The role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammation index in predicting the necessity for surgery and therapeutic surgery in patients with anterior abdominal stab wounds.

BACKGROUND: In this diagnostic accuracy study, we examined the effectiveness of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) in predicting the need for surgical intervention in patients with anterior abdominal stab wounds (AASW) who exhibit unclear findings on physical examination yet remain hemodynamically stable. METHODS: Over a 7-year period, patients with AASW were retrospectively analyzed. Patients were divided into two groups as surgical (SG) and nonsurgical group (nSG). The SG were also divided into two groups as therapeutic surgery (TS) group and the non-therapeutic surgery (nTS) group. The groups were compared in terms of NLR, PLR values and SII scores. RESULTS: In a retrospective analysis of 199 patients with AASW, NLR, PLR and SII obtained during clinical follow-up of patients with AASW in whom the necessity for immediate surgery was unclear significantly predicted therapeutic surgery (p < 0.001 for all). These parameters did not show a significant difference in predicting the need for surgery at the admission. NLR showed an AUC of 0.971 and performed significantly better than PLR and SII (AUC = 0.874 and 0.902, respectively) in predicting TS. The optimal cut-off value for NLR was 3.33, with a sensitivity of 98.2%, a specificity of 90%, and a negative likelihood ratio of 0.02. Time from admission to surgery was significantly shorter in the TS group (p = 0.001). CONCLUSION: NLR, PLR and SII values may be useful in predicting therapeutic surgery during clinical follow-up in AASW patients with unclear physical examination findings and in whom immediate surgical decisions cannot be made.

Aspartate aminotransferase and alanine aminotransferase elevation in suspected physical abuse: Can the threshold to obtain an abdominal computed tomography be raised?

BACKGROUND: Identification of abdominal injury (AI) in children with concern for physical abuse is important, as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines, which use a cutoff of AST >200 IU/L or ALT >125 IU/L. METHODS: This was a retrospective review of children aged 0 to 60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: midrange (AST ≤200 IU/L and ALT ≤125 IU/L) and high-range (AST >200 IU/L and/or ALT >125 IU/L) LFTs. RESULTS: Abdominal CTs were performed in 55% (131 of 237) of subjects, 38% (50 of 131) with midrange LFTs and 62% (81 of 131) with high-range LFTs. Abdominal injury was identified in 19.8% (26 of 131) of subjects. Subjects with AI were older than those without AI (mean [SD] age, 18.7 [12.5] vs. 11.6 [12.2] months; p = 0.009). The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13 of 25; 95% confidence interval, 31.3-72.2%). The negative predictive value of having midrange LFTs and no signs or symptoms of AI was 100% (95% confidence interval, 97.0-100%). CONCLUSION: Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST ≤200 IU/L and ALT ≤125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level IV.

The role of leukocytes in predicting whether laparotomy is required in patients with penetrating abdominal stab wound.

BACKGROUND: This study aimed to determine the importance of leukocytes, leukocyte subgroups, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio in deciding whether laparotomy is required during observation in patients with penetrating abdominal stab wounds who were followed up because there was no indication for an emergency laparotomy. METHODS: Patients who did not indicate an emergency laparotomy were monitored. After 48 hours from initial hospitalization, patients who did not require laparotomy were discharged nonoperatively. The total leukocytes, leukocyte subsets, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio of patients who underwent laparotomy during the follow-up compared with those who were discharged nonoperatively. The sensitivity and specificity of these laboratory values in predicting the necessity of laparotomy were calculated. RESULTS: In the operated group (n = 71), leukocytes, neutrophils, monocytes, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio examined during observation were significantly higher (P < .001). Eosinophils and lymphocytes were significantly lower (P < .001) than in nonoperated (n = 476). Based on the deviation in the reference ranges of leukocyte and its subgroups, we report the sensitivity and specificity for predicting the necessity of laparotomy as 86% and 72% for leukocyte, 88% and 75% for neutrophil, 92% and 83% for neutrophil-to-lymphocyte ratio, and 72% and 77% for platelet-to-lymphocyte ratio, respectively. In receiver operating characteristic curve analysis, the cut-off value was found to be 4 for neutrophil-to-lymphocyte ratio and 125 for platelet-to-lymphocyte ratio (area under the curve/receiver operating characteristic curve of 0.929 and 0.808, respectively). CONCLUSION: Leukocyte, leukocyte subgroups, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio may be useful to determine if a laparotomy is necessary in patients in whom the necessity of laparotomy is undetermined owing to unclear examination findings.

