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Yang YY, Tsai IT, Lai CH, Chen CP, Chen C, Hsu YC. Time to positivity of Klebsiella pneumoniae in blood cultures as prognostic marker in patients with intra-abdominal infection: A retrospective study. Virulence 2024; 15:2329397. [PMID: 38548677 PMCID: PMC10984124 DOI: 10.1080/21505594.2024.2329397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 03/06/2024] [Indexed: 04/02/2024] Open
Abstract
Klebsiella pneumoniae is a common causative pathogen of intra-abdominal infection with concomitant bacteraemia, leading to a significant mortality risk. The time to positivity (TTP) of blood culture is postulated to be a prognostic factor in bacteraemia caused by other species. Therefore, this study aimed to investigate the prognostic value of TTP in these patients. The single-centred, retrospective, observational cohort study was conducted between 1 July 2016 and 30 June 2021. All adult emergency department patients with diagnosis of intra-abdominal infection and underwent blood culture collection which yield K. pneumoniae during this period were enrolled. A total of 196 patients were included in the study. The overall 30-day mortality rate was 12.2% (24/196), and the median TTP of the studied cohort was 12.3 h (10.5-15.8 h). TTP revealed a moderate 30-day mortality discriminative ability (area under the curve 0.73, p < 0.001). Compared with the late TTP group (>12 h, N = 109), patients in the early TTP (≤12 h, N = 87) group had a significantly higher risk of 30-day morality (21.8% vs. 4.6%, p < 0.01) and other adverse outcomes. Furthermore, TTP (odds ratio [OR] = 0.79, p = 0.02), Pitt bacteraemia score (OR = 1.30, p = 0.03), and implementation of source control (OR = 0.06, p < 0.01) were identified as independent factors related to 30-day mortality risk in patients with intra-abdominal infection and K. pneumoniae bacteraemia. Therefore, physicians can use TTP for prognosis stratification in these patients.
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Affiliation(s)
- Yong-Ye Yang
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - I-Ting Tsai
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chung-Hsu Lai
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Ping Chen
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chia‐Chi Chen
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Pathology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yin-Chou Hsu
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
- School of Medicine for International Student, I-Shou University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Nakao S, Katsura M, Yagi M, Ogura H, Oda J. Assessing associated factors for failure of nonoperative management in pediatric blunt liver and spleen injuries: a secondary analysis of the SHIPPs study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02575-y. [PMID: 38886237 DOI: 10.1007/s00068-024-02575-y] [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: 04/07/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE The purpose of this study was to describe the characteristics of pediatric patients who underwent nonoperative management (NOM) for blunt splenic and hepatic injuries and to explore factors associated with NOM failure. METHODS This was a secondary analysis of a multicenter cohort study of pediatric patients with blunt liver and spleen injuries in Japan. Participants included pediatric trauma patients aged 16 years or younger between 2008 and 2019 with NOM, which was defined as no surgery provided within 6 h of hospital arrival. NOM failure, defined as abdominal surgery performed after 6 h of hospital arrival, was the primary outcome. Descriptive statistics were provided and exploratory analysis to assess the associations with outcome using logistic regression. RESULTS During the study period, 1339 met our eligibility criteria. The median age was 9 years, with a majority being male. The median Injury Severity Score (ISS) was 10. About 14.0% required transfusion within 24 h, and 22.3% underwent interventional radiology procedures. NOM failure occurred in 1.0% of patients and the in-hospital mortality was 0.7%. Factors associated with NOM failure included age, positive focused assessment with sonography for trauma (FAST), contrast extravasation on computed tomography (CT), severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and ISS. CONCLUSIONS In our study, NOM failure were rare. Older age, positive FAST, contrast extravasation on CT, severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and higher ISS were suggested as possible risk factors for NOM failure.
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Affiliation(s)
- Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Morihiro Katsura
- Department of Surgery, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Masayuki Yagi
- Emergency Medicine and Acute Care Surgery, Matsudo City General Hospital, Matsudo, Chiba, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Jones B, Elbakri AS, Murrills C, Patil P, Scollay J. Splenic artery embolisation for blunt splenic trauma: 10 years of practice at a trauma centre. Ann R Coll Surg Engl 2024; 106:283-287. [PMID: 37365934 PMCID: PMC10904261 DOI: 10.1308/rcsann.2023.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION Splenic artery embolisation (SAE) has transformed the management of splenic trauma. The aim of this study was to review the outcomes and postprocedural management of blunt splenic trauma patients treated with SAE at a trauma centre over a 10-year period. METHODS Details of patients undergoing SAE for blunt trauma between January 2012 and January 2022 were acquired from a prospectively maintained database. Patient records were reviewed for demographic information, splenic injury grades, embolisation efficacy, complications, and associated injuries and mortality. Data relating to Injury Severity Scores (ISS) and postprocedural practice (vaccinations, antibiotic prescribing, follow-up imaging) were also obtained. RESULTS Thirty-six patients (24 male, 12 female) with a median age of 42.5 years (range 13-97 years) were identified. American Association for the Surgery of Trauma splenic injury grades were III (n = 7), IV (n = 20) and V (n = 9). Seventeen patients had isolated splenic injury and 19 had additional injuries to other organ systems. Median ISS was 18.5 (range 5-50). SAE succeeded first time in 35/36 cases, and upon the second attempt in 1/36 cases. No patients died because of splenic injury or SAE although four patients with polytrauma died owing to other injuries. SAE complications occurred in 4/36 cases. For survivors, vaccinations were administered in 17/32 cases, and long-term antibiotics were initiated in 14/32 cases. Formal follow-up imaging was arranged in 9/32 cases. CONCLUSIONS These data show that SAE is an effective means of controlling splenic haemorrhage secondary to blunt trauma with no patient requiring subsequent laparotomy. Major complications occurred in 11% of cases. Follow-up practice varied regarding further imaging, antibiotic and vaccination administration.
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Alhassan NS, Altwuaijri MA, Alshammari SA, Alshehri KM, Alkhayyal YA, Alfaiz FA, Alomar MO, Alkhowaiter SS, Amaar NYA, Traiki TAB, Khayal KAA. Clinical outcomes of lower gastrointestinal bleeding in patients managed with lower endoscopy: A tertiary center results. Saudi J Gastroenterol 2024; 30:83-88. [PMID: 38099540 PMCID: PMC10980294 DOI: 10.4103/sjg.sjg_316_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/10/2023] [Accepted: 11/23/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is an urgent presentation with increasing prevalence and remains a common cause of hospitalization. The clinical outcome can vary based on several factors, including the cause of bleeding, its severity, and the effectiveness of management strategies. The aim of this study is to provide a comprehensive report on the clinical outcomes observed in patients with LGIB who underwent lower endoscopy. METHODS All patients who underwent emergency lower endoscopy for fresh bleeding per rectum, from May 2015 to December 2021, were included. The primary outcome was to identify the rate of rebleeding after initial control of bleeding. The second was to measure the clinical outcomes and the potential predictors leading to intervention and readmission. RESULTS A total of 84 patients were included. Active bleeding was found in 20% at the time of endoscopy. Rebleeding within 90 days occurred in 6% of the total patients; two of which (2.38%) were within the same admission. Ninety-day readmission was reported in 19% of the cases. Upper endoscopy was performed in 32.5% of the total cases and was found to be a significant predictor for intervention (OR 4.1, P = 0.013). Personal history of inflammatory bowel disease (IBD) and initial use of sigmoidoscopy were found to be significant predictors of readmission [(OR 5.09, P = 0.008) and (OR 5.08, P = 0.019)]. CONCLUSIONS LGIB is an emergency that must be identified and managed using an agreed protocol between all associated services to determine who needs upper GI endoscopy, ICU admission, or emergency endoscopy within 12 hours.
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Affiliation(s)
- Noura S. Alhassan
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mansour A. Altwuaijri
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sulaiman A. Alshammari
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khaled M. Alshehri
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yazeed A. Alkhayyal
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad A. Alfaiz
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad O. Alomar
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saad S. Alkhowaiter
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Nuha Y. Al Amaar
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Thamer A. Bin Traiki
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khayal A. Al Khayal
- Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Clements W, Fitzgerald M, Chennapragada SM, Mathew J, Groombridge C, Ban EJ, Lukies MW. A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury. CVIR Endovasc 2023; 6:62. [PMID: 38103054 PMCID: PMC10725392 DOI: 10.1186/s42155-023-00414-6] [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: 10/20/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality. METHODS The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument. RESULTS Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275. CONCLUSIONS This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.
