A video-oculographic study of acute vestibular syndromes.

OBJECTIVES: To quantitate the vestibulo-ocular reflex (VOR) gain in patients with acute vestibular neuritis (VN) and repeat this daily using a portable video head impulse test device to assess vestibular recovery in the acute stage of VN. MATERIALS AND METHODS: We enrolled adults with symptoms and signs of VN presenting to the emergency department within 48 h of symptom onset. We recorded the eye movement response to rapid head impulses using the ICS Impulse(™) video head impulse test device on each day of their hospital admission. RESULTS: There were eight patients (75% men, aged 35-85 years) who had marked variation in their initial vestibulo-ocular reflex gains. Three patients had vestibulo-ocular reflex gains in the normal range initially, despite having physical signs of VN. Two patients had initial contralesional gains below the normal range, associated with markedly reduced ipsilesional gains. Most patients' vestibulo-ocular reflex gains increased during admission, but four patients' ipsilesional gains remained in the abnormal range. Patients with lower vestibulo-ocular reflex gains were less likely to improve into the normal range. No patient with initially abnormal VOR gain recovered normal vestibulo-ocular reflex gain along with resolution of physical signs. CONCLUSION: Early video head impulse testing in the emergency department and each day of admission is feasible and well tolerated. There is marked variation in VOR gain in patients with symptoms and signs of VN, and low initial VOR gains are a predictor for low VOR gains on subsequent days. Improvement in VOR gains was seen in most patients.

Dipstick urinalysis and the accuracy of the clinical diagnosis of urinary tract infection.

The aim of this study was to determine whether dipstick urinalysis (DU) augmented the accuracy of clinical assessment in the diagnosis of urinary tract infection (UTI). The study was performed in 627 consecutive patients attending an adult emergency department (ED) in whom the clinical diagnosis of UTI was considered. We excluded 227 patients. Treating clinicians gave the probability of a UTI on an ordinal and continuous scale, before and after DU. The assigned clinical probabilities were then compared to the results of formal urine culture. The areas under receiver-operating characteristic curves (AUC) were calculated. We found that clinical assessment alone was effective in detecting those patients with a UTI from those without (AUC 0.75; p < 0.0001). There was, however, a statistically significant difference in the accuracy of diagnosing UTI after DU (AUC 0.87; p < 0.0001). Proportionately more patients with a moderate pre-test probability of UTI were re-assigned to a different probability rating following DU, compared to the low or high pre-test probability groups (p < 0.001). We conclude that DU in combination with clinical assessment is a superior method for diagnosing UTI than clinical assessment alone.