The impact of blood type on the mortality of patients with severe abdominal trauma: a multicenter observational study.

Few studies have investigated the relationship between blood type and trauma outcomes according to the type of injury. We conducted a retrospective multicenter observational study in twelve emergency hospitals in Japan. Patients with isolated severe abdominal injury (abbreviated injury scale for the abdomen ≥ 3 and that for other organs < 3) that occurred between 2008 and 2018 were divided into four groups according to blood type. The association between blood type and mortality, ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate regression models. A total of 920 patients were included, and were divided based on their blood type: O, 288 (31%); A, 345 (38%); B, 186 (20%); and AB, 101 (11%). Patients with type O had a higher in-hospital mortality rate than those of other blood types (22% vs. 13%, p < 0.001). This association was observed in multivariate analysis (adjusted odds ratio [95% confidence interval] = 1.48 [1.25-2.26], p = 0.012). Furthermore, type O was associated with significantly higher cause-specific mortalities, fewer VFD, and larger transfusion volumes. Blood type O was associated with significantly higher mortality and larger transfusion volumes in patients with isolated severe abdominal trauma.

Characterization of the cortisol response to traumatic hemorrhage and intra-abdominal contamination models in Cynomologus Macaques.

INTRODUCTION: Trauma, hemorrhage, and peritonitis have widely varying impacts on endocrine response in the injured patient. We sought to examine cortisol response in established non-human primate models of traumatic hemorrhage and intra-abdominal contamination. METHODS: Cynomologus Macaques were separated into two experimental groups, the polytrauma and hemorrhage model, involving a laparoscopic liver resection with uncontrolled hemorrhage, cecal perforation, and soft tissue excision; and the traumatic hemorrhage model, involving only liver resection and uncontrolled hemorrhage. Cortisol levels were measured pre-operatively, at the time of injury, and at regular intervals until post-operative day 1. RESULTS: Cortisol levels increased 600% from the pre-operative value in the polytrauma and hemorrhage model, with minimal changes (20%) in the hemorrhage only model. CONCLUSION: Cortisol levels increase dramatically in response to polytrauma and intra-abdominal contamination as compared to hemorrhage only. The lack of response in the hemorrhage only group may be due to relative adrenal insufficiency caused by the shock state or lack of enticing stimuli from fecal peritonitis.

Bacillus cereus bacteremia in a patient with an abdominal stab wound / Bacteriemia por Bacillus cereus en paciente con herida de arma blanca abdominal

Abstract Bacillus cereus is a gram positive microorganism commonly involved in gastrointestinal infection but capable of causing severe infections and bacteremia. We describe here a case of bacteremia caused by B. cereus in a previously healthy young woman admitted to the intensive care unit following emergency surgery due to a penetrating abdominal stab wound and subsequent hepatic lesion. She developed fever during admission and cultures were taken. B. cereus was isolated in blood and hepatic fluid collection cultures. Treatment was adjusted according to the isolate, with good clinical results. It is important to highlight the pathogenic potential of this microorganism and not underestimate it as a contaminant when it is isolated from blood samples.

Resumen Bacillus cereus es un microorganismo gram positivo comúnmente involucrado en infecciones gastrointestinales, pero capaz de causar infecciones graves y bacteriemia. Presentamos un caso de bacteriemia por B. cereus en una mujer joven previamente sana que ingresa en la unidad de cuidados intensivos luego de una cirugía de emergencia, debido a una herida abdominal por arma blanca con lesión hepática. La paciente desarrolla fiebre durante la internación, por lo que se toman cultivos. Se aísla B. cereus en hemocultivos y material de colección hepática. Se ajusta el tratamiento según los hallazgos, con buena evolución clínica. Esta comunicación ilustra una fuente poco común de bacteriemia por B. cereus. Asimismo, destaca el potencial patogénico de este microorganismo, cuyo hallazgo en muestras de sangre no siempre debe conducir a su rápida desjerarquización como contaminante.

