L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication: A Systematic Review

PURPOSE: The purpose of this study is to review the evidence comparing the efficacy and safety between L-carnitine and extracorporeal elimination therapy in the management of acute valproic acid L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication METHODS: PubMed, Embase, Cochrane library, Web of Science, KoreaMed, KMbase, and KISS were searched, using the terms carnitine and valproic acid. All studies, regardless of design, reporting efficacy or safety endpoints were included. Reference citations from identified publications were reviewed. Both English and Korean languages were included. Two authors extracted primary data elements including poisoning severity, presenting features, clinical management, and outcomes. RESULTS: Thirty two articles including 33 cases were identified. Poisoning severity was classified as 3 mild, 11 moderate, and 19 severe cases. Nine cases were treated with L-carnitine while 24 cases received extracorporeal therapy without L-carnitine. All patients except one expired patient treated with hemodialysis recovered clinically and no adverse effects were noted. A case report comparing two patients who ingested the same amount of valproic acid showed increased ICU stay (3 vs 11 days) in case of delayed extracorporeal therapy. CONCLUSION: Published evidence comparing L-carnitine with extracorporeal therapy is limited. Based on the available evidence, it is reasonable to consider L-carnitine for patients with acute valproic acid overdose. In case of severe poisoning, extracorporeal therapy would also be considered in the early phase of treatment.

Assessing Safety Attitudes among Healthcare Providers after a Hospital-Wide High-Risk Patient Care Program

PURPOSE: Cardiopulmonary resuscitation (CPR) is commonly performed in high-risk, high intensity situations and is therefore a good procedure around which to develop and implement safety culture strategies in the hospital. The purpose of this study was to evaluate the impact of a hospital-wide quality improvement program on the management of sudden cardiac arrests by assessing healthcare providers' attitudes towards patient safety. MATERIALS AND METHODS: This study was designed as a prospective cohort study at a single academic medical center. The comprehensive hospital-based safety program included steps to identify areas of hazard, partner units with the Resuscitation Committee, and to conduct a Safety Attitudes Questionnaire (SAQ). The SAQ evaluated 35 questions in seven domains to assess changes in patient safety culture by comparing the results before and after the hospital-wide high risk patient care improvement program. RESULTS: The response rates of the pre- and post-SAQ survey were 489 out of 1121 (43.6%) and 575 out of 1270 (45.3%), respectively. SAQ survey responses revealed significant improvement in all seven domains of the questionnaire (p-values of 0.006 and lower). In a subgroup analysis, doctors and nurses showed improvement in five domains. Both doctors and nurses did not show improvement in the "sharing information" domain. CONCLUSION: A hospital-wide quality improvement program for high-risk, high reliability patient care involving CPR care was shown to be associated with a change in healthcare providers' attitudes towards patient safety. Through an immersive and active program on CPR care, change in healthcare providers' attitudes towards patient safety was initiated.

A Systematic Review of Injury or Poisoning Related to Mercury Thermometer

PURPOSE: The purpose of this systematic review was to evaluate the evidence regarding injury and poisoning associated with the clinical mercury thermometer. METHODS: Electronic literature searches were conducted for identification of relevant studies and case reports of injury and poisoning associated with the clinical mercury thermometer. The search outcomes were limited to literature with English and Korean languages published from 1966. Studies related to occupational mercury exposure, or mercury exposure from sphygmomanometer, barometer, and fluorescent light were excluded. RESULTS: A total of 60 reports, including 59 case reports, were finally included. Of those, nine cases pertained to an intact thermometer as a foreign body, 25 injuries were related to a thermometer, and 26 cases involved exposures to mercury from a broken thermometer. Case reports were classified according to severity into 16 mild, 41 moderate, and two severe cases. Two cases of mortality were reported, one was deliberate intravenous injection of mercury and the other was acute vapor inhalation of mercury from broken thermometers. CONCLUSION: Findings of this systematic review suggested that the mercury thermometer could cause various forms of poisoning and injury. In particular, inhalation of mercury vapor from a broken thermometer can lead to systemic toxicity requiring chelating therapy.

Two Cases of Intoxication with Phentermine

Phentermine has been widely used as an appetite suppressant since 2004 in Korea. The authors experienced two cases of acute phentermine overdose and report with the literature review. A 36-year-old man and a 24-year-old woman presented together to the emergency department with taking 13 tablets (390 mg) of phentermine 16 hours ago. They had tachycardia, hypertension and complained visual symptoms, nausea, insomnia and anxiety. These symptoms were resolved by conservative management.

