The risk of hemorrhagic complications after anticoagulation therapy in trauma patients: A multicenter evaluation

BACKGROUND

The use of anticoagulation therapy (ACT) in trauma patients during the postinjury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions.

METHODS

In this retrospective cohort study, all trauma admissions at two Level I trauma centers between January 2015 and December 2020 were reviewed. Patients with preexisting ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury.

RESULTS

A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the postinjury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7 days to 14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively.

CONCLUSION

The use of ACT in trauma during the postinjury period is not without risk. Waiting 7 days to 14 days postinjury might greatly reduce the risk of hemorrhagic complications.

LEVEL OF EVIDENCE

Therapeutic/Care Management Study; Level IV.

A Real-Time Automated Machine Learning Algorithm for Predicting Mortality in Trauma Patients: Survey Says it's Ready for Prime-Time

BACKGROUND

Though artificial intelligence ("AI") has been increasingly applied to patient care, many of these predictive models are retrospective and not readily available for real-time decision-making. This survey-based study aims to evaluate implementation of a new, validated mortality risk calculator (Parkland Trauma Index of Mortality, "PTIM") embedded in our electronic healthrecord ("EHR") that calculates hourly predictions of mortality with high sensitivity and specificity.

METHODS

This is a prospective, survey-based study performed at a level 1 trauma center. An anonymous survey was sent to surgical providers and regarding PTIM implementation. The PTIM score evaluates 23 variables including Glasgow Coma Score (GCS), vital signs, and laboratory data.

RESULTS

Of the 40 completed surveys, 35 reported using PTIM in decision-making. Prior to reviewing PTIM, providers identified perceived top 3 predictors of mortality, including GCS (22/38, 58%), age (18/35, 47%), and maximum heart rate (17/35, 45%). Most providers reported the PTIM assisted their treatment decisions (27/35, 77%) and timing of operative intervention (23/35, 66%). Many providers agreed that PTIM integrated into rounds and patient assessment (22/36, 61%) and that it improved efficiency in assessing patients' potential mortality (21/36, 58%).

CONCLUSIONS

Artificial intelligence algorithms are mostly retrospective and lag in real-time prediction of mortality. To our knowledge, this is the first real-time, automated algorithm predicting mortality in trauma patients. In this small survey-based study, we found PTIM assists in decision-making, timing of intervention, and improves accuracy in assessing mortality. Next steps include evaluating the short- and long-term impact on patient outcomes.

Primary Repair Versus Resection for AAST Grade I and II Colon Injuries: Does the Type of Repair Matter?

INTRODUCTION

The management of traumatic colon injuries has evolved over the past two decades. Recent evidence suggests that primary repair or resection over colostomy may decrease morbidity and mortality. Data comparing patients undergoing primary repair versus resection are lacking. We sought to compare the outcomes of patients undergoing primary repair versus resection for low-grade colon injuries.

METHODS

A retrospective review of all patients who presented with American Association for the Surgery of Trauma grade I and II traumatic colon injuries to our Level I trauma center between 2011 and 2021 was performed. Patients were further dichotomized based on whether they underwent primary repair or resection with anastomosis. Outcome measures included length of stay data, infectious complications, and mortality.

RESULTS

A total of 120 patients met inclusion criteria. The majority of patients (76.7%) were male, and the average age was 35.6 ± 13.1 y. Most patients also underwent primary repair (80.8%). There were no statistically significant differences between the groups in arrival physiology or in injury severity score. Length of stay data including hospital length of stay, intensive care unit length of stay, and ventilator days were similar between groups. Postoperative complications including pneumonia, surgical site infections, fascial dehiscence, the development of enterocutaneous fistulas, and unplanned returns to the operating room were also all found to be similar between groups. The group who underwent resection with anastomosis did demonstrate a higher rate of intra-abdominal abscess development (3.1% versus 26.1%, P < 0001). Mortality between both groups was not found to be statistically significant (7.2% versus 4.3%, P = 0.4) CONCLUSIONS: For low-grade (American Association for the Surgery of Trauma I and II) traumatic colon injuries, patients undergoing primary repair demonstrated a decreased rate of intra-abdominal abscess development when compared to patients who underwent resection with anastomosis.

Evaluation of high dose N- Acetylcysteine on airway inflammation and quality of life outcomes in adults with bronchiectasis: A randomised placebo-controlled pilot study

BACKGROUND

High dose N acetylcysteine (NAC), a mucolytic, anti-inflammatory and antioxidant agent has been shown to significantly reduce exacerbations, and improve quality of life in placebo controlled, double blind randomised (RCT) studies in patients with COPD, and in an open, randomised study in bronchiectasis. In this pilot, randomised, double-blind, placebo-controlled study, we wished to investigate the feasibility of a larger clinical trial, and the anti-inflammatory and clinical benefits of high dose NAC in bronchiectasis.

AIMS

Primary outcome: to assess the efficacy of NAC 2400 mg/day at 6 weeks on sputum neutrophil elastase (NE), a surrogate marker for exacerbations. Secondary aims included assessing the efficacy of NAC on sputum MUC5B, IL-8, lung function, quality of life, and adverse effects.

METHODS

Participants were randomised to receive 2400 mg or placebo for 6 weeks. They underwent 3 visits: at baseline, week 3 and week 6 where clinical and sputum measurements were assessed.

RESULTS

The study was stopped early due to the COVID pandemic. In total 24/30 patients were recruited, of which 17 completed all aspects of the study. Given this, a per protocol analysis was undertaken: NAC (n = 9) vs placebo (n = 8): mean age 72 vs 62 years; male gender: 44% vs 50%; baseline median FEV11.56 L (mean 71.5 % predicted) vs 2.29L (mean 82.2% predicted). At 6 weeks, sputum NE fell by 47% in the NAC group relative to placebo (mean fold difference (95%CI: 0.53 (0.12,2.42); MUC5B increased by 48% with NAC compared with placebo. Lung function, FVC improved significantly with NAC compared with placebo at 6 weeks (mean fold difference (95%CI): 1.10 (1.00, 1.20), p = 0.045. Bronchiectasis Quality of life measures within the respiratory and social functioning domains demonstrated clinically meaningful improvements, with social functioning reaching statistical significance. Adverse effects were similar in both groups.

CONCLUSION

High dose NAC exhibits anti-inflammatory benefits, and improvements in aspects of quality of life and lung function measures. It is safe and well tolerated. Further larger placebo controlled RCT's are now warranted examining its role in reducing exacerbations.

