-
BMC Medicine Apr 2015Complex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds... (Review)
Review
BACKGROUND
Complex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds is a significant patient and societal healthcare concern and cost-effective wound care management remains unclear. This article summarizes the cost-effectiveness of interventions for complex wound care through a systematic review of the evidence base.
METHODS
We searched multiple databases (MEDLINE, EMBASE, Cochrane Library) for cost-effectiveness studies that examined adults treated for complex wounds. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed methodological quality using the Drummond 10-item methodological quality tool. Incremental cost-effectiveness ratios were reported, or, if not reported, calculated and converted to United States Dollars for the year 2013.
RESULTS
Overall, 59 cost-effectiveness analyses were included; 71% (42 out of 59) of the included studies scored 8 or more points on the Drummond 10-item checklist tool. Based on these, 22 interventions were found to be more effective and less costly (i.e., dominant) compared to the study comparators: 9 for diabetic ulcers, 8 for venous ulcers, 3 for pressure ulcers, 1 for mixed venous and venous/arterial ulcers, and 1 for mixed complex wound types.
CONCLUSIONS
Our results can be used by decision-makers in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thereby indicating areas of resource savings. Please see related article: http://dx.doi.org/10.1186/s12916-015-0288-5.
Topics: Adult; Cost-Benefit Analysis; Female; Humans; Male; North America; Wounds and Injuries
PubMed: 25899057
DOI: 10.1186/s12916-015-0326-3 -
Reviews on Environmental Health Jun 2016Fibromyalgia syndrome (FMS) is a clinical disorder predominant in females with unknown etiology and medically unexplained symptoms (MUS), similar to other afflictions,... (Review)
Review
Fibromyalgia syndrome (FMS) is a clinical disorder predominant in females with unknown etiology and medically unexplained symptoms (MUS), similar to other afflictions, including irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), post-traumatic stress disorder (PTSD), Gulf War illness (GFI), and others. External environmental stimuli drive behavior and impact physiologic homeostasis (internal environment) via autonomic functioning. These environments directly impact the individual affective state (mind), which feeds back to regulate physiology (body). FMS has emerged as a complex disorder with pathologies identified among neurotransmitter and enzyme levels, immune/cytokine functionality, cortical volumes, cutaneous innervation, as well as an increased frequency among people with a history of traumatic and/or emotionally negative events, and specific personality trait profiles. Yet, quantitative physical evidence of pathology or disease etiology among FMS has been limited (as with other afflictions with MUS). Previously, our group published findings of increased peptidergic sensory innervation associated with the arterio-venous shunts (AVS) in the glabrous hand skin of FMS patients, which provides a plausible mechanism for the wide-spread FMS symptomology. This review focuses on FMS as a model affliction with MUS to discuss the implications of the recently discovered peripheral innervation alterations, explore the role of peripheral innervation to central sensitization syndromes (CSS), and examine possible estrogen-related mechanisms through which external and internal environmental factors may contribute to FMS etiology and possibly other afflictions with MUS.
Topics: Central Nervous System; Environmental Exposure; Fibromyalgia; Homeostasis; Humans; Life Style; Medically Unexplained Symptoms; Peripheral Nervous System; Risk Factors; Skin; Stress, Physiological; Stress, Psychological; Wounds and Injuries
PubMed: 27105483
DOI: 10.1515/reveh-2015-0040 -
Revista Do Colegio Brasileiro de... Oct 2018to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the...
OBJECTIVE
to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution.
METHODS
an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence.
RESULTS
two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases.
CONCLUSION
distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.
Topics: Adult; Amputation, Surgical; Arteries; Brazil; Female; Health Services Accessibility; Humans; Incidence; Male; Middle Aged; Retrospective Studies; Risk Factors; Sex Distribution; Vascular System Injuries; Veins
PubMed: 30304097
DOI: 10.1590/0100-6991e-20181844 -
Scandinavian Journal of Trauma,... Jun 2023Veno-arterial carbon dioxide tension difference (ΔPCO) and mixed venous oxygen saturation (SvO) have been shown to be markers of the adequacy between cardiac output and... (Observational Study)
Observational Study
BACKGROUND
Veno-arterial carbon dioxide tension difference (ΔPCO) and mixed venous oxygen saturation (SvO) have been shown to be markers of the adequacy between cardiac output and metabolic needs in critical care patients. However, they have hardly been assessed in trauma patients. We hypothesized that femoral ΔPCO (ΔPCO) and SvO (SvO) could predict the need for red blood cell (RBC) transfusion following severe trauma.
METHODS
We conducted a prospective and observational study in a French level I trauma center. Patients admitted to the trauma room following severe trauma with an Injury Severity Score (ISS) > 15, who had arterial and venous femoral catheters inserted were included. ΔPCO SvO and arterial blood lactate were measured over the first 24 h of admission. Their abilities to predict the transfusion of at least one pack of RBC (pRBC) or hemostatic procedure during the first six hours of admission were assessed using receiver operating characteristics curve.
