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1.
Background
Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay.Methods
We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion.Results
Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p < 0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6–30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p < 0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p = 0.12).Conclusions
We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge. 相似文献2.
Andrés M. Rubiano Alvaro I. Sanchez Glyn Estebanez Andrew Peitzman Jason Sperry Juan Carlos Puyana 《Injury》2013
Introduction
Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate.Methods
We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values.Results
There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value < 0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50–1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre.Conclusion
The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation. 相似文献3.
Object
To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI).Methods
This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity.Results
Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p = 0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p = 0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p = 0.001), but not infection (p = 0.251) or resorption of bone flap (p = 0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty.Conclusions
Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy. 相似文献4.
Staphylococcus aureus bacteremia after thermal injury: The clinical impact of methicillin resistance
Panagiotis Theodorou Rolf Lefering Walter Perbix Timo A. Spanholtz Marc Maegele Gerald Spilker Oliver C. Thamm 《Burns : journal of the International Society for Burn Injuries》2013
Objective
To evaluate the impact of methicillin resistance in Staphylococcus aureus bacteremia (SAB) on mortality and length of stay in burn patients.Design
Retrospective cohort study.Setting
A 750-bed tertiary care university hospital in Cologne, Germany.Patients
Patients registered in the database of the burn intensive care unit (BICU) between 1989 and 2009 with complete data sets (n = 1688).Results
Over the 21-year study period, 74 patients with SAB were identified; 33 patients had methicillin-resistant S. aureus (MRSA) and 41 methicillin-susceptible S. aureus (MSSA). Comparing the MRSA with the MSSA population the following parameters were significantly different in the univariate analysis: BMI (27.2 kg/m2 vs. 23.6 kg/m2; P = 0.05), extent of deep partial thickness burns (17.8% vs. 9.0% of total body surface area; P = 0.007), antibiotic requirement on admission (45.5% vs. 22.0%; P = 0.046), median length of hospitalization prior SAB (24 days vs. 7 days; P < 0.001), packed red blood cells administration (47.6 units vs. 26.1 units; P = 0.003), intubation requirement (100% vs. 80.5%; P = 0.007), intubation period (43.5 days vs. 26.8 days; P = 0.008), catecholamine requirement (90.9% vs. 61.0%; P = 0.004), sepsis (60.6% vs. 34.1%; P = 0.035) and organ failures (81.8% vs. 39.0%; P < 0.001). Regarding outcome parameters, methicillin resistance was not significantly related with mortality (adjusted OR 1.55, 95% CI 0.56–4.28; P = 0.40) and length of BICU stay after SAB (Kaplan–Meier analysis log-rank test P = 0.32; Cox's proportional hazards regression HR 1.22, 95% CI 0.65–2.27, P = 0.535) in the univariate and multivariate analyses.Conclusion
Our data suggest that methicillin resistance is not associated with significant increases in mortality and length of BICU stay among burn patients with SAB. 相似文献5.
Mark Powis Boo Messahel Rachel Hobson Peter Gornall Jenny Walker Kathy Pritchard-Jones 《Journal of pediatric surgery》2013
Purpose
To compare surgical complication rates after immediate nephrectomy versus delayed nephrectomy following preoperative chemotherapy in children with non-metastatic Wilms’ tumour enrolled in UKW3, both in randomised patients and in those for whom the treatment approach was defined by parental or physician choice.Methods
Records for all patients enrolled into UKW3 were reviewed. Any record of tumour rupture or surgical complication was extracted and comparisons made between the two treatment strategies in both populations of randomised and non-randomised patients.Results
Of 525 children enrolled, 205 patients were randomised to either immediate nephrectomy (n = 103) or pre-operative chemotherapy followed by delayed nephrectomy (n = 102). Of the 320 children not randomised, data were available on 189 cases treated with immediate nephrectomy and 103 treated with pre-operative chemotherapy. There were significantly fewer surgical complications in randomised children given pre-operative chemotherapy before surgery compared to children undergoing immediate nephrectomy (1% vs. 20.4%, P < 0.001); this difference was most marked for tumour rupture (0% vs. 14.6%, P < 0.001).Conclusions
Delayed nephrectomy for Wilms’ tumour, preceded by pre-operative chemotherapy was associated with fewer surgical complications compared with immediate nephrectomy. 相似文献6.
