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1.
Surg Infect (Larchmt) ; 23(5): 489-494, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35647893

RESUMO

Background: There is no consensus on the duration of antibiotic use after appendectomy. We hypothesized that restricted antibiotic use is associated with better clinical outcomes. Patients and Methods: We performed a post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America-Acute, Perforated, and Gangrenous (MUSTANG) study using the desirability of outcome ranking/response adjusted for duration of antibiotic risk (DOOR/RADAR) framework. Three separate datasets were analyzed based on restricted versus liberal post-operative antibiotic groups: simple appendicitis (no vs. yes); complicated appendicitis, only four days (≤24 hours vs. 4 days); and complicated appendicitis, four or more days (≤24 hours vs. ≥4 days). Patients were assigned to one of seven mutually exclusive DOOR categories RADAR ranked within each category. DOOR/RADAR score pairwise comparisons were performed between all patients. Each patient was assigned either 1, 0, or -1 if they had better, same, or worse outcomes than the other patient in the pair, respectively. The sum of these numbers (cumulative comparison score) was calculated for each patient and the group medians of individual sums were compared by Wilcoxon rank sum. Results: For simple appendicitis, the restricted group had higher median sums than the liberal group (552 [552,552] vs. -1,353 [-1,353, -1,353], p < 0.001). For both complicated appendicitis analyses, the restricted group had higher median sums than the liberal: only 4 (196 [23,196] vs. -121 [-121, -121], p < 0.02) and 4 or more (660 [484,660] vs -169 [-444,181], p < 0.001). Conclusions: Restricted post-operative antibiotic use in patients after appendectomy is a dominant strategy when considering treatment effectiveness and antibiotic exposure.


Assuntos
Apendicectomia , Apendicite , Antibacterianos/uso terapêutico , Apendicectomia/efeitos adversos , Apendicite/complicações , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Gangrena/etiologia , Humanos , Período Pós-Operatório
2.
Am Surg ; : 31348221082277, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35652129

RESUMO

BACKGROUND: Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics. METHODS: A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only. RESULTS: From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury. DISCUSSION: While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.

3.
J Craniofac Surg ; 33(3): 734-737, 2022 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-35727666

RESUMO

INTRODUCTION: Female genital mutilation/cutting (FGM/C) refers to ritual surgical procedures performed that intentionally alter genitalia for nonmedical purposes. Female genital mutilation/ cutting is a lifelong problem for women that can have detrimental effects on menstruation, pregnancy, sexual health, and self-esteem. In 2016 the Centers for Disease Control and Prevention estimated 513,000 women and children in the United States were victims of or at risk for FGM/C. Currently, few studies discuss potential management options for FGM/C and their associated complications. Aims of this study are to review contemporary research on FGM/C, discuss current surgical therapies in the pediatric and adult populations, and draw attention to the urgent need for further education. METHODS: The authors conducted a literature review using PubMed, and identified 731 articles in the adult and pediatric populations. The articles were cross-referenced with 2 systematic reviews, and duplicates were discarded. Based on our criteria, 9 articles were included. RESULTS: Based on our findings, defibulation offers patients a better quality of life with a low rate of complication. Similarly, clitoral reconstruction has shown favorable results for treatment of FGM/C. Using the Female Sexual Function Index can better help standardize measurements of sexual health outcomes. Currently, established clinical guidelines are lacking and there is limited training on the recognition and treatment of FGM/C. CONCLUSIONS: This study supports clitoral reconstruction and defibulation as effective therapies for FGM/C. Reconstructive surgeons are at the forefront of developing and providing these surgical treatments. Further research including randomized controlled studies and long-term follow-up are needed to better elucidate the best therapeutic options.

4.
J Am Coll Surg ; 234(6): 1238-1247, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35703822

RESUMO

Trauma-informed care (TIC) is a set of principles and practices designed to improve the ways professionals treat people who have been traumatized. This study reviews fundamental concepts of TIC and applies them to the work of surgeons. TIC is described in relation to fundamental medical ethical concepts, and evidence for TIC-based intervention is reviewed. Implementation of TIC in medical education is also described, and recommendations for practice changes are made.


