Sex-based utilization and outcomes of cold-stored whole blood for trauma resuscitation: Analysis of a prospective multicenter study.

BACKGROUND: Resuscitation with cold-stored whole blood (WB) has outcome benefits, but benefits varied by patient sex is unknown. There are also concerns about alloimmunization risk for premenopausal females given WB, leading to some protocols excluding this cohort. We sought to analyze WB utilization, outcomes, and disparities by patient sex. METHODS: This is a secondary analysis of a prospective multicenter study of WB resuscitation. Patients were stratified by sex and compared by transfusion strategy of WB or component therapy (CT). Generalized estimated equation models using inverse probability of treatment weighting were utilized. RESULTS: There were 1,617 patients (83% male; 17% female) included. Females were less likely to receive WB versus males (55% vs. 76%; p < 0.001), with wide variability between individual centers (0%-33% female vs. 66%-100% male, p < 0.01). Male WB had more blunt trauma (45% vs. 31%) and higher shock index (1.0 vs. 0.8) compared with the male CT cohort (all p < 0.05) but similar Injury Severity Score. The female WB cohort was older (53 vs. 36) and primarily blunt trauma (77% vs. 62%) compared with the female CT cohort (all p < 0.05) but had similar shock index and Injury Severity Score. Male WB had lower early and overall mortality (27% vs. 42%), but a higher rate of acute kidney injury (16% vs. 6%) vs. the male CT cohort (all p < 0.01). Female cohorts had no difference in mortality, but the WB cohort had higher bleeding complications. Whole blood use was independently associated with decreased mortality (OR, 0.6; p < 0.01) for males but not for females (OR, 0.9; p = 0.78). CONCLUSION: Whole blood was independently associated with a decreased mortality for males with no difference identified for females. Whole blood was significantly less utilized in females and showed wide variability between centers. Further study of the impact of patient sex on outcomes with WB and WB utilization is needed. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Surgical trends and outcomes of open, laparoscopic, and robotic colostomy reversal for benign disease.

BACKGROUND: Despite the increasing use of minimally invasive surgeries, the outcome benefits of adopting minimally invasive surgery for colostomy reversal remain unclear. We aimed to analyze nationwide trends in the use of minimally invasive surgery for colostomy reversal and compare patient outcomes between different surgical approaches. METHODS: The National Inpatient Sample was queried for patients who underwent colostomy reversal for benign disease from 2015 to 2021. National trends in the use of minimally invasive surgery for colostomy reversal were analyzed by Cochran-Armitage tests. Multivariable linear and logistic regressions accounting for hospital sample weights were developed to examine the association between operative approach (open, laparoscopic, and robotic) and patient outcomes, including hospital complications, length of stay, and hospital charges. RESULTS: A total of 23,260 patients underwent colostomy reversal: 18,880 (81.2%) open, 3,245 (14.0%) laparoscopic, and 1,135 (4.9%) robotic surgery. From 2015 to 2021, the proportion of robotic approaches increased >5-fold (range 2.1-12.5%; Ptrend < .001), whereas the increase in laparoscopic approaches was not significant (range 11.5-16.2%; Ptrend = .34). Multivariable analysis showed that the laparoscopic approach was associated with a lower incidence of pulmonary complications (adjusted odds ratio, 0.49; 95% confidence interval, 0.28-0.87), surgical-site infection (odds ratio, 0.37; 95% CI, 0.19-0.72), peritonitis/abdominal abscess (odds ratio, 0.45; 95% confidence interval, 0.26-0.78), and paralytic ileus (odds ratio, 0.67; 95% confidence interval, 0.48-0.92). The robotic approach was associated with a lower incidence of paralytic ileus (odds ratio, 0.58; 95% confidence interval, 0.33-0.99). Laparoscopic and robotic approaches were associated with 22.9% and 29.9% shorter length of stay, respectively. The robotic approach was associated with 33.0% greater hospital charge. CONCLUSIONS: This study observed a significant trend toward the increased use of robotics in colostomy reversal and potential clinical benefits with minimally invasive surgery. Robotic colostomy reversal, along with laparoscopic approach, may provide better postoperative recovery compared with the open approach; however, the utility of robotic surgeries needs to be reevaluated in the future, given the limited clinical benefits despite greater hospital charges.

