Journal of Surgical Research最新文献_第4页

Trends in Contralateral Prophylactic Mastectomies Before and After the American Society of Breast Surgeons Consensus Statement 美国乳腺外科医生学会共识声明前后对侧预防性乳房切除术的趋势。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-19 DOI: 10.1016/j.jss.2024.09.071

Introduction

In 2016, an American Society of Breast Surgeons (ASBrS) statement discouraged contralateral prophylactic mastectomy (CPM) in average-risk women with unilateral breast cancer. Despite evidence of no oncologic benefit and related attempts to discourage the practice, CPM remains prevalent. This study aims to assess CPM trends post-ASBrS statement and factors associated with these trends.

Methods

A retrospective cohort study of patients with primary unilateral breast cancer undergoing complete mastectomy at a single-tertiary center between January 2014 and December 2020 was performed. We assessed the proportion opting for CPM, compared pre- and post-ASBrS statement CPM rates, and examined associated patient and tumor factors. Pearson's Chi-square test, Fisher's exact test, and equal variance t-tests were used to compare subsets who underwent CPM versus those who did not.

Results

Of 605 patients, 161 (27%) underwent CPM during our study period, with the median follow-up time for all patients being 58 mo (IQR: 38 to 81). Among all patients, CPM rates ranged from 30% to 14% before the ASBrS statement and then declined from 36% to 19% after the statement. For average-risk patients (no genetic mutation), these rates ranged from 20.2% to 10.2% from 2014 to 2016 and had a steady decline from 23.2% in 2017 to 13.2% in 2020. Only two cases (1.2%) had incidental contralateral breast cancer. Patients undergoing CPM tended to be younger, more likely to have a breast cancer gene mutation, pursue reconstruction, and elect for nipple- or skin-sparing mastectomy. Recurrence and mortality events did not differ significantly. Genetic testing and pathogenic variant rates were greater among CPM patients.

Conclusions

After an initial time lag, CPM rates appear to be decreasing post-ASBrS statement, with ongoing data needed to confirm this trend. CPM rates among breast cancer gene patients align appropriately with guidelines catering to this higher risk population. Better educational tools and decision aids may impact CPM trends and facilitate shared decision-making.

导言：2016 年，美国乳腺外科医生学会（ASBrS）发表声明，不鼓励对患单侧乳腺癌的一般风险女性进行对侧预防性乳房切除术（CPM）。尽管有证据表明这种做法对肿瘤没有益处，而且也有人试图阻止这种做法，但 CPM 仍然很盛行。本研究旨在评估 ASBrS 声明后 CPM 的趋势以及与这些趋势相关的因素：我们对 2014 年 1 月至 2020 年 12 月期间在一家三级医院接受全乳切除术的原发性单侧乳腺癌患者进行了一项回顾性队列研究。我们评估了选择 CPM 的比例，比较了 ASBrS 声明前后的 CPM 率，并研究了相关的患者和肿瘤因素。我们使用皮尔逊卡方检验、费雪精确检验和等方差 t 检验来比较接受 CPM 与未接受 CPM 的子集：在 605 名患者中，有 161 人（27%）在研究期间接受了 CPM，所有患者的中位随访时间为 58 个月（IQR：38 至 81）。在所有患者中，CPM 的比例在 ASBrS 声明之前从 30% 到 14% 不等，声明之后从 36% 下降到 19%。就平均风险患者（无基因突变）而言，2014 年至 2016 年，这些比率从 20.2% 到 10.2% 不等，并从 2017 年的 23.2% 稳步下降到 2020 年的 13.2%。只有两例（1.2%）偶发对侧乳腺癌。接受CPM的患者往往更年轻，更有可能出现乳腺癌基因突变，追求重建，并选择乳头或皮肤保留乳房切除术。复发率和死亡率没有明显差异。CPM患者的基因检测率和致病变异率更高：结论：经过最初的时间滞后，ASBrS 声明后 CPM 的发生率似乎在下降，但需要持续的数据来证实这一趋势。乳腺癌基因患者的 CPM 率与针对这一高风险人群的指南保持一致。更好的教育工具和决策辅助工具可能会影响 CPM 的趋势并促进共同决策。

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引用次数: 0

Geographic Information Systems Mapping of Trauma Center Development in Florida 佛罗里达州创伤中心发展的地理信息系统绘图。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-19 DOI: 10.1016/j.jss.2024.09.060

Introduction

There has been a substantial increase in the number of trauma centers (TCs) opened in the US over the past decade which coincided with population increases and policy changes. Our hypotheses were that new TC locations would likely be related to the socioeconomic profile of the surrounding locale—likely favoring higher-income areas—and that hospital ownership status may play a role in the distribution of new centers. Our aim was to use geographic information systems (GIS) analysis to evaluate the growth of an established regional TC and to delineate factors associated with the site chosen for new centers.