Assuntos
Internato e Residência , Cirurgiões , Pessoal de Saúde , Humanos , Princípios Morais
5.
Artigo em Inglês | MEDLINE | ID: mdl-35687805

RESUMO

ABSTRACT: Trauma surgeons have a mission to prevent injury as well as to treat it, and must address the underlying social and structural factors that expose individuals, communities, and populations to preventable injury. Laws regulating the sale, possession, carriage, and use of firearms have major health consequences deserving of our attention. This EAST evidence-based statement reviews and summarizes the literature on Stand Your Ground laws. Whereas previously civilians had a duty to retreat prior to the use of deadly force, Stand Your Ground laws remove this duty and allow civilians to use deadly force as a first response to a perceived threat. 42 states have a version of this policy in place. Strong, consistent evidence demonstrates that Stand Your Ground laws have no benefit in preventing violent crime and are instead associated with increases in homicide and inequity.

6.
Am Surg ; 88(6): 1054-1058, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35465697

RESUMO

As hospital systems plan for health care utilization surges and stress, understanding the necessary resources of a trauma system is essential for planning capacity. We aimed to describe trends in high-intensity resource utilization (operating room [OR] usage and intensive care unit [ICU] admissions) for trauma care during the initial months of the COVID-19 pandemic. Trauma registry data (2019 pre-COVID-19 and 2020 COVID-19) were collected retrospectively from 4 level I trauma centers. Direct emergency department (ED) disposition to the OR or ICU was used as a proxy for high-intensity resource utilization. No change in the incidence of direct ED to ICU or ED to OR utilization was observed (2019: 24%, 2020 23%; P = .62 and 2019: 11%, 2020 10%; P = .71, respectively). These results suggest the need for continued access to ICU space and OR theaters for traumatic injury during national health emergencies, even when levels of trauma appear to be decreasing.


Assuntos
COVID-19 , Pandemias , COVID-19/epidemiologia , Serviço Hospitalar de Emergência , Humanos , Unidades de Terapia Intensiva , Estudos Retrospectivos , Centros de Traumatologia
7.
Am Surg ; : 31348221078958, 2022 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-35437020

RESUMO

BACKGROUND: Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown. METHODS: A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use. RESULTS: From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI. DISCUSSION: Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.

8.
Injury ; 53(6): 1979-1986, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35232568

RESUMO

BACKGROUND: Results from single-region studies suggest that stay at home orders (SAHOs) had unforeseen consequences on the volume and patterns of traumatic injury during the initial months of the Coronavirus disease 2019 (COVID-19). The aim of this study was to describe, using a multi-regional approach, the effects of COVID-19 SAHOs on trauma volume and patterns of traumatic injury in the US. METHODS: A retrospective cohort study was performed at four verified Level I trauma centers spanning three geographical regions across the United States (US). The study period spanned from April 1, 2020 - July 31, 2020 including a month-matched 2019 cohort. Patients were categorized into pre-COVID-19 (PCOV19) and first COVID-19 surge (FCOV19S) cohorts. Patient demographic, injury, and outcome data were collected via Trauma Registry queries. Univariate and multivariate analyses were performed. RESULTS: A total 5,616 patients presented to participating study centers during the PCOV19 (2,916) and FCOV19S (2,700) study periods.  Blunt injury volume decreased (p = 0.006) due to a significant reduction in the number of motor vehicle collisions (MVCs) (p = 0.003). Penetrating trauma experienced a significant increase, 8% (246/2916) in 2019 to 11% (285/2,700) in 2020 (p = 0.007), which was associated with study site (p = 0.002), not SAHOs. Finally, study site was significantly associated with changes in nearly all injury mechanisms, whereas SAHOs accounted for observed decreases in calculated weekly averages of blunt injuries (p < 0.02) and MVCs (p = 0.003). CONCLUSION: Results of this study suggest that COVID-19 and initial SAHOs had variable consequences on patterns of traumatic injury, and that region-specific shifts in traumatic injury ensued during initial SAHOs. These results suggest that other factors, potentially socioeconomic or cultural, confound trauma volumes and types arising from SAHOs. Future analyses must consider how regional changes may be obscured with pooled cohorts, and focus on characterizing community-level changes to aid municipal preparation for future similar events.