Interval cholecystectomy following drainage procedures for acute cholecystitis: percutaneous transhepatic vs endoscopic transpapillary gallbladder drainage.

BACKGROUND: Gallbladder drainage procedures are often considered for acute cholecystitis (AC) patients with significant peri-operative risks. While percutaneous transhepatic gallbladder drainage (PTGBD) has been evaluated in previous studies, there is scarce data on the feasibility and efficacy of endoscopic transpapillary gallbladder stenting (ETGBS) in patients with AC. This study aimed to compare the characteristics of interval cholecystectomy following ETGBS and PTGBD. METHODS: This retrospective descriptive study included patients who underwent ETGBS and/or PTGBD for AC and subsequently underwent interval cholecystectomy between 2018 and 2023. Demographics, operative technique, and postoperative complications of patients with ETGBS and PTGBD were compared. RESULTS: A total of 59 patients were included (14 ETGBS and 45 PTGBD). The median days between ETGBS and cholecystectomy were significantly longer than the PTGBD group (64 [45-150] days vs. 16 [10-42] days, p=0.045). The median operation time was significantly longer in the ETGBS group.　Among 33 patients who underwent subtotal cholecystectomy, the ERGBS group more frequently required closure of the gallbladder stump due to the difficulty in ligating the cystic duct compared to the PTGBD group (75.0% vs. 28.0%, p=0.035). Similarly, the fundus-first approach was more commonly selected in the ERGBS group (62.5% vs. 28.0%, p=0.01). No significant differences in the incidence of postoperative complications were observed between the two groups. CONCLUSIONS: Interval cholecystectomy following ETGBS is more technically demanding compared to PTGBD. Laparoscopic subtotal cholecystectomy following ETGBS could be a potential treatment option for patients who are unfit for early surgery, with the recognition of the difficulty in ligating the cystic duct.

Association between whole blood ratio and risk of mortality in massively transfused trauma patients: retrospective cohort study.

BACKGROUND: Although whole blood (WB) transfusion was reported to improve survival in trauma patients with hemorrhagic shock, little is known whether a higher proportion of WB is associated with an improved survival. This study aimed to evaluate the association between whole blood ratio (WBR) and the risk of mortality in trauma patients requiring massive blood transfusion. METHODS: We performed a retrospective cohort study from the ACS-TQIP between 2020 and 2021. Patients were aged ≥ 18 years and received WB within 4 h of hospital arrival as a part of massive blood transfusion. Study patients were categorized into four groups based on the quartiles of WBR. Primary outcome was 24-h mortality and secondary outcome was 30-day mortality. Multivariable logistic regression analysis, fitted with generalized estimating equations, was performed to adjust for confounding factors and accounted for within-hospital clustering. RESULTS: A total of 4087 patients were eligible for analysis. The median age was 37 years (interquartile range [IQR]: 27-53 years), and 85.0% of patients were male. The median number of WB transfusions was 2.3 units (IQR 2.0-4.0 units), and the total transfusion volume was 4940 ml (IQR 3350-8504). When compared to the lowest WBR quartile, the highest WBR quartile had lower adjusted 24-h mortality (adjusted odds ratio [AOR]: 0.61, 95% confidence interval [CI]: 0.46-0.81) and 30-day mortality (AOR 0.58; 95% CI 0.45-0.75). CONCLUSION: The probability of mortality consistently decreased with higher WBR in trauma patients requiring massive blood transfusion.

Incidence of pseudoaneurysm after follow-up computed tomography for nonoperatively managed splenic injury: Systematic review.

