The aim of the present study was to compare the ability of four clinical prediction rules to predict adverse outcome in perforated peptic ulcer (PPU): the Boey score, the American Society of Anesthesiologists (ASA) score, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the sepsis score.
an observational multicenter study.
a total of 117 patients surgically treated for PPU between 1 January 2008 and 31 December 2009 in seven gastrointestinal departments in Denmark were included. Pregnant and breastfeeding women, non-surgically treated patients, patients with malignant ulcers, and patients with perforation of other organs were excluded.
30-day mortality rate.
the ability of four clinical prediction rules to distinguish survivors from non-survivors (discrimination ability) was evaluated by the area under the receiver operating characteristic curve (AUC), positive predictive values (PPVs), negative predictive values (NPVs), and adjusted relative risks.
Median age (range) was 70 years (25-92 years), 51% of the patients were females, and 73% of the patients had at least one co-existing disease. The 30-day mortality proportion was 17% (20/117). The AUCs: the Boey score, 0.63; the sepsis score, 0.69; the ASA score, 0.73; and the APACHE II score, 0.76. Overall, the PPVs of all four prediction rules were low and the NPVs high.
The Boey score, the ASA score, the APACHE II score, and the sepsis score predict mortality poorly in patients with PPU.
BACKGROUND: No guidelines exist for the planning of aeromedical repatriation after acute myocardial infarction (AMI). In 2004, we employed a risk evaluation-based decision-making system for repatriation of patients after AMI. The objective was to evaluate the safety of transports during 2005 managed by this system. METHODS: A total of 116 patients were transported according to the algorithm, 64 unescorted and 52 escorted. The decision-making system was based on the recommendations given by the European Society of Cardiology. Whenever possible, patients were evaluated by coronary angiogram or exercise electrocardiogram. Patients at high risk were treated locally if appropriate facilities were available or evacuated to the nearest heart center. Patients at low risk were allowed to fly unescorted home if no other concomitant diseases needed the attention of a physician. The composite end point of death of any cause during transport or departure from the planned repatriation due to worsening of the condition was registered. RESULTS: No patients reached the end point. Patients who were not risk evaluated more often needed escort (p
The objective of this paper was to develop an agent-based modeling framework in order to simulate the spread of influenza virus infection on a layout based on a representative hospital emergency department in Winnipeg, Canada. In doing so, the study complements mathematical modeling techniques for disease spread, as well as modeling applications focused on the spread of antibiotic-resistant nosocomial infections in hospitals. Twenty different emergency department scenarios were simulated, with further simulation of four infection control strategies. The agent-based modeling approach represents systems modeling, in which the emergency department was modeled as a collection of agents (patients and healthcare workers) and their individual characteristics, behaviors, and interactions. The framework was coded in C++ using Qt4 libraries running under the Linux operating system. A simple ordinary least squares (OLS) regression was used to analyze the data, in which the percentage of patients that became infected in one day within the simulation was the dependent variable. The results suggest that within the given instance context, patient-oriented infection control policies (alternate treatment streams, masking symptomatic patients) tend to have a larger effect than policies that target healthcare workers. The agent-based modeling framework is a flexible tool that can be made to reflect any given environment; it is also a decision support tool for practitioners and policymakers to assess the relative impact of infection control strategies. The framework illuminates scenarios worthy of further investigation, as well as counterintuitive findings.
The revised cardiac risk index (RCRI) holds a central role in preoperative cardiac risk stratification in noncardiac surgery. Its performance in unselected populations, including different age groups, has, however, not been systematically investigated. We assessed the relationship of RCRI with major adverse cardiovascular events in an unselected cohort of patients undergoing elective, noncardiac surgery overall and in different age groups.
We followed up all individuals = 25 years who underwent major elective noncardiac surgery in Denmark (January 1, 2005, to November 30, 2011) for the 30-day risk of major adverse cardiovascular events (ischemic stroke, myocardial infarction, or cardiovascular death). There were 742 of 357,396 (0.2%), 755 of 74.889 (1.0%), 521 of 11,921 (4%), and 257 of 3146 (8%) major adverse cardiovascular events occurring in RCRI classes I, II, III, and IV. Multivariable odds ratio estimates were as follows: ischemic heart disease 3.30 (95% confidence interval, 2.96-3.69), high-risk surgery 2.70 (2.46-2.96), congestive heart failure 2.65 (2.29-3.06), cerebrovascular disease 10.02 (9.08-11.05), insulin therapy 1.62 (1.37-1.93), and kidney disease 1.45 (1.33-1.59). Modeling RCRI classes as a continuous variable, C statistic was highest among age group 56 to 65 years (0.772) and lowest for those aged >85 years (0.683). Sensitivity of RCRI class >I (ie, having = 1 risk factor) for capturing major adverse cardiovascular events was 59%, 71%, 64%, 66%, and 67% in patients aged = 55, 56 to 65, 66 to 75, 76 to 85, and >85 years, respectively; the negative predictive values were >98% across all age groups.
In a nationwide unselected cohort, the performance of the RCRI was similar to that of the original cohort. Having = 1 risk factor was of moderate sensitivity, but high negative predictive value for all ages.
Alberta's integrated approach to chronic disease management programming embraces client-centred care, supports self-management and facilitates care across the continuum. This paper presents strategies implemented through collaboration with primary care to improve care of individuals with chronic conditions, evaluation evidence supporting success and lessons learned from the Alberta perspective.
