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Patients with chronic obstructive pulmonary disease (COPD) who sustain rib fractures are at increased risk of respiratory complications due to impaired pulmonary reserve. Surgical stabilization of rib fractures (SSRFs) has demonstrated benefits in selected trauma populations; however, its impact in patients with COPD remains unclear. Adult COPD patients aged &#x2265;35 with multiple rib fractures were identified from the National Trauma Data Bank (2017-2022). Patients were stratified according to treatment strategy: SSRF versus nonoperative management. Propensity score matching (1:1) was performed to balance baseline characteristics and injury severity between groups. Primary outcomes included in-hospital mortality and resource utilization. Subgroup analyses compared early fixation within 72 hours with delayed fixation after 72 hours, stratified by the presence of flail chest. Among 21,757 eligible patients, 626 underwent SSRF and 21,131 received nonoperative management. In-hospital mortality did not differ significantly between the SSRF and nonoperative groups. However, SSRF was associated with greater resource utilization, including higher rates of mechanical ventilation (45.5% vs. 28.9%; p<0.001), unplanned intensive care unit (ICU) admission (11.7% vs. 7.1%; p=0.013), and unplanned intubation (13.9% vs. 8.9%; p=0.013), as well as longer ICU stay (7 vs. 3&#xa0;d; p<0.001) and hospital stay (14 vs. 10&#xa0;d; p<0.001). Early fixation was associated with shorter ICU and hospital stays in both flail and non-flail chest subgroups. In patients without flail chest, early SSRF was also associated with lower ventilation rates (31.9% vs. 47.1%; p=0.007). Mortality did not differ by SSRF timing. In COPD patients with multiple rib fractures, SSRF was not associated with a significant mortality benefit and was associated with greater respiratory support requirements and resource utilization than nonoperative management. However, early SSRF was associated with shorter ICU and hospital stays in both flail and non-flail injury patterns and with reduced mechanical ventilation in patients without flail chest. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Retrospective Cohort Study; Level III.

One third of organ donors die due to catastrophic brain injury (CBI). CBI causes massive physiological derangements that can damage organs and prevent organ donation. Hormone replacement therapy (HRT) can mitigate this damage when given in the critical care setting, but no standardized protocol for use at trauma centers exists. Single-center studies show that HRT increases organ donation, but there has not been an investigation on which hormone combinations are most beneficial. This prospective, observational EAST multicenter trial included adult CBI patients at 38 Level I and II trauma centers from January 2022 to June 2025. CBI was defined as a brain injury causing loss of function above the brain stem and subsequent death. A generalized linear mixed model analyzed the association of HRT and organ donation. Of 1,184 CBI patients, 704 received at least one hormone. There were 269 organ donors, and 227 received HRT. HRT patients were younger, more often male, sustained higher rates of penetrating brain injuries, and had lower rates of known comorbidities compared with non-HRT patients. HRT patients had higher ISS, but there was no difference in abbreviated injury scale-head scores between groups. GLMM analysis accounted for demographic and clinical differences between groups and found that single-hormone replacement with steroids, levothyroxine, vasopressin, dopamine, DDAVP, or insulin was associated with increased odds ratios of organ donation compared with no HRT. The combination of methylprednisolone and levothyroxine was associated with the greatest increased odds of donation. When administered to CBI patients before brain death, HRT is associated with significantly increased odds of organ donation. A standardized protocol incorporating HRT should be utilized across trauma centers to maximize organ donation in patients who have suffered nonsurvivable head trauma. (J Trauma Acute Care Surg. 2026;00: 000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Prognostic and Epidemiological; Level II.

