Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management.

IMPORTANCE: Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to parents. A variety of practitioners, including obstetrician-gynecologists and pediatricians, may be asked to see patients with this presenting complaint, yet many do not receive adequate training in pediatric gynecology. EVIDENCE ACQUISITION: Review of the published literature in PubMed, focusing on the last 20 years, regarding the incidence, etiologies, diagnosis, and management strategies for the common causes of prepubertal vaginal bleeding. RESULTS: Careful history taking and pediatric-specific gynecological examination skills, including awareness of normal anatomy across the age spectrum and the ability to identify an estrogenized hymen, are keys to the appropriate assessment of this clinical problem. CONCLUSIONS AND RELEVANCE: Prepubertal vaginal bleeding has many causes and requires a thorough targeted history and pediatric genitourinary examination, requiring knowledge of the variants of normal pediatric genitourinary anatomy. Most causes can be easily treated and are less likely to be due to sexual abuse or malignancy.

Five-level triage system more effective than three-level in tertiary emergency department.

INTRODUCTION: The study objectives were to compare reliability and validity of a 3-level (3L) triage system with a new 5-level (5L) triage system and determine the effect of nursing experience on triage reliability. METHODS: The study was conducted in a southeastern tertiary emergency department. With a stratified random sample, reliability of 3L triage ratings was measured with weighted kappa (time 1). The 5L system was then implemented, and weighted kappa was remeasured (time 2). Validity was assessed by comparing case mix, sensitivity, and specificity at times 1 and 2, and comparing 5L ratings with physician billing (Evaluation and Management) codes and nursing resource intensity at time 2. RESULTS: Time 1 case mix (15,324 patients) was: level 1, 6%; level 2, 36%; level 3, 59%, and time 2 (16,024 patients) was: level 1, 1%; level 2, 8%; level 3, 38%; level 4, 41%; level 5, 13%. Three hundred-five triage ratings were evaluated from time 1, and 303 were evaluated from time 2. Weighted kappa was 0.53 for time 1 and 0.68 for time 2. Spearman correlations were: 5L and nursing resource intensity, 0.55 (P <.0001); and 5L and Em, 0.57 (P <.0001). Sensitivity was 58% for the 3L and 68% for the 5L. Specificity was 83% for the 3L and 91% for the 5L. Under-triage rates were 28% for the 3L and 12% for the 5L, and less-experienced nurses were more likely to under-triage using the 3L system. DISCUSSION: The 5L triage system is safer and provides greater discrimination, better reliability, and improved sensitivity and specificity than the 3L triage system.