The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma.

Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.

Bacillus cereus bacteremia in a patient with an abdominal stab wound.

Bacillus cereus is a gram positive microorganism commonly involved in gastrointestinal infection but capable of causing severe infections and bacteremia. We describe here a case of bacteremia caused by B. cereus in a previously healthy young woman admitted to the intensive care unit following emergency surgery due to a penetrating abdominal stab wound and subsequent hepatic lesion. She developed fever during admission and cultures were taken. B. cereus was isolated in blood and hepatic fluid collection cultures. Treatment was adjusted according to the isolate, with good clinical results. It is important to highlight the pathogenic potential of this microorganism and not underestimate it as a contaminant when it is isolated from blood samples.

Is I-FABP not only a marker for the detection abdominal injury but also of hemorrhagic shock in severely injured trauma patients?

Background: Hemorrhagic shock can lead to intestinal damage with subsequent hyperinflammation and multiple organ dysfunction syndrome (MODS). The intestinal fatty acid-binding protein (I-FABP) is solely expressed in the intestine and is released extracellulary after tissue damage. This study evaluates the validity of I-FABP as an early biomarker to detect hemorrhagic shock and abdominal injury. Patients and methods: Severely injured patients with an Injury Severity Score (ISS) ≥ 16 points and an age ≥ 18 years, admitted from January 2010 to December 2016, were included. Overall, 26 patients retrospectively presented with hemorrhagic shock to the emergency room (ER): 8 patients without abdominal injury ("HS noAbd") and 18 patients with abdominal injury ("HS Abd"). Furthermore, 16 severely injured patients without hemorrhagic shock and without abdominal injury ("noHS noAbd") were retrospectively selected as controls. Plasma I-FABP levels were measured at admission to the ER and up to 3 days posttraumatic (d1-d3). Results: Median I-FABP levels were significantly higher in the "HS Abd" group compared with the "HS noAbd" group (28,637.0 pg/ml [IQR = 6372.4-55,550.0] vs. 7292.3 pg/ml [IQR = 1282.5-11,159.5], p < 0.05). Furthermore, I-FABP levels of both hemorrhagic shock groups were significantly higher compared with the "noHS noAbd" group (844.4 pg/ml [IQR = 530.0-1432.9], p < 0.05). The time course of I-FABP levels showed a peak on the day of admission with a subsequent decline in the post-traumatic course. Furthermore, significant correlations between I-FABP levels and clinical parameters of hemorrhagic shock, such as hemoglobin, lactate value, systolic blood pressure (SBP), and shock index, were found.The optimal cut-off level of I-FABP for detection of hemorrhagic shock was 1761.9 pg/ml with a sensitivity of 85% and a specificity of 81%. Conclusion: This study confirmed our previous observation that I-FABP might be used as a suitable early biomarker for the detection of abdominal injuries in general. In addition, I-FABP may also be a useful and a promising parameter in the diagnosis of hemorrhagic shock, because of reflecting low intestinal perfusion.

Higher Mortality Rate in Moderate-to-Severe Thoracoabdominal Injury Patients with Admission Hyperglycemia Than Nondiabetic Normoglycemic Patients.

