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Outcomes of Patients With Traumatic Brain Injury Transferred to Trauma Centers. 转至创伤中心的创伤性脑损伤患者的疗效。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3254
Sai Krishna Bhogadi, Collin Stewart, Hamidreza Hosseinpour, Adam Nelson, Michael Ditillo, Marc R Matthews, Louis J Magnotti, Bellal Joseph

Importance: Wide variations exist in traumatic brain injury (TBI) management strategies and transfer guidelines across the country.

Objective: To assess the outcomes of patients with TBI transferred to the American College of Surgeons (ACS) level I (LI) or level II (LII) trauma centers (TCs) on a nationwide scale.

Design, setting, and participants: In this secondary analysis of the ACS Trauma Quality Improvement Program database (2017 to 2020), adult patients with isolated TBI (nonhead abbreviated injury scale = 0) with intracranial hemorrhage (ICH) who were transferred to LI/LII TCs we re included. Data were analyzed from January 1, 2017, through December 31, 2020.

Main outcomes and measures: Outcomes were rates of head computed tomography scans, neurosurgical interventions (cerebral monitors, craniotomy/craniectomy), hospital length of stay, and mortality. Descriptive statistics and hierarchical mixed-model regression analyses were performed.

Results: Of 117 651 patients with TBI with ICH managed at LI/LII TCs 53 108; (45.1%; 95% CI, 44.8%-45.4%) transferred from other centers were identified. The mean (SD) age was 61 (22) years and 30 692 were male (58%). The median (IQR) Glasgow Coma Scale score on arrival was 15 (14-15); 5272 patients had a Glasgow Coma Scale score of 8 or less on arrival at the receiving trauma center (10%). A total of 30 973 patients underwent head CT scans (58%) and 2144 underwent repeat head CT scans at the receiving TC (4%). There were 2124 patients who received cerebral monitors (4%), 6862 underwent craniotomy/craniectomy (13%), and 7487 received mechanical ventilation (14%). The median (IQR) hospital length of stay was 2 (1-5) days and the mortality rate was 6.5%. There were 9005 patients (17%) who were discharged within 24 hours and 19 421 (37%) who were discharged within 48 hours of admission without undergoing any neurosurgical intervention. Wide variations between and within trauma centers in terms of outcomes were observed in mixed-model analysis.

Conclusions: In this study, nearly half of the patients with TBI managed at LI/LII TCs were transferred from lower-level hospitals. Over one-third of these transferred patients were discharged within 48 hours without any interventions. These findings indicate the need for systemwide guidelines to improve health care resource use and guide triage of patients with TBI.

