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This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences., (© 2022 Society for Academic Emergency Medicine.)

Background: Given the time, expense, and radiation exposure associated with computed tomography (CT), ultrasonography (US) is considered an alternative imaging study that could expedite patient care in patients with suspected obstructive uropathy. However, there is a paucity of literature regarding bedside US for obstructive uropathy in the emergency department (ED), and it is unknown how much experience is required for competency in such exams., Objectives: The objective was to assess the learning curve for the detection of obstructive uropathy of resident physicians training in ED bedside US (EUS) during a dedicated EUS elective., Methods: This was a prospective cohort study of residents participating in an EUS elective. Patients presenting with acute abdominal or flank pain suggestive of an obstructive uropathy were enrolled and underwent EUS prior to noncontrast CT. Physicians who had previously performed at least 10 EUS exams for obstructive uropathy recorded results on a standardized data sheet, which was subsequently compared to the results of noncontrast CT read by board-certified radiologists blinded to the results of the EUS. In addition to an unadjusted chi-square test for trend, a multivariable logistic regression analysis, adjusting for stone size and operator, was performed. Finally, generalized estimating equations were used to describe test characteristics while accounting for potential clustering between exams by operator., Results: Twenty-three resident physicians participated and enrolled a convenience sample of 393 patients. A total of 157 patients (40%) were diagnosed with an obstructing ureterolith, and three (1%) were diagnosed with nonobstructing ureterolithiasis. An unadjusted chi-square test for trend demonstrated a statistically significant increase in both sensitivity (χ(2) = 11.4, p = 0.02) and specificity (χ(2) = 6.4, p = 0.04) for each level of increase in number of exams. On multivariable regression analysis, when adjusting for size of stone and operator, for every five additional exams after the first 10 EUS exams, the odds ratio for a true positive for obstruction increased by 1.7 (95% confidence interval [CI] = 1.2 to 2.5, p = 0.003). After accounting for clustering of exams by operator, overall EUS sensitivity and specificity for obstructive uropathy were 82% (95% CI = 77% to 87%) and 88% (95% CI = 85% to 92%). Stratifying by number of exams, the sensitivity was 72% (95% CI = 62% to 80%) for the 11th through 20th exams, 90% (95% CI = 83% to 96%) for the 21st through 30th exams, and 95% (95% CI = 91% to 99%) for the 31st through 43rd exams. Likewise, specificity was 82% (95% CI = 75% to 89%) for the 11th through 20th exams, 90% (95% CI = 85% to 95%) for the 21st through 30th exams, and 92% (95% CI = 86% to 98%) for the 31st through 50th exams., Conclusions: Physicians training in EUS may be able to accurately assess for obstructive uropathy after 30 exams., (2010 by the Society for Academic Emergency Medicine.)

Objectives: Acute retinal detachments (RD) can be difficult to diagnose and may require emergent intervention. This study was designed to assess the performance of emergency department ocular ultrasound (EOUS) for the diagnosis of RD., Methods: This was a prospective, observational study using a convenience sample of emergency department (ED) patients. Physicians performed EOUS for the diagnosis of RD prior to evaluation by an ophthalmologist. The criterion standard was the diagnosis of a RD by the ophthalmologist who was blinded to the results of EOUS., Results: Fifteen physicians evaluated 48 patients with acute visual changes. Eighteen patients (38%) had RDs and all were correctly identified (true positives). Of the 30 patients (62%) without RD, 25 patients were correctly identified (true negatives), and five patients with vitreous hemorrhages were misidentified as having RDs (false positives). Therefore, the sensitivity and specificity of EOUS for RD were 100% (95% confidence interval [CI] = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively., Conclusions: Emergency department ocular ultrasound is sensitive for the diagnosis of RD and may have a role in excluding RD in patients presenting to the ED., (2010 by the Society for Academic Emergency Medicine)