THE PATIENT-SPECIFIC INJURY SCORE: PRECISION MEDICINE IN TRAUMA PATIENTS PREDICTS ORGAN DYSFUNCTION AND OUTCOMES

poster abstractIntroduction: Current injury scoring systems in polytraumatized patients are limited at predicting patient outcomes. We present a novel method that quantifies mechanical tissue damage and cumulative hypoperfusion using a precision medicine approach. We hypothesized that a Patient-Specific Injury score formulated from individualized injury indices would stratify patient risk for developing organ dysfunction after injury. We compared correspondence between PSI and the Injury Severity Score with outcomes of organ dysfunction and MOF. Methods: Fifty Multiply-injured-patients (MIPs) were studied. Tissue Damage Volume scores were measured from admission pan-axial CT scans using purpose-designed post-processing software to quantify volumetric magnitude and distribution of injuries. Ischemic injury was quantified using Shock Volumes. SV is a time-magnitude integration of shock index. Values above 0.9 were measured in the 24-hours after injury. Metabolic response was quantified by subtracting the lowest first 24 hr pH from 7.40. PSI combines these indices into the formula: PSI=[0.2TDV+SV]*MR. Correspondence coefficients from regression modeling between PSI and organ dysfunction, measured by the Marshall Multiple Organ Dysfunction score averaged from days 2-5 post-injury, were compared to similar regression models of ISS vs. day 2-5 MOD-scores. We compared PSI and ISS in patients that did or did not develop MOF. Results: PSI demonstrated better correlation to organ dysfunction (r2=0.576) in comparison to ISS (r2=0.393) using the MOD-score on days 2-5. Mean PSI increased 3.4x(58.5vs.17.0;p<0.02) and ISS scores increased 1.4x(39.0vs.28.0;p=0.10) in patients that developed MOF versus those that did not. Conclusions: This study shows that a precision medicine approach that integrates patient-specific indices of mechanical tissue damage, ischemic tissue injury, and metabolic response better corresponds to phenotypic changes including organ dysfunction and MOF compared to ISS in MIPs. The PSI-score can be calculated within 24 hours of injury, making it useful for stratifying risk and predicting the magnitude of organ dysfunction to anticipate

Financial Toxicity Is Associated With Worse Physical and Emotional Long-term Outcomes After Traumatic Injury

Background Increasing healthcare costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health related quality of life outcomes (HRQOL). The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQOL. Methods Adult patients with an injury severity score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1, 2, 4 and 12 months. Screens for depression and post-traumatic stress syndrome (PTSD) were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. Results 500 patients were enrolled and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80–85%). Factors independently associated with financial toxicity were lower age (OR 0.96 [0.94–0.98]), and lack of health insurance (OR 0.28 [0.14–0.56]) and larger household size (OR 1.37 [1.06–1.77]). After risk adjustment, patients with financial toxicity had worse HRQOL, and more depression and PTSD in a step-wise fashion based on severity of financial toxicity. Conclusions Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified and interventions to counteract the negative effects should be developed to improve long-term outcomes. Level of Evidence Prognostic/epidemiologic study, level II

Intestinal Ischemia-Reperfusion Injury Alters Purinergic Receptor Expression in Clinically Relevant Extraintestinal Organs

Intestinal ischemia-reperfusion (IIR) injury is known to initiate the systemic inflammatory response syndrome which often progresses to multiple organ failure. We investigated changes in purinoceptor expression in clinically relevant extra-intestinal organs following IIR injury

Splenic artery embolization: technically feasible but not necessarily advantageous.

The spleen is the second most commonly injured organ in cases of abdominal trauma. Management of splenic injury depends on the clinical status of the patient and can include nonoperative management (NOM), splenic artery embolization (SAE), surgery (operative splenic salvage or splenectomy), or a combination of these treatments. In nonoperatively managed cases, SAE is sometimes used to control haemorrhage. However, the indications for SAE have not been clearly defined and, in some cases, the potential complications of the procedure may outweigh its benefits.This article is freely available via Open Access. Click on the Additional Link above to access the full-text via the publisher's site

Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review

Background The management of asymptomatic blunt cerebrovascular injury (BCVI) with respect to stroke prevention and vessel healing is challenging.Objectives The aim of this systematic review was to determine if a specific treatment results in lower stroke rates and/or improved vessel healing in asymptomatic BCVI.Data sources An electronic literature search of MEDLINE, EMBASE, Cochrane Library, CINAHL, SCOPUS, Web of Science, and ClinicalTrials.gov performed from inception to March 2020.Study eligibility criteria Studies were included if they reported on a comparison of any treatment for BCVI and stroke and/or vessel healing rates.Participants and interventions Adult patients diagnosed with asymptomatic BCVI(s) who were treated with any preventive medication or procedure.Study appraisal and synthesis methods All studies were systematically reviewed and bias was evaluated by the Newcastle-Ottawa Scale. No meta-analysis was performed secondary to significant heterogeneity across studies in patient population, screening protocols, and treatment selection. The main outcomes were stroke and healing rate.Results Of 8781 studies reviewed, 19 reported on treatment effects for asymptomatic BCVI and were included for review. Any choice of medical management was better than no treatment, but no specific differences between choice of medical management and stroke outcomes were found. Vessel healing was rare and the majority of healed vessels were following low-grade injuries.Limitations Majority of the included studies were retrospective and at high risk of bias.Conclusions or implications of key findings Asymptomatic BCVI should be treated medically using a consistent, local protocol. High-quality studies on the effect of individual antithrombotic agents on stroke rates and vessel healing for asymptomatic BCVI are required

Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries

Background: Management strategies for blunt solid viscus injuries often include blood transfusion. However, transfusion has previously been identified as an independent predictor of mortality in unselected trauma admissions. We hypothesized that transfusion would adversely affect mortality and outcome in patients presenting with blunt hepatic and splenic injuries after controlling for injury severity and degree of shock. Methods: We retrospectively reviewed records from all adults with blunt hepatic and/or splenic injuries admitted to a Level I trauma center over a 4-year period. Demographics, physiologic variables, injury severity, and amount of blood transfused were analyzed. Univariate and multivariate analysis with logistic and linear regression were used to identify predictors of mortality and outcome. Results: One hundred forty-three (45%) of 316 patients presenting with blunt hepatic and/or splenic injuries received blood transfusion within the first 24 hours. Two hundred thirty patients (72.8%) were selected for nonoperative management, of whom 75 (33%) required transfusion in the first 24 hours. Transfusion was an independent predictor of mortality in all patients (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.014) and in those managed nonoperatively (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043) after controlling for indices of shock and injury severity. The risk of death increased with each unit of packed red blood cells transfused (OR per unit, 1.16; 95% CI, 1.10-1.24; p \u3c 0.0001). Blood transfusion was also an independent predictor of increased hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.005). Conclusion: Blood transfusion is a strong independent predictor of mortality and hospital length of stay in patients with blunt liver and spleen injuries after controlling for indices of shock and injury severity. Transfusion-associated mortality risk was highest in the subset of patients managed nonoperatively. Prospective examination of transfusion practices in treatment algorithms of blunt hepatic and splenic injuries is warranted. Copyright © 2005 by Lippincott Williams & Wilkins, Inc