共找到 20 条结果
暂无摘要（点击查看详情）
Cataract surgery is usually performed with topical anesthesia and sedation, which may be provided through a number of different care models with or without involvement of a physician anesthesiologist. We sought to describe anesthesiology care for cataract surgery in Ontario, Canada, and examine the association between the model of anesthesiology care and health service and perioperative outcomes after cataract surgery. We conducted a population-based study of patients who underwent cataract surgery in Ontario using linked health administrative data between 2012 and 2021. The primary outcome was a composite of death, acute hospital admission, or emergency department visit up to 7 days postoperatively. We also collected data on health system costs and operative complications (from physician billing codes). We used multilevel, multivariable regression to estimate adjusted associations between anesthesiology care - fee-for-service anesthesiology care (FFS), care from an anesthesiology care team (ACT), or no physician anesthesiologist care - and outcomes. Of 1 271 251 patients who underwent cataract surgery, 670 754 (52.8%) received FFS care, 256 760 (20.2%) received ACT care, and 343 737 (27.0%) had no physician anesthesiologist care. Adjusted analyses estimated slightly lower odds of the primary composite outcome for patients who received FFS care (n = 8682, 1.3%; adjusted odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88 to 0.99) or ACT care (n = 3034, 1.2%; adjusted OR 0.83, 95% CI 0.76 to 0.89) compared with those with no physician anesthesiologist care (n = 5056, 1.5%). Odds of operative complications were lower and overall costs were higher with any type of physician-provided anesthesiology care. Primary results differed by whether care was provided in a teaching or nonteaching hospital. Care provided or overseen by a physician anesthesiologist was associated with significantly lower odds of an emergency department visit, hospital admission, or death; however, effect sizes were small and of limited clinical importance, and costs were higher. Given these findings, the use of physician anesthesiology care for routine cataract surgery should be reconsidered. Open Science Framework identifier https://osf.io/9y3mt/overview.
Trauma is a leading cause of morbidity and mortality in the Kingdom of Morocco, where rapid socioeconomic development and the 2023 Al Haouz earthquake intensified demands on the health system. The American Association for the Surgery of Trauma was invited to visit the country to assess trauma care capacity and identify opportunities for system strengthening. A multidisciplinary delegation visited Morocco in November 2024. Meetings were held with the Ministry of Health in Rabat, and the delegation visited the Université Mohammed V de Rabat, Al Ghassani Hospital in Fes, and Mohammed VI University Hospital in Marrakech. Site visits and structured discussions with clinicians, administrators, and policymakers occurred. Findings were organized using a trauma prevention framework. Primary prevention challenges included road traffic injuries as the leading cause of injury death, inequities between urban and rural populations, and cultural barriers to blood and organ donation. Secondary prevention gaps centered on prehospital care, which is minimally equipped and relies on the French SAMU model of providing medical care in the field ("stay-and-play" model), fragmented trauma governance without a national authority, variation in hospital infrastructure, and absence of a trauma registry. Tertiary prevention weaknesses included workforce shortages, limited trauma-specific education, scarce rehabilitation and mental health services, and insufficient pediatric capacity. The 2023 earthquake highlighted both resilience-through central coordination and rapid mobilization of care to an exceedingly rural site-and a valuable opportunity to build on this foundation by formalizing a national trauma system response to enhance consistency and equity of care delivery. Morocco is at a pivotal moment in trauma system development. Addressing challenges across prevention levels offers opportunities to reduce preventable mortality and disability, improve equity, and strengthen preparedness. Lessons learned may inform national policy and provide insights for other low- and middle-income countries.
