Background Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics who present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction, tools based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales, and derive a novel decision tree, to improve identification of stroke mimics. Methods We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients who were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. Results Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63–0.87). However, all 4 scores performed similarly (DeLong p > 0.05). Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1 to 97.5%) and low negative predictive values (4.7 to 32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). Conclusion Four tested stroke mimic prediction scales performed similarly to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

Objectives: The objective was to externally validate the ability of the San Francisco Syncope Rule (SFSR) to accurately identify patients who will experience a 7-day serious clinical event in an Asian population.Methods: This was a prospective cohort study, with a sample of adult patients with syncope and nearsyncope enrolled. Patients 12 years old and below and patients with loss of consciousness after head trauma, a witnessed seizure, with known alcohol or illicit drug ingestion, and altered level of consciousness or persistent new neurologic deficits were excluded. The patients were evaluated for the presence of one or more of the five SFSR variables: shortness of breath, history of heart failure, hematocrit <30%, systolic blood pressure <90 mm Hg, and abnormal electrocardiogram (ECG). The patients were followed up by medical record review or telephone interview. Seven-day outcomes were death, arrhythmia, myocardial infarction, acute pulmonary edema, significant structural heart disease, pulmonary embolism, major cardiac procedure, stroke, subarachnoid hemorrhage, major bleeding, and anemia.Results: A total of 1,250 patients from two centers were recruited. Fifty-six patients were excluded from primary analysis because of incomplete data (n = 55) and/or they were noncontactable for follow-up (n = 32). Of the 1,194 patients analyzed, 138 patients (11.6%) experienced adverse outcomes at 7 days. The rule performed with a sensitivity of 94.2% (95% confidence interval [CI] = 89.0% to 97.0%) and a specificity of 50.8% (95% CI = 47.7% to 53.8%). Conclusions:In this study, SFSR rule had a sensitivity of 94.2%. This suggests caution on the strict application of the rule to all patients presenting with syncope. It should only be used as an aide in clinical decision-making in this population.ACADEMIC EMERGENCY MEDICINE 2013; 20:487-497

The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.

The early diagnosis and immediate surgical treatment of spinal abscesses remain cornerstones in improving the outcomes of the disease. From our series, risk factor assessment appear to be more useful than the classical triad of fever, spine pain and neurological deficits to screen ED patients with spine pain for spinal abscess.

Telemedicine is an invaluable tool that enables hospitals without 24-h onsite neurology service to offer emergency thrombolysis to eligible stroke patients, who otherwise will not be able to benefit from this therapy.

Background Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics, whom present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction tools, based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales and aim to derive a novel decision tree, to improve identification of stroke mimics. Methods We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients whom were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. Results Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63–0.87), although it was not statistically significantly better. Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1–97.5%) and low negative predictive values (4.7–32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). Conclusion Four tested stroke mimic prediction scales performed similarly well to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

IntroductionAdministering intravenous thrombolytic therapy within 60 minutes on arrival in any healthcare facility is challenging, especially when done by Emergency Medicine Physicians (EMP) via telemedicine in centres without onsite neurology cover. Prior quality improvement interventions have improved median Door-to-Needle (DTN) timings in our centre; however, it still falls short of the DTN target of 60 minutes. MethodsVarious quality improvement interventions were implemented over four months by a multi-disciplinary telestroke workgroup led by EMPs to improve DTN timings for patients presenting with acute ischaemic strokes. A retrospective observational study was conducted to review if these interventions resulted in an improvement in DTN timings while keeping the rates of stroke mimics given thrombolytic therapy, haemorrhagic conversions and 30-day mortality rates low. ResultsA total of 279 patients were evaluated. Median DTN timings significantly improved from 71.0 minutes preintervention to 62.0 minutes post-intervention (p=0.012). Correspondingly, the proportion of patients with DTN ≤ 60 minutes increased from 31.7% pre-intervention to 47.0% post-intervention, giving an odds ratio of 1.91 (95% CI 1.17 -3.11, p=0.009). There were no significant differences found in the rates of stroke mimics, haemorrhagic conversions and 30-day mortality pre and post-intervention. ConclusionThe implementation of EMP led to systemic quality improvement interventions is associated with improved DTN timings without compromising clinical quality outcome measures like haemorrhagic conversion rates and 30-day mortality rates. EMPs, with a broad knowledge base and familiarity, interacting with various specialities and co-ordinating care, are uniquely suited in this role to drive change. More work in the public health sector would also have to be done to improve the population's response to acute stroke symptoms.

This is a report on an unusual presentation of ectopic pregnancy. A 34-year-old lady presented to the Emergency Department with anal pain for 3 days. She had earlier sought consult from the general practitioner, who told her there was nothing wrong. Clinically, her heart rate was 100 bpm, blood pressure was 94/62 mmHg. The abdomen was soft but tender over the lower abdomen associated with mild guarding. Examination of the perianal region revealed no fissures, external piles, perianal hematoma or abscess. There was tenderness over the pouch of Douglas, but no bogginess. The rectum was empty. Proctoscopy revealed small hemorrhoids.Bedside abdominal ultrasound revealed free fluid in the abdomen (Fig. 1). Urine human chorionic gonadotropin (HCG) was positive. Blood tests revealed anemia (hemoglobin 10.0 g/dl, hematocrit 32.0%). The clinical diagnosis of a ruptured ectopic pregnancy was made. The patient was resuscitated with fluid and blood products, and underwent right salpingectomy.The classical triad of abdominal pain with vaginal bleeding and amenorrhea may not present in its entirety in ectopic pregnancy. Furthermore, these symptoms are by no means specific. If signs of hypovolemia are present in a woman of childbearing age with lower abdominal pain or tenderness, it is imperative to exclude ectopic pregnancy, necessitating quantitative serum HCG estimations, should urine HCG be negative.In all patients with perianal pain, it is right to exclude common causes, such as perianal abscess, anal fissure, perianal hematoma and hemorrhoids. If, however, the pain is out of proportion with the condition found, or if early signs of shock is seen (as in this patient), life-threatening conditions such as ectopic pregnancy must be ruled out. The abdominal examination is mandatory.Ectopic pregnancy as a cause of rectal or anal pain is extremely rare. A literature search from 1950 to date revealed only one case report of ectopic pregnancy presenting as rectal pain [1]. The pathophysiology of ano-rectal pain is not clear. One might speculate that ectopic pregnancy with gestational sac in or connected to the pouch of Douglas might account for such symptoms, but in our patient, the gestational sac was in the right fallopian tube. The more probable explanation would be that the collection of blood after the rupture of the ectopic sac in the pouch of Douglas, causing distension and local irritation. As indeed, this patient had free fluid detected in the bedside ultrasound. Fig. 1 (a) (b) Bedside ultrasound images show free fluid in the right hypochondrium (Morrison's pouch) (a) and left hypochondrium, at the splenorenal angle (b).