Societal Costs of Inappropriate Emergency Department Thoracotomy Passos, Edward M., MD; Engels, Paul T., MD, FACS; Doyle, Jeffrey D., MD ...
Journal of the American College of Surgeons,
2012, 2012-Jan, 2012-01-00, 20120101, Letnik:
214, Številka:
1
Journal Article
Recenzirano
Background Emergency department (ED) thoracotomy can be lifesaving. It can also lead to resource waste and exposure to blood-borne infections. We investigated the frequency with which ED thoracotomy ...was performed for inappropriate indications and the resulting societal costs. Study Design This retrospective cohort study examined all trauma patients admitted directly from the scene of injury from 1992 to 2009 who underwent ED thoracotomy. The main outcomes included inappropriate ED thoracotomy. Secondary outcomes included resource use and societal costs for performing ED thoracotomy for improper indications. Specifically, we analyzed for operating room use, blood transfusions, ICU and hospital stay, needlestick injuries, survivor rate, and neurological outcomes in this group. Results One hundred and twenty-three patients underwent ED thoracotomy during the study period. Of those, 63 (51%) were considered inappropriate. In this group, we observed no survivors, none became organ donors, 3 cases of needlestick injuries to health care providers occurred, and 335 U of blood products were used in their care. Also, 4 patients of 63 survived to the operating room and required a total of 6 separate operating room visits. Three of these patients had an ICU stay of 1 day and 1 died on day 5. Conclusions ED thoracotomy should be reserved for potentially salvageable patients, but discouraged for other indications. From the societal point of view, inappropriate use of the procedure resulted in substantial costs and waste of resources, exposure of health care providers to possible blood-borne infections, and offered no survival benefit.
Considerable effort has gone into improving outcomes from out-of-hospital cardiac arrest (OHCA). Studies suggest that survival is improving; however, prior studies had insufficient data to pursue the ...relationship between markers of guideline compliance and temporal trends. The objective of the study was to evaluate trends in OHCA survival over an 8-year period that included the implementation of the 2005 and 2010 international cardiopulmonary resuscitation (CPR) guidelines.
This was a population-based cohort study of all consecutive treated OHCA patients of presumed cardiac cause between 2006 and 2013 in the City of Toronto, Canada, and surrounding regions. Temporal changes were measured by χ
trend test. The association between year of the OHCA and survival was evaluated using logistic regression and joinpoint analysis. A total of 23 619 patients with OHCA met study inclusion criteria. During the study period, survival to hospital discharge doubled (4.8% in 2006 to 9.4% in 2013;
<0.0001), and survival with good neurological outcome increased (6.2% in 2010 to 8.5% in 2013;
=0.005). Improvements occurred in the rates of bystander CPR and automated external defibrillator application, high-quality CPR metrics, and in-hospital targeted temperature management. After adjusting for the Utstein variables, survival to hospital discharge (odds ratio, 1.12; 95% confidence interval, 1.09-1.15) and survival with good neurological outcome (odds ratio, 1.13; 95% confidence interval, 1.05-1.22) increased with each year of study.
Survival after OHCA has improved over time. This trend was associated with improved rates of bystander CPR, automated external defibrillator use, high-quality CPR metrics, and in-hospital targeted temperature management. The results suggest that multiple factors, each improving over time, may have contributed to the observed increase in survival.
BACKGROUND:Acute coagulopathy after traumatic brain injury (TBI) involves a complex multifactorial hemostatic response that is poorly characterized. ObjectivesTo examine early posttraumatic ...alterations in coagulofibrinolytic, endothelial, and inflammatory blood biomarkers in relation to sympathetic nervous system (SNS) activation and 6-month patient outcomes, using multivariate partial least-squares (PLS) analysis.
PATIENTS AND METHODS:A multicenter observational study of 159 adult isolated TBI patients admitted to the emergency department at an urban level I trauma center, was performed. Plasma concentrations of 6 coagulofibrinolytic, 10 vascular endothelial, 19 inflammatory, and 2 catecholamine biomarkers were measured by immunoassay on admission and 24 h postinjury. Neurological outcome at 6 months was assessed using the Extended Glasgow Outcome Scale. PLS-discriminant analysis was used to identify salient biomarker contributions to unfavorable outcome, whereas PLS regression analysis was used to evaluate the covariance between SNS correlates (catecholamines) and biomarkers of coagulopathy, endotheliopathy, and inflammation.
RESULTS:Biomarker profiles in patients with an unfavorable outcome displayed procoagulation, hyperfibrinolysis, glycocalyx and endothelial damage, vasculature activation, and inflammation. A strong covariant relationship was evident between catecholamines and biomarkers of coagulopathy, endotheliopathy, and inflammation at both admission and 24 h postinjury.
CONCLUSIONS:Biomarkers of coagulopathy and endotheliopathy are associated with poor outcome after TBI. Catecholamine levels were highly correlated with endotheliopathy and coagulopathy markers within the first 24 h after injury. Further research is warranted to characterize the pathogenic role of SNS-mediated hemostatic alterations in isolated TBI.
