Journal of Trauma and Acute Care Surgery最新文献

Background: Road traffic crashes (RTCs) are a global health burden, particularly in India, where response times for first responders can be prolonged. Prior to enactment of a Good Samaritan Law (GSL) in 2016, involved bystanders could face criminal and financial liability for assisting at an RTC site. This study evaluates the impact of GSL on bystander RTC attitudes, awareness, and experiences in India, comparing outcomes pre- and post-GSL implementation across metropolitan cities (MCs) and nonmetropolitan cities (NMCs). We hypothesized that GSL would lead to increased bystander willingness to assist the RTC victim.

Methods: This retrospective, cross-sectional, observational study analyzed data from two national surveys conducted in 2013 (pre-GSL, n = 1,027) and 2018 (post-GSL, n = 3,667) across 7 and 11 Indian cities, respectively. Difference-in-difference analysis, propensity score matching, and regression models were used to assess changes in willingness to assist RTC victims, awareness of GSL, legal and financial fears, and awareness of GSL.

Results: Post-GSL implementation saw an increase in willingness to assist RTC victims (Δ = +65.4%, p < 0.001) and substantial decreases in fear regarding legal (Δ = -81%, p < 0.001) and financial consequences (Δ = -75.8%, p < 0.001) of rendering assistance. GSL awareness was higher in NMCs (n = 2,215, 31.2%) compared with MCs (n = 838, 9.25%) among general citizens ( p < 0.001). Males showed higher willingness to assist RTC victims ( p < 0.01), whereas individuals with postgraduate education demonstrated increased awareness of GSL ( p < 0.01).

Conclusion: The implementation of GSL in India has transformed bystander intervention in RTCs, increasing the reported likelihood of assistance and substantially reducing legal and financial concerns. This shift demonstrates GSL's potential to improve outcomes for RTC victims. However, disparities in awareness between MCs and NMCs, as well as sex- and education-based differences, highlight the need for targeted educational campaigns. Future initiatives should focus on improving application of the law and strengthening the entire trauma chain of survival.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Blood shortages and utilization stewardship have motivated the trauma community to evaluate futility cutoffs during massive transfusions (MTs). Recent single-center studies have confirmed meaningful survival in ultra-MT (≥20 U) and super-MT (≥50 U), while others advocate for earlier futility cut points. We sought to evaluate whether transfusion volume and intensity cut points could predict 100% mortality in a multicenter analysis.

Methods: A prospective, multicenter, observational cohort study was performed at seven trauma centers. Injured patients at risk for MT who required both blood transfusion and hemorrhage control procedures were enrolled. Four-hour volumes and intensities (average units per hour) were evaluated. Primary outcome of interest was 28-day mortality.

Results: A total of 1,047 patients met the study inclusion with an overall mortality rate of 17% (n = 176). The median age was 35 years, 80% were male, and 62% had a penetrating mechanism, with an Injury Severity Score of 22. At 4 hours, transfusion volumes below 110 U and transfusion intensity averaging up to 21 U/h did not demonstrate futility. Total transfusion volume above 110 U was associated with 100% mortality (n = 9). Multivariable analysis noted only nonmodifiable risk factors as predictors of increased mortality (blunt mechanism, shock index).

Conclusion: In this study from seven Level 1 trauma centers, survival was observed at transfusion volumes up to 110 U and at transfusion velocities up to 21 U/h during the first 4 hours of resuscitation. Data are limited on transfusion volumes above 110 U in the first 4 hours. Survival can be observed in both the ultra and super-MT settings.

Level of evidence: Therapeutic/Care Management; Level II.

Background: Emergency surgical admissions represent the majority of general surgical workload. Interhospital variations in outcomes are well recognized. This analysis of a national laparotomy data set compared the best- and worst-performing hospitals according to 30-day mortality and examined differences in process and structural factors.

Methods: A retrospective multicenter cohort study was performed using data from the England and Wales National Emergency Laparotomy Audit (December 2013 to November 2020). The data set was divided into quintiles based on the risk-adjusted mortality calculated using the National Emergency Laparotomy Audit score risk prediction model. Primary outcome was 30-day mortality. Hospital-level factors were compared across all five quintiles, and logistic regression analysis was conducted comparing the lowest with the highest risk-adjusted mortality quintiles.

