24-hour Mortality Research Articles

A Comparison between Traumatic and Atraumatic Over-The-Scope-Clips in patients with Duodenal Ulcer Bleeding: a Retrospective Analysis with Propensity-Score-based Matching.

The over-the-scope-clip (OTSC) substantially improved the endoscopic armamentarium for the treatment of severe gastrointestinal bleeding and can potentially overcome limitations of standard clips. Recent data indicated a superiority of OTSC in hemostasis as first and second line therapy. However, the impact of the OTSC design (traumatic (-t) or atraumatic (-a) type) in particular in duodenal ulcer bleeding has not been analyzed so far. Retrospective analysis of a prospective collected database from 2009 until 2020 of six German endoscopic centers. All patients who underwent emergency endoscopy and were treated by an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by Fisher's exact test, chi-square- or Mann-Whitney U-test as appropriate. A propensity-score based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups. The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall-Score and treatment regimen had similar distributions in the two groups. However, OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a: 90.9%, OTSC-t: 87.9%, p=0.82) or 72h-mortality (OTSC-a: 4.5%, OTSC-t: 6.0%, p>0.99) were not significantly different but the OTSC-t group revealed a clearly higher rate of rebleeding (34.9% vs. 7.6%, p<0.001) and necessity of red blood cell transfusions (5.1±3.4 vs. 2.5±2.4 concentrates, p<0.001). OTSC-a should be the preferred option for duodenal ulcer bleeding if the endoscopist aims for an over-the-scope-clip.

Improving Mortality Risk Prediction with Routine Clinical Data: A Practical Machine Learning Model Based on eICU Patients.

Mortality risk prediction helps clinicians make better decisions in patient healthcare. However, existing severity scoring systems or algorithms used in intensive care units (ICUs) often rely on laborious manual collection of complex variables and lack sufficient validation in diverse clinical environments, thus limiting their practical applicability. This study aims to evaluate the performance of machine learning models that utilize routinely collected clinical data for short-term mortality risk prediction. Using the eICU Collaborative Research Database, we identified a cohort of 12,393 ICU patients, who were randomly divided into a training group and a validation group at a ratio of 9:1. The models utilized routine variables obtained from regular medical workflows, including age, gender, physiological measurements, and usage of vasoactive medications within a 24-hour period prior to patient discharge. Four different machine learning algorithms, namely logistic regression, random forest, extreme gradient boosting (XGboost), and artificial neural network were employed to develop the mortality risk prediction model. We compared the discrimination and calibration performance of these models in assessing mortality risk within 1-week time window. Among the tested models, the XGBoost algorithm demonstrated the highest performance, with an area under the receiver operating characteristic curve (AUROC) of 0.9702, an area under precision and recall curves (AUPRC) of 0.8517, and a favorable Brier score of 0.0259 for 24-hour mortality risk prediction. Although the model's performance decreased when considering larger time windows, it still achieved a comparable AUROC of 0.9184 and AUPRC of 0.5519 for 3-day mortality risk prediction. The findings demonstrate the feasibility of developing a highly accurate and well-calibrated model based on the XGBoost algorithm for short-term mortality risk prediction with easily accessible and interpretative data. These results enhance confidence in the application of the machine learning model to clinical practice.

Development and Validation of Two Prediction Models for 72-Hour Mortality in High-Risk Trauma Patients Using a Benchmark Dataset: A Comparative Study of Logistic Regression and Neural Networks Models.

