Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. METHODS: We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. RESULTS: Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%). CONCLUSION: This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

Unlocking the potential of TIPS placement as a bridge to elective and emergency surgery in cirrhotic patients: a meta-analysis and future directions for endovascular resuscitation in acute care surgery.

BACKGROUND: In this systematic review and meta-analysis, we examined the evidence on transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to elective and emergency surgery in cirrhotic patients. We aimed to assess the perioperative characteristics, management approaches, and outcomes of this intervention, which is used to achieve portal decompression and enable the safe performance of elective and emergent surgery. METHODS: MEDLINE and Scopus were searched for studies reporting the outcomes of cirrhotic patients undergoing elective and emergency surgery with preoperative TIPS. The risk of bias was evaluated using the methodological index for non-randomized studies of interventions, and the JBI critical appraisal tool for case reports. The outcomes of interest were: 1. Surgery after TIPS; 2. Mortality; 3. Perioperative transfusions; and 4. Postoperative liver-related events. A DerSimonian and Laird (random-effects) model was used to perform the meta-analyses in which the overall (combined) effect estimate was presented in the form of an odds ratio (summary statistic). RESULTS: Of 426 patients (from 27 articles), 256 (60.1%) underwent preoperative TIPS. Random effects MA showed significantly lower odds of postoperative ascites with preoperative TIPS (OR = 0.40, 95% CI 0.22-0.72; I2 = 0%). There were no significant differences in 90-day mortality (3 studies: OR = 0.76, 95% CI 0.33-1.77; I2 = 18.2%), perioperative transfusion requirement (3 studies: OR = 0.89, 95% CI 0.28-2,84; I2 = 70.1%), postoperative hepatic encephalopathy (2 studies: OR = 0.97, 95% CI 0.35-2.69; I2 = 0%), and postoperative ACLF (3 studies: OR = 1.02, 95% CI 0.15-6.8, I2 = 78.9%). CONCLUSIONS: Preoperative TIPS appears safe in cirrhotic patients who undergo elective and emergency surgery and may have a potential role in postoperative ascites control. Future randomized clinical trials should test these preliminary results.

Hypertonic saline infusion does not improve the chance of primary fascial closure after damage control laparotomy: a randomized controlled trial.

BACKGROUND: Previous observational studies showed higher rates of abdominal wall closure with the use of hypertonic saline in trauma patients with abdominal injuries. However, no randomized controlled trials have been performed on this matter. This double-blind randomized clinical trial assessed the effect of 3% hypertonic saline (HS) solution on primary fascial closure and the timing of abdominal wall closure among patients who underwent damage control laparotomy for bleeding control. METHODS: Double-blind randomized clinical trial. Patients with abdominal injuries requiring damage control laparotomy (DCL) were randomly allocated to receive a 72-h infusion (rate: 50 mL/h) of 3% HS or 0.9 N isotonic saline (NS) after the index DCL. The primary endpoint was the proportion of patients with abdominal wall closure in the first seven days after the index DCL. RESULTS: The study was suspended in the first interim analysis because of futility. A total of 52 patients were included. Of these, 27 and 25 were randomly allocated to NS and HS, respectively. There were no significant differences in the rates of abdominal wall closure between groups (HS: 19 [79.2%] vs. NS: 17 [70.8%]; p = 0.71). In contrast, significantly higher hypernatremia rates were observed in the HS group (HS: 11 [44%] vs. NS: 1 [3.7%]; p < 0.001). CONCLUSION: This double-blind randomized clinical trial showed no benefit of HS solution in primary fascial closure rates. Patients randomized to HS had higher sodium concentrations after the first day and were more likely to present hypernatremia. We do not recommend using HS in patients undergoing damage control laparotomy. Trial registration The trial protocol was registered in clinicaltrials.gov (identifier: NCT02542241).

Outcomes of Patients with Severe Obesity and Cirrhosis with Portal Hypertension Undergoing Bariatric Surgery: a Systematic Review.

