Jason S. Haukoos

Routine Opt-Out Rapid HIV Screening and Detection of HIV Infection in Emergency Department Patients

CONTEXT The Centers for Disease Control and Prevention (CDC) recommends routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. The utility of this approach in EDs remains unknown. OBJECTIVE To determine whether nontargeted opt-out rapid HIV screening in the ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing. DESIGN, SETTING, AND PATIENTS Quasi-experimental equivalent time-samples design in an urban public safety-net hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing. INTERVENTIONS Nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 15, 2007, and April 15, 2009. MAIN OUTCOME MEASURES Number of patients with newly identified HIV infection and the association between nontargeted opt-out rapid HIV screening and identification of HIV infection. RESULTS In the opt-out phase, of 28,043 eligible ED patients, 6933 patients (25%) completed HIV testing (6702 patients were screened; 231 patients were diagnostically tested). Ten of 6702 patients (0.15%; 95% CI, 0.07%-0.27%) who did not decline HIV screening in the opt-out phase had new HIV diagnoses, and 5 of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new HIV diagnoses. In the diagnostic phase, of 29,925 eligible patients, 243 (0.8%) completed HIV testing. Of these, 4 patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses. The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and 4 in 29,925 (0.01%; 95% CI, 0.004%-0.03%), respectively. Nontargeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status, and whether diagnostic testing was performed in the opt-out phase. The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/microL (IQR, 17-430) and 13/microL (IQR, 11-15) , respectively (P = .02). CONCLUSION Nontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease.

Association of Neighborhood Characteristics with Bystander-Initiated CPR

BACKGROUND For persons who have an out-of-hospital cardiac arrest, the probability of receiving bystander-initiated cardiopulmonary resuscitation (CPR) may be influenced by neighborhood characteristics. METHODS We analyzed surveillance data prospectively submitted from 29 U.S. sites to the Cardiac Arrest Registry to Enhance Survival between October 1, 2005, and December 31, 2009. The neighborhood in which each cardiac arrest occurred was determined from census-tract data. We classified neighborhoods as high-income or low-income on the basis of a median household income threshold of

The Propensity Score

40,000 and as white or black if more than 80% of the census tract was predominantly of one race. Neighborhoods without a predominant racial composition were classified as integrated. We analyzed the relationship between the median income and racial composition of a neighborhood and the performance of bystander-initiated CPR. RESULTS Among 14,225 patients with cardiac arrest, bystander-initiated CPR was provided to 4068 (28.6%). As compared with patients who had a cardiac arrest in high-income white neighborhoods, those in low-income black neighborhoods were less likely to receive bystander-initiated CPR (odds ratio, 0.49; 95% confidence interval [CI], 0.41 to 0.58). The same was true of patients with cardiac arrest in neighborhoods characterized as low-income white (odds ratio, 0.65; 95% CI, 0.51 to 0.82), low-income integrated (odds ratio, 0.62; 95% CI, 0.56 to 0.70), and high-income black (odds ratio, 0.77; 95% CI, 0.68 to 0.86). The odds ratio for bystander-initiated CPR in high-income integrated neighborhoods (1.03; 95% CI, 0.64 to 1.65) was similar to that for high-income white neighborhoods. CONCLUSIONS In a large cohort study, we found that patients who had an out-of-hospital cardiac arrest in low-income black neighborhoods were less likely to receive bystander-initiated CPR than those in high-income white neighborhoods. (Funded by the Centers for Disease Control and Prevention and others.).

Volume regression of abdominal aortic aneurysms and its relation to successful endoluminal exclusion

Two recent studies published in JAMA involved the analysis of observational data to estimate the effect of a treatment on patient outcomes. In the study by Roze et al,1 a large observational data set was analyzed to estimate the relationship between early echocardiography screening for patent ductus arteriosus and mortality among preterm infants. The authors compared mortality rates of 847 infants who were screened for patent ductus arteriosus and 666 who were not. The 2 infant groups were dissimilar; infants who were screened were younger, more likely female, and less likely to have received corticosteroids. The authors used propensity score matching to create 605 matched infant pairs from the original cohort to adjust for these differences. In the study by Huybrechts et al,2 the Medicaid Analytic eXtract data set was analyzed to estimate the association between antidepressant use during pregnancy and persistent pulmonary hypertension of the newborn. The authors included 3 789 330 women, of which 128 950 had used antidepressants. Women who used antidepressants were different from those who had not, with differences in age, race/ethnicity, chronic illnesses, obesity, tobacco use, and health care use. The authors adjusted for these differences using, in part, the technique of propensity score stratification.

Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study.