A Systematic Review of Injury or Poisoning Related to Mercury Thermometer

PURPOSE: The purpose of this systematic review was to evaluate the evidence regarding injury and poisoning associated with the clinical mercury thermometer. METHODS: Electronic literature searches were conducted for identification of relevant studies and case reports of injury and poisoning associated with the clinical mercury thermometer. The search outcomes were limited to literature with English and Korean languages published from 1966. Studies related to occupational mercury exposure, or mercury exposure from sphygmomanometer, barometer, and fluorescent light were excluded. RESULTS: A total of 60 reports, including 59 case reports, were finally included. Of those, nine cases pertained to an intact thermometer as a foreign body, 25 injuries were related to a thermometer, and 26 cases involved exposures to mercury from a broken thermometer. Case reports were classified according to severity into 16 mild, 41 moderate, and two severe cases. Two cases of mortality were reported, one was deliberate intravenous injection of mercury and the other was acute vapor inhalation of mercury from broken thermometers. CONCLUSION: Findings of this systematic review suggested that the mercury thermometer could cause various forms of poisoning and injury. In particular, inhalation of mercury vapor from a broken thermometer can lead to systemic toxicity requiring chelating therapy.

Two Cases of Intoxication with Phentermine

Phentermine has been widely used as an appetite suppressant since 2004 in Korea. The authors experienced two cases of acute phentermine overdose and report with the literature review. A 36-year-old man and a 24-year-old woman presented together to the emergency department with taking 13 tablets (390 mg) of phentermine 16 hours ago. They had tachycardia, hypertension and complained visual symptoms, nausea, insomnia and anxiety. These symptoms were resolved by conservative management.

Evaluating the Utility of Rapid Point-of-Care Potassium Testing for the Early Identification of Hyperkalemia in Patients with Chronic Kidney Disease in the Emergency Department

PURPOSE: Severe hyperkalemia leads to significant morbidity and mortality if it is not immediately recognized and treated. The concentration of potassium (K+) in the serum increases along with deteriorating renal function. The use of point-of-care K+ (POC-K+) in chronic kidney disease (CKD) could reduce the time for an accurate diagnosis and treatment, saving lives. We hypothesized that POC-K+ would accurately report K+ serum level without significant differences compared to reference testing, regardless of the renal function of the patient. MATERIALS AND METHODS: The retrospective study was performed between January 2008 and September 2011 at an urban hospital in Seoul. The screening program using POC was conducted as a critical pathway for rapid evaluation and treatment of hyperkalemia since 2008. When a patient with CKD had at least one warning symptom or sign of hyperkalemia, both POC-K+ and routine laboratory tests were simultaneously ordered. The reliability of the two assays for serum-creatinine was assessed by intra-class correlation coefficient (ICC) analysis using absolute agreement of two-way mixed model. RESULTS: High levels of reliability were found between POC and the laboratory reference tests for K+ (ICC=0.913, 95% CI 0.903-0.922) and between two tests for K+ according to changes in the serum-creatinine levels in CKD patients. CONCLUSION: The results of POC-K+ correlate well with values obtained from reference laboratory tests and coincide with changes in serum-creatinine of patients with CKD.

The Usefulness of the Kurashiki Prehospital Stroke Scale in Identifying Thrombolytic Candidates in Acute Ischemic Stroke

PURPOSE: The severity of a stroke cannot be described by widely used prehospital stroke scales. We investigated the usefulness of the Kurashiki Prehospital Stroke Scale (KPSS) for assessing the severity of stroke, compared to the National Institutes of Health Stroke Scale (NIHSS), in candidate patients for intravenous or intra-arterial thrombolysis who arrived at the hospital within 6 hours of symptom onset. MATERIALS AND METHODS: We retrospectively analyzed a prospective registry database of consecutive patients included in the Emergency Stroke Therapy program. In the emergency department, the KPSS was assessed by emergency medical technicians. A cutoff KPSS score was estimated for candidates of thrombolysis by comparing KPSS and NIHSS scores, as well as for patients who actually received thrombolytic therapy. Clinical outcomes were compared between patients around the estimated cut-off. The independent predictors of outcomes were determined using multivariate logistic regression analysis. RESULTS: Excellent correlations were demonstrated between KPSS and NIHSS within 6 hours (R=0.869) and 3 hours (R=0.879) of hospital admission. The optimal threshold value was a score of 3 on the KPSS in patients within 3 hours and 6 hours by Youden's methods. Significant associations with a KPSS score > or =3 were revealed for actual intravenous administration of tissue plasminogen activator (IV-tPA) usage [odds ratio (OR) 125.598; 95% confidence interval (CI) 16.443-959.368, p<0.0001] and actual IV-tPA or intra-arterial urokinase (IA-UK) usage (OR 58.733; 95% CI 17.272-199.721, p<0.0001). CONCLUSION: The KPSS is an effective prehospital stroke scale for identifying candidates for IV-tPA and IA-UK, as indicated by excellent correlation with the NIHSS, in the assessment of stroke severity in acute ischemic stroke.

