Penicillin Reintroduction Using the PEN-FAST Score Reduces Infectious Complications in Maxillofacial Surgery.

Background: Retrograde intrarenal surgery (RIRS) has become an established minimally invasive treatment for kidney stones, particularly in cases where extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy are unsuitable. However, stone-free (SF) outcomes vary, and identifying preoperative factors associated with success remains essential for improving patient selection and surgical planning. Objective: To identify factors associated with SF outcomes after RIRS and to develop a simple model-based clinical decision rule using preoperative variables. Materials and Methods: The present study was a retrospective study that included 114 patients who underwent RIRS. Baseline characteristics were compared between SF and non-stone-free (non-SF) groups. All variables were screened using bivariate logistic regression, and those with significant results were included in a multivariable analysis. Model performance was evaluated using standard statistical measures, and a simple decision rule was constructed from key preoperative factors. Results: Stone diameter was independently associated with SF outcomes (AOR 0.86, 95% CI 0.76 to 0.98, p=0.024). Prior open surgery (AOR 0.09, 95% CI 0.01 to 1.21, p=0.070) and log-transformed estimated blood loss (AOR 0.29, 95% CI 0.07 to 1.11, p=0.071) showed borderline associations. The final model demonstrated good discriminative performance (AUC 0.87) and acceptable calibration (Hosmer-Lemeshow, p=0.47). A simple decision rule incorporating kidney stone diameter and surgical history stratified patients into low- and high-risk groups, with residual fragment rates of 12.0% and 33.7%, respectively. Conclusion: Preoperative factors, particularly stone diameter and prior surgical history, play a key role in SF outcomes after RIRS. A simple clinical rule based on these variables may support risk stratification and guide patient counseling in routine practice.

The global challenge of population aging continues to intensify. Current estimates project that by 2050, the world's population will approach 10billion, with elderly people comprising an estimated 1.6billion individuals. Due to age-related immunosenescence, older adults face a significantly elevated risk of serious influenza complications compared to younger individuals. During influenza epidemic seasons, determining the appropriate disposition (discharge, hospital admission or Intensive Care Unit admission) of elderly patients with influenza presents a significant challenge. In 2018, Chung et al. developed the Geriatric Influenza Death (GID) score as a potential clinical decision rule to aid clinical decision-making for older adults with influenza. We conducted this study to externally validate the GID score. In this prospective cohort study geriatric patients (aged ≥ 65 years) presenting to the Emergency Department (ED) between September 2023 and March 2024 with fever, cough, and a positive influenza test were enrolled using convenience sampling. Patients were excluded if they left against medical advice or lacked sufficient data for scoring. The GID score was calculated for each patient using clinical and laboratory data: severe coma (2 scores), history of cancer or coronary artery disease, elevated C-Reactive Protein, bandemia (1 score each). Based on the GID score, patients were categorized into low (0-1), medium [2], or high-risk (≥ 3) groups. The primary outcome was 30-day all-cause mortality. Performance of the score was assessed using the area under the receiver operating characteristic curve (AUC). Of 378 patients screened, 120 met inclusion criteria. Thirty-day mortality rates increased with the GID score: 15.9% for score 1, 41.7%% for score 2, and 44.4% for score 3. When used for predicting mortality, the GID score with a threshold of ≥ 2 demonstrated moderate performance with an AUC of 0.66 (95% Confidence Interval: 0.53-0.83) and sensitivity and specificity of 70.6% and 61.6%, respectively. In summary, the GID score offers a practical and efficient method for predicting 30-day mortality and informing disposition decisions for older ED patients with influenza.

