This website is intended for healthcare professionals only.

Newsletter      
Hospital Healthcare Europe
HOPE LOGO
Hospital Healthcare Europe

Press Releases

Take a look at a selection of our recent media coverage:

Standalone AI reader could significantly reduce radiologist workload in lung cancer screening

13th January 2022

A standalone AI reader outperformed four experienced radiologists in CT lung cancer screening and could reduce their workload by over 80%

Using a standalone artificial intelligence (AI) reader for lung cancer screening with ultra low-dose computed tomography (ULDCT) could potentially reduce the workload of radiologists by over 80%. This was the conclusion of a study by a team from the Department of Epidemiology, University of Groningen, Groningen, The Netherlands.

Lung cancer was responsible for 2.21 million cases and 1.8 million deaths in 2020 and volume-based, low-dose CT screening of high-risk patients has been shown to significantly reduce lung-cancer mortality compared to those who underwent no screening. Moreover, low-dose CT lung cancer screening has become an evidence-based reality. However, the introduction of such screening will undoubtedly create an enormous increase in the workload of radiologists and while the use of a standalone AI as a second reader for lung cancer screening with CT has shown much promise, how well an AI system could perform as a standalone system remains uncertain.

For the present study, the Dutch researchers, sought to evaluate the performance of a standalone AI as an impartial reader in ULDCT lung cancer baseline screening compared to that of experienced radiologists and a consensus read reference standard. They used a dataset of CT scans from participants who underwent a baseline scan and who were found to have at least one solid nodule of any size in their scan. Other inclusion criteria for the study were: participants aged 50 – 80 years, > 30 pack-years smoking history, current or former smoker and those who did not develop lung cancer within two years of their baseline scan. All of the participant’s scans were independently analysed by five thoracic radiologists and the standalone AI then independently analysed all the scans to detect, measure and classify nodules. In addition, an independent consensus read was performed by a panel of three, experienced radiologists and who sought to determine the number of positive misclassifications (PM) and negative misclassifications (NM). A PM was classified as nodules > 100 cubic mms and NM < 100 cubic mms. The results from the 5 radiologist reader and the standalone AI were compared to the consensus read to determine the number of PM and NM results as well as the number of discrepancies.

Findings

A total of 283 participants with a mean age of 64.6 years (56.9% male) with a total of 1149 lung nodules were analysed.

The consensus read was 83 PMs and 200 NMs and the standalone AI had 61 discrepancies (53 PM and 8 NM) compared to a total of 43, 36, 29, 28 and 50 from the five respective radiologists. From these results, the authors calculated that when using a standalone AI as the main reader for general lung cancer screening, there would be a workload reduction of between 77.4% and 86.7%.

The authors concluded that a standalone AI could significantly reduce the workload of radiologists in lung cancer screening.

Citation

Lancaster HL et al. Outstanding negative prediction performance of solid pulmonary nodule volume AI for ultra-LDCT baseline lung cancer screening risk stratification. Lung Cancer 2022

Three key factors predictive of abnormal CT scan in children with minor head trauma

6th December 2021

Three key factors that are predictive of an abnormal CT scan in children with minor head trauma have been determined from a prospective study

Three key factors that can be used to predict an abnormal computed tomography (CT) in children who have suffered a minor head trauma have been identified by a team from the Department of Emergency Medicine, Zanjan, Iran.

Head traumas are a common presentation in emergency departments with one US study estimating that the annual injury rate per 10,000 population had increased from 55.2 in 2007 to 85.4 in 2011, with the largest increases seen in children under 11 years of age and in adults >65 years of age. Patients with a minor head injury, defined by a Glasgow Coma Scale (GCS) score of 13-15, will have a small but important risk of an intracranial injury that requires early identification and neurosurgical treatment. In fact, one analysis of over 42,000 children with head injuries revealed that clinically important intracranial injuries occurred in less than 5% of children and injuries requiring neurosurgical intervention occurring in less than 1% of children.

Although cranial CT scans are seen as the reference standard for the diagnosis of traumatic brain injury, these scans are expensive and the unnecessary use of such scans could represent a waste of valuable resources. Moreover, it has been found that over 90% of CT scans are negative for clinically important brain injury. It is therefore necessary to determine the relative importance of various clinical symptoms in assessing which children would need a CT scan.