Results: Risk-adjusted 30-day mortality in the poorest performing quintile was significantly higher than that of the best performing (11.4% vs. 6.6%) despite equivalent predicted mortality (9.4% vs. 9.7%). The best-performing quintile was more likely to be a tertiary surgical (49.5% vs. 37.1%, p < 0.001) or medical school-affiliated center (26.4% vs. 18.0%, p < 0.001). In logistic regression analysis, the strongest associations were for surgery performed in a tertiary center (odds ratio, 0.690 [95% confidence interval, 0.652-0.731], p < 0.001) and if surgery was performed by a gastrointestinal specialist (0.655 [0.626-0.685], p < 0.001). Smaller differences were seen for postoperative intensive care stay (0.848 [0.808-0.890], p < 0.001) and consultant anesthetist involvement (0.900 [0.837-0.967], p = 0.004).

Discussion: This study has identified significant variability in postoperative mortality across hospitals. Structural factors such as gastrointestinal specialist delivered emergency laparotomy and tertiary surgical center status appear to be associated with improved outcomes.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Traumatic hemothoraces (HTXs) are common, and tube thoracostomy (TT) insertion is generally the initial management. However, a retained HTX can develop into a fibrothorax or empyema requiring secondary intervention. We hypothesized that irrigation of the thoracic cavity at the time of TT may prevent retained HTX.

Methods: Pubmed, EMBASE, and Scopus were searched from inception to May 2024. Studies with adult trauma patients with traumatic HTX who received a TT and had patients who underwent thoracic irrigation were included. The primary outcome was failure rate, defined as retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 for dichotomous variables and unpaired t test for continuous variables. A fixed-effects model was applied for meta-analysis.

Results: Six studies were included in the analysis; two retrospective and four prospective observational studies. These studies included 1,319 patients (513 irrigated TT, 837 nonirrigated TT). The mean age of patients was 45 years, 81% were male, mean Injury Severity Score was 21, and 42% had penetrating trauma. Failure rate was significantly lower in the irrigation group on cumulative analysis (10.7% vs. 18.2%, p < 0.001) and meta-analysis (effect size, 0.704; 95% confidence interval, 0.218-1.190; I2 = 0.4; p < 0.001]. In addition, on meta-analysis, the irrigation group had a shorter TT duration and hospital and ICU length of stay (all p < 0.05). There were no differences in overall infectious complications, readmission, or mortality; however, all the models favored the irrigation group.

Conclusion: Patients who undergo simultaneous TT and thoracic irrigation have a lower rate of retained HTX and require fewer secondary interventions. Thoracic irrigation for traumatic HTX should be considered; however, randomized studies are needed prior to development of guidelines.

Level of evidence: Systematic Review/Meta-analysis; Level III.

Background: Despite advances in trauma care, the effects of social determinants of health continue to be a barrier to optimal health outcomes. Health-related social needs (HRSNs), now the basis of a Centers for Medicare and Medicaid Services national screening program, may contribute to poor health outcomes, inequities, and low-value care, but the impact of HRSNs among injured patients remains poorly understood at the national level.

Methods: Using data from the nationally representative 2021 Medical Expenditure Panel Survey, injured patients were matched with uninjured controls via coarsened exact matching on age and sex. We then determined the prevalence of HRSNs based on core needs identified by Centers for Medicare and Medicaid Services: food, utilities, living situation, transportation, and personal safety. We used multivariable regression models to evaluate the association between HRSNs and health, delays in care, and emergency department visits.

Results: Overall, 43% of injured patients reported one or more HRSNs. Compared with uninjured controls, injured patients were more likely to have unmet needs in all five HRSN domains (adjusted odds ratio, 1.44-2.00; p < 0.05 for all). In stratified analyses, HRSNs were highest among patients with lower income (65.1%), those who identified as Non-Hispanic Black patients (61.3%), and patients with Medicaid (66.1%). Increasing number of HRSNs was associated with worse physical and mental health ( p < 0.05). Injured patients with three or more HRSNs were also more likely to delay care because of cost (adjusted odds ratio, 3.79; 95% confidence interval, 2.29-6.27) and had greater emergency department utilization (adjusted incidence rate ratio, 1.47; 95% confidence interval, 1.16-1.87).

Conclusion: In this nationally representative study, nearly half of injured patients had one or more HRSNs. Greater numbers of HRSNs were associated with worse health outcomes, delayed care, and low-value care. As national screening for HRSNs is implemented, strategies to address these factors are needed and may serve to optimize health and health care utilization among injury survivors.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Burn injuries trigger a systemic hyperinflammatory response, leading to multiple organ dysfunction, including significant hepatic damage. The liver plays a crucial role in regulating immune responses and metabolism after burn injuries, making it critical to develop strategies to mitigate hepatic impairment. This study investigates the role of methylation-controlled J protein (MCJ), an inner mitochondrial protein that represses complex I in burn-induced oxidative stress and mitochondrial dysfunction, using an in vitro Alpha Mouse Liver 12 cell model.

