Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021.

Importance: Subarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied. Objective: To determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection. Design, Setting, and Participants: This retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged >17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023. Exposures: CT cerebral angiography and/or lumbar puncture during the ED encounter. Main Outcomes and Measures: Primary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis. Results: Among 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (-11.1%; 95% CI, -12.0% to -10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = -.34, respectively). Conclusions and Relevance: In this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.

Bacterial Meningitis With Cerebral Edema in a Young Adult: A Simulation Case for Medical Students.

Introduction: Simulation in the preclinical medical education setting is a beneficial tool for students to develop clinical skills, supplement preexisting knowledge, and prepare for clinical rotations and beyond. We detail the complete simulation scenario, including a participant postresponse questionnaire, of a 28-year-old male who developed bacterial meningitis after experiencing an upper respiratory infection in the days prior. Methods: Simulation fellows and faculty at the Alabama College of Osteopathic Medicine created a simulation scenario pertaining to bacterial meningitis. The scenario utilized a high-fidelity patient simulator, one standardized participant for patient voiceover, one standardized participant as a patient family member, and one standardized participant as a physician consultant on an as-needed basis. Sixteen preclinical medical students from various specialty interest groups were recruited to participate in the scenario and complete the postscenario questionnaire. Results: The simulation scenario was well received by the participants, and 15 of 16 completed the postscenario questionnaire. Ninety-three percent strongly agreed the simulation was a valuable clinical experience. Additionally, 73% of participants strongly agreed that the simulation experience was realistic, 80% strongly agreed that it tested their clinical reasoning ability, and 53% strongly agreed it was appropriate for their level of clinical knowledge. Discussion: Medical simulation is a valuable educational tool tailored to maximize student learning and supplement the traditional didactic curriculum. The successful development and implementation of our meningitis simulation case further supports the continued use of medical simulation in the preclinical setting.

Daptomycin versus vancomycin in treatment of methicillin-resistant Staphylococcus aureus meningitis in an experimental rabbit model.

In this study, we aimed to compare the antibacterial activities of daptomycin and vancomycin in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) meningitis (induced by MRSA strain ATCC 43300) in an experimental rabbit meningitis model. After an 8-h period of treatment, bacterial counts decreased significantly in both treatment groups compared to the control group (P < 0.05). However, there was no statistically significant difference between treatment groups. Our results suggest that the antibacterial activity of daptomycin is similar to vancomycin for treatment in the experimental MRSA meningitis model in rabbits.

Should corticosteroids be used in bacterial meningitis in children?

Bacterial meningitis is one of the most serious infections in infants and children, with considerable morbidity and mortality. Despite the spreading of conjugated vaccines against Haemophilus influenzae type b (Hib), the most important pneumococcal serotypes and serogroup C meningococcus has reduced the incidence of this infection in developed countries, it still remains a global public health problem and an important cause of mortality and disability. Whether corticosteroids should be used as a complementary therapy to antibacterials is still not clear because of the disparate findings from clinical trials and clinical evidence. The aim of this review is to analyze the available evidence on the impact of corticosteroid therapy in infants and children with bacterial meningitis in developed countries in order to define whether they should be added routinely in the empiric therapy of such disease. Our analysis concluded that in high-income countries dexamethasone has shown good results to prevent hearing loss in Hib meningitis if administered before or at the same time as the first dose of antibiotics. Dexamethasone should be evaluated in pneumococcal meningitis: it may be less beneficial in children with delayed presentation to medical attention and may be unfavourable in case of cephalosporin-resistant pneumococci. On the contrary, there is no evidence to recommend the use of corticosteroids in meningococcal meningitis. Further studies that take into account the epidemiologic changes of recent years, consider enrolment based on the onset of symptoms and evaluate outcomes such as hearing loss and neurologic sequelae with advanced techniques are urgently needed.

Distributed, limbic gray matter atrophy in patients after bacterial meningitis.

BACKGROUND AND PURPOSE: The structural basis of cognitive sequelae after bacterial meningitis in humans is still poorly understood. In animal models and human autopsy cases, neuronal apoptosis of the hippocampal formation in particular seems to play an important role. Here, we aimed to analyze if BM entails MR imaging structural consequences in humans in vivo. MATERIALS AND METHODS: We applied voxel-based morphometry in a cohort of BM survivors with normal conventional MR imaging after resolution of the acute inflammation to assess morphologic differences. RESULTS: We found clear gray matter volume loss in the limbic system including the hippocampal formation, thalamus, and cingulate gyri bilaterally as well as in the temporal lobe. These results were corroborated by an alternative atlas-based method. CONCLUSIONS: Even in patients with normal routine MR imaging results, clear-cut gray matter atrophy with a mesial temporal/limbic pattern was evident. The anatomic distribution is compatible with the neuropsychological deficit commonly observed in patients after BM. The similarity of the observed atrophy may point to causal link between BM and mesial temporal epilepsy.

