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Allan S Detsky

Publications and source records attributed to Allan S Detsky.

At least 19 recordsLinked to original sources
PubMed2006

Does this patient have hearing impairment?

CONTEXT: Hearing impairment is prevalent among the elderly population but commonly underdiagnosed. OBJECTIVE: To review the accuracy and precision of bedside clinical maneuvers for diagnosing hearing impairment. DATA SOURCES: MEDLINE and EMBASE databases (1966 to April 2005) were searched for English-language articles related to screening for hearing impairment. STUDY SELECTION: Original studies on the accuracy or precision of screening questions and tests were included. Articles that used unaccepted reference standards or contained insufficient data were excluded. Medical Subject Headings or keywords used in the search included hearing loss, hearing handicap, hearing tests, tuning fork, deafness, physical examination, sensitivity, specificity, audiometry, tuning fork tests, Rinne, Weber, audioscope, Hearing Handicap Inventory for the Elderly-Screening version, whispered voice test, sensorineural, and conductive. DATA EXTRACTION: One author screened all potential articles and 2 authors independently abstracted data. Differences were resolved by consensus. Each included study (n = 24) was assigned a methodological grade. DATA SYNTHESIS: A yes response when asking individuals whether they have hearing impairment has a summary likelihood ratio (LR) of 2.5 (95% confidence interval [CI], 1.7-3.6); a no response has an LR of 0.13 (95% CI, 0.09-0.19). A score of 8 or greater on the screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) has an LR of 3.8 (95% CI, 3.0-4.8); a score less than 8 has an LR of 0.38 (95% CI, 0.29-0.51). An abnormal Weber tuning fork test response has an LR of 1.6 (95% CI, 1.0-2.3); a normal response has an LR of 0.70 (95% CI, 0.48-1.0). An abnormal Rinne tuning fork test response has LRs ranging from 2.7 to 62; a normal response has LRs from 0.01 to 0.85. Inability to perceive a whispered voice has an LR of 6.1 (95% CI, 4.5-8.4); normal perception has an LR of 0.03 (95% CI, 0-0.24). Not passing the audioscope test has an LR of 2.4 (95% CI, 1.4-4.1); passing has an LR of 0.07 (95% CI, 0.03-0.17). CONCLUSIONS: Elderly individuals who acknowledge they have hearing impairment require audiometry, while those who reply no should be screened with the whispered-voice test. Individuals who perceive the whispered voice require no further testing, while those unable to perceive the voice require audiometry. The Weber and Rinne tests should not be used for general screening.

Aged↗
PubMed2005

Kappa statistic.

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Evidence-Based Medicine↗
PubMed2005

Can routine laboratory tests discriminate between severe acute respiratory syndrome and other causes of community-acquired pneumonia?

BACKGROUND: The clinical presentation of severe acute respiratory syndrome (SARS) resembles that of other etiologies of community-acquired pneumonia, making diagnosis difficult. Hematological and biochemical abnormalities, particularly lymphopenia, are common in patients with SARS. METHODS: With the use of 2 databases, we compared the ability of the absolute lymphocyte count, absolute neutrophil count, lactate dehydrogenase level, creatine kinase level, alanine aminotransferase level, and serum calcium level at hospital admission to discriminate between cases of SARS and cases of community-acquired pneumonia. The SARS database contained data for 144 patients with SARS from the 2003 Toronto SARS outbreak. The community-acquired pneumonia database contained data for 8044 patients with community-acquired pneumonia from Edmonton, Canada. Patients from the SARS database were matched to patients from the community-acquired pneumonia database according to age, and receiver operating characteristic curves were constructed for each laboratory variable. RESULTS: The areas under the receiver operating characteristic curves (AUCs) demonstrated fair to poor discriminatory ability for all laboratory variables tested except absolute neutrophil count, which had an AUC of 0.80, indicating good discriminatory ability (although there was no cutoff value of the absolute neutrophil count at which reasonable sensitivity or specificity could be obtained). Combinations of any 2 tests did not perform significantly better than did the absolute neutrophil count alone. CONCLUSIONS: Routine laboratory tests, including determination of absolute lymphocyte count, should not be used in the diagnosis of SARS or incorporated into current case definitions of SARS. The role of the absolute neutrophil count in SARS diagnosis is likely limited, but it should be assessed further.

