Nationwide Analysis of Penetrating Thoracic Aortic Injury: Injury Patterns, Management, and Outcomes.

INTRODUCTION: Penetrating thoracic aortic injuries (PTAI) represent a rare form of thoracic trauma. Unlike blunt thoracic aortic injuries (BTAI), only scarce data, included in small case series, are currently available for PTAI. The purpose of this study was to describe injury patterns, surgical management, and outcomes of patients with PTAI and compare to those with BTAI. MATERIALS AND METHODS: A 9-y retrospective cohort study (2007-2015) was conducted using the National Trauma Data Bank. Patient demographics, injury profile, procedures performed, and patient outcomes were compared between the PTAI and BTAI group. RESULTS: A total of 2714 patients with PTAI and 14,037 patients with BTAI were identified. Compared to BTAI, PTAI patients were younger (28 versus 42 y, P < 0.001), more often male (89.1% versus 71.7%, P < 0.001), and more likely to arrive without signs of life (27.6% versus 7.5%, P < 0.001). PTAI patients had less associated injuries, overall, compared to those with BTAI; however, were more likely to have injuries to the esophagus, diaphragm, and heart. Patients with PTAI were less likely to undergo endovascular (5.8% versus 30.5%, P < 0.001) or open surgical repair (3.0% versus 4.2%, P < 0.001) compared to BTAI. While the large majority of PTAI patients expired before their hospital arrival or in the emergency department, the in-hospital mortality rate among those who survivedemergency department stay was 43.1%. CONCLUSIONS: Most patients with PTAI present to the hospital without any signs of life, and their overall mortality rate is extremely high. Only a small portion of PTAI patients who survived the initial resuscitation period underwent surgical interventions for thoracic aortic injuries. Further studies are still warranted to clarify the indications and types of surgical interventions for PTAI.

Appendiceal goblet cell adenocarcinoma newly classified by WHO 5th edition: a case report (a secondary publication).

BACKGROUND: Appendiceal goblet cell adenocarcinoma (AGCA) is a newly proposed cancer type in the 5th edition of the WHO Classification of Tumours in 2019. We experienced this rare form of appendiceal primary neoplasm. CASE PRESENTATION: An 85-year-old male presented a positive fecal occult blood test. A series of imagings revealed a type 1 tumor, located on the appendiceal orifice. The subsequent biopsy made the diagnosis of signet-ring cell carcinoma. Consequently, he underwent the laparoscopic-assisted ileocecal resection. Initially, the tumor was suspected to be a Goblet cell carcinoid (GCC). There was a discrepancy between the histological and immunostaining findings: the tumor cells exhibited morphological similarities to GCCs, however displayed limited staining upon immunostaining. Ultimately, we concluded that the tumor should be classified as AGCA, by following WHO 5th Edition. AGCA represents a newly categorized subtype of adenocarcinomas. Because of our preoperative suspicion of malignancy, we performed tumor resection with regional lymph node dissection, despite the fact that most appendiceal malignant tumors are typically identified after an appendectomy. CONCLUSION: We experienced a case that provides valuable insights into the comprehension of AGCA, a recently established pathological entity in the WHO 5th Edition. This article is an acceptable secondary publication of a case report that appeared in Azuma et al. (J Jpn Surg Assoc 83:1103-1108, 2022).

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds.

BACKGROUND: Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW. METHODS: This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed. RESULTS: Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99). CONCLUSION: While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level II.

Trauma Computed Tomography in the Modern Era: Not Always Quick and Safe.

BACKGROUND: Computed tomography (CT) has emerged as the diagnostic modality of choice in trauma patients. Recent studies suggest its use in hemodynamically unstable patients is safe and potentially lifesaving; however, the incidence of adverse events (AE) during the trauma CT scanning process remains unknown. STUDY DESIGN: Over a 6-month period at a Level 1 trauma center, data on patients undergoing trauma CT (whole-body CT (WBCT) +/- additional CT studies) were prospectively collected. All patients requiring a trauma team activation (TTA) were included. Adverse events and specific time intervals were recorded from the time of TTA notification to the time of return to the resuscitation bay from the CT suite. RESULTS: Of the 94 consecutive patients included in the study, 47.9% experienced 1 or more AE. Median duration away from the resuscitation bay for all patients was 24 minutes. Patients with AE spent a significantly longer time away from the resuscitation bay and had longer scan times. Vasopressor support and ongoing transfusion requirement at the time of CT scanning were associated with AE. CONCLUSION: Adverse events of varying clinical significance occur frequently in patients undergoing emergent trauma CT. A standard trauma CT protocol could improve the efficiency and safety of the scanning process.

