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1.
World J Surg ; 46(6): 1278-1287, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35253076

RESUMO

OBJECTIVE: The goal of this study was to estimate the prevalence of surgical conditions among refugees in East Africa. BACKGROUND: Surgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions in low- and middle-income countries. Despite numbering over 80 million people globally, forced migrant populations have often been neglected from this body of research. METHODS: We administered a validated survey using random cluster sampling to determine surgical need among refugees in western Tanzania. Primary outcome was history or presence of a surgical problem. Analysis included descriptive and multivariable logistic regression including an average marginal effects model. RESULTS: We analyzed data from 3,574 refugee participants in East Africa. A total of 1,654 participants (46.3%) reported a history or presence of at least one problem that may be surgical in nature. Of those 1,654 participants who did report a problem 1,022 participants (61.8%) reported the problem was still ongoing. Multivariable analysis revealed several factors associated with having a surgical problem (increasing age, occupation, illness within past year). CONCLUSION: To our knowledge, this is the first and largest population-based survey in estimating the prevalence of surgical disease among refugees in sub-Saharan Africa. Our results imply that more than one-in-four refugees has an ongoing surgical problem, suggesting over double the burden of surgical need in refugee populations compared to non-refugee settings.


Assuntos
Refugiados , Migrantes , Estudos Transversais , Humanos , Renda , Tanzânia/epidemiologia
3.
J Am Coll Surg ; 234(2): 214-225, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-35213443

RESUMO

Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.


Assuntos
Cirurgia Geral , Procedimentos Cirúrgicos Operatórios , Emergências , Mortalidade Hospitalar , Hospitalização , Humanos , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos
4.
5.
PLoS One ; 16(4): e0250875, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33914809

RESUMO

BACKGROUND: The standard method of sharing information in academia is the scientific journal. Yet health advocacy requires alternative methods to reach key stakeholders to drive change. The purpose of this study was to analyze the impact of social media and public narrative for advocacy in matters of firearm-related injury and death. STUDY DESIGN: The movement This Is Our Lane was evaluated through the #ThisIsOurLane and #ThisIsMyLane hashtags. Sources were assessed from November 2018 through March 2019. Analyses specifically examined message volume, time course, global engagement, and content across Twitter, scientific literature, and mass media. Twitter data were analyzed via Symplur Signals. Scientific literature reviews were performed using PubMed, EMBASE, Web of Science, and Google Scholar. Mass media was compiled using Access World News/Newsbank, Newspaper Source, and Google. RESULTS: A total of 507,813 tweets were shared using #ThisIsOurLane, #ThisIsMyLane, or both (co-occurrence 21-39%). Fifteen scientific items and n = 358 mass media publications were published during the study period; the latter included articles, blogs, television interviews, petitions, press releases, and audio interviews/podcasts. Peak messaging appeared first on Twitter on November 10th, followed by mass media on November 12th and 20th, and scientific publications during December. CONCLUSIONS: Social media enables clinicians to quickly disseminate information about a complex public health issue like firearms to the mainstream media, scientific community, and general public alike. Humanized data resonates with people and has the ability to transcend the barriers of language, culture, and geography. Showing society the reality of caring for firearm-related injuries through healthcare worker stories via digital media appears to be effective in shaping the public agenda and influencing real-world events.


Assuntos
Defesa do Consumidor , Pessoal de Saúde , Disseminação de Informação/métodos , Ferimentos por Arma de Fogo/prevenção & controle , Armas de Fogo/legislação & jurisprudência , Humanos , Meios de Comunicação de Massa , Saúde Pública/métodos , Mídias Sociais , Ferimentos por Arma de Fogo/psicologia
6.
World J Surg ; 45(11): 3295-3301, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-33554296

RESUMO

BACKGROUND: In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA versus GA. METHODS: We conducted a post hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. All patients ≥ 16 years-old who underwent an open appendectomy between October 2016 and March 2017 in one of the 14 participating hospitals were included. Patients were stratified into two groups: NA-defined as spinal or epidural-and GA. All-cause morbidity, hospital length of stay (LOS), and pain severity were assessed using univariate analysis followed by multivariable logistic regression adjusting for the following preoperative characteristics: age, gender, body mass index (BMI), smoking, history of opioid use, emergency status, and country. RESULTS: A total of 655 patients were included, 353 of which were in the NA group and 302 in the GA group. The countries operating under NA were Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Overall, NA patients were younger (mean age (SD): 34.5 (14.4) vs. 40.7 (17.9), p-value < 0.001) and had a lower BMI (mean (SD): 23.5 (3.8) vs. 24.3 (5.2), p-value = 0.040) than GA patients. On multivariable analysis, NA was independently associated with less postoperative complications (OR, 95% CI: 0.30 [0.10-0.94]) and shorter hospital LOS (LOS > 3 days, OR, 95% CI: 0.47 [0.32-0.68]) compared to GA. There was no difference in postoperative pain severity between the two techniques. CONCLUSIONS: Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery.