This study aimed to evaluate and compare perioperative outcomes of robotic versus laparoscopic cholecystectomy in patients with acute cholecystitis within an Acute Care Surgery setting. A retrospective cohort study was conducted including patients who underwent cholecystectomy for acute cholecystitis between January 1, 2023, and March 1, 2026. Patients were stratified by operative approach (robotic vs. laparoscopic). Baseline demographics, comorbidities, and postoperative outcomes were analyzed. Continuous variables were compared using Mann-Whitney U test, and categorical variables were assessed with Pearson χ². Statistical significance was defined as p < 0.05. A total of 322 patients were included, with 107 undergoing robotic and 215 laparoscopic cholecystectomies. Baseline characteristics were similar between groups. Median operative time did not differ significantly (78.0 [63.0-107.0] minutes robotic vs. 77.0 [60.0-95.0] minutes laparoscopic, p = 0.31). Conversion to open surgery occurred in one laparoscopic case (0.5%) and none in the robotic group. Length of hospital stay was comparable. Early postoperative complications were similar (10.3% robotic vs. 12.6% laparoscopic, p = 0.97), including comparable rates of severe (Clavien-Dindo III-IV) complications. Readmission and reintervention rates did not differ significantly. Two postoperative bile leaks occurred, one in each group. Subgroup analysis of gangrenous cholecystitis showed no significant differences in operative time, length of stay, or postoperative outcomes. Robotic cholecystectomy demonstrates comparable safety and efficacy to laparoscopic cholecystectomy for acute cholecystitis, including in severe cases, supporting its feasibility in acute care settings.
Colorectal cancer (CRC) is a leading cause of cancer mortality, and up to one-third of patients present with obstruction, perforation, or bleeding. Emergency presentation is associated with advanced stage, higher rates of open surgery and stoma formation, and worse survival. This review synthesizes current evidence and provides practical guidance for emergency and acute care management of CRC. We conducted a comprehensive search of MEDLINE and EMBASE for English-language studies from 2000 through July 2025, including randomized trials, meta-analyses, and cohort studies. Data were synthesized by members of the SAGES Colorectal and Acute Care Surgery Committees to identify consensus practices and safe strategies across resource settings. Contrast-enhanced CT is the diagnostic cornerstone; endoscopy adds diagnostic and therapeutic value when feasible. For right-sided cancers, oncologic right colectomy with primary anastomosis is generally safe in obstruction and selected perforations; diversion or staged surgery is preferred in unstable or contaminated fields. For left-sided obstruction, options include Hartmann's procedure, resection with primary anastomosis (± diversion), loop colostomy, or self-expandable metal stents (SEMS). SEMS provide effective decompression and enable minimally invasive interval resection with lower stoma rates when available. Perforation requires individualized strategies based on contamination; Hartmann's procedure and subtotal colectomy are commonly employed. In rectal cancer, emergency care should prioritize stabilization, decompression, biopsy, and facilitation of neoadjuvant therapy rather than immediate resection. Optimal emergency CRC care requires rapid diagnosis, oncologic principles, and individualized operative planning. Bridge-to-surgery strategies, selective diversion, and judicious use of minimally invasive techniques can reduce morbidity, expedite oncologic therapy, and improve outcomes.
Acute kidney injury (AKI) is a key contributor to multiorgan dysfunction and mortality in ruptured abdominal aortic aneurysm (rAAA). Intra-abdominal hypertension and abdominal compartment syndrome (ACS), complications potentially resulting in AKI, can be prevented or managed with open abdomen treatment (OAT). Using consensus-based definitions, this study characterizes AKI in rAAA patients managed with OAT and examines the impact of abdominal wall closure on renal function. A single-center observational cohort study including all consecutive patients treated with OAT after open surgical repair for rAAA from September 2009 to January 2024. AKI was diagnosed and staged based on urine output (UO) and S-creatinine (SCr) as defined by the KDIGO classification, reassessed at closure of the abdomen and at discharge. Seventy-three patients (mean age 73 years, 85% male) received OAT, prophylactically in 63 (85%) and due to ACS in 11 (15%). AKI occurred in 71 patients (97%) at a median of 2 (IQR, 2-3) days of admittance; 22 patients (30%) had stage 3 AKI, including 13 (18%) needing renal replacement therapy. The multivariable logistic regression showed SCr at admittance (p = .034) and perioperative diuresis (p = .018) as predictors of stage 3 AKI. The UO criterion diagnosed more patients than SCr alone (p = .001). Abdominal closure did not aggravate kidney function. In AKI stage 3, 90-day survival was 46% versus 80% in AKI stage 1 and 2 (p = .008). Forty-seven out of 51 survivors (92%) had resolution of their AKI before discharge. Defined by KDIGO, AKI developed in 71/73 (97%) of rAAA patients with OAT after surgical repair. UO was the most sensitive parameter. AKI was diagnosed at median 2 days of admittance and was transient in majority of survivors. There was no aggravation of kidney function at delayed primary abdominal closure.
