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1.
N Engl J Med ; 382(14): 1320-1330, 2020 04 02.
Artículo en Inglés | MEDLINE | ID: mdl-32242357

RESUMEN

BACKGROUND: Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national burden of C. difficile infection is unclear. METHODS: The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person ≥1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care-associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types. RESULTS: The number of cases of C. difficile infection in the 10 U.S. sites was 15,461 in 2011 (10,177 health care-associated and 5284 community-associated cases) and 15,512 in 2017 (7973 health care-associated and 7539 community-associated cases). The estimated national burden of C. difficile infection was 476,400 cases (95% confidence interval [CI], 419,900 to 532,900) in 2011 and 462,100 cases (95% CI, 428,600 to 495,600) in 2017. With accounting for NAAT use, the adjusted estimate of the total burden of C. difficile infection decreased by 24% (95% CI, 6 to 36) from 2011 through 2017; the adjusted estimate of the national burden of health care-associated C. difficile infection decreased by 36% (95% CI, 24 to 54), whereas the adjusted estimate of the national burden of community-associated C. difficile infection was unchanged. The adjusted estimate of the burden of hospitalizations for C. difficile infection decreased by 24% (95% CI, 0 to 48), whereas the adjusted estimates of the burden of first recurrences and in-hospital deaths did not change significantly. CONCLUSIONS: The estimated national burden of C. difficile infection and associated hospitalizations decreased from 2011 through 2017, owing to a decline in health care-associated infections. (Funded by the Centers for Disease Control and Prevention.).


Asunto(s)
Infecciones por Clostridium/epidemiología , Clostridium difficile , Infecciones Comunitarias Adquiridas/epidemiología , Infección Hospitalaria/epidemiología , Mortalidad Hospitalaria/tendencias , Hospitalización/tendencias , Humanos , Incidencia , Vigilancia de la Población , Recurrencia , Resultado del Tratamiento , Estados Unidos/epidemiología
2.
Am Surg ; 86(3): 190-194, 2020 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-32223796

RESUMEN

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRT after; these are the "CRRT" and "CRRT/hTEE" groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of "CRRT" with "CRRT/hTEE" and "hTEE." We also analyzed several quality measures including ICU length of stay and cost. "CRRT" had a lower AKIN score (1.6) than "CRRT/hTEE" (2.9) (P = 0.0003). "hTEE" had an AKIN score of 2.1 (P = 0.0387). "CRRT" also had increased ICU days (25.1) compared with "CRRT/hTEE" (20.2) (P = 0.014) and "hTEE" (16.8) (P = 0.003). "CRRT" accrued on average $198,695.81 per patient compared with "CRRT/hTEE" ($167,534.19) and "hTEE" ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.


Asunto(s)
Lesión Renal Aguda/terapia , Terapia de Reemplazo Renal Continuo/métodos , Ecocardiografía Transesofágica/métodos , Hemodinámica/fisiología , Mortalidad Hospitalaria/tendencias , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/mortalidad , Anciano , Reanimación Cardiopulmonar/métodos , Enfermedad Crítica/mortalidad , Enfermedad Crítica/terapia , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Centros Traumatológicos , Resultado del Tratamiento
3.
Am Surg ; 86(3): 200-207, 2020 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-32223798

RESUMEN

The nascent robotic approach for hepatic resections is gaining momentum in the United States because it offers solutions to the known limitations of laparoscopic approach. Herein, we report our initial experience and short-term outcomes of the first 100 robotic hepatectomies. With Institutional Review Board approval, all patients undergoing robotic hepatectomy were prospectively followed up. Patient demographics, operative outcomes, complications, and 30-day readmissions were collected and analyzed. Data are presented as median (mean ± SD). One hundred consecutive patients underwent robotic hepatectomy. Patients were aged 62 (63 ± 13.6) years, 66 per cent were women, and BMI was 29 (29 ± 6.4) kg/m². In all, 76 per cent of the hepatectomies were undertaken for malignancy [metastatic colorectal cancer (28%), hepatocellular carcinoma (21%), and intrahepatic cholangiocarcinoma (15%)], and 20 per cent for benign lesions; 66 per cent of patients underwent nonanatomical partial hepatectomies, 17 per cent right hepatectomies, 16 per cent left hepatectomies, and 1 per cent trisegmentectomy. Operative time was 233 (268 ± 109.3) minutes, and the estimated blood loss was 123 (269 ± 322.1) mL. Conversion to "open" approach was necessary in one patient. The length of stay was 3 (5 ± 4.6) days. There were no intraoperative complications. Twelve patients experienced postoperative complications. Six patients required readmission to the hospital within 30 days of discharge. Robotic hepatectomy is safe and feasible with favorable short-term outcomes. The robotic system enhances application of minimally invasive surgery for complex hepatobiliary operations.


Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatectomía/métodos , Mortalidad Hospitalaria/tendencias , Neoplasias Hepáticas/cirugía , Readmisión del Paciente/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Pérdida de Sangre Quirúrgica/fisiopatología , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/parasitología , Estudios de Cohortes , Femenino , Hepatectomía/mortalidad , Humanos , Tiempo de Internación , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Seguridad del Paciente , Estudios Retrospectivos , Medición de Riesgo , Procedimientos Quirúrgicos Robotizados/efectos adversos , Resultado del Tratamiento
4.
Am Surg ; 86(3): 237-244, 2020 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-32223804

RESUMEN

Racial and gender disparities in end-of-life decision-making practices have not been well described in surgical patients. We performed an eight-year retrospective analysis of surgical patients within the Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. ICU patients with documented admission code status, and death or ICU discharge code status, respectively, were included. Logistic regression analysis was performed to assess change in code status. Of 468,000 ICU patients, 97,968 (20.9%) were surgical, 63,567 (95%) survived, and 3,343 (5%) died during their hospitalization. Of those, 50,915 (80.1%) and 2,625 (78.5%) had complete code status data on admission and discharge or death, respectively. Women were less likely than men to remain full code at ICU discharge and death (n = 20,940, 95.6% and n = 141, 11.9% vs n = 29,320, 97.4% and n = 233, 16.3%, P < 0.001). Compared with whites, blacks and other minorities had a 0.46 odds (95% confidence interval [CI]: 0.33-0.64, P < 0.001) and 0.54 odds (95% CI: 0.34-0.85, P = 0.01) of changing from full code status before death, respectively. Before ICU discharge, blacks and other minorities had a 0.56 odds of changing from full code status when compared with whites (95% CI: 0.40-0.79, P < 0.001 vs 95% CI: 0.36-0.87, P = 0.01, respectively). Women were more likely to be discharged or die after a change in code status from full code (odds ratio 1.27, 95% CI: 1.06-1.07, P < 0.001; odds ratio 1.39, 95% CI: 1.09-1.79, P = 0.009). Men and minorities are more likely to be discharged from the ICU or die with a full code status designation.


Asunto(s)
Reanimación Cardiopulmonar/mortalidad , Mortalidad Hospitalaria/tendencias , Unidades de Cuidados Intensivos/estadística & datos numéricos , Grupos Minoritarios , Evaluación de Resultado en la Atención de Salud , Adulto , Afroamericanos/estadística & datos numéricos , Anciano , Causas de Muerte , Toma de Decisiones Clínicas , Intervalos de Confianza , Enfermedad Crítica/mortalidad , Enfermedad Crítica/terapia , Bases de Datos Factuales , Femenino , Encuestas de Atención de la Salud , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Admisión del Paciente , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores Sexuales , Procedimientos Quirúrgicos Operativos
5.
Medicine (Baltimore) ; 99(13): e19563, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32221074

