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With the increasing prevalence of obesity, there has been a parallel increase in the incidence of rectal cancer. The association of body mass index (BMI) and end-colostomy creation versus primary anastomosis in patients undergoing proctectomy for rectal cancer has not been described. This is a retrospective study of patients with rectal cancer from 2012 to 2018 using data from the National Surgical Quality Improvement Project. 16,446 (92.1%) underwent primary anastomosis and 1,418 (7.9%) underwent creation of an end-colostomy. Patients with a BMI of 25-29.9 (overweight) comprised the most frequent group to have a proctectomy (reference group), but the least likely to have an end-colostomy. Patients with severe obesity (BMI 50+) had an adjusted odds ratio for end-colostomy of 2.7 (95% CI 1.5-4.7) compared to the reference group. Patients who have severe obesity should be counseled regarding the likelihood of an end-colostomy and may benefit from medical weight management or weight-loss surgery. [ABSTRACT FROM AUTHOR]

Background: Studies indicate a link between allogeneic blood transfusion and venous thromboembolism (VTE) post‐major surgery. Analyzing trends and predictors of these outcomes after hepatectomy can inform risk management. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used for a retrospective analysis. Primary outcomes were perioperative red blood cell (RBC) transfusion and VTE events within 30 days of hepatectomy. Seven‐year trends and predictors were evaluated. Results: Among 29,131 hepatectomy patients, transfusion rates showed no statistically significant decreasing trends (p =.122) from 2014 to 2020 (18.13%–16.71%), while VTE rates showed a downward trend over the 7 years (p =.021); 17.2% received RBC transfusion, with higher rates in surgeries lasting ≥282 min (median: 220 min). Calculated RBC mass [hematocrit (%) × body weight (kg) × 10−5 × 70/√(body mass index/22)] at or below 1.5 L substantially increased transfusion odds. VTE was reported postoperatively in 2.6% of cases more frequently in longer cases involving transfusions. The adjusted odds ratio (aOR) of VTE escalated from the shortest operative time to the longest (3.17; 95% confidence interval [CI], 2.37–4.22). The adjusted odds of VTE doubled for transfused patients compared to non‐transfused patients (aOR, 2.19; 95% CI, 1.86–2.57). Conclusions: Rates of RBC transfusion and VTE rates hepatectomy have minimally changed in the recent years. VTE prevention is challenging in extended surgeries at increased risk of bleeding and RBC transfusions. Patient‐level data on coagulation and thromboprophylaxis can potentially refine risk assessment for postoperative VTE. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection (SSI) is an infrequent but costly complication after elective spine surgery. Identification of important temporal changes and predictive factors may inform targeted prevention efforts. Patients and Methods: A retrospective study of elective spine surgery patients was performed using the National Surgical Quality Improvement Programs (NSQIP) database from 2011 and 2019. Temporal changes in SSI and related factors were examined descriptively. Recursive partitioning and bootstrap forest techniques were used to inform the development of predictive models for SSI. Results: A total of 6,038 (1.66%) of 363,754 patients had an SSI recorded. Peri-operative transfusion and preoperative anemia decreased over the nine-year period, however, obesity and diabetes mellitus increased, whereas the SSI rate remained essentially unchanged. A full model including 15 variables had an area under the curve (AUC) of 0.693 (95% confidence interval [CI], 0.686–0.700) whereas a reduced model with just nine variables had an AUC of 0.690 (95% CI, 0.683–0.697). Adjusted odd ratios (aOR) greater than two were noted for only three variables; a posterior approach (aOR, 2.32; 95% CI, 2.14–2.50), body mass index (BMI) >40 kg/m2 (aOR, 2.63; 95% CI, 2.39–2.90), and surgical duration longer than 350 minutes (aOR, 2.39; 95% CI, 2.14–2.67). Remaining retained variables included albumin <3.5 g/dL, inpatient procedure, peri-operative transfusion, diabetes mellitus (both insulin/non-insulin), anemia, and smoking. Conclusions: Surgical site infection rate remained unchanged over a nine-year period despite the lower rates of allogeneic blood transfusion. Class 3 obesity, long operative times, and a posterior approach mainly for thoracic/lumbar spine procedures seemed more pragmatic, but their predictive performance was only modest in our prediction models for SSI. [ABSTRACT FROM AUTHOR]