Nationwide Analysis of Dog Bite Injuries: Different Age Groups, Different Injury Patterns.

BACKGROUND: As the number of households with dogs in the United States has increased, so has the incidence of dog bites. Contemporary analysis of nationwide epidemiological data regarding such injuries is scarce. The purpose of this study is to describe dog bite injury patterns and related surgical interventions with a focus on differences between pediatric and adult age groups. STUDY DESIGN: This is a retrospective study (2015-2017) using the National Trauma Data Bank. 10 569 patients were included. RESULTS: Of these, 4729 (44.7%) qualified as pediatric (age ≤ 12 years) and 5840 (55.3%) qualified as adults (age ≥ 13 years). Pediatric patients were more frequently admitted with facial injuries (78.1% vs. 29.3%, P < .01) and facial fractures (4.8% vs. 2.5%, P < .01), and had a higher incidence of facial bone surgical procedures (1.3% vs. .5%, P < .01). Adult patients were more frequently admitted with upper extremity injuries (65.8% vs. 21.2%, P < .01) and upper extremity vascular arterial injuries (2.3% vs. .2%, P < .01) with a higher incidence of upper extremity arterial procedures (1.3% vs. .2%, P < .01). CONCLUSION: This study demonstrates the contrast in injury patterns from dog bite between adults and children. These findings can dictate injury prevention policies and prepare clinicians to treat dog bite victims.

"Safer at home": The effect of the COVID-19 lockdown on epidemiology, resource utilization, and outcomes at a large urban trauma center.

BACKGROUND: The COVID-19 pandemic has affected the entire global health care system. In California, because of a high burden of cases, a lockdown order was announced on March 19, 2020. This study investigated the impact of the lockdown on the epidemiology and outcomes of trauma admissions at the largest trauma center in Los Angeles. METHODS: A retrospective study comparing epidemiological and clinical characteristics and outcomes of trauma admissions during the lockdown period (March 20, 2020, to June 30, 2020) to a similar period in the previous year (March 20, 2019, to June 30, 2019) was performed. Data collection included demographics, mechanism of injury, prehospital transportation, substance use, injury severity, resource utilization, and outcomes. FINDINGS: There were 1,202 admissions during the lockdown period in 2020 and 1,143 during the same calendar period in 2019. Following the lockdown, there was a reduction in the automobile versus pedestrian admissions by 42.5%, motorcycle injuries by 38.7%, and bicycle accidents by 28.4% but no significant effect on the number of motor vehicle accident admissions. There was an increase in ground level falls by 32.5%, especially in the elderly group. The absolute number of gunshot wounds increased by 6.2% and knife injuries by 39.3%. Suicides increased by 38.5%. Positive testing for substance use increased by 20.9%. During the lockdown, patients suffered less severe trauma, with Injury Severity Score of <9 (p < 0.001), as well as less severe head (p = 0.001) and severe chest trauma (p < 0.001). Trauma deaths were reduced by 27.9%, and the crude overall mortality was significantly lower during the lockdown period (4.1% vs. 5.9%, p = 0.046). Intensive care unit admission rates, mechanical ventilation, and intensive care unit length of stay were all reduced. CONCLUSION: The COVID-19 lockdown in 2020 had a significant effect on the epidemiology, clinical characteristics, and critical care resource utilization of trauma admissions in a large academic trauma center. These findings may help in planning and optimization of hospital resources during the pandemic. LEVEL OF EVIDENCE: Epidemiological study, level III; Retrospective observational, level III.

Hybrid emergency room system improves timeliness of angioembolization for pelvic fracture.