RESUMEN

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease, and its mortality rate is 10% to 20%. However, there are currently only a few markers to predict the prognosis in patients with TTP. We aimed to identify several clinical indices and laboratory parameters for predicting the prognosis of TTP at admission.A single-centre observational cohort study that included patients with TTP from the First Affiliated Hospital of Zhengzhou University in China was conducted from January 1, 2012 to November 30, 2018. The primary outcome was prognosis, including in-hospital mortality, major thromboembolic events, or failure to achieve remission at discharge. We used the random forest method to identify the best set of predictors.Eighty-seven patients with TTP were identified, of whom 12 died during the treatment. The total number of patients within-hospital mortality, major thromboembolic events, and failure to achieve remission at discharge was 58. The machine learning method showed that the D-dimer level was the strongest predictor of the primary outcome. Receiver operating characteristic (ROC) analysis demonstrated that the sensitivity and specificity of the D-dimer level alone for identifying high-risk patients were 78% and 81%, respectively, with an optimum diagnostic cut-off value of 770 ng/mL. The area under the ROC curve (AUC) was 0.80, and the 95% confidence interval (CI) was 0.70 to 0.90.This study found that the D-dimer level exhibited a good predictive ability for prognosis in patients with TTP. These findings may aid in the development of new and intensive treatment strategies to achieve remission among high-risk patients. However, external validation is necessary to confirm the generalizability of our approach across populations and treatment practices.


Asunto(s)
Mortalidad Hospitalaria/tendencias , Púrpura Trombocitopénica Trombótica/sangre , Púrpura Trombocitopénica Trombótica/complicaciones , Tromboembolia/etiología , Adulto , Anciano , Biomarcadores , China , Comorbilidad , Femenino , Productos de Degradación de Fibrina-Fibrinógeno , Humanos , Aprendizaje Automático , Masculino , Persona de Mediana Edad , Pronóstico , Púrpura Trombocitopénica Trombótica/diagnóstico , Púrpura Trombocitopénica Trombótica/mortalidad , Curva ROC , Inducción de Remisión , Estudios Retrospectivos , Factores de Riesgo
6.
PLoS One ; 15(2): e0228966, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32084167

RESUMEN

OBJECTIVE: To assess the value of the inability to walk unassisted to predict hospital mortality in patients with suspected infection in a resource-limited setting. METHODS: This is a post hoc study of a prospective trial performed in rural Rwanda. Patients hospitalized because of a suspected acute infection and who were able to walk unassisted before this disease episode were included. At hospital presentation, the walking status was graded into: 1) can walk unassisted, 2) can walk assisted only, 3) cannot walk. Receiver operating characteristic (ROC) analyses and two-by-two tables were used to determine the sensitivity, specificity, negative and positive predictive values of the inability to walk unassisted to predict in-hospital death. RESULTS: One-thousand-sixty-nine patients were included. Two-hundred-one (18.8%), 315 (29.5%), and 553 (51.7%) subjects could walk unassisted, walk assisted or not walk, respectively. Their hospital mortality was 0%, 3.8% and 6.3%, respectively. The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90-100%) to predict in-hospital death (p = 0.00007). The value of the inability to walk unassisted to predict in-hospital mortality (AUC ROC, 0.636; CI95%, 0.564-0.707) was comparable to that of the qSOFA score (AUC ROC, 0.622; CI95% 0.524-0.728). Fifteen (7.5%), 34 (10.8%) and 167 (30.2%) patients who could walk unassisted, walk assisted or not walk presented with a qSOFA score count ≥2 points, respectively (p<0.001). The inability to walk unassisted correlated with the presence of risk factors for death and danger signs, vital parameters, laboratory values, length of hospital stay, and costs of care. CONCLUSIONS: Our results suggest that the inability to walk unassisted at hospital admission is a highly sensitive predictor of in-hospital mortality in Rwandese patients with a suspected acute infection. The walking status at hospital admission appears to be a crude indicator of disease severity.


Asunto(s)
Pruebas Diagnósticas de Rutina/métodos , Índice de Severidad de la Enfermedad , Triaje/métodos , Adolescente , Adulto , Área Bajo la Curva , Niño , Femenino , Mortalidad Hospitalaria/tendencias , Hospitalización , Humanos , Infecciones , Unidades de Cuidados Intensivos/tendencias , Tiempo de Internación , Masculino , Pronóstico , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Rwanda/epidemiología , Sensibilidad y Especificidad , Sepsis/mortalidad , Caminata/fisiología
7.
Am Heart J ; 222: 15-25, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32004796

RESUMEN

BACKGROUND: Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. OBJECTIVE: To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes. METHODS AND RESULTS: Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001). CONCLUSIONS: CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival. CONDENSED ABSTRACT: Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.


