RESUMEN
Background: This study aims to investigate the safety and efficacy of guideline-directed fluid resuscitation (GDFR) compared with conservative fluid management in end-stage renal disease (ESRD) patients with sepsis by evaluating 90-day mortality and intubation rate. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases using specific keywords and controlled vocabulary. The search strategy, implemented until October 1, 2023, aimed to identify studies examining fluid resuscitation in ESRD patients with sepsis. The review process was streamlined using Covidence software. A fourth reviewer resolved discrepancies in study inclusion. A random-effects model with the generic Mantel-Haenszel method was preferred for integrating odds ratios (ORs). Sensitivity analysis and publication bias analysis were performed. Results: Of the 1274 identified studies, 10 were selected for inclusion, examining 1184 patients, 593 of whom received GDFR. Four studies were selected to investigate the intubation rate, including 304 patients. No significant mortality or intubation rate difference was spotted between both groups [OR = 1.23; confidence interval (CI) = 0.92-1.65; I2 = 0% and OR = 1.91; CI = 0.91-4.04]. In most studies, sensitivity analysis using the leave-one-out approach revealed higher mortality and intubation rates. The Egger test results indicated no statistically significant publication bias across the included studies. Conclusion: Our research contradicts the common assumption about the effectiveness of GDFR for sepsis patients with ESRD. It suggests that this approach, while not superior to the conservative strategy, may potentially be harmful.
RESUMEN
OBJECTIVE: Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. BACKGROUND: Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. METHODS: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001]. CONCLUSION: One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE: Level III Prognostic. STUDY TYPE: Prognostic.
Asunto(s)
Hospitales , Readmisión del Paciente , Adulto , Humanos , Factores de Riesgo , Alta del Paciente , Mortalidad Hospitalaria , Estudios Retrospectivos , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: The femoral artery is commonly injured following lower extremity trauma. If not identified early and addressed properly, it can lead to compartment syndrome (CS) and limb amputation. The aim of this study is to examine traumatic femoral artery injuries and identify risk factors for the development of lower extremity CS. METHODS: Adult (≥18 years) patients who presented with traumatic femoral artery injuries were identified in the Trauma Quality Improvement Program 2017. Patients were stratified into two groups, those with evidence of lower extremity compartment syndrome (CS) and those without CS (NCS), for comparison. Multivariate regression analysis was performed. RESULTS: A total of 1,297 adult trauma patients with femoral artery injury were identified. Mean age was 36 ± 15 y, 86% were male, and 68% had penetrating injuries. Median extremity abbreviated injury scale (AIS) was 3 [3,4], and median injury severity score (ISS) was 27 [22-41]. 68 (5.2%) patients were diagnosed with CS of the lower extremity, 66 (97.1%) of those patients underwent fasciotomy and one (1.5%) patient eventually had an amputation. On multivariate regression analysis, concomitant femoral vein, femoral nerve, and popliteal artery injuries and early need for blood transfusions were independent risk factors for the development of CS (OR 3.1, 3.8, 4.3, and 2.5 respectively). CONCLUSIONS: CS following traumatic femoral artery injury is a relatively common finding. Physicians must maintain a high index of suspicion and should consider prophylactic fasciotomy in the setting of combined femoral vein and nerve injuries, combined popliteal artery injury, and multiple blood transfusions.
Asunto(s)
Síndromes Compartimentales/epidemiología , Arteria Femoral/lesiones , Lesiones del Sistema Vascular/complicaciones , Adulto , Síndromes Compartimentales/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.
Asunto(s)
Abdomen/cirugía , Traumatismos Abdominales/cirugía , Laparotomía , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Heridas Penetrantes/cirugía , Absceso Abdominal/epidemiología , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/mortalidad , Adolescente , Adulto , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Laparotomía/efectos adversos , Masculino , Persona de Mediana Edad , Dehiscencia de la Herida Operatoria/epidemiología , Infección de la Herida Quirúrgica/epidemiología , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/cirugía , Heridas Penetrantes/complicaciones , Heridas Penetrantes/mortalidad , Heridas Punzantes/complicaciones , Heridas Punzantes/cirugía , Adulto JovenRESUMEN
BACKGROUND: Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST). METHODS: We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression. RESULTS: We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (ß = 0.079, [-0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (ß = -0.011, [-0.298 to 0.471]; P = 0.35). CONCLUSIONS: Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio. LEVEL OF EVIDENCE: Level III therapeutic.
