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1.
Vasc Med ; 22(1): 51-56, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27811236

RESUMO

Published reports indicate low retrieval rates for retrievable inferior vena cava (IVC) filters. We performed a historic-controlled study of a 5-year intervention (March 2007 to February 2012) to improve IVC filter retrieval rates at a university medical center serving a rural area. All adults with a retrievable filter placed were included, except those with a life expectancy <6 months. The intervention included initial verbal counseling and printed educational materials, correspondence after discharge, and a hematology consultation. The control group included patients with retrievable filters placed in the 15 months preceding study initiation. In the control group, 116 filters were placed and 27 (23%) were removed, compared to 378 filters placed and 169 (45%) removed during the intervention. Adjusting for patient characteristics, the odds ratio of retrieval during the intervention was 3.03 (95% CI 1.85-4.27) compared to the control period. An intervention including patient education and hematology follow-up appeared to significantly improve IVC filter retrieval rates.


Assuntos
Remoção de Dispositivo/métodos , Equipe de Assistência ao Paciente , Avaliação de Processos em Cuidados de Saúde , Implantação de Prótese/instrumentação , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Filtros de Veia Cava , Centros Médicos Acadêmicos , Adulto , Idoso , Remoção de Dispositivo/normas , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Hematologia , Estudo Historicamente Controlado , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Equipe de Assistência ao Paciente/normas , Educação de Pacientes como Assunto , Avaliação de Processos em Cuidados de Saúde/normas , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Encaminhamento e Consulta , Estudos Retrospectivos , Serviços de Saúde Rural , Fatores de Tempo , Resultado do Tratamento , Vermont
2.
JAMA Surg ; 148(10): 924-31, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23945834

RESUMO

IMPORTANCE: Severe renal injuries after blunt trauma cause diagnostic and therapeutic challenges for the treating clinicians. The need for an operative vs a nonoperative approach is debated. OBJECTIVE: To determine the rate, causes, predictors, and consequences of failure of nonoperative management (NOM) in grade IV and grade V blunt renal injuries (BRIs). DESIGN: Retrospective case series. SETTING: Twelve level I and II trauma centers in New England. PARTICIPANTS: A total of 206 adult patients with a grade IV or V BRI who were admitted between January 1, 2000, and December 31, 2011. MAIN OUTCOMES AND MEASURES: Failure of NOM, defined as the need for a delayed operation or death due to renal-related complications during NOM. RESULTS: Of 206 patients, 52 (25.2%) were operated on immediately, and 154 (74.8%) were managed nonoperatively (with the assistance of angiographic embolization for 25 patients). Nonoperative management failed for 12 of the 154 patients (7.8%) and was related to kidney injury in 10 (6.5%). None of these 10 patients had complications because of the delay in BRI management. The mean (SD) time from admission to failure was 17.6 (27.4) hours (median time, 7.5 hours; range, 4.5-102 hours), and the cause was hemodynamic instability in 10 of the 12 patients (83.3%). Multivariate analysis identified 2 independent predictors of NOM failure: older than 55 years of age and a road traffic crash as the mechanism of injury. When both risk factors were present, NOM failure occurred for 27.3% of the patients; when both were absent, there were no NOM failures. Of the 142 patients successfully managed nonoperatively, 46 (32.4%) developed renal-related complications, including hematuria (24 patients), urinoma (15 patients), urinary tract infection (8 patients), renal failure (7 patients), and abscess (2 patients). These patients were managed successfully with no loss of renal units (ie, kidneys). The renal salvage rate was 76.2% for the entire population and 90.3% among patients selected for NOM. CONCLUSIONS AND RELEVANCE: Hemodynamically stable patients with a grade IV or V BRI were safely managed nonoperatively. Nonoperative management failed for only 6.5% of patients owing to renal-related injuries, and three-fourths of the entire population retained their kidneys.