Background Many studies have been conducted to develop scoring systems for trauma patients, with the majority using logistic regression (LR) models. Neural networks (NN), which is a machine learning algorithm, has a potential to increase the performance of these models. Objectives The aim of this study was to develop and validate two separate prediction models for 72-hour mortality of high-risk trauma patients using LR and NN and to compare the performances of these models in detail. We also aimed to share the SPSS calculators for our models. Materials and methods This is a retrospective, single-center study conducted using a benchmark dataset where the patients were retrospectively gathered from a level 1 trauma center. Patients older than 18 years of age, who had multiple injuries, and were treated at the University Hospital Zurich between January 1, 1996, and January 1, 2013, were included. Patients with a condition that may have an impact on the musculoskeletal system, with Injury Severity Score<16, and with missing outcome data were excluded. Results A total of 3,075 patients were included in the analysis. The area under the curve values of the LR and NN models for predicting 72-hour mortality in patients with high-risk trauma in the hold-out cohort were 0.859 (95% CI=0.836 to 0.883) and 0.856 (95% CI=0.831 to 0.880), respectively. There was no statistically significant difference in the performance of the models (p = 0.554, DeLong's test). Conclusion Both of the models showed good discrimination. Our study suggests that the NN and LR models we developed hold promise as screening tools for predicting 72-hour mortality in high-risk trauma patients. These models were made available to clinicians as clinical prediction tools via SPSS calculators. However, further external validation studies in diverse populations are necessary to substantiate their clinical utility. Moreover, in subsequent studies, it would be beneficial to derive NN models with substantial events per predictor variable to attain more robust and greater predictive accuracy. If the dataset is relatively limited, using LR seems to be a viable alternative.

In-Hospital Deaths From Ambulatory Care–Sensitive Conditions Before and During the COVID-19 Pandemic in Japan

The COVID-19 pandemic may have played a role in the deterioration of access to medical care for ambulatory care-sensitive conditions (ACSCs). To ascertain whether the number of in-hospital deaths and in-hospital mortality rate associated with ACSC changed after the declaration of the COVID-19 national state of emergency in Japan. This cohort study used a difference-in-differences design to compare outcomes for ACSC in the period before (January 1, 2015, to December 31, 2019) vs the period after (January 1, 2020, to December 31, 2020) Japan declared a national state of emergency for the COVID-19 pandemic. Analyses used discharge summary data from 242 acute care hospitals across Japan. The sample comprised unscheduled hospitalizations of patients with ACSC during the study period (January 1, 2015, to December 31, 2020). Data analyses were performed between August 16 and December 7, 2022. The declaration of the COVID-19 national state of emergency announced by the Japanese government in April 2020 was considered to be an exogenous shock. Primary outcomes were the ACSC-associated number of in-hospital deaths, number of hospitalizations, and in-hospital mortality rate. A total of 28 321 ACSC-related hospitalizations were observed involving 15 318 males (54.1%), with a median (IQR) age of 76 (58-85) years. The number of in-hospital deaths was 2117 (7.5%). The number of hospitalizations decreased overall (incidence rate ratio [IRR], 0.84; 95% CI, 0.75-0.94), for chronic conditions (IRR, 0.84; 95% CI, 0.77-0.92), and for vaccine-preventable conditions (IRR, 0.58; 95% CI, 0.44-0.76). However, in-hospital deaths (IRR, 1.66; 95% CI, 1.15-2.39) and in-hospital deaths within 24 hours of hospital arrival (IRR, 7.27 × 106; 95% CI, 1.83 × 106 to 2.89 × 107) increased for acute conditions. The in-hospital mortality rate increased for acute conditions (IRR, 1.71; 95% CI, 1.16-2.54), and the 24-hour in-hospital mortality rates also increased overall (IRR, 1.87; 95% CI, 1.19-2.96), for acute conditions (IRR, 2.15 × 106; 95% CI, 5.25 × 105 to 8.79 × 106), and for vaccine-preventable conditions (IRR, 4.64; 95% CI, 1.28-16.77). This cohort study found that in Japan, the number of in-hospital deaths increased after the declaration of the COVID-19 national state of emergency in 2020, particularly for acute ACSC and deaths within 24 hours of hospital admission. This finding suggests that access to good-quality primary care and inpatient care for patients with acute ACSC may have been compromised during the pandemic.

