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Buzzard L, Smith S, Dixon A, Kenny J, Appleman M, Subramanian S, Behrens B, Rick E, Madtson B, Goodman A, Murphy J, McCully B, Kanlerd A, Trivedi A, Pati S, Schreiber M. Principal component analysis of a swine injury model identifies multiple phenotypes in trauma. J Trauma Acute Care Surg 2024; 96:634-640. [PMID: 37599420 DOI: 10.1097/ta.0000000000004098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Trauma is the third leading cause of death in the United States and the primary cause of death for people between the ages of 1 year and 44 years. In addition to tissue damage, trauma may also activate an inflammatory state known as trauma-induced coagulopathy (TIC) that is associated with clotting malfunctions, acidemia, and end-organ dysfunction. Prior work has also demonstrated benefit to acknowledging the type and severity of endothelial injury, coagulation derangements, and systemic inflammation in the management of trauma patients. This study builds upon prior work by combining laboratory, metabolic, and clinical metrics into an analysis of trauma phenotypes, evolution of phenotypes over time after trauma, and significance of trauma phenotype on mortality. METHODS Seventy 3-month-old female Yorkshire crossbred swine were randomized to injury and resuscitation groups. Principal component analysis (PCA) of longitudinal swine TEG data (Reaction time, Alpha-Angle, Maximum Amplitude, and Clot Lysis at 30 minutes), pH, lactate, and MAP was completed in R at baseline, 1 hour postinjury, 3 hours postinjury, 6 hours postinjury, and 12 hours postinjury. Subjects were compared by principal component factor scores to assess differences in survival, injury severity, and treatment group. RESULTS Among injured animals, three phenotypes were observed at each time point. Five phenotypes were associated with differences in survival, and of these, four were associated with differences in injury severity. Phenotype alignment was not significantly different by treatment group. CONCLUSION This application of PCA to a set of coagulation, hemodynamic, and organ perfusion variables has identified multiple evolving phenotypes after trauma. Some of these phenotypes may correlate with injury severity and may have implications for survival. Next steps include validating these findings over greater numbers of subjects and exploring other machine-learning techniques for phenotype identification. LEVEL OF EVIDENCE Level IV, Therapeutic/Care Management.
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Affiliation(s)
- Lydia Buzzard
- From the Department of Surgery (L.B., J.K., M.A., E.R., B.M., A.G., J.M., B.M., A.K., M.S.), Oregon Health and Science University, Portland, Oregon; University of Wisconsin Madison School of Medicine and Public Health (L.M.B.), Madison, Wisconsin; Department of Surgery (S.M.), University of California-Davis, Davis, CA; Department of Surgery (A.D.), Harborview Medical Center, Seattle, Washington; Department of Surgery (S.S.), Texas Tech University Health Sciences Center, Lubbock, Texas; Department of Surgery (B.B.), University of New Mexico, Albuquerque, New Mexico; and Department of Pathology and Laboratory Medicine (A.T., S.P.), University of California-San Francisco, San Francisco, California
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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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Horst JA, Spinella PC, Leonard JC, Josephson CD, Leeper CM. Cryoprecipitate for the treatment of life-threatening hemorrhage in children. Transfusion 2023; 63 Suppl 3:S10-S17. [PMID: 37070338 PMCID: PMC10364587 DOI: 10.1111/trf.17340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Hypofibrinogenemia is an important risk factor for poor outcomes in children with severe bleeding. There is a paucity of data on the impact of cryoprecipitate transfusion on outcomes in pediatric patients with life-threatening hemorrhage (LTH). STUDY DESIGN AND METHODS This secondary analysis of a multicenter prospective observational study of children with LTH investigated subjects who were categorized by receipt of cryoprecipitate during their resuscitation and according to the etiology of their bleeding: trauma, operative, and medical. Bivariate analysis was performed to identify variables associated with 6-h, 24-h, and 28-day mortality. Cox Hazard regression models were generated to adjust for potential confounders. RESULTS Cryoprecipitate was transfused to 33.9% (152/449) of children during LTH. The median (Interquartile range) time to cryoprecipitate administration was 108 (47-212) minutes. Children in the cryoprecipitate group were younger, more often female, with higher BMI and pre-LTH PRISM score and lower platelet counts. After adjusting for PRISM score, bleeding etiology, age, sex, RBC volume, platelet volume, antifibrinolytic use and cardiac arrest, cryoprecipitate administration was independently associated with lower 6-h mortality, Hazard Ratio (95% CI), 0.41 (0.19-0.89), (p = 0.02) and 24-h mortality, Hazard Ratio (95% CI), 0.46 (0.24-0.89), (p = 0.02). CONCLUSION Cryoprecipitate transfusion to children with LTH was associated with reduced early mortality. A prospective randomized trial is needed to determine if cryoprecipitate can improve outcomes in children with LTH.
