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Artificial Intelligence Evaluation of Focused Assessment with Sonography In Trauma

The focused assessment with sonography for trauma (FAST) is a widely used imaging modality to identify the location of life-threatening hemorrhage in a hemodynamically unstable trauma patient. This study evaluates the role of artificial intelligence (AI) in interpretation of the FAST exam abdominal views, as it pertains to adequacy of the view and accuracy of fluid survey positivity. FAST exam images from 2015-2022, from trauma activations, were acquired from a quaternary care level 1 trauma center with over 3500 adult trauma evaluations, annually. Images pertaining to the right upper quadrant (RUQ) and left upper quadrant (LUQ) views were obtained and read by a surgeon or radiologist. Positivity was defined as fluid present in the hepatorenal or splenorenal fossa, while adequacy was defined by the presence of both the liver and kidney or the spleen and kidney for the RUQ or LUQ views, respectively. Four convolutional neural network architecture models (DenseNet121, InceptionV3, ResNet50, Vgg11bn) were evaluated. 6608 images, representing 109 cases were included for analysis within the "Adequate" and "Positive" datasets. The models relayed 88.7% accuracy, 83.3% sensitivity and 93.6% specificity for the "Adequate" test cohort, while the "Positive" cohort conferred 98.0% accuracy, 89.6% sensitivity, and 100.0% specificity against similar models. Augmentation improved the accuracy and sensitivity of the "Positive" models to 95.1% accurate and 94.0% sensitive. DenseNet121 demonstrated the best accuracy across tasks. AI can detect positivity and adequacy of FAST exams with 94% and 97% accuracy, aiding in the standardization of care delivery with minimal expert clinician input. AI is a feasible modality to improve patient care imaging interpretation accuracy and should be pursued as a point of care clinical decision-making tool.Level III, Diagnostic test/criteria.

Current Use and Utility of MRCP, ERCP and Pancreatic Duct Stents: A Secondary Analysis from the WTA Multicenter Trials Group on Pancreatic Injuries

The single most important predictor of pancreas-specific complications (PSC) after pancreatic trauma is injury to the main pancreatic duct (MPD). Pancreatography has been recommended to evaluate the integrity of the MPD. Additionally, pancreatic duct stents have been proposed to prevent or treat PSC. The primary purpose of this study was to determine the accuracy of MRCP in diagnosing MPD injury. We further sought to determine whether stents were effective in preventing PSC, or facilitated the resolution of pancreatic leaks or fistulae. Secondary analysis of a multicenter retrospective review of pancreatic injuries in patients age 15 and older from 2010-2018, focusing on patients who underwent MRCP or ERCP. Final pancreatic injury grade was determined based on all available assessments, ultimately adjudicated by the site principal investigator. Data were analyzed using various statistical tests where appropriate. 33 centers reported on 1243 patients. 216 underwent pancreatography- 137 had MRCP and 115 ERCP, with 36 having both. The sensitivity of MRCP for MPD injury was 37%, specificity 94%, positive predictive value 77%, and negative predictive value 73%. When compared with ERCP, MRCP findings were discordant in 64% of cases. Pancreatic stents were placed in 77 patients- 48 (62%) were to treat PSC, with no clear benefit. 29 had prophylactic stents placed. There did not appear to be benefit in reduced PSC compared with the entire study group, or among patients with high-grade pancreatic injuries. The accuracy of MRCP to evaluate the integrity of the MPD does not appear to be superior to CT scan. Consequently, the results of MRCP should be interpreted with caution. The current data do not support prophylactic use of pancreatic stents; they should be studied in a prospective trial. Level III, Retrospective diagnostic/therapeutic study.

Prehospital tranexamic acid is associated with a dose-dependent decrease in syndecan-1 after trauma: A secondary analysis of a prospective randomized trial

In the Study of Tranexamic Acid During Air and Ground Prehospital Transport (STAAMP) Trial, prehospital tranexamic acid (TXA) was associated with lower mortality in specific patient subgroups. The underlying mechanisms responsible for a TXA benefit remain incompletely characterized. We hypothesized that TXA may mitigate endothelial injury and sought to assess whether TXA was associated with decreased endothelial or tissue damage markers among all patients enrolled in the STAAMP Trial. We collected blood samples from STAAMP Trial patients and measured markers of endothelial function and tissue damage including syndecan-1, soluble thrombomodulin (sTM), and platelet endothelial cell adhesion molecule-1 (PECAM-1) at hospital admission (0 hours) and 12, 24, and 72 hours after admission. We compared these marker values for patients in each treatment group during the first 72 hours, and modeled the relationship between TXA and marker concentration using regression analysis to control for potential confounding factors. We analyzed samples from 766 patients: 383 placebo, 130 abbreviated dosing, 119 standard dosing, and 130 repeat dosing. Lower levels of syndecan-1, TM, and PECAM measured within the first 72 hours of hospital admission were associated with survival at 30 days (P < 0.001). At hospital admission, syndecan-1 was lower in the TXA group (28.30 [20.05, 42.75] vs. 33.50 [23.00, 54.00] P = 0.001) even after controlling for patient, injury, and prehospital factors (P = 0.001). For every 1 g increase in TXA administered over the first 8 hours of prehospital transport and hospital admission, there was a 4 ng/mL decrease in syndecan-1 at 12 hours controlling for patient, injury, and treatment factors (P = 0.03). Prehospital TXA was associated with decreased syndecan-1 at hospital admission. Syndecan-1 measured 12 hours after admission was inversely related to the dose of TXA received. Early pre- and in-hospital TXA may decrease endothelial glycocalyx damage or upregulate vascular repair mechanisms in a dose-dependent fashion. Level II, Secondary analysis of a prospective randomized trial.