BACKGROUND: The aim of this systematic review was to assess the estimated incidence of pseudoaneurysm (PSA) with follow-up computed tomography (CT) for adult splenic injury with nonoperative management (NOM). METHODS: A systematic literature search was conducted in MEDLINE, Central, CINAHL, Clinical Trials, and ICTRP databases between January 1, 2010, and December 31, 2023. Quality assessment was performed using the Risk of Bias in Non-randomized Studies of Exposures (ROBINS-E) tool. Adult splenic injury patients who were initially managed with NOM and followed-up by protocolized CT were included. The primary outcome was the incidence of delayed PSA. Secondary outcome measures were delayed angiography and delayed splenectomy. Subgroup analyses were performed between NOM patients without initial splenic angioembolization (SAE) and NOM patients with initial SAE. RESULTS: Twelve studies were enrolled, including 11 retrospective studies and one prospective study, with 1746 patients in total. The follow-up CT rate in the included patients was 94.9%. The estimated incidence of PSA was 14% (95% confidence interval (CI), 8%-21%). The estimated delayed angiography and delayed splenectomy incidence rates were 7% (95% CI, 4%-12%) and 2% (95% CI, 1%-6%), respectively. Subgroup analyses showed that the estimated PSA incidence was 12% in NOM patients without initial SAE (95% CI, 7%-20%) and was also 12% in NOM patients with SAE (95% CI, 5%-24%). CONCLUSIONS: The estimated incidence of delayed PSA after follow-up CT for adult splenic injury with NOM was 14%. The estimated incidence of PSA in NOM with initial SAE was similar to that in NOM without initial SAE.

Risk factors for stroke in penetrating cerebrovascular injuries.

OBJECTIVE: Penetrating cerebrovascular injuries (PCVI) are associated with a high incidence of mortality and neurological events. The optimal treatment strategy of PCVI, especially when damage control measures are required, remains controversial. The aim of this study was to describe the management of PCVI and patient outcomes at a level 1 trauma center where vascular injuries are managed predominantly by trauma surgeons. METHODS: An institutional trauma registry was queried for patients with PCVI from 2011 to 2021. Patients with common carotid artery (CCA), internal carotid artery (ICA), or vertebral artery injuries were included for analysis. The primary outcome was in-hospital stroke. The secondary outcomes were in-hospital mortality and in-hospital stroke or death. A subgroup analysis was completed of arterial repair (primary repair or interposition graft) vs ligation or embolization vs temporary intravascular shunting at the index procedure. RESULTS: We analyzed 54 patients with PCVI. Overall, the in-hospital stroke rate was 17% and in-hospital mortality was 26%. Twenty-one patients (39%) underwent arterial interventions for PCVI. Ten patients underwent arterial repair, six patients underwent ligation or embolization, and five patients underwent intravascular shunting as a damage control strategy with a plan for delayed repair. The rate of in-hospital stroke was 30% after arterial repair, 0% after arterial ligation or embolization, and 80% after temporary intravascular shunting. There was a significant difference in the stroke rate between the three subgroups (P = .015). Of the 32 patients who did not have an intervention to the CCA, ICA, or vertebral artery, 1 patient with ICA occlusion and 1 patient with CCA intimal injury developed in-hospital stroke. The mortality rate was 0% after arterial repair, 50% after ligation or embolization, and 60% after intravascular shunting. The rate of stroke or death was 30% in the arterial repair group, 50% in the ligation or embolization group, and 100% in the temporary intravascular shunting group. CONCLUSIONS: High rates of stroke and mortality were seen in patients requiring damage control after PCVI. In particular, temporary intravascular shunting was associated with a high incidence of in-hospital stroke and a 100% rate of stroke or death. Further investigation is needed into the factors related to these finding and whether the use of temporary intravascular shunting in PCVI is an advisable strategy.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the presence of associated severe traumatic brain injury: A propensity-score matched study.