Assuntos
Rim/lesões , Ferimentos não Penetrantes/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo , New England/epidemiologia , Estudos Retrospectivos , Terapia de Salvação , Fatores de Tempo , Centros de Traumatologia , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos não Penetrantes/classificação , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia
3.
J Trauma Acute Care Surg ; 72(4): 815-20; quiz 1124-5, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22491591

RESUMO

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and percutaneous dilatational tracheostomy (PDT) are frequently performed bedside in the intensive care unit. Critically ill patients frequently require anticoagulant (AC) and antiplatelet (AP) therapies for myriad indications. There are no societal guidelines proffering strategies to manage AC/AP therapies periprocedurally for bedside PEG or PDT. The aim of this study is to evaluate the management of AC/AP therapies around PEG/PDT, assess periprocedural bleeding complications, and identify risk factors associated with bleeding. METHODS: A retrospective, observational study of all adult patients admitted from October 2004 to December 2009 receiving a bedside PEG or PDT was conducted. Patients were identified by procedure codes via an in-hospital database. A medical record review was performed for each included patient. RESULTS: Four hundred fifteen patients were included, with 187 PEGs and 352 PDTs being performed. Prophylactic anticoagulation was held for approximately one dose before and two doses or less after the procedure. There was wide variation in patterns of holding therapy in patients receiving anticoagulation via continuous infusion. There were 19 recorded minor bleeding events, 1 (0.5%) with PEG and 18 (5.1%) with PDT, with no hemorrhagic events. No association was found between international normalized ratio, prothrombin time, or activated partial thromboplastin time values and bleed risk (p = 0.853, 0.689, and 0.440, respectively). Platelet count was significantly lower in patients with a bleeding event (p = 0.006). CONCLUSIONS: We found that while practice patterns were quite consistent in regard to the management of prophylactic anticoagulation, it varied widely in patients receiving therapeutic anticoagulation. It seems that prophylactic anticoagulation use did not affect bleed risk with PEG/PDT.


Assuntos
Anticoagulantes/uso terapêutico , Gastrostomia/métodos , Traqueostomia/métodos , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Perda Sanguínea Cirúrgica , Feminino , Gastroscopia/efeitos adversos , Gastroscopia/métodos , Gastrostomia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Contagem de Plaquetas , Sistemas Automatizados de Assistência Junto ao Leito , Tempo de Protrombina , Estudos Retrospectivos , Fatores de Risco , Traqueostomia/efeitos adversos
4.
J Trauma ; 71(1): 49-54; discussion 55, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21818014

RESUMO

BACKGROUND: Rural trauma victims often require prolonged transport by s with limited scopes of practice. We evaluated the impact of telemedicine (TM) to a moving ambulance on outcomes in simulated trauma patients. METHODS: This is an institutional review board approved, prospective double-blind study. Three trauma scenarios (blunt torso trauma, epigastric stab wound, and closed head injury) were created for a human patient simulator. Intermediate emergency medical technicians (EMTs; n = 20) managed the human patient simulator, in a moving ambulance. In the TM group, physicians (n = 12) provided consultation. In the non-TM group, EMTs communicated with medical control by radio, as necessary. We tabulated the fraction of 13 key signs, 5 pathologic processes, and 12 key interventions that were performed. Vital signs and Sao2 (%) were recorded. Data were compared using the Wilcoxon rank-sum test. RESULTS: Lowest Sao2 (84 ± 0.7 vs. 78 ± 0), lowest systolic blood pressure (70 ± 1 vs. 53 ± 1), and highest heart rate (144 ± 0.9 vs. 159 ± 0.5) were significantly improved in the TM group (p < 0.001). Recognition rates for key signs (0.96 ± 0.01 vs. 0.79 ± 0.05), processes (0.98 ± 0.02 vs. 0.75 ± 0.05), and critical interventions (0.92 ± 0.02 vs. 0.49 ± 0.03) were higher in the TM group (p < 0.003). EMTs were successfully guided through needle decompression procedures in 22 of 24 cases (zero in the non-TM group). CONCLUSION: TM to a moving ambulance improved the care of simulated trauma patients. Furthermore, procedurally naïve EMTs were able to perform needle thoracostomy and pericardiocentesis with TM guidance.


