Does a collecting system injury with grade iv renal blunt trauma always need urinary intervention?

PURPOSE: This study aimed to identify the characteristics associated with the need for urinary intervention for a blunt renal injury with collection system involvement using a computed tomography (CT) protocol for trauma. MATERIALS AND METHODS: Abdominal CT images of patients with blunt renal injuries from 2016 to 2020 were reviewed. Patients with low-grade renal trauma, non-collecting system involvement, American Association for the Surgery of Trauma grade V shattered kidney, and emergent nephrectomy were excluded. The largest perinephric mass thickness was measured in the axial view using CT, and a cutoff value was obtained using a receiver-operating characteristic curve analysis. Risk factors for further urinary intervention were analyzed. RESULTS: Among the 70 patients included in this study, those with perinephric mass thicknesses < 25 mm (n = 36) had a significantly lower rate of urinary intervention than those with perinephric mass thicknesses ≥ 25 mm (0 vs. 5; p = 0.023). There was no significant difference in the follow-up durations of the groups (19 days vs. 38 days; p = 0.198). More than 90% of the perinephric mass in the < 25 mm group resolved within a median follow-up duration of 38 days, whereas nearly half of the ≥ 25 mm group had a residual perinephric mass during a median follow-up duration of 19 days. CONCLUSION: The initial CT protocol for trauma was useful for predicting the need for further urinary interventions for collecting system injuries. A perinephric mass thickness < 25 mm is predictive of a low likelihood of requiring urinary intervention.

The Role of Diagnostic Laparoscopy in the Evaluation of Abdominal Trauma Patients: A Trauma Quality Improvement Program Study.

PURPOSE: We aimed to identify factors related to delayed intervention in abdominal trauma patients who underwent diagnostic laparoscopy using a nationwide databank. METHODS: From 2017 to 2019, abdominal trauma patients who underwent diagnostic laparoscopy were retrospectively evaluated using the Trauma Quality Improvement Program. Patients who underwent delayed interventions after a primary diagnostic laparoscopy were compared with those who did not. Factors associated with poor outcomes that are usually correlated with overlooked injuries and delayed interventions were also analyzed. RESULTS: Of the 5221 studied patients, 4682 (89.7%) underwent inspection without any intervention. Only 48 (0.9%) patients underwent delayed interventions after primary laparoscopy. Compared with patients receiving immediate interventions during primary diagnostic laparoscopy, patients receiving delayed interventions were more likely to have small intestine injuries (58.3% vs. 28.3%, p < 0.001). Among patients with hollow viscus injuries, a significantly higher probability of overlooked injuries that required delayed intervention was observed in patients with small intestine injuries (small intestine injury: 16.8%; gastric injury: 2.5%; large intestine injury: 5.2%). However, delayed small intestine repair did not significantly affect the risk of surgical site infection (SSI) (p = 0.249), acute kidney injury (AKI) (p = 0.998), or hospital length of stay (LOS) (p = 0.053). In contrast, significantly positive relationships between delayed large intestine repair and poor outcomes were observed (SSI, odds ratio = 19.544, p = 0.021; AKI, odds ratio = 27.368, p < 0.001; LOS, ß = 13.541, p < 0.001). CONCLUSIONS: Most examinations and interventions (near 90%) were successful during primary laparoscopy for abdominal trauma patients. Small intestine injuries were easily overlooked. Delayed small intestine repair-related poor outcomes were not observed.

Speeding pelvic fracture fixation: CT scan with simultaneous 3-D pelvic reconstruction in the emergency department.

