A Controlled Study in CPR-Survival in Propensity Score Matched Full-Code and Do-Not-Resuscitate ICU Patients.

BACKGROUND: Cardiopulmonary Resuscitation (CPR) causes significant injuries and increased cost among transiently resuscitated patients that do not survive their hospitalizations. Descriptive studies show zero and near-zero percent survival for CPR recipients with high Apache II scores. Despite these factors, no controlled studies exist in CPR to guide patient selection for CPR candidacy. Our objective was therefore to perform a controlled study in CPR to inform recommendations for CPR candidacy. We hypothesize that the protective effects of CPR decrease as illness severity increases, and that Full-Code status provides no survival benefit over Do-Not-Resuscitate (DNR) status for patients with the highest predicted mortality by Apache IV score. METHODS: We performed propensity-score matched survival analyses between Full-Code and DNR patients after stratifying by predicted mortality quartiles using Apache IV scores. Primary outcomes were mortality hazard ratios. Secondary outcomes were Median Survival Differences, ICU LOS, and tracheostomy rates. RESULTS: Among 17,710 propensity-score matched ICU encounters, DNR status was associated with greater mortality in the first through third predicted mortality quartiles. There was no difference in survival outcomes in the fourth quartile (HR 0.99, p = .96). There was a stepwise decrease in the mortality hazard ratio for DNR patients as quartiles increased. CONCLUSION: Full-Code status provides no survival benefit over DNR status in individuals with greater than 75% predicted mortality by Apache IV score. There is a stepwise decrease in survival benefit for Full-Code patients as predicted mortality increases. We propose that it is reasonable to consider a very high predicted mortality by Apache IV score a contraindication to CPR given the lack of survival benefit seen in these patients. Larger studies with similar methods should be performed to reinforce or refute these findings.

Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax.

OBJECTIVE: Ultrasound (US) has been shown to be effective at identifying a pneumothorax (PTX); however, the additional value of adding multiple views has not been studied. Single- and four-view protocols have both been described in the literature. The objective of this study was to compare the diagnostic accuracy of single-view versus four-view lung US to detect clinically significant PTX in trauma patients. METHODS: This was a randomized, prospective trial on trauma patients. Adult patients with acute traumatic injury undergoing computed tomography (CT) scan of the chest were eligible for enrollment. Patients were randomized to a single view or four views of each hemithorax prior to any imaging. USs were performed and interpreted by credentialed physicians using a 7.5-Mhz linear array transducer on a portable US machine with digital clips recorded for later review. Attending radiologist interpretation of the chest CT was reviewed for presence or absence of PTX with descriptions of small foci of air or minimal PTX categorized as clinically insignificant. RESULTS: A total of 260 patients were enrolled over a 2-year period. A total of 139 patients received a single view of each chest wall and 121 patients received four views. There were a total of 49 patients that had a PTX (19%), and 29 of these were clinically significant (11%). In diagnosis of any PTX, both single-view and four-view techniques showed poor sensitivity (54.2 and 68%) but high specificity (99 and 98%). For clinically significant PTX, single-view US demonstrated a sensitivity of 93% (95% confidence interval [CI] = 64.1% to 99.6%) and a specificity of 99.2% (95% CI = 95.5% to 99.9%), with sensitivity of 93.3% (95% CI = 66% to 99.7%) and specificity of 98% (95% CI = 92.1% to 99.7%) for four views. CONCLUSIONS: Single-view and four-view chest wall USs demonstrate comparable sensitivity and specificity for PTX. The additional time to obtain four views should be weighed against the absence of additional diagnostic yield over a single view when using US to identify a clinically significant PTX.

Hepatic follicular dendritic cell sarcoma without Epstein-Barr virus expression.

Follicular dendritic cell sarcoma of the liver is an uncommon pathologic entity, and only 5 cases have been reported previously. Herein, we report the first case, to our knowledge, of hepatic follicular dendritic cell sarcoma without evidence of Epstein-Barr virus infection. The patient is an elderly man who was found to have an incidental liver mass and then developed weight loss and fever. The diagnosis was based on the typical morphologic appearance of spindle cell proliferation associated with a brisk lymphoplasmacytic infiltrate and strong immunoreactivity to CD21 and CD35. Based on our experience and a review of the published reports, we summarize the clinical and pathologic features of hepatic follicular dendritic cell sarcoma and its surgical management.