The incidence of SEA has progressively increased over the past several decades;it has more than tripled over the past decade at our institution and with this, the risk of serious neurologic morbidity has risen commensurately.Although early recognition is essential to preventing irreversible neurologic deficits, diagnostic delays are common.Perhaps the best opportunity for early diagnosis occurs at the time of initial clinical presentation. The majority of patients with SEA present to a healthcare facility with clinical manifestations more than once within 30 days of diagnosis; in most cases, these visits are to the ED.Therefore, a clinical scoring tool that could reliably discriminate potential cases and stratify them for emergent spinal imaging at the time of initial clinical presentation would be of value to optimize clinical outcomes in SEA, while also providing stewardship and prioritization of imaging resources. Diabetes mellitus and other, chronic, co-morbid illnesses are often listed as predisposing risks for SEA in the extant literature.Recently reported data from our institution, representing the largest, single-site, published SEA case series with an attendant control group, failed to confirm these as risk factors.Although further refinement of the model may improve these classification characteristics,indoor plant table maximizing sensitivity and specificity may not be optimal for clinical application. Because of the potentially severe consequences of delaying the diagnosis of SEA, it may be more clinically exigent to maximize sensitivity and thereby sacrifice some degree of specificity.

Using our scoring tool with a cut point at six, sensitivity appeared to be optimized at the expense of a modest decrease in specificity. At a higher cut point of seven, sensitivity – the ability of the model to correctly detect positives – was reduced to 77%. At this cut point the PPV was 93% , but the NPV was only 67%. At a lower cut point of five, the modest increase in sensitivity was associated with substantial decrement in specificity that was felt to be too low for clinical utility. A previous study evaluated a clinical decision guideline based on elevated serum inflammatory markers to determine the need for advanced spinal imaging in patients potentially at risk for SEA in the ED13 Although use of the guideline at one institution appeared to reduce diagnostic delays as compared with historical controls, detailed information on the use of MRI was not provided. Additionally, the guideline relies on laboratory testing, which could introduce further delays. We sought to develop a clinically relevant model that was based exclusively on epidemiologic and clinical features that are apparent on initial clinical presentation in order to appropriately triage MR spinal imaging and to reliably facilitate the early recognition of SEA as distinct from other potential spinal pathologies. Our model has several limitations. The data were drawn from a retrospective, 10-year cohort; thus, the model is based on clinical variables collected at the time of admission or shortly thereafter and available in the record. Although we strove to collect complete data on all variables, it is possible that some potentially useful factors were not considered. Additionally, to optimize the clinical utility of our model, we purposefully limited it to clinical data that would be apparent on initial presentation. We did not consider serum inflammatory markers or other laboratory data in this category. Review of erythrocyte sedimentation rate levels in our cohort revealed that this marker was only obtained in approximately 60% of the patients, and the vast majority of these were cases, suggesting that ESR was requested only in the clinical presentations that were highly suspicious for SEA.

Another important limitation of our model is that it was derived from data from a decade-long, retrospective cohort of patients with a confirmed SEA case prevalence of 65% from a single institution; thus, the clinical presentations in this cohort raised at least some level of suspicion for the diagnosis. This scoring model may therefore only be relevant when SEA is reasonably suspected. Our work underscores the known importance of clinical judgment in suspecting the diagnosis of SEA;1,3 the objective model detailed herein serves to complement this subjective consideration. Because our institution is a regional, tertiary-care, academic medical center, it is also important to determine whether our data can be extrapolated to other care settings. A prospective evaluation and validation of this model is needed to understand whether it may be useful in an unselected sample of patients presenting for medical attention with a constellation of symptoms and/or signs potentially warranting investigation for SEA. Such an evaluation may also determine if the model can be substantially improved by incorporating additional data that could be ascertained within a short time frame after ED presentation.Patients diagnosed with sexually transmitted infections are common in the emergency department setting. The Centers for Disease Control and Prevention estimates that nearly 20 million new STIs occur annually.Patients undergoing evaluation for potential STIs will often have had comprehensive evaluation that includes gonococcal and chlamydia testing, wet prep, urinalysis, and urine culture. The clinical presentations for STIs and urinary tract infections may overlap, and symptoms of dysuria and urinary frequency/ urgency occur with both STIs and UTIs.Abnormal urinalysis findings of leukocyte esterase and pyuria are common in both UTIs and STIs.STIs have been previously found to be associated with pyuria without bacteriuria. Furthermore, high STI rates have been reported in women evaluated in an urban ED and diagnosed with UTI.Emergency physicians must make decisions as to whether to empirically treat for UTIs based on initial UA results alone because confirmatory urine culture results are not readily available for several days after the patient’s ED visit.