BACKGROUND: Hyperglycemia at admission is associated with an increase in worse outcomes in trauma patients. However, admission hyperglycemia is not only due to diabetic hyperglycemia (DH), but also stress-induced hyperglycemia (SIH). This study was designed to evaluate the mortality rates between adult moderate-to-severe thoracoabdominal injury patients with admission hyperglycemia as DH or SIH and in patients with nondiabetic normoglycemia (NDN) at a level 1 trauma center. METHODS: Patients with a glucose level ≥200 mg/dL upon arrival at the hospital emergency department were diagnosed with admission hyperglycemia. Diabetes mellitus (DM) was diagnosed when patients had an admission glycohemoglobin A1c ≥6.5% or had a past history of DM. Admission hyperglycemia related to DH and SIH was diagnosed in patients with and without DM. Patients who had a thoracoabdominal Abbreviated Injury Scale score <3, a polytrauma, a burn injury and were below 20 years of age were excluded. A total of 52 patients with SIH, 79 patients with DH, and 621 patients with NDN were included from the registered trauma database between 1 January 2009, and 31 December 2018. To reduce the confounding effects of sex, age, comorbidities, and injury severity of patients in assessing the mortality rate, different 1:1 propensity score-matched patient populations were established to assess the impact of admission hyperglycemia (SIH or DH) vs. NDN, as well as SIH vs. DH, on the outcomes. RESULTS: DH was significantly more frequent in older patients (61.4 ± 13.7 vs. 49.8 ± 17.2 years, p < 0.001) and in patients with higher incidences of preexisting hypertension (2.5% vs. 0.3%, p < 0.001) and congestive heart failure (3.8% vs. 1.9%, p = 0.014) than NDN. On the contrary, SIH had a higher injury severity score (median [Q1-Q3], 20 [15-22] vs. 13 [10-18], p < 0.001) than DH. In matched patient populations, patients with either SIH or DH had a significantly higher mortality rate than NDN patients (10.6% vs. 0.0%, p = 0.022, and 5.3% vs. 0.0%, p = 0.043, respectively). However, the mortality rate was insignificantly different between SIH and DH (11.4% vs. 8.6%, odds ratio, 1.4; 95% confidence interval, 0.29-6.66; p = 0.690). CONCLUSION: This study revealed that admission hyperglycemia in the patients with thoracoabdominal injuries had a higher mortality rate than NDN patients with or without adjusting the differences in patient's age, sex, comorbidities, and injury severity.

Serum levels of NLRP3 and HMGB-1 are associated with the prognosis of patients with severe blunt abdominal trauma.

OBJECTIVES: To investigate the relationship between the serum levels of NLRP3 and HMGB-1 and the prognosis of patients with severe blunt abdominal trauma. METHODS: In total, 299 patients were included in the current study from July 2014 to December 2015. All patients were divided into the mild/moderate blunt abdominal trauma group and the severe blunt abdominal trauma group according to their injury severity scores. Serum levels of NLRP3 and HMGB-1 were measured upon admission (0 h) and at 12 h, 24 h, 48 h, 72 h and 7 days after admission. RESULTS: Compared with the healthy controls, both the mild/moderate and severe blunt abdominal trauma groups had higher serum levels of NLRP3 and HMGB-1 at admission. At all points, the serum levels of NLRP3 and HMGB-1 were significantly higher in the severe group than in the mild/moderate group. The serum levels of both NLRP3 and HMGB-1 were significantly higher in the deceased patients than in the living patients. The Kaplan-Meier curve showed that compared with patients with higher levels of NLRP3 or HMGB-1, those with lower levels had longer survival times. The serum levels of both NLRP3 and HMGB-1 were independent risk factors for 6-month mortality in severe blunt abdominal trauma patients. CONCLUSION: The serum levels of NLRP3 and HMGB-1 were significantly elevated in severe blunt abdominal trauma patients, and the serum levels of both NLRP3 and HMGB-1 were correlated with 6-month mortality in severe blunt abdominal trauma patients.

Is early chemical thromboprophylaxis in patients with solid organ injury a solid decision?

BACKGROUND: The optimal time to initiate chemical thromboprophylaxis (CTP) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOI) remains controversial. The aim of our study was to assess the impact of early initiation of CTP in patients with blunt abdominal SOIs. METHODS: We performed a 2-year (2013-2014) retrospective analysis of American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients (age, ≥ 18 years) with blunt SOI who underwent NOM. Patients were stratified into three groups based on timing of CTP (early, ≤48 hours of injury; late, >48 hours of injury,; and no prophylaxis group). Our primary outcomes were rates of failure of NOM, pRBC transfusion, and mortality. Our secondary outcomes were the rate of venous thromboembolic (VTE) events (i.e., deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) and length of stay. RESULTS: A total of 36,187 patients met the inclusion criteria. Mean age was 49.5 ± 19 years and 36% of patients received CTP (early, 37% (n = 4,819) versus late, 63% (n = 8,208)). After controlling for confounders, patients receiving early CTP had lower rates of DVT (p = 0.01) and PE (p = 0.01) compared with the no prophylaxis and late CTP groups. There was no difference between the three groups regarding the postprophylaxis pRBC transfusions, failure of NOM, and mortality. CONCLUSION: Our results suggest that in patients undergoing NOM of blunt abdominal SOI, early initiation of CTP should be considered. It is associated with decreased rates of DVT and PE, with no significant difference in post prophylaxis pRBC transfusion, failure of nonoperative management, and mortality. LEVEL OF EVIDENCE: Therapeutic, level V.

