Journal of Trauma and Acute Care Surgery最新文献

Background: In this study, we develop a standardized porcine model of distant injury plus lung bacterial inoculation to allow translational investigations of the effects of tissue injury on susceptibility to infection. This generalizable model will allow testing of immune interventions on the evolution of infection.

Methods: A standardized liver crush (5 cm × 2.5 cm/3 kg) plus hemoperitoneum (6 mL/kg) or sham procedure was performed in 30-kg Yorkshire pigs, followed by intratracheal inoculation of bacteria ( Actinobacillus pleuropneumoniae ). We then compared gross pathology, histology, lung bacterial counts, danger-associated molecular pattern molecules, and serum cytokines between the two groups.

Results: The lungs of injured pigs demonstrated significantly enhanced responses to infection compared with sham injured pigs, both on the macroscopic and microscopic levels. Lung bacterial clearance was significantly impaired after trauma, with increased infiltration of neutrophils and differential location of myeloid cells on immunostaining. In lung parenchyma expression of the stress response genes, Hmox1 and Nrf2 were increased in both trauma alone and trauma plus infection. Plasma from pigs subjected to trauma showed increased levels of the danger-associated molecular patters heme and mitochondrial DNA and promoted bacterial growth in vitro compared with plasma from uninjured pigs.

Conclusion: We have developed a novel, clinically relevant, reproducible porcine model of abdominal injury with subsequent A. pleuropneumoniae pneumonia for the study and development of therapeutics against immune dysregulation induced by trauma. Additionally, a novel finding is that plasma from traumatized pigs provides a permissive environment for bacterial growth.

Background: The benefit of transfusion of fresh frozen plasma (FFP) and platelets in a 1:1 ratio with packed red blood cells (PRBCs) is well established; however, the benefit of a particular ratio of cryoprecipitate to PRBC is not. The Joint Trauma System updated its 2019 Damage Control Resuscitation Guideline by recommending empiric 1:1 cryoprecipitate/PRBCs. We hypothesized that patients receiving product within the cryoprecipitate/PRBC guideline range (high ratio) would have an associated reduction in mortality.

Methods: We included adult patients in the Trauma Quality Improvement Program data registry (2013-2021) who received at least 5 U of PRBCs and 1 U of FFP within 4 hours. Death within 30 minutes, nonsurvivable injury patterns, preexisting coagulopathy, advanced directives, transfers, and burns were excluded. Patients were partitioned into high (≥1:1), medium (≥1:2 to <1:1), and low (<1:2) cryoprecipitate/PRBC ratios. Treatment effects were estimated with propensity score-weighted risk adjustment models, clustering by center. The primary outcome was 6-hour mortality. Secondary outcomes included 24-hour and inpatient mortality. Adjusting for FFP, platelets, and whole blood was included as a sensitivity analysis.

Results: A total of 49,301 patients (high, 5,284; medium, 3,630; low, 40,387) were included. The mean age was 39, 79% were male, 58% suffered blunt trauma, and the mean Injury Severity Score was 29. Unadjusted 6-hour mortality was 11.8%, 18.8%, and 21.3% for high, medium, and low ratios. High ratio was protective as compared with low at 6 hour (adjusted odds ratio [aOR], 0.52; 95% confidence interval [CI], 0.45-0.58) and 24 hours (aOR, 0.74; 95% CI, 0.67-0.82), and medium ratio was protective as compared with low ratio at 6 hours (aOR, 0.78; 95% CI, 0.70-0.87). Blood product sensitivity analysis demonstrated that high and medium ratios were protective of 6-hour, 24-hour, and inpatient mortality.

Conclusion: High cryoprecipitate ratios were independently associated with decreased mortality in massively transfused civilian trauma patients during the first 24 hours. Future prospective multicenter randomized trials are warranted.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Acute care surgery (ACS) involves rapid, high-stakes decisions with limited opportunity for preoperative planning. While machine learning (ML) may improve risk prediction and decision making in this setting, its development, validation, and implementation in ACS remain understudied. We therefore evaluated the techniques, predictor features, and outcomes used in ML-driven risk prediction models in ACS and generated recommendations to inform future research and support clinically meaningful implementation.

