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INTRODUCTION: Veterans Affairs Surgical Quality Improvement Program (VASQIP) benchmarking algorithms helped the Veterans Health Administration (VHA) reduce postoperative mortality. Despite calls to consider social risk factors, these algorithms do not adjust for social determinants of health (SDoH) or account for services fragmented between the VHA and the private sector. This investigation examines how the addition of SDoH change model performance and quantifies associations between SDoH and 30-d postoperative mortality. METHODS: VASQIP (2013-2019) cohort study in patients ≥65 y old with 2-30-d inpatient stays. VASQIP was linked to other VHA and Medicare/Medicaid data. 30-d postoperative mortality was examined using multivariable logistic regression models, adjusting first for clinical variables, then adding SDoH. RESULTS: In adjusted analyses of 93,644 inpatient cases (97.7% male, 79.7% non-Hispanic White), higher proportions of non-veterans affairs care (adjusted odds ratio [aOR] = 1.02, 95% CI = 1.01-1.04) and living in highly deprived areas (aOR = 1.15, 95% CI = 1.02-1.29) were associated with increased postoperative mortality. Black race (aOR = 0.77, CI = 0.68-0.88) and rurality (aOR = 0.87, CI = 0.79-0.96) were associated with lower postoperative mortality. Adding SDoH to models with only clinical variables did not improve discrimination (c = 0.836 versus c = 0.835). CONCLUSIONS: Postoperative mortality is worse among Veterans receiving more health care outside the VA and living in highly deprived neighborhoods. However, adjusting for SDoH is unlikely to improve existing mortality-benchmarking models. Reduction efforts for postoperative mortality could focus on alleviating care fragmentation and designing care pathways that consider area deprivation. The adjusted survival advantage for rural and Black Veterans may be of interest to private sector hospitals as they attempt to alleviate enduring health-care disparities.
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Determinantes Sociais da Saúde , Veteranos , Humanos , Idoso , Masculino , Feminino , Estados Unidos/epidemiologia , Idoso de 80 Anos ou mais , Veteranos/estatística & dados numéricos , United States Department of Veterans Affairs/estatística & dados numéricos , United States Department of Veterans Affairs/organização & administração , Fatores de Risco , Melhoria de Qualidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/epidemiologiaRESUMO
PURPOSE: Surgery for anal fistulas can result in devastating complications, including reoperations and fecal incontinence. There is limited contemporary evidence comparing outcomes since the adoption of the ligation of intersphincteric fistula tract procedure into mainstream practice. The purpose of this study is to compare recurrence rates and long-term outcomes of anal fistula following repair. METHODS: Data was collected from the electronic medical records or patient reported outcomes from patients aged 18 or older with a primary or recurrent cryptoglandular anal fistula. Primary outcome was recurrence defined as the identification of at least one fistula os or a high clinical suspicion of anal fistula. Secondary outcomes included fecal incontinence and postoperative quality of life. RESULTS: A total of 171 patients underwent definitive surgical repairs for their anal fistula. So 66.5% had a simple fistula, and 33.5% had a complex fistula. Of the 171 patients, 12.5% had a recurrence. The recurrence rates were 5.9% for simple fistula and 25.4% for complex fistula. Predictors of recurrence included diabetes mellitus, history of anorectal abscess, complex fistula, and sphincter sparing surgery. LIFT or plug/biologic procedures were both associated with a 50% or greater recurrence rate. No significant differences were found in fecal incontinence or associated quality of life between sphincter sparing or non-sphincter sparing surgical resections. CONCLUSION: The study provides insights into the long-term outcomes of surgical repair for anal fistula. We demonstrate that sphincter sparing operations are associated with increased recurrence, meanwhile, non-sphincter sparing surgeries did not increase the risk of fecal incontinence or worsen quality of life.
