Using MRI appendicitis scale and DWI for the diagnosis of acute appendicitis in pregnant women.

OBJECTIVES: To assess the performance of MRI scale for the diagnosis of acute appendicitis in pregnant women and to determine the added diagnostic value of diffusion-weighted imaging (DWI). METHODS: From January 2018 to December 2020, 80 patients were included. All MRI were performed with a 1.5-Tesla scanner with anterior array body coil. This analysis included (1) T2-weighted imaging (T2WI), (2) fat-saturated T2WI, and (3) DWI. Two radiologists blinded to the diagnosis recorded their assessment of four findings: appendiceal diameter, appendiceal wall thickness, luminal mucus, and periappendiceal inflammation. The MRI scale of acute appendicitis which ranged from 0 to 4 was determined from these factors. An additional one point was added to the MRI appendicitis scale in those patients with evidence of appendiceal restricted diffusion on DWI. The diagnostic values and predictive factors were computed. RESULTS: Multivariate analysis demonstrated that the calculated MRI appendicitis scale was a significant independent predictor of acute appendicitis with a sensitivity of 96.6%, specificity of 90.2%, and PPV of 84.8%. The odds ratio of appendicitis is increased by 22.3 times for every increase in one point on the MRI appendicitis scale. Therefore, the addition of one point for restricted diffusion in the appendix on DWI imaging can add substantial value, both positive and negative predictive value, towards making an accurate diagnosis of acute appendicitis. CONCLUSIONS: MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. Incorporation of diffusion weighted imaging to MRI can improve diagnosis of acute appendicitis. CLINICAL RELEVANCE STATEMENT: MRI appendicitis scale is an objective and significant independent predictor of acute appendicitis in pregnant women. Incorporation of DWI/ADC map to MRI examinations can improve diagnosis of acute appendicitis in pregnant women. KEY POINTS: • MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. • The odds ratio of appendicitis can be increased by 22.3 times for every increase of one unit in MRI scale. • Incorporation of diffusion-weighted imaging to MRI examinations can add value to the scale (4.2 ± 0.7 vs. 0.7 ± 1.1; p < 0.001) among pregnant women with appendicitis versus pregnant women without appendicitis.

Glucosamine and Silibinin Alter Cartilage Homeostasis through Glycosylation and Cellular Stresses in Human Chondrocyte Cells.

Osteoarthritis is more prevalent than any other form of arthritis and is characterized by the progressive mechanical deterioration of joints. Glucosamine, an amino monosaccharide, has been used for over fifty years as a dietary supplement to alleviate osteoarthritis-related discomfort. Silibinin, extracted from milk thistle, modifies the degree of glycosylation of target proteins, making it an essential component in the treatment of various diseases. In this study, we aimed to investigate the functional roles of glucosamine and silibinin in cartilage homeostasis using the TC28a2 cell line. Western blots showed that glucosamine suppressed the N-glycosylation of the gp130, EGFR, and N-cadherin proteins. Furthermore, both glucosamine and silibinin differentially decreased and increased target proteins such as gp130, Snail, and KLF4 in TC28a2 cells. We observed that both compounds dose-dependently induced the proliferation of TC28a2 cells. Our MitoSOX and DCFH-DA dye data showed that 1 µM glucosamine suppressed mitochondrial reactive oxygen species (ROS) generation and induced cytosol ROS generation, whereas silibinin induced both mitochondrial and cytosol ROS generation in TC28a2 cells. Our JC-1 data showed that glucosamine increased red aggregates, resulting in an increase in the red/green fluorescence intensity ratio, while all the tested silibinin concentrations increased the green monomers, resulting in decreases in the red/green ratio. We observed increasing subG1 and S populations and decreasing G1 and G2/M populations with increasing amounts of glucosamine, while increasing amounts of silibinin led to increases in subG1, S, and G2/M populations and decreases in G1 populations in TC28a2 cells. MTT data showed that both glucosamine and silibinin induced cytotoxicity in TC28a2 cells in a dose-dependent manner. Regarding endoplasmic reticulum stress, both compounds induced the expression of CHOP and increased the level of p-eIF2α/eIF2α. With respect to O-GlcNAcylation status, glucosamine and silibinin both reduced the levels of O-GlcNAc transferase and hypoxia-inducible factor 1 alpha. Furthermore, we examined proteins and mRNAs related to these processes. In summary, our findings demonstrated that these compounds differentially modulated cellular proliferation, mitochondrial and cytosol ROS generation, the mitochondrial membrane potential, the cell cycle profile, and autophagy. Therefore, we conclude that glucosamine and silibinin not only mediate glycosylation modifications but also regulate cellular processes in human chondrocytes.

