RESUMEN
PURPOSE: This study aimed to validate the previously reported association between delayed bladder repair and increased infection rates using the National Trauma Data Bank (NTDB). METHODS: Bladder injury patients with bladder repair in the NTDB from 2013 to 2015 were included. Propensity score matching (PSM) was used to compare mortality, infection rates, and hospital length of stay (LOS) between patients who underwent bladder repair within 24 h and those who underwent repair after 24 h. Linear regression and multivariate logistic regression analyses were also performed. RESULTS: A total of 1658 patients were included in the study. Patients who underwent bladder repair after 24 h had significantly higher infection rates (5.4% vs. 1.2%, p = 0.032) and longer hospital LOS (17.1 vs. 14.0 days, p = 0.032) compared to those who underwent repair within 24 h after a well-balanced 1:1 PSM (N = 166). Linear regression analysis showed a positive correlation between time to bladder repair and hospital LOS for patients who underwent repair after 24 h (B-value = 0.093, p = 0.034). Multivariate logistic regression analysis indicated that bladder repair after 24 h increased the risk of infection (odds = 3.162, p = 0.018). Subset analyses were performed on patients who underwent bladder repairs within 24 h and were used as a control group. These analyses showed that the time to bladder repair did not significantly worsen outcomes. CONCLUSIONS: Delayed bladder repair beyond 24 h increases the risk of infection and prolongs hospital stays. Timely diagnosis and surgical intervention remain crucial for minimizing complications in bladder injury patients.
Asunto(s)
Traumatismos Abdominales , Traumatismos Torácicos , Humanos , Vejiga Urinaria/cirugía , Tiempo de Internación , Procedimientos Quirúrgicos Urológicos , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
BACKGROUND: Obesity is associated with adverse outcomes after major operations. The role of operative rib fixation (RF) in obese patients with flail chest is not clear. The presence of other associated injuries may complicate the interpretation of outcomes. This study compared outcomes after RF to nonoperative management (NOM) in obese patients with isolated flail chest injury. METHODS: Adult obese patients (BMI > 29.9) with flail chest were identified from the Trauma Quality Improvement Program (TQIP) database (2016-2018). Hospital transfers, death within 72 h, and extrathoracic injuries were excluded. RF patients were propensity score matched (1:2) to similar NOM patients. Multivariate regression identified independent factors predicting adverse outcomes. RESULTS: Overall, 367 patients with isolated flail chest who underwent RF were matched with 734 in the NOM group. After matching, the mortality rate was significantly lower in the RF group (1.4% vs. 3.7%; p < 0.05). RF had longer HLOS (15.7 days vs. 12.8 days; p < 0.05) and ICU LOS (10.1 days vs. 8.6 days; p < 0.05), shorter ventilator days (9.2 days vs. 11.5 days; p < 0.05), and a higher rate of venous thromboembolism (7.1% vs. 3.5%, p < 0.05). On multivariate analysis, RF was associated with decreased mortality (OR 0.27; p < 0.05). Early RF (≤ 72 h) was associated with shorter ICU stay and mechanical ventilation. CONCLUSION: RF for isolated flail chest in obese patients is associated with decreased mortality and fewer ventilator days. When performed early, fixation decreases the need for prolonged ventilator use and ICU stay. A more aggressive VTE prophylaxis should be considered in patients undergoing RF.
Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Adulto , Humanos , Tórax Paradójico/complicaciones , Tórax Paradójico/cirugía , Estudios de Cohortes , Fracturas de las Costillas/cirugía , Tiempo de Internación , Costillas , Obesidad/complicaciones , Estudios RetrospectivosRESUMEN
OBJECTIVES: Early adequate resuscitation of patients with trauma is crucial in preventing shock and early mortality. Thus, we aimed to determine the performance of the inferior vena cava (IVC) volume and other risk factors and scores in predicting massive transfusion and mortality. METHODS: We included all patients with trauma who underwent computed tomography (CT) scan of the torso, which included the abdominal area, in our emergency department (ED) from January 2014 to January 2017. We calculated the 3-dimensional IVC volume from the left renal vein to the IVC bifurcation. The primary outcome was the performance of IVC volume in predicting massive transfusion, and the secondary outcome was the performance of IVC volume in predicting 24-hour and 30-day in-hospital mortality. RESULTS: Among the 236 patients with trauma, 7.6% received massive transfusions. The IVC volume and revised trauma score (RTS) were independent predictors of massive transfusion (adjusted odds ratio [OR]: 0.79 vs 1.86, 95% confidence interval [CI], 0.71-0.89 vs 1.4-2.47, respectively). Both parameters showed the good area under the curve (AUC) for the prediction of massive transfusion (adjusted AUC: 0.83 and 0.82, 95% CI, 0.74-0.92 vs 0.72-0.93, respectively). Patients with a large IVC volume (fourth quartile) were less likely to receive massive transfusion than those with a small IVC volume (first quartile, ≥28.29 mL: 0% vs <15.08 mL: 20.3%, OR: 0.13, 95% CI, 0.03-0.66). CONCLUSIONS: The volume of IVC measured on CT scan and RTS are independent predictors of massive transfusion in patients with trauma in the ED.
Asunto(s)
Transfusión Sanguínea , Volumen Sanguíneo , Choque , Vena Cava Inferior , Humanos , Mortalidad , Valor Predictivo de las Pruebas , Resucitación , Estudios Retrospectivos , Vena Cava Inferior/diagnóstico por imagenRESUMEN
Alpha- and beta-linked 1,3-glucans have been subjected to conversion with p-toluenesulfonic acid (tosyl) chloride and triethylamine under homogeneous reaction conditions in N,N-dimethyl acetamide/LiCl. Samples with a degree of substitution of tosyl groups (DSTs) of up to 1.91 were prepared by applying 5 mol reagent per mole repeating unit. Hence, the reactivity of α-1,3-glucan is comparable with cellulose and starch, while the ß-1,3-linked glucan curdlan is less reactive. The samples dissolve in aprotic dipolar media independent of the DSTs and possess a solubility in less polar solvents that depends on the DSTs. NMR studies on the tosyl glucans and of the peracylated derivatives showed a preferred tosylation of position 2 of the repeating unit. However, the selectivity is less pronounced compared with starch. It could be concluded that the α-configurated glycosidic bond directs tosyl groups towards position 2.
Asunto(s)
Glucanos/química , Compuestos de Tosilo/química , beta-Glucanos/química , Espectroscopía de Resonancia Magnética con Carbono-13 , Ésteres/química , Glucanos/síntesis química , Estereoisomerismo , beta-Glucanos/síntesis químicaRESUMEN
BACKGROUND: Corrosive ingestion results in necrosis of the digestive tract, spillage of intraluminal fluid, and spread of bacteria that threatens the lives of patients. Some authors advise extensive surgery, although others recommend conservative operation. This study presents the outcomes of the patients of corrosive injury who undergo emergent surgery. METHODS: We conducted a retrospective review including patients with corrosive injury from Jan 2007 to Dec 2013. We retrieved and analyzed the demographic characteristics, injury location and extent, endoscopic grade, presence of surgery, surgical timing and procedure, and mortality. RESULTS: The cohort consisted of 112 patients; 23 of the patients underwent an emergent operation. Patients who needed emergent surgery had the worse endoscopic severity and a higher mortality rate of 47.8% (12/23). Perforation of the digestive tract [odds ratio (OR) 13.5, p = 0.011] and unscheduled reoperation (OR 13.2, p = 0.033) were factors that predict mortality. CONCLUSION: Corrosive injury resulted in a dismal prognosis, especially when patients required an operation. The mortality is related to digestive tract perforation and unscheduled reoperation. Inadequate resection might lead to unscheduled reoperations, which lead to a dismal prognosis.
