The changes and the potential clinical applications of cytokines in Taiwan's major venomous snakebites patients.

BACKGROUND: Taiwan habu (Protobothrops mucrosquamatus), green bamboo viper (Viridovipera stejnegeri), and Taiwan cobra (Naja atra) are the most venomous snakebites in Taiwan. Patients commonly present with limb swelling but misdiagnosis rates are high, and currently available diagnostic tools are limited. This study explores the immune responses in snakebite patients to aid in differential diagnosis. METHODS: This prospective observational study investigated the changes in cytokines in snakebite patients and their potential for diagnosis. RESULTS: Elevated pro-inflammatory cytokines IL-6 and TNF-α were observed in all snakebite patients compared to the healthy control group. While no significant disparities were observed in humoral immune response cytokines, there were significant differences in IFN-γ levels, with significantly higher IL-10 levels in patients bitten by cobras. Patients with TNF-α levels exceeding 3.02 pg/mL were more likely to have been bitten by a cobra. CONCLUSION: This study sheds light on the immune responses triggered by various venomous snakebites, emphasizing the potential of cytokine patterns for snakebite-type differentiation. Larger studies are needed to validate these findings for clinical use, ultimately improving snakebite diagnosis and treatment.

Evaluating the clinical impact of resuscitative endovascular balloon occlusion of the aorta in patients with blunt trauma with hemorrhagic shock and coexisting traumatic brain injuries: a retrospective cohort study.

BACKGROUND: The impact of resuscitative endovascular balloon occlusion of the aorta (REBOA) on traumatic brain injuries remains uncertain, with potential outcomes ranging from neuroprotection to exacerbation of the injury. The study aimed to evaluate consciousness recovery in patients with blunt trauma with shock and traumatic brain injuries. MATERIAL AND METHODS: Data were obtained from the American College of Surgeons Trauma Quality Improvement Program from 2017-2019. During the study period, 3,138,896 trauma registries were examined, and 16,016 adult patients with blunt trauma, shock, and traumatic brain injuries were included. Among these, 172 (1.1%) underwent REBOA. Comparisons were conducted between patients with and without REBOA after implementing 1:3 propensity score matching to mitigate disparities. The primary outcome was the highest Glasgow Coma Scale score during admission. The secondary outcomes encompassed the volume of blood transfusion, the necessity for hemostatic interventions and therapeutic neurosurgery, and mortality rate. RESULTS: Through well-balanced propensity score matching, a notable difference in mortality rate was observed, with 59.7% in the REBOA group and 48.7% in the non-REBOA group (P=0.015). In the REBOA group, the median 4-hour red blood cell transfusion was significantly higher (2800 mL [1500, 4908] vs. 1300 mL [600, 2500], P<0.001). The REBOA group required lesser hemorrhagic control surgeries (31.8% vs. 47.7%, P<0.001) but needed more transarterial embolization interventions (22.2% vs 15.9%, P=0.076). The incidence of therapeutic neurosurgery was 5.1% in the REBOA group and 8.7% in the non-REBOA group (P=0.168). Among survivors in the REBOA group, the median highest Glasgow Coma Scale score during admission was significantly greater for both total (11 [8, 14] vs. 9 [6, 12], P=0.036) and motor components (6 [4, 6] vs. 5 [3, 6], P=0.037). The highest GCS score among the survivors with predominant pelvic injuries was not different between the two groups (11 [8, 13] vs. 11 [7, 14], P=0.750). CONCLUSIONS: Patients experiencing shock and traumatic brain injury have high mortality rates, necessitating swift resuscitation and prompt hemorrhagic control. The use of REBOA as an adjunct for bridging definitive hemorrhagic control may correlate with enhanced consciousness recovery.

Feasibility of non-operative management for patients sustained blunt splenic traumas with concomitant aortic injuries.

PURPOSE: This study aimed to elucidate the treatment approach for blunt splenic injuries concurrently involving the aorta. We hypothesized that non-operative management failure rates would be higher in such cases, necessitating increased hemorrhage control surgeries. METHODS: Data from the Trauma Quality Improvement Program spanning 2017 to 2019 were utilized. All patients with blunt splenic trauma were considered for inclusion. We conducted comparisons between blunt splenic trauma patients with and without thoracic or abdominal aortic injuries to identify any potential disparities in treatment. RESULTS: Among the 32,051 patients with blunt splenic injuries during the study period, 752 (2.3%) sustained concurrent aortic injuries. Following 2:1 propensity score matching, it was determined that the presence of aortic injuries did not significantly affect the utilization of splenic transarterial angioembolization (TAE) (7.2% vs. 8.7%, p = 0.243) or the necessity for splenectomy or splenorrhaphy (15.3% vs. 15.7%, p = 0.853). Moreover, aortic injuries were not a significant factor contributing to TAE failure, regardless of the location or severity of the injury. Patients with simultaneous splenic and aortic injuries required more red blood cell transfusion within first 4 hours (0 ml [0, 900] vs. 0 ml [0, 650], p = 0.001) and exhibited a higher mortality rate (10.6% vs. 7.9%, p = 0.038). CONCLUSION: This study demonstrated that patients with concurrent aortic and splenic injuries presented with more severe conditions, higher mortality rates, and extended hospital stays. The presence of aortic injuries did not substantially influence the utilization of TAE or the necessity for splenectomy or splenorrhaphy. Patients of this type can be managed in accordance with current treatment guidelines. Nonetheless, given their less favorable prognosis, they necessitate prompt and proactive intervention.

