Multi-Biomarker Prediction Models for Multiple Infection Episodes Following Blunt Trauma.

Severe trauma predisposes patients to multiple independent infection episodes (MIIEs), leading to augmented morbidity and mortality. We developed a method to identify increased MIIE risk before clinical signs appear, which is fundamentally different from existing approaches entailing infections' detection after their establishment. Applying machine learning algorithms to genome-wide transcriptome data from 128 adult blunt trauma patients' (42 MIIE cases and 85 non-cases) leukocytes collected ≤48 hr of injury and ≥3 days before any infection, we constructed a 15-transcript and a 26-transcript multi-biomarker panel model with the least absolute shrinkage and selection operator (LASSO) and Elastic Net, respectively, which accurately predicted MIIE (Area Under Receiver Operating Characteristics Curve [AUROC] [95% confidence intervals, CI]: 0.90 [0.84-0.96] and 0.92 [0.86-0.96]) and significantly outperformed clinical models. Gene Ontology and network analyses found various pathways to be relevant. External validation found our model to be generalizable. Our unique precision medicine approach can be applied to a wide range of patient populations and outcomes.

Associations between clinical characteristics and the development of multiple organ failure after severe burns in adult patients.

To determine the association between potential risk factors and multiple organ failure (MOF) in severe burn adult patients, we performed a secondary analysis of data from the "Inflammation and the Host Response to Injury" database, which included patients from six burn centers in the United States between 2003 and 2009. Three hundred twenty-two adult patients (aged ≥16 years) with severe burns (≥20.0% total body surface area [TBSA]) were included. MOF was defined according to the Denver score. Potential risk factors were analyzed for their association with MOF. Models were built using multivariable logistic regression analysis. Eighty-eight patients (27.3%) developed MOF during the study period. We found that TBSA, age, and inhalation injury were significant risk factors for MOF. This predictive model showed good performance, with the total area under the receiver operating characteristic curve being 0.823. Moreover, among patients who developed MOF, inhalation injury was significantly associated with the development of MOF in the acute phase (within three days of injury) (adjusted odds ratio 3.1; 95% confidence interval 1.1-8.3). TBSA, age, lactate, and Denver score within 24h were associated with the late phase development of MOF. Thus, we have identified key risk factors for the onset of MOF after severe burn injury. Our findings contribute to the understanding of individualized treatment and will potentially allow for efficient allocation of resources and a lower threshold for admission to an intensive care unit, which can prevent the development of MOF and eventually reduce mortality.

Selective Intraoperative Vasopressor Use Is Not Associated with Increased Risk of DIEP Flap Complications.

BACKGROUND: During deep inferior epigastric perforator (DIEP) flap cases, anesthesiologists commonly avoid intravenous vasopressor administration because of the theoretical concern of inducing vasospasm, thrombosis, or congestion in the vessels of the anastomosis, potentially resulting in poor flap perfusion and ischemia and necessitating revision. In the setting of hypotension, however, vasopressor administration may actually improve outcomes by augmenting flap perfusion by means of increased mean arterial pressure. METHODS: The authors reviewed 475 consecutive DIEP flap cases in 333 patients at a single large academic medical center over a 3-year period, addressing potential confounders using univariate analyses. RESULTS: Ephedrine administration was significantly associated with decreased risk of intraoperative flap complications (OR, 0.88), including vasospasm, thrombosis, and congestion requiring revision, compared with controls, after controlling for the severity and duration of hypotension. Phenylephrine had no significant association with complication rates. Vasopressor administration was not associated with an increased risk of reoperation in the setting of necrosis within 60 days. CONCLUSIONS: Ephedrine treatment for hypotension during DIEP flap cases is associated with decreased intraoperative flap complication rates compared with controls who did not receive vasopressors, whereas phenylephrine has no significant association. The common clinical practice of complete abstinence from vasopressors out of concern for worsening DIEP flap outcomes is not supported by this study. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Alpha-fetoprotein (AFP)-producing ovarian tumor in an elderly woman.

Apart from typical yolk sac tumors, ovarian tumors with elevated alfa-fetoprotein (AFP) are uncommon and the differential diagnosis needs to consider the hepatoid pattern of a yolk sac tumor, hepatocellular carcinoma metastatic to the ovary, hepatoid carcinoma, and other epithelial ovarian tumors. We report here an AFP-producing ovarian tumor with uncertain pathological diagnosis, which was extremely responsive to chemotherapy. A 59-year-old Japanese woman presented with lower abdominal distension and was found to have a left ovarian mass on pelvic examination and magnetic resonance imaging (MRI) scan. Laboratory tests showed serum AFP, 73 687 ng/ml; carbohydrate antigen 125 (CA125), 1599 U/ml; and carcinoembryonic antigen (CEA), 13.9 ng/ml. Total hysterectomy with bilateral salpingo-oophorectomy, partial omentectomy, and low anterior resection of the rectum was performed, without any residual macroscopic tumor. Microscopically, the tumor was characterized by a hepatoid carcinomatous component composed of solid sheets of large eosinophilic cells with pleomorphic nuclei. The pathological stage was pT2N0M0. Tumor cells were diffusely immunoreactive for AFP and cytokeratin (CAM5.2), but monoclonal CEA and CA19-9 were focally positive in the cytoplasm, while CA125 was negative. The patient was treated postoperatively with three cycles of chemotherapy consisting of bleomycin, etoposide, and cisplatin; with this regimen, serum AFP decreased to 16 ng/ml from 12 600 ng/ml just before the initiation of chemotherapy. The patient received secondary cytoreductive surgery of systemic lymphadenectomy, which revealed no evidence of residual tumor.

Two cases of epidural anesthesia-associated postoperative decubitus.

Very few cases of postoperative decubitus have been reported. We report two cases of hip decubitus after myomectomy. Case 1 is a 32-year-old Japanese woman who underwent an uncomplicated myomectomy under the combination of general and epidural anesthesia. Twelve hours after surgery, a palpable soft tissue mass developed in the sacral region. On day 3, the soft tissue mass had disappeared and the patient was discharged on day 8. Case 2 is a 33-year-old woman. Under a combination of spinal and epidural anesthesia, a myomectomy was carried out. On day 1 after surgery, a hard mass with redness was detected. On day 8, decubitus improved and she was discharged. We evaluated the temporal changes in anesthetic level in four independent cases. Eighteen hours after surgery, the anesthetic effect still continued below the L2 level. We conclude that the extended effect of epidural anesthesia might be one of the mechanisms causing postoperative decubitus.