Imaging studies for

evaluation of acute
appendicitis
in children
Sarah S. Long, MD

Capnography to
detect endotracheal
tube dislodgement
Robert W. Wilmott, MD

Iron and hepcidin in

the preterm
Alan H. Jobe, MD, PhD

Obesity treatment:
putting guidelines
to work
Stephen R. Daniels, MD, PhD

A2

achur et al performed a retrospective study of utilization of imaging and outcomes

in children evaluated in Emergency Departments for acute appendicitis using an
administrative database that included 38 freestanding United States childrens hospitals. The study spanned 5 years (2005 through 2009) and permitted several interesting
observations about the use of ultrasonography (US), computed tomography (CT), or
both. Overall, the median institutional rate of using either modality was 48% (interquartile range 37% to 57%). Thirty-four percent of patients had CT and 6% had US
performed, also with marked variability between modalities across institutions. Rates
and modes of imaging varied by age and sex females and patients younger than 5
years were more likely to have imaging performed. Following a known rise in CT performance early in the decade, use peaked in 2007 and fell 6% from 2007 through 2009,
while use of US increased almost 8% over the study years. Other than the rate of negative appendectomy (ie, finding no appendicitis at surgery) being slightly lower in institutions using more US, variation in advanced diagnostic imaging between
institutions did not correlate with major outcomes, including rates of appendiceal perforation or hospital return for missed appendicitis.
The study packs the weight of inclusion of 35 238 children with appendicitis, but
also accentuates the leanness of an administrative database, which lacks patient-level
clinical data (eg, duration and degree of illness/findings at the time of evaluation) and
physician-level reasoning for diagnosis, imaging, and management.
Article page 1034<

ediatric residents were trained in intubation and resuscitation in a simulation lab

at Yale University, and a randomized control study was performed to see whether
standard monitoring plus capnography increased the ability to recognize dislodgement of the endotracheal tube. This study of 27 pediatric residents showed that those
who had received training in capnography and had capnography available, in addition
to standard monitoring, corrected endotracheal tube dislodgement significantly faster
than the control group. The authors suggest that capnography should be considered as
essential for intubated patients to enhance patients safety.
Article page 1009<

ron metabolism is problematic in the very preterm infant because of low iron stores
at birth and the multiple effects of inflammation, blood loss for testing, nutritional
deficits, and transfusion. The optimal amounts of iron supplementation and the timing and levels of hemoglobin requiring transfusion remain uncertain. In this issue of
The Journal, M
uller et al report that urine hepcidin levels may be a good biomarker
for iron and hematologic status in these infants. The 25 amino-acid form of hepcidin
is synthesized by the liver and excreted in urine. It is a key regulator of iron homeostasis, acting through the iron exporter, ferropostin. A single biomarker in urine
would be welcome as a replacement for multiple measurements of iron status using
blood.
Article page 949<

here has been substantial research on the treatment of obesity in children and adolescents. These results have been incorporated in the American Medical Association/Centers for Disease Control and Prevention recommendations for the prevention
and treatment of obesity. Although these recommendations are relatively straightforward, it is not clear how best to implement them in a clinical practice to get the best
outcomes. In this issue of The Journal, Coleman et al report on the use of computerassisted decision tools to implement the guidelines in an integrated health care system.
The decision tools included alerts that were based on body mass index percentile and
reminded the primary-care physician about screening for related conditions and
Vol. 160, No. 6