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Antibiotics Are Not Equal to Appendectomy for Appendicitis

Keypoint: The incidence of peritonitis at 30 days was higher in the antibiotic group than in the surgery group; 68% of patients treated with antibiotics did not require appendectomy

Citation: Vons C, Barry C, Pautrat K, etal. Amoxicillinplus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, ran- domised controlled trial. Lancet. 2011;377(9777): 1573-1579.

Four recent randomized trials suggest that antibiotics alone can cure uncomplicated appendicitis or be used as first-line treatment. In this noninferiority trial, 239 adults with computed tomography- confirmed acute uncomplicated appendicitis at six academic hospitals in France were randomized to receive amoxicillin plus clavulanic acid (3 g daily for 8-15 days) for emergent appendectomy. Incidence of peritonitis at 30 days, the primary endpoint, was significantly higher in the antibiotic group than the surgery group (8% vs 2%). Overall, 68% of antibiotic-treated patients did not require appendectomy during 1 year of follow-up.
Published in JWatch Emerg Med. June 3, 2011 — John A. Marx, MD, FAAEM.

Diagnostic Imaging Is Common in Children

Key point: More than 40% of continuously enrolled children in a nationalhealthcare organizationunderwentatleastoneimaging procedure during a 3-year period.

Citation: Dorfman AL, Fazel R, Einstein AJ, et al. Use of med- ical imaging procedures with ionizing radiation in children: a population-based study. Arch Pediatr Adolesc Med. 2011;165(5): 458-464.
The rapid increase in diagnostic imaginghas raised concern about low-dose ionizing radiation exposure in children. Two new studies shed light on this problem.

In one study, investigators used claims data from a large national healthcare organization to determine how many diagnostic imaging procedures with ionizing radiation were performed in continuously enrolled children (age, <18 years) between 2005 and 2007. Among 355,000 children, 151,000 (43%) underwent 437,000 imaging procedures; 25% underwent two or more procedures, and 16% underwent three or more. Plain radiographs accounted for 85% of procedures, and computed tomography(CT) accounted for 12%. Overall, 8% of all children had at least one CT scan, and 3.5% had two or more.

Another study drew from a nationally representative annual survey of emergency department (ED) visits. Between 1995 and 2008, the proportion of ED visits by children (age, <18 years) that included CT scanning rose from 1.2% to 5.9%. This fivefold increase was noted in all age groups, from infant and toddler to adoles- cent. The most common complaints for which CT scanning was performed were head injury, headache, and abdominal pain.
Published in JWatch Pediatr Adolesc Med. June 15, 2011 — Howard Bauchner, MD, and Allan S. Brett, MD. n

Which Treatment Is Most Effective for Children With Acute Bronchiolitis?

Key point: Epinephrine (adrenaline) is the only treatment shown in clinical studies to reduce the rate o fadmission of children younger than 2 years who are treated in the emergency department fo racute bronchiolitis (numberneeded to treat = 15).

Citation: Hartling L, Fernandes RM, Bialy L, et al. Steroids and bronchodilators foracute bronchiolitis in the first two years of life: systemic review and meta-analysis. BMJ. 2011;342:d1714.
These authors combined the results of 48 studies with a total of 4897 children younger than 2 years with a first episode of acute  onset bronchiolitis, defined as acute wheezing and respiratory dis- tress associated with evidence of viral infection. The randomized controlled trials were identified by searching many databases, including the Cochrane Central Register of Controlled Trials. Two reviewers selected studies for inclusion and extracted the data. Only eight of the studies were of high quality.

In four studies of 920 children initially treated in an emergency department, only epinephrine decreased admissions at the time of treatment, with 1 admission prevented for every 15 children treated (95% CI, 10-45). Steroid treatment alone was no more effective in decreasing admissions in eight studies of 1762 patients, and other treatments were ineffective though they were studied in many fewer patients. Using a probabilistic approach to analysis, epinephrine with or without steroids had the highest prob- ability of success. No treatment was better than placebo in decreasing the length of stay in hospitalized children.

