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Biomedical subjects

Jason S Haukoos

Publications and source records attributed to Jason S Haukoos.

At least 19 recordsLinked to original sources
PubMed2006

Evaluation of three scoring systems predicting non sentinel node metastasis in breast cancer patients with a positive sentinel node biopsy.

BACKGROUND: Completion axillary lymph node dissection (cALND), performed after a positive sentinel lymph node biopsy (SLNB) in breast cancer patients, often results in no additional positive nodes. Scoring systems have been published to aid in the prediction of nonsentinel node metastasis. Our purpose was to assess the validity of these scoring systems in our patient population. METHODS: For 39 consecutive patients who underwent cALND after a positive SLNB, scores were calculated using retrospective patient data for each of the three scoring systems used. Receiver operating characteristics (ROC) curves were drawn, and the areas under the curves were calculated to assess the discriminative power of each system. Univariate analysis was performed to assess the predictability of individual patient and tumor characteristics. RESULTS: Nonsentinel nodes were positive in 23 (59%) patients. The areas under the ROC curves were 0.63, 0.70, and 0.68, respectively. The proportion of sentinel nodes that were positive and the total number of sentinel nodes retrieved were the only individual predictors of nonsentinel node metastasis. CONCLUSIONS: Given the high incidence of retrieving no additional metastasis on cALND, individualized patient management according to risk is desirable. Scoring systems provide additional information regarding the likelihood of metastasis in nonsentinel nodes, but their predictability remains less than optimal. The use of scoring systems must be applied with caution until future studies provide a more accurate assessment of risk for patients with a positive SLNB.

Biopsy↗
PubMed2006

Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma.

STUDY OBJECTIVE: The Glasgow Coma Scale (GCS) score is widely used in the initial evaluation of patients with traumatic brain injury. This 15-point score, however, has been criticized as unnecessarily complex. Recently, a 3-point Simplified Motor Score (defined as obeys commands=2; localizes pain=1; withdrawals to pain or worse=0) was developed from the motor component of the GCS and was found to have a similar test performance for predicting outcomes after traumatic brain injury when compared with the GCS score as the criterion standard. The purpose of this study was to validate the Simplified Motor Score in a large heterogeneous trauma population. METHODS: This was a secondary analysis of a prospectively maintained trauma registry with consecutive trauma patients who presented to a Level I trauma center from 1995 through 2004. Test performance of the GCS and the Simplified Motor Score relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, clinically significant brain injury, neurosurgical intervention, and mortality) was evaluated with areas under the receiver operating characteristic curves (AUCs). RESULTS: Of 21,170 patients included in the analysis, 18% underwent emergency intubation, 14% had clinically significant brain injuries, 7% underwent neurosurgical intervention, and 5% died. The AUCs for the GCS and its components ranged from 0.76 to 0.92 across the 4 outcome measures. The AUCs for the Simplified Motor Score ranged from 0.71 to 0.89, and the relative differences from the GCS AUCs ranged from 3% to 7%, with a median difference of 5%. CONCLUSION: In this external validation study, the 3-point Simplified Motor Score demonstrated similar test performance when compared with the 15-point GCS score and its components for the prediction of 4 clinically important traumatic brain injury outcomes.

Adolescent↗
PubMed2006

Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage.

PURPOSE: There is no definite consensus on the management of intra-abdominal abscesses in adults. This retrospective study evaluated the use of antibiotic therapy and percutaneous image-guided drainage in adult patients with intra-abdominal abscesses. METHODS: A retrospective chart review of 114 patients with intra-abdominal abscesses was conducted. Data collected included patient demographics, presenting symptoms, radiographic interpretation, vital signs, antibiotic coverage, laboratory values, and details of the hospital course. Bivariate statistical tests were performed using the Wilcoxon rank-sum test, chi-squared test, or Fisher's exact test, where appropriate. RESULTS: Sixty-seven of 114 patients (59 percent) had intra-abdominal abscesses resulting from appendicitis, diverticulitis in 30 patients (26 percent), postoperative in 13 patients (11 percent), and undetermined in 4 patients (4 percent). Three patients (3 percent; 95 percent confidence interval, 1-8 percent) failed conservative management and underwent urgent operation. Sixty-one (54 percent; 95 percent confidence interval, 44-63 percent) patients improved with intravenous antibiotic therapy alone. Fifty patients (44 percent; 95 percent confidence interval, 35-54 percent) underwent image-guided percutaneous drainage after 48 to 72 hours of antibiotic therapy. Patients who improved on antibiotics alone had average abscess diameter of 4 cm, whereas patients who underwent percutaneous drainage had average diameter of 6.5 cm (P<0.0001). Maximal temperature at time of admission was 100.8 degrees F for antibiotic group and 101.2 degrees F for percutaneous drainage group (P=0.0067). CONCLUSIONS: The majority of the patients with intra-abdominal abscesses improved with antibiotic therapy alone. Those patients with an abscess diameter>6.5 cm and temperature at admission>101.2 degrees F have higher likelihood of failing conservative therapy with antibiotics alone and requiring percutaneous drainage.