重要性:全国各地的创伤性脑损伤(TBI)管理策略和转院指南存在很大差异:评估全国范围内转入美国外科学院(ACS)一级(LI)或二级(LII)创伤中心(TC)的创伤性脑损伤患者的治疗效果:在这项对ACS创伤质量改进计划数据库(2017年至2020年)的二次分析中,我们纳入了转入LI/LII级创伤中心(TC)的伴有颅内出血(ICH)的孤立性创伤性脑损伤(非头部简略损伤量表=0)成人患者。数据分析时间为2017年1月1日至2020年12月31日:主要结果和测量指标:头部计算机断层扫描率、神经外科干预率(脑监测仪、开颅手术/颅骨切除术)、住院时间和死亡率。研究人员进行了描述性统计和分层混合模型回归分析:在117 651名在LI/LII TC接受治疗的TBI合并ICH患者中,有53 108人(45.1%;95% CI,44.8%-45.4%)是从其他中心转来的。平均(标清)年龄为61(22)岁,男性30 692人(58%)。到达时格拉斯哥昏迷量表评分的中位数(IQR)为15(14-15);5272名患者到达接收创伤中心时格拉斯哥昏迷量表评分为8分或以下(10%)。共有 30 973 名患者接受了头部 CT 扫描(58%),2144 名患者在接收创伤中心重复接受了头部 CT 扫描(4%)。有 2124 名患者接受了大脑监护仪(4%),6862 名患者接受了开颅/颅骨切除术(13%),7487 名患者接受了机械通气(14%)。住院时间中位数(IQR)为 2(1-5)天,死亡率为 6.5%。有 9005 名患者(17%)在入院 24 小时内出院,有 19 421 名患者(37%)在入院 48 小时内出院,未接受任何神经外科干预。在混合模型分析中观察到,不同创伤中心之间以及创伤中心内部的结果差异很大:在这项研究中,近一半在LI/LII TCs接受治疗的创伤性脑损伤患者是从下级医院转来的。超过三分之一的转院患者在 48 小时内出院,未采取任何干预措施。这些研究结果表明,有必要制定全系统指南,以改善医疗资源的使用并指导创伤性脑损伤患者的分流。
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引用次数: 0
JAMA Surgery. JAMA Surgery.
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2023.5177
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引用次数: 0
Fresh Frozen Plasma to Red Blood Cell Ratios and Survival Benefit. 新鲜冷冻血浆与红细胞的比率与生存益处
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3110
Jason L Sperry, Christine M Leeper, Joshua Brown
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引用次数: 0
High Fresh Frozen Plasma to Red Blood Cell Ratio and Survival Outcomes in Blunt Trauma. 新鲜冷冻血浆与红细胞的高比率与钝性创伤患者的生存结果
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3097
Gaku Fujiwara, Yohei Okada, Wataru Ishii, Tadashi Echigo, Naoto Shiomi, Shigeru Ohtsuru

Importance: Current trauma-care protocols advocate early administration of fresh frozen plasma (FFP) in a ratio close to 1:1 with red blood cells (RBCs) to manage trauma-induced coagulopathy in patients with severe blunt trauma. However, the benefits of a higher FFP to RBC ratio have not yet been established.

Objective: To investigate the effectiveness of a high FFP to RBC transfusion ratio in the treatment of severe blunt trauma and explore the nonlinear relationship between the ratio of blood products used and patient outcomes.

Design, setting, and participants: This was a multicenter cohort study retrospectively analyzing data from the Japan Trauma Data Bank, including adult patients with severe blunt trauma without severe head injury (Injury Severity Score ≥16 and head Abbreviated Injury Scale <3) between 2019 and 2022.

Exposures: Patients were categorized into 2 groups based on the ratio of FFP to RBC: the high-FFP group (ratio >1) and the low-FFP group (ratio ≤1).

Main outcomes and measures: All-cause in-hospital mortality was the primary outcome. Additionally, the occurrence of transfusion-related adverse events was evaluated.

Results: Among the 1954 patients (median [IQR] age, 61 [41-77] years; 1243 male [63.6%]) analyzed, 976 (49.9%) had a high FFP to RBC ratio. Results from logistic regression, weighted by inverse probability treatment weighting, demonstrated an association between the group with a high-FFP ratio and lower in-hospital mortality (odds ratio, 0.73; 95% CI, 0.56-0.93) compared with a low-FFP ratio. Nonlinear trends were noted, suggesting a potential ceiling effect on transfusion benefits.

Conclusions and relevance: In this cohort study, a high FFP to RBC ratio was associated with favorable survival in patients with severe blunt trauma. These outcomes highlight the importance of revising the current transfusion protocols to incorporate a high FFP to RBC ratio, warranting further research on optimal patient treatment.