PURPOSE: Thus far, little attention has been paid to bariatric surgery (BS) in patients with severe obesity (SO) and cirrhosis with portal hypertension (PH). To address this knowledge gap, we systematically reviewed the available literature and evidence about BS in patients with SO and cirrhosis with PH. We inform on the perioperative and long-term outcomes of this intervention. MATERIALS AND METHODS: Articles were identified in MEDLINE, SCOPUS, LILACS, and SCIELO, and included if they analyzed SO patients with clinically significant PH and reported the characteristics and outcomes of BS. RESULTS: Six articles, including 32 patients, were included. The most frequent type of BS was sleeve gastrectomy performed in 27 patients. Perioperative transfusions were often not required, with only one case report describing the use of 1 unit of packed red blood cells post-operatively. Neither intraoperative nor post-op deaths were reported. All patients reported significant weight loss with improvements in comorbidities during the follow-up periods. Overall, 27 out of 29 patients had T2DM resolution, and 13 out of 23 had arterial hypertension resolution. One study reported improvements in the parameters of fibroscan. CONCLUSION: This systematic review described the outcomes of BS among patients with SO with cirrhosis and PH. Performing this kind of surgery among these patients appears safe and associated with acceptable perioperative and long-term outcomes. However, further studies are required to provide evidence-based, strong recommendations.

NAFLD as the metabolic hallmark of obesity.

Non-alcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease worldwide, associated with a high risk of progression to NASH, liver cirrhosis and hepatocarcinoma. Its prevalence is closely related to obesity (understood as adipose-based disease and insulin resistance), which makes that at present NAFLD can be considered a metabolic dysfunction hallmark, regardless of the body mass index. Despite being such a prevalent condition, with such severe consequences, at present there are no reliable biomarkers for its diagnosis or specific treatment. Significant and sustained weight loss, as well as some antidiabetic treatments, has shown promising results for NAFLD but data needs confirmation in larger clinical trials and longer follow-up. Efforts should be made for a better and more accurate baseline diagnosis (including large-scale genetics), identification of patients at higher risk for progression to NASH as well as adequate treatment, to allow us to offer a personalized approach in NAFLD in the context of precision medicine.

Impact of the COVID-19 pandemic on the care and outcomes of people with NAFLD-related cirrhosis.

Background & Aims: The COVID-19 pandemic has had a major negative impact on health systems and many chronic diseases globally. We aimed to evaluate the impact of the first year of the pandemic on the outcomes of people with NAFLD cirrhosis. Methods: We conducted a before-after study in four University hospitals in Catalonia, Spain. Study subperiods were divided into Pre-pandemic (March/2019-February/2020) vs. Pandemic (March/2020-February/2021). The primary outcome was the rate of first liver-related event (LRE). Overall clinical outcomes (LREs plus cardiovascular plus all-cause mortality) were also assessed. Results: A total of 354 patients were included, all of whom were compensated at the beginning of the study period; 83 individuals (23.5%) had a history of prior hepatic decompensation. Mean age was 67.3 years and 48.3% were female. Median BMI was 31.2 kg/m2 and type 2 diabetes was present in 72.8% of patients. The rates of first LRE in the Pre-pandemic and Pandemic periods were 7.4% and 11.3% (p = 0.12), respectively. Whilst the rate of overall events was significantly higher in the Pandemic period (9.9% vs. 17.8%; p = 0.009), this was strongly associated with COVID-19-related deaths. The rate of worsened metabolic status was significantly higher in the Pandemic period (38.4% vs. 46.1%; p = 0.041), yet this was not associated with the risk of first LRE during the Pandemic period, whereas type 2 diabetes (odds ratio [OR] 3.77; 95% CI 1.15-12.32; p = 0.028), albumin <4 g/L (OR 4.43; 95% CI 1.76-11.17; p = 0.002) and Fibrosis-4 score >2.67 (OR 15.74; 95% CI 2.01-123.22; p = 0.009) were identified as risk factors in the multivariable analysis. Conclusion: Overall, people with NAFLD cirrhosis did not present poorer liver-related outcomes during the first year of the pandemic. Health system preparedness seems key to ensure that people with NAFLD cirrhosis receive appropriate care during health crises. Lay summary: Mobility restrictions and social stress induced by the COVID-19 pandemic have led to increased alcohol drinking and worsened metabolic control (e.g., weight gain, poor control of diabetes) in a large proportion of the population in many countries. We aimed to analyze whether people with cirrhosis due to non-alcoholic fatty liver disease, who are particularly vulnerable to such lifestyle modifications, were significantly impacted during the first year of the pandemic. We compared the clinical situation of 354 patients one year before the pandemic and one year after. We found that although metabolic control was indeed worse after the first year of the pandemic and patients presented worse clinical outcomes, the latter was mostly due to non-liver causes, namely COVID-19 itself. Moreover, the care provided to these patients did not worsen during the first year of the pandemic.