Comparison of Outcomes Relating to REBOA Inflation Zones: Report from the ABO Trauma Registry

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporary management modality for non-compressible torso haemorrhage that can be deployed in the pre- and intrahospital setting. This study aimed to compare outcomes following balloon placement in the three aortic zones.&#x0D; Methods: This is a retrospective study using data from the ABO Trauma Registry. Relevant entries from January 2014 to December 2019 were used and stratified into three groups: those who received Zone 1, 2, or 3 balloon placements.&#x0D; Results: The study sample consisted of 237 patients: 63 (27%) women and 174 (73%) men, median age 35 years. The primary location of the REBOA balloon was in Zone 1 for 180 patients, while it was nine in Zone 2 and 48 in Zone 3. Complication rates and total durations did not differ significantly between inflation zones. Emergency department mortality rates for Zones 1 and 2 patients were significantly higher than for Zone 3 (P = 0.04), but there was no difference between groups in 24-hour and 30-day mortality rates.&#x0D; Conclusions: REBOA is currently used in the emergency setting for temporary stabilisation of the bleeding patient. In this cohort, balloon placement occurred in all zones of the aorta for similar durations, with no difference in complication rates between zones. Inadvertent Zone 2 placement was not found to be associated with increased complication rates.

Optimal dose of cryoprecipitate in massive transfusion following trauma.

While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. Prognostic and Epidemiologic; Level IV.

Experience of surgical treatments for abdominal inferior vena cava injuries in a regional trauma center in Korea.

Inferior vena cava (IVC) injuries are a rare type of traumatic abdominal injuries that are challenging to treat and have a very high mortality rate. This study described our experience with the surgical treatment of traumatic IVC injuries, and we investigated the demographics, clinical profiles, and surgical outcomes of cases at a regional trauma center. Among the 16 patients who were treated for a traumatic IVC injury between January 2014 and March 2022, 14 underwent surgery. The surgical outcomes included overall mortality and 24-hour mortality, and we investigated the factors associated with these surgical outcomes. The 14 patients were divided into two groups according to the location of the IVC injury (retrohepatic IVC or higher vs. subhepatic IVC), and differences between the two groups were analyzed. A body mass index (BMI) >23.0 kg/m2 (P=0.046), an elevated serum lactate level (P=0.043), and a shorter operation time (P=0.016) were associated with overall mortality. A higher BMI (P=0.050), higher serum lactate level (P=0.004), shorter operation time (P=0.005), and an injury at the retrohepatic IVC or higher level (P=0.031) were associated with 24-hour mortality. Younger age (P=0.028), higher BMI (P=0.005), more acidic pH, higher lactatemia (P=0.012), a higher hemoglobin level (P=0.012), and shorter door-to-operating room time (P=0.028) were associated with injury at the retrohepatic IVC or higher level. Patients with subhepatic IVC injuries had a high rate of direct repair (75.0%) and a significantly lower 24-hour mortality rate (37.5%, P=0.031). Subhepatic IVC injuries are easy to access and are usually expected to treat with a direct repair method. Injuries at the retrohepatic IVC or higher level are difficult to treat surgically and require a systematic and multidisciplinary treatment strategy.

PULSE WAVE VELOCITY AND BLOOD PRESSURE VARIABILITY AS PROGNOSTIC INDICATORS IN VERY ELDERLY PATIENTS WITH DECOMPENSATED CHRONIC CONDITIONS

Objective: There is scarce evidence of the prognostic importance of hemodynamic measures, such as blood pressure (BP), BP variability and arterial stiffness in the very elderly population with advanced chronic conditions. We aimed to evaluate the prognostic importance of 24-hour BP, BP variability and arterial stiffness in a cohort of very elderly patients admitted to the hospital due to a decompensated chronic disease. Design and method: We studied 249 patients older than 80 (66% women), admitted due to a chronic disease decompensation (60% congestive heart failure). During admission, 24-hour brachial and central BP, BP and heart rate variabilities, aortic pulse wave velocity and BP variability ratio were determined through non-invasive 24-hour monitoring. The primary outcome was 1-year mortality. Secondary outcome was the composite of 1-year mortality or readmission. Results: Increased arterial stiffness (aortic pulse wave velocity and BP variability ratio) was associated with 1-year mortality. For each standard deviation (SD) increase in aortic pulse wave velocity and BP variability ratio, mortality increased 3.3 times and 31%, respectively, after adjustments for clinical confounders and BP. Increased BP variability (38% increase for each SD change) and reduced heart rate variability (32% increase for each SD change) also predicted 1-year mortality in fully adjusted models. No association was found between 24-hour BP (either brachial or aortic) and 1-year mortality. Conclusions: Increased aortic stiffness and BP and heart rate variabilities predict 1-year mortality in very elderly patients with decompensated chronic conditions. Measurements of such estimates could be useful in the prognostic evaluation of this specific population.