Incidence of colorectal cancer (CRC) among young patients has increased in the last 20 y often with more aggressive tumor biology. It is unclear if age < 50 y is an independent factor for shorter overall survival in CRC patients. Our objective was to determine if younger age at diagnosis was associated with worse overall survival. This study used the National Cancer Data Base (2004-2016), retrospectively reviewing patients who underwent surgical resection for CRC. Patients were limited to only those without comorbidities and primary outcome was overall survival for all patients. Older patients have worse overall survival as compared to younger patients at a lower stage of disease (I and II) after adjusting for tumor location, gender, histology, stage, and systemic chemotherapy (< 36 y old versus 36-55 y old hazard ratio [HR] 1.16, confidence interval [CI] 1.03-1.29). This survival benefit is eliminated at a higher stage of disease, stage III in 36-55 y old versus < 36 y old (HR 0.96 [CI 0.90-1.03.99]) and stage IV (HR 0.94 [CI 0.89-0.99]). Older patients (aged > 36 y) have worse overall survival at a lower stage of disease, but the survival among all age groups was similar for stage III or IV disease in CRC. [ABSTRACT FROM AUTHOR]

The article discusses a multivariate model developed by Zhang et al. to predict the risk of red blood cell (RBC) transfusion in patients undergoing cardiopulmonary bypass (CPB). The model's predictive ability was impressive, but there are concerns about its scope and methodology. The authors used the Delphi method to select variables for the model, which introduces human error and selection bias. They also failed to adjust the model for potential variability in risk profile associated with emergent CPB surgery. The generalizability of the model for the Asian population is also questioned due to population-dependent risk factors. Additionally, the model's accuracy in predicting transfusion risk in the highest risk category is questionable. Overall, the article suggests that further research is needed to refine and expand on predictive tools for transfusion risk. [Extracted from the article]

Simple Summary: Colorectal cancer (CRC) is one of the leading causes of cancer-related death, with an increasing incidence in younger patients presenting with more aggressive tumor biology. One clinical marker of immune response that has been studied and found to correlate with overall survival and cancer-specific survival is the lymph node ratio. The goal of our study was to find if age alone, adjusting for known factors that impact nodal harvest, independently impacted lymph node ratio in CRC. We found that age does not impact lymph node ratio in a clinically relevant manner, but that lymph node ratio is strongly corelated with grade and histology of the tumor. Introduction: Colon cancer among young patients has increased in incidence and mortality over the past decade. Our objective was to determine if age-related differences exist for total positive nodes (TPN), total lymph node harvest (TLH), and lymph node ratio (LNR). Material and Methods: A retrospective review of stage III surgically resected colorectal cancer patient data in the National Cancer Database (2004–2016) was performed, reviewing TPN, TLH, and LNR (TPN/TLH). Results: Unadjusted analyses suggested significantly higher levels of TLH and TPN (p < 0.0001) in younger patients, while LNR did not differ by age group. On adjusted analysis, TLH remained higher in younger patients (<35 years 1.56 (CI 95 1.54, 1.59)). The age-related effect was less pronounced for LNR (<35 years 1.16 (CI 95 1.13, 1.2)). Conclusion: Younger patients have increased TLH, even after adjusting for known confounders, while age does not have a strong independent impact on LNR. [ABSTRACT FROM AUTHOR]