Accuracy of the Automatic External Defibrillator on an Electric Mattress: Simulation Study

PURPOSE: The accuracy of the automated external defibrillator (AED) is susceptible to environmental factors such as vibration, motion artifacts, and electromagnetic interference (EMI). The purpose of this study was to evaluate whether the EMI produced by an electric mattress can affect the performance of AEDs. METHODS: Four commercially available AEDs were evaluated under four ECG rhythm settings (normal sinus rhythm, asystole, ventricular fibrillation, and ventricular tachycardia) with or without an electric mattress. The sensitivity, specificity, positive predictable value, negative predictable value, and accuracy of AEDs were calculated to differentiate shockable from nonshockable rhythms. Times required to interpret the ECGs were checked with and without an electric mattress. RESULTS: A total of 320 tests were recorded, and each AED was tested a total of 80 times. Depending on the AED model used on an electric mattress, sensitivity ranged from 55% to 90% with a specificity of 100%, and accuracy ranged from 77.5% to 95%. For some AEDs, sensitivity was reduced compared to the control. Although there was no significant difference in times required to interpret ECG signals with or without an electric mattress, some AEDs detected a relatively small interference as motion artifacts when an electric mattress was used. All recorded ECG rhythms on an electric mattress showed baseline artifacts and these artifacts lessened with increasing distance from an electric mattress. CONCLUSION: This study suggests that an electric mattress could affect the shockable rhythm performance of some AEDs. Electromagnetic interference generated by an electric mattress could interfere with the ability of some commercial AEDs to correctly interpret stimulated ECG rhythms and provide appropriate defibrillation.

Accuracy of the Automatic External Defibrillator on an Electric Mattress: Simulation Study

PURPOSE: The accuracy of the automated external defibrillator (AED) is susceptible to environmental factors such as vibration, motion artifacts, and electromagnetic interference (EMI). The purpose of this study was to evaluate whether the EMI produced by an electric mattress can affect the performance of AEDs. METHODS: Four commercially available AEDs were evaluated under four ECG rhythm settings (normal sinus rhythm, asystole, ventricular fibrillation, and ventricular tachycardia) with or without an electric mattress. The sensitivity, specificity, positive predictable value, negative predictable value, and accuracy of AEDs were calculated to differentiate shockable from nonshockable rhythms. Times required to interpret the ECGs were checked with and without an electric mattress. RESULTS: A total of 320 tests were recorded, and each AED was tested a total of 80 times. Depending on the AED model used on an electric mattress, sensitivity ranged from 55% to 90% with a specificity of 100%, and accuracy ranged from 77.5% to 95%. For some AEDs, sensitivity was reduced compared to the control. Although there was no significant difference in times required to interpret ECG signals with or without an electric mattress, some AEDs detected a relatively small interference as motion artifacts when an electric mattress was used. All recorded ECG rhythms on an electric mattress showed baseline artifacts and these artifacts lessened with increasing distance from an electric mattress. CONCLUSION: This study suggests that an electric mattress could affect the shockable rhythm performance of some AEDs. Electromagnetic interference generated by an electric mattress could interfere with the ability of some commercial AEDs to correctly interpret stimulated ECG rhythms and provide appropriate defibrillation.