Disparities in health care continue to affect marginalized populations in the United States, contributing to increased morbidity, mortality, and health care costs. Although disparities have been extensively studied in arthroplasty and spine surgery, there is limited understanding of how they manifest in orthopaedic trauma, where treatment is often emergent. Therefore, to explore associations between patient demographics and orthopaedic trauma care beyond the emergent timeframe, this study investigated timing to care in patients that required acute external fixation followed by staged definitive fixation. A retrospective review of trauma patients who underwent lower extremity external fixation at a level 1 trauma center from January 2014 to March 2024 was conducted. Data collected included patient sex, race, age, insurance, comorbidities, fracture type (open vs closed), and substance use. Key outcomes were days from admission to external fixation and from external fixation to open reduction internal fixation (ORIF). Negative binomial post hoc testing was used, with significance set at P <.05. A total of 129 patients met the inclusion criteria. There was a significant difference in timing to ORIF between genders (P = .034) but no significant difference in timing to ORIF between races (P = .093); no differences were seen in timing to external fixation. After post hoc analysis, only femur fractures showed a significant difference in timing spending 44% shorter time in external fixation (P = .03). These findings suggest that, following initial stabilization, gender may correlate with the timing of definitive fixation in orthopaedic trauma care. Identifying and addressing disparities is essential to reducing inequities in clinical outcomes and health care utilization. This study highlights the need for further research aimed at understanding and mitigating delays in treatment. Level III, retrospective data from single institution.
Despite widespread adoption and investment of resources nationally, the pediatric acute care cardiology (ACC) model of care has not been previously evaluated prospectively. To test the hypothesis that adoption of an ACC model will be associated with improved clinical outcomes. This single-center prospective quality improvement study was conducted in a 26-bed ACC unit of a high surgical volume, freestanding children's hospital. The baseline period was May 15 to October 31, 2023, and the intervention period was November 1, 2023, to November 30, 2024. All ACC unit encounters during the baseline and intervention periods were included. Data sources were hospital administrative data, local Pediatric Acute Care Cardiology Collaborative registry, and Patient and Family Experience (PFE) scores. Full-scale change in the model of care: transitioned unit leadership from hospital pediatrics to cardiology, changed attending of record for medical patients to cardiologist, hired nurse practitioners as frontline clinicians, integrated residents into the team, implemented multidisciplinary family-centered rounding, updated communication processes, and transitioned cardiology fellows to in-house overnight call. Complication rate and back transfer to the intensive care unit (ICU) were outcome measures, discharge time was a process measure, 7-day unplanned readmissions and length of stay (LOS) were balancing measures. Standard rules for identifying special cause variation (SCV) were applied. The percentage of patients and families with positive PFE scores (defined as scores of 9 or 10) before and after the intervention were compared using an independent t test. Hypothesis was formulated prior to data collection. There were 483 encounters (45.2% among children aged 1-18 years) in the baseline period and 973 (52.7% among children aged 1-18 years) in the intervention period. Outcome and process measures significantly improved showing SCV following adoption of the ACC model (mean complications: baseline, 23.6% vs intervention, 16.0%; mean back transfer to ICU: baseline, 11.4% vs intervention, 6.9%; mean patient discharge time: baseline, 15.37 hours vs intervention, 14.43 hours). LOS and 7-day unplanned readmissions were unchanged, suggesting no major inadvertent negative consequences of the ACC model. Mean LOS for medical patients decreased (7.83 vs 4.97 days). PFE improved after the intervention (median [SD], preintervention: 76.9% [3.7] vs postintervention: 82.9% [4.3]; P = .04). In this quality improvement study of an ACC model, multiple outcomes improved without evidence of negative consequences. These clinical improvements may justify necessary investment of resources to support ACC models. Adaptation of this model for other subspecialties may help address pediatric resident workforce changes. Ongoing evaluation of resource utilization, sustainability of improvement, and newly embedded improvement efforts is underway.