- National Trauma Research Institute, Melbourne, Australia.
| | - Mark Fitzgerald
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - S Murthy Chennapragada
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
- Department of Medical Imaging, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Joseph Mathew
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Christopher Groombridge
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Ee Jun Ban
- National Trauma Research Institute, Melbourne, Australia
- Acute General Surgical Unit, Alfred Health, Melbourne, Australia
| | - Matthew W Lukies
- Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
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Dorkhani E, Darzi B, Foroutani L, Ebrahim Soltani Z, Ahmadi Tafti SM. Characterization and in vivo evaluation of a fabricated absorbable poly(vinyl alcohol)-based hernia mesh. Heliyon 2023; 9:e22279. [PMID: 38045132 PMCID: PMC10689958 DOI: 10.1016/j.heliyon.2023.e22279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/05/2023] Open
Abstract
The most widely taken medical approach toward hernia repair involves the implementation of a prosthetic mesh to cover the herniated site and reinforce the weakened area of the abdominal wall. Biodegradable meshes can serve as biocompatible grafts with a low risk of infection. However, their major complication is associated with a high rate of degradation and hernia recurrence. We proposed a facile and cost-effective method to fabricate a poly(vinyl alcohol)-based mesh, using the solution casting technique. The inclusion of zinc oxide nanoparticles, citric acid, and three cycles of freeze-thaw were intended to ameliorate the mechanical properties of poly(vinyl alcohol). Several characterization, cell culture, and animal studies were conducted. Swelling and water contact angle measurements confirmed good water uptake capacity and wetting behavior of the final mesh sample. The synthesized mesh acquired a high mechanical strength of 52.8 MPa, and its weight loss was decreased to 39 %. No cytotoxicity was found in all samples. In vivo experiments revealed that less adhesion and granuloma formation, greater tissue integration, and notably higher neovascularization rate were resulted from implanting this fabricated hernia mesh, compared to commercial Prolene® mesh. Furthermore, the amount of collagen deposition and influential growth factors were enhanced when rats were treated with the proposed mesh instead of Prolene®.
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Affiliation(s)
- Erfan Dorkhani
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran 1411713138, Iran
- School of Chemical Engineering, College of Engineering, University of Tehran, Tehran 1417614411, Iran
| | - Bahareh Darzi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran 1411713138, Iran
- School of Chemical Engineering, College of Engineering, University of Tehran, Tehran 1417614411, Iran
| | - Laleh Foroutani
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran 1411713138, Iran
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran 1419733141, Iran
| | - Zahra Ebrahim Soltani
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran 1411713138, Iran
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran 1419733141, Iran
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Yu Q, Lionberg A, Zane K, Ungchusri E, Du J, Nijhawan K, Clarey A, Navuluri R, Ahmed O, Prakash P, Leef J, Funaki B. Transarterial interventions in civilian gunshot wound injury: experience from a level-1 trauma center. CVIR Endovasc 2023; 6:47. [PMID: 37843596 PMCID: PMC10579195 DOI: 10.1186/s42155-023-00396-5] [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: 06/02/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023] Open
Abstract
PURPOSE To assess the effectiveness of trans-arterial vascular interventions in treatment of civilian gunshot wounds (GSW). MATERIALS AND METHODS A retrospective review was performed at a level-1 trauma center to include 46 consecutive adults admitted due to GSW related hemorrhage and treated with endovascular interventions from July 2018 to July 2022. Patient demographics and procedural metrics were retrieved. Primary outcomes of interest include technical success and in-hospital mortality. Factors of mortality were assessed using a logistic regression model. RESULTS Twenty-one patients were brought to the endovascular suite directly (endovascular group) from the trauma bay and 25 patients after treatment in the operating room (OR group). The OR group had higher hemodynamic instability (48.0% vs 19.0%, p = 0.040), lower hemoglobin (12.9 vs 10.1, p = 0.001) and platelet counts (235.2 vs 155.1, p = 0.003), and worse Acute Physiology and Chronic Health Evaluation (APACHE) score (4.1 vs 10.2, p < 0.0001) at the time of initial presentation. Technical success was achieved in all 40 cases in which targeted embolization was attempted (100%). Empiric embolization was performed in 6/46 (13.0%) patients based on computed tomographic angiogram (CTA) and operative findings. Stent-grafts were placed in 3 patients for subclavian artery injuries. Availability of pre-intervention CTA was associated with shorter fluoroscopy time (19.8 ± 12.1 vs 30.7 ± 18.6 min, p = 0.030). A total of 41 patients were discharged in stable condition (89.1%). Hollow organ injury was associated with mortality (p = 0.039). CONCLUSION Endovascular embolization and stenting were effective in managing hemorrhage due to GSW in a carefully selected population. Hollow organ injury was a statistically significant predictor of mortality. Pre-intervention CTA enabled targeted, shorter and equally effective procedures.
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Affiliation(s)
- Qian Yu
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - Alex Lionberg
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Kylie Zane
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Ethan Ungchusri
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Jonathan Du
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Karan Nijhawan
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Austin Clarey
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Rakesh Navuluri
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Osman Ahmed
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Priya Prakash
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Jeffrey Leef
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Brian Funaki
- Department of Radiology, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL, 60637, USA
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Ghazanfar H, Javed N, Balar B. The Role of Timely Angiography in Elderly Patients Presenting With Lower Gastrointestinal Bleeding. Cureus 2023; 15:e47701. [PMID: 38021564 PMCID: PMC10674099 DOI: 10.7759/cureus.47701] [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: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Lower gastrointestinal bleeding (LGIB) is associated with significant morbidity and mortality in the elderly population. Timely diagnosis and establishing the etiology of the LGIB can guide appropriate treatment and management. Our patient is a 91-year-old female who presented to the ER with the complaint of several episodes of hematochezia that started four hours before her presentation. The patient underwent an urgent CT angiography showing active bleeding in the proximal ascending colon. She underwent a super-selective arteriogram followed by embolization of the ascending colon arterial culprit bleeding territory using two coils. Her clinical condition improved, and she had no further episodes of hematochezia. Her case highlights the importance of timely diagnosis of the underlying etiology of a patient presenting with LGIB.
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Affiliation(s)
| | - Nismat Javed
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Bhavna Balar
- Gastroenterology, BronxCare Health System, Bronx, USA
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Tsai CH, Chen YC, Chen PY, Lai CC, Tang HJ, Chuang YC, Chen CC, Ho CH, Hsu WY, Chang TH. Antimicrobial Susceptibility of E. coli Isolates from Intra-Abdominal Infections in the Asia-Pacific Region: Trends in Ciprofloxacin, Ceftriaxone, Cefepime, and Piperacillin/Tazobactam Susceptibility. Infect Drug Resist 2023; 16:5599-5611. [PMID: 37650005 PMCID: PMC10464894 DOI: 10.2147/idr.s422203] [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: 06/06/2023] [Accepted: 08/15/2023] [Indexed: 09/01/2023] Open
Abstract
Purpose To investigate the antibiotic susceptibility of Escherichia coli isolates in patients diagnosed with intra-abdominal infections (IAIs) in the Asia-Pacific region. Patients and Methods This study was conducted at 50 medical hospitals across 9 countries/regions as part of the Study for Monitoring Antimicrobial Resistance Trends (SMART) surveillance program from 2014 to 2018. Nonduplicate isolates of aerobic and facultative gram-negative bacilli were collected and processed for further antimicrobial susceptibility testing. Results A total of 10,709 isolates were collected, with E. coli (n=4737, 44.2%) being the leading pathogen causing IAIs, followed by Klebsiella pneumoniae (n=2429, 22.7%) and Pseudomonas aeruginosa (n=931, 8.7%). Community-associated (CA) E. coli isolates generally exhibited higher susceptibility rates for most antibiotics than hospital-associated (HA) isolates. In countries/regions other than Hong Kong, South Korea, and Singapore, HA isolates displayed lower susceptibility rates for multiple classes (≥4) of antibiotics. Among the commonly used antibiotics in IAIs, the overall susceptibility rate for ciprofloxacin was low, with an average of 41.3%. Ceftriaxone susceptibility rates in all selected countries were below 80% starting in 2018, ranging from 23.3% to 75.8%. The cefepime susceptibility rates varied across regions, with consistently reduced susceptibility ranging from 45.5% to 57.8% in India, Thailand, and Vietnam. Piperacillin/tazobactam demonstrated effectiveness against E. coli isolates in almost all countries except India, with a downward trend observed in the Philippines and Taiwan. Carbapenems remained effective against more than 90% of E. coli isolates, except in India. Conclusion Prudent use of fluoroquinolones and ceftriaxone is advised when treating both CA and HA IAIs in the Asia-Pacific region. The low susceptibility rate of cefepime in India, Thailand, and Vietnam needs careful consideration in its administration. Moreover, the increase in nonsusceptibility to piperacillin/tazobactam in the Philippines and Taiwan poses a potential risk that should be closely monitored.
