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1.
J Am Coll Surg ; 229(3): 236-243, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30978395

RESUMO

BACKGROUND: Recent attention has been paid to the role trauma centers play in responding to mass shootings. Although high-profile public events are the primary focus of media and policy makers, firearm-injured patients (FIPs) present in clusters to urban trauma centers every day. We examined the burden of FIP clusters from an urban trauma system perspective. STUDY DESIGN: In this descriptive epidemiologic study, we used data from the Philadelphia Police Department registry of shootings from 2005 to 2015. Variables included patient demographics, injury date and time, receiving hospital, and mortality. We defined clustered FIPs as those arriving within 15 minutes of another FIP. We used rolling temporal windows to calculate the number of FIP clusters for each hospital, assessed patient demographic characteristics and mortality, and used linear regression models to evaluate trends in FIP cluster rates. RESULTS: Of the 14,217 FIPs included, 22.1% were clustered. There were 54 events when 4 or more FIPs presented within 15 minutes and 92 events when 4 or more FIPs presented within 60 minutes. Clusters of FIP occurred most frequently during night shifts (7:00 pm to 7:00 am) (73.1%) at level I trauma centers (93.6%), with geographic clustering demonstrated at the hospital level. Compared with the overall FIP population, clustered FIPs were more likely to be female (p = 0.039), injured at night (p = 0.031), but less likely to die (p = 0.014). The rate of FIP clusters and mortality remained steady over the course of the study. CONCLUSIONS: In the trauma system studied, FIP clusters are common and are likely to occur at similar rates in other urban centers. Therefore, the immediate burden on health care resources caused by multiple FIPs presenting within a short period of time is not limited to traditionally defined mass shootings.


Assuntos
Centros de Traumatologia , Ferimentos por Arma de Fogo/epidemiologia , Adulto , Análise por Conglomerados , Feminino , Hospitais Urbanos , Humanos , Masculino , Philadelphia/epidemiologia , Transporte de Pacientes/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade
2.
J Surg Res ; 218: 29-34, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28985863

RESUMO

BACKGROUND: Aggressive management of patients prior to and after determination of death by neurologic criteria (DNC) is necessary to optimize organ recovery, transplantation, and increase the number of organs transplanted per donor (OTPD). The effects of time management are understudied but potentially pivotal component. The objective of this study was to analyze specific time points (time to DNC, time to procurement) and the time intervals between them to better characterize the optimal timeline of organ donation. METHODS: Using data over a 5-year time period (2011-2015) from the largest US OPO, all patients with catastrophic brain injury and donated transplantable organs were retrospectively reviewed. Active smokers were excluded. Maximum donor potential was seven organs (heart, lungs [2], kidneys [2], liver, and pancreas). Time from admission to declaration of DNC and donation was calculated. Mean time points stratified by specific organ procurement rates and overall OTPD were compared using unpaired t-test. RESULTS: Of 1719 Declaration of Death by Neurologic Criteria organ donors, 381 were secondary to head trauma. Smokers and organs recovered but not transplanted were excluded leaving 297 patients. Males comprised 78.8%, the mean age was 36.0 (±16.8) years, and 87.6% were treated at a trauma center. Higher donor potential (>4 OTPD) was associated with shorter average times from admission to brain death; 66.6 versus 82.2 hours, P = 0.04. Lung donors were also associated with shorter average times from admission to brain death; 61.6 versus 83.6 hours, P = 0.004. The time interval from DNC to donation varied minimally among groups and did not affect donation rates. CONCLUSIONS: A shorter time interval between admission and declaration of DNC was associated with increased OTPD, especially lungs. Further research to identify what role timing plays in the management of the potential organ donor and how that relates to donor management goals is needed.


Assuntos
Morte Encefálica , Transplante de Órgãos/estatística & dados numéricos , Gerenciamento do Tempo , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/métodos , Adulto , Lesões Encefálicas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Obtenção de Tecidos e Órgãos/organização & administração , Obtenção de Tecidos e Órgãos/estatística & dados numéricos
3.
J Trauma Acute Care Surg ; 83(6): 1095-1101, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28700413

RESUMO

BACKGROUND: Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI. METHODS: A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]). RESULTS: The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72). CONCLUSION: Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.


