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1.
Cardiovasc Diabetol ; 20(1): 176, 2021 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-34481513

RESUMO

BACKGROUND: It remains uncertain if prior use of oral anticoagulants (OACs) in COVID-19 outpatients with multimorbidity impacts prognosis, especially if cardiometabolic diseases are present. Clinical outcomes 30-days after COVID-19 diagnosis were compared between outpatients with cardiometabolic disease receiving vitamin K antagonist (VKA) or direct-acting OAC (DOAC) therapy at time of COVID-19 diagnosis. METHODS: A study was conducted using TriNetX, a global federated health research network. Adult outpatients with cardiometabolic disease (i.e. diabetes mellitus and any disease of the circulatory system) treated with VKAs or DOACs at time of COVID-19 diagnosis between 20-Jan-2020 and 15-Feb-2021 were included. Propensity score matching (PSM) was used to balance cohorts receiving VKAs and DOACs. The primary outcomes were all-cause mortality, intensive care unit (ICU) admission/mechanical ventilation (MV) necessity, intracranial haemorrhage (ICH)/gastrointestinal bleeding, and the composite of any arterial or venous thrombotic event(s) at 30-days after COVID-19 diagnosis. RESULTS: 2275 patients were included. After PSM, 1270 patients remained in the study (635 on VKAs; 635 on DOACs). VKA-treated patients had similar risks and 30-day event-free survival than patients on DOACs regarding all-cause mortality, ICU admission/MV necessity, and ICH/gastrointestinal bleeding. The risk of any arterial or venous thrombotic event was 43% higher in the VKA cohort (hazard ratio 1.43, 95% confidence interval 1.03-1.98; Log-Rank test p = 0.029). CONCLUSION: In COVID-19 outpatients with cardiometabolic diseases, prior use of DOAC therapy compared to VKA therapy at the time of COVID-19 diagnosis demonstrated lower risk of arterial or venous thrombotic outcomes, without increasing the risk of bleeding.


Assuntos
Assistência Ambulatorial/métodos , Anticoagulantes/administração & dosagem , COVID-19/tratamento farmacológico , Cardiopatias/tratamento farmacológico , Doenças Metabólicas/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , COVID-19/diagnóstico , COVID-19/mortalidade , Inibidores do Fator Xa/administração & dosagem , Feminino , Seguimentos , Cardiopatias/diagnóstico , Cardiopatias/mortalidade , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Doenças Metabólicas/diagnóstico , Doenças Metabólicas/mortalidade , Pessoa de Meia-Idade , Mortalidade/tendências , Resultado do Tratamento
2.
J Trauma Acute Care Surg ; 91(2): 287-294, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34397952

RESUMO

BACKGROUND: Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management. METHODS: This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020. RESULTS: All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis. CONCLUSION: In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.


Assuntos
Aorta , Oclusão com Balão , Procedimentos Endovasculares , Hemorragia/terapia , Ressuscitação/métodos , Adulto , Idoso , Feminino , Hemorragia/diagnóstico por imagem , Hemorragia/mortalidade , Humanos , Escala de Gravidade do Ferimento , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Tomografia Computadorizada por Raios X
3.
Transfusion ; 61 Suppl 1: S252-S263, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269434

RESUMO

BACKGROUND: Multiple thresholds are defined to identify patients at risk of death from hemorrhage, including massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI). All fail to account for the use of whole blood (WB). We hypothesized that a definition including WB transfusion would better predict early mortality following trauma. METHODS: This is a retrospective review of all trauma patients with activation of the MT protocol from December 2018 to February 2020. Combinations of WB, RBCs, and fresh frozen plasma (FFP) units transfused during the initial hour of resuscitation were compared using receiver operating characteristic and area under the receiver curve (AUC) for 3- and 6-h mortality. WB massive transfusion (WB MT) score was defined as the sum of each unit RBC plus three times each unit of WB transfused within the first hour of resuscitation. RESULTS: There were 235 patients eligible for analysis with 60 resuscitated using ≥1 unit of WB. Overall, 27 and 29 patients died in the first 3 and 6 h, respectively. WB MT ≥7 had the greatest 3-h and 6-h mortality AUC values (0.78 and 0.79, respectively) when compared to MT, CAT, RI4+, and other attempted definitions using units of WB, RBC, and FFP. Compared to WB MT-, WB MT+ patients died at significantly higher rates at 3 h (28.9% vs. 3.1%, p < .001), 24 h (35.5% vs. 5.7%, p < .001), and 28 days (42.1% vs. 11.9%, p < .001). CONCLUSION: WB MT is the first measure of massive resuscitation to incorporate WB and better identifies early mortality than other definitions.


