RESUMEN
BACKGROUND: The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis. METHOD: The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results. RESULTS: Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks. CONCLUSION: The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.
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Diverticulitis del Colon , Humanos , Estudios Retrospectivos , Femenino , Masculino , Persona de Mediana Edad , Factores de Riesgo , Francia/epidemiología , Anciano , Diverticulitis del Colon/cirugía , Diverticulitis del Colon/epidemiología , Urgencias Médicas , Adulto , Enfermedades del Sigmoide/cirugía , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricosRESUMEN
BACKGROUND: Cervical cerclage is the only effective treatment for cervical insufficiency, effectively preventing late miscarriage and preterm birth. The effectiveness and safety of emergency cervical cerclage (ECC) as an emergency treatment when the cervix is already dilated or when there is protrusion of the fetal membranes into the vagina remain controversial, especially in pregnancies at 24-28 weeks when the fetus is viable. There is still no consensus on whether emergency cervical cerclage should be performed in such cases. PURPOSE: To investigate the effectiveness and safety of emergency cervical cerclage in singleton pregnant women at 24-28 weeks of gestation. METHODS: This study employed a single-center prospective cohort design, enrolling singleton pregnant women at 24-28 weeks of gestation with ultrasound or physical examination indicating cervical dilation or even membrane protrusion. Emergency cervical cerclage was compared with conservative treatment. The primary endpoints included a comprehensive assessment of perinatal pregnancy loss, significant neonatal morbidity, and adverse neonatal outcomes. Secondary endpoints included prolonged gestational age, preterm birth, neonatal hospitalization rate, premature rupture of membranes, and intrauterine infection/chorioamnionitis. RESULTS: From June 2021 to March 2023, a total of 133 pregnant women participated in this study, with 125 completing the trial, and were allocated to either the Emergency Cervical Cerclage (ECC) group (72 cases) or the conservative treatment group (53 cases) based on informed consent from the pregnant women. The rate of adverse neonatal outcomes was 8.33% in the ECC group and 26.42% in the conservative treatment (CT) group, with a statistically significant difference (P = 0.06). There were no significant differences between the two groups in terms of perinatal pregnancy loss and significant neonatal morbidity. The conservative treatment group had a mean prolonged gestational age of 63.0 (23.0, 79.5) days, while the ECC group had 84.0 (72.5, 89.0) days, with a statistically significant difference between the two groups (P < 0.001). Compared with CT group, the ECC group showed a significantly reduced incidence of preterm birth before 28 weeks, 32 weeks, and 34 weeks, with statistical significance (P = 0.046, 0.007, 0.001), as well as a significantly decreased neonatal hospitalization rate (P = 0.013, 0.031). Additionally, ECC treatment did not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis, with no statistically significant differences (P = 0.406, 0.397). CONCLUSION: In singleton pregnant women with cervical insufficiency at 24-28 weeks of gestation, emergency cervical cerclage can reduce adverse neonatal pregnancy outcomes, effectively prolong gestational age, decrease preterm births before 28 weeks, 32 weeks, and 34 weeks, lower neonatal hospitalization rates, and does not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis.