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Incontinência Fecal , Fístula Retal , Humanos , Incontinência Fecal/etiologia , Estudos Retrospectivos , Canal Anal/cirurgia , Qualidade de Vida , Resultado do Tratamento , Tratamentos com Preservação do Órgão , Recidiva Local de Neoplasia , Fístula Retal/cirurgia , Fístula Retal/complicações , Ligadura/efeitos adversos , Ligadura/métodos , Medidas de Resultados Relatados pelo Paciente , RecidivaRESUMO
OBJECTIVES: To determine if an association exists between the number of driving under the influence (DUI) convictions required to activate federal firearms prohibitions and annual firearm homicide and suicide rates by state. METHODS: Ecological cross-sectional study of all US states from 2013 to 2017. We collected DUI law data from Thomson Reuters Westlaw database and firearm mortality data from the Centers for Disease Control and Prevention Vital Statistics programme. RESULTS: Five states had laws such that one or two DUI convictions could result in prohibitions to firearms access according to federal law. Four states had no legal framework that would restrict firearms access because of DUI convictions; the remaining states could activate federal restrictions at three or more DUI convictions. Firearm-specific homicide (victimisations) rates were 19% lower among women in states where federal restrictions of firearms access occurred after one or two DUI offences (incidence rate ratio (IRR) 0.81; 95% CI 0.64 to 1.01) and 18% lower in states with firearm prohibitions after three or more offences (IRR 0.82; 95% CI 0.71 to 0.95) compared with the states with no legal framework for prohibiting firearms after DUI convictions. There was no association between number of DUI activations and overall, or firearm-specific, suicide among the entire population (men and women) or among only women, or only men. CONCLUSIONS: DUI penalties that activate federal firearms prohibitions may be one pathway to reduce firearm homicide of female victims.
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Dirigir sob a Influência , Armas de Fogo , Prevenção do Suicídio , Ferimentos por Arma de Fogo , Estudos Transversais , Feminino , Homicídio , Humanos , Masculino , Estados Unidos/epidemiologiaRESUMO
Objectives. To determine differences among US states in how driving under the influence of alcohol (DUI) laws activate federal firearm possession and purchase prohibitions.Methods. We performed primary legislative research to characterize DUI laws in each state. The primary outcome was the number of DUI convictions an individual must be convicted of in each state to activate the federal firearm possession and purchase prohibition. We also determined the time interval in which previous DUI convictions count for future proceedings.Results. Forty-seven states had DUI laws that activated the federal prohibition of firearm possession and purchase for a threshold number of repeated DUIs. Variation exists among states in the number of convictions (1-4) and length of liability period (5 years-lifetime) required to prohibit firearm possession and purchase.Conclusions. Variation in state laws on DUI results in differences in determining who is federally prohibited from possessing and purchasing firearms. Future research should explore whether these federal prohibitions arising from DUI convictions are enforced and whether an association exists between stricter DUI policies and reduction in firearm crimes, injuries, and deaths.
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Dirigir sob a Influência/legislação & jurisprudência , Armas de Fogo/legislação & jurisprudência , Humanos , Governo Estadual , Estados UnidosRESUMO
BACKGROUND: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may distinguish necrotizing soft tissue infection (NSTI) from non-NSTI. The association of higher preoperative LRINEC scores with escalations of intraoperative anesthesia care in NSTI is unknown and may be useful in communicating illness severity during patient handoffs. MATERIALS AND METHODS: We conducted a retrospective cohort study of first operative debridement for suspected NSTI in a single referral center from 2013 to 2016. We assessed the association between LRINEC score and vasopressors, blood products, crystalloid, invasive monitoring, and minutes of operative and anesthesia care. RESULTS: We captured 332 patients undergoing their first operative debridement for suspected NSTI. For every 1-point higher LRINEC score, there was a higher risk of norepinephrine and vasopressin use (relative risk [RR] = 18%, 95% confidence interval [CI] [10%, 26%] and [10%, 27%], respectively), packed red blood cell use (RR = 28% [95% CI 13%, 45%]), and additional crystalloid (17.57 mL/h [95% CI 0.37, 34.76]). Each additional LRINEC point was associated with longer anesthesia (3.42 min, 95% CI 0.94, 5.91) and operative times (2.35 min, 95% CI 0.29, 4.40) and a higher risk of receiving invasive arterial monitoring (RR 1.11, 95% CI 1.05, 1.18). The negative predictive value for an LRINEC score < 6 was > 90% for use of vasopressors and packed red blood cells. CONCLUSIONS: Preoperative LRINEC scores were associated with escalations in intraoperative care in patients with NSTI. A low score may predict patients unlikely to require vasopressors or blood and may be useful in standardized handoff tools for patients with NSTI.
