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Biomedical subjects

D G Jacobs

Publications and source records attributed to D G Jacobs.

At least 19 recordsLinked to original sources
PubMed2001

Safety and accuracy of bedside carbon dioxide cavography for insertion of inferior vena cava filters in the intensive care unit.

BACKGROUND: Bedside insertion of inferior vena caval filters (IVCFs) avoids risks associated with transporting these critically ill patients to the operating room or to the radiology suite. But because IVCF insertion requires preinsertion caval imaging, the risk of contrast-induced renal failure remains a concern. Carbon dioxide (CO2) as a contrast agent does not cause renal failure, but its accuracy in determining vena caval diameter (a critical factor in filter selection) and its safety in the critical care population are unknown. This study is designed to assess the safety of using CO2 as a contrast agent in this patient population and to evaluate its accuracy in determining the diameter of the inferior vena cava when used at the bedside. STUDY DESIGN: A prospective study comparing CO2 with iodinated contrast (IC) material was performed in critically ill patients undergoing vena cavography before bedside IVCF placement. CO2 cavagrams were performed with one or more hand injections of 60 mL of CO2; a single injection of 40 mL of IC material was used. Digital subtraction techniques were used for all of the studies. Blood pressure, pulse rate, and arterial oxygen saturation, end-tidal CO2, and intracranial pressure (when available) were recorded before, during, and after contrast injection. Statistical analysis was performed using the paired t-test, with p < 0.05 being considered significant. Data are expressed as mean +/- SD. RESULTS: Twenty-three patients were studied. Mean transverse inferior vena cava (IVC) diameters measured 20.4 +/- 0.7mm (IC) and 20.0 +/- 0.7mm (CO2); p = 0.003. The difference in the measurements was 0.4 +/- 0.1 mm, with the largest difference being 1.7mm. In the remaining 10 patients, CO2 differed from IC in determining IVC diameter by only 0.4mm, a statistically significant (p < 0.05) but clinically insignificant difference. No adverse effects on blood pressure, pulse, arterial oxygen saturation, end-tidal CO2, or intracranial pressure were noted with the use of CO2. CONCLUSIONS: Carbon dioxide as a contrast agent is safe and provides accurate determination of vena caval diameter and anatomy. Carbon dioxide should be considered the contrast agent of choice in critically ill patients.

Adult↗
PubMed2001

Bedside insertion of inferior vena cava filters in the intensive care unit.

BACKGROUND: Several authors have showed that bedside insertion of inferior vena cava filters (IVCF) is feasible and cost effective, with the additional benefit of not having to transport a critically ill patient to the operating room or radiology department. The objective of this study was to examine our experience of 158 IVCF insertions at the bedside in the intensive care unit. STUDY DESIGN: A prospective, observational study of bedside IVCF insertion performed by the authors from February 1996 through August 2000 was undertaken. RESULTS: One hundred fifty-eight patients underwent bedside IVCF insertion in the intensive care unit. The mean age was 42.2 years (SD 17.5 years). The mean Injury Severity Score of the trauma patients was 27.3 (SD 14.5). The majority of patients (90%) had a prophylactic indication for IVCF insertion using our institutional guidelines for venous thromboembolic prophylaxis for trauma patients. All IVCF insertions were successfully performed at the bedside after iodinated contrast or carbon dioxide cavography. The mortality was 11% (n = 18), none attributable to the IVCF insertion or cavagram. There was one asymptomatic cava occlusion and one postinsertion pulmonary embolus in a patients with a subclavian vein thrombosis. CONCLUSIONS: Our results demonstrate the safety and efficacy of IVCF insertion at the bedside in the ICU. This method offers less resource use and more safety for critically ill patients, avoiding the hazards of intrahospital transport.

Adult↗
PubMed2001

Blunt traumatic rupture of the thoracic aorta: a report of an unusual mechanism of injury.

Classic teaching suggests that blunt thoracic aortic rupture (BTAR) results from high-speed deceleration injury mechanisms. Our recent experience with a patient who sustained fatal aortic rupture resulting from a low-speed crushing injury emphasizes the importance of maintaining a high index of suspicion for BTAR, even in patients with "low-risk" injury mechanisms. Several potential pathophysiologic mechanisms of BTAR are discussed.

Aorta, Thoracic↗
PubMed2001

Suicide, depression, and isotretinoin: is there a causal link?

This paper examines the existing literature and MedWatch reports concerning a proposed relationship between isotretinoin and depression and suicide. The authors provide a brief overview of the biology of isotretinoin and depressive disorder and find no basis for a putative molecular mechanism linking the two. They also address the complexities of Substance-Induced Mood Disorder (SIMD) as a psychiatric diagnosis and its relevance to isotretinoin. Based on this review, the authors conclude that there is no evidence to support a causal connection between isotretinoin and major depression or suicide, because reported cases do not meet the established criteria for causality. The authors also conclude, however, that it is important for dermatologists to be aware of the risk factors for suicide and to monitor patients who exhibit depressive symptoms.