Shannon N. Acker David A. Partrick James T. Ross Nicole A. Nadlonek Michael Bronsert Denis D. Bensard 《Journal of pediatric surgery》2014
Purpose
Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT.Methods
A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002–2011.Results
A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P < .0001), as was a platelet count of greater than 400,000 (P < .0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P < .05).Conclusions
In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years. 相似文献7.
Syed Nabeel Zafar Adil H. Haider Kent A. Stevens Nik Ray-Mazumder Mehreen T. Kisat Eric B. Schneider Albert Chi Samuel M. Galvagno Jr. Edward E. Cornwell rd David T. Efron Elliott R. Haut 《Injury》2014
Background
Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV).Study design
We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007–2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility.Results
74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66–85%), PV (median 11%, IQR 7–17%), or others (median 7%, IQR 2–18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p < 0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR = 2.0, 95% CI 1.73–2.35).Conclusions
Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question. 相似文献8.
Yin Lei Mehrdad Alemozaffar Stephen B. Williams Nathanael Hevelone Stuart R. Lipsitz Blakely A. Plaster Channa A. Amarasekera William D. Ulmer Andy C. Huang Keith J. Kowalczyk Jim C. Hu 《European urology》2011
Background
Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP).Objective
To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC).Design, settings, and participants
Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures.Surgical procedure
RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection.Measurements
Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day.Results and limitations
Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p < 0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p < 0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p < 0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p = 0.033), and one DVC-SSL versus zero SL-DVC were transfused (p = 0.442). Overall (12.2% vs 12.0%, p = 1.0) and apical (1.3% vs 2.7%, p = 0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p < 0.001) and continence (61.4% vs 39.6%, p < 0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE] ± standard error [SE]: 16.84 ± 2.56, p < 0.001), and better 5-mo urinary function (PE ± SE: 19.93 ± 3.09, p < 0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07–5.57, p < 0.001).Conclusions
DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control. 相似文献9.
L. Reydellet V. Blasco M.-F. Mercier F. Antonini C. Nafati K. Harti-Souab M. Leone J. Albanese 《Annales fran?aises d'anesthèsie et de rèanimation》2014
Objective
Liver transplantation carries major risks during the perioperative period. Few studies focused on the hemodynamics of patients undergoing liver transplantation. The present study was aimed to evaluate the impact of the implementation of a protocol including goal-directed therapy in patients undergoing liver transplantation. Our first goal was to determine its impact on the fluid balance. Secondarily, we evaluated possible improvements in the patient outcomes.Study design
A before and after study.Patients and methods
Fifty patients undergoing liver transplantation were included during two successive six-month periods. During the first period, the management of the patients was left at the discretion of the senior physicians (control group, n = 25). During the second period, the patients were treated according to a predetermined protocol including a specific hemodynamic monitoring (protocol group, n = 25).Results
The fluid balance was negative in the protocol group and positive in the control group at 24 h (−606 mL vs. +3445 mL, P < 0.01) and 48 h (−2315 mL vs. +1170 mL, P < 0.01) after liver transplantation. The volume of the crystalloid administration was lower in the protocol group than in the control group (5000 mL vs. 8000 mL, P < 0.01, and 1500 mL vs. 6000 mL, P < 0.01, during surgery and 48 h after liver transplantation, respectively). The duration of mechanical ventilation and postoperative ileus were significantly reduced in the protocol group, as compared with the control group, 20 h vs. 94 h (P < 0.01) and 4 days vs. 6 days (P < 0.01), respectively.Conclusion
For patients undergoing liver transplantation, the implementation of a protocol aiming to optimize hemodynamics was associated with reduced fluid balance and decreased requirement for mechanical ventilation and postoperative ileus duration. 相似文献10.
