Robert L. Trowbridge, MD; Nicole K. Rutkowski, MD; Kaveh G. Shojania, MD
JAMA. 2003;289:80-86.
Context Although few patients with acute abdominal painwill prove to have cholecystitis, ruling in or ruling out acutecholecystitis consumes substantial diagnostic resources.
Objective To determine if aspects of the history and physicalexamination or basic laboratory testing clearly identify patientswho require diagnostic imaging tests to rule in or rule outthe diagnosis of acute cholecystitis.
Data Sources Electronic search of the Science CitationIndex, Cochrane Library, and English-language articles fromJanuary 1966 through November 2000 indexed in MEDLINE. We alsohand-searched Index Medicus for 1950-1965, and scanned referencesin identified articles and bibliographies of prominent textbooksof physical examination, surgery, and gastroenterology. To identifyrelevant articles appearing since the comprehensive search,we repeated the MEDLINE search in July 2002.
Study Selection Included studies evaluated the role ofthe history, physical examination, and/or laboratory tests inadults with abdominal pain or suspected acute cholecystitis.Studies had to report data from a control group found not tohave acute cholecystitis. Acceptable definitions of cholecystitisincluded surgery, pathologic examination, hepatic iminodiaceticacid scan or right upper quadrant ultrasound, or clinical courseconsistent with acute cholecystitis and no evidence for an alternatediagnosis. Studies of acalculous cholecystitis were included.Seventeen of 195 identified studies met the inclusion criteria.
Data Extraction Two authors independently abstracted datafrom the 17 included studies. Disagreements were resolved bydiscussion and consensus with a third author.
Data Synthesis No clinical or laboratory finding had asufficiently high positive likelihood ratio (LR) or low negativeLR to rule in or rule out the diagnosis of acute cholecystitis.Possible exceptions were the Murphy sign (positive LR, 2.8;95% CI, 0.8-8.6) and right upper quadrant tenderness (negativeLR, 0.4; 95% CI, 0.2-1.1), though the 95% CIs for both included1.0. Available data on diagnostic confirmation rates at laparotomyand test characteristics of relevant radiological investigationssuggest that the diagnostic impression of acute cholecystitishas a positive LR of 25 to 30. Unfortunately, the availableliterature does not identify the specific combinations of clinicaland laboratory findings that presumably account for this diagnosticsuccess.
Conclusions No single clinical finding or laboratory testcarries sufficient weight to establish or exclude cholecystitiswithout further testing (eg, right upper quadrant ultrasound).Combinations of certain symptoms, signs, and laboratory resultslikely have more useful LRs, and presumably inform the diagnosticimpressions of experienced clinicians. Pending further researchcharacterizing the pretest probabilities associated with differentclinical presentations, the evaluation of patients with abdominalpain suggestive of cholecystitis will continue to rely heavilyon the clinical gestalt and diagnostic imaging.
Infection is a common cause of morbidity and mortality in end-stage renal disease patients. Unintentional pathogens are introduced into an immunocompromised host during hemodialysis and peritoneal dialysis by means of the access (arteriovenous fistula, arteriovenous graft, central venous catheter, or peritoneal dialysis catheter). Gram positive organisms are most common with Staphylococcus aureus and coagulase negative Staphylococcus predominating. Preventive measures are mandatory and the key to decreasing infection rates. 相似文献
Syringe-exchange programs (SEPs) in Connecticut operate with caps on the number of syringes exchanged per visit. We investigated
the effects of legislation increasing the cap on drug injectors' access to clean syringes through the SEPs in New Haven and
Hartford. The mixed design of this study included longitudinal and crosssectional data from individuals and ecological data
from program operations. Five parameters—syringe return rate, syringes per visit to the SEP, syringe reuse rate, syringe human
immunodeficiency virus (HIV) prevalence, and syringe sharing—were monitored through syringe tracking and testing of SEP syringes
and by interviewing injectors. Two increases in the cap—from 5 to 10 and then from 10 to 30—had little effect on the five
parameters that measured injectors' access to clean syringes. In contrast, access to clean syringes increased when the New
Haven SEP first began operations, when syringes first became available at pharmacies in Hartford, and when the agency running
the Hartford SEP changed. Legislation providing piecemeal increases in the cap may not, by themselves, be sufficient to increase
injectors' access to clean syringes and decrease the risk of human immunodeficiency virus transmission in this population. 相似文献