Orthopaedic trauma remains a major public health problem, particularly in rural India, where preventive strategies and trauma-care resources are often limited. This single‑centre descriptive observational study aimed to describe the epidemiological profile of orthopaedic trauma patients admitted to a major trauma centre in rural North India, with emphasis on age, sex, mechanism of injury, and pattern of skeletal involvement. This observational study included 2,340 consecutive patients of all ages admitted under orthopaedics with acute traumatic injuries after initial presentation to the emergency department between December 2022 and December 2024. Repeat admissions for the same injury episode were excluded, and polytrauma patients were included if they had at least one orthopaedic injury. Data were collected prospectively from patient interviews and direct observation, and supplemented by the hospital medical record system. Descriptive statistics were used to analyse the demographic characteristics, mechanisms of injury, injury types, and anatomical fracture sites; age‑group differences in selected injury categories were analysed using chi‑square tests. Out of 2,340 patients, the study population consisted of 1,760 (75.21%) male and 580 (24.79%) female patients. The most common age group was 20-29 years (480; 20.51%), followed by 30-39 years (419; 17.91%) and 10-19 years (390; 16.67%). Road traffic accidents were the leading mechanism of injury (1,242; 53.08%), followed by slip-and-fall on the ground (394; 16.84%) and falls from height (385; 16.45%). Other mechanisms included mechanical injury (98; 4.19%), hit by animal (88; 3.76%), assault (67; 2.86%), fall of heavy object (32; 1.37%), railway injury (18; 0.77%), and sports injury (16; 0.68%). Fractures were the most common injury type (2,182; 93.25%), followed by dislocations (80; 3.42%) and soft tissue injuries (78; 3.33%). Limb amputation/crush injury was recorded in 80 patients (3.42%). Single-bone involvement was seen in 2,006 patients (85.73%), while 176 (7.52%) had more than one fractured bone. Open fractures were 445 (19.02%) cases, and closed fractures were 1,737 (74.23%). The commonly involved anatomic sites included femur, distal radius, both-bone leg, ankle region, and foot. The number of recorded fracture sites exceeded the number of fracture patients because some patients had bilateral or multi-site injuries. In age-wise analysis, dislocations were most frequent in the 20-39-year group, while limb amputation/crush injuries and open fractures were most common in the 40-59-year group. There was no significant overall association between age group and selected injury categories. Most patients of orthopaedic trauma in rural North India are young adult males, most commonly injured in road traffic accidents. Fractures remain the leading injury pattern, with the femur and distal radius among the most commonly involved sites. Preventive strategies should focus on road safety, occupational protection, and strengthening trauma-care services.
Decompressive craniectomy has been widely evaluated across heterogeneous types of brain injury but its effect in patients with large acute epidural haematoma complicated by tentorial herniation remains unclear. We aimed to assess whether decompressive craniectomy improves functional and safety outcomes compared with standard craniotomy in this patient group. The Prospective Randomised Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Haematoma (PREDICT-AEDH) trial was a nationwide, multicentre, open-label, parallel-group, randomised controlled trial conducted at 28 hospitals in China. Adults aged 18-65 years with clinical signs of transtentorial herniation, CT-confirmed large acute epidural haematoma, and obliterated ambient cistern within 12 h of injury were randomly assigned (1:1) to primary decompressive craniectomy or standard craniotomy with bone-flap replacement, using a secure, central, web-based randomisation system with block sizes of four. Although masking of patients and surgeons was not feasible, all assessments and analyses were done by masked investigators. The primary outcome was functional status at 6 months in all randomised patients according to intention to treat (ITT), assessed using the Glasgow Outcome Scale-Extended (GOSE) and analysed with a proportional-odds model. No imputation for missing outcome data was done since no participants were lost to follow-up. Safety outcomes were assessed in the ITT population. The trial is registered with ClinicalTrials.gov (NCT04261673) and is complete. Between Sept 7, 2020, and March 14, 2025, 142 patients were screened for eligibility, of whom 120 patients (15 [12%] females and 105 [88%] males) were randomly assigned to decompressive craniectomy (n=58) or standard craniotomy (n=62). One patient assigned to the decompressive craniectomy group received craniotomy and ten patients assigned to craniotomy received decompressive craniectomy. At 6 months, a favourable functional outcome (GOSE ≥5) occurred in 46 (79%) of 58 patients assigned to decompressive craniectomy and 52 (84%) of 62 patients assigned to standard craniotomy. Ordinal analysis of GOSE failed to show a significant difference between groups (common OR 0·79 [0·41-1·58]; p=0·51). Rates were similar between the decompressive craniectomy and standard craniotomy groups for 30-day mortality (five [9%] of 58 patients vs three [5%] of 62 patients) and postoperative cerebral infarction (11 [19%] vs 11 [18%]). Delayed intracranial haemorrhage occurred more frequently after decompressive craniectomy (21 [36%] of 58 patients) than after standard craniotomy (eight [13%] of 62 patients; OR 3·79, 95% CI 1·43-11·00; p=0·0049). In patients with large acute epidural haematoma and tentorial herniation, decompressive craniectomy did not improve 6-month functional outcomes compared with standard craniotomy and increased the risk of delayed intracranial haemorrhage. These findings therefore do not support routine prophylactic decompressive craniectomy in this population. None.
