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2.
J Trauma Acute Care Surg ; 91(5): 829-833, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34695059

RESUMO

BACKGROUND: Trauma care is associated with unplanned readmissions, which may occur at facilities other than the index treatment facility. This "fragmentation of care" may be associated with adverse outcomes. We evaluated a statewide database that includes readmissions to analyze the incidence and impact of FC. METHODS: The California Office of Statewide Health Planning and Development patient discharge data set was evaluated for calendar years 2016 to 2018. Patients 15 years or older diagnosed with blunt abdominal solid organ injury during the index admission were identified. Readmissions were evaluated postdischarge at 1, 3, and 6 months. Patients readmitted within 6 months to a facility other than the index admission facility (fragmented care [FC]) were compared with those readmitted to their index admission facility (non-FC). Logistic regression modeling was used to evaluate risk of FC. RESULTS: Of the total 1,580 patients, there were 752 FC (47.6%) and 828 (52.4%) non-FC. Readmissions representing FC at months 1, 3, and 6 were 40.3%, 49.3%, and 53.4%, respectively. At index admission, the groups were demographically and clinically similar, with similar rates of abdominal operations and complications. Non-FC patients had a higher rate of abdominal reoperation at readmission (5.8% non-FC vs. 2.9% FC, p = 0.006). In an adjusted model, multiple readmissions (odds ratio [OR] 1.11, p = 0.014), readmission >30 days after index facility discharge (OR, 1.98; p < 0.001), and discharge to a nonmedical facility (OR, 2.46; p < 0.0001) were associated with increased odds of FC. Operative intervention at index admission was associated with lower odds of FC (OR, 0.77; p = 0.039). However, FC was not independently associated with demographic or insurance characteristics. CONCLUSION: The rate of FC among patients with blunt abdominal injury is high. The risk of FC is mitigated when patients are managed operatively during the index admission. Trauma systems should implement measures to ensure that these patients are followed postdischarge. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III; Care management, level IV.

4.
J Med Chem ; 64(18): 13704-13718, 2021 Sep 23.
Artigo em Inglês | MEDLINE | ID: mdl-34491761

RESUMO

The epidermal growth factor receptor (EGFR) harboring activating mutations is a clinically validated target in non-small-cell lung cancer, and a number of inhibitors of the EGFR tyrosine kinase domain, including osimertinib, have been approved for clinical use. Resistance to these therapies has emerged due to a variety of molecular events including the C797S mutation which renders third-generation C797-targeting covalent EGFR inhibitors considerably less potent against the target due to the loss of the key covalent-bond-forming residue. We describe the medicinal chemistry optimization of a biochemically potent but modestly cell-active, reversible EGFR inhibitor starting point with sub-optimal physicochemical properties. These studies culminated in the identification of compound 12 that showed improved cell potency, oral exposure, and in vivo activity in clinically relevant EGFR-mutant-driven disease models, including an Exon19 deletion/T790M/C797S triple-mutant mouse xenograft model.

5.
Artigo em Inglês | MEDLINE | ID: mdl-34538823

RESUMO

This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax (PTX). The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Figure 1) and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE: V, Consensus algorithm from the Western Trauma Association.

6.
J Fam Pract ; 70(5): 220-228, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34410912

RESUMO

After confirmation of the diagnosis, follow up with recommendations for lifestyle adjustment and, in certain clinical situations, pursue medical therapy.


Assuntos
Hipertensão/diagnóstico , Pediatria/métodos , Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial/instrumentação , Determinação da Pressão Arterial/métodos , Humanos , Hipertensão/tratamento farmacológico , Pediatria/tendências
7.
J Surg Res ; 268: 491-497, 2021 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-34438190

RESUMO

BACKGROUND: Traumatic intracranial hemorrhage (ICH) is a highly morbid injury, particularly among elderly patients on preinjury anticoagulants (AC). Many trauma centers initiate full trauma team activation (FTTA) for these high-risk patients. We sought to determine if FTTA was superior compared with those who were evaluated as a trauma consultation (CON). METHODS: Patients aged ≥55 on preinjury AC who presented from January 2015 to December 2019 with blunt isolated head injury (non-head AIS ≤2) and confirmed ICH were identified. CON patients and FTTA patients were matched by age and head AIS. Cox proportional hazard model was used to assess patient and injury characteristics with mortality and survivor discharge disposition. REASULTS: There were 45 CON patients and 45 FTTA patients. Mean age was 80 years in both groups. Fall was the most common mechanism (98% CON vs. 92% FTTA). Glasgow Coma Score (GCS) was lower in FTTA (14 vs. 15, p<0.01). CON had a significantly longer time from arrival to CT scan (1.3 vs. 0.4 hrs, p<0.01). Hospital days were similar (CON: 3.9 vs. FTTA: 3.7 days). However, CON had increased ventilator use (p=0.03). Lower admission GCS was the only factor associated with increased risk of death. Among survivors, only head AIS increased the risk of discharge to a level of care higher than that of preinjury (p=0.01). CONCLUSION: There was no difference in mortality or adverse discharge disposition between FTTA and CON, although FTTA was associated with a more rapid evaluation and diagnosis. Any alteration in GCS was strongly associated with mortality and should prompt evaluation by FTTA.

