JURNAL READING

LUMBAR PUNCTURES: USE AND DIAGNOSTIC EFFICIENCY IN EMERGENCY MEDICAL DEPARTMENTS

Bilal Majed & Hlne Zephir & Valrie Pichonnier-Cassagne & Yazdan Yazdanpanah & Philippe Lestavel & Pierre Valette & Patrick Vermersch

Dipresentasikan oleh : Estu Nila Widuri, dr Pembimbing : Paulus Sugianto, dr, Sp.S

Abstract
Background
LP regularly and effortlessly used in the emergency medical epartments (EMD). LP use and efficiency have not been fully explored in the published literature.

Aims
to assess in a French EMD, the frequency of use and the diagnostic efficiency of LP, the final diagnoses, and related medical practices

Abstract
Methods
Retrospective all patients who underwent an LP after admission to adult EMD 2004 - 2005. Patients medical files were reviewed to collect clinical and paraclinical features. We defined efficient LP as abnormal LP, which confirmed a suspected diagnosis in an emergency setting.

Abstract
Results
247 patients LP were efficient in fewer than 15% of cases and confirmed aseptic meningitis (8.5%), bacterial meningitis (2.4%), Guillain-Barr syndromes (1.6%), subarachnoid hemorrhages (SAH, 0.4%), and carcinomatous meningitis (0.4%).

Abstract
The principal differential diagnoses were infections outside the central nervous system (CNS, 30%), noninfectious neurological disorders (28.7%), and benign headaches (14.2%). The main assumed LP indications were to search for CNS infection (62%) and for SAH (25%). LP efficiency decreased dramatically according to patients age.

Abstract
Brain imaging was performed in 90% of patients prior to LP. Excessive use of PCR to detect herpes simplex in cerebrospinal fluid was observed. LP complications found were postdural puncture headaches (6.1% of cases). The rate of traumatic LP was 17%.

Abstract
Conclusions
Our results are in accordance with the few published surveys on this topic. LP efficiency is modest but must be considered in light of the seriousness of suspected diagnoses. However, the search for differential diagnoses should not be neglected.

Introduction
Efficient diagnosis strategies (using LP) are required for EMD patients with suspected meningitis, SAH or GBS. LP use and efficiency have not been fully explored in the published literature none of the published studies used French populations.

SAH and GBS

infrequently supported by LP results in the EMD missed diagnoses of SAH in the EMD have been reported need for further investigations to explore the use and the efficiency of LP performed in the EMD. The main associated investigations, such as CT of the brain prior to LP, and CSF tests, are also important to assess.

lack of published literature on the use of LP in the EMD

conducted an observational retrospective study

frequency of LP use in an emergency setting, the diagnostic efficiency of LP, and the usefulness of CSF tests.

also assessed medical practices associated with the use of LP, such as performing a CT scan prior to an LP; LP complications were also investigated

Material and methods

Population studied retrospective study all patients who underwent an LP in the adults EMD a general hospital in Arras, in the north of France, Between January 2004 and December 2005. during the phase of care in the EMD Were collected patients clinical, biological, and brain imaging findings.

Methods
assessed the frequency of LP use in our EMD compared to the number of admissions (in 2004 and 2005) We reviewed the medical files of the selected patients. Final diagnoses, patients clinical features, CSF test findings, and the other paraclinical explorations (CT) were assessed and entered in a database.

 assess LP indications and final diagnoses using independent examinations of patients medical files performed by two emergency physicians a descriptive analysis to explore patients features and to assess associations with final diagnoses. Efficient LP were defined as abnormal LP, which confirmed suspected specific diagnoses in an emergency setting (infections of the CNS, SAH, and GBS)

 Proportions were computed with confidence intervals of 95% (95% CI) and chi-square tests Standard CSF test findings were compared according to the type of meningitis diagnosed :
aseptic (lymphocytic) or Bacterial

expected modest efficiency of LP in the EMD nonparametric tests were used S-Plus statistical software was used for the data analysis.

Results
Frequency of LP use
total of 247 patients from 46,483 admissions during January 2004 December 2005 Monthly the proportion varied widely, from a minimum of 0.24% to a maximum of 0.94%. no significant difference was found that could indicate a possible seasonal variation in the use of LP (p=0.28).

Patients clinical features

median age 52 years (3672), sex ratio (male to female) 1.12.

 The main sites reported suggestive of infections outside the CNS were pulmonary, urinary, and in the upper respiratory tracts Pulmonary and urinary sites were more frequently observed among elderly patients, whilst upper respiratory tract sites were more often reported among young and middle-aged patients

 the youngest patients more frequently presented with benign viral infections (7.1% of all diagnoses) and benign headaches (30.4%). They also presented with fewer noninfectious neurological disorders: 16% of final diagnoses versus 38% among middle-aged patients and 30% among elderly patients (p<0.05).