Simon P. Kim Nilay D. Shah R. Jeffrey Karnes Christopher J. Weight Nathan D. Shippee Leona C. Han Stephen A. Boorjian Marc C. Smaldone Igor Frank Matthew T. Gettman Matthew K. Tollefson R. Houston Thompson 《European urology》2013
Background
With health technology innovation responsible for higher health care costs, it is essential to have accurate estimates regarding the differential costs between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP).Objective
To describe the total hospitalization costs attributable to robotic and open surgery for radical prostatectomy (RP).Design, setting, and participants
Using a population-based cohort by merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 29 837 prostate cancer patients who underwent RP.Interventions
ORP and RARP.Outcome measurements and statistical analysis
The primary outcome was total hospitalization costs adjusted to year 2008 US dollars. Generalized estimating equations were used to identify patient and hospital characteristics associated with total hospitalization costs and to estimate costs of ORP and RARP adjusted for case mix and hospital teaching status, location, and annual case volume.Results and limitations
Overall, 20 424 (68.5%) patients were surgically treated with RARP, and 9413 (31.5%) patients underwent ORP. Compared to ORP, patients undergoing RARP had shorter median length of stay (1 d vs 2 d; p < 0.001) and were less likely to experience any postoperative complications (8.2% vs 11.3%; p < 0.001). However, patients undergoing RARP had higher median hospitalization costs ($10 409 vs $8862; p < 0.001). After adjusting for patient and hospital features, RARP was associated with higher total hospitalization costs compared to ORP ($11 932 vs $9390; p < 0.001). Our results are limited by a study design using retrospective population-based data.Conclusions
Despite RARP having lower complications and shorter length of stay than ORP, total hospitalization costs are higher for patients treated with RARP compared with those treated with ORP. 相似文献11.
C. Baillard F. Depret V. Levy M. Boubaya S. Beloucif 《Annales fran?aises d'anesthèsie et de rèanimation》2014
Background
Preoxygenation aims to obtain an expired oxygen fraction (FEO2) ≥ 90%. Little is known about the incidence and predictors of inadequate preoxygenation in the clinical setting.Patients and methods
Over a 12-month period, 1050 consecutive preoperative patients were prospectively included. Preoxygenation was performed for 3 minutes with a facial mask using a machine circuit and 12-L/min oxygen flow. Inadequate preoxygenation was defined as an FEO2 < 90%. A logistic regression was performed to identify incidence and independent predictors.Results
The patient characteristics were: age 51 ± 20 years, 47% male, BMI of 26 ± 5 kg/m2, and ASA score (median [extremes]) of 2 [1–4]. Inadequate preoxygenation was observed in 589 patients (56%). The effective FiO2 delivered was lower in the patients with inadequate preoxygenation than in those with adequate preoxygenation, 95 ± 3% vs. 98 ± 2%, P < 0.001. The difference between the FiO2 and the FEO2 was higher (12 ± 6% vs. 6 ± 3%, P < 0.0001) in patients with inadequate preoxygenation compared with those with adequate preoxygenation. The independent risk factors for inadequate preoxygenation were: firstly, bearded male (odds ratio [OR] of 9.1 [2.7–31.4] P < 0.001); secondly, beardless male (OR 2.4 [1.6–3.4] P < 0.001), thirdly, ASA score of 4 (OR 9.1 [2.6–31.2] P < 0.015); fourthly, ASA score of 2–3 (OR 2.4 [1.6–3.4] P < 0.015); fifthly, lack of teeth (OR 2.4 [1.2–4.5] P < 0.006), and lastly age > 55 years (OR 1.8 [1.2–2.7] P < 0.005).Conclusion
Inadequate preoxygenation, defined as an FEO2 < 90% despite 3-min tidal volume breathing, was a common occurrence. The predictive factors share an overlap with those previously identified for difficult mask ventilation. 相似文献12.
Massimo Lazzeri Alexander Haese Alexandre de la Taille Joan Palou Redorta Thomas McNicholas Giovanni Lughezzani Vincenzo Scattoni Vittorio Bini Massimo Freschi Amy Sussman Bijan Ghaleh Philippe Le Corvoisier Josep Alberola Bou Salvador Esquena Fernández Markus Graefen Giorgio Guazzoni 《European urology》2013
Background
Strategies to reduce prostate-specific antigen (PSA)–driven prostate cancer (PCa) overdiagnosis and overtreatment seem to be necessary.Objective
To test the accuracy of serum isoform [−2]proPSA (p2PSA) and its derivatives, percentage of p2PSA to free PSA (fPSA; %p2PSA) and the Prostate Health Index (PHI)—called index tests—in discriminating between patients with and without PCa.Design, setting, and participants
This was an observational, prospective cohort study of patients from five European urologic centers with a total PSA (tPSA) range of 2–10 ng/ml who were subjected to initial prostate biopsy for suspected PCa.Outcome measurements and statistical analysis
The primary end point was to evaluate the specificity, sensitivity, and diagnostic accuracy of index tests in determining the presence of PCa at prostate biopsy in comparison to tPSA, fPSA, and percentage of fPSA to tPSA (%fPSA) (standard tests) and the number of prostate biopsies that could be spared using these tests. Multivariable logistic regression models were complemented by predictive accuracy analysis and decision curve analysis.Results and limitations
Of >646 patients, PCa was diagnosed in 264 (40.1%). Median tPSA (5.7 vs 5.8 ng/ml; p = 0.942) and p2PSA (15.0 vs 14.7 pg/ml) did not differ between groups; conversely, median fPSA (0.7 vs 1 ng/ml; p < 0.001), %fPSA (0.14 vs 0.17; p < 0.001), %p2PSA (2.1 vs 1.6; p < 0.001), and PHI (48.2 vs 38; p < 0.001) did differ significantly between men with and without PCa. In multivariable logistic regression models, p2PSA, %p2PSA, and PHI significantly increased the accuracy of the base multivariable model by 6.4%, 5.6%, and 6.4%, respectively (all p < 0.001). At a PHI cut-off of 27.6, a total of 100 (15.5%) biopsies could have been avoided. The main limitation is that cases were selected on the basis of their initial tPSA values.Conclusions
In patients with a tPSA range of 2–10 ng/ml, %p2PSA and PHI are the strongest predictors of PCa at initial biopsy and are significantly more accurate than tPSA and %fPSA.Trial registration
The study is registered at http://www.controlled-trials.com, ref. ISRCTN04707454. 相似文献13.