INTRODUCTION: Contrast-enhanced computed tomography (CT) scans are usually needed in the emergency department (ED) to evaluate intra-abdominal injuries associated with pelvic fractures. Three-dimensional (3-D) images for pelvis reconstruction are also needed for planning surgical fixation after admission. This study investigates the advantages integrating a one-stage computed tomography (CT) scan with these two diagnostic modalities simultaneously to reduce the time to surgery and improve the outcomes of pelvic fracture fixation. METHODS: A retrospective cohort study (2018-2021) of patients with pelvic fractures was performed. Patients were categorized into the one-stage CT group or the two-stage CT group, and propensity score matching was used to address biases. The outcome measures included time to surgical fixation, time to CT scan for 3-D pelvis reconstruction, and overall length of hospital stay. RESULTS: Four hundred forty-four pelvic fracture patients who underwent definite surgical fixation were identified. Of those, 320 underwent a one-stage CT scan, while the remaining 124 underwent a two-stage CT scan. After well-balanced matching, those in the one-stage CT group had a significantly shorter time to surgical fixation than those in the two-stage CT group (4.6 vs. 6.8 days, p < 0.001). Even among critically ill patients necessitating intensive care unit (ICU) admission, the one-stage CT scan group had a shorter time to definitive surgical fixation (5.5 vs. 7.2 days, p = 0.002) and a shorter hospital stay (19.0 vs. 32.7 days, p = 0.006). CONCLUSION: A one-stage contrast-enhanced CT scan combined with simultaneous 3-D pelvis reconstruction is promising for expediting surgical fixation in pelvic fracture patients. This innovative strategy may improve patient outcomes by facilitating timely surgical interventions and minimizing delays associated with additional CT scans.

Sarcopenia provides extra value outside the PULP score for predicting mortality in older patients with perforated peptic ulcers.

BACKGROUND: Perforated peptic ulcer (PPU) remains challenging surgically due to its high mortality, especially in older individuals. Computed tomography (CT)-measured skeletal muscle mass is a effective predictor of the surgical outcomes in older patients with abdominal emergencies. The purpose of this study is to assess whether a low CT-measured skeletal muscle mass can provide extra value in predicting PPU mortality. METHODS: This retrospective study enrolled older (aged ≥ 65 years) patients who underwent PPU surgery. Cross-sectional skeletal muscle areas and densities were measured by CT at L3 and patient-height adjusted to obtain the L3 skeletal muscle gauge (SMG). Thirty-day mortality was determined with univariate, multivariate and Kaplan-Meier analysis. RESULTS: From 2011 to 2016, 141 older patients were included; 54.8% had sarcopenia. They were further categorized into the PULP score ≤ 7 (n=64) or PULP score > 7 group (n=82). In the former, there was no significant difference in 30-day mortality between sarcopenic (2.9%) and nonsarcopenic patients (0%; p=1.000). However, in the PULP score > 7 group, sarcopenic patients had a significantly higher 30-day mortality (25.5% vs. 3.2%, p=0.009) and serious complication rate (37.3% vs. 12.9%, p=0.017) than nonsarcopenic patients. Multivariate analysis showed that sarcopenia was an independent risk factor for 30-day mortality in patients in the PULP score > 7 group (OR: 11.05, CI: 1.03-118.7). CONCLUSION: CT scans can diagnose PPU and provide physiological measurements. Sarcopenia, defined as a low CT-measured SMG, provides extra value in predicting mortality in older PPU patients.

The effect of transarterial embolization versus nephrectomy on acute kidney injury in blunt renal trauma patients.

PURPOSE: The impact of transarterial embolization (TAE) and nephrectomy on acute kidney injury (AKI) in blunt renal trauma patients remains unclear, and we used the National Trauma Data Bank (NTDB) to investigate this issue. METHODS: Adult patients from the NTDB between 2007 and 2015 who survived traumatic events with blunt injuries were eligible for inclusion. The exclusion criteria were those without outcome information, who required dialysis, or with chronic renal failure prior to the traumatic injury. Patients sustaining hepatic, splenic, or pelvic fractures or who had bilateral nephrectomy were also excluded. The patients were divided into three treatment groups, including conservative treatment, TAE, and nephrectomy. Two statistical models, logistic regression (LR) and inverse probability treatment weighting (IPTW), were used to clarify the AKI predictors. RESULTS: The study included 10,096 patients. There were 9697 (96.0%), 202 (2.0%) and 197 (2.0%) patients in the conservative, TAE and nephrectomy groups, respectively. Nephrectomy was a statistically significant predictor of AKI in blunt renal trauma patients in the standard LR (odds ratio [OR], 4.58; 95% confidence interval [CI] 1.92-10.38; p < 0.001) and IPTW (OR, 5.16; 95% CI 1.07-24.85; p = 0.023) models. In addition, TAE was not a risk factor for AKI in blunt renal trauma patients (p > 0.05 in all models). CONCLUSION: AKI is less likely affect patients with blunt renal trauma with TAE than those with nephrectomy. Nephrectomy is a risk factor for AKI in blunt renal trauma patients. TAE should be considered first when blunt renal trauma patients need a hemostatic procedure.