9.
Surgery ; 2021 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-34253322

RESUMO

BACKGROUND: Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood. METHODS: Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates. RESULTS: The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group. CONCLUSION: Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.

10.
Ann Surg ; 274(3): 434-440, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34132701

RESUMO

OBJECTIVES: A courtesy author is an individual who has not met authorship criteria but is listed as an author. This practice is common and often seen as victimless. Because publications are used for funding and promotion decisions, it is critical to understand biases in this practice. METHODS: An anonymous survey was conducted from March to October 2020 of first and senior authors of publications from 2014 to 2015 in 8 surgical journals. Authors were surveyed about demographic data, practice setting, and courtesy author practices. RESULTS: Three hundred forty-one authors responded (16% response rate). 75% were from academic practice settings. 14% reported adding courtesy authors 5 or more times in the past year. Courtesy authors were more often male (80%, P = 0.023), older (75%), and of higher academic rank (65%) than first/senior authors. All author groups were >75% white. When a reason was reported, 46% added a courtesy author due to avoid retaliation; 64% to avoid awkwardness. 26% expected reciprocal authorship offers. 92% of respondents acknowledge understanding International Committee of Medical Journal Editors authorship criteria. Women were less common among those added from goodwill than those added from fear (P = 0.039.) When courtesy authors were of a lower rank than first/senior authors, they were nearly twice as likely to be female (P = 0.0056) or non-white (P = 0.0184.). CONCLUSION: Courtesy authors were more often male, older, and higher rank than first/senior authors. Fear of career consequences was a major motivator for including courtesy authors. Understanding the motivations and pressures leading to courtesy authorship will help to correct this practice.


Assuntos
Autoria , Cirurgia Geral , Motivação , Publicações Periódicas como Assunto/estatística & dados numéricos , Editoração/estatística & dados numéricos , Sexismo , Pesquisa Biomédica , Feminino , Humanos , Relações Interpessoais , Masculino , Inquéritos e Questionários
14.
Respirology ; 26(7): 666-672, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33939245

RESUMO

BACKGROUND AND OBJECTIVE: Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker that reflects IL-4/IL-13 production and therefore represents T2 allergic inflammation. FeNO has previously been used to guide inhaled corticosteroid (ICS) treatment in asthma. The purpose of this study was to determine if a low FeNO (≤27 ppb) could be used to reliably identify patients with symptoms suggestive of asthma who would not benefit from initiating treatment with an ICS. METHODS: A total of 180 steroid-naïve adults with healthcare professional suspected asthma and an FeNO of ≤27 ppb were randomized to receive either 400 mcg of budesonide or placebo daily for 3 months. The primary outcome was the difference in the Asthma Control Questionnaire 7 (ACQ7) between treatment groups and the study was powered to determine equivalence. Secondary outcomes were the difference in FEV1 , Medical Research Council and Leicester Cough Questionnaire scores. RESULTS: One hundred and thirty-four patients (68 budesonide and 66 placebo) completed the study and were included in the analysis. The between-group mean difference in ACQ7 from baseline to the end of the study was -0.25 and the 95% CI around this difference was -0.004 to 0.495 confirming equivalence (p < 0.05). Differences in forced expiratory volume over 1 s and other secondary outcomes were also small and clinically unimportant. CONCLUSION: The results of this study suggest that steroid-naïve patients with symptoms suggestive of asthma and an FeNO ≤ 27 ppb are unlikely to benefit from initiating treatment with an ICS over 3 months. However, further research is recommended to confirm these findings before withholding ICS treatment.


Assuntos
Corticosteroides/uso terapêutico , Asma , Óxido Nítrico , Administração por Inalação , Adulto , Asma/diagnóstico , Asma/tratamento farmacológico , Testes Respiratórios , Expiração , Humanos
15.
Shock ; 2021 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-34033617

RESUMO

ABSTRACT: Hemorrhage, and particularly noncompressible torso hemorrhage (NCTH) remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely-injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

16.
J Trauma Acute Care Surg ; 91(2S Suppl 2): S146-S153, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33797495

RESUMO

INTRODUCTION: Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments. METHODS: Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion. RESULTS: There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact. CONCLUSION: Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups. LEVEL OF EVIDENCE: Prospective observational study, level III.


Assuntos
Salas Cirúrgicas , Ressuscitação/métodos , Ferimentos e Lesões/cirurgia , Adulto , Protocolos Clínicos , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Prospectivos , Fatores de Tempo , Centros de Traumatologia , Traumatologia/métodos , Ferimentos Penetrantes/cirurgia
17.
J Trauma Acute Care Surg ; 91(3): 537-541, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33901051

RESUMO

BACKGROUND: Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE). METHODS: Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE. RESULTS: There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH. CONCLUSION: Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications. LEVEL OF EVIDENCE: Prognostic and epidemiological, level II; Therapeutic, level III.


Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Embolia Pulmonar/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Adulto , Idoso , Anticoagulantes/economia , California/epidemiologia , Feminino , Heparina/economia , Heparina de Baixo Peso Molecular/economia , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/epidemiologia , Centros de Traumatologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia
18.
J Trauma Acute Care Surg ; 91(4): 584-589, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33783419

RESUMO

INTRODUCTION: Pediatric adjusted shock index (SIPA) has demonstrated the ability to prospectively identify children at the highest risk for early mortality. The addition of neurological status to shock index has shown promise as a reliable triage tool in adult trauma populations. This study sought to assess the utility of combining SIPA with Glasgow Coma Scale (GCS) for predicting early trauma-related outcomes. METHODS: Retrospective review of the 2017 Trauma Quality Improvement Program Database was performed for all severely injured patients younger than 18 years old. Pediatric adjusted shock index and reverse SIPA × GCS (rSIG) were calculated. Age-specific cutoff values were derived for reverse shock index multiplied by GCS (rSIG) and compared with their SIPA counterparts for early mortality assessment using area under the receiver operating characteristic curve analyses. RESULTS: A total of 10,389 pediatric patients with an average age of 11.4 years, 67% male, average Injury Severity Score of 24.1, and 4% sustaining a major penetrating injury were included in the analysis. The overall mortality was 9.3%. Furthermore, 32.1% of patients displayed an elevated SIPA score, while only 27.5% displayed a positive rSIG. On area under the receiver operating characteristic curve analysis, rSIG was found to be superior to SIPA as a predictor for in hospital mortality with values of 0.854 versus 0.628, respectively. CONCLUSION: Reverse shock index multiplied by GCS more readily predicted in hospital mortality for pediatric trauma patients when compared with SIPA. These findings suggest that neurological status should be an important factor during initial patient assessment. Further study to assess the applicability of rSIG for expanded trauma-related outcomes in pediatric trauma is necessary. LEVEL OF EVIDENCE: Prognostic study, level IV.

19.
Am J Surg ; 221(6): 1246-1251, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33707080

RESUMO

BACKGROUND: Methamphetamine (METH) is associated with an elevated risk of injury and the outcomes in the elderly remain unclear. We analyzed METH's impact in elderly trauma patients. METHODS: Retrospective analysis (2009-2018) of trauma patients at a Level I trauma center. Elderly patients were defined as age ≥55. Substance use was identified by blood alcohol test and urine drug screen. Cox proportional hazard model was used to assess patient and injury characteristics with mortality. RESULTS: Of 15,770 patient encounters with substance use testing, 5278 (34%) were elderly. Elderly METH use quadrupled over time (2%-8%; p < 0.01). Elderly METH + patients were more likely to require surgical intervention (35% vs. 17%), mechanical ventilation (15% vs. 7%), and a longer hospitalization (6.5 vs. 3.6 days) compared with elderly substance negative. Multivariate analysis showed increasing age, ventilator use, and injury severity were associated with mortality (ps < 0.01); METH was not related to mortality. CONCLUSION: Substance use in elderly trauma patients increased significantly. METH use in elderly trauma patients is a risk factor for significantly greater resource utilization.


Assuntos
Transtornos Relacionados ao Uso de Anfetaminas/complicações , Metanfetamina/efeitos adversos , Ferimentos e Lesões/etiologia , Fatores Etários , Idoso , Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/epidemiologia , Transtornos Relacionados ao Uso de Anfetaminas/epidemiologia , California/epidemiologia , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Metanfetamina/uso terapêutico , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Detecção do Abuso de Substâncias , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia
20.
Am J Surg ; 221(6): 1121-1126, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33745689

RESUMO

BACKGROUND: We compared surgical device malfunction reports in the Food and Drug Administration (FDA) public Manufacturer and User Facility Device Experience (MAUDE) with those in the FDA nonpublic Alternative Summary Reporting (ASR). METHODS: General surgery device product code categories in MAUDE and ASR from 1999 to 2018 were identified. Changes in the rates of categories and adverse events were evaluated by Poisson regression. RESULTS: There were 283,308 (72%) general surgical device malfunctions in MAUDE and 109,954 (28%) in ASR. Reports increased annually in ASR versus MAUDE, particularly for surgical staplers and clip devices (p < 0.05). ASR contained approximately 80% of these reports; MAUDE 20%. In MAUDE, 42.9% of surgical device malfunctions and 20.2% of stapler/clip malfunctions resulted in patient injury or death. ASR listed no injury or death information. CONCLUSIONS: ASR contained a significant portion of surgical device malfunctions hidden from public scrutiny. Access to such data is essential to safe surgical care.


Assuntos
Falha de Equipamento/estatística & dados numéricos , Instrumentos Cirúrgicos/efeitos adversos , Bases de Dados Factuais , Análise de Falha de Equipamento , Humanos , Estudos Retrospectivos , Estados Unidos , United States Food and Drug Administration
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