Abdominal Abscess↗
PubMed2006

How well do paramedics predict admission to the hospital? A prospective study.

A study was designed to determine whether paramedics accurately predict which patients will require admission to the hospital, and in those requiring admission, whether they will need a ward bed or intensive care unit (ICU) monitoring. This prospective, cross-sectional study of consecutive Emergency Medical Service (EMS) transport patients was conducted at an urban city hospital. Paramedics were asked to predict if the patient they were transporting would require admission to the hospital, and if so, whether that patient would be admitted to a ward bed or require an ICU bed. Predictions were compared to actual patient disposition. During the study period, 1349 patients were transported to our hospital. Questionnaires were submitted in 985 cases (73%) and complete data were available for 952 (97%) of these patients. Paramedics predicted 202 (22%) patients would be admitted to the hospital, of whom 124 (61%) would go the ward and 78 (39%) would require intensive care. The actual overall admission rate was 21%, although the sensitivity of predicting any admission was 62% with a positive prediction value (PPV) of 59%. Further, the paramedics were able to predict admission to intensive care with a sensitivity of 68% and PPV of 50%. It is concluded that paramedics have very limited ability to predict whether transported patients require admission and the level of required care. In our EMS system, the prehospital diversion policies should not be based solely on paramedic determination.

Allied Health Personnel↗
PubMed2006

Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome.

BACKGROUND: The purpose of this study was to determine the clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with nonoperative management of patients with primary subclavian vein thrombosis. METHODS: Sixty-four patients treated for Paget-Schroetter syndrome from 1996 to 2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First-rib resection was performed in 29 patients (45%) within the first 3 months, with a success rate of 93%. The remaining 35 patients (55%) were treated nonoperatively and constitute this study's population. RESULTS: Of the 35 patients with successful nonoperative management, 8 (23%) developed recurrent thrombotic events of the same extremity at a mean follow-up time of 13 months after thrombolysis (range, 6-33 months). These eight patients subsequently underwent first-rib resection with a 100% success rate without further sequelae at a mean follow-up time of 51 months (range, 2-103 months). The other 27 patients remained symptom free at a mean follow-up interval of 55 months (range, 10-110 months). Bivariate analyses determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P = .05). The recurrence group was also significantly younger than the asymptomatic group (22 vs 36 years; P = .01). Sex, being a competitive athlete, a history of trauma, whether the dominant arm was affected, time of delay to lysis, initial clot burden, response to original lysis, use of adjunctive balloons or mechanical thrombectomy devices, residual stenosis on venography, length of time on warfarin, and patency of the vein on follow-up duplex examination were all characteristics not associated with long-term recurrence after nonoperative management. CONCLUSIONS: Conservative nonoperative management of primary subclavian vein thrombosis can be successfully used with acceptable long-term results. A younger age (<28 years old) and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.

Adult↗
PubMed2006

Derivation of a clinical decision rule to exclude thoracic aortic imaging in patients with blunt chest trauma after motor vehicle collisions.