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Affiliation(s)
- Jennifer A Horst
- Department of Pediatrics, Washington University, St. Louis, Missouri, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julie C Leonard
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Cassandra D Josephson
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Christine M Leeper
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Tanner TE, Drapkin Z, Fino N, Russell K, Chaulk D, Hewes HA. Thromboelastography and Its Use in Pediatric Trauma Patients. Pediatr Emerg Care 2023; 39:e41-e47. [PMID: 36719393 DOI: 10.1097/pec.0000000000002642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/PURPOSE Thromboelastography's (TEG's) use in pediatric trauma patients is not widely studied. Identifying clotting cascade defects can direct decision making regarding blood product transfusion. METHODS We performed a single-center retrospective review of all level 1 pediatric trauma patients. Data collected included demographics, diagnoses, Injury Severity Score, intensive care unit length of stay (ICU LOS), mortality, TEG values, and blood products received. We identified TEG values associated with mortality, ICU LOS, and need for blood product transfusion. RESULTS A total of 237 trauma 1 patients were identified. After exclusions, 148 patients were included for analysis. Most patients were below TEG transfusion cut points. Patients with elevated reaction time, K value, and fibrinolysis at 30 minutes had increased odds of mortality with odds ratios of 1.71 (95% confidence interval [CI], 1.22-2.40), 1.94 (95% CI, 1.23-3.05), and 1.15 (95% CI, 1.03-1.28), respectively. For ICU LOS, elevated reaction time, K value, and fibrinolysis at 30 minutes, α angle, and maximum amplitude demonstrated hazard ratios of 0.76 (95% CI, 0.65-0.88), 0.82 (95% CI, 0.64-1.0), 0.95 (95% CI, 0.88-0.99), 1.05 (95% CI, 1.02-1.08), and 1.04 (95% CI, 1.01-1.06), respectively. There was no association between TEG and blood product transfusion. CONCLUSIONS Coagulopathic patients based on TEG had higher mortality. All TEG values, as they moved toward transfusion-trigger cut points, were associated with increased mortality.
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Affiliation(s)
- Thomas E Tanner
- From the Department of Pediatrics, Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, TX
| | | | - Nora Fino
- Department of Internal Medicine, University of Utah Health
| | - Katie Russell
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT
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Admission maximum amplitude-reaction time ratio: Association between thromboelastography values predicts poor outcome in injured children. J Trauma Acute Care Surg 2023; 94:212-219. [PMID: 36694332 DOI: 10.1097/ta.0000000000003834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Thromboelastography (TEG)-derived maximum amplitude-reaction time (MA-R) ratio that accounts for both hypocoagulable and hypercoagulable changes in coagulation is associated with poor outcomes in adults. The relationship between these TEG values and outcomes has not been studied in children. METHODS In a retrospective cohort study, a level I pediatric trauma center database was queried for children younger than 18 years who had a TEG assay on admission between 2016 and 2020. Demographics, injury characteristics, and admission TEG values were recorded. The MA-R ratio was calculated and divided into quartiles. Main outcomes included mortality, transfusion within 24 hours of admission, and thromboembolism. A logistic regression model was generated adjusting for age, Injury Severity Score, injury mechanism, admission shock, and Glasgow Coma Scale. RESULTS In total, 657 children were included, of which 70% were male and 75% had blunt mechanism injury. The median (interquartile range) age was 11 (4-14) years, the median (interquartile range) Injury Severity Score was10 (5-22), and in-hospital mortality was 7% (n = 45). Of these patients, 17% (n = 112) required transfusion. Most R and MA values were within normal limits. On unadjusted analysis, the lowest MA-R ratio quartile was associated with increased mortality (15% vs. 4%, 5%, and 4%, respectively; p < 0.001) and increased transfusion need (26% vs. 12%, 16%, and 13%, respectively; p = 0.002) compared with higher quartiles. In the logistic regression models, a low MA-R ratio was independently associated with increased in-hospital mortality (odds ratio [95% confidence interval], 4.4 [1.9-10.2]) and increased need for transfusion within 24 hours of admission (odds ratio [95% confidence interval], 2.0 [1.2-3.4]) compared with higher MA-R ratio. There was no association between MA-R ratio and venous thromboembolic events (venous thromboembolic event rate by quartile: 4%, 2%, 1%, and 3%). CONCLUSION Although individual admission TEG values are not commonly substantially deranged in injured children, the MA-R ratio is an independent predictor of poor outcome. Maximum amplitude-reaction time ratio may be a useful prognostic tool in pediatric trauma; validation is necessary. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Association of Thromboelastography with Progression of Hemorrhagic Injury in Children with Traumatic Brain Injury. Neurocrit Care 2022; 38:326-334. [PMID: 35896767 DOI: 10.1007/s12028-022-01562-8] [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: 04/18/2022] [Accepted: 06/16/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Progression of hemorrhagic injury (PHI) in children with traumatic brain injury portends poor outcomes. The association between thromboelastography (TEG), functional coagulation assays, and PHI is not well characterized in children. METHODS This was a retrospective cohort study of children presenting with PHI at a pediatric level I academic trauma center from 2015 to 2020. Inclusion criteria were as follows: age less than 18 years, intracranial hemorrhage on admission head computed tomography scan, and admission rapid TEG assay and conventional coagulation tests. PHI was defined by the following radiographic criteria: any expansion of or new intracranial hemorrhage on subsequent head computed tomography scan. Rapid TEG values included Activated Clotting Time (ACT), alpha angle, maximum amplitude, and lysis at 30 min. Wilcoxon rank-sum test was used to assess baseline differences between groups with PHI and without PHI, including laboratory assays. Univariate analysis was performed to examine the association between