Jennifer H. Chao

Point-of-Care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections

BACKGROUND Traditionally, emergency department (ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft tissue infections (SSTI). Management of an abscess requires incision and drainage, whereas cellulitis generally requires a course of antibiotics. Misdiagnosis often results in unnecessary invasive procedures, sedations (for incision and drainage in pediatric patients), or a return ED visit for failed antibiotic therapy. OBJECTIVE The objective was to describe the operating characteristics of point-of-care ultrasound (POCUS) compared to clinical examination in identifying abscesses in ED patients with SSTI. METHODS We systematically searched Medline, Web of Science, EMBASE, CINAHL, and Cochrane Library databases from inception until May 2015. Trials comparing POCUS with clinical examination to identify abscesses when evaluating SSTI in the ED were included. Trials that included intraoral abscesses or abscess drainage in the operating room were excluded. The presence of an abscess was defined by drainage of pus. The absence of an abscess was defined as no pus drainage upon incision and drainage or resolution of SSTI without pus drainage at follow-up. Quality of trials was assessed using the QUADAS-2 tool. Operating characteristics were reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-), with their respective 95% confidence intervals (CI). Summary measures were calculated by generating a hierarchical summary receiver operating characteristic (HSROC) model. RESULTS Of 3,203 references identified, six observational studies (four pediatric trials and two adult trials) with a total of 800 patients were included. Two trials compared clinical examination with clinical examination plus POCUS. The other four trials directly compared clinical examination to POCUS. The POCUS HSROC revealed a sensitivity of 97% (95% CI = 94% to 98%), specificity of 83% (95% CI = 75% to 88%), LR+ of 5.5 (95% CI = 3.7 to 8.2), and LR- of 0.04 (95% CI = 0.02 to 0.08). CONCLUSION Existing evidence indicates that POCUS is useful in identifying abscess in ED patients with SSTI. In cases where physical examination is equivocal, POCUS can assist physicians to distinguish abscess from cellulitis.

Posterior urethral valves diagnosed by bedside ultrasound in the ED

Posterior urethral valves are the most common cause of urinary obstruction in male children. Presentations of posterior urethral valves beyond the neonatal period include urinary tract infection, abdominal mass, renal failure,diminished urinary stream, crying during micturition,incontinence, dysuria, hematuria, or failure to thrive. Early diagnosis is imperative because early surgical relief of the obstruction is believed to help prevent the progression to endstage renal disease.This case serves to remind us that, in the male child who presents with urinary symptoms and/or abdominal symptoms,the bedside sonogram is a valuable tool that can clarify the diagnosis and expedite care.

Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department

AIM To determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) in young men seeking care in the emergency department (ED) for non-sexually transmitted infection (STI) related symptoms. METHODS This was a prospective, cross-sectional study in an urban ED. The main outcome was the rate of positive CT and GC on urine nucleic acid amplification testing in males aged 16-21 presenting with non-STI related complaints. RESULTS Two hundred and eighty-four patients were enrolled, 271 were included in the final data analysis [age range 16-21, median: 18 (quartiles 16-18, 19-21)]. Overall, 17 (6.3%, 95%CI: 4%-10%) tested positive for CT and 0% (95%CI: 0%-2%) were found to have GC. The proportion of sexually active subjects was 71% (95%CI: 65%-76%) and 2% (95%CI: 0.6%-4%) reported sex with men. Previous STI testing was reported in 46% (95%CI: 43%-54%) and 13% (95%CI: 8%-20%) of those patients previously tested had a history of STI. Of the patients who tested positive for CT in the ED, 88% (95%CI: 64%-98%) were successfully followed up. CONCLUSION The prevalence of CT infection found by screening was 6.3%. Screening and follow-up from the ED was successful. The findings justify routine STI screening in male adolescents presenting to the ED with non-STI related complaints.

Is Nebulized Hypertonic Saline Solution Effective for Acute Bronchiolitis

Annals of Emergency Medicine - In Press.Proof corrected by the author Available online since dimanche 21 aout 2016

Comparison of lung ultrasonography and chest radiography for diagnosis of childhood pneumonia

This was a prospective cohort study to determine the interrater reliability (IRR) of lung ultrasonography (LUS) and chest radiography (CXR), and evaluate the accuracy of LUS compared with CXR for detecting pediatric pneumonia compared with chest computed tomography (CT) scan. Children aged 3 months to 18 years with a CXR and LUS performed with or without a clinical diagnosis of pneumonia were included in the study. Four pediatric radiologists blinded to clinical information reported findings for the CXR and LUS images, and two radiologists reviewed CT scans to determine an overall finding. IRR was estimated for 50 LUS and CXR images. The main outcome was the finding from CT ordered clinically or the probability of the CT finding for patients clinically requiring CT. Latent class analysis was used to evaluate the sensitivity and specificity for findings (eg, consolidation) for LUS and CXR compared with CT.

Does This Emergency Department Patient Have a Penicillin Allergy

Methods Data Sources An English-language MEDLINE search from 1996 to 2000 was conducted, and the bibliographies were reviewed for additional references. Study Selection Original studies describing the accuracy or precision of skin testing in the diagnosis of an immunoglobulin E–mediated penicillin allergy were included. Fourteen studies met the inclusion criteria; 4 studies compared clinical history with skin test results in patients with and without a history of penicillin allergy. Data Extraction and Synthesis Confidence intervals for the likelihood ratios of having a positive skin test result, given a positive history of penicillin allergy, and having a negative skin test result, given a history of no penicillin allergy, were compared. Sensitivity and specificity for a history of penicillin allergy versus skin testing were also presented.