Phillip J. Gray Stacey A. Fedewa William U. Shipley Jason A. Efstathiou Chun Chieh Lin Anthony L. Zietman Katherine S. Virgo 《European urology》2013
Background
Despite its lethal potential, many patients with muscle-invasive bladder cancer (MIBC) do not receive aggressive, potentially curative therapy consistent with established practice standards.Objective
To characterize the treatments received by patients with MIBC and analyze their use according to sociodemographic, clinical, pathologic, and facility measures.Design, setting, and participants
Using the National Cancer Data Base, we analyzed 28 691 patients with MIBC (stages II–IV) treated between 2004 and 2008, excluding those with cT4b tumors or distant metastases. Treatments included radical or partial cystectomy with or without chemotherapy (CT), chemoradiotherapy (CRT), radiation therapy (RT), or CT alone and observation following biopsy. Aggressive therapy (AT) was defined as radical or partial cystectomy or definitive RT/CRT (total dose ≥50 Gy).Outcome measurements and statistical analysis
AT use and correlating variables were assessed by multivariable, generalized estimating equation models adjusted for facility clustering.Results and limitations
According to the database, 52.5% of patients received AT; 44.9% were treated surgically, 7.6% received definitive CRT or RT, and 25.9% of patients received observation only. AT use decreased with advancing age (odds ratio [OR]: 0.34 for age 81–90 yr vs ≤50 yr; p < 0.001). AT use was also lower in racial minorities (OR: 0.74 for black race; p < 0.001), the uninsured (OR: 0.73; p < 0.001), Medicaid-insured patients (OR: 0.81; p = 0.01), and at low-volume centers (OR: 0.64 vs high-volume centers; p < 0.001). Use of AT was higher with increasing tumor stage (OR: 2.23 for T3/T4a vs T2; p < 0.001) and nonurothelial histology (OR: 1.25 and 1.43 for squamous and adenocarcinoma, respectively; p < 0.001). Study limitations include retrospective design and lack of information about patient and provider motivations regarding therapy selection.Conclusions
AT for MIBC appears underused, especially in the elderly and in groups with poor socioeconomic status. These data point to a significant unmet need to inform policy makers, payers, and physicians regarding appropriate therapies for MIBC. 相似文献14.
Purpose
To investigate the relationship between severity of hypernatremia and the risk of death for patients with traumatic brain injury (TBI) who have been admitted to the neurosurgical intensive care unit (NICU).Methods
A total of 1044 patients with TBI were admitted to our NICU from January 2005 to January 2010. Of these patients, 881 were included in this study. Based on blood serum sodium level in the NICU the 881 patients were divided into four groups: 614 had normal serum sodium (Na < 150 mmol/L), 34 had mild hypernatremia (Na 150–<155 mmol/L), 66 had moderate hypernatremia (Na 155–160 mmol/L) and 167 had severe hypernatremia (Na ≥ 160 mmol/L).Results
The mortality rates for the mild, moderate, and severe hypernatremia groups were 20.6%, 42.4%, and 86.8%, respectively; the mortality rate for the normal group was 2.0%. In multivariable analysis, mild, moderate, and severe hypernatremia were independent risk factors for mortality; compared with the normal group the odds ratios of mild, moderate, and severe hypernatremia were 9.50, 4.34, and 29.35, respectively.Conclusions
Severe hypernatremia is an independent risk factor with extremely high odds ratio for death in patients with TBI who are admitted to the NICU. 相似文献15.