Objective: This study deals with headache in relation to other major sequelae of traumatic brain injury (TBI) in veterans of Iraq and Afghanistan wars over 8 years after experiencing a deployment‐related TBI (DTBI). Background: TBI occurred in 14%–23% of veterans deployed to the Iraq or Afghanistan campaigns. This study evaluates sequelae of TBI (STBI) over 1–8 years after a DTBI. Methods: This is a secondary, cross‐sectional analysis of previously collected data, which was taken from review of medical records of the first 500 veterans with a DTBI seen in the TBI clinic of the Oklahoma City Veterans Health Center. This report deals with five of the most common STBIs and represents the presence and severity of, or absence of, the particular symptom at the time of a patient's initial visit to the clinic. All subjects were evaluated between June 1, 2008, and April 30, 2011. The STBI used here include: headache, dizziness, balance, coordination difficulties, and difficulty with decisions. In the TBI clinic, the burden of these symptoms was evaluated with a Likert Scale of none, mild, moderate, severe, or very severe. For this report, the scale was compressed into three categories: none, mild/moderate, and severe/very severe. Data were complete for age at TBI and mechanism of TBI in 500 subjects, for symptom severity in 497 subjects, for TBI severity in 491 subjects, and for presence of prior TBI in 496 subjects. Results: For the 497 subjects with complete symptom severity data, headache was seen in 476 (95.8%) and absent in 21 (4.2%). Regarding headache severity, 236 (47.5%) reported mild/moderate and 240 (48.3%) reported severe/very severe headache burden. For other sequelae, including severity of dizziness, balance, and coordination problems, these symptoms were absent in 85 (17.1%), 85 (17.1%), and 106 (21.3%) patients, respectively; of mild/moderate severity in 356 (71.6%), 355 (71.4%), and 321 (64.6%) patients; and of severe/very severe intensity in 56 (11.3%), 57 (11.5%), and 70 (14.1%) patients. Difficulty with decisions, which was used as an indication of cognitive difficulty, was noted in 429 (86.3%) of the subjects, of which 252 (50.7%) noted mild/moderate and 177 (35.6%) severe/very severe intensity. To evaluate changes over time, the subjects were divided into 2‐year cohorts of 1–2, 3–4, 5–6, and 7–8 years since DTBI. Comparing symptom burden within these four 2‐year cohorts, there was no statistically significant change in symptom burden analyzing by time interval from DTBI to TBI clinic evaluation. For analysis by severity of the DTBI in 491 subjects with complete data, categories were constructed based on alteration of consciousness (AOC) or duration of loss of consciousness (LOC) as follows: AOC (264/491 [53.8%]); LOC <1 min (95/491 [19.4%]); LOC, 1–30 min (115/491 [23.4%]); and LOC >30 min (17/491 [3.5%]). The proportion of subjects with severe/very severe symptom intensity increased as the severity of the DTBI increased (from p = 0.043 to p = 0.001). Additional evaluations included groupings by age at DTBI (20–29, 30–39, and ≥40 years), by presence or absence of a TBI prior to the DTBI, and by causation of the DTBI (blast or direct head trauma). No significant differences were observed with any of these comparisons. Conclusion: For veterans experiencing a DTBI, these TBI‐related sequelae persist with little improvement over time up to 8 years. A trend toward symptoms becoming worse as DTBI severity increased was observed. Headache was the most frequent sequela of TBI, occurring in 96% of the patients with almost half of these reporting severe/very severe intensity of headache burden. The basis for the prolonged persistence of these STBI is not known. [ABSTRACT FROM AUTHOR]

The article discusses a study that developed a model to predict the length of stay in the intensive care unit (ICU) after pediatric liver transplantations. The authors identified certain risk factors, such as pretransplant hospital admission and postoperative adverse events, that were associated with prolonged ICU stay. However, the article points out that the model has limitations, such as not providing details on the factors that led to hospital admission or return to the operating room (OR), which limits its practical application. The authors suggest that further clarification and additional information would strengthen the predictive model and improve clinical decisions. [Extracted from the article]

This article is a response to a study that investigated the relationship between epsilon aminocaproic acid (EACA) and acute kidney injury (AKI) in pediatric patients with life-threatening hemorrhage. The authors of the response identified several limitations in the study's analytical methods and interpretation. They noted that the study was not specifically designed or adequately powered to assess the incidence of AKI, and the small sample sizes made it impractical to directly compare EACA and tranexamic acid (TXA) with respect to AKI. The authors also raised concerns about the inclusion of heterogeneous populations and the potential for selection bias and residual confounding. They concluded that further research with larger sample sizes and adjustments for relevant confounders is needed to accurately assess the risks and benefits of EACA and TXA in this patient population. [Extracted from the article]

