Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma.

OBJECTIVE: Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. METHODS: We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. RESULTS: We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). CONCLUSIONS: Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.

Vascular trauma in the Amazon: updating the challenge. / Trauma vascular na Amazônia: atualizando o desafio.

OBJECTIVE: to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution. METHODS: an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence. RESULTS: two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases. CONCLUSION: distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.

OBJETIVO: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. MÉTODOS: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. RESULTADOS: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. CONCLUSÃO: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.

Trauma vascular na Amazônia: atualizando o desafio / Vascular trauma in the Amazon: updating the challenge

RESUMO Objetivo: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. Métodos: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. Resultados: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. Conclusão: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.

ABSTRACT Objective: to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution. Methods: an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence. Results: two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases. Conclusion: distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.

Eventos adversos em uma unidade de internação cirúrgica: estudo descritivo / Adverse events in a hospital surgical unit: a descriptive study / Eventos adversos en una unidad de internación quirúrgica: estudio descriptivo

Objetivo: Verificar a ocorrência de infecção do sítio cirúrgico, perda ou infecção do acesso venoso e quedas em pacientes internados em Unidade de Internação Cirúrgica de um Hospital de Ensino. Método: Estudo descritivo de abordagem quantitativa. O período de coleta de dados foi entre 23 de março e 14 de abril de 2015, em dias alternados, totalizando 94 pacientes. Resultado: A média do tempo de internação foi de 8,46 dias, com desvio padrão de 11,294. Observou-se um total de 20 (7,9%) eventos adversos. Houve nove (3,6%) notificações de perda do acesso venoso, sete notificações de infecção do sítio cirúrgico (2,8%) e quatro (1,6%) notificações de infecção do acesso venoso. Conclusão: Observou­se que o índice de ocorrência dos eventos adversos foi superior a um estudo semelhante, evidenciando a necessidade de ações que estimulem a notificação de eventos adversos e a promoção da segurança do paciente.

Objective: Verify the occurrence of infection at surgical sites, loss, or infection of venous access and falls in patients hospitalized in the Surgical Inpatient Unit of a Teaching Hospital. Method: Descriptive study with a quantitative approach. The period of data collection was between March 23 and April 14, 2015 on alternating days, totaling 94 patients. Results: The average hospitalization time was 8.46 days, with a standard deviation of 11.294. A total of 20 (7.9%) adverse events were observed. There were nine (3.6%) records of venous access loss, seven records of surgical site infections (2.8%), and four (1.6%) records of venous access infection. Conclusion: It was observed that the occurrence index of the adverse events was greater than in a similar study, showing the need for actions that stimulate the recording of adverse events and the promotion of patient's safety.

Objetivo: Verificar la ocurrencia de infección del sitio quirúrgico, pérdida o infección del acceso venoso y caídas de pacientes internados en Unidad de Internación Quirúrgica de un Hospital Escuela. Método: Estudio descriptivo de abordaje cuantitativo. El período de colecta de datos fue entre el 23 de marzo y el 14 de abril de 2015, en días alternados, totalizando 94 pacientes. Resultado: El promedio del tiempo de internación fue de 8,46 días, con desvío estándar de 11,294. Se observó un total de 20 (7,9%) eventos adversos. Hubo nueve (3,6%) notificaciones de pérdida del acceso venoso, siete notificaciones de infección del sitio quirúrgico (2,8%) y cuatro (1,6%) notificaciones de infección del acceso venoso. Conclusión: Se observó que el índice de ocurrencia de los eventos adversos fue superior a un estudio semejante, evidenciando la necesidad de acciones que estimulen la notificación de eventos adversos y la promoción de la seguridad del paciente.

Towards a low-cost mobile subcutaneous vein detection solution using near-infrared spectroscopy.

Excessive venipunctures are both time- and resource-consuming events, which cause anxiety, pain, and distress in patients, or can lead to severe harmful injuries. We propose a low-cost mobile health solution for subcutaneous vein detection using near-infrared spectroscopy, along with an assessment of the current state of the art in this field. The first objective of this study was to get a deeper overview of the research topic, through the initial team discussions and a detailed literature review (using both academic and grey literature). The second objective, that is, identifying the commercial systems employing near-infrared spectroscopy, was conducted using the PubMed database. The goal of the third objective was to identify and evaluate (using the IEEE Xplore database) the research efforts in the field of low-cost near-infrared imaging in general, as a basis for the conceptual model of the upcoming prototype. Although the reviewed commercial devices have demonstrated usefulness and value for peripheral veins visualization, other evaluated clinical outcomes are less conclusive. Previous studies regarding low-cost near-infrared systems demonstrated the general feasibility of developing cost-effective vein detection systems; however, their limitations are restricting their applicability to clinical practice. Finally, based on the current findings, we outline the future research direction.

