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1.
Einstein (Sao Paulo) ; 18: eAO4739, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31553355

RESUMO

OBJECTIVE: To use magnetic resonance imaging to assess the prevalence of foot and ankle ligament injuries and fractures associated with ankle sprain and not diagnosed by x-ray. METHODS: We included 180 consecutive patients with a history of ankle sprain, assessed at a primary care service in a 12-month period. Magnetic resonance imaging findings were recorded and described. RESULTS: Approximately 92% of patients had some type of injury shown on the magnetic resonance imaging. We found 379 ligament injuries, 9 osteochondral injuries, 19 tendinous injuries and 51 fractures. Only 14 magnetic resonance imaging tests (7.8%) did not show any sort of injury. We observed a positive relation between injuries of the lateral complex, syndesmosis and medial ligaments. However, there was a negative correlation between ankle ligament injuries and midfoot injuries. CONCLUSION: There was a high rate of injuries secondary to ankle sprains. We found correlation between lateral ligament injuries and syndesmosis and deltoid injuries. We did not observe a relation between deltoid and syndesmosis injuries or between lateral ligamentous and subtalar injuries. Similarly, no relation was found between ankle and midfoot injuries.


Assuntos
Traumatismos do Tornozelo/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Adulto , Idoso , Traumatismos do Tornozelo/diagnóstico por imagem , Brasil/epidemiologia , Cartilagem Articular/lesões , Criança , Feminino , Humanos , Ligamentos Laterais do Tornozelo/lesões , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Prevalência , Adulto Jovem
2.
Medicine (Baltimore) ; 98(41): e17479, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593111

RESUMO

BACKGROUND: Community-acquired pneumonia (CAP) is a potentially life-threatening condition. The aim of this study is to investigate the stratified and prognostic value of admission lactate and severity scores (confusion, urea >7 mmol/L, respiratory rate ≥30/min, blood pressure <90 mm Hg systolic and/or ≤60 mm Hg diastolic, and age ≥65 years [CURB65], pneumonia severity index [PSI], sequential organ failure assessment [SOFA], qSOFA) in patients with CAP in emergency department. METHODS: Adult patients diagnosed with CAP admitted between January 2017 and January 2019 were enrolled and divided into severe CAP (SCAP) group and nonSCAP (NSCAP) group according to international guidelines, death group, and survival group according to 28-day prognosis. Predicting performance of parameters above was compared using receiver operating characteristic curves and logistic regression model. Cox proportional hazard regression model was used to identify variables independently associated with 28-day mortality. RESULTS: A total of 350 patients with CAP were enrolled. About 196 patients were classified as SCAP and 74 patients died after a 28-day follow-up. The levels of CURB65, PSI, SOFA, qSOFA, and admission lactate were higher in the SCAP group and death group. SOFA showed advantage in predicting SCAP, while qSOFA is superior in predicting 28-day mortality. The combination of SOFA and admission lactate outperformed other combinations in predicting SCAP, and the combination of qSOFA and lactate showed highest superiority over other combinations in predicting 28-day mortality. CONCLUSION: The SOFA is a valuable predictor for SCAP and qSOFA is superior in predicting 28-day mortality. Combination of qSOFA and admission lactate can improve the predicting performance of single qSOFA.


Assuntos
Infecções Comunitárias Adquiridas/mortalidade , Ácido Láctico/sangue , Escores de Disfunção Orgânica , Admissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/sangue , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pneumonia/sangue , Prognóstico , Curva ROC , Estudos Retrospectivos
3.
Medicine (Baltimore) ; 98(41): e17569, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593143

RESUMO

Near misses and unsafe conditions have become more serious for patients in emergency departments (EDs). We aimed to search the near misses and unsafe conditions that occurred in an ED to improve patient safety.This was a retrospective analysis of a 10-year observational period from January 1, 2007 to December 31, 2016. We gained access to the adverse event notification forms (AENFs) sent to the hospital quality department from the ED. Patient age, sex, and date of presentation were recorded. The near misses and unsafe conditions were classified into 7 types: medication errors, falls, management errors, penetrative-sharp tool injuries, incidents due to institution security, incidents due to medical equipment, and forensic events. The outcome of these events was recorded.A total of 220 AENF were reported from 294,673 ED visits. The median age of the 166 patients was 60 (21-95) years. Of these, 57.1% of the patients were females and 47.9% were males. The most commonly reported events were medication errors (32.7%) and management errors (27.3%). The median age of falling patients was 67.5 years. The nurse-patient ratio between 2007 to 2011 and 2011 to 2016 were 1/10 and 1/7, respectively. We found that when this ratio increased, the adverse events results were less significant (P < .003).This was the 1st study investigating the adverse events in ED in Turkey. The reporting ratio of 0.07% for the total ED visits was too low. This showed that adverse events were under-reported.


