Clinical impression and ascites appearance do not rule out bacterial peritonitis.

BACKGROUND: Previous research has demonstrated that physician clinical suspicion, determined without assessing fluid appearance, is not adequate to rule out spontaneous bacterial peritonitis (SBP) without fluid testing. STUDY OBJECTIVE: To determine the sensitivity of physician clinical suspicion, including a bedside assessment of fluid appearance, in the detection of SBP in Emergency Department (ED) patients undergoing paracentesis. METHODS: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis at three academic facilities. The enrolling physician recorded the clinical suspicion of SBP ("none," "low," "moderate," or "high"), and ascites appearance ("clear," "hazy," "cloudy," or "bloody"). SBP was defined as an absolute neutrophil count ≥ 250 cells/mm(3), or culture pathogen growth. We defined "clear" ascites fluid as negative for SBP, and "hazy," "cloudy," or "bloody" as positive. A physician clinical suspicion of "none" or "low" was considered negative for SBP, and an assessment of "moderate" or "high" was considered positive. The primary outcome measure was sensitivity of physician clinical impression and ascites appearance for SBP. RESULTS: There were 348 cases enrolled, with SBP diagnosed in 43 (12%). Physician clinical suspicion had a sensitivity of 42% (95% confidence interval [CI] 29-55%) for the detection of SBP. Fluid appearance had a sensitivity of 72% (95% CI 58-83%). CONCLUSION: Physician clinical impression, which included an assessment of fluid appearance, had poor sensitivity for the detection of SBP and cannot be used to exclude the diagnosis. Routine laboratory fluid analysis is indicated after ED paracentesis, even in patients considered to have a low degree of suspicion for SBP.

Physician clinical impression does not rule out spontaneous bacterial peritonitis in patients undergoing emergency department paracentesis.

STUDY OBJECTIVE: We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis. METHODS: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm(3) or positive fluid culture result. RESULTS: There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization. CONCLUSION: Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.

Experience-dependent asymmetric variation in primate prefrontal morphology.

Theories of human development suggest that experiences embedded in social relationships alter prefrontal brain systems that mediate emotional self-regulation. This study tests for experience-dependent effects on prefrontal gray and white matter volumes determined in 39 young adult monkeys (Saimiri sciureus) 4 years after conditions that modified early maternal availability. These conditions were previously shown to alter subsequent measures of emotional behavior, social propensities, and hypothalamic-pituitary-adrenal axis stress physiology. Here we identify significant differences in right but not left adult prefrontal volumes, with experience-dependent asymmetric variation most clearly expressed in ventral medial cortex measured in vivo by magnetic resonance imaging (MRI). Follow-up studies now need to determine whether maternal availability directly affects or interacts with subsequent experiences to alter prefrontal substrates of emotional processing and sensitivity to stress.