Purpose: Computed tomography (CT) scans play a vital role in the diagnosis and evaluation of trauma patients. Repeat CT scans occurred often among transferred trauma patients. The objective was to describe CT use and identify patient- and hospital-level factors associated with repeat CT scans among inter-facility transferred major trauma patients.Methods: A retrospective cohort study was conducted using data extracted from the Oklahoma State Trauma Registry between 2009 and 2015. Both bivariate and multivariate analyses were employed to assess the factors associated with repeat CT scans.Results: During the 7-year study period, 8678 major trauma patients were transferred between acute-care hospitals in Oklahoma. Among them, 4311 patients had at least one repeat CT scan. Head CT scans were the most commonly performed as well as repeated. Bivariate analysis showed that differences in repeat CT scans were associated with age, injury type, injury severity score, head injury severity, revised trauma score, payer source, transport mode to referring facilities, and facility levels at the 5% level. Multivariate analysis showed the odds of repeat CT scans were higher for adult and geriatric patients, patients with blunt injuries, severely injured patients, patients with severe head injuries, patients with a good revised trauma score, patients discharged alive, and mode to referring facilities.Conclusions: Our study demonstrated that inter-facility transfers within an organized rural trauma system often underwent repeat CT scans. The large proportion of patients with multiple and repeated CT scans should underline the importance of trauma systems evaluating the necessity of CT scans, image-sharing capability, and obtaining appropriate scans in order to optimize use. Overall, reducing unnecessary CT scans should be an essential part of trauma care quality improvement efforts. [ABSTRACT FROM AUTHOR]

Objective Evaluate the extent and severity of headache following deployment-related TBI (D-TBI) in veterans of the Iraq (OIF) and Afghanistan (OEF) wars over a follow-up period of 4-11 years with comparison to age, sex, race, and time of deployment matched controls. Background TBI has been recognized as the 'signature Injury' of the OEF/OIF campaigns occurring in 14-20% of deployed soldiers. Currently, there are very few data on the longer term follow-up of soldiers with D-TBI. This study deals with prevalence and severity of headache and headache burden at 4-11 years following D-TBI for OEF/OIF veterans with comparison to controls without D-TBI. Methods This is a matched case controlled-study. All subjects were recruited from Operation New Dawn (OND), a voluntary program for OEF/OIF Veterans at the Oklahoma VAMC designed to assist with re-integrating into civilian life. On entry into OND a medical questionnaire was administered that included a brief screen for D-TBI, and those with a possible D-TBI were referred to a TBI clinic, For this study, the first 500 TBI clinic patients who were found to have had a D-TBI (TBIS) were matched by age, sex, race, and time of deployment to control subjects (CS), drawn from the 4411 OND program members with no D-TBI, creating a pool of 500 TBIS/CS pairs. From this pool, 55 pairs (11%) were randomly selected for this study. Data were collected from both TBIS and CS by telephone interview with questionnaires regarding the DTBI, headache, depression, and PTSD. TBI severity was measured by duration of loss of consciousness (LOC) as: [a] Very Mild (VMTBI, dazed only, no LOC), [b] Mild (MTBI, LOC 1-30 minutes), and [c] Moderate-Severe (MSTBI, LOC > 30 minutes). Intensity for individual headaches was measured by disability produced by the headache as: [a] Disabling (must be in bed), [b] Severe (50-90% decrease in activity), or [c] Mild-Moderate (>50% of usual activity possible). Statistical analysis employed Fisher's exact test and odds ratio. Results The 55 TBIS/CS pairs were segregated by severity of TBI for the TBIS. For the TBIS there were no significant differences among these three subgroups as to mechanism producing the TBI (blast injury or direct head trauma). Comparing TBIS vs CS for phenotypic classification of headaches, for TBIS - 89% had migraine, 2% probable migraine, 9% had tension, and 0% had no headaches, while for CS - 36% had migraine, 15% probable migraine, 27% tension, and 22% no headache ( P < .0001). Migraine with aura occurred in 38% of TBIS and 6% of CS ( P < .0001). As to headache frequency, for TBIS - chronic daily headache (CDH) occurred in 44%, frequent headache in 33%, and infrequent or no headache in 23%, while for CS - CDH occurred in 7%, frequent headache in 13%, and infrequent or no headache in 80% ( P < .0001). For TBIS, 54% had severe or disabling headache ≥2 days/week as opposed to only 16% of CS (OR 6.13 [2.5-14.9]). As to onset of most severe and frequent headaches, this occurred shortly after TBI in 89% of TBIS while only 27% of CS reported most severe headaches starting during deployment. There was no correlation of severity of headache problem with severity of TBI. Comparing TBIS at 4-7 vs 8-11 years after injury, there was no difference in frequency or severity of headache between these groups. Conclusions At 4-11 years after D-TBI for TBIS, or after deployment for CS, the TBIS as compared to CS suffered much more frequent and severe headaches. For TBIS, there was no relation of headache intensity or phenotype to severity or cause of the TBI, and the Headache Burden has not improved over time up to 11 years after D-TBI. The process initiated by the D-TBI that relates to the headache has a prolonged effect up to and beyond 11 years. [ABSTRACT FROM AUTHOR]

