[Rape and the "minute-after" law in Minas Gerais, Brazil: socio-demographic factors associated with emergency prophylaxis]. / Estupro e lei do minuto seguinte em Minas Gerais, Brasil: fatores sociodemográficos associados às profilaxias de emergência.

This research project investigated the relationship between sociodemographic characteristics of girls and women who were the victims of rape of in Minas Gerais between 2013 and 2021, and the likelihood of receiving emergency treatment as stipulated in Law No. 12,845/2013, known as the "Minute-After" (Minuto Seguinte) Law. Data from the Notifiable Diseases Information System (SINAN) for rape cases were used to estimate binary choice models. The results indicate that the sociodemographic factors of the victims, aligned with the theory and practice of intersectionality (race, age, place of residence within health regions, relationship with the perpetrator, and year of crime registration), negatively influence the probability of receiving emergency treatment. Specifically, indigenous victims, minors, those raped by acquaintances, and residents in certain health regions, were found to have a lower probability of receiving immediate medical care after rape. Furthermore, it was found that the implementation of public policy did not result in an improvement, as there has been a decrease in the number of medical appointments since the enactment of the law in 2013 through to the year 2021.

Esta pesquisa investigou a relação entre características sociodemográficas das meninas e mulheres vítimas de estupro em Minas Gerais, no período de 2013 a 2021, e a probabilidade de receberem tratamentos de emergência, conforme estabelecido na Lei nº 12.845/2013, conhecida como Lei do Minuto Seguinte. Utilizou-se os dados do Sistema de Informação de Agravos de Notificação (SINAN) para casos de estupro para estimação de modelos de escolhas binárias. Os resultados indicam que fatores sociodemográficos das vítimas, alinhados à teoria e à prática da interseccionalidade (raça, idade, local de residência dentro das regiões de saúde, relação com o agressor e ano do registro do crime) influenciam, negativamente, a probabilidade de receberem o tratamento de emergência. Em particular, vítimas indígenas, menores de idade, agredidas por conhecidos e residentes em determinadas regiões de saúde demonstraram ter menor probabilidade de receber cuidados médicos imediatos. após o estupro. Além disso, constatou-se que a implementação da política pública não resultou em melhoria, já que, desde a promulgação da Lei, em 2013, até o ano 2021, houve diminuição no número de atendimentos médicos realizados.

Impact of Procedure Risk vs Frailty on Outcomes of Elderly Patients Undergoing Emergency General Surgery: Results of a National Analysis.

BACKGROUND: The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty. STUDY DESIGN: Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes. RESULTS: A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty. CONCLUSIONS: Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.

Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals.

BACKGROUND: The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis. METHOD: The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results. RESULTS: Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks. CONCLUSION: The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Analysis of perinatal outcomes for emergency cervical cerclage in singleton pregnancies at 24-28 weeks of gestation.