Asunto(s)
Quemaduras Químicas/cirugía , Cáusticos/toxicidad , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Tracto Gastrointestinal/lesiones , Tracto Gastrointestinal/cirugía , Adulto , Anciano , Quemaduras Químicas/diagnóstico , Quemaduras Químicas/mortalidad , Ingestión de Alimentos , Urgencias Médicas , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: The split-thickness skin graft (STSG) procedure is frequently used in the reconstruction of burn-injured patients. This study assessed the impact of graft timing on associated skin complications in patients with torso burns using a comprehensive national database. METHODS: Truncal burn (2nd-degree and 3rd-degree burns covering 20-89% TBSA) patients who underwent STSG in the National Trauma Data Bank from 2011 to 2015 were studied. The outcomes examined were graft-related complications (superficial surgical site infections, deep surgical site infections, and graft failure), overall mortality and hospital length of stay (LOS). Patients were compared based on the presence or absence of grafting complications. A linear regression model was used to assess the relationship between hospital LOS and graft timing, considering other variables. RESULTS: Among the 853 studied patients, the cohort with graft complications exhibited a significantly prolonged time to STSG (413.0 h compared to 264.6 h, P<0.001) and a higher percentage of patients with pre-existing diabetes (18.5 vs. 8.0%, P=0.008). The multiple logistic regression analysis revealed that both the extended time to STSG (odds=1.001, P=0.003) and pre-existing diabetes (odds=2.790, P=0.010) significantly elevated the likelihood of complications associated with STSG. Notably, this delay did not elevate mortality risks. A positive relationship was found between grafting delay and LOS. CONCLUSION: The findings underscore that a prolonged duration to skin grafting contributes to extended hospital stays and increased graft-related complications. However, the role of grafting delay in influencing the mortality of truncal burn patients appeared inconsequential, indicating that mortality may be influenced by various factors.
Asunto(s)
Quemaduras , Tiempo de Internación , Trasplante de Piel , Humanos , Quemaduras/cirugía , Quemaduras/mortalidad , Trasplante de Piel/métodos , Trasplante de Piel/efectos adversos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Bases de Datos Factuales , Estudios de Cohortes , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Adulto Joven , Factores de Tiempo , Anciano , Torso/cirugía , Torso/lesionesRESUMEN
INTRODUCTION: Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma. METHODS: The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups. RESULTS: After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 â% vs. 21 â%; p â< â0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p â< â0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups. CONCLUSIONS: Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.
Asunto(s)
Enfermedades del Colon , Estomía , Heridas Penetrantes , Humanos , Colon/cirugía , Colon/lesiones , Estudios de Cohortes , Estudios Retrospectivos , Enfermedades del Colon/cirugía , Anastomosis Quirúrgica , Colostomía , Heridas Penetrantes/cirugíaRESUMEN
Background: Hip fracture is a common disease in the elderly. Among these patients, surgical intervention for hip fracture should be carefully considered because of old age and multiple comorbidities. There are still insufficient comparisons between nonagenarian patients treated with surgery and those treated non-surgically. We studied hip fracture nonagenarian patients to compare the different outcomes between surgical and non-surgical treatments. Materials and methods: Nonagenarian patients visiting the emergency department with hip fractures between March 2010 and December 2020 were identified. Overall survival was estimated using multivariate Cox proportional hazards models. The mortality rates, the length of hospital stay, complication and readmission rates were also recorded. Results: A total of 173 patients who underwent surgery and 32 who received conservative treatments were included. The median survival time was 58.47 months in the OP group, which was significantly higher than the 24.28 months in the non-OP group. After adjusting for covariates, including age, sex, Charlson Comorbidity Index (CCI), injury severity score, and fracture type, the risk of death was reduced by surgery (hazard ratio [HR] = 0.427; 95 % confidence interval [CI]: 0.207-0.882; p = 0.021). CCI was also an independent risk factor for poor survival rate (HR = 1.3; 95 % CI: 1.115-1.515; p = 0.001). After adjusting for several factors, surgery within 48 h improved overall survival (HR: 2.518; 95 % CI: 1.299-4.879; p = 0.006) in operative group. Conclusion: Our study suggests that surgical treatment may provide better survival for nonagenarian patients with hip fractures than non-operation, especially patients with less concurrent comorbidities.