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Anestesia/métodos , Cuidados Intraoperatórios/métodos , Índice de Gravidade de Doença , Infecções dos Tecidos Moles/diagnóstico , Adulto , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Desbridamento/efeitos adversos , Diagnóstico Diferencial , Fasciite Necrosante/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Necrose/diagnóstico , Necrose/cirurgia , Duração da Cirurgia , Período Pré-Operatório , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Infecções dos Tecidos Moles/cirurgiaRESUMO
OBJECTIVE: The aim of this study was to examine the risk of delirium in geriatric trauma patients with rib fractures treated with systemic opioids compared with those treated with regional analgesia (RA). SUMMARY OF BACKGROUND DATA: Delirium is a modifiable complication associated with increased morbidity and mortality. RA may reduce the need for opioid medications, which are associated with delirium in older adults. METHODS: Cohort study of patients ≥65 years admitted to a regional trauma center from 2011 to 2016. Inclusion factors were ≥ 3 rib fractures, blunt trauma mechanism, and admission to intensive care unit (ICU). Exclusion criteria included head AIS ≥3, spine AIS ≥3, dementia, and death within 24âhours. The primary outcome was delirium positive ICU days, defined using the CAM-ICU assessment. Delirium incident rate ratios (IRRs) and 95% confidence intervals (95% CIs) were estimated using generalized linear mixed models with Poisson distribution and robust standard errors. RESULTS: Of the 144 patients included in the study, 27 (19%) received Acute Pain Service consultation and RA and 117 (81%) received opioid-based systemic analgesia. Patients with RA had more severe chest injury than those without. The risk of delirium decreased by 24% per day per patient with use of RA (IRR 0.76, 95% CI 0.61 to 0.96). Individual opioid use, as measured in daily morphine equivalents (MEDs), was significantly reduced after initiation of RA (mean difference -7.62, 95% CI -14.4 to -0.81). CONCLUSION: Although use of RA techniques in geriatric trauma patients with multiple rib fractures was associated with higher MED, opioid use decreased after RA initiation and Acute Pain Service consultation, and the risk of delirium was lower.
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Analgésicos Opioides/administração & dosagem , Anestesia por Condução/métodos , Delírio/epidemiologia , Delírio/prevenção & controle , Manejo da Dor/métodos , Fraturas das Costelas/complicações , Ferimentos não Penetrantes/complicações , Idoso , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva , Masculino , Traumatismo Múltiplo , Medição da Dor , Estudos Retrospectivos , Fatores de Risco , Centros de Traumatologia , Resultado do TratamentoRESUMO
BACKGROUND: Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world's population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries such as Nepal. The aim of this study was to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. METHODS: A countrywide survey using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged >18 y were included in this analysis. RESULTS: A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%). CONCLUSIONS: The Nepal health care system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a health care professional and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.
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Doenças do Colo/epidemiologia , Hemorragia Gastrointestinal/epidemiologia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Doenças Retais/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/diagnóstico , Doenças do Colo/cirurgia , Estudos Transversais , Países em Desenvolvimento , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Nepal/epidemiologia , Prevalência , Doenças Retais/diagnóstico , Doenças Retais/cirurgia , RetoRESUMO
INTRODUCTION: Income inequality is associated with poor health outcomes, but its association with colorectal cancer is not well-studied. The authors aimed to determine the association between income inequality and colorectal cancer incidence/mortality in U.S. counties, and hypothesized that this association was mediated by deprivation. METHODS: The authors performed a cross-sectional study of U.S. counties from 2015-2019 using statewide cancer registries and the Centers for Disease Control and Prevention WONDER database. Generalized linear negative binomial regression was performed in 2024 to estimate the association between Gini coefficient (income inequality) and colorectal cancer incidence/mortality using incidence rate ratios (IRRs) for the entire cohort and stratified by rurality. RESULTS: A total of 697,981 colorectal cancer cases were diagnosed in the 5-year study period. On adjusted regression, for every 0.1 higher Gini coefficient, there was an 11% higher risk of both colorectal cancer incidence and mortality (IRR 1.11, 95%CI 1.03,1.19 and IRR 1.11, 95%CI 1.05, 1.18 respectively). The association between income inequality and incidence/mortality peaked in more rural counties, however there was not an overall dose-dependent relationship between rurality and these associations. Deprivation mediated the association between income inequality and colorectal cancer incidence (indirect effect B coefficient 0.088, p<0.001) and mortality (B coefficient 0.088, p<0.001). The magnitude and direction of the direct, indirect, and total effects differed in each rurality strata. CONCLUSIONS: Much of income inequality's association with colorectal cancer outcomes operates through deprivation. Rural counties have a stronger association between higher income inequality and higher mortality, which works in tandem with deprivation.