Seraph 100 Microbind Affinity Blood Filter Does Not Clear Antibiotics: An Analysis of Antibiotic Concentration Data from PURIFY-OBS

INTRODUCTION

Novel hemoperfusion systems are emerging for the treatment of sepsis. These devices can directly remove pathogens, pathogen-associated molecular patterns, cytokines, and other inflammatory markers from circulation. However, significant safety concerns such as potential antibiotic clearance need to be addressed prior to these devices being used in large clinical studies.

METHODS

Prospective, observational study of 34 participants undergoing treatment with the Seraph 100® Microbind Affinity Blood Filter (Seraph 100) device at 6 participating sites in the USA. Patients were included for analysis if they had a record of receiving an antibiotic concurrent with Seraph 100 treatment. Patients were excluded if there was missing information for blood flow rate. Blood samples were drawn pre- and post-filter at 1 h and 4 h after treatment initiation. These average pre- and post-filter time-concentration observations were then used to estimate antibiotic clearance in L/h (CLSeraph) due to the Seraph 100 device.

RESULTS

Of the 34 participants in the study, 17 met inclusion and exclusion criteria for the antibiotic analysis. Data were obtained for 7 antibiotics (azithromycin, cefazolin, cefepime, ceftriaxone, linezolid, piperacillin, and vancomycin) and one beta-lactamase inhibitor. Mean CLSeraph for the antibiotics investigated ranged from -0.57 to 0.47 L/h. No antibiotic had a CLSeraph statistically significant from 0.

DISCUSSION/CONCLUSION

The Seraph 100 did not significantly clear any measured antibiotic in clinical samples. These data give further evidence to suggest that these therapies may be safely administered to critically ill patients and will not impact concentrations of administered antibiotics.

Implementation of a novel thoracostomy tube trainer with real-time feedback

Objectives

Simulation-based training leads to improved clinical performance but may be influenced by quality and frequency of training. Within simulation training, chest tube insertion remains a challenge as one of the main pitfalls of insertion is a controlled pleural entry. This study evaluates the efficacy of a novel training model with real-time pressure monitoring, the average force to pleural entry in a model and the utility of audio and visual feedback.

Methods

This proprietary training model comprised a modified Kelly clamp device with three force sensors at the index finger (sensor 1) and two finger loops (sensors 2 and 3), and a manikin with a replaceable chest wall pad. Standard force values (Newtons (N)) were obtained by experts; expert data revealed that 3-5 s was an acceptable time range to complete the chest tube insertion. Participant level ranged from Post-graduate Year (PGY)-1 to PGY-6 with 13 total participants. Each individual was provided an introduction to the procedure and chest tube trainer. Force (N) and time (ms) measurements were obtained from entry through dermis to pleural space puncture. A significant pressure drop suggested puncturing through the chest wall (completion of the procedure).

Results

Force data were captured during each phase of the procedure-linear, plateau, and drop. Linear phase (~3000 ms) was from start of procedure to point of maximum force (<30 N). Plateau phase was from maximum force to just before a drop in pressure. Drop phase was a drop in pressure by 5+ N in a span of 150 ms signaling completion of procedure. All participants were able to complete the task successfully. Force for pleural entry ranged from 17 N to 30 N; time to pleural entry ranged from 7500 to 15 000 ms. There was variability in use of all three sensors. All participants used the index sensor, however there was variability in the use of the loop sensors depending on the handedness of the participant. Left-handed users relied more on sensors 1 and 3 while right-handed users relied more on sensors 1 and 2. Given this variability, only force measurements from sensor 1 were used for assessment.

Conclusions

This novel force-sensing chest tube trainer with continuous pressuring monitoring has a wide range of applications in simulation-based training of emergency surgical tasks. Next steps include evaluating its impact on accuracy and efficiency. Applications of real-time feedback measuring force are broad, including vascular access, trocar placement and other common procedures.

Level of evidence

Level IV, prospective study.

Burn and Trauma Burden and Screening for Interpersonal Violence During the COVID-19 Pandemic

INTRODUCTION

Nationwide shelter-in-place (SIP) orders during the pandemic have had long-lasting effects, including increased rates of domestic violence and interpersonal violence. Screening for violence varies by institution, which tool is used, and when. Given increases in burn and trauma admissions over the course of the pandemic, we sought to examine trends at our institution during this time period to better guide care and anticipate system-level effects.

METHODS

We performed a retrospective cohort study of pediatric burn and adult burn and trauma patients at our level 1 trauma/burn center between March-May 2019 and March-May 2020. Home safety screening was performed by nursing staff using a 1-part screening questionnaire. Patients presenting before March 15, 2020, were defined as "pre-SIP; " between March 16-May 19, 2020, were "during SIP; " and those after May 19, 2020, were designated as "post-SIP." Descriptive and chi-square statistics were used. Demographic, injury patterns, and screening information were collected.

RESULTS

Blunt trauma comprised 60% of injuries, followed by burns (30%) then penetrating injury (7%). Over the entire time period analyzed, 1822 patients had documented home safety screening; ∼2% of patients screened reported a safety concern pre-SIP, compared to 3% of patients during SIP. There were higher rates of burns and penetrating injury during SIP compared to other periods (P ≤ 0.0001). Home safety screening rates were 94%-95% pre- and during SIP, but dropped to 85% post-SIP (P < 0.0001). Home safety concerns were reported almost 2% of the time pre-SIP and 3% during SIP (P = 0.016).

CONCLUSIONS

We noted an increase in trauma and burns during and after SIP orders, consistent with the experiences of other institutions. Implementation of a nurse-driven screening process demonstrated high compliance with appropriate referrals. The burden of burn and traumatic injury remains significant, highlighting a need for continued psychosocial screening and the provision of psychosocial support resources in the acute trauma setting.

The Distinction Between Social Connectedness and Support When Examining Depressive Symptoms Among Children and Adolescents During the COVID-19 Pandemic

Childhood depression is associated with significant social and functional impairment, suicide risk, and persistence throughout adulthood. Recent evidence demonstrates that social connectedness and social support may serve as protective factors against the development of depression. The current study aimed to examine the effect of change in social connectedness and social support on depressive symptoms among children and adolescents during the COVID-19 pandemic. Hierarchical regression was performed. Results indicated that parent-reported measures of change in social connectedness were inversely associated with depressive symptom severity, and could significantly predict future depressive symptom severity. In contrast, parent-reported measures of social support (i.e., from family and friends) did not significantly predict future depressive symptom severity. The presence of a pre-COVID psychiatric and/or neurodevelopmental diagnosis and baseline depressive symptom severity were also important factors associated with future depressive symptom severity. The findings suggest that an awareness of the presence of social supports (i.e., family or friends) is not sufficient for children to feel connected, but rather the mechanisms of social relationships are crucial. As our approach to public health restrictions evolves, the risk transmission of COVID-19 should be carefully balanced with the risks associated with decreased connectedness among youth.

