An Uncommon Diagnosis in a Child Presenting With Double Vision and Imbalance.

Acute disseminated encephalomyelitis (ADEM) is exceptionally uncommon, with approximately 3 pediatric cases reported in the United States each year. Given the uncommon nature of ADEM, most of the current data rely heavily on case reports. The overwhelming majority of cases have been reported after an acute viral infection or vaccination. Although up to 90% of cases exhibit full remission after intravenous steroids, those in which treatment is delayed can display debilitating sequelae. Here, we present a case of ADEM in a 7-year-old boy who presented with double vision and imbalance with no recent history of acute viral infections or vaccinations.

Higher success rates and satisfaction in difficult venous access patients with a guide wire-associated peripheral venous catheter.

STUDY OBJECTIVE: This study compares first pass success rates and patient and physician satisfaction scores of using a guide wire-associated peripheral venous catheter (GAPIV) vs a traditional peripheral venous catheter in difficult to obtain venous access patients. METHODS: A total of 200 patients were enrolled prospectively from a convenience sample in a large urban academic emergency department. Patients were included when they were deemed difficult access per study criteria. Patients were alternated to receiving either a traditional peripheral venous catheter or a GAPIV. The number of attempts, the number of catheters used, and patient and physician satisfaction scores were recorded. RESULTS: A total of 100 patients were enrolled into each group. First attempt success was 85% with GAPIV vs 22% with the traditional peripheral venous catheter (P < .0001). Sixty-two percent of patients required a second stick with the conventional catheter compared to 15% with the GAPIV. The average number of attempts overall for the GAPIV product was 1.2 with an SD of 0.4 attempts vs 1.9 and an SD of 0.6 attempts with the traditional peripheral venous catheter; P < .0001. Using a 5-point Likert scale, the GAPIV had a median patient satisfaction score of 5 at insertion compared with the traditional peripheral venous catheter score of 2; P < .0001. Median physician satisfaction with the GAPIV study device was 5 at time of insertion, compared to 3 for the traditional peripheral venous catheter. CONCLUSION: The GAPIV product demonstrated significantly higher first attempt success and patient satisfaction compared to a traditional peripheral venous catheter in difficult to obtain venous access patients. Physician satisfaction was also favorable due to ease of access, time, and efficiencies gained.

Integrating Pre-test Probability and Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED) Diagnosis of Small Bowel Obstruction (SBO).

Introduction A computed tomography (CT) scan and point-of-care ultrasound (POCUS) are commonly employed for diagnosing small bowel obstructions (SBOs). Prior studies demonstrated that POCUS has 90-95% sensitivity and specificity compared with CT scanning, which is the gold standard. Unlike other imaging modalities (in which the ordering and performing clinician are not the same), POCUS-performing/interpreting sonologists must recognize the risk of confirmation bias in the POCUS application. Per Bayesian analysis, the likelihood of a diagnosis being true following a diagnostic test is based on the ordering clinician's pre-test probability and the test characteristics (sensitivity and specificity, from which positive and negative likelihood ratios can be calculated). Consequently, establishing pre-test probability is important in informing downstream diagnostic or therapeutic interventions, as pre-test probability influences post-test odds. Little research has been done on the role of POCUS sonologist's pre-test probability and actual POCUS results regarding SBO. This study assessed the role of POCUS, integrating pre-test probability and POCUS results to determine post-test odds. Methods One hundred six patients were recruited on a convenience basis and underwent POCUS and CT between April 2017 and December 2022. All sonographers were credentialed in POCUS. POCUS sonologists' pre-test probabilities and POCUS and CT results were captured, which were compared. Sensitivity, specificity, LR+, and LR- were calculated, and correlations were made between pre-test probability and POCUS and CT results.  Results POCUS exhibited a sensitivity of 92% and specificity of 90%, with a corresponding positive likelihood ratio (LR+) of 9.3 and a negative likelihood ratio (LR-) of 0.09 for diagnosing SBO. Among patients with a high pre-test probability of SBO, a negative ultrasound yielded post-test odds of 0.4%, whereas a positive POCUS yielded post-test odds of 39.6%. Among patients with a low pre-test probability, a negative POCUS resulted in post-test odds of 0%, while a positive POCUS led to post-test odds of 2.1%, yielding a number needed to scan (NNS) of ~50 to identify a patient with an SBO on CT. Conclusion This study confirmed POCUS's sensitivity and specificity of ~90-95% and a corresponding LR+ of 9.2 and LR- of 0.9. Pre-test probability substantially affected post-test odds. Patients with a high pre-test probability and a positive POCUS had post-test odds of 39.6 and should have a confirmatory CT, while those with a negative POCUS have very low post-test odds and very likely will not benefit from CT. Patients with low pre-test probability and a positive POCUS have post-test odds of 2.1%, similar to the Wells Score and HEART score; such patients may not benefit from a CT, though clinicians should use their judgment/discretion. Patients with a low pre-test probability and a negative POCUS have post-test odds of 0% and should not have a CT. Among low pre-test probability patients, the NNS was ~50 to identify patients with an SBO on CT.