Interleukin-6 transiently promotes proliferation of osteoclast precursors and stimulates the production of inflammatory mediators.

BACKGROUND: Clinical data and phenotypes of several in vivo models demonstrated that interleukin-6 (IL-6) is an essential positive regulator in inflammation-induced bone loss. However, how IL-6 affect bone resorption and the osteoclast differentiation remains in debate. In this study we elucidate the cellular responses of receptor activator of nuclear factor kappa-Β ligand (RANKL)-stimulated RAW254.7 macrophage, the process mimicking osteoclast differentiation, upon IL-6 co-stimulation. IL-6 is a pleiotropic cytokine triggering various cellular responses, ranging from pro-inflammatory responses, differentiation to proliferation or apoptosis in different cell types. Those cellular events in the RANKL-stimulated RAW cells were examined to understand how differentiating monocytic cells respond to IL-6 exposure. MATERIALS AND METHODS: Proliferation, apoptosis, differentiation and Pro-inflammatory responses of RANKL-stimulated RAW254.7 macrophage treated with or without IL-6 were measured by MTT assay, quantitative PCR assay of the expression of apoptotic genes, osteoclast differentiation markers, and pro-inflammatory genes, respectively. The results were collected from different time points in a 6-day differentiation period. Also, western blot on STAT3, ERK and AKT were also performed to investigate the IL-6 signaling in those cells. CONCLUSIONS: IL-6 triggered transient proliferation, but not apoptosis, in RANKL-stimulated RAW cells. Osteoclastogenesis was disrupted as the expression of essential genes for bone resorption were inhibited, and the osteoclast precursors maintained their undifferentiated phenotypes, with pro-inflammatory genes upregulated. Our results suggested that IL-6 interferes osteoclastogenesis. Additionally, IL-6 promote pro-inflammatory responses of monocytic cells and aggravate inflammation.

Interferon-gamma regulates the levels of bone formation effectors in a stage-dependent manner.

BACKGROUND: Interferon-gamma (IFN-γ) is an immune-derived cytokines in the innate and adaptive immune responses, and functions as a major pro-inflammatory cytokine. IFNγ has previously been reported involving in the regulation of bone metabolism. However, contradictory results about the roles of IFN-γ in bone formation or bone resorption have been reported. It is possible that the functions of IFN-γ in bone formation is dose-dependent or time-dependent. In this study we examined the effect of IFN-γ on different stages of osteoblastogenesis and bone formation. MATERIALS AND METHODS: Cell proliferation, gene expression and protein levels of the critical effectors involving in different stages of differentiation were compared between differentiating preosteoblast MC3T3-E1 treated with or without IFN-γ at different stages. Cell proliferation were determined by MTT assay. Expression levels of osteoblast differentiation markers was performed by quantitative PCR assay. Also, western blot was conducted to investigate the protein levels in those effectors. CONCLUSION: IFN-γ regulates osteoblast and bone formation in a stage-dependent manner. IFN-γ did not alter and the expression of critical osteogenic transcription factors, such as Runx2 and Cbfb, suggesting that the differentiation was not disrupted by IFN-γ. The cell number and the levels of matrix proteins, including COL1A and BSP, at both early and late stage of osteoblastogenesis were downregulated by IFN-γ, indicating its negative regulating roles in early stages. In contrast, the mineralization protein ALP and OCN was upregulated at late stages. The results suggested that IFN-γ might act as a negative regulator in osteoblast differentiation and bone formation at early stages but switch into positive regulator at late stage. Our data revealed the complex features of the effects of IFN-γ on osteoblast differentiation. The detailed mechanisms of how IFN-γ influence on the bone formation and balance of bone remodeling will be further studied.

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.

An Image-Based Mobile Health App for Postdrainage Monitoring: Usability Study.