Abstract: Background: The Abbreviated Injury Scale (AIS) recently underwent a major revision from AIS 98 to AIS 05. AIS injury codes form the basis of widely used injury severity scores such as the injury severity score (ISS). ISS thresholds are often used in trauma case definitions and ISS is widely used in injury research to adjust for injury severity. This study evaluated changes from AIS 98 to AIS 05, the changes’ effect on ISS distributions, and presents an application of the results. Methods: Injury descriptions from medical records of 137 randomly selected patients in the Oklahoma Trauma Registry (OTR) were obtained. A single trained coder used AIS 98 and AIS 05 to code each injury. ISS values were calculated and grouped into 4 categories: 1–8, 9–14, 16–24, >24. Paired ISS was compared using Kappa statistics and tests of symmetry. We identified common injury diagnoses for which AIS severity changed between versions. Estimates of the proportion of patients changing ISS groups were applied to the entire OTR to assess the impact on reporting and on a model for reimbursement. Results: OTR AIS 98 and manual AIS 98-based ISS values had a weighted Kappa of 0.71. OTR AIS 98 and manual AIS 05-based ISS values had a Kappa of 0.58. Manual AIS 98 and manual AIS 05 ISS had the highest Kappa of 0.81, however, though the scores differed by only 1 ISS category, there were 30 discordant pairs. The distribution of these discordant pairs was not symmetrical (Bowker''s S =30; df =6; p <0.0001) with AIS 05-based ISS values consistently shifted to a lower ISS category. Reductions in AIS severity and ISS values using AIS 05 were common for extremity fractures and thorax injuries. The results suggest fewer patients would be reported to the OTR or be eligible for reimbursement. Discussion: Changing from AIS 98 to AIS 05 injury coding resulted in systematic changes in AIS codes and ISS. Specific injuries and body regions were differentially affected. Trauma registries and injury researchers that use AIS based injury coding can use this information to evaluate the potential impact of changes in AIS 2005. [Copyright &y& Elsevier]