Findings of significant UA pyuria on these patients have the potential to lead EPs to treat the patient for a presumed “UTI” in patients who may actually have STIs and negative urine cultures.Additionally, nitrite-positive dipsticks have previously shown high specificity for UTIs,but this has not been studied specifically in STI-positive patients. Positive urine cultures have been defined by previous studies as growth of a bacterial pathogen >100,000 colonies.Sterile pyuria is classified as the presence of more than 5-8 leukocytes per high-power field on microscopy,plant growing stand in the setting of negative urine cultures.Treating a patient with sterile pyuria for a UTI can have negative effects, including antibiotic resistance and unnecessary cost to the patient.7 Antibiotic resistance and limited antibiotic selections are a worldwide public health concern. The patient taking an unnecessary antibiotic can have potential adverse effects, such as allergic reaction, anaphylaxis, or secondary, antibiotic-associated infection such as C.difficile.Antibiotic stewardship has become a responsibility for healthcare institutions and antibiotic prescribers, and recently a new standard of Joint Commission Requirements.The CDC identified that 20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate.Not treating a UTI, on the other hand, can lead to pyelonephritis or even sepsis.This poses a dilemma for EPs trying to best treat these patients. Previous studies in ED settings have demonstrated over diagnosis of UTIs and under-diagnosis of STIs.However, prior studies have not specifically evaluated the incidence of sterile pyuria in patients with confirmed STIs. For EPs to provide their patients with optimal empiric antibiotic therapy, it can be helpful to identify whether patients with confirmed STIs commonly have associated culture-positive UTIs. The purpose of this study was to determine the frequency of sterile pyuria in patients with confirmed STIs seen in a community hospital ED. In addition, we examined the urine cultures of STI-positive patients who were prescribed an antibiotic for presumed UTI, and determined how many of those patients actually required antibiotics for positive urine cultures. We hypothesized that STI-confirmed patients who have pyuria on initial urinalysis would have a high prevalence of sterile pyuria, as the urinalysis results were likely contaminated. We also hypothesized that prescribing UTI antibiotics for patients with suspected STI is unnecessary, and that the majority of these patients will have negative urine cultures. Previous studies have found that women with urinary symptoms are over-diagnosed with UTI and under-diagnosed with STIs,but no prior research has specifically analyzed urine results of known STI-positive patients. In this retrospective review of women testing positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis over a five-year period at a large metropolitan ED, we found that of the cases with pyuria, 74% of those were sterile pyuria.

Our study found a very low overall incidence of positive urine cultures in the setting of women with positive STIs. Of the patients with pyuria, patients with culture-positive urines vs. culture-negative urines had identical ranges of urine leukocytes , but the mean leukocytes were higher in the culture-positive group. Prior literature indicates that in the general population the urine-dipstick, nitrite reaction has a low sensitivity but a very high specificity, making a positive result useful in confirming the diagnosis of UTI caused by organisms capable of converting nitrates to nitrite such as Escherichia coli.However, the urine-dipstick test for nitrites has not been studied in STI-positive patients. We found that in the setting of positive STI cases, positive nitrite on the urine dipstick is not a good indication of UTI. Our results showed that in STI positive cases, nitrite-positive urines were actually 18% more likely to be associated with negative urine cultures. Current scientific literature emphasizes the need to reduce the use of inappropriate antimicrobials in all healthcare settings due primarily to antimicrobial resistance, but also because of the associated costs and potential adverse effects.Our study found that of the 295 patients with confirmed STIs who were also prescribed an antibiotic for a presumed UTI, 66% of those were unnecessary, as they had negative urine cultures.Paramedics embedded with SWAT teams are trained to coordinate with team movements within the hot zone, providing medical support for the team as it progresses. Conversely, the current paradigm is that EMS personnel can be trained to enter the warm zone to conduct rescue operations when escorted by law enforcement. However, paramedics familiar with the RTF model are neither equipped nor trained sufficiently to provide care while under a direct threat.While these skill sets overlap they are not synonymous, and medical directors must not assume tactical paramedics integrated with the law enforcement SWAT will provide a sufficient medical resource for an RTF model. The contrast between SWAT paramedics and RTF paramedics was highlighted in two ways. First, as the event unfolded, it became evident that responding fire and EMS units were not accustomed to combined operations with law enforcement. Their corresponding equipment packages and communications networks were different from those of the law enforcement responders. Furthermore, while clearly identified as an “active shooter” event by the first patrol units, the initial setup closely followed that of a mass casualty incident. The tactical command post was established to the north and the casualty collection area/treatment to the south. It is estimated that the south location was possibly within the blast radius of the IEDs left in the building. If this estimation was correct, by definition it means that the triage area was established in the hot zone and not on the warm/cold border as is traditionally taught. Regardless, in the presence of a dynamic threat it may become necessary to ensure traffic control to and create a perimeter for the treatment area. Secondly, SWAT medics do not carry complete Advanced Life Support equipment due to their operational mandate for mobility. While they are often paramedics or physicians, their role as a SWAT medic is to provide medical aid only when operationally appropriate because their primary mission is to ensure the effectiveness of the law enforcement team. [The caveat is that a member of the public will receive priority because the duty of law enforcement is to ensure the safety and well being of citizens.] Although a SWAT medic may enter deep within the hot zone with their tactical element, he or she does not carry equipment sufficient to provide sustained care for a large number of casualties in that zone. The support for ongoing evacuation care must come from follow-up resources, such as those provided by the RTF medical elements.Finally, within the current milieu of civilian, public, mass-shooting incidents, the latest data on civilian wounding patterns do not fit the prototype of the exsanguinating extremity injury, and thus are not amenable to the hemorrhage control techniques mastered by the tactical medic such as the use of tourniquets.