Does Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Increase the Probability of Delayed Intra-abdominal Hemorrhage in Patients With Concomitant Blunt Abdominal Trauma?

PURPOSE: Most blunt thoracic aortic injuries (BTAIs) may be treated using thoracic endovascular aortic repair (TEVAR), and most blunt abdominal traumas (BATs) are managed conservatively. We hypothesized that severe trauma that needs TEVAR may increase the risk of delayed intra-abdominal hemorrhage in patients with concomitant BTAI and BAT because of the potential hemorrhagic shock, disseminated intravascular coagulopathy, blood loss, consequent need for blood transfusion, and procedure-associated heparinization. MATERIALS AND METHODS: From 2015 to 2019, blunt trauma patients with concomitant severe chest trauma and abdominal trauma who could be managed conservatively were studied. The probability of delayed intra-abdominal hemorrhage was compared between patients with concomitant BTAI who received or did not undergo TEVAR. Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and multivariate logistic regression (MLR) were used to eliminate discrepancies between these 2 groups. RESULTS: Among the 341 studied patients, there were 26 patients with BTAI, and 19 of them underwent TEVAR. Delayed intra-abdominal hemorrhage was observed in 4 patients (21.1%, 4/19) who underwent TEVAR. Both PSM and IPTW showed that patients who underwent TEVAR for concomitant BTAI had a greater delayed need for blood transfusions and a larger proportion of delayed intra-abdominal hemorrhage than patients who did not undergo the procedure. The MLR analysis showed that TEVAR for BTAI was an independent risk factor for delayed intra-abdominal hemorrhage (odds ratio: 10.534, 95%, p<0.001). CONCLUSION: An increased probability of delayed intra-abdominal hemorrhage in patients with BAT (who could be managed conservatively) was observed in patients who underwent TEVAR for concomitant BTAI. CLINICAL IMPACT: More attention should be give in patients with high grade aortic injuries and concomitant abdominal trauma.

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

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

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures.

BACKGROUND: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. METHOD: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. RESULTS: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. CONCLUSION: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

Diagnosis-Related Group (DRG)-Based Prospective Hospital Payment System can be well adopted for Acute Care Surgery: Taiwanese Experience with Acute Cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is a common procedure for cholelithiasis paid by diagnostic-related groups (DRGs) systems. However, acute cholecystitis (AC) patients usually have heterogeneous conditions that compromise the successful implementation of DRGs. We evaluated the quality/efficiency of treating AC patients under the DRG system in Taiwan. METHODS: All AC patients who underwent LC between October 2015 and December 2016 were included. Patient demographics, treatment outcomes, and financial results were analyzed. Patients were reimbursed by one of the two DRG schemes based on their comorbidities/complications (CC): DRG-1, LC without CC; and DRG-2, LC with CC. Hospitals were reimbursed the costs incurred if they were below the lower threshold (balanced sector); with the outlier threshold if costs were between the lower and outlier thresholds (profitable sector); and with the outlier threshold plus 80% of the exceeding cost if costs were higher than the outlier threshold (profit-losing sector). RESULTS: Among 246 patients, 114 were paid by DRG-1, and 132 were by DRG-2. In total, 195 of 246 patients underwent LC within 1 day after admission, and patients with mild AC had shorter hospital stays than those with moderate or severe AC. The complication rate was 7.3% with only one mortality. In total, 92.1% of patients in DRG-1 and 90.9% of patients in DRG-2 were profitable. The average margin per patient was 11,032 TWD for DRG-1 and 24,993 TWD for DRG-2. CONCLUSIONS: DRGs can be well adopted for acute care surgery, and hospitals can still provide satisfactory services without losing profit.

Obesity May Require a Higher Level of Trauma Care: A Propensity-Matched Nationwide Cohort Study.

