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Yeniocak AS, Tercan C, Dagdeviren E, Arabacı O, Genc EE. Evaluation of a scoring system to predict treatment success with single-dose methotrexate in ectopic pregnancy. Arch Gynecol Obstet 2024; 309:2047-2055. [PMID: 38488896 DOI: 10.1007/s00404-024-07458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE This study sought to assess the efficacy of a newly developed scoring system in predicting treatment outcomes for ectopic pregnancy among patients undergoing single-dose methotrexate therapy. The primary research question centered on the reliability and predictive accuracy of objective parameters in determining methotrexate therapy success. METHODS Conducted as a retrospective single-center cohort study, data from 172 ectopic pregnancy patients treated with methotrexate between January 2021 and January 2023 were analyzed. Parameters including adnexal mass size, peritoneal fluid presence, yolk sac identification, endometrial thickness, ectopic pregnancy location, and initial B-hCG levels were meticulously evaluated for their association with treatment outcomes. RESULTS Following the exclusion of 21 emergency surgery cases, the final analysis comprised 151 patients. Notable associations were observed between specific parameters (fetal cardiac activity, adnexal mass size > 3.5 cm, peritoneal fluid presence, yolk sac identification, endometrial thickness > 10 mm, and initial B-hCG levels) and treatment outcomes (p < 0.001). Additionally, the novel scoring system demonstrated promising predictive performance. At a cutoff of 2.50, it achieved a sensitivity of 91.7% and a specificity of 59.7%. Increasing the cutoff to 3.50 resulted in a sensitivity of 94.0%, with a specificity of 46.3%. CONCLUSION Objective parameters, particularly those integrated into the developed scoring system, exhibited substantial associations with methotrexate therapy outcomes in ectopic pregnancy. These findings underscore the potential of an objective scoring model to significantly influence clinical decision-making in therapy, offering avenues for enhanced prognostication and patient care in treatment outcomes.
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Affiliation(s)
- Ali Selcuk Yeniocak
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Can Tercan
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emrah Dagdeviren
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Onur Arabacı
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emine Elif Genc
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Pacagnella RC, Borovac-Pinheiro A, Silveira C, Siani Morais S, Argenton JLP, Souza JP, Weeks AD, Cecatti JG. The golden hour for postpartum hemorrhage: Results from a prospective cohort study. Int J Gynaecol Obstet 2021; 156:450-458. [PMID: 34254311 DOI: 10.1002/ijgo.13823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the predictive capacity of vital signs for the diagnosis of postpartum hemorrhage (PPH). METHODS A prospective cohort study performed at the University of Campinas, Brazil, between February 2015 and March 2016 with women who delivered vaginally. Vital signs and postpartum bleeding were collected over 24 h. Exploratory data analysis was performed plus receiver operating characteristic curve analysis where the areas under the curve was used to determine the best cutoff points for sensitivity, specificity, likelihood ratio, and diagnostic odds ratio. RESULTS For the 270 women recruited, mean blood loss after 120 min was 427.49 ± 335.57 ml, while 84 (31.1%) and 22 (8.1%) women had blood loss ≥500 and ≥1000 ml, respectively. Heart rate cutoff point of 105 bpm measured between 21-40 min after birth identified blood loss ≥1000 ml with 90% specificity. A shock index (SI) of 0.965 at 41-60 min after birth identified blood loss ≥500 and ≥1000 ml within 2 h with approximately 95% specificity. CONCLUSION Shock index and heart rate measured after birth showed high specificity with low sensitivity to identify PPH. In clinical practice, "The rule of 1s" should receive special attention: SI ≥1, or heart rate >100 bpm, or estimated blood loss ≥1 L.
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Affiliation(s)
- Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carla Silveira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Sirlei Siani Morais
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - Joao Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil
| | - Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - José G Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Al Aseri Z, Al Ageel M, Binkharfi M. The use of the shock index to predict hemodynamic collapse in hypotensive sepsis patients: A cross-sectional analysis. Saudi J Anaesth 2020; 14:192-199. [PMID: 32317874 PMCID: PMC7164438 DOI: 10.4103/sja.sja_780_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 01/09/2020] [Indexed: 12/29/2022] Open
Abstract
Objectives: Septic shock, defined as sepsis with hypotension not responding to fluid resuscitation or requiring vasopressor support, results in the worst outcomes in sepsis patients. This subtype of the patient is often difficult to detect. The shock index (SI) has demonstrated the potential for predicting hemodynamic compromise and collapse and predicting patient outcomes in multiple medical and surgical settings. In our study, we assessed the utility of the SI as a hemodynamic screening tool to identify patients likely to fail to respond to fluids and ultimately to be diagnosed with septic shock. Methodology: A single-center cross-sectional analysis of patients presenting with hypotension and septicemia over 1 year. The study was conducted using the electronic medical records of the emergency department patients presenting to King Saud University Medical City. The charts were reviewed from 2 May 2015 to 24 April 2016 using the local medical registry. The study was approved by the hospital institutional review board (IRB). Data extraction was performed using a standardized form. Results: The area under the curve was 0.77 (P < 0.001) for the prediction of hemodynamic collapse. An initial SI ≥0.875 had a sensitivity of 81% and a specificity of 72% for the identification of patients in whom fluid resuscitation would fail. Conclusions: Based on our findings, we found that the SI was a reliable screening tool for the identification of hypotensive patients with sepsis who would ultimately be diagnosed with septic shock.
