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Jang H, Lee N, Jeong E, Park Y, Jo Y, Kim J, Kim D. Abdominal compartment syndrome in critically ill patients. Acute Crit Care 2023; 38:399-408. [PMID: 38052507 DOI: 10.4266/acc.2023.01263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/13/2023] [Indexed: 12/07/2023] Open
Abstract
Intra-abdominal hypertension can have severe consequences, including abdominal compartment syndrome, which can contribute to multi-organ failure. An increase in intra-abdominal hypertension is influenced by factors such as diminished abdominal wall compliance, increased intraluminal content, and certain systemic conditions. Regular measurement of intra-abdominal pressure is essential, and particular attention must be paid to patient positioning. Nonsurgical treatments, such as decompression of intraluminal content using a nasogastric tube, percutaneous drainage, and fluid balance optimization, play crucial roles. Additionally, point-of-care ultrasonography aids in the diagnosis and treatment of intra-abdominal hypertension. Emphasizing the importance of regular measurements, timely decompressive laparotomy is a definitive, but complex, treatment option. Balancing the urgency of surgical intervention against potential postoperative complications is challenging.
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Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Naa Lee
- Division of Trauma, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Euisung Jeong
- Division of Trauma, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yunchul Park
- Division of Trauma, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Younggoun Jo
- Division of Trauma, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jungchul Kim
- Division of Trauma, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Dowan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Dreizin D, Champ K, Dattwyler M, Bodanapally U, Smith EB, Li G, Singh R, Wang Z, Liang Y. Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention. J Trauma Acute Care Surg 2023; 94:125-132. [PMID: 35546417 PMCID: PMC9652480 DOI: 10.1097/ta.0000000000003684] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND. Several ordinal grading systems are employed in deciding whether to perform angioembolization or splenectomy following blunt splenic injury. The 2018 AAST Organ Injury Scale (OIS) incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision-making. PURPOSE. To compare performance of CT volumetry-based quantitative modeling to the 1994 and 2018 AAST OIS and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or angioembolization (AE) MATERIALS AND METHODS. Adult BSI patients (age ≥ 18 years) scanned with dual-phase CT prior to intervention at a single level I trauma center from 2017-2019 were included in this retrospective study (n=174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included 1. SPY and 2. The composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. AUCs for ordinal systems and volumetric models were compared. RESULTS. Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85- SPY, 0.82-composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p=0.66, 0.14) for both endpoints, and were significantly improved over Thompson scoring (0.76, p=0.02; 0.77, p=0.04). CONCLUSION: Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring. Study Type: Prognostic Level of Evidence: IV CT volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research.
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Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine (D.D., M.D., U.B., E.B.S., G.L., Z.W., K.C., R.S.); and Department of Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, Baltimore, Maryland
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Dreizin D, Nixon B, Hu J, Albert B, Yan C, Yang G, Chen H, Liang Y, Kim N, Jeudy J, Li G, Smith EB, Unberath M. A pilot study of deep learning-based CT volumetry for traumatic hemothorax. Emerg Radiol 2022; 29:995-1002. [PMID: 35971025 DOI: 10.1007/s10140-022-02087-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/08/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE We employ nnU-Net, a state-of-the-art self-configuring deep learning-based semantic segmentation method for quantitative visualization of hemothorax (HTX) in trauma patients, and assess performance using a combination of overlap and volume-based metrics. The accuracy of hemothorax volumes for predicting a composite of hemorrhage-related outcomes - massive transfusion (MT) and in-hospital mortality (IHM) not related to traumatic brain injury - is assessed and compared to subjective expert consensus grading by an experienced chest and emergency radiologist. MATERIALS AND METHODS The study included manually labeled admission chest CTs from 77 consecutive adult patients with non-negligible (≥ 50 mL) traumatic HTX between 2016 and 2018 from one trauma center. DL results of ensembled nnU-Net were determined from fivefold cross-validation and compared to individual 2D, 3D, and cascaded 3D nnU-Net results using the Dice similarity coefficient (DSC) and volume similarity index. Pearson's r, intraclass correlation coefficient (ICC), and mean bias were also determined for the best performing model. Manual and automated hemothorax volumes and subjective hemothorax volume grades were analyzed as predictors of MT and IHM using AUC comparison. Volume cut-offs yielding sensitivity or specificity ≥ 90% were determined from ROC analysis. RESULTS Ensembled nnU-Net achieved a mean DSC of 0.75 (SD: ± 0.12), and mean volume similarity of 0.91 (SD: ± 0.10), Pearson r of 0.93, and ICC of 0.92. Mean overmeasurement bias was only 1.7 mL despite a range of manual HTX volumes from 35 to 1503 mL (median: 178 mL). AUC of automated volumes for the composite outcome was 0.74 (95%CI: 0.58-0.91), compared to 0.76 (95%CI: 0.58-0.93) for manual volumes, and 0.76 (95%CI: 0.62-0.90) for consensus expert grading (p = 0.93). Automated volume cut-offs of 77 mL and 334 mL predicted the outcome with 93% sensitivity and 90% specificity respectively. CONCLUSION Automated HTX volumetry had high method validity, yielded interpretable visual results, and had similar performance for the hemorrhage-related outcomes assessed compared to manual volumes and expert consensus grading. The results suggest promising avenues for automated HTX volumetry in research and clinical care.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA.
