IMPORTANCE: Adhesive small-bowel obstruction (aSBO) is a potentially chronic, recurring surgical illness. Although guidelines suggest trials of nonoperative management, the long-term association of ...this approach with recurrence is poorly understood. OBJECTIVE: To compare the incidence of recurrence of aSBO in patients undergoing operative management at their first admission compared with nonoperative management. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, propensity-matched, retrospective cohort study used health administrative data for the province of Ontario, Canada, for patients treated from April 1, 2005, through March 31, 2014. The study population included adults aged 18 to 80 years who were admitted for their first episode of aSBO. Patients with nonadhesive causes of SBO were excluded. A total of 27 904 patients were included and matched 1:1 by their propensity to undergo surgery. Factors used to calculate propensity included patient age, sex, comorbidity burden, socioeconomic status, and rurality of home residence. Data were analyzed from September 10, 2017, through October 4, 2018. EXPOSURES: Operative vs nonoperative management for aSBO. MAIN OUTCOMES AND MEASURES: The primary outcome was the rate of recurrence of aSBO among those with operative vs nonoperative management. Time-to-event analyses were used to estimate hazard ratios of recurrence while accounting for the competing risk of death. RESULTS: Of 27 904 patients admitted with their first episode of aSBO, 6186 (22.2%) underwent operative management. Mean (SD) patient age was 61.2 (13.6) years, and 51.1% (14 228 of 27 904) were female. Patients undergoing operative management were younger (mean SD age, 60.2 14.3 vs 61.5 13.4 years) with fewer comorbidities (low burden, 382 6.2% vs 912 4.2%). After matching, those with operative management had a lower risk of recurrence (13.0% vs 21.3%; hazard ratio, 0.62; 95% CI, 0.56-0.68; P < .001). The 5-year probability of experiencing another recurrence increased with each episode until surgical intervention, at which point the risk of subsequent recurrence decreased by approximately 50%. CONCLUSIONS AND RELEVANCE: According to this study, operative management of the first episode of aSBO is associated with significantly reduced risk of recurrence. Guidelines advocating trials of nonoperative management for aSBO may assume that surgery increases the risk of recurrence putatively through the formation of additional adhesions. The long-term risk of recurrence of aSBO should be considered in the management of this patient population.
Background Patients with severe traumatic brain injury (sTBI) are at high risk for developing venous thromboembolism (VTE). Nonetheless, pharmacologic VTE prophylaxis is often delayed out of concern ...for precipitating extension of intracranial hemorrhage (ICH). The purpose of this study was to compare the effectiveness of early vs late VTE prophylaxis in patients with sTBI, and to characterize the risk of subsequent ICH-related complication. Study Design Adults with isolated sTBI (head Abbreviated Injury Scale score ≥3 and total Glasgow Coma Scale score ≤8) who received VTE prophylaxis with low-molecular-weight or unfractionated heparin were derived from the American College of Surgeons Trauma Quality Improvement Program (2012 to 2014). Patients were divided into EP (<72 hours) or LP (≥72 hours) groups. Propensity score matching was used to minimize selection bias. The primary end point was VTE (pulmonary embolism or deep vein thrombosis). Secondary outcomes were defined as late neurosurgical intervention (≥72 hours) or death. Results We identified 3,634 patients with sTBI. Early prophylaxis was given in 43% of patients. Higher head injury severity, presence of ICH, and early neurosurgery were associated with late prophylaxis. Propensity score matching yielded a well-balanced cohort of 2,468 patients. Early prophylaxis was associated with lower rates of both pulmonary embolism (odds ratio = 0.48; 95% CI, 0.25–0.91) and deep vein thrombosis (odds ratio = 0.51; 95% CI, 0.36–0.72), but no increase in risk of late neurosurgical intervention or death. Conclusions In this observational study of patients with sTBI, early initiation of VTE prophylaxis was associated with decreased risk of pulmonary embolism and deep vein thrombosis, but no increase in risk of late neurosurgical intervention or death. Early prophylaxis may be safe and should be the goal for each patient in the context of appropriate risk stratification.