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Affiliation(s)
- Zohair Al Aseri
- Emergency Medicine and Critical Care Departments, College of Medicine, King Saud University, 11472, Riyadh, Saudi Arabia
| | - Mohammed Al Ageel
- Emergency Medicine and Critical Care Departments, College of Medicine, King Saud University, 11472, Riyadh, Saudi Arabia
| | - Mohammed Binkharfi
- Emergency Medicine and Critical Care Departments, College of Medicine, King Saud University, 11472, Riyadh, Saudi Arabia
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Borovac-Pinheiro A, Pacagnella RC, Cecatti JG, Miller S, El Ayadi AM, Souza JP, Durocher J, Blumenthal PD, Winikoff B. Postpartum hemorrhage: new insights for definition and diagnosis. Am J Obstet Gynecol 2018; 219:162-168. [PMID: 29660298 DOI: 10.1016/j.ajog.2018.04.013] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/23/2018] [Accepted: 04/09/2018] [Indexed: 11/17/2022]
Abstract
The current definition of is inadequate for early recognition of this important cause of maternal death that is responsible for >80,000 deaths worldwide in 2015. A stronger definition of postpartum hemorrhage should include both blood loss and clinical signs of cardiovascular changes after delivery, which would help providers to identify postpartum hemorrhage more promptly and accurately. Along with the amount of blood loss, clinical signs, and specifically the shock index (heart rate divided by systolic blood pressure) appear to aid in more accurate diagnosis of postpartum hemorrhage.
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Affiliation(s)
- A Borovac-Pinheiro
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - R C Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.
| | - J G Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - S Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA
| | - A M El Ayadi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA
| | - J P Souza
- Department of Social Medicine, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirao Preto, Brazil
| | | | - P D Blumenthal
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University, Stanford, CA
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Aydoğmuş S, Aydoğmuş H, Gençdal S, Kelekçi S. Density of tubal ring vascularization: A new marker for prediction of success of medical treatment in tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2017; 217:113-118. [PMID: 28888180 DOI: 10.1016/j.ejogrb.2017.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 07/19/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The diagnosis of ectopic pregnancy has been facilitated especially by the use of Doppler ultrasonography. In previous studies the presence of peri-trophoblastic blood flow by Doppler ultrasound and the detection of a low-resistance, high-velocity flow pattern were defined as specific signs for trophoblastic tissue. The aim of this study was to evaluate the efficacy of Doppler ultrasonography in the prediction of treatment success in tubal pregnancies being treated with single dose conservative methotrexate. STUDY DESIGN A total of 104 patients with non-ruptured ectopic pregnancy who were hemodynamically stable and eligible for methotrexate treatment were included in the study. The spectral wave form of the mass was classified according to the vascularization density by Power Doppler. It was defined as Grade 1, 2 and 3, respectively. All patients received a single 50mg/m2 dose of systemic methotrexate. Serum β-hCG levels were measured on the 4th and 7th days of treatment. The treatment was considered unsuccessful in patients without a decrease of 15% or more in the serum β-hCG levels between days 0 and 7. RESULTS Twenty-four patients with grade I vascularity, 11 patients with grade II vascularity and 13 patients with grade III vascularity were referred as Group I, II and III, respectively, according to the degree of adnexal vascularity assessed by Doppler ultrasonography. Overall success rate of MTX treatment was found to be 72.9%. The response rates to systemic MTX treatment in cases with Grade I, II and III ectopic pregnancy mass vascularization were found to be 58.3%, 81.8% and 92.3%, respectively. Comparison of the groups' treatment responses revealed a linear-by-linear correlation with the Chi-square test. Increased vascularization grade of ectopic pregnancy was associated with a higher likelihood of responding to MTX treatment. CONCLUSIONS Detection of the vascularization grade with Doppler ultrasound could be considered a remarkable parameter in predicting treatment success considering its ease of utilization and low cost.
