The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute nontraumatic headaches in the emergency department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis, while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists' perspective, written on behalf of the Refractory, Inpatient, Emergency Care section of the American Headache Society (AHS). The commentary have been reviewed and approved by Board of Directors of the AHS.
View details for DOI 10.1111/head.13744
View details for PubMedID 31944291
Background: The impact of diagnostic stewardship and testing algorithms on utilization and performance of the FilmArray® Meningitis/Encephalitis (ME) Panel has received limited investigation.Methods: We performed a retrospective single-center cohort study assessing all individuals with suspected ME between February 2017 and April 2019 for whom the ME Panel was ordered. Testing was restricted to patients with cerebrospinal fluid (CSF) pleocytosis. Positive ME Panel results were confirmed before reporting through correlation with direct stain (Gram and Calcofluor white) and CSF Cryptococcal antigen or by repeat ME Panel testing. Outcomes included ME Panel test utilization rate, negative predictive value of non-pleocytic CSF samples, test yield and false-positivity rate, and time to appropriate de-escalation of acyclovir.Results: Restricting testing to pleocytic CSF samples reduced ME Panel utilization by 42.7% (263 vs 459 tests performed) and increased test yield by 61.8% (18.6% vs 11.5% positivity rate; P < 0.01) with application of criteria. The negative predictive value of normal CSF WBC for ME Panel targets was 100% (195/195) for non-viral targets and 98.0% (192/196) overall. All pathogens detected in non-pleocytic CSF samples were herpesviruses. Application of a selective testing algorithm based on repeat testing of non-viral targets avoided 75% (3/4) of false-positive results without generating false-negative results. Introduction of the ME panel reduced the duration of acyclovir treatment from an average of 66 hours (SD, 43) to 46 hours (SD, 36) (P = 0.03).Conclusions: Implementation of the ME Panel with restriction criteria and a selective testing algorithm for non-viral targets optimizes its utilization, yield and accuracy.
View details for DOI 10.1128/JCM.00311-20
View details for PubMedID 32493787
View details for DOI 10.1177/1941874418809869
View details for Web of Science ID 000471642900011
View details for PubMedID 31244976
View details for PubMedCentralID PMC6582390
