Proposal for a New Score-Based Approach To Improve Efficiency of Diagnostic Laboratory Workflow for Acute Bacterial Meningitis in Adults.

Microbiological tests on cerebrospinal fluid (CSF) utilize a common urgent-care procedure that does not take into account the chemical and cytological characteristics of the CSF, resulting sometimes in an unnecessary use of human and diagnostic resources. The aim of this study was to retrospectively validate a simple scoring system (bacterial meningitis-Careggi score [BM-CASCO]) based on blood and CSF sample chemical/cytological parameters for evaluating the probability of acute bacterial meningitis (ABM) in adults. BM-CASCO (range, 0 to 6) was defined by the following parameters: CSF cell count, CSF protein levels, CSF lactate levels, CSF glucose-to-serum glucose ratio, and peripheral neutrophil count. BM-CASCO was retrospectively calculated for 784 cases of suspected ABM in adult subjects observed during a four-and-a-half-year-period (2010 to 2014) at the emergency department (ED) of a large tertiary-care teaching hospital in Italy. Among the 28 confirmed ABM cases (3.5%), Streptococcus pneumoniae was the most frequent cause (16 cases). All ABM cases showed a BM-CASCO value of ≥3. Most negative cases (591/756) exhibited a BM-CASCO value of ≤1, which was adopted in our laboratory as a cutoff to not proceed with urgent microbiological analysis of CSF in cases of suspected ABM in adults. During a subsequent 1-year follow-up, the introduction of the BM-CASCO in the diagnostic workflow of ABM in adults resulted in a significant decrease in unnecessary microbiological analysis, with no false negatives. In conclusion, BM-CASCO appears to be an accurate and simple scoring system for optimization of the microbiological diagnostic workflow of ABM in adults.

Causes of diplopia in the emergency department: diagnostic accuracy of clinical assessment and of head computed tomography.

BACKGROUND: Studies on frequency and underlying diseases causing binocular diplopia in patients presenting to the emergency department (ED) are lacking. OBJECTIVE: To evaluate the prevalence of different diseases causing diplopia and the role of medical history, clinical examination, and unenhanced head computed tomography (UHCT) in the identification of secondary diplopia. METHODS: Diplopic patients presenting to the ED were enrolled prospectively. Cardiovascular risk factors and associated neurological signs and symptoms were reported. UHCT was performed in the ED. RESULTS: Secondary diplopia was diagnosed in 93 of 260 (35.8%) diplopic patients. Among patients with secondary diplopia, the most frequent diagnoses were stroke (45.2%), multiple sclerosis (18.3%), brain tumors (11.8%), and cerebral aneurysms (7.5%). The prevalence of cardiovascular risk factors was similar in primary and secondary diplopia. Among the 118 (45.4%) patients without associated neurological signs or symptoms (isolated diplopia), secondary diplopia was diagnosed in 13 (11%); UHCT was negative in all 13 cases, with a derived null sensitivity. Eighty of 142 (56.3%) patients with associated signs or symptoms had secondary diplopia. The presence of signs or symptoms associated with diplopia showed a sensitivity of 87% [95% confidence interval (CI): 80-92%] and a specificity of 63% (95% CI: 59-66%) for the diagnosis of secondary diplopia. In this group, UHCT identified 30 of 80 (37.5%) cases, increasing the specificity to 98% (95% CI: 96-99%). CONCLUSION: One-third of diplopic patients had secondary diplopia. In patients with isolated diplopia, UHCT does not increase diagnostic sensitivity. In patients with associated neurological signs or symptoms, the prevalence of secondary diplopia was high and UHCT showed incremental diagnostic value.

Diagnostic performance of emergency transthoracic focus cardiac ultrasound in suspected acute type A aortic dissection.