The impact of thromboelastography on patients with penetrating abdominal trauma requiring intensive care.

Trauma-induced coagulopathy (TIC) is a complex multifaceted process which contributes to higher mortality rates in severely injured trauma patients. Thromboelastography (TEG) is effective in detecting TIC which assists in instituting goal-directed therapy as part of damage control resuscitation. This retrospective study included all adult patients over a 36-month period with penetrating abdominal trauma who required a laparotomy, blood products and admission for critical care. Analysis included demographics, admission data, 24-hour interventions, TEG parameters and 30-day outcomes. Eighty-four patients with a median age of 28 years were included. The majority (93%; 78/84) suffered from a gunshot injury, with 75% (63/84) receiving a damage control laparotomy. Forty-eight patients (57%) had a TEG. Injury severity score and total fluid and blood product administered in the first 24 hours were all significantly higher in patients who had a TEG (p < 0.05). TEG profiles were: 42% (20/48) normal, 42% (20/48) hypocoagulable, 12% (6/48) hypercoagulable and 4% (2/48) mixed parameters. Fibrinolysis profiles were: 48% (23/48) normal, 44% (21/48) fibrinolysis shutdown and 8% (4/48) hyperfibrinolysis. Mortality rate was 5% (4/84) at 24 hours and 26% (22/84) at 30 days, with no difference between the two groups. High-grade complication rates, days on a ventilator and intensive care unit length of stay were all significantly higher in patients who did not have a TEG. TIC is common in severely injured penetrating trauma patients. The usage of a thromboelastogram did not impact on 24-hour or 30-day mortality but did result in a decreased intensive care stay and a decreased high-grade complication rate.

Virulent and attenuated strains of Trichoderma citrinoviride mediated resistance and biological control mechanism in tomato.

Root-knot nematode disease is one of the world's most serious vegetable crop diseases. In recent years, Trichoderma spp. has been widely used in root-knot nematode disease control as a biological control agent. Virulent and attenuated strains of Trichoderma citrinoviride mediated resistance and biological control mechanism in tomato were determined. Preliminary experiments found differences in nematicidal virulence among Trichoderma citrinoviride. The 24-hour corrected mortality rate of the virulent strainT1910 was as high as 92.37%, with an LC50 of 0.5585 against the second juveniles (J2s) of Meloidogyne incognita. And the attenuated strain TC9 was 23.01%, the LC50 was 2.0615, so the virulent strain T1910 had a more substantial effect on the J2s than the attenuated strain. We found that the strong virulent strain T1910 have a good control effect on M. incognita by the pot experiment of tomato than that of the attenuated virulent strain TC9,especially the J2 and J4 numbers were inhibited inside the root knots of tomato. Theinhibition rates of virulent strains reached 85.22% and 76.91%, followed by attenuatedstrain TC9, which were 63.16% and 59.17%, respectively. To reveal the differences intomato defense pathways induced by different virulent strains, qRT-PCR was further usedto detect changes in the expression of inducement-related genes. The results showed thatthe TC9 was significantly upregulated at 5dpi, LOX1, PR1, and PDF1.2. The PR5 gene ofthe virulent strain T1910 was highly upregulated, and the JA pathway was activated laterbut weaker than the attenuated strain. The results of this study revealed that thebiocontrol mechanism of T. citrinoviride as poison killing through the virulent strain T1910 and induced resistance to M. incognita through attenuated strain, although virulence degradation also has an induced resistance effect. Moreover, the attenuated strain TC9 stimulated tomato immune response earlier than the virulent strain by nematode-associated molecular pattern-triggered (NAMP). Therefore, the research elucidated the mechanism of multiple control of Trichoderma spp. against M. incognita.

Long-term outcomes following exclusive use of endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysms.

Long-term outcomes following exclusive use of endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysms.

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

Optimal hemostatic resuscitation in pediatric trauma is not well defined. To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.

