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.

The effect of transarterial embolization and nephrectomy on acute kidney injury in patients with blunt renal trauma: An American College of Surgeons - Trauma Quality Improvement Program analysis.

INTRODUCTION: Transarterial embolization (TAE) or nephrectomy for patients with blunt renal trauma might result in acute kidney injury (AKI). Thus, we analyzed the American College of Surgeons - Trauma Quality Improvement Program (TQIP) to validate this. We hypothesized that nephrectomy, and not TAE, would be a risk factor for AKI in patients with blunt renal trauma. MATERIAL AND METHODS: Adult patients with blunt injuries from the TQIP between 2017 and 2019 were eligible for inclusion. The patients were divided into three treatment groups: conservative treatment, TAE, and nephrectomy. Multivariable logistic regression was used to clarify the AKI predictors. RESULTS: The study included 12,843 patients, wherein 12,373 (96.3 %), 229 (1.8 %), and 241 (1.9 %) patients were in the conservative, TAE, and nephrectomy groups, respectively. A total of 269 (2.2 %), 20 (8.7 %), and 29 (12.0 %) patients had AKI in the three groups, respectively. Both TAE (odds ratio [OR], 2.367; 95 % confidence interval [CI], 1.372-3.900; p = 0.001) and Nephrectomy (OR, 2.745; 95 % CI, 1.629-4.528; p < 0.001) were a statistically significant predictor for AKI in the multivariable logistic regression. CONCLUSIONS: TAE and nephrectomy were statistically associated with AKI in patients with blunt renal trauma. This result differs from our previous research findings that nephrectomy, but not TAE, was a risk factor for AKI in patients with blunt renal trauma. Further prospective and well-designed research may be needed.

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.

Opposite effects of Covid-19 infection on pitchers and batters: a retrospective study on Chinese Professional Baseball League players.

BACKGROUND: The influence of COVID-19 infection on elite athletes remains largely unknown, especially on baseball players. The goal of this study is to examine the actual performance of infected elite baseball players from the Chinese Professional Baseball League (CPBL) from a sabermetric point of view. METHODS: This was a retrospective observational cohort study. CPBL players who were infected with COVID-19 from April 27th to May 31st, 2022, were eligible for this study. The performance of study participants before and after COVID-19 infection was compared, and statistics from the batters and pitchers were analyzed separately. RESULTS: During the study interval, 56 players were infected with COVID-19, including 35 batters and 21 pitchers. After excluding injured players and players with inadequate playing opportunities, 23 batters and 12 pitchers were enrolled. For batters, there were no significant differences before and after COVID-19 infection. However, batters older than 28 years of age showed a decline in slugging percentage (0.372 vs. 0.292, P=0.049). Analysis of pitchers revealed significantly boosted fastball velocity after COVID-19 infection (142.10 km/h vs. 142.82 km/h, P=0.028) and improved strikeouts per nine innings (6.89 vs. 8.56, P=0.021). CONCLUSIONS: COVID-19 might have a potential influence on professional baseball players. For batters, veteran players more than 28 years of age were more likely to be negatively affected by COVID-19, whereas the effect of COVID-19 on pitchers was generally positive, with significantly improved fastball velocity and K/9 numbers.

Long-term survival after major trauma: a retrospective nationwide cohort study from the National Health Insurance Research Database.

BACKGROUND: Most trauma-related studies are focused on short-term survival and complications within the index admission, and the long-term outcomes beyond discharge are mainly unknown. The purpose of this study was to analyze the data from the National Health Insurance Research Database (NHIRD) and to assess the long-term survival of major trauma patients after being discharged from the index admission. MATERIAL AND METHODS: This retrospective, observational study included all patients with major trauma (injury severity score ≥16) in Taiwan from 2003 to 2007, and a 10-year follow-up was conducted on this cohort. Patients aged 18-70 who survived the index admission were enrolled. Patients who survived less than one year after discharge (short survival, SS) and those who survived for more than one year (long survival, LS) were compared. Variables, including preexisting factors, injury types, and short-term outcomes and complications, were analyzed, and the 10-year Kaplan-Meier survival analysis was conducted. RESULTS: In our study, 9896 patients were included, with 2736 in the SS group and 7160 in the LS group. Age, sex, comorbidities, low income, cardiopulmonary resuscitation event, prolonged mechanical ventilation, prolonged ICU length of stay (LOS), and prolonged hospital LOS were identified as the independent risk factors of SS. The 10-year cumulative survival for major trauma patients was 63.71%, and the most mortality (27.64%) occurred within the first year after discharge. CONCLUSION: 27.64% of patients would die one year after being discharged from major trauma. Major trauma patients who survived the index admission still had significantly worse long-term survival than the general population, but the curve flattened and resembled the general population after one year.