RESUMEN
BACKGROUND: The objective of this study was to identify factors associated with the use of spleen-conserving surgeries, as well as patient outcomes, on a national scale. METHODS: This retrospective cohort study (2010-2015) included patients (age≥16 years) with splenic injury in the National Trauma Data Bank. Patients who received a total splenectomy or a spleen-conserving surgery were compared for demographics and clinical outcomes. RESULTS: During the study period, 18,425 received a total splenectomy and 1,825 received a spleen-conserving surgery. Total splenectomy was more likely to be performed for patients with age>65 (odds ratio [OR]: 0.63, p â< â0.001), systolic blood pressure<90 (OR: 0.63, p â< â0.001), heart rate>120 (OR: 0.83, p â= â0.007), and high-grade injuries (OR: 0.18, p â< â0.001). Penetrating trauma patients were more likely to undergo a spleen-conserving surgery (OR: 3.31, p â< â0.001). The use of spleen-conserving surgery was associated with a lower risk of pneumonia (OR: 0.79, p â= â0.009) and venous thromboembolism (OR: 0.72, p â= â0.006). CONCLUSIONS: Spleen-conserving surgeries may be considered for patients with penetrating trauma, age<65, hemodynamic stability, and low-grade injuries. Spleen-conserving surgeries have decreased risk of pneumonia and venous thromboembolism.
Asunto(s)
Bases de Datos Factuales , Bazo , Esplenectomía , Humanos , Esplenectomía/estadística & datos numéricos , Esplenectomía/métodos , Femenino , Masculino , Bazo/lesiones , Bazo/cirugía , Estudios Retrospectivos , Persona de Mediana Edad , Adulto , Anciano , Resultado del Tratamiento , Estados Unidos/epidemiología , Tratamientos Conservadores del Órgano/métodos , Tratamientos Conservadores del Órgano/estadística & datos numéricos , Adulto Joven , Adolescente , Complicaciones Posoperatorias/epidemiología , Puntaje de Gravedad del TraumatismoRESUMEN
BACKGROUND: Due to the presence of other comorbidities and multi-therapeutic modalities in breast cancer, renally cleared chemotherapeutic regimens may cause nephrotoxicity. The aim of this retrospective study is to compare the chemotherapy types and outcomes in breast cancer patients with or without chronic renal disease. PATIENTS AND METHODS: We retrospectively enrolled 62 female patients with breast cancer and underlying late stages (stage 3b, 4, and 5) of chronic kidney disease (CKD) treated from 2000 to 2017. They were propensity score-matched 1:1 with patients in our database with breast cancer and normal renal function (total n = 124). RESULTS: The main subtype of breast cancer was luminal A and relatively few patients with renal impairment received chemotherapy and anti-Her-2 treatment. The breast cancer patients with late-stage CKD had a slightly higher recurrent rate, especially at the locally advanced stage. The 5-year overall survival was 90.1 and 71.2% for patients without and with late-stage CKD, but the breast cancer-related mortality rate was 88.9 and 24.1%, respectively. In multivariate analyses, dose-reduced chemotherapy was an independent negative predictor of 5-year recurrence-free survival and late-stage CKD was associated with lower 5-year overall survival rate. CONCLUSIONS: Breast cancer patients with late-stage CKD may receive insufficient therapeutic modalities. Although the recurrence-free survival rate did not differ significantly by the status of CKD, patients with breast cancer and late-stage CKD had shorter overall survival time but a lower breast cancer-related mortality rate, indicated that the mortality was related to underlying disease.