Risk factors for auditory neuropathy spectrum disorder in NICU infants compared to normal-hearing NICU controls.

OBJECTIVES: To evaluate independent etiologic factors associated with auditory neuropathy spectrum disorder (ANSD) in infants who have been admitted to the neonatal intensive care unit (NICU) compared to normal-hearing controls. STUDY DESIGN: Case-control study. METHODS: We included all infants (n = 9) with the ANSD profile admitted to the NICU of Sophia Children's Hospital between 2004 and 2009. Each patient was matched with four normal-hearing controls of the same gender and postconceptional age. The following possible risk factors were studied: birth weight, dysmorphic features, APGAR scores (at 1, 5, and 10 minutes), respiratory distress (IRDS), cytomegalovirus (CMV) infection, sepsis, meningitis, cerebral bleeding, hyperbilirubinemia requiring phototherapy, peak total bilirubin level, furosemide, dexamethason, vancomycin, gentamycin, and tobramycin administration. RESULTS: Nine infants met the ANSD criteria in one or both ears. IRDS (P = .02), meningitis (P = .04), and vancomycin administration (P = .009) were significantly increased in infants with ANSD compared to controls. CONCLUSIONS: In high-risk NICU infants IRDS, meningitis and vancomycin administration are associated with auditory neuropathy spectrum disorder.

Therapy of community-acquired acute bacterial meningitis: the clock is running.

Despite antibiotic therapy and supportive intensive medical care, bacterial meningitis remains a disease with high mortality and morbidity. Rapid recognition of symptoms is crucial to direct physicians quickly towards appropriate diagnostic measures and, initially, empiric antibiotic therapy. It has become evident that time from arrival at the hospital to application of the first dose of antibiotics is a crucial independent factor that influences outcome. Here, we review the clinical and laboratory presentation of community-acquired bacterial meningitis and the antibiotic regiments that are currently recommended for its treatment; future therapeutic options are also discussed. Finally, suggestions for the approach to a patient with suspected bacterial meningitis are presented.

Septicemia and meningitis in the newborn calf.

Neonatal infections and sepsis occur most frequently in calves with failure of passive transfer. If the invading bacteria are not rapidly controlled, they can set up focal infections, such as in growth plates, joints, or meninges, or generalized sepsis may occur. If not successfully treated, sepsis can lead to a systemic inflammatory response, multiple organ dysfunction syndromes, septic shock, and death. Treatments are based on selecting an appropriate antimicrobial drug and dosage, supportive therapy, fluid therapy, nonsteroidal anti-inflammatory drugs, and plasma transfusion. Preventing the failure of passive transfer through good colostrum management is essential.

Role of auditory stimulation in maturation of the auditory pathway.

OBJECTIVE: To compare the maturation of the auditory pathway, as shown by electrical brainstem auditory potentials (EABRs), in ears with and without prior auditory stimulation. MATERIAL AND METHODS: Electrophysiological data were collected prospectively from ears which had received cochlear implants. Implant-evoked (Imp)EABRs were recorded. Thirty children, implanted after January 2000, were selected according to a strict inclusion/exclusion protocol. All the children had received a 22-channel Nucleus cochlear implant (CI24 series). Intraoperatively, ImpEABRs were recorded using the Medelec Synergy Evoked Response system in conjunction with Nucleus Neural Response Telemetry software. The ImpEABR latencies of waves eII, eIII and eV and the morphology of wave eV were assessed. RESULTS: ImpEABRs alter during the first 12 months of life. The latency becomes shorter during this period and the morphology of wave eV alters from a broad shape to a more distinct waveform. This appears to occur independently, even in the absence of auditory stimulation. CONCLUSION: The development of electrical brainstem auditory potentials is not dependent on auditory stimulation.

Meningitis por Streptococcus agalactiae en el anciano / Streptococcus agalactiae meningitis in the elderly

La meningitis bacteriana continúa siendo una enfermedad con una alta mortalidad en ancianos, a pesar de la moderna antibioterapia. En los últimos años, la meningitis bacteriana ha cambiado y es frecuente en adultos, especialmente en ancianos. El déficit de la función inmunológica relacionada con el envejecimiento y la mayor propensión a padecer enfermedades agudas o crónicas comórbidas pueden predisponer a la infección por estreptococos del grupo B en el anciano. Las manifestaciones clínicas pueden ser atípicas en la población geriátrica. La fiebre, la cefalea y la rigidez de nuca pueden estar ausentes. Presentamos un caso de meningitis por Streptococcus agalactiae en una mujer anciana sin factores comórbidos. Debemos tener presente esta enfermedad como posible diagnóstico ante un paciente anciano con confusión o bajo nivel de conciencia. (AU)

Cost-utility analysis of patient care in children with meningeal signs.

