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1.
J Surg Res ; 231: 201-209, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30278930

RESUMO

BACKGROUND: Metrics exist to assess and validate trauma system outcomes; however, these are clinically focused and do not evaluate the appropriateness of admission patterns, relative to geography and triage category. We propose the term "functional inclusivity", defined as the number and proportion of triage-negative, and/or nonseverely injured patients, who were injured in proximity to a level II/III trauma center but admitted to a level I facility. The aim of this study was to evaluate this metric in the North West London Trauma Network. METHODS: Retrospective, geospatial, observational analysis of registry data from the North West London Trauma Network. We included all adult (≥16 years) patients transported to the level I trauma center at St. Mary's Hospital between 1/1/13-31/12/16. Incident location data were geocoded into longitude/latitude, and drive times were calculated from incident location to each hospital in London's Trauma System, using Google Maps. RESULTS: Of 2051 patients, 907 (44%) were severely injured (injury severity score [ISS] ≥15), and 1144 (56%) were nonseverely injured (ISS 1-15). Seven hundred ninety five of the 1144 nonseverely injured patients (69%) were injured in proximity to a level II/III but taken to the level I facility. A total of 488 (24%) patients were triage-negative, and 229 (47%) of these were injured in proximity to a level II/III, but taken to the level I trauma center. CONCLUSIONS: This study has demonstrated the concept of functional inclusivity in characterizing trauma system performance. Further work is required to establish what constitutes an acceptable level of functional inclusivity and what the denominator should be, as well as validating and further evaluating the concept of functional inclusivity.


Assuntos
Centros de Traumatologia/organização & administração , Adulto , Idoso , Feminino , Humanos , Londres , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Análise Espacial , Centros de Traumatologia/estatística & dados numéricos , Centros de Traumatologia/provisão & distribuição
2.
World J Surg ; 41(9): 2207-2214, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28508236

RESUMO

BACKGROUND: The city of Shenzhen, China, is planning to establish a trauma system. At present, there are few data on the geographical distribution of incidents, which is key to deciding on the location of trauma centres. The aim of this study was to perform a geographical analysis in order to inform the development of a trauma system in Shenzhen. METHODS: Retrospective analysis of trauma incidents attended by Shenzhen Emergency Medical Services (EMS) in 2014. Data were obtained from Shenzhen EMS. Incident distribution was explored using dot and kernel density estimate maps. Clustering was determined using the nearest neighbour index. The type of healthcare facilities which patients were taken to was compared against patients' needs, as assessed using the Field Triage Decision Scheme. RESULTS: There were 49,082 recorded incidents. A total of 3513 were classed as major trauma. Mapping demonstrates that incidents predominantly occurred in the western part of Shenzhen, with identifiable clusters. Nearest neighbour index was 0.048. Of patients deemed to have suffered major trauma, 8.5% were taken to a teaching hospital, 13.6% to a regional hospital, 42.6% to a community hospital, and 35.3% to a private hospital. The proportions of Step 1 or 2 negative patients were almost identical. CONCLUSION: The majority of trauma patients, including trauma patients who are at greater likelihood of severe injury, are taken to regional and community hospitals. There are areas with identifiable concentrations of volume, which should be considered for the siting of high-level trauma centres, although further modelling is required to make firm recommendations.


Assuntos
Planejamento em Saúde Comunitária , Serviços Médicos de Emergência/estatística & dados numéricos , Mapeamento Geográfico , Centros de Traumatologia , Ferimentos e Lesões/epidemiologia , Adulto , China/epidemiologia , Análise por Conglomerados , Feminino , Hospitais Comunitários/estatística & dados numéricos , Hospitais Privados/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Humanos , Masculino , Estudos Retrospectivos , Triagem , Adulto Jovem
3.
Artigo em Inglês | MEDLINE | ID: mdl-35798972