Asunto(s)
Angina Estable/cirugía , Intervención Coronaria Percutánea/estadística & datos numéricos , Sistema de Registros , Medición de Riesgo/métodos , Carga de Trabajo/estadística & datos numéricos , Anciano , Angina Estable/mortalidad , Bases de Datos Factuales , Inglaterra/epidemiología , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Gales/epidemiología
8.
Am Heart J ; 222: 73-82, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32018204

RESUMEN

BACKGROUND: Underweight and obesity represent classical risk factors for adverse outcome in patients treated for cardiovascular disease. AIMS: The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy. METHODS AND RESULTS: From August 2010 until July 2013, 799 patients (age 75.3 ±â€¯8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicenter German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into 4 groups: BMI <20 kg/m2 (underweight), BMI 20.0 to <25.0 kg/m2 (normal weight, reference group), BMI 25.0 to <30.0 kg/m2 (overweight) and BMI ≥30 kg/m2 (obese). Significant increased rates of procedural failure, transfusion/bleeding, sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, P < .01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine ≥1.5 mg/dL, diabetes, left ventricular ejection fraction <30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95% confidence interval (CI): 1.01-2.46, P = .044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55-0.93; P = .011). CONCLUSIONS: Compared to other weight groups, underweight patients undergoing MitraClip implantation are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates and should therefore be carefully discussed in the heart-team.


Asunto(s)
Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/epidemiología , Sistema de Registros , Delgadez/complicaciones , Ecocardiografía , Estudios de Seguimiento , Alemania/epidemiología , Mortalidad Hospitalaria/tendencias , Incidencia , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/diagnóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento
9.
PLoS One ; 15(2): e0228458, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32023315

RESUMEN

OBJECTIVES: This study evaluated the impact of the presence of a certified nurse specialist in critical care (CNS) as ICU head nurse in an open ICU on clinical outcomes. METHODS: The presence of a CNS as ICU head nurse was implemented in practice in April 2017. To evaluate the impact on patient outcomes before and after the implementation, patients were divided into two groups: before (April 2014 to March 2017; 1988 patients) and after (April 2017 to March 2019; 1664 patients). Patients' demographic data were collected from the ICU database. RESULTS: Multivariable logistic regression analysis revealed that the presence of a CNS as ICU head nurse was associated with lower ICU mortality (odds ratio (OR): 0.52, 95% CI: 0.36-0.73, p < .001) and fewer patients receiving mechanical ventilation in the ICU (OR: 0.20, 95% CI: 0.15-0.26, p < .001). CONCLUSION: CNSs are defined as one type of advanced practice nurses. Having a CNS as a head nurse in the ICU may have helped improve patient outcomes by leveraging these practical skills in nursing management.


Asunto(s)
Enfermería de Cuidados Críticos/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Unidades de Cuidados Intensivos/estadística & datos numéricos , Enfermeras Especialistas/estadística & datos numéricos , Supervisión de Enfermería/estadística & datos numéricos , Respiración Artificial/mortalidad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/terapia , Niño , Femenino , Enfermedades Gastrointestinales/terapia , Humanos , Masculino , Persona de Mediana Edad , Síndrome de Dificultad Respiratoria del Adulto/terapia , Estudios Retrospectivos , Tasa de Supervivencia , Adulto Joven
11.
Braz. J. Psychiatry (São Paulo, 1999, Impr.) ; 42(1): 40-45, Jan.-Feb. 2020. tab
Artículo en Inglés | LILACS | ID: biblio-1055358

RESUMEN

Objective: To describe and analyze data on self-injurious behavior (SIB) and related mortality in children under 10 years old in Brazil. Methods: A descriptive study was performed using secondary public health care data extracted from the Hospital Information System (Sistema de Informações Hospitalares, SIH) and Mortality Information System (Sistema de Informações sobre Mortalidade, SIM) in Brazil. The databases are available for online access at http://datasus.saude.gov.br/. Results: In Brazil, according to SIH data, 11,312 hospitalizations of patients under 10 years of age were recorded from 1998 to 2018 as resulting from SIB (ICD-10 X60-X84 codes). Of these, 65 resulted in death. According to the SIM, from 1996 to 2016, 91 deaths related to SIB were recorded, 81 (89%) in children aged 5 to 9 years, nine (9.9%) in children aged 1 to 4 years, and one (1.1%) in a child below 1 year of age. Conclusion: These results highlight the relevance of creating measures to better understand SIB and related mortality in this age group. They also reveal the vulnerability of children in Brazil and warrant further studies to address these issues.