Acne Vulgaris↗
PubMed2000

Laparoscopic repair of a ruptured diaphragm secondary to blunt trauma.

The diagnosis of acute diaphragmatic rupture can be a challenge for even the most experienced clinician. The treatment of the rupture and its concomitant injuries, particularly in the elderly, can be associated with significant morbidity and mortality. The advent of laparoscopy for both the diagnosis and repair of this condition has allowed a more minimally invasive approach. We present the case of a 70-year-old woman who was hurt in a motor vehicle crash. On admission, her physical exam showed left upper quadrant tenderness and bruising. The chest radiograph was suggestive of a ruptured diaphragm. She was taken to the operating room and explored laparoscopically. After a thorough exploration of all the abdominal contents, a tear in the diaphragmatic hiatus to the right of the esophagus was noted. The stomach and small intestine were returned to the abdomen, and the diaphragmatic rupture was repaired. We conclude that laparoscopic exploration and repair of a ruptured diaphragm in a bluntly injured patient is a safe and effective option in selected cases.

Accidents, Traffic↗
PubMed2000

Abdominal CT scanning for trauma: how low can we go?

PURPOSE: computed tomography (CT) of the abdomen is an established, albeit expensive and perhaps overused, diagnostic modality for the evaluation of the injured patient. We developed a practice management guideline for blunt abdominal trauma intended to reduce the percentage of negative CT scans, yet minimize delayed recognition of injury and non-therapeutic laparotomy. PROCEDURES: between April 1996 and March 1997, 1147 adult patients at risk for blunt abdominal injury were admitted to our Level I trauma centre and underwent abdominal evaluation according to the practice management guideline. MAIN FINDINGS: abdominal CT was performed in 522 patients (45%), and 441 scans were negative (85%). Delayed recognition of injury and non-therapeutic laparotomy rates were low, 4% and 1.6%, respectively. PRINCIPAL CONCLUSION: abdominal CT scanning in trauma patients can achieve low non-therapeutic laparotomy and delayed recognition of injury rates but at the expense of high negative CT scan rates. Greater reliance on the physical examination and perhaps abdominal ultrasound may reduce negative CT scan rates and yet preserve low non-therapeutic laparotomy and delayed recognition of injury rates.

Abdominal Injuries↗
PubMed2000

Value of point-of-care blood testing in emergent trauma management.

BACKGROUND: No prospective study demonstrates the value of point-of-care laboratory testing (POCT) in the management of major trauma. METHODS: In a prospective, noninterventional, study of 200 major trauma patients, we evaluated the influence of a blood POCT profile (hemoglobin, Na+, K+, Cl-, blood urea nitrogen, glucose, pH, PCO2, PO2, HCO3-, base deficit, and lactate) on emergent diagnostic and therapeutic interventions. Physicians responded to a standardized set of questions on their diagnostic and therapeutic plans before and after the availability of POCT results. Management plan changes were deemed emergently appropriate, if they were influenced by the POCT results and, within the ensuing 30 minutes, the change in management was likely to reduce morbidity or conserve resources. RESULTS: For emergently appropriate plan changes, Na+, Cl-, K+, and blood urea nitrogen were never influential, whereas in each of 6.0% of cases (95% confidence interval [CI], 3.5%-10.2%) at least one of the remaining POCT parameters was influential. An emergently appropriate change was based on hemoglobin in 3.5% of cases (95% CI, 1.0%-6.1%), blood gas parameters in 3.0% of cases (95% CI, 0.64%-5.7%), lactate in 2.5% of cases (95% CI, 1.1%-5.7%), and glucose in 0.5% of cases (95% CI, 0.1%-2.8%). All of these cases involved blunt injury. CONCLUSION: Na+, Cl-, K+, and blood urea nitrogen levels do not influence the initial management of major trauma patients. In patients with severe blunt injury, hemoglobin, glucose, blood gas, and lactate measurements occasionally result in morbidity-reducing or resource-conserving management changes.

Adolescent↗
PubMed2000

Development of a brief screening instrument: the HANDS.

BACKGROUND: The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience. METHODS: We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30. RESULTS: The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist. CONCLUSION: The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

Adolescent↗
PubMed2000

Treatment for depression following the 1996 National Depression Screening Day.

OBJECTIVE: Characteristics of the subsequent treatment received by people who screened positive for depression in the 1996 National Depression Screening Day were investigated. METHOD: A follow-up telephone survey was completed by 1,502 randomly selected participants from 2,800 sites. RESULTS: Of 927 people for whom additional evaluation was recommended, 602 (64.9%) obtained evaluations and 503 (83.6%) received treatment. Of these 503, 260 (51.7%) received psychotherapy and medication, 130 (25.8%) received medication only, and 93 (18.5%) received psychotherapy only. Compared with people without health or mental health insurance, individuals with health insurance (66.7% versus 57.5%) and mental health insurance (74.6% versus 55.3%) were more likely to comply with the recommendation to obtain follow-up evaluation. CONCLUSIONS: One-half of the people treated for depression received a combination of psychotherapy and medication. Lack of insurance was associated with not following the recommendation to obtain further evaluation and treatment.

