RESUMO
BACKGROUND & AIMS: Colonoscopy quality indicators provide measurable assessments of performance, but significant provider-level variations exist. We performed a systematic review and meta-analysis to assess whether endoscopist specialty is associated with adenoma detection rate (ADR) - the primary outcome - or cecal intubation rate, adverse event rates, and post-colonoscopy colorectal cancer rates. METHODS: We searched EMBASE, Google Scholar, MEDLINE, and the Cochrane Central Registry of Controlled Trials from inception to December 14, 2020. Two reviewers independently screened titles and abstracts. Citations underwent duplicate full-text review, with disagreements resolved by a third reviewer. Data were abstracted in duplicate. The DerSimonian and Laird random effects model was used to calculate pooled odds ratios (ORs) with respective 95% confidence intervals (CIs). Risk of bias was assessed using Risk of Bias in Non-randomised Studies of Interventions. RESULTS: Of 11,314 citations, 36 studies representing 3,500,832 colonoscopies were included. Compared with colonoscopies performed by gastroenterologists, those by surgeons were associated with lower ADRs (OR, 0.81; 95% CI, 0.74-0.88) and lower cecal intubation rates (OR, 0.76; 95% CI, 0.63-0.92). Compared with colonoscopies performed by gastroenterologists, those by other (non-gastroenterologist, non-surgeon) endoscopists were associated with lower ADRs (OR, 0.91; 95% CI, 0.87-0.96), higher perforation rates (OR, 3.02; 95% CI, 1.65-5.51), and higher post-colonoscopy colorectal cancer rates (OR, 1.23; 95% CI, 1.14-1.33). Substantial to considerable heterogeneity existed for most analyses, and overall certainty in the evidence was low according to the Grading of Recommendations, Assessment, Development, and Evaluations framework. CONCLUSION: Colonoscopies performed by surgeons or other endoscopists were associated with poorer quality metrics and outcomes compared with those performed by gastroenterologists. Targeted quality improvement efforts may be warranted.
Assuntos
Adenoma , Neoplasias Colorretais , Gastroenterologistas , Ceco , Colonoscopia , HumanosRESUMO
BACKGROUND: Acute kidney injury (AKI) is common after surgery and associated with increased mortality, costs, and lengths of hospitalization. We examined associations between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), diuretic, or nonsteroidal anti-inflammatory drug (NSAID) use after major surgery and AKI. MATERIALS AND METHODS: We conducted a nested case-control study of patients who underwent major cardiac, thoracic, general, or vascular surgery in Calgary, Alberta, Canada. Cases with AKI were matched on age, gender, and surgery type with up to five controls without AKI within 30-d after surgery. Adjusted odds ratios (ORs) for AKI were determined based on postoperative administration of ACEIs/ARBs, diuretics, or NSAIDs. RESULTS: Among 33,648 patients in the cohort, 2911 cases with AKI were matched to 9309 controls without AKI. Postoperative diuretic [OR = 1.96; 95% confidence interval (CI) = 1.68-2.29], but not ACEI/ARB (OR = 0.83; 95% CI = 0.72-0.95) or NSAID (OR = 1.12; 95% CI = 0.96-1.31), use was independently associated with higher odds of AKI (including stages 1 and 2/3 AKI) after all types of major surgery. There were increased adjusted odds of AKI 1 to 5 d after first exposure to diuretics and 1 d after first exposure to NSAIDs (but not after later exposures). Relationships between ACEI/ARB use and AKI varied by surgery type (p-interaction = 0.004), with lower odds of AKI observed among ACEI/ARB use after cardiac surgery (OR = 0.70; 95% CI = 0.57-0.81), but no difference after other major surgeries. CONCLUSIONS: Postoperative administration of diuretics and NSAIDs was associated with increased odds of AKI after major surgery. These findings characterize potentially modifiable medication exposures associated with AKI after surgery.