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Affiliation(s)
- Serpil Aydoğmuş
- İzmir Katip Çelebi University, School of Medicine Department of Obstetrics and Gynecology, İzmir, Turkey; İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey.
| | - Hüseyin Aydoğmuş
- İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
| | - Servet Gençdal
- İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
| | - Sefa Kelekçi
- İzmir Katip Çelebi University, School of Medicine Department of Obstetrics and Gynecology, İzmir, Turkey; İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
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Sloan EP, Koenigsberg M, Clark JM, Weir WB, Philbin N. Shock index and prediction of traumatic hemorrhagic shock 28-day mortality: data from the DCLHb resuscitation clinical trials. West J Emerg Med 2014; 15:795-802. [PMID: 25493120 PMCID: PMC4251221 DOI: 10.5811/westjem.2014.7.21304] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 06/19/2014] [Accepted: 07/31/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION To assess the ability of the shock index (SI) to predict 28-day mortality in traumatic hemorrhagic shock patients treated in the diaspirin cross-linked hemoglobin (DCLHb) resuscitation clinical trials. METHODS We used data from two parallel DCLHb traumatic hemorrhagic shock efficacy trials, one in U.S. emergency departments, and one in the European Union prehospital setting to assess the relationship between SI values and 28-day mortality. RESULTS In the 219 patients, the mean age was 37 years, 64% sustained a blunt injury, 48% received DCLHb, 36% died, and 88% had an SI≥1.0 at study entry. The percentage of patients with an SI≥1.0 dropped by 57% (88 to 38%) from the time of study entry to 120 minutes after study resuscitation (p<0.001). Patients with a SI≥1.0, 1.4, and 1.8 at any time point were 2.3, 2.7, and 3.1 times, respectively, more likely to die by 28 days than were patients with SI values below these cutoffs (p<0.001). Similarly, after 120 minutes of resuscitation, patients with a SI≥1.0 were 3.9× times more likely to die by 28 days (40 vs. 15%, p<0.001). Although the distribution of SI values differed based on treatment group, the receiver operator characeristics data showed no difference in SI predictive ability for 28-day mortality in patients treated with DCLHb. CONCLUSION In these traumatic hemorrhagic shock patients, the shock index correlates with 28-day mortality, with higher SI values indicating greater mortality risk. Although DCLHb treatment did alter the distribution of SI values, it did not influence the ability of the SI to predict 28-day mortality.
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Affiliation(s)
- Edward P Sloan
- University of Illinois at Chicago, Department of Emergency Medicine, Chicago, Illinois
| | - Max Koenigsberg
- Advocate Illinois Masonic Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - James M Clark
- Rush Medical College, Rush University Medical Center, Chicago, Illinois
| | - William B Weir
- University of Illinois College of Medicine at Urbana-Champaign, Carle Physician Group, Department of Emergency Medicine, Illinois
| | - Nora Philbin
- Unity Point Methodist, Department of Pediatrics, Peoria, Illinois
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Cut-off value of initial serum β-hCG level predicting a successful MTX therapy in tubal ectopic pregnancy: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2014; 179:175-80. [PMID: 24956362 DOI: 10.1016/j.ejogrb.2014.05.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/20/2014] [Accepted: 05/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the optimal serum β-hCG cut-off level to predict MTX treatment success in tubal ectopic pregnancy (EP). STUDY DESIGN Data of 240 women, who presented between 2003 and 2011 at the Department of Gynecology and Obstetrics, Medical University of Vienna, with tubal EP and who received MTX as primary treatment, were retrieved from the hospital information system (KIS). 198 patients could be included for final evaluation. Statistical analysis included area under the ROC curve, maximal Euclidean and Youden index, chi-squared and a five-fold cross validation. RESULTS The serum β-hCG level cut-off value was calculated at 2121mlU/ml with a specificity of 76.54% and sensitivity of 80.56% (AUC 0.789; p<0.001). Patients with an initial serum β-hCG level below 2121mlU/ml (n=131) experienced MTX treatment failure in 5.3% (n=7), compared to 43.3% (n=29) of patients with an initial serum β-hCG level equal to or above 2121mlU/ml (n=67). There was no statistically significant correlation between clinical symptoms and the MTX therapy outcome (p=0.580; likelihood quotient p=0.716). CONCLUSION The correct decision of therapy in patients with tubal ectopic pregnancy still represents a challenge. In this study we can conclude that, according to our results there is no endpoint of initial serum β-hCG levels, which can be clearly used as cut-off value for the optimal management of tubal EP. However, an initial serum β-hCG level of less than 2121mlU/ml seems to be a good value to expect a successful MTX treatment. Limitations are the retrospective study design and the inability of classifying clinical symptoms like pain as an objective parameter. Wider implications of the findings may include more detailed patient information and more accurate selection of suitable patients for MTX therapy.