Assuntos
Ambulâncias/provisão & distribuição , Avaliação de Resultados em Cuidados de Saúde , Simulação de Paciente , Telemedicina/instrumentação , Ferimentos e Lesões/terapia , Método Duplo-Cego , Desenho de Equipamento , Humanos , Estudos Prospectivos , Estados Unidos
5.
Am J Health Syst Pharm ; 68(2): 130-4, 2011 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-21200059

RESUMO

PURPOSE: Use of continuous phentolamine infusion therapy for management of serious cardiovascular complications during adrenalectomy for pheochromocytoma is reported. SUMMARY: In preparation for surgical resection of a pheochromocytoma, a 38-year-old woman received outpatient oral therapy with the α-adrenergic-receptor blocker phenoxybenzamine for 25 days with the goal of reducing cardiovascular risks associated with catecholamine surge during surgery. Due to inappropriate dosage adjustment, however, outpatient phenoxybenzamine therapy did not achieve adequate α-adrenergic-receptor blockade; during the laparoscopic resection procedure, the woman developed severe hypertension, leading to cardiac arrest and discontinuation of the operation. After resuscitative measures, the patient was admitted to the surgical intensive care unit for mechanical ventilation, medical management (including intermittent bolus injections of phentolamine and a continuous i.v. infusion of esmolol for control of blood pressure and heart rate), and hemodynamic monitoring; despite those measures, cardiovascular instability persisted during the immediate postoperative period. The day after the abortive surgery attempt, a continuous infusion of phentolamine mesylate (1 mg/hr, adjusted hourly to achieve the blood pressure target) was initiated. Four days after initiation of continuous phentolamine infusion, the patient was deemed to be hemodynamically stable, and the surgery was successfully performed. CONCLUSION: A continuous infusion of phentolamine was used in a patient with pheochromocytoma to control perioperative hypertensive episodes during surgical adrenalectomy.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Anti-Hipertensivos/administração & dosagem , Infusões Intravenosas/métodos , Fentolamina/administração & dosagem , Feocromocitoma/cirurgia , Adulto , Anti-Hipertensivos/farmacologia , Feminino , Humanos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Fentolamina/farmacologia , Complicações Pós-Operatórias , Resultado do Tratamento
6.
Telemed J E Health ; 14(3): 266-72, 2008 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-18570551

RESUMO

Emergency healthcare systems in rural communities often have limited access to experienced trauma and emergency physicians. Advanced telecommunication technologies may offer an opportunity to help meet this need. We evaluated healthcare providers' satisfaction with the audio and visual components of an existing telemedicine system, and asked them whether emergency medical services (EMS) personnel could be supported via telemedicine guidance, using video laryngoscopy and ultrasonography, during vulnerable transport periods. Physicians and technologists at a central workstation were linked to a telemedicine-equipped ambulance providing real-time audio and visual communications during patient transport. A scoring system was created for system evaluation using a scale of 1-9. Seven evaluators observed ultrasonography of the carotid vessels and abdominal aorta. Nine evaluators observed an intubation with video laryngoscopy. These observers rated the quality of the images transmitted from the ambulance. Evaluators were asked if this telemedicine system would be suitable for telementoring advanced technical procedures. Mean rating for technical satisfaction with ultrasound was 5.1, the majority of evaluators estimated that they could telementor an abdominal ultrasound examination. The mean rating for technical satisfaction with laryngoscopy was 7.2 with 100% of evaluators estimating they could use the system to telementor intubation. The rating for laryngoscopy was significantly higher than for ultrasound (p = 0.01). Results of this study suggest that telemedicine may provide an advanced support mechanism for rural EMS personnel and patients. Procedures for advanced airway management and ultrasound diagnosis may someday be managed using a remote telepresence.


Assuntos
Laringoscopia/métodos , Unidades Móveis de Saúde , Consulta Remota , Telemedicina , Ultrassonografia , Cirurgia Vídeoassistida , Adulto , Serviços Médicos de Emergência , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
7.
Ann Pharmacother ; 42(2): 185-91, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18212256