Research has demonstrated improved outcomes for younger adults with severe injury [injury severity score (ISS) >15] treated at a Level 1 trauma center (L1TC). There is limited research comparing L1TCs to Level 3 TCs (L3TC) in both younger and older adults. The purpose of this study was to compare mortality rates for all age and injury severity groups at L1TCs and L3TCs. All trauma patients aged 18 to 89 years, admitted 2017-2023, were selected from the Trauma Quality Program Participant Use File files, excluding burns, transfers-in, and transfers-out. Inverse propensity score weighting balanced 14 baseline characteristics (eg, age, sex, comorbidities, frailty, ISS, Glasgow Coma Scale, vital signs, TBI status), with top 500 extreme weights trimmed. L1TC patients were compared with L3TC patients on total mortality (death+hospice) using multivariable logistic regression. This analysis examined multiple patient subsets. All analyses were stratified by younger adults (18-64 y) and older adults (65-89 y). A total of 526 L1/3TCs submitted 2,788,401 patients (median age, 55 y; median ISS, 9; 88.2% blunt; 5.2% total mortality). After balancing, L1TC patients had significantly lower adjusted odds (95% CI) of total mortality overall than L3TCs in younger [0.83 (0.81-0.85)] and older adults [0.95 (0.93-0.97)]. For the various subsets, the adjusted odds ratio for younger adults at L1TCs ranged from 0.64 to 0.87 and from 0.83 to 1.06 for older adults. In older adults, most absolute percentage differences in mortality between L1TCs and L3TCs were small (<1%) except for Glasgow Coma Scale 3 to 8 (6.7%) and ISS >25 (1.3%), both favoring L1TCs. While younger adults experienced a substantial survival advantage at L1TCs overall and in all subsets, these data suggest that only certain subsets of older adults (eg, severe TBI and ISS >25) might benefit from transfer to L1TCs. Other subsets of older adults may, therefore, be successfully managed at L3TCs, highlighting important complementary roles of L1TCs and L3TCs in the care of older adult trauma patients. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Therapeutic/Care Management; Level III.

Each year, hundreds of thousands of children are treated for injuries related to micromobility use. Helmet use is a proven preventive measure, yet use remains low. Recently, the rise in electric vehicles (EVs) has introduced new risks. The study aimed to characterize pediatric micromobility accidents from motorized and nonmotorized bicycle, scooter, and skateboard accidents, with a focus on helmet use and its impact on injury severity. We conducted a retrospective study at a Level 1 adult and Level 2 pediatric trauma center, analyzing 285 cases of pediatric injury from motorized and nonmotorized bicycle, scooter, and skateboard accidents between January 1, 2020, and December 31, 2024. Data from the trauma registry and electronic health records were reviewed. Helmet use and its association with demographic factors, injury severity score, and clinical outcomes were analyzed. On average, there were 57 cases of micromobility injuries each year, with cases increasing from 45 to 77 between 2020 and 2024. Overall, helmet use was 23.5%. Helmet use declined from 31.1% in 2020 to 23.4% in 2024. Lower helmet use was significantly associated with lower socioeconomic status and non-White riders. From 2020 to 2024, EV-related injuries increased from 0% to 37.7%. Increased EV use was significantly associated with older age and male gender. Despite a helmet mandate in New Jersey, helmet use in our cohort was lower than national estimates, and the issue is getting worse in recent years, especially among non-White individuals from low-opportunity neighborhoods. While helmet use among patients presenting for trauma care did not correlate with lower injury severity, this likely reflects injuries prevented or lessened by helmets, reducing the need for trauma care. EVs constitute an increasingly large percentage of injury mechanisms in our cohort, especially among young males. Our work highlights the need for targeted interventions among the most vulnerable populations. (J Trauma Acute Care Surg. 2026;00: 000-000. Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Prognostic/Epidemiology; Level III.

Traumatic abdominal wall hernias (TAWHs), though rare in pediatric trauma, may signal severe associated intra-abdominal injury, particularly hollow viscus injury (HVI). This study evaluated whether pediatric TAWH is associated with a higher incidence of HVI and solid organ injury (SOI) compared with abdominal wall hematoma or ecchymosis. We performed a retrospective analysis of the National Trauma Data Bank (2018-2022), including patients 18 years of age or older with TAWH or abdominal wall hematoma/ecchymosis. Bivariate statistics and multivariable logistic regression assessed the association between TAWH and HVI and SOI, adjusting for demographics, vitals, and injury severity score (ISS). Among 13,261 patients, 414 (3.1%) had TAWH and 12,847 (98.1%) had abdominal wall hematomas/ecchymoses. TAWH patients presented with lower median SBP (116 vs. 120&#xa0;mm&#xa0;Hg, p<0.0001) and median ISS (5 vs. 9, p<0.0001). Median hospital length of stay was shorter in TAWH patients (2 vs. 3&#xa0;d, p=0.0003). However, TAWH patients had increased rates of HVI (10.3% vs. 2.5%, p<0.0001), but no difference in rates of SOI (19.8% vs. 20.1%, p=0.89). TAWH patients also had increased rates of thoracic and lumbar spine injuries (20.5% vs. 14.7%, p<0.0001), as well as thoracic and abdominal aortic injuries (20.7% vs. 2.8%, p<0.0001). Multivariable analysis confirmed TAWH was independently associated with increased odds of HVI (odds ratio, 1.08; confidence interval, 1.067-1.105; p<0.0001), but not associated with SOI (odds ratio, 0.98; confidence interval, 0.95-1.02; p=0.55). Pediatric TAWHs are associated with increased risk of HVI despite lower ISS, highlighting the need for heightened clinical suspicion and thorough evaluation. The difference in injury patterns between TAWH and abdominal hematoma highlights the need for treating TAWH as a distinct entity. Recognition of TAWH should prompt careful assessment for intra-abdominal injuries and consideration for early operative intervention. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright &#xa9; 2026 Wolters Kluwer Health, Inc. All rights reserved.). Retrospective Cohort Study; Level IV.