| | - Bryan Nixon
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jiazhen Hu
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Benjamin Albert
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Chang Yan
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Gary Yang
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Haomin Chen
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Yuanyuan Liang
- Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nahye Kim
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elana B Smith
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA
| | - Mathias Unberath
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
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Dreizin D, Yu T, Motley K, Li G, Morrison JJ, Liang Y. Blunt splenic injury: Assessment of follow-up CT utility using quantitative volumetry. FRONTIERS IN RADIOLOGY 2022; 2. [PMID: 36120383 PMCID: PMC9479763 DOI: 10.3389/fradi.2022.941863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: Trials of non-operative management (NOM) have become the standard of care for blunt splenic injury (BSI) in hemodynamically stable patients. However, there is a lack of consensus regarding the utility of follow-up CT exams and relevant CT features. The purpose of this study is to determine imaging predictors of splenectomy on follow-up CT using quantitative volumetric measurements. Methods: Adult patients who underwent a trial of non-operative management (NOM) with follow-up CT performed for BSI between 2017 and 2019 were included (n = 51). Six patients (12% of cohort) underwent splenectomy; 45 underwent successful splenic salvage. Voxelwise measurements of splenic laceration, hemoperitoneum, and subcapsular hematoma were derived from portal venous phase images of admission and follow-up scans using 3D slicer. Presence/absence of pseudoaneurysm on admission and follow-up CT was assessed using arterial phase images. Multivariable logistic regression was used to determine independent predictors of decision to perform splenectomy. Results: Factors significantly associated with splenectomy in bivariate analysis incorporated in multivariate logistic regression included final hemoperitoneum volume (p = 0.003), final subcapsular hematoma volume (p = 0.001), change in subcapsular hematoma volume between scans (p = 0.09) and new/persistent pseudoaneurysm (p = 0.003). Independent predictors of splenectomy in the logistic regression were final hemoperitoneum volume (unit OR = 1.43 for each 100 mL change; 95% CI: 0.99–2.06) and new/persistent pseudoaneurysm (OR = 160.3; 95% CI: 0.91–28315.3). The AUC of the model incorporating both variables was significantly higher than AAST grading (0.91 vs. 0.59, p = 0.025). Mean combined effective dose for admission and follow up CT scans was 37.4 mSv. Conclusion: Follow-up CT provides clinically valuable information regarding the decision to perform splenectomy in BSI patients managed non-operatively. Hemoperitoneum volume and new or persistent pseudoaneurysm at follow-up are independent predictors of splenectomy.