With the advent of lung cancer screening, lung nodules are being discovered at an increasing rate. With improvements in transbronchial biopsy technology, it is important for thoracic surgeons to be involved with diagnostic procedures. The aim of this project is to relate the thoracic surgeon experience in implementing an electromagnetic navigational bronchoscopy (ENB) program at our institution and describe the factors that led to successful navigation (the ability to position a biopsy instrument in range for biopsy) and diagnostic biopsy of nodules. The thoracic surgery ENB program was initiated in 2014. A retrospective analysis of patients referred to thoracic surgery from 2014 to 2019 for lung nodule evaluation was performed. Patients who underwent ENB and biopsy were included. Recursive partitioning (CART) and multivariable regression analyses were used to identify predictors of successful navigation and biopsy. There were 73 patients who underwent ENB evaluation of 91 nodules from 2014 to 2019. There was successful navigation in 75.8% of nodules, and on multivariable analysis, bronchus sign, lesion size, and pleural distance were significant predictors of successful navigation. Of the lesions that had successful navigation, 65.2% had a diagnostic biopsy. Based on CART analysis, positive bronchus sign and lesion size ≥ 1.3 cm were most predictive of obtaining a diagnostic biopsy with a probability of 0.75. Nodule size, distance to the pleura, and bronchus size are independent variables of successful navigation when using ENB. However, of the lesions that were successfully reached, combined lesion size >1.3 cm and a positive bronchus sign were most predictive of obtaining a diagnostic biopsy. These factors should be considered when implementing an ENB program in a thoracic surgery practice. • With electromagnetic navigational bronchoscopy, successful navigation can be improved with the presence of a bronchus sign, a nodule >2 cm, and distance from the pleura >1.4 cm. • A nodule size >1.3 cm with a positive bronchus sign led to the best probability of diagnostic biopsy. [ABSTRACT FROM AUTHOR]

Andexanet alfa is a Gla-domainless mutant (S195A) factor Xa (GDXa) approved for acute reversal of oral factor Xa inhibitors. Cardiac surgery patients exposed to andexanet before cardiopulmonary bypass often exhibit severe heparin resistance. There is a paucity of data on the effectiveness and optimal dosage of antithrombin use in this setting. The objective of this study was to evaluate the in vitro effect of increased heparin with antithrombin levels on attenuating heparin resistance induced by GDXa. Heparinised normal pooled plasma and cardiopulmonary bypass plasma were spiked with GDXa 4 μM. Tissue factor-activated thrombin generation was used to assess heparin reversal effects of GDXa and restoration of anticoagulation with additional heparin with and without antithrombin. Serum thrombin–antithrombin complex, antithrombin activity, and tissue factor pathway inhibitor were also measured in tissue factor-activated, recalcified cardiopulmonary bypass plasma spiked with GDXa. In normal pooled plasma, GDXa-induced heparin reversal was mitigated by maintaining a high heparin concentration (12 U ml−1) and supplementing antithrombin (1.5–4.5 μM) based on peak and velocity of thrombin generation. Heparin reversal by GDXa was also demonstrated in cardiopulmonary bypass plasma, but supplementing both heparin (8 U ml−1) and antithrombin (3 μM) attenuated GDXa-induced changes in peak and velocity of thrombin generation by 72.5% and 72.2%, respectively. High heparin and antithrombin levels attenuated thrombin–antithrombin complex formation in tissue factor-activated, GDXa-spiked cardiopulmonary bypass plasma by 85.7%, but tissue factor pathway inhibitor remained depleted compared with control cardiopulmonary bypass plasma. Simultaneous supplementation of heparin and antithrombin mitigate GDXa-induced heparin resistance by compensating for the loss of tissue factor pathway inhibitor. [ABSTRACT FROM AUTHOR]

Introduction: Incidence of blunt cerebrovascular injury (BCVI) following hanging in the pediatric population is ill-defined. Current guidelines recommend screening imaging during the initial trauma evaluation. Necessity of screening is questioned given BCVI is considered rare after hanging, especially when asymptomatic. This study aims to elucidate the incidence of BCVI in pediatric hangings and determine the value of radiographic work-up. Methods: A retrospective cohort study was performed of pediatric hangings reported to the National Trauma Data Bank (NTDB), 2017-2019. Imaging, diagnoses, and findings suggestive of BCVI, such as Glasgow Coma Scale (GCS) ≤8, presence of cervical injury, and soft tissue injury were considered. Statistical analysis was carried out to compare incidence. Results: 197 patients met study criteria, with 179 arriving in the trauma bay with signs of life. BCVI incidence was 5.6% (10 of 179). Computed Tomography Angiography (CTA) of the neck was the only reported screening modality in this data set. A CTA was completed in 46% of the cases. Discussion: BCVI incidence following pediatric hanging is more common than previously thought. Less than half of patients had a CTA reported in this cohort. This may result in an underestimate. Given the potentially devastating consequences of a missed BCVI, the addition of CTA to initial work-up may be worthwhile to evaluate for cervical vascular injury, but further studies into the outcomes of children who do receive prophylactic therapy are needed. [ABSTRACT FROM AUTHOR]