The aim was to develop a theoretical understanding of the decision-making process leading to appendectomy. A qualitative interview study was performed in the grounded theory tradition using the constant comparative method to analyze data. The study setting was one county hospital and two local hospitals in Sweden, where 11 surgeons and 15 surgical nurses were interviewed. A model was developed which suggests that surgeons' decision making regarding appendectomy is formed by the interplay between their medical assessment of the patient's condition and a set of contextual characteristics. The latter consist of three interacting factors: (1) organizational conditions, (2) the professional actors' individual characteristics and interaction, and (3) the personal characteristics of the patient and his or her family or relatives. In case the outcome of medical assessment is ambiguous, the risk evaluation and final decision will be influenced by an interaction of the contextual characteristics. It was concluded that, compared to existing, rational models of decision making, the model presented identified potentially important contextual characteristics and an outline on when they come into play.
Patients with critical limb ischaemia have a relative short life expectancy. However, if the limb can be preserved or amputation postponed for at least 1-2 years there can be justification for revascularisation if it is possible. Published Scandinavian data indicate that of those operated on about one-third are primarily amputated and two-third revascularised. At least one-third in the revascularisation group are subjected to secondary amputation within six months, and about 50% are alive with the limb intact. Hence, prediction of successful reconstruction should be amended to reduce costs and reduce burden to the patients. In order to achieve statistical models, which preoperatively could predict outcome with an acceptable diagnostic accuracy, national as well as international cooperation with standardisation of predictors and appropriate use of statistical models should be strived for. Prediction, based on a statistical model, is always associated with some uncertainty, and will never replace qualified clinical judgement.
Substitution for a harmful chemical implies that the desired function is maintained without using the harmful chemical in question. Improvement can be achieved if a less harmful chemical can be used or the same function obtained by changing the process and eliminating the harmful chemical agent. In 1982, Denmark introduced an authority regulation requiring substitution if functional and economical alternatives exist. This paper summarizes the results of 162 examples of substitution investigated by the Danish Occupational Health Services. The identification and implementation of substitution alternatives is described as an iterative process with seven distinct steps. Several tools that are useful in evaluating alternatives are described, including Hansen solubility parameters and vapor hazard ratios. In addition to the technical issues surrounding substitution, this paper describes the social interactions necessary to include all affected individuals, along with those having the proper expertise in the decision-making process. The use of the described methods may result in a safer work-place by eliminating certain hazardous chemicals or practices that have historically been used in specific industries.
To conduct an economic analysis of the implementation of the Ottawa Knee Rule.
The decision analysis compared usual practice based on physician judgment with practice based on a clinical decision rule, which allows more selective use of radiography. The study participants were all adults with blunt knee trauma. The likelihood and cost of radiography, missed fracture, lost productivity, and medicolegal actions were defined by published data and an expert panel. Separate analyses considered US Medicare and Canadian hospital costs. Sensitivity analyses considered a range of values for each variable in the model, including costs in a US fee-for-service setting. The study outcome was the mean cost per patient.
The mean cost savings associated with practice based on the Ottawa Knee Rule was $31 (95% confidence interval 22 to 44) to $34 (95% confidence interval 24 to 47) per patient. These results were robust to reasonable changes in the values of variables in the model.
Implementation of the Ottawa Knee Rule would be associated with meaningful reductions in societal health care costs both in the United States and Canada without a reduction in quality of care.
Comment In: Ann Emerg Med. 1999 Oct;34(4 Pt 1):535-710499954
OBJECTIVE--To assess the cost-effectiveness of identifying asymptomatic carriers of Chlamydia trachomatis among adolescent males. DESIGN--Cost-effectiveness analysis based on cohort analytic studies previously reported and average salaries and costs of medical care in Sweden. SETTING--Adolescent males attending a primary care center for routine health checks. PARTICIPANTS--Estimates of costs and benefits are based on a cohort of 1000 adolescent males and their female contacts. INTERVENTION--Screening with enzyme immunoassay (EIA), either on leukocyte esterase (LE)--positive urine samples (LE-EIA screening) or on all urine samples (EIA screening), was compared with no screening (no treatment or contact tracing). The effects of confirming positive EIA results with a blocking assay and alternative antibiotic regimens on the outcome of the screening strategies were also evaluated. RESULTS--Compared with no screening, the LE-EIA and EIA screening strategies reduced the overall costs when the prevalence of chlamydial infection in males exceeded 2% and 10%, respectively. Enzyme immunoassay screening achieved an overall cure rate that was 12.2% to 12.6% (95% confidence interval) better, but reduced the incremental savings by at least $2144 per cured male, in comparison with LE-EIA screening. Confirmation of positive EIA results reduced the overall cost of the LE-EIA screening strategy when the prevalence of C trachomatis among males was less than 8%. Compared with a 7-day course of doxycycline, a single oral dose of azithromycin administered under supervision in the clinic improved the cure rates of both EIA and LE-EIA screening strategies by 15.1% to 16.3% and 11.2% to 12.0%, respectively, while reducing the corresponding overall costs by 5% and 9%, respectively, regardless of the prevalence of chlamydial infection in males. CONCLUSION--The use of LE-EIA screening combined with treatment of positive cases with azithromycin was the most cost-effective intervention strategy focusing on asymptomatic male carriers of C trachomatis. Positive EIA results should be confirmed when screening low-risk populations.
Comment In: JAMA. 1993 Nov 3;270(17):2097-88411579