Pawan Acharya

BACKGROUND: Interfacility transfers for facial trauma are common but often avoidable. However, the magnitude of these potentially avoidable interfacility transfers (PAITs), which can strain trauma systems and incur avoidable costs to the patients, remains unknown. This study aimed to quantify the burden of PAITs for isolated facial trauma in the US. STUDY DESIGN: A retrospective analysis using the 2022 Nationwide Emergency Department Sample was performed. Patients aged 16 years and older with isolated facial injuries were identified using ICD-10-CM codes and the Abbreviated Injury Scale. A multiple logistic regression model was developed from level I trauma center (TC) data to predict emergency department home discharge, internally validated, and applied to transfers from level III or non-TCs to identify PAITs based on high predicted discharge probabilities. RESULTS: Among 856,197 patients with isolated facial trauma, 661,149 were initially treated at level III or non-TCs, of whom 2.4% were transferred to higher-level facilities. Using a Youden Index-derived predicted home discharge probability of greater than or equal to 0.946, 43.2% (95% CI 40.9% to 45.4%) of these transfers were classified as potentially avoidable. These transfers were more common among younger, male individuals, White race, those with private insurance, urban residence and those injured by being struck, treated in Southern hospitals, or private not-for-profit facilities. CONCLUSIONS: A substantial proportion of interfacility transfers for isolated facial trauma may be avoidable when benchmarked against discharge practices at level I TCs. These findings highlight a critical opportunity to optimize secondary triage decision-making, possibly in conjunction with telehealth consultations, before patient transfer.

Background: Previous studies suggest that in children with hemorrhagic shock following injury, prehospital blood transfusion improves survival. Quantifying and understanding the current demand for blood transfusion will help us improve the use and availability of prehospital blood for pediatric patients. This study sought to describe the current demand for and utilization of prehospital blood resuscitation following motor vehicle crash (MVC) in pediatric trauma populations from 2020 to 2023. Study design and methods: Hypotensive patients ≤14 years after MVC included in the National Emergency Medical Services Information System (NEMSIS) from 2020 to 2023 were identified. Hemodynamic instability was based on age‐defined systolic blood pressure and heart rate parameters. Total number and percentage of children who received prehospital blood transfusion, including components or whole blood, were calculated. Results: The database included 391,764 children involved in an MVC. Of these, 1913/391,764 (0.5%) were potentially eligible for prehospital blood transfusion based on prehospital hemodynamic status, yet of the 1913 patients, only 39/1913 (2%) received prehospital blood. Eligible patients were generally older than 10 years (64%) and MVCs occurred in urban areas (77%). Discussion: Only 2% of hemodynamically unstable pediatric MVC patients received prehospital blood. Prehospital blood resuscitation is underutilized in pediatric MVC populations, suggesting an urgent need for focused evaluation to identify barriers and promote increased utilization.

Background: Hemorrhage remains the leading cause of preventable traumatic deaths, with many fatalities occurring before hospital arrival. Although geographic differences in prehospital time (PHT) are recognized, contemporary national estimates and their implications for resuscitation readiness are not well defined. This study aimed to characterize geographic variation in PHT among trauma patients at risk of hemorrhagic shock to inform strategies for earlier intervention. Study Design and Methods: We analyzed 2020–2023 data from the National Emergency Medical Services (EMS) Information System (NEMSIS) and included trauma patients aged ≥16 years at risk of hemorrhagic shock, defined as shock index (heart rate/systolic blood pressure) ≥1 at the scene. PHT was defined as the interval from dispatch to hospital arrival and compared across urbanicity (urban, suburban, rural, wilderness) and transport mode (ground or air). Results: Among 939,335 eligible encounters, the median prehospital time (PHT) differed significantly across urbanicity categories, increasing progressively from urban to wilderness regions (urban 39 min [IQR 30–51], suburban 45 [32–63], rural 50 [34–71], wilderness 56 [37–78]; p < .001). All three components of PHT—system response, scene, and transport time—were longer in rural and wilderness. Total PHTs remained stable, with only minor year‐to‐year variation. Air PHT was consistently longer than ground PHT ( p < .001) and showed no temporal improvement across 2020–2023. Discussion: National EMS data show persistently prolonged prehospital times for trauma patients at risk of hemorrhagic shock, especially in rural and wilderness areas. Bringing transfusion capability closer to patients through prehospital blood programs may be critical to reducing time‐dependent mortality.