OBJECTIVES Evaluating the success of endoluminal repair of abdominal aortic aneurysms (AAAs) is frequently based on diameter measurements and determining the presence of endoleaks. The use of three-dimensional volumetric data and observation of morphologic changes in the aneurysm and device have been proposed to be more appropriate for postdeployment surveillance. The purpose of this study was to analyze the long-term volumetric and morphologic data of 161 patients who underwent endovascular AAA exclusion and to assess the utility of volume measurements for determining successful AAA repair. METHODS Patients with spiral computed tomography scans obtained preoperatively, within the first postoperative month, at 6 months, and annually thereafter, were included in this analysis. Computerized interactive three-dimensional reconstruction of each AAA scan was performed. Total aneurysm sac volume was measured at each time interval (mean preoperative volume 169.0 +/- 78.5 mL), and the significance of volume changes was determined by mixed linear modeling, a form of repeated measures analysis, to account for longitudinal data clustered at the individual level. Sixty-two patients (38%) developed endoleaks at some time during follow-up-15 type I leaks, 45 type II leaks, and 2 type III leaks. The patients with type I and type III leaks were treated with cuffs, and the type II leaks were treated either with observation, side-branch embolization, or required open conversion. RESULTS Aneurysm sac volume increased slightly at 1-month follow-up (+3.3%), and then decreased steadily to -12.9% at 5 years (P <.0001). This effect remained unchanged after controlling for the three device types used in our study population. Patients who did not exhibit an endoleak (n = 99) showed a significant decrease in aneurysm volume across the entire follow-up duration when compared with those who did exhibit an endoleak (n = 62) (P <.0001). The presence of a 10% or greater decrease in volume at 6 months demonstrated a sensitivity of 64%, a specificity of 95%, a positive predictive value of 95%, a negative predictive value of 62%, and an accuracy of 75% for predicting primary clinical success defined by successful deployment of the device; freedom from aneurysm- or procedure-related death; freedom from endoleak, rupture, migration, or device malfunction; or conversion to open repair. CONCLUSIONS Volumetric analysis may be used to predict successful endoluminal exclusion of AAAs. Volume regression appears to be device-independent and should be expected in most clinically successful cases. The presence of volume increases in the first 6 months is suspicious for an endoleak that is pressurizing the aneurysm sac and heralds the need for closer evaluation and possible intervention. A volume decrease of 10% or greater at 6 months and continuing regression over time is associated with successful endovascular repair.

Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome (SIRS)

STUDY OBJECTIVE We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. METHODS We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (Canadian Assessment of Tomography for Childhood Head Injury [CATCH], Childrens Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. RESULTS Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). CONCLUSION Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.

The role of primary tumour resection in patients with stage IV colorectal cancer

Objective: To prospectively and externally validate the Mortality in Emergency Department Sepsis (MEDS) score as a predictor of 28-day mortality in patients who present to the emergency department with a systemic inflammatory response syndrome. Design: Multicentered prospective cohort study. Setting: Emergency departments at the University of Colorado Hospital and Denver Health Medical Center in Denver, CO, and Albert Einstein Medical Center and the Hospital of the University of Pennsylvania in Philadelphia, PA. Subjects: Adult patients who presented to the emergency department, who met criteria for systemic inflammatory response syndrome, and who were admitted to the hospital. Measurements: The MEDS score was calculated by recording the presence of terminal illness, tachypnea or hypoxemia, septic shock, platelet count <150,000 cells/mm3, band count as a percentage of total white blood cell count >5%, age >65 yrs, lower respiratory infection, nursing home residence, and altered mental status. Outcome: Mortality within 28 days or discharged alive from the hospital. Results: In all, 385 patients were enrolled between 18 and 100 yrs of age. The overall mortality was 9%. As in the original article, the MEDS score was categorized into five groups: very low, low, moderate, high, and very high for 28-day mortality. Mortality rates for each group were 0.6% (95% confidence interval [CI], 0%–3%), 5% (95% CI, 1%-13%), 19% (95% CI, 11%-29%), 32% (95% CI, 15%-54%), and 40% (95% CI, 12%-74%), respectively. The MEDS score had an area under the receiver operating characteristic curve of 0.88 (95% CI, 0.83-0.92). Conclusions: The MEDS score accurately predicts 28-day mortality in patients who present to the emergency department with systemic inflammatory response syndrome and who are admitted to the hospital.

The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers

Objective  The management of stage IV colorectal cancer is controversial. Resection of the primary tumour to prevent obstruction, bleeding or perforation is the traditional approach, although survival benefit is undetermined. Management consisting of diverting ostomy, enteric bypass, laser recanalization or endoscopic stenting is an alternative to radical resection. The purpose of this study was to determine the role of resection of the primary tumour in patients with stage IV colorectal cancer, with specific attention paid to survival benefit and safety.

Evaluation of Three Scoring Systems Predicting Non Sentinel Node Metastasis in Breast Cancer Patients with a Positive Sentinel Node Biopsy

Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was

Nomenclature and Definitions for Emergency Department Human Immunodeficiency Virus (HIV) Testing: Report from the 2007 Conference of the National Emergency Department HIV Testing Consortium

5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to