BACKGROUND:Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS:Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010(PRE, -2013 POST, 2014 POST, -2018 using various statistical tests where appropriate. RESULTS:Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION:Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

Background: Immunothrombosis and coagulopathy in the lung microvasculature may lead to lung injury and disease progression in coronavirus disease 2019 .We aim to identify biomarkers of coagulation, endothelial function, and fibrinolysis that are associated with disease severity and may have prognostic potential. Methods:We performed a single-center prospective study of 14 adult COVID-19(+) intensive care unit patients who were age-and sex-matched to 14 COVID-19(−) intensive care unit patients, and healthy controls. Daily blood draws, clinical data, and patient characteristics were collected. Baseline values for 10 biomarkers of interest were compared between the three groups, and visualized using Fisher's linear discriminant function. Linear repeated-measures mixed models were used to screen biomarkers for associations with mortality. Selected biomarkers were further explored and entered into an unsupervised longitudinal clustering machine learning algorithm to identify trends and targets that may be used for future predictive modelling efforts.Results: Elevated D-dimer was the strongest contributor in distinguishing COVID-19 status; however, D-dimer was not associated with survival. Variable selection identified clot lysis time, and antigen levels of soluble thrombomodulin (sTM), plasminogen activator inhibitor-1 (PAI-1), and plasminogen as biomarkers associated with death.Longitudinal multivariate k-means clustering on these biomarkers alone identified two clusters of COVID-19(+) patients: low (30%) and high (100%) mortality groups. Biomarker trajectories that characterized the high mortality cluster were higher clot lysis times (inhibited fibrinolysis), higher sTM and PAI-1 levels, and lower plasminogen levels. Conclusions: Longitudinal trajectories of clot lysis time, sTM, PAI-1, and plasminogen may have predictive ability for mortality in COVID-19.| 1547 JUNEJA Et Al.

INTRODUCTION:Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS:Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS:Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intraabdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION:The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma.

BACKGROUND:The impact of injury mechanism on outcomes of pancreatic trauma has not been well studied, and current guidelines do not differentiate recommendations for blunt and penetrating injuries. The purpose of this study was to analyze interventions and outcomes as they relate to mechanism. We hypothesized that penetrating pancreatic trauma results in greater morbidity than blunt trauma because of more frequent operative exploration without imaging and thus more aggressive surgical management. METHODS:Secondary analysis of a multicenter retrospective review of pancreatic injuries in patients 15 years and older from 2010 to 2018 was performed. Deaths within 24 hours of admission were excluded from analysis of the primary outcome, pancreas-related complications (PRCs). Data were analyzed by injury mechanism using various statistical tests where appropriate. RESULTS:Thirty-three centers reported on 1,240 patients (44% penetrating). Penetrating trauma patients were twice as likely to undergo resection (45% vs. 23%) and suffer PRCs (39% vs. 20%). However, differences varied widely based on injury grade and management. There were fewer resections and more nonoperative management in blunt grades I to III injury. Pancreas-related complications occurred in 40% of high-grade injuries with no difference between mechanisms and in 40% of patients after resection, regardless of mechanism or injury grade. High-grade pancreatic injury (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.55-3.67), penetrating injury (OR, 1.99; 95% CI, 1.31-3.05), and management in a low-volume center (i.e., five or fewer cases/ year) (OR, 1.65; 95% CI, 1.16-2.35) were independent predictors of PRCs. CONCLUSION:Management of grades I to III, but not grades IV/V, pancreatic injuries varies based on mechanism. Penetrating injury is an independent risk factor for PRCs, but main pancreatic duct injury and resection are associated with high rates of PRCs regardless of the injury mechanism. Resection appears to offer better outcomes for grade IV/V injuries, and grade I and II injuries should be managed nonoperatively.