BACKGROUND: Cervical cerclage is the only effective treatment for cervical insufficiency, effectively preventing late miscarriage and preterm birth. The effectiveness and safety of emergency cervical cerclage (ECC) as an emergency treatment when the cervix is already dilated or when there is protrusion of the fetal membranes into the vagina remain controversial, especially in pregnancies at 24-28 weeks when the fetus is viable. There is still no consensus on whether emergency cervical cerclage should be performed in such cases. PURPOSE: To investigate the effectiveness and safety of emergency cervical cerclage in singleton pregnant women at 24-28 weeks of gestation. METHODS: This study employed a single-center prospective cohort design, enrolling singleton pregnant women at 24-28 weeks of gestation with ultrasound or physical examination indicating cervical dilation or even membrane protrusion. Emergency cervical cerclage was compared with conservative treatment. The primary endpoints included a comprehensive assessment of perinatal pregnancy loss, significant neonatal morbidity, and adverse neonatal outcomes. Secondary endpoints included prolonged gestational age, preterm birth, neonatal hospitalization rate, premature rupture of membranes, and intrauterine infection/chorioamnionitis. RESULTS: From June 2021 to March 2023, a total of 133 pregnant women participated in this study, with 125 completing the trial, and were allocated to either the Emergency Cervical Cerclage (ECC) group (72 cases) or the conservative treatment group (53 cases) based on informed consent from the pregnant women. The rate of adverse neonatal outcomes was 8.33% in the ECC group and 26.42% in the conservative treatment (CT) group, with a statistically significant difference (P = 0.06). There were no significant differences between the two groups in terms of perinatal pregnancy loss and significant neonatal morbidity. The conservative treatment group had a mean prolonged gestational age of 63.0 (23.0, 79.5) days, while the ECC group had 84.0 (72.5, 89.0) days, with a statistically significant difference between the two groups (P < 0.001). Compared with CT group, the ECC group showed a significantly reduced incidence of preterm birth before 28 weeks, 32 weeks, and 34 weeks, with statistical significance (P = 0.046, 0.007, 0.001), as well as a significantly decreased neonatal hospitalization rate (P = 0.013, 0.031). Additionally, ECC treatment did not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis, with no statistically significant differences (P = 0.406, 0.397). CONCLUSION: In singleton pregnant women with cervical insufficiency at 24-28 weeks of gestation, emergency cervical cerclage can reduce adverse neonatal pregnancy outcomes, effectively prolong gestational age, decrease preterm births before 28 weeks, 32 weeks, and 34 weeks, lower neonatal hospitalization rates, and does not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis.

Emergency Department Visits and Deaths from Cardiovascular Diseases at a Referral Center for Cardiology During the COVID-19 Pandemic

Abstract Background The COVID-19 pandemic has imposed measures of social distancing and, during this time, there has been an elevation in cardiovascular mortality rates and a decrease in the number of emergency visits. Objectives To assess and compare in-hospital mortality for cardiovascular diseases and emergency department visits during the COVID-19 pandemic and the same period in 2019. Methods Retrospective, single-center study that evaluated emergency visits and in-hospital deaths between March 16, 2020 and June 16, 2020, when the steepest fall in the number of emergency admissions for COVID-19 was registered. These data were compared with the emergency visits and in-hospital deaths between March 16 and June 16, 2019. We analyzed the total number of deaths, and cardiovascular deaths. The level of significance was set at p < 0.05. Results There was a 35% decrease in the number of emergency visits and an increase in the ratio of the number of deaths to the number of emergency visits in 2020. The increase in the ratio of the number of all-cause deaths to the number of emergency visits was 45.6% and the increase in the ratio of the number of cardiovascular deaths to the number of emergency visits was 62.1%. None of the patients who died in the study period in 2020 tested positive for COVID-19. Conclusion In-hospital mortality for cardiovascular diseases increased proportionally to the number of emergency visits during the COVID-19-imposed social distancing compared with the same period in 2019. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

Natural history, growth rates, and treatment of popliteal artery aneurysms.

BACKGROUND: The natural history of a cohort of patients monitored for popliteal artery aneurysms (PAAs) has not been well described. A prevailing uncertainty exists regarding the optimal surveillance strategies and timing of treatment. The primary aim of the present study was to describe the care trajectory of all patients with PAAs identified at two tertiary vascular centers, both in surveillance and eventually treated. The secondary aim was to define the PAA growth rates. METHODS: A retrospective, multicenter cohort study was performed of all patients with PAAs at two vascular centers in two countries (Sweden, 2009-2016; New Zealand, 2009-2017). Data were collected from electronic medical records regarding the comorbidities, treatment, and outcomes and analyzed on a patient- and extremity-specific level. Treatment was indicated at the occurrence of emergent symptoms or considered at a PAA threshold of >2 cm. The PAAs were divided into small (≤15 mm) and large (>15 mm) aneurysms. The mean surveillance follow-up was 5.1 years. RESULTS: Most of the 241 identified patients (397 limbs) with a diagnosis of PAAs had bilateral aneurysms (n = 156). Most patients were treated within the study period (163 of 241; 68%), and one half of the diagnosed extremities with PAA had been treated (54%; 215 of 397). Among those who had undergone elective repair, treatment had usually occurred within 1 year after the diagnosis (66%; 105 of 158). More small PAAs were detected in the group that had required emergent repair compared with elective repair (6 of 57 [11%] vs 12 of 158 [8%]; P < .001). No differences were found in the mean diameters between the elective and emergent groups (30.1 mm vs 32.2 mm; P = .39). Growth was recorded in 110 PAAs and on multivariate analysis was associated with a larger index diameter (odds ratio, 1.138; 95% confidence interval, 1.040-1.246; P = .005) and a concurrent abdominal aortic aneurysm (odds ratio, 2.553; 95% confidence interval, 1.018-6.402; P = .046). CONCLUSIONS: The present cohort of patients represented a true contemporary clinical setting of monitored PAAs and showed that most of these patients will require elective repair, usually within 1 year. The risk of emergent repair is not negligible for patients with smaller diameter PAAs. However, the optimal selection strategy for preventive early repair is still unknown. Future morphologic studies are needed to support the development of individualized surveillance protocols.

Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.

OBJECTIVE: The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients. METHODS: From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively. RESULTS: At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories. CONCLUSIONS: Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.

Geographic Variation in the Utilization of and Mortality After Emergency General Surgery Operations in the Northeastern and Southeastern United States.

OBJECTIVE: To define geographic variations in emergency general surgery (EGS) care, we sought to determine how much variability exists in the rates of EGS operations and subsequent mortality in the Northeastern and Southeastern United States (US). SUMMARY BACKGROUND DATA: While some geographic variations in healthcare are normal, unwarranted variations raise questions about the quality, appropriateness, and cost-effectiveness of care in different areas. METHODS: Patients ≥18 years who underwent 1 of 10 common EGS operations were identified using the State Inpatient Databases (2011-2012) for 6 states, representing Northeastern (New York) and Southeastern (Florida, Georgia, Kentucky, North Carolina, Mississippi) US. Geographic unit of analysis was the hospital service area (HSA). Age-standardized rates of operations and in-hospital mortality were calculated and mapped. Differences in rates across geographic areas were compared using the Kruskal-Wallis test, and variance quantified using linear random-effects models. Variation profiles were tabulated via standardized rates of utilization and mortality to compare geographically heterogenous areas. RESULTS: 227,109 EGS operations were geospatially analyzed across the 6 states. Age-standardized EGS operation rates varied significantly by region (Northeast rate of 22.7 EGS operations per 10,000 in population versus Southeast 21.9; P < 0.001), state (ranging from 9.9 to 29.1; P < 0.001), and HSA (1.9-56.7; P < 0.001). The geographic variability in age-standardized EGS mortality rates was also significant at the region level (Northeast mortality rate 7.2 per 1000 operations vs Southeast 7.4; P < 0.001), state-level (ranging from 5.9 to 9.0 deaths per 1000 EGS operations; P < 0.001), and HSA-level (0.0-77.3; P < 0.001). Maps and variation profiles visually exhibited widespread and substantial differences in EGS use and morality. CONCLUSIONS: Wide geographic variations exist across 6 Northeastern and Southeastern US states in the rates of EGS operations and subsequent mortality. More detailed geographic analyses are needed to determine the basis of these variations and how they can be minimized.

Machine learning for outcome predictions of patients with trauma during emergency department care.