BACKGROUND: The application of mobile health (mHealth) platforms to monitor recovery in the postdischarge period has increased in recent years. Despite widespread enthusiasm for mHealth, few studies have evaluated the usability and user experience of mHealth in patients with surgical drainage. OBJECTIVE: Our objectives were to (1) develop an image-based smartphone app, SurgCare, for postdrainage monitoring and (2) determine the feasibility and clinical value of the use of SurgCare by patients with drainage. METHODS: We enrolled 80 patients with biliary or peritoneal drainage in this study. A total of 50 patients were assigned to the SurgCare group, who recorded drainage monitoring data with the smartphone app; and 30 patients who manually recorded the data were assigned to the conventional group. The patients continued to record data until drain removal. The primary aim was to validate feasibility for the user, which was defined as the proportion of patients using each element of the system. Moreover, the secondary aim was to evaluate the association of compliance with SurgCare and the occurrence of unexpected events. RESULTS: The average submission duration was 14.98 days, and the overall daily submission rate was 84.2%. The average system usability scale was 83.7 (SD 3.5). This system met the definition of "definitely feasible" in 34 patients, "possibly feasible" in 10 patients, and "not feasible" in 3 patients. We found that the occurrence rates of complications in the SurgCare group and the conventional group were 6% and 26%, respectively, with statistically significant differences P=.03. The rate of unexpected hospital return was lower in the SurgCare group (6%) than in the conventional groups (26%) (P=.03). CONCLUSIONS: Patients can learn to use a smartphone app for postdischarge drainage monitoring with high levels of user satisfaction. We also identified a high degree of compliance with app-based drainage-recording design features, which is an aspect of mHealth that can improve surgical care.

The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture.

BACKGROUND: Conventionally, pelvic fracture-related acute retroperitoneal hemorrhage (ARH) is life threatening and difficult to control. However, the use of angioembolization to treat fracture-associated ARH improves the hemodynamic stability of patients with pelvic fractures. The role of angioembolization in the management of patients with pelvic fracture-related ARH was examined. MATERIALS AND METHODS: We retrospectively reviewed a large case series of patients with pelvic fractures between January 2010 and December 2014. Comparisons were made between patients with and without ARH. In addition, the characteristics of mortality were delineated, whereas the causes of death in patients with pelvic fracture were discussed and analyzed. RESULTS: A total of 1070 patient records were reviewed during the 60-month study period, and the overall mortality rate of pelvic fracture was 7.7% (82/1070). However, there were only seven patients who died due to uncontrolled ARH (0.7%). The patients with ARH had more injuries to other organs than did the patients without ARH (head: 79.7% vs. 31.7%, p < 0.001; chest: 50.3% vs. 10.9%, p < 0.001; abdomen: 72.0% vs. 22.7%, p < 0.001; spine: 12.6% vs. 4.4%, p < 0.001; extremities: 69.2% vs. 44.3%, p < 0.001). CONCLUSION: The treatment for pelvic fracture patients declared dead upon arrival remains limited. However, pelvic fracture-related ARH could be controlled effectively with angioembolization. In addition to ARH, injuries to other organs may play a key role in the mortality of patients with pelvic fractures.

Different susceptibilities of osteoclasts and osteoblasts to glucocorticoid-induced oxidative stress and mitochondrial alterations.

Glucocorticoid-induced bone loss is the most common form of secondary osteoporosis. This toxic effect has not been efficiently managed, possibly due to the incomplete understanding of the extraordinarily diverse cellular responses induced by glucocorticoid treatment. Previous literatures revealed that high dose of exogenous glucocorticoid triggers apoptosis in osteocytes and osteoblasts. This cell death is associated with glucocorticoid-induced oxidative stress. In this study, we aimed to investigate the mechanisms of glucocorticoid-induced apoptosis in osteoblasts and examine the responses of osteoclasts to the synthetic glucocorticoid, dexamethasone. We demonstrated the biphasic effects of exogenous glucocorticoid on osteoblastic mitochondrial functions and elevated intracellular oxidative stress in a dose- and time-dependent manner. On comparison, similar treatment did not induce mitochondrial dysfunctions and oxidative stress in osteoclasts. The production of reactive oxygen/nitrogen species was decreased in osteoclasts. The differences are not due to varying efficiency of cellular antioxidant system. The opposite effects on nitrogen oxide synthase might provide an explanation, as the expression levels of nos2 gene are suppressed in the osteoclast but elevated in the osteoblast. We further revealed that glucocorticoids have a substantial impact on the osteoblastic mitochondria. Basal respiration rate and ATP production were increased upon 24 h incubation of glucocorticoids. The increase in proton leak and nonmitochondrial respiration suggests a potential source of glucocorticoid-induced oxidative stress. Long-term incubation of glucocorticoids accumulates these detrimental changes and results in cytochrome C release and mitochondrial breakdown, consequently leading to apoptosis in osteoblasts. The mitochondrial alterations might be other sources of glucocorticoid-induced oxidative stress in osteoblasts.