Restrictive transfusion strategies and antifibrinolytic therapy as part of patient blood management contributed to the recent transfusion practice changes.[5] Therefore, performing a subgroup analysis with year as a covariate would be insightful in future studies. Keywords: bleeding; blood transfusion; coagulation testing; surgery EN bleeding blood transfusion coagulation testing surgery 893 894 2 04/13/23 20230401 NES 230401 We read with great interest a recently published work by Lim and colleagues. on the association between preoperative coagulation tests and perioperative red blood cell (RBC) transfusion.[1] This retrospective analysis included 672,075 elective major surgical cases that occurred between 2004 and 2018 using the National Surgical Quality Improvement Program (NSQIP) database. For example, colectomy patients represented the majority of their general surgery codes, but transfusion rates substantially varied between laparoscopic and open colectomies for partial (4.1% vs. 9.4%) and total resection (15.2% vs. 29.6%) (Table 1). [Extracted from the article]

Andexanet alfa is a Gla-domainless FXa (GDXa) analog used as an antidote to FXa inhibitors. Despite its clinical use, laboratory monitoring for anti-Xa reversal and the effect of andexanet on fibrinolysis has not been explored. We used a GDXa with a serine-to-alanine mutation at position 195 (chymotrypsin numbering) to model the interaction between andexanet and apixaban. Six batches of pooled plasma, and whole blood from healthy volunteers were treated with increasing concentrations of apixaban with/without GDXa. Thrombin generation and plasmin generation (TG and PG) were tested in plasma, and whole blood thrombus formation was tested using thromboelastometry or a flow-chamber system. FXa was also tested in isolation for its ability to support plasmin activation with/without apixaban and GDXa. Apixaban (250–800 nM) concentration-dependently decreased the velocity and peak of TG in plasma. Apixaban prolonged the onset of thrombus formation in thromboelastometry and flow-chamber tests. GDXa normalized apixaban-induced delays in TG and whole blood thrombus formation. However, GDXa minimally affected the low PG velocity and peak caused by apixaban at higher concentrations (500–800 nM). FXa promoted plasmin generation independent of fibrin that was inhibited by apixaban at supratherapeutic concentrations. This study demonstrated the feasibility of assessing coagulation lag time recovery in plasma and whole blood following in vitro apixaban reversal using GDXa, a biosimilar to andexanet. In contrast, GDXa-induced changes in plasmin generation and fibrinolysis were limited in PG and tPA-added ROTEM assays, supporting the endogenous profibrinolytic activity of FXa and its inhibition at elevated apixaban concentrations. Schemata of putative mechanisms of factor Xa modulation of plasmin generation. A trace amount of fibrin initiates the formation of plasmin (Pln), which proteolyzes phospholipid-bound factor Xaα into Xaβ. The latter is further proteolyzed by plasmin into a heterodimer of 33 kDa and 13 kDa fragments (Xa33/13). Both Xaβ and Xa33/13 express carboxy-terminal lysine residues (⊕ in yellow) to which plasminogen (Plg) can be bound and subsequently activated by tissue plasminogen activator (tPA), facilitating the initiation of fibrinolysis. After binding of apixaban to factor Xaα, thrombin (IIa) generation is slowed down (|| in red), and Xa33/13 formation is blocked (× in red), resulting in reduced velocities of plasmin generation. [Display omitted] • Gla-domainless factor Xa S195A (GDXa) is useful in modeling a factor Xa inhibitor reversal with andexanet alpha in vitro • Profibrinolytic activity of factor Xa is inhibited by apixaban. • Despite the recovery of thrombin generation, GDXa had minimal effect on the changes in plasmin generation and fibrinolysis at elevated apixaban concentrations. [ABSTRACT FROM AUTHOR]