RESULTS
59 trauma patients were included in the study. Median ISS was 26 (22-32). 28 patients (47%) received at least one pRBC and 21 patients (35,6%) had a hemostatic procedure performed during the first six hours of admission. At admission, ΔPCO was 9.1 ± 6.0 mmHg, SvO 61.5 ± 21.6% and blood lactate was 2.7 ± 1.9 mmol/l. ΔPCO was significantly higher (11.6 ± 7.1 mmHg vs. 6.8 ± 3.7 mmHg, P = 0.003) and SvO was significantly lower (50 ± 23 mmHg vs. 71.8 ± 14.1 mmHg, P < 0.001) in patients who were transfused than in those who were not transfused. Best thresholds to predict pRBC were 8.1 mmHg for ΔPCO and 63% for SvO. Best thresholds to predict the need for a hemostatic procedure were 5.9 mmHg for ΔPCO and 63% for SvO. Blood lactate was not predictive of pRBC or the need for a hemostatic procedure.
CONCLUSION
In severe trauma patients, ΔPCO and SvO at admission were predictive for the need of RBC transfusion and hemostatic procedures during the first six hours of management while admission lactate was not. ΔPCO and SvO appear thus to be more sensitive to blood loss than blood lactate in trauma patients, which might be of importance to early assess the adequation of tissue blood flow with metabolic needs.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Blood Gas Analysis; Carbon Dioxide; Femoral Artery; Femoral Vein; Hemorrhage; Hemostatics; Injury Severity Score; Lactic Acid; Oxygen; Prospective Studies; Wounds and Injuries; Predictive Value of Tests
PubMed: 37340485
DOI: 10.1186/s13049-023-01095-9 -
Prehospital Emergency Care 2016The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether...
BACKGROUND
The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology.
METHODS
Following IRB approval, patients arriving to a level-1 trauma center between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2-8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement.
RESULTS
A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets (p < 0.01). The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%; p = 0.03). Acute renal failure (3.2 vs. 0%, p = 0.72), compartment syndrome (2.1 vs. 0%, p = 0.80), nerve palsies (5.3 vs. 0%; p = 0.57), and venous thromboembolic events (9.1 vs. 8.5%; p = 0.65) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use.
CONCLUSION
The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.
Topics: Adult; Cohort Studies; Emergency Medical Services; Extremities; Female; Hemorrhage; Humans; Male; Middle Aged; Registries; Retrospective Studies; Tourniquets; Trauma Centers; United States; Wounds and Injuries
PubMed: 27245978
DOI: 10.1080/10903127.2016.1182606 -
Scientific Reports Dec 2020The dural venous sinuses play an integral role in draining venous blood from the cranial cavity. As a result of the sinuses anatomical location, they are of significant...
The dural venous sinuses play an integral role in draining venous blood from the cranial cavity. As a result of the sinuses anatomical location, they are of significant importance when evaluating the mechanopathology of traumatic brain injury (TBI). Despite the importance of the dural venous sinuses in normal neurophysiology, no mechanical analyses have been conducted on the tissues. In this study, we conduct mechanical and structural analysis on porcine dural venous sinus tissue to help elucidate the tissues' function in healthy and diseased conditions. With longitudinal elastic moduli values ranging from 33 to 58 MPa, we demonstrate that the sinuses exhibit higher mechanical stiffness than that of native dural tissue, which may be of interest to the field of TBI modelling. Furthermore, by employing histological staining and a colour deconvolution protocol, we show that the sinuses have a collagen-dominant extracellular matrix, with collagen area fractions ranging from 84 to 94%, which likely explains the tissue's large mechanical stiffness. In summary, we provide the first investigation of the dural venous sinus mechanical behaviour with accompanying structural analysis, which may aid in understanding TBI mechanopathology.
Topics: Animals; Brain Injuries, Traumatic; Cerebral Veins; Comorbidity; Cranial Sinuses; Disease Models, Animal; Dura Mater; Hematoma, Subdural, Acute; Swine; Vascular Stiffness
PubMed: 33303894
DOI: 10.1038/s41598-020-78694-4 -
CEN Case Reports May 2021A 78-year-old woman who sustained traumatic liver injury with hemorrhagic shock was hospitalized. She was admitted to the ICU after blood transfusion and emergent...
