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1.
Injury ; 54(10): 110823, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37217400

RESUMO

Geriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric patients, and frail patients in particular, may sometimes benefit from de-escalation of care in a palliative setting rather than curative treatment. To provide more person-centred care, better strategies for improved shared decision-making need to be developed and implemented in clinical practice. A shift in thinking from a disease-oriented paradigm to a patient-goal-oriented paradigm is required to provide better person-centred care for older patients. We may greatly improve the collaboration with patients if we move parts of the decision-making process to the pre-acute phase. In the pre-acute phase appointing legal representatives, having goals of care conversations, and advance care planning can help give physicians an idea of what is important to the patient in acute settings. When making decisions as equal partners is not possible, a greater degree of physician responsibility may be appropriate. Physicians should tailor the "sharedness" of the decision-making process to the needs of the patient and their family.


Assuntos
Tomada de Decisões , Cirurgiões , Humanos , Idoso , Participação do Paciente , Hospitais , Comunicação
2.
Eur J Trauma Emerg Surg ; 49(3): 1383-1392, 2023 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-36856781

RESUMO

INTRODUCTION: Anterior shoulder dislocations are commonly seen in the emergency department for which several closed reduction techniques exist. The aim of this systematic review is to identify the most successful principle of closed reduction techniques for an acute anterior shoulder dislocation in the emergency department without the use of sedation or intra-articular lidocaine injection. METHODS: A literature search was conducted up to 15-08-2022 in the electronic databases of PubMed, Embase and CENTRAL for randomized and observational studies comparing two or more closed reduction techniques for anterior shoulder dislocations. Included techniques were grouped based on their main operating mechanism resulting in a traction-countertraction (TCT), leverage and biomechanical reduction technique (BRT) group. The primary outcome was success rate and secondary outcomes were reduction time and endured pain scores. Meta-analyses were conducted between reduction groups and for the primary outcome a network meta-analysis was performed. RESULTS: A total of 3118 articles were screened on title and abstract, of which 9 were included, with a total of 987 patients. Success rates were 0.80 (95% CI 0.74; 0.85), 0.81 (95% CI 0.63; 0.92) and 0.80 (95% CI 0.56; 0.93) for BRT, leverage and TCT, respectively. No differences in success rates were observed between the three separate reduction groups. In the network meta-analysis, similar yet more precise effect estimates were found. However, in a post hoc analysis the BRT group was more successful than the combined leverage and TCT group with a relative risk of 1.33 (95% CI 1.19, 1.48). CONCLUSION: All included techniques showed good results with regard to success of reduction. The BRT might be the preferred technique for the reduction of an anterior shoulder dislocation, as patients experience the least pain and it results in the fastest reduction.


Assuntos
Luxação do Ombro , Humanos , Luxação do Ombro/terapia , Lidocaína , Dor , Injeções Intra-Articulares
3.
Injury ; 53(3): 1144-1148, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-35063259

RESUMO

INTRODUCTION: Identification of high-risk hip fracture patients in an early stage is vital for guiding surgical management and shared decision making. To objective of this study was to perform an external international validation study of the U-HIP prediction model for in-hospital mortality in geriatric patients with a hip fracture undergoing surgery. MATERIALS AND METHODS: In this retrospective cohort study, data were used from The American College of Surgeons National Surgical Quality Improvement Program. Patients aged 70 years or above undergoing hip fracture surgery were included. The discrimination (c-statistic) and calibration of the model were investigated. RESULTS: A total of 25,502 patients were included, of whom 618 (2.4%) died. The mean predicted probability of in-hospital mortality was 3.9% (range 0%-55%). The c-statistic of the model was 0.74 (95% CI 0.72-0.76), which was comparable to the c-statistic of 0.78 (95% CI 0.71-0.85) that was found in the development cohort. The calibration plot indicated that the model was slightly overfitted, with a calibration-in-the-large of 0.015 and a calibration slope of 0.780. Within the subgroup of patients aged between 70 and 85, however, the c-statistic was 0.78 (95% CI 0.75-0.81), with good calibration (calibration slope 0.934). DISCUSSION AND CONCLUSION: The U-HIP model for in-hospital mortality in geriatric hip fractures was externally validated in a large international cohort, and showed a good discrimination and fair calibration. This model is freely available online and can be used to predict the risk of mortality, identify high-risk patients and aid clinical decision making.


