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1.
J Trauma Acute Care Surg ; 93(1): 75-83, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35358121

RESUMO

BACKGROUND: The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals. METHODS: Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort. RESULTS: More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27-47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02-6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07-8.01). CONCLUSION: Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.


Assuntos
Serviços Médicos de Emergência , Cirurgia Geral , Prisioneiros , Adulto , Estabelecimentos Correcionais , Cuidados Críticos , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Masculino
2.
Am Surg ; 88(3): 455-462, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34797198

RESUMO

BACKGROUND: Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE. METHODS: The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS). RESULTS: 1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (ß = 43.9, P < .001). CONCLUSIONS: Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.


Assuntos
Anticoagulantes/uso terapêutico , Tempo para o Tratamento , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Adulto , Idoso , Algoritmos , Anticoagulantes/administração & dosagem , Transfusão de Sangue , Colorado/epidemiologia , Enoxaparina/administração & dosagem , Enoxaparina/uso terapêutico , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Análise de Regressão , Estudos Retrospectivos , Tromboembolia Venosa/mortalidade , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/mortalidade , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/mortalidade
3.
J Trauma Acute Care Surg ; 90(3): 557-564, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33507026

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). METHODS: This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method. RESULTS: From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively. CONCLUSION: Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Serviço Hospitalar de Emergência , Hospitalização , Laparotomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Diálise Renal , Respiração Artificial , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Medição de Risco
4.
Am J Surg ; 221(5): 1069-1075, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32917366

RESUMO

INTRODUCTION: We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). METHODS: This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old). RESULTS: 715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). CONCLUSION: ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
5.
J Trauma Acute Care Surg ; 90(1): 87-96, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33332782

RESUMO

BACKGROUND: The American Association for the Surgery of Trauma (AAST) patient assessment committee has created grading systems for emergency general surgery diseases to assist with clinical decision making and risk adjustment during research. Single-institution studies have validated the cholecystitis grading system as associated with patient outcomes. Our aim was to validate the grading system in a multi-institutional fashion and compare it with the Parkland grade and Tokyo Guidelines for acute cholecystitis. METHODS: Patients presenting with acute cholecystitis to 1 of 8 institutions were enrolled. Discrete data to assign the AAST grade were collected. The Parkland grade was collected prospectively from the operative surgeon from four institutions. Parkland grade, Tokyo Guidelines, AAST grade, and the AAST preoperative grade (clinical and imaging subscales) were compared using linear and logistic regression to the need for surgical "bailout" (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion to open, surgical complications (bile leak, surgical site infection, bile duct injury), all complications, and operative time. RESULTS: Of 861 patients, 781 underwent cholecystectomy. Mean (SD) age was 51.1 (18.6), and 62.7% were female. There were six deaths. Median AAST grade was 2 (interquartile range [IQR], 1-2), and median Parkland grade was 3 (interquartile range [IQR], 2-4). Median AAST clinical and imaging grades were 2 (IQR, 2-2) and 1 (IQR, 0-1), respectively. Higher grades were associated with longer operative times, and worse outcomes although few were significant. The Parkland grade outperformed the AAST grade based on area under the receiver operating characteristic curve. CONCLUSION: The AAST cholecystitis grading schema has modest discriminatory power similar to the Tokyo Guidelines, but generally lower than the Parkland grade, and should be modified before widespread use. LEVEL OF EVIDENCE: Diagnostic study, level IV.