Use of REBOA in the universe of magical realism: a real-world review / Uso de REBOA en el universo del realismo mágico: revisión de vida real

Abstract While reading the novella "Chronicle of a Death Foretold" by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.

Resumen Leyendo la novela "Crónica de una muerte anunciada" del Nobel de Literatura Gabriel García Márquez, nos sorprendió reconocer que las heridas provocadas al personaje principal se habrían podido tratar exitosamente en un centro de trauma moderno donde hubieran optado por REBOA. Hacemos referencia al asesinato del señor Nasar para explorar la posibilidad de que se hubiera podido salvar de haberse utilizado REBOA como adyuvante de la cirugía para reanimación y control de la hemorragia. En la lectura de la novela de García Márquez tomamos nota de los sucesos que tuvieron lugar en el momento del asesinato de Santiago Nasar. Para contextualizar la afirmación de que Nasar habría podido sobrevivir si le hubieran manejado sus heridas con REBOA, exploramos e ilustramos lo que habría podido hacerse de otra manera y porqué. El día en que murió, el señor Nasar sufrió múltiples heridas por arma blanca y si bien muchas de ellas fueron en el torso, el libro describe siete heridas mortales que comprometieron los órganos sólidos, además de lesiones vasculares mayores. Presentamos una descripción práctica del algoritmo para el manejo clínico y quirúrgico que habríamos seguido en el caso del señor Nasar. Este algoritmo incluye el uso de REBOA para el control de la hemorragia y la reanimación, el cual, como parte de los procedimientos quirúrgicos realizados, habría podido salvarle la vida a la víctima. Basados en nuestro conocimiento actual acerca del uso de REBOA en la cirugía de trauma, planteamos que, junto con la atención quirúrgica apropiada para controlar la hemorragia, este procedimiento habría podido salvarle la vida a Santiago Nasar y, por tanto, evitar una muerte anunciada.

Emergency surgery workforce and its inverse relationship with multidimensional poverty in Colombia.

PURPOSE: General surgeons, anesthesiologists, obstetricians and gynecologists (ob-gyns), and orthopedic surgeons are the vital disciplines to provide emergency surgery within a healthcare system. This paper aims to examine the relationship (if any) between multidimensional poverty (MDP) and GDP per-capita with the emergency surgery workforce density in Colombia. METHODS: We performed an ecological study, where the observation units were the 32 Colombian departments. The total numbers of general surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons were obtained from the "Registro Unico Nacional de Talento Humano en Salud" (ReTHUS) registry. The 2020 population projections, the incidence of MDP and the GDP per capita were obtained from the Colombian National Administrative Department of Statistics. A spearman's correlation coefficient was calculated to measure the strength of the correlations between the surgical workforce density with MDP and GDP per-capita. RESULTS: There were significant moderate inverse linear correlations between the incidence of multidimensional poverty and workforce density. The correlation coefficients for the incidence of multidimensional poverty and the workforce density were - 0.5273, - 0.5620, - 0.4704, and - 0.4612 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. Conversely, the correlation coefficients for the GDP per-capita and the workforce density were 0.4045, 0.3822, 0.4404, and 0.3742 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. CONCLUSION: This study found that Colombian trauma and emergency surgery workforce density was inversely and directly correlated with multidimensional poverty and GDP per-capita levels, respectively. The relationship of these economic indicators with the surgical capacity deserves further investigation.

