The Association Between C-Reactive Protein Levels and Pediatric Appendicitis Score and the Severity of Appendicitis in Children

BACKGROUND

Acute appendicitis is a common cause of abdominal pain leading to emergent abdominal surgery in children. C-reactive protein (CRP), an inflammatory marker typically elevated in acute appendicitis, and Pediatric Appendicitis Score (PAS), a clinical scoring system used for the diagnosis of appendicitis, have the potential to predict the severity of inflammation of the appendix. This may be useful in helping the physician make a treatment plan prior to surgery.

OBJECTIVE

The purpose of this study was to assess whether CRP value and PAS differ with the extent of inflammation of the appendix seen on histologic examination.

METHODS

This was a prospective observational study of patients diagnosed with acute appendicitis via computed tomography or ultrasound. Enrolled patients had CRP levels drawn, PAS calculated, and appendix pathology reviewed. Appendix pathology was categorized by the pathologist on the basis of the level of inflammation: simple, suppurative, gangrenous, and perforated.

RESULTS

One hundred sixty-three patients were enrolled. CRP levels and PAS were statistically different (p < 0.002) among the four pathology classifications. Patients with simple appendicitis (n = 3) had a mean CRP of 2.95 mg/L and PAS of 3.9, patients with suppurative appendicitis (n = 99) had a mean CRP of 26.89 mg/L and PAS of 6.5, patients with gangrenous appendicitis (n = 56) had a mean CRP of 91.11 mg/L and PAS of 7.5, and patients with perforated appendicitis (n = 6) had a mean CRP of 154.17 mg/L and PAS of 7. The results remained statistically significant (p < 0.002) after adjusting for age, race, and sex. When combined-PAS ≥ 8 and CRP level > 40 mg/L-the specificity of complicated appendicitis was 91.2% and positive predictive value was 72.7%.

CONCLUSIONS

Higher CRP levels and PAS were associated with increased histologic inflammation of the appendix. This study provides preliminary evidence that CRP and PAS could potentially assist in treatment decisions for appendicitis.

Ondansetron Safety Regarding Prolong QTc for Children with Head Trauma

BACKGROUND

There have been recent reports of increased QT interval after head trauma in concussed athletes and adult patients. Ondansetron, which is widely used in treatment of nausea and vomiting symptoms in head injuries, was issued a safety warning from the U.S. Food and Drug Administration regarding QT prolongation and risk of fatal dysrhythmias.

OBJECTIVE

The purpose of this study was to evaluate the safety of ondansetron regarding QT prolongation for patients experiencing nausea or vomiting after head trauma.

METHODS

Patients aged 1-20 years presenting to a pediatric emergency department with head trauma and who required a dose of ondansetron for nausea or vomiting were enrolled in the study. Patients received a baseline 12-lead electrocardiogram (ECG) prior to administration of either oral or IV ondansetron. A second post-ondansetron 12-lead ECG was performed after administration of ondansetron. All ECGs were reviewed and the QTc calculated manually by a board-certified pediatric cardiologist.

RESULTS

Forty-two patients met enrollment criteria. Five patients received IV ondansetron and 37 received oral ondansetron. Mean QTc pre ondansetron was 387.5 ms and mean QTc post ondansetron was 400.9 ms (p = 0.120). We found no statistically significant difference in other ECG parameters pre and post ondansetron.

CONCLUSIONS

Ondansetron is safe in regard to QTc prolongation in patients with head trauma. Based on this research, ondansetron should continue to be used for the treatment of nausea and vomiting in emergency department patients who present with head injury.

Frontline STI Screening Starts with Primary Care

In this supplement to Family Practice, Heather M. Territo, MD, and Gale R. Burstein, MD, MPH discuss how primary care physicians play an essential role in screening for STIs in young patients.

Trichomonas Infection Rates in Males Presenting to the Emergency Department for Sexually Transmitted Infections

BACKGROUND

Trichomonas vaginalis (TV) is one of the most common sexually transmitted infections (STIs). Overall prevalence is reported to be 3.1%, with rates approaching 12.9-14.4% in high-risk female populations. Although there is a plethora of data on TV in the female population, the corresponding data for the male population are limited.

OBJECTIVE

Our aim was to determine the infection rate of TV in male patients seeking care for STIs in the emergency department (ED) and determine the symptoms associated with TV infection in male patients.

METHODS

We conducted a retrospective study of male patients aged 13 years or older who presented to the ED for STI evaluation. Male patients included had nucleic acid amplification test (NAAT) TV testing as part of standard STI evaluation.

RESULTS

Of the 2137 male patients included, 95 (4.4%) were positive for TV. Male patients who tested positive were significantly older (mean age 38.9 years vs. 30.7 years for male patients who tested negative; p < 0.05). Black male patients were more likely than White male patients to be positive for TV (6.3% prevalence vs. 1.8%; p < 0.05). TV-positive male patients were more likely to have discharge, specifically clear penile discharge, on examination (p < 0.05), and were less likely to have testicular pain or testicular tenderness (p < 0.05). Higher rates of TV were seen in an urban (4.9%) compared with suburban ED (1.6%; p < 0.05).

CONCLUSIONS

Rates of TV in male patients who receive STI testing in the ED are similar to rates published previously for female patients. We found higher rates among older and African-American male patients. TV among male patients is prevalent and testing should continue when evaluating for STIs.

A New Strategy for Trichomonas Testing Female Adolescents in the Emergency Department

STUDY OBJECTIVE

Sensitive trichomonas diagnostic testing has become available, including nucleic acid amplification tests (NAATs) and a rapid antigen test. The study purpose was to determine if adding sensitive trichomonas testing to routine female sexually transmitted infection (STI) evaluations would increase trichomonas identification and treatment.

DESIGN

Two study time periods. Study time 1 (T1) was used for a retrospective review. Study time 2 (T2) was used for a prospective study.

SETTING

Emergency Department.

PARTICIPANTS

Symptomatic female patients aged 13-20 years (N = 447).

INTERVENTIONS

Implementation of routing trichomonas testing in the Emergency Department during T2.

MAIN OUTCOME MEASURES

Trichomonas diagnosis and treatment rates were compared during T1 and T2.

RESULTS

During T1 31 of 234 of eligible patients (13%) were trichomonas-tested. Laboratory-confirmed trichomonas was identified in 3 of 234 (1.3%). During T2, 212 of 213 of eligible patients (99.5%) were trichomonas-tested; 39 of 212 tested trichomonas-positive (18.4%); 29 of 212 tested rapid trichomonas antigen test-positive (13.6%; P < .001), and 33 of 188 tested trichomonas NAAT-positive (15.5%; P < .001). Trichomonas treatment was given to 3 of 3 laboratory-confirmed trichomonas cases during T1 (100%) compared with 37 of 39 during T2 (95%; P = .688). During T1, 14 of 17 women who received trichomonas treatment (82.4%) did not have a laboratory-confirmed trichomonas diagnosis and during T2 13 of 52 women without a laboratory-confirmed trichomonas diagnosis (25%) were treated for trichomonas (P < .001). Rapid trichomonas antigen tests and trichomonas NAATs were concordant in 178 of 188 patients (94.6%).

CONCLUSION

Incorporating trichomonas rapid antigen tests and NAATs into routine female adolescent STI testing significantly increased the number of laboratory-confirmed adolescent trichomonas diagnosis and treatment and are useful Emergency Department STI screening tools.