Assuntos
Medição de Risco/métodos , Lesões do Sistema Vascular/complicações , Tromboembolia Venosa/etiologia , Adulto , Anticoagulantes/uso terapêutico , Feminino , Seguimentos , Humanos , Incidência , Escala de Gravidade do Ferimento , Período Intraoperatório , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/cirurgia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle , Adulto Jovem
4.
Dig Surg ; 34(5): 421-428, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28668951

RESUMO

BACKGROUND: Aging has been associated with increasing common bile duct (CBD) diameter and reported as independently predictive of the likelihood of choledocolithiasis. These associations are controversial with uncertain diagnostic utility in patients presenting with symptomatic disease. The current study examined the relationship between age, CBD size, and the diagnostic probability of choledocolithiasis. METHODS: Symptomatic patients undergoing evaluation for suspected choledocolithiasis from January 2008 to February 2011 were reviewed. In the cohort without choledocolithiasis, the relationship between aging and CBD size was examined as a continuous variable and by comparing mean CBD size across stratified age groups. Multivariate analysis examined the relationship between increasing age and diagnostic probability of choledocolithiasis in all patients. RESULTS: Choledocolithasis was diagnosed by MR cholangiopancreatography (MRCP) or endoscopic retrograde (ERCP) in 496 of 1,000 patients reviewed. Mean CBD was 6.0 mm (±2.8 mm) in the 504 of 1,000 patients without choledocolithiasis on ERCP/MRCP. Increasing age had no correlation with CBD size as a continuous variable (r2 = 0.011, p = 0.811). No difference occurred across age groups (Kruskal-Wallis, p = 0.157). Age had no association with diagnostic likelihood of choledocolithiasis (AOR [95% CI] 0.99 [0.98-1.01], adjusted-p = 0.335). CONCLUSION: In a large population undergoing investigation for biliary disease, increasing age was neither associated with increasing CBD diameter nor predictive of the likelihood of choledocolithiasis.


Assuntos
Envelhecimento/patologia , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/patologia , Ducto Colédoco/patologia , Adulto , Fatores Etários , Idoso , Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Probabilidade , Estudos Retrospectivos
5.
Ann Surg ; 266(3): 432-440, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28657951

RESUMO

OBJECTIVE: We sought to determine whether state firearm legislation correlated with firearm-related fatality rates (FFR) during a 15-year period. BACKGROUND: The politicized and controversial topic of firearm legislation has been grossly understudied when the relative impact of American firearm violence is considered. Scientific evidence regarding gun legislation effectiveness remains scant. METHODS: Demographic and intent data (1999-2013) were collected from the Centers for Disease Control and Prevention's Web-Based Injury Statistics Query and Reporting System database and compared by state firearm legislation rankings with respect to FFR. State scorecards were obtained from firearm-restrictive (Brady Campaign/Law Center against Gun Violence [BC/LC]) and less-restrictive (National Rifle Association) groups. FFR were compared between restrictive and least-restrictive states during 3 periods (1999-2003, 2004-2008, 2009-2013). RESULTS: During 1999 to 2013, 462,043 Americans were killed by firearms. Overall FFR did not change during the 3 periods (10.89 ±â€Š3.99/100,000; 10.71 ±â€Š3.93/100,000; 11.14 ±â€Š3.91/100,000; P = 0.87). Within each period, least-restrictive states had greater unintentional, pediatric, and adult suicide, White and overall FFR than restrictive states (all P < 0.05). Conversely, no correlation was seen, during any of the 3 time periods, with either homicide or Black FFR-population subsets accounting for 41.7% of firearm deaths. CONCLUSIONS: Restrictive firearm legislation is associated with decreased pediatric, unintentional, suicide, and overall FFR, but homicide and Black FFR appear unaffected. Future funding and research should be directed at both identifying the most effective aspects of firearm legislation and creating legislation that equally protects every segment of the American population.