Accelerated fixation is associated with fewer pulmonary embolism in patients with isolated and unilateral femoral shaft fractures: A TQIP analysis.

INTRODUCTION: The optimal time to intramedullary internal fixation for patients with isolated and unilateral femoral shaft fractures was investigated by the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP). MATERIAL AND METHODS: Adult patients from the TQIP between 2017 and 2019 were eligible for inclusion. The associations between time to fixation and target outcomes (pulmonary embolism [PE], deep vein thrombosis [DVT], acute respiratory distress syndrome [ARDS], and mortality) were assessed. Maximization of the sum of sensitivity and specificity was used to determine the optimal cut point. The patients were divided into three groups according to different time to fixation intervals. A multinomial propensity scores weighting using generalized boosted models was performed for all unbiased pre-treatment factors between the groups. Multivariate logistic regression was used to clarify the outcomes predictors. RESULTS: The univariate and multivariate analysis before weighting showed that only PE was significantly associated with time to fixation (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; p = 0.012). The optimal cut point of time to fixation was 13.88 h. The patients were divided into accelerated (≤ 13.88 h), standard (> 13.88 and ≤ 24 h), and delayed (> 24 and < 36 h) groups. After weighting for all unbiased pre-treatment factors between the groups, multivariate logistic regression showed that standard group significantly increased the risk of PE compared with accelerated group (OR, 4.436; 95% CI, 1.844-10.672; p = 0.001). CONCLUSION: Accelerated intramedullary internal fixation within 13.88 h was associated with a significantly decreased risk of PE compared with standard fixation in patients with isolated and unilateral femoral shaft fractures without additional mortality risks.

The Application of Design Thinking in Developing a Deep Learning Algorithm for Hip Fracture Detection.

(1) Background: Design thinking is a problem-solving approach that has been applied in various sectors, including healthcare and medical education. While deep learning (DL) algorithms can assist in clinical practice, integrating them into clinical scenarios can be challenging. This study aimed to use design thinking steps to develop a DL algorithm that accelerates deployment in clinical practice and improves its performance to meet clinical requirements. (2) Methods: We applied the design thinking process to interview clinical doctors and gain insights to develop and modify the DL algorithm to meet clinical scenarios. We also compared the DL performance of the algorithm before and after the integration of design thinking. (3) Results: After empathizing with clinical doctors and defining their needs, we identified the unmet need of five trauma surgeons as "how to reduce the misdiagnosis of femoral fracture by pelvic plain film (PXR) at initial emergency visiting". We collected 4235 PXRs from our hospital, of which 2146 had a hip fracture (51%) from 2008 to 2016. We developed hip fracture DL detection models based on the Xception convolutional neural network by using these images. By incorporating design thinking, we improved the diagnostic accuracy from 0.91 (0.84-0.96) to 0.95 (0.93-0.97), the sensitivity from 0.97 (0.89-1.00) to 0.97 (0.94-0.99), and the specificity from 0.84 (0.71-0.93) to 0.93(0.990-0.97). (4) Conclusions: In summary, this study demonstrates that design thinking can ensure that DL solutions developed for trauma care are user-centered and meet the needs of patients and healthcare providers.

Timely surgical fixation confers beneficial outcomes in patients' concomitant flail chest with mild-to-moderate traumatic brain injury: a trauma quality improvement project analysis - a cohort study.

BACKGROUND: Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. RESEARCH QUESTION: Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? STUDY DESIGN AND METHODS: Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. RESULTS: Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p <0.001), a longer length of stay (coefficient ß , 4.664; SE, 0.789; p <0.001), longer ventilator days (coefficient ß , 2.020; SE, 0.528; p <0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p <0.001). INTERPRETATION: Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury.

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.

Is It Beneficial to Optimize Vital Signs Before Embolization for Pelvic Fractures? A Dilemma Between Resuscitation and Hemostasis.