Diverting ostomy creation is commonly performed after traumatic colon injuries, yet data on long-term outcomes, reversal predictors, and ostomy complications in trauma patients remain scarce. A 5-year retrospective review at an urban level 1 trauma center identified patients with colon injuries who underwent ostomy creation. Demographics, follow-up duration, reversal rates, and complications were analyzed. Factors linked to successful reversal were compared. Among 559 patients who underwent operative colon injury management, 94 received an ostomy. Most were male (84%) with penetrating injuries (76%). Early stoma complications included ischemia in three (3%) and retraction in two (2%) patients. Late complications included parastomal hernia in two (2%), prolapse in one (1%), and retraction in one (1%) patient. Eleven patients died before discharge, leaving 83 with a median follow-up of 269 days (IQR, 178-448). Stoma-related readmissions occurred in 12 of 83 patients (15%), with 11 of 12 (92%) for dehydration. At 6, 12, 24, and 60 months, 22%, 48%, 60%, and 64% of patients completed ostomy reversal, respectively. Twenty-seven patients had a concomitant ventral hernia (VH), of whom 11 of 27 (40.7%) completed hernia repair with reversal. VH correlated with lower reversal likelihood (p=0.011). Multivariable logistic regression showed increasing age [adjusted odds ratio (AOR), 0.949; p=0.012] and concomitant VH (AOR, 0.330; p=0.042) as predicting decreased likelihood of reversal, with loop-type ostomy (AOR, 2.98; P=0.052) increasing reversal likelihood. Of the 53 patients who underwent reversal, 9 (17%) experienced complications, including one reversal-related death. Patients with ostomies for traumatic colon injuries have favorable reversal rates. VH repair concomitant with ostomy reversal is feasible but associated with lower reversal rates. Given overall complication rates, surgeons should carefully weigh the use of a diverting ostomy for colon injuries. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Prognostic/Epidemiologic; Level III.

Bleeding after trauma is aggravated by trauma-induced coagulopathy (TIC). In trauma patients with shock, ADAMTS13 (a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13) antigen is decreased, but its activity can be increased, possibly due to specific cleavage by plasmin. Increased ADAMTS13 activity could aggravate TIC and bleeding. Therefore, this study aimed to determine whether knocking-out ADAMTS13 is protective after trauma with uncontrolled bleeding. Furthermore, we examined the effect of plasmin inhibition with tranexamic acid (TXA) on ADAMTS13 antigen and activity. Wild-type and ADAMTS13 knockout (ADAMTS13KO) mice were anesthetized, mechanically ventilated, and subjected to traumatic injury with uncontrolled hemorrhage. In a separate experiment, wild-type mice underwent the same traumatic injury, but with additional blood withdrawal to induce shock and treatment with a single dose of TXA or vehicle. Outcomes included mortality, ADAMTS13 activity, von Willebrand factor (VWF) multimers, and rotational thromboelastometry (ROTEM). ADAMTS13KO mice showed significantly lower mortality rates after trauma compared with wild-type mice (13% vs. 47%, P=0.046), with significantly higher VWF multimers. ROTEM parameters did not differ significantly between ADAMTS13KO and wild-type mice. In the wild-type mice subjected to trauma and shock, there was a significant increase in ADAMTS13 activity, which correlated with shock severity. Treatment with TXA significantly reduced mortality, but had no significant effect on ADAMTS13 antigen or activity. Knocking-out ADAMTS13 is associated with improved early survival following trauma, demonstrating a role for ADAMTS13 in contributing to early TIC and bleeding. While ADAMTS13 activity increases after trauma and shock, its levels appear unaffected by TXA. (J Trauma Acute Care Surg 2026;00:000-000 &#xa9; 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). Level V.