Methods: Alpha Mouse Liver 12 cells were treated with serum from burn-injured mice (SBIM) to simulate burn injury in vitro. Methylation-controlled J protein was silenced using shRNA. Cell viability, apoptosis markers, reactive oxygen species levels, antioxidant response elements, electron transport chain components, and mitochondrial respiration were assessed using various techniques, including Cell Counting Kit-8 assay, Western blotting, MitoSOX Red staining, and Seahorse XF analysis.

Results: Serum from burn-injured mice treatment (10%) for 8 hours reduced Alpha Mouse Liver 12 cell viability to 50% of control levels and increased MCJ expression fivefold. It also significantly upregulated apoptosis markers: cleaved caspase-3 (4-fold), Bax (3.8-fold), and cytosolic cytochrome c (3.5-fold). Methylation-controlled J protein silencing improved cell viability to 85% of control levels and reduced apoptosis markers by 75% to 78%. Serum from burn-injured mice increased reactive oxygen species levels by 3-fold, while MCJ silencing reduced this by 2.5-fold. Antioxidant proteins (NRF2, HO-1, NQO-1, GCLC, catalase) were suppressed by SBIM but upregulated 3.2- to 3.8-fold with MCJ silencing. Serum from burn-injured mice reduced electron transport chain components (NDUFS1, SDHB, MTCO2) by 45% to 65%, which MCJ silencing restored 2.5- to 3-fold. Mitochondrial respiration improved significantly with MCJ silencing: basal respiration (+26%), maximal respiration (+66%), adenosine triphosphate production (+25%), and spare respiratory capacity (+63%).

Conclusion: Methylation-controlled J protein plays a critical role in burn-induced hepatocyte damage. Its silencing alleviates SBIM-induced cytotoxicity, oxidative stress, and mitochondrial dysfunction. These findings highlight MCJ as a potential therapeutic target for preserving liver function in burn patients, warranting further in vivo studies to explore its clinical potential.

Background: The prolonged use of percutaneous cholecystostomy tubes (PCTs) in patients with acute cholecystitis, deemed inoperable, is fraught with complications. Transpapillary cholecystoduodenal stenting (TCDS) is an alternative technique that restores the physiologic outflow of bile, avoiding the need for an external drain. However, the long-term safety and efficacy of this approach remain unclear. We sought to prospectively assess the safety and efficacy of this procedure, performed via percutaneous or endoscopic approach, in high-risk patients presenting with acute cholecystitis.

Methods: This prospective study included consecutive patients with acute cholecystitis and long-lasting, prohibitive surgical risk, in whom TCDS was offered at two partnering tertiary care centers between August 1, 2018, and December 31, 2022. Patients with a need for endoscopic retrograde cholangiopancreatography (ERCP) underwent ERCP-guided TCDS. In patients without a need for ERCP, a temporary PCT was followed by fluoroscopic-guided TCDS 4 weeks to 6 weeks later. Interval cholecystectomy was performed in patients who became surgical candidates later. All patients were followed up until January 1, 2023.

Results: Transpapillary cholecystoduodenal stenting was successful in 67 (percutaneous in 45/50; endoscopic in 22/23) of 73 patients (92%) attempted. Over a median follow-up period of 17 months (7, 26), 10 patients (15%) developed stent blockage or migration; all but two had their stent successfully replaced. Five patients (7%) developed mild, self-limited pancreatitis. Five (7%) patients underwent interval cholecystectomy at a median time of 7 months.

Conclusion: Transpapillary cholecystoduodenal stenting is a safe and promising definitive alternative to chronic PCT in high-risk patients with acute cholecystitis that eliminates the discomfort and complications of long-term external drainage.

Level of evidence: Therapeutic/Care Management; Level II.

Level of evidence: Systematic Review/Meta-analysis; Level IV.

Abstract: Nearly 4% of pregnant patients have an injury-related visit to the emergency department during their pregnancy. There are important physiologic changes that occur during pregnancy that make managing pregnant trauma patients different from the standard management of a nonpregnant patient. This review discusses these changes and the initial assessment, laboratory, and imaging workups for the pregnant trauma patient. In addition, management of specific injuries in pregnancy including pelvic fractures, hemorrhagic shock, and postpartum hemorrhage are reviewed as well as key points regarding resuscitative hysterotomy and fetal support that trauma surgeons should be aware of.