US Navy general surgeons deployed on naval warships routinely provide a wide spectrum of surgical care-a vastly different experience compared with military and civilian hospitals. The Maritime Surgical Quality Improvement Program gathers and analyzes case log data; however, no specific clinical practice guidelines exist for deployed naval surgeons and their chains of command. We sought to close this gap by seeking the consensus of experienced maritime surgeons. A modified Delphi method with three rounds was used. A cohort of physician leaders and surgeons with warship deployment experience was asked to state their level of agreement for statements involving elective and emergency surgical care using a 5-point Likert scale. In the first two rounds, open-ended comments were used to generate additional clarifying statements. Consensus was defined as 70% of respondents answering strongly agree/agree or strongly disagree/disagree. Statements not reaching consensus were repeated in subsequent rounds. Of 91 participants, 90% were surgeons. Across all rounds, a final list of 76 statements was evaluated; 58 (76%) reached consensus. Of these, 52 (90%) had a strong agreement between respondents based on median Likert scores with narrow interquartile ranges. There was broad consensus on the management of urgent/emergent conditions and on nongeneral surgery and systems factors, but less consensus on the elective management of surgical conditions. A consensus regarding the management of surgical conditions was reached for many disease processes. Despite the varied strength of that consensus, this is an important first step to developing guidance for surgery at sea aboard a naval warship. The iterative nature of the process elucidated situational nuances within specific disease processes, increasing its applicability. These statements will be used to create a comprehensive, expeditionary surgery at sea guidelines ("SeaPG"), aiding surgeons and their chains of command in ensuring a safe, reasonable approach to expeditionary surgery at sea. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Therapeutic Care Management; Level V.
Trauma remains a leading cause of death globally, with the greatest burden borne by low- and middle-income countries (LMICs), where prehospital systems are often underdeveloped, fragmented, or constrained by insecurity. In these settings, injured patients frequently reach care through informal pathways, and police officers commonly function as de facto first responders-providing initial assistance, coordinating evacuation, and, in some cases, directly transporting patients to hospitals. Despite their central role, police involvement in trauma care is rarely formalized or integrated into trauma system frameworks. Evidence from LMICs shows that police and other lay responders often lack formal training in trauma first aid, yet targeted, low-cost training programs can significantly improve knowledge, confidence, and willingness to provide care. In parallel, increasing violence and insecurity-such as in the Western Cape, South Africa-have further embedded police within prehospital care pathways. This article argues that the key limitation is not the absence of responders, but the absence of systems that define, train, equip, and govern their roles. We propose a pragmatic, scalable framework for integrating police into LMIC trauma systems, emphasizing defined roles, competency-based training, essential equipment, governance, and data integration to improve early trauma care and system resilience.
Recurrent acute rhinosinusitis (RARS) decreases quality of life. The effects of endoscopic sinus surgery (ESS) in RARS are understudied. To compare the quality of life between patients with RARS who had surgery and medical treatment vs medical treatment alone. This is an open-label randomized clinical trial with 2 parallel groups with a 6-month follow-up. Patients referred to Oulu University Hospital Otolaryngology Clinic between May 2020 and June 2024 were recruited to participate in the trial. Inclusion criteria were adults with physician-diagnosed RARS episodes occurring at least 3 times during the past 6 months, 4 times during the past year, or twice per year for 3 consecutive years. Conservative treatment had been insufficient for symptom relief. Data collection and analyses were planned before commencing recruitment. Data collection was performed from May 2020 to December 2024, and analysis from January 2025 to January 2026. The operative group received ESS and medical treatment, and the conservative group received medical treatment alone. The main outcome was the difference between groups in mean SinoNasal Outcome Test 22 (SNOT-22) score change from baseline to a 6-month follow-up. The SNOT-22 questionnaire measures rhinosinusitis-related quality of life. Sinonasal symptoms, number of health care visits, antibiotic courses, absences from work or study, and the adverse effects of operative treatment were also studied. A total of 59 patients (mean [SD] age, 40 [14] years; 52 women [88%]) were recruited, 30 in the operative and 29 in the conservative group. Intention-to-treat analysis of the primary outcomes was performed. The mean SNOT-22 score change from baseline to 6 months was greater after ESS compared to medical treatment only (difference, 22.41 points (95% CI, 13.67-31.10 points). Per-protocol analyses of secondary outcomes supported the primary findings for the most part. Only 4 patients received intervention for an operative complication (3 infections, 1 synechia with septal perforation). In this randomized clinical trial, ESS improved patient-related outcomes at a 6-month follow-up in adults with RARS. Conservative treatment had no clinically meaningful effect. These results suggest that ESS is an effective treatment without major problems. ClinicalTrials.gov Identifier: NCT04241016.