Assuntos
Serviço Hospitalar de Emergência/normas , Erros de Medicação/estatística & dados numéricos , Segurança do Paciente/normas , Acidentes por Quedas/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Erros Médicos/classificação , Erros Médicos/estatística & dados numéricos , Erros de Medicação/classificação , Pessoa de Meia-Idade , Ferimentos Penetrantes Produzidos por Agulha/classificação , Segurança do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Medidas de Segurança/classificação , Turquia/epidemiologia
4.
JAMA ; 322(14): 1371-1380, 2019 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-31593271

RESUMO

Importance: Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life. Objective: To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes. Design, Setting, and Participants: Single-site randomized clinical trial conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016. Interventions: The intervention (n = 120) involved a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by nurses with special training on supporting patients with COPD using standardized tools. Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care. Main Outcomes and Measures: The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful). Results: Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; 61.7% women), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 62.3 (18.8) in the intervention group and 63.6 (17.4) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 1.40 (95% CI, 1.01-1.79) in the intervention group vs 0.72 (95% CI, 0.45-0.97) in the usual care group (difference, 0.68 [95% CI, 0.22-1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was 2.81 in the intervention group and -2.69 in the usual care group (adjusted difference, 5.18 [95% CI, -2.15 to 12.51]; P = .11). During the study period, there were 15 deaths (intervention: 8; usual care: 7) and 339 hospitalizations (intervention: 202; usual care: 137). Conclusions and Relevance: In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding. Trial Registration: ClinicalTrials.gov Identifier: NCT02036294.


Assuntos
Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/terapia , Qualidade de Vida , Autogestão , Cuidado Transicional , Idoso , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos
6.
Ig Sanita Pubbl ; 75(3): 211-229, 2019.
Artigo em Italiano | MEDLINE | ID: mdl-31645063

RESUMO

Emergency Department (ED) waiting times are a relevant concern both to health care professionals and consumers, because ED crowding may affect the quality of and access to health care. This has prompted a large amount of studies in the scientific literature, addressing the problem of waiting times as an "international crisis". The causes of long waiting times are complex and multifaceted and feasible solutions must consider this and other aspects such as limitation of resources and unpredicted surges in demand. In the present article, we address the issue of modeling ED flow of patients with a low score at the triage evaluation. This study aimed to develop a model to predict expected waiting times for patients with a "green" or "white" code at triage, by analyzing the patient flow in a regional referral hospital in an Italian district. The simulation model was developed through flow analysis; moreover, input analysis was performed by using registration data collected in the ED during daily activities. The simulation results were compared to data collected through direct observation at the hospital ED and to data extracted from the existing hospital information system, which represents an online transaction system tailored for routine care and patient services in the ED as well as in other hospital departments. The applied model was shown to be able to emulate patient flow in the ED and to find key critical points of the health care process, for patients who received a low category score at the triage. To face the problem of ED waiting times, adoption of patient flow analysis and improvement strategies are recommended, together with improvement of triage evaluation procedures. Simulation models can help to manage this complex issue.