Mortality from anti-personnel mines before and during the Colombian peace process / Mortalidad secundaria a minas antipersona antes y durante el proceso de paz colombiano

Abstract Introduction: Although the peace process in Colombia resulted in a significant reduction in the number of anti-personnel mines across the country, there are no reliable data on the effects of this phenomenon on outcomes for patients who were victims of these devices. Objective: The objective of this study was to assess mortality from landmine injuries before and during the Colombian peace process. Furthermore possible associations between peace negotiations and mortality were explored. Methods: For this study, we used the "Colombian Victims of Antipersonnel Mines Injuries registry" (MAP/MUSE database) data from 2002 to 2018. This registry was launched in 2001 by the government of Colombia with the aim of prospectively and systematically collect information on all the cases of anti-personnel mine injuries in the country. The period between 2002-2012 was classified as the pre-negotiation period (período de guerra), and 2014-2018 as the peace negotiations period, with 2013 classified as a washout year. Multivariate logistic regression was used to explore the association between peace negotiations and mortality among anti-personnel landmine injured individuals. Results: A total of 10306 landmine injury cases were registered. Of these, 1180 (11.4%) occurred in the peace-negotiation period. Mortality was significantly lower during the period of peace negotiations. After adjusting for sex, age group, race, active duty soldier status, rural area, and geographic Departamentos case volumes, the peace negotiation period was found to be associated with lower risk-adjusted odds of mortality after suffering a landmine injury (OR= 0.6, 95% CI, 0.5-0.7; p<0.001). Conclusions: Our findings suggest an association between the period of peace negotiation and a lower likelihood of mortality among victims of anti-personnel landmines.

Resumen Introducción: Aunque el proceso de paz colombiano produjo una reducción en la cantidad de minas antipersona en el país, no hay estimativos sobre el efecto de este fenómeno en los desenlaces de los pacientes víctimas de estos artefactos. Objetivo: Nuestro objetivo fue evaluar la mortalidad por minas antipersona antes y durante la negociación del proceso de paz en Colombia. Además, exploramos posibles asociaciones entre las negociaciones de paz y la mortalidad. Métodos: Para este estudio utilizamos los datos del "Registro de víctimas colombianas de lesiones de minas antipersona" (base de datos MAP / MUSE) de 2002 a 2018. Este registro fue lanzado en 2001 por el gobierno de Colombia con el objetivo de recolectar información de manera prospectiva y sistemática de los casos de trauma por minas antipersona en el país. Clasificamos el período comprendido entre 2002 y 2012 como el período previo a la negociación (período de guerra), el comprendido entre 2014 y 2018 como el período de negociaciones de paz y el año 2013 como período de "depuración". Se utilizaron modelos de regresión logística multivariados para explorar las asociaciones entre las negociaciones de paz y la mortalidad. Resultados: Se registraron un total de 10306 casos de lesiones por minas antipersona. De estos, 1180 (11.4%) ocurrieron en el período de negociación de paz. La mortalidad fue significativamente menor durante el período de negociaciones de paz. El análisis de regresión logística multivariado determinó que el período de negociación de paz se asoció con una menor probabilidad de mortalidad después de sufrir una lesión por minas antipersona (OR = 0,6, IC 95%, 0,5-0,7; p <0,001). Conclusiones: Nuestros hallazgos sugieren una asociación entre el período de negociación de paz y una menor probabilidad de mortalidad entre las víctimas de las minas antipersona.

Ethnic disparities in mortality from landmines: A country-level analysis / Ethnic disparities in mortality from landmines: A country-level analysis

Introducción. El Registro Colombiano de Víctimas de Lesiones por Minas Antipersona fue lanzado por el gobierno de Colombia con el objetivo de recolectar información sobre los casos de heridos por minas antipersona en el país. El propósito de este estudio fue investigar las disparidades de mortalidad entre las víctimas de lesiones por minas antipersona, en función de la pertenencia a una minoría étnica. Métodos. Se hizo una regresión logística multivariable para examinar la asociación entre minorías étnicas y mortalidad en las personas heridas por minas antipersona. Resultados. Se registraron 10.306 casos de lesiones por minas antipersona, de los cuales 430 eran personas pertenecientes a grupos étnicos minoritarios (indígenas o afrodescendientes). De estos, 85 (19,7 %) eran mujeres, 156 (36,2 %) eran menores de 18 años y 427 (99,3%) vivían en áreas rurales. La mortalidad fue significativamente mayor (29,3 %) en comparación con la población mestiza (18,5 %; p < 0,001). Después de ajustar por sexo, edad, soldado en servicio activo, área rural y volumen de casos por departamento, encontramos que las minorías étnicas tenían mayores probabilidades de morir (OR = 2,03; IC95% 1,61- 2,56; p < 0,001).Discusión. Encontramos una asociación entre la pertenencia a una minoría étnica y una mayor probabilidad de mortalidad con lesiones causadas por minas antipersona. Estos hallazgos deberían alentar a los legisladores de las zonas rurales de Colombia a trabajar más diligentemente, para reducir las consecuencias nocivas de las lesiones causadas por estos artefactos en los grupos étnicos minoritarios