variables of interest and PHI. Patients were dichotomized on the basis of this cut point to generate a "low ACT" group and a "high ACT" group. These variables were included in a multivariable logistic regression model to determine independent association with traumatic brain injury progression. RESULTS In total, 219 patients met criteria for analysis. In this cohort, the median (interquartile range [IQR]) age = 6 (2-12) years, median (IQR) Injury Severity Score = 21 (11-27), 68% were boys, and 69% sustained blunt injury. The rate of PHI was 25% (54). Median (IQR) time to PHI was 1 (0-4) days. Children with PHI had a higher Injury Severity Score (p < 0.001), lower Glasgow Coma Scale (p < 0.001), greater incidence of shock (p = 0.04), and lower admission hemoglobin (p = 0.02) compared with those without PHI. Children with PHI had a higher International Normalized Ratio (INR) and longer TEG-ACT; other TEG values (alpha angle, maximum amplitude, and lysis at 30 min) were not associated with PHI. In the logistic regression model accounting for other covariates associated with PHI, elevated ACT remained an independent predictor of progression (odds ratio = 2.25, 95% confidence interval 1.09-4.66; p = 0.03; area under the receiver operating characteristic curve = 0.76). After adjusting for confounders, INR fell out of the model and was not an independent predictor of progression (odds ratio = 1.32, 95% confidence interval 0.60-2.93; p = 0.49). CONCLUSIONS Although INR was elevated in children with PHI and has been associated with poor clinical outcomes, only admission TEG-ACT was independently associated with PHI. Further study is warranted to determine whether TEG-ACT reflects an actionable therapeutic target.
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Prehospital Factors Predict Outcomes in Pediatric Trauma: A Principal Component Analysis. J Trauma Acute Care Surg 2022; 93:291-298. [PMID: 35546247 DOI: 10.1097/ta.0000000000003680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma team activation leveling decisions are complex and based on many variables. Accurate triage decisions improve patient safety and resource utilization. Our purpose was to establish proof-of-concept for using principal component analysis (PCA) to identify multivariate predictors of injury severity and to assess their ability to predict outcomes in pediatric trauma patients. We hypothesized that we could identify significant principal components (PCs) among variables used for decisions regarding trauma team activation and that PC scores would be predictive of outcomes in pediatric trauma. METHODS We conducted a retrospective review of the trauma registry (1/2014-12/2020) at our pediatric trauma center, including all pediatric patients (age < 18 y) who triggered a trauma team activation. Data included patient demographics, prehospital report, Injury Severity Score, and outcomes. Four significant principal components were identified using PCA. Differences in outcome variables between the highest and lowest quartile for PC score were examined. RESULTS 1090 pediatric patients were included. The 4 significant PCs accounted for >96% of the overall date variance. The first PC was a composite of prehospital Glasgow Coma Scale and Revised Trauma Score (RTS) and was predictive of outcomes, including injury severity, length of stay, and mortality. The second PC was characterized primarily by prehospital systolic blood pressure (SBP) and high PC scores were associated with increased length of stay. The third and fourth PCs were characterized by patient age and by prehospital RTS and SBP, respectively. CONCLUSIONS We demonstrate that, using information available at the time of trauma team activation, PCA can be used to identify key predictors of patient outcome. While the ultimate goal is to create a machine learning-based predictive tool to support and improve clinical decision making, this study serves as a crucial step toward developing a deep understanding of the features of the model and their behavior with actual clinical data. LEVEL OF EVIDENCE III; Diagnostic test.
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It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion. Pediatr Surg Int 2021; 37:1613-1620. [PMID: 34533617 PMCID: PMC8445780 DOI: 10.1007/s00383-021-04944-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death in pediatric trauma patients. In adults, goal-directed thrombelastography (TEG) has been shown to reduce mortality when used to guide massive transfusion (MT) resuscitation. There remains a paucity of data on the utility of TEG in directing resuscitation of pediatric trauma patients. We hypothesize that abnormalities on admission TEG will differ in pediatric trauma patients who undergo MT, compared to those who do not. METHODS Pediatric patients (≤ 18 years) who were highest level trauma activations at two trauma centers from 2015 to 2018 were analyzed. We included patients who had admission TEGs and excluded those who did not. Patients were stratified into two groups: those who received MT (> 40 cc/kg total blood product within 6 h of admission) and those who did not. We defined TEG abnormalities based on each institution's normative values and compared TEG abnormalities between the groups. RESULTS Of 117 children included, 39 had MT. MT patients had higher injury severity scores (30 vs. 23, p = 0.0004), lactates levels (7.0 vs. 3.5, p < 0.001), base deficit levels ( - 12.2 vs. - 5.8, p < 0.001), and INR values (1.8 vs. 1.3, p < 0.001). MT patients had significantly shortened alpha-angles (35.9% vs. 15.4%, p = 0.023), maximum amplitude (MA) values (43.6% vs. 10.3%, p < 0.001), and significantly lower platelet counts (165 vs. 281, p < 0.001) compared to those who did not receive MT. There was no difference in the trends in R-time, LY30 (lysis or shutdown), or fibrinogen concentration between the groups. Logistic regression identified a decreased MA as a significant predictor for MT [OR 3.68 (CI 1.29-10.52)] CONCLUSIONS: Pediatric trauma patients who undergo MT are more likely to have lower alpha-angles and MA values, as well as lower platelet counts. These findings support the use of TEG to identify hemorrhaging pediatric trauma patients, who may benefit from cryoprecipitate and/or platelet transfusions. TEG provides real-time information on coagulation status, which may expedite the delivery of specific blood products during trauma resuscitation. LEVEL OF EVIDENCE LEVEL III: Type of study: Retrospective comparative study.