Assuntos
COVID-19 , Ferimentos Penetrantes , COVID-19/epidemiologia , Humanos , Pandemias , Estudos Retrospectivos , SARS-CoV-2 , Centros de Traumatologia , Estados Unidos/epidemiologia , Ferimentos Penetrantes/epidemiologia
9.
Surg Infect (Larchmt) ; 23(3): 232-247, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35196154

RESUMO

Background: The principles of antimicrobial stewardship promote the appropriate prescribing of agents with respect to efficacy, safety, duration, and cost. Antibiotic resistance often results from inappropriate use (e.g., indication, selection, duration). We evaluated practice variability in duration of antimicrobials in surgical infection treatment (Rx) or prophylaxis (Px). Hypothesis: There is lack of consensus regarding the duration of antibiotic Px and Rx for many common indications. Methods: A survey was distributed to the Surgical Infection Society (SIS) regarding the use of antimicrobial agents for a variety of scenarios. Standard descriptive statistics were used to compare survey responses. Heterogeneity among question responses were compared using the Shannon Index, expressed as natural units (nats). Results: Sixty-three SIS members responded, most of whom (67%) have held a leadership position within the SIS or contributed as an annual meeting moderator or discussant; 76% have been in practice for more than five years. Regarding peri-operative Px, more than 80% agreed that a single dose is adequate for most indications, with the exceptions of gangrenous cholecystitis (40% single dose, 38% pre-operative +24 hours) and inguinal hernia repair requiring a bowel resection (70% single dose). There was more variability regarding the use of antibiotic Px for various bedside procedures with respondents split between none needed (range, 27%-66%) versus a single dose (range, 31%-67%). Opinions regarding the duration of antimicrobial Rx for hospitalized patients who have undergone a source control operation or procedure varied widely based on indication. Only two of 20 indications achieved more than 60% consensus despite available class 1 evidence: seven days for ventilator-associated pneumonia (77%), and four plus one days for perforated appendicitis (62%). Conclusions: Except for peri-operative antibiotic Px, there is little consensus regarding antibiotic duration among surgical infection experts, despite class 1 evidence and several available guidelines. This highlights the need for further high-level research and better dissemination of guidelines.


Assuntos
Anti-Infecciosos , Cirurgiões , Antibacterianos/uso terapêutico , Anti-Infecciosos/uso terapêutico , Antibioticoprofilaxia , Consenso , Humanos , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/prevenção & controle
10.
J Pediatr Surg ; 57(5): 915-917, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35109994

RESUMO

PURPOSE: Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs. METHODS: From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children. RESULTS: Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (<1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1). CONCLUSION: Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.


Assuntos
Lesões Encefálicas Traumáticas , Traumatismos Craniocerebrais , Acidentes de Trânsito , Adolescente , Ciclismo/lesões , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/etiologia , Lesões Encefálicas Traumáticas/prevenção & controle , Criança , Traumatismos Craniocerebrais/epidemiologia , Demografia , Feminino , Dispositivos de Proteção da Cabeça , Humanos , Masculino
11.
J Trauma Acute Care Surg ; 92(6): 1031-1038, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35195095

RESUMO

BACKGROUND: Controversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis. METHODS: In this post hoc analysis of the Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared. RESULTS: A total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR [95% confidence interval], 0.3 [0.2-0.4]). CONCLUSION: In contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.


Assuntos
Apendicectomia , Apendicite , Antibacterianos/uso terapêutico , Apendicectomia/métodos , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Drenagem , Humanos , Infecção da Ferida Cirúrgica/tratamento farmacológico , Resultado do Tratamento
12.
Surg Infect (Larchmt) ; 23(2): 174-177, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-35021885

RESUMO

Background: It is unclear if the addition of antifungal therapy for perforated peptic ulcers (PPU) leads to improved outcomes. We hypothesized that empiric antifungal therapy is associated with better clinical outcomes in critically ill patients with PPU. Patients and Methods: The 2001-2012 Medical Information Mart for Intensive Care (MIMIC-III) database was searched for patients with PPU and the included subjects were divided into two groups depending on receipt of antifungal therapy. Propensity score matching by surgical intervention, mechanical ventilation (MV), and vasopressor administration was then performed and clinically important outcomes were compared. Multiple logistic regression was performed to calculate the odds of a composite end point (defined as "alive, hospital-free, and infection-free at 30 days"). Results: A total of 89 patients with PPU were included, of whom 52 (58%) received empiric antifungal therapy. Propensity score matching resulted in 37 pairs. On logistic regression controlling for surgery, vasopressors, and MV, receipt of antifungal therapy was not associated with higher odds (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.5-4.7; p = 0.4798) of the composite end point. Conclusions: In critically ill patients with perforated peptic ulcer, receipt of antifungal therapy, regardless of surgical intervention, was not associated with improved clinical outcomes. Selection bias is possible and therefore randomized controlled trials are required to confirm/refute causality.