Assuntos
Injúria Renal Aguda/epidemiologia , Anti-Inflamatórios não Esteroides/efeitos adversos , Diuréticos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Antagonistas de Receptores de Angiotensina/administração & dosagem , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Anti-Inflamatórios não Esteroides/administração & dosagem , Estudos de Casos e Controles , Diuréticos/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Fatores de RiscoRESUMO
BACKGROUND: Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations. METHODS: We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set. RESULTS: Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients. CONCLUSIONS: Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.
Assuntos
Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Sistemas de Apoio a Decisões Clínicas , Registros Eletrônicos de Saúde , Alberta , Feminino , Hospitais , Humanos , MasculinoRESUMO
SUMMARY: The topic of unemployment and underemployment of Canadian general surgeons is being discussed more frequently despite relatively little evidence on the magnitude or impact of the problem. Using existing and new sources of health human resource data, a more accurate understanding of the situation can be attained. Although outright surgeon unemployment is rare, there is a population of dissatisfied new graduates who feel cornered into underemployment or locums. The number of practising general surgeons has outpaced population growth in recent years. However, the number of new trainees peaked in 2010 and has been decreasing steadily since then. There are many pressures that stand in the way of more accurate management of the general surgery workforce. A better understanding of the subject and better leadership at the national level may help improve system performance.
Assuntos
Emprego/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Canadá , Humanos , Desemprego/estatística & dados numéricosRESUMO
This article characterizes the Canadian hepato-pancreato-biliary (HPB) surgery workforce (demographics, practice patterns, career satisfaction, education and recruitment plans). This information will serve as a baseline for future national comparisons, allow informed workforce planning and facilitate mathematical modelling of the HPB workforce in Canada.
Assuntos
Gastroenterologia , Especialidades Cirúrgicas , Adulto , Canadá , Estudos Transversais , Coleta de Dados , Procedimentos Cirúrgicos do Sistema Digestório/educação , Educação de Pós-Graduação em Medicina/estatística & dados numéricos , Feminino , Gastroenterologia/educação , Humanos , Satisfação no Emprego , Masculino , Pessoa de Meia-Idade , Seleção de Pessoal , Padrões de Prática Médica/estatística & dados numéricos , Especialidades Cirúrgicas/educação , Recursos HumanosRESUMO
PURPOSE: The goal of this study was to determine the unplanned hospital readmission rate following ileal pouch-anal anastomosis, prior to loop ileostomy closure. METHODS: Patients undergoing ileal pouch-anal anastomosis over a five-year period were included in this retrospective study. Unplanned readmissions and readmission diagnoses were compiled. Gender, age, type of disease, duration of illness, elective vs. urgent surgical indication, operative method, steroid use, American Society of Anesthesiologists score, and regional anesthesia use at initial ileal pouch-anal anastomosis were evaluated as potential factors for readmission. Total length of stay was compared between patients readmitted and not readmitted. RESULTS: One hundred and ninety-five patients underwent ileal pouch-anal anastomosis with diverting ileostomy. Fifty-nine patients (30 percent) required readmission. Forty-one patients had a single readmission, and 18 patients had at least 2 readmissions. Small bowel obstruction (28/86) and pelvic sepsis/ anastomotic leak (28/86) were the most common diagnoses upon readmission. Seventeen of 59 patients (28.8 percent) required surgical intervention following readmission and 42 patients were managed nonoperatively. Patients using systemic steroids at the time of surgery were more likely to be readmitted [47/116 (41 percent) vs. 12/79 (15 percent), P = 0.001). Length of stay (including initial admission for ileal pouch-anal anastomosis) for patients requiring readmission averaged 19.6 days vs. 9.6 days for patients not readmitted. CONCLUSIONS: Hospital readmission after ileal pouch-anal anastomosis is common. We plan to institute a more intensive follow-up in an effort to prevent readmission of selected high-risk patients who might be effectively managed as outpatients.
