Allergy, Article

Acute appendicitis: emergency medicine physician and surgeon clinical judgment vs abdominal computed tomographic scan

(Table 1). Indeed, activating mutations were recently found in c-kit, which codes for KIT, the receptor for stem cell factor, which is essential for mast cell development, proliferation, survival, adhesion, and homing [13]. We postulate that these events result in hyperresponsive mast cell phenotype with increased release of mast cell tryptase and other Inflammatory mediators that are able to induce Kounis syndrome and differentiate mast cell content. This could also explain why few patients develop chest pain with/or electrocardiographic changes during allergic, hyper- sensitivity, anaphylactic, or anaphylactoid episodes. We believe that further studies are necessary to clarify the important role of mast cells in endogenous thrombolysis and coagulation cascade. We agree with the authors that, in any case of anaphylaxis, coagulation assessment should always be performed.

Nicholas G. Kounis MD, PhD Grigorios Tsigkas MD George Almpanis MD Sophia N. Kouni BSc, MSc George N. Kounis MD, MSc Andreas Mazarakis MD, PhD Department of Cardiology

University of Patras Medical School

Patras, Greece E-mail address: [email protected]

doi:10.1016/j.ajem.2011.06.002

References

  1. Lombardini C, Helia RE, Boehlen F, Merlani P. “Heparinization” and hyperfibrinogenolysis by wasp sting. Am J Emerg Med 2009;27(1176): e1-3.
  2. Kounis NG. Kounis syndrome (Allergic angina and allergic myocardial infarction: a natural paradigm? Int J Cardiol 2006;110:7-14.
  3. Soulat JM, Bouju P, Oxeda C, Amiot JF. Anaphylactoid shock due to metabisulfites during caesarean section under peridural anesthesia. Cah Anesthesiol 1991;39:257-9.
  4. Ameratunga R, Webster M, Patel H. Unstable angina following anaphylaxis. Postgrad Med J 2008;84:659-61.
  5. Hasegawa S, Pawankar R, Suzuki K, Nakahata T, Furukawa S, Okumura K, et al. Functional expression of the high affinity receptor for IgE (FcepsilonRI) in human platelets and its intracellular expression in human megakaryocytes. Blood 1999;93:2543-51.
  6. Mehta SR, Yusuf S. Short- and long-term oral Antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention. J Am Coll Cardiol 2003;41(4 Suppl S):79S-88S.
  7. Schwartz LB, Badford TR, Littman BH, Wintroub BU. The fibrinogenolytic activity of purified tryptase from human lung mast cells. J Immunol 1985;135:2762-7.
  8. Stack MS, Johnson DA. Human mast cell tryptase activates single chain urinary- type plasminogen activator (pro-urokinase). J Biol Chem 1994;269:9416-9.
  9. Pejler G, Karlstrom A. Thrombin is inactivated by mast cell secretory granule chymase. J Biol Chem 1993;268:11817-22.
  10. Sakai K, Ren S, Schwartz LB. A novel heparin-dependent processing pathway for human tryptase. Autocatalysis followed by activation with dipeptidyl peptidase I. J Clin Invest 1996;97:895-6.
  11. Stein PL, van-Zonneveld AJ, Pannekoek H, Strickland S. Structural domains of human tissue type plasminogen activator that confer stimulation by heparin. J Biol Chem 1989;264:15441-4.
  12. Sillaber C, Baghestanian M, Bevec D, Willheim M, Agis H, Kapiotis S, et al. The mast cell as site of tissue type plasminogen activator production and fibrinolysis. J Immunol 1999;162:1032-41.
  13. Metcalfe DD, Schwartz LB. Assessing anaphylactic risk? Consider mast cell clonality. J Allergy Clin Immunol 2009;123:687-8.

Acute appendicitis: emergency medicine physician and surgeon clinical judgment vs Abdominal computed tomography scan

To the Editor,

We read, with great interest, the article by Jo et al [1], “The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis,” which states that, in patients with Right lower quadrant abdominal pain who have already been evaluated by an emergency medicine resident, consultation evaluation by a surgical resident does not appear to improve clinical diagnostic accuracy, and routine performance of computed tomography (CT) before Surgical consultation should be considered for these patients [1]. Although we agree with the authors that CT scanning is a useful option for detection or ruling out of acute appendicitis, in patients who have typical findings in history and physical examination, routine CT is not a necessary option, and early consultation with surgical resident will reduce the preoper- ative time and also avoids the patient from radiation exposure and cost of unnecessary CT scan. Indeed, we want to emphasize that even the best imaging modalities can never replace the clinical judgment of an experienced surgeon or emergency medicine physician.