BACKGROUND: Experimental work suggested that resuscitative Endovascular Balloon Occlusion of the aorta (REBOA) preserves cerebral circulation in animal models of traumatic brain injury. No clinical work has evaluated the role of REBOA in the presence of associated severe traumatic brain injury (TBI). We investigated the impacts of REBOA on neurological and survival outcomes. METHODS: Propensity-score matched study, using the American College of Surgeons Trauma Quality Improvement Program database. Patients with severe TBI patients (Abbreviated Injury Scale ≥3) receiving REBOA within 4 â€‹h from arrival were matched with similar patients not receiving REBOA. Neurological matching included head AIS, pupils, and midline shift. Clinical outcomes were compared between the two groups. RESULTS: 434 REBOA patients were matched with 859 patients without REBOA. Patients in the REBOA group had higher rates of in-hospital mortality (63.6 â€‹% vs 44.2 â€‹%, p â€‹< â€‹0.001), severe sepsis (4.4 â€‹% vs 2.2 â€‹%, p â€‹= â€‹0.029), acute kidney injury (10.1 â€‹% vs 6.6 â€‹%, p â€‹= â€‹0.029), and withdrawal of life support (25.4 â€‹% vs 19.6 â€‹%, p â€‹= â€‹0.020) despite of lower craniectomy/craniotomy rate (7.1 â€‹% vs 12.7 â€‹%, p â€‹< â€‹0.002). CONCLUSION: In patients with severe TBI, REBOA use is associated with an increased risk of in-hospital mortality, AKI, and infectious complications.

Lack of Concordance Between Abbreviated Injury Scale and American Association for the Surgery of Trauma Organ Injury Scale in Patients with High-Grade Solid Organ Injury.

BACKGROUND: The Abbreviated Injury Scale (AIS) is widely used for body region-specific injury severity. The American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) provides organ-specific injury severity but is not included in trauma databases. Previous researchers have used AIS as a surrogate for OIS. This study aims to assess AIS-abdomen concordance with AAST-OIS grade for liver and spleen injuries, hypothesizing concordance in terms of severity (grade of OIS and AIS) and patient outcomes. STUDY DESIGN: This retrospective study (July 2020 to June 2022) was performed at 3 trauma centers. Adult trauma patients with AAST-OIS grade III to V liver and spleen injury were included. AAST-OIS grade for each organ was compared with AIS-abdomen by evaluating the percentage of AAST-OIS grade correlating with each AIS score as well as rates of operative intervention for these injuries. Analysis was performed with chi-square tests and univariate analysis. RESULTS: Of 472 patients, 274 had liver injuries and 205 had spleen injuries grades III to V. AAST-OIS grade III to V liver injuries had concordances rates of 85.5%, 71%, and 90.9% with corresponding AIS 3 to 5 scores. AAST-OIS grade III to V spleen injuries had concordances rates of 89.7%, 87.8%, and 87.3%, respectively. There was a statistical lack of concordance for both liver and spleen injuries (both p < 0.001). Additionally, there were higher rates of operative intervention for AAST-OIS grade IV and V liver injuries and grade III and V spleen injuries vs corresponding AIS scores (p < 0.05). CONCLUSIONS: AIS should not be used interchangeably with OIS due to lack of concordance. AAST-OIS should be included in trauma databases to facilitate improved organ injury research and quality improvement projects.

Mechanism Matters: Differential benefits of cold-stored whole blood for trauma resuscitation from a prospective multicenter study.

BACKGROUND: Resuscitation with cold-stored low-titre whole blood (LTOWB) has increased despite the paucity of robust civilian data. Most studies are in predominately blunt trauma and lack analysis of specific subgroups or mechanism of injury. We sought to compare outcomes between patients receiving LTOWB vs. balanced component therapy (BCT) after blunt (BL) and penetrating (PN) trauma. METHODS: Secondary analysis of a prospective multicenter study of patients receiving either LTWOB-containing or BCT resuscitation was performed. Patients were grouped by mechanism of injury (BL vs PN). A generalized estimated equations model using inverse probability of treatment weighting was employed. Primary outcome was mortality and secondary outcomes were acute kidney injury, venous thromboembolism, pulmonary complications, and bleeding complications. Additional analyses were performed on non-traumatic brain injury (TBI), severe torso injury, and LTOWB-only resuscitation patients. RESULTS: 1617 patients (BL 47% vs PN 54%) were identified; 1175 (73%) of which received LTOWB. PN trauma patients receiving LTOWB demonstrated improved survival compared to BCT (77% vs. 56%; p<0.01). Interval survival was higher at 6 hrs (95% vs. 88%), 12 hrs (93% vs. 80%) and 24 hrs (88% vs. 57%) (all p<0.05). The survival benefit following LTOWB was also seen across PN non-TBI (83% vs. 52%), and severe torso injuries (75% vs. 43%) (all p <0.05). After controlling for age, sex, injury severity, and trauma center, LTWOB was associated with decreased odds of death (OR .31, p<.05) in PN trauma. However, no difference in overall mortality was seen across the BL groups. Both PN and BL patients receiving LTOWB had more frequent AKI compared to BCT (19% vs. 7% and 12% vs 6%, respectively; p<0.05). CONCLUSIONS: LTOWB resuscitation was independently associated with decreased mortality following PN trauma, but not BL trauma. Further analysis in BL trauma is required to identify subgroups that may demonstrate survival benefit. LEVEL OF EVIDENCE: Therapeutic/Care Management, III.

Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy.

INTRODUCTION: Emergent laparotomy is associated with significant wound complications including surgical site infections (SSIs) and fascial dehiscence. Triclosan-coated barbed (TCB) suture for fascial closure has been shown to reduce local complications but primarily in elective settings. We sought to evaluate the effect of TCB emergency laparotomy fascial closure on major wound complications. METHODS: Adult patients undergoing emergency laparotomy were prospectively evaluated over 1 year. Patients were grouped into TCB versus polydioxanone (PDS) for fascial closure. Subanalysis was performed on patients undergoing single-stage laparotomy. Primary outcomes were SSI and fascial dehiscence. Multivariate analysis identified independent factors associated with SSI and fascial dehiscence. RESULTS: Of the 206 laparotomies, 73 (35%) were closed with TCB, and 133 (65%) were closed with PDS. Trauma was the reason for laparotomy in 73% of cases; damage-control laparotomy was performed in 27% of cases. The overall rate of SSI and fascial dehiscence was 18% and 10%, respectively. Operative strategy was similar between groups, including damage-control laparotomy, wound vac use, skin closure, and blood products. Surgical site infection events trended lower with TCB versus PDS closure (11% vs. 21%, p = 0.07), and fascial dehiscence was significantly lower with TCB versus PDS (4% vs. 14%, p < 0.05). Subanalysis of trauma and nontrauma cases showed no difference in SSI or fascial dehiscence. Multivariable analysis found that TCB decreased the likelihood of fascial dehiscence (odds ratio, 0.07; p < 0.05) following emergency laparotomy. Increased odds of fascial dehiscence were seen in damage-control laparotomy (odds ratio, 3.1; p < 0.05). CONCLUSION: Emergency laparotomy fascial closure with TCB showed significantly decreased rates of fascial dehiscence compared with closure with PDS and a strong trend toward lower SSI events. Triclosan-coated barbed suture was independently associated with decreased fascial dehiscence rates after emergency laparotomy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Clinical factors and outcomes of spleen-conserving surgery versus total splenectomy in splenic injuries: A nationwide database study.

BACKGROUND: The objective of this study was to identify factors associated with the use of spleen-conserving surgeries, as well as patient outcomes, on a national scale. METHODS: This retrospective cohort study (2010-2015) included patients (age≥16 years) with splenic injury in the National Trauma Data Bank. Patients who received a total splenectomy or a spleen-conserving surgery were compared for demographics and clinical outcomes. RESULTS: During the study period, 18,425 received a total splenectomy and 1,825 received a spleen-conserving surgery. Total splenectomy was more likely to be performed for patients with age>65 (odds ratio [OR]: 0.63, p â€‹< â€‹0.001), systolic blood pressure<90 (OR: 0.63, p â€‹< â€‹0.001), heart rate>120 (OR: 0.83, p â€‹= â€‹0.007), and high-grade injuries (OR: 0.18, p â€‹< â€‹0.001). Penetrating trauma patients were more likely to undergo a spleen-conserving surgery (OR: 3.31, p â€‹< â€‹0.001). The use of spleen-conserving surgery was associated with a lower risk of pneumonia (OR: 0.79, p â€‹= â€‹0.009) and venous thromboembolism (OR: 0.72, p â€‹= â€‹0.006). CONCLUSIONS: Spleen-conserving surgeries may be considered for patients with penetrating trauma, age<65, hemodynamic stability, and low-grade injuries. Spleen-conserving surgeries have decreased risk of pneumonia and venous thromboembolism.