Asunto(s)
Anticoagulantes/administración & dosificación , Hemorragia/inducido químicamente , Heparina de Bajo-Peso-Molecular/administración & dosificación , Traumatismos Vertebrales/complicaciones , Tromboembolia Venosa/prevención & control , Adulto , Anciano , Anticoagulantes/efectos adversos , Femenino , Heparina de Bajo-Peso-Molecular/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Traumatismos Vertebrales/cirugíaRESUMEN
BACKGROUND: Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. METHODS: We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. RESULTS: A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP <90 mmHg and SBP >190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. CONCLUSIONS: The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. LEVEL OF EVIDENCE: Level III Prognostic.
Asunto(s)
Presión Sanguínea , Lesiones Traumáticas del Encéfalo/mortalidad , Sistema de Registros , Adulto , Anciano , Anciano de 80 o más Años , Lesiones Traumáticas del Encéfalo/fisiopatología , Servicio de Urgencia en Hospital/normas , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Mejoramiento de la Calidad , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients. METHODS: We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed. RESULTS: We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01). CONCLUSIONS: Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients. LEVEL OF EVIDENCE: Level III Prognostic.
Asunto(s)
Presión Sanguínea , Frecuencia Cardíaca , Choque/fisiopatología , Heridas y Lesiones/mortalidad , Niño , Preescolar , Femenino , Mortalidad Hospitalaria , Humanos , Lactante , Recién Nacido , Masculino , Evaluación de Resultado en la Atención de Salud , Modelos de Riesgos Proporcionales , Choque/mortalidad , TriajeRESUMEN
INTRODUCTION: Firearm-related injuries (FRI) are an important public health crisis in the US. There is relatively less city level data examining the injury-related trends in Tucson, Arizona. Our study aims to examine FRI, in Southern Arizona's only Level I trauma center. METHODS: We conducted a (2014-2019) review of our Level-I trauma center registry. We selected all patients who were evaluated for a FRI. We collected patient and center related variables. Our outcomes were the trends of FRI, injury-related characteristics, and mortality. Cochran-Armitage trend analysis was performed. RESULTS: A total of 1012 FRI patients were identified. The majority of patients were teenagers (32%) and young adults (30%), and 88% were male. Greater than 80% of patients belonged to the low/low-middle socioeconomic class, and 18.5% completed college. The most common firearm utilized was the handgun (45%). The prevalence of FRI increased significantly (2014:15%; 2019:21%; P< 0.01). The most common injury intention was assault (75%). The median ISS was 17(9-25) with most injuries sustained to the extremities (23%). Also, 25% required emergent operative intervention. There is a significant rise in the number of severely injured patients (ISS≥25) (2014:12.1%, 2019:20%; P< 0.01), self-inflicted injuries (2014:10%, 2019:17%; P < 0.01), unintentional injuries (2014:6%, 2019:12%; P< 0.01), and mortality (2014:11%; 2019:19%; P< 0.01). A high prevalence of substance abuse was noted (73% alcohol, 64% drugs). CONCLUSIONS: The prevalence of FRI at our center has been rising over the past decade with a shift towards more severe injuries and higher mortality rates. Addressing these alarming changes requires targeted interventions on multiple frontiers.
Asunto(s)
Centros Traumatológicos/estadística & datos numéricos , Heridas por Arma de Fuego/epidemiología , Adolescente , Adulto , Anciano , Arizona/epidemiología , Femenino , Armas de Fuego , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Health literacy (HL) is an important component of national health policy. The aim of our study was to assess the prevalence of low HL (LHL) and determine its impact on outcomes after emergency general surgery (EGS). METHODS: We performed a (2016-2017) prospective cohort analysis of adult EGS patients. HL was assessed using the Short Assessment of HL score. LHL was defined as Short Assessment of HL score <14. Outcomes were the prevalence of LHL, compliance with medications, wound/drain care, 30-d complications, 30-d readmission, and time to resuming activities of daily living. RESULTS: We enrolled 900 patients. The mean age was 43 ± 11 y. Overall, 22% of the patients had LHL. LHL patients were more likely to be Hispanics (59% versus 15%, P < 0.01), uninsured (50% versus 20%, P < 0.01), have lower socioeconomic status (80% versus 40%, P < 0.02), and are less likely to have completed college (5% versus 60%, P < 0.01) compared with HL patients. On regression analysis, LHL was associated with lower medication compliance (OR: 0.81, [0.4-0.9], P = 0.02), inadequate wound/drain care (OR: 0.75, [0.5-0.8], P = 0.01), 30-d complications (OR: 1.95, [1.3-2.5], P < 0.01), and 30-d readmission (OR: 1.51, [1.2-2.6], P = 0.02). The median time of resuming activities of daily living was longer in patients with LHL than HL patients (4 d versus 7 d, P < 0.01). CONCLUSIONS: One in five patients undergoing EGS has LHL. LHL is associated with decreased compliance with discharge instructions, medications, and wound/drain care. Health literacy must be taken into account when discussing the postoperative plan and better instruction is needed for patients with LHL. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Prognostic.