For the present study, the Iranian team sought to identify whether any clinical symptoms in children with a minor head trauma, had predictive accuracy of the need for a subsequent CT scan. In a prospective study, they included children, aged 2 to 14 years of age, who presented at the emergency department with a blunt head trauma within 24 hours and who had a GCS > 14. They collected data on physical clinical findings, the results of the CT scan and follow-up information. Individuals were categorised into three groups according to the emergency care physician assessment; 6 hour follow-up, brain CT and discharge. Thus, patients with a high suspicion of brain trauma were referred for a CT scan, the other group were monitored in the department and the final group with a low suspicion were discharged. Clinical findings documented included three key factors, repetitive vomiting, headache, decreased level of consciousness and other factors examined were seizures and signs of skull based fracture. The primary outcome was an abnormal brain CT scan.

Findings

The study included 200 children with a mean age of 6.5 years (67% male), 90 of whom received a brain CT scan. The most common clinical finding was headache (34%) and the most frequent cause of injury was a fall from height (37.5%). The team identified that there were three key factors that were predictive of an abnormal brain CT scan; headache (odd ratio, OR = 12.1, 95% CI 1.19 – 122.47, p = 0.0035), vomiting (OR = 12.29, p = 0.017) and loss of consciousness (OR = 26.53, p = 0.002). Interestingly, experiencing only one of these three key factors, was not predictive of a positive brain CT.

The authors concluded that only three key factors, repetitive vomiting, headache and a decreased level of consciousness, were significantly associated with a positive brain CT in children with minor head trauma.

Citation

Naghibi T et al. Predicting factors for abnormal brain computed tomography in children with minor head trauma BMC Emerg Med 2021

Ultrasound imaging of value for diagnosis of Achilles tendon rupture in ED

3rd December 2021

Ultrasound imaging has been found to be highly sensitive modality for the diagnosis of both partial and complete Achilles tendon rupture in ED

The use of ultrasound imaging for the detection of both a partial and complete rupture of the Achilles tendon has been found to be a highly sensitive modality according to a systematic review and meta-analysis by a team from Department of Emergency Medicine, University of California, US.

The Achilles tendon is the strongest tendon in the body and rupture of the tendon has become a common problem among athletes involved in activities such as running, jumping and ball sports. An acute rupture of the tendon will often result in a sudden onset of pain and in some cases an audible “snapping” sound can be heard at the site of injury, leading to significant pain and disability. However, the diagnosis tendon rupture is not always clinically clear and any delay or misdiagnosis can result in a significant patient morbidity and in fact, it has been suggested that sush injuries are often misdiagnosed as an ankle sprain in 20% to 25% of patients. 

The use of ultrasound imaging for the diagnosis of Achilles tendon rupture has been described in the literature although there have been no meta-analytic studies assessing the overall performance of this imaging modality as a diagnostic tool in emergency departments. For the present study, the US team sought to systematically evaluate the sensitivity and specificity of ultrasound imaging for detecting complete and partial Achilles tendon ruptures in patients who were treated surgically.

The researchers performed a literature search in all the major databases for studies that included at least 5 patients and which reported on the sonographic diagnosis of Achilles tendon rupture compared with surgery as the reference standard. The set the primary outcome measure as complete tear of the Achilles tendon and they calculated the sensitivity, specificity and positive/negative likelihood ratios.

Findings

The literature search identified 15 eligible studies with 808 patients, all of whom were suspected of having an acute Achilles tendon injury. In addition, the ultrasound imaging procedure used was similar across all studies. The overall sensitivity of ultrasound for detecting a complete rupture was 94.8% (95% CI 91.3% – 97.2%) and the specificity 98.7% (95% CI 97.03% – 99.6%). The positive likelihood ratio was 74 and the negative likelihood ratio 0.05. Based on these results, it was therefore 74 times more likely that there would be a positive ultrasound in a patient with a complete Achilles tendon rupture compared to a patient without such a rupture. Similarly, there is a 20-fold decrease in the odds that a negative ultrasound will occur in a patient with a complete rupture.

There were 13 of the 15 studies which enabled assessment of a partial Achilles tendon rupture. The corresponding sensitivity was 93.7% (95% CI 95.3% – 98.7%) and the specificity was 97.4% (95% CI 95.3% – 98.7%). The positive likelihood ratio was 35.6% and the negative likelihood ratio 0.07.