Pediatric Liver Injury: Physical Examination, Fast and Serum Transaminases Can Serve as a Guide.

BACKGROUND: The aim of our study was to determine if the combination of physical examination (PE), serum transaminases along with Focused Assessment with Sonography in Trauma (FAST) would effectively rule out major hepatic injuries (HIs) after blunt abdominal trauma (BAT) in hemodynamically stable pediatric patients. METHODS: We conducted a 9-year retrospective study of pediatric patients (<18 y) with BAT. We collected data on liver enzymes (aspartate transaminase [AST] and alanine transaminase [ALT]), FAST, and PE findings. Definitive diagnosis and staging of HI were based on abdominal CT scanning. The sensitivity and specificity of ALT/AST, FAST, and PE were then calculated individually and in combination. RESULTS: We identified a total of 423 pediatric patients with BAT. Mean age was 11 y, median abdominal Abbreviated Injury Scale was 3 [2-4], and mean ED-SBP was 132 mm Hg. One hundred ninety-eight patients had HI of which 107 were major HI, defined by the American Association for the Surgery of Trauma as ≥grade III. Using ROC curve analysis, optimum ALT and AST thresholds were determined to be 90 U/L and 120 U/L, respectively. The sensitivity of FAST was 50% while that of PE was 40%. Combining PE with AST/ALT and FAST had an overall sensitivity of 97%, a specificity of 95%, a positive predictive value of 87%, and a negative predictive value of 98%. CONCLUSIONS: In hemodynamically stable pediatric blunt abdominal trauma patients, CT scanning can be avoided using a combination of readily available tests thus avoiding unnecessary radiation exposure. However, pediatric patients with positive PE, FAST, and elevated AST/ALT may eventually require CT scan to further evaluate liver injuries.

Serum levels of NLRP3 and HMGB-1 are associated with the prognosis of patients with severe blunt abdominal trauma

OBJECTIVES: To investigate the relationship between the serum levels of NLRP3 and HMGB-1 and the prognosis of patients with severe blunt abdominal trauma. METHODS: In total, 299 patients were included in the current study from July 2014 to December 2015. All patients were divided into the mild/moderate blunt abdominal trauma group and the severe blunt abdominal trauma group according to their injury severity scores. Serum levels of NLRP3 and HMGB-1 were measured upon admission (0 h) and at 12 h, 24 h, 48 h, 72 h and 7 days after admission. RESULTS: Compared with the healthy controls, both the mild/moderate and severe blunt abdominal trauma groups had higher serum levels of NLRP3 and HMGB-1 at admission. At all points, the serum levels of NLRP3 and HMGB-1 were significantly higher in the severe group than in the mild/moderate group. The serum levels of both NLRP3 and HMGB-1 were significantly higher in the deceased patients than in the living patients. The Kaplan-Meier curve showed that compared with patients with higher levels of NLRP3 or HMGB-1, those with lower levels had longer survival times. The serum levels of both NLRP3 and HMGB-1 were independent risk factors for 6-month mortality in severe blunt abdominal trauma patients. CONCLUSION: The serum levels of NLRP3 and HMGB-1 were significantly elevated in severe blunt abdominal trauma patients, and the serum levels of both NLRP3 and HMGB-1 were correlated with 6-month mortality in severe blunt abdominal trauma patients.

Continuous hemoglobin monitoring in pediatric trauma patients with solid organ injury.