Adolescent↗
PubMed1999

Depression screening as an intervention against suicide.

Depression is a common psychiatric disorder that can disrupt a person's health, work, and relationships, and--in some cases--lead to suicide. Disparity between the prevalence of depression and diagnosis and treatment of the disorder led to the creation in 1991 of National Depression Screening Day (NDSD), an annual nationwide screening program for depression. By raising awareness and reducing the stigma of depression, the national screening program addresses the problems of underdiagnosis and lack of treatment in persons suffering from the depressive disorder. Mental health professionals and colleagues in other specialties must reach out to depressed individuals and make it easier for them to access the health care system. This article discusses the origin and goals of NDSD, the NDSD model for the current community-based program, the results of NDSD screening, and the proposed future expansion of NDSD and the voluntary screening concept.

Community Mental Health Services↗
PubMed1998

Antibiotic prophylaxis for intracranial pressure monitors.

To determined the safety and efficacy of prophylactic antibiotics in head-injured patients requiring intracranial pressure monitors, the files of 30 consecutive patients with isolated, severe head injuries admitted over a 1-year period were reviewed. Patients .15 years with severe closed-head injury who did not have severe concomitant, extracranial injury (Abbreviated Injury Score, 3) and survived .48 hours following hospital admission were included. Fourteen patients underwent intracranial pressure monitor placement and received prophylactic antibiotics for the duration of monitoring and the remaining 16 patients were neither monitored nor given prophylactic antibiotics. Length of hospital stay, length of intensive care stay, overall and septic complication rate, and death rate were compared for the two treatment groups. The groups were similar with regard to patient characteristics, associated injuries, and injury severity. Patients who received prophylactic antibiotics demonstrated statistically higher septic morbidity rates (78.6% versus 31.3%) and statistically higher pneumonia rates (57.1% versus 18.8%) compared with patients who did not. No patient developed central nervous system infection related to the monitor itself. These results indicate that the administration of prophylactic antibiotics to head-injured patients for the duration of intracranial pressure monitoring is unnecessary and potentially detrimental. Antibiotics, if given at all, should be limited to the period immediately surrounding intracranial pressure monitor placement.

Adult↗
PubMed1997

Effectiveness of community-based screening for depression.

OBJECTIVE: The effectiveness of a voluntary depression screening program was assessed by determining 1) whether participants in the 1994 National Depression Screening Day went for recommended follow-up examinations and 2) the characteristics that differentiated those who did and did not return. METHOD: Randomly selected participants (N = 1,169) from 99 facilities completed a follow-up telephone survey. RESULTS: Of 805 people for whom follow-up was recommended, 56.5% (N = 455) went for an appointment. The severity of depressive symptoms in these subjects ranged from severe (33.4%, N = 152) and marked (41.3%, N = 188) to minimal (17.1%, N = 78) and normal (8.1%, N = 37). Subjects with marked or severe depression were more likely to respond to the screening recommendation than were those with minimal depressive symptoms. However, at each level of symptom severity, subjects who had received previous treatment were more likely to adhere to the screening recommendation than were those with no previous treatment. Of those who returned for a recommended follow-up, 72.1% were diagnosed with depression. Of those who did not return, 29.5% cited lack of insurance, under insurance, or inadequate finances, and 38.0% felt they could "handle" depression on their own. CONCLUSIONS: Voluntary screening for depression is an effective way to bring certain untreated depressed individuals to treatment. Inadequate insurance and the belief that individuals can manage depression on their own continue to be barriers to seeking treatment among some depressed individuals who attend a depression screening program.

Adolescent↗
PubMed1996

Analysis of deaths within 24 hours of injury: cost-benefit implications for organ and tissue donations.

OBJECTIVE: To determine useful predictors of successful organ donation in patients who die within 24 hours of injury (early deaths). DESIGN: Retrospective review of a 3-year experience at a Metropolitan Level I Trauma Center. MATERIALS AND METHODS: All 223 early deaths among 5,719 trauma patients in a 3-year period were reviewed. This group represented 62% of all trauma deaths. RESULTS: Forty-six patients (21%) donated 102 vascularized organs and made 66 donations of tissues. Patients with isolated severe head injuries had the highest rate of successful donation (33%). Those with severe head injury and another severe organ injury had a lower rate of donation (13%), and donation was rare (1%) among patients with severe organ injury in the absence of head injury (p < 0.001). There were no organ donors among victims >65 years old or in 64 of 65 patients with a Revised Trauma Score of <2.2. The Revised Trauma Score was significantly higher in organ donors (3.39 vs. 3.07, p < 0.05). The cost-benefit ratio for early deaths was $6,512 per organ/tissue recovered. CONCLUSIONS: Decisions regarding the resuscitation of trauma patients who have characteristics associated with a recognized low rate of organ donation should be made exclusive of the potential for organ recovery.

Adult↗