Discussing their results, the authors suggested in the presence of a normal Achilles tendon on ultrasound, there is a very low likelihood that the patient had suffered a complete tendon rupture. For a partial rupture, the low negative likelihood ratio (0.07) indicated that it was 14-fold less likely that a negative ultrasound would occur in a patient with a partial tendon rupture.

They concluded that ultrasound imaging is a useful and valuable modality to minimise the misdiagnosis of a partial or complete Achilles tendon rupture with an emergency department.

Citation

Aminlari A et al. Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis. J Emerg Med 2021

Opioid treatment infrequently started after suspected overdose visit to ED

Opioid treatment after a suspected overdose at ED provides an opportunity to reduce subsequent harm but appears to be infrequently initiated

The initiation of opioid treatment in patients who present at emergency departments (EDs) with a suspected opioid overdose provides an ideal opportunity to reduce subsequent harm but appears to be infrequently initiated. This was the finding of a 21-month study at EDs by a team from the Department of Pediatrics, Child Health Evaluation and Research Center, University of Michigan, US.

In a study of over 17,000 patients treated for a suspected opioid overdose at EDs, the one-year mortality rate has been found to be around 5.5% with 20.5% of these deaths occurring within a month of discharge. Moreover, evidence suggests that naloxone programs can reduce subsequent opioid overdose death rates and the need to introduce such programs has become much more critical during the COVID-19 pandemic due to the observed increased rate of ED visits for opioid overdoses.

For the present study, researchers undertook a retrospective study and turned to an all-payer database which provided data on pharmacy and medical claims, to assess the rates of naloxone and buprenorphine prescribing within 30 days of an ED visit for a suspected opioid overdose between August 2019 and April 2021. In terms of prescribed items, the researchers focused on those formulations of buprenorphine approved for opioid use disorder.

Findings

During the period of the study, there were 68,072,261 ED visits, of which 148,966 (0.2%) were for opioid overdose. Among these visits, 53,073 (35.6%) were for women and 42.1% of patients were aged 18 to 34 years. For the 148,966 ED opioid-overdose visits, 7.4% (95% CI 7.3% – 7.5%) of individuals were prescribed at least 1 naloxone prescription within 30 days of their ED visit and 6.3% (95% CI 6.2% – 6.4%) had at least one naloxone prescription dispensed.

For buprenorphine, 8.5% (95% CI 8.3% – 8.6%) of patients were issued with at least 1 buprenorphine prescriptions within 30 days of their ED visit and 8.2% (95% CI 8.0% – 8.3%) at a buprenorphine prescription dispensed within 30 days of their visit.

Commenting on their results, the authors calculated that after an ED visit for a suspected overdose, opioid treatment with naloxone or buprenorphine was initiated in only 1 in 13 and 1 in 12 respectively for all ED visits. They suggested that clinicians were therefore missing an ideal opportunity to prevent subsequent opioid overdose-related mortality, although they recognised that the onus to prescribe was not the sole responsibility of ED clinicians but that this could happen within the outpatient setting.

In their conclusion, they suggested that future studies should focus on interventions to overcome and minimise the barriers to prescribing opioid treatment to reduce this potential missed opportunity.

Citation

Chua KP et al. Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021 Ann Emerg Med 2021

Convenience sampling leads to selection bias in ED studies

8th November 2021

Convenience sampling is a potential source of sampling bias in ED studies and which is best avoided due to its impact on internal validity.

Utilising a convenience sampling (CS) approach in studies can introduce selection bias and negatively impact upon internal validity. This was the conclusion of an interesting study by a team of researchers from the Department of Emergency Medicine, St Vincent’s Hospital, Melbourne Australia. Convenience sampling represents a non-probability sampling approach in which people are included (i.e., sampled) simply because they are at the right place and time and hence a “convenient” sources of data for researchers. Emergency department (ED) studies often use CS although an important disadvantage is that it provides no guarantee that the patients recruited are truly representative of the whole cohort visiting an ED. For instance, since intoxicated patients are more likely to visit an ED during the evening or night, sampling only during the day would provide an unrepresentative sample, introduce selection bias and undermine the internal validity of the study. While a commonly used approach in research, convenience sampling has been identified as a source of bias in other areas of research such as neurology and oncology.