Acute appendicitis is the leading cause of acute abdomen in young adults, typically managed by appendectomy. A growing body of evidence supports non-operative management as an alternative for uncomplicated cases. This study aimed to compare the effectiveness of non-operative management (NOM) versus operative management (OM) for uncomplicated acute appendicitis. A prospective, longitudinal, randomized controlled trial was conducted at Connaught Hospital, Sierra Leone. Sixty patients were randomized: 30 to NOM and 30 to OM. NOM patients received intravenous metronidazole and ceftriaxone for 48 h, followed by oral metronidazole and ciprofloxacin for 5 days. OM patients underwent open appendectomy. NOM patients were monitored for symptom resolution or progression; failure required appendectomy. Both groups were followed up on days 7, 10, 30, 60, and 90 post-admissions to assess recurrence, cost of care, and quality of life (QoL). The median age was 26 years (IQR 14-42) for NOM and 27 years (IQR 18-54) for OM. Most patients were males (NOM: 66.7%, OM: 63.3%). Antibiotic treatment was successful in 18 (60%) NOM patients. Failure occurred in 12 (40%) NOM patients, 11 during the index admission, with 1 (3.3%) experiencing recurrence within a week of discharge. Successful NOM resulted in a significantly improved QoL score (5.98), a shorter mean hospital stays (4 days), a lower mean cost of care (NLe 482.29; $49.08), and no catastrophic health expenditure, compared to both OM and failed NOM. Statistically significant differences were observed in favor of successful NOM over surgery (including OM and failed NOM requiring surgery) for the cost of care and time to return to normal activities. NOM for uncomplicated acute appendicitis achieved a 60% success rate with a low recurrence rate (3.3%). It is associated with lower costs, reduced risk of catastrophic health expenditure, shorter hospital stays, faster return to normal activities, and improved QoL compared to operative management. The Pan African Clinical Trials Registry (PACTR). PACTR202605655002550. Date of registration:20th April 2026. "Retrospectively registered".
Despite significant advances in angiosurgery, the treatment of acute limb ischemia remains a challenging clinical problem. Historically, the mainstay of therapy consisted of open thrombectomy and bypass surgery, later supplemented by selective thrombolysis and percutaneous angioplasty techniques. However, even with these approaches, there remains a high risk of adverse outcomes, including amputations and mortality. A breakthrough in the treatment of occlusive-stenotic lesions in the femoropopliteal segment has been the advent of modern endovascular technologies. Numerous studies confirm their clinical efficacy and promise in acute ischemia. Particular importance has been given to a multidisciplinary approach combining advancements in vascular surgery, interventional radiology, and intensive care. Among innovative methods, rotational atherectomy deserves special attention as a technology demonstrating excellent results in treating acute occlusions of the femoropopliteal zone. The article presents clinical cases of successful treatment of femoral-popliteal lesions in acute ischemia of the lower extremities using rotational atherectomy devices.