Stent farmacológico para o tratamento da doença arterial coronariana (DAC) / Pharmacological Stent for the Treatment of Coronary Artery Disease (CAD)

CONTEXTO: A Doença Arterial Coronariana (DAC) é em 90% dos casos, resultante da oclusão ou do estreitamento das artérias coronarianas. Os objetivos do tratamento da DAC são prevenir o Infarto agudo do miocárdio (IAM), reduzir a mortalidade, os sintomas e a ocorrência da isquemia miocárdica. Esses objetivos podem ser atingidos por modificações do estilo de vida, tratamento clínico ou por meio de revascularização do miocárdio, realizada por Cirurgia de Revascularização Miocárdica (CRVM) ou Intervenção Coronariana Percutânea (ICP). As ICPs se referem a um grupo de técnicas utilizadas para restaurar o fluxo nas artérias coronarianas obstruídas, incluindo a angioplastia coronária transluminal percutânea (PTCA) com ou sem implante de stent, que podem ser convencionais ou farmacológicos. Atualmente o Sistema Único de Saúde disponibiliza somente stents convencionais. TRATAMENTO RECOMENDADO: Um guia elaborado no sistema de saúde britânico pelo National Institute for Health and Clinical Excellence (NICE) publicado em 2003 e atualizado em 2008 descreve que para intervenção coronariana percutânea (ICP) é recomendado o uso de stent farmacológico nos casos em que a artéria alvo tenha menos de três mm de calibre (diâmetro interno) ou a lesão seja maior do que 15 mm, e a diferença de preço entre o stent farmacológico e o stent convencional seja menor que £300 (NICE 2003; NICE, 2008). A TECNOLOGIA: Dispositivo intra-coronariano (stent) - Utilização do dispositivo stent farmacológico na intervenção coronária percutânea por meio da realização de angioplastia coronária ­ método não cirúrgico ­ para a desobstrução das artérias coronárias na presença de estenoses significativas. EVIDÊNCIAS CIENTÍFICAS: As evidências científicas de eficácia apresentadas pelo demandante foram consideradas inadequadas. Busca suplementar incluiu quatorze revisões sistemáticas que avaliaram a comparação de stent farmacológico vs. stent convencional, das quais quatro avaliaram exclusivamente stent eluidor de sirolimo vs. stent convencional e uma avaliou exclusivamente stent eluidor de paclitaxel vs. stent convencional. Não houve diferença estatisticamente significante entre os pacientes que receberam stent farmacológico ou stent convencional nos dez estudos que avaliaram a mortalidade em qualquer que fosse o tempo de seguimento - que variou entre seis meses e cinco anos. Não houve diferença estatisticamente significante entre os pacientes que receberam stent farmacológico ou stent convencional em dez estudos que avaliaram a incidência de Infarto Agudo do Miocárdio (IAM) em até cinco anos de acompanhamento. Em todos os estudos, os stents farmacológicos (stent eluidor de sirolimo e stent eluidor de paclitaxel) apresentaram menor taxa de reintervenção que o stent convencional, em qualquer tempo de seguimento. Dez estudos avaliaram o risco de trombose entre pacientes que receberam stents farmacológicos comparado a pacientes que receberam stent convencional. CONSIDERAÇÕES FINAIS: Com relação à evidência científica baseada em ensaios clínicos randomizados e controlados e revisões sistemáticas com metanálise, os stents farmacológicos eluidores de sirolimo ou paclitaxel não apresentaram superioridade aos stents convencionais, demonstrando benefícios apenas em relação aos eventos cardiovasculares adversos maiores e à taxa de reintervenção. Para a avaliação econômica, estudos realizados em outros países têm demonstrado que o stents farmacológicos apresentam relação custo-efetividade favorável ao stent convencional somente em pacientes de alto risco cardiovascular, tais como diabéticos e pacientes com lesões de calibre inferir a 2,5 mm e extensão maior do que 18 mm. Estudos realizados no Brasil demonstraram que o uso do stent farmacológico não apresenta uma razão de custo-efetividade favorável na perspectiva do SUS com base nos preços do referido produto no mercado nacional. 7. DELIBERAÇÃO FINAL: Na 25ª Reunião da CONITEC, realizada nos dias 07 e 08/05/2014, os membros do plenário deliberaram por unanimidade recomendar a incorporação do stent farmacológico coronariano em pacientes diabéticos e pacientes com lesões em vasos finos (lesões de calibre inferior a 2,5 mm e extensão maior do que 18 mm), condicionada ao mesmo valor de ressarcimento da tabela de procedimento do SUS para o stent convencional, que é atualmente de R$ 2.034,50 (dois mil e trinta e quatro reais e cinquenta centavos). DECISÃO: PORTARIA Nº 29, de 27 de agosto de 2014 - Torna pública a decisão de incorporar o stent farmacológico coronariano em pacientes diabéticos e pacientes com lesões em vasos finos (lesões de calibre inferior a 2,5 mm e extensão maior do que 18 mm), condicionada ao mesmo valor de ressarcimento da tabela de procedimento do SUS para o stent convencional, que é atualmente de R$ 2.034,50 (dois mil e trinta e quatro reais e cinquenta centavos) no âmbito do Sistema Único de Saúde - SUS.