Asunto(s)
Humanos , Masculino , Femenino , Lactante , Preescolar , Niño , Conducta Autodestructiva/mortalidad , Mortalidad del Niño/tendencias , Brasil , Estudios Retrospectivos , Factores de Riesgo , Mortalidad Hospitalaria/tendencias , Distribución por Sexo , Distribución por Edad , Hospitalización/estadística & datos numéricos
12.
PLoS One ; 15(2): e0229210, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32078640

RESUMEN

BACKGROUND: To allow early identification of patients at risk of sepsis in the emergency department (ED), a variety of risk stratification scores and/or triage systems are used. The first aim of this study was to develop a risk stratification score for sepsis based upon vital signs and biomarkers using a statistical approach. Second, we aimed to validate the Rapid Emergency Triage and Treatment System (RETTS) for sepsis. RETTS combines vital signs with symptoms for risk stratification. METHODS: We retrospectively analysed data from two prospective, observational, multicentre cohorts of patients from studies of biomarkers in ED. A candidate risk stratification score called Sepsis Heparin-binding protein-based Early Warning Score (SHEWS) was constructed using the Least Absolute Shrinkage and Selector Operator (LASSO) method. SHEWS and RETTS were compared to National Early Warning Score 2 (NEWS2) for infection-related organ dysfunction, intensive care or death within the first 72h after admission (i.e. sepsis). RESULTS: 506 patients with a diagnosed infection constituted cohort A, in which SHEWS was derived and RETTS was validated. 435 patients constituted cohort B of whom 184 had a diagnosed infection where both scores were validated. In both cohorts (A and B), AUC for infection-related organ dysfunction, intensive care or death was higher for NEWS2, 0.80 (95% CI 0.76-0.84) and 0.69 (95% CI 0.63-0.74), than RETTS, 0.74 (95% CI 0.70-0.79) and 0.55 (95% CI 0.49-0.60), p = 0.05 and p <0.01, respectively. SHEWS had the highest AUC, 0.73 (95% CI 0.68-0.79) p = 0.32 in cohort B. CONCLUSIONS: Even with a statistical approach, we could not construct better risk stratification scores for sepsis than NEWS2. RETTS was inferior to NEWS2 for screening for sepsis.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Modelos Estadísticos , Medición de Riesgo/métodos , Sepsis/diagnóstico , Triaje/normas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos
13.
Medicine (Baltimore) ; 99(1): e18687, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31895836

RESUMEN

The impact of time of day or day of week on the survival of emergency trauma patients is still controversial. The purpose of this study was to evaluate the outcomes of these patients according to time of day or day of week of emergency admission by using data from the nationwide Japan Trauma Data Bank (JTDB).This study enrolled 236,698 patients registered in the JTDB database from 2004 to 2015, and defined daytime as 09:00 AM to 16:59 PM and nighttime as 17:00 PM to 08:59 AM, weekdays as Monday to Friday, and weekends as Saturday, Sunday, and national holidays. The outcome measures were death in the emergency room (ER) and discharge to death.In total, 170,622 patients were eligible for our analysis. In a multivariable logistic regression adjusted for confounding factors, both death in the ER and death at hospital discharge were significantly lower during the daytime than at nighttime (623/76,162 [0.82%] vs 954/94,460 [1.01%]; adjusted odds ratio [AOR] 0.79; 95% confidence interval [CI] 0.71-0.88 and 5765/76,162 [7.57%] vs 7270/94,460 [7.70%]; AOR 0.88; 95% CI 0.85-0.92). In contrast, the weekdays/weekends was not significantly related to either death in the ER (1058/114,357 [0.93%] vs 519/56,265 [0.92%]; AOR 0.95; 95% CI 0.85-1.06) or death at hospital discharge (8975/114,357 [7.85%] vs 4060/56,265 [7.22%]; AOR 1.02; 95% CI 0.97-1.06).In this population of emergency trauma patients in Japan, both death in the ER and death at hospital discharge were significantly lower during the daytime than at night, but the weekdays/weekends was not associated with outcomes of these patients.