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Affiliation(s)
- Chia-Hung Tsai
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Chin Chen
- Department of Pediatrics, Chi Mei Medical Center, Chiali, Tainan, Taiwan
| | - Po-Yu Chen
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Hung-Jen Tang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yin-Ching Chuang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chi-Chung Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Food Science, National Chiayi University, Chiayi, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Wei-Yun Hsu
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Tu-Hsuan Chang
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
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Chen H, Unberath M, Dreizin D. Toward automated interpretable AAST grading for blunt splenic injury. Emerg Radiol 2023; 30:41-50. [PMID: 36371579 DOI: 10.1007/s10140-022-02099-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) splenic organ injury scale (OIS) is the most frequently used CT-based grading system for blunt splenic trauma. However, reported inter-rater agreement is modest, and an algorithm that objectively automates grading based on transparent and verifiable criteria could serve as a high-trust diagnostic aid. PURPOSE To pilot the development of an automated interpretable multi-stage deep learning-based system to predict AAST grade from admission trauma CT. METHODS Our pipeline includes 4 parts: (1) automated splenic localization, (2) Faster R-CNN-based detection of pseudoaneurysms (PSA) and active bleeds (AB), (3) nnU-Net segmentation and quantification of splenic parenchymal disruption (SPD), and (4) a directed graph that infers AAST grades from detection and segmentation results. Training and validation is performed on a dataset of adult patients (age ≥ 18) with voxelwise labeling, consensus AAST grading, and hemorrhage-related outcome data (n = 174). RESULTS AAST classification agreement (weighted κ) between automated and consensus AAST grades was substantial (0.79). High-grade (IV and V) injuries were predicted with accuracy, positive predictive value, and negative predictive value of 92%, 95%, and 89%. The area under the curve for predicting hemorrhage control intervention was comparable between expert consensus and automated AAST grading (0.83 vs 0.88). The mean combined inference time for the pipeline was 96.9 s. CONCLUSIONS The results of our method were rapid and verifiable, with high agreement between automated and expert consensus grades. Diagnosis of high-grade lesions and prediction of hemorrhage control intervention produced accurate results in adult patients.
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Affiliation(s)
- Haomin Chen
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Mathias Unberath
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Timing of Colonoscopy for Hemodynamically Stable Patients With Acute Lower Gastrointestinal Bleeding. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:76-78. [PMID: 36729881 DOI: 10.1097/sle.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/12/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The detection rate of the etiology of the lower gastrointestinal system (GIS) hemorrhage has been low, although urgent colonoscopy has been performed. Even if the etiology has been specified, the possibility of rebleeding is uncertain. Furthermore, adequate bowel cleansing required for colonoscopy cannot be achieved in emergency situations, so the procedure may fail. The aim of this study is to compare the etiological diagnoses of patients with lower GIS bleeding after bowel preparation at their first hospitalization and after discharge. MATERIAL AND METHOD Patients who were hemodynamically stable after upper GIS bleeding were identified and divided into 2 groups. Colonoscopy was performed in the first group of patients at their first hospitalization. The second group of patients was called again for colonoscopy within 2 weeks after discharge. Patients were classified according to their age, gender, bleeding etiology, whether complete colonoscopy procedure was possible (The cecum was intubated, and the bowel cleansing was sufficient to evaluate the intestinal mucosa), and whether the colonoscopic intervention was performed. RESULTS The rate of patients who are hemodynamically stable and require emergency intervention at their first hospitalization is 5%. The colonoscopy repeat rate is 70% for the first hospitalization group, and the patients with no findings despite the second colonoscopy at a rate of 50% are re-evaluated electively. DISCUSSION Our study suggests that colonoscopy should be performed in elective conditions after a complete bowel cleansing in hemodynamically stable patients.
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12
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Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023; 118:208-231. [PMID: 36735555 DOI: 10.14309/ajg.0000000000002130] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.
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13
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Spiritos Z, Horton A, Parish A, Niedzwiecki D, Wilson G, Kim CY, Wild D. Clinical Predictors of a Positive Ct Angiogram Study Used for the Evaluation of Acute Gastrointestinal Hemorrhage. Dig Dis Sci 2023; 68:181-186. [PMID: 35556194 DOI: 10.1007/s10620-022-07514-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 04/06/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute gastrointestinal (GI) bleeding is one of the leading causes of emergency department visits and hospital admissions. CT angiography (CTA) has had an expanding role in the evaluation of acute GI bleeding because it is rapidly performed, widely available, reasonably sensitive and provides precise localization when positive. We attempted to identify patient and clinical characteristics that predict CTA results in order to help guide the utilization of this modality in patients with acute GI bleeding. METHODS In this retrospective study, we analyzed all CTAs performed for the evaluation of GI bleeding in the Duke University healthcare system between October 2019 and March 2020. We captured patient characteristics including age, sex, vital signs, hemoglobin, platelets, PT/INR, and anticoagulation status. Study indications were grouped by suspected source of bleeding: upper GI bleeding (hematemesis or coffee-ground emesis) vs small bowel bleeding (melena or "dark stools") vs lower GI bleeding (hematochezia or bright red blood per rectum (BRBPR)). Chi-square, Wilcoxon, t test, and multivariate logistic regression were used to describe and assess the relationship between patient characteristics and study outcomes (Table 1). Table 1 Univariate analysis of patient characteristics by CT angiography outcome Patient Characteristics by Positive CT for GI Bleed No (N = 274) Yes (N = 43) Total (N = 317) p value Gender 0.451 Female 138 (50.4%) 19 (44.2%) 157 (49.5%) Male 136 (49.6%) 24 (55.8%) 160 (50.5%) Age, median (Q1,Q3) 65 (51,75) 70 (62,80) 66 (52, 76) < 0.012 Heart rate, median (Q1,Q3) 86 (74,100) 89 (72,98) 86 (74, 99) 0.782 MAP, mean (SD) 87.32 (15.52) 81.72 (16.53) 86.56 0.033 Shock index, median (Q1,Q3) 0.70 (0.58, 0.85) 0.78 (0.55, 1.00) 0.71 (0.58, 0.85) 0.352 Hemoglobin 0.332 N 273 43 316 Median (Q1, Q3) 8.50 (6.90, 11.00) 7.70 (6.50, 11.30) 8.45 (6.90, 11.00) Baseline hemoglobin 0.202 N 258 39 297 Median (Q1, Q3) 11.20 (9.40, 13.00) 12.00 (9.40, 14.00) 11.20 (9.40, 13.00) Hemoglobin drop from baseline 0.062 N 258 39 297 Median (Q1, Q3) 2.10 (0.60, 3.70) 2.70 (1.20, 4.80) 2.20 (0.70, 3.80) Platelets, median (Q1, Q3) 219.5 (141, 301) 183 (139, 246) 217 (139, 282) 0.102 INR 0.272 N 263 42 305 Median (Q1, Q3) 1.10 (1.00, 1.30) 1.20 (1.00, 1.30) 1.10 (1.00, 1.30) Anticoagulation 0.131 No 155 (56.6%) 19 (44.2%) 174 (54.9%) Yes 119 (43.4%) 24 (55.8%) 143 (45.1%) Upper GI bleeding 0.401 No 251 (91.6%) 41 (95.3%) 292 (92.1%) Yes 23 (8.4%) 2 (4.7%) 25 (7.9%) Small Bowel bleeding 0.761 No 216 (78.8%) 33 (76.7%) 249 (78.5%) Yes 58 (21.2%) 10 (23.3%) 68 (21.5%) Lower GI bleeding 0.091 No 134 (48.9%) 15 (34.9%) 149 (47.0%) Yes 140 (51.1%) 28 (65.1%) 168 (53.0%) 1Chi-Square 2Wilcoxon 3Equal Variance T-Test RESULTS: A total of 317 patients underwent CTA between October 2019 and March 2020. Forty-three patients (13.6%) had a CTA positive for active bleeding. Multivariable logistic regression showed that after controlling for age, mean arterial pressure (MAP) and indication, only a hemoglobin drop from baseline was significantly associated with a positive CTA. For each 1 g / dL drop in hemoglobin from the patient's baseline, the odds of a positive CT increased by 1.17 (OR 1.17 95% CI 1.00 - 1.36, p = 0.04). Age (OR 1.02 95% CI 0.99 - 1.04, p = 0.06) and hematochezia / BRBPR (OR 2.09 95% CI 0.94-4.64, p = 0.07) approached statistical significance. CONCLUSIONS In patients who present to the hospital with GI bleeding, CTA can be a helpful triage tool that is most helpful in older patients with suspected lower GI bleeding with a drop in hemoglobin from baseline. Other clinical factors including MAP and the use of anticoagulants were not predictive of a positive CTA.
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Affiliation(s)
- Zachary Spiritos
- Division of Gastroenterology, Duke University Medical Center, DUMC Box 3913, Durham, NC, 27710, USA
| | - Anthony Horton
- Division of Gastroenterology, Duke University Medical Center, DUMC Box 3913, Durham, NC, 27710, USA.
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Geargin Wilson
- Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Charles Y Kim
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Daniel Wild
- Division of Gastroenterology, Duke University Medical Center, DUMC Box 3913, Durham, NC, 27710, USA
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Munasinghe BM, Fernando UPM, Kumar T, Huruggamuwa C, Kuruppu KARL, Hewawasam GGC. An unusual case of a traumatic splenic rupture masquerading as myocardial ischemia: a case report. Int J Emerg Med 2022; 15:63. [PMCID: PMC9670044 DOI: 10.1186/s12245-022-00469-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
Abstract
Background
The spleen is one of the most frequently injured abdominal organs during trauma, which can result in intraperitoneal bleeding of life-threatening magnitude. Although splenic injury secondary to trivial trauma comprises a minor fraction of abdominal injuries, undiagnosed or delayed diagnosis may result in a complicated clinical course.
Case presentation
One such event is presented here, wherein a late diagnosis of an advanced grade splenic injury following a trivial trauma initially presented in disguise as acute myocardial ischaemia in a previously healthy South Asian woman in her late 30s. Emergency laparotomy and splenectomy were performed with simultaneous massive transfusion for a 3.5-L blood loss. She subsequently had an uncomplicated clinical course with regular surgical follow-up.