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Affiliation(s)
- David Dreizin
- Trauma and Emergency Radiology, Department of Diagnostic Radiology and Nuclear Medicine, School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States
- CORRESPONDENCE: David Dreizin
| | - Theresa Yu
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kaitlynn Motley
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jonathan J. Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yuanyuan Liang
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
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Dreizin D, Rosales R, Li G, Syed H, Chen R. Volumetric Markers of Body Composition May Improve Personalized Prediction of Major Arterial Bleeding After Pelvic Fracture: A Secondary Analysis of the Baltimore CT Prediction Model Cohort. Can Assoc Radiol J 2021; 72:854-861. [PMID: 32910695 PMCID: PMC8011455 DOI: 10.1177/0846537120952508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
METHODS This work is a retrospective secondary analysis of a single institution cohort used in the development of the Baltimore CT prediction model. The cohort includes 115 consecutive patients that underwent admission contrast-enhanced CT of the abdomen and pelvis for blunt trauma with pelvic ring disruption followed by conventional angiography. Major arterial injury requiring angioembolization served as the outcome variable. Angioembolization was required in 73/115 patients (63% of the cohort). Average age was 46.9 years (±SD 20.4). Body composition measurements were determined as 2-dimensional (2D) or 3-dimensional (3D) parameters and included mid-L3 trabecular bone attenuation, abdominal visceral fat area or volume, and percent muscle fat fraction (as a marker of sarcopenia) measured using segmentation and histogram analysis. RESULTS Models incorporating 2D (Model B) or 3D markers (model C) of body composition showed improvement over the original Baltimore model (model A) in all parameters of performance, quality, and fit (area under the receiver-operating curve [AUC], Akaike information criterion, Brier score, Hosmer-Lemeshow test, and adjusted-R2). Area under the receiver-operating curve increased from 0.83 (A), to 0.86 (B), and 0.88 (C). The greatest improvement was seen with 3D parameters. CONCLUSION Once automated, quantitative visualization tools providing "free" 3D body composition information can be expected to improve personalized precision diagnostics, outcome prediction, and decision support in patients with bleeding pelvic fractures.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Remberto Rosales
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hassan Syed
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rong Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Dreizin D, Chen T, Liang Y, Zhou Y, Paes F, Wang Y, Yuille AL, Roth P, Champ K, Li G, McLenithan A, Morrison JJ. Added value of deep learning-based liver parenchymal CT volumetry for predicting major arterial injury after blunt hepatic trauma: a decision tree analysis. Abdom Radiol (NY) 2021; 46:2556-2566. [PMID: 33469691 PMCID: PMC8205942 DOI: 10.1007/s00261-020-02892-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE In patients presenting with blunt hepatic injury (BHI), the utility of CT for triage to hepatic angiography remains uncertain since simple binary assessment of contrast extravasation (CE) as being present or absent has only modest accuracy for major arterial injury on digital subtraction angiography (DSA). American Association for the Surgery of Trauma (AAST) liver injury grading is coarse and subjective, with limited diagnostic utility in this setting. Volumetric measurements of hepatic injury burden could improve prediction. We hypothesized that in a cohort of patients that underwent catheter-directed hepatic angiography following admission trauma CT, a deep learning quantitative visualization method that calculates % liver parenchymal disruption (the LPD index, or LPDI) would add value to CE assessment for prediction of major hepatic arterial injury (MHAI). METHODS This retrospective study included adult patients with BHI between 1/1/2008 and 5/1/2017 from two institutions that underwent admission trauma CT prior to hepatic angiography (n = 73). Presence (n = 41) or absence (n = 32) of MHAI (pseudoaneurysm, AVF, or active contrast extravasation on DSA) served as the outcome. Voxelwise measurements of liver laceration were derived using an existing multiscale deep learning algorithm trained on manually labeled data using cross-validation with a 75-25% split in four unseen folds. Liver volume was derived using a pre-trained whole liver segmentation algorithm. LPDI was automatically calculated for each patient by determining the percentage of liver involved by laceration. Classification and regression tree (CART) analyses were performed using a combination of automated LPDI measurements and either manually segmented CE volumes, or CE as a binary sign. Performance metrics for the decision rules were compared for significant differences with binary CE alone (the current standard of care for predicting MHAI), and the AAST grade. RESULTS 36% of patients (n = 26) had contrast extravasation on CT. Median [Q1-Q3] automated LPDI was 4.0% [1.0-12.1%]. 41/73 (56%) of patients had MHAI. A decision tree based on auto-LPDI and volumetric CE measurements (CEvol) had the highest accuracy (0.84, 95% CI 0.73-0.91) with significant improvement over binary CE assessment (0.68, 95% CI 0.57-0.79; p = 0.01). AAST grades at different cut-offs performed poorly for predicting MHAI, with accuracies ranging from 0.44-0.63. Decision tree analysis suggests an auto-LPDI cut-off of ≥ 12% for minimizing false negative CT exams when CE is absent or diminutive. CONCLUSION Current CT imaging paradigms are coarse, subjective, and limited for predicting which BHIs are most likely to benefit from AE. LPDI, automated using deep learning methods, may improve objective personalized triage of BHI patients to angiography at the point of care.