Background/IntroductionCurrent breathlessness evaluation protocols rely primarily on clinical expertise and biomarker interpretation, achieving variable diagnostic accuracy across healthcare settings. Traditional protocols focus on diagnostic efficiency without systematically addressing patient empowerment, healthcare equity, or integration of safety, understanding, research, authenticity, ethics, and technology principles. Emergency department protocols for heart failure diagnosis demonstrate accuracy limitations with sensitivity ranging 65-66% using conventional approaches, while specialist interpretation varies significantly with Fleiss's kappa of 0.46 indicating moderate agreement among clinicians [1].PurposeTo develop and apply the CURACO framework (Clinical safety, Understanding, Research-informed care, Authentic patient-centred approaches, Conscientious ethics, and Optimised technology) for systematic enhancement of existing breathlessness evaluation protocols. We aimed to demonstrate framework utility in transforming traditional diagnostic approaches into patient-centred, ethically robust clinical tools.MethodsWe developed the CURACO framework through systematic integration of six foundational principles: safety-first protocols ensuring patient protection, understanding enhancement through patient education, research-informed guidelines incorporating evidence-based practices, authentic patient-centred approaches respecting individual values, conscientious ethics addressing healthcare equity, and optimized technology facilitating collaboration. The framework was applied to analyse existing breathlessness protocols, including BNP-based algorithms, clinical decision rules, and imaging-guided approaches.ResultsCURACO framework application revealed significant enhancement opportunities in existing breathlessness protocols. Current approaches demonstrate substantial diagnostic accuracy variations: BNP testing achieves sensitivity of 94.1% and specificity of 74.5% for cardiac dyspnoea [2], while AI-enhanced protocols reach 96.5% overall accuracy [1]. Framework analysis identified critical gaps in patient understanding components, with studies showing variable clinician interpretation accuracy (Fleiss's kappa 0.46) [1]. Bedside ultrasonography protocols showed superior performance (AUC 86.4%) compared to traditional BNP approaches (AUC 66.3%) [2], yet lack systematic ethical integration.ConclusionThe CURACO framework provides systematic methodology for enhancing existing breathlessness evaluation protocols through ethical integration and patient-centred design. This approach transforms traditional diagnostic protocols into comprehensive tools serving both clinical excellence and healthcare equity. While this framework development shows broad applicability, prospective validation studies across multiple healthcare settings are needed to establish implementation effectiveness.

Prehospital spinal immobilization and motion restriction strategies: A scoping review of the literature.

Development of a new clinical prediction rule for candidaemia.

Background Spinal epidural abscess (SEA) is a serious complication of Staphylococcus aureus bacteraemia (SAB) that can be difficult to diagnose. We aimed to describe the proportion of SAB cases with SEA and evaluate useful history or physical exam findings to help diagnose SEA. Methods This single-centre retrospective cohort study included consecutive SAB patients from 2021 to 2023. The index tests included risk factors, symptoms and signs of SEA as documented in patient charts. The reference standard was diagnosis of SEA based on spinal MRI or intra-operative finding during 90-day follow-up. Results Of 357 SAB patients, 29 (8.1%) patients had a SEA. Saddle anaesthesia, radicular pain, numbness or paresthaesia, and spine tenderness were most useful to rule in SEA based on positive likelihood ratio (PLR) of 22.6, 13.8, 9.9 and 7.5 respectively. Absence of acute back pain, no objective limb weakness, no subjective limb weakness and no spine tenderness were most useful to rule out SEA based on negative likelihood ratio (NLR) of 0.19, 0.46, 0.57, and 0.62 respectively. A clinical prediction rule based on these findings had a sensitivity of 97% (95% CI 83%-100%), specificity of 77% (95% CI 73%-82%), PLR of 4.3 (95% CI 3.5–5.3) and NLR of 0.05 (95% CI 0.01–0.31). Conclusions All SAB patients should undergo systematic neurologic evaluation for SEA as we found SEA is not an uncommon complication of SAB. A clinical prediction rule may be helpful to identify high-risk patients needing an urgent spinal MRI to assess for SEA.