重要性:目前的创伤护理方案主张尽早使用新鲜冰冻血浆(FFP),与红细胞(RBC)的比例接近 1:1,以控制严重钝性创伤患者因创伤引起的凝血功能障碍。然而,提高 FFP 与红细胞比例的益处尚未得到证实:研究高FFP与RBC输血比例在治疗严重钝性创伤中的有效性,并探索血液制品使用比例与患者预后之间的非线性关系:这是一项多中心队列研究,对日本创伤数据库的数据进行回顾性分析,研究对象包括严重钝性创伤但无严重头部损伤(损伤严重程度评分≥16分,头部简略损伤量表暴露)的成年患者:根据FFP与RBC的比例将患者分为两组:高FFP组(比例>1)和低FFP组(比例≤1):主要结果和测量指标:主要结果是全因住院死亡率。此外,还评估了输血相关不良事件的发生率:在分析的1954名患者(中位数[IQR]年龄,61[41-77]岁;1243名男性[63.6%])中,976名患者(49.9%)的FFP与RBC比率较高。通过反概率治疗加权的逻辑回归结果显示,与低 FFP 比率相比,高 FFP 比率组与较低的院内死亡率之间存在关联(几率比 0.73;95% CI,0.56-0.93)。非线性趋势表明输血效益可能存在上限效应:在这项队列研究中,FFP与RBC的高比率与严重钝性创伤患者的良好存活率相关。这些结果凸显了修订现行输血方案以纳入高 FFP 与 RBC 比值的重要性,因此有必要对患者的最佳治疗方法进行进一步研究。
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引用次数: 0
Admission and Patients Undergoing Surgery at Risk of Patient-Directed Discharges. 入院和接受手术的患者面临患者自主出院的风险。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.2565
Hannah C Decker, Amy Shui, Hemal K Kanzaria, Logan Pierce, Elizabeth Wick
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引用次数: 0
Counseling Intervention and Cardiovascular Events in People With Peripheral Artery Disease: A Post Hoc Analysis of the BIP Randomized Clinical Trial. 咨询干预与外周动脉疾病患者的心血管事件:BIP 随机临床试验的事后分析。
IF 2.9 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3083
Jonathan Golledge, Alkira Venn, Lisan Yip, Anthony S Leicht, Jason S Jenkins, Maria A Fiatarone Singh, Christopher M Reid, Belinda J Parmenter, Nicola W Burton, Joseph V Moxon
<p><strong>Importance: </strong>It is unclear whether counseling to promote walking reduces the risk of major adverse cardiovascular events (MACE) in people with peripheral artery disease (PAD).</p><p><strong>Objective: </strong>To test whether a counseling intervention designed to increase walking reduced the risk of MACE in patients with PAD.</p><p><strong>Design, setting, and participants: </strong>The BIP trial was a randomized clinical trial, with recruitment performed between January 2015 and July 2018 and follow-up concluded in August 2023. Participants with walking impairment due to PAD from vascular departments in the Australian cities of Brisbane, Sydney, and Townsville were randomly allocated 1:1 to the intervention or control group. Data were originally analyzed in March 2024.</p><p><strong>Intervention: </strong>Four brief counseling sessions aimed to help patients with the challenges of increasing physical activity.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was the between-group difference in risk of MACE, which included myocardial infarction (MI), stroke, and cardiovascular death. The relationship between Intermittent Claudication Questionnaire (ICQ) scores, PAD Quality of Life (PADQOL) scores, and MACE was examined with Cox proportional hazard regression analyses.</p><p><strong>Results: </strong>A total of 200 participants were included, with 102 allocated to the counseling intervention (51.0%) and 98 to the control group (49.0%).Participants were followed up for a mean (SD) duration of 3.5 (2.6) years. Median (IQR) participant age was 70 (63-76) years, and 56 of 200 participants (28.0%) were female. A total of 31 individuals had a MACE (composed of 19 MIs, 4 strokes, and 8 cardiovascular deaths). Participants allocated to the