Assuntos
Transfusão de Sangue/métodos , Hemorragia/terapia , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Adulto , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ferimentos e Lesões/sangue , Ferimentos e Lesões/mortalidade
4.
Transfusion ; 61 Suppl 1: S243-S251, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269443

RESUMO

BACKGROUND: In traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet-to-red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet-to-RBC. METHODS: Pubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30-day mortality, thromboembolic events, organ failure, and correction of coagulopathy. RESULTS: In total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53-0.89]) and 30- day mortality (OR 0.78 [0.63-0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma-induced coagulopathy. CONCLUSIONS: In traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.


Assuntos
Contagem de Eritrócitos , Hemorragia/sangue , Contagem de Plaquetas , Ferimentos e Lesões/sangue , Plaquetas/citologia , Eritrócitos/citologia , Hemorragia/mortalidade , Humanos , Ferimentos e Lesões/mortalidade
5.
J Trauma Acute Care Surg ; 91(1): 24-33, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34144557

RESUMO

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
Transfusão de Componentes Sanguíneos/métodos , Hemorragia/terapia , Ressuscitação/métodos , Trombocitopenia/epidemiologia , Ferimentos e Lesões/terapia , Adulto , Fatores Etários , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Feminino , Escala de Coma de Glasgow , Hemorragia/diagnóstico , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Trombocitopenia/etiologia , Trombocitopenia/terapia , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
6.
Am J Gastroenterol ; 116(9): 1868-1875, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34158462

RESUMO

INTRODUCTION: Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center. METHODS: Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention. RESULTS: We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality. DISCUSSION: The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.


Assuntos
Fibrinolíticos/efeitos adversos , Gastrostomia/efeitos adversos , Hemorragia/etiologia , Hemorragia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Feminino , Gastrostomia/métodos , Humanos , Intubação Gastrointestinal , Masculino , Pessoa de Meia-Idade , Risco
7.
J Trauma Acute Care Surg ; 91(2): 279-286, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34108423

RESUMO

BACKGROUND: Studies comparing mortality following massive transfusion (MT) with fresher versus longer-stored red blood cells (RBCs) have focused on trauma patients. The Australian and New Zealand Massive Transfusion Registry collects data on all adult MT cases (≥5 RBCs within 4 hours, any bleeding context, ≥18 years) at participating hospitals. METHODS: Years 2007 to 2018 data from 29 hospitals were analyzed to quantify the association between mortality and RBC storage time in adult MT cases. We ran three logistic regression models separately on each of seven bleeding contexts, with in-hospital mortality as the outcome and, in turn, (1) mean storage time (STmean) quartiles, (2) proportion of RBCs ≥30 days old (propOLD), and (3) scalar age of blood index as predictors. RESULTS: A total of 8,685 adult MT cases involving transfusion of 126,622 RBCs were analyzed with Australian and New Zealand data analyzed separately. Mean storage times for these cases were (by quartile in ascending order) as follows: Australia, 12.5 days (range, 3.1-15.5 days), 17.7 (15.5-19.9), 22.3 (19.9-24.9), and 29.8 (24.9-41.7); New Zealand, 11.3 days (3.6-13.7), 15.3 (13.7-16.8), 18.7 (16.8-20.7), and 24.5 (20.7-35.6). The odds ratios comparing in-hospital mortality for each quartile with that of the control first quartile (freshest blood), proportion of longer-stored (≥30 days) RBCs, and scalar age of blood index were not statistically significant across all bleeding contexts. CONCLUSION: We find no correlation between in-hospital mortality and storage time of transfused RBCs in a large cohort of adult MT patients representing all bleeding contexts. These results are consistent with those of recent large multicenter trials. LEVEL OF EVIDENCE: Epidemiologic, level III; Therapeutic, level IV.


