August 2019

Synopsis: Firearm injuries are one of the most common causes of death in the pediatric population. In this study, the authors utilized a novel pre-hospital EMS registry, the National Emergency Medical Services Information Systems (NEMSIS) database, to identify areas of focus for on-scene interventions to improve the prehospital care of pediatric gunshot victims. There were 16,808 children who suffered a firearm injury (2010-2015), with a 6.1% mortality rate. Despite the recent well-publicized, tragic mass casualty events in schools, the majority of firearm injuries and deaths occurred at home (only 4.2% of injuries and 1.4% of deaths occurred in a public building), where 49.8% of firearms deaths were self-inflicted (i.e., suicide). The highest number of on-scene deaths before EM arrival was a result of cardiac arrest. The majority of on-scene fatalities after EMS intervention were due to non-compressible injuries (categorized as head and chest injuries) which had a case mortality rate of 5.3%, accounting for 28.6% of injuries and 26.3% of mortalities. Comparatively, compressible injuries (categorized as extremity injuries) only had a 0.1% case fatality rate. The authors suggest that pre-hospital mortality from pediatric firearm injury can be reduced be teaching bystanders basic life saving techniques and first-aid intervention, such as CPR, and hypothesize that the more widespread civilian use of tourniquets is effective in reducing on-scene mortality from compressible injuries. The authors fail to comment on strategies to reduce the lion share of mortalities, namely those from firearm-assisted suicide – where issues of gun safety, accountability and access to mental health care will need to be further explored. 

Synopsis: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly being considered as an adjunct in the management of non-compressible torso hemorrhage in civilian trauma. First described in the Korean War, REBOA uses an endovascular approach to achieve balloon occlusion of the aorta, control distal hemorrhage, and augment cardiac preload. Prospective registry studies from the AAST suggest REBOA is a viable alternative to open aortic occlusion. This study from Joseph et al. in JAMA Surgery uniquely excluded patients who underwent resuscitative thoracotomy, and utilized a propensity score-matched analysis of the ACS Trauma Quality Improvement Program (2015-2016) to evaluate the utility of REBOA in the resuscitation of the severely injured trauma patients. Of 593,181 trauma patients, 140 patients underwent REBOA within the 1 hour of admission. Blunt injury was the mechanism of injury in 92.1% of REBOA patients although specific information regarding the indication for REBOA placement was not available. These patients were matched 1:2 to 280 non-REBOA patients to minimize bias from demographics, vitals, mechanism of injury, and injury type and severity. The REBOA group had a higher mortality rate in the first 24 hours of admission compared to the No-REBOA Group (26.4% vs. 11.8%, P=0.01). Mortality in the ED and after 24 hours was not different between groups, nor were transfusion requirements or length of stay in the hospital or ICU. Regarding complications, REBOA group exhibited higher rates of acute kidney injury (10.7% vs. 3.2%, P=0.02) and lower extremity amputation (3.6% vs. 0.7%, P=0.04), although information on the zone or duration of balloon occlusion was not available to further interpret this data. Interestingly, authors found that the REBOA group experienced longer times from ED presentation to angioembolization or exploratory laparotomy (59 vs. 46 minutes and 45 vs. 33 minutes respectively, both P=0.04). These findings highlight the need for further randomized prospective research to dissect which populations truly benefit from REBOA and when to use it. 

Synopsis: The first and largest study to show the improved survival of perioperative chemotherapy in locally advanced, resectable gastric cancer was the Medical Research Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial. This trial showed a 5-year survival advantage of perioperative epirubicin, cisplatin, and flurouracil (ECF) over surgery alone (36% vs 23%). This Phase III randomized control trial of 716 patients compared perioperative FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel) to the standard of care (at least in Europe) perioperative ECF. The phase 2 study published in 2017 showed FLOT was superior to ECF in terms of complete pathological regression (15% vs 6%, p = 0.02). In the trial, ECF was administered for 3 preoperative and 3 postoperative cycles, while FLOT was administered for 4 preoperative and 4 postoperative cycles. Surgery, which occurred 4 weeks after the last dose of preoperative chemotherapy, was protocolized depending on tumor location with at least a D2 lymphadenectomy. Fifty-two percent of the ECF group and 60% of the FLOT group completed all allocated cycles with over 95% of the entire cohort proceeding to surgery. A higher rate of the FLOT group required GCSFs (34% vs 21%). The incidence of postoperative complications, hospital stay, and re-operations were similar in both groups. Ninety day mortality was 5% in the FLOT group, compared to 8% in the ECF group. Interestingly, while baseline T and N staging were similarly distributed between the groups, a higher proportion of the FLOT group were pathologically staged as T1 (25% vs 15%, p < 0.01) and N0 (49% vs 41%, p = 0.025) following chemotherapy and achieved a margin-free resection (85% vs 78%, p = 0.0162). Significant nausea, vomiting, thromboembolic events, and anemia were higher in the ECF group while, infections, neutropenia, diarrhea, and neuropathy were higher in the FLOT group. Finally, median survival was 35 months in the ECF group and 50 months in the FLOT group (p = 0.012). Overall, this was a well designed study that succeeded in showing improved benefit over standard of care ECF, albeit with the higher risk of neutropenic complications. Interestingly, tumors of the GE junction, which can alternatively be treated with preoperative chemoradiation as suggested by the CROSS trial, were included in this trial and as a subgroup showed benefit with FLOT over ECF. It is, however, difficult to compare across trials and make conclusions. Luckily, there are currently two phase 3 trials, the ESOPEC and TOPGEAR trials, that will help us understand which patients may benefit from which treatment.