Assuntos
Antifúngicos , Úlcera Péptica Perfurada , Antifúngicos/uso terapêutico , Humanos , Modelos Logísticos , Razão de Chances , Úlcera Péptica Perfurada/complicações , Úlcera Péptica Perfurada/tratamento farmacológico , Úlcera Péptica Perfurada/cirurgia , Pontuação de Propensão
13.
Eur J Trauma Emerg Surg ; 48(2): 791-797, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34773466

RESUMO

PURPOSE: Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients' abdomen. METHODS: An online query using the search term "direct peritoneal resuscitation" was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles' references was resulted in the addition of 1 article, for a total of 20 included articles. RESULTS: The 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications. CONCLUSION: DPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.


Assuntos
Choque Hemorrágico , Animais , Edema , Hidratação/métodos , Humanos , Ratos , Ratos Sprague-Dawley , Ressuscitação/métodos , Choque Hemorrágico/terapia
14.
J Trauma Acute Care Surg ; 92(2): 347-354, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34739003

RESUMO

BACKGROUND: Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS: An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS: Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION: Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level IV.


Assuntos
Lesões das Artérias Carótidas/complicações , Traumatismo Cerebrovascular/complicações , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Artéria Vertebral/lesões , Ferimentos não Penetrantes/complicações , Adulto , Anticoagulantes/uso terapêutico , Lesões das Artérias Carótidas/diagnóstico por imagem , Traumatismo Cerebrovascular/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Estados Unidos , Artéria Vertebral/diagnóstico por imagem , Ferimentos não Penetrantes/diagnóstico por imagem
16.
J Surg Res ; 269: 69-75, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34520984

RESUMO

BACKGROUND: There are significant practice variations in antibiotic treatment for appendicitis, ranging from short-course narrow spectrum to long-course broad-spectrum. We sought to describe the modern microbial epidemiology of acute and perforated appendicitis in adults to help inform appropriate empiric coverage and support antibiotic stewardship initiatives. METHODS: This is a post-hoc secondary analysis of the Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) which prospectively enrolled adult patients (age ≥ 18 years) diagnosed with appendicitis between January 2017 and June 2018 across 28 centers in the United States. We included all subjects with positive microbiologic cultures during primary or secondary (rescue after medical failure) appendectomy or percutaneous drainage. Culture yield was compared between low- and high-grade appendicitis as per the AAST classification. RESULTS: A total of 3,471 patients were included: 230 (7%) had cultures performed, and 179/230 (78%) had positive results. Cultures were less likely to be positive in grade 1 compared to grades 3, 4, or 5 appendicitis with 2/18 (11%) vs 61/70 (87%) (p < .001). Only 1 subject had grade 2 appendicitis and culture results were negative. E. coli was the most common pathogen and cultured in 29 (46%) of primary appendectomy samples, 16 (50%) of secondary, and 44 (52%) of percutaneous drainage samples. CONCLUSION: Culturing low-grade appendicitis is low yield. E. coli is the most commonly cultured microbe in acute and perforated appendicitis. This data helps inform empiric coverage for both antibiotics alone and as an adjunct to operative or percutaneous intervention.


Assuntos
Gestão de Antimicrobianos , Apendicite , Adolescente , Adulto , Antibacterianos/uso terapêutico , Apendicectomia/métodos , Apendicite/complicações , Apendicite/epidemiologia , Apendicite/cirurgia , Drenagem/métodos , Escherichia coli , Humanos , Estudos Retrospectivos , Estados Unidos
17.
Ann Vasc Surg ; 82: 30-40, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-34954038

RESUMO

BACKGROUND: Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. METHODS: A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. RESULTS: Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P = 0.001), high body mass index (P = 0.001), blunt injury (P = 0.001), associated fractures (P = 0.005), significant soft tissue injury (P = 0.007), delayed repair after shunt placement (P = 0.003), bypass revascularization (P = 0.001), initial revascularization failure (P = 0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n = 7), revascularization failure (n = 9), bleeding (n = 3), and vascular surgical wound complications (n = 5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. CONCLUSION: Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.


