Abstract Objective Wound complications (WCs) after lower extremity arterial surgery (LEAS) are common, resulting in readmissions and reinterventions. Whereas diabetes and obesity are known risk ...factors for WCs, gender-specific variability in body fat distribution (android vs gynoid) may drive differential risks of WCs after LEAS. We analyzed the independent and synergistic effects of gender and body mass index (BMI) on WCs. Methods We performed a retrospective review of prospectively collected data from a published, randomized, multicenter trial assessing the incidence of WCs (dehiscence, surgical site infections, seroma, and hematoma) after LEAS. Postoperative outcomes were compared between genders. A multivariable regression model assessed the impact of gender and BMI on WCs. Subanalysis focused on the synergy of gender and body habitus, groin-only incisions, and clinical outcomes. Results There were 502 patients who underwent LEAS between October 2010 and September 2013. The cohort was elderly (67.6 ± 10.5 years), mostly male (72%), and overweight (BMI, 27.6 ± 5.7); 225 (45%) patients had a groin-only incision. In 171 patients (37.9%), a WC developed within 30 days, 85% of which were infectious in etiology. On multivariable regression, obesity (odds ratio OR, 2.10; 95% confidence interval CI, 1.17-3.77), morbid obesity (OR, 2.87; 95% CI, 1.32-6.23), and female gender (OR, 1.17; 95% CI, 1.06-2.75) were independent predictors of infectious WCs at 30 days. When stratified by groin-only incision, BMI was no longer significant, but female gender (OR, 2.70; 95% CI, 1.24-5.87) was predictive of infectious WCs at 30 days. There was no synergistic effect of BMI and gender on WCs. Conclusions WCs are common after LEAS. BMI is an independent risk factor for the development of any WC. Female gender, a potential surrogate for high hip to waist ratio body habitus, is also an independent predictor of groin WCs, suggesting the clinical importance of gynoid vs android fat distribution.
Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. ...Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval CI 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
Objective To describe factors associated with computed tomography (CT) use for children with minor blunt head trauma that are evaluated in emergency departments. Study design Planned secondary ...analysis of a prospective observational study of children <18 years with minor blunt head trauma between 2004 and 2006 at 25 emergency departments. CT scans were obtained at the discretion of treating clinicians. We risk-adjusted patients for clinically important traumatic brain injuries and performed multivariable regression analyses. Outcome measures were rates of CT use by hospital and by clinician training type. Results CT rates varied between 19.2% and 69.2% across hospitals. Risk adjustment had little effect on the differential rate of CT use. In low- and middle-risk patients, clinicians obtained CTs more frequently at suburban and nonfreestanding children's hospitals. Physicians with emergency medicine (EM) residency training obtained CTs at greater rates than physicians with pediatric residency or pediatric EM training. In multivariable analyses, compared with pediatric EM–trained physicians, the OR for CT use among EM-trained physicians in children <2 years was 1.24 (95% CI 1.04-1.46), and for children >2 years was 1.68 (95% CI 1.50-1.89). Physicians of all training backgrounds, however, overused CT scans in low-risk children. Conclusions Substantial variation exists in the use of CT for children with minor blunt head trauma not explained by patient severity or rates of positive CT scans or clinically important traumatic brain injuries.
Background Kidney disease is associated with increased complications in total joint arthroplasty (TJA). The purpose of this study was to determine the association of kidney disease severity as ...measured by the chronic kidney disease (CKD) staging system with complications after TJA. Methods A retrospective review of 12,308 primary TJAs (6,361 hips, 5,947 knees) from 2008-2013 was performed. The following preoperative variables were obtained from medical records: chemistry 7 panel, Elixhauser comorbidities, and demographic factors. CKD stages were defined based on estimated glomerular filtration rate (eGFR) in ml/min/1.73m2 : (1) 90+, (2) 60-89, (3A) 45-59, (3B) 30-44, (4) 15-29, and (5) <15. Multivariate analysis was performed to assess the independent influence of CKD stage on the aforementioned endpoints. Results Patients with CKD stage greater than 2 demonstrated an increased odds of receiving transfusions (p=0.001), length of stay >3 days (p=0.010), acute kidney injury (p<0.001), septic revisions (p=0.002) and in-hospital complications (p<0.001) compared to all patients with eGFR > 60 when controlling for potential confounders. Only CKD stage 3A was significantly associated with septic revisions (90 days, p=0.004; 2 years p=0.002). Additionally, the relationship between eGFR and the above complications increased linearly rather than demonstrating a clear threshold at which the risk increased substantially. Discussion Severe CKD is associated with increased transfusion, length of stay, and in-hospital complications; and complications increased linearly with disease severity. Surgeons should be cognizant of this increase when evaluating TJA patients with renal disease.
NIH Roundtable on Emergency Trauma Research Cairns, Charles B., MD; Maier, Ronald V., MD; Adeoye, Opeolu, MD ...