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Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged ≥ 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as > 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% (n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09-5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43-1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06-1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.
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Analgésicos Opioides , Artroplastia do Joelho , Dor Pós-Operatória , Determinantes Sociais da Saúde , Humanos , Artroplastia do Joelho/efeitos adversos , Masculino , Feminino , Idoso , Analgésicos Opioides/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Estados Unidos , Estudos Retrospectivos , VeteranosRESUMO
Laparoscopic total abdominal colectomy (TAC) is the optimal operative approach for patients with medically refractory inflammatory bowel disease and other benign colon conditions. Minimally invasive techniques for TAC are safe, appropriate, and associated with faster recovery than open surgery. This may be of particular importance in patients who ultimately undergo proctectomy with or without intestinal pouch reconstruction. We describe approaches to the laparoscopic TAC.
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Colite Ulcerativa , Doenças do Colo , Laparoscopia , Colectomia , Colite Ulcerativa/cirurgia , Doenças do Colo/cirurgia , Humanos , Resultado do TratamentoRESUMO
Over 80% of bias-motivated violent victimization is motivated by race or ethnicity and over 50% of bias victimization occurs in non-Hispanic Whites (NHW). Our aim was to determine the risk and health impacts of race/ethnicity-motivated violent victimization by victim race/ethnicity. We examined data from the National Crime Victimization Survey (2003-2015) to estimate violent victimization risk by victim race/ethnicity across race/ethnicity bias victimization, other types of bias victimizations, and non-bias violent victimizations. We examined incident and offender characteristics for race/ethnicity-motivated victimization by victim race/ethnicity. The risk of race/ethnicity-motivated violent victimization was greater for non-Hispanic Blacks (NHB) and Hispanics than for NHWs (incidence rate ratios [IRR] = 1.4; 95% confidence interval [CI] = [1.0, 2.0], and IRR = 1.6; 95% CI = [1.2, 2.1]). This translates into an additional 46.7 incidents per 100,000 person-years (95% CI = [1.4, 92.1]) for the NHB population and an additional 60.3 incidents per 100,000 person-years (95% CI = [20.3, 100.4]) for the Hispanic population. Violent incidents for NHB victims more frequently resulted in injury or medical care. Nearly 40% of NHB victims reported difficulties at school or work related to the incident where only 21.5% of NHWs and 11.7% of Hispanic victims reported similar problems. Roughly 37% of NHB victims identified a NHW offender and 45% of NHW victims identified a NHB offender. Hispanic victims identified NHB or NHW offenders in over 70% of incidents. Although literature suggests that NHWs account for the majority of bias victimizations, the risk of non-fatal violent victimization motivated by race/ethnicity is greater for NHBs and Hispanics. Crimes perpetrated against NHBs are likely more severe and victim/offender racial incongruity is common. Findings provide empiric evidence on race/ethnicity-related structural disadvantage with adverse health consequences.
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Vítimas de Crime , Criminosos , Agressão , Crime , Etnicidade , HumanosRESUMO
BACKGROUND/PURPOSE: Our objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma. METHODS: We queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18â¯years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics. RESULTS: The 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children'sâ¯=â¯$6575 [$4333-$10,862], nonchildren's $7027 [$4230-$12,219] pâ¯=â¯0.47) and high-grade (children'sâ¯=â¯$10,984 [$6211- $20,007] nonchildren's $10,156 [$5439-$18,404] pâ¯=â¯0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CRâ¯=â¯2.35 95% CI 2.02, 2.74, high-grade CRâ¯=â¯2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status. CONCLUSION: Hospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients. LEVEL OF EVIDENCE: III.