Asunto(s)
Neoplasias de la Mama , Insuficiencia Renal Crónica , Humanos , Femenino , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/tratamiento farmacológico , Estudios Retrospectivos , Tasa de Filtración Glomerular , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/terapia , Tasa de SupervivenciaRESUMEN
BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used as a damage control procedure in trauma patients. We hypothesized that REBOA increases risk of venous thromboembolic (VTE) complications. METHODS: This was an American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database study. Excluded were transfers, deaths within 24 h, and severe head injuries. Included were trauma patients receiving REBOA within 4 h from arrival. Outcomes in the two groups were compared after using propensity score matching (PSM) for demographic and clinical characteristics, body area abbreviated injury scale, injury severity score, pelvis and lower extremity fractures, angiographic intervention, preperitoneal pelvic packing, pharmacological VTE prophylaxis, laparotomy, laparotomy and specific orthopedic procedures. RESULTS: After PSM, 339 REBOA patients were matched with 663 patients with No REBOA. REBOA patients were significantly more likely to develop pulmonary embolism (PE) (5.3% vs. 2.7%, p = .037) and VTE (14.7% vs. 10.0%, p = .025). CONCLUSION: REBOA is associated with an increased risk of PE and VTE complications. Patients managed with REBOA should receive adequate thromboprophylaxis and be monitored closely for VTE complications.
Asunto(s)
Oclusión con Balón , Procedimientos Endovasculares , Choque Hemorrágico , Tromboembolia Venosa , Humanos , Estudios de Cohortes , Anticoagulantes , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Aorta/cirugía , Puntaje de Gravedad del Traumatismo , Resucitación/métodos , Oclusión con Balón/efectos adversos , Oclusión con Balón/métodos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Estudios Retrospectivos , Choque Hemorrágico/etiología , Choque Hemorrágico/terapiaRESUMEN
BACKGROUND: Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS: Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS: 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS: REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.
Asunto(s)
Oclusión con Balón , Procedimientos Endovasculares , Fracturas Óseas , Choque Hemorrágico , Tromboembolia Venosa , Humanos , Estudios de Cohortes , Tromboembolia Venosa/etiología , Estudios Retrospectivos , Aorta , Fracturas Óseas/complicaciones , Fracturas Óseas/terapia , Resucitación/efectos adversos , Choque Hemorrágico/etiología , Choque Hemorrágico/terapia , Puntaje de Gravedad del TraumatismoRESUMEN
BACKGROUND: The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH. METHODS: This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism study. Patients with head Abbreviated Injury Scale score of > 2 and with immediate VTEp held because of ICH were included. Patients were divided into VTEp ≤ or >48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism, progression of intracranial hemorrhage (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed. RESULTS: There were 881 patients in total; 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs. 7.2%, p = 0.01) and DVT (11.0% vs. 6.1%, p = 0.01) rates than the early group. The incidence of pulmonary embolism (2.1% vs. 2.2%, p = 0.94), pICH (1.9% vs. 1.8%, p = 0.95), or any other bleeding event (1.9% vs. 3.0%, p = 0.28) was equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (odds ratio [OR], 1.86), ventilator days >3 (OR, 2.00), and risk assessment profile score of ≥5 (OR, 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR, 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR, 0.75) or risk of other bleeding events (OR, 1.28) (both p = NS). CONCLUSION: Early initiation of VTEp (≤48 hours) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Asunto(s)
Hemorragia Intracraneal Traumática , Embolia Pulmonar , Tromboembolia Venosa , Humanos , Anticoagulantes/efectos adversos , Enoxaparina/efectos adversos , Heparina/efectos adversos , Hemorragia Intracraneal Traumática/complicaciones , Hemorragias Intracraneales/inducido químicamente , Estudios Prospectivos , Embolia Pulmonar/etiología , Embolia Pulmonar/prevención & control , Embolia Pulmonar/epidemiología , Estudios Retrospectivos , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/epidemiologíaRESUMEN
PURPOSE: In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients. METHODS: Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass. RESULTS: Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common. CONCLUSION: LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