Lior Rosenberg Yuval Krieger Alex Bogdanov-Berezovski Eldad Silberstein Yaron Shoham Adam J. Singer 《Burns : journal of the International Society for Burn Injuries》2014
Objectives
Excisional debridement followed by autografting is the standard of care (SOC) for deep burns, but is associated with serious potential complications. Conservative, non-surgical and current enzymatic debridement methods are inefficiently slow. We determined whether a non-surgical option of rapid enzymatic debridement with the debriding enzyme NexoBrid™ (NXB) would reduce need for surgery while achieving similar esthetic and functional outcomes as SOC.Methods
We conducted a multi-center, open-label, randomized, controlled clinical trial including patients aged 4-55 years with deep partial and full thickness burns covering 5-30% of their total body surface area (TBSA). Patients were randomly assigned to burn debridement with NXB (applied for 4 h) or SOC, which included surgical excisional or non-surgical debridement.Results
NXB significantly reduced the time from injury to complete débridement (2.2 vs. 8.7 days, P < 0.0001), need for surgery (24.5% vs. 70.0%, P < 0.0001), the area of burns excised (13.1% vs. 56.7%, P < 0.0001) and the need for autografting (17.9% vs. 34.1%, P = 0.01). Scar quality and quality of life scores were similar in both study groups as were the rates of adverse events.Conclusions
Enzymatic débridement with NXB resulted in reduced need for and extent of surgery compared with SOC while achieving comparable long-term results in patients with deep burns.Trial registration
: Clinical Trials.gov NCT00324311. 相似文献16.
Purpose
This meta-analysis compares the clinical outcomes of joint preservation versus arthroplasty in the treatment of displaced proximal humerus fractures.Methods
Medline, CINAHL, and EMBASE were searched for studies published between 1970 and 2011 reporting outcomes of the treatment of 3- or 4-part proximal humerus fractures using the Constant–Murley score in skeletally mature patients. Randomised and cohort studies with ≥1-year follow-up were included. Two individuals independently extracted data, and study results were divided into subgroups based on type of treatment.Results
A meta-analysis with meta regressions was performed on the mean Constant score. Of 610 total participants in the studies analysed, 340 were treated with joint-preserving techniques. The random-effects mean Constant score across all treatment types was 62.7 (95% CI, 61.6–63.9, P < 0.001), with joint-preserving treatments demonstrating higher scores than arthroplasty (70 vs. 49, P < 0.001). The studies displayed significant heterogeneity (Q statistic = 516, P < 0.001, I2 = 94.8). In the meta-regression analyses, Constant scores decreased significantly with increasing age, fracture severity, and rate of osteonecrosis (P < 0.001).Conclusions
In the existing literature, displaced proximal humerus fractures demonstrate improved Constant scores when treated with joint-preserving options. Age, fracture pattern, and complication rate are significant predictors of the Constant score independent of the selected treatment. Given the observed heterogeneity and variance in treatment techniques in the included studies, more comparative studies are needed to definitively recommend joint-preserving techniques versus arthroplasty for specific fracture patterns. 相似文献17.
Y. Coisel A. Jourdan M. Conseil Y. Pouzeratte D. Verzilli B. Jung G. Chanques S. Jaber 《Annales fran?aises d'anesthèsie et de rèanimation》2014
Objective
To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery.Patients and methods
We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994–2009). Statistical analysis was done on 4 chronologic quartiles of same sample size.Results
Two hundred and seven consecutive patients were included during the 4 periods 1994–1997 (n = 52), 1997–1999 (n = 52), 1999–2003 (n = 52) and 2004–2009 (n = 51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6–10.6] vs 7.6[7.0–8.3] mL/kg of ideal body weight (IBW), p < 0.01), increased use of Positive End Expiratory Pressure (0 vs 83 %, p < 0.001) and increased use of post-operative non-invasive ventilation (0 vs 51 %, p < 0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0–24.6] vs 12.6 [9.7–16.2] mL/h/kg of IBW, p < 0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57 %, p < 0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn’t change.Conclusions
During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed. 相似文献18.