Persistent disparities between trauma center types in the management of children with high-grade blunt splenic injuries.

BACKGROUND: In the early 2000s, substantial variations were reported in the management of pediatric patients with blunt splenic injury (BSI). The purpose of this study was to assess the recent trends and disparities between different types of trauma centers. We hypothesized that there would be persistent disparities despite decreased trends in the rate of splenectomy. METHODS: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database. We included patients (age ≤18 years) with high-grade BSI (Abbreviated Injury Scale 3-5) between 2014 and 2021. The patients were divided into three groups based on trauma center types (adult trauma centers [ATCs], mixed trauma centers [MTCs], and pediatric trauma centers [PTCs]). The primary outcome was the splenectomy rate. Logistic regression was performed to evaluate the association between trauma center types and clinical outcomes. Additionally, the trends in the rate of splenectomy at ATCs, MTCs, and PTCs were evaluated. RESULTS: A total of 6601 patients with high-grade BSI were included in the analysis. Overall splenectomy rates were 524 (17.5%), 448 (16.3%), and 32 (3.7%) in the ATC, MTC, and PTC groups, respectively. ATCs and MTCs had significantly higher splenectomy rates compared to PTCs (ATCs: OR = 5.72, 95%CI = 3.78-8.67, and p < 0.001 and MTCs: OR = 4.50, 95%CI = 2.97-6.81, and p < 0.001), while decreased trends in the splenectomy rates were observed in ATCs and MTCs (ATCs: OR = 0.92, 95%CI = 0.87-0.97, and p = 0.003 and MTCs: OR = 0.92, 95%CI = 0.87-0.98, and p = 0.013). CONCLUSIONS: This study suggested persistent disparities between different trauma center types in the management of children with high-grade BSI.

Pregnant patients undergoing cholecystectomy: nationwide assessment of clinical characteristics and outcomes.

BACKGROUND: Gallstone disease in pregnancy is one of the most common indications for nonobstetrical surgery during pregnancy. National-level data on contemporary surgical practice and outcomes are limited. OBJECTIVE: This study aimed to assess the clinical characteristics and outcomes of patients undergoing cholecystectomy during pregnancy. STUDY DESIGN: This cross-sectional study examined the Healthcare Cost and Utilization Project's 2 nationwide databases in the United States: the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample. The study population included 18,630 patients who had cholecystectomy during pregnancy from January 2016 to December 2020. The exposure was gestational age, grouped sequentially into the following 5 groups: first trimester (<14 weeks), early second trimester (14-20 weeks), late second trimester (21-27 weeks), early third trimester (28-36 weeks), and late third trimester (≥37 weeks). The main outcomes were clinical demographics, medical comorbidities, surgical information, and pregnancy characteristics and outcomes, assessed by gestational age. RESULTS: Cholecystectomy was most common in the early second trimester (32.1%), followed by the first trimester (25.2%), late second trimester (23.1%), early third trimester (12.4%), and late third trimester (7.2%). Patients in the first-trimester group were more likely to be aged ≥35 years, to smoke, and to have acute cholecystitis, severe hyperemesis gravidarum including metabolic disturbance, pregestational diabetes, multifetal gestation, and sepsis/shock (P<.001). Patients in the early-third-trimester group were more likely to be obese and have gestational diabetes, Charlson Comorbidity Index of ≥1, premature rupture of membranes, and intrauterine growth restriction, whereas those in the late-third-trimester group were more likely to have gallstone pancreatitis, biliary colic, chorioamnionitis, gestational hypertension, preeclampsia, and severe maternal morbidity including sepsis (P<.001). At the cohort level, a laparoscopic approach was used in most cholecystectomy procedures (97.5%), and bile duct injury was uncommon (<0.1%). Delivery during the admission occurred in 0.3%, 0%, 0.6%, 17.8%, and 60.6% in the 5 gestational age groups, respectively (P<.001). Among the cases that had delivery in the early- and late-third-trimester groups, the delivery event preceded cholecystectomy in 61.4% and 86.2%, respectively, whereas both delivery and cholecystectomy occurred on the same day in 34.3% and 13.8%, respectively. CONCLUSION: This nationwide analysis suggests that clinical and pregnancy characteristics and outcomes of patients undergoing cholecystectomy differ by pregnancy stage with a bimodal distribution. Although patients in the first and third trimesters have distinct medical conditions, more clinically significant pregnancy and maternal outcomes were found in both groups compared with patients in the second trimester.