Parkland Trauma Index of Mortality in Orthopaedic Trauma Patients: An Initial Report

OBJECTIVES

The extent and timing of surgery in severely injured patients remains an unsolved problem in orthopaedic trauma. Different laboratory values or scores have been used to try to predict mortality and estimate physiological reserve. The Parkland Trauma Index of Mortality (PTIM) has been validated as an electronic medical record-integrated algorithm to help with operative timing in trauma patients. The aim of this study was to report our initial experience with PTIM and how it relates to other scores.

METHODS

A retrospective chart review of level 1 and level 2 trauma patients admitted to our institution between December 2020 and November 2022 was conducted. Patients scored with PTIM with orthopaedic injuries were included in this study. Exclusion criteria were patients younger than 18 years.

RESULTS

Seven hundred seventy-four patients (246 female patients) with a median age of 40.5 (18-101) were included. Mortality was 3.1%. Patients in the PTIM high-risk category (≥0.5) had a 20% mortality rate. The median PTIM was 0.075 (0-0.89) and the median Injury Severity Score (ISS) was 9.0 (1-59). PTIM (P < 0.001) and ISS (P < 0.001) were significantly lower in surviving patients. PTIM was mentioned in 7.6% of cases, and in 1.7% of cases, providers indicated an action in response to the PTIM. PTIM and ISS were significantly higher in patients with documented PTIM.

CONCLUSION

PTIM is better at predicting mortality compared with ISS. Our low rate of PTIM documentation in provider notes highlights the challenges of implementing a new algorithm.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Primary Total Shoulder Arthroplasty is Superior to Hemiarthroplasty for the Treatment of Glenohumeral Arthritis: Analysis of 5-year Outcomes in a Large Surgical Database

Background

Total shoulder arthroplasty (TSA) is the preferred treatment for glenohumeral arthritis refractory to nonoperative measures. However, some surgeons have argued for a role for hemiarthroplasty (HA) in the setting of a smooth glenoid that articulates appropriately with the humeral head. The purpose of this study is to evaluate long-term revision rates and short-term postoperative complications in patients undergoing either HA or TSA for glenohumeral arthritis.

Methods

A retrospective review of patients who underwent HA and TSA was conducted using a commercially available national database. Demographics, postoperative complications, risk factors, revision rates, and costs were analyzed using 2 sample t-tests, chi-squared tests, and multivariate logistic regressions.

Results

Patients were stratified by operation: (1) HA (n = 1615) or 2) TSA (n = 7845). Patients undergoing primary TSA had higher rates of prior ipsilateral rotator cuff repair and corticosteroid injections. At 2 years, patients who underwent HA, 3.0% of patients had revision surgery, compared to 1.6% of patients who underwent TSA (P = .002); at 5 years, 3.7% of the HA cohort (P < .0001) had revision surgery, compared to 1.9% of patients who underwent TSA.

Conclusions

Patients undergoing TSA or RTSA for glenohumeral arthritis had higher preoperative co-morbidities but had no difference in short-term complication rates with a lower risk of revision surgery at both 2-year and 5-year follow-up when compared to HA. Increasing age, female sex, hyperlipidemia, postoperative infection, shoulder instability, and thromboembolism all independently increased odds for revision shoulder arthroplasty for glenohumeral arthritis.

Level of evidence Level

III.

Early administration of high dose enoxaparin after traumatic brain injury

BACKGROUND

Early enoxaparin 30 mg BID administration at 24 h post-injury has been demonstrated in patients with traumatic brain injury (TBI). However this dose can also yield subtherapeutic anti-Xa levels in 30-50% of trauma patients, suggesting that larger doses may be required for adequate prophylaxis against venous thromboembolism (VTE). The safety of enoxaparin 40 mg BID in trauma patients has previously been shown - however, these studies have largely excluded TBI patients. Therefore, we sought to demonstrate the safety of early enoxaparin 40 mg BID in a low-risk group of TBI patients.

METHODS

A retrospective review of TBI patients at a Level 1 trauma center was performed. Patients with stable computed tomography (CT) of the head at 6 to 24 h post-injury who received enoxaparin 40 mg BID were included and serial GCS evaluations to identify possible clinical complications. To evaluate the safety of this dosing regimen, data was then compared to patients from our institution with similar TBI profiles who had received 5,000 units (U) of subcutaneous heparin (SQH) prophylaxis.

RESULTS

199 TBI patients were identified over a nine month period, 40/199 (19.7%) received DVT prophylaxis after traumatic injury. Of these 40, 19 (47.5%) received enoxaparin 40 mg BID and 21 (52.5%) received 5,000U of SQH. Low risk TBI patients who were either given enoxaparin (n = 7) or SQH (n = 4), demonstrated no clinical decline in mental status during their inpatient stay.

CONCLUSION

Prior studies have demonstrated that enoxaparin 40 mg BID dosing is superior to traditional VTE prophylaxis in trauma patients. However, TBI patients are often excluded from this dosing due to concern for progression. Our study showed no clinical decline in mental status in a small cohort of low-risk TBI patients who received enoxaparin 40 mg BID.

Balloons on the battlefield: REBOA implementation in the UK Defence Medical Services

Established in 2018, the Defence Endovascular Resuscitation (DefER) group recognised that resuscitative endovascular balloon occlusion of the aorta (REBOA) offered an option to improve survival in battle casualties dying from haemorrhage, particularly in remote and austere surgical settings. Following a successful jHub opportunity assessment, DefER purchased training and operational kit at pace. By 1 April 2019, the first forward surgical group undertook a bespoke endovascular training and assessment package. Results of the pilot were presented back to a jHub 4* Innovation Board, which initially awarded £500 000 to fund the project to full implementation. Med Op Cap provided a solution to establish REBOA as a core capability on to the 370 modules. REBOA catheters and arterial access kit are now available to deployed Role 2 facilities across defence as an adjunct to damage control resuscitation in specific circumstances. REBOA has, from a standing start, gained pan-Defence Medical Services (DMS) endorsement and has been integrated into deployed damage control resuscitation. To establish a new resuscitation capability across all Role 2 platforms within 15 months of inception represents implementation at pace. This agility was unlocked by empowering clinicians to develop the platform in conjunction with commercial procurement. This article describes how this innovative pathway facilitated the rapid introduction of a lifesaving haemorrhage control technique to equip DMS clinicians.