Conclusion
Splenic injuries might present with ambiguous symptoms such as atypical chest pain and shoulder pain, necessitating attending clinicians to have a high degree of suspicion, especially in busy units such as the emergency department (ED).
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Abstract
Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.
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Affiliation(s)
- M Boullier
- Digestive surgery department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France.
| | - A Fohlen
- Uro-digestive imaging and interventional radiology department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France; Équipe CERVOxy, ISTCT UMR 6030-CNRS, CEA, University of Caen-Normandie, GIP Cycéron, boulevard H. Becquerel, BP5229, 14074 Caen cedex, France
| | - S Viennot
- Gastroenterology department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - A Alves
- Digestive surgery department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France; Unité Inserm 1086 "ANTICIPE", Centre François Baclesse "Cancers & Préventions", avenue du Général Harris, BP5026, 14076 Caen cedex, France
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16
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Giordano G, La Mirata E, Politi V, Veroux M, Meli GA, Evola G, Palmucci S, Basile A, Basile G. Left Paraduodenal Hernia in a Young Patient with Recurrent Abdominal Pain: A Case Report and Short Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2022; 23:e935413. [PMID: 35660720 PMCID: PMC9175513 DOI: 10.12659/ajcr.935413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/30/2022] [Accepted: 04/07/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Internal hernias are a rare cause of small bowel obstruction in patients, which usually have a long history of mild abdominal symptoms, sometimes leading to emergency surgery due to acute abdominal pain. Occasionally, it takes a long time to make the correct diagnosis because of symptoms vagueness and transience of typical imaging findings; at times, a definitive diagnosis is possible only through surgery, especially in cases of acute presentations in a low-resource setting where high-performance diagnostic equipment may be unavailable. CASE REPORT We report the case of a young male patient with a long history of mild abdominal symptoms and some episodes of acute abdominal pain. Following one of these episodes, several diagnostic examinations were performed and he was diagnosed with left paraduodenal hernia after typical signs were found on imaging exams, both CT and MRI; the patient underwent laparotomy with reduction of intestinal loops in the peritoneal cavity and suturing of the sac and was eventually discharged with no further symptoms whatsoever. CONCLUSIONS Among internal hernias, left paraduodenal hernias account for the major part and are characterized by the protrusion of bowel loops through the fossa of Landzert; herniated loops produce a sac-like appearance (typical imaging sign on both CT and MRI) and may cause partial displacement of other organs and blood vessels. Internal hernias should always be considered as a rare differential diagnosis in the workup of a patient with abdominal pain or intestinal obstruction: knowledge of both typical imaging features and specific surgical techniques are mandatory so that these patients may be properly cared for.
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Affiliation(s)
- Gabriele Giordano
- Department of Medical-Surgical Sciences and Advanced Technologies “G.F. Ingrassia” – Radiology I Unit, University Hospital Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Elena La Mirata
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Valentina Politi
- UOC MCAU (Urgent Surgery), University Teaching Hospital Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Massimiliano Veroux
- Organ Transplantation Unit, Department of Medical and Surgical Sciences and Advanced Technologies, University Hospital of Catania, Catania, Italy
| | - Gaetano Alfio Meli
- Department of Medical-Surgical Sciences and Advanced Technologies “G.F. Ingrassia” – Radiology I Unit, University Hospital Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Giuseppe Evola
- Department of General and Emergency Surgery, Garibaldi Hospital, Catania, Italy
| | - Stefano Palmucci
- Department of Medical-Surgical Sciences and Advanced Technologies “G.F. Ingrassia” – Radiology I Unit, University Hospital Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Antonio Basile
- Department of Medical-Surgical Sciences and Advanced Technologies “G.F. Ingrassia” – Radiology I Unit, University Hospital Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Guido Basile
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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Pouw ME, Albright JW, Kozhimala MJ, Baird GL, Nguyen VT, Prince EA, Scappaticci AA, Ahn SH. Adding non-contrast and delayed phases increases the diagnostic performance of arterial CTA for suspected active lower gastrointestinal bleeding. Eur Radiol 2022; 32:4638-4646. [PMID: 35147778 DOI: 10.1007/s00330-022-08559-z] [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: 07/10/2021] [Revised: 12/23/2021] [Accepted: 01/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES When assessing for lower gastrointestinal bleed (LGIB) using CTA, many advocate for acquiring non-contrast and delayed phases in addition to an arterial phase to improve diagnostic performance though the potential benefit of this approach has not been fully characterized. We evaluate diagnostic accuracy among radiologists when using single-phase, biphasic, and triphasic CTA in active LGIB detection. METHOD AND MATERIALS A random experimental block design was used where 3 blinded radiologists specialty trained in interventional radiology retrospectively interpreted 96 CTA examinations completed between Oct 2012 and Oct 2017 using (1) arterial only, (2) arterial/non-contrast, and (3) arterial/non-contrast/delayed phase configurations. Confirmed positive and negative LGIB studies were matched, balanced, and randomly ordered. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive and negative predictive values, and time to identify the presence/absence of active bleeding were examined using generalized estimating equations (GEE) with sandwich estimation assuming a binary distribution to estimate relative benefit of diagnostic performance between phase configurations. RESULTS Specificity increased with additional contrast phases (arterial 72.2; arterial/non-contrast 86.1; arterial/non-contrast/delayed 95.1; p < 0.001) without changes in sensitivity (arterial 77.1; arterial/non-contrast 70.2; arterial/non-contrast/delayed 73.1; p = 0.11) or mean time required to identify bleeding per study (s, arterial 34.8; arterial/non-contrast 33.1; arterial/non-contrast/delayed 36.0; p = 0.99). Overall agreement among readers (Kappa) similarly increased (arterial 0.47; arterial/non-contrast 0.65; arterial/non-contrast/delayed 0.79). CONCLUSION The addition of non-contrast and delayed phases to arterial phase CTA increased specificity and inter-reader agreement for the detection of lower gastrointestinal bleeding without increasing reading times. KEY POINTS • A triphasic CTA including non-contrast, arterial, and delayed phase has higher specificity for the detection of lower gastrointestinal bleeding than arterial-phase-only protocols. • Inter-reader agreement increases with additional contrast phases relative to single-phase CTA. • Increasing the number of contrast phases did not increase reading times.
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Affiliation(s)
- Matthew E Pouw
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA.
| | | | - Meagan J Kozhimala
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Grayson L Baird
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Van T Nguyen
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Ethan A Prince
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Albert A Scappaticci
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Sun H Ahn
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
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18
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Snelling S, Ghaffar R, Ward ST. CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital. Ann R Coll Surg Engl 2022; 104:100-105. [PMID: 34730424 PMCID: PMC9773912 DOI: 10.1308/rcsann.2021.0127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics. METHODS A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. RESULTS In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. CONCLUSION In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.
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Affiliation(s)
- S Snelling
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - R Ghaffar
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - ST Ward
- University Hospitals Birmingham NHS Foundation Trust, UK
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19
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Cerruti T, Maillard MH, Hugli O. Acute Lower Gastrointestinal Bleeding in an Emergency Department and Performance of the SHA 2PE Score: A Retrospective Observational Study. J Clin Med 2021; 10:jcm10235476. [PMID: 34884177 PMCID: PMC8658478 DOI: 10.3390/jcm10235476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 11/16/2022] Open
Abstract
Lower gastrointestinal bleeding (LGIB) is a frequent cause of emergency department (ED) consultation, leading to investigations but rarely to urgent therapeutic interventions. The SHA2PE score aims to predict the risk of hospital-based intervention, but has never been externally validated. The aim of our single-center retrospective study was to describe patients consulting our ED for LGIB and to test the validity of the SHA2PE score. We included 251 adult patients who consulted in 2017 for hematochezia of <24 h duration; 53% were male, and the median age was 54 years. The most frequent cause of LGIB was unknown (38%), followed by diverticular disease and hemorrhoids (14%); 20% had an intervention. Compared with the no-intervention group, the intervention group was 26.5 years older, had more frequent bleeding in the ED (47% vs. 8%) and more frequent hypotension (8.2% vs. 1.1%), more often received antiplatelet drugs (43% vs. 18%) and anticoagulation therapy (28% vs. 9.5%), more often had a hemoglobin level of <10.5 g/dl (49% vs. 6.2%) on admission, and had greater in-hospital mortality (8.2% vs. 0.5%) (all p < 0.05). The interventions included transfusion (65%), endoscopic hemostasis (47%), embolization (8.2%), and surgery (4%). The SHA2PE score predicted an intervention with sensitivity of 71% (95% confidence interval: 66–83%), specificity of 81% (74–86%), and positive and negative predictive values of 53% (40–65%) and 90% (84–95%), respectively. SHA2PE performance was inferior to that in the original study, with a 1 in 10 chance of erroneously discharging a patient for outpatient intervention. Larger prospective validation studies are needed before the SHA2PE score can be recommended to guide LGIB patient management in the ED.