BACKGROUND: Thoracic aortic injury (TAI) is associated with high mortality. It is not practical to evaluate all patients with blunt chest trauma with dedicated aortic imaging. The purpose of this study was to define a group of patients with blunt chest trauma after motor vehicle collision (MVC) that do not require aortic imaging based on information available in the emergency department. METHODS: This was a secondary analysis of a prospectively-collected database. Consecutive patients with blunt chest trauma after MVC were included. Characteristics of mechanism, examination, and chest radiographic findings were collected for each patient. All patients underwent chest computed tomography (CT), aortography, or both for TAI evaluation. Binary recursive partitioning was used to derive and validate a clinical decision rule to predict exclusion of TAI. RESULTS: During the study period, 1,096 patients were included, and 22 (2.0%) were diagnosed with TAI. The decision rule for exclusion of TAI included findings from the chest radiograph, incorporating left paraspinous line displacement, obscured aortic knob, and mediastinal widening. The rule resulted in a sensitivity of 86% (95% confidence interval [CI]: 65% to 97%), a specificity of 77% (95% CI: 75% to 80%), a positive predictive value of 7% (95% CI: 4% to 11%), a negative predictive value (NPV) of 99.6% (95% CI: 99.0% to 99.9%), a positive likelihood ratio of 3.8 (95% CI: 1.1-12.9), and a negative likelihood ratio of 0.18 (95% CI: 0.05-0.61). This would potentially reduce aortic imaging by 76% (95% CI: 74% to 79%). CONCLUSION: We report a clinical decision rule with a high NPV for exclusion of TAI. This may standardize the approach to such patients and may reduce the need for CT.

Accidents, Traffic↗
PubMed2005

Recognition of undiagnosed HIV infection: an evaluation of missed opportunities in a predominantly urban minority population.

The goals of this study were to quantify delays in diagnosing HIV infection in patients presenting for medical care prior to the identification of their HIV infection, and to determine characteristics of visits preceding the identification of HIV infection. This was a retrospective cohort study of consecutive newly diagnosed HIV infected patients in a large urban setting. Patients were predominantly minorities and identified from all inpatient and outpatient HIV tests performed between December 29, 1998 and December 27, 1999. Data were collected from all emergency department and clinic visits for each patient included in this study for a 3-year period preceding the first diagnosis of HIV infection. Two hundred seventy-eight patients tested positive for HIV during the study period. Of these, 76 (27%) met inclusion criteria. Twenty-three patients made a total of 53 health care visits preceding the diagnosis of their HIV infection. The median delay in diagnosis of HIV infection was 2 days (interquartile range [IQR], 1-22 days; range, 0-1093 days) for all subjects, although 19 (25%; 95% confidence interval [CI]: 16%-36%) patients had a delay in diagnosis of 30 days or more. Among those patients who had made prior health care visits, the median delay in diagnosis was 112 days (IQR, 33-690 days; range, 2-1093 days). No specific risk factor, historical clue, physical examination finding, or laboratory finding reliably identified patients with HIV infection. Documentation in the medical record of specific risk factors and clinical characteristics suggestive of HIV infection was poor. This study documented missed opportunities and delays in diagnosis of patients with unrecognized HIV infection. Clinicians must maintain a high index of suspicion for HIV infection in all patients.

AIDS Serodiagnosis↗
PubMed2005

The effect of older blood on mortality, need for ICU care, and the length of ICU stay after major trauma.

The purpose of this study was to determine if the quantity and age of blood is an independent risk factor for in-hospital mortality, need for intensive care unit (ICU) care, and an increased length of stay in the ICU. This was a retrospective cohort study performed at a level I trauma center between 2001 and 2003. Consecutive trauma patients who received at least 1 unit of packed red blood cells (PRBCs) were included. The number of units of PRBCs transfused and the ages of each unit of PRBCs were recorded. Other variables including the patient's age, sex, Trauma-Related Injury Severity Score (TRISS), and whether the blood was leukopoor were collected. End points included in-hospital mortality, need for ICU care, and the length of stay in the ICU (in days). Multivariable logistic and Poisson regression analyses were performed to model the independent effect of the dose of aged blood (defined as the product of the average age of all units received and the total number of units received) with respect to each end point while controlling for age, TRISS, the total number of units administered, and the proportion of blood that was leukopoor. During the study period, 275 patients were studied. Patients who received older blood had a significantly longer ICU stay (RR 1.15, 95% CI: 1.11-1.20), possibly reflecting a higher level of organ dysfunction. Patients who received older blood, however, did not have a significantly higher in-hospital mortality rate (OR 1.21, 95% CI: 0.87-1.69) or a significantly higher need for ICU care (OR 1.20, 95% CI: 0.87-1.64). The quantity of aged blood is an independent risk factor for length of ICU care. This may be a proxy indicator for multiple organ failure. Further research is required to define which patients may benefit from newer blood.