Methods

ARC-GIS mapping software was utilized to generate a map of all TCs within two Florida metropolitan areas—Jacksonville and Miami. Hospital ownership was classified as for-profit (FP) or government, and opening dates were obtained from publicly available data. US census data (2020) was utilized to add sociodemographic data (race, income, insurance status) by zip code.

Results

The majority of newer TCs opened in Duval/Clay and Dade/Broward counties were FP. GIS mapping demonstrated that 100% of new TCs demonstrated higher mean charges compared to established TC and were located in higher-income neighborhoods where residents were more likely to have health insurance with fewer African-American residents.

Conclusions

Most TCs added to two of the largest metropolitan areas within Florida over the past decade were FP. These TCs demonstrated higher mean charges and tended to be located in areas of higher-income neighborhoods with better insured residents and fewer African-Americans. Such data suggest that more oversight is potentially needed to regulate and organize trauma system development to address trauma need rather than financial incentive alone.

导言：过去十年间，随着人口的增长和政策的变化，美国开设的创伤中心（TC）数量大幅增加。我们的假设是，新创伤中心的选址很可能与周边地区的社会经济状况有关--可能偏向于高收入地区，而且医院所有权状况可能在新中心的分布中发挥作用。我们的目的是利用地理信息系统（GIS）分析来评估一个已建立的地区医疗中心的发展情况，并确定与新中心选址相关的因素：方法：利用 ARC-GIS 制图软件生成佛罗里达州两个大都会区--杰克逊维尔和迈阿密--内所有治疗中心的地图。医院所有制分为营利性（FP）和政府所有制，开业日期从公开数据中获取。利用美国人口普查数据（2020 年）按邮政编码添加了社会人口数据（种族、收入、保险状况）：杜瓦尔/克莱县和戴德/布劳沃德县新开设的大多数技术合作中心都是 FP。地理信息系统（GIS）地图显示，100% 的新社区医疗中心与老社区医疗中心相比平均收费较高，且位于收入较高的社区，那里的居民更有可能拥有医疗保险，非裔美国人居民较少：结论：在过去十年中，佛罗里达州最大的两个都市区新增的大多数社区医疗中心都是 FP。这些技术合作中心的平均收费较高，而且往往位于收入较高的居民区，那里的居民有较好的医疗保险，非裔美国人较少。这些数据表明，可能需要更多的监督来规范和组织创伤系统的发展，以满足创伤需求，而不仅仅是经济激励。

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引用次数: 0

CD163+ Tumor-Associated Macrophage Recruitment Predicts Papillary Thyroid Cancer Recurrence CD163+肿瘤相关巨噬细胞招募可预测甲状腺乳头状癌复发

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-19 DOI: 10.1016/j.jss.2024.09.035

Introduction

Skewed immune response plays a pivotal role in tumor progression. Systemic inflammatory responses represented by combined peripheral leukocyte fractions are prognostic predictors of multiple cancers, including thyroid cancer. We previously reported the prognostic significance of lymphocyte–to–monocyte ratio (LMR) in curatively resected papillary thyroid cancer (PTC). Therefore, this study aimed to analyze immune cell profiles in the tumor microenvironment and their association with LMR in curatively resected PTC.

Materials and methods

The immune cell profiles of primary tumors in 162 patients with curatively resected PTC were analyzed clinicopathologically. Immunohistochemistry of tumor-associated macrophages (TAMs), myeloid-derived suppressor cells, and lymphocytes was performed using CD163, CD33, and CD3 antibodies, respectively. Prognostic analysis and correlation assays were performed using the immunocyte profiles. The gene expression of tumor-derived chemokines was assessed using a The Cancer Genome Atlas database.