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Cerclaje Cervical , Nacimiento Prematuro , Incompetencia del Cuello del Útero , Humanos , Femenino , Embarazo , Adulto , Estudios Prospectivos , Nacimiento Prematuro/prevención & control , Nacimiento Prematuro/epidemiología , Incompetencia del Cuello del Útero/cirugía , Edad Gestacional , Resultado del Embarazo , Recién Nacido , Segundo Trimestre del Embarazo , Rotura Prematura de Membranas Fetales/epidemiología , Urgencias Médicas , Aborto Espontáneo/prevención & control , Aborto Espontáneo/epidemiología , Tratamiento de Urgencia/estadística & datos numéricosAsunto(s)
Procedimientos Quirúrgicos Electivos/efectos adversos , Tratamiento de Urgencia/efectos adversos , Complicaciones Posoperatorias/epidemiología , Factores Sexuales , Cirujanos , Canadá/epidemiología , Comunicación , Procedimientos Quirúrgicos Electivos/mortalidad , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Tratamiento de Urgencia/mortalidad , Tratamiento de Urgencia/estadística & datos numéricos , Femenino , Humanos , Masculino , Dolor Postoperatorio , Readmisión del Paciente/estadística & datos numéricos , Resultado del TratamientoRESUMEN
Abstract Background The COVID-19 pandemic has imposed measures of social distancing and, during this time, there has been an elevation in cardiovascular mortality rates and a decrease in the number of emergency visits. Objectives To assess and compare in-hospital mortality for cardiovascular diseases and emergency department visits during the COVID-19 pandemic and the same period in 2019. Methods Retrospective, single-center study that evaluated emergency visits and in-hospital deaths between March 16, 2020 and June 16, 2020, when the steepest fall in the number of emergency admissions for COVID-19 was registered. These data were compared with the emergency visits and in-hospital deaths between March 16 and June 16, 2019. We analyzed the total number of deaths, and cardiovascular deaths. The level of significance was set at p < 0.05. Results There was a 35% decrease in the number of emergency visits and an increase in the ratio of the number of deaths to the number of emergency visits in 2020. The increase in the ratio of the number of all-cause deaths to the number of emergency visits was 45.6% and the increase in the ratio of the number of cardiovascular deaths to the number of emergency visits was 62.1%. None of the patients who died in the study period in 2020 tested positive for COVID-19. Conclusion In-hospital mortality for cardiovascular diseases increased proportionally to the number of emergency visits during the COVID-19-imposed social distancing compared with the same period in 2019. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)
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Humanos , Masculino , Femenino , Enfermedades Cardiovasculares/mortalidad , Mortalidad Hospitalaria , Servicio de Urgencia en Hospital , Enfermedades Cardiovasculares/epidemiología , Tratamiento de Urgencia/estadística & datos numéricos , Distanciamiento Físico , COVID-19/complicaciones , HospitalizaciónRESUMEN
OBJECTIVE: The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients. METHODS: From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively. RESULTS: At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories. CONCLUSIONS: Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Tratamiento de Urgencia , Calidad de Vida , Choque Cardiogénico , Procedimientos Quirúrgicos Vasculares , Factores de Edad , Anciano , Anciano de 80 o más Años , Disección Aórtica/complicaciones , Disección Aórtica/mortalidad , Disección Aórtica/psicología , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/psicología , Aneurisma de la Aorta Torácica/cirugía , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/estadística & datos numéricos , Comorbilidad , Tratamiento de Urgencia/efectos adversos , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Factores de Riesgo , Choque Cardiogénico/epidemiología , Choque Cardiogénico/etiología , Análisis de Supervivencia , Estados Unidos/epidemiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
OBJECTIVE: To define geographic variations in emergency general surgery (EGS) care, we sought to determine how much variability exists in the rates of EGS operations and subsequent mortality in the Northeastern and Southeastern United States (US). SUMMARY BACKGROUND DATA: While some geographic variations in healthcare are normal, unwarranted variations raise questions about the quality, appropriateness, and cost-effectiveness of care in different areas. METHODS: Patients ≥18 years who underwent 1 of 10 common EGS operations were identified using the State Inpatient Databases (2011-2012) for 6 states, representing Northeastern (New York) and Southeastern (Florida, Georgia, Kentucky, North Carolina, Mississippi) US. Geographic unit of analysis was the hospital service area (HSA). Age-standardized rates of operations and in-hospital mortality were calculated and mapped. Differences in rates across geographic areas were compared using the Kruskal-Wallis test, and variance quantified using linear random-effects models. Variation profiles were tabulated via standardized rates of utilization and mortality to compare geographically heterogenous areas. RESULTS: 227,109 EGS operations were geospatially analyzed across the 6 states. Age-standardized EGS operation rates varied significantly by region (Northeast rate of 22.7 EGS operations per 10,000 in population versus Southeast 21.9; P < 0.001), state (ranging from 9.9 to 29.1; P < 0.001), and HSA (1.9-56.7; P < 0.001). The geographic variability in age-standardized EGS mortality rates was also significant at the region level (Northeast mortality rate 7.2 per 1000 operations vs Southeast 7.4; P < 0.001), state-level (ranging from 5.9 to 9.0 deaths per 1000 EGS operations; P < 0.001), and HSA-level (0.0-77.3; P < 0.001). Maps and variation profiles visually exhibited widespread and substantial differences in EGS use and morality. CONCLUSIONS: Wide geographic variations exist across 6 Northeastern and Southeastern US states in the rates of EGS operations and subsequent mortality. More detailed geographic analyses are needed to determine the basis of these variations and how they can be minimized.
