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PURPOSE: Severe obesity is a barrier to listing for kidney transplantation due to concern for poor outcomes. This study aims to compare bariatric surgery with medical weight loss as a means of achieving weight loss and subsequent listing for renal transplant. We hypothesize that bariatric surgery will induce greater frequency of listing for transplant within 18 months of study initiation. MATERIALS AND METHODS: We performed a randomized study of metabolic bariatric surgery (MBS) vs medical weight loss (MM) in patients on dialysis with a body mass index (BMI) of 40-55 kg/m2. The primary outcome was suitability for renal transplant within 18 months of initiating treatment. Secondary outcomes included weight loss, mortality, and complications. RESULTS: Twenty patients enrolled, only 9 (5 MBS, 4 MM) received treatment. Treated groups did not differ in age, gender, or race (P ≥ .44). There was no statistically significant difference in the primary endpoint: 2 MBS (40%) and 1 MM (25%) listed for transplant ≤18 months (P = 1.00). With additional time, 100% MBS and 25% MM patients achieved listing status (P = .048); 100% of MBS and 0 MM received kidney transplants to date (P = .008). Weight, weight loss, and BMI trajectories differed between the groups (P ≤ .002). One death from COVID-19 occurred in the MM group, and 1 MBS patient had a myocardial infarction 3.75 years after baseline evaluation. CONCLUSION: These results suggest MBS is superior to MM in achieving weight loss prior to listing for kidney transplantation. Larger studies are needed to ensure the safety profile is acceptable in patients with ESRD undergoing bariatric surgery.
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Background: We applied the novel Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated CVD risk, including heart failure (HF), after bariatric surgery. Methods: Among 7804 patients (20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999-2022, CVD risk factors at pre-surgery, 1-year, and 2-year post-surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD (ASCVD), coronary heart disease (CHD), stroke, and HF were estimated for patients without a history of CVD or its subtypes at each time point, using the social deprivation index-enhanced PREVENT equations. Paired t-tests or McNemar tests were used to compare pre- with post-surgery CKM health and CVD risk. Two-sample t-tests were used to compare CVD risk reduction between patient subgroups defined by age, sex, race, operation type, weight loss, and history of diabetes, hypertension, and dyslipidemia. Results: CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density-lipoprotein cholesterol (non-HDL), and diabetes prevalence, but higher HDL and estimated glomerular filtration rate (eGFR). The 10-year total CVD risk decreased from 6.51% at pre-surgery to 4.81% and 5.08% at 1- and 2-year post-surgery (relative reduction: 25.9% and 16.8%), respectively. Significant risk reductions were seen for all CVD subtypes (i.e., ASCVD, CHD, stroke, and HF), with the largest reduction for HF (relative reduction: 55.7% and 44.8% at 1- and 2-year post-surgery, respectively). Younger age, White race, >30% weight loss, diabetes history, and no dyslipidemia history were associated with greater HF risk reductions. Similar results were found for the 30-year risk estimates. Conclusions: Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 45-56% within 1-2 years post-surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.
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This Viewpoint describes potential benefits and hurdles to implementing a more personalized approach to obesity treatment through a comprehensive multidisciplinary evaluation that considers surgical, medical, and combined therapies.
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Obesidade , Humanos , Obesidade/terapia , Cirurgia BariátricaRESUMO
AIM: To compare the incidence of adverse events (AEs) related to antiobesity medications (AOMs; glucagon-like peptide-1 receptor agonists [GLP-1RAs] vs. non-GLP-1RAs) after bariatric surgery. METHODS: This single-centre retrospective cohort included patients (aged 16-65 years) who had undergone laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy (cohort entry date) and initiated AOMs. Participants were categorized as users of US Food and Drug Administration (FDA)-approved, off-label, or GLP-1RA AOMs if documented as receiving the medication on or after cohort entry date. Non-GLP-1RA AOMs were phentermine, orlistat, topiramate, canagliflozin, dapagliflozin, empagliflozin, naltrexone, bupropion/naltrexone and phentermine/topiramate. GLP-1RA AOMs included: semaglutide, dulaglutide, exenatide and liraglutide. The primary outcome was AE incidence. Logistic regression was used to determine the association of AOM exposure with AEs. RESULTS: We identified 599 patients meeting our inclusion criteria, 83% of whom were female. Their median (interquartile range [IQR]) age was 47.8 (40.9-55.4) years. The median duration of surgery to AOM exposure was 30 months. GLP-1RAs use was not associated with higher odds of AEs: adjusted odds ratio (aOR) 1.1 (95% confidence interval [CI] 0.5-2.6) and aOR 1.1 (95% CI 0.6-2.3) for GLP-1RA versus FDA-approved and off-label AOM use, respectively. AOM initiation ≥12 months after surgery was associated with lower risk of AEs compared to <12 months (aOR 0.01 [95% CI 0.0-0.01]; p < 0.001). CONCLUSION: Our results showed that GLP-1RA AOMs were not associated with an increased risk of AEs compared to non-GLP-1RA AOMs in patients who had previously undergone bariatric surgery. Prospective studies are needed to identify the optimal timeframe for GLP-1RA initiation.