Background The incidence of colorectal cancer is rising in adults <50 years of age. As a primarily unscreened population, they may have clinically important delays to diagnosis and treatment. This study aimed to review the literature on delay intervals in patients <50 years with colorectal cancer (CRC), and explore associations between longer intervals and outcomes. Methods MEDLINE, Embase, and LILACS were searched until December 2, 2021. We included studies published after 1990 reporting any delay interval in adults <50 with CRC. Interval measures and associations with stage at presentation or survival were synthesized and described in a narrative fashion. Risk of bias was assessed using the Newcastle-Ottawa Scale, Institute of Health Economics Case Series Quality Appraisal Checklist, and the Aarhus Checklist for cancer delay studies. Results 55 studies representing 188,530 younger CRC patients were included. Most studies used primary data collection (64%), and 47% reported a single center. Sixteen unique intervals were measured. The most common interval was symptom onset to diagnosis (21 studies; N = 2,107). By sample size, diagnosis to treatment start was the most reported interval (12 studies; N = 170,463). Four studies examined symptoms onset to treatment start (total interval). The shortest was a mean of 99.5 days and the longest was a median of 217 days. There was substantial heterogeneity in the measurement of intervals, and quality of reporting. Higher-quality studies were more likely to use cancer registries, and be population-based. In four studies reporting the relationship between intervals and cancer stage or survival, there were no clear associations between longer intervals and adverse outcomes. Discussion Adults <50 with CRC may have intervals between symptom onset to treatment start greater than 6 months. Studies reporting intervals among younger patients are limited by inconsistent results and heterogeneous reporting. There is insufficient evidence to determine if longer intervals are associated with advanced stage or worse survival. Other This study’s protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020179707).

Background: Urinary catheters are placed after rectal surgery to prevent urinary retention, but prolonged use may increase the risk of urinary tract infection (UTI). This review evaluated the non-inferiority of early urinary catheter removal compared with late removal for acute urinary retention risk after rectal surgery. Methods: MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched from January 1980 to February 2019. RCTs comparing early versus late catheter removal after rectal surgery were eligible. Primary outcomes were acute urinary retention and UTI; the secondary outcome was length of hospital stay. Early catheter removal was defined as removal up to 2 days after surgery, with late removal after postoperative day 2. The non-inferiority margin from an included trial was used for analysis of change in urinary retention (NI = 15 per cent). Pooled estimates of risk differences (RDs) were derived from random-effects models. Risk of bias was assessed using a modified Cochrane risk-of-bias tool. Results: Four trials were included, consisting of 409 patients. There was insufficient evidence to conclude non-inferiority of early versus late catheter removal for acute urinary retention (RD 9 (90 per cent c.i. −1 to 19) per cent; P NI = 0⋅31). Early catheter removal was superior for UTI (RD −11 (95 per cent c.i. −17 to −4) per cent; P = 0⋅001). Results for length of stay were mixed. There were insufficient data to conduct subgroup analyses. Conclusion: The existing literature is inconclusive for non-inferiority of early versus late urinary catheter removal for acute urinary retention. Early catheter removal is superior in terms of reducing the risk of UTI.

BackgroundClinical delays may be important contributors to outcomes among younger adults (<50 years) with colorectal cancer (CRC). We aimed to describe delay intervals for younger adults with CRC using health administrative data to understand drivers of delay in this population.MethodsThis was a population-based study of adults <50 diagnosed with CRC in Ontario, Canada from 2003 to 2018. Using administrative code-based algorithms (including billing codes), we identified four time points along the pathway to treatment—first presentation with a CRC-related symptom, first investigation, diagnosis date and treatment start. Intervals between these time points were calculated. Multivariable quantile regression was performed to explore associations between patient and disease factors with the median length of each interval.Results6853 patients aged 15–49 were diagnosed with CRC and met the inclusion criteria. Males comprised 52% of the cohort, the median age was 45 years (IQR 40–47), and 25% had stage IV disease. The median time from presentation to treatment start (overall interval) was 109 days (IQR 55–218). Time between presentation and first investigation was short (median 5 days), as was time between diagnosis and treatment start (median 23 days). The greatest component of delay occurred between first investigation and diagnosis (median 78 days). Women, patients with distal tumours, and patients with earlier stage disease had significantly longer overall intervals.ConclusionsSome younger CRC patients experience prolonged times from presentation to treatment, and time between first investigation to diagnosis was an important contributor. Access to endoscopy may be a target for intervention.

No abstract