Assuntos
Transfusão de Sangue , Hemorragia/mortalidade , Mortalidade Hospitalar , Manejo de Espécimes , Adolescente , Adulto , Austrália , Estudos de Coortes , Transfusão de Eritrócitos , Feminino , Hemorragia/terapia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Sistema de Registros , Risco , Fatores de Tempo , Adulto Jovem
8.
J Trauma Acute Care Surg ; 91(3): 473-479, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34086662

RESUMO

BACKGROUND: Resuscitative endovascular occlusion of the aorta (REBOA) is used for temporary aortic occlusion of trauma patients in the management of noncompressible hemorrhage. Previous studies have focused on how to properly perform REBOA in the trauma environment to improve survival rates, but high-grade evidence defining the ideal patient population does not yet exist. This post hoc analysis of the Emergent Truncal Hemorrhage Control Study seeks to identify the most important clinical factors for physicians to consider when selecting for REBOA candidates and their potential survival following REBOA. METHODS: Post hoc analysis of a large, multicenter, prospective observational study conducted at six level 1 trauma centers, 2017 to 2018, was performed. An onsite data collector documented all time points for REBOA patients since admission. Candidate predictors were demographics; injury severity; physiology preprocedure, during procedure, and postprocedure; cardiopulmonary resuscitation; and REBOA-specific variables (time to procedure, procedure-related time intervals, access site, technique, sheath size, catheter length, balloon volume, deployment zone). Predictive models for survival at three different time points along the trauma triage and REBOA process timeline ("Admission," "REBOA Initiation," and "Postaortic Occlusion") were devised by logistic regression. RESULTS: Eighty-eight patients had REBOA placement. The Admission model selected age, Glasgow Coma Scale, and admission systolic blood pressure as significant predictors of survival (area under the receiver operating characteristic curve [AUROC], 0.86; 95% CI, 0.77-0.94). The REBOA Initiation and Postaortic Occlusion models selected age, Glasgow Coma Scale, and the systolic blood pressure measured just before balloon inflation as predictors for survival (AUROC, 0.87 [95% CI, 0.78-0.97] and AUROC, 0.90 [95% CI, 0.81-0.99], respectively). No REBOA procedural variables were identified as predictors of patient survival. CONCLUSION: Only patient-specific criteria of age, neurologic status, and severity of shock predicted survival. The hemodynamic stability of the patient at the time REBOA is initiated is more important than how REBOA is initiated. These findings suggest that earlier preparation for REBOA placement may be a key to improved survival. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Aorta , Oclusão com Balão/métodos , Hemorragia/terapia , Ressuscitação/métodos , Ferimentos e Lesões/complicações , Adulto , Procedimentos Endovasculares/métodos , Feminino , Escala de Coma de Glasgow , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Estudos Retrospectivos , Fatores de Tempo , Centros de Traumatologia , Adulto Jovem
9.
Ann Surg ; 274(3): 419-426, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34132695

RESUMO

OBJECTIVE: We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits. BACKGROUND: TXA has been shown to be safe in the prehospital setting post-injury. METHODS: We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships. RESULTS: EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo. CONCLUSIONS: Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.


Assuntos
Antifibrinolíticos/administração & dosagem , Serviços Médicos de Emergência , Hemorragia/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Adulto , Transfusão de Sangue/estatística & dados numéricos , Método Duplo-Cego , Feminino , Hemorragia/mortalidade , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/mortalidade , Choque Hemorrágico/tratamento farmacológico , Análise de Sobrevida , Fatores de Tempo
10.
J Surg Res ; 266: 1-5, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33975026

RESUMO

INTRODUCTION: Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients. RESULTS: A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.


