RESUMEN
OBJECTIVES: To describe the incidence of pulmonary embolism (PE) in a critically ill UK major trauma centre (MTC) patient cohort. METHODS: A retrospective, multidataset descriptive study of all trauma patients requiring admission to level 2 or 3 care in the East of England MTC from 1 November 2014 to 1 May 2017. Data describing demographics, the nature and extent of injuries, process of care, timing of PE prophylaxis, tranexamic acid (TXA) administration and CT scanner type were extracted from the Trauma Audit and Research Network database and hospital electronic records. PE presentation was categorised as immediate (diagnosed on initial trauma scan), early (within 72 hours of admission but not present initially) and late (diagnosed after 72 hours). RESULTS: Of the 2746 trauma patients, 1039 were identified as being admitted to level 2 or 3 care. Forty-eight patients (4.6%) were diagnosed with PE during admission with 14 immediate PEs (1.3%). Of 32.1% patients given TXA, 6.3% developed PE compared with 3.8% without TXA (p=0.08). CONCLUSION: This is the largest study of the incidence of PE in UK MTC patients and describes the greatest number of immediate PEs in a civilian complex trauma population to date. Immediate PEs are a rare phenomenon whose clinical importance remains unclear. Tranexamic acid was not significantly associated with an increase in PE in this population following its introduction into the UK trauma care system.
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Traumatismo Múltiple/complicaciones , Embolia Pulmonar/epidemiología , Centros Traumatológicos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Conjuntos de Datos como Asunto , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Embolia Pulmonar/etiología , Estudios Retrospectivos , Factores de Tiempo , Reino Unido/epidemiología , Adulto JovenRESUMEN
OBJECTIVE: Methods that model surgical learning curves are frequently descriptive and lack the mathematical rigor required to extract robust, meaningful, and quantitative information. We aimed to formulate a method to model learning that is tailored to dealing with the high variability seen in surgical data and can readily extract important quantitative information such as learning rate, length of learning, and learnt level of performance. METHODS: We developed a method where progressively more complex models are fitted to learning data. These include novel models that split the learning data into 2 linear phases and fit adjoining lines using least squares regression. The models were compared and the least complex model was selected unless a more complex one was significantly better. Significance was tested by Fischer tests. We applied this method to total hip and knee replacements using imageless navigation, analyzing the operative time for a surgeon's first 50 and 60 operations, respectively. This method was then tested against 4 sets of simulated learning data. RESULTS: The proposed method of progressive model complexity successfully modeled the learning curve among real operative data. It was also effective in deducing the underlying trends in simulated scenarios, created to represent typical situations that can practically arise in any learning process. CONCLUSIONS: The novel modeling method can be used to extract meaningful and quantitative information from learning data displaying high variability seen in surgical practice. By using simple and intuitive models, the method is accessible to researchers and educators without the need for specialist statistical knowledge.
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Artroplastia de Reemplazo de Cadera/educación , Artroplastia de Reemplazo de Rodilla/educación , Competencia Clínica , Modelos Educacionales , Cirugía Asistida por Computador , Bases de Datos Factuales , Femenino , Humanos , Curva de Aprendizaje , Masculino , Tempo Operativo , Estudios Retrospectivos , Cirujanos/educaciónRESUMEN
BACKGROUND: Conversion to mammalian target of rapamycin inhibitors (mTORi) is often used in liver transplantation to overcome calcineurin inhibitor (CNI) nephrotoxicity but the evidence base for this approach is not well defined. To summarize the evidence, from randomized clinical trials (RCTs), for conversion from CNI to mTORi-based immunosuppression after liver transplantation. METHODS: Databases and conference abstracts were searched up to August 2015. The RCTs evaluating conversion from CNI to mTORi-based maintenance immunosuppression after adult liver transplantation. Descriptive and quantitative information was extracted; summary mean difference and risk ratio (RR) estimates were synthesized under a random-effects model. Heterogeneity was assessed using the Q statistic and I. RESULTS: Ten RCTs, with a total of 1927 patients, met the final inclusion criteria. Patients converted to mTORi had significantly better renal function at 1 year after randomization compared with patients remaining on CNI (mean difference, 7.48 mL/min per 1.73 m; 95% confidence interval [95% CI], 3.18-11.8). The risks of graft loss (RR, 0.77; 95% CI, 0.29-2.09; I, 31%) and patient death (RR, 1.05; 95% CI, 0.63-1.73; I, 0%) were similar for patients converted to mTORi and patients remaining on CNI. However, conversion to mTORi was associated with a higher risk of acute rejection (RR, 1.76; 95% CI, 1.33-2.34; I, 0%) and study discontinuation due to adverse events (RR, 2.17; 95% CI, 1.38-3.44; I, 63%) up to 1 year after randomization. CONCLUSIONS: Conversion from CNI to mTORi after liver transplantation is associated with improved renal function after 1 year but increases the risk of acute rejection and may be poorly tolerated.
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Inhibidores de la Calcineurina/administración & dosificación , Sustitución de Medicamentos , Rechazo de Injerto/prevención & control , Supervivencia de Injerto/efectos de los fármacos , Inmunosupresores/administración & dosificación , Trasplante de Hígado , Inhibidores de Proteínas Quinasas/administración & dosificación , Serina-Treonina Quinasas TOR/antagonistas & inhibidores , Inhibidores de la Calcineurina/efectos adversos , Distribución de Chi-Cuadrado , Rechazo de Injerto/inmunología , Rechazo de Injerto/mortalidad , Humanos , Inmunosupresores/efectos adversos , Riñón/efectos de los fármacos , Riñón/fisiopatología , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Inhibidores de Proteínas Quinasas/efectos adversos , Medición de Riesgo , Factores de Riesgo , Serina-Treonina Quinasas TOR/metabolismo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Human cytomegalovirus (HCMV) infection and reactivation are a major cause of morbidity in immune-suppressed patients. Interestingly, epidemiological studies have shown that patients administered the mammalian target of rapamycin (mTOR) inhibitor, sirolimus (rapamycin), exhibit more favourable outcomes, suggestive of activity against HCMV in vivo. Given its relative lack of activity against lytic infection, it is postulated that rapamycin inhibits HCMV reactivation. Here, we showed that rapamycin administered acutely or chronically has little impact on induction of immediate early (IE) gene expression in experimentally latent dendritic cells or cells from naturally latent individuals. Furthermore, we extended these observations to include other inhibitors of mTORC1 and mTORC 2, which similarly have minimal effects on induction of IE gene expression from latency. Taken together, these data suggest that favourable outcomes associated with sirolimus are attributable to indirect effects that influence HCMV reactivation, rather than a direct mechanistic action against HCMV itself.