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Fármacos Antiobesidade , Cirurgia Bariátrica , Receptor do Peptídeo Semelhante ao Glucagon 1 , Humanos , Feminino , Pessoa de Meia-Idade , Adulto , Masculino , Receptor do Peptídeo Semelhante ao Glucagon 1/agonistas , Estudos Retrospectivos , Fármacos Antiobesidade/uso terapêutico , Fármacos Antiobesidade/efeitos adversos , Adulto Jovem , Adolescente , Cirurgia Bariátrica/efeitos adversos , Idoso , Liraglutida/uso terapêutico , Exenatida/uso terapêutico , Obesidade Mórbida/cirurgia , Peptídeos Semelhantes ao Glucagon/uso terapêutico , Peptídeos Semelhantes ao Glucagon/análogos & derivados , Peptídeos Semelhantes ao Glucagon/efeitos adversos , Fragmentos Fc das Imunoglobulinas/uso terapêutico , Fragmentos Fc das Imunoglobulinas/efeitos adversos , Proteínas Recombinantes de Fusão/uso terapêutico , Proteínas Recombinantes de Fusão/efeitos adversos , Agonistas do Receptor do Peptídeo 1 Semelhante ao GlucagonRESUMO
BACKGROUND: Weight loss response after bariatric surgery is highly variable, and several demographic factors are associated with differential responses to surgery. Preclinical studies demonstrate numerous sex-specific responses to bariatric surgery, but whether these responses are also operation dependent is unknown. OBJECTIVE: To examine sex-specific weight loss outcomes up to 5 years after laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING: Single center, university, United States. METHODS: Retrospective, observational cohort study including RYGB (n = 5057) and vertical SG (n = 2041) patients from a single, academic health center. Percentage total weight loss (TWL) over time was examined with generalized linear mixed models to determine the main and interaction effects of surgery type on weight loss by sex. RESULTS: TWL demonstrated a strong sex-by-procedure interaction, with women having a significant advantage with RYGB compared with SG (adjusted difference at 5 yr: 8.0% [95% CI: 7.5-8.5]; P < .001). Men also experienced greater TWL over time with RYGB or SG, but the difference was less and clinically insignificant (adjusted difference at 5 yr: 2.9% [2.0-3.8]; P < .001; P interaction between sex and procedure type = .0001). Overall, women had greater TWL than men, and RYGB patients had greater TWL than SG patients (adjusted difference at 5 yr: 3.1% [2.4-3.2] and 6.9% [6.5-7.3], respectively; both P < .0001). Patients with diabetes lost less weight compared with those without (adjusted difference at 5 yr: 3.0% [2.7-3.2]; P < .0001). CONCLUSIONS: Weight loss after bariatric surgery is sex- and procedure-dependent. There is an association suggesting a clinically insignificant difference in weight loss between RYGB and SG among male patients at both the 2- and 5-year postsurgery time points.
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Gastrectomia , Derivação Gástrica , Obesidade Mórbida , Redução de Peso , Humanos , Masculino , Feminino , Redução de Peso/fisiologia , Estudos Retrospectivos , Adulto , Obesidade Mórbida/cirurgia , Pessoa de Meia-Idade , Fatores Sexuais , Gastrectomia/métodos , Resultado do Tratamento , Laparoscopia/métodos , Cirurgia Bariátrica/métodosRESUMO
BACKGROUND: High-grade liver injuries with extravasation (HGLI â+ âExtrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â+ âExtrav. Therefore, we evaluated the management of HGLI â+ âExtrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â+ âExtrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â= â0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â> â0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â+ âExtrav patients.