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Affiliation(s)
- David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD, 21201, USA.
| | - Tina Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yuyin Zhou
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University, Baltimore, MD, USA
| | - Fabio Paes
- Emergency and Trauma Imaging, Department of Radiology, University of Miami - Miller School of Medicine, Jackson Memorial Hospital - Ryder Trauma Center, Miami, USA
| | - Yan Wang
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University, Baltimore, MD, USA
| | - Alan L Yuille
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick Roth
- Emergency and Trauma Imaging, Department of Radiology, University of Miami - Miller School of Medicine, Jackson Memorial Hospital - Ryder Trauma Center, Miami, USA
| | - Kathryn Champ
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashley McLenithan
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Abdou H, Du J, Harfouche MN, Patel N, Edwards J, Richmond M, Elansary N, Morrison JJ. Development of an Endovascular Model of Pelvic Hemorrhage Using Volumetric Computed Tomography Validation. J Endovasc Ther 2021; 28:614-622. [PMID: 34018880 DOI: 10.1177/15266028211016422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Uncontrolled pelvic hemorrhage from trauma is associated with mortality rates above 30%. The ability of an intervention to reduce blood loss from pelvic trauma is paramount to its success. The objective of this study was to determine if computed tomography volumetric analysis could be used to quantify blood loss in a porcine endovascular pelvic hemorrhage model. MATERIALS AND METHODS Yorkshire swine under general anesthesia underwent balloon dilation and rupture of the profunda femoris artery, which was confirmed by digital subtraction angiography. Computed tomography angiography and postprocessing segmentation were performed to quantify pelvic hemorrhage volume at 5 and 30 minutes after injury. Continuous hemodynamic and iliofemoral flow data were obtained. Baseline and postinjury hemoglobin, hematocrit and lactate were collected. RESULTS Of 6 animals enrolled, 5 survived the 30-minute post-injury period. One animal died at 15 minutes. Median volume of pelvic hemorrhage was 141±106 cm3 at 5 minutes and 302±79 cm3 at 30 minutes with a 114% median increase in hematoma volume over 25 minutes (p=0.040). There was a significant decrease in mean arterial pressure (107 to 71 mm Hg, p=0.030) and iliofemoral flow (561 to 122 mL/min, p=0.014) at 30 minutes postinjury, but no significant changes in hemoglobin, hematocrit, or heart rate. CONCLUSION Computed tomography volumetric analysis can be used to quantify rate and volume of blood loss in a porcine endovascular pelvic hemorrhage model. Future studies can incorporate this approach when evaluating the effect of hemorrhage control interventions associated with pelvic fractures.
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Affiliation(s)
- Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan Du
- Georgetown University School of Medicine, Washington, DC, USA
| | - Melike N Harfouche
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Neerav Patel
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Michael Richmond
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Noha Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
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Intra-abdominal hypertension and abdominal compartment syndrome: a current review. Curr Opin Crit Care 2021; 27:164-168. [PMID: 33480617 DOI: 10.1097/mcc.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Intra-abdominal hypertension (IAH) and its deleterious effects are present in at least one-third of ICU patients. Increased recognition of IAH has led to significant reduction in the incidence of abdominal compartment syndrome (ACS). Many questions remain regarding what therapeutic interventions truly reduce morbidity and mortality associated with IAH/ACS. Recent research sheds new light on the effects of IAH in individual organ systems and unique disease states. This paper will review recent research in IAH/ACS recognition, treatment, and management. RECENT FINDINGS Recent research on IAH/ACS includes an improved understanding of the prevalence of IAH/ACS and confirmation of its independent association with organ failure. Specifically, new research adds clarity to the effects of IAH/ACS on individual organ systems and specific disease states. These results combine to improve the clinical ability to diagnose, monitor, and treat IAH/ACS. SUMMARY There is significant research on the broad impact of IAH/ACS in the ICU setting. Focus on IAH/ACS has gone beyond the purview of intensivists and surgeons to include outstanding work by specialists in multiple sub-specialties. These advances have generated improvements in current treatment algorithms. We review recent IAH/ACS literature and have categorized the most pertinent results into organ system-specific contributions.