Assuntos
Bolsas Cólicas , Readmissão do Paciente , Adulto , Bolsas Cólicas/efeitos adversos , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
Quality indicators can be defined as "specific and measurable elements of practice that can be used to assess the quality of care". Surgical blood loss is one of the most significant perioperative predictors of patient outcome. Blood loss is a modifiable quality indicator for oncologic cancer surgery. Surgical oncologists need to alter their surgical technique to promote bloodless surgery and decrease the variability in reported blood loss and rates of blood transfusion.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Neoplasias/cirurgia , Indicadores de Qualidade em Assistência à Saúde , Reação Transfusional , Humanos , Recidiva Local de Neoplasia , Análise de SobrevidaRESUMO
BACKGROUND: Rural citizens die more frequently because of trauma than their urban counterparts. Skill maintenance is a potential issue among rural surgeons because of infrequent exposure to severely injured patients. The primary goal was to evaluate the outcomes of multiple injuries patients who required a laparotomy after referral from level III trauma centers. METHODS: All severely injured patients (injury severity score >12) referred to a level I trauma center from level III hospitals, during a 48-month period were evaluated. Comparisons between referrals (level III and IV) as well as survivors and nonsurvivors used standard statistical methodology. RESULTS: One thousand two hundred and thirty patients (35%) were transferred from level III (33%) and level IV (67%) centers (43% underwent an operative procedure). Only 13% required a laparotomy, whereas 87% needed procedures from other subspecialists. Referred patients had a mean injury severity score of 28, length of stay of 28 days, and mortality rate of 26%. More patients arrived hemodynamically unstable from level IV (55%) versus level III (35%) hospitals (p < 0.05). Nonsurvivors from level III centers were more likely to transfer via aircraft (100%) than from level IV hospitals (55%) (p < 0.05). Most (91%) definitive general surgery procedures could have been completed by surgeons at level III centers; however, 90% also had multisystem injuries requiring treatment by other subspecialists. CONCLUSIONS: Most severely injured patient referrals from level III and IV trauma centers in Western Canada are appropriate. The lack of consistent subspecialty coverage mandates most transfers from level III hospitals. This data will be used to engage rural Alberta physicians in an educational outreach program.
Assuntos
Hospitais Rurais/organização & administração , Laparotomia/estatística & dados numéricos , Traumatismo Múltiplo/cirurgia , Encaminhamento e Consulta/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto JovemRESUMO
Microscopic colitis (MC) is an inflammatory condition of the colon distinct from Crohn disease or ulcerative colitis that can cause chronic diarrhea as well as cramping and bloating. Although it was first described 30 years ago, awareness of this entity as a cause of diarrhea has only become more widespread recently. Up to 20% of adults with chronic diarrhea who have an endoscopically normal colonoscopy may have MC. Endoscopic and radiological examinations are usually normal, but histology reveals increased lymphocytes in the colonic mucosa, which typically cause watery nonbloody diarrhea. Treatment is initially supportive but can include corticosteroids and immunomodulatory therapy for resistant cases. Since surgeons perform a large number of colonoscopies and sigmoidoscopies to assess diarrhea, it is important to be aware of this disease and to look for it with mucosal biopsy in appropriate patients.