Assuntos
Armas de Fogo/legislação & jurisprudência , Violência/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Adulto Jovem
6.
Am J Surg ; 214(1): 19-23, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27769542

RESUMO

INTRODUCTION: A daily Chest X-ray (CXR) is obtained in many surgical intensive care units (SICU). This study implemented a selective CXR protocol in a high volume, academic SICU and evaluated its impact on clinical outcomes. METHODS: All SICU patients admitted in 2/2010 were compared with patients admitted in 2/2012. Between the time periods, a protocol eliminating the routine daily CXRs was instituted. RESULTS: In 02/2010 and 02/2012, 107 and 90 patients were admitted to the SICU, respectively, for a total of 1384 patient days. CXRs decreased from 365 (57.1% of patient-days) in 2010 to 299 (40.9% of patient days; p < 0.001) in 2012. A greater proportion of Physician Directed CXRs (PDCXRs) had new findings (80.8%) compared to Automatic Daily CXRs (ADCXRs) (23.5%, p < 0.001). There was no difference in overall or SICU length of stay, ventilator-free days, morbidity or mortality. CONCLUSION: Eliminating ADCXRs decreased the number of CXRs performed, without affecting LOS, mechanical ventilation, morbidity or mortality. Physician-directed ordering of CXRs increased the diagnostic value of the CXR and decreased the number of clinically irrelevant CXRs performed.


Assuntos
Protocolos Clínicos , Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Radiografia Torácica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Los Angeles , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial , Procedimentos Desnecessários , Adulto Jovem
7.
J Trauma Acute Care Surg ; 79(2): 232-7;quiz 332-3, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26218691

RESUMO

BACKGROUND: Unlike in the military setting, where the use of tourniquets has been well established, in the civilian sector their use has been far less uniform. The purpose of this study was to examine the outcomes associated with the use of tourniquets for civilian extremity trauma. STUDY DESIGN: Adult (≥18 years) patients admitted to our institution with an extremity injury requiring tourniquet application from January 2007 to June 2014 were retrospectively reviewed. The primary outcome analyzed was limb loss. Secondary outcomes included death, hospital length of stay, and complications. RESULTS: There were 87 patients who met inclusion criteria. Average age was 35.3 years, 90.8% were male, and 66.7% had penetrating injuries, with a median Injury Severity Score (ISS) of 6. Tourniquets were placed in the prehospital setting in 50.6%, in the emergency department in 39.1%, and in the operating room in 10.3% of patients. The windlass type Combat Application Tourniquet was the most commonly used type (67.8%), followed by a pneumatic system (24.1%) and self-made tourniquet (8.0%). The median duration of use was 75 minutes (interquartile range, 91) with no differences between groups (p = 0.547). Overall, 80.5% had a vascular injury (70.1% arterial), and a total of 99 limb operations were performed, including 15 amputations. Fourteen amputations (93.3%) occurred at the scene or were directly attributed to the extent of tissue damage with a median Mangled Extremity Severity Score (MESS) of 7 (interquartile range, 2). In the remaining patient, the tourniquet was lifesaving but likely contributed to limb loss. Seven patients sustained 13 other complications; however, none was directly attributed to tourniquet use. CONCLUSION: Tourniquet use in the civilian sector is associated with a low rate of complications. With the low complication rate and high potential for benefit, aggressive use of this potentially lifesaving intervention is justified. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.