For the present study, researchers sought to illustrate how a CS approach could introduce selection bias on studies undertaken in an ED and hence undermine the value of such a study. They focused on four specific clinical conditions in adults: abdominal pain; chest pain; headache and dyspnoea. Using routinely available data, they retrospectively examined information from five EDs in Melbourne and extracted patient’s arrival time, which was categorised as day (8am to 4 pm), evening (4 pm to 12 pm) and night (12pm to 8 am) as well as demographics, i.e., age, gender etc. The primary outcome of interest was a patient’s discharge diagnosis at each of the three arrival times.

Findings

A total of 2,500 patients were enrolled in each of the four clinical areas. Among patients with abdominal pain there was a significant difference in discharge diagnosis across the time periods (p < 0.001) with a higher proportion of ‘unspecified/unknown’ diagnoses during the evening compared to the day (47.4% vs 41.7%). In addition, there were differences in departure status with more leaving before treatment was complete in the evening (16.7%) and night (12.2%) compared to the day (7.1%, p < 0.001).

For patients with chest pain, there was no difference in discharge diagnoses over the three time periods, although again there were differences in the departure status, with more leaving before treatment completion in the evening and night than during the day.

While there were no important differences for headache patients, for dyspnoea patients, a diagnosis of asthma was more commonly made at night compared to during the day (12.6% vs 7.5%) and more patients were admitted to the short stay unit during the day compared to the night (15.3% vs 9.8%).

Commenting on their findings, the authors stated how these results revealed significant differences in discharge diagnosis and patient characteristics across the three time periods and how using a CS to enrol patients only during office hours, would create an unrepresentative sample of ED patients. They recommended that future studies should employ consecutive sampling across all hours of the day and that CS could be mitigated by various statistical techniques such as propensity score matching. They concluded that convenience sampling should be avoided if possible or where this was unavoidable, it would be necessary to demonstrate that the use of this approach would not to have a significant impact on the primary outcome measure of a study.

Citation

Lines T et al. Nature and extent of selection bias resulting from convenience sampling in the emergency department. Emerg Med J 2021

ACS presentations via emergency services at ED increased after warning signs campaign

ACS presentations via emergency services at ED increased significantly after the introduction of a public health warning signs campaign.

Acute coronary syndrome (ACS) presentations using emergency medical services increased after the introduction of a public health ‘warning signs’ campaign. This was the finding of a retrospective study by researchers from the department of  Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.

Any delay in ACS presentations has a major impact on outcomes for patients, despite major advances in the care of such patients yet few fully understand the importance of early treatment. For example, a focus group study revealed a general ignorance of ACS symptoms and this has arisen in part, due to the perceptions derived from films and TV in which heart attack symptoms were displayed as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. The study also highlighted a lack of awareness of the benefits of rapid action and using emergency service transport (EST) to hospital over alternative methods for reaching hospital. In fact, other work has shown that only 60% of patients used EST when experiencing ST-segment–elevation myocardial infarction.

The National Heart Foundation of Australia (NHFA) in recognising the importance of EST for patients with suspected ACS, launched a mass media campaign to improve Australian’s ACS symptom knowledge and address barriers to emergency transport use. Nevertheless, despite the media campaign, in a subsequent survey of 100 patients hospitalised with an acute myocardial infarction (AMI) only 26%  recognised that they were having an AMI and only 34% had called an ambulance. This led the researchers from Monash University to examine the impact of the NHFA warning signs campaign on ACS EST use and to explore any pre- and post-campaign changes on ED presentations via general practitioners for those with unspecified chest pain (U-CP). The team used the Victorian Department of Health and Human Services administrative database to collect information of ED admissions, patient characteristics, mode of arrival and referral sources. The primary outcomes of interest were ACS arrivals via ETS and ED presentations. Data were collected from 2003 to 2015, that included the period of the campaign which ran from 2009 to 2013. In their analysis, the researchers adjusted for factors such as age, gender, ethnicity, residential status (i.e., living alone etc) and location.

Findings

Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 612,758 with U-CP. There was an 11% increase in ED presentations for ACS (incidence rate ratio, IRR = 1.11, 95% CI 1.07 – 1.15) during the campaign compared to the pre-campaign period. Similarly, there was an 8% increase (IRR = 1.08, 95% CI 1.05 – 1.12) for U-CP compared to the pre-campaign period.