Asunto(s)
Tratamiento de Urgencia/estadística & datos numéricos , Cirugía General/estadística & datos numéricos , Alfabetización en Salud/estadística & datos numéricos , Resultado del Tratamiento , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. METHODS: We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. RESULTS: A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. CONCLUSIONS: The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. LEVEL OF EVIDENCE: Level III prognostic.
Asunto(s)
Hemorragia Intracraneal Traumática/terapia , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Inhibidores de Agregación Plaquetaria/efectos adversos , Transfusión de Plaquetas/estadística & datos numéricos , Anciano , Progresión de la Enfermedad , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Hemorragia Intracraneal Traumática/diagnóstico , Hemorragia Intracraneal Traumática/mortalidad , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Tele-ICU is a technology-based model designed to deliver effective critical care in the intensive care unit (ICU). The tele-ICU system has been developed to address the increasing demand for intensive care services and the shortage of intensivists. A finite number of intensivists from remote locations provide real-time services to multiple ICUs and assist in the treatment of critically ill patients. Risk prediction algorithms, smart alarm systems, and machine learning tools augment conventional coverage and can potentially improve the quality of care. Tele-ICU is associated with substantial improvements in mortality, reduced hospital and ICU length of stay, and decreased health care costs. Although multiple studies show improved outcomes following the implementation of tele-ICU, results are not consistent. Several factors, including the heterogeneity of tele-ICU infrastructure deployed in different facilities and the reluctance of health care workers to accept tele-ICU, could be associated with these varied results. Considerably high installation and ongoing operational costs might also be limiting the widespread utilization of this innovative service. While we believe that the implementation of tele-ICU offers potential advantages and makes critical care delivery more efficient, further research on the impact of this technology in critical care settings is warranted.
Asunto(s)
Unidades de Cuidados Intensivos , Telemedicina , Cuidados Críticos , HumanosRESUMEN
BACKGROUND: Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients. METHODS: We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay. RESULTS: We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2-2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1-1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1-1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1-1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics. CONCLUSION: Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.
Asunto(s)
Etnicidad , Anciano Frágil , Negro o Afroamericano , Anciano , Disparidades en Atención de Salud , Hispánicos o Latinos , Humanos , Población BlancaRESUMEN
OBJECTIVE: To evaluate racial disparities among White and Black pediatric firearm injury patients on a national level. BACKGROUND: Pediatric firearm-related morbidity and mortality are rising in the United States. There is a paucity of data examining racial disparities in those patients. METHODS: The Pediatric Trauma Quality Improvement Program (2017) was queried for pediatric (age ≤17 years) patients admitted with firearm injuries. Patients were stratified by race: White and Black. Injury characteristics were assessed. Outcomes were mortality, hospital length of stay, and discharge disposition. Hierarchical regression models were performed to determine predictors of mortality and longer hospital stays. RESULTS: A total of 3717 pediatric firearm injury patients were identified: Blacks (67.0%) and Whites (33.0%). The majority of patients were male (84.2%). The most common injury intent in both groups was assault (77.3% in Blacks vs in 45.4% Whites; P<0.001), followed by unintentional (21.1% vs 35.4%; P<0.001), and suicide (1.0% vs 14.0%; P<0.001). The highest fatality rate was in suicide injuries (62.6%). On univariate analysis, White children had higher mortality (17.5% vs 9.8%; P<0.001), longer hospital stay [3 (1-7) vs 2 (1-5) days; P = 0.021], and more psychiatric hospital admissions (1.3% vs 0.1%; P<0.001). On multivariate analysis, suicide intent was found to be an independent predictor of mortality (aOR 2.67; 95% CI 1.35-5.29) and longer hospital stay (ßâ+â4.13; P<0.001), while White race was not. CONCLUSION: Assault is the leading intent of injury in both Black and White children, but White children suffer more from suicide injuries that are associated with worse outcomes. LEVEL OF EVIDENCE: Level III Prognostic.