OBJECTIVE: Stable patients with less severe injuries are not necessarily triaged to high-level trauma centers according to current guidelines. Obese patients are prone to comorbidities and complications. We hypothesized that stable obese patients with low-energy trauma have lower mortality and fewer complications if treated at Level-I/II trauma centers. Methods: Blunt abdominal trauma (BAT) patients with systolic blood pressures ≥90mmHg, Glasgow coma scale ≥14, and respiratory rates at 10-29 were derived from the National Trauma Data Bank between 2013-2015. Per current triage guidelines, these patients are not necessarily triaged to high-level trauma centers. The relationship between obesity and mortality of stable BAT patients was analyzed. A subset analysis of patients with injury severity scores (ISS) <16 was performed with propensity score matching (PSM) to evaluate outcomes between Level-I/II and Level-III/IV trauma centers. Outcomes of obese patients were compared between Level-I/II and Level-III/IV trauma centers. Non-obese patients were analyzed as a control group using a similar PSM cohort analysis. Results: 48,043 stable BAT patients in 707 trauma centers were evaluated. Non-survivors had a significantly higher body mass index (BMI) (28.7 vs. 26.9, p < 0.001) and higher proportion of obesity (35.6% vs. 26.5%, p < 0.001) than survivors. After a PSM (1,502 obese patients: 751 in Level-I/II trauma centers and 751 in Level-III/IV trauma centers), obese patients treated in Level-I/II trauma centers had significantly lower complication rates than obese patients treated in other trauma centers (20.2% vs. 26.6%, standardized difference = 0.151). The complication rate of obese patients treated at Level-I/II trauma centers was 20.6% lower than obese patients treated at other trauma centers. Conclusion: Obesity plays a role in the mortality of stable BAT patients. Obese patients with ISS < 16 have lower complication rates at Level-I/II trauma centers compared to obese patients treated at other trauma centers. Obesity may be a consideration for triaging to Level-I/II trauma centers.

Early brain computed tomographic angiography to screen for blunt cerebrovascular injuries in patients with polytrauma: Is it necessary?

BACKGROUND: Early diagnosis of blunt cerebrovascular injury (BCVI) is among the most difficult challenges in trauma treatment. This study aimed to determine the optimal timing of computed tomographic angiography (CTA) screening for suspicious BCVI in patients with polytrauma. METHODS: We reviewed the trauma registry and medical records of patients with head and neck injuries from a Level I trauma center between January 2012 and December 2016. Those receiving CTA within 24 h of presentation at the emergency department were the primary CTA group; those who received CTA after 24 h were the delayed CTA group. The basic demographics, indications for CTA, CTA severity grading, and outcomes were compared. RESULTS: In all, 228 patients received brain CTA. Most were male (75%); the mean age was around 40 years. The 38 patients with positive BCVI had a significantly higher ratio of severe chest trauma (52.6% vs 25.8%, p = 0.001); 26 of them received primary CTA and 12 received delayed CTA. Patients with polytrauma predominated in the delayed CTA group (66.7% vs 30.8%, p = 0.037). Of the patients in the primary CTA group, 26.9% received CTA due to symptomatic presentation (p = 0.047). Patients in the delayed group had better neurological outcomes (83% neurologically intact, vs 38.5%, p = 0.01) and lower mortality (0% vs 26.9%, p = 0.047). The only independent positive prognostic factor was initial motor response ≥M5 (Odds Ratio 21.46, 95% Confidence Interval 2.01-228.71). CONCLUSIONS: For patients with polytrauma, performing brain CTA for BCVI screening in the first 24-h or after may not affect clinical outcome. Initial motor response is the sole indicator for outcome. Delaying the study for to the next 24-hour can be considered in such patients, when regarding hemodynamic stability, the dose of contrast medium, and the radiation exposure.

Predicting outcomes of abdominal surgical emergencies in the elderly population using a CT muscle gauge.