OBJECTIVES: To develop and evaluate a machine learning model for predicting patient with trauma mortality within the US emergency departments. METHODS: This was a retrospective prognostic study using deidentified patient visit data from years 2007 to 2014 of the National Trauma Data Bank. The predictive model intelligence building process is designed based on patient demographics, vital signs, comorbid conditions, arrival mode and hospital transfer status. The mortality prediction model was evaluated on its sensitivity, specificity, area under receiver operating curve (AUC), positive and negative predictive value, and Matthews correlation coefficient. RESULTS: Our final dataset consisted of 2 007 485 patient visits (36.45% female, mean age of 45), 8198 (0.4%) of which resulted in mortality. Our model achieved AUC and sensitivity-specificity gap of 0.86 (95% CI 0.85 to 0.87), 0.44 for children and 0.85 (95% CI 0.85 to 0.85), 0.44 for adults. The all ages model characteristics indicate it generalised, with an AUC and gap of 0.85 (95% CI 0.85 to 0.85), 0.45. Excluding fall injuries weakened the child model (AUC 0.85, 95% CI 0.84 to 0.86) but strengthened adult (AUC 0.87, 95% CI 0.87 to 0.87) and all ages (AUC 0.86, 95% CI 0.86 to 0.86) models. CONCLUSIONS: Our machine learning model demonstrates similar performance to contemporary machine learning models without requiring restrictive criteria or extensive medical expertise. These results suggest that machine learning models for trauma outcome prediction can generalise to patients with trauma across the USA and may be able to provide decision support to medical providers in any healthcare setting.

The preoperative risk tool SURPAS accurately predicts outcomes in emergency surgery

O Sistema de Avaliação Pré-operatória de Risco Cirúrgico (SURPAS) utiliza oito variáveis para prever com precisão complicações pós-operatórias , mas não foi suficientemente estudado em cirurgia de emergência. Avaliamos o SURPAS em cirurgia de emergência, comparando-o com o Emergency Surgery Score (ESS). As estimativas SURPAS e ESS de mortalidade em 30 dias e morbidade geral foram calculadas para operações de emergência no banco de dados ACS-NSQIP de 2009­2018 e comparadas usando gráficos e taxas observadas com as esperadas, índices c e pontuações de Brier. Foram excluídos os casos com dados incompletos. Em 205.318 pacientes de emergência, o SURPAS subestimou (8,1%; 35,9%) enquanto a ESS superestimou (10,1%; 43,8%) observou mortalidade e morbidade (8,9%; 38,8%). Cada um mostrou boa calibração em gráficos observados e esperados. O SURPAS apresentou melhores índices c (0,855 vs. 0,848 de mortalidade; 0,802 vs. 0,755 de morbidade), enquanto o escore de Brier foi melhor para ESS para mortalidade (0,0666 vs. 0,0684) e para SURPAS para morbidade (0,1772 vs. 0,1950). O SURPAS previu com precisão a mortalidade e a morbidade em cirurgias de emergência usando oito variáveis preditoras.

Health care workers experiences in emergency obstetric care following implementation of an in-service training program: case of 2 Referral Hospitals in Botswana.

BACKGROUND: Maternal mortality rate remains a challenge in many developing countries. OBJECTIVES: This study explored experiences of Health Care Workers on Emergency Obstetrics Care (EMOC) in-service training and its effect on maternal mortality. METHODS: Descriptive qualitative study design was conducted using in-depth interviews and focus group discussions. Participants were EMOC trained midwives and doctors purposively selected from the 2 referral hospitals in the country. Data were transcribed verbatim, coded, and analysed using Grounded Theory approach. RESULTS: Four themes emerged including training, EMOC implementation, maternal death factors and EMOC prioritisation. The duration of training was viewed inadequate but responsiveness to and confidence in managing obstetric emergencies improved post EMOC training. Staff shortage, HCWs non-adherence and negative attitude to EMOC guidelines; delays in instituting interventions, inadequate community involvement, minimal or no health talk to women and their partners and communities on sexual reproductive matters and non-prioritisation of EMOC by authorities were concerns raised. CONCLUSION: Strengthening health education at health facility levels, stakeholders' involvement; and prioritising EMOC in-service training are necessary in reducing the national maternal mortality.

Determinants of the decision-to-delivery interval and the effect on perinatal outcome after emergency caesarean delivery: a cross-sectional study.