RESUMO

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

4.
Injury ; 52(2): 182-188, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33160609

RESUMO

INTRODUCTION: Hemorrhage is a leading cause of death among trauma patients, and is the most common cause of preventable death after trauma. Since the advent of blood component fractioning, most patients receive blood components rather than whole blood (WB). WB contains all of the individual blood components and has the advantages of simplifying resuscitation logistics, providing physiological ratios of components, reducing preservative volumes and allowing transfusion of younger red blood cells (RBC). Successful experience with fresh whole blood (FWB) by the US military is well documented. In the civilian setting, transfusion of cold-stored low titer type O whole blood (LTOWB) was shown to be safe. Reports of WB are limited by small numbers and low transfusion volumes. STUDY DESIGN: We conducted a systematic review of the available published studies, comparing efficacy and safety of resuscitation with WB to resuscitation with blood components, in hemorrhaging trauma patients, using MEDLINE, EMBASE and ISI Web of Science. The main outcomes of interest were 24 hour and 30-day survival, blood product utilization and adverse events. Two reviewers independently abstracted the studies and assessed for bias. Sub-group analyses were pre-planned on the FWB and LTOWB groups separately. RESULTS: Out of 126 references identified through our search strategy, five studies met the inclusion criteria. Only one study of FWB showed a significant benefit on 24 hour and 30-day survival. Other studies of both FWB and LTOWB showed no statistically significant difference in survival. There is an apparent benefit in blood product utilization with the use of WB across most studies. There were no reports of transfusion related reactions, however there was an increase in the organ failure rates in the FWB groups. CONCLUSIONS: WB was not associated with a significant survival benefit or reduced blood product utilization. Nonetheless, it seems that the use of LTOWB is safe and might carry a significant logistic benefit. The quality of the existing data is poor and further high quality studies are required.


Assuntos
Reação Transfusional , Ferimentos e Lesões , Transfusão de Componentes Sanguíneos , Transfusão de Sangue , Hemorragia/prevenção & controle , Humanos , Ressuscitação , Ferimentos e Lesões/terapia
5.
J Surg Res ; 163(2): 197-200, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20538295

RESUMO

BACKGROUND: As the Fundamentals of Research and Career Development Course (FRCDC) is conducted internationally, questions have arisen regarding the cultural appropriateness of the United States (US) course. We therefore assessed the US-based teaching methodology during the FRCDC in Abuja, Nigeria. We hypothesized that the US-based instructional methods would be effective. METHODS: Twenty questions were distributed to attendees of the FRCDC prior to commencement. The same 20 questions were administered at the conclusion of the course after random reordering. Differences between the pre- and post-test results were assessed for normalcy and compared using the paired t-test. RESULTS: There were 89 attendees, of whom 60 completed the pre-test and 77 completed the post-test. The pre-test group answered 12.3 ± 2.6 questions correctly, which improved to 15.0 ± 2.6 in the post-test group (P < 0.001). On the pre-test, the least common correct answers were for questions regarding type 1 and 2 error (16.7% correct), the definition of health services and outcomes research (26.7%), and how to best address missing data (26.7%). On the post-test, the questions with the least common correct answers were regarding the definition of health services and outcomes research (35%), and the components of an NIH grant (37.7%). CONCLUSIONS: Our results suggest that the FRCDC in Nigeria as given by US faculty has short-term efficacy. Attendees were able to improve their scores despite the cultural differences between them and the lecturers. Our next goal will be to demonstrate long-term efficacy at future courses in the region using similar questionnaire strategies.


Assuntos
Cirurgia Geral/educação , Pesquisa , Ensino/métodos , Humanos , Nigéria , Inquéritos e Questionários , Estados Unidos
6.
J Trauma ; 67(1): 190-4; discussion 194-5, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19590334

RESUMO

BACKGROUND: After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances. METHODS: The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital. RESULTS: Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability. CONCLUSION: A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.