Usefulness of Delta Neutrophil Index in Prediction of Septic Shock in Patients with Community-acquired Pneumonia

PURPOSE: The delta neutrophil index (DNI) corresponds to the calculated immature granulocyte counts and the severity of sepsis. The aim of this study was to investigate the diagnostic value of DNI as a predictable laboratory marker for septic shock in patients with severe community-acquired pneumonia in emergency department. METHODS: The present study was a retrospective analysis of patients with pathologically confirmed community-acquired pneumonia from December 2011 to February 2012 at a hospital. The DNI was automatically calculated as a subset of routine complete blood count test. The diagnostic performance of DNI for septic shock in patients with community-acquired pneumonia was evaluated. RESULTS: During the study period, 105 patients were enrolled. Among them, 27 patients (25.7%) were confirmed as having septic shock according to predetermined criteria. The initial value of DNI was significantly higher in septic shock group than in non-shock group (8.7% vs 2.3%, p=0.008). The peak value of DNI was also significantly higher in septic shock group (18.6% vs 4%, p<0.001). The sensitivity and specificity of the initial and peak DNI values for predicting septic shock in patients with community-acquired pneumonia were 48.2%, 96.2%, 74.1%, and 87.2%, respectively, at initial and peak cutoff levels of 11.2% and 8.7% with an area under the curve (AUC) of 0.72 and 0.81 on the Receiver Operating Characteristic (ROC) curve. The AUC to predict septic shock was 0.74 for the CURB-65 scale. The AUC was significantly increased when peak DNI was added to CURB-65 scale (p=0.007). CONCLUSION: This study suggested that the DNI is associated with septic shock in patients with community-acquired pneumonia. Clinically, the peak value of DNI added to CURB-65 scale could improve predictable performance of septic shock in patients with community-acquired pneumonia.

Improving Communication Skill Competency in the Emergency Department through Role Play and Direct Observation

PURPOSE: Good communication between patient and medical staff in an emergency department (ED) fosters patient satisfaction and improves healthcare outcomes. Assessment and implementation of training is key in providing better patient care. The purpose of this study is to evaluate the effect of providing communication skills training to ED physicians and nurses using problem identification, role playing and direct observation. METHODS: The ED faculty in collaboration with an external communications expert group developed a communication skills training manual. The training group participated in simulated patient scenarios followed by video feedback and debriefing sessions. The participants were assessed on their communication skills while delivering care to live patients in real clinical situations before and after the training. The communication skills of the training group were compared with those of the control group. RESULTS: A total of 28 residents and nurses from two departments were enrolled in this study. Pre- to post-training scores (scale 1-5) for the training group improved from 3.0 [2.8, 3.9] to 3.9 [3.1, 4.3] (p=0.025). However, the pre- and post-score difference between the training and control groups was not statistically significant. CONCLUSION: Role play training has been found to be effective in improving communication skills. However, future research is required to develop a more effective training method and determine how to facilitate training implementation in complex clinical healthcare settings, such as the ED.

Guidewire-Assisted Nasogastric Tube Insertion in Intubated Patients in an Emergency Center / 대한구급학회지

BACKGROUND: The purpose of this study is to identify the usefulness of guidewire-assisted nasogastric tube insertion in intubated patients with cervical spine immobilization or unstable vital signs in an emergency center. METHODS: Thirty-four intubated patients in an emergency center were enrolled in the study. Patients were randomly allocated to the control group or the guidewire group. All patient necks were kept in neutral position during the procedure. In the control group, the nasogastric tube was inserted with the conventional method. A guidewire-supporting nasogastric tube was used in the guidewire group. The success rates of the first attempts and overall were recorded along with complications. RESULTS: The first attempt success rate was 88.2% in the guidewire group compared with 35.2% in the control group (p < 0.001). The overall success rate was 94.2% in the guidewire group and 52.9% in the control group (p = 0.017). Five cases of self-limiting nasal bleeding were reported in the guidewire group, and two cases occurred in the control group. No statistical differences were identified between groups. CONCLUSIONS: Guidewire-assisted nasogastric tube insertion is a simple and useful method in intubated patients with cervical spine immobilization or unstable vital signs.

A 45degrees set Square Method for Accurate Needle Insertion in Ultrasound-guided Internal Jugular Venous Catheterization

PURPOSE: Until now, there has been no standardized method for insertion of the introducer needle in ultrasound-guided internal jugular venous catheterization (IJVC). The needle insertion site and angle have been determined by the performer's experiences. In an effort to improve first attempt success rates and reduce complications, we designed a new standardized approach (called the 45degrees set square method) for determination of the site and angle of needle insertion during ultrasound-guided IJVC. This study investigated that the clinical usefulness of the novel 45degrees set square method for ultrasound-guided IJVC in the emergency department. METHODS: We conducted a prospective study in the emergency department (ED) of a tertiary teaching hospital. Forty one patients requiring central venous catheterization were enrolled in the study. They were randomized to either the conventional ultrasound guidance group or the 45degrees set square group. The primary outcome measure was success rate within three attempts and secondary measures were the number of trials, first-attempt success, puncture time, complications, and technical difficulty score. RESULTS: All 41 participants completed this study successfully. Twenty one consecutive patients were enrolled in the 45degrees set square group and 20 were enrolled in the conventional group. The 45degrees set square group (100%) was superior to the conventional group (60%) in overall success rate within three attempts (p=0.001) and the number of attempts (p<0.001). Significant differences in puncture time (p=0.004), hematoma (p=0.048), and technical difficulty score (p<0.001) were observed between the groups. CONCLUSION: The 45degrees set square method is an effective and safe method for ultrasound-guided internal jugular venous catheterization.

