To determine whether data available to physicians in the emergency room can accurately identify which patients with acute chest pain are having myocardial infarctions, we analyzed 482 patients at one hospital. Using recursive partitioning analysis, we constructed a decision protocol in the format of a simple flow chart to identify infarction on the basis of nine clinical factors. In prospective testing on 468 other patients at a second hospital, the protocol performed as well as the physicians. Moreover, an integration of the protocol with the physicians' judgments resulted in a classification system that preserved sensitivity for detecting infarctions, significantly improved the specificity (from 67 per cent to 77 per cent, P less than 0.01) and positive predictive value (from 34 per cent to 42 per cent, P = 0.016) of admission to an intensive-care area. The protocol identified a subgroup of 107 patients among whom only 5 per cent had infarctions and for whom admission to non-intensive-care areas might be appropriate. This decision protocol warrants further wide-scale prospective testing but is not ready for routine clinical use.
IN a preliminary study,10 reported two years ago, from observations made upon the exteriorized, unobstructed appendix, evidence was presented which suggested that the vermiform appendix of man secreted fluid. It was also shown, at that time, that obstruction of the cecal appendage of the rabbit was followed consistently by evidence of rapid fluid secretion. During the time that has intervened since then, these studies have been extended considerably. In the present communication evidence of the secretory capacity of the vermiform appendix of man will be cited.The behavior of the appendix when obstructed temporarily will be described and factual proof of the reproduction of the pathologic picture of spontaneous appendicitis through the agency of obstruction will be presented.Method.-From studies made upon the obstructed cecal appendage of the rabbit and the vermiform appendix of the chimpanzee," it was apparent that in order to adduce convincing proof of the secretory capacity of the appendix of man it was necessary to incannulate the obstructed exteriorized appendix. Unobstructed appendicostomies permitting incannulation had been established incidentally when colostomy was performed for malignant disease of the colon. Exteriorization of the appendix in this manner had been accomplished readily through a button-hole incision and did not complicate the operative procedure.10In a patient presenting a carcinoma of the ascending colon, it was possible to exteriorize, with the blood supply intact, after the Bloch-Mikulicz principle, the greater portion of the right half of the colon and the terminal ileum. A few days later, when the exteriorized bowel had become fairly well covered with fibrin and effectual sealing of the wound had occurred, the base of the appendix was ligated securely. The attachment of a closed water system connected to a recording manometer permitted determination of the ensuant increase in intraluminal pressure. The manometer used required addition of 0.58 cc. of fluid to raise the pressure reading IOO cm. of water.It was obvious that this type of case, permitting determination of the secretory capacity of the vermiform appendix, would not be encountered frequently. After considerable deliberation the method depicted in Figure I was worked out. When preliminary colostomy was being performed for malignancy of the large bowel or rectum prior to excision of the lesion, the appendix
Two hundred thirty-seven patients with cancer of the breast treated with radical mastectomy were reviewed. Coefficients of correlation between patient's and doctor's delay vs. survival were not significant at p smaller than 0.05. No significant relationship between delay and time of recurrence was found.
The authors hereby express their most appreciative recognition of the contribution of our machinist, Mr. Hilbert Huso, without whom the present machine could not have been constructed. They also wish to express gratitude to Miss La-Vonne Young and Miss Donna Nissen, technicians, and to Mr. titc'iard Kelly, a pre-medical student helper, who have volunteered uncounted extra hours to the prosecution of this work.
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