Adult↗
PubMed2005

Advanced statistics: bootstrapping confidence intervals for statistics with "difficult" distributions.

The use of confidence intervals in reporting results of research has increased dramatically and is now required or highly recommended by editors of many scientific journals. Many resources describe methods for computing confidence intervals for statistics with mathematically simple distributions. Computing confidence intervals for descriptive statistics with distributions that are difficult to represent mathematically is more challenging. The bootstrap is a computationally intensive statistical technique that allows the researcher to make inferences from data without making strong distributional assumptions about the data or the statistic being calculated. This allows the researcher to estimate confidence intervals for statistics that do not have simple sampling distributions (e.g., the median). The purposes of this article are to describe the concept of bootstrapping, to demonstrate how to estimate confidence intervals for the median and the Spearman rank correlation coefficient for non-normally-distributed data from a recent clinical study using two commonly used statistical software packages (SAS and Stata), and to discuss specific limitations of the bootstrap.

Confidence Intervals↗
PubMed2005

An evaluation of out-of-hospital advanced airway management in an urban setting.

OBJECTIVES: To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. METHODS: This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. RESULTS: A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. CONCLUSIONS: Reasonable success and complication rates of endotracheal intubation in the out-of-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications.

Airway Obstruction↗
PubMed2005

Paramedic response time: does it affect patient survival?

OBJECTIVES: One marker of quality emergency medical services care is measured by meeting an 8-minute response time guideline. This guideline was based on results of paramedic response times for nontraumatic cardiac arrest patients and has not been studied in unselected patients. The objective of this study was to evaluate the effect of paramedic response time on survival to hospital discharge in unselected patients in a large urban setting while controlling for a number of potentially important confounders, including level of illness severity. METHODS: This was a retrospective cohort study performed in an urban 911-based ambulance service system. Patients transported by paramedics to a single urban county teaching hospital from January 1, 1998, to December 31, 1998, were included. Data collected included patient demographics; paramedic response, scene, and transport times; the nature of the medical complaint; and whether the patient survived to hospital discharge. Multivariable logistic regression models were developed using response time as the primary independent variable and survival to hospital discharge as the dependent variable. Covariates included scene time, transport time, age, gender, and level of illness severity. RESULTS: Of 34,111 calls involving emergency response, 11,078 patients (32%) were transported to the study institution and 10,382 (94%) had response time data available. Of these, 9,559 patients (92%) had data available to categorize them into groups based on their level of illness severity and were thus included in the study. A survival benefit was identified for response times <or=4 minutes (odds ratio [OR], 0.70; 95% confidence interval [CI] = 0.52 to 0.95). No survival benefit was identified when response time was modeled as a continuous variable (OR, 1.01; 95% CI = 0.98 to 1.04) or when dichotomized at 8 minutes (OR, 1.06; 95% CI = 0.80 to 1.42). CONCLUSIONS: A paramedic response time within 8 minutes was not associated with improved survival to hospital discharge after controlling for several important confounders, including level of illness severity. However, a survival benefit was identified when the response time was within 4 minutes for patients with intermediate or high risk of mortality. Adherence to the 8-minute response time guideline in most patients who access out-of-hospital emergency services is not supported by these results.

Adolescent↗
PubMed2005

The effect of financial incentives on adherence with outpatient human immunodeficiency virus testing referrals from the emergency department.