Effect of Cardiac Arrest Team Training Using Script on the Quality of Simulated Resuscitation / 대한구급학회지

BACKGROUND: The purpose of this study was to compare the quality of simulated resuscitation between the conventional simulation training group and the script based training group. METHODS: This was a retrospective analysis of video clips from a previous study of cardiopulmonary resuscitation (CPR) team simulation training. A total of eighty-four video clips were analyzed. Each video clip belonged to either the conventional group or the script group, of either pre-training or post-training. One of the authors analyzed all the video clips. The qualities of resuscitation team plays were compared in terms of the hands-on compression time, the interval to meaningful measures and the number of utterances of the team leader and members. RESULTS: The hands-on time of the conventional group improved after training whereas that of the script group deteriorated (22.2 vs -7.0 sec, p = 0.009). The time to defibrillation also improved in the conventional group whereas that of the script group deteriorated (-24.0 vs 33.0 sec, p = 0.002). There were no differences in the utterances of team leaders and members between groups and between pre- and post-training. CONCLUSIONS: This study suggested that the effect of script-based training on quality of CPR was less useful than that of conventional training using simulation and debriefing. Therefore, CPR team training using a script alone should not be recommended.

Assessment and Training of Teamwork and Leadership for Critical Care Nurses: A Pilot Study / 대한구급학회지

BACKGROUND: Teamwork and leadership training have been shown to improve subsequent resuscitation performance in a variety of clinical situations. Critical care nurses, in addition to those who may be part of resuscitation team leaders and members, have also the need for such training. This study examines the teamwork and leadership skills of critical care nurses and their perceptions of the need for teamwork and leadership training. METHODS: We developed a pilot, interactive 3-hour teamwork, and the leadership training program based on the objectives and teaching methods of the Advanced Life Support (ACLS) course. Participants completed a 1-hour lecture, and discussion for team roles and obstacles, 30 min of script-based role play in resuscitation team training, and finally, a 2-hour simulation-based team training program. Before the completion of the course, participants were anonymously surveyed on the perceived educational value of the teamwork and leadership program. Expert raters reviewed videos of simulated resuscitation events in the course, and scored each video by two existing checklist for the team dynamic. RESULTS: Fifty-one nurses voluntarily participated and six videotaped simulation were rated by an expert rater. Most of the students believed the course was delivered at an appropriate level for them, and that it is a necessary training in their continuing professional education. The video rated average scores were from 68.5 to 72.9 according to the checklists. CONCLUSIONS: Critical care nurses can learn teamwork and leadership skills from appropriately designed programs, and believe it is a necessity in their training.

Comparative Evaluation of the Harmless Acute Pancreatitis Score and CT Severity Index to Predict Mild Clinical Course of Acute Pancreatitis in the Emergency Department

PURPOSE: Several scoring systems and biochemical markers have been proposed for the early prediction of acute pancreatitis. The Harmless Acute Pancreatitis Score (HAPS) is a novel scoring system to recognize acute pancreatitis patients with a non-severe clinical course. This study was conducted to evaluate the usefulness of HAPS to predict good prognosis of acute pancreatitis in the emergency department (ED). METHODS: We retrospectively reviewed the electronic medical records of patients who presented to the ED with acute pancreatitis from January 2010 to December 2011. The parameters constituting HAPS, including physical signs of peritonitis (rebound abdominal tenderness), hematocrit and serum creatinine levels were abstracted. Severe clinical course was defined as having one of the following: mortality while in hospital, necrosis as assessed by contrast CT, need for artificial ventilation or dialysis. The diagnostic performance of HAPS for predicting harmless course was evaluated by sensitivity, specificity, and predictive values. RESULTS: During the study period, 144 patients with a final diagnosis of acute pancreatitis were included. Among these 144 patients, 79 were predicted to have a non-severe course by HAPS, of whom 4 patients progressed to severe pancreatitis. The sensitivity, specificity, positive and negative predictive values were 61.5%, 81.8%, 94.9% and 27.7%, respectively. CONCLUSION: This study suggests that HAPS is simple and can be assessed within a few hours in the ED. HAPS also showed a high positive predictive value that predicts a non-severe course of acute pancreatitis. Therefore, HAPS may be used as a scoring system to identify non-severe acute pancreatitis in the ED.