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Embolização Terapêutica , Extravasamento de Materiais Terapêuticos e Diagnósticos , Fígado , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Fígado/lesões , Fígado/diagnóstico por imagem , Embolização Terapêutica/métodos , Radiologia Intervencionista , Conduta Expectante , Estudos Retrospectivos , Angiografia , Idoso , Adulto , Meios de ContrasteRESUMO
BACKGROUND: Perforated marginal ulcers (PMUs) are a rare but known complication of bariatric surgery. Management typically involves prompt surgical intervention, but limited data exists on non-operative approaches. This study reviews published data on non-operative management of PMUs and presents a case series of patients who were managed non-operatively. Our hypothesis is that certain patients with signs of perforation can be successfully managed non-operatively with close observation. METHODS: We completed a systematic review searching PubMed, Embase, Web of Science, Cochrane, and clinicaltrials.gov. Ultimately 3 studies described the presentation and non-operative management of 5 patients. Additionally, we prospectively collected data from our institution on all patients who presented between Dec. 2022 and Dec. 2023 with PMUs confirmed on imaging and managed non-operatively. RESULTS: In our literature review, three patients had Roux-en-Y gastric bypass (RYGB), while two had one anastomosis gastric bypass. One patient required surgery two days after admission. Another underwent elective conversion surgery weeks later for a non-healing ulcer. Two received endoscopic interventions. One patient recovered with nil-per-os (NPO) status, and intravenous proton pump inhibitor (PPI) treatment. The patients in our case series presented with normal vital signs, an average of 30 months after RYGB, and with CT scan signs of perforation. None of these patients required surgical or endoscopic intervention. CONCLUSION: In conclusion, while perforated marginal ulcers have traditionally been considered a surgical emergency, some patients can be successfully treated with non-operative management. More research is needed to identify the clinical presentation features, comorbidities, and imaging findings of this group.
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Derivação Gástrica , Úlcera Péptica , Humanos , Administração Intravenosa , Derivação Gástrica/efeitos adversos , Pesquisa , ÚlceraRESUMO
INTRODUCTION: Genetic obesity susceptibility in postoperative bariatric surgery weight regain (PBSWR) remains largely unexplored. METHODS: A retrospective case series of adult (N = 27) PBSWR patients who had undergone genetic obesity testing was conducted between Sept. 2020 and March 2022. PRIMARY OUTCOME: frequency of genetic variants in patients experiencing weight regain following bariatric surgery. SECONDARY OUTCOMES: prevalence of obesity-related comorbidities, nadir BMI achieved post-bariatric surgery, and percent total body weight loss (%TBWL) achieved with obesity pharmacotherapies. RESULTS: Heterozygous mutations were identified in 22 (81%) patients, with the most prevalent mutations occurring in CEP290, RPGR1P1L, and LEPR genes (3 patients each). Median age was 56 years (interquartile range (IQR) 46.8-65.5), 88% female. Types of surgery were 67% RYGB, 19% SG, 4% gastric band, and 13% revisions. Median nadir BMI postoperatively was 34.0 kg/m2 (IQR 29.0-38.5). A high prevalence of metabolic derangements was noted; patients presented median 80 months (IQR 39-168.5) postoperative for medical weight management with 40% weight regain. BMI at initiation of anti-obesity medication (AOMs) was 41.7 kg/m2 (36.8-44.4). All received AOM and required at least 3 AOMs for weight regain. Semaglutide (N = 21), topiramate (N = 14), and metformin (N = 12) were most prescribed. Median %TBWL for the cohort at the first, second, and third visit was 1.7, 5.0, and 6.5 respectively. Fourteen (52%) achieved 5%TBWL, 10 (37%) achieved 10%TBWL, and 4 (15%) achieved 15%TBWL with combination AOMs and supervised medical intervention. CONCLUSION: An unusually high prevalence of genetic obesity variants in PBSWR was found, warranting further research.