Results

Patients with a higher density of CD163⁺ TAMs exhibited a significantly worse prognosis than their counterparts (10-y recurrence-free survival: 80.9% versus 91.2%, P = 0.011). Multivariate prognostic analyses revealed that high CD163⁺ cell density (P = 0.011), low preoperative LMR (P = 0.003), pN1b (P = 0.005), and high thyroglobulin level (P = 0.038) were independent predictors of recurrence. High CD163⁺ cell density had a prognostic impact on stage II and III PTC. Interestingly, high CD163⁺ cell density correlated with low LMR and high monocyte fraction in peripheral blood. Indeed, the expression of TAM-inducible, tumor-derived chemokines is increased in the The Cancer Genome Atlas database.

Conclusions

A high density of infiltrated CD163⁺ TAMs predicts recurrence in correlation with low LMR and circulating monocyte accumulation. Thus, TAMs should be considered when assessing advanced PTC.

简介免疫反应失衡在肿瘤进展中起着关键作用。以外周血白细胞组合分数为代表的全身炎症反应是包括甲状腺癌在内的多种癌症的预后预测指标。我们曾报道过淋巴细胞与单核细胞比值（LMR）在治愈性切除的甲状腺乳头状癌（PTC）中的预后意义。因此，本研究旨在分析肿瘤微环境中的免疫细胞图谱及其与治愈切除的PTC淋巴细胞比值的关系：对162例治愈切除的PTC患者原发肿瘤的免疫细胞谱进行临床病理分析。分别使用 CD163、CD33 和 CD3 抗体对肿瘤相关巨噬细胞（TAMs）、髓源抑制细胞和淋巴细胞进行免疫组化。利用免疫细胞图谱进行了预后分析和相关性测定。使用癌症基因组图谱数据库评估了肿瘤衍生趋化因子的基因表达：结果：CD163+ TAMs密度较高的患者的预后明显差于同类患者（10年无复发生存率：80.9%对91.2%，P = 0.011）。多变量预后分析显示，CD163+细胞密度高（P = 0.011）、术前LMR低（P = 0.003）、pN1b（P = 0.005）和甲状腺球蛋白水平高（P = 0.038）是复发的独立预测因素。高CD163+细胞密度对II期和III期PTC的预后有影响。有趣的是，CD163+细胞密度高与低LMR和外周血中单核细胞比例高相关。事实上，在癌症基因组图谱数据库中，TAM诱导的肿瘤衍生趋化因子的表达量有所增加：结论：高密度浸润的 CD163+ TAM 与低 LMR 和循环单核细胞聚集相关，可预测复发。因此，在评估晚期 PTC 时应考虑 TAMs。

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引用次数: 0

Pediatric Firearm Reinjury: A Retrospective Statewide Risk Factor Analysis 小儿火器再伤害：全州风险因素回顾性分析。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-19 DOI: 10.1016/j.jss.2024.09.066

Introduction

Pediatric firearm injuries are a significant public health concern in the United States. This study examines risk factors for firearm reinjury in Maryland’s pediatric population.

Methods

Pediatric patients (age 0-19 y) who presented to any hospital in Maryland with a firearm injury between October 1, 2015, and December 31, 2019, were identified in the Maryland Health Services Cost Review Commission database and were followed for repeat firearm injuries through March 31, 2020. Logistic regression was used to analyze risk factors for reinjury. Geospatial analysis was used to identify communities with the highest prevalence of reinjury.

Results

Of 1351 index presentations for firearm injuries, 102 (7.3%) were fatal. Among children with nonfatal injuries, 40 (3.1%) re-presented with a second firearm injury, 25% of which were fatal. The median interval to reinjury was 149 d [interquartile range: 73-617]. Reinjury was more common in children aged ≥15 y (90% versus 76%), males (100% versus 87%), of Black race (90% versus 69%) or publicly insured (90% versus 68%) (all P < 0.05). Most lived in highly deprived neighborhoods of Baltimore City. No single factor was significant in multivariable models.

Conclusions

Pediatric firearm reinjury is rare but highly morbid in Maryland. While prior studies have shown Black race to be independently associated with firearm reinjury, we found the effect of race was entirely attenuated after controlling for neighborhood deprivation. These findings underscore the urgent need for targeted interventions in areas identified as high risk in addition to policies to reduce youth firearm access.