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Tratamiento de Urgencia/estadística & datos numéricos , Complicaciones Posoperatorias/mortalidad , Utilización de Procedimientos y Técnicas/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Estudios de Cohortes , Cirugía General , Humanos , New England/epidemiología , Estudios Retrospectivos , Sudeste de Estados Unidos/epidemiologíaAsunto(s)
Tratamiento de Urgencia/estadística & datos numéricos , Oftalmopatías/terapia , Oftalmología/métodos , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , COVID-19/prevención & control , COVID-19/transmisión , Tratamiento de Urgencia/normas , Oftalmopatías/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oftalmología/estadística & datos numéricosRESUMEN
BACKGROUND: The natural history of a cohort of patients monitored for popliteal artery aneurysms (PAAs) has not been well described. A prevailing uncertainty exists regarding the optimal surveillance strategies and timing of treatment. The primary aim of the present study was to describe the care trajectory of all patients with PAAs identified at two tertiary vascular centers, both in surveillance and eventually treated. The secondary aim was to define the PAA growth rates. METHODS: A retrospective, multicenter cohort study was performed of all patients with PAAs at two vascular centers in two countries (Sweden, 2009-2016; New Zealand, 2009-2017). Data were collected from electronic medical records regarding the comorbidities, treatment, and outcomes and analyzed on a patient- and extremity-specific level. Treatment was indicated at the occurrence of emergent symptoms or considered at a PAA threshold of >2 cm. The PAAs were divided into small (≤15 mm) and large (>15 mm) aneurysms. The mean surveillance follow-up was 5.1 years. RESULTS: Most of the 241 identified patients (397 limbs) with a diagnosis of PAAs had bilateral aneurysms (n = 156). Most patients were treated within the study period (163 of 241; 68%), and one half of the diagnosed extremities with PAA had been treated (54%; 215 of 397). Among those who had undergone elective repair, treatment had usually occurred within 1 year after the diagnosis (66%; 105 of 158). More small PAAs were detected in the group that had required emergent repair compared with elective repair (6 of 57 [11%] vs 12 of 158 [8%]; P < .001). No differences were found in the mean diameters between the elective and emergent groups (30.1 mm vs 32.2 mm; P = .39). Growth was recorded in 110 PAAs and on multivariate analysis was associated with a larger index diameter (odds ratio, 1.138; 95% confidence interval, 1.040-1.246; P = .005) and a concurrent abdominal aortic aneurysm (odds ratio, 2.553; 95% confidence interval, 1.018-6.402; P = .046). CONCLUSIONS: The present cohort of patients represented a true contemporary clinical setting of monitored PAAs and showed that most of these patients will require elective repair, usually within 1 year. The risk of emergent repair is not negligible for patients with smaller diameter PAAs. However, the optimal selection strategy for preventive early repair is still unknown. Future morphologic studies are needed to support the development of individualized surveillance protocols.