Concomitant external and internal hemorrhage: Challenges to managing patients with open pelvic fracture.

INTRODUCTION: Managing patients with open pelvic fractures continues to be challenging and requires a multidisciplinary approach. In this study, we examined the characteristics of patients with open pelvic fractures and strategies for managing such patients. MATERIALS AND METHODS: The records of patients with open pelvic fractures from January 2010 to August 2016 were retrospectively reviewed. Emergency surgery was performed to control hemorrhaging in patients with an active external hemorrhage. Transcatheter arterial embolization (TAE) was used for definitive hemostasis. The relation between cause of death and timing of death was examined. We also compared the characteristics of surviving and non-surviving patients. Furthermore, patients who received both surgery and post-operative TAE were analyzed in detail. RESULTS: In total, 42 patients with open pelvic fractures were enrolled in the study. The overall mortality rate among patients with open pelvic fractures was 26.2%. Patients whose deaths were related to hemorrhaging and associated injuries died significantly earlier than patients whose deaths were related to sepsis and multiple organ failure (1.3days vs. 12.3days, p<0.001). Sixteen patients (38.1%) received TAE for hemostasis, and their systolic blood pressure (SBP) improved significantly following TAE (from 88.4mmHg to 111.6mmHg, p<0.05). In the patients who received both surgery and post-operative TAE (n=8), the SBP increased significantly after surgery (from 58.8mmHg to 81.1mmHg, p<0.05). Similarly, the patients' SBP after TAE was significantly higher than their post-operative SBP (110.5mmHg vs. 81.1mmHg, p<0.05). CONCLUSION: Active external hemorrhaging was initially controlled when managing patients with open pelvic fractures; however, most patients also required TAE for definitive hemorrhage control. Early TAE should be considered due to the high probability of concomitant internal and external hemorrhage. Close observation and further infection control are important following the hemostatic procedure.

Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification.

BACKGROUND: To evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD). METHODS: Between August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome. RESULTS: Of the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%. CONCLUSION: Based on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries.

Computed tomography angiography provides limited benefit in the evaluation of patients with pelvic fractures.

INTRODUCTION: Computed tomography angiography (CTA) has been applied in imaging studies for the assessment of most abdominal and pelvic injuries in some trauma centers. However, in most institutions, CTA is not routinely performed as part of the computed tomography scan protocol. In this study, we aimed to assess the efficiency of CTA in the evaluation of patients with pelvic fractures. MATERIALS AND METHODS: During the study period, patients with pelvic fracture were retrospectively analyzed. In addition to conventional computed tomography scanning that includes only the single venous phase, CTA with an additional arterial phase was used to obtain more information regarding vascular injuries. Further angiographic examination was performed in the patients with positive results in either the arterial or venous phase. The sensitivity and specificity of the multiphasic CTA images in the evaluation of active arterial hemorrhage were investigated. Furthermore, the results obtained for the arterial and venous phases were also combined to evaluate associated active arterial hemorrhage. RESULTS: A total of 144 patients with pelvic fractures who underwent CTA were enrolled in this study. Of these patients, 49 (34.0%) had active arterial hemorrhage. The sensitivities of the venous and arterial phase CTA images in the evaluation of active arterial hemorrhage were 100% (49/49) and 89.8% (44/49), respectively. Furthermore, all of the patients with positive results based on the arterial phase images were included in the group of patients with positive results based on the venous phase images. Although there were 4 patients without active arterial hemorrhage based on the angiographic examination, they still underwent embolization. CONCLUSIONS: In the management of patients with pelvic fractures, CTA provides limited benefits in the evaluation of the active arterial hemorrhage. The additional arterial phase may be helpful for distinguishing between arterial and venous hemorrhage. However, this study showed that subsequent treatment was not changed.

The diminishing role of pelvic x-rays in the management of patients with major torso injuries.