PURPOSE: Adequate resuscitation and definitive hemostasis are both important in the management of hemorrhage related to pelvic fracture. The goal of this study was to analyze the relationship between the amount of blood transfused before transcatheter arterial embolization (TAE) and the clinical outcome later in the disease course. METHODS: Patients with pelvic fractures who underwent TAE for hemostasis from January 2018 to December 2019 were studied. The characteristics of patients who received blood transfusions of >2 U (1000 mL) and ≤2 U before TAE were compared. The mortality rate, blood transfusion-related complications, and length of stay were compared between these two groups. RESULTS: Among the 75 studied patients, 39 (52.0%) received blood transfusions of ≤2 U before TAE, and the other 36 (48.0%) patients received blood transfusions of >2 U before TAE. The incidence rates of systemic inflammatory response syndrome, sepsis, and coagulopathy were significantly higher in the >2 U group (97.2% vs 81.1%, P = .027; 50.0% vs 27.0%, P = .045; and 44.4% vs 5.4%, P < .01, respectively). After nonsurvivors were excluded, the >2 U group had a significantly higher proportion (43.8% vs 14.7%, P < .001) of prolonged intensive care unit (ICU) length of stay (7 days or more) and a longer hospital length of stay (33.8 ± 15.1 vs 21.9 ± 94.0, P < .01) than the ≤2 U group. Pre-TAE blood transfusion >2 U serves as an independent risk factor for prolonged ICU length of stay and increased hospital length of stay. CONCLUSION: Early hemostasis for pelvic fracture-related hemorrhage is suggested to prevent pre-TAE blood transfusion-associated adverse effects of blood transfusion.

The Surgical Timing and Complications of Rib Fixation for Rib Fractures in Geriatric Patients.

Rib fractures (RF) are a common injury that cause significant morbidity and mortality, especially in geriatric patients. RF fixation could shorten hospital stay and improve survival. The aim of this retrospective study was to evaluate the clinical impact and proper surgical timing of RF fixation in geriatric patients. We reviewed all the medical data of patients older than 16 years old with RF from the trauma registry database between January 2017 and December 2019 in Chang Gung Memorial Hospital. A total of 1078 patients with RF were enrolled, and 87 patients received RF fixation. The geriatric patients had a higher chest abbreviated injury scale than the non-geriatric group (p = 0.037). Univariate analysis showed that the RF fixation complication rates were significantly related to the injury severity scores (Odds ratio 1.10, 95% CI 1.03-1.20, p = 0.009) but not associated with age (OR 0.99, 95% CI 0.25-3.33, p = 0.988) or the surgical timing (OR 2.94, 95% CI 0.77-12.68, p = 0.122). Multivariate analysis proved that only bilateral RF was an independent risk factor of complications (OR 6.60, 95% CI 1.38-35.54, p = 0.02). RF fixation can be postponed for geriatric patients after they are stabilized and other lethal traumatic injuries are managed as a priority.

The role of acute care surgeons in treating rib fractures-a retrospective cohort study from a single level I trauma center.

BACKGROUND: Rib fractures are the most common thoracic injury in patients who sustained blunt trauma, and potentially life-threatening associated injuries are prevalent. Multi-disciplinary work-up is crucial to achieving a comprehensive understanding of these patients. The present study demonstrated the experience of an acute care surgery (ACS) model for rib fracture management from a single level I trauma center over 13 years. METHODS: Data from patients diagnosed with acute rib fractures from January 2008 to December 2020 were collected from the trauma registry of Chang Gung Memorial Hospital (CGMH). Information, including patient age, sex, injury mechanism, Abbreviated Injury Scale (AIS) in different anatomic regions, injury severity score (ISS), index admission department, intensive care unit (ICU) length of stay (LOS), total admission LOS, mortality, and other characteristics of multiple rib fracture, were analyzed. Patients who received surgical stabilization of rib fractures (SSRF) were analyzed separately, and basic demographics and clinical outcomes were compared between acute care and thoracic surgeons. RESULTS: A total of 5103 patients diagnosed with acute rib fracture were admitted via the emergency department (ED) of CGMH in the 13-year study period. The Department of Trauma and Emergency Surgery (TR) received the most patients (70.8%), and the Department of Cardiovascular and Thoracic Surgery (CTS) received only 3.1% of the total patients. SSRF was initiated in 2017, and TR performed fixation for 141 patients, while CTS operated for 16 patients. The basic demographics were similar between the two groups, and no significant differences were noted in the outcomes, including LOS, LCU LOS, length of indwelling chest tube, or complications. There was only one mortality in all SSRF patients, and the patient was from the CTS group. CONCLUSIONS: Acute care surgeons provided good-quality care to rib fracture patients, whether SSRF or non-SSRF. Acute care surgeons also safely performed SSRF. Therefore, we propose that the ACS model may be an option for rib fracture management, depending on the deployment of staff in each institute.