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Affiliation(s)
- Titouan Cerruti
- Emergency Department, Lausanne University Hospital, 1011 Lausanne, Switzerland;
| | - Michel Haig Maillard
- Division of Gastroenterology and Hepatology, Lausanne University Hospital, 1011 Lausanne, Switzerland;
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, 1011 Lausanne, Switzerland;
- Faculty of Biology and Medicine, Lausanne University, 1011 Lausanne, Switzerland
- Correspondence:
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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Tse JR, Shen J, Shah R, Fleischmann D, Kamaya A. Extravasation Volume at Computed Tomography Angiography Correlates With Bleeding Rate and Prognosis in Patients With Overt Gastrointestinal Bleeding. Invest Radiol 2021; 56:394-400. [PMID: 33449577 DOI: 10.1097/rli.0000000000000753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Despite the identification of active extravasation on computed tomography angiography (CTA) in patients with overt gastrointestinal bleeding (GIB), a large proportion do not have active bleeding or require hemostatic therapy at endoscopy, catheter angiography, or surgery. The objective of our proof-of-concept study was to improve triage of patients with GIB by correlating extravasation volume of first-pass CTA with bleeding rate and clinical outcomes. MATERIALS AND METHODS All patients who presented with overt GIB and active extravasation on CTA from January 2014 to July 2019 were reviewed in this retrospective, institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study. Extravasation volume was assessed using 3-dimensional software and correlated with hemostatic therapy (primary endpoint) and with intraprocedural bleeding, blood transfusions, and mortality as secondary endpoints using logistic regression models (P < 0.0125 indicating statistical significance). Odds ratios were used to determine the effect size of a threshold extravasation volume. Quantitative data (extravasation volume, aorta attenuation, extravasation attenuation and time) were input into a mathematical model to calculate bleeding rate. RESULTS Fifty consecutive patients including 6 (12%) upper, 18 (36%) small bowel, and 26 (52%) lower GIB met inclusion criteria. Forty-two underwent catheter angiography, endoscopy, or surgery; 16 had intraprocedural active bleeding, and 24 required hemostatic therapy. Higher extravasation volumes correlated with hemostatic therapy (P = 0.007), intraprocedural active bleeding (P = 0.003), and massive transfusion (P = 0.0001), but not mortality (P = 0.936). Using a threshold volume of 0.80 mL or greater, the odds ratio of hemostatic therapy was 8.1 (95% confidence interval, 2.1-26), active bleeding was 11.8 (2.6-45), and massive transfusion was 18 (2.3-65). With mathematical modeling, extravasation volume had a direct and linear relationship with bleeding rate, and the lowest calculated detectable bleeding rate with CTA was less than 0.1 mL/min. CONCLUSIONS Larger extravasation volumes correlate with higher bleeding rates and may identify patients who require hemostatic therapy, have intraprocedural bleeding, and require blood transfusions. Current CTAs can detect bleeding rates less than 0.1 mL/min.
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Affiliation(s)
- Justin R Tse
- From the Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles
| | | | - Rajesh Shah
- Interventional Radiology, Stanford University School of Medicine, California
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Predicting the Outcome of Non-operative Management of Splenic Trauma in South Africa. World J Surg 2021; 44:1485-1491. [PMID: 31933042 DOI: 10.1007/s00268-020-05370-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION We aimed to expand on the global surgical discussion around splenic trauma in order to understand locally and clinically relevant factors for operative (OP) and non-operative management (NOM) of splenic trauma in a South African setting. METHODS A retrospective cohort study was performed using 2013-2017 data from the Pietermaritzburg Metropolitan Trauma Service. All adult patients (≥15 years) were included. Those managed with OP or NOM for splenic trauma were identified and analyzed descriptively. Multiple logistic regression analysis identified patients and clinical factors associated with management type. RESULTS There were 127 patients with splenic injury. Median age was 29 [19-35] years with 42 (33%) women and 85 (67%) men. Blunt injuries occurred in the majority (81, 64%). Organ Injury Scale (OIS) grades included I (25, 20%), II (43, 34%), III (36, 28%), IV (15, 11%), and V (8, 6%). Nine patients expired. On univariate analysis, increasing OIS was associated with OP management, need for intensive care unit (ICU) admission, and hospital and ICU duration of stay, but not mortality. In patients with a delayed compared to early presentation, ICU utilization (62% vs. 36%, p = 0.008) and mortality (14% vs. 4%, p = 0.03) were increased. After adjusting for age, sex, presence of shock, and splenic OIS, penetrating trauma (adjusted odds ratio, 5.7; 95%CI, 1.7-9.8) and admission lactate concentration (adjusted odds ratio, 1.4; 95%CI 1.1-1.9) were significantly associated with OP compared to NOM (p = 0.002; area under the curve 0.81). CONCLUSIONS We have identified injury mechanism and admission lactate as factors predictive of OP in South African patients with splenic trauma. Timely presentation to definitive care affects both ICU duration of stay and mortality outcomes. Future global surgical efforts may focus on expanding non-operative management protocols and improving pre-hospital care in patients with splenic trauma.
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Abstract
Colon ascendens stent peritonitis (CASP) is one of the well-established models of experimental abdominal sepsis. In CASP surgery, an open link between the gut lumen and the abdominal cavity is created by placing a stent into the colon ascendens. This mimics well the insufficient intestinal anastomosis. It causes a continuous leakage of the gut contents into the peritoneum and leads therefore to peritonitis and sepsis. The abdominal cavity is opened under general anesthesia and a plastic stent is located through and sutured to the colonic wall. The septic severity in CASP models can be titrated by altering the size of the stent catheter. Therefore, CASP models with small stents sizes are suitable for long-term studies and studies with mild/moderate sepsis severity. Within 24 h, animals develop clinical signs of sepsis. Monitoring of the clinical state, sufficient analgesia, appropriate antibiotics and fluid resuscitation should be performed postoperatively.
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Affiliation(s)
- Anna Herminghaus
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany.
| | - Olaf Picker
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
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Nguyen A, Orlando A, Yon JR, Mentzer CJ, Banton K, Bar-Or D. Predictors of splenectomy after failure of non-operative management: An analysis of the nation trauma database from 2013 to 2014. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408620911489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction There is practice variability in non-operative management (NOM) of blunt splenic trauma. This is particularly true for management decisions following failure of NOM, i.e. splenectomy versus angioembolization (AE). The objective of this study was to identify predictors of splenectomy versus AE in patients who failed NOM. Methods We included adult patients from the National Trauma Data Bank for 2013–2014, who had a splenic injury and who were admitted to a Level I Trauma Center (L1TC). Patients undergoing splenectomy after 2 h of emergency department arrival were deemed to have failed NOM. Multivariate logistic regression modeling was used to identify independent predictors of intervention after failed NOM. Results There were 2284 patients admitted for splenic injury between 2013 and 2014 who failed NOM. A total of 1253 patients underwent AE and 1031 patients underwent splenectomy. Seven independent factors were identified that predicted failure of NOM: penetrating injury, community L1TC, hospital bed size, number of trauma surgeons on call, functional dependence, chronic steroid use, and cirrhosis. Conclusions Seven independent variables were identified that predicted failure of NOM. These results contribute to the body of data regarding management of blunt splenic injury. Knowing predictive factors could help personalize management of patients, minimize delay of care, efficient resource allocation, and inform future studies.
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Affiliation(s)
| | - Alessandro Orlando
- Swedish Medical Center, Englewood, CO, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- The Medical Center of Plano, Plano, TX, USA
- Penrose Hospital, Colorado Springs, CO, USA
| | | | | | | | - David Bar-Or
- Swedish Medical Center, Englewood, CO, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- The Medical Center of Plano, Plano, TX, USA
- Penrose Hospital, Colorado Springs, CO, USA
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Abstract
INTRODUCTION Acute gastrointestinal (GI) bleed is a common reason for hospitalization with 2%-10% risk of mortality. In this study, we developed a machine learning (ML) model to calculate the risk of mortality in intensive care unit patients admitted for GI bleed and compared it with APACHE IVa risk score. We used explainable ML methods to provide insight into the model's prediction and outcome. METHODS We analyzed the patient data in the Electronic Intensive Care Unit Collaborative Research Database and extracted data for 5,691 patients (mean age = 67.4 years; 61% men) admitted with GI bleed. The data were used in training a ML model to identify patients who died in the intensive care unit. We compared the predictive performance of the ML model with the APACHE IVa risk score. Performance was measured by area under receiver operating characteristic curve (AUC) analysis. This study also used explainable ML methods to provide insights into the model's outcome or prediction using the SHAP (SHapley Additive exPlanations) method. RESULTS The ML model performed better than the APACHE IVa risk score in correctly classifying the low-risk patients. The ML model had a specificity of 27% (95% confidence interval [CI]: 25-36) at a sensitivity of 100% compared with the APACHE IVa score, which had a specificity of 4% (95% CI: 3-31) at a sensitivity of 100%. The model identified patients who died with an AUC of 0.85 (95% CI: 0.80-0.90) in the internal validation set, whereas the APACHE IVa clinical scoring systems identified patients who died with AUC values of 0.80 (95% CI: 0.73-0.86) with P value <0.001. DISCUSSION We developed a ML model that predicts the mortality in patients with GI bleed with a greater accuracy than the current scoring system. By making the ML model explainable, clinicians would be able to better understand the reasoning behind the outcome.
