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BackgroundThe COVID-19 pandemic, caused by a novel coronavirus termed SARS-CoV-2, has spread quickly worldwide. Convalescent plasma (CP) obtained from patients following recovery from COVID-19 infection and development of antibodies against the virus is an attractive option for either prophylactic or therapeutic treatment, since antibodies may have direct or indirect antiviral activities and immunotherapy has proven effective in principle and in many clinical reports. ObjectiveWe seek to characterize the latest advances and evidence in the use of CP for COVID-19 through a systematic review and quantitative analysis, identify knowledge gaps in this setting, and offer recommendations and directives for future research. MethodsPubMed, Web of Science, and Embase were continuously searched for studies assessing the use of CP for COVID-19, including clinical studies, commentaries, reviews, guidelines or protocols, and in vitro testing of CP antibodies. The screening process and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal of all clinical studies was conducted using a universal tool independent of study designs. A meta-analysis of case-control and randomized controlled trials (RCTs) was conducted using a random-effects model. ResultsSubstantial literature has been published covering various aspects of CP therapy for COVID-19. Of the references included in this review, a total of 243 eligible studies including 64 clinical studies, 79 commentary articles, 46 reviews, 19 guidance and protocols, and 35 in vitro testing of CP antibodies matched the criteria. Positive results have been mostly observed so far when using CP for the treatment of COVID-19. There were remarkable heterogeneities in the CP therapy with respect to patient demographics, donor antibody titers, and time and dose of CP administration. The studies assessing the safety of CP treatment reported low incidence of adverse events. Most clinical studies, in particular case reports and case series, had poor quality. Only 1 RCT was of high quality. Randomized and nonrandomized data were found in 2 and 11 studies, respectively, and were included for meta-analysis, suggesting that CP could reduce mortality and increase viral clearance. Despite promising pilot studies, the benefits of CP treatment can only be clearly established through carefully designed RCTs. ConclusionsThere is developing support for CP therapy, particularly for patients who are critically ill or mechanically ventilated and resistant to antivirals and supportive care. These studies provide important lessons that should inform the planning of well-designed RCTs to generate more robust knowledge for the efficacy of CP in patients with COVID-19. Future research is necessary to fill the knowledge gap regarding prevention and treatment for patients with COVID-19 with CP while other therapeutics are being developed.

This article highlights the crucial role of blood transfusion in trauma care and explores the historical and contemporary use of whole blood and freeze-dried plasma in Canadian health care. Early use of whole blood and freeze-dried plasma during global conflicts led to advancements in transfusion medicine. The transition to blood component therapy improved transfusion safety and precision. However, there is an increasing interest in using whole blood and freeze-dried plasma, supported by recent evidence suggesting potential benefits over blood component therapy, particularly in trauma cases. Canadian initiatives, such as leukoreduced whole blood production for the military, indicate efforts to address logistical challenges in delivering trauma care, especially in remote areas. Challenges remain, including logistical issues and regulatory complexities, requiring coordinated efforts for effective implementation. Overall, there's growing support for integrating whole blood and freeze-dried plasma into trauma care across Canada., EARLY USE OF WHOLE BLOOD AND FREEZE-DRIED PLASMA Blood transfusions have evolved dramatically over the past 4 centuries, from the earliest experiments in the 17th century to the sophisticated transfusions [...]

BACKGROUND: Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized. RESULTS: Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control. CONCLUSION: Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments. LEVEL OF EVIDENCE: Level 5, systematic review.