Asunto(s)
Negro o Afroamericano/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Heridas por Arma de Fuego/mortalidad , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes. METHODS: We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days. RESULTS: We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups. CONCLUSIONS: Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes. LEVEL OF EVIDENCE: Level III prognostic.
Asunto(s)
Alcoholismo/epidemiología , Neumonía/epidemiología , Síndrome de Dificultad Respiratoria/epidemiología , Fracturas de las Costillas/terapia , Sepsis/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Alcoholismo/complicaciones , Comorbilidad , Femenino , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Intubación/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Neumonía/etiología , Neumonía/terapia , Síndrome de Dificultad Respiratoria/etiología , Síndrome de Dificultad Respiratoria/terapia , Estudios Retrospectivos , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/diagnóstico , Fracturas de las Costillas/mortalidad , Factores de Riesgo , Sepsis/etiología , Sepsis/terapia , Centros Traumatológicos/estadística & datos numéricos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Surgical exploration for gunshot wounds to the abdomen has been a surgical standard for the greater part of the past century. Recently, nonoperative management (NOM) has been deemed as a safe option for abdominal gunshot wounds (AGWs). The aim of this analysis was to review the utilization of NOM and mortality after AGWs. METHODS: We performed a 2010-2014 retrospective analysis of the American College of Surgeons Trauma Quality and Improvement Program. We included all adult (aged 18 and older) patients with AGWs. NOM was defined as nonsurgical intervention within the first 6 h. Outcome measures were trends of utilization of NOM and mortality. Cochrane-Armitage trend analysis was performed. RESULTS: A total of 808,272 trauma patients were identified, and 16,866 patients with AGWs were included. During the study period, the incidence of AGWs increased, whereas the proportion of bowel injury (P = 0.75) and solid organ injury (P = 0.44) did not change. The NOM rate of AGW increased (2010: 19.5% versus 2014: 27%, P < 0.001). This was accompanied by a decrease in mortality rate (11% versus 9.4%, P = 0.01). Likewise, there was an increase in the use of angiography (7.5% versus 27%, P < 0.001) and laparoscopy (0.9% versus 2.6%, P < 0.001). Overall, 9.8% of the patients had failed NOM. There was no difference in mortality in patients who were managed successfully or failed NOM (5% versus 4.6%, P = 0.45). CONCLUSIONS: NOM of AGW is more prevalent and is associated with a decrease in mortality rate. Selective NOM may be practiced safely after AGWs.
Asunto(s)
Traumatismos Abdominales/terapia , Angiografía/tendencias , Tratamiento Conservador/tendencias , Laparoscopía/tendencias , Heridas por Arma de Fuego/terapia , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/mortalidad , Adulto , Angiografía/normas , Angiografía/estadística & datos numéricos , Tratamiento Conservador/normas , Tratamiento Conservador/estadística & datos numéricos , Femenino , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Laparoscopía/normas , Laparoscopía/estadística & datos numéricos , Tiempo de Internación , Masculino , Selección de Paciente , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Análisis de Supervivencia , Insuficiencia del Tratamiento , Estados Unidos/epidemiología , Heridas por Arma de Fuego/diagnóstico , Heridas por Arma de Fuego/mortalidad , Adulto JovenRESUMEN
Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management.
RESUMEN
Recent American College of Cardiology (ACC), American Heart Association (AHA), American College of Clinical Pharmacy (ACCP), and Heart Rhythm Society (HRS) guidelines suggest that patients with atrial fibrillation (AF) at intermediate to low annual risk of ischemic stroke can benefit from consideration of factors that might modify their risk of stroke. The role of nontraditional risk factors, such as primary hyperparathyroidism (PHPT), remains unexplored. In our study, we investigated the potential association between PHPT and the risk of ischemic stroke in patients with AF. Using data from the Nationwide Inpatient Sample Database, a retrospective cohort study focused on the adult population with AF, we stratified the participants based on PHPT presence. Demographic information, co-morbidities, and hospitalization details were extracted using International Classification of Diseases, Tenth revision codes. Propensity score matching was applied, encompassing over 20 confounding variables, including the risk factors outlined in the CHA2DS2-VASc (Congestive heart failure (C), Hypertension (H), Age ≥75 years (A2), Diabetes Mellitus (D), Stroke/Transient Ischemic Attack (TIA)/Thromboembolism (S2), Vascular disease (V), Age 65-74 years (A), Sex category [female] (Sc)) score. Multivariate logistic regression analysis was performed after matching to assess the independent impact of PHPT as an ischemic stroke risk factor. A total of 2,051 of the identified 395,249 patients with AF had PHPT. The PHPT group had an average age of 74 years and consisted of more women (66.1% vs 53.0%). After matching, it was observed that the PHPT group had longer hospital stays (5 vs 4 days) and higher hospitalization charges ($45,126 vs $36,644). This group exhibited higher rates of ischemic stroke (6.0% vs 4.4%) and mortality (6.3% vs 4.9%). The adjusted outcomes showed a 1.4-fold increased risk for ischemic stroke and a 1.32-fold increased risk for mortality in the PHPT cohort. The subgroup analysis showed a higher incidence of mortality in men with a high CHA2DS2-VASc score. In conclusion, this study highlights a marked association between PHPT and ischemic stroke in patients with AF, independent of the conventional CHA2DS2-VASc score. The potential mechanisms implicated include vascular changes, cardiac dysfunction, and coagulation cascade alterations. The presence of PHPT should be taken into consideration when deciding the assessment of thromboembolic risk.