Acute Complications of Pre-Resection CSF Diversion in Posterior Fossa Tumors with Hydrocephalus

Study background and significance: Posterior fossa tumors are a common pathology worldwide and often present with obstructive hydrocephalus. In the year 2021 CSF diversion for acute hydrocephalus from brain tumors was the most common performed emergency procedure in Tikur Anbessa hospital. It is a clinical dilemma choosing the mode of management for the hydrocephalus as it could be a lifesaving procedure but with a risk of unfortunate and devastating outcome. Objective: The aim of the study will be to evaluate the acute complications that occur with CSF diversion procedures that are done for obstructive hydrocephalus in the presence of posterior fossa mass before tumor resection. Method: It will be prospective observational study conducted at Tikur anbessa specialized hospital, which will be held from March 2021 up to October 2022. The research will involve all patients who have undergone CSF diversion procedure for obstructive hydrocephalus from posterior fossa tumors prior to tumor resection and patients will be followed for the first 48 hours post operatively. Patient’s presentation, nature of the posterior fossa tumor on imaging, post-operative clinical status and post op imaging will be taken to account. Result: In the study time frame of 18 months there were 89 patients who came with acute obstructive hydrocephalus from posterior fossa of which all underwent CSF diversion procedure before tumor resection. 52.8% were pediatrics and 47.2% where adults. The most common tumor location was vermian (31.5%) followed by cerebellar hemisphere (29.2%), 4th ventricular (25.8%) and the rest 9% account for cranial nerve and extra axial location. The largest tumor was 9.8cm but the median was 5.1cm. Based on the size they were categorized in to 3 groups, 71.9% were tumor size 4-6cm, 22.5% had a tumor size of &gt;6cm and there were 5.6% with tumor size &lt;4cm. Of the CSF diversion procedures performed 93.3% were VPS, EVD and ETV account for 3.4% each. All were followed for 48 hours post op and 8 patients had clinical deterioration after CSF diversion was done, and all patients with clinical deterioration underwent urgent non -contrast CT scan. They were found to have upward herniation, intra-tumoral bleeding, intraventricular hemorrhage or a combination of these findings. Of the 8 patients that deteriorated 5 died without successful resuscitation. The rest 3 improved and underwent definitive surgery. The risk for postoperative deterioration was 8.9% and 48-hour mortality was 5.6%. Variables were chosen to check association with the outcome (post-operative deterioration). Variables tested include age of the patient, tumor size and tumor location, all did not have statistically significant relationship with outcome (post-operative deterioration and 48-hour mortality). The association between the type of intervention and outcome could not be checked as there were not enough samples representing ETV/EVD performed, and majority (93.3%) were VPS. Conclusion: Through our research we tried to investigate the causes of acute deterioration after CSF diversion done for obstructive hydrocephalus from posterior fossa tumors by assessing the tumor size, location the type of intervention. Through our research we were not able to find any association from investigated factors and post-operative deterioration. Because of our limitation (the low number of sample size and not having enough number of ETV and EVD in the study population) we recommend further research is needed to have more information in this problem.

Whole blood transfusion in the treatment of acute hemorrhage, a systematic review and meta-analysis.

Whole blood (WB) transfusion received renewed interest after recent armed conflicts. The effectiveness as compared with blood component transfusion (BCT) is, however, still topic of debate. Therefore, this study investigated the effect of WB ± BCT as compared with BCT transfusion on survival in trauma patients with acute hemorrhage. Studies published up to January 16, 2023, including patients with traumatic hemorrhage comparing WB ± BCT and BCT were included in meta-analysis. Subanalyses were performed on the effectiveness of WB in the treatment of civilian or military trauma patients, patients with massive hemorrhage and on platelet (PLT)/red blood cell (RBC), plasma/RBC and WB/RBC ratios. Methodological quality of studies was interpreted using the Cochrane risk of bias tool. The study protocol was registered in PROSPERO under number CRD42022296900. Random effect pooled odds ratio (OR) for 24 hours mortality in civilian and military patients treated with WB as compared with BCT was 0.72 (95% confidence interval [CI], 0.53-0.97). In subanalysis of studies conducted in civilian setting (n = 20), early (4 hours, 6 hours, and emergency department) and 24 hours mortality was lower in WB groups compared with BCT groups (OR, 0.65; 95% CI, 0.44-0.96 and OR, 0.71; 95% CI, 0.52-0.98). No difference in late mortality (28 days, 30 days, in-hospital) was found. In military settings (n = 7), there was no difference in early, 24 hours, or late mortality between groups. The WB groups received significant higher PLT/RBC ( p = 0.030) during early treatment and significant higher PLT/RBC and plasma/RBC ratios during 24 hours of treatment ( p = 0.031 and p = 0.007). The overall risk of bias in the majority of studies was judged as serious due to serious risk on confounding and selection bias, and unclear information regarding cointerventions. Civilian trauma patients with acute traumatic hemorrhage treated with WB ± BCT as compared to BCT had lower odds on early and 24-hour mortality. In addition, WB transfusion resulted in higher PLT/RBC and plasma/RBC ratios. Systematic Review and Meta-Analysis; Level III.