Background: Epidermal growth factor receptor (EGFR)-targeted tyrosine kinase inhibitors (TKIs) have exhibited efficacy in EGFR-mutant non-small cell lung cancer (NSCLC) patients. However, the response is modest in patients with wild-type (wt)-EGFR, and approximately 30–40% of patients develop TKI resistance. Recently, a role for BRG1 (SMARCA4) in regulating gene expression and its frequent alteration in various cancers, including NSCLC, has been reported. Yet, its specific function in response to EGFR-TKI therapy remains elusive. Herein, we investigated the role of BRG1 in EGFR-TKI response in vitro and in vivo using lung cancer models. Methods: In vitro, A549, H358, and HCC827 cell lines that varied in their EGFR and BRG1 status were assessed for response to EGFR-TKI upon overexpression or gene silencing of BRG1 through cell viability, cell migration, and Western blotting assays. In vivo, A549 and H358 tumor xenografts that overexpressed BRG1 or had BRG1 silenced were investigated for tumor growth response to EGFR-TKI. Results: EGFRwt/BRG1mt (A549) cells were resistant to TKI, and restoration of wt-BRG1 expression reverted them to TKI sensitivity both in vitro and in vivo. In contrast, silencing of BRG1wt in H358 cells showed a tendency toward TKI resistance. Additionally, wt-EGFR and pAKT^Ser473 protein complex formation in A549 cells was disrupted with an AKT inhibitor (MK2206), resulting in enhanced cytotoxicity in vitro. Conclusions: Our study demonstrates that EGFR-TKI response in wt-EGFR cells is dictated by BRG1 status. These findings propose screening of wt-EGFR NSCLC patients for BRG1 status for identifying individuals likely to benefit from EGFR-TKI therapy versus patients who will benefit from AKT inhibitor treatment.

Objective: Calibration and discrimination indicators alone are insufficient for evaluating the clinical usefulness of prediction models, as they do not account for the cost of misclassification errors. This study aimed to modify the Geriatric Trauma Outcome Score (GTOS) and assess the clinical utility of the modified model using net benefit (NB) and decision curve analysis (DCA) for predicting in‐hospital mortality.Methods: The Trauma Quality Improvement Program (TQIP) 2017 was used to identify geriatric trauma patients (≥ 65 years) treated at Level I trauma centers. The outcome of interest was in‐hospital mortality. The GTOS was modified to include additional patient, injury, and treatment characteristics identified through machine learning methods, focusing on early risk stratification. Calibration and discrimination indicators, along with NB and DCA, were utilized for evaluation.Results: Of the 67,222 admitted geriatric trauma patients, 5.6% died in the hospital. The modified GTOS score included the following variables with associated weights: initial airway intervention (5), Glasgow Coma Scale ≤13 (5), packed red blood cell transfusion within 24 h (3), penetrating injury (2), age ≥ 75 years (2), preexisting comorbidity (1), and torso injury (1), with a total range from 0 to 19. The modified GTOS demonstrated a significantly higher area under the curve (0.92 vs. 0.84, p < 0.0001), lower misclassification error (4.9% vs. 5.2%), and lower Brier score (0.036 vs. 0.042) compared to the original GTOS. DCA showed that using the modified GTOS for predicting in‐hospital mortality resulted in higher NB than treating all, treating none, and treating based on the original GTOS across a wide range of clinician preferences.Conclusions: The modified GTOS model exhibited superior predictive ability and clinical utility compared to the original GTOS. NB and DCA offer valuable complementary methods to calibration and discrimination indicators, comprehensively evaluating the clinical usefulness of prediction models and decision strategies.