BACKGROUND/PURPOSE: Hemoglobin monitoring is required in pediatric trauma patients with solid organ injury. We hypothesized that noninvasive hemodynamic monitoring (NIHM) represents an effective, safe alternative to laboratory hemoglobin (LabHb) monitoring in clinically stable patients. METHODS: A retrospective cohort study was conducted regarding pediatric trauma patients (<18 years old) with blunt solid organ injury over six consecutive months. Continuous NIHM was initiated at the time of admission, and LabHb measurements were obtained per institutional guidelines. Measurements were correlated within two hours of assessment and patient outcomes were analyzed. RESULTS: Twenty-one patients met inclusion criteria and had evaluable data. Blunt trauma was the exclusive mechanism of injury, and mean injury severity score was 16.6 for the cohort. Bland Altman analysis showed an average deviation of 0.80 g/dL between NIHM and LabHb values for all data pairs. Measurement trends were highly correlated in patients with stable hemoglobin levels and those requiring blood transfusion. CONCLUSIONS: NIHM demonstrated clinically acceptable accuracy when following hemoglobin trends in the defined pediatric trauma patient population. Slight variances between NIHM and LabHb values were occasionally noted, but did not affect clinical management. Continuous NIHM represents a potentially valuable adjunct to traditional laboratory hemoglobin monitoring. LEVEL OF EVIDENCE RATING: IV.

Identification of Pancreatic Injury in Patients with Elevated Amylase or Lipase Level Using a Decision Tree Classifier: A Cross-Sectional Retrospective Analysis in a Level I Trauma Center.

BACKGROUND: In trauma patients, pancreatic injury is rare; however, if undiagnosed, it is associated with high morbidity and mortality rates. Few predictive models are available for the identification of pancreatic injury in trauma patients with elevated serum pancreatic enzymes. In this study, we aimed to construct a model for predicting pancreatic injury using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry in a Level I trauma center. METHODS: A total of 991 patients with elevated serum levels of amylase (>137 U/L) or lipase (>51 U/L), including 46 patients with pancreatic injury and 865 without pancreatic injury between January 2009 and December 2016, were allocated in a ratio of 7:3 to training (n = 642) or test (n = 269) sets. Using the data on patient and injury characteristics as well as laboratory data, the DT algorithm with Classification and Regression Tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. RESULTS: Among the trauma patients with elevated amylase or lipase levels, three groups of patients were identified as having a high risk of pancreatic injury, using the DT model. These included (1) 69% of the patients with lipase level ≥306 U/L; (2) 79% of the patients with lipase level between 154 U/L and 305 U/L and shock index (SI) ≥ 0.72; and (3) 80% of the patients with lipase level <154 U/L with abdomen injury, glucose level <158 mg/dL, amylase level <90 U/L, and neutrophil percentage ≥76%; they had all sustained pancreatic injury. With all variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 91.4% and specificity of 98.3%) for the training set. In the test set, the DT achieved an accuracy of 93.3%, sensitivity of 72.7%, and specificity of 94.2%. CONCLUSIONS: We established a DT model using lipase, SI, and additional conditions (injury to the abdomen, glucose level <158 mg/dL, amylase level <90 U/L, and neutrophils ≥76%) as important nodes to predict three groups of patients with a high risk of pancreatic injury. The proposed decision-making algorithm may help in identifying pancreatic injury among trauma patients with elevated serum amylase or lipase levels.

Role of Vascular Endothelial Cells in Disseminated Intravascular Coagulation Induced by Seawater Immersion in a Rat Trauma Model.

Trauma complicated by seawater immersion is a complex pathophysiological process with higher mortality than trauma occurring on land. This study investigated the role of vascular endothelial cells (VECs) in trauma development in a seawater environment. An open abdominal injury rat model was used. The rat core temperatures in the seawater (SW, 22°C) group and normal sodium (NS, 22°C) group declined equivalently. No rats died within 12 hours in the control and NS groups. However, the median lethal time of the rats in the SW group was only 260 minutes. Among the 84 genes involved in rat VEC biology, the genes exhibiting the high expression changes (84.62%, 11/13) on a qPCR array were associated with thrombin activity. The plasma activated partial thromboplastin time and fibrinogen and vWF levels decreased, whereas the prothrombin time and TFPI levels increased, indicating intrinsic and extrinsic coagulation pathway activation and inhibition, respectively. The plasma plasminogen, FDP, and D-dimer levels were elevated after 2 hours, and those of uPA, tPA, and PAI-1 exhibited marked changes, indicating disseminated intravascular coagulation (DIC). Additionally, multiorgan haemorrhagia was observed. It indicated that seawater immersion during trauma may increase DIC, elevating mortality. VECs injury might play an essential role in this process.