Assuntos
Traumatismos Abdominais/mortalidade , Anticoagulantes/efeitos adversos , Hemorragia/etiologia , Baço/lesões , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/mortalidade , Hemorragia/terapia , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
11.
J Trauma Acute Care Surg ; 91(3): 514-520, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33990533

RESUMO

BACKGROUND: Uncontrolled truncal hemorrhage remains the most common cause of potentially preventable death after injury. The notion of earlier hemorrhage control and blood product resuscitation is therefore attractive. Some systems have successfully implemented prehospital advanced resuscitative care (ARC) teams. Early identification of patients is key and is reliant on rapid decision making and communication. The purpose of this simulation study was to explore the feasibility of early identification of patients who might benefit from ARC in a typical US setting. METHODS: We conducted a prospective observational/simulation study at a level I trauma center and two associated emergency medical service (EMS) agencies over a 9-month period. The participating EMS agencies were asked to identify actual patients who might benefit from the activation of a hypothetical trauma center-based ARC team. This decision was then communicated in real time to the study team. RESULTS: Sixty-three patients were determined to require activation. The number of activations per month ranged from 2 to 15. The highest incidence of calls occurred between 4 pm to midnight. Of the 63 patients, 33 were transported to the trauma center. The most common presentation was with penetrating trauma. The median age was 27 years (interquartile range, 24-45 years), 75% were male, and the median Injury Severity Score was 11 (interquartile range, 7-20). Based on injury patterns, treatment received, and outcomes, it was determined that 6 (18%) of 33 patients might have benefited from ARC. Three of the patients died en-route to or soon after arrival at the trauma center. CONCLUSION: The prehospital identification of patients who might benefit from ARC is possible but faces challenges. Identifying strategies to adapt existing processes may allow better utilization of the existing infrastructure and should be a focus of future efforts. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level III.


Assuntos
Serviços Médicos de Emergência/organização & administração , Hemorragia/mortalidade , Ressuscitação/métodos , Ferimentos e Lesões/mortalidade , Adulto , Alabama/epidemiologia , Serviços Médicos de Emergência/métodos , Feminino , Hemorragia/etiologia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Estudos Prospectivos , Centros de Traumatologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto Jovem
12.
J Surg Res ; 266: 222-229, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34023578

RESUMO

INTRODUCTION: Trauma is the leading cause of death among young people. These patients have a high incidence of kidney injury, which independently increases the risk of mortality. As valproic acid (VPA) treatment has been shown to improve survival in animal models of lethal trauma, we hypothesized that it would also attenuate the degree of acute kidney injury. METHODS: We analyzed data from two separate experiments where swine were subjected to lethal insults.  Model 1: hemorrhage (50% blood volume hemorrhage followed by 72-h damage control resuscitation). Model 2: polytrauma (traumatic brain injury, 40% blood volume hemorrhage, femur fracture, rectus crush and grade V liver laceration). Animals were resuscitated with normal saline (NS) +/- VPA 150 mg/kg after a 1-h shock phase in both models (n = 5-6/group). Serum samples were analyzed for creatinine (Cr) using colorimetry on a Liasys 330 chemistry analyzer. Proteomic analysis was performed on kidney tissue sampled at the time of necropsy. RESULTS: VPA treatment significantly (P < 0.05) improved survival in both models. (Model 1: 80% vs 20%; Model 2: 83% vs. 17%). Model 1 (Hemorrhage alone): Cr increased from a baseline of 1.2 to 3.0 in NS control animals (P < 0.0001) 8 h after hemorrhage, whereas it rose only to 2.1 in VPA treated animals (P = 0.004). Model 2 (Polytrauma): Cr levels increased from baseline of 1.3 to 2.5 mg/dL (P = 0.01) in NS control animals 4 h after injury but rose to only 1.8 in VPA treated animals (P = 0.02). Proteomic analysis of kidney tissue identified metabolic pathways were most affected by VPA treatment. CONCLUSIONS: A single dose of VPA (150 mg/kg) offers significant protection against acute kidney injury in swine models of polytrauma and hemorrhagic shock.


Assuntos
Injúria Renal Aguda/prevenção & controle , Hemorragia/complicações , Inibidores de Histona Desacetilases/uso terapêutico , Traumatismo Múltiplo/complicações , Ácido Valproico/uso terapêutico , Injúria Renal Aguda/sangue , Injúria Renal Aguda/etiologia , Animais , Creatinina/sangue , Avaliação Pré-Clínica de Medicamentos , Hemorragia/sangue , Hemorragia/mortalidade , Inibidores de Histona Desacetilases/farmacologia , Rim/efeitos dos fármacos , Rim/metabolismo , Lipocalina-2/sangue , Traumatismo Múltiplo/sangue , Traumatismo Múltiplo/mortalidade , Proteoma/efeitos dos fármacos , Suínos , Ácido Valproico/farmacologia
13.
World J Emerg Surg ; 16(1): 21, 2021 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-33941216

RESUMO

BACKGROUND: Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture. METHODS: A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0-30, 30-60, 60-90, 90-120, 120-150, and 150-180 min). We compared the adjusted 30-day mortality rate according to time to embolization. RESULTS: We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48-79) years and 55% were male. The median injury severity score was 26 (18-38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran-Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0-30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2-23.9) for the 150-180 min group. CONCLUSION: Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.