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Aneurisma/cirugía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Arteria Poplítea/cirugía , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico , Progresión de la Enfermedad , Procedimientos Quirúrgicos Electivos/métodos , Tratamiento de Urgencia/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Suecia , Tiempo de Tratamiento/estadística & datos numéricos , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/métodosAsunto(s)
Analgésicos/administración & dosificación , Anestésicos Intravenosos/administración & dosificación , Tratamiento de Urgencia/estadística & datos numéricos , Etomidato/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Ketamina/administración & dosificación , Intubación e Inducción de Secuencia Rápida/métodos , Analgésicos/efectos adversos , Anestésicos Intravenosos/efectos adversos , Servicio de Urgencia en Hospital , Etomidato/efectos adversos , Humanos , Hipnóticos y Sedantes/efectos adversos , Intubación Intratraqueal , Ketamina/efectos adversosRESUMEN
OBJECTIVES: To develop and evaluate a machine learning model for predicting patient with trauma mortality within the US emergency departments. METHODS: This was a retrospective prognostic study using deidentified patient visit data from years 2007 to 2014 of the National Trauma Data Bank. The predictive model intelligence building process is designed based on patient demographics, vital signs, comorbid conditions, arrival mode and hospital transfer status. The mortality prediction model was evaluated on its sensitivity, specificity, area under receiver operating curve (AUC), positive and negative predictive value, and Matthews correlation coefficient. RESULTS: Our final dataset consisted of 2 007 485 patient visits (36.45% female, mean age of 45), 8198 (0.4%) of which resulted in mortality. Our model achieved AUC and sensitivity-specificity gap of 0.86 (95% CI 0.85 to 0.87), 0.44 for children and 0.85 (95% CI 0.85 to 0.85), 0.44 for adults. The all ages model characteristics indicate it generalised, with an AUC and gap of 0.85 (95% CI 0.85 to 0.85), 0.45. Excluding fall injuries weakened the child model (AUC 0.85, 95% CI 0.84 to 0.86) but strengthened adult (AUC 0.87, 95% CI 0.87 to 0.87) and all ages (AUC 0.86, 95% CI 0.86 to 0.86) models. CONCLUSIONS: Our machine learning model demonstrates similar performance to contemporary machine learning models without requiring restrictive criteria or extensive medical expertise. These results suggest that machine learning models for trauma outcome prediction can generalise to patients with trauma across the USA and may be able to provide decision support to medical providers in any healthcare setting.
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Servicio de Urgencia en Hospital , Aprendizaje Automático , Adulto , Niño , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Femenino , Humanos , Masculino , Pronóstico , Estudios RetrospectivosRESUMEN
Background: Preventing prolongation of the decision-to-delivery interval (DDI) for emergency caesarean delivery (CD) remains central to improving perinatal health. This study evaluated the effects of the DDI on perinatal outcome following emergency CD. Methods: A prospective cross-sectional study involving 205 consenting women who had emergency CD at a tertiary hospital in Nigeria was conducted. The time-motion documentation of events from decision to delivery was documented; the outcome measures were perinatal morbidity (neonatal resuscitation, 5-minute Apgar score, neonatal intensive admission) and mortality. Data analysis was performed with IBM SPSS Statistics version 20.0, and P<0.05 was considered significant. Results: The overall mean DDI was 233.99±132.61 minutes (range 44-725 minutes); the mean DDI was shortest for cord prolapse (86.25±86.25 minutes) and was shorter for booked participants compared with unbooked participants (207.19±13.88 minutes vs 249.25±12.05 minutes; P=0.030) and for general anaesthesia compared with spinal anaesthesia (219.48±128.60 minutes vs 236.19±133.42 minutes; P=0.543). All neonatal parameters were significantly worse for unbooked women compared with booked women, including perinatal mortality (10.8% vs 1.3%; P=0.012). Neonatal morbidity increased with DDI for clinical indications, UK National Institute of Health and Care Excellence (NICE) and Robson classification for CDs; perinatal mortality was 73.2 per 1000 live births, all were category 1 CDs and all except one occurred with DDI greater than 90 minutes. Severe preeclampsia/eclampsia, obstructed labour and placenta praevia tolerated DDI greater than 90 minutes compared with abruptio placentae and umbilical cord prolapse. However, logistic regression showed no statistical correlation between the DDI and neonatal outcomes. Conclusion: Perinatal morbidity and mortality increased with DDI relative to the clinical urgency but perinatal deaths were increased with DDI greater than 90 minutes. For no category of emergency CD should the DDI exceed 90 minutes, while patient and institutional factors should be addressed to reduce the DDI.