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Fármacos Antiobesidade , Cirurgia Bariátrica , Obesidade Mórbida , Adulto , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Prevalência , Aumento de Peso , Obesidade/epidemiologia , Obesidade/genética , Obesidade/cirurgia , Fármacos Antiobesidade/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Gastrojejunal strictures (GJS) are rare but significant adverse events following Roux-en-Y Gastric Bypass, with limited options for effective non-operative interventions. Lumen-apposing metal stents (LAMS) represent a new therapy for treatment of intestinal strictures, but the effectiveness in treating GJS is unknown. This study aims to evaluate the safety and effectiveness of LAMS in GJS. METHODS: This is a prospective, observational study of patients with prior Roux-en-Y Gastric bypass who underwent LAMS placement for GJS. The primary outcome of interest is resolution of GJS following LAMS removal defined by toleration of bariatric diet after LAMS removal. Secondary outcomes include need for additional procedures, LAMS-related adverse events, and need for revisional surgery. RESULTS: Twenty patients were enrolled. The cohort was 85% female with median age of 43. 65% had marginal ulcers associated with the GJS. Presenting symptoms included nausea and vomiting (50% of patients), dysphagia (50%), epigastric pain (20%), and failure to thrive (10%). Diameter of LAMS placed were 15 mm in 15 patients, 20 mm in 3 patients, and 10 mm in 2 patients. LAMS were placed for a median of 58 days (IQR 56-70). Twelve patients (60%) achieved resolution of GJS after LAMS removal. Of the eight patients without GJS resolution or with recurrence, seven (35%) required repeat placement of LAMS. One patient was lost to follow up. One perforation and two migrations occurred. Four patients required revisional surgery after LAMS removal. CONCLUSION: LAMS placement is well-tolerated and effective with most patients achieving short-term symptom resolution and with few reported complications. While stricture resolution occurred in over half the patients, nearly 1/4th of patients required revisional surgery. More data is needed to predict who would benefit from LAMS versus surgical intervention.
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Derivação Gástrica , Stents , Humanos , Feminino , Masculino , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Stents/efeitos adversos , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodosRESUMO
INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.
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Embolização Terapêutica , Ferimentos não Penetrantes , Humanos , Estudos Prospectivos , Embolização Terapêutica/métodos , Ferimentos não Penetrantes/complicações , Fígado/diagnóstico por imagem , Fígado/lesões , Tomografia Computadorizada por Raios X , Estudos Retrospectivos , Escala de Gravidade do FerimentoRESUMO
INTRODUCTION: Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database. METHODS AND PROCEDURES: The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people). RESULTS: Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001). CONCLUSIONS: Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.
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Medicare , Cirurgiões , Idoso , Colonoscopia , Endoscopia Gastrointestinal , Humanos , População Rural , Estados UnidosRESUMO
INTRODUCTION: Use of sleeve gastrectomy (SG) for weight loss has grown exponentially; however, clear indications for SG versus Roux-en-Y gastric bypass (RNYGB) are lacking. Certain populations may be more likely to undergo SG due to its simpler technique and without clear clinical indications. We aim to examine underlying predictors of patients undergoing SG vs RNY across a single state. METHODS: We queried the Colorado All Payers Claim Database for patients undergoing laparoscopic SG or RNY. Patient-level variables included patient demographics, comorbidities, distance traveled for surgery, and distressed communities index (DCI), a zip code-based measure of socioeconomic status. Hospital-level variables included annual bariatric surgery volume, academic status, and whether hospitals were a bariatric Center of Excellence. We performed mixed-effects logistic regression adjusting for demographics, insurance coverage, and comorbidities to compare odds of undergoing SG vs RNY, with a random effect for hospital. RESULTS: 5,017 patients were included with 3,042 (60.6%) undergoing SG and 1,975 (39.4%) undergoing RNY. On multivariable analysis, patients with a high DCI were not more likely to undergo a SG (OR 1.18, CI 0.89-1.55, p = 0.25). However, patients who underwent surgery at hospitals serving the greatest proportion of those from highly distressed communities were significantly more likely to undergo SG (OR 4.22, CI 1.38-12.96, p = 0.01). Patients managed at Bariatric Centers of Excellence were less likely to undergo SG (OR 0.22, CI 0.07-0.62, p = 0.005). Patients with higher BMI, diabetes, or GERD were all more likely to undergo RNY. CONCLUSION: While patients with high DCI were more likely to undergo SG on univariate analysis, these associations disappeared after addition of a hospital-level random effect, suggesting that disparities may be due access to surgeons or systems with preference for one procedure. However, hospitals serving a higher proportion of high-DCI patients are more likely to utilize SG.
