Diagnostic accuracy of combining C-Reactive protein and Alvarado Score among 2-to-20-year-old patients with acute appendicitis suspected presenting to Emergency Departments

OBJECTIVE

Main objective was whether the combination of C-Reactive Protein (CRP) and Alvarado Score (AS) increase the diagnosis accuracy of AS among 2-to-20-year-old patients with suspected acute appendicitis presenting to Emergency Departments.

METHODS

This is a secondary analysis of prospective cohort study consecutively including all patients from 2 to 20 years of age attended for suspected acute appendicitis in 4 Spanish Emergency Departments during 6-month period. We collected demographic, clinical, analytic and radiographic, and surgical data. AS categories were retrospectively calculated as low (0-4 points), intermediate (5-6 points) or high (7-10 points). The cut-off levels were >0.5 mg/dl for CRP. The outcome was diagnosis of acute appendicitis within 14 days of the index visit.

RESULTS

A total of 331 patients with suspected of acute appendicitis (mean age 11.8 (SD 3.8) years; 52.9% males) were recruited. According to AS, 108 (32.6%) were at low risk, 76 at (23.0%) intermediate risk and 147 (44.4%) at high risk of acute appendicitis. One hundred and sixteen (35.0%) cases had confirmed histopathological diagnosis of acute appendicitis. The AUCs of ROC were 0.76 (0.70-0.81) for AS and 0.79 (95% CI 0.75-0.84) for CRP-AS being the difference statistically significant (p=0.003). The CRP for diagnosis acute appendicitis in low risk AS group had negative predictive value of 95.8% (95%CI 87.3-98.9) and likelihood ratio negative of 0.4 (95%CI 0.2-1.0)..

CONCLUSIONS

CRP-AS has shown to increase the diagnostic accuracy of AS for acute appendicitis. This approach may be useful to rule out the diagnosis of acute appendicitis in paediatric patients attended for abdominal pain suggestive of acute appendicitis.

Outcomes and infectious etiologies of febrile neutropenia in non-immunocompromised children who present in an emergency department

There are no unified protocols governing the management of healthy children with febrile neutropenia in the emergency department (ED). Conservative management is the norm, with admission and empirical broad-spectrum antibiotics prescribed, although viral infections are considered the most frequent etiology. The aim of this study was to describe the clinical outcomes and identified etiologies of unsuspected neutropenia in febrile immunocompetent children assessed in the ED. This was a retrospective study: well-appearing healthy children <18 years old with febrile moderate [absolute neutrophil count (ANC) 500-999 neutrophils ×10(9)/l] or severe (ANC <500 neutrophils ×10(9)/l) neutropenia diagnosed in ED between 2005 and 2013 were included. Patients newly diagnosed with hematologic or oncologic disease were excluded. We included 190 patients: 158 (83.2 %) with moderate and 32(16.8 %) with severe neutropenia. One hundred and one (53.2 %) were admitted; 48(47.5 %) with broad-spectrum antibiotics. The median length of stay was 3 days (IQR 3-5) and the median duration of neutropenia was 6 days (IQR 3-12). An infectious agent was identified in 23(12.1 %); 21 (91.3 %) were viruses. Four (2.1 %) children had a serious bacterial infection (SBI): urinary tract infection and lobar pneumonia (two cases each). All blood cultures performed (144; 75.8 %) were negative. Over the 1-year follow-up, one or several blood tests were performed on 167 patients (87.9 %); two (1.2 %) were diagnosed with autoimmune chronic neutropenia. Previously healthy children with moderate or severe febrile neutropenia have a low risk of SBI and a favorable clinical outcome. Less aggressive management could be carried out in most of them. Although chronic hematological diseases are infrequently diagnosed, serial ANC are necessary to detect them.

Do retinal haemorrhages occur in infants with convulsions?

AIM

To determine the prevalence of retinal haemorrhages in infants presenting with convulsions and admitted to hospital, and to consider whether this finding indicates shaken baby syndrome.

METHODS

Prospective study of children aged 15 days to 2 years admitted with a diagnosis of first convulsion over a 2-year period (May 2004-May 2006). All infants were examined by an experienced ophthalmologist using indirect ophthalmoscopy within 72 h of admission.

RESULTS

182 of 389 children seen in the accident and emergency department were admitted and two were found to have retinal haemorrhages. Both children were eventually diagnosed as being abused.

CONCLUSIONS

Convulsions alone are unlikely to cause retinal haemorrhages in children under 2 years of age.

Late-onset form of beta-electron transfer flavoprotein deficiency

Multiple acyl-CoA-dehydrogenase deficiency (MADD) or glutaric aciduria type II (GAII) are a group of metabolic disorders due to deficiency of either electron transfer flavoprotein (ETF) or electron transfer flavoprotein ubiquinone oxidoreductase (ETF-QO). We report the clinical features and biochemical and molecular genetic analyses of a patient with a mild late-onset form of GAII due to beta-ETF deficiency. Biochemical data showed an abnormal urine organic acid profile, low levels of free carnitine, increased levels of C(10:1n-6), and C(14:1n-9) in plasma, and decreased oxidation of [9,10-3H]palmitate and [9,10-3H]myristate in fibroblasts, suggesting MAD deficiency. In agreement with these findings, mutational analysis of the ETF/ETFDH genes demonstrated an ETFB missense mutation 124T>C in exon 2 leading to replacement of cysteine-42 with arginine (C42R), and a 604_606AAG deletion in exon 6 in the ETFB gene resulting in the deletion of lysine-202 (K202del). The present report delineates further the phenotype of mild beta-ETF deficiency and illustrates that the differential diagnosis of GAII is readily achieved by mutational analysis.