OBJECTIVES: Undiagnosed human immunodeficiency virus (HIV) infection is not uncommon among patients who seek care in urban inner-city emergency departments (EDs). The optimal method for providing appropriate HIV counseling, testing, and referral in this setting is unclear. A previous evaluation of an outpatient referral system for HIV testing among patients seen in the ED demonstrated that only 11% returned to be tested; of those tested, 7% were seropositive. The purpose of this study was to evaluate the effect of a financial incentive on the proportion of referred ED patients who completed outpatient HIV counseling and testing. METHODS: This was a quasi-experiment performed at an urban county teaching hospital. ED patients identified using Centers for Disease Control and Prevention guidelines as being at risk for HIV infection were referred for outpatient HIV counseling and testing at our institution within one week. This study was divided into three study periods. During the first and third periods, no financial incentive was offered for completing HIV counseling and testing. During the second period, a 25 dollars incentive was offered for completing HIV counseling and testing. RESULTS: During the study, 372 patients were referred for HIV counseling and testing. During the control periods, 20 (8%) of 252 patients completed HIV counseling and testing; during the intervention period, 27 (23%) of 120 patients completed HIV counseling and testing (odds ratio, 3.4; 95% confidence interval = 1.8 to 6.3). Of the 47 patients who completed HIV counseling and testing, none (0%; 95% confidence interval = 0% to 8%) tested positive for HIV infection. CONCLUSIONS: The use of a modest financial incentive increased the proportion of patients who completed HIV counseling and testing after being referred from the ED. It is unclear whether the use of a financial incentive increases the identification of HIV-infected patients unaware of their status or if it is cost-effective.

Adult↗
PubMed2005

Impact of the Final Rule on the rate of clinical cardiac arrest research in the United States.

BACKGROUND: The federal government placed a moratorium on human emergency resuscitation research in 1993 due to concerns related to informed consent. In 1996, the Food and Drug Administration introduced the Final Rule in order to allow clinical resuscitation research to proceed in special cases without prospective informed consent. It is unclear, however, how this change has impacted the performance of this research. OBJECTIVES: To measure the potential impact of the Final Rule by determining the number of clinical cardiac arrest studies performed in the United States (US) before and after 1993, and to compare it with the number of studies performed in the European Union (EU) during the same periods. METHODS: A MEDLINE search was performed for cardiac arrest studies that were prospective, interventional, randomized, and performed in the US or EU from 1983 through 2003. RESULTS: Of the 3,115 cardiac arrest publications identified, 66 (2%) met inclusion criteria. Of the 40 studies conducted in the US, 24 (60%) were published prior to or during 1993, whereas of the 27 studies conducted in the EU, six (22%) were published prior to or during 1993 (odds ratio = 0.5; 95% confidence interval = 0.3 to 0.8). CONCLUSIONS: There has been a significant decrease in the number of published clinical cardiac arrest trials in the US since 1993. In contrast, there has been a significant increase in the number of published EU trials since 1993. The current informed consent requirements may have reduced the number of clinical cardiac arrest studies performed in the US.

Data Collection↗
PubMed2004

Evaluation of an emergency department referral system for outpatient HIV testing.

BACKGROUND: Undiagnosed HIV infection is prevalent among patients who present to urban emergency departments (EDs). Providing appropriate counseling, testing, and follow-up in the ED is difficult. The aim of this study was to evaluate the effectiveness of a referral-based outpatient HIV testing system for patients referred from the ED. METHODS: This was a prospective cohort study performed at an urban teaching hospital. Consecutive patients referred from the emergency department (ED) for outpatient HIV testing were enrolled. Data were collected from each patient's ED record and HIV clinic record, if applicable. RESULTS: Of the 586 referrals made from our ED, 494 (84%) met inclusion criteria. Only 56 patients (11%, 95% CI: 9-15%) arrived at the HIV clinic and completed pretest counseling. Of these, 51 (91%, 95% CI: 80-97%) tested negative for HIV, 4 (7%, 95% CI: 2-17%) tested positive for HIV, and 1 (2%, 95% CI: 0-10%) refused the test. CONCLUSIONS: This referral system was ineffective at identifying unrecognized HIV infection due to poor adherence. Changes in the structure of the referral system or the use of point-of-care testing in the ED may improve the ability to detect HIV infection in this setting.

Ambulatory Care↗
PubMed2004

Identification of admission values predictive of complicated acute alcoholic pancreatitis.