Abstract 542: Short Term High Consumption Of Aspartame Does Not Increase Infarct Volume And Stroke Mortality In Mouse Models Of Focal Ischemic Stroke

Background: Aspartame is an artificial sweetener that has been widely used in beverages and foods. Recently, higher intake of artificially sweetened beverages was shown to be associated with increased risk of stroke. Objective: To investigate if short-term high consumption of aspartame could increase cerebral infarct volume and mortality in mouse models of focal ischemic stroke. Methods: Eleven-week-old male C57BL/6N mice (n=90) received one of the following three treatments for 7 days: phosphate-buffered saline (PBS), aspartame 200 mg/kg in PBS, and aspartame in Zero Coke (with the final dose of aspartame being 200 mg/kg). Thereafter, either transient middle cerebral artery occlusion for 1 hour (1h-tMCAO; n=27, 9/group) or common carotid artery occlusion (CCAO)-related hemispheric ischemia with cerebral autoregulatory dysfunction (CCAO+CAD; n=63, 21/group) was induced. To measure the infarct volume, 2,3,5-Triphenyltetrazolium chloride staining was performed at 24 hours after tMCAO and 6 days after CCAO+CAD. Results: 1h-tMCAO-related 24-hour mortality and infarct volume (of survived animals) did not differ significantly among the three groups (both p&gt;0.05): PBS (5/9 death and 93.7±30.0mm 3 ), aspartame in PBS (2/9 death and 102±50.0mm 3 ), and aspartame in Zero Coke (4/9 death and 111.4±17.4mm 3 ). CCAO+CAD-related mortality 6-day mortality did not show inter-group differences (p&gt;0.05): PBS (n=9/21, 42.9 %), aspartame in PBS (n=12/21, 57.1 %), and aspartame in Zero Coke (n=8/21, 38 %). Among the survived, infarct volume did not significantly differ, either (p&gt;0.05): PBS (60.8±68.0mm 3 ), aspartame in PBS (58.5±68.0mm 3 ), and aspartame in Zero Coke (54.2±48.3mm 3 ). Conclusions: Short-term high consumption of aspartame did not increase cerebral infarct volume and stroke-related mortality in our experimental setting. Category: Peripheral Artery Disease, Carotid Artery Disease and Stroke

Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement.

Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients. The American College of Surgeons TQIP 2017 to 2019 database was analyzed. Adult trauma patients who received at least 1 unit of WB within the first 2 hours of admission were included. Patients were stratified by time to first unit of WB transfusion (first 30 minutes, second 30 minutes, and second hour). Primary outcomes were 24-hour and in-hospital mortality, adjusting for potential confounders. A total of 1,952 patients were identified. Mean age and systolic blood pressure were 42 ± 18 years and 101 ± 35 mmHg, respectively. Median Injury Severity Score was 17 [10 to 26], and all groups had comparable injury severities (p = 0.27). Overall, 24-hour and in-hospital mortality rates were 14% and 19%, respectively. Transfusion of WB after 30 minutes was progressively associated with increased adjusted odds of 24-hour mortality (second 30 minutes: adjusted odds ratio [aOR] 2.07, p = 0.015; second hour: aOR 2.39, p = 0.010) and in-hospital mortality (second 30 minutes: aOR 1.79, p = 0.025; second hour: aOR 1.98, p = 0.018). On subanalysis of patients with an admission shock index >1, every 30-minute delay in WB transfusion was associated with higher odds of 24-hour (aOR 1.23, p = 0.019) and in-hospital (aOR 1.18, p = 0.033) mortality. Every minute delay in WB transfusion is associated with a 2% increase in odds of 24-hour and in-hospital mortality among hemorrhaging trauma patients. WB should be readily available and easily accessible in the trauma bay for the early resuscitation of hemorrhaging patients.