BACKGROUND: Timely angioembolization (AE) is known to improve outcomes of patients with hemorrhage resulting from pelvic fracture. The hybrid emergency room system (HERS) is a novel trauma resuscitation room equipped with a computed tomography scanner, fluoroscopy equipment, and an operating room setup. We hypothesized that the HERS would improve the timeliness of AE for pelvic fracture. METHODS: A retrospective medical record review of patients who underwent AE for pelvic fracture at our institution from April 2015 to December 2018 was conducted. Patients' demographics, location of AE, Injury Severity Score, Revised Trauma Score, probability of survival by the trauma and injury severity score (TRISS Ps) method, presence of interventional radiologists (IRs) upon patient arrival, time from arrival to AE, and in-hospital mortality were analyzed. These data were compared between patients who underwent AE in the HERS (HERS group) and in the regular angio suite (non-HERS group). RESULTS: Ninety-six patients met the inclusion criteria. The HERS group comprised 24 patients, and the non-HERS group, 72 patients. Interventional radiologists were more frequently present upon patient arrival in the HERS than non-HERS group (IRs, 79% vs. 22%, p < 0.01). The time from arrival to AE was shorter in the HERS than non-HERS group (median [range], 46 [5-75] minutes vs. 103 [2-690] minutes, p < 0.01). There were no differences in the rate of in-hospital mortality (13% vs. 15%, p = 0.52) between the two groups. Survivors in the HERS group had a lower probability of survival by the trauma and injury severity score (median [range], 61% [1%-98%] vs. 93% [1%-99%], p < 0.01) than survivors in the non-HERS group. CONCLUSION: The HERS improved the timeliness of AE for pelvic fracture. More severely injured patients were able to survive in the HERS. The new team building involving the addition of IRs to the traditional trauma resuscitation team will enhance the benefit of the HERS. LEVEL OF EVIDENCE: Therapeutic, level IV.

Emergency trauma laparotomy and/or thoracotomy in the emergency department: risks and benefits.

BACKGROUND: It is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice. METHODS: The data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared. RESULTS: Compared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation. DISCUSSION: Emergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping. LEVEL OF EVIDENCE: IV.

Two Nucleolar Proteins, GDP1 and OLI2, Function As Ribosome Biogenesis Factors and Are Preferentially Involved in Promotion of Leaf Cell Proliferation without Strongly Affecting Leaf Adaxial-Abaxial Patterning in Arabidopsis thaliana.

Leaf abaxial-adaxial patterning is dependent on the mutual repression of leaf polarity genes expressed either adaxially or abaxially. In Arabidopsis thaliana, this process is strongly affected by mutations in ribosomal protein genes and in ribosome biogenesis genes in a sensitized genetic background, such as asymmetric leaves2 (as2). Most ribosome-related mutants by themselves do not show leaf abaxialization, and one of their typical phenotypes is the formation of pointed rather than rounded leaves. In this study, we characterized two ribosome-related mutants to understand how ribosome biogenesis is linked to several aspects of leaf development. Previously, we isolated oligocellula2 (oli2) which exhibits the pointed-leaf phenotype and has a cell proliferation defect. OLI2 encodes a homolog of Nop2 in Saccharomyces cerevisiae, a ribosome biogenesis factor involved in pre-60S subunit maturation. In this study, we found another pointed-leaf mutant that carries a mutation in a gene encoding an uncharacterized protein with a G-patch domain. Similar to oli2, this mutant, named g-patch domain protein1 (gdp1), has a reduced number of leaf cells. In addition, gdp1 oli2 double mutants showed a strong genetic interaction such that they synergistically impaired cell proliferation in leaves and produced markedly larger cells. On the other hand, they showed additive phenotypes when combined with several known ribosomal protein mutants. Furthermore, these mutants have a defect in pre-rRNA processing. GDP1 and OLI2 are strongly expressed in tissues with high cell proliferation activity, and GDP1-GFP and GFP-OLI2 are localized in the nucleolus. These results suggest that OLI2 and GDP1 are involved in ribosome biogenesis. We then examined the effects of gdp1 and oli2 on adaxial-abaxial patterning by crossing them with as2. Interestingly, neither gdp1 nor oli2 strongly enhanced the leaf polarity defect of as2. Similar results were obtained with as2 gdp1 oli2 triple mutants although they showed severe growth defects. These results suggest that the leaf abaxialization phenotype induced by ribosome-related mutations is not merely the result of a general growth defect and that there may be a sensitive process in the ribosome biogenesis pathway that affects adaxial-abaxial patterning when compromised by a mutation.