Assuntos
Lesões dos Tecidos Moles , Lesões do Sistema Vascular , Ferimentos não Penetrantes , Adolescente , Adulto , Amputação/efeitos adversos , Feminino , Humanos , Salvamento de Membro/efeitos adversos , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Lesões dos Tecidos Moles/complicações , Lesões dos Tecidos Moles/cirurgia , Centros de Traumatologia , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto Jovem
18.
Surg Infect (Larchmt) ; 22(10): 1014-1020, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34357820

RESUMO

Background: Infections represent a major component of surgical practice. Risk mitigation, seeking eradication and optimal patient outcomes, require a concerted, multifocal effort to understand disease and microbiology, prevent infections, and treat them. The present study was undertaken to re-define the Surgical Infection Society (SIS) research agenda for the next decade. Hypothesis: We utilized the expertise of the SIS membership to identify research questions regarding surgical infections, hypothesizing that consensus among participants could be used to re-define the future research agenda. Methods: Members of the SIS were surveyed using a modified Delphi. The three rounds of the survey were targeted at: question generation; question ranking; and reaching consensus. Each of the 15 questions to emerge was evaluated according to level of consensus, feasibility, and data availability. Results: One hundred twenty-four participants contributed. Initially, 226 questions were generated that were condensed to 35 unique questions for consideration in the subsequent two rounds. The 35 questions encompassed several research themes, with antibiotic prophylaxis (n = 8), prevention of surgical site infections (SSIs; n = 6), and improved diagnostics (n = 5) being most common. Standard deviation of importance scores was inversely proportional to the question rank, indicating greater consensus among higher ranking questions. All 15 questions had a feasibility score of greater than three (five-point Likert scale), and the majority (12/15) had a mean data availability score of less than three. In the final round of the survey, the top three topics for further research surrounded non-antimicrobial treatments, optimal treatment duration for bacteremia, and treatment duration for necrotizing soft tissue infections. Conclusions: Using a modified Delphi process, 15 research questions addressing surgical infections were identified. Such questions can assist the SIS and the SIS Foundation for Research and Education in prioritizing and enabling research efforts, and development of a strategic research plan for the next decade.


Assuntos
Pesquisa Biomédica , Consenso , Técnica Delfos , Humanos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Inquéritos e Questionários
19.
Surg Infect (Larchmt) ; 22(6): 604-610, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34270359

RESUMO

Background: Randomized controlled trials (RCTs) are generally regarded as the gold standard for demonstrating causality because they effectively mitigate bias from both known and unknown confounders. However, conducting an RCT is not always feasible because of logistical and ethical considerations. This is especially true when evaluating surgical interventions, and non-randomized study designs must be utilized instead. Methods: Statistical methods that adjust for baseline differences in non-randomized studies were reviewed. Results: The three methods used most commonly to adjust for confounding factors are multiple logistic regression, Cox proportional hazard, and propensity scoring. Multiple logistic regression (MLR) is implemented to analyze the influence of categorical and/or continuous variables on a single dichotomous outcome. The model controls for multiple covariates while also quantifying the magnitude of each covariate's influence on the outcome. Selecting which variables to include in a model should be the most important consideration, and authors must report how and why variables were chosen. Cox proportional hazards modeling is conceptually similar to logistic regression and is used when analyzing survival data. When applied to survival curves, Cox proportional hazards can adjust for baseline group differences and provide a hazard ratio to quantify the effect that any single factor contributes to the survival curve. Propensity scores (PS) range from zero to one and are defined as the probability of receiving an intervention based on observed baseline characteristics. Propensity score matching (PSM) is especially useful when the outcome of interest is a rare event. Treated and untreated subjects with similar propensity scores are paired, forming balanced samples for further analysis. Conclusions: The method by which to address confounding should be selected according to the data format and sample size. Reporting of methods should provide justification for selected covariates, confirmation that data did not violate model assumptions, and measures of model performance.


Assuntos
Pontuação de Propensão , Modelos de Riscos Proporcionais , Estatística como Assunto , Viés , Humanos , Modelos Logísticos
20.
J Trauma Acute Care Surg ; 91(5): 891-897, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34225343

RESUMO

BACKGROUND: There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals. METHODS: The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals. RESULTS: Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days. CONCLUSION: Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs. LEVEL OF EVIDENCE: Epidemiological study, level III.


Assuntos
Tratamento de Emergência/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Idoso , Efeitos Psicossociais da Doença , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
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