OBJECTIVES: We designed a model of diagnostic and therapeutic interventions applied in children with meningeal signs. Using this model, we determined in a cost-utility analysis the consequences for society of different diagnostic strategies in terms of quality-adjusted life-years (QALYs) and costs. METHODS: Data were used from 360 children (0.1-15 years) visiting the pediatric emergency department of the Sophia Children's Hospital Rotterdam, The Netherlands (1988-98) with meningeal signs. Model inputs included probabilities of meningitis and adverse outcome, QALYs for years lived with long-term sequelae, and costs of tests and treatments. Mean outcome measures were costs and effects of diagnostic and therapeutic interventions in children suspected of bacterial meningitis, key determinants of the model outcomes, and evaluation of alternative diagnostic strategies and two vaccination programs in an analysis. RESULTS: The population comprised 99 children with bacterial meningitis (adverse outcome in 10), 36 with serious other bacterial infections, and 225 with self-limiting diseases. Key determinants were the risk of bacterial meningitis or sequelae, costs of treatment, and long-term morbidity. Minimizing lumbar punctures and empirical treatments using a diagnostic decision rule, without missing a single case of meningitis, was a dominant strategy to actual practice. Vaccination strategies of Streptococcus pneumoniae and Neisseria meningitidis resulted in our model in incremental cost-utility ratios of 401,965 Euro dollar ([symbol: see text])/QALY and [symbol: see text]22,635/QALY, respectively. CONCLUSIONS: Costs of long-term morbidity of bacterial meningitis largely outweigh diagnostic and treatment costs. Modeling interventions in children at risk of bacterial meningitis should include long-term consequences in terms of costs and QALYs.

Cerebrospinal fluid penetration of high doses of intravenous ciprofloxacin in meningitis.

Nosocomial meningitis due to gram-negative organisms is a difficult clinical problem to manage because of both antibiotic resistance and poor penetration of many antimicrobials across the blood-brain barrier. Ciprofloxacin has potential in treating this condition when used in high doses. We investigated the plasma and cerebrospinal fluid (CSF) levels of ciprofloxacin in a patient with Pseudomonas aeruginosa meningitis who was treated with 400 mg of intravenous ciprofloxacin every 8 hours. Ciprofloxacin levels in plasma peaked at 10.29 mg/L without resulting in accumulation (8-hour trough levels, <1 mg/L), whereas the CSF level increased to 0.9 mg/L. This CSF level was confirmed to be similar 1 week later. After 1 week of therapy, during which there were no side effects attributable to ciprofloxacin, the organism was eradicated, and there was some clinical improvement. We recommend that 400 mg of intravenous ciprofloxacin every 8 hours be considered for treatment of difficult-to-treat gram-negative bacillary meningitis.

Salmonella meningitis and multiple cerebral abscesses in an infant.

The history of a 4-week-old infant with meningitis and multiple cerebral abscesses caused by Salmonella enteritidis is reported. Management included successful treatment with a prolonged course of antibiotics, including ciprofloxacin, neurosurgical drainage and long-term immunoglobulin supplements. No adverse effects of joint toxicity were detected.

Salmonella meningitis in Thai infants: clinical case reports.

Between June 1988 and September 1996 12 of 65 infants (18%) admitted to the Department of Pediatrics, Ramathibodi Hospital, Bangkok, Thailand with purulent meningitis were infected with Salmonella spp. Their ages ranged from 1.5 to 6 months. Six of the infants had diarrhoea, 9 had seizures, and 11 had subdural effusion or empyema. Six infants required surgical treatment; 2 had brain abscesses. Salmonella was recovered from the cerebrospinal fluid of 11 infants and from the subdural fluid of 10. Eight infants were successfully treated with cefotaxime alone or in combination with co-trimoxazole, one with co-trimoxazole, and one with the combination of co-trimoxazole and ampicillin. The duration of treatment was 6 weeks, except for one patient who had a large brain abscess and was treated for 8 weeks. The last 2 patients, despite the fact that the organisms were susceptible to cefotaxime, failed to respond clinically to appropriate doses of it. Both were cured after ciprofloxacin was added to the therapy. Ciprofloxacin is probably the drug of choice to be used in addition to the previously used antibiotics for severe cases of Salmonella meningitis in infants.

An outbreak of pneumonia and meningitis caused by a previously undescribed gram-negative bacterium in a hot spring spa.

An outbreak of infection caused by a previously undescribed Gram-negative bacterium affected people attending a hot (37 degrees C) spring spa in France in 1987. Thirty-five case of pneumonia and two cases of meningitis occurred. None of these patients died. Attack rates were significantly higher for patients above 70 years old and for male patients. An epidemiological comparison of the 26 hospitalized cases with 52 matched controls suggests that spa treatment early on the first day (OR = 4.8) and attendance at the vapour baths (OR = 10.7) were significant risk factors for acquiring the infection. Person-to-person spread was not thought to have occurred. The same bacterium was isolated from the hot spring water. All strains studied shows a single rRNA gene restriction pattern. Epidemiological data indicated that the thermal water was the source of infection. This outbreak stresses the need for increased surveillance of infections in people attending hot spring spas.