Assuntos
Eficiência Organizacional/economia , Traumatismo Múltiplo/cirurgia , Equipe de Assistência ao Paciente/organização & administração , Administração de Recursos Humanos em Hospitais/economia , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Escala Resumida de Ferimentos , Adulto , Análise Custo-Benefício/economia , Honorários Médicos/estatística & dados numéricos , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Incidência , Tempo de Internação/economia , Masculino , Traumatismo Múltiplo/economia , Traumatismo Múltiplo/epidemiologia , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Estados Unidos/epidemiologia , Revisão da Utilização de Recursos de Saúde
7.
Injury ; 50(4): 877-882, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30935745

RESUMO

INTRODUCTION: Trauma is a global problem. The goal of optimising multidisciplinary trauma care through speciality education is a challenge. No single pathway exists to educate care providers in trauma knowledge, management and skills. Queen Mary University of London (QMUL) devised an online electronic learning (e-learning) Master's degree (MSc) in Trauma Sciences in 2011. E-learning is increasingly popular however low progression rates question effectiveness. The further post-graduate impact is unknown. Our goal was to establish whether this program is a successful method of delivering multidisciplinary trauma education to an international community. We hypothesized that graduating students make a global impact in trauma care, education and research. METHODS: The Trauma Sciences MSc programs launched in 2011. Electronic surveys were distributed worldwide to students who successfully completed the program between 2013-2016. Graduation rates, degree/qualification awarded, clinical involvement in trauma management, presentation of MSc work, academic progression and roles in trauma education were explored. Supporting demographics were extracted from the QMUL student database. RESULTS: A total of 176 students, of 29 nationalities, enrolled in the two year course between 2011 and 2014. Clinical backgrounds included multi-speciality physicians (83.5%), nurses (9.6%) and paramedics (6.8%). 119 (67.6%) graduated within the study period, 108 (60.8%) with the full masters award. Completion was independent of clinical background (p = 0.20) and age (p = 0.99). Highest completion rates were seen in students from Australia and New Zealand, Asia and Europe (p = 0.03). All survey responders were currently providing regular clinical care to trauma patients. 73% (n = 36) were delivering trauma education, many at national or international level. 49% (n = 24) had presented work from the MSc and 23% (n = 11) published their dissertation.12% (n = 6) subsequently enrolled in a PhD program. CONCLUSION: Compared with other e-learning courses this Masters program has an enviable completion rate. Graduates go on to make an international multidisciplinary impact with diverse roles in clinical management, research and trauma education. This programme provides a robust trauma education curriculum. The QMUL Trauma Sciences MSc program is an excellent resource for clinicians participating in any form of trauma care or who wish to augment sub-speciality training in trauma.


Assuntos
Currículo , Educação a Distância , Educação de Pós-Graduação , Traumatologia/educação , Adulto , Escolha da Profissão , Avaliação Educacional , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Reino Unido
8.
Am Surg ; 74(2): 103-7, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18306857

RESUMO

Traditionally, conventional arteriography is the diagnostic modality of choice to evaluate for arterial injury. Recent technological advances have resulted in multidetector, fine resolution computed tomographic angiography (CTA). This study examines CTA for evaluation of extremity vascular trauma compared with conventional arteriography. Our hypothesis is that CTA provides accurate and timely diagnosis of peripheral vascular injuries and challenges the gold standard of arteriogram. Traumatic extremity injuries over a 5-year period were identified using a Level I trauma center registry and radiology database. Information collected included patient demographics, mechanism, imaging modality, vascular injuries, management, and follow-up. Two thousand two hundred and fifty-one patients were identified with extremity trauma. Twenty-four patients were taken directly to the operating room for evaluation and management of vascular injuries. Fifty-two underwent vascular imaging. Fourteen patients had conventional arteriograms with 13 abnormal studies: 7 were managed operatively, 2 embolized, and 4 observed. Thirty-eight patients underwent CTA with 17 abnormal scans: 9 were managed operatively, 3 embolized, and 5 observed. There were no false negatives or missed injuries. CTA provides accurate peripheral vascular imaging while additionally offering advantages of noninvasiveness and immediate availability. Secondary to these advantages, CTA has supplanted arteriography for initial radiographic evaluation of peripheral vascular injuries at our Level I trauma center. This study supports CTA as an effective alternative to conventional arteriography in assessing extremity vascular trauma.