INTRODUCTION: A pelvic x-ray (PXR) can be used as an effective screening tool to evaluate pelvic fractures and stability. However, associated intra-abdominal/retroperitoneal organ injuries and hemorrhage should also be considered and evaluated in patients with major torso injuries. An abdominal/pelvic computed tomographic (CT) scan may provide higher resolution and more information than a PXR. The role of conventional PXRs was delineated in the current study in the context of the development of the CT scan. MATERIALS AND METHODS: We retrospectively reviewed patients with major torso injuries in our institution. The characteristics of the patients who received different diagnostic modalities (PXR only, CT scan only, or both) were investigated and compared. The characteristics of patients who underwent transcatheter arterial embolization (TAE) for the hemostasis of pelvic fracture-related retroperitoneal hemorrhage were also analyzed. RESULT: There were 726 patients enrolled in current stud. Only 72.0% (523/726) of the patients who had major torso injuries were examined using PXRs, and 69.6% (505/726) of the patients underwent an abdominal/pelvic CT scan. For the patients who were examined using PXRs, there was no significant difference in the usage rate of an additional CT scan between the patients with positive (52.7%, 108/205) and negative (61.0%, 194/318) PXR examinations (P = .070). Four patients underwent TAE immediately following PXR examinations only, without a CT scan. These four patients had unstable pelvic fractures on the PXR examination and significantly a lower systolic blood pressure (61.0 ± 13.0 mmHg), a lower revised trauma score (3.560 ± 2.427), a greater requirement for blood transfusions (1750 ± 957.2 ml) than the patients who underwent TAE after a CT scan. CONCLUSION: For the management of patients with major torso injuries, the role of PXR is diminishing due to the development of the CT scan. However, the PXR is still valuable for patients who are in critical condition and have an obviously high probability of retroperitoneal hemorrhaging.

Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures.

INTRODUCTION: Transcatheter arterial embolization (TAE) is usually necessary in the management of hemodynamically unstable patients with concomitant pelvic fractures. Given the critical conditions of such patients, TAE is at times performed only according to the results of a primary evaluation without computed tomographic (CT) imaging. Therefore, the evaluation of associated intra-abdominal injuries (IAIs) might be insufficient. Clinically, some patients have required post-TAE laparotomy due to further deterioration. In this study, we attempted to determine a feasible protocol for post-TAE observation. MATERIALS AND METHODS: This study focused on patients who received TAE to achieve hemostasis of retroperitoneal hemorrhage and who did not undergo CT imaging due to their unstable hemodynamics. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. We also analyzed the effects of the timing of post-TAE CT imaging on patients with IAIs requiring surgery. RESULTS: A total of 41 patients were enrolled in the study. Of these patients, all of whom underwent primary TAE without preprocedure CT imaging; 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Comparisons between the 2 patient groups revealed no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P=.480), loss of consciousness (66.7% vs 73.1%, P=.730), or abdominal symptoms (20.0% vs 23.1%, P=1.000). CONCLUSION: In the management of hemodynamically unstable patients with concomitant pelvic fractures, greater attention should be paid to associated IAIs. Early CT imaging is encouraged after the patient's hemodynamic status is stabilized with TAE.

An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study.

BACKGROUND: We present a series of patients with blunt abdominal trauma who underwent damage control laparotomy (DCL) and introduce a nomogram that we created to predict survival among these patients. METHODS: This was a retrospective study. From January 2002 to June 2012, 91 patients underwent DCL for hemorrhagic shock. We excluded patients with the following characteristics: a penetrating abdominal injury, age younger than 18 or older than 65 years, a severe or life-threatening brain injury (Abbreviated Injury Scale [AIS] ≥ 4), emergency department (ED) arrival more than 6 hours after injury, pregnancy, end-stage renal disease, or cirrhosis. In addition, we excluded patients who underwent DCL after ICU admission or later in the course of hospitalization. RESULTS: The overall mortality rate was 61.5%: 35 patients survived and 56 died. We identified independent survival predictors, which included a preoperative Glasgow Coma Scale (GCS) score < 8 and a base excess (BE) value < -13.9 mEq/L. We created a nomogram for outcome prediction that included four variables: preoperative GCS, initial BE, preoperative diastolic pressure, and preoperative cardiopulmonary cerebral resuscitation (CPCR). CONCLUSIONS: DCL is a life-saving procedure performed in critical patients, and devastating clinical outcomes can be expected under such dire circumstances as blunt abdominal trauma with exsanguination. The nomogram presented here may provide ED physicians and trauma surgeons with a tool for early stratification and risk evaluation in critical, exsanguinating patients.

Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers.

INTRODUCTION: Patients with pelvic fracture usually require transfers to trauma centers for additional advanced treatment. Patient safety during the transfer should always be a priority. The noninvasive pelvic circumferential compression device (PCCD) can reportedly provide a tamponade effect, which reduces hemorrhage. In the present study, we evaluated the feasibility and efficiency of PCCD in patients with pelvic fracture who required transfer to trauma centers. MATERIALS AND METHODS: In the present study, we aimed to evaluate patients with pelvic fractures who were transferred from other hospitals. We investigated and compared the characteristics of these types of patients with and without pretransfer PCCD. We compared 2 groups (with and without pretransfer PCCD) of patients under different situations (unstable pelvic fracture, stable pelvic fracture, or indicated for transcatheter arterial embolization). We also analyzed the characteristics of patients with unstable pelvic fracture who were initially evaluated as having stable pelvic fracture primarily before being transferred. RESULTS: During the 53-month period, we enrolled 585 patients in the study. The patients with unstable pelvic fractures who received pretransfer PCCDs required significantly fewer blood transfusions (398.4 ± 417.6 mL vs 1954.5 ± 249.0 mL, P < .001), shorter intensive care unit length of stay (LOS; 6.6 ± 5.2 days vs 11.8 ± 7.7 days, P = .024), and shorter hospital LOS (9.4 ± 7.0 days vs 19.5 ± 13.7 days, P = .006) compared with patients who did not receive the pretransfer PCCD. The stable patients who received pretransfer PCCDs required significantly fewer blood transfusions (120.2 ± 178.5 mL vs 231.8 ± 206.2 mL, P = .018) and had shorter intensive care unit LOS (1.7 ± 3.3 days vs 3.4 ± 2.9 days, P = .029) and shorter hospital LOS (6.8 ± 5.1 days vs 10.4 ± 7.6 days, P = .018) compared with patients who did not receive the pretransfer PCCD. CONCLUSION: Pelvic circumferential compression devices benefit patients with pelvic fracture who need to be transferred to trauma centers. Pretransfer PCCDs appeared to be a feasible and safe procedure during the transfer. In discussions between the referring physicians and the receiving physicians, we recommend using pretransfer PCCDs.

Prospective study of computed tomography in patients with suspected acute appendicitis and low Alvarado score.

BACKGROUND: Computed tomography (CT) has been used in diagnosing acute appendicitis since late 1990s. Appropriate use of CT has not been studied prospectively in patients with suspected acute appendicitis and relative low Alvarado score. METHODS: Sixty participants with suspected acute appendicitis and an Alvarado score of 4 to 7 points were enrolled for analysis. Clinical and laboratory differences were compared between patients with histologically proven acute appendicitis (AA group) and patients without evidence of acute appendicitis (non-AA group) in the first part of the analysis. In the second part of the analysis, participants were divided into 2 groups: leukocytosis (LK group) and nonleukocytosis (non-LK group). RESULTS: In the first phase of the analysis, there were statistically significant differences in white blood cell count (13.5 K vs 10.9 K per µL), neutrophilia (81.5% vs 73.5%), and hospital stay (4.9 vs 3.5 days) between the 2 groups. Disease spectrum between LK and non-LK groups was obtained in second part of analysis. CONCLUSION: Computed tomography scan is necessary for patients with relatively low Alvarado score when leukocytosis is noted. In female patients without leukocytosis, further large-scale prospective studies are necessary to change the current diagnostic strategy.

Bioinspired Sandcastle Worm-Derived Peptide-Based Hybrid Hydrogel for Promoting the Formation of Liver Spheroids.