The age-adjusted D-dimer cutoff (age × 10 µg/L in patients 50 years or older), safely increases the diagnostic yield of D-dimer in patients with suspected pulmonary embolism but has not been validated in patients with suspected leg deep vein thrombosis (DVT). To prospectively validate whether using an age-adjusted D-dimer cutoff allows clinicians to safely rule out DVT. Multicenter, multinational prospective management outcome study conducted in 27 centers in Belgium, Canada, France, and Switzerland between January 2015 and October 2022 (last follow-up visit, January 30, 2023) and including outpatients presenting to the emergency department with suspected DVT. Patients were assessed by a sequential diagnostic strategy based on the assessment of clinical pretest probability by the Wells score, a highly sensitive D-dimer test, and leg compression ultrasonography. Patients in whom DVT was ruled out were followed up for a 3-month period. The primary outcome was the rate of adjudicated symptomatic venous thromboembolic events during follow-up in patients in whom DVT was ruled out based on a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff. A total of 3205 patients were included. Median age was 59 years, and 1737 (54%) were female. DVT prevalence was 14%. Among the 2169 patients with a non-high or unlikely clinical probability, 531 (24.5% [95% CI, 22.7%-26.4%]) had a D-dimer level less than 500 µg/L, and 161 additional patients (7.4% [95% CI, 6.4%-8.6%]) had a D-dimer level between 500 µg/L and their age-adjusted cutoff. No failures were identified in patients with a D-dimer level 500 µg/L or greater but below the age-adjusted cutoff (0% [95% CI, 0%-2.3%]). Among patients 75 years or older, using the age-adjusted cutoff instead of the 500-µg/L cutoff increased the proportion of negative D-dimer from 33 of 379 (8.7% [95% CI, 6.3%-12.0%]) to 99 of 379 (26.1% [95% CI, 22.0%-30.8%]), without any false-negative test results. The age-adjusted D-dimer cutoff may safely rule out DVT and was associated with a larger number of patients in whom DVT could be effectively ruled out. ClinicalTrials.gov Identifier: NCT02384135.

ObjectiveThe aim of this study was to assess the variation in the use of head computed tomography (CT) scan in patients attending EDs with ground-level fall-related minor head injury. Secondary objectives were: i) to measure the prescription rate of appropriate head CT scan, ii) to identify patients’ and EDs characteristics associated with head CT scan prescription iii) to explore potential correlation between head CT scan use and traumatic intracranial hemorrhage (ICH) yield rate in this population.Materials and methodsThis research was a planned sub-analysis of a cross-sectional prospective multicentric study performed in 63 EDs in France (EPI-TC study). Patients sustaining ground-level fall-related with minor head injury were included in this sub-analysis. The main outcome was head CT scan performed during ED stay. Variations in the use of head CT scan were described depending on each ED and French region. Multiple fixed effects mixed logistic regression model was performed to identify factors associated with head CT scan.ResultsA total of 631 patients admitted for head injury after ground-level fall were included. Median age was 79 [63–88] years. A head CT scan was performed in 409 patients (64.8%, CI95% 61.0–68.5); 19.6% (CI95% 15.8–23.7) of them were appropriated; and 29 (7.1%, CI95% 4.8–10.0) showed a traumatic ICH. At regional level, head CT scan prescription rate ranged from 45.5% (CI95%: 24.4–67.8) to 84.6% (CI95% 54.5–98.1). Head CT scan use was not correlated with the yield rate of traumatic ICH. In multivariable analysis, preinjury antiplatelets (OR 29.2, CI95%: 12.2–69.9), anticoagulants (OR 69.9, CI95%: 20.0–243.9), syncope (OR 6.9, CI95%: 2.0–24.2), post-trauma amnesia (3.2, CI95%: 1.0–10.5) and post-trauma loss of consciousness (OR 5.6, CI95%: 2.0–15.9) were associated with head CT scan use.ConclusionsHead CT scan use in patient presenting to EDs with head injuries after ground-level falls is highly variable. High rate of head CT scan use is not correlated with high traumatic intracranial hemorrhage yield rate. The use of a clinical decision rule dedicated to this population would be suitable for harmonizing our practices.

Personalized risk assessment of frailty in long-term cancer survivors.

Measurable residual disease intervention in AML: a new therapeutic horizon.