Defence Medical Services' REBOA training course

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors' perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation.

ECMO simulation: How much, who to train, and a review of cost, fidelity and performance

BACKGROUND

Extracorporeal Membrane Oxygenation (ECMO) is a high-risk, low-volume procedure requiring repetition, skill and multiple disciplines with fidelity of communication. Yet many barriers exist to maintain proficiency and skills with variable cost and fidelity. We designed and implemented a low-cost monthly ECMO simulation and hypothesized providers would have increased familiarity and improved teamwork. We also review some key elements of cost, fidelity and evaluation of effectiveness.

METHODS

A structured, 1-hour ECMO simulation was performed on a customized mannikin on a monthly basis in 2022. Qualitative surveys were administered to each member post-simulation. Answers were categorized by theme, including satisfaction of patient care, evaluation of self and team dynamics, and areas for improvement.

RESULTS

Most participants were satisfied with their ability to take care of the patient, with common themes of communication and coordination of roles. Identified areas of improvement were mostly limited to technical skills, and soft skills such as communication and teamwork.

CONCLUSIONS

We designed and implemented a low-cost, monthly and multi-disciplinary ECMO simulation program with overall positive feedback and identified areas for improvement. There remains variability in cost, fidelity and evaluation of performance and retention. There may be a need to create guidelines for ECMO simulation training that can be applied at all institutions utilizing ECMO for patient care.

Relationship between impaired myocardial blood flow by positron emission tomography and low-attenuation plaque burden and pericoronary adipose tissue attenuation from coronary computed tomography: From the prospective PACIFIC trial

BACKGROUND

Positron emission tomography (PET) is the clinical gold standard for quantifying myocardial blood flow (MBF). Pericoronary adipose tissue (PCAT) attenuation may detect vascular inflammation indirectly. We examined the relationship between MBF by PET and plaque burden and PCAT on coronary CT angiography (CCTA).

METHODS

This post hoc analysis of the PACIFIC trial included 208 patients with suspected coronary artery disease (CAD) who underwent [15O]H2O PET and CCTA. Low-attenuation plaque (LAP, < 30HU), non-calcified plaque (NCP), and PCAT attenuation were measured by CCTA.

RESULTS

In 582 vessels, 211 (36.3%) had impaired per-vessel hyperemic MBF (≤ 2.30 mL/min/g). In multivariable analysis, LAP burden was independently and consistently associated with impaired hyperemic MBF (P = 0.016); over NCP burden (P = 0.997). Addition of LAP burden improved predictive performance for impaired hyperemic MBF from a model with CAD severity and calcified plaque burden (P < 0.001). There was no correlation between PCAT attenuation and hyperemic MBF (r = - 0.11), and PCAT attenuation was not associated with impaired hyperemic MBF in univariable or multivariable analysis of all vessels (P > 0.1).

CONCLUSION

In patients with stable CAD, LAP burden was independently associated with impaired hyperemic MBF and a stronger predictor of impaired hyperemic MBF than NCP burden. There was no association between PCAT attenuation and hyperemic MBF.

A Call for Formalized Training of Surgical Educators

Current training curricula for future surgeons do not prioritize teaching residents how to teach. With increased expectations but decreased opportunities to operate, developing efficient and effective educators is a pressing necessity. In this article, we discuss the need to formalize the role of the surgical educator, and future directions to implement better training paradigms for surgical educators.

First Observation of the β3αp Decay of ^{13}O via β-Delayed Charged-Particle Spectroscopy

The β-delayed proton decay of ^{13}O has previously been studied, but the direct observation of β-delayed 3αp decay has not been reported. Rare 3αp events from the decay of excited states in ^{13}N^{⋆} provide a sensitive probe of cluster configurations in ^{13}N. To measure the low-energy products following β-delayed 3αp decay, the Texas Active Target (TexAT) time projection chamber was employed using the one-at-a-time β-delayed charged-particle spectroscopy technique at the Cyclotron Institute, Texas A&M University. A total of 1.9×10^{5} ^{13}O implantations were made inside the TexAT time projection chamber. A total of 149 3αp events were observed, yielding a β-delayed 3αp branching ratio of 0.078(6)%. Four previously unknown α-decaying excited states were observed in ^{13}N at 11.3, 12.4, 13.1, and 13.7 MeV decaying via the 3α+p channel.

Immunotherapy for keratinocyte cancers. Part I: Immune-related epidemiology, risk factors, pathogenesis, and immunotherapy management of keratinocyte cancers

The important role of the immune system in the surveillance and control of keratinocyte cancers (KCs), namely squamous and basal cell carcinomas, is increasingly appreciated, as new immunotherapies have recently become available. As the field of immunotherapy is rapidly evolving, this review synthesizes key concepts and highlights important cellular components within the immune system responsible for attacking KCs. We review the most current data on the epidemiology, risk factors, and immunotherapy management for KCs. Patients will seek advice from dermatologists to help explain why immunotherapies work for KCs and whether they might be appropriate for different clinical scenarios. Collaboration with medical colleagues across different disciplines to evaluate KCs for response to immunotherapy and early recognition of immune-related adverse events will help to optimize patient outcomes.

Correlation of Ultraviolet Radiation Levels With the Incidence of Cutaneous Squamous Cell and Merkel Cell Carcinomas in Non-sunbelt Locales in the United States: 2010-2017

BACKGROUND

Non-melanoma skin cancer (NMSC) is the most common human malignancy worldwide, with increasing incidence in the United States (US). Recent environmental data have shown that ultraviolet radiation (UVR) levels have increased in the US, particularly in the higher latitudes, but the potential impact of this on NMSC incidence is not well known, despite estimates that 90% of NMSC is due to sun exposure. Our exploratory study synthesizes environmental data with demographic and clinical data to determine whether UV indices (UVIs) and non-sunbelt (non-SB) locale (latitudes >40 degrees, which comprises most of the US) might contribute to incidence rates of two types of NMSC: cutaneous squamous cell and Merkel cell carcinomas.

METHODS

UVIs from 2010 to 2017 were obtained from the National Oceanic and Atmospheric Administration database and meshed with corresponding locales in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database (version 8.4.0.1). Four SB and five NSB locales contained sufficient data for analysis. Linear mixed modeling was performed with the outcome variable of the age-adjusted incidence of NMSC cancer (comprised of cutaneous squamous cell carcinoma of the head and neck (CSCCHN) and Merkel cell carcinoma (MCC)), the two most common types of NMSC contained within SEER). Non-SB locale and percent of days with UVI >3 were independent variables.