Open Access
The Reports of my Death are Greatly Exaggerated: An Evaluation of Futility Cut-Points in Massive Transfusion

Following COVID and the subsequent blood shortage, several investigators evaluated futility cut-points in massive transfusion. We hypothesized that early, aggressive use of damage control resuscitation, including whole blood (WB), would demonstrate that these cut-points of futility were significantly underestimating potential survival among patients receiving >50 units of blood in the first four hours. Adult trauma patients admitted from 11/2017-10/2021 who received emergency-release blood products in prehospital or ED setting were included. Deaths within 30 min of arrival were excluded. Total blood products were defined as total RBC, plasma, WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or > 50 units of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy (COMP). 30-day survival was evaluated for all included patients. 2,299 patients met inclusion (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or gender, the >50 U group was more likley to sustain penetrating injury (47 vs 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and ED resuscitation volumes (p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31 vs 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared to those who received COMP (n = 1,008)(1.09-1.87, p = 0.009) as well as higher 30-day survival at transfusion volumes >50 U. Patient survival rates in patients receiving >50 units of blood in the first 4 hours of care are as high as 50-60%, with survival still at 15-25% after 100 units. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone. Level III, Retrospective comparative study without negative criteria.

Characterization of fatal blunt injuries using postmortem computed tomography

Rapid triage of blunt agonal trauma patients is necessary to maximize survival, but autopsy is uncommon, slow, and rarely informs resuscitation guidelines. Post-mortem computed tomography (PMCT) can serve as an adjunct to autopsy in guiding blunt agonal trauma resuscitation. Retrospective cohort review of trauma decedents who died at or within 1 hour of arrival following blunt trauma and underwent non-contrasted PMCT. Primary outcome was the prevalence of mortal injury defined as potential exsanguination (e.g., cavitary injury, long bone and pelvic fractures), traumatic brain injury, and cervical spine injury. Secondary outcomes were potentially mortal injuries (e.g., pneumothorax) and misplacement airway devices. Patients were grouped by whether arrest occurred pre-/in-hospital. Univariate analysis was used to identify differences in injury patterns including polytrauma injury patterns. Over a 9-year period, 80 decedents were included. Average age was 48.9 ± 21.7 years, 68% male, and an average ISS of 42.3 ± 16.3. The most common mechanism was motor vehicle accidents (67.5%) followed by pedestrian struck (15%). Of all decedents, 62 (77.5%) had traumatic arrest prehospital while 18 (22.5%) arrived with pulse. Between groups there were no significant differences in demographics including ISS. The most common mortal injuries were traumatic brain injury (40%), long bone fractures (25%), moderate/large hemoperitoneum (22.5%), and cervical spine injury (25%). Secondary outcomes included moderate/large pneumothorax (18.8%) and esophageal intubation rate of 5%. There were no significant differences in mortal or potentially mortal injuries, and no differences in polytrauma injury patterns. Fatal blunt injury patterns do not vary between pre- vs in-hospital arrest decedents. High rates of pneumothorax and endotracheal tube misplacement should prompt mandatory chest decompression and confirmation of tube placement in all blunt arrest patients. III, prognostic and epidemiological.