Mucoactive agents are widely used in patients with acute respiratory failure despite limited evidence of their effectiveness or safety. We conducted a multicenter, open-label, randomized trial with a 2-by-2 factorial design that involved critically ill, mechanically ventilated participants 16 years of age or older with acute respiratory failure and difficult-to-clear secretions. All participants received usual care along with carbocisteine (750 mg three times daily enterally), 6% or 7% nebulized hypertonic saline (HTS) (4 ml four times daily), both interventions, or usual care alone for up to 28 days. The primary outcome was duration of mechanical ventilation (from randomization to first successful unassisted breathing). The primary comparisons were between any carbocisteine and no carbocisteine and between any HTS and no HTS, with each comparison comprising two treatment groups. A total of 1956 participants underwent randomization: 486 were assigned to carbocisteine, 485 to HTS, 492 to both treatments, and 493 to usual care alone (472, 474, 479, and 478, respectively, were included in the primary analysis). No evidence of treatment interaction was found (hazard ratio, 1.01, 95% confidence interval [CI], 0.83 to 1.22; P = 0.91). The median duration of mechanical ventilation was 186.1 hours (95% CI, 168.3 to 196.6) with carbocisteine and 172.7 hours (95% CI, 165.2 to 190.4) with no carbocisteine (adjusted hazard ratio, 0.96; 95% CI, 0.87 to 1.05; P = 0.34) and 184.5 hours (95% CI, 165.6 to 194.1) with HTS and 174.3 hours (95% CI, 166.9 to 192.7) with no HTS (adjusted hazard ratio, 1.00; 95% CI, 0.91 to 1.10; P = 0.98). Clinically important upper gastrointestinal bleeding occurred significantly more often with carbocisteine than with no carbocisteine (13 of 965 [1.4%] vs. 2 of 966 [0.2%]; risk ratio, 6.51; 95% CI, 1.47 to 28.76; P = 0.01). Bronchoconstriction leading to bronchodilator use occurred significantly more often with HTS than with no HTS (23 of 967 [2.4%] vs. 4 of 964 [0.4%]; risk ratio, 5.73; 95% CI, 1.99 to 16.52; P = 0.001), as did hypoxemia during nebulization (40 of 967 [4.1%] vs. 3 of 964 [0.3%]; risk ratio, 13.29; 95% CI, 4.12 to 42.83; P<0.001). One serious adverse reaction was reported in the combination group. Among critically ill patients with acute respiratory failure, neither carbocisteine nor HTS significantly reduced the duration of mechanical ventilation, and each was associated with harm. (Funded by the NIHR Health Technology Assessment Programme and the Belfast Health and Social Care Trust Charitable Trust Fund; MARCH ISRCTN Registry number, ISRCTN17683568.).
Pre-operative anxiety is present in most day surgery patients and is associated with increased postoperative pain. However, most anaesthetists do not objectively evaluate pre-operative anxiety. Both Surgical Fear Questionnaire (SFQ) and Anxiety Numeric Rating Scale (ANRS) are tools that can be used for standardised anxiety assessment. To compare the SFQ and ANRS in assessing pre-operative anxiety and predicting postoperative pain; to identify predictive factors for high pre-operative anxiety. Secondary analysis of a multicentre prospective observational study. Three Portuguese ambulatory surgery units.PATIENTS Two hundred and ninety-six patients underwent open inguinal hernia repair between September 2018 and March 2020. Patients were assessed for pre-operative anxiety using the SFQ and ANRS before surgery. Postoperative evaluations were conducted at 24 h, 7 days, 3 months and 1 year. Pre-operative anxiety and postoperative pain, Global Surgery Recovery Index and patient satisfaction. Two hundred and fifty-four patients completed the 12-month follow-up, with 260 men and 31 women analysed. The mean pre-operative SFQ score was 21.6 ± 15.8, with cutoffs of 20/24 for predicting acute/chronic pain. The mean pre-operative ANRS score was 3.7 ± 2.5, with an optimal cutoff of 4. Patients with SFQ at least 21 had worse postoperative outcomes at all time points (P < 0.03). The SFQ could predict pain at least 4 at all analysed time points while the ANRS could only predict pain 1 year after surgery. Independent predictors of high pre-operative anxiety included younger age, female sex, BMI less than 30 and pre-operative pain score at least 4. Pre-operative anxiety evaluation allows for the identification of patients at a high risk for postoperative complications. Both instruments demonstrated some ability to predict postoperative pain and might be valuable in the pre-operative setting, with the SFQ showing better performance. NCT03499730.