RESULTS

Percent of days with UVI >3 increased during this period, as did the overall NMSC (combined CSCCHN and MCC) skin cancer incidence, though MCC incidence alone did not increase during our study period. Environmental factors that significantly contributed to the age-adjusted overall NMSC (combined CSCCHN and MCC) cancer incidence (per 100,000 individuals) included NSB locale (b=1.227, p=0.0019) and percent of days with UVIs >3 (b=0.028, p<0.0001), as well as clinical factors of percent white race and percent male, by linear mixed modeling.

CONCLUSIONS

Our results are limited by the completeness of the NOAA and SEER databases, and do not include basal cell carcinoma. Nevertheless, our data demonstrate that environmental factors, such as latitude in NSB locale and UVI indices, can affect the age-adjusted overall NMSC (defined as CSCCHN and MCC in this study) incidence even in this relatively short period of time. Prospective studies over longer time periods are needed to identify the extent to which these findings are clinically significant so that increased educational efforts to promote sun-safe behaviors can be maximally effective.

Artificial intelligence in cardiovascular imaging: enhancing image analysis and risk stratification

In this review, we summarize state-of-the-art artificial intelligence applications for non-invasive cardiovascular imaging modalities including CT, MRI, echocardiography, and nuclear myocardial perfusion imaging.

Under the Lens: Team Perception of Trauma Video Review

BACKGROUND

Video-based assessment and review are becoming increasingly common, and trauma video review (TVR) has been shown to be an effective educational, quality improvement, and research tool. Yet, trauma team perception of TVR remains incompletely understood.

OBJECTIVE

We evaluated positive and negative perceptions of TVR across multiple team member groups. We hypothesized that members of the trauma team would find TVR educational and that anxiety would be low across all groups.

METHODS

An anonymous electronic survey was provided to nurses, trainees, and faculty during weekly multidisciplinary trauma performance improvement conference following each TVR activity. Surveys assessed perception of performance improvement and anxiety or apprehension (Likert scale: 1 "strongly disagree" to 5 "strongly agree"). We report individual and normalized cumulative scores (average of responses for each positive [n = 6] and negative [n = 4] question stem).

RESULTS

We analyzed 146 surveys over 8 months, with 100% completion rate. Respondents were trainees (58%), faculty (29%), and nurses (13%). Of the trainees, 73% were postgraduate year (PGY) 1-3 and 27% were PGY 4-9. Of all respondents, 84% had participated previously in a TVR conference. Respondents reported an improved perception of resuscitation education quality and personal leadership skills development. Participants found TVR to be more educational than punitive overall. Analysis of team member types showed lower scores for faculty for all positive stemmed questions. Trainees were more likely to agree with negative stemmed questions if they were a lower PGY, and nurses were least likely to agree with negative stemmed questions.

CONCLUSIONS

TVR improves trauma resuscitation education in a conference setting, with trainees and nurses reporting the greatest benefit. Nurses were noted to be the least apprehensive about TVR.

Correlation between improved leptin signaling and cognitive function post bariatric surgery

Determining whether changes in leptin signaling plays a role in the improvement of cognitive function post-bariatric surgery may aid in the understanding and development of novel therapeutic approaches targeting cognitive dysfunction through the greater understanding of processes connecting obesity and brain health. Several studies have explored the effects of cognition post bariatric surgery, and others have studied leptin and its changes post surgery. However the amalgamation of the effects of leptin signaling in relation to cognition post bariatric surgery have yet to be considered as key tools in the understanding of cognitive dysfunction in obese subjects with leptin resistance or insensitivity. This review serves to highlight the potential correlations, to further elucidate the effect of improved leptin signaling on cognition post bariatric surgery, and to propose a direct cause for the improvement of cognitive function via the amelioration of the leptin Janus kinase/Signal transducer and activator of transcription (JAK/STAT) signaling pathway as a result of the reversal of inflammatory processes involved in diseased individuals.

Ten second triage: A novel and pragmatic approach to major incident triage

Triage is a key principle in the effective management of major incidents and has traditionally been performed using an assessment of a casualty's physiology. However, it has become apparent from recent experiences of major incidents that physiological triage may practically not be possible, especially in the early stages of an incident. A key factor is the speed with which it is possible to perform triage, and subsequently, the speed at which key life-saving interventions (e.g., management of external haemorrhage and airway opening manoeuvres) are able to be performed simultaneously as part of the triage process. Addressing this issue was a priority for the review of major incident triage undertaken by NHS England and culminated in the development of the Ten Second Triage (TST) tool.

Sex differences in computed tomography angiography-derived coronary plaque burden in relation to invasive fractional flow reserve

BACKGROUND

Distinct sex-related differences exist in coronary artery plaque burden and distribution. We aimed to explore sex differences in quantitative plaque burden by coronary CT angiography (CCTA) in relation to ischemia by invasive fractional flow reserve (FFR).

METHODS

This post-hoc analysis of the PACIFIC trial included 581 vessels in 203 patients (mean age 58.1 ​± ​8.7 years, 63.5% male) who underwent CCTA and per-vessel invasive FFR. Quantitative assessment of total, calcified, non-calcified, and low-density non-calcified plaque burden were performed using semiautomated software. Significant ischemia was defined as invasive FFR ≤0.8.

RESULTS

The per-vessel frequency of ischemia was higher in men than women (33.5% vs. 7.5%, p ​< ​0.001). Women had a smaller burden of all plaque subtypes (all p ​< ​0.01). There was no sex difference on total, calcified, or non-calcified plaque burdens in vessels with ischemia; only low-density non-calcified plaque burden was significantly lower in women (beta: -0.183, p ​= ​0.035). The burdens of all plaque subtypes were independently associated with ischemia in both men and women (For total plaque burden (5% increase): Men, OR: 1.15, 95%CI: 1.06-1.24, p ​= ​0.001; Women, OR: 1.96, 95%CI: 1.11-3.46, p ​= ​0.02). No significant interaction existed between sex and total plaque burden for predicting ischemia (interaction p ​= ​0.108). The addition of quantitative plaque burdens to stenosis severity and adverse plaque characteristics improved the discrimination of ischemia in both men and women.

CONCLUSIONS

In symptomatic patients with suspected CAD, women have a lower CCTA-derived burden of all plaque subtypes compared to men. Quantitative plaque burden provides independent and incremental predictive value for ischemia, irrespective of sex.

Changes in insulin resistance following antidepressant treatment mediate response in major depressive disorder

BACKGROUND

Insulin resistance (IR) is a potential predictor of antidepressant treatment response.