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Cesárea/estadística & datos numéricos , Toma de Decisiones , Tratamiento de Urgencia/métodos , Adulto , Puntaje de Apgar , Estudios Transversales , Tratamiento de Urgencia/estadística & datos numéricos , Femenino , Humanos , Recién Nacido , Nigeria/epidemiología , Mortalidad Perinatal , Médicos , Embarazo , Resultado del Embarazo , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Maternal mortality rate remains a challenge in many developing countries. OBJECTIVES: This study explored experiences of Health Care Workers on Emergency Obstetrics Care (EMOC) in-service training and its effect on maternal mortality. METHODS: Descriptive qualitative study design was conducted using in-depth interviews and focus group discussions. Participants were EMOC trained midwives and doctors purposively selected from the 2 referral hospitals in the country. Data were transcribed verbatim, coded, and analysed using Grounded Theory approach. RESULTS: Four themes emerged including training, EMOC implementation, maternal death factors and EMOC prioritisation. The duration of training was viewed inadequate but responsiveness to and confidence in managing obstetric emergencies improved post EMOC training. Staff shortage, HCWs non-adherence and negative attitude to EMOC guidelines; delays in instituting interventions, inadequate community involvement, minimal or no health talk to women and their partners and communities on sexual reproductive matters and non-prioritisation of EMOC by authorities were concerns raised. CONCLUSION: Strengthening health education at health facility levels, stakeholders' involvement; and prioritising EMOC in-service training are necessary in reducing the national maternal mortality.
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Servicios Médicos de Urgencia/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Personal de Salud/psicología , Adulto , Evaluación Educacional , Femenino , Grupos Focales , Humanos , Capacitación en Servicio , Entrevistas como Asunto , Investigación CualitativaRESUMEN
INTRODUCTION: Coronavirus disease 2019 (COVID-19) impacted emergency services worldwide. AIM: We aimed to evaluate COVID-19 effect on the number of stroke code activations and timings during the first two months of the pandemic. MATERIAL AND METHODS: We reviewed the stroke code database of a single comprehensive stroke centre in Portugal for the number of activations through 2019-2020. We compared the pathway timings between March and April 2020 (COVID-19 period) and the homologous months of the previous four years (pre-COVID-19 period), whilst using February as a control. RESULTS: Monthly stroke code activation rates decreased up to 34.2% during COVID-19 pandemic. Compared to the pre-COVID-19 period, we observed an increase in the time from symptom onset to emergency call, with a significant number of patients waiting more than four hours (March 20.8% vs. 6.8%, p = 0.034; April 23.8% vs. 6%, p = 0.01); as well as an increase in the time from symptom onset to hospital arrival (March: median 136 minutes [IQR 106-410] vs. 100 [IQR 64-175], p = 0.001; April: median 188 [IQR 96-394] vs. 98 [IQR 66-168], p = 0.007). No difference between both periods was found concerning in-hospital times, patient characteristics, stroke/mimic diagnosis, stroke severity, and mortality. CONCLUSION: COVID-19 related factors probably reduced healthcare services utilization, and delayed emergency calls and hospital arrival after stroke onset. These highlight the importance of health education to improve the effectiveness of medical assistance. The preservation of in-hospital times validates the feasibility of the protected stroke code protocol.
TITLE: El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.Introducción. La enfermedad por coronavirus 2019 (COVID-19) provocó un considerable impacto mundial en los servicios de emergencia. Objetivo. Se pretende evaluar el efecto de la COVID-19 sobre el número y los tiempos de activaciones del Código Ictus en el comienzo de la pandemia. Material y métodos. Se revisó la base de datos del Código Ictus de un centro de ictus de Portugal entre 2016 y 2020. Se compararon los tiempos de activación entre marzo y abril de 2020 (período COVID-19) y los meses homólogos de los cuatro años anteriores, mientras que se utilizó febrero como control. Resultados. Las tasas mensuales de activación disminuyeron hasta el 34,2% durante la pandemia. En comparación con el período previo, se observó un aumento del tiempo desde los síntomas hasta la llamada de emergencia, con un aumento de pacientes que esperaron más de cuatro horas (marzo: 20,8 frente a 6,8%, p = 0,034; abril: 23,8 frente a 6%, p = 0,01) y del tiempo desde los síntomas hasta la llegada al hospital marzo: mediana de 136 minutos (rango intercuartílico [RIC]: 106-410) frente a 100 (RIC: 64-175), p = 0,001; abril: mediana de 188 (RIC: 96-394) frente a 98 (RIC: 66-168), p = 0,007. No hubo diferencias en los tiempos de internamiento, las características de los pacientes, el diagnóstico de ictus/stroke mimics, la gravedad del ictus o la mortalidad. Conclusión. Los factores relacionados con la COVID-19 redujeron la utilización de los servicios sanitarios y retrasaron las llamadas de emergencia y el tiempo de llegada al hospital. Esto demuestra la importancia de la educación sanitaria para mejorar la eficacia de la asistencia médica.