Assuntos
Embolização Terapêutica/métodos , Fraturas Ósseas/mortalidade , Hemorragia/mortalidade , Hemorragia/terapia , Ossos Pélvicos/lesões , Tempo para o Tratamento , Idoso , Hemodinâmica , Humanos , Escala de Gravidade do Ferimento , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
PLoS One ; 16(4): e0250373, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33891629

RESUMO

In this before and after cross-sectional analysis, the authors aim to assess the impact of the bundle of research and training initiatives implemented between 2013 and 2018, and coordinated by the Italian Obstetric Surveillance System (ItOSS) to reduce obstetric haemorrhagic emergencies in five selected Italian Regions. To this purpose, the haemorrhagic Maternal Mortality Ratios (MMR) per 100,000 live births were estimated before and after implementing the bundle, through the ItOSS's vital statistic linkage procedures and incident reporting and Confidential Enquiries. The research and training bundle was offered to all health professionals involved in pregnancy and birth care in the selected regions, representing 40% of national live births, and participating in the ItOSS audit cycle since its institution. The haemorrhagic MMR significantly decreased from 2.49/100,000 live births [95% CI 1.75 to 3.43] in the years 2007-2013 prior to the bundle implementation, to 0.77/100,000 live births [95% CI 0.31 to 1.58] in the years 2014-2018 after its implementation. According to the study results, the bundle of population-based initiatives might have contributed to reducing the haemorrhagic MMR in the participating regions, thus improving the quality of care of the major obstetric haemorrhage.


Assuntos
Causas de Morte/tendências , Hemorragia/mortalidade , Mortalidade Materna/tendências , Complicações na Gravidez/mortalidade , Qualidade da Assistência à Saúde/tendências , Estudos Transversais , Feminino , Humanos , Itália/epidemiologia , Gravidez
15.
Crit Care Med ; 49(6): e624-e633, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33861553

RESUMO

OBJECTIVES: No standard therapy, including anticoagulation regimens, is currently recommended for coronavirus disease 2019. Aim of this study was to evaluate the efficacy of anticoagulation in coronavirus disease 2019 hospitalized patients and its impact on survival. DESIGN: Multicenter international prospective registry (Health Outcome Predictive Evaluation for Corona Virus Disease 2019). SETTING: Hospitalized patients with coronavirus disease 2019. PATIENTS: Five thousand eight hundred thirty-eight consecutive coronavirus disease 2019 patients. INTERVENTIONS: Anticoagulation therapy, including prophylactic and therapeutic regimens, was obtained for each patient. MEASUREMENTS AND MAIN RESULTS: Five thousand four hundred eighty patients (94%) did not receive any anticoagulation before hospitalization. Two-thousand six-hundred one patients (44%) during hospitalization received anticoagulation therapy and it was not associated with better survival rate (81% vs 81%; p = 0.94) but with higher risk of bleeding (2.7% vs 1.8%; p = 0.03). Among patients admitted with respiratory failure (49%, n = 2,859, including 391 and 583 patients requiring invasive and noninvasive ventilation, respectively), anticoagulation started during hospitalization was associated with lower mortality rates (32% vs 42%; p < 0.01) and nonsignificant higher risk of bleeding (3.4% vs 2.7%; p = 0.3). Anticoagulation therapy was associated with lower mortality rates in patients treated with invasive ventilation (53% vs 64%; p = 0.05) without increased rates of bleeding (9% vs 8%; p = 0.88) but not in those with noninvasive ventilation (35% vs 38%; p = 0.40). At multivariate Cox' analysis mortality relative risk with anticoagulation was 0.58 (95% CI, 0.49-0.67) in patients admitted with respiratory failure, 0.50 (95% CI, 0.49-0.67) in those requiring invasive ventilation, 0.72 (95% CI, 0.51-1.01) in noninvasive ventilation. CONCLUSIONS: Anticoagulation therapy in general population with coronavirus disease 2019 was not associated with better survival rates but with higher bleeding risk. Better results were observed in patients admitted with respiratory failure and requiring invasive ventilation.