For patients with ACS, 58% had arrived using emergency transport and compared with the pre-campaign period there was a slight increase in the adjusted odds of direct arrival via emergency transport (odds ratio, OR = 1.10, 95% CI 1.05 – 1.17) and a significant decrease in the adjusted odds of a GP referral (OR = 0.77, 95% CI 0.70 to 0.86). For U-CP, there was a modest increase during the campaign period of emergency transport arrivals (OR = 1.03, p = 0.019) but a more substantial reduction in GP referral compared to pre-campaign levels (OR = 0.79, 96% CI 0.75 – 0.82, p < 0.0001).

The authors concluded that the NHFA’s warning signs campaign was associated with an increase in ACS presentations and use of emergency transport and a reduction in GP referrals to ED.

Citation

Eastwood K et al. Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome. BMJ Open heart 2021

Guideline discordant antibiotic prescribing for ED patients with severe CAP increases mortality

7th October 2021

The presence of guideline discordant antibiotic prescribing for ED patients with severe CAP has been found to increase 30-day mortality.

Community-acquired pneumonia (CAP) is an infection acquired in the community, i.e., outside of a hospital setting. The worldwide incidence of community-acquired pneumonia has been estimated to vary between 1.5 to 14 cases per 1000 person-years. Mortality rates for CAP are very low (< 2%) for patients treated in the community but increase among those hospitalised (5 – 20%) and are higher still (up to 50%) for patients who are admitted to intensive care. Treatment of CAP involves the use of empirical antibiotics and several guidelines exist for the management of CAP. Moreover, evidence suggests that guideline-concordant prescribing for CAP is associated with improved health outcomes and lower resource use in adults. But to what extent would guideline discordant antibiotic prescribing impact on health outcomes and mortality?

This was the question posed by a team from the Department of Emergency Medicine, Seoul National University Bundang Hospital, Republic of Korea. The team undertook a retrospective analysis of adult patients with severe CAP, hospitalised in the emergency department (ED) after the diagnosis of severe CAP, defined by the 2007, Infectious Diseases Society of America/American Thoracic Society guidelines. For the treatment of severe CAP, the guidelines recommend a beta-lactam antibiotic plus either a macrolide or fluoroquinolone. Among penicillin allergic patients, a respiratory fluoroquinolone plus aztreonam is recommended. Data on prescribing , together with demographic and co-morbidity information were obtained from hospital medical records. Patients were then categorised as either being prescribed guideline concordant antibiotics or guideline discordant antibiotics. Propensity score matching was used to reduce selection bias and 30-day survival was estimated with logistic regression.

Findings

A total of 630 patients were included, of whom 179 (28.4%) died within 30 days of being hospitalised. After propensity matching, a total of 255 individuals were included in each group with an approximate age of 75 years (66% male). After propensity matching, guideline discordant prescribing was significantly associated with 30-day mortality (hazard ratio, HR = 1.43, 95% CI 1.05 – 1.93, p = 0.022). In addition, 30-day mortality was found to be lower in the guideline concordant group (23.9% vs 33.3%, concordant vs discordant, p = 0.024).

Commenting on these findings, the authors noted that 43% of patients were prescribed guideline discordant antibiotics for severe CAP and concluded that this was independently associated with 30-day survival.

Citation

Hyun KS et al. Antibiotic prescription consistent with guidelines in emergency department is associated with 30-day survival in severe community-acquired pneumonia. BMC Emerg Med 2021.

Lung ultrasound severity index score predicts COVID-19 diagnosis

20th September 2021

A lung ultrasound severity index tool has been shown to be able to identify those with COVID-19 and predict in-hospital mortality.

Although a formal diagnosis of COVID-19 is based on a positive PCR test, it can take up to 24 hours before the result is available. Given that COVID-19 is a respiratory infection, clinicians have often turned to chest imaging with lung ultrasound, X-rays and CT scans, to diagnose the infection prior to confirmation from a PCR test. In fact, a Cochrane review has concluded that the use of a lung ultrasound correctly diagnoses COVID-19 in 86.4% of infected patients.