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Lee HS, Kang SH, Rou WS, Eun HS, Joo JS, Kim JS, Lee ES, Moon HS, Kim SH, Sung JK, Lee BS, Jeong HY. Computed tomography versus lower endoscopy as initial diagnostic method for evaluating patients with hematochezia at emergency room. Medicine (Baltimore) 2020; 99:e20311. [PMID: 32481401 DOI: 10.1097/md.0000000000020311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
For acute lower gastrointestinal bleeding (LGIB), lower gastrointestinal endoscopy is the preferred initial diagnostic test. However, it is difficult to perform urgently. Computed tomography (CT) is a convenient alternative.This study aimed to determine the diagnostic performance of CT compared to lower endoscopy as an initial test for evaluating acute LGIB.The medical records of 382 patients who visited our emergency department with hematochezia between January 2012 and January 2017 were retrospectively analyzed. Of them, 112 underwent CT, 65 underwent colonoscopy, and 205 underwent sigmoidoscopy as an initial test. For each method, sensitivity, specificity, positive predictive value, and negative predictive value were calculated upon active bleeding site detection and LGIB etiology diagnosis.The sensitivity, specificity, positive predictive value, and negative predictive value of CT for active bleeding site detection were 85.7%, 100%, 100%, and 96.9%, respectively, while those for identifying the etiology of LGIB were 87.4%, 40.0%, 83.5, and 47.6%, respectively.CT was not inferior to lower endoscopy for active bleeding site detection. Early localization and the exclusion of active bleeding were possible with CT. Etiology was diagnosed with high sensitivity and PPV by CT. Thus, CT can be an alternative initial diagnostic tool for evaluating acute LGIB.
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Affiliation(s)
- Hee Sung Lee
- Division of Gastroenterology, Department of Internal medicine, Chungnam National University School of Medicine, Daejeon, Korea
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Jarvis S, Salottolo K, Meinig R, Corrigan C, Patel N, Carrick M, Lieser M, Reynolds C, Bar-Or D. Utilization of pre-hospital pelvic circumferential compression devices for pelvic fractures: survey of U.S. level I trauma centers. Patient Saf Surg 2020; 14:12. [PMID: 32308738 PMCID: PMC7149863 DOI: 10.1186/s13037-020-00233-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/21/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There is a lack of data on the use and effectiveness of pre-hospital pelvic circumferential compression devices (PCCD) as a temporary intervention for pelvic fracture management; they are thought to decrease pelvic volume and hemorrhage but are not without risks. The purpose of this study is to examine pre-hospital PCCD practices at US Level I trauma centers. METHODS This was a prospective cross-sectional survey of trauma medical directors at US Level I trauma centers. The aim of this study was to describe patterns of pre-hospital PCCD utilization for pelvic fractures. Responses were compared by region, length in time the center was designated Level I, trauma patient volume, pelvic management guideline followed and blood product guidelines. Data were compared using Fisher's exact and chi-squared tests. RESULTS Of the 158 Level I trauma centers invited, 25% responded. All Level I trauma centers use in-hospital PCCDs, whereas 71% of participant's paramedic agencies trained on pre-hospital PCCD application. Of those, 44% trained to apply pre-hospital PCCDs to all suspected pelvic fractures. A higher proportion of high-volume centers (77%) than low-volume centers (25%) trained on pre-hospital PCCD placement, p = 0.06. PCCD practices were not dependent on the trauma center's region, trauma volume, length in time as a Level I trauma center, or pelvic fracture guideline followed. CONCLUSIONS There is widespread application of in-hospital and pre-hospital PCCD at US Level I trauma centers, however pre-hospital PCCDs are not applied to all suspected pelvic fractures. Future studies should focus on efficacy, safety, and contraindications for pre-hospital PCCDs.
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Affiliation(s)
| | | | - Richard Meinig
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Chad Corrigan
- Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214 USA
| | - Nimesh Patel
- St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - Mark Lieser
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO 64132 USA
| | | | - David Bar-Or
- ION Research, 383 Corona St. #319, Denver, CO 80218 USA
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
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Jarvis S, Kelly M, Mains C, Corrigan C, Patel N, Carrick M, Lieser M, Banton K, Bar-Or D. A descriptive survey on the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for pelvic fractures at US level I trauma centers. Patient Saf Surg 2019; 13:43. [PMID: 31857823 PMCID: PMC6909568 DOI: 10.1186/s13037-019-0223-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/03/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is not widely adopted for pelvic fracture management. Western Trauma Association recommends REBOA for hemodynamically unstable pelvic fractures, whereas Eastern Association for the Surgery of Trauma and Advanced Trauma Life Support do not. METHOD Utilizing a prospective cross-sectional survey, all 158 trauma medical directors at American College of Surgeons-verified Level I trauma centers were emailed survey invitations. The study aimed to determine the rate of REBOA use, REBOA indicators, and the treatment sequence of REBOA for hemodynamically unstable pelvic fractures. RESULTS Of those invited, 25% (40/158) participated and 90% (36/40) completed the survey. Nearly half of trauma centers [42% (15/36)] use REBOA for pelvic fracture management. All participants included hemodynamic instability as an indicator for REBOA placement in pelvic fractures. In addition to hemodynamic instability, 29% (4/14) stated REBOA is used for patients who are ineligible for angioembolization, 14% (2/14) use REBOA when interventional radiology is unavailable, 7% (1/14) use REBOA for patients with a negative FAST. Fifty percent (7/14) responded that hemodynamically unstable pelvic fractures exclusively indicates REBOA placement. Hemodynamic instability for pelvic fractures was most commonly defined as systolic blood pressure of < 90 [56% (20/36)]. At centers using REBOA, REBOA was the first line of treatment for hemodynamically unstable pelvic fractures 40% (6/15) of the time. CONCLUSIONS There is little consensus on REBOA use for pelvic fractures at US Level I Trauma Centers, except that hemodynamically unstable pelvic fractures consistently indicated REBOA use.
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Affiliation(s)
| | - Michael Kelly
- Orthopedic Trauma Surgeon, Penrose Hospital, 2222 North Nevada Ave. Colorado Springs, Englewood, CO 80907 USA
| | - Charles Mains
- Trauma Systems Director, Centura Health Systems, 9100 E. Mineral Circle, Centennial, CO 80112 USA
| | - Chad Corrigan
- Orthopedic Trauma Surgeon, Wesley Medical Center, 550 N Hillside St., Wichita, KS 67214 USA
| | - Nimesh Patel
- Orthopedic Trauma Surgeon, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Matthew Carrick
- Trauma Medical Director, Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - Mark Lieser
- Trauma Medical Director, Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO 64132 USA
| | - Kaysie Banton
- Trauma Medical Director, Swedish Medical Center, 501 E. Hampdem Ave., Englewood, CO 80113 USA
| | - David Bar-Or
- Trauma Research, LLC. 383 Corona St. #319, Denver, CO 80218 USA
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Jarvis S, Orlando A, Blondeau B, Banton K, Reynolds C, Berg GM, Patel N, Meinig R, Carrick M, Bar-Or D. The effect of orthopaedic surgeons' and interventional radiologists' availability on the priority treatment sequence for hemodynamically unstable pelvic fractures: a survey of US Level I trauma centers. J Orthop Surg Res 2019; 14:411. [PMID: 31801568 PMCID: PMC6894122 DOI: 10.1186/s13018-019-1417-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/15/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Most guidelines recommend both pelvic packing (PP) and angioembolization for hemodynamically unstable pelvic fractures, however their sequence varies. Some argue to use PP first because orthopaedic surgeons are more available than interventional radiologists; however, there is no data confirming this. METHODS This cross-sectional survey of 158 trauma medical directors at US Level I trauma centers collected the availability of orthopaedic surgeons and interventional radiologists, the number of orthopaedic trauma surgeons trained to manage pelvic fractures, and priority treatment sequence for hemodynamically unstable pelvic fractures. The study objective was to compare the availability of orthopaedic surgeons to interventional radiologists and describe how the availability of orthopaedic surgeons and interventional radiologists affects the treatment sequence for hemodynamically unstable pelvic fractures. Fisher's exact, chi-squared, and Kruskal-Wallis tests were used, alpha = 0.05. RESULTS The response rate was 25% (40/158). Orthopaedic surgeons (86%) were on-site more often than interventional radiologists (54%), p = 0.003. Orthopaedic surgeons were faster to arrive 39% of the time, and interventional radiologists were faster to arrive 6% of the time. There was a higher proportion of participants who prioritized PP before angioembolization at centers with above the average number (> 3) of orthopaedic trauma surgeons trained to manage pelvic fractures, as among centers with equal to or below average, p = 0.02. Arrival times for orthopaedic surgeons did not significantly predict prioritization of angioembolization or PP. CONCLUSIONS Our results provide evidence that orthopaedic surgeons typically are more available than interventional radiologists but contrary to anecdotal evidence most participants used angioembolization first. Familiarity with the availability of orthopaedic surgeons and interventional radiologists may contribute to individual trauma center's treatment sequence.