导言：在美国，儿童枪支伤害是一个重大的公共卫生问题。本研究探讨了马里兰州儿科人群枪支再伤害的风险因素：在马里兰州健康服务成本审查委员会数据库中确定了在 2015 年 10 月 1 日至 2019 年 12 月 31 日期间因枪支伤害到马里兰州任何一家医院就诊的儿科患者（0-19 岁），并对其重复枪支伤害情况进行了跟踪调查，直至 2020 年 3 月 31 日。采用逻辑回归分析再次伤害的风险因素。利用地理空间分析确定再次伤害发生率最高的社区：在 1351 例因枪支伤害而就诊的病例中，102 例（7.3%）为致命伤。在非致命伤儿童中，有 40 名（3.1%）儿童因第二次枪伤再次就诊，其中 25% 为致命伤。再次受伤的时间间隔中位数为 149 d [四分位间范围：73-617]。再次伤害更常见于年龄≥15 岁的儿童（90% 对 76%）、男性（100% 对 87%）、黑人（90% 对 69%）或有公共保险的儿童（90% 对 68%）（所有 P 均为结论：在马里兰州，小儿枪支再伤害很少见，但发病率很高。尽管之前的研究表明黑人种族与枪支再伤害有独立的关联，但我们发现在控制了邻里贫困程度后，种族的影响完全减弱了。这些发现突出表明，除了制定政策减少青少年接触枪支的机会外，还迫切需要在已确定的高风险地区采取有针对性的干预措施。

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引用次数: 0

A Flattened Curve: National Trends of Women Physicians and Residents in Surgery Over the Last Decade 平坦的曲线：过去十年全国外科女医生和女住院医师的发展趋势》（A Flattened Curve: National Trends of Women Physicians and Residents in Surgery Over the Last Decade）。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-18 DOI: 10.1016/j.jss.2024.09.058

Introduction

Women comprise over half of enrolled United States medical students. Yet, they continue to be under-represented in the active physician workforce, particularly among surgical specialties. This study investigates recent trends in the representation of women across surgical specialties in comparison to nonsurgical specialties within the US physician and resident workforce.

Methods

Data on active physicians and residents across 48 specialties were extracted from the Association of American Medical College's biennial (2010-2021) and annual reports (2018-2022), respectively. Descriptive statistics were performed on the proportion of physicians who were women in surgical and nonsurgical specialties. Poisson regressions were utilized with proportion of women as the outcome and specialty and year as the predictors.

Results

In 2021, 37.1% of all active physicians (946,790) were women, with a higher proportion of women in nonsurgical (38.4%) compared to surgical specialties (29.1%). In the resident workforce, women constituted 47.3% of the total workforce (149,296) in 2022, with a relatively comparable proportion of women in nonsurgical (47.4%) and surgical specialties (47.0%). The rate of yearly change decreased significantly (P < 0.01) for women in all surgical specialties except obstetrics and gynecology (1 of 10), with nonsurgical specialties as reference.

Conclusions

Although the proportion of women in surgery has increased over the last decade, this is the first study to identify that the rate of yearly change in women in the active physician and resident workforce is decreasing significantly in almost all (9 of 10) surgical specialties relative to nonsurgical specialties. This emphasizes the urgent need for systemic interventions that address the major barriers in recruitment and retention of women surgeons.

导言：在美国注册的医科学生中，女生占一半以上。然而，在活跃的医生队伍中，尤其是在外科专业中，女性的比例仍然偏低。本研究调查了在美国医生和住院医师队伍中，与非外科专业相比，外科专业女性比例的最新趋势：48个专业的在职医师和住院医师数据分别来自美国医学院协会的两年期（2010-2021年）和年度报告（2018-2022年）。对外科和非外科专业中女性医生的比例进行了描述性统计。以女性比例为结果，以专业和年份为预测因素，进行泊松回归：2021 年，在所有在职医生（946,790 人）中，女性占 37.1%，与外科专业（29.1%）相比，非外科专业（38.4%）的女性比例更高。在住院医师队伍中，2022 年女性占总人数（149 296 人）的 47.3%，非手术专业（47.4%）和外科专业（47.0%）的女性比例相对相当。每年的变化率明显下降（P 结论：女性在外科中的比例有所下降：尽管在过去十年中女性在外科中的比例有所上升，但这项研究首次发现，与非外科专业相比，几乎所有（10 个专业中的 9 个）外科专业中女性在职医师和住院医师队伍的年变化率都在显著下降。这强调了迫切需要采取系统性干预措施，以解决招聘和留住女外科医生的主要障碍。