With the potential value of lung ultrasound as a diagnostic aid in COVID-19, an Italian team from the Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy, undertook a prospective, observational study to further examine the value of the imaging modality in those with suspected COVID-19. Patients were those consecutively admitted to the emergency department of a single hospital with suspected COVID-19. Each underwent a standard lung ultrasound examination which included 12 thoracic areas. The team then calculated several different measures with a view to determining whether any of these could be used prognostically for COVID-19. The scores for each thoracic areas were added to calculate a regional lung ultrasound severity score (rLUSS) and a lung ultrasound severity score (LUSS) was calculated by summing all rLUSS values. The number of different ultrasound patterns found in each area defined the regional lung ultrasound heterogeneity score (rLUHS). A regional lung ultrasound severity index (rLUSI) was then calculated as rLUSS/rLUHS for each area. Finally, the team computed a lung ultrasound severity index (LUSI), which was the sum of all the rLUSI scores. The team were interested in whether LUSI, rLUSS or LUHS. The outcomes of interest were a diagnosis of COVID-19 pneumonia and in-hospital mortality and the area under the receiver operating curves (AUROC) analysis was used to determine the relationship between LUSS, LUHS, LUSI and the severity of pneumonia.

Findings
The study included 159 patients with a mean age of 64.6 years (66% male) of whom, 49% had respiratory failure upon admission. For each of the three lung ultrasound measures (i.e., LUSS, LUHS and LUSI), in relation to the differentiation of COVID-19 positive and negative cases, LUSI offered the greatest sensitivity and specificity with an AUROC of 0.72 (95% CI 0.64 – 0.78), giving a sensitivity of 63% and a specificity of 75%. With respect to overall in-hospital mortality, again LUSI scores provided the best AUROC, at 0.81 (95% CI 0.73 – 0.86) providing a sensitivity of 90.9% and a specificity of 65.6%. Finally, when considering only COVID-19 patients, LUSI also gave the highest AUROC, 0.76 (95% CI 0.66 – 0.84) with a sensitivity of 63.1% and a specificity of 90%.

The authors concluded that their newly developed lung ultrasound severity index provided the highest accuracy with respect to COVID-19 diagnosis and prognosis. They also added that a further advantage was how the lung ultrasound could be performed in under 10 minutes, allowing LUSI scores to quickly identify patients at a higher risk of both COVID-19 and mortality and called for future studies to understand LUSI’s role for different clinical goals such as monitoring of treatment or progression.

Citation
Spampinato MD et al. Lung Ultrasound Severity Index: Development and Usefulness in Patients with Suspected SARS-Cov-2 Pneumonia. A Prospective Study. Ultrasound Med Biol 2021

Procalcitonin levels unable to distinguish between viral and bacterial community-acquired pneumonia

13th September 2021

The use of procalcitonin levels in an emergency department is unable to distinguish between viral and bacterial community-acquired pneumonia.

Symptoms of community-acquired pneumonia (CAP) include shortness of breath, coughing, fever and chest pain some of which such as fever and coughing, overlap with COVID-19. Determining whether the causative agent in CAP is bacterial or viral can be difficult and measurement of procalcitonin levels can serve as an important biomarker for the presence of a bacterial cause. Given that higher procalcitonin levels are more likely to indicate a bacterial rather than viral cause for CAP, a team from the Emergency Department, University Libre Bruxelles, Belgium, wondered if the measurement of procalcitonin levels could help distinguish between viral and bacterial CAP in patients infected with COVID-19 and retrospectively analysed data for a cohort of patients admitted to their emergency department.

All patients who were admitted with a suspicion of CAP had their procalcitonin levels measured. Subsequently, enrolled patients were those with clinical signs of a lower respiratory tract infection and with at least one symptom of acute respiratory illness, e.g., cough, dyspnoea, sputum production, tachypnoea and pleuritic chest pain. Other inclusion criteria were those with signs of an acute infection, e.g., temperature > 38oC, chills, altered mental status and a leucocyte count > 10,000/microL and oxygen saturation < 94%. Only patients who underwent both bacteriological, viral and radiological imaging (CT) within 48 hours of admission were subsequently included. Patients were classified as having bacterial CAP based on both microbiological analysis and the findings from the CT scan. Alternatively, patients were classed as having viral CAP in the absence of positive bacteriological findings and where the CT scan indicated a high suspicion of viral pneumonia.