OBJECTIVE:We set out to compare the incidence of bowel repair and/or resection in a large cohort of patients with adhesive small bowel obstruction (SBO) managed operatively.
BACKGROUND:Laparoscopic ...lysis of adhesions for adhesive SBO (aSBO) is becoming more common, yet might increase the risk of bowel injury given the distended and/or potentially compromised small bowel.
METHODS:We used administrative discharge data derived from a large geographic region, identifying patients who underwent surgery for their first episode of aSBO during 2005 to 2014. Procedure codes were used to determine the exposureeither an open approach or a laparoscopic approach (including procedures converted to open). The primary outcome was incidence of bowel intervention, defined as intraoperative enterotomy, suture repair of intestine, or bowel resection. We estimated the odds of bowel intervention after adjusting for patient and clinical factors.
RESULTS:A total of 8584 patients underwent operation for aSBO. Patients undergoing laparoscopic procedures were younger with fewer comorbid conditions. The rate of laparoscopic approaches increased more than 3-fold during the study period (4.3%–14.3%, P < 0.0001). The incidence of bowel intervention was 53.5% versus 43.4% in laparoscopic versus open procedures (P < 0.0001). After adjustment for potential confounders, the odds of bowel intervention among patients treated laparoscopically versus open was 1.6 (95% confidence interval1.4–1.9).
CONCLUSIONS:Laparoscopic procedures for aSBO are associated with a greater likelihood of intervention for bowel injury and/or repair. This increase might be due to challenges inherent with laparoscopic approaches in patients with distended small bowel. Surgeons should approach laparoscopic lysis of adhesions with a higher level of awareness and use strategies to mitigate this risk.
Femoral shaft fractures are common in major trauma. Early definitive fixation, within 24 hours, is feasible in most patients and is associated with improved outcomes. Nonetheless, variability might ...exist between trauma centers in timeliness of fixation. Such variability could impact outcomes and would therefore represent a target for quality improvement. We evaluated variability in delayed fixation (≥24 hours) between trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and measured the resultant association with important clinical outcomes at the hospital level.
A retrospective cohort study was performed using data derived from the ACS TQIP database. Adults with severe injury who underwent definitive fixation of a femoral shaft fracture at a level I or II trauma center participating in ACS TQIP (2012-2015) were included. Patient baseline and injury characteristics that might affect timing of fixation were considered. A hierarchical logistic regression model was used to identify predictors of delayed fixation. Hospital variability in delayed fixation was measured using 2 approaches. First, the random effects output of the hierarchical model was used to identify outlier hospitals where the odds of delayed fixation were significantly higher or lower than average. Second, the median odds ratio (MOR) was calculated to quantify heterogeneity in delayed fixation between hospitals. Finally, complications (pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, pneumonia, decubitus ulcer, and death) and hospital length of stay were compared across quartiles of risk-adjusted delayed fixation. We identified 17,993 patients who underwent definitive fixation at 216 trauma centers. The median injury severity score (ISS) was 13 (interquartile range IQR 9-22). Median time to fixation was 15 hours (IQR 7-24 hours) and delayed fixation was performed in 26% of patients. After adjusting for patient characteristics, 57 hospitals (26%) were identified as outliers, reflecting significant practice variation unexplained by patient case mix. The MOR was 1.84, reflecting heterogeneity in delayed fixation across centers. Compared to hospitals in the lowest quartile of delayed fixation, patients treated at hospitals in the highest quartile of delayed fixation suffered 2-fold higher rates of pulmonary embolism (2.6% versus 1.3%; rate ratio RR 2.0; 95% CI 1.2-3.2; P = 0.005) and required greater length of stay (7 versus 6 days; RR 1.15; 95% CI 1.1-1.19; P < 0.001). There was no significant difference with respect to mortality (1.3% versus 0.8%; RR 1.6; 95% CI 1.0-2.8; P = 0.066). The main limitations of this study include the inability to classify fractures by severity, challenges related to the heterogeneity of the study population, and the potential for residual confounding due to unmeasured factors.