RESUMO

BACKGROUND: Concerns surrounding the potential extra gut complication of gastric acid suppression are becoming increasingly realized. OBJECTIVE: To determine whether chronic antisecretory treatment with a proton pump inhibitor (PPI) or histamine(2)-receptor antagonist (H(2)RA) is associated with the presence of Candida spp. in cases of complicated intraabdominal infection. METHODS: We conducted a case-controlled study of adult surgical intensive care unit patients with complicated intraabdominal infection during a 5-year period. Exclusion criteria consisted of primary peritonitis, diagnosis of intraabdominal infection more than 72 hours before hospital admission, or a stay in the intensive care unit of less than 72 hours. Patients were categorized into either the antisecretory group (H(2)RA or PPI therapy prior to admission) or control group (no prior antisecretory therapy). RESULTS: One hundred eighteen patients met inclusion criteria. Chronic antisecretory (n = 41) and control (n = 77) patients were similar except in median age (69.0 vs 59.0 y; p = 0.026) and preadmission antibiotic use (36.6% vs 15.6%; p = 0.010). The 2 groups had a similar proportion of patients with Candida (30.3% vs 32.1%; p = 0.857); the cultures included C. albicans, C. glabrata, and C. parapsilosis. Yeast was recovered more often in patients diagnosed with community-acquired intraabdominal infection and in patients who had used PPIs before hospital admission (p = 0.066). Additionally, Candida was cultured more often in antisecretory patients with a history of prior abdominal surgery than in control patients (91.7% vs 62.5%; p = 0.066). CONCLUSIONS: No significant difference was found in the number of patients in the antisecretory and control groups from whom peritoneal Candida was recovered. However, patients with prior abdominal surgery and those in the community with chronic PPI use may be predisposed to Candida-associated intraabdominal infections.


Assuntos
Abdome/microbiologia , Candida/isolamento & purificação , Candidíase/etiologia , Infecção Hospitalar/etiologia , Antagonistas dos Receptores H2 da Histamina/uso terapêutico , Inibidores da Bomba de Prótons/uso terapêutico , Idoso , Candidíase/induzido quimicamente , Candidíase/prevenção & controle , Estudos de Casos e Controles , Infecção Hospitalar/induzido quimicamente , Infecção Hospitalar/prevenção & controle , Feminino , Antagonistas dos Receptores H2 da Histamina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Bomba de Prótons/efeitos adversos , Estudos Retrospectivos
8.
Am Surg ; 71(8): 690-3, 2005 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-16217954

RESUMO

Systems of trauma care in urban areas have a demonstrated survival benefit. Little is known of the benefit of trauma system organization in rural areas. We hypothesized that examination of all trauma deaths during a 1-year period would provide opportunities to improve care in our rural state. We used a medical examiner database of trauma deaths occurring during a 1-year period. Five board-certified surgeons analyzed deaths as preventable (P), potentially preventable (PP), and non-preventable (NP) using modified Delphi technique. There were 223 trauma deaths during a 1-year period. Most (63%) died at the scene prior to any medical intervention. Adjudication of the deaths demonstrated 5 P (2%; 95% CI 1-5%), 36 PP (16%; 95% CI 12-27%), and 179 NP (81%; 95% CI 76-86%). Agreement among trauma surgeons was only moderate with a k of 0.46. Suicide accounted for a significant number of the overall trauma deaths at 32 per cent. Rural trauma system design should focus on discovery, as that is where the majority of deaths occur. Suicide is a significant problem in this rural state that should be aggressively targeted with prevention programs.


Assuntos
Avaliação das Necessidades , Programas Médicos Regionais/organização & administração , População Rural , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Feminino , Hospitais Rurais/organização & administração , Humanos , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Estudos Retrospectivos , Vermont , Ferimentos e Lesões/prevenção & controle
9.
J Trauma ; 58(5): 911-4; discussion 914-6, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15920402

RESUMO

BACKGROUND: The new Accreditation Council for Graduate Medical Education-mandated 80-hour resident work week has resulted in busy trauma services struggling to meet these strict guidelines, or face loss of accreditation. METHODS: Beginning in July 2003, our Level I trauma service began a policy of direct admission of isolated neurosurgical or orthopedic injuries to the specific subspecialty service after complete evaluation by the trauma service in the emergency department for associated injuries. Complications, missed injuries, delayed diagnoses, and admission rates were compared in two 6-month periods: PRE, before the policy change; and POST, after the new policy had been instituted. Resident work hours were likewise compared over the two time periods. RESULTS: Selected single-system injury admission to subspecialty services resulted in a 15% reduction in admissions to the trauma service. There were no significant differences in the overall complication rate, delayed diagnoses, or missed diagnoses between the PRE and POST time periods. Overall, there was a 9.7% reduction in resident work hours (p = 0.45; analysis of variance) between the PRE and POST periods, which allowed them, on average, to meet the Accreditation Council for Graduate Medical Education 80-hour workweek mandate. CONCLUSION: Direct admission of patients with isolated injuries to subspecialty services is safe and decreases the workload of residents on busy trauma services.