Assuntos
Colecistite Aguda/diagnóstico , Índice de Gravidade de Doença , Idoso , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia , Colecistite Aguda/patologia , Colecistite Aguda/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Medição de Risco , Resultado do Tratamento , Estados Unidos
6.
J Trauma Acute Care Surg ; 89(1): 118-124, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32176177

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Emergências , Cirurgia Geral , Medição de Risco/métodos , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Prospectivos , Ferimentos e Lesões/mortalidade
7.
J Trauma Acute Care Surg ; 87(5): 1119-1124, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31389913

RESUMO

BACKGROUND: End-tidal carbon dioxide (ETCO2) is routinely used during elective surgery to monitor ventilation. The role of ETCO2 monitoring in emergent trauma operations is poorly understood. We hypothesized that ETCO2 values underestimate plasma carbon dioxide (pCO2) values during resuscitation for hemorrhagic shock. METHODS: Multicenter trial was performed analyzing the correlation between ETCO2 and pCO2 levels. RESULTS: Two hundred fifty-six patients resulted in 587 matched pairs of ETCO2 and pCO2. Correlation between these two values was very poor with an R of 0.04. 40.2% of patients presented to the operating room acidotic and hypercarbic with a pH less than 7.30 and a pCO2 greater than 45 mm Hg. Correlation was worse in patients that were either acidotic or hypercarbic. Forty-five percent of patients have a difference greater than 10 mm Hg between ETCO2 and pCO2. A pH less than 7.30 was predictive of an ETCO2 to pCO2 difference greater than 10 mm Hg. A difference greater than 10 mm Hg was predictive of mortality independent of confounders. CONCLUSION: Nearly one half (45%) of patients were found to have an ETCO2 level greater than 10 mm Hg discordant from their PCO2 level. Reliance on the discordant values may have contributed to the 40% of patients in the operating room that were both acidotic and hypercarbic. Early blood gas analysis is warranted, and a lower early goal of ETCO2 should be considered. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Dióxido de Carbono/análise , Hipoventilação/diagnóstico , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/cirurgia , Adulto , Gasometria/métodos , Feminino , Humanos , Hipoventilação/sangue , Hipoventilação/etiologia , Hipoventilação/terapia , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Plasma/química , Valor Preditivo dos Testes , Valores de Referência , Ressuscitação/efeitos adversos , Estudos Retrospectivos , Choque Hemorrágico/sangue , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/etiologia , Volume de Ventilação Pulmonar , Ferimentos e Lesões/sangue , Ferimentos e Lesões/complicações , Adulto Jovem
8.
BMC Public Health ; 15: 1056, 2015 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-26474979

RESUMO

BACKGROUND: Patient empowerment represents a potent tool for addressing racial, ethnic and socioeconomic disparities in health care, particularly for chronic conditions such as HIV infection that require active patient engagement. This multimodal intervention, developed in concert with HIV patients and clinicians, aims to provide HIV patients with the knowledge, skills, attitudes and tools to become more activated patients. METHODS/DESIGN: Randomized controlled trial of a multimodal intervention designed to activate persons living with HIV. The intervention includes four components: 1) use of a web-enabled hand-held device (Apple iPod Touch) loaded with a Personal Health Record (ePHR) customized for HIV patients; 2) six 90-minute group-based training sessions in use of the device, internet and the ePHR; 3) a pre-visit coaching session; and 4) clinician education regarding how they can support activated patients. Outcome measures include pre- post changes in patient activation measure score (primary outcome), eHealth literacy, patient involvement in decision-making and care, medication adherence, preventive care, and HIV Viral Load. DISCUSSION: We hypothesize that participants receiving the intervention will show greater improvement in empowerment and the intervention will reduce disparities in study outcomes. Disparities in these measures will be smaller than those in the usual care group. Findings have implications for activating persons living with HIV and for other marginalized groups living with chronic illness. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02165735, 6/13/2014.


Assuntos
Infecções por HIV/tratamento farmacológico , Conhecimentos, Atitudes e Prática em Saúde , Adesão à Medicação , Participação do Paciente , Poder Psicológico , Autocuidado , Telemedicina , Adulto , Doença Crônica , Computadores de Mão , Feminino , HIV , Infecções por HIV/virologia , Letramento em Saúde , Disparidades em Assistência à Saúde , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Projetos de Pesquisa , Carga Viral
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