Asunto(s)
Enfermedades de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Traumatismos Torácicos , Humanos , Arteria Subclavia/cirugía , Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Resultado del Tratamiento , Factores de Riesgo , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/cirugía , Isquemia/cirugía , Traumatismos Torácicos/complicaciones , Estudios RetrospectivosRESUMEN
BACKGROUND: An accident event may necessitate triage of multiple cases of traumatic out-of-hospital cardiac arrest (TOHCA). However, factors for prioritizing treatment among multiple TOHCA patients have not been established. This study aims to use easily assessible predictors of TOHCA outcomes to develop a triage scoring system. METHODS: Patients with TOHCA brought to our hospital by emergency medical services (EMS) were included for analysis to identify independent risk factors for poor outcomes. A scoring system was developed and validated internally and externally. RESULTS: Of the 401 included patients, 86 (21.4%) had return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) for 30 min (81 patients, 94.2%) or 45 min (86 patients, 100%). The emergency department (ED) mortality rate was 89.3% and overall in-hospital mortality rate was 99%. Univariate and multivariate analyses identified body temperature <33 °C (OR, 4.65; 95% CI, 1.37-15.86), obvious chest injury (OR, 2.11; 95% CI, 1.03-4.34), and presumable etiology of out-of-hospital cardiac arrest (OR, 1.73; 95% CI, 1.01-2.98) as significant independent risk factors for non-ROSC. The TOHCA score, calculated as 1 point per risk factor, correlated significantly with the rate of non-ROSC and ED mortality (TOHCA score 0, 1, 2, 3: non-ROSC rate, 63.0%, 80.4%, 90.8%, 100%, respectively; ED mortality rate, 79.5%, 91.5%, 96.1%, and 100% respectively). The results of internal and external validations show a similar trend in both non-ROSC and mortality in the ED with increasing score. CONCLUSIONS: Termination of CPR for TOHCA after 45 min is reasonable; a 30-min resuscitation is acceptable in case of insufficient medical staff or resources. The TOHCA score may be able to be used with caution for triage.
Asunto(s)
Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Humanos , Estudios Retrospectivos , Retorno de la Circulación EspontáneaRESUMEN
Most nail gun injuries involve the extremities and result from work-related accidents. Injuries to the brain or thorax are relatively rare, and cases with injuries to both regions are even rarer and often lethal. Initial evaluation, resuscitation, and surgical planning can be challenging for emergency physicians and surgeons. We present the details of a man with multiple nail gun injuries to the brain, lung, and heart following a suicide attempt. The patient presented to the emergency department in shock. After immediate resuscitation, emergent sternotomy, and subsequent craniotomy, he was discharged without significant morbidity. According to the literature, this is the only reported case involving multiple nail gun injuries to the brain, lungs, and heart. The mortality rate of multiple nail gun injuries involving the head and chest is approximately 20%. Rapid evaluation, immediate resuscitation, and appropriate imaging and surgery are crucial for increasing survival and achieving a good prognosis. Emergency sternotomy for cardiac injury is the foremost priority, and the timing of craniotomy depends on the patient's vital sign status and whether brain injury is evident.A preprint of this article is available online: DOI: 10.21203/rs.3.rs-35448/v1.
Asunto(s)
Cuerpos Extraños , Traumatismo Múltiple , Heridas Penetrantes , Encéfalo , Cuerpos Extraños/diagnóstico por imagen , Cuerpos Extraños/cirugía , Humanos , Pulmón , Masculino , Tomografía Computarizada por Rayos XRESUMEN
Two kinds of regioselectively substituted curdlan hetero ester, 2,4-di-O-acetyl-6-O-propionyl-curdlan (CD24Ac6Pr) and 2,4-di-O-propionyl-6-O-acetyl-curdlan (CD24Pr6Ac), were synthesized. By repeating detritylation and esterification, a new method to remove trityl group from 6-O-trityl-curdlan without acyl migration was developed. Their molecular structures, thermal and mechanical properties and crystal structures were analyzed by NMR, TGA, DSC, tensile test and WAXD. It was concluded that the ester groups substituted on secondary hydroxyl groups at C2 and C4 positions play the decisive role in the melting behavior and crystalline formation of curdlan esters. Also, the mechanical properties of curdlan esters are controllable by the adjustment on its molecular structures.