{"title":"A Flattened Curve: National Trends of Women Physicians and Residents in Surgery Over the Last Decade","authors":"","doi":"10.1016/j.jss.2024.09.058","DOIUrl":"10.1016/j.jss.2024.09.058","url":null,"abstract":"<div><h3>Introduction</h3><div>Women comprise over half of enrolled United States medical students. Yet, they continue to be under-represented in the active physician workforce, particularly among surgical specialties. This study investigates recent trends in the representation of women across surgical specialties in comparison to nonsurgical specialties within the US physician and resident workforce.</div></div><div><h3>Methods</h3><div>Data on active physicians and residents across 48 specialties were extracted from the Association of American Medical College's biennial (2010-2021) and annual reports (2018-2022), respectively. Descriptive statistics were performed on the proportion of physicians who were women in surgical and nonsurgical specialties. Poisson regressions were utilized with proportion of women as the outcome and specialty and year as the predictors.</div></div><div><h3>Results</h3><div>In 2021, 37.1% of all active physicians (946,790) were women, with a higher proportion of women in nonsurgical (38.4%) compared to surgical specialties (29.1%). In the resident workforce, women constituted 47.3% of the total workforce (149,296) in 2022, with a relatively comparable proportion of women in nonsurgical (47.4%) and surgical specialties (47.0%). The rate of yearly change decreased significantly (<em>P</em> < 0.01) for women in all surgical specialties except obstetrics and gynecology (1 of 10), with nonsurgical specialties as reference.</div></div><div><h3>Conclusions</h3><div>Although the proportion of women in surgery has increased over the last decade, this is the first study to identify that the rate of yearly change in women in the active physician and resident workforce is decreasing significantly in almost all (9 of 10) surgical specialties relative to nonsurgical specialties. This emphasizes the urgent need for systemic interventions that address the major barriers in recruitment and retention of women surgeons.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142468421","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

A Surgeon–Scientist’s Pursuit of the Elusive R01 一位外科医生-科学家追逐难以捉摸的 R01 的故事。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-18 DOI: 10.1016/j.jss.2024.09.032

引用次数: 0

An Interprofessional Approach to Assessing Musculoskeletal Pain and Ergonomics in Surgery Residents 评估外科住院医生肌肉骨骼疼痛和人体工程学的跨专业方法。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-18 DOI: 10.1016/j.jss.2024.09.069

Introduction

Work-related musculoskeletal injuries are common in general surgeons, causing chronic pain and lost work. However, formal ergonomic curriculums in residency programs are rare. We aimed to assess the feasibility of an interprofessional educational approach to ergonomics in general surgery residents, in collaboration with occupational therapy (OT) students.

Methods

General surgery residents completed a survey regarding musculoskeletal pain and ergonomics. OT students captured photos of trainees performing open and laparoscopic abdominal surgery over a 4-wk period. Rapid entire body assessment (REBA) and the rapid upper limb assessment were used to assess ergonomic efficiency and postural risk. Higher scores represent unfavorable posture and correlate with the need for ergonomic change.

Results

There were 37/44 (84%) responses. Everyone reported some degree of pain related to surgery, most commonly neck pain (75%), shoulder (61%), and foot pain (53%). Most residents (66%) felt the pressure to perform surgery regardless of the pain. Ergonomic breaks directed by faculty were reported by less than 11% of residents. A total of 11 intraoperative observations were made by OT students of surgical trainees, with a mean rapid upper limb assessment score of 6.1 and a mean rapid entire body assessment score of 7.3. These scores demonstrated suboptimal posture with recommendations for prompt change.

Conclusions

This study conveys a successful interprofessional educational approach to assessing surgical ergonomics in general surgery residents. Musculoskeletal symptoms and intraoperative ergonomic dysfunctions are prevalent among general surgery residents, without workplace measures for management or prevention. This needs assessment will be used to create an ergonomics initiative for the surgery residency.