Type A aortic dissection (AD) is a deadly disease. Rapid identification of patients requiring immediate advanced aortic imaging or transfer to specialized centers is needed to improve outcomes. We evaluated the diagnostic performance of transthoracic focus cardiac ultrasound (FOCUS) performed by emergency physicians, alone and in combination with the aortic dissection detection (ADD) risk score in suspected type A AD. This was a prospective study performed on patients with suspected type A AD. FOCUS evaluated the presence of intimal flap/intramural hematoma (direct signs of AD), ascending aorta dilatation, aortic valve insufficiency or pericardial effusion/tamponade (indirect signs of AD). The ADD risk score of each patient was calculated according to guidelines. The final diagnosis was established after review of complete clinical data. 50 (18%) patients of 281 had a final diagnosis of type A AD. Detection of any FOCUS sign (direct or indirect) of AD had a sensitivity of 88% (95% CI 76-95%) for the diagnosis of type A AD. Presence of ADD risk score > 0 or detection of any FOCUS sign increased diagnostic sensitivity to 96% (95% CI 86-99%). Detection of direct FOCUS signs had a specificity of 94% (95% CI 90-97%), while combination of ADD risk score > 1 with detection of direct FOCUS signs had a specificity of 98% (95% CI 96-99%). FOCUS demonstrated acceptable accuracy as a triage tool to rapidly identify patients with suspected type A AD needing advanced aortic imaging or transfer, but it cannot be used as a stand-alone test even if combined with ADD risk score classification.

Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis.

OBJECTIVES: To evaluate the accuracy and safety of an emergency duplex ultrasound (EDUS) evaluation performed by emergency physicians in the emergency department. METHODS: Consecutive adult patients suspected of having their first episode of deep vein thrombosis (DVT) presenting to the emergency department were included in the study. All examinations were performed by emergency physicians trained with a 30-hour ultrasound course. Based on EDUS findings, patients were classified into one of three groups: normal, abnormal, and uncertain. Patients with abnormal and uncertain findings were initially treated as having a DVT. Patients with normal EDUS findings were discharged from the emergency department without anticoagulant therapy. A formal duplex ultrasound evaluation was repeated by a radiologist in all patients within 24-48 hours. Patients with normal findings on duplex ultrasound evaluation were followed up for symptomatic venous thromboembolism for up to one month. RESULTS: A total of 399 patients were studied. The EDUS findings were normal in 301 (75%), abnormal in 90 (23%), and uncertain in eight (2%). All abnormal test results were confirmed by the formal duplex ultrasound evaluation, and three patients (0.8%) with uncertain findings on EDUS examination were subsequently diagnosed as having a distal DVT (positive predictive value, 95% [95% confidence interval, 92% to 95%]; negative predictive value, 100% [95% confidence interval = 99% to 100%]). No patients with normal findings on EDUS examination died or experienced venous thromboembolism at the one-month follow-up. CONCLUSIONS: EDUS examination yielded a high negative predictive value and good positive predictive value, allowing rapid discharge and avoiding improper anticoagulant treatment.

Prognostic indexes of septic syndrome in the emergency department.

OBJECTIVE: Sepsis is a frequent and often lethal condition. Rapid identification and aggressive therapy in the emergency department (ED) are essential for outcome. Several indexes were found to be significantly related to short-term clinical outcome, but only bedside, rapidly available tests are thought to be useful in the ED. To define the prevalence and mortality of patients with severe sepsis presenting to the ED of a tertiary care hospital in Italy, we furthermore investigated the ability of bedside, non-invasive prognostic indexes to identify patients with adverse short-term clinical outcome. METHODS: All patients admitted to the ED with a diagnosis of severe sepsis or septic shock were included. Retrospective data were collected by a dedicated software program using predefined searching criteria including clinical data, vital sign parameters, sepsis-related organ failure assessment (SOFA) score, and blood tests. The relationship between prognostic indexes and 24-h or 28-day mortality was evaluated by multivariate logistic regression analysis. RESULTS: Ninety patients were enrolled from June 2004 to June 2005 (0.2% of all incoming patients to ED and 0.7% of all critical patients). Mean age was 77 +/- 15 years, 54.4% were women. During follow-up (28 days) 46 patients died (51.1%), 21 patients (23.3%) within 24 h. At multivariate analyses, age >80 (odds ratio [OR] 4.10; 95% confidence intervals [CI] 1.39-11.90, p = 0.01), serum lactate >5 mmol/l (OR 3.40; 95% CI 1.21-9.60, p = 0.02) and acute renal failure (OR 18.90; 95% CI 1.80-200, p = 0.02) were independent predictors of 28-day mortality. CONCLUSIONS: Among critical patients admitted to an Italian ED, those with severe sepsis/septic shock represent about 1%, with a very high mortality rate. Bedside non-invasive prognostic indexes are able to identify with high accuracy patients with adverse short-term clinical outcome.