Asunto(s)
Servicios Médicos de Urgencia/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Adulto , Anciano , Servicios Médicos de Urgencia/normas , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
14.
N Engl J Med ; 382(1): 51-59, 2020 01 02.
Artículo en Inglés | MEDLINE | ID: mdl-31893515

RESUMEN

BACKGROUND: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. METHODS: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. RESULTS: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. CONCLUSIONS: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).


Asunto(s)
Instituciones Asociadas de Salud , Hospitales , Calidad de la Atención de Salud , Anciano , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Medicare , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/tendencias , Medición de Resultados Informados por el Paciente , Indicadores de Calidad de la Atención de Salud , Estados Unidos
15.
J Cardiovasc Surg (Torino) ; 61(2): 234-242, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-31937080

RESUMEN

BACKGROUND: Cardiac surgery is associated with perioperative bleeding and carries high risk of allogeneic blood transfusion. Recently new scores for prediction of severe bleeding have been developed. This study aims to compare the WILL-BLEED, CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting major bleeding after CABG in patients with low estimated operative risk. METHODS: A multicenter observational study included 1391 patients who underwent isolated CABG from July 2015 to January 2018. We tested the hypothesis that the WILL-BLEED score, specifically designed for CABG, would perform at least as well as the CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting postoperative major bleeding in low operative risk patients. The primary endpoint was the performance of known bleeding risk scores after CABG. The secondary endpoint was the evaluation of in-hospital mortality. RESULTS: Mean age was 68.2±9.4 years and median Euroscore II value was 1.69% (IQR 1.15-2.81%). Mean blood losses in the first 12 postoperative hours was 339.75 mL. Seventy-three (5.2%) subjects underwent administration of blood products. The rate of severe-massive bleeding according to UDPB grades 3-4 was 1.5%. WILL-BLEED, TRUST, TRACK and ACTION scores were significantly associated with severe postoperative bleeding. WILL-BLEED presented the best c-index (AUC: 0.658; 95% CI: 0.600,0.716). Reclassification analysis showed a worsening in sensitivity and significant negative reclassification of CRUSADE, PAPWORTH, TRACK and ACTION scores when compared with WILL-BEED. The combination of WILL-BLEED and TRUST scores improved the prediction ability (AUC: 0.673; 95% CI: 0.615-0.732). Overall in-hospital mortality was 1.65%. Early mortality in patients with severe versus no-severe bleeding was found to be 11.8% vs. 1.0% Severe bleeding (OR: 13.26; P value<0.001) was found to be significantly associated with early mortality. CONCLUSIONS: Severe bleeding after CABG is a harmful event associated with adverse outcomes. WILL-BLEED Score has the better performance in predicting severe-massive bleeding after CABG. The TRUST Score, although suboptimal, represents a valuable alternative in this setting.


Asunto(s)
Transfusión Sanguínea/métodos , Puente de Arteria Coronaria/efectos adversos , Mortalidad Hospitalaria/tendencias , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/mortalidad , Anciano , Área Bajo la Curva , Causas de Muerte , Intervalos de Confianza , Angiografía Coronaria/métodos , Puente de Arteria Coronaria/métodos , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/mortalidad , Estenosis Coronaria/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/terapia , Pronóstico , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento
16.
Aust N Z J Public Health ; 44(1): 53-58, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31535416

RESUMEN

OBJECTIVE: To determine the clinical characteristics, outcomes and longitudinal trends of sepsis occurring in cancer patients. METHOD: Retrospective study using statewide Victorian Cancer Registry data linked to various administrative datasets. RESULTS: Among 215,763 incident cancer patients, incidence of sepsis within one year of cancer diagnosis was estimated at 6.4%. The incidence of sepsis was higher in men, younger patients, patients diagnosed with haematological malignancies and those with de novo metastatic disease. Of the 13,316 patients with a first admission with sepsis, 55% had one or more organ failures, 29% required care within an intensive care unit and 13% required mechanical ventilation. Treatments associated with the highest sepsis incidence were stem cell/bone marrow transplant (33%), major surgery (4.4%), chemotherapy (1.1%) and radical radiotherapy (0.6%). The incidence of sepsis with organ failure increased between 2008 and 2015, while 90-day mortality decreased. CONCLUSIONS: Sepsis in patients with cancer has high mortality and occurs most frequently in the first year after cancer diagnosis. Implications for public health: The number of cancer patients diagnosed with sepsis is expected to increase, causing a substantial burden on patients and the healthcare system.