RESUMEN
Here we conducted a retrospective analysis of hospital-based trauma registry database for evaluating the impacts of comorbidities on the prognosis for traumatized patients using Index of Coexistent Comorbidity Disease (ICED) scores. We analyzed the data of patients with blunt trauma who visited emergency department between January 1, 2011, and December 31, 2015 in Chang-Gung Memorial Hospital, Keelung branch, a single level I trauma center in the Northern Taiwan. All consecutive patients with blunt trauma who admitted to the intensive care unit or ordinary ward after initial managements in the emergency department were included. We measured the hospital mortality of blunt traumatized patients using alive discharge as a competing risk. To investigate conditional independence of mortality and ICED scores given Injury Severity Score (ISS), we used log-linear models for modeling independence structures. Overall, we included 4997 patients (median age [IQR], 59 years old (44-75 years); 55.3% male). The mortality rate of blunt traumatized patients was higher in the higher ICED scores group compared to lower ICED scores group (4.7% vs 1.8%, p < 0.001). Meanwhile, the higher ICED scores group were associated with older age, higher ISS, and longer hospital stay than lower ICED scores group. Higher ICED group had higher probability of transition-to-death and lower probability of transition-to-discharge under the competing risk model. In the multivariable analysis of transition-specific Cox models, higher ICED group were associated with higher risk for hospital mortality compared to lower ICED group (HR 1.60; [95% CI 1.04-2.47]; p = 0.032). Also, higher ICED group were associated with lower probability of transition-to-discharge (HR 0.79; [95%CI 0.73-0.86]; p < 0.001). Additionally, higher ICED scores accounted for hospital mortality among patients with ISS < 25. In conclusion, our study suggested that severity of comorbidity was associated with higher hospital mortality among traumatized patients, particularly lower ISS.
Asunto(s)
Heridas y Lesiones/diagnóstico , Heridas y Lesiones/epidemiología , Adulto , Anciano , Comorbilidad , Femenino , Mortalidad Hospitalaria , Hospitalización , Hospitales , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Pronóstico , Sistema de Registros , Estudios Retrospectivos , Taiwán/epidemiología , Centros Traumatológicos , Heridas no Penetrantes/mortalidadRESUMEN
Regioselectively substituted curdlan esters were synthesized by protecting the C6 primary hydroxyl group with a triphenylmethyl group followed by the acylation of the secondary hydroxyl groups at C2 and C4. The subsequent detritylation of C6 trityl group under acidic conditions revealed an unexpected acyl migration from C4 to C6. This unique acyl migration in curdlan was first observed, which haven't been reported in other polysaccharides such as cellulose. The rate of this migration was found to be dependent on the length of the acyl group, leading to the proposal of a new mechanism for this transformation. Based on these results, we synthesized 2,6-di-O-acetyl-4-O-propionyl-curdlan, which was fully characterized by 1H NMR, 13C NMR, COSY, HSQC and HMBC analyses. Thermogravimetric analysis and differential scanning calorimetry measurements revealed that the regioselective esterification to curdlan promoted its crystallization compared with randomly mixed ester derivatives.
RESUMEN
BACKGROUND: In most cases of envenoming by the green habu Viridovipera stejnegeri in Taiwan coagulopathy is not observed. CASE PRESENTATION: Herein, we describe the case of a patient with liver cirrhosis who developed venom-induced consumptive coagulopathy after V. stejnegeri bite. Laboratory investigation revealed the following: prothrombin time > 100 s (international normalized ratio > 10), activated partial thromboplastin time > 100 s, fibrinogen < 50 mg/dL, and fibrin degradation product > 80 µg/mL. The patient recovered after administration of bivalent hemorrhagic antivenom, vitamin K, fresh frozen plasma and cryoprecipitate. CONCLUSION: The liver, directly involved in the acute phase reaction, is the main responsible for neutralization of animal toxins. Any patient with history of liver cirrhosis bitten by a venomous snake, even those whose venoms present low risk of coagulopathy, should be very carefully monitored for venom-induced consumptive coagulopathy (VICC), since the hemostatic balance may be disrupted.