Methods: A systematic review of ML-driven predictive models in ACS (emergency general surgery, surgical critical care, trauma) was conducted. Models were analyzed by predictor features, outcomes, algorithms, and performance. The best-performing models for the most commonly predicted outcome were identified.

Results: Of 52 studies, 57.7% focused on trauma populations. Most models used registry data (76.8%), fewer used electronic health records (28.8%), and only five studies performed external validation after model development. Common algorithms included logistic regression (44.2%), random forest (34.6%), and decision trees (26.9%). Mortality (59.6%), complications (30.8%), and triage/severity (15.4%) were the most frequent outcomes; patient-centered/reported outcomes were absent. Features commonly included demographics, physiologic scores, and vital signs, while imaging and intraoperative data were underused. Natural language processing was used in four studies. Model performance was typically assessed using area under the receiver operating characteristic curve (88.5%), with support vector machines demonstrating the highest performance. Machine learning models generally outperformed conventional risk scores among 11 comparative studies.

Conclusion: Machine learning-driven predictive models in ACS show promising performance but are constrained by limited methodological rigor, real-world validation, and substantial heterogeneity in features, outcomes, and algorithms, challenging systematic adoption and oversight. A grounded understanding of ACS decision making workflows and their postimplementation impact may ensure clinically relevant, seamless, and safe integration of ML-based risk prediction.

Level of evidence: Systematic Review Without Meta-analysis; Level IV.

Background: CAQK (cysteine-alanine-lysine glutamine) is a homing peptide shown to selectively target injured regions of the brain. This study evaluated CAQK in a rodent model of spinal cord injury (SCI) to determine its localization capacity, dose-response characteristics, and temporal binding properties.

Methods: This is a preclinical pharmacology study of a nanotherapeutic drug delivery system. Twenty-four adult rats underwent C6 right-sided spinal cord hemicontusion. Animals received a tail vein injection of cyanine5-labeled CAQK (CAQK-Cy5) at low (0.5 mg/kg), medium (1.0 mg/kg), or high dose (2.5 mg/kg) or matched doses of free Cy5 dye as a control (n = 3 per group). Localization was monitored via in vivo fluorescence imaging at 1 and 24 hours in all animals and up to 7 days in an additional cohort of high-dose CAQK-Cy5 and Cy5 animals. Spinal cords were harvested for ex vivo imaging and histological confirmation of CAQK-Cy5 accumulation.

Results: In vivo imaging demonstrated CAQK-Cy5 signal at the SCI site within 1-hour postinjection, which persisted up to 7 days in the high-dose group. Signal intensity was dose dependent and declined over time. No significant localization was observed in control animals or uninjured spinal regions.

Conclusion: CAQK rapidly and selectively localizes to injured spinal cord tissue in a dose-responsive manner, with peak accumulation observed within 24 hours. These findings support its potential as a targeted delivery vector for injectable therapeutics in acute SCI.

Abstract: Popliteal artery injuries are rare even in busy urban trauma centers. The vast majority result from penetrating mechanisms of injury. These injuries are uncommon; therefore, few trauma surgeons and trauma centers have developed significant experience with their management. Experiences from both military and urban arenas of warfare consistently report the highest complications and amputation rates of all vascular injuries secondary to popliteal artery injuries. The popliteal artery is an end artery. Injuries cause significant ischemia, which threaten limb viability. From a surgical standpoint, they are difficult to expose and require excellent surgical technique to repair and restore blood flow in a timely fashion, prioritizing operative efficiency to decrease ischemia. This is of the utmost importance to obtain excellent results. Past and recent military conflicts have provided trauma surgeons with excellent experiences to develop a framework to manage these injuries, specifically the Vietnam War. If there are any lessons to be learned from the recent conflicts in Iraq, Afghanistan, and, currently, Ukraine, it is that trauma surgeons must be prepared to effectively and rapidly operate on these injuries.

Level of evidence: Therapeutic Study; Level III.