Asunto(s)
Mortalidad Hospitalaria/tendencias , Hospitalización/estadística & datos numéricos , Neoplasias/complicaciones , Sepsis/epidemiología , Femenino , Humanos , Incidencia , Masculino , Neoplasias/epidemiología , Estudios Retrospectivos , Web Semántica , Victoria/epidemiología
17.
Am J Cardiol ; 125(1): 1-10, 2020 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-31685213

RESUMEN

The benefit-risk ratio of a pharmacoinvasive strategy (PI) in patients ≥70 years of age with ST-segment elevation myocardial infarction (STEMI) remains uncertain resulting in its limited use in this population. This study compared efficacy and safety of PI with primary percutaneous coronary intervention (pPCI). Data from 2,841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either PI (n = 269) or pPCI (n = 2,572), were analyzed. The primary end point was in-hospital major adverse cardiovascular events (MACE) defined as the composite of all-cause mortality, nonfatal MI, stroke, and definite stent thrombosis. Secondary end points included all-cause death, major bleeding, net adverse clinical events, and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the PI (n = 247) and pPCI (n = 958) groups, (11.3% vs 9.0%, respectively, odds ratio 1.25, 95% confidence interval 0.81 to 1.94; p = 0.31). Secondary end points were comparable between groups at the exception of a lower rate of development of Killip class III or IV heart failure after PI. The rate of intracranial hemorrhage was significantly higher in the PI group (2.3% vs 0.0%, p = 0.03). In conclusion, the present study demonstrated no difference regarding in-hospital MACE following PI or pPCI in STEMI patients ≥70 years of age. An adequately-powered randomized trial is needed to precisely define the role of PI in this high-risk subgroup.


Asunto(s)
Intervención Coronaria Percutánea/normas , Guías de Práctica Clínica como Asunto , Sistema de Registros , Infarto del Miocardio con Elevación del ST/terapia , Terapia Trombolítica/normas , Anciano , Anciano de 80 o más Años , Causas de Muerte/tendencias , Femenino , Estudios de Seguimiento , Francia/epidemiología , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Intervención Coronaria Percutánea/métodos , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/mortalidad , Tasa de Supervivencia/tendencias , Terapia Trombolítica/métodos , Tiempo de Tratamiento
18.
Am J Cardiol ; 125(1): 87-91, 2020 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-31685214

RESUMEN

Atrial fibrillation-flutter (AF) has been described in 10% to 24% of patients after heart transplant (HT). Data on AF hospitalizations after HT are limited to single-center experiences. To bridge this gap, we performed an analysis of admissions for AF in HT patients from the National Inpatient Sample (NIS) years 2000 to 2014. All hospitalizations with a primary diagnosis of 427.31 or 427.32 and V42.1 were used to identify hospitalizations with AF and previous HT respectively. Among a total of 211,961 HT related hospitalizations, 1,304 (0.62%) (955 males, 349 females, mean age 59 years, median CHA2DS2Vasc score 2 [Interquartile range 1 to 3]) were admitted with a primary diagnosis AF. Most hospitalizations were nonelective (80.17%). In-hospital mortality was 2.3% and the mean length of stay (LOS) was 3.7 days. Among those patients who were discharged from hospital, 85 % were discharged to home with self-care. Most commonly reported secondary diagnoses included hypertension (57.9%), diabetes (33%), renal failure (31.3%), and congestive heart failure (22%). The event rates for ischemic stroke and gastrointestinal bleeding in the same admission with the AF hospitalization were low (1.2% and 1.2% respectively). Cardioversion was performed in 37% and ablation in 11.2% of admissions. The adjusted median cost of hospitalization was $6478.7 (IQR $3561.8 to $12352.3) and did not change significantly during the study period. AF is a relatively infrequent cause of hospitalization among HT recipients. The number of hospitalizations, ablations, cardioversions, disposition, LOS, and cost of hospitalization for AF remained stable during the study period.