Assuntos
Anticoagulantes/uso terapêutico , COVID-19/tratamento farmacológico , Avaliação de Resultados em Cuidados de Saúde , Sistema de Registros , COVID-19/mortalidade , Estudos de Casos e Controles , Correlação de Dados , Comparação Transcultural , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Hospitalização , Humanos , Estudos Multicêntricos como Assunto , Estudos Prospectivos , Respiração Artificial , Insuficiência Respiratória/tratamento farmacológico , Insuficiência Respiratória/mortalidade , Risco , Taxa de Sobrevida , Resultado do Tratamento
16.
Indian J Pathol Microbiol ; 64(2): 410-412, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33851648

RESUMO

We present a case of a 48-year-old man's unexpected death affected by a relapsed clivalchordoma. After partial excision surgery of the neoplasm, he manifested 5 days later, in conditions of well-being, a sudden lethal extracranial hemorrhage from nose and mouth. The autopsy examination and the subsequent histological investigations did not allow us to clarify the exact origin of the bleeding. Based on the negativity of the accurate examinations performed, the extent of the bleeding, and the findings highlighted by the means of the nuclear magnetic resonance (NMR) carried out a few days before death, we have considered reasonable to localize the source of hemorrhage in the intrapetrous tract of the left internal carotid artery. Since this is a unique event, never previously documented, we believe that our report may be of interest to the scientific community.


Assuntos
Cordoma/cirurgia , Morte Súbita , Hemorragia/mortalidade , Choque Hemorrágico/mortalidade , Autopsia , Artéria Carótida Interna/patologia , Cordoma/patologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Notocorda/patologia , Base do Crânio/patologia , Base do Crânio/cirurgia
17.
Vasc Med ; 26(4): 426-433, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33818200

RESUMO

Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE). Limited data are available on the utilization of the Pulmonary Embolism Response Team (PERT) in the setting of the COVID-19 global pandemic. We performed a single-center study to evaluate treatment, mortality, and bleeding outcomes in patients who received PERT consultations in March and April 2020, compared to historical controls from the same period in 2019. Clinical data were abstracted from the electronic medical record. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding. The frequency of PERT utilization was nearly threefold higher during March and April 2020 (n = 74) compared to the same period in 2019 (n = 26). During the COVID-19 pandemic, there was significantly less PERT-guided invasive treatment (5.5% vs 23.1%, p = 0.02) with a numerical but not statistically significant trend toward an increase in the use of systemic fibrinolytic therapy (13.5% vs 3.9%, p = 0.3). There were nonsignificant trends toward higher in-hospital mortality or moderate-to-severe bleeding in patients receiving PERT consultations during the COVID-19 period compared to historical controls (mortality 14.9% vs 3.9%, p = 0.18 and moderate-to-severe bleeding 35.1% vs 19.2%, p = 0.13). In conclusion, PERT utilization was nearly threefold higher during the COVID-19 pandemic than during the historical control period. Among patients evaluated by PERT, in-hospital mortality or moderate-to-severe bleeding were not significantly different, despite being numerically higher, while invasive therapy was utilized less frequently during the COVID-19 pandemic.


Assuntos
COVID-19/terapia , Recursos em Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Equipe de Assistência ao Paciente/tendências , Padrões de Prática Médica/tendências , Embolia Pulmonar/terapia , Terapia Trombolítica/tendências , Tromboembolia Venosa/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/mortalidade , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/mortalidade
19.
Semin Thromb Hemost ; 47(4): 372-391, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33851386