Trauma related injury remains the leading cause of mortality in pediatric patients, many of which are preventable. The goal of our study was to identify the mechanism of injury (MOI) in pediatric trauma-related fatalities and determine if these injuries were preventable to direct future injury prevention efforts within trauma programs. After IRB approval, a retrospective, single-institution review of pediatric (age ≤18) trauma fatalities from 2010 to 2019 was performed. MOI, use of protective devices, demographics, and whether the injury was preventable were collected. Patients were divided into five age cohorts, and frequencies and proportions were used to summarize data. Bivariate testing was done using Fisher's exact and Monte Carlo estimates for the exact test. MOI was found to vary by age with non-accidental trauma found to be the most common cause of trauma related deaths in children <1 (88.5%) and 1-4 (33.3%). MVC was the most common MOI in children >5 y, with 68.4% in the 5-9, 34.4% in the 10-14, and 45.8% in the 15-18 age group. The majority of fatalities resulted from a preventable injury (P < 0.0001) in the younger children with a negative association as age increased: 92.3% <1, 53.3% in 1-4, 36.8% in 5-9, 46.9% in 10-14 and 48.6% in 15-18. Of the preventable injuries, non-accidental trauma was the most common MOI in children <5, while GSW was the most common MOI in children >10. This study demonstrates many pediatric fatalities are the result of a preventable traumatic injury. This data can guide focused traumatic injury prevention efforts. [ABSTRACT FROM AUTHOR]

Objective: In 2012, the Centers for Disease Control and Prevention (CDC) Advisory Council on Immunization Practice recommended an additional post-splenectomy booster vaccine at 8 weeks following the initial vaccine. The objective of this study was to evaluate our vaccination compliance rate and what sociodemographic factors were associated with noncompliance following this recommendation.Materials and Methods: A retrospective review of a performance improvement database of trauma patients eligible for post-splenectomy vaccination (PSV) at a level I trauma center was carried out between 2009 and 2018. Overall and institutional compliance with PSV was compared before and after the addition of booster vaccine recommendation. Factors associated with booster noncompliance were also identified.Results: A total of 257 patients were identified. PSV compliance rate in the pre-booster was 98.4%, while overall and institutional post-booster compliance rate were significantly lower at 66.9% (P ≤ .001) and 50.0% (P ≤ .001), respectively. Compared to booster institutional compliers, institutional noncompliers lived farther from the trauma center (48 vs. 86 miles, P = .02), and though not statistically significant, these patients were generally older (34.9 vs. 40.5, P = .05).Discussion: PSV booster compliance is low even with the current educational materials and recommendations. Additional approaches to improve compliance rates need to be implemented, such as sending letters to the patient and their primary care providers (PCPs), collaborating with rehab/long-term acute care centers, communicating with city and county health departments and city pharmacies, or mirroring other countries and creating a national database for asplenic patients to provide complete information. [ABSTRACT FROM AUTHOR]

Background: We hypothesize that women undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis from appendiceal cancer will have a survival advantage compared to men. Methods: The National Cancer Database (NCDB) public user file (2004–2014) was used to select patients with PC undergoing CRS and HIPEC from appendiceal cancer. Univariate and multivariable analyses were performed. Results: 1,190 patients with PC from appendiceal cancer underwent HIPEC and CRS. OS was significantly longer for women than for men, with mean and median OS being 73.8 months and 98.2 months for women vs 58.7 months and 82.5 months for men, respectively (p = 0.0032). On multivariable analysis, male sex (HR: 1.444, 95% CI: 1.141–1.827, p = 0.0022) and increasing age (HR: 1.017, 95% CI: 1.006–1.027, p = 0.0017) were both found to be independent risk factors for worse OS. Conclusion: Women undergoing CRS and HIPEC for PC from appendiceal origin live longer than men undergoing the same treatment. Increasing age was also found to be independent risk factors for worse survival [ABSTRACT FROM AUTHOR]