Annals of emergency medicine,
11/2010, Letnik:
56, Številka:
5
Journal Article, Conference Proceeding
Recenzirano
Study objective The National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine to enhance NIH support for emergency care research. The NIH Trauma Research ...Roundtable was convened on June 22 to 23, 2009. The objectives of the roundtable are to identify key research questions essential to advancing the scientific underpinnings of emergency trauma care and to discuss the barriers and best means to advance research by exploring the role of trauma research networks and collaboration between NIH and the emergency trauma care community. Methods Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. During and after the conference, the lists were circulated among the participants and revised to reach a consensus. Results Emergency trauma care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype of patients on the time spectrum of acuity and severity after injury and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency trauma research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical injuries, and the development of treatments capable of halting or reversing them; the need for novel experimental models of acute injury; the need to assess the effect of development and aging on the postinjury response; and the need to understand why there are regional differences in outcomes after injury. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. Conclusion The science of emergency trauma care may be advanced by facilitating the following: (1) development of an acute injury template for clinical research; (2) developing emergency trauma clinical research networks; (3) integrating emergency trauma research into Clinical and Translational Science Awards; (4) developing emergency care–specific initiatives within the existing structure of NIH institutes and centers; (5) involving acute trauma and emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; (7) performing research to address ethical and regulatory issues; and (8) training emergency care investigators with research training programs.
Endovascular Repair of Abdominal Aortic Aneurysms Arnaoutakis, Dean J., MD, MBA; Zammert, Martin, MD; Karthikesalingam, Alan, MD, PhD ...
Best practice & research. Clinical anaesthesiology,
09/2016, Letnik:
30, Številka:
3
Journal Article
Recenzirano
Abstract Endovascular repair of abdominal aortic aneurysms is an important technique in the vascular surgeon’s armamentarium which has created a seismic shift in the management of aortic pathology ...over the last two decades. In comparison to traditional open repair, the endovascular approach is associated with significantly improved perioperative morbidity and mortality. The early survival benefit of endovascular abdominal aortic aneurysm repair is sustained up to 3 years postoperatively, but longer-term life expectancy remains poor regardless of operative modality. Nonetheless, most abdominal aortic aneurysms are now repaired using endovascular stent-grafts. The technology is not perfect as several postoperative complications, namely endoleak, stent-graft migration, and graft limb thrombosis, can develop and therefore lifelong imaging surveillance is required. In addition, a postoperative inflammatory response has been documented after endovascular repair of aortic aneurysms; the clinical significance of this finding has yet to be determined. Going forward, the safety and applicability of endovascular stent-grafts are likely to improve and expand with the introduction of newer generation devices and with the simplification of fenestrated systems.
Objective To examine whether pre-abuse rates and patterns of emergency department (ED) visits between children with supported child abuse and age-matched control subjects are useful markers for abuse ...risk. Study design A population-based case-control study using probabilistic linkage of four statewide data sets. Cases were abused children <13 years of age, identified between January 1, 2002, and December 31, 2002. For each case, a birth date–matched, population-based control was obtained. Outcome measures were rate ratios of ED visits in cases compared with control subjects. Results Cases (n = 9795) and control subjects (n = 9795) met inclusion criteria; 4574 cases (47%) had an ED visit; thus linked to the ED database versus 2647 control subjects (27%). The crude ED visit rate per 10 000 person-days of exposure was 8.2 visits for cases compared with 3.9 visits for control subjects. Cases were almost twice as likely as control subjects (adjusted rate ratio = 1.8; 95% CI, 1.5, 1.8) to have had a prior ED visit. Leading ED discharge diagnoses were similar for both groups. Conclusions Children with supported child abuse have higher ED use before abuse diagnosis, when compared with the general pediatric population. However, neither the rate of ED use nor the pattern of diagnoses offers sufficient specificity to be useful markers of risk for abuse.
Abstract Purpose Existing intensive care unit (ICU) mortality measurement systems address in-hospital mortality only. However, early postdischarge mortality contributes significantly to overall ...30-day mortality. Factors associated with early postdischarge mortality are unknown. Methods We performed a retrospective study of 8484 ICU patients. Our primary outcome was early postdischarge mortality: death after hospital discharge and 30 days or less from ICU admission. Cox regression models assessed the association between patient, hospital, and utilization factors and the primary outcome. Results In multivariate analyses, the hazard for early postdischarge mortality increased with rising severity of illness and decreased with full-code status (hazard ratio HR, 0.33; 95% confidence interval CI, 0.21-0.49). Compared with discharges home, early postdischarge mortality was highest for acute care transfers (HR, 3.18; 95% CI, 2.45-4.12). Finally, patients with very short ICU length of stay (<1 day) had greater early postdischarge mortality (HR, 1.86; 95% CI; 1.32-2.61) than those with longest stays (≥7 days). Conclusions Early postdischarge mortality is associated with patient preferences (full-code status) and decisions regarding timing and location of discharge. These findings have important implications for anyone attempting to measure or improve ICU performance and who rely on in-hospital mortality measures to do so.
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