Asunto(s)
Fibrilación Atrial , Hiperparatiroidismo Primario , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Tromboembolia , Masculino , Adulto , Humanos , Femenino , Anciano , Fibrilación Atrial/complicaciones , Estudios Retrospectivos , Hiperparatiroidismo Primario/complicaciones , Medición de Riesgo , Accidente Cerebrovascular/epidemiología , Factores de Riesgo , Tromboembolia/epidemiología , Accidente Cerebrovascular Isquémico/complicaciones , AnticoagulantesRESUMEN
BACKGROUND: The impact of type 2 diabetes mellitus (T2DM) on acute respiratory distress syndrome (ARDS) is debatable. T2DM was suspected to reduce the risk and complications of ARDS. However, during coronavirus disease 2019 (COVID-19), T2DM predisposed patients to ARDS, especially those who were on insulin at home. AIM: To evaluate the impact of outpatient insulin use in T2DM patients on non-COVID-19 ARDS outcomes. METHODS: We conducted a retrospective cohort analysis using the Nationwide Inpatient Sample database. Adult patients diagnosed with ARDS were stratified into insulin-dependent diabetes mellitus (DM) (IDDM) and non-insulin-dependent DM (NIDDM) groups. After applying exclusion criteria and matching over 20 variables, we compared cohorts for mortality, duration of mechanical ventilation, incidence of acute kidney injury (AKI), length of stay (LOS), hospitalization costs, and other clinical outcomes. RESULTS: Following 1:1 propensity score matching, the analysis included 274 patients in each group. Notably, no statistically significant differences emerged between the IDDM and NIDDM groups in terms of mortality rates (32.8% vs 31.0%, P = 0.520), median hospital LOS (10 d, P = 0.537), requirement for mechanical ventilation, incidence rates of sepsis, pneumonia or AKI, median total hospitalization costs, or patient disposition upon discharge. CONCLUSION: Compared to alternative anti-diabetic medications, outpatient insulin treatment does not appear to exert an independent influence on in-hospital morbidity or mortality in diabetic patients with non-COVID-19 ARDS.
RESUMEN
BACKGROUND: Monoclonal gammopathy of undetermined significance (MGUS) is a non-malignant precursor of multiple myeloma (MM). MGUS has been suggested to be associated with a higher risk of cardiovascular diseases, including AFIB, but it is still unclear whether this association is real. Studies are lacking on the impact of atrial fibrillation on health outcomes in this population. The association of AFIB in this population is lagging and merits further investigation. METHODS: The study conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) for 2018, including adult patients with primary diagnoses of MGUS and AFIB. Patients were divided into two groups based on AFIB presence. Outcomes assessed included complications, length of stay, mortality, hospital charges, and discharge disposition. RESULTS: The study included 9007 patients with MGUS of whom 2404 had AFIB. Patients with both MGUS and AFIB had higher rates of acute kidney injury [AKI] (31.5% vs. 27.5%; p = 0.002) and pericarditis (2% vs. 1.2%; p = 0.029). They also had longer hospital stays (5 vs. 4 days; p < 0.001) and higher hospitalization costs ($43,729 vs. $41,169; p < 0.001). CONCLUSIONS: The study showed that the prevalence of AFIB in MGUS patients is high. Patients with AFIB had increased rates of complications (AKI and pericarditis) and higher mortality compared to patients without AFIB. Further studies screening for AFIB in this patient population are warranted.