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ACR Appropriateness Criteria® Major Blunt Trauma: Update 2025.
No full textTrauma remains the leading cause of mortality in the United States for those \u3c 45 years of age, and it is the fourth leading cause of death overall. Polytrauma is defined as an injury to at least two body parts, including the head, neck, chest, abdomen, pelvis, or an extremity, with any one or a combination of these injuries being potentially fatal. This document covers imaging of major blunt trauma or polytrauma resulting in multiple organ injuries. Burn injuries, and injuries to pediatric patients are excluded. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation
Predictors of Skeletal-Related Events and Quality-of-Life Dimensions Among Patients With High-Risk Asymptomatic Bone Metastases With or Without Early Radiation Therapy: Secondary Analysis of a Multicenter Randomized Phase II Clinical Trial.
No full textBACKGROUND: Early radiation therapy (RT) reduces the rate of skeletal-related events (SRE), which can affect patients\u27 functionality and quality of life (QoL). We aimed to determine predictors of SRE and the effect of early RT on individual QoL dimensions.
METHODS: We conducted a secondary analysis of a multicenter, randomized phase II trial (ClinicalTrials.gov identifier: NCT03523351) assessing early RT to asymptomatic, high-risk bone metastases. A competing risks analysis evaluated patient-level factors associated with SRE. Linear mixed models evaluated dimensions of the EuroQol 5-Dimension 5-Level (EQ-5D-5L) QoL assessment (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) over time by study arm.
RESULTS: Overall, 78 patients with 122 bone metastases were enrolled; 71 (91%) patients were evaluable for the primary endpoint of SRE (35 patients in the early RT arm vs 36 in the control arm). A total of 15 SREs occurred among 11 unique patients during the 1-year follow-up period. Receipt of early RT was statistically significantly correlated with a lower risk of SRE (hazard ratio, 0.09; 95% CI, 0.01-0.66; P=.018). In the linear mixed model predicting self-care, the interaction between time and study arm was statistically significant (P=.022). At 6 months, the control arm had a decline in self-care, whereas patients in the RT arm experienced an improvement. Anxiety/depression was worse at 3 months in the RT arm, but this was not statistically significant (P=.120).
CONCLUSIONS: Rates of SRE were high among patients with bone metastases, and these findings underscore the importance of early RT in their prevention. Patient-reported QoL suggests preservation of self-care with early RT, and that survival beyond 6 months may be needed to observe a benefit. Further research regarding patient selection and the impact of SRE on QoL and functionality are needed, and a phase III randomized trial (NRG CC014; NCT06745024) is in progress.
CLINICALTRIALS: gov identifier: NCT03523351
Racial disparities in stroke outcomes within a large telestroke network.
No full textOBJECTIVE: Stroke care disparities related to race and ethnicity have been well-documented, with African American populations experiencing higher stroke incidence and receiving less timely treatments like intravenous tissue plasminogen activator (tPA). Telemedicine, particularly telestroke, has emerged as a potential solution to address geographic and racial disparities in acute stroke care, yet some studies have reported persistent racial differences in treatment. This retrospective study was conducted to analyze data from a telestroke network consisting of a hub hospital and 38 spoke centers in Pennsylvania.
METHODS: Patients who had presented with acute ischemic stroke and required a virtual consult with a neurovascular specialist were included in the study. The data collected from electronic medical records included baseline characteristics, stroke-related variables, treatment details, and outcomes. Descriptive statistics, chi-square tests, and a Kruskal-Wallis test were used to analyze the data. In addition, univariate and multivariable logistic regression analyses were performed to evaluate the association between race and key outcomes.
RESULTS: A total of 4256 patients were included, of whom 2925 were White and 1122 were African American. On multivariable logistic regression, African American patients, as compared to White patients, were less likely to undergo mechanical thrombectomy (OR 0.58, 95% CI 0.35-0.96, p = 0.03) and were more likely to be discharged to rehabilitation (OR 1.39, 95% CI 1.06-1.84, p = 0.01), with no significant differences in tPA administration or death between the two racial groups.