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Traumatismos Abdominais , Custos Hospitalares/estatística & dados numéricos , Ferimentos não Penetrantes , Traumatismos Abdominais/economia , Traumatismos Abdominais/epidemiologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/economia , Ferimentos não Penetrantes/epidemiologiaRESUMO
Importance: If changes over time in trauma care apply to both firearm injuries and motor vehicle crashes (MVCs) similarly, differences in mechanism-specific case-fatality trends may suggest changes over time in injury severity. Objectives: To analyze national trends in case-fatality percentages at levels I and II trauma centers for injuries due to MVC, firearm assault, self-inflicted firearm injury, and unintentional firearm injury by age and to analyze trends in injury severity scores (ISSs) and the percentage of out-of-hospital deaths by mechanism. Design, Setting, and Participants: From November 15, 2017, to July 4, 2018, repeated cross-sectional measures analysis of 1â¯335â¯044 patients treated at level I or II trauma centers from January 1, 2003, through December 31, 2013, was conducted using 2 data sources: the National Trauma Data Bank National Sample Program, with survey weights to estimate annual median ISS, total injuries and total deaths at levels I and II trauma centers, and the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research for percentages of out-of-hospital deaths. Main Outcome Measures: The main outcome was annual case-fatality percentage (total died/total injured), calculated by mechanism across 3 age groups (15-34 years, 35-54 years, and ≥55 years) and 5 categories of ISS (1-15 [mild] 16-24, 25-40, 41-66, and 67-75 [severe]). Linear regression was performed to estimate annual trends in case-fatality percentage by mechanism, age group, and ISS. Annual trends in percentages of out-of-hospital deaths and median ISSs by mechanism were estimated. Sensitivity analyses included the Durbin-Watson statistic for autocorrelation and Prais-Winsten regression models. Results: Among 1â¯335â¯044 patients treated at level I or II trauma centers, self-inflicted firearm injury had a case-fatality percentage of 42.8%, and assault with a firearm had a case-fatality percentage of 11.1%, the 2 highest of the injuries studied. The injury case-fatality percentage was lower each year for MVCs but did not change for any firearm intent overall or for any age group. Overall, median ISS increased annually for firearm suicide (0.31; 95% CI, 0.00-0.61). The annual percentage of out-of-hospital deaths was lower each year for MVCs (-0.24; 95% CI, -0.43 to -0.05) but not for any firearm intents. In sensitivity analyses, the annual percentage of out-of-hospital deaths for MVCs no longer showed a decline. Conclusions and Relevance: Stagnant case-fatality percentages for firearm injuries juxtaposed to improvements for MVCs across age-groups and ISS categories suggests worsening severity of firearm injuries over the study period.
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Acidentes de Trânsito/mortalidade , Suicídio/estatística & dados numéricos , Violência/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Adolescente , Adulto , Fatores Etários , Estudos Transversais , Bases de Dados Factuais , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Pessoa de Meia-Idade , Mortalidade/tendências , Suicídio/tendências , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
INTRODUCTION: This study sought to determine the association between changes in state-level beer excise tax and firearm homicide rates among individuals aged 15-34years. METHODS: A time series analysis with synthetic controls was conducted for the years 2003-2015. Exposed states changed the beer excise tax during the study period. Synthetic controls were weighted mimics that combined portions of unexposed states using state-year specific demographic and firearm covariates. Average annual incidence rate differences were calculated between each exposed state and its synthetic control. Alcohol taxes were available through the National Institute of Alcohol Abuse and Alcoholism and firearm homicide rates were obtained from theCenters for Disease Control and Prevention. States that changed the beer excise tax but forwhich <2years of pre-exposure data were available were excluded. Data were collected in 2017 and analyzedin 2018. RESULTS: Five states met inclusion criteria, and all raised the beer excise tax: Illinois (2009), New York (2009), North Carolina (2009), Connecticut (2011), and Rhode Island (2013). The percentage increase in beer excise tax ranged from 10% to 27%. Differences in pre-exposure firearm homicide rates between exposed states and synthetic controls were minimal. The increase in beer excise tax was associated with a lower average annual firearm homicide rate in all states except Illinois (Rhode Island: incidence rate difference= -2.48, Connecticut: incidence rate difference= -2.57, New York: incidence rate difference= -1.45, North Carolina: incidence rate difference= -0.45, and Illinois: incidence rate difference=1.54 per 100,000 population). CONCLUSIONS: Among individuals aged 15-34years, price-sensitive consumption of beer may representone feasible tool for policymakers seeking to reduce rates of firearm homicide.