RESUMO

We conducted a systematic review and a meta-analysis to assess the association of anticoagulants and their dosage with in-hospital all-cause mortality in COVID-19 patients. Articles were retrieved until January 8, 2021, by searching in seven electronic databases. The main outcome was all-cause mortality occurred during hospitalization. Data were combined using the general variance-based method on the effect estimate for each study. Separate meta-analyses according to type of COVID-19 patients (hospitalized or intensive care unit [ICU] patients), anticoagulants (mainly heparin), and regimens (therapeutic or prophylactic) were conducted. A total of 29 articles were selected, but 23 retrospective studies were eligible for quantitative meta-analyses. No clinical trial was retrieved. The majority of studies were of good quality; however, 34% did not distinguish heparin from other anticoagulants. Meta-analysis on 25,719 hospitalized COVID-19 patients showed that anticoagulant use was associated with 50% reduced in-hospital mortality risk (pooled risk ratio [RR]: 0.50, 95% confidence interval [CI]: 0.40-0.62; I 2: 87%). Both anticoagulant regimens (therapeutic and prophylactic) reduced in-hospital all-cause mortality, compared with no anticoagulation. Particularly in ICU patients, the anticoagulant therapeutic regimen was associated with a reduced in-hospital mortality risk (RR: 0.30, 95% CI: 0.15-0.60; I 2: 58%) compared with the prophylactic one. However, the former was also associated with a higher risk of bleeding (RR: 2.53, 95% CI: 1.60-4.00; I 2: 65%). Anticoagulant use, mainly heparin, reduced all-cause mortality in COVID-19 patients during hospitalization. Due to the higher risk of bleeding at therapeutic doses, the use of prophylactic dosages of anticoagulant is probably to be preferred in noncritically ill COVID-19 patients.


Assuntos
Anticoagulantes , COVID-19/tratamento farmacológico , COVID-19/mortalidade , Hemorragia , Mortalidade Hospitalar , SARS-CoV-2 , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Intervalo Livre de Doença , Hemorragia/mortalidade , Hemorragia/prevenção & controle , Hospitalização , Humanos , Taxa de Sobrevida
20.
Open Heart ; 8(1)2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33741689

RESUMO

OBJECTIVES: Growth differentiation factor 15 (GDF-15) is a biomarker independently associated with bleeding and death in anticoagulated patients with atrial fibrillation (AF). GDF-15 is also used as one component in the more precise biomarker-based ABC (age, biomarkers, clinical history)-AF-bleeding and ABC-AF-death risk scores. Data from large trials indicate a geographic variability in regard to overall outcomes, including bleeding and mortality risk. Our aim was to assess the consistency of the association between GDF-15, ABC-AF-bleeding score and ABC-AF-death score, with major bleeding and death, across world geographic regions. METHODS: Data were available from 14 767 patients with AF from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial and 8651 patients with AF from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial in this cohort study. GDF-15 was analysed from plasma samples obtained at randomisation. The geographical consistency of the associations between outcomes and GDF-15, ABC-AF-bleeding score and ABC-AF-death scores were assessed by Cox-regression models including interactions with predefined geographical region. RESULTS: GDF-15 and the ABC-AF-bleeding score were associated with major bleeding in both trials across regions (p<0.0001). Similarly, GDF-15 and the ABC-AF-death score were associated with all-cause mortality in both trials across regions (p<0.0001). Overall, the association between GDF-15, the ABC-AF-bleeding score and ABC-AF-death risk score with major bleeding and death was consistent across regions in both ARISTOTLE and the RE-LY trial cohorts. The ABC-AF-bleeding and ABC-AF-death risk scores were consistent regarding discriminative ability when comparing geographic regions in both trial cohorts. The C-indices ranged from 0.649 to 0.760 for the ABC-AF-bleeding and from 0.677 to 0.806 for the ABC-AF-death score by different geographic regions. CONCLUSIONS: In patients with AF on anticoagulation, GDF-15 and the biomarker-based ABC-AF-bleeding and ABC-AF-death risk scores are consistently associated with respectively increased risk of major bleeding and death and have similar prognostic value across world geographic regions. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry NCT00412984 and NCT00262600.


Assuntos
Fator 15 de Diferenciação de Crescimento/sangue , Hemorragia/sangue , Medição de Risco/métodos , Idoso , Fibrilação Atrial/sangue , Fibrilação Atrial/mortalidade , Biomarcadores/sangue , Feminino , Saúde Global , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco , Taxa de Sobrevida/tendências
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