In this large cohort study of 216 trauma centers, significant practice variability was observed in delayed fixation of femoral shaft fractures, which could not be explained by differences in patient case mix. Patients treated at centers where delayed fixation was most common were at significantly greater risk of pulmonary embolism and required longer hospital stay. Trauma centers should strive to minimize delays in fixation, and quality improvement initiatives should emphasize this recommendation in best practice guidelines.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Motor vehicle crashes (MVCs) are a leading public health concern. Emergency medical service (EMS) response time is a modifiable, system-level factor with the potential to influence trauma ...patient survival. The relationship between EMS response time and MVC mortality is unknown. OBJECTIVES: To measure the association between EMS response times and MVC mortality at the population level across US counties. DESIGN, SETTING, AND STUDY POPULATION: This population-based study included MVC-related deaths in 2268 US counties, representing an estimated population of 239 464 121 people, from January 1, 2013, through December 31, 2015. Data were analyzed from October 1, 2017, through April 30, 2018. EXPOSURE: The median EMS response time to MVCs within each county (county response time), derived from data collected by the National Emergency Medical Service Information System. MAIN OUTCOMES AND MEASURES: The county rate of MVC-related death, calculated using crash fatality data recorded in the Fatality Analysis Reporting System of the National Highway Traffic Safety Administration. RESULTS: During the study period, 2 214 480 ambulance responses to MVCs were identified (median, 229 responses per county interquartile range (IQR), 73-697 responses per county) in 2268 US counties. The median county response time was 9 minutes (IQR, 7-11) minutes. Longer response times were significantly associated with higher rates of MVC mortality (≥12 vs <7 minutes; mortality rate ratio, 1.46; 95% CI, 1.32-1.61) after adjusting for measures of rurality, on-scene and transport times, access to trauma resources, and traffic safety laws. This finding was consistent in both rural/wilderness and urban/suburban settings, where a significant proportion of MVC fatalities (population attributable fraction: rural/wilderness, 9.9%; urban/suburban, 14.1%) were associated with prolonged response times (defined by the median value, ≥10 minutes and ≥7 minutes, respectively). CONCLUSIONS AND RELEVANCE: Among 2268 US counties, longer EMS response times were associated with higher rates of MVC mortality. A significant proportion of MVC-related deaths were associated with prolonged response times in both rural/wilderness and urban/suburban settings. These findings suggest that trauma system–level efforts to address regional disparities in MVC mortality should evaluate EMS response times as a potential contributor.
Chronic lymphocytic leukaemia (CLL) is a malignancy of the immune B lymphocyte cells and is the most common leukaemia diagnosed in developed countries. In this paper, we report the synthesis and ...antiproliferative effects of a series of (
)-9-(2-nitrovinyl)anthracenes and related nitrostyrene compounds in CLL cell lines and also in Burkitt's lymphoma (BL) cell lines, a rare form of non-Hodgkin's immune B-cell lymphoma. The nitrostyrene scaffold was identified as a lead structure for the development of effective compounds targeting BL and CLL. The series of structurally diverse nitrostyrenes was synthesised via Henry-Knoevenagel condensation reactions. Single-crystal X-ray analysis confirmed the structure of (
)-9-chloro-10-(2-nitrobut-1-en-1-yl)anthracene (
) and the related 4-(anthracen-9-yl)-1
-1,2,3-triazole (
). The (
)-9-(2-nitrovinyl)anthracenes
and
were found to elicit potent antiproliferative effects in both BL cell lines EBV
MUTU-1 (chemosensitive) and EBV
DG-75 (chemoresistant) with >90% inhibition at 10 μM. Selected (
)-9-(2-nitrovinyl)anthracenes demonstrated potent antiproliferative activity in CLL cell lines, with IC
values of 0.17 μM (HG-3) and 1.3 μM (PGA-1) for compound
. The pro-apoptotic effects of the most potent compounds
,
,
,
and
were demonstrated in both CLL cell lines HG-3 and PGA-1. The (
)-nitrostyrene and (
)-9-(2-nitrovinyl)anthracene series of compounds offer potential for further development as novel chemotherapeutics for CLL.
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