Disruption of trauma research: an analysis of the top cited versus disruptive trauma research publications.

Introduction: The analysis of surgical research using bibliometric measures has become increasingly prevalent. Absolute citation counts (CC) or indices are commonly used markers of research quality but may not adequately capture the most impactful research. A novel scoring system, the disruptive score (DS) has been found to identity academic work that either changes paradigms (disruptive (DIS) work) or entrenches ideas (developmental (DEV) work). We sought to analyze the most DIS and DEV versus most cited research in civilian trauma. Methods: The top papers by DS and by CC from trauma and surgery journals were identified via a professional literature search. The identified publications were then linked to the National Institutes of Health iCite tool to quantify total CC and related metrics. The top 100 DIS and DEV publications by DS were analyzed based on the area of focus, citation, and perceived clinical impact, and compared with the top 100 papers by CC. Results: 32 293 articles published between 1954 and 2014 were identified. The most common publication location of selected articles was published in Journal of Trauma (31%). Retrospective reviews (73%) were common in DIS (73%) and top CC (67%) papers, while DEV papers were frequently case reports (49%). Only 1 publication was identified in the top 100 DIS and top 100 CC lists. There was no significant correlation between CC and DS among the top 100 DIS papers (r=0.02; p=0.85), and only a weak correlation between CC and DS score (r=0.21; p<0.05) among the top 100 DEV papers. Conclusion: The disruption score identifies a unique subset of trauma academia. The most DIS trauma literature is highly distinct and has little overlap with top trauma publications identified by standard CC metrics, with no significant correlation between the CC and DS. Level of evidence: Level IV.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study.

BACKGROUND: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE: Level 4; Therapeutic/Care management.

Association Between Whole Blood Transfusion and Mortality Among Injured Pediatric Patients.

OBJECTIVE: The aim of this study was to assess the association between whole blood (WB) and mortality among injured children who received immediate blood transfusion. BACKGROUND: The use of WB for transfusion therapy in trauma has been revisited, and recent studies have reported an association between WB and improved survival among adults. However, evidence of a similar association lacks in children. METHODS: We performed a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2020 and 2021. Patients were aged less than or equal to 16 years and had immediate blood transfusion within 4 hours of hospital arrival. Survival at 24 hours and 30 days were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, injury type, vital signs on admission, trauma severity scores, hemorrhage control procedures, hospital characteristics, and the need for massive transfusion. RESULTS: A total of 2729 patients were eligible for analysis. The median age was 14 years (interquartile range: 8-16 years); 1862 (68.2%) patients were male; and 1207 (44.2%) patients were White. A total of 319 (11.7%) patients received WB. After a 1:1 ratio propensity score matching, 318 matched pairs were compared. WB transfusion was associated with improved survival at 24 hours, demonstrating a 42% lower risk of mortality (hazard ratio, 0.58; 95% CI, 0.34-0.98; P =0.042) Similarly, the survival benefit associated with WB transfusion remained consistent at 30 days (hazard ratio, 0.65; 95% CI, 0.46-0.90; P =0.011). CONCLUSION: The use of WB was associated with improved survival among injured pediatric patients requiring immediate transfusion.

A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

The Risk of Hemorrhagic Complications After Anticoagulation Therapy in Trauma Patients: A Multicenter Evaluation.

BACKGROUND: The use of anticoagulation therapy (ACT) in trauma patients during the post-injury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions. METHODS: In this retrospective cohort study, all trauma admissions at two Level 1 trauma centers between January 2015 and December 2020 were reviewed. Patients with pre-existing ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury. RESULTS: A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the post-injury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7-14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively. CONCLUSIONS: The use of ACT in trauma during the post-injury period is not without risk. Waiting 7-14 days post-injury might greatly reduce the risk of hemorrhagic complications. STUDY TYPE/LEVEL OF EVIDENCE: Therapeutic/care management study: Level IV.