This article evaluates the effectiveness and implementation of two clinical decision rules for assessing cervical spine injuries after blunt trauma: the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR). Both rules aim to reduce unnecessary imaging, which can be costly and expose patients to radiation, by identifying individuals at low risk who do not require cervical spine CT. The five NEXUS criteria are easy to apply but may have inconsistent interpretations. Although more complex and time-consuming, the CCR provides a structured algorithm to more effectively reduce unnecessary imaging. Both rules have high sensitivity for detecting clinically significant injuries. Potential pitfalls include incomplete documentation and variability in clinician interpretation, emphasizing the importance of proper training in implementing these rules. The American College of Radiology recommends CT as the initial imaging method for adults meeting NEXUS or CCR criteria. Pediatric clinical decision support rules vary by patient age and may use radiography and MRI in different instances, but older children are typically assessed like adults. With the increased availability of cervical spine CT, it is essential to improve imaging decisions with respect to patient impact and health care costs while minimizing radiation exposure, especially in younger patients.

The impact of previous head trauma and history of cranial surgery on clinical findings in acute pediatric head injury.

Radiation exposure, transition delays and costs associated with unnecessary imaging in children have stimulated research into clinical decision rules and other interventions to reduce imaging in the emergency department (ED). The objective of this systematic review is to examine the effectiveness of implementing interventions to reduce imaging in children with upper/lower extremity injuries in the ED. Seven databases and the grey literature were searched up to May 2024. Comparative studies assessing interventions to reduce imaging in children with upper/lower extremity injuries implemented in the ED were eligible. Two independent reviewers screened for study eligibility, quality assessment and data extraction, with disagreements settled via third-party adjudication. Changes in imaging are reported as ORs with 95% CIs, using a random effects model. From 9387 citations, eight unique studies enrolling 7793 children were included with the majority using a before-after design. Potential concerns for bias were documented due to a lack of reporting of key quality domains. Decision rules for ankle injuries successfully reduced radiography (OR=0.11; 95% CI 0.07 to 0.16, I2=38%). A decision rule for wrist injuries reduced imaging (OR=0.06; 95% CI 0.03 to 0.11); however, eight injuries were missed. Two studies implementing clinical guidelines reported decreases in radiographs per patient (p<0.001). One trial reported increased imaging in children assessed by triage nurses using an established clinical decision rule (OR=5.44; 95% CI 2.96 to 10.02), with 16 missed injuries identified. Guidelines incorporating clinical decision rules, particularly decision rules for ankle injuries, can reduce radiography for children with extremity injuries in the ED. Further investigations are warranted to identify other extremity injuries, the components of the intervention and the most efficient clinicians to target. CRD42016042875.

ABSTRACT Objective This study expands on the Montefiore Einstein Robust Geriatric (MERGER) norms by providing normative data for two word reading tests (WTAR, AMNART). We also developed regression-based prediction formulas for these tests using demographics and a novel measure of cognitive literacy engagement, establishing base rates for discrepancies between actual and predicted scores. Discrepancy base rates for global cognition, derived from regression-based norms using word reading and demographic factors, were also examined to support detection of cognitive decline. Method The MERGER sample included 420 community-dwelling older adults. Backward regression analyses predicted WTAR and AMNART scores. Base rates were calculated for discrepancies on the WTAR, AMNART, and the RBANS Global Cognition Index (GCI). One-way ANOVAs compared discrepancy scores across MERGER, mild cognitive impairment (MCI), and dementia groups. Clinically meaningful cutoffs were set at the 10% base rate, and ROC curves assessed diagnostic accuracy. Results Normative data for WTAR and AMNART are presented. Cognitive literacy engagement significantly predicted both WTAR and AMNART scores, explaining small but significant variance. Base rate tables for discrepancies in word reading and GCI are provided. Mean discrepancies in the MERGER sample between actual and predicted word reading scores were near zero. ANOVAs showed MERGER participants had significantly smaller negative discrepancies than the MCI and dementia groups. For MCI detection, WTAR and AMNART discrepancies showed low sensitivity (17–24%) at 90% specificity. In the dementia group, sensitivities were fair (24–29%), improving in a subgroup diagnosed at their initial study visit (30–40%) with acceptable diagnostic accuracy. Conclusions This study provides normative data and discrepancy base rates for word reading and global cognition, enhancing the clinical applicability of MERGER norms. These results support more precise interpretation of word reading abilities in older adults, aiding in the differentiation of typical versus atypical cognitive profiles and improving diagnostic confidence when evaluating potential cognitive decline.