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Peterson KL, Hardy BT, Hall K. Assessment of shock index in healthy dogs and dogs in hemorrhagic shock. J Vet Emerg Crit Care (San Antonio) 2013; 23:545-50. [PMID: 24034472 DOI: 10.1111/vec.12090] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 07/30/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the shock index (SI) in a population of healthy dogs to a population of dogs with confirmed hemorrhagic shock. DESIGN Retrospective analysis of data collected prospectively from 2 previous studies. SETTING University teaching hospital. ANIMALS Seventy-eight healthy control dogs enrolled in a study to establish a reference interval for a tissue oxygen monitor; 38 dogs with confirmed hemorrhagic shock enrolled in a study to evaluate the tissue oxygen monitor in hemorrhagic shock. The heart rate and systolic blood pressure obtained during the respective studies were used to calculate the SI. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Shock index was significantly higher in the hemorrhage group (median 1.37, range 0.78-4.35) than the control group (median 0.91, range 0.57-1.53); 92% of the dogs in hemorrhagic shock had an SI of >0.91. Compared with controls, dogs in hemorrhagic shock had significantly lower body temperatures (median 38.3°C, range 35.6-39.9°C versus median 38.7°C, range 37.5-39.9°C), higher heart rates (median 150/min, range 120-220/min versus median 110/min range 80-150/min), lower systolic blood pressures (mean 112 mm Hg, SD ±35.8 mm Hg versus mean 125 mm Hg, SD ±21.5 mm Hg), higher lactate concentrations (median 0.51 mmol/L, range 0.078-1.41 mmol/L versus median 0.11 mmol/L, range 0.033-0.33 mmol/L), and lower hemoglobin concentrations (median 81 g/L, range 56-183 g/L versus median 162.5 g/L, range 133-198 g/L). CONCLUSIONS Shock index is a simple and easy calculation that can be used as an additional triage tool and should prompt further investigation for hemorrhage if the values are >0.9.
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Affiliation(s)
- Katherine L Peterson
- Department of Veterinary Clinical Sciences, University of Minnesota, College of Veterinary Medicine, St Paul, MN, 55108
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An Increase in Initial Shock Index Is Associated With the Requirement for Massive Transfusion in Emergency Department Patients With Primary Postpartum Hemorrhage. Shock 2013; 40:101-5. [DOI: 10.1097/shk.0b013e31829b1778] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Identifying Risk for Massive Transfusion in the Relatively Normotensive Patient: Utility of the Prehospital Shock Index. ACTA ACUST UNITED AC 2011; 70:384-8; discussion 388-90. [DOI: 10.1097/ta.0b013e3182095a0a] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Identifying life-threatening shock in the older injured patient: an analysis of the National Trauma Data Bank. ACTA ACUST UNITED AC 2010; 68:1134-8. [PMID: 20453769 DOI: 10.1097/ta.0b013e3181d87488] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Reliance on traditional vital signs (TVS), particularly in older patients, to identify life-threatening shock after injury may be unreliable. Shock index (SI), defined as heart rate divided by systolic blood pressure (SBP), may be a better indicator of early shock after injury than TVS. Multiplying age by SI (age x SI) may be better in older injured patients. We hypothesized that age x SI would be a better predictor of 48-hour mortality in old patients (age, >55 years) compared with TVS, whereas for young patients (age, <or=55 years), SI would be a better predictor than TVS. METHODS Version 8.1 of the National Trauma Data Bank was queried for incidents of blunt, non-neurologic injury occurring during 2007, to patients aged 18 to 81 years. Areas under the receiver operating characteristic curves (AUC) were compared for TVS, SI, and age x SI in young and old patients for predicting 48-hour mortality. RESULTS A total of 189,574 incidents were identified. Overall 48-hour mortality was 1.18%. For young patients, there was no difference between SBP (AUC, 0.654) and SI (AUC, 0.655) for predicting 48-hour mortality. For old patients, age x SI (AUC, 0.693) was a better predictor of 48-hour mortality compared with heart rate (AUC, 0.626; p < 0.0001), SBP (AUC, 0.657; p < 0.0002), or SI (AUC, 0.684; p < 0.008). CONCLUSION TVS are inadequate predictors of shock after non-neurologic blunt injury. Using SI in the young and age x SI in old to identify patients at risk for early mortality after blunt injury could result in earlier definitive treatment.
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Laparoscopic treatment of interstitial twin pregnancy. Fertil Steril 2009; 92:390.e13-7. [DOI: 10.1016/j.fertnstert.2009.03.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 03/11/2009] [Accepted: 03/13/2009] [Indexed: 11/23/2022]
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Zarzaur BL, Croce MA, Fischer PE, Magnotti LJ, Fabian TC. New Vitals After Injury: Shock Index for the Young and Age × Shock Index for the Old. J Surg Res 2008; 147:229-36. [DOI: 10.1016/j.jss.2008.03.025] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 03/11/2008] [Accepted: 03/12/2008] [Indexed: 10/22/2022]
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