Assuntos
Angiografia/métodos , Braço/irrigação sanguínea , Vasos Sanguíneos/lesões , Perna (Membro)/irrigação sanguínea , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Criança , Pré-Escolar , Humanos , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
9.
J Trauma ; 65(2): 367-72, 2008 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-18695473

RESUMO

BACKGROUND: Strict glucose control with insulin is associated with decreased mortality in a mixed patient population in the intensive care unit. Controversy exists regarding the relative benefits of glucose control versus a direct advantageous effect of exogenous insulin. As a combined medical/surgical population differs significantly from the critically injured patient primed for secondary insult, our purpose was to determine the influence of insulin on activated macrophages. Our hypothesis was that insulin would directly abrogate the inflammatory cascade. METHODS: Differentiated human monocytic THP-1 cells were stimulated with endotoxin (lipopolysaccharide [LPS], 100 ng/mL) for 6 hours. Cells were treated +/-10(-7) M insulin for 1 hour and 24 hours. Total RNA was isolated and gene expression for TNF-alpha and IL-6 performed using Q-RT-PCR. Supernatants were assayed for TNF-alpha and IL-6 protein by ELISA. RESULTS: At 1 hour, compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (11.4 +/- 5.9 pg/mL vs. 32.5 +/- 3.1 pg/mL; p < 0.03). At 24 hours compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (83 +/- 2.02 pg/mL vs. 114 +/- 6.54 pg/mL; p < 0.01). However, gene expression of TNF-alpha and IL-6 was not different in LPS stimulated macrophages with and without insulin treatment at both 1 hour and 24 hours. CONCLUSION: Contrary to our hypothesis, insulin does not have direct anti-inflammatory properties in this experimental model. In fact, insulin increases proinflammatory cytokine protein levels from activated macrophages.


Assuntos
Hipoglicemiantes/farmacologia , Insulina/farmacologia , Interleucina-6/metabolismo , Macrófagos/metabolismo , Fator de Necrose Tumoral alfa/metabolismo , Células Cultivadas , Humanos , Lipopolissacarídeos/farmacologia , Insuficiência de Múltiplos Órgãos/metabolismo , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Sepse/metabolismo
10.
J Trauma ; 65(6): 1253-7, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19077609

RESUMO

BACKGROUND: Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport. METHODS: Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change. RESULTS: For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy. CONCLUSIONS: Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Traumatismo Múltiplo/classificação , Índices de Gravidade do Trauma , Triagem/classificação , California , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Humanos , Traumatismo Múltiplo/diagnóstico , Avaliação de Resultados em Cuidados de Saúde , Transferência de Pacientes/estatística & dados numéricos , Estudos Retrospectivos , Sensibilidade e Especificidade , Centros de Traumatologia , Triagem/estatística & dados numéricos
11.
Injury ; 49(6): 1070-1078, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29602489

RESUMO

BACKGROUND: An understanding of stakeholders' views is key to the successful development and operation of a rural trauma system. Scotland, which has large remote and rural areas, is currently implementing a national trauma system. The aim of this study was to identify key barriers and enablers to the development of an effective trauma system from the perspective of rural healthcare professionals. METHODS: This is a qualitative study, which was conducted in rural general hospitals (RGH) in Scotland, from April to June 2017. We used an opportunistic sampling strategy to include hospital providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and transcribed. Thematic analysis was used to identify and group participant perspectives on key barriers and enablers to the development of the new trauma system. RESULTS: We conducted 15 interviews with 18 participants in six RGHs. Study participants described barriers and enablers across three themes: 1) quality of care, 2) interfaces within the system and 3) interfaces with the wider healthcare system. For quality of care, enablers included confidence in basic trauma management, whilst a perceived lack of change from current management was seen as a barrier. The theme of interfaces within the system identified good interaction with other services and a single point of contact for referral as enablers. Perceived barriers included challenges in referring to tertiary care. The final theme of interfaces with the wider healthcare system included an improved transport system, increased audit resource and coordinated clinical training as enablers. Perceived barriers included a rural staffing crisis and problematic patient transfer to further care. CONCLUSIONS: This study provides insight into rural professionals' perceptions regarding the implementation of a trauma system in rural Scotland. Barriers included practical issues, such as retrieval, transfer and referral processes. Importantly, there is a degree of uncertainty, discontent and disengagement towards trauma system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and the effective delivery of rural trauma systems.