Pediatric cervical spine injury (CSI) is a rare occurrence; however, CSI can result in significant disability and death. It is essential to determine the optimal CSI clinical prediction rule to risk stratify children with potential CSI after blunt trauma who require cervical spine imaging. To compare the test characteristics and projected imaging rates between 3 prospectively derived CSI clinical prediction rules: the Pediatric Emergency Care Applied Research Network CSI prediction rule (PECARN CSI rule), the National Emergency X-Radiography Utilization Study (NEXUS), and the Canadian Cervical Spine (c-spine) rule (CCR). This comparative effectiveness study was a planned secondary analysis of a prospective observational study enrolling from December 2018 to October 2021 in 18 PECARN emergency departments. Eligible participants were children up through age 17 years presenting after blunt trauma. Data were analyzed between March 2024 and January 2025. Enrollment in the primary study to develop and validate the PECARN CSI prediction rule. Test characteristics with 95% CIs (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV]) and area under the curve (AUC) for the receiver operator curves (ROC) for the detection of CSI using each of the 3 rules. We also estimated the projected c-spine imaging rate (radiography or computed tomography [CT]) based on criteria for each of the 3 rules. There were 22 430 eligible children enrolled (median [IQR] age 8 [2.0-13.0] years; 13 068 male [58.3%]) and 433 (1.9%) had CSI. C-spine imaging was performed 12 768 children (56.9%): 8912 (39.7%) had radiography and 3856 (17.2%) were imaged with CT. The sensitivity of the 3 rules was: PECARN CSI rule, 93.3% (95% CI, 90.9%-95.7%); NEXUS, 85.7% (95% CI, 82.4%-89.0%); and CCR, 90.8% (95% CI, 88.0%-93.5%). The NPV of the 3 rules was: PECARN, 99.8% (95% CI, 99.7%-99.9%); NEXUS, 99.6% (95% CI, 99.5%-99.7%); and CCR, 99.7% (95% CI, 99.6%-99.8%). Strictly applying each rule resulted in projected CT imaging of 1549 children (6.9%) for PECARN, 2419 (10.8%) for NEXUS, and 2968 (13.2%) for CCR. In this comparative effectiveness study of CSI prediction rules in children, the PECARN CSI rule had the highest sensitivity and NPV for identifying children at risk for CSI after blunt trauma, with the lowest projected CT imaging rate.

Published clinical prediction rules propose to determine risks of event recurrence and serious underlying condition in infants with brief resolved unexplained event (BRUE). The objective of this study was to evaluate these rules in a prospectively recruited cohort of infants with BRUE to test the hypothesis that the rules may be helpful in predicting risk but their test characteristics may differ from those previously reported. To determine the validity of prediction rules for risk of recurrent events and serious diagnoses, we applied the calculators to patients with BRUE who were prospectively recruited at our institution. Infants were recruited during their index hospitalization, caregiver-reported symptoms were obtained by questionnaires during the 6-month follow-up period, and charts reviewed for clinical data. Receiver operating characteristic (ROC) analyses were used to calculate values for the sensitivity and specificity of each calculator. The cohort included 178 subjects and 73% (130) completed questionnaires. Overall, 78% (101/130) had persistent caregiver-reported symptoms, 12% (16/130) recurrent BRUE, and 28% (50/178) a serious condition diagnosis. The most common serious condition was oropharyngeal dysphagia with aspiration (78% of serious diagnoses, representing 22% of the cohort). On ROC analysis, area under the curve was 0.7 (95% confidence interval [CI]: 0.57-0.83, p = 0.004) for recurrent BRUE and 0.59 (95% CI: 0.49-0.68, p = 0.08) for serious underlying condition. The calculators provided 81% sensitivity, 52% specificity, 20% positive predictive value, and 96% negative predictive value for predicting recurrent BRUE and 54% sensitivity, 68% specificity, 40% positive predictive value, and 79% negative predictive value for predicting a serious condition in our cohort. Our results suggest that published clinical prediction rules may accurately predict event recurrence but may have relatively low discriminatory power and tend to underestimate risk of serious underlying diagnoses, which may limit their clinical impact.