LP efficiency and CSF tests

Contributive LP represented 13.4% (95% CI: 9.117.6) of the cases and varied significantly according to patients age: the proportion of efficient LP decreased from 25% among young patients to 14.2% among middle-aged patients and to less than 5% among elderly patients

Table 2 Comparison of biological test characteristics (medians) between bacterial and lymphocytic/aseptic meningitis (p value according to nonparametric tests)

Medical practices and complications related to LP use

Almost all patients underwent a CT prior to the LP [89.9% (86.194.6)], independently of LP indications (table 1) When LP were performed within the first 24 h after admission, the median delay between admission and cranial CT was 2 h; the median delay for patients admitted between midnight and 6 A.M. was 7 h The median delay between admission and LP results was 6 h, whereas delays of up to 10 h were recorded for some of the patients admitted between midnight and 6 A.M.

 A positive correlation was found between the delay before cranial CT and the delay before obtaining LP results: the correlation coefficient was 0.6 (p<0.0001).

Discussion
Among efficient LP, aseptic (lymphocytic) meningitis was the most frequent diagnosis, whereas the search for an infection of the CNS was the most frequent indication for LP. Thus, patients could benefit from optimal treatments and strategies of care, based upon the results of CSF analyses. In cases of ineffective LP, the principal differential diagnoses were infections outside the CNS, noninfectious neurological disorders (seizures and strokes), and benign headaches.

 Though LP efficiency decreased dramatically according to age, differential diagnoses (diagnoses found in cases of inefficient LP) also varied substantially according to patients age.

 Considering the seriousness of meningitis, SAH, and acute GBS disorders, which may compromise patients functional and vital prognoses, LP represent a consistent tool to rule out SAH or meningitis and to support a diagnosis of suspected acute GBS in an EMD setting

Our results were in line with the findings of the few published studies exploring LP use and efficiency in EMD settings
Mdol et al. Powers and Warshaw et al. Perry et al.s and McGillicuddy et al.s

The commonest complication of LP is PDPH, more serious complications have exceptionally been observed:
cerebral herniation, spinal hematoma, iatrogenic spinal tumor, induced meningitis.

The incidence of PDPH after a diagnostic LP procedure can vary from 6 to 40% Information not reported in patients files and early discharge from the EMD to home (14% of patients) represent potential mechanisms of misclassification.

Significant differences between aseptic and bacterial meningitis were found in our study, when standard CSF tests were considered some authors have suggested that these standard tests are only moderately useful in the event of a negative Gram-stained smear

specific CSF and blood serum tests have been proposed to better appreciate the likelihood of bacterial meningitis

The usefulness of the occurrence of soluble antigens in CSF was limited in our survey; however, this CSF test was infrequently employed (6% of CSF) in accordance with published data the rates of traumatic LP observed in our study were similar to previously published data by Shah et al Among elderly patients, fewer than 5% of LP were efficient, whilst almost four fifths of LP were employed to search for a CNS infection

Among elderly patients, fewer than 5% of LP were efficient, whilst almost four fifths of LP were employed to search for a CNS infection
The majority of infections detected among elderly patients were principally located in the respiratory or urinary tracts

Greater yield of LP was found among young (25% of cases) and middle-aged patients (a little less than 15% of cases).
Among these subpopulations, efficient LP documented primarily infections of the CNS (mainly aseptic meningitis)

LP indications
among younger patients corresponded to a higher clinical suspicion of meningitis. elderly patients to rule out the possibility of a CNS infection.

Clinical suspicion of CNS infection is assumed to have differed widely between these subpopulations and can explain the differences observed in LP efficiency

The usefulness of performing a CT prior to an LP depends on the patients clinical condition and the suspected diagnosis in our study a brain CT prior to LP seems to be routinely employed: clinical signs (focal neurological signs, seizures, or abnormal consciousness) requiring a brain CT prior to the performance of an LP were found among less than a third of our population Unexpectedly, approximately 90% of patients who underwent an LP to search for an infection of the CNS had CT prior to LP. Significant delays have been observed between admission, the brain CT, and LP results, especially when admissions occurred between midnight and 6 A.M.

 When LP are performed in order to search for an infection of the CNS, ordering a CT prior to an LP can lead to an important delay of the LP procedure.

Thus, administration of antibiotics may also be delayed, compromising the prognosis of patients with bacterial meningitis

SAH is suspected...??
SAH diagnoses are more frequently confirmed using brain imaging usually performed as the first-line diagnostic tool However, in spite of brain CT enhancement using fifth generation CT scanners, which improves the diagnosis of SAH, the sensitivity of noncontrast CT imaging may, in some cases, remain insufficient

the use of LP remains necessary to rule out SAH

In our study, assumed SAH indications for LP represented only 25.5% of the cases and only one case of SAH was found using an LP.