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Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion 2021; 60 Suppl 6:S33-S51. [PMID: 33089933 DOI: 10.1111/trf.16074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy. STUDY DESIGN AND METHODS We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters. RESULTS Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM. CONCLUSIONS This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.
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Affiliation(s)
- Andrew C Sayce
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Lin ZM, Chen JF, Xu FT, Liu CM, Chen JS, Wang Y, Zhang C, Huang PT. Principal component regression-based contrast-enhanced ultrasound evaluation system for the management of BI-RADS US 4A breast masses: objective assistance for radiologists. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1737-1746. [PMID: 33838937 DOI: 10.1016/j.ultrasmedbio.2021.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 06/12/2023]
Abstract
A portion of detected breast masses might be overrated by using the Breast Imaging-Reporting and Data System ultrasonography (BI-RADS US) lexicon. A principal component regression-based contrast-enhanced ultrasound (PCR-CEUS) evaluation system was built to quantitatively illustrate whether CEUS could help radiologists to differentiate 4A masses. The PCR-CEUS evaluation system, based on principal component analysis (PCA) and logistic regression, was verified by random assignment into training and test sets and shown to reduce the data dimension and avoid collinearity in CEUS variables. This prospective study consecutively collected 238 patients with 238 4A masses confirmed pathologically. All enrolled patients accepted CEUS examination. The diagnostic performance of senior and junior radiologists, PCR-CEUS and combined methods was compared. The PCR-CEUS system had consistent diagnostic performance in both the training and test sets, with an area under the curve (AUC) of 0.831 (0.765-0.897), 0.798 (0.7034-0.892) and 0.854 (0.765-0.943) (all P > 0.05). The AUC of the combined diagnostic model (PCR-CEUS + Senior radiologists) was higher than that of senior radiologists, and the combined model had higher sensitivity (0.875 (0.781-0.969) vs. 0.729 (0.603-0.855)) without compromising specificity. Furthermore, the AUC and specificity of the combined model (PCR-CEUS + Junior radiologists) (0.852 (0.787-0.916)) was higher than that of junior radiologists (0.665 (0.592-0.737) (P < 0.00001)). PCR-CEUS demonstrated good ability in differentiating malignant BI-RADS-US 4A masses and was helpful for both senior and junior radiologists.
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Affiliation(s)
- Zi-Mei Lin
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ji-Fan Chen
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Fang-Ting Xu
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chun-Mei Liu
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jian-She Chen
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yao Wang
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chao Zhang
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Pin-Tong Huang
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
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Qi Y, Jia JA, Li H, Wan N, Zhang S, Ma X. Lymphocyte-monocyte-neutrophil index: a predictor of severity of coronavirus disease 2019 patients produced by sparse principal component analysis. Virol J 2021; 18:115. [PMID: 34088324 PMCID: PMC8176446 DOI: 10.1186/s12985-021-01561-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 04/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND It is important to recognize the coronavirus disease 2019 (COVID-19) patients in severe conditions from moderate ones, thus more effective predictors should be developed. METHODS Clinical indicators of COVID-19 patients from two independent cohorts (Training data: Hefei Cohort, 82 patients; Validation data: Nanchang Cohort, 169 patients) were retrospected. Sparse principal component analysis (SPCA) using Hefei Cohort was performed and prediction models were deduced. Prediction results were evaluated by receiver operator characteristic curve and decision curve analysis (DCA) in above two cohorts. RESULTS SPCA using Hefei Cohort revealed that the first 13 principal components (PCs) account for 80.8% of the total variance of original data. The PC1 and PC12 were significantly associated with disease severity with odds ratio of 4.049 and 3.318, respectively. They were used to construct prediction model, named Model-A. In disease severity prediction, Model-A gave the best prediction efficiency with area under curve (AUC) of 0.867 and 0.835 in Hefei and Nanchang Cohort, respectively. Model-A's simplified version, named as LMN index, gave comparable prediction efficiency as classical clinical markers with AUC of 0.837 and 0.800 in training and validation cohort, respectively. According to DCA, Model-A gave slightly better performance than others and LMN index showed similar performance as albumin or neutrophil-to-lymphocyte ratio. CONCLUSIONS Prediction models produced by SPCA showed robust disease severity prediction efficiency for COVID-19 patients and have the potential for clinical application.