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Cerveja/economia , Comércio/economia , Armas de Fogo/estatística & dados numéricos , Homicídio/estatística & dados numéricos , Impostos/economia , Adolescente , Adulto , Connecticut , Feminino , Humanos , Illinois , Masculino , New York , North Carolina , Política Pública , Rhode Island , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Although some geriatric trauma patients may be at low risk of complications, poor outcomes are pronounced if complications do occur. Prevention in this group decreases the risk of excess morbidity and mortality. METHODS: We performed a case-control study of trauma patients 65 years or older treated from January 2015 to August 2016 at a Level I trauma center with a Trauma Quality Improvement Program-predicted probability of complication of less than 20%. Cases had one of the following complications: unplanned admission to the intensive care unit (ICU), unplanned intubation, pneumonia, or unplanned return to the operating room. Two age-matched controls were randomly selected for each case. We collected information on comorbidities, home medications, and early medical care and calculated odds ratios using multivariable conditional logistic regression. RESULTS: Ninety-four patients experienced unplanned admission to ICU (n = 51), unplanned intubation (n = 14), pneumonia (n = 21), and unplanned return to the operating room (n = 8). The 188 controls were more frequently intubated and had higher median ISS but were otherwise similar to cases. The adjusted odds of complication were higher for patients on a home ß-blocker (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.2-4.0) and home anticoagulation (aOR, 2.2; 95% CI, 1.2-4.1). Patients with diabetes (aOR 2.0; 95% CI, 1.1-3.7) and dementia (aOR, 2.0; 95% CI, 1.0-4.3) also had higher odds of complication. The adjusted odds of complication for patients receiving geriatrics consultation was 0.4 (95% CI, 0.2-1.0; p = 0.05). Pain service consultation and indwelling pain catheter placement may be protective, but CIs included 1. There was no association between opiates, benzodiazepines, fluid administration, or blood products in the first 24 hours and odds of complication. CONCLUSIONS: Geriatrics consultation was associated with lower odds of unplanned admission to the ICU, unplanned intubation, pneumonia, and unplanned return to the operating room in low-risk older adult trauma patients. Pathways that support expanding comanagement strategies with geriatricians are needed. LEVEL OF EVIDENCE: Therapeutic/Care management, Level IV.
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Ferimentos e Lesões/complicações , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Medição de Risco , Fatores de Risco , Fatores Sexuais , Ferimentos e Lesões/cirurgiaRESUMO
PURPOSE: We sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients. METHODS: Using the 2004 to 2014 National Cancer Database (NCDB), patients ≤21â¯years (pediatric) were retrospectively compared to >21â¯years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences. RESULTS: Of the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, pâ¯=â¯0.006) and stage 4 disease (56% vs 41%, pâ¯=â¯0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (Pâ¯<â¯0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, pâ¯<â¯0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73-1.15). CONCLUSION: While gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: III.
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Adenocarcinoma , Neoplasias Gástricas , Adenocarcinoma/diagnóstico , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Adulto , Fatores Etários , Idoso , Criança , Terapia Combinada , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapia , Análise de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Regionalization of trauma care is a national priority and hospitalization for blunt abdominal trauma, which may include transfer, is common among children. The objective of this study was to determine whether there were differences in mortality, treatment, or length of stay between patients treated at or transferred to a higher level trauma center and those not transferred and admitted to a lower level trauma center. METHODS: Cohort from Washington state trauma registry from 2000 to 2014 of patients 16 years or younger with isolated Grade I-III spleen, liver, or kidney injury. RESULTS: Among 54,034 patients 16 years or younger, the trauma registry captured 1177 (2.2%) patients with isolated low grade solid organ injuries; 226 (19.2%) presented to a higher level trauma center, 600 (51.0%) presented to a lower level trauma center and stayed there for care, and 351 (29.8%) were transferred to a higher level trauma center. Forty (3.4%) patients underwent an abdominal operation. Among the 950 patients evaluated initially at a lower level trauma center, the risk of surgery did not differ significantly between those who were not transferred compared to those who were (relative risk, 2.19; 95% confidence interval, 0.80-6.01). The risk of total splenectomy was no different for patients who stayed at a lower level trauma center compared with those who were transferred to a higher level trauma center (RR, 0.84; 95% CI, 0.33-2.16). Nontransferred patients had a 0.63 (95% confidence interval, 0.45-0.88) times lower risk of staying in the hospital for an additional day compared with patients who were transferred to a higher level trauma center. One patient died. CONCLUSION: Few pediatric patients with isolated low grade blunt solid organ injury require intervention and thus may not need to be transferred; trauma systems should revise their transfer policies. Prevention of unnecessary transfers is an opportunity for cost savings in pediatric trauma. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.