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Affiliation(s)
- S. Jarvis
- Clinical Epidemiologist, ION Research, 383 Corona St. #319, Denver, CO 80218 USA
| | - A. Orlando
- Clinical Epidemiologist, ION Research, 383 Corona St. #319, Denver, CO 80218 USA
| | - B. Blondeau
- Research Medical Center, 2316 East Meyer Blvd., Kansas City, MO 64132 USA
- University of Connecticut Hartford Hospital, Hartford, CT 06106 USA
| | - K. Banton
- Swedish Medical Center, 501 E Hampden Ave., Englewood, CO 80113 USA
| | - C. Reynolds
- Swedish Medical Center, 501 E Hampden Ave., Englewood, CO 80113 USA
| | - G. M. Berg
- Wesley Medical Center, 550 N. Hillside St., Wichita, KS 67214 USA
| | - N. Patel
- Orthopaedic Trauma Surgeon, St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - R. Meinig
- Orthopaedic Trauma Surgeon, Penrose Hospital, 2222 North Nevada Ave., Colorado Springs, CO 80907 USA
| | - M. Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - D. Bar-Or
- Swedish Medical Center, 501 E Hampden Ave., Englewood, CO 80113 USA
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The impact of a multidisciplinary algorithmic approach to acute lower gastrointestinal bleeding. Am J Emerg Med 2019; 37:1751-1753. [DOI: 10.1016/j.ajem.2019.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/19/2022] Open
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Jarvis S, Orlando A, Blondeau B, Banton K, Reynolds C, Berg GM, Patel N, Kelly M, Carrick M, Bar-Or D. Variability in the timeliness of interventional radiology availability for angioembolization of hemodynamically unstable pelvic fractures: a prospective survey among U.S. level I trauma centers. Patient Saf Surg 2019; 13:23. [PMID: 31249625 PMCID: PMC6587295 DOI: 10.1186/s13037-019-0201-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with hemodynamically unstable pelvic fractures have high mortality due to delayed hemorrhage control. We hypothesized that the availability of interventional radiology (IR) for angioembolization may vary in spite of the mandated coverage at US Level I trauma centers, and that the priority treatment sequence would depend on IR availability. METHODS This survey was designed to investigate IR availability and pelvic fracture management practices. Six email invitations were sent to 158 trauma medical directors at Level I trauma centers. Participants were allowed to skip questions and irrelevant questions were skipped; therefore, not all questions were answered by all participants. The primary outcome was the priority treatment sequence for hemodynamically unstable pelvic fractures. Predictor variables were arrival times for IR when working off-site and intervention preparation times. Kruskal-Wallis and ordinal logistic regression were used; alpha = 0.05. RESULTS Forty of the 158 trauma medical directors responded to the survey (response rate: 25.3%). Roughly half of participants had 24-h on-site IR coverage, 24% (4/17) of participants reported an arrival time ≥ 31 min when IR was on-call. 46% (17/37) of participants reported an IR procedure setup time of 31-120 min. Arrival time when IR was working off-site, and intervention preparation time did not significantly affect the sequence priority of angioembolization for hemodynamically unstable pelvic fractures. CONCLUSIONS Trauma medical directors should review literature and guidelines on time to angioembolization, their arrival times for IR, and their procedural setup times for angioembolization to ensure utilization of angioembolization in an optimal sequence for patient survival.
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Affiliation(s)
| | | | - Benoit Blondeau
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO 64132 USA
- University of Connecticut, Hartford Hospital, Hartford, CT 06106 USA
| | - Kaysie Banton
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
| | | | - Gina M. Berg
- Wesley Medical Center, 550 N. Hillside St, Wichita, KS 67214 USA
| | - Nimesh Patel
- St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Michael Kelly
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - David Bar-Or
- Trauma Research, LLC, 383 Corona St. #319, Denver, CO 80218 USA
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
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Tolonen M, Sallinen V, Leppäniemi A, Bäcklund M, Mentula P. The role of the intra-abdominal view in complicated intra-abdominal infections. World J Emerg Surg 2019; 14:15. [PMID: 30976292 PMCID: PMC6441193 DOI: 10.1186/s13017-019-0232-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/05/2019] [Indexed: 12/29/2022] Open
Abstract
Background The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality. Methods The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission. Results A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05–3.73), diffuse peritonitis (OR 2.15, 1.02–4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12–15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11–30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions. Conclusions The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems. Trial registration The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932). Electronic supplementary material The online version of this article (10.1186/s13017-019-0232-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matti Tolonen
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Ville Sallinen
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland.,2Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ari Leppäniemi
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Minna Bäcklund
- 3Department of Anesthesiology, Intensive Care and Pain Medicine, Division of Intensive Care Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
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Self D, Reece M, Dilernia S. Predicting the need for transfer and interventional angiography for patients with acute colonic haemorrhage in a regional setting. ANZ J Surg 2019; 89:E109-E112. [PMID: 30856681 DOI: 10.1111/ans.15064] [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: 03/28/2018] [Revised: 11/07/2018] [Accepted: 12/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Radiological angioembolization is an important strategy in management of acute colonic bleeding. Due to requirement for specialized interventional radiology, many hospitals rely on transfer for this service. This study aimed to identify patient and clinical factors associated with positive (blush) computed tomography mesenteric angiogram (CTMA) or need for invasive angiography. The secondary aim was to identify a patient population who may forego transfer and be safely managed in a regional centre. METHODS All presentations to Central Coast Local Health District with colonic bleeding from June 2013-June 2017 were included. A guideline for transfer of patients with positive CTMA from Central Coast Local Health District to Royal North Shore Hospital had been established prior to the study period. Demographics, medical background, transfusion requirement, presentation details and mortality data were collected on all patients. RESULTS Of 2378 patients presenting with colonic bleeding, 71 of 247 patients investigated with CTMA had a blush. Forty-six patients were transferred to Royal North Shore Hospital. Of these, 28 proceeded to interventional angiography with 19 undergoing angioembolization. Acute transfusion ≥5 units (odds ratio 6.78, P < 0.01) was the only significant predictor of needing interventional angiography. There was no association between age, bleeding site (right or left), use of antiplatelet or anticoagulation, diverticular disease or chronic kidney disease and identification of arterial bleeding on interventional angiography. There was no mortality or significant procedure-related morbidity. CONCLUSION A patient's medical background demonstrates a lack of correlation to identification of active bleeding on interventional angiography. Patients requiring ≥5 units blood transfusion should be considered for transfer and interventional angiography.
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Affiliation(s)
- Duncan Self
- Department of General Surgery, Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Mifanwy Reece
- Department of General Surgery, Concord Repatriation Hospital, Sydney, New South Wales, Australia
| | - Shannon Dilernia
- Department of General Surgery, Central Coast Local Health District, Gosford, New South Wales, Australia
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Blondeau B, Orlando A, Jarvis S, Banton K, Berg GM, Patel N, Meinig R, Tanner A, Carrick M, Bar-Or D. Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers. Patient Saf Surg 2019; 13:3. [PMID: 30675184 PMCID: PMC6334446 DOI: 10.1186/s13037-019-0183-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mortality from hemodynamically unstable pelvic fractures remains high. Guidelines offer varying care approaches including the use of pelvic packing (PP), which was recently adopted for potential control of bleeding for this condition. However, the implementation of PP is uncertain as the debate on the optimal resuscitation strategy, angioembolization or PP continues. The study was designed to assess current practices among level 1 trauma centers in the US in regard to PP treatment for hemodynamically unstable pelvic fractures. METHODS A cross-sectional survey was created to assess when to apply PP, application approach, and the respondent's anecdotal perception on safety and effectiveness. Trauma Medical Directors at 158 US level 1 trauma centers were sent biweekly email invitations for 3 months. Participants were allowed to skip questions for any reason. The study hypothesis was that PP practices vary by US census bureau region, annual trauma admissions, and length of time in years since each trauma center received their respective level 1 trauma center designation. RESULTS Twenty-five percent (40/158) of trauma medical directors participated and 75% (118/158) of the trauma medical directors did not participate. Of those who took the survey, 36/40 (90%) completed the survey and 4/40 (10%) partially completed the survey. Only 36 trauma medical directors responded on their perception of safety and effectiveness; 72% (26/36) of participants perceived PP as safe, whereas only a third (12/36) of participants perceived PP as effective. There were 25 trauma medical directors who provided the sequence of treatment modalities utilized at their level 1 trauma center, 76% (19/25) of participants reported that PP is utilized as the third or fourth priority. None of the participating level 1 trauma centers reported a preference towards utilization of PP as the first priority treatment. Half of the participants reported a preference towards applying PP only as a last resort to control hemorrhage. Northeastern and Western level 1 trauma centers were significantly more likely than Midwestern and Southern level 1 trauma centers to have reported application of PP to all hemodynamically unstable patients (p = 0.05). Midwestern, Southern, and Western level 1 trauma centers were significantly more likely to have perceived PP as safe than Northeastern level 1 trauma centers (p = 0.04). All low-volume and 38% high-volume level 1 trauma centers perceived PP to increase infection risks, (p = 0.03). We observed no association between the length of time each trauma center was designated a level 1 trauma center, and all participant responses. CONCLUSION Controversy and varying anecdotal perception regarding safety and effectiveness of PP prevails among trauma medical directors at level 1 trauma centers in the US.