BACKGROUND: Hospital admission indexes (serum urea nitrogen level, serum glucose level, heart rate, and white blood cell count) have been previously identified as useful predictors for the development of both severe systemic complications and death in patients with gallstone pancreatitis. HYPOTHESIS: We hypothesized that (1) these same 4 indexes would predict complications and/or death in first-time acute alcoholic pancreatitis and (2) these indexes would compare favorably with an admission Ranson score. DESIGN: Retrospective cohort study. SETTING: A university-affiliated, urban, public teaching hospital. PATIENTS: One hundred five patients who experienced first episodes of alcoholic pancreatitis treated between January 1, 1992, and June 30, 2003. MAIN OUTCOME MEASURES: Major systemic complications (pulmonary, cardiac, renal, infectious) requiring intensive care unit admission and/or death. RESULTS: A total of 105 patients were identified. Twenty-six patients (25%) (95% confidence interval [CI], 17%-34%) had a major systemic complication, and 6 patients (6%) (95% CI, 2%-12%) died. A serum glucose level of 160 mg/dL (8.9 mmol/L) or higher combined with a white blood cell count of 17 x 10(3)/ micro L or more had a positive predictive value of 80% (95% CI, 44%-98%), and an admission Ranson score of 3 or higher had a positive predictive value of 100% (95% CI, 48%-100%) for determining the likelihood of a systemic complication. Both an admission Ranson score of 1 or more and a white blood cell count of 17 x 10(3)/ micro L or more, independent of each other, had equally high negative predictive values (100% [95% CI, 94%-100%] and 99% [95% CI, 94%-100%], respectively) with respect to mortality. CONCLUSIONS: Two simple admission laboratory values--white blood cell count and serum glucose level--are useful predictors for development of major systemic complications and/or mortality in patients with first-time alcoholic pancreatitis. The predictive values of leukocytosis and hyperglycemia compare favorably with those of the admission Ranson score.

Acute Disease↗
PubMed2004

Prediction rules for estimating neurologic outcome following out-of-hospital cardiac arrest.

BACKGROUND: No valid model has been developed to predict survival following out-of-hospital cardiac arrest. The purpose of this study was to develop a prediction model for meaningful survival following out-of-hospital cardiac arrest using variables available during resuscitation. METHODS: This was a retrospective cohort study. Consecutive adult cardiac arrest patients were studied between 1994 and 2001. Variables included age, sex, race/ethnicity, arrest location, whether the arrest was witnessed, initial rhythm, whether CPR was performed, patient downtime, paramedic response time, survival to hospital discharge, and Glasgow Coma Score (GCS) at hospital discharge. Classification and Regression Tree analysis was used to develop decision rules to predict meaningful survival, as defined by the patient's discharge GCS. RESULTS: Of the 754 patients, 16 (2%) survived with a GCS > or =13, 15 (2%) survived with a GCS = 14, and 5 (0.7%) survived with a GCS = 15. The decision rule for survival with a GCS > or = 13 incorporated whether the arrest was witnessed and the patient's age, resulting in a negative predictive value (NPV) of 99.8%. The rule for survival with a GCS > or = 14 incorporated the initial arrest rhythm, whether the arrest was witnessed, and the patient's age, resulting in a NPV of 99.6%. The rule for survival with a GCS = 15 incorporated only the interval between collapse and the initiation of life support, resulting in a NPV of 99.8%. CONCLUSIONS: This study reports decision rules for potential meaningful survival following out-of-hospital cardiac arrest with high NPVs for each. Future studies need to be performed to prospectively validate these models.

Aged↗
PubMed2004

Diverticulitis: truly minimally invasive management.

The purpose of this study is to evaluate the treatment of patients with acute diverticulitis in the inpatient setting using minimal intervention. This was a retrospective study of 75 patients admitted over a 3-year period with acute diverticulitis as evidenced by computed tomography (CT) and clinical scenario. Of the patients enrolled, 24 (32%) had abscesses identified on their initial CT scan. An additional four patients had abscesses noted on a subsequent CT scan obtained because of lack of complete improvement with medical management, thus raising the total number of abscesses to 28 (37%). Of the patients with abscesses, 10 (36%) underwent drainage using a CT-guided percutaneous or ultrasound-guided transrectal approach an average of 6 days after admission. Of the 75 patients, five (7%) required operative intervention during the initial hospitalization for failure of medical management, two (40%) of whom had abscesses on presentation. The overall median length of hospitalization was 5 (interquartile range [IQR] 4-9) days, and 18 patients (24%) had recurrences during the study period. Our conservative approach to percutaneous and surgical intervention resulted in relatively low percutaneous drainage, a low operative rate, and a reasonable length of hospitalization and recurrence rate.

Abdominal Abscess↗