Assuntos
Serviços Médicos de Emergência/métodos , Extremidades/irrigação sanguínea , Extremidades/lesões , Hemorragia/terapia , Torniquetes , Lesões do Sistema Vascular/terapia , Adolescente , Adulto , Idoso , Feminino , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Lesões do Sistema Vascular/complicações , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto Jovem
8.
Transfusion ; 55(3): 532-43, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25582335

RESUMO

BACKGROUND: The Mirasol system has been demonstrated to effectively inactivate white blood cells (WBCs) and reduce pathogens in whole blood in vitro. The purpose of this study was to compare the safety and efficacy of Mirasol-treated fresh whole blood (FWB) to untreated FWB in an in vivo model of surgical bleeding. STUDY DESIGN AND METHODS: A total of 18 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 33°C, and a standardized liver injury. Animals were then randomly assigned to resuscitation with either Mirasol-treated or untreated FWB, and intraoperative blood loss was measured. After abdominal closure, the animals were observed for 14 days, after which the animals were euthanized and tissues were obtained for histopathologic examination. Mortality, tissue near-infrared spectroscopy, red blood cell (RBC) variables, platelets (PLTs), WBCs, and coagulation indices were analyzed. RESULTS: Total intraoperative blood loss was similar in test and control arms (8.3 ± 3.2 mL/kg vs. 7.7 ± 3.9 mL/kg, p = 0.720). All animals survived to Day 14. Trended values over time did not show significant differences-tissue oxygenation (p = 0.605), hemoglobin (p = 0.461), PLTs (p = 0.807), WBCs (p = 0.435), prothrombin time (p = 0.655), activated partial thromboplastin time (p = 0.416), thromboelastography (TEG)-reaction time (p = 0.265), or TEG-clot formation time (p = 0.081). Histopathology did not show significant differences between arms. CONCLUSIONS: Mirasol-treated FWB did not impact survival, blood loss, tissue oxygen delivery, RBC indices, or coagulation variables in a standardized liver injury model. These data suggest that Mirasol-treated FWB is both safe and efficacious in vivo.


Assuntos
Segurança do Sangue , Transfusão de Sangue/métodos , Sangue/efeitos dos fármacos , Sangue/efeitos da radiação , Hemorragia/terapia , Ressuscitação/métodos , Riboflavina/farmacologia , Raios Ultravioleta , Animais , Células Sanguíneas/efeitos dos fármacos , Células Sanguíneas/efeitos da radiação , Testes de Coagulação Sanguínea , Preservação de Sangue , Índices de Eritrócitos , Feminino , Hemodiluição , Hemorragia/etiologia , Hipotermia Induzida , Lacerações/complicações , Lacerações/terapia , Laparotomia , Fígado/lesões , Fígado/patologia , Masculino , Distribuição Aleatória , Sus scrofa , Suínos , Tromboelastografia
9.
Am J Surg ; 209(4): 742-6, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25194758

RESUMO

BACKGROUND: The role of angiointervention (ANGIO) in the management of high-grade liver injuries is not clear and there are concerns about increased complications. METHODS: National Trauma Data Bank study, isolated grade IV and V blunt liver injuries. Patients with major associated intra-abdominal or extra-abdominal injuries were excluded. Logistic regression analysis was performed to identify independent predictors of mortality and complications. RESULTS: Six thousand four hundred two patients met the criteria for inclusion. Laparotomy was performed in 32% of the patients and nonoperative management in 68%. Overall, 11% of the patients underwent ANGIO. Patients in the ANGIO group were significantly more likely to be older than 55 years than non-ANGIO patients and more likely to have Injury Severity Scores greater than 25. After stepwise logistic regression, ANGIO was an independent predictor of survival (P < .001). In the group of patients managed operatively, it was independently associated with a lower mortality (P < .001). Similarly, in the nonoperative group, it was independently associated with a lower mortality (5.4% vs 9.5%, P = .008). ANGIO was associated with increased systemic complications. CONCLUSIONS: ANGIO in blunt, severe liver injuries is associated with reduced mortality and increased complications, in both operative and nonoperative management.