Background: Virtual patient simulations are interactive, computer-based cases. We designed scenarios based on the McGill Simulation Complexity Score (MSCS), a previously described objective complexity score. We aimed to establish validity of the MSCS and introduce a novel learning tool in trauma education at our institution. Methods: After design of an easy and difficult patient scenario, we randomized medical students and residents to each perform 1 of the 2 scenarios. We conducted a 2-way analysis of variance of training level (medical student, resident) and scenario complexity (easy, difficult) to assess their effects on virtual time, the number of steps taken in the scenario, beneficial and harmful actions, and the ratio of beneficial over harmful actions. Results: Virtual patient scenarios were successfully designed using the MSCS. Twenty-four medical students and 12 residents participated in the easy scenario (MSCS = 3), and 27 medical students and 12 residents did the difficult scenario (MSCS = 18). Though beneficial actions were similar between students and residents, sudents performed more harmful actions, particularly when the scenario was difficult. One virtual patient died in the easy scenario and 3 died in the diffcult one (all medical students). Performance varied with level of complexity and there was significant interaction between level of training and number of steps, as well as with number of harmful actions. Decreasing performance with increasing level of complexity, as defined by the MSCS, suggests this score can accurately quantify difficulty. Conclusion: We established validity of the MSCS and showed its successful application on virtual patient scenario design. Contexte : Les simulations medicales virtuelles sont des cas interactifs informatises. Nous avons concu des scenarios en utilisant le score de complexite des simulations McGill (SCSM), un score de complexite objectif decrit precedemment. Nous avons voulu confirmer la validite du SCSM et presenter un nouvel outil d'apprentissage en traumatologie pour notre etablissement. Methodes : Apres avoir concu le scenario d'un cas facile et d'un cas difficile, nous avons assigne aleatoirement des etudiants en medecine et des residents a 1 des 2 scenarios pour qu'ils y travaillent. Nous avons procede a une analyse de la variance a 2 facteurs, formation (etudiant en medecine, resident) et complexite des cas (facile, difficile,) pour mesurer leurs effets sur le temps virtuel, le nombre d'etapes franchies dans le scenario, les interventions benefques et nuisibles et le rapport entre les deux. Resultats : Les scenarios de cas virtuels ont ete concus avec succes a l'aide du SCSM. Vingt-quatre etudiants en medecine et 12 residents ont travaille au scenario facile (SCSM = 3), et 27 etudiants en medecine et 12 residents ont travaille au scenario difficile (SCSM = 18). Meme si les interventions benefques etaient similaires entre les etudiants et les residents, les etudiants ont applique plus d'interventions nuisibles que les residents, particulierement lorsque le scenario etait difficile. Un patient virtuel du scenario facile et 3 du scenario difficile sont decedes (etudiants dans tous les cas). Le rendement a varie selon le degre de complexite et on a note un lien significatif entre le niveau de formation et le nombre d'etapes et de mesures nuisibles. Le fait que le rendement ait ete inversement proportionnel a la complexite definie par le SCSM, suggere que ce dernier mesure avec exactitude le degre de complexite. Conclusion : Nous avons confirme la validite du score SCSM et montre son utilite dans la conception de scenarios de cas virtuels., Virtual patient simulations are interactive, computer -based cases through which trainees can navigate by selecting various management options offered to them. As Cook and colleagues illustrated, (1) in a world [...]

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology., Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. (1-4) International literature has described the indications, technique and outcomes of 7- to 12-French [...]

Aims and Background: The spleen is the most frequently injured solid organ after blunt trauma and a trial non-operative management (NOM) has become the standard of care in hemodynamically stable patients. It remains uncertain which patients are at increased risk of non-operative management failure (NOMF) at initial presentation. We explored whether clinical variables including the contemporary rotational thromboelastography (ROTEM) parameters are predictive of NOMF. Materials and Methods: Data for all adult patients with a blunt splenic injury was collected retrospectively at St. Michael's Hospital in Toronto, Canada between 2005 and 2021. Those who underwent a splenectomy within 4 hours of presentation were classified as direct operative management (OM), while those who had a splenectomy after 4 hours of observation were classified as NOM failure. Vital signs on arrival and injury characteristics were collected. Logistic regression was used to identify predictors of OM and predictors of NOM failure. Results: Seven hundred and seventeen patients were identified with splenic injury during our study period. The median Injury Severity Score (ISS) was 27 (IQR 17–36), and 19% (n = 134) had a shock index of 1 or more. One hundred and eleven (15.5%) underwent direct operative management. A shock index above 1 and increasing spleen injury severity were strong predictors of patients undergoing direct OM. The remaining 606 patients underwent NOM of which 59% (n = 357) of these were admitted to the ICU. NOM failure occurred in 7.4% (n = 45) with a median time to NOM failure of 23 (IQR 8–72) hours. The American Association for the Surgery of Trauma (AAST) spleen injury severity was the major factor significantly associated with NOM failure. Conclusions: The only major predictor of NOMF available on arrival is increased spleen injury grade. Other clinical variables such as age, vital signs on arrival, and bloodwork were not significantly able to predict NOM failure. Additional investigation is required to identify novel predictors of NOM failure. [ABSTRACT FROM AUTHOR]

Objective: Rib fractures lead to altered breathing mechanics, impaired gas exchange, and in some patients to respiratory failure. Multimodal analgesia has become one of the pillars of management; however, barriers toward widespread adoption remain. We reviewed the trends in multimodal pain management strategies and their drivers over a 10-year period at a lead trauma hospital in Canada. Methods: This is a cross-sectional study in which demographic, injury, pharmacological, as well as outcome data were collected for all adult patients admitted with rib fractures. Data were collected retrospectively and the study period was divided into three eras (2011–2014; 2015–2018; 2019–2022). Multimodal pain management was defined as either patient-controlled (PCA) or regional analgesia (epidural or continuous plane block) in combination with acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs). All patients received pro re nata (PRN) narcotics. Data were stratified based on rib fracture severity, age, and intubation on arrival. Results: We identified 2586 patients with rib fractures (mild non-flail 32.6%; moderate non-flail 50.2%; flail 17.2%). The use of standing acetaminophen and NSAIDs increased over time for all groups. Regional analgesia use increased while PCA use reduced, particularly in the flail group. Only 7% of flail patients intubated on arrival received regional analgesia. Among those not intubated on arrival, only 35% of flail and 23% of non-flail patients received multimodal pain management. Over time, multimodal pain management decreased in the non-flail group due to a reduction in PCA use without an equal rise in regional anesthesia. Those without multimodal pain management were older and the mechanism of injury was more likely a fall. Among those with a flail, who were non-intubated at presentation, only 31% of those aged >65 received multimodal pain regimens compared to 45% in those ≤65y. Conclusions: Although multimodal pain management strategies have improved over time, a large proportion of patients, even among those with flail chest, still do not receive multimodal pain management. Elderly patients, at highest risk of adverse outcomes, were less likely to receive multimodal pain management strategies and should be the target of performance improvement initiatives. [ABSTRACT FROM AUTHOR]