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Affiliation(s)
- Yingjie Qi
- The First Affiliated Hospital of University of Science and Technology of China (Anhui Provincial Hospital Infection Hospital), Susong Road 218#, Hefei, 230022, Anhui Province, China
| | - Jian-An Jia
- Department of Laboratory Medicine, The 901Th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Hefei, 230031, Anhui, China
| | - Huiming Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Nagen Wan
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Shuqin Zhang
- Centre for Computational Systems Biology, School of Mathematical Sciences, Fudan University, Shanghai, 200433, China
| | - Xiaoling Ma
- The First Affiliated Hospital of University of Science and Technology of China (Anhui Provincial Hospital Infection Hospital), Susong Road 218#, Hefei, 230022, Anhui Province, China.
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Mitani S, Nishio N, Kitani T, Ugumori T, Wakisaka H, Tanaka K, Miao B, Chan JYK, Holsinger FC, Hato N. Verbalization, Categorization, and Evaluation of Fundamental Surgical Skills: An Expert Consensus in Open Head and Neck Surgery. ANNALS OF SURGERY OPEN 2021; 2:e059. [PMID: 37636552 PMCID: PMC10455147 DOI: 10.1097/as9.0000000000000059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/13/2021] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to verbalize fundamental surgical skills required for open head and neck surgery (OHNS), to organize them by categorization, and to establish a consensus among surgeons regarding the importance and difficulty of each skill. Summary Background Data Improvement of fundamental surgical skills is the core of surgical education; however, surgical skills are not yet organized, and consensus in any surgical field remains uncertain. Methods Fundamental surgical skills during OHNS were collected from surgical textbooks, real surgeries, and expert interviews. The items were analyzed to calculate the frequency of words and were categorized by 2 expert surgeons. After consensus on the importance and difficulty of each item was established by 15 expert surgeons using a Delphi survey, principal component (PC) analysis was performed to integrate importance and difficulty into a single parameter. Results Sixty skills were verbalized and categorized into 7 categories: "skin flap elevation (n = 6)," "vessel management (n = 9)," "nerve preservation (n = 8)," "instrument handling (n = 11)," "counter traction (n = 7)," "tissue exposure (n = 9)," and "flow and planning (n = 10)." In the Delphi survey, expert consensus was established after 2 voting rounds (Cronbach's α ≥ 0.80). The "counter traction" and "flow and planning" categories had high PC scores, which indicate priority in surgical education. Conclusion Fundamental OHNS skills were verbalized, categorized, and evaluated via expert consensus. Assessment of surgeons' skills by the structured items hereby developed will help standardize the quality of OHNS and improve patient outcomes.
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Affiliation(s)
- Sohei Mitani
- From the Department of Otolaryngology-Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Naoki Nishio
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Kitani
- From the Department of Otolaryngology-Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Toru Ugumori
- From the Department of Otolaryngology-Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
- Ugumori ENT Clinic, Matsuyama, Ehime, Japan
| | - Hiroyuki Wakisaka
- From the Department of Otolaryngology-Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
- Ehime Prefectural University of Health Sciences, Tobe, Ehime, Japan
| | - Keiko Tanaka
- Department of Epidemiology and Preventive Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Beiping Miao
- Department of Otolaryngology, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Jason Y. K. Chan
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR
| | - F. Christopher Holsinger
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, CA
| | - Naohito Hato
- From the Department of Otolaryngology-Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Li S, Zheng X, Fang Q, Gong Y, Wang H. Exploring the potential of photosynthetic induction factor for the commercial production of fucoxanthin in Phaeodactylum tricornutum. Bioprocess Biosyst Eng 2021; 44:1769-1779. [PMID: 33844074 DOI: 10.1007/s00449-021-02559-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/20/2021] [Indexed: 12/19/2022]
Abstract
Currently, the market price of fucoxanthin-based drugs remains high primarily because, on one hand, the main natural source of fucoxanthin, Phaeodactylum tricornutum (P. tricornutum), is extremely low in endogenous fucoxanthin, while, on the other hand, fucoxanthin mass production has proved to be very challenging. In this study, we demonstrated the feasibility of increasing fucoxanthin bioaccumulation in P. tricornutum by promoting photosynthetic activity of this diatom. Specifically, this study investigated the effects of different concentrations of the photosynthetic induction factor (PIF) on fucoxanthin content and biosynthesis, on chlorophyll fluorescence characteristics, and on the expression of photosynthesis-related genes in P. tricornutum. The results showed that the optimal PIF concentration was 1 µg L-1, while optimal time was 48 h, with the effect decreasing at 72 h. Fucoxanthin content increased by 44.2% compared to that of the control group in 48 h. Correlation analysis showed a significant positive correlation between fucoxanthin content and the actual photosynthetic yield of PS II (r = 0.949, P < 0.01). The total amount of energy actually used in photosystem II (PS II) by photosynthesis may be used as the main components affecting the biosynthesis of fucoxanthin in P. tricornutum. In addition, we found that using PIF to promote photosynthesis in P. tricornutum effectively increased the growth rate and bioaccumulation of fucoxanthin to an economically advantageous level, thereby providing a novel strategy for the commercial production of fucoxanthin.