Alanine Transaminase↗
PubMed2005

How should patients with unstable angina and non-ST-segment elevation myocardial infarction be managed? A meta-analysis of randomized trials.

PURPOSE: Patients with unstable angina or non-ST-segment elevation myocardial infarction (MI) may be managed with either an "invasive" or "conservative" strategy. It is unclear which of these strategies is superior. METHODS: We identified studies with MEDLINE and EMBASE searches (1966-September 2003) and by reviewing reference lists. Studies were included if they were randomized controlled trials comparing management strategies for patients in the early post-unstable angina/non-ST-segment elevation MI period and had follow-up data for at least 3 months. RESULTS: Seven trials that randomized a total of 9212 patients were included. The pooled odds ratio (OR) for all-cause mortality was 0.96 (95% confidence interval [CI]: 0.72 to 1.27). The occurrence of fatal or nonfatal re-infarction was reduced with an invasive strategy (OR 0.73; 95% CI: 0.61 to 0.88) as was readmission to hospital (OR 0.67; 95% CI: 0.48 to 0.94). The endpoints of nonfatal MI and the composite of death or nonfatal MI showed nonsignificant trends favoring an invasive strategy. Trials that included a higher proportion of patients with ST-segment depression on admission and trials in which a larger proportion of patients underwent revascularization showed a greater magnitude of benefit for an invasive strategy. CONCLUSION: For patients with unstable angina/non-ST-segment elevation MI, an invasive strategy reduces rates of fatal or nonfatal re-infarction and hospital readmission, but not all-cause mortality, when compared with a noninvasive strategy. These results suggest that an invasive management strategy should be considered for all patients with unstable angina/non-ST-segment elevation MI and perhaps in particular those with ST-segment depression.

Angina, Unstable↗
PubMed2005

Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels.

OBJECTIVE: To determine whether phlebotomy contributes to changes in hemoglobin and hematocrit levels in hospitalized general internal medicine patients. DESIGN: Retrospective cohort study. SETTING: General internal medicine inpatient service at a tertiary care hospital. PARTICIPANTS: All adult patients discharged from the Toronto General Hospital's internal medicine service between January 1 and June 30, 2001. A total of 989 hospitalizations were reviewed and 404 hospitalizations were included in our analysis. MEASUREMENTS AND MAIN RESULTS: Mean (SD) hemoglobin and hematocrit changes during hospitalization were 7.9 (12.6) g/L (P<.0001) and 2.1% (3.8%) (P<.0001), respectively. The mean (SD) volume of phlebotomy during hospital stay was 74.6 (52.1) mL. On univariate analysis, changes in hemoglobin and hematocrit were predicted by the volume of phlebotomy, length of hospital stay, admission hemoglobin/hematocrit value, age, Charlson comorbidity index, and admission intravascular volume status. The volume of phlebotomy remained a strong predictor of drop in hemoglobin and hematocrit after adjusting for other predictors using multivariate analysis (P<.0001). On average, every 100 mL of phlebotomy was associated with a decrease in hemoglobin and hematocrit of 7.0 g/L and 1.9%, respectively. CONCLUSIONS: Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients admitted to an internal medicine service and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Knowing the expected changes in hemoglobin and hematocrit due to diagnostic phlebotomy will help guide when to investigate anemia in hospitalized patients.

Aged↗
PubMed2004

Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest.