Assuntos
Fraturas do Quadril , Idoso , Idoso de 80 Anos ou mais , Calibragem , Estudos de Coortes , Fraturas do Quadril/cirurgia , Mortalidade Hospitalar , Humanos , Estudos Retrospectivos , Fatores de Risco
4.
Eur J Surg Oncol ; 46(3): 415-419, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31676200

RESUMO

INTRODUCTION: Bowel obstruction increases risk of emergency surgery and leads to suboptimal physical and nutritional condition. Preventing emergency surgery and prehabilitation might improve outcomes. This pilot study aimed to examine the effect of a multimodal obstruction protocol for bowel obstruction patients on the risk of emergency surgery and postoperative morbidity and mortality. MATERIALS AND METHODS: All bowel obstruction patients treated according to the obstruction protocol in the period 2013-2017 were included in this uncontrolled observational cohort study. Benign and malignant causes of bowel obstruction were included. The protocol consisted of: 1. specific dietary adjustments to reduce prestenotic dilatation, 2. oral laxatives and 3. prehabilitation. Emergency surgery and postoperative morbidity and mortality rates were compared to known rates from the literature. RESULTS: Sixty-one patients were included: 44 (72%) were treated for colorectal cancer and 17 (28%) for Crohn's disease or diverticulitis. Four patients (7%) underwent emergency surgery. Primary anastomosis was constructed in 49 out of 57 elective patients (86%). Severe complications (Clavien-Dindo ≥ III) occurred in four patients (7%). No bowel perforation, anastomotic leakages or 30-day mortality was observed. These rates were much lower than rates reported in the literature after surgery for colorectal cancer (3% bowel perforation, 8% anastomotic leakage, 4% 30-day mortality, 15% severe complications) and benign disease (30-day mortality 17%, severe complications 7%). CONCLUSION: Using the obstruction protocol in patients with bowel obstruction reduced emergency surgery and postoperative morbidity and mortality in this pilot study. This protocol seems to be a viable and efficient alternative to emergency surgery.


Assuntos
Neoplasias Colorretais/cirurgia , Terapia por Exercício/métodos , Obstrução Intestinal/terapia , Apoio Nutricional/métodos , Complicações Pós-Operatórias/terapia , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Seguimentos , Humanos , Incidência , Obstrução Intestinal/epidemiologia , Obstrução Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Projetos Piloto , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
5.
World J Emerg Surg ; 13: 18, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29682003

RESUMO

Background: Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system. Methods: This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands. Results: One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2). Conclusion: The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care.


Assuntos
Fraturas Ósseas/classificação , Triagem/normas , Ferimentos e Lesões/classificação , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Fraturas Ósseas/etiologia , Humanos , Escala de Gravidade do Ferimento , Extremidade Inferior/lesões , Masculino , Pessoa de Meia-Idade , Países Baixos , Estudos Retrospectivos , Estatísticas não Paramétricas , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Triagem/métodos
6.
Eur J Trauma Emerg Surg ; 43(1): 43-51, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27586198

RESUMO

OBJECTIVE: The postoperative care regimes of ankle fractures are studied for over 30 years and recommendations have shifted only slightly in the last decades. However, study methodology might have evolved. The aim of this study was to evaluate the changes in time in the design, quality and outcome measures of studies investigating the postoperative care of ankle fractures. METHODS: The MEDLINE and EMBASE database were searched for both RCTs and cohort studies. The original studies were divided into decades of publication over the last 30 years. The methodological quality of the studies was assessed using the 'traditional' risk of bias assessment tool provided by The Cochrane Collaboration and the 'newer' MINORS criteria. RESULTS: The percentage of RCTs on this subject declined from 67 to 38 % in the last decades. According to the Cochrane tool, the reported quality of RCTs has improved in the last three decades whereas the reported quality of observational studies has remained unchanged. However, when quality was evaluated with the MINORS criteria, equal improvement was observed for both RCTs and observational studies. In the 80s, 67 % of all studies used the range of motion as the primary outcome measure, which decreased to 45 % in the 90s. In the 00s, none of the studies used the range of motion as the primary outcome. CONCLUSION: For postoperative care of ankle fractures, results of this study showed a relative decrease in the published number of RCTs. The overall quality of the published articles did not decline. In addition, a gradual shift from physician measured to patient-reported outcome variables was observed. However, it should be borne in mind that the findings are based on a small sample (n = 25).


Assuntos
Fraturas do Tornozelo/cirurgia , Pesquisa Biomédica , Avaliação de Processos e Resultados em Cuidados de Saúde , Cuidados Pós-Operatórios , Projetos de Pesquisa , Humanos , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
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