Assuntos
Atenção à Saúde/organização & administração , Hospitais Rurais , Desenvolvimento de Programas/normas , Centros de Traumatologia , Atitude do Pessoal de Saúde , Pessoal de Saúde , Hospitais Rurais/organização & administração , Hospitais Rurais/normas , Hospitais Rurais/tendências , Humanos , Entrevistas como Assunto , Inovação Organizacional , Pesquisa Qualitativa , Garantia da Qualidade dos Cuidados de Saúde , Melhoria de Qualidade , População Rural , Escócia , Centros de Traumatologia/organização & administração
12.
J Trauma ; 63(3): 608-14, 2007 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18073608

RESUMO

BACKGROUND: During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays. METHODS: Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children <1 to 19 years of age from January 1993 to December 2002. Data collected included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale score, Injury Severity Score, hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. Analysis involved 140 (4.8%) of 2,944 patients requiring operation. Two cohorts were characterized: (1) immediate operation (IO), defined as laparotomy 3 hours after arrival (n = 59; 42%). RESULTS: Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates. CONCLUSION: IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.


Assuntos
Traumatismos Abdominais/cirurgia , Ferimentos não Penetrantes/cirurgia , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Fatores Etários , Transfusão de Sangue/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Escala de Coma de Glasgow , Hemodinâmica , Humanos , Lactente , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Modelos Lineares , Masculino , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Ferimentos não Penetrantes/mortalidade
14.
J Trauma Acute Care Surg ; 83(5): 934-943, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29068875

RESUMO

BACKGROUND: Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI. METHODS: A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome. RESULTS: Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries. CONCLUSION: Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.


Assuntos
Embolização Terapêutica , Baço/lesões , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/terapia , Teorema de Bayes , Transfusão de Sangue , Embolização Terapêutica/efeitos adversos , Humanos , Falha de Tratamento , Ferimentos não Penetrantes/mortalidade
15.
Arch Surg ; 141(2): 177-80, 2006 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-16490896

RESUMO

HYPOTHESIS: Traumatic thoracic aortic injury (TAI) is traditionally treated with immediate surgery. Previously published studies have established the safety and efficacy of treating TAI with endovascular stents. Our hypothesis was that stents are supplanting operative repair as the primary therapy for TAI. DESIGN: Retrospective cohort. SETTING: University level I trauma center. PATIENTS AND METHODS: Blunt trauma patients admitted to a level I trauma center diagnosed with TAI between September 1997 and November 2003 were identified from an institutional trauma registry (N = 25). Data were abstracted from medical records and analyzed. Three groups were defined: surgical repair (cardiopulmonary bypass or clamp and sew) (n = 10); medical management (n = 8); and endovascular stent (n = 7). RESULTS: Prior to 2002, 9 (75%) of 12 patients were treated by surgical repair, 2 (17%) by medical management, and 1 (8%) by endovascular stent. Since 2002, 1 patient (8%) was treated by surgical repair, 6 (46%) by medical management, and 6 (46%) by endovascular stent. Injury Severity Scores were comparable between the surgical cohort (mean +/- SEM score, 34.9 +/- 3.4), stent placement (35.1 +/- 3.7), and medical management (29.9 +/- 2.8) (P = .48). Overall survival was 80% with no differences in morbidity or mortality. The stented group had shorter hospital lengths of stay compared with surgical management (28 vs 46 days) (P<.05). The 1 operative case since 2002 was a combined arch/innominate injury that anatomically precluded stent placement. CONCLUSION: Initial reports suggested thoracic aortic stents as an alternative for injured patients with prohibitive operative risks. Our data suggest stent placement is quickly evolving into the primary therapy for TAI across all Injury Severity Score profiles.


