Rochester Criteria and Yale Observation Scale Score to Evaluate Febrile Neonates with Invasive Bacterial Infection.

BACKGROUND: Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis. OBJECTIVE: Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool. METHODS: Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age ≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool. RESULTS: Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis). CONCLUSION: Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study.

Prehospital Stroke Identification: Factors Associated with Diagnostic Accuracy.

BACKGROUND: Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to receive delayed in-hospital care. We aim at determining the diagnostic accuracy of Fire Department of New York (FDNY) EMS providers for stroke and identifying potential reasons for misdiagnosis. METHODS: Prehospital care reports of all patients transported by FDNY EMS to 3 hospitals from January 1, 2010, to December 31, 2011, were compared against the American Heart Association Get With The Guidelines (GWTG) database (reference standard) for the diagnosis of stroke. Age-adjusted logistic regression models were generated to explore prehospital patient characteristics which are associated with stroke misdiagnosis. RESULTS: Of 72,984 patient transports during the study period, 750 had a GWTG diagnosis of stroke, 468 (62%) of which were identified correctly in the field and 282 (38%) were missed. An additional 268 patients were misdiagnosed as stroke when in fact they had an alternative diagnosis. Overall sensitivity was 62.4% (95% confidence interval [CI], 58.9-65.8) and specificity was 99.6% (95% CI, 99.6-99.7). No patients who presented with unilateral weakness, facial weakness, or speech problems were missed, whereas patients with atypical complaints like general malaise, dizziness, and headache were more likely to be missed. Seizures led the EMS providers to both overcall a stroke and miss the diagnosis. CONCLUSIONS: FDNY EMS care providers missed more than a third of stroke cases. Seizures and other atypical presentations contribute significantly to stroke misdiagnosis in the field. Our findings highlight the need for better prehospital stroke identification methods.

Prehospital stroke scales in urban environments: a systematic review.

OBJECTIVE: To identify and compare the operating characteristics of existing prehospital stroke scales to predict true strokes in the hospital. METHODS: We searched MEDLINE, EMBASE, and CINAHL databases for articles that evaluated the performance of prehospital stroke scales. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We abstracted the operating characteristics of published prehospital stroke scales and compared them statistically and graphically. RESULTS: We retrieved 254 articles from MEDLINE, 66 articles from EMBASE, and 32 articles from CINAHL Plus database. Of these, 8 studies met all our inclusion criteria, and they studied Cincinnati Pre-Hospital Stroke Scale (CPSS), Los Angeles Pre-Hospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS), Ontario Prehospital Stroke Screening Tool (OPSS), Recognition of Stroke in the Emergency Room (ROSIER), and Face Arm Speech Test (FAST). Although the point estimates for LAPSS accuracy were better than CPSS, they had overlapping confidence intervals on the symmetric summary receiver operating characteristic curve. OPSS performed similar to LAPSS whereas MASS, Med PACS, ROSIER, and FAST had less favorable overall operating characteristics. CONCLUSIONS: Prehospital stroke scales varied in their accuracy and missed up to 30% of acute strokes in the field. Inconsistencies in performance may be due to sample size disparity, variability in stroke scale training, and divergent provider educational standards. Although LAPSS performed more consistently, visual comparison of graphical analysis revealed that LAPSS and CPSS had similar diagnostic capabilities.

Leukocytosis as prognostic indicator of major injury.

OBJECTIVE: To test the diagnostic use of the triage white blood cell (WBC) count in differentiating major from minor injuries. METHODS: We conducted a retrospective study of a prospectively collected database of trauma patients 13 years of age or older at a Level I trauma center from January 2005 through December 2008. We excluded all patients with obvious life-threatening injuries requiring immediate surgery, isolated head trauma, transferred from another institution or dead on arrival. We recorded age, sex, injury mechanism, vital signs, WBC, base deficit (BD), lactate (LAC) and calculated injury severity scores (ISS). Major injury was defined as either a change in hematocrit >10 points or blood transfused within 24 hours, or ISS >15. RESULTS: 805 patients were included in the study with an average age of 38.6 years (Range 13-95 yrs) years. 75.3% of patients were male, 45.6% had blunt and 34.4% had penetrating trauma. For vital signs, blood pressure was not significantly different between major and minor injury patients. Major compared to minor injury patients had a statistically but not clinically significant higher heart rate. Major injury patients had significantly (p < 0.0001) higher WBC count (10.53 K/µl, 95% CI: 9.7-11.3) compared to patients with minor injuries (8.92 K/µl, 95% CI: 8.7-9.2), but both were in the normal range. Patients with major compared to minor injury had significantly (p < 0.0001) higher BD (-3.1 versus -0.027 mmol/L) and higher LAC (3.9 versus 2.48 mmol/L). Areas under the curve for WBC count (0.60, 95% CI: 0.54-0.66) are similar to BD (0.69, 95% CI: 0.63-0.74) and LAC (0.66, 95% CI: 0.60-0.71). CONCLUSION: WBC count is not a useful addition as a diagnostic indicator of major trauma in our study population.

Penile discharge as a presentation of perirectal abscess.

Anorectal abscesses are a common presentation to the Emergency Department, but are frequently misdiagnosed. We report a patient in whom penile discharge was the presenting symptom of an ischiorectal abscess. A 42-year-old man presented with scrotal pain, swelling, and penile discharge. The genitourinary examination revealed a tender scrotum, and a fluctuant mass was identified on digital rectal examination. Computed tomography (CT) scan revealed an ischiorectal abscess with extension into the corpus cavernosum. We believe our patient's penile discharge was a manifestation of this abscess extension. Penile discharge is typically suggestive of sexually transmitted infections. Although rare, perirectal abscess should be considered in the differential diagnosis of penile discharge. A thorough digital rectal examination should be performed seeking the presence of mass or fluctuance.