BACKGROUND: Frailty has been shown to be an independent negative predictor of surgical outcomes in geriatric patients. Traditional measurements of muscle strength and mass are impractical in emergency settings, and computed tomography (CT)-measured skeletal muscle mass has been proposed as an alternative. However, the cutoff values for low muscle mass are still unknown, and their impact on abdominal emergencies in the elderly population is unclear. METHODS: A total of 462 young trauma patients aged 18-40 years were analyzed to establish sex-specific reference cutoff values for the CT-measured muscle index (MI) and muscle gauge (MG) values. The impacts of low MI and MG values were investigated in 1192 elderly patients (aged ≥ 65 years) undergoing abdominal surgery. RESULTS: The sex-specific cutoff values for MI and MG were determined by adopting European Working Group on Sarcopenia in Older People 2 guidelines. The correlation between MG and aging was significantly stronger than that between MI and ageing. With regard to the MG, the L4 psoas muscle gauge (L4 PMG) was further investigated in an elderly cohort owing to its high predictive value and ease of use in the clinical setting. A low L4 PMG value was an independent risk factor for overall complications and mortality in elderly patients with abdominal emergencies. CONCLUSION: The current study was the largest study investigating the correlations between MG values and aging in the Asian population. A low L4 PMG value may help surgeons during preoperative decision making regarding geriatric patients with abdominal emergencies.

Systematic Review of Diagnostic Sensors for Intra-Abdominal Pressure Monitoring.

Intra-abdominal pressure (IAP) is defined as the steady-state pressure within the abdominal cavity. Elevated IAP has been implicated in many medical complications. This article reviews the current state-of-the-art in innovative sensors for the measurement of IAP. A systematic review was conducted on studies on the development and application of IAP sensors. Publications from 2010 to 2021 were identified by performing structured searches in databases, review articles, and major textbooks. Sixteen studies were eligible for the final systematic review. Of the 16 articles that describe the measurement of IAP, there were 5 in vitro studies (31.3%), 7 in vivo studies (43.7%), and 4 human trials (25.0%). In addition, with the advancement of wireless communication technology, an increasing number of wireless sensing systems have been developed. Among the studies in this review, five presented wireless sensing systems (31.3%) to monitor IAP. In this systematic review, we present recent developments in different types of intra-abdominal pressure sensors and discuss their inherent advantages due to their small size, remote monitoring, and multiplexing.

The clinicopathological and molecular analysis of gastric cancer with altered SMARCA4 expression.

AIMS: In this study, we examine the clinicopathological and molecular features of gastric cancer (GC) with SMARCA4 alterations. METHODS AND RESULTS: We screened SMARCA4 alterations using immunohistochemistry on 1199 surgically resected GCs with information on Epstein-Barr virus (EBV), microsatellite instability (MSI) and other SWI/SNF subunits. SMARCA4, SMARCA2 and ARID1A mutations were investigated by targeted sequencing. The clinicopathological significance was determined by statistical analysis. Twenty-seven cases (2%) with altered SMARCA4 expression were identified, exhibiting completely lost (six), reduced (nine) or heterogeneous (12) patterns. Frequent concomitant alterations of other SWI/SNF subunits were noted with an unusual discordant spatial heterogeneity. In comparison with SMARCA4-retained GCs, SMARCA4-lost GCs were observed more frequently in the non-EBV/MSI subgroup (five of six) and reduced or heterogeneous SMARCA4 expression mainly occurred in EBV- or MSI-associated cases (six of nine and six of 12, respectively; P < 0.001). Histologically, SMARCA4-altered GC, irrespective of expression pattern, demonstrated divergent histomorphology, spanning tubular, poorly cohesive or mixed, neuroendocrine to solid and undifferentiated carcinoma, with a predilection to the latter two (P < 0.001). De-differentiation-like transition and rhabdoid features were noted in a minority of cases. For overall survival, altered SMARCA4 expression was an unfavourable prognostic factor in stage III, EBV-associated GC and non-EBV/MSI intestinal subtype (P ≤ 0.001). SMARCA4 or ARID1A mutations were detected mainly in SMARCA4-lost or reduced GC, respectively. CONCLUSIONS: SMARCA4-altered GCs are rare and have intratumoral heterogeneity, histomorphological diversity, conditional prognostic significance and various genetic drivers. SMARCA4-lost GC may represent a genuine SMARCA4-deficient neoplasm, but most SMARCA4-reduced/heterogeneous cases are secondary to ARID1A collapse or associated with different genotypes.

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

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

An Image-Based Mobile Health App for Postdrainage Monitoring: Usability Study.