Introduction. The Colombian Victims of Antipersonnel Mines Injuries registry was launched by the Colombian government with the objective of collecting information on all the cases of injuries caused by antipersonnel landmines in the country. The purpose of this study was to investigate the mortality disparities among ethnic minority victims of antipersonnel landmine injuries.Methods. A multivariate logistic regression was performed to examine the association between ethnic minorities and mortality in people injured by antipersonnel mines. Results. A total of 10,306 cases of injuries caused by antipersonnel landmines were registered, of which 430 were people belonging to minority ethnic groups (indigenous or Afro-descendant). Of these, 85 (19.7%) were women and 156 (36.2%) were under 18 years of age. Almost all people from ethnic minority groups were located in rural areas (n=427, 99.3%) and mortality was significantly higher compared to the mestizo population (mestizo 18.5% vs. individuals from ethnic minorities 29, 3%; p <0.001). After adjusting for sex, age group, active duty soldier status, rural area, and case volume for each geographic department, we found that ethnic minorities were more likely to die after suffering an antipersonnel mine injury (OR = 2.03; 95% CI 1.61-2.56; p <0.001). Discussion. We found an association between belonging to an ethnic minority and a higher probability of mortality with injuries caused by antipersonnel mines. These findings should encourage legislators in rural Colombia to work more diligently to reduce the harmful consequences of injuries caused by these devices in ethnic minority groups

Disparidades por etnia en la mortalidad por minas antipersona: un análisis a nivel país / Ethnic disparities in mortality from landmines: A country-level analysis

Resumen Introducción. El Registro Colombiano de Víctimas de Lesiones por Minas Antipersona fue lanzado por el gobierno de Colombia con el objetivo de recolectar información sobre los casos de heridos por minas antipersona en el país. El propósito de este estudio fue investigar las disparidades de mortalidad entre las víctimas de lesiones por minas antipersona, en función de la pertenencia a una minoría étnica. Métodos. Se hizo una regresión logística multivariable para examinar la asociación entre minorías étnicas y mortalidad en las personas heridas por minas antipersona. Resultados. Se registraron 10.306 casos de lesiones por minas antipersona, de los cuales 430 eran personas pertenecientes a grupos étnicos minoritarios (indígenas o afrodescendientes). De estos, 85 (19,7 %) eran mujeres, 156 (36,2 %) eran menores de 18 años y 427 (99,3%) vivían en áreas rurales. La mortalidad fue significativamente mayor (29,3 %) en comparación con la población mestiza (18,5 %; p < 0,001). Después de ajustar por sexo, edad, soldado en servicio activo, área rural y volumen de casos por departamento, encontramos que las minorías étnicas tenían mayores probabilidades de morir (OR = 2,03; IC95% 1,61- 2,56; p < 0,001). Discusión. Encontramos una asociación entre la pertenencia a una minoría étnica y una mayor probabilidad de mortalidad con lesiones causadas por minas antipersona. Estos hallazgos deberían alentar a los legisladores de las zonas rurales de Colombia a trabajar más diligentemente, para reducir las consecuencias nocivas de las lesiones causadas por estos artefactos en los grupos étnicos minoritarios.

Abstract Introduction. The Colombian Victims of Antipersonnel Mines Injuries registry was launched by the Colombian government with the objective of collecting information on all the cases of injuries caused by antipersonnel landmines in the country. The purpose of this study was to investigate the mortality disparities among ethnic minority victims of antipersonnel landmine injuries. Methods. A multivariate logistic regression was performed to examine the association between ethnic minorities and mortality in people injured by antipersonnel mines. Results. A total of 10,306 cases of injuries caused by antipersonnel landmines were registered, of which 430 were people belonging to minority ethnic groups (indigenous or Afro-descendant). Of these, 85 (19.7%) were women and 156 (36.2%) were under 18 years of age. Almost all people from ethnic minority groups were located in rural areas (n=427, 99.3%) and mortality was significantly higher compared to the mestizo population (mestizo 18.5% vs. individuals from ethnic minorities 29, 3%; p <0.001). After adjusting for sex, age group, active duty soldier status, rural area, and case volume for each geographic department, we found that ethnic minorities were more likely to die after suffering an antipersonnel mine injury (OR = 2.03; 95% CI 1.61-2.56; p <0.001). Discussion. We found an association between belonging to an ethnic minority and a higher probability of mortality with injuries caused by antipersonnel mines. These findings should encourage legislators in rural Colombia to work more diligently to reduce the harmful consequences of injuries caused by these devices in ethnic minority groups.