Developing effective disease-modifying therapies for neurodegenerative diseases (NDs) requires reliable diagnostic, disease activity, and progression indicators. While desirable, identifying ...biomarkers for NDs can be difficult because of the complex cytoarchitecture of the brain and the distinct cell subsets seen in different parts of the central nervous system (CNS). Extracellular vesicles (EVs) are heterogeneous, cell-derived, membrane-bound vesicles involved in the intercellular communication and transport of cell-specific cargos, such as proteins, Ribonucleic acid (RNA), and lipids. The types of EVs include exosomes, microvesicles, and apoptotic bodies based on their size and origin of biogenesis. A growing body of evidence suggests that intercellular communication mediated through EVs is responsible for disseminating important proteins implicated in the progression of traumatic brain injury (TBI) and other NDs. Some studies showed that TBI is a risk factor for different NDs. In terms of therapeutic potential, EVs outperform the alternative synthetic drug delivery methods because they can transverse the blood–brain barrier (BBB) without inducing immunogenicity, impacting neuroinflammation, immunological responses, and prolonged bio-distribution. Furthermore, EV production varies across different cell types and represents intracellular processes. Moreover, proteomic markers, which can represent a variety of pathological processes, such as cellular damage or neuroinflammation, have been frequently studied in neurotrauma research. However, proteomic blood-based biomarkers have short half-lives as they are easily susceptible to degradation. EV-based biomarkers for TBI may represent the complex genetic and neurometabolic abnormalities that occur post-TBI. These biomarkers are not caught by proteomics, less susceptible to degradation and hence more reflective of these modifications (cellular damage and neuroinflammation). In the current narrative and comprehensive review, we sought to discuss the contemporary knowledge and better understanding the EV-based research in TBI, and thus its applications in modern medicine. These applications include the utilization of circulating EVs as biomarkers for diagnosis, developments of EV-based therapies, and managing their associated challenges and opportunities.
To determine if reducing prehospital time and time-to-craniotomy is associated with decreased mortality in trauma patients with acute subdural hematomas.
Time-to-treatment is an important performance ...filter for trauma systems, yet very little evidence exists to support its use. Despite the biological rationale supporting the notion of the "Golden Hour" for trauma patients, no evidence exists to support it. Likewise, it remains controversial whether or not time-to-craniotomy is associated with survival in patients with subdural hematomas. Previous studies may have been affected by selection bias.
Retrospective cohort study of all trauma patients who arrived directly from the scene of injury. Study patients were all patients with acute subdural hematomas and without severe torso injuries, who required craniotomy at a Canadian level 1 trauma center from January 1 1996 to December 31 2007. The independent variables of interest were prehospital time and time-to-craniotomy. The primary outcome measure was in-hospital mortality.
Of 12,105 trauma patients assessed, 149 patients met inclusion criteria. Overall, 40% (n = 60) patients died. On univariate analysis, there was a strong trend suggesting that patients arriving within the "Golden Hour after trauma" had decreased mortality (37% vs. 53%, P = 0.09). However, there was no difference in mortality for patients undergoing craniotomy within 4 hours and after 4 hours (42% vs. 36%, P = 0.4). On multivariate logistic regression, increased prehospital time was found to be associated with increased mortality (odds ratio 1.03 per minute, 95% CI 1.004-1.05, P = 0.024). Surprisingly, there was a trend showing that increased trauma room to craniotomy times were associated with lower mortality (odds ratio 0.995 per minute, 95% CI 0.99-1.0, P = 0.056). However, patients who quickly had their craniotomy seemed to have more severe neurological injury.
Rapid transport of patients with traumatic subdural hematomas hospital is associated with decreased mortality.
Transfusion in trauma is often empiric or based on traditional lab tests. Viscoelastic tests such as thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been proposed as ...superior to traditional lab tests. Due to the similarities between the two tests, general opinion seems to consider them equivalent with interchangeable interpretations. However, it is not clear whether the results can be similarly interpreted. This review evaluates the comparability between TEG and ROTEM and performs a descriptive review of the parameters utilized in each test in adult trauma patients.
PUBMED database was reviewed using the keywords "thromboelastography" and "compare", between 2000 and 2011. Original studies directly comparing TEG® with ROTEM® in any area were retrieved. To verify the individual test parameter used in studies involving trauma patients, we further performed a review using the keywords "thromboelastography" and "trauma" in the PUBMED database.
Only 4 studies directly compared TEG® with ROTEM®. One in liver transplantation found that transfusion practice could differ depending on the device in use. Another in cardiac surgery concluded that all measurements are not completely interchangeable. The third article using commercially available plasma detected clinically significant differences in the results from the two devices. The fourth one was a head-to-head comparison of the technical aspects. The 24 articles reporting the use of viscoelastic tests in trauma patients, presented considerable heterogeneity.
Both tests are potentially useful as means to rapidly diagnose coagulopathy, guide transfusion and determine outcome in trauma patients. Differences in the activators utilized in each device limit the direct comparability. Standardization and robust clinical trials comparing the two technologies are needed before these tests can be widely recommended for clinical use in trauma.
Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated ...this association, and the predictive value of hypothermia on mortality.
Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures.
Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval CI, 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality.
Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted.
Prognostic, level III.
The current COVID-19 pandemic situation has stimulated an unplanned clinical research paradigm which is evident from the surge of clinical trial registrations and the increasing number of ...COVID-related publications. We aimed to explore the standards for research conduction, publications and retraction of articles related to COVID-19 pharmacotherapy research during the pandemic. We analysed data from the contemporary literatures on studies reporting pharmacological agents for COVID-19 using MEDLINE, PubMed, WHO database and Google Scholar between January 01, 2020 and March 20, 2021. The initial search revealed a total of 61,801 articles. Based on the inclusion criteria, a total of 124 studies related to various pharmacological agents were included in the final analysis. Most of the studies were reported from the United States (n = 30, 24%). Of the 124 studies, 50 (40%) were randomized controlled trials (RCTs). Immunomodulatory drugs-related (n = 17, 34%) and COVID-19 vaccine-related studies (n = 14, 28%) were the main topics in the relevant RCTs. The median days for dissemination of findings in journals were 114 days (IQR 61–189). A comparative analysis revealed that RCTs were disseminated earlier (median 79 days; IQR 52–131) when compared to observational studies (median = 144 days; IQR 69–206) (p = 0.003). Six papers were retracted from high impact journals; in which the average period till publication was 33 days. Retraction of papers occurred within 10–48 days. Expedited reviews, research approval and early publications of COVID-19 related pharmaceutical studies could have an impact on the quality of publications. However, the huge number of publications in short time creates confusion for readers during the early phases of the pandemic. Retraction of papers is alarming but ensures research integrity and correctness of scientific information. These abbreviated processes could affect patient care and public awareness. It is imperative to follow rapid but rigours ethical standards for research approval and peer-review process for publications during health pandemics.
We present a 30-year-old male who sustained a mild traumatic brain injury and then was intubated due to deterioration of consciousness. A head CT scan revealed mild brain oedema, a fractured nasal ...bone and mild left thoracic wall haematoma. Despite complete clinical and radiological normalisation within 36 hours, he failed to wean off the ventilator. The patient was found to have subtle bulbar manifestations including dysphonia, dysarthria, and dysphagia, with recurrent left lung collapse. He responded to an empirical pyridostigmine trial despite negative biochemical tests for myasthenia gravis (MG). The patient was weaned successfully from the ventilator, transferred to a long-term care facility, and then discharged home. Classic symptoms and signs of a disease may be absent, but the presence of dysarthria, dysphagia, transient vocal cord palsy, nasal speech, absent gag reflex and respiratory failure in difficult-to-wean patients, with no definitive diagnosis, may warrant an empirical trial of therapy for suspected MG and for the benefit of any doubt.
"Hidden" cranial injuries may account for subtle bulbar symptoms in victims of traumatic brain injury and should be searched for.Myasthenia gravis has been reported in association with trauma, which comes first and is often difficult to ascertain.A trial of pyridostigmine may be reasonable in difficult-to-wean patients when all other causes have been excluded for the benefit of the doubt.
Blood biomarkers are valuable tools for elucidating complex cellular and molecular mechanisms underlying traumatic brain injury (TBI). Profiling distinct classes of biomarkers could aid in the ...identification and characterization of initial injury and secondary pathological processes. This study characterized the prognostic performance of a recently developed multi-marker panel of circulating biomarkers that reflect specific pathogenic mechanisms including neuroinflammation, oxidative damage, and neuroregeneration, in moderate-to-severe TBI patients.
Peripheral blood was drawn from 85 isolated TBI patients (n = 60 severe, n = 25 moderate) at hospital admission, 6-, 12-, and 24-h post-injury. Mortality and neurological outcome were assessed using the extended Glasgow Outcome Scale. A multiplex platform was designed on MULTI-SPOT(®) plates to simultaneously analyze human plasma levels of s100 calcium binding protein beta (s100B), glial fibrillary acidic protein (GFAP), neuron specific enolase (NSE), brain-derived neurotrophic factor (BDNF), monocyte chemoattractant protein (MCP)-1, intercellular adhesion molecule (ICAM)-5, and peroxiredoxin (PRDX)-6. Multivariable logistic regression and area under the receiver-operating characteristic curve (AUC) were used to evaluate both individual and combined predictive abilities of these markers for 6-month neurological outcome and mortality after TBI.
Unfavorable neurological outcome was associated with elevations in s100B, GFAP, and MCP-1. Mortality was related to differences in six of the seven markers analyzed. Combined admission concentrations of s100B, GFAP, and MCP-1 were able to discriminate favorable versus unfavorable outcome (AUC = 0.83), and survival versus death (AUC = 0.87), although not significantly better than s100B alone (AUC = 0.82 and 0.86, respectively).
The multi-marker panel of TBI-related biomarkers performed well in discriminating unfavorable and favorable outcomes in the acute period after moderate-to-severe TBI. However, the combination of these biomarkers did not outperform s100B alone.
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