Preinjury warfarin does not cause failure of nonoperative management in patients with blunt hepatic, splenic or renal injuries.

BACKGROUND: For patients sustaining major trauma, preinjury warfarin use may make adequate haemostasis difficult. This study aimed to determine whether preinjury warfarin would result in more haemostatic interventions (transarterial embolization [TAE] or surgeries) and a higher failure rate of nonoperative management for blunt hepatic, splenic or renal injuries. METHODS: This was a retrospective cohort study from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with hepatic, splenic or renal injuries were identified. The primary outcome measurement was the need for invasive procedures to stop bleeding. One-to-two propensity score matching (PSM) was used to minimize selection bias. RESULTS: A total of 37,837 patients were enrolled in the study, and 156 (0.41%) had preinjury warfarin use. With proper 1:2 PSM, patients who received warfarin preinjury were found to require more haemostatic interventions (39.9% vs. 29.1%, p=0.016). The differences between the two study groups were that patients with preinjury warfarin required more TAE than the controls (16.3% vs 8.2%, p = 0.009). No significant increases were found in the need for surgeries (exploratory laparotomy (5.2% vs 3.6%, p = 0.380), hepatorrhaphy (9.2% vs 7.2%, p = 0.447), splenectomy (13.1% vs 13.7%, p = 0.846) or nephrectomy (2.0% vs 0.7%, p = 0.229)). Seven out of 25 patients (28.0%) in the warfarin group required further operations after TAE, which was not significantly different from that in the nonwarfarin group (four out of 25 patients, 16.0%, p = 0.306) CONCLUSION: Preinjury warfarin increases the need for TAE but not surgeries. With proper haemostasis with TAE and resuscitation, nonoperative management can still be applied to patients with preinjury warfarin sustaining blunt hepatic, splenic or renal injuries. Patients with preinjury warfarin had a higher risk for surgery after TAE.

The Feasibility and Efficiency of Remote Spirometry System on the Pulmonary Function for Multiple Ribs Fracture Patients.

BACKGROUND: Multiple rib fractures is a common chest trauma with a significant and sustained impact on pulmonary function and quality of life. Continuous monitoring of the pulmonary function parameter was necessary to adjust the therapeutic goals in these patients. We developed an internet-based remote system for lung function monitoring with a remote spirometry and smart device application to follow up these patients consecutively. METHOD: From Jan 2021 to April 2021, we conducted a prospective study that applied an intelligent spirometry system for patients with multiple rib fractures. With informed consent, we collected clinical data from them and introduced the remote spirometry system. We followed up with these patients for 12 weeks after trauma and compared the recovery of pulmonary function parameters and clinical outcomes. RESULT: A total of 21 patients were enrolled in our study. We divided them into two groups by the compliance to this remote spirometry system. The improvement of forced vital capacity was better in the good compliance group than the poor compliance group (110% versus 21%, p value 0.049). Moreover, the complication rate was also lower in the good compliance group than the poor compliance group (10% versus 66.7% p value 0.017). CONCLUSIONS: Remote spirometry system is a novel system that can help in lung rehabilitation in patients with multiple rib fractures. Patients that cooperate well with this system presented superior lung function improvement and inferior complication rate.

How much could a low COVID-19 pandemic change the injury trends? A single-institute, retrospective cohort study.

OBJECTIVES: COVID-19 has changed the epidemiology of trauma. However, Taiwan is a country with a low COVID-19 threat, and people's daily lives have remained mostly unchanged during this period. The purpose of this study is to investigate whether the trend of trauma incidence and the service of trauma care is affected by the relatively minor COVID-19 pandemic in Taiwan. DESIGN: A single-institute, retrograde cohort study. SETTING: An observational study based on the trauma registry of Chang Gung Memorial Hospital (CGMH). PARTICIPANTS: Trauma patients presented to the emergency department of CGMH in the period of 1 January to 30 June 2020 (week 1 to week 26) were designated as the COVID-19 group, with 1980 patients in total. Patients of the same period in 2015-2019 were designated as the pre-COVID-19 group, with 10 334 patients overall. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome is the incidence of trauma admission. Differences in trauma mechanism, severity, location and outcome were also compared in both groups. RESULTS: A decrease in trauma incidence during March and April 2020 was noticed. Significant change (p<0.001) in trauma mechanisms was discovered, with decreased burn (5.8% vs 3.6%) and assault (4.8% vs 1.2%), and increased transport accidents (43.2% vs 47.2%) and suicide (0.2% vs 1.0%) in the COVID-19 cohort. A shift in injury locations was also found with a 5% decrement of workplace injuries (19.8% vs 14.8%, p<0.001). CONCLUSION: The limited COVID-19 outbreak in Taiwan has led to a decreased incidence of trauma patients, and the reduction is mostly attributed to the decline in workplace injuries.

