Is it possible to predict the severity of acute appendicitis? Reliability of predictive models based on easily available blood variables.

INTRODUCTION: Recent evidence confirms that the treatment of acute appendicitis is not necessarily surgical, and selected patients with uncomplicated appendicitis can benefit from a non-operative management. Unfortunately, no cost-effective test has been proven to be able to effectively predict the degree of appendicular inflammation as yet, therefore, patient selection is too often left to the personal choice of the emergency surgeon. Our paper aims to clarify if basic and readily available blood tests can give reliable prognostic information to build up predictive models to help the decision-making process. METHODS: Clinical notes of 2275 patients who underwent an appendicectomy with a presumptive diagnosis of acute appendicitis were reviewed, taking into consideration basic preoperative blood tests and histology reports on the surgical specimens. Variables were compared with univariate and multivariate analysis, and predictive models were created. RESULTS: 18.2% of patients had a negative appendicectomy, 9.6% had mucosal only inflammation, 53% had transmural inflammation and 19.2% had gangrenous appendicitis. A strong correlation was found between degree of inflammation and lymphocytes count and CRP/Albumin ratio, both at univariate and multivariate analysis. A predictive model to identify cases of gangrenous appendicitis was developed. CONCLUSION: Low lymphocyte count and high CRP/Albumin ratio combined into a predictive model may have a role in the selection of patients who deserve appendicectomy instead of non-operative management of acute appendicitis.

Central precocious puberty after resection of a virilising adrenocortical oncocytic tumour.

Adrenocortical oncocytic tumours are a histological subtype of adrenal neoplasms with a distinctive morphological appearance. Since these tumours are composed of cells of the adrenal cortex, they may act as functional tumours with excess hormone production. They may cause Cushing's syndrome, inappropriate virilisation or precocious puberty. Though rare during childhood, adrenocortical oncocytic tumours should be suspected in a child with peripheral precocious puberty and marked elevation of dehydroepiandrosterone sulfate levels. We describe a 6-year girl who presented with peripheral precocious puberty due to a functional adrenocortical oncocytic tumour. Three months after tumour removal, she developed true central precocious puberty. This report highlights that peripheral precocious puberty may trigger central precocious puberty, particularly after resolution of the underlying cause of the peripheral precocious puberty.

Effectiveness of Metformin for Weight Reduction in Children and Adolescents Treated with Mixed Dopamine and Serotonin Receptor Antagonists: A Naturalistic Cohort Study.

Objectives: Mixed dopamine and serotonin receptor antagonists (DSRAs) are associated with significant weight gain and its complications. Our aim was to evaluate the effectiveness of metformin in reducing body mass index (BMI) and metabolic parameters in children treated with DSRAs. Methods: We report a naturalistic study of 49 children and adolescents (mean age 14.9 ± 3.7 years), with BMI >85 percentile for age, treated with DSRAs during 2018-2020 in a child psychiatry clinic. Clinical data, anthropometric measurements, and laboratory tests were compared between those who were (study group, n = 31) and were not (control group, n = 18) treated with metformin. Results: The mean study duration was 9.7 ± 5.9 months. The BMI standard deviation scores (BMI-SDS) of the study group declined significantly (from 2.08 ± 0.40 to 1.81 ± 0.54, p < 0.001), while the BMI-SDS of the control group did not change (from 2.03 ± 0.45 to 2.04 ± 0.47, p = 0.838). In the study group, the decline in the delta BMI-SDS/month was more robust among those with good than poor adherence to metformin (-0.047 ± 0.039 vs. -0.004 ± 0.017, p = 0.003). The decrease in BMI-SDS was greater for patients treated with risperidone and clothiapine than with other DSRAs. Fasting insulin and insulin resistance index (homeostasis model assessment of insulin resistance [HOMA-IR]) declined in the study group (from 25.4 ± 13.8 to 19.9 ± 10.7, p = 0.033 and from 5.4 ± 2.7 to 4.2 ± 2.1, p = 0.028, respectively). Conclusions: Metformin treatment was associated with significant decreases in BMI, fasting insulin, and HOMA-IR. The effect of metformin seems to be dependent on adherence and type of DSRAs.

Pharmacotherapy of attention-deficit hyperactivity disorder: common quandaries, dilemmas and challenges.

Multiple studies have shown that pharmacologic treatments for attention-deficit hyperactivity disorder (ADHD), especially stimulants, are generally effective. There is yet a paucity of empirical data, however, for some common clinical conditions overlooked in the ADHD treatment guidelines. Some examples include: in cases of first line treatment failure, it is unclear whether switching from one type of stimulant to another is beneficial. In cases of comorbid ADHD and severe aggressive/disruptive behavior in children, it is unclear whether the best first-line treatment is stimulants or atypical antipsychotics like risperidone. In cases of ADHD with comorbid anxiety disorders, there is no clear evidence regarding optimal treatment. The objectives of this article are to review these issues and propose possible answers for such clinical dilemmas.