Background: Preventing prolongation of the decision-to-delivery interval (DDI) for emergency caesarean delivery (CD) remains central to improving perinatal health. This study evaluated the effects of the DDI on perinatal outcome following emergency CD. Methods: A prospective cross-sectional study involving 205 consenting women who had emergency CD at a tertiary hospital in Nigeria was conducted. The time-motion documentation of events from decision to delivery was documented; the outcome measures were perinatal morbidity (neonatal resuscitation, 5-minute Apgar score, neonatal intensive admission) and mortality. Data analysis was performed with IBM SPSS Statistics version 20.0, and P<0.05 was considered significant. Results: The overall mean DDI was 233.99±132.61 minutes (range 44-725 minutes); the mean DDI was shortest for cord prolapse (86.25±86.25 minutes) and was shorter for booked participants compared with unbooked participants (207.19±13.88 minutes vs 249.25±12.05 minutes; P=0.030) and for general anaesthesia compared with spinal anaesthesia (219.48±128.60 minutes vs 236.19±133.42 minutes; P=0.543). All neonatal parameters were significantly worse for unbooked women compared with booked women, including perinatal mortality (10.8% vs 1.3%; P=0.012). Neonatal morbidity increased with DDI for clinical indications, UK National Institute of Health and Care Excellence (NICE) and Robson classification for CDs; perinatal mortality was 73.2 per 1000 live births, all were category 1 CDs and all except one occurred with DDI greater than 90 minutes. Severe preeclampsia/eclampsia, obstructed labour and placenta praevia tolerated DDI greater than 90 minutes compared with abruptio placentae and umbilical cord prolapse. However, logistic regression showed no statistical correlation between the DDI and neonatal outcomes. Conclusion: Perinatal morbidity and mortality increased with DDI relative to the clinical urgency but perinatal deaths were increased with DDI greater than 90 minutes. For no category of emergency CD should the DDI exceed 90 minutes, while patient and institutional factors should be addressed to reduce the DDI.

Avaliação da eficiência das unidades de urgência e emergência: Análise Envoltória de Dados / Efficiency assessment of urgency and emergency units: Data Envelopment Analysis

Presumindo-se que os gestores de unidade de saúde do SUS tenham dois objetivos principais: 1. maximizar o número de internações (modelo orientado à produção), 2. reduzir os recursos consumidos em excesso, ou seja, quanto poderia reduzir em número de leitos, pessoal e valor de AIH para produzir as mesmas altas (modelo orientado à redução de consumo). O índice de eficiência, que assume o valor no intervalo de [0, 1], é capaz de fazer a relação entre os resultados atingidos pelas unidades de saúde no sentido de minimizar gastos/consumos e maximizar a produção. A análise envoltória de dados (DEA ­ do inglês data envelopment analysis) é uma técnica de pesquisa operacional, cujo objetivo é analisar comparativamente unidades independentes no que se refere ao desempenho relativo. Uma unidade de tomada de decisão (DMU ­ do inglês Decision Making Units) é considerada eficiente se pertencer à fronteira de eficiência dos dados, ou seja, quanto mais próximo a 1, mais eficiente é considerada a DMU, sendo que valores iguais a 1 indicam eficiência máxima. A análise envoltória de dados (DEA ­ do inglês data envelopment analysis) é uma técnica de pesquisa operacional, cujo objetivo é analisar comparativamente unidades independentes no que se refere ao desempenho relativo. Uma unidade de tomada de decisão (DMU ­ do inglês Decision Making Units) é considerada eficiente se pertencer à fronteira de eficiência dos dados, ou seja, quanto mais próximo a 1, mais eficiente é considerada a DMU, sendo que valores iguais a 1 indicam eficiência máxima

Assuming that SUS health unit managers have two main objectives: 1. Maximize the number of hospitalizations (production-oriented model),2. reduce the resources consumed in excess, that is, how much could be reduced in the number of beds, personnel and value of AIH to produce the same discharges (model oriented to the reduction of consumption). The efficiency index, which assumes the value in the range of [0, 1], is able to make the relationship between the results achieved by the health units in order to minimize expenses/consumptions and maximize production. Data envelopment analysis (DEA) is an operations research technique whose objective is to comparatively analyze independent units with regard to relative performance. A decision making unit (DMU) is considered efficient if it belongs to the data efficiency frontier, that is, the closer to 1, the more efficient the DMU is considered, with values ​​equal to 1 indicating maximum efficiency. Data envelopment analysis (DEA) is an operations research technique whose objective is to comparatively analyze independent units with regard to relative performance. A decision making unit (DMU) is considered efficient if it belongs to the data efficiency frontier, that is, the closer to 1, the more efficient the DMU is considered, with values ​​equal to 1 indicating maximum efficiency

Long-term survival in high-risk older adults following emergency general surgery admission.