Umberto Capitanio Shahrokh F. Shariat Hendrik Isbarn Alon Weizer Mesut Remzi Marco Roscigno Eiji Kikuchi Jay D. Raman Christian Bolenz Karim Bensalah Theresa M. Koppie Wassim Kassouf Mario I. Fernández Philipp Ströbel Jeffrey Wheat Richard Zigeuner Cord Langner Matthias Waldert Mototsugu Oya Charles C. Guo Casey Ng Francesco Montorsi Christopher G. Wood Vitaly Margulis Pierre I. Karakiewicz 《European urology》2009
Background
Data regarding the oncologic efficacy of laparoscopic nephroureterectomy (LNU) compared to open nephroureterectomy (ONU) are scarce.Objective
We compared recurrence and cause-specific mortality rates of ONU and LNU.Design, setting, and participants
Thirteen centers from three continents contributed data on 1249 patients with nonmetastatic upper tract urothelial carcinoma (UTUC).Measurements
Univariable and multivariable survival models tested the effect of procedure type (ONU [n = 979] vs LNU [n = 270]) on cancer recurrence and cancer-specific mortality. Covariables consisted of institution, age, Eastern Cooperative Oncology Group (ECOG) performance status score, pT stage, pN stage, tumor grade, lymphovascular invasion, tumor location, concomitant carcinoma in situ, ureteral cuff management, previous urothelial bladder cancer, and previous endoscopic treatment.Results and limitations
Median follow-up for censored cases was 49 mo (mean: 62). Relative to ONU, LNU patients had more favorable pathologic stages (pT0/Ta/Tis: 38.1% vs 20.8%, p < 0.001) and less lymphovascular invasion (14.8% vs 21.3%, p = 0.02) and less frequently had tumors located in the ureter (64.5 vs 71.1%, p = 0.04). In univariable recurrence and cancer-specific mortality models, ONU was associated with higher cancer recurrence and mortality rates compared to LNU (hazard ratio [HR]: 2.1 [p < 0.001] and 2.0 [p = 0.008], respectively). After adjustment for all covariates, ONU and LNU had no residual effect on cancer recurrence and mortality (p = 0.1 for both).Conclusions
Short-term oncologic data on LNU are comparable to ONU. Since LNU was selectively performed in favorable-risk patients, we cannot state with certainty that ONU and LNU have the same oncologic efficacy in poor-risk patients. Long-term follow-up data and morbidity data are necessary before LNU can be considered as the standard of care in patients with muscle-invasive or high-grade UTUC. 相似文献19.
P. Theodorou T.A. Spanholtz P. Amini C.A. Maurer T.Q.V. Phan W. Perbix R. Lefering G. Spilker 《Burns : journal of the International Society for Burn Injuries》2009
Objective
To evaluate demographic and socioeconomic factors associated with assault burn injuries.Background
Assault by burning demonstrates a rare but severe public health issue and accounts for unique injury characteristics in the burn intensive care unit (BICU).Methods
We conducted a retrospective cohort study involving patients with thermal injuries admitted to the BICU of a university hospital. The patient cohort was divided into two groups (ABI group: patients with assault burns, n = 41; Control group: population of all other burned patients admitted to the BICU, n = 1202). Bivariate and multivariate analyses including demographic and socioeconomic data were used to identify factors associated with assault burns.Results
Forty-one assault-related burn victims were identified in the study period. This represents 3.3% of all significant burns admitted. Comparing battery victims with the control population, assault patients were more likely to be young (mean age 36.2 years vs. 42.2 years) and immigrants (41.5% vs. 15.1%). Furthermore, marital status (65.9% vs. 40.8% singles), employment status (36.6% vs. 9.7% unemployed) and insurance status (41.5% vs. 12.3% social insurance) were significantly different in the bivariate analysis. Logistic regression evaluation identified three variables that were independently associated with assault burns: younger age (≤25 years) (odds ratio, 2.54 [95% confidence interval, 1.29–5.02]; p = 0.007), ethnic minority (odds ratio, 3.71 [95% confidence interval, 1.91–7.20]; p < 0.001) and unemployment (odds ratio, 4.02 [95% confidence interval, 2.03–7.97]; p < 0.001).Conclusions
The high incidence of youngsters, unemployment and the great proportion of immigrants in victims of assault might provide several opportunities for community-based psychosocial and occupational programs. A multidisciplinary approach targeting issues specific to the violent nature of the injury and the socioeconomic background of the victims may be of benefit to improve their perspectives for rehabilitation. 相似文献20.