Findings
During the period of the study, 3593 patients visited the emergency department with symptoms potentially related to COVID-19 and 151 were subsequently included in the analysis after applying the inclusion criteria, of whom, 138 had a microbiologically confirmed bacterial pathogen. Among those with diagnosed viral CAP, 112 had COVID-19-related pneumonia. The discriminatory accuracy of procalcitonin levels for bacterial and viral CAP were calculated from receiver operating characteristic (ROC) curves. The median procalcitonin levels were higher in bacterial CAP (0.53ng/ml vs 0.16ng/ml, bacterial vs viral, p = 0.005). Using the ROC curves to discriminate between viral and bacterial CAP generated an area under the curve (AUC) of 0.68 (95% CI 0.53 – 0.83). Based on a threshold procalcitonin level of > 0.5ng/ml, to identify bacterial CAP, gave a sensitivity of 52.2% and a specificity of 82%.

Commenting on their findings, the authors noted that there were no procalcitonin levels which were able to differentiate between bacterial CAP and COVID-19 associated pneumonia. Based on their findings, the authors calculated that the administration of antibiotics to those with procalcitonin levels > 0.5ng/ml would have resulted in the inappropriate treatment of 65.7% of patients with radiological signs of CAP.

They concluded that procalcitonin measurements upon admission in those with suspected CAP cannot accurately differentiate between bacterial or viral CAP.

Citation
Malinverni S et al. Is procalcitonin a reliable marker of bacterial community-acquired pneumonia in adults admitted to the emergency department during SARS-CoV-2 pandemic? Eur J Emerg Med 2021

RCT compares HIV screening strategies in the emergency department

4th August 2021

Targeted screening for HIV in an emergency care department did not increase the rate of positive diagnoses compared with non-targeted methods.

In 2020, the US Department of Health and Human services launched Ending the HIV Epidemic: A Plan for America, with the aim of diagnosing all people with HIV as early as possible. The receipt of a HIV diagnosis is critical for assessing treatment and prevention services yet, despite recommendations from the World Health Organization (WHO), a study in 2020 concluded that global adherence to the WHO strategy remained low. A targeted HIV screening approach can be either provider-initiated, where a healthcare professional identifies specific risk factors which prompt a test or client-initiated, where an individual feels that they are at risk. There are clear benefits to a targeted approach, for instance, the opportunity for service providers to engage and counsel high-risk individuals as well as delivery of services through a range of different settings. In fact, evidence suggests that community-based targeted HIV screening is more effective than universal screening. One targeted HIV screening tool, the Denver Human Immunodeficiency Virus risk score, includes several factors such as age, ethnicity, receptive anal intercourse and injection drug use and has been shown to accurately categorise patients into groups with increasing probabilities of HIV infection. Whether such a tool could be used to improve HIV screening within an emergency department has been largely unexplored, prompting a team from the Department of Emergency Medicine, Denver Health Medical Centre, Colorado, US, to undertake a randomised trial to compare targeted HIV screening with a non-targeted approach. The team used three arms: non-targeted, i.e., without any risk assessment of HIV; the Denver risk assessment tool and finally, a traditional targeted approach. This latter method involved the use of a behavioural risk screening tool and a positive answer to any risk questions triggered a HIV test. The primary outcome for the study was confirmed new HIV diagnoses.

Findings
A total of 76,561 individuals were randomised to non-targeted screening (25,469), Denver risk assessment (25,453) and traditional screening (25,639). The median age of the sample was 40 years (51.2% female) and with 32.6% of black ethnicity. Of those assigned to non-targeted screening, there were 10 (0.15%) new HIV diagnoses compared to 7 (0.16%) for Denver risk assessment and 7 (0.22%) for the traditional targeted screening. When comparing non-targeted with targeted screening (combining both methods), there was no significant difference (risk ratio, RR = 0.70, 95% CI 0.30–1.56, p = 0.38). Furthermore, the enhanced targeted HIV screening (Denver) identified about twice as many people at increased risk compared to traditional targeted screening (54.5% vs 27.7%, enhanced vs traditional screening).

Commenting on their results, the authors noted that while targeted HIV screening did not increase the number of new diagnoses, screening within an emergency department is still important to ensure prompt antiretroviral therapy and to avert further transmission of the virus. They concluded that while targeted HIV screening was not superior to a non-targeted strategy at identifying new patients, a targeted approach did reduce the number of tests performed.

Citation
Haukoos JS et al. Comparison of HIV Screening Strategies in the Emergency Department: a randomized clinical trial. JAMA Netw Open 2021