AIMS

We assess changes in IR after antidepressant treatment and whether these changes have any effect on treatment response. Also, to see whether changes in IR mediates relationship between C-reactive protein (CRP) and antidepressant efficacy.

METHODS

This is a secondary analysis of an 8-week, open-label clinical trial with 95 adults experiencing a major depressive episode. Response to vortioxetine was measured using the Montgomery-Åsberg Depression Rating Scale (MADRS). Generalized estimating equation models were utilized for this intent-to-treat analysis.

RESULTS

When adjusted for age, sex, and body mass index, there was a significant increase in IR following treatment in the overall sample (p = 0.035). This finding was detected in treatment non-responders (p = 0.019), whereas it was not observed in responders (p = 0.329). Mediation analysis revealed that change in IR during treatment was responsible for change in MADRS as well as the relationship between baseline CRP and treatment response.

CONCLUSIONS

Exacerbation of IR during antidepressant treatment mediated non-response. Conversely in treatment responders IR reduced. Like previous studies, baseline CRP moderated treatment response. This relationship was also mediated by changes in IR. These findings further elucidate the role of IR in terms of antidepressant response as well as potentially explain inflammation's relationship with the latter.

OS08.6.A Novel role of ARF4-mediated retrograde trafficking as a driver of chemoresistance in GBM

Background

Glioblastoma (GBM) is the most common type of adult malignant brain tumor, with a median survival of only 21 months. This is partly due to the high rate of resistance to conventional therapy, including temozolomide (TMZ), leading to recurrence rates close to 100%. To identify the unknown genes driving the development of this resistance, we performed a genome-wide CRISPR knockout screen comparing a DMSO-treated population with a TMZ-treated population over 14 days. Results showed substantial enrichment of ~200 novel genes, including a previously unstudied gene ARF4—involved in retrograde trafficking to the nucleus. Here, we set out to characterize the mechanism by which ARF4 may be acting to promote chemoresistance.

Material and Methods

A whole-genome CRISPR-Cas9 sensitivity screen as well as a variety of in vitro and in vivo experiments, such as live-cell imaging, cell viability assays, and western blotting were conducted.

Results

Initial investigation into ARF4 showed significant elevations in expression at RNA and protein levels (p&lt;0.05) in recurrent patient tumors, as well as a significant survival benefit in patient datasets when downregulated (p&lt;0.05). Knocking out ARF4 resulted in significantly heightened sensitivity to TMZ in multiple GBM patient-derived xenograft lines and extended survival compared to the controls (p&lt;0.01) in vivo. Further investigation via live-cell imaging of transferrin receptors, a retrograde transport marker, revealed that ARF4-knockdowns significantly inhibited retrograde trafficking, while ARF4-overexpressions resulted in an untenable increase in retrograde trafficking in vitro. This effect was also seen in TMZ-treated cells, which displayed enhanced trafficking dynamics, suggesting that ARF4-mediated retrograde trafficking is elevated during therapy to drive nuclear localization of key chemoresistance-promoting factors. We then performed an unbiased proteomics screen to identify which genes were being uniquely transported to the nucleus as a product of ARF4-mediated retrograde trafficking, which revealed enrichment of the EGFR signaling pathway in particular. Validation experiments confirmed a decrease in EGFR trafficking and nuclear EGFR expression in ARF4-knockdowns and an increase in EGFR trafficking and nuclear EGFR expression in ARF4-overexpression and TMZ-treated GBM cells. Furthermore, nuclear DNA-PK, a DNA repair protein known to be transcriptionally activated by EGFR, was similarly found to be downregulated in ARF4-knockdown conditions and elevated in ARF4-overexpression and TMZ-treated conditions.

Conclusion: Here, we show that ARF4 may be responsible for promoting chemoresistance through altered retrograde trafficking of EGFR specifically. Thus, our study has yielded a promising and novel therapeutic target for GBM, a disease desperately in need of new therapeutic strategies.

P02.01.B The telomere maintenance mechanism spectrum and its dynamics in gliomas

The activation of the telomere maintenance mechanism (TMM) is one of the critical drivers of cancer cell immortality. In gliomas, TERT expression and TERT promoter mutation are considered to reliably indicate telomerase activation, while ATRX mutation indicates alternative lengthening of telomeres (ALT). However, these relationships have not been extensively validated in tumor tissues. Here, we show through the direct measurement of telomerase activity and ALT in a large set of glioma samples that the TMM in glioma cannot be defined in the dichotomy of telomerase activity and ALT, regardless of TERT expression, TERT promoter mutation and ATRX mutation. Moreover, we observed that a considerable proportion of gliomas lack both telomerase activity and ALT (Neither group). And this Neither group exhibited evidence of slow growth potential. From a set of longitudinal samples from a separate cohort of glioma patients, we discovered that the TMM is not fixed but changes with glioma progression. Collectively, these results suggest that the TMM is a dynamic entity and that reflects the plasticity of the oncogenic biological status of tumor cells and that the TMM should be defined by the direct measurement of telomerase enzyme activity and evidence of ALT.

Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury

Importance

Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.

Objective

To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury.

Design, Setting, and Participants

A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation.

Intervention

The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team.

Main Outcomes and Measures

The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.

Results

Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P < .001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P = .03).

Conclusions and Relevance

In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.

Vitronectin-Derived Peptide Promotes Reparative Dentin Formation

Exposed dental pulp can maintain its vitality through a pulp-capping procedure with biocompatible materials, followed by reparative dentin formation. Our previous study demonstrated that a vitronectin-derived peptide (VnP-16) promotes osteoblast differentiation and concomitantly restrains osteoclast differentiation and resorptive function. In this study, we aimed to demonstrate that VnP-16 promotes odontoblast differentiation, mineralization, and reparative dentin formation in a pulp exposure model using a rat tooth. VnP-16 showed no cytotoxicity and promoted cellular behavior in human dental pulp cells, enhancing their differentiation into odontoblast-like cells and mineralization, effects that are comparable to those obtained with vitronectin. In a rat pulp exposure model, VnP-16 showed mild inflammatory responses at 2 and 4 wk or none. Mineral trioxide aggregate (MTA) demonstrated a tendency of early formation of reparative dentin at 2 wk when compared with recombinant human bone morphogenetic protein 2 (rhBMP-2) and VnP-16. However, VnP-16 induced reparative dentin formation similar to MTA and rhBMP-2 without inflammation at 4 wk. In addition, VnP-16 showed a thicker and homogeneous reparative dentin formation versus MTA and rhBMP-2. Collectively, these results suggest that VnP-16 can be a useful, direct pulp-capping agent for highly qualified reparative dentin formation by promoting cell behavior and odontoblastic differentiation of human dental pulp cells.