Assuntos
Aorta Torácica/lesões , Ruptura Aórtica/cirurgia , Traumatismos Torácicos/complicações , Procedimentos Cirúrgicos Vasculares/tendências , Ferimentos não Penetrantes/complicações , Adulto , Ruptura Aórtica/etiologia , Ruptura Aórtica/mortalidade , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Índices de Gravidade do Trauma , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos
16.
Arch Surg ; 141(5): 451-8; discussion 458-9, 2006 May.
Artigo em Inglês | MEDLINE | ID: mdl-16702516

RESUMO

HYPOTHESIS: Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified. DESIGN: Multicenter historical cohort. SETTING: Seven urban level I trauma centers. PATIENTS: Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours. INTERVENTION: Nonoperative treatment of complex blunt hepatic injuries. MAIN OUTCOME MEASURES: Complications and treatment strategies. RESULTS: Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis. CONCLUSIONS: Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.


Assuntos
Traumatismos Abdominais/terapia , Transfusão de Sangue/métodos , Hepatopatias/epidemiologia , Fígado/lesões , Morbidade/tendências , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Hepatopatias/etiologia , Hepatopatias/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia
17.
Arch Gen Psychiatry ; 62(5): 523-8, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15867105

RESUMO

CONTEXT: Minimizing negative consequences of major depression following traumatic brain injury is an important public health objective. Identifying high-risk patients and referring them for treatment could reduce morbidity and loss of productivity. OBJECTIVE: To develop a model for early screening of patients at risk for major depressive episode at 3 months after traumatic brain injury. DESIGN: Prediction model using receiver operating characteristic curve. SETTING: Level I trauma center in a major metropolitan area. PARTICIPANTS: Prospective cohort of 129 adults with mild traumatic brain injury. MAIN OUTCOME MEASURES: Center for Epidemiologic Studies Depression Scale score and current major depressive episode module of the Structured Clinical Interview for the DSM-IV. RESULTS: A prediction model including higher 1-week Center for Epidemiologic Studies Depression Scale score, older age, and computed tomographic scans of intracranial lesions yielded 93% sensitivity and 62% specificity. CONCLUSION: This study supports the feasibility of identifying patients with mild traumatic brain injury who are at high risk for developing major depressive episode by 3 months' postinjury, which could facilitate selective referral for potential treatment and reduction of negative outcomes.


Assuntos
Lesões Encefálicas/diagnóstico , Transtorno Depressivo Maior/diagnóstico , Adulto , Assistência Ambulatorial , Lesões Encefálicas/complicações , Estudos de Coortes , Transtorno Depressivo Maior/etiologia , Transtorno Depressivo Maior/prevenção & controle , Manual Diagnóstico e Estatístico de Transtornos Mentais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Modelos Estatísticos , Probabilidade , Estudos Prospectivos , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Curva ROC , Fatores de Risco , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Índices de Gravidade do Trauma
18.
Scand J Trauma Resusc Emerg Med ; 24: 30, 2016 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-26968161

RESUMO

BACKGROUND: Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. METHODS: The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. RESULTS AND DISCUSSION: 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. CONCLUSIONS: This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries.


