Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 90
Filtrar
1.
Urology ; 2022 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-35618138

RESUMO

OBJECTIVE: To examine opioid use following Urological trauma. Increased opioid use is associated with inferior outcomes and risk of dependence, particularly in vulnerable populations. In contrast, multimodal analgesia following trauma allows decreased pain and readmission. Currently there is a paucity of data describing opioid usage following urological trauma. The purpose of this study was to assess utilization of opioids and multimodal pain regimens following urologic trauma. METHODS: We retrospectively examined 116 patients hospitalized following urologic trauma from 2016-2021. Inpatient and discharge utilization of opioids, multimodal analgesia and length of stay were stratified by affected organ. Analyses were performed in STATA with p<0.05 reaching significance. RESULTS: 116 patients were assessed; 84 (72.4%) required surgery. In the first 10 days, bladder injuries incurred higher mean and median OMEQ than other urological injuries. In nearly all groups, OMEQ prescribed at discharge is less than average inpatient OMEQ. Eighty-six (74.1%) patients received at least 2 different opioid medications while inpatient. Those with a history of opioid use received a significantly higher OMEQ dose per day (p<0.001). There were no significant differences between opioid prescribing patterns or average OMEQ dosages prescribed at discharge between those patients managed either surgically or non-operatively. Only 24 (20.7%) patients met the criteria for utilization of multimodal analgesia. CONCLUSION: Multimodal analgesia is severely underutilized following urological trauma. Combined with the development of opioid tolerance over long hospital stays, this creates an avenue for opioid misuse following discharge and provides an opportunity for improvement.

2.
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
4.
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
5.
6.
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
7.
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
8.
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
9.
J Surg Res ; 258: 100-104, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33002662

RESUMO

BACKGROUND: Participation of women at national surgery conferences is an important aspect of achieving gender equity; however, participation has to be meaningful and representative of scientific and clinical achievement. We hypothesized that the presence of women on planning committees would increase the number of women speakers and the presence of women as moderators would increase the number of women panelists. Furthermore, we hypothesized that although women may be included as speakers, they are less likely to speak on clinical and technical surgical topics than men. METHODS: Four 2018 national surgery conferences were chosen for investigation: Eastern Association for the Surgery of Trauma, Society of American Gastrointestinal and Endoscopic Surgeons, Academic Surgical Conference, and the American Society of Breast Surgeons because of varied subject matter. The published online conference programs were reviewed and participant gender, presentation role, type, and topic were recorded. Submitted abstract and scientific articles were excluded from analysis; moderators of these sessions were included. Statistical analyses were performed using chi-squared tests and t-tests where appropriate. RESULTS: The overall mean percentage of female speakers was 28%. The percentage of women on the program committees positively correlated with the number of women speaking at the conference (Eastern Association for the Surgery of Trauma, 15.4% women on committee vs 18.92% speakers; Society of American Gastrointestinal and Endoscopic Surgeons, 27% versus 22%; Academic Surgical Conference, 38.5% versus 32%; and the American Society of Breast Surgeons, 50% versus 58.55 %; P < 0.001). Panels with greater than 50% female moderators were more likely to have female panelists than those with less than 50% female moderators (23.6% versus 14.8%; P < 0.001). Women were most likely to present awards, introductions, and keynote speeches, then most likely to speak on professionalism (54.84% and 36.29%; P < 0.001). They were significantly less likely to present on a clinical topic, technical skill, or moderate a scientific presentation (25.68% and 26.75%; P < 0.001). CONCLUSION: Despite increasing attention on improving diversity at surgical conferences, disparities continue to persist. As demonstrated in nonsurgical literature, planning committee gender diversity positively correlated with speaker diversity, and moderator diversity positively correlated with panel diversity. Women were more likely to speak on topics considered "soft sciences", such as professionalism and advocacy, and less likely to present on clinical topics, technical skill, or scientific research.


Assuntos
Congressos como Assunto/estatística & dados numéricos , Equidade de Gênero , Cirurgia Geral/organização & administração , Feminino , Humanos , Masculino
11.
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
12.
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
13.
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
14.
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
16.
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
17.
J Trauma Acute Care Surg ; 89(2): 336-343, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32355101

