Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Review Meta Analysis
Can emergency physicians accurately rule out a central cause of vertigo using the HINTS exam? A systematic review and meta-analysis.
Dizziness is a common complaint presented in the emergency department (ED). A subset of these patients will present with acute vestibular syndrome (AVS). AVS is a clinical syndrome defined by the presence of vertigo, nystagmus, head motion intolerance, ataxia, and nausea/vomiting. These symptoms are most often due to benign vestibular neuritis; however, they can be a sign of a dangerous central cause, i.e., vertebrobasilar stroke. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has been proposed as a bedside test for frontline clinicians to rule out stroke in those presenting with AVS. Our objective was to assess the diagnostic accuracy of the HINTS examination to rule out a central cause of vertigo in an adult population presenting to the ED with AVS. Our aim was to assess the diagnostic accuracy when performed by emergency physicians versus neurologists. ⋯ The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.
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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged as a global pandemic in early 2020 with rapidly evolving approaches to diagnosing the clinical illness called coronavirus disease (COVID-19). The primary objective of this scoping review is to synthesize current research of the diagnostic accuracy of history, physical examination, routine laboratory tests, real-time reverse transcription-polymerase chain reaction (rRT-PCR), immunology tests, and computed tomography (CT) for the emergency department (ED) diagnosis of COVID-19. Secondary objectives included a synopsis of diagnostic biases likely with current COVID-19 research as well as corresponding implications of false-negative and false-positive results for clinicians and investigators. ⋯ With the exception of fever and disorders of smell/taste, history and physical examination findings are unhelpful to distinguish COVID-19 from other infectious conditions that mimic SARS-CoV-2 like influenza. Routine laboratory tests are also nondiagnostic, although lymphopenia is a common finding and other abnormalities may predict severe disease. Although rRT-PCR is the current criterion standard, more inclusive consensus-based criteria will likely emerge because of the high false-negative rate of PCR tests. The role of serology and CT in ED assessments remains undefined.
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Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group. ⋯ Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.
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Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group. ⋯ Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.
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Meta Analysis
Accuracy of Signs and Symptoms for the Diagnosis of Community-acquired Pneumonia: A Meta-analysis.
Community-acquired pneumonia (CAP) is an important source of morbidity and mortality. However, overtreatment of acute cough illness with antibiotics is an important problem, so improved diagnosis of CAP could help reduce inappropriate antibiotic use. ⋯ While most individual signs and symptoms were unhelpful, selected signs and symptoms are of value for diagnosing CAP. Teaching and performing these high value elements of the physical examination should be prioritized, with the goal of better targeting chest radiographs and ultimately antibiotics.