Advances in understanding and controlling genes and their expression have set the stage to alter genetic material to fight
or prevent disease with brain tumors being among one of the first human malignancies to be targeted by gene therapy. All proteins
are coded for by DNA and most neoplastic diseases ultimately result from the expression or lack thereof with one or more proteins
(e.g., coded by oncogenes or tumor suppressor genes, respectively). In theory, therefore, diseases could be treated by expression
of the appropriate protein in the affected cells. Gene therapy is an experimental treatment that involves introducing genetic
material (DNA or RNA) into cells, and it has made important advances in the past decade. Within this short time span, it has
moved from the conceptual laboratory research stage to clinical translational trials for brain tumors. The most efficient
approaches for gene delivery are based on viral vectors, which have been proven relatively safe in the CNS, despite occasional
cases of morbidity and death in non-neurosurgical trials. However, the human response to various viral vectors can not be
predicted in a reliable manner from animal experimentation, nor can size, consistency, and extent of experimental brain tumors
in mouse models reflect the large, necrotic, infiltrative nature of malignant gliomas. Furthermore, the problem of delivering
genetic vectors into solid brain tumors and the efficiency in situ gene transfer remains one of the most significant hurdles
in gene therapy. 相似文献
Background/purpose: During the recent years, many diagnostic methods have been proposed aiming at early detection of malignant melanoma. The texture of skin lesions is an important feature to differentiate melanoma from other types of lesions, and different techniques have been designed to quantify this feature. In this paper, we discuss a new approach based on independent component analysis (ICA) for extraction of texture features of skin lesions in clinical images. Methods: After preprocessing and segmentation of the images, features that describe the texture of lesions and show high discriminative characteristics are extracted using ICA, and then these features, along with the color features of the lesions, are used to construct a classification module based on support vector machines for the recognition of malignant melanoma vs. benign nevus. Results: Experimental results showed that combining melanoma and nevus color features with proposed ICA-based texture features led to a classification accuracy of 88.7%. Conclusion: ICA can be used as an effective tool for quantifying the texture of lesions. 相似文献
The aim of this study was to provide early and mid‐term results of the newly established extracorporeal membrane oxygenation (ECMO) retrieval service in a tertiary cardiothoracic center using the miniaturized portable Cardiohelp System (Maquet, Rastatt, Germany). A particular attention was paid to organizational and logistic specifics as well as challenges and pitfalls associated with initial phase of the program. From January 2015 until January 2017 a heterogenic group of 28 consecutive patients underwent ECMO implantation in distant hospitals for acute cardiac, pulmonary or combined failure as a bridge‐to‐decision and were subsequently transported to our institution. Each cannulation was performed bedside on intensive care units (ICU) using the Seldinger's technique. Early outcomes and mid‐term overall survival with up to two‐year follow‐up along with the impact of ongoing cardiopulmonary resuscitation (CPR) on outcome were presented. Also, changes in hemodynamics and tissue perfusion factors 24 h after ECMO implantation were evaluated. ECMO implantations were performed in 15 distant departments with the median distance of 23(10;40) (maximum 60) km. A total of 15 patients (54%) were cannulated under CPR with the median duration of 30(20;110) (maximum 180) min. After 24 h of support there were significant improvements in SvO2 (P = 0.021), mean arterial pressure (P = 0.027), FiO2 (P = 0.001), lactate (P = 0.001), and pH (P < 0.001). The mean ECMO support duration was 96 ± 100 (maximum 384) hours, whereas 11 patients (40%) were weaned off support and discharged from hospital. Overall cumulative survival in patients without the need for CPR was 61.5% at one week and 38.5% at 1 month, 6 month, and 1 year, whereas patients requiring CPR survived in 40% at one week, and 33.3% at 1 month, 6 month, and 1 year (Log‐Rank (Mantel‐Cox) P = 0.374, Breslow (Generalized Wilcoxon) P = 0.162). Our initial experience shows that launching new ECMO retrieval programs in centers with sufficient ICU capacities and local ECMO experience can be feasible and associated with acceptable “real world” results despite the initial learning curve. Rapid logistical organization and team flexibility are the key points to ensure comparable survival of patients requiring prolonged CPR. 相似文献