Assuntos
Serviço Hospitalar de Emergência , Qualidade da Assistência à Saúde , Listas de Espera , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/tendências , Humanos , Itália , Percepção , Fatores de Tempo , Triagem
7.
Int Heart J ; 60(5): 1043-1049, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31484867

RESUMO

Acute coronary syndrome (ACS) is the major cause of out-of-hospital cardiac arrest (OHCA). The relationship between the findings from the study of coronary images and return of spontaneous circulation (ROSC) interval is still unknown. Hence, we investigated this relationship in ACS patients with OHCA.A cohort of 2779 patients was admitted to our emergency center due to cardiopulmonary arrest (CPA) between April 2011 and March 2015. We included ACS patients who had CPA with ventricular fibrillation (VF) as an initial rhythm, were successfully resuscitated, underwent coronary angiography (CAG), had a culprit lesion, and were diagnosed with ACS (n = 58; age, 63.7 ± 12.0 years; 93.1% male).We divided the 58 patients into two groups, an early ROSC group (ROSC ≤ 20 minutes: E-ROSC) and a late ROSC group (ROSC > 20 minutes: L-ROSC), and then analyzed their characteristics.The finding of a collateral artery for the culprit lesion location, Rentrop II-III, and TIMI III flow on CAG on arrival presented no significant differences between the two groups (Rentrop II-III: 25.0% versus 23.5%, P = 0.90; TIMI III: 33.3% versus 35.3%, P = 0.88). The incidence of multivessel coronary artery disease (MVD) was lower in the E-ROSC group than in the L-ROSC group (16.7% versus 58.8%, P = 0.001).Collateral and TIMI flow were not associated with ease of resuscitation, but MVD may have a negative impact on resuscitation, especially in VF patients.


Assuntos
Síndrome Coronariana Aguda/terapia , Reanimação Cardiopulmonar/métodos , Doença da Artéria Coronariana/terapia , Circulação Coronária/fisiologia , Parada Cardíaca Extra-Hospitalar/terapia , Intervenção Coronária Percutânea/métodos , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Idoso , Reanimação Cardiopulmonar/mortalidade , Causas de Morte , Estudos de Coortes , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Japão , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Intervenção Coronária Percutânea/mortalidade , Prognóstico , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Análise de Sobrevida
8.
J Glob Health ; 9(2): 020403, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31489186

RESUMO

Background: There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal. Methods: Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days. Results: In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%). Conclusions: Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Mortalidade/tendências , Adulto , Idoso , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Nepal/epidemiologia , Estudos Prospectivos
9.
J Glob Health ; 9(2): 020404, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31489187

RESUMO

Background: Displacement after a war or an armed conflict always leads to unexpected health problems, both among migrating people and in places to which new people have migrated. This study aimed to determine the health care needs and trends of Syrian patients. Methods: This retrospective study was conducted in a secondary care hospital in the city of Nevsehir, in central Turkey, between January 2013 and December 2017. All Syrian patients who visited the outpatient clinics and emergency department (ED) were enrolled in the study. Results: Over a span of five years, 41 723 Syrian patients visited the hospital's outpatient clinics and ED. The patients' median age was 23 (inter-quartile range (IQR) = 7-34), and 57.7% of them were female. In 2017, one-third of the Syrian patients visited the ED, a rate that was higher than that found among local patients (30.3% vs 25.0%, P < 0.001, respectively). The rate of pediatric clinic admissions among Syrian patients was about four times greater than the rate of local patients (20.1% vs 5.2%, P < 0.001, respectively), and Syrians' rate of admission to the obstetrics and gynecology clinic was about three times greater than the rate of local patients' admissions (12.3% vs 4.3%, P < 0.001, respectively). Conclusions: This study showed that Syrian patients' visits to the hospital, and especially the ED, are increasing. Further, the needs and expectations of these patients in terms of health care are different from local demands. New approaches should be applied to provide an appropriate use of health care facilities.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Refugiados/estatística & dados numéricos , Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Estudos Retrospectivos , Síria/etnologia , Turquia , Adulto Jovem
10.
Pan Afr Med J ; 33: 112, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31489090