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Dreizin D, Goldmann F, LeBedis C, Boscak A, Dattwyler M, Bodanapally U, Li G, Anderson S, Maier A, Unberath M. An Automated Deep Learning Method for Tile AO/OTA Pelvic Fracture Severity Grading from Trauma whole-Body CT. J Digit Imaging 2021; 34:53-65. [PMID: 33479859 PMCID: PMC7886919 DOI: 10.1007/s10278-020-00399-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/14/2020] [Accepted: 11/10/2020] [Indexed: 01/13/2023] Open
Abstract
Admission trauma whole-body CT is routinely employed as a first-line diagnostic tool for characterizing pelvic fracture severity. Tile AO/OTA grade based on the presence or absence of rotational and translational instability corresponds with need for interventions including massive transfusion and angioembolization. An automated method could be highly beneficial for point of care triage in this critical time-sensitive setting. A dataset of 373 trauma whole-body CTs collected from two busy level 1 trauma centers with consensus Tile AO/OTA grading by three trauma radiologists was used to train and test a triplanar parallel concatenated network incorporating orthogonal full-thickness multiplanar reformat (MPR) views as input with a ResNeXt-50 backbone. Input pelvic images were first derived using an automated registration and cropping technique. Performance of the network for classification of rotational and translational instability was compared with that of (1) an analogous triplanar architecture incorporating an LSTM RNN network, (2) a previously described 3D autoencoder-based method, and (3) grading by a fourth independent blinded radiologist with trauma expertise. Confusion matrix results were derived, anchored to peak Matthews correlation coefficient (MCC). Associations with clinical outcomes were determined using Fisher's exact test. The triplanar parallel concatenated method had the highest accuracies for discriminating translational and rotational instability (85% and 74%, respectively), with specificity, recall, and F1 score of 93.4%, 56.5%, and 0.63 for translational instability and 71.7%, 75.7%, and 0.77 for rotational instability. Accuracy of this method was equivalent to the single radiologist read for rotational instability (74.0% versus 76.7%, p = 0.40), but significantly higher for translational instability (85.0% versus 75.1, p = 0.0007). Mean inference time was < 0.1 s per test image. Translational instability determined with this method was associated with need for angioembolization and massive transfusion (p = 0.002-0.008). Saliency maps demonstrated that the network focused on the sacroiliac complex and pubic symphysis, in keeping with the AO/OTA grading paradigm. A multiview concatenated deep network leveraging 3D information from orthogonal thick-MPR images predicted rotationally and translationally unstable pelvic fractures with accuracy comparable to an independent reader with trauma radiology expertise. Model output demonstrated significant association with key clinical outcomes.
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Affiliation(s)
- David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA
| | | | - Christina LeBedis
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Baltimore, MD USA
| | - Alexis Boscak
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA
| | - Matthew Dattwyler
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA
| | - Uttam Bodanapally
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD USA
| | - Stephan Anderson
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Baltimore, MD USA
| | - Andreas Maier
- Friedrich-Alexander University, Schloßplatz, Erlangen Germany
| | - Mathias Unberath
- Department of Computer Science, Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD USA
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Dreizin D, Liang Y, Dent J, Akhter N, Mascarenhas D, Scalea TM. Diagnostic value of CT contrast extravasation for major arterial injury after pelvic fracture: A meta-analysis. Am J Emerg Med 2020; 38:2335-2342. [PMID: 31864864 PMCID: PMC7253336 DOI: 10.1016/j.ajem.2019.11.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 01/05/2023] Open
Abstract
PURPOSE We conducted a meta-analysis to determine diagnostic performance of CT intravenous contrast extravasation (CE) as a sign of angiographic bleeding and need for angioembolization after pelvic fractures. MATERIALS AND METHODS A systematic literature search combining the concepts of contrast extravasation, pelvic trauma, and CT yielded 206 potentially eligible studies. 23 studies provided accuracy data or sufficient descriptive data to allow 2x2 contingency table construction and provided 3855 patients for meta-analysis. Methodologic quality was assessed using the QUADAS-2 tool. Sensitivity and specificity were synthesized using bivariate mixed-effects logistic regression. Heterogeneity was assessed using the I2-statistic. Sources of heterogeneity explored included generation of scanner (64 row CT versus lower detector row) and use of multiphasic versus single phase scanning protocols. RESULTS Overall sensitivity and specificity were 80% (95% CI: 66-90%, I2 = 92.65%) and 93% (CI: 90-96, I2 = 89.34%), respectively. Subgroup analysis showed pooled sensitivity and specificity of 94% and 89% for 64- row CT compared to 69% and 95% with older generation scanners. CE had pooled sensitivity and specificity of 95% and 92% with the use of multiphasic protocols, compared to 74% and 94% with single-phase protocols. CONCLUSION The pooled sensitivity and specificity of 64-row CT was 94 and 89%. 64 row CT improves sensitivity of CE, which was 69% using lower detector row scanners. High specificity (92%) can be maintained by incorporating multiphasic scan protocols.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201, United States.