Effect of zinc supplement on patients with trauma: A systematic review and meta-analysis.

AIMS: This study aimed to assess the effect of zinc supplementation, with or without other antioxidants and trace elements, on clinical outcomes in patients with trauma. METHODS: A systematic review was conducted for adult patients with acute trauma who had been admitted to the hospital. Those who sustained burn injuries were excluded. Studies in PubMed, Web of Science, and Embase from 1990 to 2022 regarding the additional nutrition supplementation of zinc to patients, either in a single-agent or combined regimen, were included. Comparisons were made between the zinc supplement group and those who received a placebo or regular treatment. RESULTS: The primary outcomes of the study were mortality rate, length of hospital stay, and incidence of pneumonia. Seven studies qualified for the meta-analysis. Of the 594 patients eligible for analysis, 290 and 304 were in the zinc supplementation and control groups, respectively. The meta-analysis revealed that zinc supplementation was associated with a lower risk of pneumonia in patients with acute trauma than in the control group (odds ratio [OR], 0.506; 95% CI = 0.292-0.877; P = 0.015; heterogeneity, I2 = 12.7%). Zinc supplementation did not influence the mortality rate (OR, 0.755; 95% CI = 0.492-1.16; P = 0.612; heterogeneity, I2 = 0%) or the length of hospital stay (standard difference in means, -0.24; 95% CI = -0.544 to 0.063; P = 0.121; heterogeneity, I2 = 45.0%). CONCLUSION: Zinc supplementation, with or without other antioxidants and trace elements, in patients with trauma was associated with a lower incidence of pneumonia.

Spleen size greater than 9.76 cm may impact the treatment strategy for blunt splenic injury in adults - A retrospective analysis of experience at a tertiary trauma center in Taiwan.

BACKGROUND/OBJECTIVE: The present study investigated the impact of splenomegaly on the treatment outcomes of blunt splenic injury patients. METHODS: All blunt splenic injury patients were enrolled between 2010 and 2018. The exclusion criteria were age less than 18 years, missing data, and splenectomy performed at another hospital. The patients were divided into two groups based on the presence of splenomegaly, defined as a spleen length over 9.76 cm on axial computed tomography. The primary outcome was the need for hemostatic interventions. RESULTS: A total of 535 patients were included. Patients with splenomegaly had more high-grade splenic injuries (p = 0.007). Hemostatic treatments (p < 0.001) and transarterial embolization (p = 0.003) were more frequently required for patients with splenomegaly. Multivariate analysis showed that male sex (p = 0.023), more packed red blood cell transfusions (p = 0.001), splenomegaly (p = 0.019) and grade 3-5 splenic injury (p < 0.001) were predictors of hemostatic treatment. The failure rate of transarterial embolization was not significantly different between the two groups (p = 0.180). The sensitivity and specificity for splenomegaly in predicting hemostatic procedures were 48.8% and 66.5%, respectively. The positive and negative predictive values were 62.8% and 52.9%, respectively. The overall mortality rate was 3.7%. CONCLUSION: Splenomegaly is an independent predictor for the requirement of hemostatic treatments in blunt splenic injury patients, especially transarterial embolization. Transarterial embolization is as effective for blunt splenic injury patients with splenomegaly as it is for those with a normal spleen.

Could video-assisted thoracoscopic surgery be feasible for blunt trauma patients with massive haemothorax?