Assuntos
Traumatismos Abdominais/terapia , Tomada de Decisão Clínica/métodos , Transferência de Pacientes/organização & administração , Sistema de Registros , Centros de Traumatologia/organização & administração , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/epidemiologia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Washington/epidemiologia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/epidemiologiaRESUMO
OBJECTIVE: Translation of evidence to practice is a public health priority. Worldwide, injury is a leading cause of morbidity and mortality. Case study publications are common and provide potentially reproducible examples of successful interventions in healthcare from the patient to systems level. However, data on how well case study publications are utilized are limited. To our knowledge, the World Health Organization (WHO) published the only collection of international case studies on injury care at the policy level. We aimed to determine the degree to which these injury care case studies have been translated to practice and to identify opportunities for enhancement of the evidence-to-practice pathway for injury care case studies overall. METHODS: We conducted a systematic review across 19 databases by searching for the title, "Strengthening care for the injured: Success stories and lessons learned from around the world." Data synthesis included realist narrative methods and two authors independently reviewed articles for injury topics, reference details, and extent of utilization. FINDINGS: Forty-seven publications referenced the compilation of case studies, 20 of which included further descriptions of one or more of the specific cases and underwent narrative review. The most common category utilized was hospital-based care (15 publications), with the example of Thailand's quality improvement (QI) programme (10 publications) being the most commonly cited case. Also frequently cited were case studies on prehospital care (10 publications). There was infrequent utilization of case studies on rehabilitation (3 publications) and trauma systems (2 publications). No reference described a case translated to a new scenario. CONCLUSIONS: The only available collection of policy-level injury care case studies has been utilized to a moderate extent however we found no evidence of case study translation to a new circumstance. QI programs seem especially amenable for knowledge-sharing through case studies. Prehospital care also showed promise. Greater emphasis on rehabilitation and health policy related to trauma systems is warranted. There is also a need for greater methodologic rigor in evaluation of the use of case study collections in general.
Assuntos
Bases de Dados Factuais/estatística & dados numéricos , Atenção à Saúde/normas , Medicina de Emergência Baseada em Evidências/estatística & dados numéricos , Melhoria de Qualidade/normas , Organização Mundial da Saúde , Política de Saúde , Humanos , Pesquisa QualitativaRESUMO
INTRODUCTION: Implanting a magnetic lower esophageal sphincter augmentation device (LINX, Torax Medical) has become an increasingly common option in the surgical management of gastroesophageal reflux disease. As the enthusiasm for placing this device increases, experience in the management of device-related complications-including erosion-is necessary. METHODS: We report a staged approach to LINX removal in a 64-year-old female with symptoms of odynophagia secondary to partial erosion of a LINX device into the esophagus. RESULTS: The patient had a 12-bead LINX device placed in 2011 at an outside, international facility. In late 2013, she began experiencing symptoms of odynophagia. An esophagogastroduodenoscopy at our institution in October 2015 demonstrated two metallic beads eroding through the distal esophageal lumen. An elective endoscopic removal of the two visible beads was performed. A postoperative esophagram confirmed that there was no resulting esophageal perforation. The patient noted mild improvement in her symptoms. After a 12-week period to allow for complete healing, the remaining 10 beads of the LINX device were explanted laparoscopically without complication. No further procedures were undertaken. At 2 months' follow-up, the patient noted complete resolution of her symptoms. CONCLUSION: Transmural erosion of the LINX device into the esophageal lumen is a rare occurrence, with only five such complications reported in the published literature. We present the first account of LINX explantation for esophageal erosion in the United States. We demonstrated that a staged laparoendoscopic approach to LINX removal in these cases is feasible with minimal morbidity.