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Derivação Gástrica , Obesidade Mórbida , Humanos , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Índice de Massa Corporal , Gastrectomia/métodos , Redução de Peso , Demografia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Prior studies have found rates of emergency department (ED) visits after bariatric surgery approach 15% with the majority (>60%) not requiring admission. The timeframe for which ED utilization remains elevated postoperatively remains unknown. We hypothesize that ED utilization following bariatric surgery remains elevated for months after surgery with the majority of visits not requiring admission. OBJECTIVE: No study has determined the impact bariatric surgery has on health care resource utilization in the two years following surgery. The aim of this study is to determine the frequency of ED visitation in the 2 years following bariatric surgery. SETTINGS: Database study, single state-wide insurance database. METHODS: We queried the Colorado All Payers Claim Database. Patients with data 1 year before and 2 years after surgery were included. Primary outcomes of interest were ED visits or readmissions during the 2-year period. Bariatric surgeries were identified using CPT codes. Diagnoses for an ED visit or readmission were determined by ICD codes. RESULTS: A total of 5399 patients underwent bariatric surgery from January 2013-November 2017. Of these, 59% underwent sleeve gastrectomy, 38% Roux-en-Y, 2% gastric band, and 1% another surgery. Median age was 44 (IQR 35-54) years, and 82% were female. Overall, 3103 patients (57%) visited the ED at least once with a total of 12,988 visits, 1267 of which (9.8%) resulted in admission. ED use was highest in the 30 days following surgery (17%) but remained above presurgery baseline for 8 months (7.4% at 8 mo compared with baseline mean 6.4% [95% CI 6.0%-6.8%]). CONCLUSIONS: ED visits remain elevated for 8 months post bariatric surgery with over 90% of visits not requiring an admission. Interventions that prevent emergency department utilization should be key focus of quality improvement projects to limit health care resource utilization following bariatric surgery.
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Cirurgia Bariátrica , Seguro , Obesidade Mórbida , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Incidência , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias , Estudos RetrospectivosRESUMO
BACKGROUND: Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). Although several studies have examined plasma TG post injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion (MT). STUDY DESIGN: Blood was collected from trauma activation patients at an urban Level I trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared with trauma patients, and TG values were examined in trauma patients with shock and MT requirement. RESULTS: Overall, 118 patients were included. Compared with healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n = 23) had a depressed TG, with significantly lower peak thrombin (88.3 vs 133.0 nM; p = 0.01) and slower maximum rate of TG (27.4 vs 48.3 nM/min; p = 0.04). Patients who required MT (n = 26) had significantly decreased TG, with a longer lag time (median 4.8 vs 3.9 minutes, p = 0.04), decreased peak thrombin (median 71.4 vs 124.2 nM; p = 0.0003), and lower maximum rate of TG (median 15.8 vs 39.4 nM/min; p = 0.01). Area under the receiver operating characteristics (AUROC) analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT. CONCLUSIONS: These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. In addition, whole blood TG predicts MT, suggesting point-of-care whole blood TG can be a useful tool for diagnostic and therapeutic strategies in trauma.
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Transtornos da Coagulação Sanguínea/epidemiologia , Transfusão de Sangue/estatística & dados numéricos , Trombina/análise , Ferimentos e Lesões/complicações , Adulto , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/diagnóstico , Estudos de Viabilidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Tromboelastografia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/sangue , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapiaRESUMO
INTRODUCTION: More than 3 million patients have a cardiac implanted electronic device (CIED) such as a pacemaker or implanted cardioverter-defibrillator in the USA. These devices are susceptible to electromagnetic interference (EMI) leading to malfunction and injury. Radiofrequency energy, the most common modality for obtaining hemostasis during endoscopy, is the most common source of EMI. Few studies have evaluated the effect of endoscopic radiofrequency energy on CIEDs. We aim to characterize CIED dysfunction related to endoscopic procedures. We hypothesize that EMI from endoscopic energy can result in patient injury. METHODS: We queried the Manufacturer and User Facility Device Experience (MAUDE) database for CIED dysfunction related to electrosurgical devices over a 10-year period (2009-2019). CIED dysfunction events were identified using seven problem codes (malfunction, electromagnetic interference, ambient noise, pacing problem, over-sensing, inappropriate shock, defibrillation). These were cross-referenced for the terms "cautery, electrocautery, endoscopy, esophagus, colonoscopy, colon, esophagoscopy, and esophagogastroduodenoscopy." Reports were individually reviewed to confirm and characterize CIED malfunction due to an endoscopic procedure. RESULTS: A search for CIED dysfunction resulted in 43,759 reports. Three hundred and eleven reports (0.7%) were associated with electrocautery, and of these, 45 reports (14.5%) included endoscopy. Ten reports involving endoscopy (22%) specified upper (3, 7%) or lower (7, 16%) endoscopy while the remainder were non-specific. Twenty-six of reports involving endoscopy (58%) suffered injury because of CIED dysfunction: Of these, 17 (65%) received inappropriate shocks, 5 (19%) had pacing inhibition with bradycardia or asystole, 3 (12%) had CIED damage requiring explant and replacement, and 1 (4%) patient suffered ventricular tachycardia requiring hospital admission. CONCLUSION: The use of energy during endoscopy can cause dysfunction of CIEDs. This most commonly results in inappropriate defibrillation, symptomatic bradycardia, and asystole. Patients with CIEDs undergoing endoscopy should undergo pre- and post-procedure device interrogation and re-programming to avoid patient injury.