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - James Dent
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Nabeel Akhter
- Department of Diagnostic Radiology and Nuclear Medicine, Vascular and Interventional Radiology, University of Maryland School of Medicine, United States.
| | - Daniel Mascarenhas
- Orthopedic Surgery, Rutgers Robert Wood Johnson Medical School, United States
| | - Thomas M Scalea
- Francis X Kelly Distinguished Professor in Trauma Surgery, Physician in Chief, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, United States.
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Dreizin D, Zhou Y, Fu S, Wang Y, Li G, Champ K, Siegel E, Wang Z, Chen T, Yuille AL. A Multiscale Deep Learning Method for Quantitative Visualization of Traumatic Hemoperitoneum at CT: Assessment of Feasibility and Comparison with Subjective Categorical Estimation. Radiol Artif Intell 2020; 2:e190220. [PMID: 33330848 PMCID: PMC7706875 DOI: 10.1148/ryai.2020190220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the feasibility of a multiscale deep learning algorithm for quantitative visualization and measurement of traumatic hemoperitoneum and to compare diagnostic performance for relevant outcomes with categorical estimation. MATERIALS AND METHODS This retrospective, single-institution study included 130 patients (mean age, 38 years; interquartile range, 25-50 years; 79 men) with traumatic hemoperitoneum who underwent CT of the abdomen and pelvis at trauma admission between January 2016 and April 2019. Labeled cases were separated into five combinations of training (80%) and test (20%) sets, and fivefold cross-validation was performed. Dice similarity coefficients (DSCs) were compared with those from a three-dimensional (3D) U-Net and a coarse-to-fine deep learning method. Areas under the receiver operating characteristic curve (AUCs) for a composite outcome, including hemostatic intervention, transfusion, and in-hospital mortality, were compared with consensus categorical assessment by two radiologists. An optimal cutoff was derived by using a radial basis function-based support vector machine. RESULTS Mean DSC for the multiscale algorithm was 0.61 ± 0.15 (standard deviation) compared with 0.32 ± 0.16 for the 3D U-Net method and 0.52 ± 0.17 for the coarse-to-fine method (P < .0001). Correlation and agreement between automated and manual volumes were excellent (Pearson r = 0.97, intraclass correlation coefficient = 0.93). The algorithm produced intuitive and explainable visual results. AUCs for automated volume measurement and categorical estimation were 0.86 and 0.77, respectively (P = .004). An optimal cutoff of 278.9 mL yielded accuracy of 84%, sensitivity of 82%, specificity of 93%, positive predictive value of 86%, and negative predictive value of 83%. CONCLUSION A multiscale deep learning method for traumatic hemoperitoneum quantitative visualization had improved diagnostic performance for predicting hemorrhage-control interventions and mortality compared with subjective volume estimation. Supplemental material is available for this article. © RSNA, 2020.
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Affiliation(s)
- David Dreizin
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Yuyin Zhou
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Shuhao Fu
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Yan Wang
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Guang Li
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Kathryn Champ
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Eliot Siegel
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Ze Wang
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Tina Chen
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
| | - Alan L. Yuille
- From the Section of Trauma and Emergency Radiology, R. Adams Cowley Shock Trauma Center (D.D.) and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, University of Maryland, 22 S Greene St, Baltimore, MD 21201 (G.L., K.C., E.S., Z.W., T.C.); and Department of Computer Science, Computational Cognition Vision and Learning, Johns Hopkins University, Baltimore, Md (Y.Z., S.F., Y.W., A.L.Y.)
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