A 78-year-old woman who sustained traumatic liver injury with hemorrhagic shock was hospitalized. She was admitted to the ICU after blood transfusion and emergent angiography. AKI was observed on the following day. Blood transfusion was continued because initial assessment was prerenal AKI due to hypovolemia. Despite transfusion of blood products and administration of diuretics, aggravated renal dysfunction, and low urine output continued, resulting in respiratory failure due to pulmonary edema. Renal venous congestion was suspected as the primary cause of AKI, since IVC compression from a hematoma with IVC injury was observed on CT imaging captured on admission, and renal Doppler ultrasonography demonstrated an intermittent biphasic pattern of renal venous flow. It was finally concluded that renal venous congestion resulted from IVC compression, since urine output increased remarkably after RRT without additional diuretics, and follow-up CT and renal Doppler ultrasonography revealed improvements in IVC compression and renal venous flow pattern, respectively. Renal venous congestion has been often reported to be associated with acute decompensated heart failure and, to our knowledge, this is the first report to describe trauma-induced renal venous congestion. Trauma patients are at risk for renal venous congestion due to massive blood transfusion after recovery from hemorrhagic shock; therefore, if they develop AKI that cannot be explained by other etiologies, physicians should consider the possibility of trauma-induced renal venous congestion and perform renal Doppler ultrasonography.
Topics: Aged; Female; Humans; Hyperemia; Kidney Diseases; Liver; Shock, Hemorrhagic; Ultrasonography; Wounds and Injuries
PubMed: 33038002
DOI: 10.1007/s13730-020-00540-3 -
Journal of Vascular Surgery Jun 2020Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought...
OBJECTIVE
Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI.
METHODS
The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI.
RESULTS
From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001).
CONCLUSIONS
In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.
Topics: Abdominal Injuries; Accidents, Traffic; Adult; Aged; Aorta, Abdominal; Databases, Factual; Female; Hemopneumothorax; Humans; Incidence; Male; Middle Aged; Multiple Trauma; Pedestrians; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; United States; Vena Cava, Inferior; Wounds, Nonpenetrating; Young Adult
PubMed: 31699513
DOI: 10.1016/j.jvs.2019.07.095 -
World Journal of Emergency Surgery :... Apr 2022Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of... (Meta-Analysis)
Meta-Analysis
Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis.
BACKGROUND
Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively.
METHODS
Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality.
RESULTS
Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01-3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22-0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82-2.75, p = 0.19). All studies were at serious risk of bias due to confounding.
CONCLUSIONS
Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.
Topics: Abdominal Injuries; Adult; Anticoagulants; Blood Transfusion; Humans; Venous Thromboembolism; Wounds, Nonpenetrating
PubMed: 35468835
DOI: 10.1186/s13017-022-00423-1 -
Journal of Vascular Surgery. Venous and... Nov 2019Inferior vena cava (IVC) injuries are potentially lethal and require prompt intervention. Repair of complex IVC injuries may require the use of a prosthetic graft or a... (Comparative Study)
Comparative Study
OBJECTIVE
Inferior vena cava (IVC) injuries are potentially lethal and require prompt intervention. Repair of complex IVC injuries may require the use of a prosthetic graft or a complicated panel or spiral vein graft reconstruction to avoid the need for ligation. Collateral venous drainage may be sufficient to allow acceptable results from IVC ligation; however, previous studies have suffered from low numbers and have differing results. The aims of this study were to assess the outcomes of isolated IVC injuries overall and to compare IVC ligation with repair.
METHODS
Patients in the National Trauma Data Bank from 2007 to 2014 with an IVC injury were evaluated. Isolated IVC injury was defined as patients with nonvascular Abbreviated Injury Scale scores <4 and no other named vascular injury. The primary outcome was mortality; secondary outcomes were in-hospital amputation-free survival, major lower extremity amputation, lower extremity compartment syndrome, acute kidney injury (AKI), deep venous thrombosis (DVT), and pulmonary embolism (PE).
RESULTS
Overall, 1075 (0.018%) patients had IVC injuries and 443 met inclusion criteria. On univariate analysis, in comparing IVC ligation and primary repair, ligation was not associated with mortality (23% vs 16%; P = .102) but was associated with blunt mechanism (22% vs 11%; P = .009), higher fasciotomy rate (11% vs 0%; P < .001), trend toward lower in-hospital amputation-free survival (76% vs 84.4%, P = .056), and higher rates of AKI (9% vs 4%; P = .060) and PE (3% vs 1%, P = .087). Similarly, major lower extremity amputation, compartment syndrome, and DVT were not different between groups. IVC ligation was not independently associated with mortality (adjusted odds ratio [AOR], 1.54; P = .197), in-hospital amputation-free survival (AOR, 0.61; P = .141), major amputation (AOR, Inf; P = .99), lower extremity compartment syndrome (AOR, 0.82; P = .827), or PE (AOR, 6.72; P = .052), but it was independently associated with fasciotomy (AOR, 31.4; P = .002), AKI (AOR, 2.7; P = .048), and DVT (AOR, 2.3; P = .021).
CONCLUSIONS
IVC ligation was not independently associated with mortality or lower extremity amputation, but it was associated with AKI and need for fasciotomy.
Topics: Adult; Amputation, Surgical; Databases, Factual; Female; Humans; Injury Severity Score; Ligation; Limb Salvage; Male; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular Surgical Procedures; Vascular System Injuries; Vena Cava, Inferior; Young Adult
PubMed: 31515201
DOI: 10.1016/j.jvsv.2019.06.013