Parkland Trauma Index of Mortality: Real-Time Predictive Model for Trauma Patients

OBJECTIVE

Vital signs and laboratory values are used to guide decisions to use damage control techniques in lieu of early definitive fracture fixation. Previous models attempted to predict mortality risk but have limited utility. There is a need for a dynamic model that captures evolving physiologic changes during a trauma patient's hospital course.

METHODS

The Parkland Trauma Index of Mortality (PTIM) is a machine learning algorithm that uses electronic medical record data to predict mortality within 48 hours during the first 3 days of hospitalization. It updates every hour, recalculating as physiology changes. The model was developed using 1935 trauma patient encounters from 2009 to 2014 and validated on 516 patient encounters from 2015 to 2016. Model performance was evaluated statistically. Data were collected retrospectively on its performance after 1 year of clinical use.

RESULTS

In the validation data set, PTIM accurately predicted 52 of the sixty-three 12-hour time intervals within 48 hours of mortality, for sensitivity of 82.5% [95% confidence interval (CI), 73.1%-91.9%]. The specificity was 93.6% (95% CI, 92.5%-94.8%), and the positive predictive value (PPV) was 32.5% (95% CI, 25.2%-39.7%). PTIM predicted survival for 1608 time intervals and was incorrect only 11 times, yielding a negative predictive value of 99.3% (95% CI, 98.9%-99.7%). The area under the curve of the receiver operating characteristic curve was 0.94.During the first year of clinical use, when used in 776 patients, the last PTIM score accurately predicted 20 of the twenty-three 12-hour time intervals within 48 hours of mortality, for sensitivity of 86.9% (95% CI, 73%-100%). The specificity was 94.7% (95% CI, 93%-96%), and the positive predictive value was 33.3% (95% CI, 21.4%-45%). The model predicted survival for 716 time intervals and was incorrect 3 times, yielding a negative predictive value of 99.6% (95% CI, 99.1%-100%). The area under the curve of the receiver operating characteristic curve was 0.97.

CONCLUSIONS

By adapting with the patient's physiologic response to trauma and relying on electronic medical record data alone, the PTIM overcomes many of the limitations of previous models. It may help inform decision-making for trauma patients early in their hospitalization.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

A shared decision-making communications workshop improves internal medicine resident skill, risk-benefit education, and counseling attitude

OBJECTIVE

We assessed the impact of a workshop on first-year medicine residents (PGY1) shared decision-making (SDM) communication skill, risk-benefit education, and attitude.

METHODS

A SDM skills-focused workshop was integrated into an academic medical center PGY1 ambulatory rotation in 2016-2017. Pre/post recordings of virtual Objective Structured Clinical Examinations (OSCEs) with standardized patients sharing decisions were scored using OPTION5. Risk-benefit education, including decision aid use, was measured. Pre/post surveys assessed SDM practice attitudes and perceived barriers.

RESULTS

31 of 48 (65%) PGY1 workshop attendees completed pre/post OSCEs yielding 62 videos. OPTION5 scores improved from 27/100 pre to 56/100 post (p < 0.001). Pre/post increases in integration of qualitative (15/31 vs 31/31, p < 0.001) and quantitative (3/31 vs 31/31, p < 0.001) risk measures, and decision aids (1/3 vs 31/31, p < 0.001) were observed. Pro-SDM attitude of decisional neutrality increased 16.6% pre to 71.9% post-survey (P < 0.001). Barriers to SDM remain.

CONCLUSION

This PGY1 workshop with virtual OSCEs improved SDM communication skills, the ability to find and provide risk-benefit education, and SDM-facilitating attitude.

PRACTICE IMPLICATIONS

Residency programs can improve SDM skills, risk-benefit education, and attitudes with a workshop intervention. Perceived time constraints and cognitive biases regarding risk-benefit estimates should be addressed to ensure quality SDM in practice.

Deep learning-enabled coronary CT angiography for plaque and stenosis quantification and cardiac risk prediction: an international multicentre study

BACKGROUND

Atherosclerotic plaque quantification from coronary CT angiography (CCTA) enables accurate assessment of coronary artery disease burden and prognosis. We sought to develop and validate a deep learning system for CCTA-derived measures of plaque volume and stenosis severity.

METHODS

This international, multicentre study included nine cohorts of patients undergoing CCTA at 11 sites, who were assigned into training and test sets. Data were retrospectively collected on patients with a wide range of clinical presentations of coronary artery disease who underwent CCTA between Nov 18, 2010, and Jan 25, 2019. A novel deep learning convolutional neural network was trained to segment coronary plaque in 921 patients (5045 lesions). The deep learning network was then applied to an independent test set, which included an external validation cohort of 175 patients (1081 lesions) and 50 patients (84 lesions) assessed by intravascular ultrasound within 1 month of CCTA. We evaluated the prognostic value of deep learning-based plaque measurements for fatal or non-fatal myocardial infarction (our primary outcome) in 1611 patients from the prospective SCOT-HEART trial, assessed as dichotomous variables using multivariable Cox regression analysis, with adjustment for the ASSIGN clinical risk score.

FINDINGS

In the overall test set, there was excellent or good agreement, respectively, between deep learning and expert reader measurements of total plaque volume (intraclass correlation coefficient [ICC] 0·964) and percent diameter stenosis (ICC 0·879; both p<0·0001). When compared with intravascular ultrasound, there was excellent agreement for deep learning total plaque volume (ICC 0·949) and minimal luminal area (ICC 0·904). The mean per-patient deep learning plaque analysis time was 5·65 s (SD 1·87) versus 25·66 min (6·79) taken by experts. Over a median follow-up of 4·7 years (IQR 4·0-5·7), myocardial infarction occurred in 41 (2·5%) of 1611 patients from the SCOT-HEART trial. A deep learning-based total plaque volume of 238·5 mm3 or higher was associated with an increased risk of myocardial infarction (hazard ratio [HR] 5·36, 95% CI 1·70-16·86; p=0·0042) after adjustment for the presence of deep learning-based obstructive stenosis (HR 2·49, 1·07-5·50; p=0·0089) and the ASSIGN clinical risk score (HR 1·01, 0·99-1·04; p=0·35).

INTERPRETATION

Our novel, externally validated deep learning system provides rapid measurements of plaque volume and stenosis severity from CCTA that agree closely with expert readers and intravascular ultrasound, and could have prognostic value for future myocardial infarction.