Hamed Ghoddusi Johari MD Trauma Research Center General Surgery Department

Shiraz University of Medical Science

Shiraz, Iran E-mail address: [email protected]

Gholam Reza Mohseni MD

Anesthesiology Department Kermanshah University of Medical Science, Iran

Shima Eskandari MD

Trauma Research Center Shiraz University of Medical Sciences

Shiraz, Iran

doi:10.1016/j.ajem.2011.06.010

Reference

  1. Jo YH, Kim K, Rhee JE, Kim TY, Lee JH, Kang SB, et al. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010;28(7):766-70.

Acute appendicitis: emergency medicine physician and surgeon clinical judgment vs abdominal computed tomographic scan?

To the Editor,

I agree with the authors that the best imaging modalities can never replace the clinical judgment of an experienced surgeon or emergency medicine physician, but it might be “in general” comment. Another study also showed that, even in clinically evident appendicitis, computed tomog- raphy (CT) has the potential to reduce negative appen- dectomies [1]. In that study, the clinically evident appendicitis was defined by emergency medicine physi- cian. Summing up with the results of the study entitled “The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis,” it is not easy to say that CT is not a necessary option in patients with typical findings in history and physical examination [2]. I would not say that CT is a mandatory in all adults with suspected appendicitis. The policy could depend on many factors such as local radiologists and surgeon’s concepts about radiation hazard (balance between radiation hazard and useless operation or delayed diagnosis complicated by abscess without CT), 24/7 availability of ultrasonography by experienced radiologist, individual institutions, and nations.

Kyuseok Kim MD

Department of Emergency Medicine Seoul National University, Bundang Hospital 300 Gumi-dong, Bundang-gu, Sungnam-si Gyeonggi-do, 463-707, South Korea

E-mail address: [email protected] doi:10.1016/j.ajem.2011.06.007

References

  1. Kim K, Rhee JE, Lee CC, et al. Impact of helical computed tomo- graphy in clinically evident appendicitis. Emerg Med J 2008;25: 482-5.
  2. Jo YH, Kim K, Rhee JE, et al. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010;28(7):766-70 [Epub 2010 Mar 25].

Transcranial sonography in prehospital setting?

To the Editor,

Until recently, emergency physicians in the prehospital setting had no tools with which to explore neurologic distress. In France, many emergency medical services are now equipped with hand-held Ultrasound devices for use in the prehospital setting. The transcranial Doppler could contribute to better management of patients with head injury or ischemic stroke [1-3]; and the transcranial sonography (TS) could allow imaging of the brain parenchyma. Several brain disorders can be depicted by TS, such as Intracranial hematomas, brain tumors, neuro- degenerative disorders, and enlargement of the ventricular system [4,5]. We present 2 cases of prehospital TS to illustrate its interest.

A medical team has been dispatched for an 80-year-old man unconscious after a fall and a head injury. On arrival, the patient was conscious but drowsy, with a Glasgow Coma Scale score of 14; blood pressure, heart rate, respiratory rate, and oxygen saturation were normal. Physical examination was normal. Transcranial sonography examination was performed by an emergency physician on the scene (V-Scan; General Electric, France) and showed enlarged cerebral ventricles. Further questioning of the patient’s family revealed the gradual development in recent months of gait disturbance, urinary incontinence, and dementia. A diagnosis of normal pressure hydrocephalus was suspected. Computed tomographic (CT) scan confirmed enlargement of the ventricular system without any other cerebral lesions (Fig. 1A). The patient underwent ventricu- loperitoneal shunting, which led to significant clinical improvement of symptoms.

A medical team has been dispatched for a 49-year-old woman who has been found unconscious at home. On arrival, the patient was conscious but confused, with a Glasgow Coma Scale score of 14. Blood pressure , heart rate, respiratory rate, and oxygen saturation were normal. The patient complained of headache. Physical examination was normal. Transcranial sonography showed a hyperechogenic lesion in Midline shift (Fig. 1B). A diagnosis of subarach- noid hemorrhage was suspected. The patient had been brought in to the hospital with neurosurgery alerted. A CT scan showed small amount of blood in the basal anterior interhemispheric fissure and confirmed subarachnoid hem- orrhage. Computed tomography angiogram showed a small aneurysm of the right anterior communicating artery. The patient underwent surgery for clipping and securing the cerebral aneurysm and left the hospital after 1 month without neurologic sequel.

The TS technique is easy to perform through the acoustic Temporal bone window with phased array transducers (1.75-

? Funding sources: None. ? Conflict of interest: None.

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