BACKGROUND: The application of mobile health (mHealth) platforms to monitor recovery in the postdischarge period has increased in recent years. Despite widespread enthusiasm for mHealth, few studies have evaluated the usability and user experience of mHealth in patients with surgical drainage. OBJECTIVE: Our objectives were to (1) develop an image-based smartphone app, SurgCare, for postdrainage monitoring and (2) determine the feasibility and clinical value of the use of SurgCare by patients with drainage. METHODS: We enrolled 80 patients with biliary or peritoneal drainage in this study. A total of 50 patients were assigned to the SurgCare group, who recorded drainage monitoring data with the smartphone app; and 30 patients who manually recorded the data were assigned to the conventional group. The patients continued to record data until drain removal. The primary aim was to validate feasibility for the user, which was defined as the proportion of patients using each element of the system. Moreover, the secondary aim was to evaluate the association of compliance with SurgCare and the occurrence of unexpected events. RESULTS: The average submission duration was 14.98 days, and the overall daily submission rate was 84.2%. The average system usability scale was 83.7 (SD 3.5). This system met the definition of "definitely feasible" in 34 patients, "possibly feasible" in 10 patients, and "not feasible" in 3 patients. We found that the occurrence rates of complications in the SurgCare group and the conventional group were 6% and 26%, respectively, with statistically significant differences P=.03. The rate of unexpected hospital return was lower in the SurgCare group (6%) than in the conventional groups (26%) (P=.03). CONCLUSIONS: Patients can learn to use a smartphone app for postdischarge drainage monitoring with high levels of user satisfaction. We also identified a high degree of compliance with app-based drainage-recording design features, which is an aspect of mHealth that can improve surgical care.

Subtraction of Epstein-Barr virus and microsatellite instability genotypes from the Lauren histotypes: Combined molecular and histologic subtyping with clinicopathological and prognostic significance validated in a cohort of 1,248 cases.

Limited studies investigated clinicopathological and prognostic significance of histologic and molecular subgroups of gastric cancer concurrently. We retrospectively enrolled 1,248 patients with gastric cancer who received radical gastrectomy with lymphadenectomy and classified these cases into the Epstein-Barr virus (EBV)-associated and microsatellite instability (MSI)-associated subtypes by EBV-encoded small RNA in situ hybridization and immunohistochemical stains for DNA mismatch repair proteins, respectively. The remaining cases were categorized as the Lauren intestinal and diffuse/mixed subtypes. The clinicopathological and prognostic significance of the subtypes was examined by statistical analysis. In total, 65 (5.2%), 116 (9.3%), 496 (39.7%), 431 (34.5%) and 140 (11.2%) cases were identified as EBV-associated, MSI-associated, intestinal, diffuse and mixed subtypes, respectively. The EBV-associated, MSI-associated, intestinal and diffuse/mixed subtypes exhibited distinctive clinicopathological characteristics, including differences in age, gender, stump cancer, gastric location, tumor size, TNM stage, margin involvement, lymphatic/perineural invasion, HER2 status and recurrence pattern. The log-rank test showed survival discrimination (p < 0.001), and the multivariate analysis identified EBV-associated and MSI-associated cases demonstrated better outcomes than the diffuse/mixed subtype (EBV, HR 0.464, 95% CI 0.296-0.727, p = 0.001; MSI, HR 0.590, 95% CI 0.407-0.856, p = 0.005). EBV-associated lymphoepithelioma-like carcinoma cases had the most favorable outcome (HR 0.138, 95% CI 0.033-0.565, p = 0.006). In different clinical groups, the subtypes exhibited survival discrepancies. The EBV-associated and diffuse/mixed cases exhibited more favorable response to chemotherapy. In conclusion, this combined classification, in parallel with the molecular subtypes specified in the Cancer Genome Atlas study, has implications for the clinical management of gastric cancer.