Assuntos
Colite Linfocítica/patologia , Colite Microscópica/epidemiologia , Colite Microscópica/patologia , Colonoscopia/métodos , Mucosa Intestinal/patologia , Adulto , Biópsia por Agulha , Doença Crônica , Colite Linfocítica/tratamento farmacológico , Colite Linfocítica/epidemiologia , Colite Microscópica/tratamento farmacológico , Colite Ulcerativa/diagnóstico , Pólipos do Colo/diagnóstico , Doença de Crohn/diagnóstico , Diagnóstico Diferencial , Endoscopia/métodos , Feminino , Fármacos Gastrointestinais/uso terapêutico , Humanos , Imuno-Histoquímica , Incidência , Mucosa Intestinal/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
OBJECTIVES: To predict variation in thoracic surgery workforce requirements with the introduction of stereotactic ablative radiotherapy (SABR) for the treatment of early-stage non-small-cell lung cancer (NSCLC). METHODS: Using Canadian census microdata and the Canadian Community Health Survey, a microsimulation model representing the national population was developed. The demand component simulates the incidence of lung cancer, incorporating the impact of computed tomography (CT) screening for high-risk individuals (>30 pack-year smoking history; age 55-74 years). The supply component simulates the number of thoracic surgeons. SABR was introduced into the model to predict changes in the number of operable NSCLC cases per thoracic surgeon, modelling 30, 60 and 90% compliance with SABR for Stage IA and then for both Stage IA and IB NSCLC. RESULTS: In the absence of SABR, the volume of operative NSCLC per surgeon increases by a peak of 49.4% (by 2027) and then gradually declines to the present day volume by 2049. More dramatic decreases are seen with increasing compliance with SABR for Stage IA/IB NSCLCs. If the number of new surgeons entering the workforce per year were reduced by 33%, the operative volume per surgeon would increase by a peak of 57.1% (30% Stage IA SABR compliance) and would decrease by up to 49.1% (90% Stage IA SABR compliance). CONCLUSIONS: With the implementation of SABR for treatment of early NSCLC, there would be a decrease in operative volume. The impact would depend on the stage of NSCLC for which SABR is recommended and on compliance. A national strategy for thoracic surgery workforce planning is necessary, given the complex interaction of CT screening and the treatment of medically operable early NSCLC with SABR.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Radiocirurgia/métodos , Cirurgia Torácica , Idoso , Canadá/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/patologia , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/patologia , Pessoa de Meia-Idade , Modelos Teóricos , Estadiamento de Neoplasias , Prevenção Secundária/métodos , Cirurgiões/estatística & dados numéricos , Cirurgia Torácica/tendências , Tomografia Computadorizada por Raios X , Recursos Humanos , Carga de Trabalho/estatística & dados numéricosRESUMO
BACKGROUND: Hospitalization costs for ulcerative colitis (UC) following the introduction of infliximab have not been evaluated. OBJECTIVE: To study predictors of costs for UC patients who were hospitalized for a flare or colectomy. METHODS: Population-based surveillance identified adults (≥18 years of age) admitted to hospital for UC flare or colectomy between 2001 and 2009 in the Calgary Health Zone (Alberta). Medical charts were reviewed and patients stratified into three admission types: responsive to inpatient medical therapy (n=307); emergent colectomy (n=227); and elective colectomy (n=208). The annual median cost with interquartile range (IQR) was calculated. Linear regression determined the effect of admission type on hospital charges after adjusting for age, sex, smoking, comorbidities, disease extent, medication use (eg, infliximab) and year. The adjusted cost increase was presented as the percent increase with 95% CIs. Joinpoint analysis assessed for an inflection point in hospital cost after the introduction of infliximab. RESULTS: Median hospitalization cost for UC flare, emergent colectomy and elective colectomy, respectively, were: $5,499 (IQR $3,374 to $8,904), $23,698 (IQR $17,981 to $32,385) and $14,316 (IQR $11,932 to $18,331). Adjusted hospitalization costs increased approximately 6.0% annually (95% CI 4.5% to 7.5%). Adjusted costs were higher for patients who underwent an elective colectomy (percent increase cost 179.8% [95% CI 151.6% to 211.1%]) or an emergent colectomy (percent increase cost 211.1% [95% CI 183.2% to 241.6%]) than medically responsive patients. Infliximab in hospital was an independent predictor of increased costs (percent increase cost 69.5% [95% CI 49.2% to 92.5%]). No inflection points were identified. CONCLUSION: Hospitalization costs for UC increased due to colectomy and infliximab.