Four Clinical Decision Rules for Suspected PE Perform Equally Well

Key point: Clinicians can feel comfortable choosing any of these rules to evaluate pulmonary embolism.
Citation: Douma RA, Mos CM, Erkens PMG, etal. Performance of 4 clinicaldecisionrules inthediagnosticmanagementofacute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011;7(154):709-718.

Several clinical decision rules (CDRs) are available to guide management of patients with suspected pulmonary embolism (PE); these CDRs use elements of medical history and physical exam to designate the pretest probability of PE as “likely” or “unlikely.” However, choosing one rule over another can be problematic because the rules have not been compared directly.

Dutchresearchers prospectively enrolled 807 patients withsus- pected acute PE and evaluated them with D-dimer testing and four CDRs: Wells rule, simplified Wells rule, original revised Gene- va rule, and the simplified revised Geneva rule. Patients under- went computed tomography testing for PE if any CDR result was “PE-likely” or if D-dimer testing was positive. Patients with his- tories of PE were excluded.

During 3 months offollow-up, the overall prevalence of PE was 23%. CDR results were discordant in 29% of patients. The prevalence of PE in patients classified as “PE-unlikely” by CDR ranged from a low of 13% (simplified Wells rule) to a high of 17% (simplified revised Geneva rule). However, when combined with normal D-dimer results, all CDRs exhibited similar performance in excluding acute PE (negative predictive value ranged from 99.4%–99.5%).

Published in JWatch Gen Med. June 23, 2011 — Jamaluddin Moloo, MD, MPH.

First In-Depth Look at the E. coli O104:H4 Outbreak in Germany, 2011

Keypoint: Asofmid-June, more than 3000 cases had bee nreported, including 39 fatalities. The outbreak-associated strain produces Shigatoxinandalsohasenhancedadherencetointestinalepithe- lial cells.

Citations: Frank C, Werber D, Cramer JP, etal. Epidemic profile of Shiga-toxin–producing Escherichia coli O104:H4 outbreakin Germany—Preliminary report. NEngl JMed. 2011. [Epub ahead of print.]
Bielaszewska M, Mellmann A, Zhang W, etal. Characterisation of the Escherichia coli strain associated with an outbreak of haemolytic uraemic syndrome in Germany, 2011: a microbiological study. Lancet Infect Dis. 2011. [Epub ahead of print.] Pennington H. Escherichia coli O104, Germany 2011. Lancet In- fect Dis. 2011. [Epub ahead of print].

In May 2011, an outbreak of Escherichia coli O104:H4–associat- ed hemorrhagic diarrhea began in Germany. Now, two research groups provide some details.

A preliminary report describes the epidemiologic, clinical, and microbiological features of the outbreak. As of June 18, 2011, 3222 cases had been reported, including 39 fatal cases. Hemolytic uremic syndrome (HUS) developed in 810 (25%) of the patients. Among those with HUS, 89% were aged >17 years, and only 1% were aged <5 years; 68% were female. The interval from onset of diarrhea to onset of HUS was 5 days for the 79 patients with such data available.

Another study analyzed stool samples from 80 patients (including 67 with HUS) hospitalized in 17 German cities and characterized the outbreak-related isolates. All isolates were serotype O104:H4, fermented sorbitol, and belonged to sequence type (ST) 678, leading the authors to conclude that they were a single clone. All produced Shiga toxin 2, characteristic of enterohemorrhagic E. coli (such as E. coli O157). In addition, all isolates had the molecular characteristics associated with an aggregative pattern of adherence to intestinal epithelial cells.

The investigators compared the 2011 isolates with three E. coli O104 reference strains two from Germany and one from Korea. One of these reference strains (isolated in 2001 from a child with HUS in Germany) had a similar virulence pattern, with Shiga toxin 2 production and the enteroaggregative trait. The outbreak iso- lates have an extended-spectrum b-lactamase phenotype (ie, re- sistance to all penicillins and cephalosporins; susceptibility to carbapenems) that is absent in the 2001 isolate. They are resistant to sulfamethoxazole-trimethoprim but remain susceptible to flu- oroquinolones and aminoglycosides.

Published in JWatch Infect Dis. June 29, 2011 — Mary E. Wilson, MD, and Larry M. Baddour, MD.

Abstracts in Urgent Care: September, 2011