Assuntos
Comportamento Cooperativo , Modelos Teóricos , Centros de Atenção Terciária , Centros de Traumatologia , Pessoal Administrativo/psicologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Inovação Organizacional , Pesquisa Qualitativa , Escócia
19.
J Am Coll Surg ; 200(6): 946-53, 2005 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15922210

RESUMO

BACKGROUND: Our goal was to identify factors that can be targeted during medical education to encourage a career in surgery. STUDY DESIGN: We conducted a cross-sectional survey of first and fourth year classes in a Liaison Committee on Medical Education-accredited medical school. Students scored 19 items about perceptions of surgery using a Likert-type scale. Students also indicated their gender and ranked their top three career choices. RESULTS: There were 121 of 210 (58%) first year and 110 of 212 (52%) fourth year students who completed the survey. First year students expressed a positive correlation between surgery and career opportunities, intellectual challenge, performing technical procedures, and obtaining a residency position, although length of training, work hours, and lifestyle during and after training were negatively correlated with choosing surgery. Fourth year student responses correlated positively with career and academic opportunities, intellectual challenge, technical skills, role models, prestige, and financial rewards. Factors that correlated negatively were length of training, residency lifestyle, hours, call schedule, and female gender of the student respondent. Forty-four percent of first year male students expressed an interest in surgery versus 27% of fourth year male students (p < 0.04). Eighteen percent of first year female students expressed an interest in surgery versus 5% of fourth year female students (p < 0.006). CONCLUSIONS: Lifestyle issues remain at the forefront of student concerns. Intellectual challenge, career opportunities, and technical skills are consistently recognized as strengths of surgery. Additionally, fourth year students identify role models, prestige, and financial rewards as positive attributes. Emphasizing positive aspects may facilitate attracting quality students to future careers in surgery.


Assuntos
Escolha da Profissão , Educação de Graduação em Medicina , Cirurgia Geral , Estudantes de Medicina/psicologia , Algoritmos , Estudos Transversais , Feminino , Humanos , Renda , Estilo de Vida , Masculino , Papel (figurativo) , Estados Unidos
20.
Shock ; 17(6): 459-62, 2002 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-12069180

RESUMO

Base deficit has been established as a predictor of mortality and endpoint of resuscitation. We hypothesized that in a significant subset of surgical intensive care patients, base deficit is secondary to hyperchloremic acidosis, and that these patients experience lower mortality than those patients whose base deficits are secondary to other causes. Seventy-five consecutive surgical intensive care patients with base deficits greater than 2.0 were prospectively studied. The etiology of the patients' base deficits was determined by admission laboratory data. Patients were divided into those with hyperchloremic acidosis, and those with acidosis from other causes. Mortality within these groups was compared by Fisher's exact test. Thirty-seven patients (49.3%) had hyperchloremic acidosis. Thirty-three patients (46.7%) had lactic acidosis. Three patients (4%) had base deficits secondary to ketosis, and two patients (2.6%) had base deficits secondary to uremia. There were no significant differences in age, APACHE II scores, or volumes of resuscitation between the hyperchloremic group and the remaining patients. There were four deaths (10.8%) in the hyperchloremic group and thirteen deaths (34.2%) in the remaining patients (P = 0.03). Hyperchloremic acidosis resulted from resuscitation with lactated Ringer's solution in 18 (48.6%) of the hyperchloremic patients. Hyperchloremic acidosis is a common etiology of base deficit in the surgical intensive care unit. It is associated with lower mortality than base deficit secondary to other causes. Moreover, it is frequently induced following resuscitation with lactated Ringer's solution. Failure to properly diagnose this subset of acidotic patients may result in inappropriate clinical interventions due to the erroneous presumption of ongoing tissue hypoxia.


Assuntos
Equilíbrio Ácido-Base , Acidose/metabolismo , Acidose/mortalidade , Cloretos/sangue , Acidose/terapia , Acidose Láctica/metabolismo , Acidose Láctica/mortalidade , Acidose Láctica/terapia , Adulto , Idoso , Cuidados Críticos , Feminino , Humanos , Soluções Isotônicas , Cetose/metabolismo , Cetose/mortalidade , Cetose/terapia , Masculino , Pessoa de Meia-Idade , Ressuscitação , Solução de Ringer , Uremia/metabolismo , Uremia/mortalidade , Uremia/terapia
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