INTRODUCTION: The study reviewed the experience of video-assisted thoracoscopic surgery (VATS) for the treatment of massive haemothorax (MHT). MATERIALS AND METHODS: All adult patients who sustained blunt trauma with a diagnosis of traumatic haemothorax or pneumothorax (ICD9 860; ICD10 S27.0-2), injury to the heart and lungs (ICD9 861; ICD10 S26, S27.3-9), and injury to the blood vessels of the thorax (ICD9 901; ICD10 S25) were queried from the trauma registry between 2014 and 2018. Patients who had chest tube drainage amounts meeting the criteria for MHT and who underwent subsequent operations were eligible for analyses. The patients were divided into VATS or thoracotomy groups based on the surgical modalities. Descriptions and analyses of the two groups were made. RESULTS: Thirty-eight patients were enroled in the study, including 8 females (21%) and 30 males. The median age was 47.0 (first quartile (Q1) 25.5 and third quartile (Q3) 59.3) years. Twenty-three patients were in the VATS group, six (26%) of whom were converted to thoracotomy. There were no obvious differences in age, sex, pulse rate, or systolic pressure on arrival to the ED or after resuscitation between the two groups. The laboratory data were worse amongst the thoracotomy group, especially the arterial blood gas analysis (ABG) results: pH 7.2 (7.1, 7.3) vs. 7.4 (7.2, 7.4); HCO3 14.6 (12.4, 18.7) vs. 19.7 (16.1, 23.9) mEq/L; base excess (BE) -12.6 (-15.8, -7.8) vs. -5.2 (-11.1, -0.9) mEq/L. The PaO2/FiO2 ratio was lower in the thoracotomy group (91.4 (68.5, 193.3) vs. 245.3 (95.7, 398.0) mmHg). The thoracotomy group had coagulopathy (INR 1.6 (1.2, 1.9) vs. 1.3 (1.1, 1.4)) and required more blood transfusions (WB and PRBC 36.0 (16.0, 48.0) vs. 12.0 (4.0, 24.0) units; FFP 20.0 (6.0, 50.0) vs. 6.0 (2.0, 20.0) unit). No factors associated with VATS conversion to thoracotomy could be identified. CONCLUSIONS: VATS could be applied to selected blunt trauma patients with MHT. The major differences between the VATS and thoracotomy groups were coagulopathy, acidosis, PaO2/FiO2 ratio < 200 mmHg, or a persistent need for blood transfusion.

The Impact on the Clinical Prognosis of Low Serum Selenium Level in Patients with Severe Trauma: Systematic Review and Meta-Analysis.

This study was designed to examine the most up-to-date evidence about how low plasma selenium (Se) concentration affects clinical outcomes, such as mortality, infectious complications, and length of ICU or hospital stay, in patients with major trauma. We searched three databases (MEDLINE, EMBASE, and Web of Science) with the following keywords: "injury", "trauma", "selenium", and "trace element". Only records written in English published between 1990 and 2021 were included for analysis. Four studies were eligible for meta-analyses. The results of the meta-analysis showed that a low serum selenium level did not exert a negative effect on the mortality rate (OR 1.07, 95% CI: 0.32, 3.61, p = 0.91, heterogeneity, I2 = 44%). Regarding the incidence of infectious complications, there was no statistically significant deficit after analyses of the four studies (OR 1.61, 95% CI: 0.64, 4.07, p = 0.31, heterogeneity, I2 = 70%). There were no differences in the days spent in the ICU (difference in means (MD) 1.53, 95% CI: -2.15, 5.22, p = 0.41, heterogeneity, I2 = 67%) or the hospital length of stay (MD 6.49, 95% CI: -4.05, 17.02, p = 0.23, heterogeneity, I2 = 58%) in patients with low serum Se concentration. A low serum selenium level after trauma is not uncommon. However, it does not negatively affect mortality and infection rate. It also does not increase the overall length of ICU and hospital stays.

Is massive hemothorax still an absolute indication for operation in blunt trauma?

BACKGROUND: Surgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery. METHODS: Patients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared. RESULTS: Forty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels. CONCLUSION: Conservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures.

BACKGROUND: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. METHOD: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. RESULTS: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. CONCLUSION: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

Eighteen years' experience of traumatic subclavian vascular injury in a tertiary referral trauma center.

PURPOSE: Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment. METHODS: From January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors. RESULTS: The enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay. CONCLUSIONS: Our results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.

Deep coma does not always predict poor outcomes among patients with polytrauma.

PURPOSES: This study aimed to clarify the prognosis of polytrauma patients presenting to the emergency department (ED) with a Glasgow Coma Scale score (GCS) of 3. METHODS: A trauma registry system has been established at our institution since 2009. The current study reviewed patients in the registry who presented to the ED with a GCS of 3 from January 2011 to December 2015. Surviving and non-surviving patients were compared to identify the prognostic factors of patient survival. The study also aimed to determine the factors contributing to patients who survived with a GCS > 13 at discharge. RESULTS: During the study period, 145 patients were enrolled in the study, 119 of whom (82.1%) did not survive the traumatic insult. Of the 26 survivors, 13 (9.0%) had a GCS of 14 or 15 at discharge. The multiple logistic regression revealed that a lack of bilateral dilated and fixed pupils (BFDP) (OR 5.967, 95% CI 1.780-19.997, p = 0.004) and a GCS > 3 after resuscitation (OR 6.875, 95% CI 2.135-22.138, p = 0.001) were independent prognostic factors of survival. Based on the multiple logistic regression, an age under 40 years (OR 16.405, 95% CI 1.520-177.066, p = 0.021) and a GCS > 3 after resuscitation (OR 12.100, 95% CI 1.058-138.352, p = 0.045) were independent prognostic factors of a GCS > 13 at discharge. CONCLUSION: Aggressive resuscitation still provided benefit to polytrauma patients presenting with a GCS of 3, especially those with a rapid response to the resuscitation. Young patients with a deep coma on arrival had a higher probability of functional recovery after resuscitation in the ED.