Clinical Characteristics of Intentional Carbon Monoxide Poisoning

PURPOSE: The purpose of this study was to identify the changes in the characteristics of patients with carbon monoxide (CO) poisoning, as well as the distinctive differences in intentionally exposed patients. METHODS: The medical records of CO poisoning patients, who visited nine emergency departments between January 2010 and December 2011, were reviewed retrospectively. The clinical information including age, gender, hospitalization, type of discharge, cause and location of exposure, site of onset, concentration of initial blood carboxyhemoglobin (COHb), methods of treatment and presence of neurological complications was examined. The subjects were divided into an intentional and non-intentional group and the differences between them was compared. RESULTS: A total 209 subjects were recruited. The median age was 38 years (29~49.5 years). They frequently complained of nausea and vomiting, and the most common exposures occurred in winter, normally in the home. The cause of exposure was usually fire, followed by incomplete combustion of fuels. The median initial blood COHb was 13.15%. The proportion of intentionally exposed patients was 21%. They were significantly younger, more frequently discharged against medical advice, and showed a higher initial blood COHb level (22.85%) than the non-intentional group. CONCLUSION: This study suggests that those with intentional CO poisoning are normally discharged against medical advice even when they have a higher initial COHb level. An adequate explanation of the delayed neurologic sequelae and short term follow-up observation is recommended for those patients with intentional exposure.

Oral vs. Intravenous Administration of N-acetylcysteine in the Acetaminophen Poisoning

PURPOSE: Serious acetaminophen (AAP) poisoning causes hepatotoxicity. N-acetylcysteine (NAC) is the most effective therapy for AAP poisoning and can be administered orally and intravenously (IV). Several studies have compared the efficacy of these two routes of administration and the results have been controversial. The purpose of this study was to compare the efficacy of oral and IV NAC for the prevention of hepatic toxicity in Korean patients whose serum AAP levels were higher than normal. METHODS: A retrospective before/after study was performed, in which the patients presented to the emergency department with an AAP overdose from February 1995 to March 2012. A 3-day oral NAC regimen was used in the beginning, and a 20-hr intravenous regimen was then used from 2007. This study assessed the complications of an AAP overdose, such as hepatotoxicity, hepatic failure and renal failure as well as the side effects of the treatment regimen. RESULTS: A total of 41patients was enrolled in this study. The median ALT and AST were 63 (IU/L) and 57 (IU/L) for the oral NAC treated patients, and 14 (IU/L) and 20 (IU/L) for the IV NAC treated patients (p=0.004 and p=0.001, respectively). The incidence of complications was similar in the treatment groups (p=0.399). Among the patients, 7 patients developed hepatotoxicity and were treated successfully with oral or IV NAC. CONCLUSION: This study suggests that IV NAC and oral NAC can prevent and successfully treat hepatic toxicity in patients whose serum AAP levels are higher than normal.

Assessment of Perforation of Acute Appendicitis using the Delta Neutrophil Index Reflecting Peripheral Immature Granulocyte Count

PURPOSE: The delta neutrophil index corresponds to calculated immature granulocyte counts and severity of sepsis. This study was conducted in order to investigate the diagnostic value of the delta neutrophil index as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis. METHODS: This study was conducted as a retrospective analysis of patients confirmed pathologically as appendicitis at two hospitals from November 2009 to September 2010. Delta neutrophil index was automatically calculated as a subset of routine complete blood count testing. The diagnostic performance of the delta neutrophil index for perforated appendicitis was evaluated. RESULTS: During the study period, 308 patients were enrolled. Among them, 32 patients (10.4%) were confirmed as perforated appendicitis. The delta neutrophil index was significantly higher in the perforated group, compared with the non-perforated group (4.8+/-7.1% vs 2.0+/-2.0%, p<0.05). Sensitivity and specificity of the delta neutrophil index for prediction of perforated appendicitis was 25.0% and 96.7%, respectively, at a cutoff level of 5% with an area under the curve of 0.78 on the ROC (receiver operating characteristics) curve. CONCLUSION: Results of this study suggested an association of the delta neutrophil index with perforated appendicitis. However, the sensitivity was not high enough for use as clinical guidance.