I-FABP is a Novel Marker for the Detection of Intestinal Injury in Severely Injured Trauma Patients.

BACKGROUND: Intestinal injury is a rare injury in multiply traumatized patients, and its diagnosis remains difficult. Delayed diagnosis of an intestinal injury increases the risk of sepsis, multiple organ failure and mortality. The intestinal fatty acid-binding protein (I-FABP) is solely expressed in the intestine and is released extracellulary after tissue damage. This study evaluates the validity of I-FABP as an early biomarker to detect an abdominal injury and particularly an injury to the intestine. PATIENTS AND METHODS: Patients with an Abbreviated Injury Scale (AIS) score for abdominal body region (AIS abdomen) ≥3 were included in this study from 07/2006 to 12/2014. Of those, ten patients retrospectively had an intestinal injury (int. injury). According to the Injury Severity Score and the AIS abdomen, corresponding patients with an abdominal injury but without an intestinal injury (no int. injury) were included for matched-pair analysis. Twenty healthy volunteers served as controls. Plasma I-FABP levels were measured at admission to the emergency room and up to 10 days daily (d1-d10). RESULTS: Median I-FABP levels were significantly higher in the "int. injury" group compared to the "no int. injury" group [2101.0 pg/ml (IQR = 1248.1-4117.8) vs. 351.4 pg/ml (IQR = 287.6-963.3), p < 0.05]. Furthermore, I-FABP levels of both groups were significantly higher compared to the control group [Ctrl: 127.2 pg/ml (IQR = 57.4-310.6), p < 0.05]. The time course of I-FABP levels showed a peak on the day of admission and a decline to the control levels in the further post-traumatic course. The development of complications such as single- or multi-organ failure, sepsis, acute respiratory distress syndrome, pneumonia and mortality was higher in the "int. injury" group; however, this difference was not statistically significant. CONCLUSION: This study confirmed our previous observation that I-FABP might be used as a suitable early biomarker for the detection of abdominal injuries in general. In addition and more specific, I-FABP may be a useful and promising parameter in the diagnosis of intestinal injuries.

Early diagnosis of hollow viscus injury using intestinal fatty acid-binding protein in blunt trauma patients.

A delay in diagnosing hollow viscus injury (HVI) causes an increase in mortality and morbidity. HVI remains a challenge to diagnose, and there is no specific diagnostic biomarker for HVI. We evaluated the utility of intestinal fatty acid-binding protein (I-FABP) in diagnosing HVI in blunt trauma patients. Within a 5-year period, 93 consecutive patients with clinically suspected HVI at our trauma center were prospectively enrolled. The diagnostic performance of I-FABP for HVI was compared with that of other various parameters (physical, laboratory, and radiographic findings). HVI was diagnosed in 13 patients (14%), and non-HVI was diagnosed in 80 patients (86%). The level of I-FABP was significantly higher in patients with HVI than in those with non-HVI (P = 0.014; area under the curve, 0.71). The sensitivity, specificity, positive predictive value, and negative predictive value were 76.9%, 70.0%, 29.4%, and 94.9%, respectively (P = 0.003). However, all other biomarkers were not significantly different between the groups. Presence of extraluminal air, bowel wall thickening on computed tomography (CT), and peritonitis signs were significantly higher in patients with HVI (P < 0.05). Of 49 patients (52.7%) who had a negative I-FABP and negative peritonitis signs, none developed HVI (sensitivity, 100%; negative predictive value, 100%). This is the first study that demonstrated the diagnostic value of a biomarker for HVI. I-FABP has a higher negative predictive value compared to traditional diagnostic tests. Although the accuracy of I-FABP alone was insufficient, the combination of I-FABP and other findings can enhance diagnostic ability.