Asunto(s)
Fibrilación Atrial/epidemiología , Aleteo Atrial/epidemiología , Trasplante de Corazón/efectos adversos , Hospitalización/tendencias , Pacientes Internos/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Receptores de Trasplantes/estadística & datos numéricos , Fibrilación Atrial/etiología , Fibrilación Atrial/terapia , Aleteo Atrial/etiología , Aleteo Atrial/terapia , Ablación por Catéter/métodos , Cardioversión Eléctrica/métodos , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiología
19.
Am J Cardiol ; 125(1): 140-145, 2020 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-31703806

RESUMEN

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) and optimal timing for total repair of TOF is controversial. We hypothesize that TOF repair in the neonatal period is associated with worse outcomes compared with those who undergo repair later in infancy. We analyzed data using the Kids' Inpatient Database (KID) from 2003 to 2012. We used multivariable logistic regression analyses to compare the in-hospital outcomes between those who underwent total repair of TOF during the neonatal period vs the postneonatal period. There were 6,856 cases of TOF and 7.83% (n = 537) of those underwent repair during the neonatal period. The average mortality in all TOF repair was 2.1% (n = 147). In multiple regression model, compared with repair in postneonatal period, neonatal repair was associated with increased mortality, with adjusted odds ratio of 2.2 (95% confidence interval [CI]: 1.1 to 4.3, p = 0.023). Regarding complications, the neonatal group was associated with higher risk of acute renal failure (8.9% vs 2.3%, p <0.001), need for cardiac catheterization (18.6% vs 8.3%, p <0.001), and ECMO use (4.4% vs1.6%, p <0.001). There was no difference in the rates of arrhythmia, respiratory failure, pulmonary hypertension, or sudden cardiac arrest. Children who underwent repair in the neonatal period had longer hospital stay compared with the postneonatal group (45.5 days [95% CI: 39.3 to 51.7] vs 12.6 days [95% CI: 11.7 to 13.4], p <0.001). Hospital charges were higher for children who underwent repair in the neonatal period compared with those in the postneonatal period. In conclusion, TOF repair in the neonatal period is associated with higher rates of mortality, more postoperative complications, longer hospital stays, and higher hospitalization cost.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Pacientes Internos , Complicaciones Posoperatorias/epidemiología , Tetralogía de Fallot/cirugía , Cateterismo Cardíaco/métodos , Estudios Transversales , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Lactante , Mortalidad Infantil/tendencias , Recién Nacido , Tiempo de Internación/tendencias , Masculino , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tetralogía de Fallot/mortalidad , Factores de Tiempo , Estados Unidos/epidemiología
20.
Am J Cardiol ; 125(1): 135-139, 2020 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-31711632

RESUMEN

There are no large reports of comparative outcomes of transcatheter pulmonic valve implantation (TPVI) and surgical pulmonic valve replacement (SPVR). Prospective studies are unlikely to be feasible in the future also. Thus, we utilized a large adult inpatient database to compare the two with respect to temporal trends, in hospital outcomes and costs. Data from the National Inpatient Sample database from 2003 to 2014 was analyzed to extract patients who underwent TPVI and SPVR using unique ICD 9-CM codes. In-hospital outcomes and charges were then analyzed. All charges were converted to 2018 dollars and a loss of wages analysis was performed using the Bureau of Labor Statistics published median weekly wages. A total of 8,449 and 555 SPVR and TPVI discharges were identified. 5.8% SPVR procedures were done in rural setting versus 1.8% of TPVI. Complications including in-hospital mortality (2.3 vs 0.9%; p = 0.02) were higher in SPVR group. Length of stay was significantly shorter for the TPVI group (1 vs 5 days; p <0.001), which also contributed to lower loss of wages ($1028.57 vs $6042.86; p <0.001) with similar hospital charges. In conclusion, volumes of both TPVI and SPVR are increasing across adult hospitals in the United States, reflecting an overall increase in the adult congenital heart disease population. TPVI offers improved short-term outcomes and decreased loss of wages through shorter recovery time in this real-world database analysis.


Asunto(s)
Cateterismo Cardíaco/métodos , Encuestas Epidemiológicas , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Pacientes Internos/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Válvula Pulmonar/cirugía , Adulto , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiología
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