Incidence and management of percutaneous transluminal angioplasty-induced venous rupture in the "fistula first" era.

PURPOSE: Percutaneous transluminal angioplasty (PTA)-induced venous rupture is a common complication of hemodialysis access interventions. The authors sought to determine if venous rupture rates and management differed between grafts and fistulas, and in the fistula subset, between transposed and nontransposed fistulas. MATERIALS AND METHODS: Patients experiencing venous rupture during hemodialysis PTA over a 5-year period were identified. Of 1,985 hemodialysis interventions, 75 ruptures occurred in 69 patients (46 women) with a mean age of 63 years (range, 31-88 y). Rupture rates, proportion of successful treatments, and treatment type and number (ie, balloon tamponade, stent, covered stent) were determined. RESULTS: Rupture was more common in fistulas overall (5.6%, 39 of 693) compared with grafts (2.8%, 36 of 1,292; P = .002), in transposed (10.7%, 20 of 187) compared with nontransposed fistulas (3.8%, 19 of 506; P = .001), and in transposed fistulas compared with grafts (P = .0001). There was no significant difference between nontransposed fistulas and grafts. Treatment success (ie, resolution of extravasation) was the same among groups: 69% (27 of 39) in fistulas overall, 70% (14 of 20) in transposed fistulas, 68% (13 of 19) in nontransposed fistulas, and 72% (26 of 36) in grafts. There was a greater need for stents in grafts (38.9%, 14 of 36) compared with fistulas (12.8%, five of 39; P = .003). CONCLUSIONS: PTA-induced rupture is more common in fistulas than grafts, and this effect seems nearly entirely driven by transposed fistulas. Although rupture treatment in fistulas of all types yielded similar success to grafts, and graft ruptures were more difficult to treat than fistula ruptures, the high rupture rates in transposed fistulas attest to the increased difficulty of treating this subset of fistulas.

A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement.

BACKGROUND: In this systematic review, we evaluated the evidence for seven strategies which have been proposed to minimize the incidence of epidural vein cannulation during lumbar epidural catheter placement in pregnant women. METHODS: Multiple databases were searched to identify prospective, randomized, controlled trials between December 1966 and October 2007 that evaluated methods to avoid epidural vein cannulation after lumbar epidural catheter placement in pregnant women. Published trials were evaluated using a quality assessment tool, and results were combined to evaluate efficacy to prevent epidural vein cannulation. RESULTS: Of 90 trials screened, 30 trials were included (n = 12,738 subjects). Five strategies reduce the risk of epidural vein cannulation: the lateral as opposed to sitting position (six trials, mean (sd) quality score = 35% [11%], odds ratio (OR) 0.53 [95% confidence interval (CI) 0.32-0.86]), fluid administered through the epidural needle before catheter insertion (8 trials, quality score 48% [18%], OR 0.49 [95% CI 0.25-0.97]), single rather than multiorifice catheter (5 trials, quality score 30% [6%], OR 0.64 [95% CI 0.45-0.91]), a wire-embedded polyurethane compared with polyamide epidural catheter (1 trial, 31%, plus 4 unscored abstracts, OR 0.14 [95% CI 0.06-0.30]) and catheter insertion depth < or =6 cm (2 trials, 47% [11%], OR 0.27 [95% CI 0.10-0.74]). The paramedian as opposed to midline needle approach and smaller epidural needle or catheter gauges do not reduce the risk of epidural vein cannulation. CONCLUSION: The risk of intravascular placement of a lumbar epidural catheter in pregnancy may be reduced with the lateral patient position, fluid predistension, a single orifice catheter, a wire-embedded polyurethane epidural catheter and limiting the depth of catheter insertion to 6 cm or less. In general, low manuscript quality weakens the strength of these conclusions.