RESUMO

Introduction: Animal bite injuries are a common public health concern in Uganda. We sought to characterize animal bite injuries among patients presenting to Mulago National Referral Hospital in Kampala, Uganda. Methods: This was a cross sectional study from 1st September to 30th November 2011. Participants were animal bite injury victims presenting to the accident and emergency (A&E) unit at Mulago hospital and were consecutively enrolled into the study. Socio-demographics, severity and patterns of injury, health seeking and dog handling behaviours were assessed using a standardized questionnaire. Descriptive statistics was used to summarize participant characteristics and the animal bite injuries. Poisson regression model's incident rate ratios (IRR) was used to explore the relationship of the number of days to accessing treatment at Mulago hospital with; a) received prior first aid, b) animal bite injury sustained during day time, c) unknown dog and d) victim resident in Kampala. Data were analyzed using STATA version 12.0 and statistical significance set at P < 0.05. Results: Of 25,420 patients that presented to the A&E unit during the study period, 207 (0.8%) had animal bite injuries, mean age 22.7 years (SD 14.3), 64.7% male, and 40.1% were <18 years. Majority 199 (96.1%) were bitten by a lone unrestrained and un-signaled dog that had bitten someone else in 22.2% of cases, and eight victims (0.4%) were attacked in canine gangs of 2-5 dogs. Rabies vaccination was confirmed in only 23 dogs (11.1%) as 109 (52.7%) were unknown to the victims or the communities. One hundred and eighteen victims (57.0%) sustained the dog bites within Kampala district whilst the rest occurred near or far from Kampala district, and the victims especially referred to access anti-rabies vaccine. Of 207, 189 victims (91.3%) presented within 2.6 days (SD ± 4.3). Two hundred victims (96.6%) sustained extremity injuries while the rest had injuries to other body parts. All injuries were minor and managed on out-patient basis with wound dressing, analgesics, prophylactic antibiotics and anti-rabies vaccination. Victims who received prior first aid had a rate of 1.7 times greater for seeking treatment at Mulago hospital (IRR 1.7, 95% CI 1.4-2.1) compared to those that had no prior first aid. Participants who sustained the animal bite injuries during day time had a rate of 1.6 times greater for seeking treatment at Mulago hospital (IRR 1.6, 95% CI 1.3-2.1) compared to those that sustained injuries at other times. Participants bitten by unknown dog and participants residing in Kampala had IRR 0.7, 95% CI 0.5-0.9 and IRR 0.6, 95% CI 0.5-0.8 respectively of accessing treatment at Mulago hospital compared to bitten by known dog and not residing in Kampala. Conclusion: Dog bites injuries from unrestrained, un-signaled dogs are the commonest source of animal bite injuries especially among children (<18 years). Vaccination against rabies was only confirmed for a very small number of dogs, as majority were unknown and likely stray dogs. Government and public sensitization is urgently required to limit stray dogs, vaccinate dogs and restrain them to prevent a grave probability of a looming canine rabies epidemic.


Assuntos
Mordeduras e Picadas/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Vacinas Antirrábicas/administração & dosagem , Raiva/prevenção & controle , Adolescente , Adulto , Fatores Etários , Animais , Mordeduras e Picadas/terapia , Criança , Estudos Transversais , Doenças do Cão/prevenção & controle , Doenças do Cão/virologia , Cães , Feminino , Primeiros Socorros/estatística & dados numéricos , Acesso aos Serviços de Saúde , Humanos , Masculino , Distribuição de Poisson , Inquéritos e Questionários , Fatores de Tempo , Uganda/epidemiologia , Adulto Jovem
11.
Vnitr Lek ; 65(7-8): 506-514, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31487994

RESUMO

Acute aortic syndromes are emergent life-threatening conditions affecting the aorta, which actual incidence is difficult to determine. Mortality of untreated patients increases steadily over time, so early diagnosis and initiation of therapy are crucial. Management of patients in Czech Republic follow, similar as in other European countries, the European Society of Cardiology guidelines from 2014, which were updated in 2018. The basis for diagnosis consists of history, physical examination, ECG, determination of vital signs, hemodynamic status and stratification of dia-gnosis probability by ADD-RS (aortic dissection detection risk score). This is followed by a series of laboratory and imaging examinations, of which the D-dimer, CT aortography and echocardiography are the most important. Recent studies show the benefit of combination of ADD-RS with D-dimer or measurement of ascendant aorta diameter by echocardiography. New emerging biomarkers are currently under investigation. Thanks to advances in technology, magnetic resonance imaging could take place as emergent diagnostic tool in the future. Initial therapy depends on the hemodynamic status of the patient. It must be followed by definitive therapy. In this publication we summarize the approach to a patient with acute aortic syndrome in the emergency department focusing on aortic dissection as its most common type.