Assuntos
Analgésicos Opioides , Apendicectomia , Adolescente , Anestesia Geral , Apendicectomia/efeitos adversos , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica , Estudos Retrospectivos
7.
J Surg Res ; 257: 92-100, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32818790

RESUMO

BACKGROUND: Alcohol use remains abundant in patients with traumatic injury. Previous studies have suggested that serum carbohydrate-deficient transferrin (%dCDT) levels, relative to blood alcohol levels (BALs), may better differentiate episodic binge drinkers from sustained heavy consumers in admitted patients with traumatic injury. We characterized %dCDT levels and BAL levels to differentiate binge drinkers from sustained heavy consumers in admitted trauma patients and their associations with outcomes. METHODS: This prospective, cross-sectional, observational study assessed %dCDT and BAL levels in admitted male and female patients with traumatic injury (≥18 y) at an American College of Surgeons Committee on Trauma level-1 center from July 2014 to June 2016. We designated patients with %dCDT levels ≥1.7% (CDT+) as chronic alcohol users and dichotomized acutely intoxicated patients using three different BAL-level thresholds. Primary outcomes included in-hospital complications, along with prolonged ventilation and intensive care unit length of stay, both defined as the top decile. Secondary outcomes included rates of drug or alcohol withdrawal and all-cause mortality. Analyses were adjusted for clinical factors. RESULTS: We studied 715 patients (77.5% men, 60.6% ≤ 40 y of age, median Injury Severity Score: 14, 41.7% motor vehicle crashes, 17.9% gunshot wounds, 11.1% falls). While 31.0% were CDT+, 48.7% were BAL>0. After adjusting for CDT levels, BAL levels >0, >100, or >200 were not associated with adverse outcomes. However, CDT+ relative to patients with CDT were associated with complications (adjusted odds ratio: 1.96 [1.24-3.09]), prolonged ventilation days (3.23 [1.08-9.65]), and prolonged intensive care unit stays (2.83 [1.20-6.68]). CONCLUSIONS: In this 2-year prospective, cross-sectional, and observational study, we found that %dCDT levels, relative to BAL levels, may better stratify admitted patients with traumatic injury into acute versus chronic alcohol users, identifying those at higher risk for in-hospital complications.


Assuntos
Transtornos Relacionados ao Uso de Álcool/sangue , Transtornos Relacionados ao Uso de Álcool/epidemiologia , Concentração Alcoólica no Sangue , Transferrina/análogos & derivados , Ferimentos e Lesões/sangue , Acidentes de Trânsito , Adolescente , Adulto , Alcoolismo/sangue , Alcoolismo/epidemiologia , Consumo Excessivo de Bebidas Alcoólicas/sangue , Consumo Excessivo de Bebidas Alcoólicas/epidemiologia , Estudos Transversais , Diagnóstico Diferencial , Feminino , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Transferrina/análise , Resultado do Tratamento , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia , Ferimentos por Arma de Fogo/sangue , Adulto Jovem
9.
Ann Surg ; 272(4): 556-561, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932306

RESUMO

OBJECTIVE: To evaluate racial disparities among White and Black pediatric firearm injury patients on a national level. BACKGROUND: Pediatric firearm-related morbidity and mortality are rising in the United States. There is a paucity of data examining racial disparities in those patients. METHODS: The Pediatric Trauma Quality Improvement Program (2017) was queried for pediatric (age ≤17 years) patients admitted with firearm injuries. Patients were stratified by race: White and Black. Injury characteristics were assessed. Outcomes were mortality, hospital length of stay, and discharge disposition. Hierarchical regression models were performed to determine predictors of mortality and longer hospital stays. RESULTS: A total of 3717 pediatric firearm injury patients were identified: Blacks (67.0%) and Whites (33.0%). The majority of patients were male (84.2%). The most common injury intent in both groups was assault (77.3% in Blacks vs in 45.4% Whites; P<0.001), followed by unintentional (21.1% vs 35.4%; P<0.001), and suicide (1.0% vs 14.0%; P<0.001). The highest fatality rate was in suicide injuries (62.6%). On univariate analysis, White children had higher mortality (17.5% vs 9.8%; P<0.001), longer hospital stay [3 (1-7) vs 2 (1-5) days; P = 0.021], and more psychiatric hospital admissions (1.3% vs 0.1%; P<0.001). On multivariate analysis, suicide intent was found to be an independent predictor of mortality (aOR 2.67; 95% CI 1.35-5.29) and longer hospital stay (ß + 4.13; P<0.001), while White race was not. CONCLUSION: Assault is the leading intent of injury in both Black and White children, but White children suffer more from suicide injuries that are associated with worse outcomes. LEVEL OF EVIDENCE: Level III Prognostic.