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.

Unstable Hemodynamics is not Always Predictive of Failed Nonoperative Management in Blunt Splenic Injury.

BACKGROUND: The advanced technology of interventional radiology may contribute to a rapid and timely angioembolization for hemostasis. We hypothesized that unstable hemodynamics is no longer an absolute contraindication of nonoperative management (NOM) in blunt splenic injury patients using rapid angioembolization. METHODS: From January 2009 to December 2019, blunt splenic injury patients with unstable hemodynamics [initial pulse >120 beats/min or systolic blood pressure <90 mm Hg] were included. Either emergency surgery or angioembolization was performed for hemostasis because of their unstable status. The characteristics of patients who underwent angioembolization or surgery were compared in each group (all patients, patients with hypotension, patients without response to resuscitation and hypotensive patients without response to resuscitation). RESULTS: A total of 73 patients were included in the current study. With respect to all patients, 68.5% (N = 50) of patients underwent NOM with angioembolization for hemostasis. Patients who underwent angioembolization for hemostasis had a significantly lower base deficit (5.3 ± 3.8 vs. 8.3 ± 5.2 mmol/L, p = 0.006) and a higher proportion of response to resuscitation (82.0% vs. 30.4%, p < 0.001) than did patients who underwent surgery. However, there was no significant difference in the proportion of hypotension (58.0% vs. 65.2%, p = 0.558) between these two groups. There were 44 patients with hypotension, and the angioembolization could be performed in 65.9% (N = 29) of them. Patients who underwent angioembolization had a significantly higher proportion of response to resuscitation than did patients who underwent surgery (89.7% vs. 33.3%, p < 0.001). In hypotensive patients without response to resuscitation (N = 13), 23.1% (N = 3) of the patients underwent angioembolization successfully. There was no significant difference in time to hemostasis procedure between patients who underwent angioembolization or surgery (24.7 ± 2.1 vs. 26.3 ± 16.7 min, p = 0.769). The demographics, vital signs, blood transfusion amount, injury severity, mortality rate and length of stay of patients who underwent angioembolization were not significantly different from patients who underwent surgery in each group. CONCLUSIONS: With a short preparation time of angioembolization, the NOM could be performed selectively for hemodynamically unstable patients with blunt splenic injury. The base deficit serves as an early detector of the requirement of surgical treatment.

Increased long-term pneumonia risk for the trauma-related splenectomized population - a population-based, propensity score matching study.

BACKGROUND: Splenectomy is the life-saving treatment for high-grade spleen trauma. Splenectomized patients are at a significant infection risk. However, the trauma-induced splenectomy results in less incidence of postsplenectomy infection than the hematologic disorder. We conducted a large-scale study to identify the infection rate and management strategy in trauma-related splenic injuries. METHODS: We included patients with the diagnosis of spleen injury in Taiwan from January 2003 to December 2013 by using the National Health Insurance Database and divided them into spleen preserved and splenectomized groups. The demographic factors including age, sex, hospital level, year of injury, trauma mechanism, associated injuries, whether injury severity score ≧16, and comorbidities were extracted. A 1:1 propensity score match was performed, and we analyzed the long-term outcome as the presence of infection-related disease (septicemia, pneumonia, and meningitis) after spleen trauma. The multivariate logistic regression analysis was used to identify the risk factor for each outcome. RESULTS: During the 11 years included in this study, a total of 8,897 patients with spleen trauma were identified. A total of 3,520 (39.6%) patients were splenectomized, and 5,377 (60.4%) were spleen preserved. After propensity score matching, 3,099 pairs of patients were enrolled for further analysis. In univariate analysis, the incidence of pneumonia is significantly higher in the splenectomized group (8.5% vs 7.0%, P = .037). There was no significant difference in septicemia and meningitis between the 2 groups. In multivariate analysis, splenectomy is an independent risk factor for pneumonia in long-term follow-up. CONCLUSION: Compared with the spleen preserved group, splenectomy is related to an increased likelihood of long-term pneumonia onset but not to an increase in the possibility of other infections.