Assuntos
Embolização Terapêutica , Fígado/lesões , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Prognóstico , Taxa de Sobrevida
10.
Ulus Travma Acil Cerrahi Derg ; 20(4): 248-52, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25135018

RESUMO

BACKGROUND: The harmful effects of smoking have been well-documented in the medical literature for decades. To further the support of smoking cessation, we investigate the effect of smoking on a less studied population, the trauma patient. METHODS: All trauma patients admitted to the surgical intensive care unit at the LAC + University of Southern California medical center between January 2007 and December 2011 were included. Patients were stratified into two groups - current smokers and non-smokers. Demographics, admission vitals, comorbidities, operative interventions, injury severity indices, and acute physiology and chronic health evaluation (APACHE) II scores were documented. Uni- and multi-variate modeling was performed. Outcomes studied were mortality, duration of mechanical ventilation, and length of hospitalization. RESULTS: A total of 1754 patients were available for analysis, 118 (6.7%) patients were current smokers. The mean age was 41.4±20.4, 81.0% male and 73.5% suffered blunt trauma. Smokers had a higher incidence of congestive heart failure (4.2% vs. 0.9%, p=0.007) and alcoholism (20.3% vs. 5.9%, p<0.001), but had a significantly lower APACHE II score. After multivariate regression analysis, there was no significant mortality difference. Patients who smoked spent more days mechanically ventilated (beta coefficient: 4.96 [1.37, 8.55, p=0.007]). CONCLUSION: Smoking is associated with worse outcome in the critically ill trauma patient. On an average, smokers spent 5 days longer requiring mechanical ventilation than non-smokers.


Assuntos
Fumar/epidemiologia , Ferimentos e Lesões/epidemiologia , APACHE , Adulto , California/epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Respiração Artificial , Estudos Retrospectivos , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/terapia , Adulto Jovem
11.
JAMA Surg ; 149(9): 934-9, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25076462

RESUMO

IMPORTANCE: A missed cervical spine (CS) injury can have devastating consequences. When CS injuries cannot be ruled out clinically using the National Emergency X-Radiography Utilization Study low-risk criteria because of either a neurologic deficit or pain, the optimal imaging modality for CS clearance remains controversial. OBJECTIVE: To investigate the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) for CS clearance. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study was conducted from January 1, 2010, through May 31, 2011, at a level I trauma center. Participants included 830 adults who were awake, alert, and able to be examined who experienced blunt trauma with resultant midline CS tenderness and/or neurologic deficits and were undergoing CT of the CS. Initial examinations, all CS imaging results, interventions, and final CS diagnoses were documented. The criterion standard for the sensitivity and specificity calculations was final diagnosis of CS injury at the time of discharge. MAIN OUTCOMES AND MEASURES: Clinically significant CS injuries, defined as injuries requiring surgical stabilization or halo placement. RESULTS: Overall, 164 CS injuries (19.8%) were diagnosed, and 23 of these (2.8%) were clinically significant. All clinically significant injuries were detected by CT. Fifteen of 681 patients (2.2%) with a normal CT scan had a newly identified finding on MRI; however, none of the injuries required surgical intervention or halo placement. There was no change in management on the basis of MRI findings. The sensitivity and specificity of CT for detecting CS injury was 90.9% and 100%, respectively. For clinically significant CS injuries, the sensitivity was 100% and specificity was 100%. CONCLUSIONS AND RELEVANCE: Computed tomography is effective in the detection of clinically significant CS injuries in adults deemed eligible for evaluation who had a neurologic deficit or CS pain. Magnetic resonance imaging does not provide any additional clinically relevant information.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Imageamento por Ressonância Magnética , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aparelhos Ortopédicos , Estudos Prospectivos , Sensibilidade e Especificidade , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto Jovem
12.
Am J Surg ; 206(5): 655-60, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24011571