Funding the war in America: A look in the mirror

Healthcare political action committees (HPACs) historically contribute more to candidates opposing firearm restrictions (FR), clashing with their affiliated medical societies. These societies have increasingly emphasized the prevention of firearm violence and it is not known if recent contributions by their HPACs have aligned with their stated goals. We hypothesized such HPACs still contribute similar amounts towards legislators up for re-election opposing FR. We identified HPACs of medical societies endorsing one or both calls-to-action against firearm violence published in the Annals of Internal Medicine (2015, 2019). House of Representatives (HOR) votes on H.R.8, a background checks bill, were characterized from GovTrack. We compiled HPAC contributions between the H.R.8 vote and election to HOR members up for re-election from the National Institute on Money in Politics. Our primary outcome was total campaign contributions by H.R.8 stance. Secondary outcomes included percentage of politicians funded and total contributions. Nineteen societies endorsed one or both call-to-action papers. 385/430 HOR members ran for re-election in 2020. Those endorsing H.R.8 (N = 226, 59%) received $2.8 M for $4,750 (IQR $1000-$15,500) per candidate. Those opposing (N = 159, 41%) received $1.5 M for $2,500 (IQR $0-$11,000) per candidate (p = 0.0057). HPACs donated towards a median of 20% (IQR 7-28) of candidates endorsing H.R.8 and 9% (IQR 4-22) of candidates opposing H.R.8 (p = 0.0014). Those endorsing H.R.8 received 1,585 total contributions for a median of 3 (IQR 1-10) contributions per candidate, while those opposing received 834 total contributions for a median of 2 (IQR 0-7) contributions per candidate (p = 0.0029). Politicians voting against background checks received substantial contributions toward reelection from the HPACs of societies advocating for firearm restrictions. However, this is the first study to suggest that HPAC's contributions have become more congruent with their respective societies. Further alignment of medical society goals and their HPAC political contributions could have a profound impact on firearm violence. Level III, Prognostic/Epidemiological.

Epidemiology and Outcomes of Traumatic Vascular Injury Repair by Trauma Surgeons and Vascular Surgeons in a Collaborative Model

Management roles for peripheral vascular injuries (PVI) are a source of ongoing debate given the concern for the loss of vascular skills among general and trauma surgeons. We sought to analyze outcomes of PVI managed by trauma surgeons (TS) or vascular surgeons (VS). This is a retrospective study of a single, level 1 trauma center. Trauma patients with PVI who underwent repair from 2010 to 2021 were included. Patients were separated into groups by the surgical specialty (TS or VS) undertaking the first intervention of the injured vessel. A total of 194 patients were included, with 101 (52%) PVI managed by TS and 93 (48%) by VS. The TS group had more penetrating injuries (84% vs 63%, p < 0.01), were more often hypotensive (17% vs 6%, p = 0.01), and had a higher median Injury Severity Score (ISS) (10 vs 9, p < 0.001). Time from arrival to OR was lower in the TS group (77 vs 257 mins, p < 0.01), with no difference in rates of preoperative imaging. The TS group performed damage control surgery (DCS) more frequently (21% vs 1.1%, p < 0.01). There was no difference in reintervention rates between the two groups after excluding patients that required reintervention for definitive repair after DCS (13% vs 9%, p = 0.34). Mortality was 8% in the TS group and 1% in the VS group (p = 0.02) with no deaths related to the PVI repair in either group. There was no difference in PVI repair complication rates between the two groups (18% vs 13%; p = 0.36). In our collaborative model at a high-volume trauma center, a wide variety of PVI are surgically managed by TS with VS immediately available for consultation or for definitive repair of more complex vascular injuries. TS performed more DCS on higher acuity patients. No difference in vascular-related complications was detected between groups. Level V, Prognostic/Epidemiological.

Bio-Adhesive Patch as a Parenchymal Sparing Treatment of Acute Traumatic Pulmonary Air Leaks

Traumatic pulmonary injuries are common in chest trauma. Persistent air leaks occur in up to 46% of patients depending on injury severity. Prolonged leaks are associated with increased morbidity and cost. Prior work from our 1st generation pectin patches successfully sealed pulmonary leaks in a cadaveric swine model. We now test the next generation pectin patch against wedge resection in the management of air leaks in anesthetized swine. A continuous air leak of 10-20% percent was created to the anterior surface of the lung in intubated and sedated swine. Animals were treated with a 2-ply pectin patch or stapled wedge resection. Tidal volumes (TV) were recorded pre and post injury. Following repair, TV were recorded, a chest tube was placed, and animals were observed for presence air leak at closure, and for an additional 90 minutes while on positive pressure ventilation. Mann Whitney u-test and Fisher's exact test used to compare continuous and categorical data between groups. Thirty-one animals underwent either stapled wedge resection (SW = 15) or pectin patch repair (PPR = 16). Baseline (BL) characteristics were similar between animals excepting BL TV (SW = 10.3 ml/kg vs PPR = 10.9 ml/kg, p = 0.03). There was no difference between groups for severity of injury based on percent of TV loss (SW = 15% vs PPR = 14%, p = 0.5). There was no difference in TV between groups following repair (SW = 10.2 ml/kg vs PPR = 10.2 ml/kg, p = 1) or at the end of observation (SW = 9.8 ml/kg vs PPR = 10.2 ml/kg, p = 0.4, see figure). One chamber intermittent air leaks were observed in 3 of the PPR animals, vs 1 in the SW group (p = 0.6). Pectin patches effectively sealed the lung following injury and were non-inferior when compared to wedge resection for the management of acute traumatic air leaks. Pectin patches may offer a parenchymal sparing option for managing such injuries, though studies evaluating bio-durability are needed.Study type: Therapeutic.