versus 4.2 (±1.8) days (P=0.01).

CONCLUSIONS:

Children presenting with ITP have a low incidence of bleeding complications and many of these patients can be managed as outpatients. A multicentre study is needed to properly delineate a low risk group suited for outpatient medical management.     

Pitfalls in diagnosis of non-Hodgkin-lymphoma of the pancreas

A 74 year-old woman was admitted because of upper abdominal pain radiating to the back. The patient was in good health prior to onset of symptoms. Both ultrasound and endoscopic ultrasound revealed a lesion of low echogenicity in the pancreatic head without indication of hepatic lesions, enlarged lymph nodes or vascular infiltration. An computed tomography (CT) did not show the lesion in the pancreas. Explorative laparotomy was performed. The biopsy specimen revealed a diffuse large cell Non-Hodgkin-Lymphoma. This case report illustrates, how simple ultrasound studies can detect lesions not seen in more expensive, complex, and time consuming imaging techniques like CT. The patient underwent a postoperative chemotherapy and is currently well.     

Emergency health and risk management in sub-saharan Africa: a lesson from the embassy bombings in Tanzania and Kenya

In 1998, terrorists simultaneously bombed United States Embassies in Dar es Salaam, Tanzania and Nairobi, Kenya. The local response to these bombings was unorganized and ad hoc, indicating the need for basic disaster preparedness and improvement of emergency management capabilities in both countries. In this context, risk and risk management are defined and are related to the health hazards affecting Tanzanians and Kenyans. In addition, the growing number of injuries in Tanzania is addressed and the relationship between risk management and injury is explored. Also, an emergency medicine-based strategy for injury control and prevention is proposed. Implications of implementing such a protocol in developing nations also are discussed.     

Clinical impact of MRI in acute wrist injuries. Indication and therapeutic consequences

PURPOSE: This prospective study was aimed at evaluating the clinical impact of magnetic resonance imaging (MRI) vs conventional radiographs in the early diagnosis of acute wrist fractures.The influence of MRI on the period of being unable to work was demonstrated. MATERIALS AND METHODS: MRI was performed within a mean of 6.6 days after initial radiographs in 54 patients (56 wrists) with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. MRI findings were read without knowledge of the initial radiographs. RESULTS: In 31 of 56 wrists MRI findings resulted in a change of diagnosis.There was a false positive diagnosis on plain radiographs in nearly one-half ( n=25) of the cases,whereas only six cases had false negative results. In 28 cases MRI allowed the detection of additional injuries of soft tissues. In 35 of 56 cases radiological follow-up was no longer necessary. In 22 of 54 patients the period of immobilization could be shortened or treatment discontinued ( n=18).The period of being unable to work was shortened in 16 of 54 patients, while in 7 of 54 patients this time span had to be prolonged for therapeutic reasons. In 31 of 54 patients MRI-based therapeutic consequences had no influence on the period of being unable to work. CONCLUSION: Our results show a high clinical impact of MRI in the detection of acute wrist fractures.Early MRI is able to reduce economic costs due to efficient therapeutic treatment and shortened periods of being unable to work.We recommend MRI immediately on the day of trauma in the presence of clinical suspicion and equivocal plain radiographs