RESUMO

BACKGROUND: Few studies have examined the impact of balanced resuscitation in pediatric trauma patients requiring massive transfusions. Adult data may not be generalizable to children. METHODS: Retrospective analysis assessed patients seen at a level I trauma center between 2003 and 2010 aged ≤18 years requiring massive packed red blood cell (PRBC) transfusion, defined as transfusion of ≥50% total blood volume. After excluding mortalities in the first 24 hours, the impact of plasma and platelet ratios on mortality was evaluated. RESULTS: Of 6,675 pediatric trauma patients, 105 were massively transfused (mean age, 12.4 ± 6.3 years; mean Injury Severity Score, 25.8 ± 11.4; mortality rate, 18.1%). All deceased patients sustained severe head injuries. Plasma/PRBC and platelet/PRBC ratios were not significantly associated with mortality. CONCLUSIONS: In this study, higher plasma/PRBC and platelet/PRBC ratios were not associated with increased survival in children. The value of aggressive blood product transfusion for injured pediatric patients requires further prospective validation.


Assuntos
Transfusão de Componentes Sanguíneos , Plaquetas , Plasma , Volume Sanguíneo , California/epidemiologia , Criança , Traumatismos Craniocerebrais/mortalidade , Traumatismos Craniocerebrais/terapia , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Análise Multivariada , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/terapia
13.
Injury ; 44(5): 639-44, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-22341771

RESUMO

BACKGROUND: There is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal gunshot wounds. However, much of the research which supports this conclusion has originated from a few centres, and the actual utilisation of SNOM by trauma surgeons is not known. We therefore conducted a survey to assess the acceptance of this strategy and evaluate variations in practise. METHODS: Electronic questionnaire survey of trauma surgeons in the United States of America, Canada, Brazil, and South Africa. Responses were compared using Chi(2) and Fisher's exact tests. RESULTS: 183 replies were received. 105 (57%) respondents practise SNOM of abdominal gunshot wounds, but there are marked regional variations in the acceptance of this strategy (p<0.01). Respondents who had completed trauma (p<0.01) or critical care (p<0.01) fellowships, and those who practise in a higher volume centre (defined as >50 penetrating abdominal injuries seen per year) (p<0.01) are more likely to practise SNOM of gunshot wounds. Most surgeons who practise SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient as a contraindication to attempting non-operative management. Almost all regard CT as essential. Respondents' preparedness to consider SNOM is related to injury extent. CONCLUSIONS: SNOM of abdominal gunshot wounds is practised by trauma surgeons in all four countries surveyed, but is not universally accepted, and there are variations in how it is practised.


Assuntos
Traumatismos Abdominais/terapia , Omento/lesões , Peritonite/terapia , Padrões de Prática Médica/estatística & dados numéricos , Ferimentos por Arma de Fogo/terapia , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/mortalidade , Adulto , Brasil/epidemiologia , Canadá/epidemiologia , Feminino , Hemodinâmica , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Peritonite/diagnóstico por imagem , Peritonite/mortalidade , Guias de Prática Clínica como Assunto , Radiografia , África do Sul/epidemiologia , Inquéritos e Questionários , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/diagnóstico por imagem , Ferimentos por Arma de Fogo/mortalidade
14.
Surg Today ; 42(8): 793-6, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22361987

RESUMO

The intra-aortic balloon pump (IABP) can be used transiently to improve cardiac function mechanically, in patients with severe cardiomyopathy and heart failure refractory to medical therapy. In the field of surgery, the IABP is most commonly used for patients with myocardial infarction, congestive heart failure, or other chronic cardiac conditions, who are undergoing cardiac surgery. Conversely, it is rarely used in hepatobiliary surgery, with only two reports found in the literature, excluding cases of emergency cholecystectomy. We describe how we used an IABP successfully during surgery to repair a transected bile duct in a patient with peripartum cardiomyopathy.