BACKGROUND: Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions. METHODS: We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups. RESULTS: A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation. CONCLUSION: Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients. LEVEL OF EVIDENCE: Epidemiological, level III.

The impact of COVID-19 pandemic in stroke code activation and time from symptom onset to hospital arrival in a Portuguese comprehensive stroke centre. / El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) impacted emergency services worldwide. AIM: We aimed to evaluate COVID-19 effect on the number of stroke code activations and timings during the first two months of the pandemic. MATERIAL AND METHODS: We reviewed the stroke code database of a single comprehensive stroke centre in Portugal for the number of activations through 2019-2020. We compared the pathway timings between March and April 2020 (COVID-19 period) and the homologous months of the previous four years (pre-COVID-19 period), whilst using February as a control. RESULTS: Monthly stroke code activation rates decreased up to 34.2% during COVID-19 pandemic. Compared to the pre-COVID-19 period, we observed an increase in the time from symptom onset to emergency call, with a significant number of patients waiting more than four hours (March 20.8% vs. 6.8%, p = 0.034; April 23.8% vs. 6%, p = 0.01); as well as an increase in the time from symptom onset to hospital arrival (March: median 136 minutes [IQR 106-410] vs. 100 [IQR 64-175], p = 0.001; April: median 188 [IQR 96-394] vs. 98 [IQR 66-168], p = 0.007). No difference between both periods was found concerning in-hospital times, patient characteristics, stroke/mimic diagnosis, stroke severity, and mortality. CONCLUSION: COVID-19 related factors probably reduced healthcare services utilization, and delayed emergency calls and hospital arrival after stroke onset. These highlight the importance of health education to improve the effectiveness of medical assistance. The preservation of in-hospital times validates the feasibility of the protected stroke code protocol.

TITLE: El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.Introducción. La enfermedad por coronavirus 2019 (COVID-19) provocó un considerable impacto mundial en los servicios de emergencia. Objetivo. Se pretende evaluar el efecto de la COVID-19 sobre el número y los tiempos de activaciones del Código Ictus en el comienzo de la pandemia. Material y métodos. Se revisó la base de datos del Código Ictus de un centro de ictus de Portugal entre 2016 y 2020. Se compararon los tiempos de activación entre marzo y abril de 2020 (período COVID-19) y los meses homólogos de los cuatro años anteriores, mientras que se utilizó febrero como control. Resultados. Las tasas mensuales de activación disminuyeron hasta el 34,2% durante la pandemia. En comparación con el período previo, se observó un aumento del tiempo desde los síntomas hasta la llamada de emergencia, con un aumento de pacientes que esperaron más de cuatro horas (marzo: 20,8 frente a 6,8%, p = 0,034; abril: 23,8 frente a 6%, p = 0,01) y del tiempo desde los síntomas hasta la llegada al hospital ­marzo: mediana de 136 minutos (rango intercuartílico [RIC]: 106-410) frente a 100 (RIC: 64-175), p = 0,001; abril: mediana de 188 (RIC: 96-394) frente a 98 (RIC: 66-168), p = 0,007­. No hubo diferencias en los tiempos de internamiento, las características de los pacientes, el diagnóstico de ictus/stroke mimics, la gravedad del ictus o la mortalidad. Conclusión. Los factores relacionados con la COVID-19 redujeron la utilización de los servicios sanitarios y retrasaron las llamadas de emergencia y el tiempo de llegada al hospital. Esto demuestra la importancia de la educación sanitaria para mejorar la eficacia de la asistencia médica.

Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts.

BACKGROUND: Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS: We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS: Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION: Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.