Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study as selected by their editors. This edition will feature an abstract from each publication.

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.

Prehn’s sign describes the eradication of testicular pain on lifting the scrotum and has been proposed as a method to differentiate causes of acute testicular pain. A short systematic review was conducted to evaluate the question: in patients presenting with acute unilateral testicular pain, is a negative Prehn’s sign an accurate sign for diagnosis of testicular torsion (TT)?Medline, Embase and Cochrane databases were searched using the OVID interface from inception to 26 February 2025. Following the removal of duplicates, the search strategy yielded a total of 11 papers. Study information, participant group, relevant outcomes and study weaknesses were extracted from each article.Four studies addressed the three-part question. The only study that had the full text available for review found that 33% of patients with TT had a positive Prehn’s sign, which equated to an OR of 5.941 (95% CI 1.432 to 24.658). Of the three remaining retrospective cohort studies, Prehn’s sign was reported to be positive in 10.5%, 37.5% and 100% of patients with TT, respectively. Therefore, the negativity of Prehn’s sign ranged from 0% to 89.5% in patients with TT.The clinical bottom line is that Prehn’s sign is insufficiently sensitive to rule out TT; however, its negativity increases the likelihood of a TT diagnosis.

ObjectivesIn fall 2022, paediatric EDs (PEDs) and urgent cares (PUCs) cared for an unprecedented number of children, leading to long waits and boarding patients. This surge mimicked the adult ED/UC COVID-19 pandemic experience. Learning from published data and surge response plans, we adapted our response using rapid cycle quality improvement methodology.MethodsA multidisciplinary PUC/PED team met to determine the current state and create interventions. After the standard seasonal surge response did not have a significant impact, we further expanded inpatient capacity, created new physical PUC space, started provider intake and transitioned PED beds to inpatient.ResultsStatistical control charts were used to monitor metrics from 4 weeks prior to the surge to when volumes returned to baseline, but improvement was seen prior to this. Our primary outcome measure, left without being seen (LWBS) rates, decreased from a peak of 40% to <5% and PUC door-to-provider time (process measure) decreased from 158 min to 106 min before the surge was over. These metrics also dropped below the prior baseline after volumes returned to normal. PED door-to-provider time (process measure) and PUC lengths of stay (LOS) (balancing measure) were maintained throughout.ConclusionsUsing rapid cycle methodology, we responded quickly to an unprecedented patient volume by innovatively increasing staffing and space. We improved LWBS rates and PUC door-to-provider time despite high volumes and large numbers of boarding patients. We created efficiencies that allowed us to maintain PUC LOS and PED door-to-provider times during the surge. This resulted in sustained improvement, and we now operate with shorter LOS and door-to-provider times than historically achieved.

BackgroundAcute appendicitis requires timely diagnosis. The diagnostic efficacy of tongue examination in making this diagnosis has not been established. This study investigates whether the Tongue Coating Index (TCI), a validated measure of tongue coating, can aid in diagnosing acute appendicitis.MethodsWe conducted a prospective cohort study (1 September 2018–31 December 2020) at a single Japanese hospital. Adults (≥20 years) with suspected acute appendicitis, presenting to either the emergency department or general outpatient clinic, were enrolled. Tongue images were taken at presentation; two independent examiners—unrelated to clinical care and blinded to patient data—later scored these images using the TCI. A composite reference standard (clinical findings, imaging, histopathology, follow-up) was used to confirm appendicitis. We compared the TCI’s diagnostic performance with the Alvarado score and its components using C-index, area under the curve (AUC), sensitivity and specificity.ResultsOf 145 included patients, 69 (47.6%) were diagnosed with acute appendicitis. The TCI demonstrated comparable discriminative ability (C-index AUC 0.62; 95% CI, 0.53 to 0.71) to that of the Alvarado score (0.66; 95% CI, 0.57 to 0.75). Of Alvarado score components, migration of pain had an AUC of 0.63 (95% CI, 0.55 to 0.71), anorexia 0.58 (95% CI, 0.50 to 0.66) and tenderness in the right lower quadrant 0.55 (95% CI, 0.50 to 0.60). At a cut-off of 3, the TCI demonstrated high sensitivity of 96% (95% CI, 88% to 98%) but low specificity of 21% (95% CI, 13% to 32%). Conversely, at a cut-off of 10, the TCI showed increased specificity of 83% (95% CI, 73% to 90%) but reduced sensitivity of 29% (95% CI, 20% to 41%).ConclusionThe TCI showed comparable diagnostic performance to the Alvarado score and its individual components. TCI may potentially serve as an additional non-invasive indicator for diagnosing or ruling out acute appendicitis. Further research is essential to validate its clinical utility.