Assuntos
Colite Ulcerativa/economia , Custos Hospitalares/tendências , Hospitalização/economia , Adolescente , Adulto , Alberta , Colectomia/economia , Colectomia/tendências , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/cirurgia , Feminino , Fármacos Gastrointestinais/economia , Fármacos Gastrointestinais/uso terapêutico , Hospitalização/tendências , Humanos , Infliximab/economia , Infliximab/uso terapêutico , Masculino , Pessoa de Meia-Idade , Vigilância da População , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: To develop a microsimulation model of thoracic surgery workforce supply and demand to forecast future labor requirements. METHODS: The Canadian Community Health Survey and Canadian Census data were used to develop a microsimulation model. The demand component simulated the incidence of lung cancer; the supply component simulated the number of practicing thoracic surgeons. The full model predicted the rate of operable lung cancers per surgeon according to varying numbers of graduates per year. RESULTS: From 2011 to 2030, the Canadian national population will increase by 10 million. The lung cancer incidence rates will increase until 2030, then plateau and decline. The rate will vary by region (12.5% in Western Canada, 37.2% in Eastern Canada) and will be less pronounced in major cities (10.3%). Minor fluctuations in the yearly thoracic surgery graduation rates (range, 4-8) will dramatically affect the future number of practicing surgeons (range, 116-215). The rate of operable lung cancer varies from 35.0 to 64.9 cases per surgeon annually. Training 8 surgeons annually would maintain the current rate of operable lung cancer cases per surgeon per year (range, 32-36). However, this increased rate of training will outpace the lung cancer incidence after 2030. CONCLUSIONS: At the current rate of training, the incidence of operable lung cancer will increase until 2030 and then plateau and decline. The increase will outstrip the supply of thoracic surgeons, but the decline after 2030 will translate into an excess future supply. Minor increases in the rate of training in response to short-term needs could be problematic in the longer term. Unregulated workforce changes should, therefore, be approached with care.
Assuntos
Previsões , Mão de Obra em Saúde/tendências , Neoplasias Pulmonares/cirurgia , Médicos/provisão & distribuição , Médicos/tendências , Cirurgia Torácica/tendências , Procedimentos Cirúrgicos Torácicos/tendências , Canadá/epidemiologia , Simulação por Computador , Educação de Pós-Graduação em Medicina/tendências , Humanos , Incidência , Internato e Residência/tendências , Neoplasias Pulmonares/epidemiologia , Modelos Teóricos , Cirurgia Torácica/educação , Procedimentos Cirúrgicos Torácicos/educação , Fatores de TempoRESUMO
BACKGROUND: This study aimed to predict variation in the thoracic surgery workforce requirements with the introduction of a national chest computed tomographic (CT) screening program for individuals at high risk of lung cancer. METHODS: Using Canadian census microdata and the Canadian Community Health Survey, a microsimulation model representing the national population was developed. The demand component simulates the incidence of lung cancer, whereas the supply component simulates the number of practicing thoracic surgeons. A national CT screening program in high-risk individuals (>30 pack-year history of smoking; age, 55-74 years) was introduced into the model to predict changes in the number of operable lung cancers per thoracic surgeon. RESULTS: From 2013 to 2040, the Canadian population increased from 34 to 43 million. The number eligible for screening varies from 1,112,800 (2013) to 513,200 (2040), peaking at 1,147,700 (2017). Comparing CT screening with chest radiography, overall lung cancer diagnoses increase 7.3% by 2040, with stage 1A increasing by 15.6% and stage IV decreasing by 7.5%. The rate of operable early lung cancers per thoracic surgeon increases by 24.2% (2020), 19.8% (2030), and 16% (2040), with CT screening relative to the baseline increase seen with chest radiography. CONCLUSIONS: With the implementation of a CT screening program there will be an increase in operable lung cancers, resulting in increased surgical volume. A national strategy for the thoracic surgery workforce is necessary to ensure that an appropriate number of surgeons are being trained to meet the future needs of the national population.