RESUMO

BACKGROUND: Cryoprecipitate was developed for the treatment of inherited and acquired coagulopathies. The role of cryoprecipitate in hemorrhaging trauma patients is still speculative. The aim of our study was to assess the role of cryoprecipitate as an adjunct to transfusion in trauma patients. METHODS: We performed a 2-year (2015-2016) analysis of the American College of Surgeons-Trauma Quality Improvement Program data set and included all adult trauma patients who received 4 or greater packed red blood cells (pRBCs)/4 hours. Patients were stratified based on receipt of cryoprecipitate within the first 24 hours (cryoprecipitate vs. no-cryoprecipitate). Outcomes were blood products transfused, in-hospital complications, and mortality. Regression analyses were performed. RESULTS: A total of 19,643 (cryoprecipitate, 4,945; no-cryoprecipitate, 14,698) were included. Mean age was 40 ± 22 years, median Injury Severity Score was 27 [18-40], and Glasgow Coma Scale score was 9 [3-14]. The overall complication rate was 45%, mortality was 47%, and 29% of the patients died in the first 24 hours. Patients in the cryoprecipitate group received a lower volume of plasma (p < 0.01), and pRBCs (p < 0.01). Additionally, patients who received cryoprecipitate had lower rates of 24-hour mortality (p < 0.01) and in-hospital mortality (p < 0.01). However, there was no difference between the two groups regarding complications (p = 0.36) or volume of platelet transfused (p = 0.22). On multivariate logistic regression, the use of cryoprecipitate was associated with decreased (odds ratio [OR], 0.78 [0.63-0.84]; p = 0.02), in-hospital mortality (OR, 0.79 [0.77-0.87]; p = 0.01), but had no association with in-hospital complications (OR, 1.48 [0.71-1.99]; p = 0.31). On linear regression analysis, the use of cryoprecipitate was not associated with 24-hour pRBCs (ß = -0.12 [-0.28 to 0.27], p = 0.47), 24-hour plasma (ß = -0.06 [-0.21 to 0.43], p = 0.29), and 24-hour platelets (ß = -0.24 [-0.09 to 0.33], p = 0.17) transfusion requirements. CONCLUSION: The adjunctive use of cryoprecipitate in hemorrhaging trauma patients may reduce mortality without affecting in-hospital complications and transfusion requirements. Further studies are needed to better understand its potentially beneficial effects. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Transfusão de Sangue , Serviço Hospitalar de Emergência/normas , Fator VIII/uso terapêutico , Fibrinogênio/uso terapêutico , Fibronectinas/uso terapêutico , Hemorragia/terapia , Hemostáticos/uso terapêutico , Melhoria de Qualidade , Ferimentos e Lesões/complicações , Adulto , Quimioterapia Adjuvante , Bases de Dados Factuais , Hemorragia/etiologia , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Traumatologia/normas , Estados Unidos , Adulto Jovem
18.
J Trauma Acute Care Surg ; 89(2): 289-300, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32332256

RESUMO

INTRODUCTION: There is a growing need to improve the quality of care while decreasing health care costs in emergency general surgery (EGS). Health care value includes costs and quality and is a targeted metric by improvement programs. The aim of our study was to evaluate the trend of health care value in EGS over time and to identify barriers to high-value surgical care. METHODS: The (2012-2015) National Readmission Database was queried for patients 18 years or older who underwent an EGS procedure (according to the American Association for the Surgery of Trauma definition). Health care value (V = quality metrics/cost) was calculated from the rates of freedom from readmission, major complications, reoperation, and failure to rescue (FTR) indexed over inflation-adjusted hospital costs. Outcomes were the trends in the quality metrics: 6-month readmission, major complications, reoperation, FTR, hospital costs, and health care value over the study period. Multivariable linear regression was performed to determine the predictors of lower health care value. RESULTS: We identified 887,013 patients who underwent EGS. Mean ± SD age was 51 ± 20 years, and 53% were male. The rates of 6-month readmission, major complications, reoperation, and FTR increased significantly over the study period. The median hospital costs also increased over the study period (2012, US $9,600 to 2015, US $13,000; p < 0.01). However, the health care value has decreased over the study period (2012, 0.35; 2013, 0.30; 2014, 0.28; 2015, 0.25; p < 0.01). Predictors of decreased health care value in EGS are age 65 years or older (ß = -0.568 [-0.689 to -0.418], more than three comorbidities (ß = -0.292 [-0.359 to -0.21]), readmission to a different hospital (ß = -0.755 [-0.914 to -0.558]), admission to low volume centers (ß = -0.927 [-1.126 to -0.682]), lack of rehabilitation (ß = -0.004 [-0.005 to -0.003]), and admission on a weekend (ß = -0.318 [-0.366 to -0.254]). CONCLUSION: Health care value in EGS appears to be declining over time. Some of the factors leading to decreased health care value in EGS are potentially modifiable. Health care value could potentially be improved by reducing fragmentation of care and promoting regionalization. LEVEL OF EVIDENCE: Economic, level IV.


Assuntos
Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/normas , Custos Hospitalares , Garantia da Qualidade dos Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/normas , Adulto , Idoso , Serviço Hospitalar de Emergência/tendências , Falha da Terapia de Resgate , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Complicações Pós-Operatórias , Análise de Regressão , Reoperação , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/tendências , Estados Unidos
20.
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
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...