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COVID-19 , Urgencias Médicas/epidemiología , Tratamiento de Urgencia/estadística & datos numéricos , Pandemias , Aceptación de la Atención de Salud/estadística & datos numéricos , SARS-CoV-2 , Accidente Cerebrovascular/epidemiología , Tiempo de Tratamiento/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital/estadística & datos numéricos , Procedimientos Endovasculares/estadística & datos numéricos , Femenino , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Portugal/epidemiología , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Trombectomía/estadística & datos numéricos , Terapia Trombolítica/estadística & datos numéricosRESUMEN
BACKGROUND: Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions. METHODS: We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups. RESULTS: A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation. CONCLUSION: Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients. LEVEL OF EVIDENCE: Epidemiological, level III.
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Urgencias Médicas/epidemiología , Tratamiento de Urgencia/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Tratamiento de Urgencia/métodos , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Estimación de Kaplan-Meier , Masculino , Casas de Salud/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/métodos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS: We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS: Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION: Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.
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Urgencias Médicas/epidemiología , Servicio de Urgencia en Hospital/normas , Tratamiento de Urgencia/estadística & datos numéricos , Pacientes Internos , Transferencia de Pacientes/normas , Mejoramiento de la Calidad , Anciano , Estudios de Cohortes , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: In response to the COVID-19 pandemic, our emergency general surgery (EGS) service underwent significant restructuring, including establishing an enhanced ambulatory service and undertaking nonoperative management of selected pathologies. The aim of this study was to compare the activity of our EGS service before and after these changes. METHODS: Patients referred by the emergency department were identified prospectively over a 4-week period beginning from the date our EGS service was reconfigured (COVID) and compared with patients identified retrospectively from the same period the previous year (Pre-COVID), and followed up for 30 days. Data were extracted from handover documents and electronic care records. The primary outcomes were the rate of admission, ambulation and discharge. RESULTS: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Admission rate decreased from 78.7% to 41.7%, while there were increased rates of ambulation from 7.1% to 17.3% and discharge from 6% to 22.6% (all p<0.001). For inpatients, mean duration of admission decreased (6.9 to 4.8 days), and there were fewer operative or endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39) and telephone reviews (0 to 39), while early computed tomography scan was increasingly used to facilitate discharge (5% vs 34.7%). There were no differences in 30-day readmission or mortality. CONCLUSIONS: Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, achieving a decrease of 952 inpatient bed days in this critical period, while maintaining patient safety.
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COVID-19/prevención & control , Servicio de Urgencia en Hospital/organización & administración , Tratamiento de Urgencia/estadística & datos numéricos , Cirugía General/organización & administración , Servicio de Cirugía en Hospital/organización & administración , Adulto , Anciano , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , COVID-19/diagnóstico , COVID-19/epidemiología , COVID-19/transmisión , Tratamiento Conservador/estadística & datos numéricos , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/normas , Femenino , Estudios de Seguimiento , Cirugía General/normas , Cirugía General/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Control de Infecciones/organización & administración , Control de Infecciones/normas , Masculino , Persona de Mediana Edad , Pandemias/prevención & control , Readmisión del Paciente/estadística & datos numéricos , Seguridad del Paciente/normas , Estudios Prospectivos , Derivación y Consulta/organización & administración , Derivación y Consulta/normas , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , SARS-CoV-2/aislamiento & purificación , Servicio de Cirugía en Hospital/normas , Servicio de Cirugía en Hospital/estadística & datos numéricosRESUMEN
BACKGROUND: There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period. METHODS: We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission. RESULTS: There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery. CONCLUSIONS: There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.