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Desfibriladores Implantáveis , Marca-Passo Artificial , Preparações Farmacêuticas , Desfibriladores Implantáveis/efeitos adversos , Fenômenos Eletromagnéticos , Endoscopia , Humanos , Marca-Passo Artificial/efeitos adversosRESUMO
BACKGROUND: Evidence guiding firearm injury prevention is limited by current data collection infrastructure. Trauma registries (TR) omit prehospital deaths and underestimate the burden of injury. In contrast, the National Violent Death Reporting System (NVDRS) tracks all firearm deaths including prehospital fatalities, excluding survivors. This is a feasibility study to link these data sets through collaboration with our state public health department, aiming to better estimate the burden of firearm injury and assess comparability of data. METHODS: We reviewed all firearm injuries in our Level I TR from 2011 to 2017. We provided the public health department with in-hospital deaths, which they linked to NVDRS using patient identifiers and time of injury/death. The NVDRS collates information about circumstances, incident type, and wounding patterns from multiple sources including death certificates, autopsy records, and legal proceedings. We considered only subjects with injury location in a single urban county to best estimate in-hospital and prehospital mortality. RESULTS: Of 168 TR deaths, 166 (99%) matched to NVDRS records. Based on data linkages, we estimate 320 prehospital deaths, 184 in-hospital deaths, and 453 survivors for a total of 957 firearm injuries. For the matched patients, there was near-complete agreement regarding simple demographic variables (e.g., age and sex) and good concordance between incident types (suicide, homicide, etc.). However, agreement in wounding patterns between NVDRS and TR varied. CONCLUSION: We demonstrate the feasibility of linking TR and NVDRS data with good concordance for many variables, allowing for good estimation of the trauma denominator. Standardized data collection methods in one data set could improve methods used by the other, for example, training NVDRS abstractors to utilize Abbreviated Injury Scale designations for injury patterns. Such data integration holds immediate promise for guiding prevention strategies. LEVEL OF EVIDENCE: Epidemiological study, level IV.
Assuntos
Armas de Fogo/estatística & dados numéricos , Sistema de Registros , Ferimentos por Arma de Fogo/epidemiologia , Colorado/epidemiologia , Efeitos Psicossociais da Doença , Estudos de Viabilidade , Feminino , Homicídio/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , Centros de Traumatologia/estatística & dados numéricos , Violência/estatística & dados numéricosRESUMO
BACKGROUND: Young-Burgess classification (YB) is a mechanistic system which classifies pelvic ring injuries into anterior-posterior compression (APC), lateral compression (LC), vertical shear (VS) injuries, and combined mechanism (CM). The objective of this study was to identify associated injuries which require urgent operative intervention by YB classification. We hypothesize that YB classification is associated with 1) need for urgent intervention for pelvic fracture-related hemorrhage and 2) patterns of injury complexes requiring surgery. METHODS: This is a retrospective study of severely injured trauma patients with pelvic ring injuries who presented to an urban Level-1 trauma center from 2007 to 2017. Associated injuries and procedures were determined by Abbreviated Injury Scale (AIS) and ICD-9/10 codes. YB classes were compared, followed by a cluster analysis to identify injury patterns and association with YB classifications. RESULTS: Overall, 135 patients were included. 98 (72%) of patients presented with LC, 16 (12%) with APC, 8 (6%) with VS, and 13 (10%) with CM. VS and APC groups had higher rates of REBOA use compared to LC and CM groups (38% and 31% versus 11% and 0%, respectively, p = 0.01). The CM group, compared to LC, APC, and VS, had higher rates of urgent operative intervention for bleeding control (69% versus 32%, 50% and 43%, respectively, p = 0.01). 39 (29%) patients had a concomitant injury which was identified by CT scan in initial trauma work up and altered management, 46% which merited urgent intervention. On cluster analysis, there were no distinct injury complexes which required urgent operative intervention by YB class. CONCLUSIONS: These data failed to identify unique injury complexes which merit urgent operative intervention by YB class. Nearly one in four patients had injuries identified by initial CT imaging which altered initial management, demonstrating the importance of early, full body CT imaging in severely injured patients with pelvic ring injuries.