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1.
J Neurotrauma ; 33(22): 2026-2033, 2016 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-26917004

RESUMO

Traumatic brain injury (TBI) is a widespread global disease, often with widely varying outcomes. Standardization of care and adherence to established guidelines are central to the effort to improve outcomes. At our level I urban trauma center, we developed and implemented a Joint Commission-certified TBI Program of Care in 2011 and compared our post-implementation patient data set with historical controls, using the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic model. Historical controls were drawn from the San Francisco General Hospital Traumatic Coma Data Bank (SFGH/TCDB) from 1987 to 1996. Recent era patients were drawn from the NeuroTracker database, a customized electronic medical record used in our clinical practice. Descriptive statistics were calculated. Adherence to four quality-of-care metrics on the clinical service was tracked for 2011-2013. The IMPACT prognostic model was used to calculate expected versus observed mortality for current and historical patient groups. In the historical control group, 832 patients were identified and 6-month mortality was available for 592. Observed 6-month mortality was 49%. In the recent era patient group, 211 patients were identified and 6-month mortality was 38%. The IMPACT prognostic model was applied to each patient group. Areas under the curve for each analysis were >0.85 and goodness of fit was satisfactory, indicating good performance of the IMPACT model. Comparison of observed versus expected deaths in the recent versus the control patient sets revealed a drop of 59% in early mortality. The greatest reductions in mortality were observed in the group of patients with IMPACT-predicted mortality ≤50%. Significant progress has been made in reducing the percentage of unexpected deaths in TBI patients. It is likely that major factors include more aggressive management and tracking of compliance with the implementation of guidelines for the management of TBI patients.


Assuntos
Benchmarking/normas , Lesões Encefálicas Traumáticas/mortalidade , Medicina Baseada em Evidências/normas , Guias de Prática Clínica como Assunto/normas , Desenvolvimento de Programas/normas , Adulto , Idoso , Benchmarking/métodos , Benchmarking/tendências , Lesões Encefálicas Traumáticas/diagnóstico , Estudos de Coortes , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Desenvolvimento de Programas/métodos , Resultado do Tratamento
2.
Neurosurgery ; 75(5): 523-9; discussion 528-9, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24979096

RESUMO

BACKGROUND: Calvarial reconstruction of large cranial defects following decompressive surgery is challenging. Autologous bone cannot always be used due to infection, fragmentation, bone resorption, and other causes. Polyetheretherketone (PEEK) is a synthetic material that has many advantages in cranial-repair surgery, including strength, stiffness, durability, and inertness. OBJECTIVE: To describe our experience with custom-made PEEK implants for the repair of large cranial defects in 3 institutions: San Francisco General Hospital, Hadassah-Hebrew University Hospital, and the National Neuroscience Institute, Singapore. METHODS: A preoperative high-resolution computed tomography scan was obtained for each patient for design of the PEEK implant. Cranioplasty was performed via standard technique with the use of self-tapping titanium screws and miniplates. RESULTS: Between 2006 and 2012, 66 cranioplasties with PEEK implants were performed in 65 patients (46 men, 19 women, mean age 35 ± 14 years) for repair of large cranial defects. There were 5 infections of implants and 1 wound breakdown requiring removal of the implant (infection and surgical removal rates of 7.6% and 9.1%, respectively). Two patients required drainage of postoperative hematoma (overall surgical complication rate, 12.7%). Nonsurgical complications in 5 patients included seizures, nonoperative collection, and cerebrospinal fluid rhinorrhea that resolved spontaneously. Overall median patient or family satisfaction with the cranioplasty and aesthetic result was good, 4 on a scale of 5. Temporal wasting was the main aesthetic concern. CONCLUSION: Custom-designed PEEK implants are a good option for patients with large cranial defects. The rate of complications is comparable to other implants or autologous bone. Given the large size of these defects, the aesthetic results are good.


Assuntos
Cetonas/uso terapêutico , Procedimentos de Cirurgia Plástica/métodos , Polietilenoglicóis/uso terapêutico , Próteses e Implantes , Crânio/cirurgia , Adulto , Benzofenonas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polímeros , Complicações Pós-Operatórias/epidemiologia , Procedimentos de Cirurgia Plástica/efeitos adversos , Estudos Retrospectivos , São Francisco , Resultado do Tratamento
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