intervention were significantly less likely to have a MACE than participants in the control group (10 of 102 participants [9.8%] vs 21 of 98 [21.4%]; hazard ratio [HR], 0.43; 95% CI, 0.20-0.91; P = .03). Greater disease-specific quality of life (QOL) scores at 4 months (ICQ: HR per 1-percentage point increase, 0.97; 95% CI, 0.95-0.99; P < .001; PADQOL factor 3 [symptoms and limitations in physical functioning]: HR per 1-unit increase, 0.91; 95% CI, 0.84-0.98; P = .01) and at 12 months (ICQ: HR per 1-percentage point increase, 0.97; 95% CI, 0.95-0.99; P = .003; PADQOL factor 3: HR per 1-unit increase, 0.91; 95% CI, 0.84-0.98; P = .02) were associated with a lower risk of MACE. In analyses adjusted for ICQ or PADQOL factor 3 scores at either 4 or 12 months, allocation to the counseling intervention was no longer significantly associated with a lower risk of MACE.</p><p><strong>Conclusions and relevance: </strong>This post hoc exploratory analysis of the BIP randomized clinical trial suggested that the brief counseling intervention designed to increase walking may reduce the risk of MACE, possibly due to improvement in QOL.</p><p><strong>Trial registration: </strong>anzctr.org.au Id
重要性:外周动脉疾病(PAD)患者通过咨询促进步行是否能降低发生重大不良心血管事件(MACE)的风险,目前尚不清楚:检验旨在增加步行的咨询干预是否能降低 PAD 患者的 MACE 风险:BIP试验是一项随机临床试验,招募时间为2015年1月至2018年7月,随访于2023年8月结束。来自澳大利亚布里斯班、悉尼和汤斯维尔等城市血管科的因PAD导致行走障碍的参与者被1:1随机分配到干预组或对照组。最初于2024年3月对数据进行分析:主要结果和测量指标:主要结果和测量指标:主要结果是MACE风险的组间差异,MACE包括心肌梗死(MI)、中风和心血管死亡。间歇性跛行问卷(ICQ)评分、PAD生活质量(PADQOL)评分与MACE之间的关系通过Cox比例危险回归分析进行检验:共纳入 200 名参与者,其中 102 人被分配到咨询干预组(51.0%),98 人被分配到对照组(49.0%)。参与者年龄的中位数(IQR)为 70(63-76)岁,200 名参与者中有 56 人(28.0%)为女性。共有 31 人发生 MACE(包括 19 例心肌梗死、4 例脑卒中和 8 例心血管死亡)。与对照组的参与者相比,接受干预的参与者发生 MACE 的几率明显较低(102 名参与者中的 10 人 [9.8%] 与 98 名参与者中的 21 人 [21.4%];危险比 [HR],0.43;95% CI,0.20-0.91;P = .03)。4 个月时疾病特异性生活质量(QOL)评分更高(ICQ:每增加 1 个百分点的 HR 为 0.97;95% CI 为 0.95-0.99;P 结论和意义:这项对 BIP 随机临床试验的事后探索性分析表明,旨在增加步行次数的简短咨询干预可能会降低 MACE 风险,这可能是由于 QOL 得到了改善。试验注册:anzctr.org.au Identifier:ACTRN12614000592640。
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引用次数: 0
Facilitating and Assessing the Benefits of Mentorship in Academic Medicine. 促进和评估学术医学中导师制的益处。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3397
Bruce L Gewertz, Michael Nurok
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引用次数: 0
Mechanical Bowel Preparation and Oral Antibiotics Prior to Rectal Resection. 直肠切除术前的机械肠道准备和口服抗生素。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.2989
Jing Yi Kwan, Giordano Perin, Sabapathy Balasubramanian
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引用次数: 0
There Are Enough Qualified Women-Intentionality Overcomes Implicit Bias. 有足够多的合格女性--意向性克服了隐性偏见。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3347
Melina R Kibbe
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引用次数: 0
Robotic or Laparoscopic Cholecystectomy-Safety First. 机器人或腹腔镜胆囊切除术--安全第一。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 DOI: 10.1001/jamasurg.2024.3765
Karem Slim, Michel Canis
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引用次数: 0
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JAMA surgery
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