Difference in outcomes of pediatric septic shock after fluid resuscitation according to the Ultrasound-guided Fluid Resuscitation (USFR) and American College of Critical Care Medicine (ACCM) protocols: A randomized clinical trial

Background Sepsis is a major cause of morbidity and mortality in children. The American College of Critical Care Medicine (ACCM) protocol currently in use in the management of septic shock carries a risk of fluid overload. With the use of ultrasonographic monitoring, the Ultrasound-guided Fluid Resuscitation (USFR) protocol may reduce the incidence of fluid overload and mortality.&#x0D; Objective To assess the difference in outcomes of fluid resuscitation in pediatric septic shock using the USFR vs. ACCM protocols.&#x0D; Methods This randomized clinical trial involved 36 subjects randomized equally into the USFR and ACCM groups. After randomization, each subject was given fluid resuscitation starting at 20 mL/kg and repeated every 5-10 minutes as needed, according to the ACCM protocol. After fluid resuscitation was given, patients in the ACCM group were evaluated for clinical signs, liver span, and rhonchi, whereas those in the USFR group underwent USCOM examination for cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI). After 60 minutes, subjects in both groups were re-assessed for clinical signs, USCOM, pulmonary edema using lung ultrasound score (LUS), and liver span. Subjects were blinded as to the protocol they received. We compared 24-hour and 72-hour mortality rates, clinical improvement of shock at 60 minutes, cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI), as well as pulmonary edema and hepatomegaly, between the two groups.&#x0D; Results At 60 minutes after resuscitation, there were significant differences between the ACCM and USFR groups in the proportion of clinical improvement (0/18 vs. 5/18, P=0.016), pulmonary edema (15/18 vs. 4/18, P&lt;0.001), and hepatomegaly (16/18 vs. 5/18, P&lt;0.001). Mortality rates at 24 hours and 72 hours in the ACCM vs. USFR groups were 17% vs. 12% (P=0.199) and 78% vs. 39% (P=0.009), respectively.&#x0D; Conclusion The USFR protocol reduces the occurrence of fluid overload and leads to a lower mortality rate at 72 hours compared to the ACCM fluid resuscitation protocol.

Optimal Prehospital Crystalloid Resuscitation Volume in Trauma Patients at Risk for Hemorrhagic Shock.

Prehospital resuscitation guidelines vary widely and blood products, although likely superior, are not available for most patients in the prehospital setting. Our objective was to determine the prehospital crystalloid volume associated with the lowest mortality among patients in hemorrhagic shock. This is a secondary analysis of the Prehospital Air Medical Plasma trial. Injured patients from the scene with hypotension and tachycardia or severe hypotension were included. Segmented regression and generalized additive models (GAM) were used to evaluate non-linear effects of prehospital crystalloid volume on 24-hour mortality. Logistic regression evaluated the association between risk-adjusted mortality and prehospital crystalloid volume ranges to identify optimal target volumes. Inverse propensity weighting was performed to account for patient heterogeneity. There were 405 patients included. Segmented regression suggested the nadir of 24-hour mortality lay within 377-1419mL of prehospital crystalloid. GAM suggested the nadir of 24-hour mortality lay within 242-1333mL of prehospital crystalloid. A clinically operationalized range of 250-1250mL was selected based on these findings. Odds of 24-hour mortality were higher for patients receiving <250mL (aOR 2.46; 95%CI 1.31-4.83, p=0.007) and >1250mL (aOR 2.57; 95%CI 1.24-5.45, p=0.012) compared to 250-1250mL. Propensity weighted regression similarly demonstrated odds of 24-hour mortality were higher for patients receiving <250mL (aOR 2.62; 95%CI 1.34-5.12, p=0.005) and >1250mL (aOR 2.93; 95%CI 1.36-6.29, p=0.006) compared to 250-1250mL. Prehospital crystalloid volumes between 250-1250mL are associated with lower mortality compared to lower or higher volumes. Further work to validate these finding may provide practical volume targets for prehospital crystalloid resuscitation.