CONCLUSIONS: The study results suggest that African American patients are significantly less likely to undergo mechanical thrombectomy and more likely to be discharged to rehabilitation compared with their White counterparts, despite similar rates of tPA administration and death. These findings highlight persistent disparities in advanced stroke interventions and postacute care, emphasizing the need to address structural and socioeconomic barriers to ensure equitable treatment and recovery for all patients
Alpha-2 Agonist Adulterants Are Not Associated With Prolonged Sedation in Emergency Department Opioid Overdose.
No full textSafety of carotid endarterectomy in the elderly and octogenarian population: a nationwide study including 80,000 patients.
No full textINTRODUCTION: Carotid endarterectomy (CEA) is an established procedure for stroke prevention in patients with carotid artery stenosis. While CEA is considered safe in younger patients, perioperative risks in octogenarians remain debated, with current guidelines classifying the procedure as high-risk in this patient population. This study aimed to evaluate short-term outcomes of CEA across age groups and to assess whether comorbidity burden better predicts outcomes than chronological age.
METHODS: The ACS-NSQIP database (2013-2020), was used to identify patients eligible for inclusion. The cohort was stratified based on age \u3c 60, 60-80, and \u3e 80 years. Propensity score matching and multivariable logistic regression were used to compare outcomes across age groups and assess predictors of 30-day complications, readmission, reoperation, non-home discharge, and mortality. Interaction analyses were performed to evaluate the combined impact of age, functional status and comorbidity (ASA classification) on outcomes.
RESULTS: Of 82,427 patients, 15,111 (18%) were \u3e 80 years. Octogenarians had significantly higher 30-day complication, readmission, reoperation, non-home discharge, and mortality rates compared with patients aged 60-80 (all p \u3c 0.001), even after propensity matching. Logistic regression confirmed increased risk in octogenarians (aOR 1.34, 95% CI 1.27-1.42), but comorbidity burden and functional dependency were stronger predictors; severe comorbidity (ASA 4-5; aOR 2.17, 95% CI 1.91-2.47) and full dependency (aOR 2.61, 95% CI 1.89-3.59). Interaction analysis demonstrated that octogenarians with low comorbidity had risks comparable to younger patients with moderate comorbidity.
CONCLUSIONS: CEA is associated with a worse risk profile among octogenarians. Nonetheless, comorbidity burden and functional status are stronger predictors of adverse outcomes, as compared to age alone. CEA can be performed safely in carefully selected octogenarians with low to moderate comorbidity, whereas severe comorbidity or dependency may represent relative contraindications. Surgical candidacy should be guided by physiological reserve and function rather than chronological age alone
Establishing a Consensus-Based Definition of Air Medical Transport Need for Rural Patients After Injury: Results from a Delphi Survey.
No full textOBJECTIVES: Air medical transport (AMT) improves survival for selected trauma patients. Improving AMT triage is limited by a lack of evidence and a standardized definition for which patients and circumstances may warrant AMT. Our objective was to develop a consensus-based definition of AMT need.
METHODS: We recruited a multidisciplinary, nationally representative panel with expertise in AMT from trauma surgery, anesthesiology, critical care, emergency medicine, and emergency medical services (EMS). Panelists were presented with criteria from the literature representing the potential for AMT need that included patient injuries, time-sensitive interventions, and system factors. Panelists voted over 4 rounds to refine and select (≥70% agreement) a final set of criteria using a web-based Delphi methodology, including potential criteria combinations.
RESULTS: A total of 32 of 45 (71.1%) invited panelists agreed to participate. From 66 initial criteria, panelists reached consensus on 18 patient factors, 6 time-sensitive interventions, 3 system factors, and 7 combinations of criteria. Two key themes emerged: the need for specialized care from air medical crews that may not be available from ground ambulance clinicians, as well as overall prehospital time-savings. After narrative feedback and refinement to eliminate redundant and overlapping criteria, an algorithm for AMT need was developed along with a decision flow diagram suitable for educational dissemination.
CONCLUSIONS: We developed a consensus-based definition of AMT need for trauma patients that can be operationalized for AMT triage. Further validation of this concept with patient outcomes and identifying implementation barriers will contribute to field deployment of a useful AMT triage tool for EMS clinicians