Assuntos
Aneurisma Dissecante , Aneurisma Aórtico , Aneurisma Dissecante/diagnóstico , Aneurisma Dissecante/terapia , Aorta , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/terapia , República Tcheca , Serviço Hospitalar de Emergência/estatística & dados numéricos , Europa (Continente) , Humanos , Síndrome
12.
Medicine (Baltimore) ; 98(32): e16370, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393346

RESUMO

Validated risk scoring systems in African American (AA) population are under studied. We utilized history, electrocardiogram, age, risk factors, and initial troponin (HEART) and thrombolysis in myocardial infarction (TIMI) scores to predict major adverse cardiovascular events (MACE) in non-high cardiovascular (CV) risk predominantly AA patient population.A retrospective emergency department (ED) charts review of 1266 chest pain patients where HEART and TIMI scores were calculated for each patient. Logistic regression model was computed to predict 6-week and 1-year MACE and 90-day cardiac readmission. Decision curve analysis (DCA) was constructed to differentiate between clinical strategies in non-high CV risk patients.Of the 817 patients included, 500 patients had low HEART score vs. 317 patients who had moderate HEART score. Six hundred sixty-three patients had low TIMI score vs. 154 patients had high TIMI score. The univariate logistic regression model shows odds ratio of predicting 6-week MACE using HEART score was 3.11 (95% confidence interval [CI] 1.43-6.76, P = .004) with increase in risk category from low to moderate vs. 2.07 (95% CI 1.18-3.63, P = .011) using TIMI score with increase in risk category from low to high and c-statistic of 0.86 vs. 0.79, respectively. DCA showed net benefit of using HEART score is equally predictive of 6-week MACE when compared to TIMI.In non-high CV risk AA patients, HEART score is better predictive tool for 6-week MACE when compared to TIMI score. Furthermore, patients presenting to ED with chest pain, the optimal strategy for a 2% to 4% miss rate threshold probability should be to discharge these patients from the ED.


Assuntos
Afro-Americanos , Doenças Cardiovasculares/etnologia , Dor no Peito/etnologia , Indicadores Básicos de Saúde , Hospitais Comunitários/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Doenças Cardiovasculares/mortalidade , Dor no Peito/etiologia , Dor no Peito/mortalidade , Eletrocardiografia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Readmissão do Paciente , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/estatística & dados numéricos , Troponina/sangue
13.
Medicine (Baltimore) ; 98(34): e16962, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31441900

RESUMO

The emergency department (ED) serves as the first point of hospital contact for most septic patients. Early mortality risk stratification using a quick and accurate triage tool would have great value in guiding management. The mortality in emergency department sepsis (MEDS) score was developed to risk stratify patients presenting to the ED with suspected sepsis, and its performance in the literature has been promising. We report in this study the first utilization of the MEDS score in a Singaporean cohort.In this retrospective observational cohort study, adult patients presenting to the ED with suspected sepsis and fulfilling systemic inflammatory response syndrome (SIRS) criteria were recruited. Primary outcome was 30-day in-hospital mortality (IHM) and secondary outcome was 72-hour mortality. MEDS, acute physiology and chronic health evaluation II (APACHE II), and sequential organ failure assessment (SOFA) scores were compared for prediction of primary and secondary outcomes. Receiver operating characteristic (ROC) analysis was conducted to compare predictive performance.Of the 249 patients included in the study, 46 patients (18.5%) met 30-day IHM. MEDS score achieved an area under the ROC curve (AUC) of 0.87 (95% confidence interval [CI], 0.82-0.93), outperforming the APACHE II score (0.77, 95% CI 0.69-0.85) and SOFA score (0.78, 95% CI 0.71-0.85). On secondary analysis, MEDS score was superior to both APACHE II and SOFA scores in predicting 72-hour mortality, with AUC of 0.88 (95% CI 0.82-0.95), 0.81 (95% CI 0.72-0.89), and 0.79 (95% CI 0.71-0.87), respectively. In predicting 30-day IHM, MEDS score ≥12, APACHE II score ≥23, and SOFA score ≥5 performed at sensitivities of 76.1%, 67.4%, and 76.1%, and specificities of 83.3%, 73.9%, and 65.0%, respectively.The MEDS score performed well in its ability for mortality risk stratification in a Singaporean ED cohort.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Sepse/mortalidade , Triagem/métodos , Área Sob a Curva , Mortalidade Hospitalar , Humanos , Medição de Risco , Índice de Gravidade de Doença , Singapura/epidemiologia
14.
BMJ ; 366: l4563, 2019 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-31405902