Emergency abdominal surgeries comprise most of emergencies and are high-risk procedures owing to their urgency and the limited time for optimization of comorbidities. Enhanced recovery after surgery (ERAS) protocols, in an adapted form, can potentially improve patient outcomes in emergency settings. The present study aimed to evaluate the safety, efficacy, and feasibility of adapted ERAS protocols in emergency abdominal operations. This open-label, single-center, superiority, randomized controlled trial was conducted over 18 months. Patients with acute abdomen planned for surgery were randomized preoperatively to an adapted ERAS or standard care group in a 1:1 ratio. Patients with refractory shock, coagulopathy, age < 18 years, American Society of Anesthesiologists class 4E, polytrauma, and pregnancy were excluded. The primary outcome was the length of hospitalization (LOH), whereas the secondary outcomes were functional recovery parameters and 30-day morbidity and mortality. A total of 50 patients were analyzed in each group, showing comparable demographic and clinicopathological characteristics. The adapted ERAS group had a 6-day shorter LOH (10 [7-17] vs 16 [11-22] days, P <.001); early functional recovery in terms of reduction in time (in days) to first flatus (2.48 vs 3.14, P =.001), start of solid diet (3 vs 4, P =.035), and first stool (4 vs 5, P =.001); and a reduction in pulmonary complications (risk ratio [RR] = 0.47, P =.011). Postoperative nausea and vomiting (RR = 0.62, P =.372), surgical site infections (RR = 0.73, P =.067), and urinary tract infections (RR = 0.25, P =.092) were similar in both groups. Adapted ERAS pathways are safe and feasible and reduce the LOH in patients undergoing emergency abdominal operations.
Stanford type A aortic dissection (TAAD) remains associated with substantial mortality despite prompt surgical repair. Glucose variability has been associated with mortality in intensive care unit (ICU) patients. However, its clinical significance after open TAAD repair remains unclear. We conducted a retrospective cohort study using the MIMIC-IV v3.1 database (2008-2022). Glucose variability was assessed using the coefficient of variation (%CV) of blood glucose measurements within the first 3 days of postoperative ICU admission. Associations between 3-day postoperative %CV and outcomes were evaluated using Kaplan-Meier (K-M) analysis, Cox proportional hazards (PH) models, and restricted cubic spline (RCS) analyses. A total of 201 adult survivors of TAAD open repair surgery who were subsequently admitted to the ICU were included in the study. In the fully adjusted model, each 1-standard deviation (SD) increase in the 3-day postoperative %CV was independently associated with higher ICU mortality (adjusted hazard ratio [aHR] = 1.820, 95% confidence interval [CI]: 1.239-2.675, p = 0.0023) and all-cause in-hospital mortality (aHR = 1.627, 95% CI: 1.134-2.334, p = 0.0082). RCS analyses showed a positive association between the 3-day postoperative %CV and each outcome, consistent with an approximately linear pattern. In addition, the 3-day postoperative %CV showed stronger discriminatory ability for both outcomes than the 3-day mean and median glucose levels. Higher 3-day postoperative glucose variability was independently associated with increased all-cause ICU mortality and in-hospital mortality after open TAAD repair. Postoperative glucose variability may reflect postoperative physiological instability in this high-risk population.
Although trauma clinical guidance has the potential to improve patient outcomes significantly, it is applied inconsistently across the USA today. Work is needed to improve guidance application among those who treat traumatic injury, including emergency medicine (EM) clinicians. A priority step of such improvement is the visual design of clinical directives, as it can markedly influence EM clinicians' satisfaction and subsequent usage of guidance. This qualitative study aims to analyze EM clinicians' needs and preferences for the visual design of trauma clinical guidance. As part of a larger exploratory sequential mixed-methods study exploring trauma clinical guidance barriers and facilitators, we conducted semistructured video conference interviews during August and September 2024 with EM clinicians. Participants were selected through purposeful criteria and snowball sampling to ensure diverse representation across professional and personal characteristics. Interviews were audio recorded and analyzed through rapid qualitative content analysis. 12 EM clinicians completed interviews, providing feedback on their preferences for the visual design of trauma clinical guidance. Clinicians emphasized the need for simple guidance that can be easily used in a time-pressured setting. Dynamic features such as expandable or "clickable" content can provide deeper explanations of guidance concepts without compromising usability. Flowsheets and visual aids can clarify guidance recommendations. Clinicians asked that recommendations be specific and action-oriented. When designing trauma clinical guidance, authors should promote visual design characteristics that prioritize simplicity, dynamic features, visual aids, and specificity. Level III.