导言：与工作相关的肌肉骨骼损伤在普外科医生中很常见，会导致慢性疼痛和误工。然而，在住院医师培训项目中，正式的人体工程学课程却很少见。我们旨在与职业治疗（OT）专业的学生合作，对普外科住院医师工效学跨专业教育方法的可行性进行评估：方法：普外科住院医师完成了一项有关肌肉骨骼疼痛和人体工程学的调查。职业治疗专业的学生拍摄了 4 周内受训者进行开腹和腹腔镜腹部手术的照片。快速全身评估（REBA）和快速上肢评估用于评估人体工程学效率和姿势风险。得分越高代表姿势越不正确，与改变人体工程学的需要相关：共有 37/44 人（84%）做出了回应。每个人都报告了与手术有关的某种程度的疼痛，最常见的是颈部疼痛（75%）、肩部疼痛（61%）和足部疼痛（53%）。大多数住院医师（66%）感到有压力，无论疼痛与否，都必须进行手术。只有不到 11% 的住院医师报告了由教师指导的符合人体工学的休息时间。职业技术学院的学生共对外科学员进行了 11 次术中观察，上肢快速评估平均得分为 6.1 分，全身快速评估平均得分为 7.3 分。这些评分显示了不理想的姿势，建议及时改变：本研究传达了一种成功的跨专业教育方法，用于评估普外科住院医师的手术工效学。普外科住院医师中普遍存在肌肉骨骼症状和术中人体工学功能障碍，但却没有采取工作场所管理或预防措施。这项需求评估将用于为外科住院医师制定一项人体工程学计划。

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引用次数: 0

Early Acute Kidney Injury in Adult Patients With Burns in Australia & New Zealand 澳大利亚和新西兰成年烧伤患者的早期急性肾损伤。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-18 DOI: 10.1016/j.jss.2024.09.053

Introduction

Acute kidney injury (AKI) following burns is associated with increased mortality and morbidity. Some patients require renal replacement therapy. There is limited large-scale data to sufficiently validate risk factors influencing the incidence and severity of early AKI, defined as AKI within the first 72 h since admission to a burn center following burn injury. The aims of this study were to compare the profile of adult patients admitted to Australian and New Zealand burn centers, with burns ≥10% total body surface area (TBSA) who developed early AKI with patients who did not develop AKI and to quantify the association between early AKI and in-hospital outcomes.

Methods

Data were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 y), with burns ≥10% TBSA admitted to Australian or New Zealand burn centers between July 2016 and June 2021. All patients with two valid serum creatinine blood tests within the first 72 h were included. Differences in patient profiles and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between early AKI and outcomes of interest.

Results

There were 1297 patients who met the inclusion criteria for this study. Eighty-three patients (6.4%) developed early AKI. Compared to patients without AKI, patients with an AKI were older (P = 0.006), had a greater median %TBSA burned (P < 0.001), and had an inhalation injury (P < 0.001). In adjusted models, the development of early AKI was significantly associated with in-hospital mortality (adjusted odds ratio (aOR) [95% CI] 2.73 [1.33, 5.62], P < 0.001) and the need for mechanical ventilation (aOR [95% CI] 3.44 [1.77, 6.68], P = 0.001), but there was no significant increase in the hospital length of stay or intensive care unit length of stay.

Conclusions

This is the first large-scale study looking at early AKI in adult burns ≥10% TBSA. The incidence of AKI was lower than previously reported and AKI was associated with higher in-hospital mortality and increased need for mechanical ventilation. These findings support the notion that development of AKI in the immediate phase post burns injury can potentially have consequences and the appropriate care should be given to prevent its development.