RESUMO

OBJECTIVE: To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP). DESIGN: Retrospective cohort study. SETTING: Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015. PARTICIPANTS: Medicare fee-for-service patients aged 65 or over. MAIN OUTCOMES: Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit. RESULTS: Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (-0.023 (-0.035 to -0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (-0.0034 (-0.012 to 0.0054)). CONCLUSIONS: In the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Unidades de Observação Clínica/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Medicare/estatística & dados numéricos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Alta do Paciente , Readmissão do Paciente/tendências , Pneumonia/epidemiologia , Pneumonia/terapia , Estudos Retrospectivos , Fatores Sexuais , Fatores de Tempo , Estados Unidos/epidemiologia
15.
Am Surg ; 85(7): 721-724, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31405415

RESUMO

Despite the incorporation of anticoagulant and antiplatelet (ACAP) drugs in our trauma triage criteria, it is unclear whether trauma team activation (TTA) impacts outcomes in geriatric patients on ACAP drugs sustaining falls. We hypothesized that TTA in this cohort was associated with improved outcomes. The hospital electronic database was queried to identify normotensive, awake patients aged ≥65 years on ACAP agent from 2014 to 2018 presenting to the emergency department after falls. The outcome was in-hospital mortality. The association between TTA and mortality was examined using logistic regression analysis and 1:1 propensity score matching analysis. In this study, 4540 patients on ACAP drugs were analyzed, with TTA occurring in 500 (11%). TTA occurred in younger but more severely injured patients with lower Glasgow Coma Score. Logistic regression revealed that TTA was not associated with mortality (odds ratio [95% confidence intervals], 2.04 [0.89-4.25]). The 1:1 propensity score analysis revealed similar mortality for the matched groups (non-TTA, 1.6% vs TTA, 2.2%, P = 0.64). In the elderly patients on ACAP agents, the current triage criteria resulted in the appropriate use of TTA for more severely injured patients. The lack of outcome benefit suggests that ACAP drug use as a criterion for TTA should be re-evaluated.


Assuntos
Acidentes por Quedas/mortalidade , Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Mortalidade Hospitalar , Centros de Traumatologia/estatística & dados numéricos , Triagem/normas , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Avaliação de Resultados (Cuidados de Saúde) , Melhoria de Qualidade , Estudos Retrospectivos , Triagem/métodos
16.
Medicine (Baltimore) ; 98(33): e16871, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415425

RESUMO

Predicting long-term outcomes after sepsis is important when caring for patients with this condition. The purpose of the present study was to develop models predicting long-term mortality of patients with sepsis, including septic shock.Retrospective data from 446 patients with sepsis (60.8% men; median age, 71 years) treated at a single university-affiliated tertiary care hospital over 3 years were reviewed. Binary logistic regression was used to identify factors predicting mortality at 180 and 365 days after arrival at the emergency department. Long-term prognosis scores for the 180- and 365-day models were calculated by assigning points to variables according to their ß coefficients.The 180- and 365-day mortality rates were 40.6% and 47.8%, respectively. Multivariate analysis identified the following factors for inclusion in the 180- and 365-day models: age ≥65 years, body mass index ≤18.5 kg/m, hemato-oncologic diseases as comorbidities, and ventilator care. Patients with scores of 0 to ≥3 had 180-day survival rates of 83.8%, 70.8%, 42.3%, and 25.0%, respectively, and 365-day survival rates of 72.1%, 64.6%, 36.2%, and 15.9%, respectively (all differences P < .001; log-rank test). The areas under the receiver operating characteristic curves of the 180- and 365-day models were 0.713 (95% confidence interval [CI] 0.668-0.756, P < .001) and 0.697 (95% CI 0.650-0.740, P < .001), respectively.These long-term prognosis models based on baseline patient characteristics and treatments are useful for predicting the 6- and 12-month mortality rates of patients with sepsis.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Choque Séptico/mortalidade , Análise de Sobrevida , APACHE , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Comorbidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/efeitos adversos , Adulto Jovem
17.
Artigo em Alemão | MEDLINE | ID: mdl-31428831

