Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis

BACKGROUND

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment.

METHOD

Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment.

RESULTS

The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020).

CONCLUSION

AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov).

Predicting the level of job satisfaction based on hardiness and its components among nurses with tension headache

Nurses are the most significant part of human resources in a sanitary and health system. Job satisfaction results in the enhancement of organizational productivity, employee commitment to the organization and ensuring his/ her physical and mental health. The present research was conducted with the aim of predicting the level of job satisfaction based on hardiness and its components among the nurses with tension headache. The research method was correlational. The population consisted of all the nurses with tension headache who referred to the relevant specialists in Tehran. The sample size consisted of 50 individuals who were chosen by using the convenience sampling method and were measured and investigated by using the research tools of "Job Satisfaction Test" of Davis, Lofkvist and Weiss and "Personal Views Survey" of Kobasa. The data analysis was carried out by using the Pearson Correlation Coefficient and the Regression Analysis. The research findings demonstrated that the correlation coefficient obtained for "hardiness", "job satisfaction" was 0.506, and this coefficient was significant at the 0.01 level. Moreover, it was specified that the sense of commitment and challenge were stronger predictors for job satisfaction of nurses with tension headache among the components of hardiness, and, about 16% of the variance of "job satisfaction" could be explained by the two components (sense of commitment and challenge).

Consequences of stopping and restarting leptin in an adolescent with lipodystrophy

BACKGROUND/AIMS

Lipodystrophy encompasses a group of rare disorders characterized by deficiency of adipose tissue resulting in hypoleptinemia, and metabolic abnormalities including insulin resistance, diabetes, dyslipidemia, and nonalcoholic steatohepatitis. Leptin replacement effectively ameliorates these metabolic derangements. We report effects of leptin discontinuation and resumption in a child with acquired generalized lipodystrophy.

METHODS

Intermittent treatment with leptin with follow-up over 5 years.

RESULTS

Pretreatment metabolic abnormalities included insulin resistance, hypertriglyceridemia and steatohepatitis. Leptin was started at the age of 10 years. After 2 years, the family requested discontinuation of leptin due to lack of visible physical changes. Nine months later, worsened metabolic abnormalities and arrest of pubertal development were observed. Leptin was restarted, followed by improvements in metabolic parameters. Laboratory changes (before vs. 6 months after restarting leptin) were: fasting glucose from 232 to 85 mg/dl, insulin from 232 to 38.9 µU/ml, HbA(1c) from 7.5 to 4.8%, triglycerides from 622 to 96 mg/dl, ALT from 229 to 61 U/l, AST from 91 to 18 U/l, and urine protein:creatinine ratio from 5.4 to 0.3. Progression of puberty was observed 1 year after restarting leptin.

CONCLUSION

Initial leptin therapy likely prevented progression of metabolic abnormalities. Treatment discontinuation led to rapid metabolic decomposition and pubertal arrest. Reintroduction of leptin reversed metabolic abnormalities and allowed normal pubertal progression.