简介：烧伤后的急性肾损伤（AKI）与死亡率和发病率的增加有关。一些患者需要进行肾脏替代治疗。早期 AKI 是指烧伤后入住烧伤中心后 72 小时内发生的 AKI，目前只有有限的大规模数据可以充分验证影响早期 AKI 发生率和严重程度的风险因素。本研究旨在比较澳大利亚和新西兰烧伤中心收治的烧伤面积≥10%、发生早期AKI的成年患者与未发生AKI的患者的情况，并量化早期AKI与院内预后之间的关系：从澳大利亚和新西兰烧伤登记处提取了2016年7月至2021年6月期间澳大利亚或新西兰烧伤中心收治的烧伤面积≥10% TBSA的成人（≥18岁）的数据。所有在最初 72 小时内进行过两次有效血清肌酐血液检测的患者均被纳入研究范围。研究了患者概况和院内预后的差异。采用单变量和多变量逻辑及线性回归模型来量化早期 AKI 与相关结果之间的关联：共有 1297 名患者符合本研究的纳入标准。83名患者（6.4%）出现了早期 AKI。与没有发生 AKI 的患者相比，发生 AKI 的患者年龄更大（P = 0.006），烧伤的中位 TBSA 百分比更高（P 结论：这是一项首次对早期 AKI 和相关结果进行研究的大规模研究：这是首次对TBSA≥10%的成人烧伤患者的早期AKI进行大规模研究。AKI 的发生率低于之前的报道，AKI 与较高的院内死亡率和机械通气需求增加有关。这些研究结果支持这样一种观点，即在烧伤后的初期阶段发生 AKI 可能会产生潜在的后果，因此应给予适当的护理以防止其发生。

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引用次数: 0

Operative Trauma and Mortality: The Role of Volume 手术创伤与死亡率：体积的作用。

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-18 DOI: 10.1016/j.jss.2024.09.036

Introduction

Operative volume is associated with improved outcomes across many surgical specialties, but this relationship has not been illustrated clearly in trauma. This study sought to evaluate the relationship between operative trauma volume and mortality, hypothesizing that increased volume would be associated with improved survival.

Materials and Methods

The National Trauma Data Bank was queried for patients ≥18 y undergoing hemorrhage control surgery at level I or II trauma centers from 2017 to 2020. Hierarchical logistic regression was performed to evaluate the association between operative volume and in-hospital mortality, controlling for demographic and clinical characteristics.

Results

55,469 patients were included and treated at 516 centers. After adjustment, the operative volume was significantly associated with reduced mortality (OR 0.999, 95% CI 0.997-0.999, P = 0.018). However, there was considerable variability in volumes, with the busiest 5% of centers performing 90-294 operations per year, compared to 7-35 in the middle 50% of centers. To evaluate whether volume exhibited a uniform effect, the top 5% of trauma centers were excluded on subset analysis, with operative volume becoming nonsignificant in the remaining 491 centers (OR 0.999, 95% CI 0.996-1.001, P = 0.274).

Conclusions

Higher operative trauma volume is associated with reduced mortality for patients undergoing hemorrhage control surgery, but this mortality benefit appears to arise solely from very high-volume centers. The time-sensitive nature of hemorrhage control surgery makes centralization at this level impractical. Future efforts should focus on investigating the relationship between patient proximity to trauma centers and center volume as well as identifying modifiable factors common to high-volume centers that may be widely implemented.

导言：在许多外科专科中，手术量都与预后的改善有关，但在创伤外科中，这种关系尚未得到明确说明。本研究试图评估创伤手术量与死亡率之间的关系，假设手术量的增加与生存率的提高有关：在国家创伤数据库中查询了 2017 年至 2020 年期间在一级或二级创伤中心接受出血控制手术的年龄≥18 岁的患者。在控制人口统计学和临床特征的前提下，进行了层次逻辑回归，以评估手术量与院内死亡率之间的关系：共纳入 55,469 名患者，他们在 516 个中心接受治疗。经调整后，手术量与死亡率的降低显著相关（OR 0.999，95% CI 0.997-0.999，P = 0.018）。然而，手术量存在很大差异，最繁忙的5%的中心每年进行90-294例手术，而中间50%的中心每年进行7-35例手术。为了评估手术量是否会产生一致的影响，在子集分析中排除了前5%的创伤中心，手术量在剩余的491个中心中变得不显著（OR 0.999，95% CI 0.996-1.001，P = 0.274）：结论：创伤手术量越大，接受出血控制手术的患者死亡率就越低，但这种死亡率的益处似乎只来自于手术量非常大的中心。由于出血控制手术具有时间敏感性，因此在这一层面进行集中管理是不切实际的。未来的工作重点应该是研究患者距离创伤中心的远近与中心规模之间的关系，以及确定可广泛实施的高规模中心的共同可调节因素。

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引用次数: 0

Characterizing a Common Phenomenon: Why do Trauma Patients Re-Present to the Emergency Department? 描述一种常见现象：创伤患者为何再次到急诊科就诊？

IF 1.8 3区医学 Q2 SURGERY

Journal of Surgical Research

Pub Date : 2024-10-18 DOI: 10.1016/j.jss.2024.09.068

Introduction

Trauma patients return to the emergency department (ED) at alarmingly high rates, despite not all patients requiring hospital resources. Reasons for ED re-presentation and associated risk factors have not been fully investigated.