FUNDING

National Heart, Lung, and Blood Institute and the Miriam & Sheldon G Adelson Medical Research Foundation.

533 Human Case Characterizations of Skin Burn Using Novel Multi-Spectral Short Wave Infrared Imaging

Introduction

Determining the depth of skin burns in patients is critical for surgical decision making, but currently lacks accuracy in clinical practice. Short-wave infrared (SWIR) light penetrates tissue more than visual or near-infrared light and is very sensitive to water content. We have shown in animal models that imaging of skin burns in the SWIR range distinguishes between superficial and deep tissue necrosis. Here we present the first 2 cases of multi-spectral SWIR imaging of human burn injury as a first step toward a non-invasive, label-free, technique for burn depth determination.

Methods

Two subjects admitted for mixed depth, thermal, 6% and 7% total body surface area (TBSA), burns were studied. Prior to burn excision, a novel system, based on a specialized camera, imaged the burn areas and normal skin at 4 different SWIR bands. Standard photographs from imaged areas were collected and presented for 5 independent, blinded, surgeons’ assessments. In SWIR images, 3-5 regions of interest (ROIs) were selected in burned and adjacent normal skin and the reflected light intensity in each ROI was averaged.

Results

Visual and SWIR images were collected for 9 burn areas in the hands, arms, and shoulder of 2 patients (Panel A). Fifty ROIs from the burn areas were assessed by the surgeons and 30 (60%) ROIs were agreed as being superficial or superficial partial thickness (n=5), deep partial thickness (n=11), or full thickness (n=14) burns by a majority (60% or above consensus together with a possible disagreement only between deep partial and full thickness burn). In Panel B the cumulative SWIR reflectance intensity at the 4 SWIR bands for the 3 burn groups, determined by expert surgeon evaluation, and normal skin are compared. The reflectance from superficial and superficial partial thickness burns (yellow) were 102.7±1.2%, 102.3±0.7% and 103.4±1.4% of the normal skin reflectance for 1200, 1650 and 1940 nm, respectively. On the other hand, the reflectance from deep partial thickness burns (grey) were 96.7±0.1% and 94.7±0.1%, and for full thickness burn (red) were 96.1±1.4% and 93.7±1.6% of normal skin reflectance for 1650 and 1940 nm, respectively.

Conclusions

We present the first human SWIR study demonstrating a distinct reflectance intensity of SWIR wavelengths for different burn depths based on surgeon assessments. The results motivate further studies of SWIR imaging of burns in the hope to non-invasively and accurately identify operative versus non-operative burns.

Monthly Trauma Training and Simulation Are Associated With Improved Resident Skill and Leadership

BACKGROUND

Training for trauma procedures has been limited to infrequent courses with little data on longitudinal performance, and few address procedural and leadership skills with granular assessment. We implemented a novel training program that emphasized an assessment of trauma resuscitation and procedural skills.

OBJECTIVE

This study aimed to determine whether this program could demonstrate improvement in both skill sets in surgical trainees over time.

METHODS

This was a prospective, observational study at a Level I trauma center between November 2018 and May 2019. A procedural skill and simulation program was implemented to train and evaluate postgraduate year (PGY) 1-5 residents. All residents participated in an initial course on procedures such as tube thoracostomy and vascular access, followed by a final evaluation. Skills were assessed by the Likert scale (1-5, 5 noting mastery). PGY 3s and above were additionally evaluated on resuscitation. A paired t test was performed on repeat learners.

RESULTS

A total of 40 residents participated in the structured procedural skills and simulation program. Following completion of the program, PGY-2 scores increased from a Mdn [interquartile range, IQR] 3.0 [2.5-4.0] to 4.5 [4.2-4.5]. The PGY-3 scores increased from a Mdn [IQR] 3.95 [3.7-4.6] to 4.8 [4.6-5.0]. Eighteen residents underwent repeat simulation training, with Mdn [IQR] score increases in PGY 2s (3.7 [2.5-4.0] to end score 4.47 [4.0-4.5], p = .03) and PGY 3s (3.95 [3.7-4.6] to end score 4.81 [4.68-5.0], p = .04). Specific procedural and leadership skills also increased over time.

Development of a high-resolution typing method for SLA-3, swine MHC class I antigen 3

We developed a high-resolution and comprehensive typing method for swine leukocyte antigen 3 (SLA-3), an MHC class I gene, employing locus-specific genomic PCR followed by subsequent direct sequencing. A total of 292 individuals from nine pure, one cross-breed and six cell lines were successfully typed. A total of 21 SLA-3 alleles were identified, of which four were found to be novel alleles. However, the allelic diversity of SLA-3 was lower than that of previously reported class I genes, SLA-1 and -2. More SLA-3 alleles were observed in the Landrace and Yorkshire breeds than the other breeds. SLA-3*04:01 was identified in seven out of nine breeds and was the most widely distributed allele across all breeds. Therefore, the typing method reported in this study completes our efforts to develop high-resolution typing methods for major SLA molecules, facilitating the combined analysis of major SLA genes from field samples, which is important to understand the relationship between the adaptive immune responses against pathogens and the immunogenetic makeup of an individual.

Resuscitative endovascular balloon occlusion of the aorta: simulation improves performance but may require interval training to prevent skill degradation

PURPOSE

Surgical trainees are exposed to less procedures with increasing need for simulation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become increasingly implemented for hemorrhage control, yet most courses are catered to faculty level with little data on trainees. We propose that routine training in this critical procedure will improve trainee performance over time.

METHODS

This is a prospective, observational study at a level I trauma center involving a monthly trauma procedural program. Early in the month, trainees received hands-on REBOA training; at the end, trainees underwent standardized, class-based evaluation on a perfused trainer. Score percentages were recorded (0-100%). Endpoints included early, mid and late performance (2-12 months). Paired T-test and Pearson's coefficient were used to evaluate differences and strength of association between time between training and performance.

RESULTS

25 trainees participated with 5 and 11 repeat learners in the PGY-2 and PGY-3 classes, respectively. Median early performance score was 62.5% (IQR 56-81) for PGY-2s and 91.6% (IQR 75-100) in PGY-3s. Pearson's coefficient between time between and training and score demonstrated a weak correlation in the PGY-2s (r² = - 0.13), but was more pronounced in the PGY-3s (r² = - 0.44) with an inflection point at 5 months.

CONCLUSIONS

Routine REBOA training in trainees is associated with improvement in performance within a short period of time. Skill degradation was most pronounced in trainees who did not receive training for more than 5 months. Trainees can be successfully trained in REBOA; however, this should be done at shorter intervals to prevent skill degradation.