This article explores the advancements in blood transfusion practices for resuscitating bleeding patients, which have been influenced by experiences on the battlefield and later adopted in civilian settings. These changes, such as using balanced ratios of blood products and prepositioning blood in emergency departments, have improved outcomes for trauma patients and those with hemorrhagic shock. However, there are still three major changes needed for wider implementation: adopting a walking blood bank, correcting reimbursement practices for prehospital blood transfusion, and ensuring military personnel are trained in transfusion practices. The article also addresses the issue of blood shortages in the United States and suggests implementing a whole blood-based resuscitation strategy as a potential solution. The authors emphasize the importance of military-civilian partnerships and call for policy changes to support the routine use of prehospital blood products and the implementation of the whole blood-based resuscitation strategy in civilian trauma systems. [Extracted from the article]

Introduction: Computerized tomography is an essential element of the early diagnostic stages of trauma care for hemodynamically stable patients. However, there are inherent challenges and risks associated with the intra-hospital transport of critically injured trauma patients to the radiology suite and during the scanning process itself. We examined the frequency and nature of adverse events during computerized tomography among critically injured patients. Methods: This is a retrospective cohort study of adverse event in critically injured adult (>18 years old) trauma patients who underwent emergent computerized tomographic scan following evaluation in the trauma bay over a 22-month period who were either admitted to the intensive care unit or the operating room post computerized tomography. Data was abstracted from the hospital's trauma registry and chart review of electronic medical records. The frequency of adverse events during computerized tomography and the associated patient transport phases was recorded. Multivariable logistic regression was performed to assess the impact of adverse event on 7-day in-hospital mortality. Results: Of the 526 critically injured trauma patients who underwent computerized tomographic scan during the study period, 17.3% (91/526) experienced one or more adverse event. The most common adverse events were hypotension n = 50 (9.5%), hypertension n = 18 (3.4%), initiation of vasopressors n = 11 (2.1%) and vomiting n = 8 (1.5%). One patient required re-intubation following endotracheal tube dislodgement and one patient required intubation following hypoxia post-sedation for agitation. Patient factors independently associated with adverse event were mechanical ventilation and blood product administration. When adjusted for injury severity score and age, patients who experienced adverse event were at increased odds of death (odds ratio: 2.2, 95% confidence interval: 1.11–4.36) compared to those who did not experience adverse event. Conclusion: Adverse events occur frequently in critically injured patients undergoing emergent trauma computerized tomography and may significantly impact clinical outcomes. This study provides important information to guide system and process-level improvements including optimized designs of the built environment and safety-informed protocols for high-risk patients undergoing emergent trauma computerized tomography. [ABSTRACT FROM AUTHOR]

BackgroundAccurate diagnosis of mosquito allergy has been hampered by the laborious task of obtaining mosquito salivary allergens. We have previously studied 3 recombinant (r) Aedes aegypti mosquito salivary allergens: rAed a 1, rAed a 2 and rAed a 3. Here, we report the expression, purification, identification and evaluation of rAed a 4, a 67-kDa α-glucosidase.MethodsrAed a 4 was expressed using a baculovirus/insect cell system, purified by a combination of anion- and cation-exchange chromatography, and identified by immunoblotting. A. aegypti saliva extract was prepared in our laboratory. An indirect enzyme-linked immunosorbent assay (ELISA) was developed to measure rAed a 4-specific immunoglobulin E (IgE) and IgG antibodies in sera from 13 individuals with a positive mosquito-bite test from a laboratory-reared mosquito. Sera from 18 individuals with a negative bite test served as controls.ResultsPurified rAed a 4 bound to the IgE in mosquito-allergic sera, as detected by ELISA and immunoblotting. The binding of rAed a 4 to IgE could be inhibited in a dose-dependent manner by the addition of an A. aegypti extract. Mosquito-allergic individuals had significantly higher mean levels of rAed a 4-specific IgE and IgG than controls. Using the mean of the controls ± 2 SD as a cut-off level, 46% of the 13 allergic individuals had a positive IgE, while none of the controls was positive (p < 0.001).ConclusionsAed a 4 is a major allergen in mosquito saliva. Its recombinant form has the hydrolase function and can be used for the diagnosis of mosquito allergy.