A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma.

BACKGROUND: We performed a systematic review (SR) and meta-analysis (MA) to determine the diagnostic accuracy of chest ultrasound (US) compared with a pericardial window (PW) for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. METHODS: A literature search in five databases identified relevant articles for inclusion in this SR and MA. Studies were eligible if they evaluated the diagnostic accuracy of chest US, compared with a PW, for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients presenting with penetrating thoracic trauma. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. Methodological quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2. We performed a MA of binary diagnostic test accuracy within the bivariate mixed-effects logistic regression modeling framework. RESULTS: We included five studies in our SR and MA. These studies included a total of 556 trauma patients. The MA found that, compared with PW, the US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients. The presence of a concomitant left hemothorax was frequent in patients with false-negative results. CONCLUSION: This SR and MA found that, compared with PW, US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. Caution interpretation of pericardial US results is suggested in the presence of left hemothorax. In these cases, a second diagnostic test should be performed. LEVEL OF EVIDENCE: Systematic Review and Meta-analysis, level II.

Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients.

PURPOSE: The purpose of this study was to examine the association of REBOA and mortality in a group of patients with penetrating trauma to the torso, treated in a level-I trauma center from Colombia. METHODS: In a retrospective cohort study, patients with penetrating trauma, requiring emergency surgery, and treated between 2014 and 2018, were included. The decision to use or not use REBOA during emergent surgery was based on individual surgeon's opinion. A propensity score (PS) was calculated after adjusting for age, clinical signs on admission (systolic blood pressure, cardiac rate, Glasgow coma scale), severe trauma in thorax and abdomen, and the presence of non-compressive torso hemorrhage. Subsequently, logistic regression for mortality was adjusted for the number of red blood cells (RBC) transfused within the first six hours after admission, injury severity score (ISS), and quintiles of PS. RESULTS: We included 345 patients; 28 of them (8.1%) were treated with REBOA. Crude mortality rates were 17.9% (5 patients) in REBOA group and 15.3% (48 patients) in control group (p = 0.7). After controlling for RBC transfused, ISS, and the PS, the odds of death in REBOA group was 78% lower than that in the control group (odds ratio [OR] 0.20, 95% confidence interval [95%CI] 0.05-0.77, p = 0.01). CONCLUSION: We found that, when compared to no REBOA use, patients treated with REBOA had lower risk-adjusted odds of mortality. These findings should be interpreted with caution and confirmed in future comparative studies, if possible.

The tenets of intrathoracic packing during damage control thoracic surgery for trauma patients: a systematic review.

PURPOSE: Although Damage Control Thoracic Surgery (DCTS) has become a provocative alternative to treat patients with chest injuries who are critically ill and physiologically depleted, the management approaches of chest-packing and the measurement of clinically relevant outcomes are not well established. In this paper, we systematically reviewed the available knowledge and evidence about intra-thoracic packing during DCTS for trauma patients. We furthermore inform on the management approaches, surgical strategies, and mortality associated with this intervention. METHODS: We identified articles in MEDLINE and SCOPUS. We reviewed all studies that included trauma patients with chest injuries and managed with intrathoracic packing during DCTS. Studies were eligible if the use of intrathoracic packing in trauma populations was reported. RESULTS: We identified 14 studies with a total of 211 patients. Overall, intrathoracic packing was used in 131 trauma patients. Packing was most commonly used to arrest persistent coagulopathic bleeding or oozing either from raw surfaces or repaired structures and in conjunction with other operative techniques. Pneumonectomy was a deadly intervention; however, one study reported survivors when pneumonectomy was deferred. CONCLUSION: Packing is a feasible, reliable and potentially effective complementary method for hemorrhage control. Therefore, we recommend that packing can be used liberally as a complement to rapid lung-sparing techniques.

Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries' income based on the World Bank Country and Lending Groups. METHODS: We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. RESULTS: A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36­1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63­3,33; p = 0.3). CONCLUSION: There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.

Pediatric Palliative Care During End of Life: A Privilege of a Few in a Tertiary Referral Hospital From Colombia.

BACKGROUND: We aim to describe the access to palliative care (PC) in hospitalized children during end-of-life care and compare the circumstances surrounding the deaths of hospitalized children as a basis for implementing a pediatric PC program at our institution. METHODS: We performed a retrospective chart review of deceased pediatric patients at a tertiary referral hospital in Colombia. The study group was selected by randomly drawing a sample of 100 observations from the 737 deceased children from 2013 to 2016. A 1:1 propensity score (PS) matching was performed to compare the characteristics and outcomes between PC and non-PC treated patients. RESULTS: We included 87 patients. After PS matching, we found that patients under the care of non-PC physicians were more likely to die in the pediatric intensive care unit (non-PC: 6/10 vs PC: 1/10; P = .02), to be on vasopressor agents and mechanical ventilation (non-PC: 7/10 vs PC: 1/10; P = .02), and to receive cardiopulmonary resuscitation at the end of life (non-PC: 5/10 vs PC: 0/10; P = .03). In contrast, a significantly higher proportion of patients under the care of the pediatric PC team died with comfort measures (non-PC: 2/10 vs 8/10; P = .02) and nonescalation of care in physician orders (non-PC: 5/10 vs PC: 10/10; 0.03). CONCLUSION: In this study, only 10 of 87 patients were treated by the pediatric PC team at the end of life. The latter finding is concerning and is a call to action to improve access to pediatric PC at our institution.

Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections!

Appropriate measures of infection prevention and management are integral to optimal clinical practice and standards of care. Among surgeons, these measures are often over-looked. However, surgeons are at the forefront in preventing and managing infections. Surgeons are responsible for many of the processes of healthcare that impact the risk for surgical site infections and play a key role in their prevention. Surgeons are also at the forefront in managing patients with infections, who often need prompt source control and appropriate antibiotic therapy, and are directly responsible for their outcome. In this context, the direct leadership of surgeons in infection prevention and management is of utmost importance. In order to disseminate worldwide this message, the editorial has been translated into 9 different languages (Arabic, Chinese, French, German, Italian, Portuguese, Spanish, Russian, and Turkish).

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients.

BACKGROUND: There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country. METHODS: Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test. RESULTS: A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions. CONCLUSION: We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

A clinical series of packing the wound tract for arresting traumatic hemorrhage from injuries of the lung parenchyma as a feasible damage control technique.

Background: Tractotomy has become the standard of care for transfixing through-and-through lung injuries as it can be performed quickly with little blood loss and a low risk of complications. However, packing with laparotomy pads could be a feasible alternative to tractotomy on selected patients. We describe a series of four patients with lung trauma in which packing of the pulmonary wound tract was used as the primary and unique surgical strategy for arresting hemorrhage from injuries of the lung parenchyma. Methods: Packing of the traumatic tract is achieved by gently pulling a laparotomy pad with a Rochester clamp and adjusting it to the cavity to stop the bleeding. The pack is removed in a subsequent surgery by moistening and tractioning it softly to avoid additional damage. The operation is completed by manual compression of the wounded lobe. We present a case series of our experience with this approach. Results: From 2012 to 2016, we treated four patients with the described method. The mechanism was penetrating in all them. The clinical condition was of exsanguinations with multiple sources of hemorrhage. There were three patients with peripheral injuries to the lung and one with a central injury to the pulmonary parenchyma. Bleeding was stopped in all the cases. Three patients survived. A patient had recurrent pneumothorax which was resolved with a second chest tube. Conclusion: Packing of the traumatic tract allowed rapid and safe treatment of transfixing through-and-through pulmonary wounds in exsanguinating patients under damage control from several bleeding sources.

Association of Medicaid Expansion Policy with Outcomes in Homeless Patients Requiring Emergency General Surgery.

BACKGROUND: Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS. METHODS: We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare. RESULTS: A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388-52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79-2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7-1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08-4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4-0.8; p = 0.01). CONCLUSION: Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.