Assuntos
Detecção Precoce de Câncer/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/epidemiologia , Modelos Estatísticos , Cirurgia Torácica , Tomografia Computadorizada por Raios X , Idoso , Previsões , Humanos , Incidência , Pessoa de Meia-Idade , Fatores de Tempo , Recursos HumanosRESUMO
INTRODUCTION: Screening CT often detects posttraumatic pneumothoraces that were not diagnosed on a preceding supine anteroposterior chest radiograph (occult pneumothoraces (OPTXs)). Because abdominal CT imaging misses OPTXs in the upper thorax, the objective of this study was to evaluate the utility of cervical spine (C-spine) CT screening for diagnosing OPTXs. METHODS: A dual-institution (Foothills Medical Centre and Grady Memorial Hospital) retrospective review of consecutive OPTXs was performed. The accuracy of various CT screening protocols in detecting OPTXs was compared. RESULTS: OPTXs were detected in 75 patients. Patient demographics and injury characteristics were similar between centres (65% male; 97% blunt mechanism; 29% hemodynamically unstable; mean ISS=27; mean length of stay=22 days; mortality=9%)(p>0.05). Patients received either abdominal (41%) or thoraco-abdominal (59%) CT imaging. Most patients (89%) also underwent C-spine CT imaging. OPTXs were evident on thoracic CT in 100% (44/44), abdominal CT in 83% (62/75), and C-spine CT in 82% (55/67) of cases. All patients with OPTXs identified solely on thoracic CT (i.e. not abdominal) who also underwent imaging of their C-spine could have had their OTPXs diagnosed by using the pulmonary windows setting of their C-spine CT series. Combining C-spine and abdominal CT screening diagnosed all OPTXs (67/67) detected on thoracic CT, for patients who also underwent these investigations. CONCLUSIONS: OPTXs were evident on thoracic (and not abdominal) CT in 17% of severely injured patients. For patients who also underwent C-spine imaging, all OPTXs isolated to thoracic CT could be diagnosed by using the pulmonary windows setting of their C-spine CT imaging protocol. All OPTXs, regardless of intra-thoracic location, could also be detected by combining C-spine and abdominal CT screening.
Assuntos
Vértebras Cervicais/diagnóstico por imagem , Pneumotórax/diagnóstico por imagem , Traumatismos Torácicos/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pneumotórax/etiologia , Radiografia Torácica , Estudos Retrospectivos , Centros de Traumatologia , Resultado do Tratamento , Adulto JovemRESUMO
A 57-year-old male presented with a complete small bowel obstruction. Computed tomography confirmed an obvious transition point in the distal ileum, as well as an adjacent small bowel target sign. At exploratory laparotomy, the CT target sign had been caused by an obstructing phytobezoar cast ejected from a Meckel's diverticulum.
RESUMO
Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized.
RESUMO
BACKGROUND: Horseback riding is considered more dangerous than motorcycle riding, skiing, automobile racing, football and rugby. The integral role of rehabilitation therapy in the recovery of patients who have sustained a major horse-related injury is previously not described. The goals of this paper were to (1) define the incidence and pattern of severe equestrian trauma, (2) identify the current level of in-patient rehabilitation services, (3) describe functional outcomes for patients, and (4) discuss methods for increasing rehabilitation therapy in this unique population. METHODS AND RESULTS: A retrospective review of the trauma registry at a level 1 center (1995-2005) was completed in conjunction with a patient survey outlining formal in-hospital therapy. Forty-nine percent of patients underwent in-patient rehabilitation therapy. Injuries predictive of receiving therapy included musculoskeletal and spinal cord trauma. Previous injury while horseback riding was predictive of not receiving therapy. The majority (55%) of respondents had chronic physical difficulties following their accident. CONCLUSION: Rehabilitation therapy is significantly underutilized following severe equestrian trauma. Increased therapy services should target patients with brain, neck and skull injuries. Improvements in the initial provision, and follow-up of rehabilitation therapy could enhance functional outcomes in the treatment resistant Western equestrian population.