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Affiliation(s)
- Benoit Blondeau
- Research Medical Center, 2316 East Meyer Blvd., Kansas City, MO 64132 USA
- University of Connecticut, Hartford Hospital, Hartford, CT 06106 USA
| | | | - Stephanie Jarvis
- Trauma Research, LLC., 383 Corona St. #319, Denver, CO 80218 USA
| | - Kaysie Banton
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
| | - Gina M. Berg
- Wesley Medical Center, 550 N. Hillside St, Wichita, KS 67214 USA
| | - Nimesh Patel
- St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Rick Meinig
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Allen Tanner
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - David Bar-Or
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
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Abstract
Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.
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Abstract
PURPOSE OF REVIEW Acute gastrointestinal bleeding is a frequent emergency situation, whose incidence will likely rise as a result of the increasing use of direct anticoagulants and of the medical progresses resulting in longer life expectancy with underlying comorbidities. Updated guidelines and improvements in the diagnostic and therapeutic tools are now available and will likely improve the management of massive gastrointestinal bleeding in the near future. RECENT FINDINGS The assessment of severity has been improved by validated scores useable upon admission. Massive blood transfusion protocols and specific care in case of bleeding of patients treated with direct anticoagulants, including concentrates of coagulation factors and monoclonal antibodies are now available. The endoscopic management has been facilitated by the use of hemostatic powders and by the use of self-expanding metal stents in case of variceal hemorrhage. New diagnostic tools include emergency video-capsule endoscopy, multiphasic computed tomography angiography and enterography. SUMMARY The implementation of multidisciplinary diagnostic and therapeutic algorithms for the management of massive bleeding requires a close collaboration between emergency physicians, intensivists, endoscopists, radiologists and surgeons. A sequential strategy involving each of these specialists is desirable for a successful management of acute and massive gastrointestinal bleeding.
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Wells ML, Hansel SL, Bruining DH, Fletcher JG, Froemming AT, Barlow JM, Fidler JL. CT for Evaluation of Acute Gastrointestinal Bleeding. Radiographics 2018; 38:1089-1107. [PMID: 29883267 DOI: 10.1148/rg.2018170138] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute gastrointestinal (GI) bleeding is common and necessitates rapid diagnosis and treatment. Bleeding can occur anywhere throughout the GI tract and may be caused by many types of disease. The variety of enteric diseases that cause bleeding and the tendency for bleeding to be intermittent may make it difficult to render a diagnosis. The workup of GI bleeding is frequently prolonged and expensive, with examinations commonly needing to be repeated. The use of computed tomography (CT) for evaluation of acute GI bleeding is gaining popularity because it can be used to rapidly diagnose active bleeding and nonbleeding bowel disease. The CT examinations used to evaluate acute GI bleeding include CT angiography and multiphase CT enterography. Understanding the clinical evaluation of acute GI bleeding, including the advantages and limitations of endoscopic evaluation, is necessary for the appropriate selection of patients who may benefit from CT. Multiphase CT enterography is used primarily to evaluate stable patients who have undergone upper and lower endoscopy without identification of a bleeding source. CT angiography is used to examine stable and unstable patients who respond to resuscitation, are believed to be actively bleeding, and are considered unlikely to have an upper GI source of hemorrhage. In the emergent setting, CT may yield critical information regarding the presence, location, and cause of active bleeding-data that can guide the choice of subsequent therapy. Recent developments in the use of and techniques for performing CT angiography have made it a potential first-line tool for evaluating acute GI bleeding. ©RSNA, 2018.
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Affiliation(s)
- Michael L Wells
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Stephanie L Hansel
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - David H Bruining
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Joel G Fletcher
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Adam T Froemming
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - John M Barlow
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Jeff L Fidler
- From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Hepatocholangiocarcinoma/intrahepatic cholangiocarcinoma: are they contraindication or indication for liver transplantation? A propensity score-matched analysis. Hepatol Int 2018; 12:167-173. [PMID: 29450868 DOI: 10.1007/s12072-018-9847-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Uncommon primary hepatic malignancies such as intrahepatic cholangiocarcinoma (ICC) and hepatocholangiocarcinoma (HCC-CC) were generally considered contraindications for liver transplantation(LT), and studies comparing the efficacy of LT and resection (LR) for ICC/HCC-CC were scarce. OBJECTIVE To compare the survival outcomes of ICC/HCC-CC patients treated by LT and LR in a propensity score-matched population. METHOD This is a retrospective study from 1995 to 2015. Consecutive patients with the pathological diagnosis of ICC or HCC-CC in the surgical specimens were included. All patients had either hepatectomy or LT with curative intent. Factors associated with survival were identified with multivariate analysis using cox-regression model. Propensity score-matched analysis was performed. RESULT There were 181 patients diagnosed to have ICC/HCC_CC. Nine patients received LT (all with incidental ICC/HCC-CC) and 172 received hepatectomy. The median follow-up period was 27.5 months. The median age was 60 years (range 3-86); Hepatitis B and C carrier status was found in 48.1 and 2.3% of the patients, respectively. The median tumor size was 6 cm and 71.3% of them had solitary tumor. Microvascular invasion was present in 47% of the patients. After propensity score matching, there were 54 (9 in LT and 45 in LR group) patients for analysis. Cox-regression analysis showed that early AJCC (7th) staging and LT were the independent factors associated with overall survival. Patients in the LT group had significantly better overall survival (5-year OS 77.8 vs 36.6%, log-rank p = 0.013). CONCLUSION ICC/HCC-CC are uncommon tumors with poor long-term oncological outcomes despite curative hepatectomy. Liver transplantation might be a better treatment option for patients with early ICC/HCC-CC.
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Hemicorporectomy as a life-saving strategy for severe pelvic ring crush injury: a case report. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:735-739. [PMID: 29427094 DOI: 10.1007/s00590-018-2140-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/27/2018] [Indexed: 10/18/2022]
Abstract
Hemicorporectomy is an ultra-radical surgery used only in extreme circumstances. Initially used for advanced pelvic neoplastic diseases and intractable pelvic infection, it may also be the only treatment option in patients with crushed pelvic trauma, in cases there are no reconstruction options. This procedure has a high mortality, and its success depends on the multidisciplinary approach, both in the initial phase and in the rehabilitation process. We present the case of a young patient with severe pelvic trauma that required a hemicorporectomy as the only treatment option and review of the literature.
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Oakland K, Isherwood J, Lahiff C, Goldsmith P, Desborough M, Colman KS, Guy R, Uberoi R, Murphy MF, East JE, Hopewell S, Jairath V. Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review. Endosc Int Open 2017; 5:E959-E973. [PMID: 28975147 PMCID: PMC5624283 DOI: 10.1055/s-0043-117958] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Investigations for lower gastrointestinal bleeding (LGIB) include flexible sigmoidoscopy, colonoscopy, computed tomographic angiography (CTA), and angiography. All may be used to direct endoscopic, radiological or surgical treatment, although their optimal use is unknown. The aims of this study were to determine the diagnostic and therapeutic yields of endoscopy, CTA, and angiography for managing LGIB, and their influence on rebleeding, transfusion, and hospital stay. PATIENTS AND METHODS A systematic search of MEDLINE, PubMed, EMBASE, and CENTRAL was undertaken to identify randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) published between 2000 and 12 November 2015 in patients hospitalized with LGIB. Separate meta-analyses were conducted, presented as pooled odds (ORs) or risk ratios (RR) with 95 % confidence intervals (CIs). RESULTS Two RCTs and 13 NRSIs were included, none of which examined flexible sigmoidoscopy, or compared endotherapy with embolization, or investigated the timing of CTA or angiography. Two NRSIs (57 - 223 participants) comparing colonoscopy and CTA were of insufficient quality for synthesis but showed no difference in diagnostic yields between the two interventions. One RCT and 4 NRSIs (779 participants) compared early colonoscopy (< 24 hours) with colonoscopy performed later; meta-analysis of the NRSIs demonstrated higher diagnostic and therapeutic yields with early colonoscopy (OR 1.86, 95 %CI 1.12 to 2.86, P = 0.004 and OR 3.08, 95 %CI 1.93 to 4.90, P < 0.001, respectively) and reduced length of stay (mean difference 2.64 days, 95 %CI 1.54 to 3.73), but no difference in transfusion or rebleeding. CONCLUSIONS In LGIB there is a paucity of high-quality evidence, although the limited studies on the timing of colonoscopy suggest increased rates of diagnosis and therapy with early colonoscopy.
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Affiliation(s)
| | - Jennifer Isherwood
- Department of General Surgery, Milton Keynes Hospital, Milton Keynes, United
Kingdom
| | - Conor Lahiff
- Translational Gastroenterology Unit, University of Oxford, John Radcliffe
Hospital, Oxford, United Kingdom
| | - Petra Goldsmith
- Department of Transplantation, Royal Liverpool Hospital, Liverpool, United
Kingdom
| | | | | | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, United
Kingdom
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals, Oxford,
United Kingdom
| | | | - James E. East
- Translational Gastroenterology Unit, University of Oxford, John Radcliffe
Hospital, Oxford, United Kingdom
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, United
Kingdom
| | - Vipul Jairath
- Division of Epidemiology and Biostatistics, Western University, London,
Ontario, Canada
- Department of Medicine, Division of Gastroenterology, University Hospital,
London, Ontario, Canada
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