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Affiliation(s)
- Shenrui Li
- Key Laboratory of Applied Marine Biotechnology of Department of Education, School of Marine Sciences, Ningbo University, Ningbo, Zhejiang, 315211, People's Republic of China
| | - Xiaoyun Zheng
- Key Laboratory of Applied Marine Biotechnology of Department of Education, School of Marine Sciences, Ningbo University, Ningbo, Zhejiang, 315211, People's Republic of China
| | - Qingshu Fang
- Key Laboratory of Applied Marine Biotechnology of Department of Education, School of Marine Sciences, Ningbo University, Ningbo, Zhejiang, 315211, People's Republic of China
| | - Yifu Gong
- Key Laboratory of Applied Marine Biotechnology of Department of Education, School of Marine Sciences, Ningbo University, Ningbo, Zhejiang, 315211, People's Republic of China.
| | - Heyu Wang
- College of Food and Pharmaceutical Sciences, Ningbo, Zhejiang, 315211, People's Republic of China
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Brännström A, von Oelreich E, Degerstedt LE, Dahlquist A, Hånell A, Gustavsson J, Günther M. The swine as a vehicle for research in trauma-induced coagulopathy: Introducing principal component analysis for viscoelastic coagulation tests. J Trauma Acute Care Surg 2021; 90:360-368. [PMID: 33093294 DOI: 10.1097/ta.0000000000002997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Uncontrolled bleeding is the leading cause of potentially preventable deaths among trauma patients. Tissue injury and shock result in trauma-induced coagulopathy (TIC). There are still uncertainties regarding detection methods and best practice management for TIC, and a deeper understanding of the pathophysiology requires robust animal models. The applicability of swine in coagulation studies, particularly after trauma has not been sufficiently elucidated. We, therefore, evaluated the swine as a vehicle for TIC research in a selection of trauma modalities. METHODS Twenty-six landrace swine (3 females/23 males) (mean weight, 60.0 kg) were anesthetized and randomized to negative controls, receiving no manipulation (n = 5), positive controls by hemodilution (n = 5), pulmonary contusion without hemorrhage (n = 5), pulmonary contusion with hemorrhage (n = 5), and blast polytrauma with hypothermia, hypoperfusion, hypoventilation, and systemic inflammation (n = 6). A comprehensive coagulation panel was analyzed at baseline, 20 minutes and 120 minutes after trauma. RESULTS PT(INR), aPTT, thrombocytes, and fibrinogen did not change after trauma. D-dimer increased (p < 0.0001), prothrombin decreased (p < 0.05) and aPC decreased (p < 0.01) after polytrauma. PAI-1 decreased after pulmonary contusion with hemorrhage (p < 0.05). Positive controls displayed changes in PT(INR), thrombocytes, fibrinogen, prothrombin, aPC (p < 0.05). Principal Component Analysis of rotational thromboelastometry presented pathologic coagulation profiles in both polytrauma and positive control groups with vectors extending outside the 95% confidence interval, which were not detected in negative controls. CONCLUSION Coagulopathy was induced after severe porcine blast polytrauma, specifically detected in rotational thromboelastometry. A novel method for principal component analysis of viscoelastic tests was introduced which may increase the detection sensitivity and differentiation of TIC phenotypes and should be further investigated in trauma populations.
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Affiliation(s)
- Andreas Brännström
- From the Department of Clinical Science and Education (A.B., L.E.D., A.D., M.G.), Department of Physiology and Pharmacology (E.v.O.), and Department of Neuroscience (A.H., J.G.), Karolinska Institutet, Stockholm, Sweden
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15
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Robinson S, Kirton J. Tools to predict acute traumatic coagulopathy in the pre-hospital setting: a review of the literature. Br Paramed J 2020; 5:23-30. [PMID: 33456394 PMCID: PMC7783962 DOI: 10.29045/14784726.2020.09.5.3.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Recognising acute traumatic coagulopathy (ATC) poses a significant challenge to improving survival in emergency care. Paramedics are in a prime position to identify ATC in pre-hospital major trauma and initiate appropriate coagulopathy management. Method: A database literature review was conducted using Scopus, CINAHL and MEDLINE. Results: Two themes were identified from four studies: prediction tools, and point-of-care testing. Prediction tools identified key common ATC markers in the pre-hospital setting, including: systolic blood pressure, reduced Glasgow Coma Score and trauma to the chest, abdomen and pelvis. Point-of-care testing was found to have limited value. Conclusion: Future research needs to explore paramedics using prediction tools in identifying ATC, which could alert hospitals to prepare for blood products for damage control resuscitation.