Methods

Retrospective cohort study of adult trauma admissions at an urban safety net level 1 trauma center (1/12018-12/312021). Risk factors for ED re-presentation were identified using purposeful selection and modeled using multivariable logistic regression.

Results

Of 2491 patients, 19% returned within 30 d (N = 475). Most patients presented for uncontrolled pain (37%, N = 175), medical concerns (25%, N = 119), and infection (10%, N = 49). The readmission rates varied as follows: 18% for uncontrolled pain (N = 32), 42% for medical concerns (N = 50), and 67% for infection (N = 33). Risk factors for uncontrolled pain included depression/anxiety (adjusted odds ratio [aOR] 2.06, 95% confidence interval [CI] 1.39-3.05), substance use disorder (SUD) (aOR 1.65, 95% CI 1.12-2.43), and penetrating mechanism of injury (aOR 2.25, 95% CI 1.59-3.18). Risk factors for medical concerns included number of medical comorbidities (aOR 1.34, 95% CI 1.18-1.52), depression/anxiety (aOR 1.97, 95% CI 1.28-3.01), SUD (aOR 2.48, 95% CI 1.65-3.74), and nonhome discharge disposition (aOR 1.56, 95% CI 1.07-2.28). Risk factors for infection included non-English primary language (aOR 3.41, 95% CI 1.82-6.39), SUD (aOR 2.00, 95% CI 1.03-3.88), and nonhome discharge disposition (aOR 2.06, 95% CI 1.15-3.67).

Conclusions

Uncontrolled pain was the most common reason for re-presentation, although only a small fraction required readmission. Patients with penetrating injury may benefit from improved pain control. Primary care provider follow-up may help mitigate risk of medical disease exacerbation, and wound care instructions for non–English speaking patients may decrease re-presentation for infection.

导言：尽管并非所有患者都需要医院资源，但创伤患者重返急诊科（ED）的比例却高得惊人。急诊科再次就诊的原因及相关风险因素尚未得到充分调查：方法：对城市安全网一级创伤中心收治的成人创伤患者进行回顾性队列研究（1/12018-12/312021）。通过有目的的选择确定了急诊室再次就诊的风险因素，并使用多变量逻辑回归建立了模型：结果：在 2491 名患者中，19% 的患者在 30 天内再次就诊（N = 475）。大多数患者因疼痛无法控制（37%，175 人）、医疗问题（25%，119 人）和感染（10%，49 人）而再次就诊。再入院率变化如下疼痛失控率为 18%（32 人），医疗问题率为 42%（50 人），感染率为 67%（33 人）。疼痛无法控制的风险因素包括抑郁/焦虑（调整后比值比 [aOR]2.06，95% 置信区间 [CI]1.39-3.05）、药物使用障碍 (SUD)（aOR 1.65，95% CI 1.12-2.43）和穿透性损伤（aOR 2.25，95% CI 1.59-3.18）。医疗问题的风险因素包括合并症数量（aOR 1.34，95% CI 1.18-1.52）、抑郁/焦虑（aOR 1.97，95% CI 1.28-3.01）、SUD（aOR 2.48，95% CI 1.65-3.74）和非家庭出院处置（aOR 1.56，95% CI 1.07-2.28）。感染的风险因素包括非英语母语（aOR 3.41，95% CI 1.82-6.39）、SUD（aOR 2.00，95% CI 1.03-3.88）和非家庭出院处置（aOR 2.06，95% CI 1.15-3.67）：疼痛无法控制是再次就诊的最常见原因，但只有一小部分患者需要再次入院。改善疼痛控制可使穿透伤患者受益。初级保健提供者的随访可能有助于降低内科疾病恶化的风险，对不会说英语的患者进行伤口护理指导可能会减少因感染而再次就诊的情况。

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