CONTEXT: Most survivors of cardiac arrest are comatose after resuscitation, and meaningful neurological recovery occurs in a small proportion of cases. Treatment can be lengthy, expensive, and often difficult for families and caregivers. Physical examination is potentially useful in this clinical scenario, and the information obtained may help physicians and families make accurate decisions about treatment and/or withdrawal of care. OBJECTIVE: To determine the precision and accuracy of the clinical examination in predicting poor outcome in post-cardiac arrest coma. DATA SOURCES AND STUDY SELECTION: We searched MEDLINE for English-language articles (1966-2003) using the terms coma, cardiac arrest, prognosis, physical examination, sensitivity and specificity, and observer variation. Other sources came from bibliographies of retrieved articles and physical examination textbooks. Studies were included if they assessed the precision and accuracy of the clinical examination in prognosis of post-cardiac arrest coma in adults. Eleven studies, involving 1914 patients, met our inclusion criteria. DATA EXTRACTION: Two authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality using predetermined criteria. Disagreement was resolved by consensus. DATA SYNTHESIS: Summary likelihood ratios (LRs) were calculated from random effects models. Five clinical signs were found to strongly predict death or poor neurological outcome: absent corneal reflexes at 24 hours (LR, 12.9; 95% confidence interval [CI], 2.0-68.7), absent pupillary response at 24 hours (LR, 10.2; 95% CI, 1.8-48.6), absent withdrawal response to pain at 24 hours (LR, 4.7; 95% CI, 2.2-9.8), no motor response at 24 hours (LR, 4.9; 95% CI, 1.6-13.0), and no motor response at 72 hours (LR, 9.2; 95% CI, 2.1-49.4). The proportion of individuals' dying or having a poor neurological outcome was calculated by pooling the outcome data from the 11 studies (n = 1914) and used as an estimate of the pretest probability of poor outcome. The random effects estimate of poor outcome was 77% (95% CI, 72%-80%). The highest LR increases the pretest probability of 77% to a posttest probability of 97% (95% CI, 87%-100%). No clinical findings were found to have LRs that strongly predicted good neurological outcome. CONCLUSIONS: Simple physical examination maneuvers strongly predict death or poor outcome in comatose survivors of cardiac arrest. The most useful signs occur at 24 hours after cardiac arrest, and earlier prognosis should not be made by clinical examination alone. These data provide prognostic information, rather than treatment recommendations, which must be made on an individual basis incorporating many other variables.

Brain Death↗
PubMed2003

Critically ill patients with severe acute respiratory syndrome.

CONTEXT: Severe acute respiratory syndrome (SARS) is a newly recognized infectious disease capable of causing severe respiratory failure. OBJECTIVE: To determine the epidemiological features, course, and outcomes of patients with SARS-related critical illness. DESIGN, SETTING, AND PATIENTS: Retrospective case series of 38 adult patients with SARS-related critical illness admitted to 13 intensive care units (ICUs) in the Toronto area between the onset of the outbreak and April 15, 2003. Data were collected daily during the first 7 days in the ICUs, and patients were followed up for 28 days. MAIN OUTCOME MEASURES: The primary outcome was mortality at 28 days after ICU admission. Secondary outcomes included rate of SARS-related critical illness, number of tertiary care ICUs and staff placed under quarantine, and number of health care workers (HCWs) contracting SARS secondary to ICU-acquired transmission. RESULTS: Of 196 patients with SARS, 38 (19%) became critically ill, 7 (18%) of whom were HCWs. The median (interquartile range [IQR]) age of the 38 patients was 57.4 (39.0-69.6) years. The median (IQR) duration between initial symptoms and admission to the ICU was 8 (5-10) days. Twenty-nine (76%) required mechanical ventilation and 10 of these (34%) experienced barotrauma. Mortality at 28 days was 13 (34%) of 38 patients and for those requiring mechanical ventilation, mortality was 13 (45%) of 29. Six patients (16%) remained mechanically ventilated at 28 days. Two of these patients had died by 8 weeks' follow-up. Patients who died were more often older, had preexisting diabetes mellitus, and on admission to hospital were more likely to have bilateral radiographic infiltrates. Transmission of SARS in 6 study ICUs led to closure of 73 medical-surgical ICU beds. In 2 university ICUs, 164 HCWs were quarantined and 16 (10%) developed SARS. CONCLUSIONS: Critical illness was common among patients with SARS. Affected patients had primarily single-organ respiratory failure, and half of mechanically ventilated patients died. The SARS outbreak greatly strained regional critical care resources.

APACHE↗
PubMed2003

Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.