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Procedimientos Quirúrgicos Ambulatorios/mortalidad , COVID-19/epidemiología , Procedimientos Quirúrgicos Electivos/mortalidad , Tratamiento de Urgencia/mortalidad , Procedimientos Quirúrgicos Ambulatorios/normas , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , COVID-19/complicaciones , COVID-19/diagnóstico , COVID-19/transmisión , Prueba de COVID-19/normas , Prueba de COVID-19/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/normas , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/normas , Tratamiento de Urgencia/estadística & datos numéricos , Inglaterra/epidemiología , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Control de Infecciones/normas , Control de Infecciones/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Pandemias/prevención & control , Pandemias/estadística & datos numéricos , Admisión del Paciente/normas , Admisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , SARS-CoV-2/aislamiento & purificación , Medicina Estatal/normas , Medicina Estatal/estadística & datos numéricosAsunto(s)
Tratamiento de Urgencia/estadística & datos numéricos , Médicos Generales/estadística & datos numéricos , Fuerza Laboral en Salud/estadística & datos numéricos , Medicina Estatal/organización & administración , COVID-19/diagnóstico , COVID-19/epidemiología , COVID-19/virología , Predicción , Médicos Generales/provisión & distribución , Necesidades y Demandas de Servicios de Salud/economía , Fuerza Laboral en Salud/tendencias , Humanos , Política Pública/economía , Política Pública/legislación & jurisprudencia , SARS-CoV-2/aislamiento & purificación , Medicina Estatal/economía , Reino Unido/epidemiologíaRESUMEN
INTRODUCTION: We aim to identify any changes in outcome for patients undergoing nonelective surgery at the start of the UK pandemic in our district general hospital. This was a single-centre retrospective cohort review of a UK district general hospital serving a population of over 250,000 people. METHODS: Participants were all patients undergoing a surgical procedure in the acute theatre list between 23 March to 11 May in both 2019 and 2020. Primary outcome was 90-day postoperative mortality. Secondary outcomes include time to surgical intervention and length of inpatient stay. RESULTS: A total of 132 patients (2020) versus 141 (2019) patients were included. Although overall 90-day postoperative mortality was higher in 2020 (9.8%) compared with 2019 (5.7%), this difference was not statistically significant (p=0.196). In 2020, eight patients tested positive for COVID-19 either as an inpatient or within 2 weeks of discharge, of whom five patients died. Time to surgical intervention was significantly faster for NCEPOD (National Confidential Enquiry into Patient Outcome and Death) code 3 patients in 2020 than in 2019 (p=0.027). There were no significant differences in mean length of inpatient stay. CONCLUSIONS: We found that patients were appropriately prioritised using NCEPOD classification, with no statistically significant differences in 90-day postoperative mortality and length of inpatient stay compared with the 2019 period. A study on a larger scale would further elucidate the profile and outcomes of patients requiring acute surgery to generate statistical significance.
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COVID-19/epidemiología , Control de Enfermedades Transmisibles , Tratamiento de Urgencia/estadística & datos numéricos , Hospitales de Distrito/estadística & datos numéricos , Hospitales Generales/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Control de Enfermedades Transmisibles/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/mortalidad , Adulto JovenRESUMEN
Background - In December 2019 following an outbreak of Novel coronavirus infection (COVID-19) in Wuhan, China, it spread rapidly overwhelming the healthcare systems globally. With little knowledge of COVID-19 virus, very few published reports on surgical outcomes; hospitals stopped elective surgery, whilst emergency surgery was offered only after exhausting all conservative treatment modalities. This study presents our experience of outcomes of emergency appendectomies performed during the pandemic. Methods - Prospectively we collected data on 132 patients in peak pandemic period from 1st March to 5th June 2020 and data compared with 206 patients operated in similar period in 2019. Patient demographics, presenting symptoms, pre-operative events, investigations, surgical management, postoperative outcomes and complications were analysed. Results - Demographics and ASA grades of both cohorts were comparable. In study cohort 84.4% and 96.7% in control cohort had laparoscopic appendicectomy. Whilst the study cohort had 13.6% primary open operations, control cohort had 5.3%. Mean length of stay and early post-operative complications (<30 days) were similar in both cohorts apart from surgical site infections (p = 0.02) and one mortality in study cohort. Conclusion - In these overwhelming pandemic times, although conservative treatment of acute appendicitis is an option, a proportion of patients will need surgery. Our study shows that with careful planning and strict theatre protocols, emergency appendicectomy can be safely offered with minimal risk of spreading COVID-19 infection. These observations warrant further prospective randomised studies. Keywords - appendicectomy, COVID-19, Coronavirus, emergency surgery, laparoscopy.