Over-expression of TNNI3K is associated with early-stage carcinogenesis of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a devastating disease with very poor prognosis due to late diagnosis and resistance to traditional chemotherapies and radiotherapies. Herein, thioacetamide (TAA)-induced rat CCA model and CGCCA cell line were used; we aim to study the cytogenetic features during tumoral development of CCA and uncover the mystery regarding carcinogenesis of CCA. The Array comparative genomic hybridization analysis, in silico method, gene knockdown, Western blot, cell count proliferation assay, clonogenecity assay, and IHC staining were applied in this study. Array comparative genomic hybridization analysis was performed on all different TAA-induced phases of rat tissues to reveal the certain pattern, +2q45, +Xq22, -12p12, have been identified for the tumor early stage, where involve the gene TNNI3K. In addition, 16 genes and 3 loci were associated with rapid tumor progression; JAK-STAT signaling pathway was highly correlated to late stage of CCA. In silico database was used to observe TNNI3K was highly express at tumor part compared with normal adjacent tissue in CCA patients from TCGA dataset. Furthermore, the growth of TNNI3K-knockdown SNU308 and HuCCT1 cells decreased when compared with cells transfected with an empty vector cell demonstrated by proliferation and colonogenecity assay. Besides, over expression of TNNI3K was especially confirmed on human CCA tumors and compared with the intrahepatic duct stone bile duct tissues and normal bile duct tissues (P < 0.001). Our findings might uncover the mystery regarding carcinogenesis of CCA, and provide the potential genetic mechanism to the clinicians some ideas for the patients' treatment.

Application of a deep learning algorithm for detection and visualization of hip fractures on plain pelvic radiographs.

OBJECTIVE: To identify the feasibility of using a deep convolutional neural network (DCNN) for the detection and localization of hip fractures on plain frontal pelvic radiographs (PXRs). Hip fracture is a leading worldwide health problem for the elderly. A missed diagnosis of hip fracture on radiography leads to a dismal prognosis. The application of a DCNN to PXRs can potentially improve the accuracy and efficiency of hip fracture diagnosis. METHODS: A DCNN was pretrained using 25,505 limb radiographs between January 2012 and December 2017. It was retrained using 3605 PXRs between August 2008 and December 2016. The accuracy, sensitivity, false-negative rate, and area under the receiver operating characteristic curve (AUC) were evaluated on 100 independent PXRs acquired during 2017. The authors also used the visualization algorithm gradient-weighted class activation mapping (Grad-CAM) to confirm the validity of the model. RESULTS: The algorithm achieved an accuracy of 91%, a sensitivity of 98%, a false-negative rate of 2%, and an AUC of 0.98 for identifying hip fractures. The visualization algorithm showed an accuracy of 95.9% for lesion identification. CONCLUSIONS: A DCNN not only detected hip fractures on PXRs with a low false-negative rate but also had high accuracy for localizing fracture lesions. The DCNN might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. KEY POINTS: • Automated detection of hip fractures on frontal pelvic radiographs may facilitate emergent screening and evaluation efforts for primary physicians. • Good visualization of the fracture site by Grad-CAM enables the rapid integration of this tool into the current medical system. • The feasibility and efficiency of utilizing a deep neural network have been confirmed for the screening of hip fractures.

Effects of cholecystectomy on recurrent biliary complications after endoscopic treatment of common bile duct stone: a population-based cohort study.

BACKGROUND: The aim of this study was to evaluate the benefits of cholecystectomy on mitigating recurrent biliary complications following endoscopic treatment of common bile duct stone. METHODS: We used the data from the Taiwan National Health Insurance Research Database to conduct a population-based cohort study. Among 925 patients who received endoscopic treatment for choledocholithiasis at the first admission from 2005 to 2012, 422 received subsequent cholecystectomy and 503 had gallbladder (GB) left in situ. After propensity score matching with 1:1 ratio, the cumulative incidence of recurrent biliary complication and overall survival was analyzed with Cox's proportional hazards model. The primary endpoint of this study is recurrent biliary complications, which require intervention. RESULTS: After matching, 378 pairs of patients were identified with a median follow-up time of 53 (1-108) months. The recurrent rate of biliary complications was 8.20% in the cholecystectomy group and 24.87% in the GB in situ group (p < 0.001). In the multivariate Cox regression analysis, the only independent risk factor for recurrent biliary complications was GB left in situ (hazard ratio [HR] 3.55, 95% CI 2.36-5.33). CONCLUSIONS: Cholecystectomy after endoscopic treatment of common bile duct stone reduced the prevalence of recurrent biliary complications.