The generation of hepatic spheroids is beneficial for a variety of potential applications, including drug development, disease modeling, transplantation, and regenerative medicine. Natural hydrogels are obtained from tissues and have been widely used to promote the growth, differentiation, and retention of specific functionalities of hepatocytes. However, relying on natural hydrogels for the generation of hepatic spheroids, which have batch to batch variations, may in turn limit the previously mentioned potential applications. For this reason, we researched a way to establish a three-dimensional (3D) culture system that more closely mimics the interaction between hepatocytes and their surrounding microenvironments, thereby potentially offering a more promising and suitable system for drug development, disease modeling, transplantation, and regenerative medicine. Here, we developed self-assembling and bioactive hybrid hydrogels to support the generation and growth of hepatic spheroids. Our hybrid hydrogels (PC4/Cultrex) inspired by the sandcastle worm, an Arg-Gly-Asp (RGD) cell adhesion sequence, and bioactive molecules derived from Cultrex BME (Basement Membrane Extract). By performing optimizations to the design, the PC4/Cultrex hybrid hydrogels can enhance HepG2 cells to form spheroids and express their molecular signatures (e.g., Cyp3A4, Cyp7a1, A1at, Afp, Ck7, Ck1, and E-cad). Our study demonstrated that this hybrid hydrogel system offers potential advantages for hepatocytes in proliferating, differentiating, and self-organizing to form hepatic spheroids in a more controllable and reproducible manner. In addition, it is a versatile and cost-effective method for 3D tissue cultures in mass quantities. Importantly, we demonstrate that it is feasible to adapt a bioinspired approach to design biomaterials for 3D culture systems, which accelerates the design of novel peptide structures and broadens our research choices on peptide-based hydrogels.

Management of complicated lumbar artery injury after blunt trauma.

STUDY OBJECTIVE: Lumbar artery injury after blunt trauma is not frequently discussed. We review our experience with blunt lumbar artery injury management, especially alternative treatments in which embolization is not feasible. METHODS: We reviewed our trauma registry for 8 years 8 months. We sought all patients who sustained blunt torso trauma and had lumbar artery injury detected by angiography. Variables collected included demographic data, trauma mechanism, vital signs in triage, Injury Severity Score, associated injuries, computed tomography results, angiography results, embolizations, and outcome. RESULTS: Sixteen of the 3,436 patients in the trauma registry system had a blunt lumbar artery injury verified by angiography. For patients with lumbar artery injury, the mean Injury Severity Score was 38.6 (SD 12), and 10 (63%) of these 16 patients were in shock and 12 patients (75%) had closed head injuries. Angioembolization caused bleeding cessation in 11 patients but failed in 5 patients, who were treated conservatively. The overall mortality rate of patients with lumbar artery injury was 50%. CONCLUSION: Lumbar artery injury in multiply injured patients with blunt trauma leads to a high mortality rate, especially if accompanied by head injury. Embolization often stops bleeding, but, if embolization is not feasible, conservative treatment without retroperitoneal surgery can be successful.

Angioembolization and laparotomy for patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma.

BACKGROUND: Treatment of patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma (BAT) is challenging. Controversies remain over the diagnostic approach and the priority of available treatment resources. METHODS: Between 1999 and 2008, 545 patients were admitted due to concomitant BAT and pelvic fracture. Seventy-six patients receiving both angiography and laparotomy were studied. Focused abdominal sonography for trauma (FAST) was used as the primary triage tool in the early 5 years and multi-detector computed tomography (MDCT) in the later 5 years. The clinical courses and results were retrospectively analyzed to determine if the evolution of the clinical pathways for managing these patients resulted in improved outcomes. RESULTS: Performing laparotomy solely based on FAST during the early 5 years resulted in a high nontherapeutic laparotomy rate (36%). Contrast enhanced MDCT, as the primary triage tool, accurately disclosed active intra-abdominal and pelvic injuries and was helpful in promptly tailoring the subsequent treatment. Additional surgical trauma was avoided in some patients and nontherapeutic laparotomy rate decreased to 16%. Multiple bleeders were found in 70% of positive angiograms; bilateral internal iliac artery embolization for the purpose of damage control showed a lower repeat angioembolization rate for these severely injured patients. CONCLUSION: The revised clinical algorithm served well for guiding the treatment pathway. Priority of laparotomy or angiography should be individualized and customized according to the clinical evaluation and CT findings. Angiography can be both diagnostic and therapeutic and simultaneously treat multiple bleeders; thus, it has a higher priority than laparotomy. The primary benefits of our later clinical pathway were in reducing nontherapeutic laparotomy and repeat angioembolization rates.

Differences of liver CT perfusion of blunt trauma treated with therapeutic embolization and observation management.

Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.