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Jared L Antevil

Publications and source records attributed to Jared L Antevil.

9 recordsLinked to original sources
PubMed2006

Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation.

BACKGROUND: Despite our regular use of CT for suspected appendicitis, a recent study at our institution demonstrated a negative appendectomy (NA) rate similar to our rate 15 years earlier. Based on analysis of this data, a diagnostic pathway was implemented prospectively for adult patients with possible appendicitis. STUDY DESIGN: Rates of CT, NA, and perforation for nonpregnant patients over 14 years of age undergoing appendectomy between August 2001 and August 2002 (PRE) were compared with prospectively collected pathway data (PATH, August 2004 to August 2005). All PATH patients were evaluated by a surgeon before CT. All females underwent CT. CT was obtained in male patients with low suspicion or pain for longer than 48 hours. After negative CT, patients were discharged from the emergency department or admitted for observation. RESULTS: There was a substantial decrease in NA rate after implementation of the pathway (4% PATH [8 of 183] versus 16% PRE [31 of 196], p < 0.001), without a change in the rate of perforation (11% PATH [20 of 175] versus 8% PRE [13 of 165], p = 0.28) or frequency of preoperative CT (59% PATH [108 of 183] versus 60% PRE [118 of 196], p = 0.84). CONCLUSIONS: Frequent appendiceal CT alone does not ensure surgical diagnostic accuracy. CT need not be used in all patients to achieve very low NA rates. An evidence-based diagnostic algorithm incorporating early surgical evaluation, objective criteria for preoperative CT, deterrence of early operation after negative CT, and use of CT to facilitate safe discharge led to substantial improvements in the care of our adult population presenting with possible appendicitis.

Acute Disease↗
PubMed2006

Abdominal computed tomography for postoperative abscess: is it useful during the first week?

While classic teaching dictates computed tomography (CT) for postoperative abdominal or pelvic abscess in the first week is of low yield, little evidence supports intentional delays in imaging for suspected abscess. This retrospective review examined all CT scans obtained for clinical suspicion of abscess between 3 and 30 days after abdominal or pelvic operation over a 3-year period. Scans were grouped into those obtained between 3 and 7 days after surgery (EARLY) and those obtained after day 7 (LATE). Diagnostic yield was compared between EARLY and LATE groups. Of 262 CT examinations (EARLY, n = 106; LATE, n = 156), 71 studies (27%) demonstrated abscess. There was no significant difference in the diagnostic yield of CT for abscess between EARLY and LATE groups (23% [24 of 106] versus 30% [47 of 156], P = 0.18). Of patients with an abscess, 63% (45 of 71) underwent percutaneous or operative drainage (EARLY 75% [18 of 24], LATE 57% [27 of 47], P = 0.15). Abdominal CT for postoperative abscess can be expected to be diagnostic in a substantial proportion of cases in the first week, the majority of which lead to percutaneous or operative drainage. Postoperative CT for intra-abdominal abscess should be obtained as clinically indicated, regardless of interval from surgery.

Abdominal Abscess↗
PubMed2006

Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale.

BACKGROUND: Retrievable vena cava filters (RFs) offer the appeal of short-term prophylaxis for trauma patients temporarily at risk for pulmonary embolism (PE) without the long-term risks of permanent vena cava filters (PFs). However, the evidence that RFs and PFs reduce the risks of PE and death in trauma patients is not conclusive. RFs were introduced at our trauma center in August 2002. The purpose of this study was to evaluate the effects of RFs on our strategy to prevent PE in trauma patients. METHODS: We reviewed our trauma registry to compare rates of filter placement, filter-related complications (FRCs), and PE before (Group I: January 2000 to August 15, 2002) and after (Group II: August 16, 2002 through December 2004) RF introduction. Indication for filter placement, filter retrieval, FRCs, and incidence of PE were compared. RESULTS: There were 5,042 patients in Group I and 5,038 patients in Group II. There was a threefold increase in filter placement in Group II compared with Group I (55 [1.1%] versus 161 [3.2%]; p < 0.001). There were no significant differences between the rates of PE (0.2% versus 0.2%, p = 0.636) or major FRCs (1.8% versus 2.5%, p = 0.777). Major FRCs included two filter infections with sepsis, one vena cava thrombotic occlusion, one filter lodged in the jugular vein during retrieval, and one PE after filter placement. RF removal was attempted in 43 (27%) patients and successful in 33 (21%). CONCLUSION: The advent of RFs was associated with a threefold increase in vena cava filter placement in our trauma center. Major FRCs were encountered and a very low incidence of PE was not altered by their use. Successful removal could be verified in only 21% of RFs. The results of this study lead us to question the rationale for a more liberal use of vena cava filters in trauma patients.