"A cross-sectional analysis of four common clinical decision rules for pulmonary embolism": The need for integrated and evolving approaches

The number of morbidity and mortality caused by Pulmonary Embolism (PE) has increased as of recent. Diagnosing PE during pregnancy and postpartum period is particularly challenging given the overlapping symptoms with physiological changes of pregnancy. Recent evidence suggests that the pregnancy-adapted YEARS algorithm, combining clinical probability assessment with D-dimer measurement, may exclude PE without the need for thoracic imaging, thereby reducing unnecessary radiation exposure. This systematic review and meta-analysis intends to evaluate the diagnostic accuracy of the pregnancy-adapted YEARS algorithm in comparison with thoracic imaging among pregnant and postpartum individuals that are suspected of PE. Three databases were searched systematically, including PubMed, Scopus, and Cochrane. Eligible studies included pregnant or postpartum women suspected of having PE who were assessed with the YEARS algorithm, using CT pulmonary angiography (CTPA) or ventilation–perfusion (V/Q) scan as the reference standard. Risk of bias was assessed meticulously using the QUADAS-2 tool. Pooled sensitivity, specificity, as well as the area under the curve (AUC) were calculated by Meta-Disc utilizing a random-effects model. Five studies comprising 1,036 patients, ultimately with low risk of bias were included. The pregnancy-adapted YEARS algorithm showed a pooled sensitivity of 1.00 (95% CI: 0.94–1.00), pooled specificity of 0.12 (95% CI: 0.10–0.14), and an AUC of 0.72, which indicated adequate rule-out ability but limited utility for ruling in PE. The YEARS algorithm that has been adapted for pregnancy may be safely used as a screening tool in excluding PE in pregnant and postpartum women, thereby reducing unnecessary maternal and fetal exposure to radiation. However, confirmatory thoracic imaging remains essential for positive cases.

The bacterial meningitis score (BMS) is a validated clinical prediction rule for identifying children at very low risk of bacterial meningitis based on five criteria. Whether BMS is safe to rule out bacterial meningitis in adults is unknown. The primary objective was to evaluate the performance of the BMS to identify adults at low risk of bacterial meningitis. This 4-year-period multicentric retrospective diagnostic study was conducted in 15 adult emergency departments (EDs) in France. Immunocompetent patients with meningitis, defined as cerebrospinal fluid (CSF) pleocytosis (CSF white blood cells ≥ 5/µl), were included among patients with an ED report including a lumbar puncture code procedure or a diagnosis of meningitis according to the International Classification of Diseases, 10th Revision classification. The reference standard for bacterial meningitis was a positive bacterial CSF culture. The main outcome was the negative predictive value (NPV) of the BMS for the diagnosis of bacterial meningitis. The secondary outcome was the proportion of meningeal-dose antibiotic treatments that could have been avoided for patients with BMS = 0. The performances of the BMS when combined with intrathecal lactate, blood procalcitonin (PCT), and C-reactive protein (CRP) were also assessed. Among the 995 patients identified, 531 (13.3%) were eligible, and 456 patients (85.9%) with meningitis and a usable BMS were included. Seventy-three (16.0%) presented bacterial meningitis, with a majority of Streptococcus pneumoniae (n = 35, 47.9%) and Neisseria meningitidis (n = 10, 13.7%), and 383 (84.0%) had aseptic meningitis. There was one patient with bacterial meningitis and a BMS score of 0 [NPV: 99.5%, 95% confidence interval (CI): 97.4-100]. The proportion of avoidable antibiotics was 64.1% (95% CI: 57.3-70.3). The NPV was 100% (95% CI: 94.6-100), 97.9% (95% CI: 92.5-99.7), and 98.9% (95% CI: 96.1-99.9) for combined BMS with intrathecal lactate greater than or equal to 2 mmol/l, blood PCT greater than or equal to 0.29 µg/l, and blood CRP greater than or equal to 24 mg/l, respectively. The BMS score presents a very high NPV, with the potential of safely ruling out bacterial meningitis among ED patients with positive CSF results.