RESUMO

BACKGROUND: The number of patients in emergency rooms without a medical emergency is increasing. Outpatient services for mutual support and relief between the in-patient and out-patient sector are not yet fully established. AIM OF THE WORK: The aim was to determine the extent to which patients in emergency rooms have real medical emergencies by comparing patients with at least two and those with a maximum of one chronic illness. An additional aim was to identify factors influencing the previous use of outpatient structures. MATERIAL AND METHODS: The study participants included emergency room patients from the cross-sectional study "PiNo-Nord." All persons in five emergency rooms in northern Germany between October 2015 and July 2016 who were not treated as "immediate" or "very urgent" were interviewed. An exploratory data analysis and multivariate logistic regression were performed. RESULTS: The 293 patients with ≥2 chronic diseases were just as often a medical emergency compared to the 847 patients with a maximum of 1 chronic disease. The most frequent occasions for consultation were musculoskeletal trauma (33%, n = 293 vs. 42%, n = 847) or trauma of the skin (11%, n = 293 vs. 13%, n = 847). In both groups, the general practitioner or specialist caregiver, as well as diagnostic or treatment options, rarely played a role in visiting the emergency department. The strongest predictors of previous outpatient treatment were the duration of the appeal in the last six months, a high subjective treatment urgency, the presence of at least two chronic conditions, and a consultation event concerning the musculoskeletal injuries. CONCLUSIONS: In both patient groups, no evidence of unnecessary visits to the emergency room was found. For the most part, outpatient structures are used in advance and the emergency department is only visited in the event of an actual medical emergency.


Assuntos
Doença Crônica/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Alta do Paciente , Doença Crônica/epidemiologia , Estudos Transversais , Alemanha , Humanos , Encaminhamento e Consulta
18.
BMC Public Health ; 19(1): 1022, 2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31366335

RESUMO

BACKGROUND: Road traffic accidents (RTA) remain a global public health concern in developing countries. The aim of the study was to document the frequency, characteristics and hospital outcomes of road traffic accidents in Guinea from 2015 to 2017. METHODS: We conducted a retrospective cohort study using medical records of RTA victims from 20 hospitals and a cross-sectional study of RTA cases from eight police stations in eight districts in Guinea, West Africa. Data analysis included descriptive statistics, trends of RTA, a sequence of interrupted time-series models and a segmented ordinary least-squares (OLS) regression. RESULTS: Police stations recorded 3,140 RTA over 3 years with an overall annual increase in RTA rates from 14.0 per 100,000 population in 2015, to 19.2 per 100,000 population in 2016 (37.1% annual increase), to 28.7 per 100,000 population in 2017 (49.5% annual increase). Overall, the injury rates in 2016 and 2017 were .05 per 100,000 population higher on average per month (95% CI: .03-.07). Deaths from RTA showed no statistical differences over the 3 years and no association of RTA trends with season was found. Overall, 27,751 RTA victims were admitted to emergency units, representing 22% of all hospitals admissions. Most victims were males (71%) and young (33%). Deaths represented 1.4% of all RTA victims. 90% of deaths occurred before or within 24 h of hospital admission. Factors associated with death were being male (p = .04), being a child under 15 years (p = .045) or an elderly person aged ≥65 years (p < .001), and having head injury or coma (p < .001). CONCLUSIONS: RTA rates in Guinea are increasing. There is a need for implementing multisectoral RTA prevention measures in Guinea.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Criança , Estudos Transversais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Guiné/epidemiologia , Humanos , Masculino , Registros Médicos , Pessoa de Meia-Idade , Polícia , Estudos Retrospectivos , Fatores de Risco , Ferimentos e Lesões/mortalidade , Adulto Jovem
19.
BMC Public Health ; 19(1): 880, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31272425

