Management of patients with cervical spine trauma in the emergency department: a systematic critical appraisal of guidelines with a view to developing standardized strategies for clinical practice.

Several guidelines on the evaluation of patients with suspected cervical spine trauma in the Emergency Department (ED) exist. High heterogeneity between different guidelines has been reported. Aim of this study was to find areas of agreement and disagreement between guidelines, to identify topics in which further research is needed and to provide an evidence-based cervical spine trauma algorithm for ED physicians. The three most relevant guidelines published on cervical spine trauma in the last 10 years were selected screening websites of the main scientific societies and through the comparison of a normalized Google Scholar and SCOPUS citation index. We compared the selected guidelines through seven a-priori defined questions. In case of disagreement between the guidelines or if the quality of evidence appeared low, evidence from published systematic reviews on the topic was added to build an evidence-based algorithm for approach to spinal trauma in the ED. The three selected guidelines were: NICE 2016, Eastern Association for the Surgery of Trauma 2009 and American Association of Neurological Surgeons and Congress of Neurological Surgeons 2013. We found complete agreement on one question, partial agreement for one questions, no agreement for two questions, while agreement was not assessable for 3 questions. The agreement between different guidelines and the evidence on which recommendations are based is low. An attempt to build an evidence-based algorithm has been made. More studies are needed on many topics.

Multicentre external validation of the Canadian Syncope Risk Score to predict adverse events and comparison with clinical judgement.

BACKGROUND: The Canadian Syncope Risk Score (CSRS) has been proposed for syncope risk stratification in the emergency department (ED). The aim of this study is to perform an external multicenter validation of the CSRS and to compare it with clinical judgement. METHODS: Using patients previously included in the SyMoNE database, we enrolled subjects older than 18 years who presented reporting syncope at the ED. For each patient, we estimated the CSRS and recorded the physician judgement on the patients' risk of adverse events. We performed a 30-day follow-up. RESULTS: From 1 September 2015 to 28 February 2017, we enrolled 345 patients; the median age was 71 years (IQR 51-81), 174 (50%) were men and 29% were hospitalised. Serious adverse events occurred in 43 (12%) of the patients within 30 days. The area under the curve of the CSRS and clinical judgement was 0.75 (95% CI 0.68 to 0.81) and 0.68 (95% CI 0.61 to 0.74), respectively. The risk of adverse events of patients at low risk according to the CSRS and clinical judgement was 6.7% and 2%, with a sensitivity of 70% (95% CI 54% to 83%) and 95% (95% CI 84% to 99%), respectively. CONCLUSION: This study represents the first validation analysis of CSRS outside Canada. The overall predictive accuracy of the CSRS is similar to the clinical judgement. However, patients at low risk according to clinical judgement had a lower incidence of adverse events as compared with patients at low risk according to the CSRS. Further studies showing that the adoption of the CSRS improve patients' outcomes is warranted before its widespread implementation.

Diagnostic Accuracy of Carotid Doppler Ultrasound for the Detection of Right-to-Left Cardiac Shunt.

BACKGROUND: Right-to-left cardiac shunt is a condition anatomically related to patent foramen ovale (PFO) and potentially related to cryptogenic cerebrovascular events. As recent studies demonstrated a reduction of recurrent stroke in patients undergoing percutaneous PFO closure after a cryptogenic cerebrovascular event, it is now of pivotal importance to screen these patients for Right-to-left shunt(RLS) presence. At this regard, transcranial color Doppler (TCCD) with contrast has a good sensitivity (97%) and specificity (93%) compared to transesophageal echocardiography and became the test of choice to assess RLS presence, thanks to its noninvasive nature. However, temporal bone window is not accessible in 6%-20% patients. Several approaches have been explored to overcome this limitation with encouraging but not definitive results for extracranial internal carotid artery (ICA) approach, proposed in previous pivotal studies. Aims of this study were to further assess the diagnostic accuracy of ICA Doppler ultrasound with contrast for RLS detection compared to TCCD, with the two tests performed simultaneously. MATERIALS AND METHODS: Sixty-four patients underwent simultaneously to TCCD and ICA Doppler ultrasound, both performed at rest and after Valsalva maneuver. Diagnosis of RLS was made, both for TCCD and ICA ultrasound, if=1 microembolic signals (MES) were detected during the examination (either at rest or after Valsalva maneuver). RESULTS: ICA Doppler ultrasound sensitivity and specificity resulted respectively of 97% (confidence interval [CI] 95%) and 100% ([CI] 95%), while negative likelihood ratio was 0.03 (CI 95%). CONCLUSIONS: ICA Doppler ultrasound represents a valid alternative to TCCD for RLS screening in patients without adequate transcranial acoustic window.

Secondary prevention of cryptogenic stroke in patients with patent foramen ovale: a systematic review and meta-analysis.

The aim of our study is to compare patent foramen ovale (PFO) closure versus medical treatment and antiplatelet versus anticoagulant therapy in patients with cryptogenic stroke (CS) and PFO. We conducted a systematic review and meta-analysis with trial sequential analysis (TSA) of randomized trials. Primary outcomes are stroke or transient ischemic attack (TIA) and all-cause mortality. Secondary outcomes are peripheral embolism, bleeding, serious adverse events, myocardial infarction and atrial dysrhythmias. We performed an intention to treat meta-analysis with a random-effects model. We include six trials (3677 patients, mean age 47.3 years, 55.8% men). PFO closure is associated with a lower recurrence of stroke or TIA at a mean follow-up of 3.88 years compared to medical therapy [risk ratio (RR) 0.55, 95% CI 0.38-0.81; I2 = 40%]. The TSA confirms this result. No difference is found in mortality (RR 0.74, 95% CI 0.35-1.60; I2 = 0%), while PFO closure is associated with a higher incidence of atrial dysrhythmias (RR 4.55, 95% CI 2.16-9.60; I2 = 25%). The rate of the other outcomes is not different among the two groups. The comparison between anticoagulant and antiplatelet therapy shows no difference in terms of stroke recurrence, mortality and bleeding. There is conclusive evidence that PFO closure reduces the recurrence of stroke or TIA in patients younger than 60 years of age with CS. More data are warranted to assess the consequences of the increase in atrial dysrhythmias and the advantage of PFO closure over anticoagulants.