Adult↗
PubMed2006

Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?

BACKGROUND: Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure. METHODS: Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured. RESULTS: There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv). CONCLUSIONS: SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.

Adult↗
PubMed2005

Safe and rapid laparoscopic access--a new approach.

Despite numerous recent technical advances in minimally invasive surgical technique, the potential exists for serious morbidity during initial laparoscopic access. Safe access depends on adhering to well-recognized principles of trocar insertion, knowledge of abdominal anatomy, and recognition of hazards imposed by previous surgery. Applying these principles, we describe a safe, rapid, and cost-effective technique for laparoscopic access using readily available instruments. This technique emphasizes identification and incision of the point at which the midline abdominal fascia is fused with the base of the umbilicus, and the importance of the application of countertraction directly at the point of insertion. This method allows penetration under direct vision with minimal controlled axial force, and without the requirement for fascial sutures or other cumbersome aspects of the traditional open technique. While previous reports describe techniques for laparoscopic access entry based on similar anatomic and surgical principles, we describe an alternative method not yet discussed in the surgical literature.

Abdomen↗
PubMed2005

Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: a prospective, randomized clinical trial.

STUDY OBJECTIVE: Glycopyrrolate is advocated for the treatment of acute pain from suspected symptomatic cholelithiasis. However, there is no clinical evidence to substantiate its use. This study is designed to evaluate the efficacy of glycopyrrolate in relieving acute abdominal pain of suspected biliary tract origin. METHODS: Between July 2002 and April 2003, a convenience sample of patients presenting to the emergency department with upper abdominal pain of suspected biliary tract origin was randomized to receive either intravenous glycopyrrolate or placebo (normal saline solution). Pain level was assessed at baseline using a visual analog scale, with a repeat assessment 20 minutes after intervention. Patients and clinicians were blinded to the study drug. RESULTS: Because of difficulty with patient enrollment, the trial was terminated before achievement of the initial goal of 54 patients. On analysis of the 38 patients completing the study protocol, glycopyrrolate and placebo groups had similar demographic and baseline characteristics. There was no significant difference in pain relief between patients receiving glycopyrrolate and those receiving placebo (median decrease in visual analog pain scale pain 3 mm [95% confidence interval -2 to 17 mm] versus 8 mm [95% confidence interval -2 to 20 mm], respectively). CONCLUSION: Although limited by small size and convenience sampling, these results fail to demonstrate any improvement in pain of suspected biliary tract origin with the administration of glycopyrrolate. Further study is needed to determine whether intravenous glycopyrrolate has any significant analgesic effect for patients with this condition.

Adult↗
PubMed2005

Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come.

BACKGROUND: Although the traditional method of diagnosing spine fractures (SF) has been plain radiography, Spiral Computed Tomography (SCT) is being used with increasing frequency. Our institution adopted SCT as the primary modality for the diagnosis of SF. The purpose of this study was to determine whether SCT scan can be used as a stand-alone diagnostic modality in the evaluation of SF. METHODS: Retrospective review of all blunt trauma patients over a two year period (1/01-12/02). Patients with neck pain, back pain, or spine tenderness underwent SCT of the symptomatic region. Patients who were unconscious or intoxicated underwent screening SCT of the entire spine. SCT was performed using 5 mm axial cuts with three-dimensional reconstructions in sagittal and coronal planes. Patients with a discharge diagnosis of cervical, thoracic, or lumbar SF were identified from the trauma registry by ICD-9 codes. RESULTS: There were 3,537 blunt trauma patients evaluated, with 236 (7%) sustaining a cervical, thoracic, or lumbar SF. Forty-five patients (19%) sustained a SF in more than one anatomic region. SCT missed SF in two patients. The cervical SF missed by SCT was a compression fracture identified by magnetic resonance imaging and was treated with a rigid collar. The thoracic SF missed by SCT was also a compression fracture identified on plain radiographs and required no treatment. CONCLUSIONS: SCT of the spine identified 99.3% of all fractures of the cervical, thoracic, and lumbar spine, and those missed by SCT required minimal or no treatment. SCT is a sensitive diagnostic test for the identification of SF. Routine plain radiographs of the spine are not necessary in the evaluation of blunt trauma patients.

Adolescent↗