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16
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Kristono GA, Holley AS, Hally KE, Brunton-O'Sullivan MM, Shi B, Harding SA, Larsen PD. An IL-6-IL-8 score derived from principal component analysis is predictive of adverse outcome in acute myocardial infarction. Cytokine X 2020; 2:100037. [PMID: 33604561 PMCID: PMC7885891 DOI: 10.1016/j.cytox.2020.100037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/01/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Many studies have shown that elevated biomarkers of inflammation following acute myocardial infarction (AMI) are associated with major adverse cardiovascular events (MACE). However, the optimal way of measuring the complex inflammatory response following AMI has not been determined. In this study we explore the use of principal component analysis (PCA) utilising multiple inflammatory cytokines to generate a combined cytokine score that may be predictive of MACE post-AMI. METHODS Thirteen inflammatory cytokines were measured in plasma of 317 AMI patients, drawn 48-72 h following symptom onset. Patients were followed-up for one year to determine the incidence of MACE. PCA was used to generate a combined score using six cytokines that were detectable in the majority of patients (IL-1β, -6, -8, and -10; MCP-1; and RANTES), and using a subset of cytokines that were associated with MACE on univariate analysis. Multivariate models using baseline characteristics, elevated individual cytokines and PCA-derived scores determined independent predictors of MACE. RESULTS IL-6 and IL-8 were significantly associated with MACE on univariate analysis and were combined using PCA into an IL-6-IL-8 score. The combined cytokine score and IL-6-IL-8 PCA-derived score were both significantly associated with MACE on univariate analysis. In multivariate models IL-6-IL-8 scores (OR = 2.77, p = 0.007) and IL-6 levels (OR = 2.18, p = 0.035) were found to be independent predictors of MACE. CONCLUSION An IL-6-IL-8 score derived from PCA was found to independently predict MACE at one year and was a stronger predictor than any individual cytokine, which suggests this may be an appropriate strategy to quantify inflammation post-AMI. Further investigation is required to determine the optimal set of cytokines to measure in this context.
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Key Words
- ACS, Acute coronary syndrome
- AF, Atrial fibrillation
- AMI, Acute myocardial infarction
- AUC, Area under the curve
- Acute myocardial infarction
- BMI, Body mass index
- CAD, Coronary artery disease
- CBA, Cytometric bead array
- CHF, Chronic heart failure
- CI, Confidence interval
- CVD, Cardiovascular disease
- Cytokine score
- EFA, Exploratory factor analysis
- ELISA, Enzyme-linked immunosorbent assay
- GDF-15, Growth differentiation factor-15
- GM-CSF, Granulocyte-macrophage colony-stimulating factor
- HTN, Hypertension
- IFNγ, Interferon gamma
- IL-(number), Interleukin-(number)
- IQR, Interquartile range
- Interleukin-6
- Interleukin-8
- MACE, Major adverse cardiovascular events
- MCP-1, Monocyte chemoattractant protein-1
- MFI, Mean fluorescence intensity
- MI, Myocardial infarction
- Major adverse cardiovascular events
- NSTEMI, Non-ST elevation myocardial infarction
- OR, Odds ratio
- PCA, Principal component analysis
- PCI, Percutaneous coronary intervention
- Principal component analysis
- RANTES, Regulated upon activation normal T-cell expressed and secreted
- ROC, Receiver operator characteristic
- STEMI, ST-elevation myocardial infarction
- TGF-β1, Tumour growth factor-beta 1
- TIA, Transient ischaemic attack
- TNF-α, Tumour necrosis factor alpha
- TRAIL-R2, Tumour necrosis factor-related apoptosis-inducing ligand receptor 2
- TnT, Troponin T
- VEGF, Vascular endothelial growth factor
- h, Hours
- p, P-value
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Affiliation(s)
- Gisela A. Kristono
- Department of Surgery and Anaesthesia, University of Otago Wellington, New Zealand
- Wellington Cardiovascular Research Group, New Zealand
| | - Ana S. Holley
- Department of Surgery and Anaesthesia, University of Otago Wellington, New Zealand
- Wellington Cardiovascular Research Group, New Zealand
| | - Kathryn E. Hally
- Department of Surgery and Anaesthesia, University of Otago Wellington, New Zealand
- Wellington Cardiovascular Research Group, New Zealand
- School of Biological Sciences, Victoria University of Wellington, New Zealand
| | - Morgane M. Brunton-O'Sullivan
- Department of Surgery and Anaesthesia, University of Otago Wellington, New Zealand
- Wellington Cardiovascular Research Group, New Zealand
| | - Bijia Shi
- Wellington Cardiovascular Research Group, New Zealand
- Cardiology Department, Capital and Coast District Health Board, New Zealand
| | - Scott A. Harding
- Wellington Cardiovascular Research Group, New Zealand
- Cardiology Department, Capital and Coast District Health Board, New Zealand
| | - Peter D. Larsen
- Department of Surgery and Anaesthesia, University of Otago Wellington, New Zealand
- Wellington Cardiovascular Research Group, New Zealand
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17
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Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. J Blood Med 2020; 11:163-172. [PMID: 32547282 PMCID: PMC7247594 DOI: 10.2147/jbm.s205132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
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Affiliation(s)
| | - Michaela Gaffley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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18
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Burggraf M, Polan C, Husen M, Mester B, Wegner A, Spodeck D, Dudda M, Kauther MD. Trauma induced clotting factor depletion in severely injured children: a single center observational study. World J Emerg Surg 2020; 15:31. [PMID: 32375899 PMCID: PMC7201748 DOI: 10.1186/s13017-020-00311-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 01/09/2023] Open
Abstract
