Annals of emergency medicine
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Multicenter Study Comparative Study
Nontraumatic subarachnoid hemorrhage in the setting of negative cranial computed tomography results: external validation of a clinical and imaging prediction rule.
Clinical variables can reliably exclude a diagnosis of nontraumatic subarachnoid hemorrhage in patients with negative cranial computed tomography (CT) results. We externally validated 2 decision rules with 100% reported sensitivity for a diagnosis of subarachnoid hemorrhage, among patients undergoing lumbar puncture after a negative cranial CT result: (1) clinical rule: presence of any combination of age 40 years and older, neck pain or stiffness, loss of consciousness, or headache onset during exertion; and (2) imaging rule: cranial CT performed within 6 hours of headache onset. ⋯ The clinical rule demonstrated useful Bayesian test characteristics when retrospectively validated against this patient cohort. The imaging rule, however, failed to identify 20% of subarachnoid hemorrhage patients with a negative cranial CT result.
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Comparative Study
Diagnostic accuracy and use of nonmydriatic ocular fundus photography by emergency physicians: phase II of the FOTO-ED study.
During the first phase of the Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department study, 13% (44/350; 95% confidence interval [CI] 9% to 17%) of patients had an ocular fundus finding, such as papilledema, relevant to their emergency department (ED) management found by nonmydriatic ocular fundus photography reviewed by neuro-ophthalmologists. All of these findings were missed by emergency physicians, who examined only 14% of enrolled patients by direct ophthalmoscopy. In the present study, we evaluate the sensitivity of nonmydriatic ocular fundus photography, an alternative to direct ophthalmoscopy, for relevant findings when photographs are made available for use by emergency physicians during routine clinical care. ⋯ Emergency physicians used nonmydriatic fundus photographs more frequently than they performed direct ophthalmoscopy, and their detection of relevant abnormalities improved. Ocular fundus photography often assisted ED care even when results were normal. Nonmydriatic ocular fundus photography offers a promising alternative to direct ophthalmoscopy.