RESUMO

BACKGROUND: Personal mobility devices (PMDs) like skate-scooters, electric bicycles (e-bikes) or motorised scooters (e-scooters) have become widely available globally. There are several studies describing the rising incidence of injury from such devices. The aim of our study was to examine PMD user factors between motorised (MotPMDs) vs non-motorised PMDs (NonPMDs) as risk factors for severe injury and the need for hospital admission. METHODS: We analysed de-identified National Trauma Registry data (2015 to 2017) from all public sector hospitals in Singapore for patients aged 12 and above presenting to emergency departments with PMD-related injuries. Multivariable logistic regression was used to identify risk factors for the primary outcome of interest (higher injury severity, defined as Injury Severity Score / ISS > =9), and the secondary outcome of interest (need for hospital admission). Additional subgroup analysis was conducted comparing only scooters (manual vs electric), the most common sub-type of PMD in our study. RESULTS: Of the 614 patients in our study, majority were male (74%), median age 33 years, with 136 (22%) sustaining injuries with ISS > =9; 185 (30%) admitted [median stay length 3 days (IQR: 1-6)] and 93 (15%) required surgery. MotPMDs were more common (480, 78%), with e-scooters being the most common motorised device (393, 64%). There were 6 deaths, all in MotPMD users. On both univariate and multivariable regression, MotPMD users [OR 3.82, 95% CI 1.51-12.9, p = 0.01] and older users (> = 60 years) [OR 9.47, 95% CI 2.45-62.9, p = 0.004] were more likely to sustain injuries with ISS > =9, and more likely to need admission (MotPMD users [OR 1.8, 95% CI 1.04-3.29, p = 0.045], age > =60 years [OR 4.72, 95% CI 1.86-13.0, p = 0.002]). CONCLUSION: MotPMDs tripled the risk of severe injury and doubled the risk of requiring hospitalisation, compared to NonPMDs, likely due to higher travelling speeds. Increased age was also associated with severe injury and requiring hospitalisation.


Assuntos
Motocicletas , Ferimentos e Lesões/epidemiologia , Adolescente , Adulto , Criança , Estudos de Coortes , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Singapura/epidemiologia , Ferimentos e Lesões/mortalidade , Adulto Jovem
20.
BMC Infect Dis ; 19(1): 662, 2019 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-31345168

RESUMO

BACKGROUND: This study aimed to determine the prevalence of infectious diseases and risk factors for one-year mortality in elderly emergency department (ED) patients. METHODS: A retrospective cohort study of patients aged 65 and over who visited the ED of one urban teaching hospital in Bangkok, Thailand and who were diagnosed with infectious diseases between 1 January 2016 and 30 June 2016. RESULTS: There were 463 elderly patients who visited ED with infectious diseases, accounting for 14.5% (463/3,196) of all elderly patients' visits. The most common diseases diagnosed by emergency physicians (EPs) were pneumonia [151 (32.6%) patients] followed by pyelonephritis [107 (23.1%) patients] and intestinal infection [53 (11.4%) patients]. Moreover, 286 (61.8%) patients were admitted during the study period. The in-hospital mortality rate was 22.7%. 181 (39.1%) patients died within 1 year. Our multivariate analysis showed that age 85 years and older [odds ratio (OR) = 1.89; 95% confidence interval (CI): 1.36-2.63], Charlson Co-morbidity Index score ≥ 5 (OR = 3.51; 95% CI2.14-5.77), lactate ≥4 mmol/l (OR = 2.66;95% CI 1.32-5.38), quick Sequential Organ Failure Assessment (qSOFA) score ≥ 2 (OR = 5.46; 95% CI 2.94-10.12), and platelet count < 100,000 cells/mm3 (OR = 3.19; 95% CI 1.15-8.83) were associated with 1-year mortality. CONCLUSIONS: In one middle-income country, infectious diseases account for 14.5% of elderly ED patients. Almost two-thirds of patients presenting to ED with infection are admitted to hospital. One-third of elderly ED patients with infection died within 1 year. Age ≥ 85 years, Charlson Co-morbidity Index score ≥ 5, lactate ≥4 mmol/l, qSOFA score ≥ 2, and platelet count < 100,000 cells/mm3 predicted 1-year mortality rate.


Assuntos
Doenças Transmissíveis/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Doenças Transmissíveis/economia , Doenças Transmissíveis/epidemiologia , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Renda , Masculino , Razão de Chances , Pacientes/estatística & dados numéricos , Prevalência , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Tailândia/epidemiologia
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