Assuntos
Internato e Residência/organização & administração , Internato e Residência/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/organização & administração , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Distribuição por Idade , Erros de Diagnóstico/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Medicina/organização & administração , Medicina/estatística & dados numéricos , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Especialização , Traumatologia/educação , Vermont
10.
J Surg Res ; 106(2): 282-6, 2002 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-12175979

RESUMO

BACKGROUND: Reflectance near-infrared spectroscopy (600-2200 nm) can noninvasively probe deep into tissues. Blood is the predominant absorber of near-infrared light in biological tissues. We investigated the feasibility of using reflectance near-infrared spectroscopy to measure blood pH in vitro. METHODS: Reflectance near-infrared spectra (600-2200 nm) were obtained with a fiberoptic probe immersed in diluted human packed red blood cells maintained at 37 degrees C. Changes in pH (6.800-7.600) were induced by: (1) varying the partial pressure of carbon dioxide by the bubbling of mixtures of humidified carbon dioxide and nitrogen gas through the blood; and (2) adding 1 N HCl/NaOH. Humidified oxygen gas was bubbled through the blood to generate variations in oxygen saturation. After each titration of pH, the spectrum was recorded and blood was sampled for the measurement of: pH, pCO(2), and pO(2) using blood gas analysis; and hemoglobin concentration and oxygen saturation using co-oximetry. Samples from three separate pH titrations were combined (120 total samples) and analyzed using partial least-squares analysis to generate a mathematical model relating spectral changes to pH (calibration set). This model was then used to predict the pH of a set of 36 pH titrations (prediction set). RESULTS: Quantitative and qualitiative analyses of the spectra in the calibration set found that spectral changes in the wavelength range, 650-1050 nm, were directly related to changes in pH. First-derivative-treated spectra from the calibration set, analyzed using partial least-squares analysis, generated a mathematical model with a cross-validated r(2) of 0.939 and a standard error of calibration of 0.046 pH unit. When this model was applied to the prediction set, with an offset correction, the r(2) was 0.936 with a standard error of prediction of 0.050 pH unit. CONCLUSION: Blood pH can be predicted in vitro with clinical significance using reflectance near-infrared spectroscopy (650-1050 nm) within a standard error of 0.050 pH unit.


Assuntos
Hidrogênio/sangue , Espectroscopia de Luz Próxima ao Infravermelho/normas , Calibragem , Previsões , Humanos , Concentração de Íons de Hidrogênio , Análise dos Mínimos Quadrados , Modelos Biológicos
11.
Circulation ; 105(8): 923-7, 2002 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-11864919

RESUMO

BACKGROUND: A method is needed to identify nonstenotic, lipid-rich coronary plaques that are likely to cause acute coronary events. Near-infrared (NIR) spectroscopy can provide information on the chemical composition of tissue. We tested the hypothesis that NIR spectroscopy can identify plaque composition and features associated with plaque vulnerability in human aortic atherosclerotic plaques obtained at the time of autopsy. METHODS AND RESULTS: A total of 199 samples from 5 human aortic specimens were analyzed by NIR spectroscopy. Features of plaque vulnerability were defined by histology as presence of lipid pool, thin fibrous cap (<65 microm by ocular micrometry), and inflammatory cell infiltration. An InfraAlyzer 500 spectrophotometer was used. Spectral absorbance values were obtained as log (1/R) data from 1100 to 2200 nm at 10-nm intervals. Principal component regression was used for analysis. An algorithm was constructed with 50% of the samples used as a reference set; blinded predictions of plaque composition were then performed on the remaining samples. NIR spectroscopy sensitivity and specificity for histological features of plaque vulnerability were 90% and 93% for lipid pool, 77% and 93% for thin cap, and 84% and 89% for inflammatory cells, respectively. CONCLUSIONS: NIR spectroscopy can identify plaque composition and features associated with plaque vulnerability in postmortem human aortic specimens. These results support efforts to develop an NIR spectroscopy catheter system to detect vulnerable coronary plaques in living patients.


Assuntos
Aorta/patologia , Arteriosclerose/patologia , Fibrose/patologia , Inflamação/patologia , Lipídeos/análise , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Algoritmos , Aorta/química , Estudos de Viabilidade , Humanos , Valor Preditivo dos Testes , Análise de Componente Principal , Fatores de Risco , Sensibilidade e Especificidade , Espectroscopia de Luz Próxima ao Infravermelho/instrumentação
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