Assuntos
Doenças dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/cirurgia , Cardiomegalia/complicações , Cardiomiopatias/complicações , Balão Intra-Aórtico , Transtornos Puerperais/cirurgia , Adulto , Doenças dos Ductos Biliares/complicações , Doenças dos Ductos Biliares/diagnóstico , Ductos Biliares Intra-Hepáticos/patologia , Cardiomegalia/diagnóstico , Cardiomiopatias/diagnóstico , Feminino , Humanos , Transtornos Puerperais/diagnóstico
15.
Arch Surg ; 146(9): 1074-8, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21576598

RESUMO

OBJECTIVE: To examine the ability of the model for end-stage liver disease (MELD) score to predict the risk of mortality in trauma patients with cirrhosis. Although cirrhosis is associated with poor outcomes after injury, the relative effect of the severity of the cirrhosis on outcomes is unclear. The MELD score is a prospectively developed and validated scoring system, which is associated with increasing severity of hepatic dysfunction and risk of death in patients with chronic liver disease. DESIGN: Retrospective review. The MELD score for each patient was calculated from the international normalized ratio, the serum creatinine level, and the serum total bilirubin level obtained from the patient at admission to the level 1 trauma center. The association of MELD score with mortality was assessed using logistic regression analysis. SETTING: Level 1 trauma center. PATIENTS: Cirrhotic patients with trauma admitted to the level 1 trauma center during the period from January 2003 to December 2009. MAIN OUTCOME MEASURE: Mortality. RESULTS: During the 7-year study period, 285 injured cirrhotic patients were admitted. The mean (SD) age was 50.0 (10.5) years, and the mean (SD) MELD score was 11.7 (4.8) (range, 6-28). Overall, patients who died had a significantly higher mean (SD) MELD score than did survivors (14.1 [5.4] vs 11.2 [4.6]; P < .001). The MELD score and the injury severity score were statistically significant risk factors that were independently associated with mortality in this group of patients (the area under the curve for the model was 0.944; cumulative R(2) = 0.545). Each unit increase in the MELD score was associated with an 18% increase in the odds for mortality (adjusted odds ratio, 1.18 [95% confidence interval, 1.08-1.29]; P < .001). CONCLUSION: The MELD score is a simple objective tool for risk stratification in cirrhotic patients who have sustained injury.


Assuntos
Doença Hepática Terminal , Cirrose Hepática/mortalidade , Índice de Gravidade de Doença , Ferimentos e Lesões/mortalidade , Adulto , Bilirrubina/sangue , Creatinina/sangue , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco
16.
Am J Audiol ; 15(1): 33-45, 2006 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-16803790

RESUMO

PURPOSE: Physicians are vital team members of early hearing detection and intervention programs (EHDIPs), particularly in encouraging parents to comply with recommendations for follow-up services for their infants in universal newborn hearing screening programs (UNHSPs). This study describes a survey approach to help audiologists partner with otolaryngologists and pediatricians in EHDIPs. METHOD: We developed and mailed a 19-item questionnaire to all 12 otolaryngologists and 66 pediatricians potentially involved in a community-based EHDIP. The questionnaire assessed respondents' demographic data and knowledge of, experiences with, and attitudes toward the service-delivery continuum of UNHSPs. RESULTS: The overall response rate was 45%; all 12 otolaryngologists responded (100%; data from 7 were analyzed), and 23 pediatricians responded (34.8%; all were analyzed). Generally, they were positive toward and knowledgeable about UNHSPs and believed that (a) parent/infant bonding is unaffected by screening, (b) hearing reevaluations following medical services are important, (c) audiologists perform their role adequately, (d) it is important that hearing losses be identified and interventions begun before infants reach 6 months of age, (e) UNHSPs deserve funding, and (f) their role is important, but the physicians also wanted improvements in parent education and referral/follow-ups. CONCLUSION: The survey method was effective in identifying participating physicians' informational needs and attitudes toward UNHSPs, and in designing outreach programs for them.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Intervenção Educacional Precoce , Perda Auditiva/diagnóstico , Perda Auditiva/terapia , Triagem Neonatal , Inquéritos e Questionários/normas , Atitude do Pessoal de Saúde , Audiologia , Continuidade da Assistência ao Paciente , Humanos , Recém-Nascido , Triagem Neonatal/economia , Triagem Neonatal/psicologia , Estudos de Casos Organizacionais , Otolaringologia , Avaliação de Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente , Pediatria , Papel do Médico
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