Background Coagulopathy following severe trauma contributes significantly to mortality. Impaired clotting factors have been observed in adult trauma patients, but in pediatric trauma victims their activity has not yet been investigated. Methods Sixteen pediatric trauma patients were evaluated according to the ISS and assigned to two cohorts. An additional control group (CO; n = 10) was formed. Routine coagulation parameters and the soluble clotting factors (F) were tested. Nonparametric data was analyzed using the Mann-Whitney U test. Results are reported as median and interquartile range. Results The ISS of severely (SI, n = 8) and mildly (MI, n = 8) injured children differed significantly (25 [19–28] vs. 5 [4–6]; p < 0.001). INR was elevated in the SI cohort only when compared to the CO (1.21 [1.04-1.58] vs. 0.96 [0.93-1.00]; p = 0.001). Differences between SI and MI were found for FII (67 [53-90] vs. 82 [76-114] %; p = 0.028), FV (76 [47-88] vs. 92 [82-99] %; p = 0.028), and FXIII (67 [62-87] vs. 90 [77-102] %; p = 0.021). Comparison of the SI with the CO (FII 122 [112-144] %; p < 0.001; FV 123 [100-142] %; p = 0.002; and FXIII 102 [79-115] %; p = 0.006) also revealed a reduction in the activity of these factors. Furthermore, fibrinogen (198 [80-242] vs. 296 [204-324] mg/dl; p = 0.034), FVII (71 [63-97] vs. 114 [100-152] %; p = 0.009), FIX (84 [67-103] vs. 110 [90-114] %; p = 0.043), and FX (70 [61-85] vs. 122 [96-140] %; p = 0.001) were reduced in the SI in comparison with the CO. Finally, FVIII was considerably, yet not significantly, increased in both patient cohorts (235 [91-320] % and 197 [164-238] %, respectively). Conclusions This study proves that children suffer a depletion of clotting factors following severe injury which basically reflects the findings for adult trauma patients. Attempts to correct the impaired clotting factor activity could be based on a specific hemostatic therapy involving administration of coagulation factors. Nevertheless, therapeutic implications need to be investigated in future studies.
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Affiliation(s)
- Manuel Burggraf
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Christina Polan
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Martin Husen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Alexander Wegner
- Department of Orthopedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Daniel Spodeck
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Max Daniel Kauther
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
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Coleman JR, Moore EE, Moore HB, Chapman MP, Cohen MJ, Silliman CC, Sauaia A. Tranexamic acid disturbs the dynamics of postinjury fibrinolysis. ANZ J Surg 2020; 90:420-422. [PMID: 32339428 DOI: 10.1111/ans.15499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Julia R Coleman
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernest E Moore
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Hunter B Moore
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael P Chapman
- Department of Radiology, University of Colorado-Denver, Denver, Colorado, USA
| | - Mitchell J Cohen
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Christopher C Silliman
- Department of Pediatrics, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA.,Vitalant Research Institute, Denver, Colorado, USA
| | - Angela Sauaia
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Health Systems, Management and Policy, University of Colorado-Anschutz Medical Campus, School of Public Health, Aurora, Colorado, USA
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It's sooner than you think: Blunt solid organ injury patients are already hypercoagulable upon hospital admission - Results of a bi-institutional, prospective study. Am J Surg 2019; 218:1065-1073. [PMID: 31540685 DOI: 10.1016/j.amjsurg.2019.08.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/15/2019] [Accepted: 08/25/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC). MATERIAL AND METHODS This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers' trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents. RESULTS On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h CONCLUSIONS: BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG.
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22
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Higher mortality in pediatric and adult trauma patients with traumatic coagulopathy, using age-adjusted diagnostic criteria. Surgery 2019; 165:1108-1115. [PMID: 31027837 DOI: 10.1016/j.surg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute traumatic coagulopathy has been described in adult trauma patients. Acute traumatic coagulopathy may be associated with higher mortality and morbidity in pediatric trauma patients. We aimed to (1) compare acute traumatic coagulopathy incidence among various age groups, using age-adjusted normal reference values for three tests of coagulation, and (2) compare acute traumatic coagulopathy-associated mortality by age. METHODS We queried our institutional trauma database for all level 1 and 2 activations with an injury severity score ≥ 9 during 2012 to 2017. Demographics, injury information, and coagulation test results were collected. Coagulopathy was defined using published age-specific and assay-specific parameters. Variables were compared among age groups (children, adults, and older adults), and logistic regression was used to determine independent associations with mortality. RESULTS A total of 1,983 patients were included with a median injury severity score of 17 and mortality of 12%. Prolonged partial thromboplastin time, prolonged international normalized ratio, and hypofibrinogenemia were all strongly associated with mortality among adults and children, but not among older adults (P < .001, P < .001, and P > .01, respectively). Logistic regression revealed an independent association between prolonged partial thromboplastin time and mortality (P < .001). CONCLUSION Prolonged partial thromboplastin time/international normalized ratio and hypofibrinogenemia were common among trauma patients of all ages and were associated with mortality among children and adults, but not older adults, perhaps implicating age-related hemostatic biologic differences.
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