SAH indications were more frequent among middle-aged and young patients

 Several limitations, linked to the retrospective nature of our study, must be considered when assessing our results. LP subsequently performed in hospitalization units after an initial admission in the EMD were not taken into account, leading to a potential selection bias.

 In this study, our aim was to assess emergency medical practices in relation to patients initial characteristics observed in the EMD. Classification and information biases can result from the retrospective reviewing of patients medical files, leading to a more difficult assessment of patients features, indications for LP, and final diagnoses. Thus, two emergency physicians reviewed patients medical files independently and the concordance of our results with the literature data suggests that these biases are limited.

A better assessment of the efficiency of LP would undoubtedly be achieved in a prospective setting with a larger study population

This would allow a more precise and reliable assessment of LP indications, patients features, delivery of anti-infective treatments (in cases of suspected meningitis), and outcomes during a follow-up.
Missed meningitis and SAH diagnoses, in the EMD, would also be appreciated. The assessment of medical practices, illustrated by the use of brain CT prior to LP (in cases of a possible infection of the CNS) and herpes simplex PCR tests, suggests that the current published guidelines and data were not fully taken into account

The assessment of medical practices, illustrated by the use of brain CT prior to LP (in cases of a possible infection of the CNS) and herpes simplex PCR tests, suggests that the current published guidelines and data were not fully taken into account

A prospective survey would permit evaluation of potential improvements in medical practices after a review of current guidelines.

CRITICAL APPRAISAL

1. Apakah terdapat ketersamaan dengan Gold Standart?

Tidak diketahui Di dalam jurnal ini tidak dijelaskan mengenai sensitivitas, spesifitas, nilai prediksi positif, nilai prediksi negatif, dan prevalensi jurnal ini hanya membahas mengenai kegunaan dan efisiensi penggunaan LP di EM department dalam penegakkan suatu diagnosis

2. Apakah sampel subyek penelitian meliputi spektrum penyakit dari yang ringan sampai berat, penyakit yang terobati dan tidak terobati Ya Tampak pada Tabel 1 dimana peneliti telah mencantumkan secara terperinci mengenai usia, berbagai macam gejala klinis, dan riwayat penyakit sebelumnya dari subyek yang diteliti.

3. Apakah lokasi penelitian disebutkan dengan jelas?

Ya Lokasi telah disebutkan secara jelas, yaitu pada Adult Emergency Medical Department di salah satu rumah sakit umum di Arras, Perancis Utara

4. Apakah presisi uji diagnosa dan variasi pengamat dijelaskan?

Iya Dalam penelitian ini, variasi pengamat telah dilakukan, namun tidak di jabarkan mengenai fluktuasi hasil pengukuran/analisa ulang dari LP Tampak pada:
The retrospective design of our survey led us to assess LP indications and final diagnoses using independent examinations of patients medical files performed by two emergency physicians

5. Apakah istilah normal dijelaskan?

Tidak Terdapat penggunaan istilah normal dalam pemeriksaan CSF dari LP, namun tidak dijelaskan secara terperinci kriteria normalnya.
Therefore, despite the modest efficiency of CSF examinations revealed by our results, negative or normal CSF findings can be informative and useful

6. Apabila uji diagnosis yg diteliti merupakan bagian dari suatu kelompok uji diagnosa, apakah kontribusinya pd kelompok uji diagnosa tersebut dijelaskan?

Iya LP merupakan suatu bagian dari suatu kelompok uji diagnosa. Dalam penelitian ini, ada beberapa kasus yang didahului dengan pemeriksaan CT scan sebelum dilakukan LP Tabel 1

7. Apakah cara dan teknik melakukan uji diagnosa yang sedang diteliti dijelaskan, sehingga dapat direplikasi? Ya Dalam penelitian ini telah dijelaskan bagaimana melakukan uji diagnosa tersebut (LP) dan bagaimana menginterpretasikan hasilnya, termasuk dijelaskan mengenai komplikasi dari tindakan uji diagnosa tersebut (LP)

8. Apakah kegunaan uji diagnosa yang sedang diteliti disebutkan?

Iya Tujuan utama dalam penelitian ini adalah untuk mengetahui kegunaan dan effisiensi penggunaan lumbal pungsi di EM department. Kelainan yang dapat diterapi dapat terdeteksi, tindakan diagnostik lebih lanjut dapat dikurangi, dan dapat menekan biaya untuk penggunaan alat radiologi pada pasien2 dengan indikasi LP.

Conclusion of Critical Appraisal

This study was not valid enough, but it was important and applicable

Terimakasih....