More emergency patients presenting with chest pain.

Throughout recent years the demand for prehospital emergency care has increased significantly. Non-traumatic chest pain is one of the most frequent complaints. Our aim was to investigate the trend in frequency of the most urgent ambulance patients with chest pain, subsequent acute myocardial infarction (AMI) diagnoses, and 48-hour and 30-day mortality of both groups. Population-based historic cohort study in the North Denmark Region during 2012-2018 including chest pain patients transported to hospital by highest urgency level ambulance following a 1-1-2 emergency call. Primary diagnoses (ICD-10) were retrieved from the regional Patient Administrative System, and descriptive statistics (distribution, frequency) performed. We evaluated time trends using linear regression, and mortality (48 hours and 30 days) was assessed by the Kaplan Meier estimator. We included 18,971 chest pain patients, 33.9% (n = 6,430) were diagnosed with"Diseases of the circulatory system" followed by the non-specific R- (n = 5,288, 27.8%) and Z-diagnoses (n = 3,634; 19.2%). AMI was diagnosed in 1,967 patients (10.4%), most were non-ST-elevation AMI (39.7%). Frequency of chest pain patients and AMI increased 255 and 22 patients per year respectively, whereas the AMI proportion remained statistically stable, with a tendency towards a decrease in the last years. Mortality at 48 hours and day 30 in chest pain patients was 0.7% (95% CI 0.5% to 0.8%) and 2.4% (95% CI 2.1% to 2.6%). The frequency of chest pain patients brought to hospital during 2012-2018 increased. One-tenth were diagnosed with AMI, and the proportion of AMI patients was stable. Almost 1 in of 4 high urgency level ambulances was sent to chest pain patients. Only 1 of 10 patients with chest pain had AMI, and overall mortality was low. Thus, monitoring the number of chest pain patients and AMI diagnoses should be considered to evaluate ambulance utilisation and triage.

Association of blood product ratios with early mortality in pediatric trauma resuscitation: A time-dependent analysis from the National Trauma Databank.

Injured children with severe hemorrhage often receive blood product transfusions with ratios of plasma and platelets to packed red blood cells (PRBCs) approaching 1:1:1. Whether blood product ratios vary during pediatric resuscitation is unknown. This study (1) described precise timing of pediatric blood product administration, (2) characterized changes in blood product ratios over time, and (3) evaluated the association of blood products with early mortality while incorporating time-varying factors. Pediatric (younger than 18 years) trauma patients receiving high-volume transfusion (>40 mL/kg total products or >2 U PRBC or whole blood, during first 4 hours) were obtained from the 2017 to 2019 Trauma Quality Improvement Program database. The time of each individual product transfusion was recorded, along with demographics, injury details, and times of death. Patients were assigned to blood product groups at 15-minute intervals: high plasma/PRBC ratio (>1:1) with platelets, high plasma/PRBC ratio (>1:1) without platelets, low plasma/PRBC ratio (<1:1), PRBC only, and whole blood. Cox proportional hazards modeling for 24-hour mortality was performed, including blood product group as a time-varying variable and adjusting for relevant covariates. Of 1,152 included patients (median age, 15 years; 32% penetrating, 28% severe traumatic brain injury [sTBI]), 18% died within 24 hours. During the resuscitation period, the number of patients in high-ratio groups increased over time, and patients switched blood product groups up to six times. There was no significant difference in mortality by blood product group. Among patients with sTBI, there was a strong trend toward lower mortality among high plasma/PRBC without platelets versus high plasma/PRBC with platelets (hazard ratio, 0.55; p = 0.07). No significant association of high ratios or whole blood with mortality was seen when time-varying factors were incorporated. The impact of balanced resuscitation strategies, particularly platelet transfusion, may be greatest among patients with sTBI. Optimizing balanced resuscitation for children requires appropriately designed prospective studies. Therapeutic/Care Management; Level IV.