CONTEXT: Severe acute respiratory syndrome (SARS) is an emerging infectious disease that first manifested in humans in China in November 2002 and has subsequently spread worldwide. OBJECTIVES: To describe the clinical characteristics and short-term outcomes of SARS in the first large group of patients in North America; to describe how these patients were treated and the variables associated with poor outcome. DESIGN, SETTING, AND PATIENTS: Retrospective case series involving 144 adult patients admitted to 10 academic and community hospitals in the greater Toronto, Ontario, area between March 7 and April 10, 2003, with a diagnosis of suspected or probable SARS. Patients were included if they had fever, a known exposure to SARS, and respiratory symptoms or infiltrates observed on chest radiograph. Patients were excluded if an alternative diagnosis was determined. MAIN OUTCOME MEASURES: Location of exposure to SARS; features of the history, physical examination, and laboratory tests at admission to the hospital; and 21-day outcomes such as death or intensive care unit (ICU) admission with or without mechanical ventilation. RESULTS: Of the 144 patients, 111 (77%) were exposed to SARS in the hospital setting. Features of the clinical examination most commonly found in these patients at admission were self-reported fever (99%), documented elevated temperature (85%), nonproductive cough (69%), myalgia (49%), and dyspnea (42%). Common laboratory features included elevated lactate dehydrogenase (87%), hypocalcemia (60%), and lymphopenia (54%). Only 2% of patients had rhinorrhea. A total of 126 patients (88%) were treated with ribavirin, although its use was associated with significant toxicity, including hemolysis (in 76%) and decrease in hemoglobin of 2 g/dL (in 49%). Twenty-nine patients (20%) were admitted to the ICU with or without mechanical ventilation, and 8 patients died (21-day mortality, 6.5%; 95% confidence interval [CI], 1.9%-11.8%). Multivariable analysis showed that the presence of diabetes (relative risk [RR], 3.1; 95% CI, 1.4-7.2; P =.01) or other comorbid conditions (RR, 2.5; 95% CI, 1.1-5.8; P =.03) were independently associated with poor outcome (death, ICU admission, or mechanical ventilation). CONCLUSIONS: The majority of cases in the SARS outbreak in the greater Toronto area were related to hospital exposure. In the event that contact history becomes unreliable, several features of the clinical presentation will be useful in raising the suspicion of SARS. Although SARS is associated with significant morbidity and mortality, especially in patients with diabetes or other comorbid conditions, the vast majority (93.5%) of patients in our cohort survived.

Adult↗
PubMed2003

A comprehensive evidence-based approach to fever of unknown origin.

BACKGROUND: Fever of unknown origin (FUO) is defined as a temperature higher than 38.3 degrees C on several occasions and lasting longer than 3 weeks, with a diagnosis that remains uncertain after 1 week of investigation. METHODS: A systematic review was performed to develop evidence-based recommendations for the diagnostic workup of FUO. MEDLINE database was searched (January 1966 to December 2000) to identify articles related to FUO. Articles were included if the patient population met the criteria for FUO and they addressed the natural history, prognosis, or spectrum of disease or evaluated a diagnostic test in FUO. The quality of retrieved articles was rated as "good," "fair," or "poor," and sensitivity, specificity, and diagnostic yield of tests were calculated. Recommendations were made in accordance with the strength of evidence. RESULTS: The prevalence of FUO in hospitalized patients is reported to be 2.9%. Eleven studies indicate that the spectrum of disease includes "no diagnosis" (19%), infections (28%), inflammatory diseases (21%), and malignancies (17%). Deep vein thrombosis (3%) and temporal arteritis in the elderly (16%-17%) were important considerations. Four good natural history studies indicate that most patients with undiagnosed FUO recover spontaneously (51%-100%). One fair-quality study suggested a high specificity (99%) for the diagnosis of endocarditis in FUO by applying the Duke criteria. One fair-quality study showed that computed tomographic scanning of the abdomen had a diagnostic yield of 19%. Ten studies of nuclear imaging revealed that technetium was the most promising isotope, showing a high specificity (94%), albeit low sensitivity (40%-75%) (2 fair-quality studies). Two fair-quality studies showed liver biopsy to have a high diagnostic yield (14%-17%), but with risk of harm (0.009%-0.12% death). Empiric bone marrow cultures showed a low diagnostic yield of 0% to 2% (2 fair-quality articles). CONCLUSIONS: Diagnosis of FUO may be assisted by the Duke criteria for endocarditis, computed tomographic scan of the abdomen, nuclear scanning with a technetium-based isotope, and liver biopsy (fair to good evidence). Routine bone marrow cultures are not recommended.

Algorithms↗