Assuntos
Afro-Americanos/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Estados Unidos/epidemiologia
10.
Ann Surg ; 272(6): 879-886, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32657939

RESUMO

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Adulto , Idoso , Feminino , Saúde Global , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estados Unidos
12.
Am J Transplant ; 20(10): 2842-2846, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32372460

RESUMO

Organs from uncontrolled DCD donors (uDCDs) have expanded donation in Europe since the 1980s, but are seldom used in the United States. Cited barriers include lack of knowledge about the potential donor pool, lack of robust outcomes data, lack of standard donor eligibility criteria and preservation methods, and logistical and ethical challenges. To determine whether it would be appropriate to invest in addressing these barriers and building this practice, we sought to enumerate the potential pool of uDCD donors. Using data from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database, between 2013 and 2016, we identified patients who had refractory cardiac arrest in the ED. We excluded patients with contraindications to both deceased donation (including infection, malignancy, cardiopulmonary disease) and uDCD (including hemorrhage, major polytrauma, burns, and poisoning). We identified 9828 (range: 9454-10 202) potential uDCDs/y; average age was 32 years, and all were free of major comorbidity. Of these, 91.1% had traumatic deaths, with major causes including nonhead blunt injuries (43.2%) and head injuries (40.1%). In the current era, uDCD donors represent a significant potential source of unused organs. Efforts to address barriers to uDCD in the United States should be encouraged.


Assuntos
Parada Cardíaca , Obtenção de Tecidos e Órgãos , Adulto , Europa (Continente) , Humanos , Fatores de Risco , Doadores de Tecidos , Estados Unidos/epidemiologia
13.
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
16.
J Pediatr Surg ; 55(1): 140-145, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31753607

RESUMO

PURPOSE: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting. METHODS: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety. RESULTS: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home. CONCLUSION: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home. LEVEL OF EVIDENCE: Level III.


Assuntos
Armas de Fogo , Promoção da Saúde/métodos , Pais/educação , Segurança , Gravação em Vídeo , Adolescente , Assistência Ambulatorial , Criança , Pré-Escolar , Computadores de Mão , Aconselhamento Diretivo , Estudos de Viabilidade , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pediatria , Projetos Piloto , Inquéritos e Questionários , Estados Unidos , Ferimentos por Arma de Fogo/prevenção & controle , Adulto Jovem
17.
Surg Endosc ; 34(10): 4562-4573, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-31741158

RESUMO

BACKGROUND: Patients requiring emergent surgery for hernia vary widely in presentation and management. The purpose of this study was to determine if the variation in timing of urgent surgery impacts surgical outcomes. METHODS: The national NSQIP database for years 2011-2016 was queried for emergent surgeries for abdominal hernia resulting in obstruction or gangrene by primary post-op diagnosis. Diaphragmatic hernias were excluded. Patients were grouped by surgical timing from admission to day of surgery: same day, next day, and longer delay. Multinomial propensity score weighting was used to address potential differences in underlying covariates' clustering across the timing groups followed by multivariable logistic regression of morbidity and mortality. RESULTS: Weighted analysis yielded an effective sample size of 76,364. Hernia types included inguinal (20.9%); femoral (6.7%); umbilical (20.2%); ventral (41.0%); and other (10.4%). Delayed surgery was associated with increased rates of major complications (26.4% vs. 20.9%, p < 0.001), longer operative times (+ 12.5 min, p < 0.001), longer postoperative lengths of stay (+ 1.6 days, p < 0.001), increased re-operations (5.9% vs. 4.7%, p = 0.019), increased readmissions (7.0% vs. 5.7%, p = 0.004), and increased 30-day mortality (2.4% vs. 1.7%, p = 0.002). When controlling for other factors, next-day surgery (OR 1.23, 95% CI 1.05-1.45, p = 0.009) and surgery delayed more than one day (OR 1.40, 95% CI 1.13-1.73, p < 0.002) were associated with an increased odds of a major complication. Mortality and readmission by timing of surgery were not independently significant. CONCLUSIONS: Delay in surgery for emergent hernias increased the odds of major morbidity but not mortality. Patients presenting with hernia and an indication for urgent surgical intervention may benefit from an operation as soon as feasible rather than warrant waiting for further physiologic optimization, medical clearance, or specialized surgical personnel.


Assuntos
Emergências , Hérnia Abdominal/cirurgia , Herniorrafia , Adulto , Feminino , Herniorrafia/efeitos adversos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Pontuação de Propensão , Resultado do Tratamento
20.
Trauma Surg Acute Care Open ; 4(1): e000336, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31392284

RESUMO

Background: For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice. Methods: We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use. Results: 32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population. Conclusion: After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers. Level of evidence: Prognostic and epidemiological, level III.

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