This is the Western Trauma Association's recommended algorithm for the management of a traumatic lung injury. The current algorithm and recommendations are based on available published randomized trials, observational studies, systematic reviews, and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represent a safe and reasonable approach to this common problem. We recognize that there may be variability in decision-making, local resources, institutional consensus, and patient-specific factors that may require deviations from the presented algorithm. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. Consensus algorithm from the Western Trauma Association, Level V. (J Trauma Acute Care Surg. 2026;101: 187-198. Copyright c 2026 Wolters Kluwer Health, LLC. All rights reserved.).

Tranexamic acid (TXA) is widely used in patients with traumatic brain injury (TBI). However, its pharmacology suggests differences in effectiveness should exist based on fibrinolytic phenotype, particularly fibrinolytic shutdown. This study examined whether fibrinolytic shutdown is associated with increased mortality in TBI and whether TXA retains its benefit in this subgroup. This retrospective cohort study included TBI patients who had thromboelastography (TEG) upon presentation at three affiliated trauma centers. Patients were excluded if they received TXA before TEG, had TXA >3 hours postadmission, Glasgow Coma Score (GCS)=3 and a nonreactive pupil or a nonsurvivable injury. The primary endpoint was all-cause mortality, either in-hospital or in-hospice, up to 28 days. Patients were stratified by fibrinolytic phenotype: shutdown (LY30<0.5%), physiologic (0.5-7.7%), or hyperfibrinolytic (>7.7%) and TXA receipt. Univariate and multivariate analyses were performed. Of 394 patients (mean age 64&#xb1;21&#xa0;y; 56% ground-level falls; 74% mild TBI), fibrinolytic shutdown predominated [72% (n=285)], followed by physiologic [27% (n=107)], and hyperfibrinolysis [0.5% (n=2)]. Unadjusted mortality was 16% with shutdown versus 9.2% without (p=0.090). After controlling for age, ISS, GCS, multicompartmental head injury, neurosurgical intervention, and TXA, there was no association between shutdown phenotype and mortality [OR (95% CI) =1.37 (0.62-3.05)]. In patients with fibrinolytic shutdown, unadjusted mortality was lower in patients who received TXA [12% (24/196) vs. 24% (21/89), p=0.015]. After controlling for age, ISS, GCS, multicompartmental head injury, and neurosurgical intervention, mortality remained lower [OR (95% CI)=0.36 (0.16-0.77)]. In patients without fibrinolytic shutdown, no difference in mortality was noted [TXA, 9.6% (7/73) vs. no TXA, 8.3% (3/36), p=1.00]. These results did not change after controlling for the above confounders [OR (95% CI)=0.96 (0.16-5.78)]. TXA remained associated with lower mortality in TBI patients with fibrinolytic shutdown, despite pharmacologic expectations. Fibrinolytic shutdown was not independently associated with higher mortality. These findings support early TXA administration without delaying treatment for TEG interpretation. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Therapeutic/Care Management; Level IV.

There is no clear consensus to which extent noninvasive treatment can be used with regard to posttraumatic pneumothorax size. This results in treatment variation among physicians. This study primarily aimed to examine the current treatment variation in the management of unilateral pneumothorax after blunt trauma, varying in size. Secondarily, clinical outcomes were evaluated in patients with the greatest treatment variation. This multicenter retrospective cohort study included adult patients admitted with unilateral pneumothorax following blunt trauma between January 1, 2021, and December 31, 2022. The primary outcome measure was the type of index treatment, and secondary outcome measures were secondary tube thoracostomy (TT), adverse events, and hospital length of stay. Of 275 eligible patients in the overall study population, 126 (45.8%) patients received noninvasive treatment, and 149 (54.2%) underwent TT. Treatment variation was greatest for pneumothorax sizes of 15% to 50%, defined as medium-sized pneumothorax (36.6% noninvasive and 63.4% TT). Secondary TT was performed in 14 (29.2%) patients with medium-sized pneumothorax. Hospital length of stay was shorter for the noninvasive group with medium-sized pneumothorax compared with the TT group, although this finding did not reach statistical significance after IPTW analysis (4&#xa0;d vs. 5&#xa0;d; p=0.313). No statistical difference was found for overall complications (32.8% vs. 30.2%; OR: 1.14 (95% CI: 0.40-3.28); p=0.811). In this study, noninvasive treatment was used in 45.8% of patients for managing pneumothorax after blunt trauma. Treatment variation was mainly seen for patients with pneumothorax sizes of 15% to 50%. Noninvasive treatment in patients with such medium-sized pneumothorax was associated with similar hospital length of stay and complication rates compared with TT, and deemed a safe treatment strategy. (J Trauma Acute Care Surg. 2026;100: 863-870. Copyright &#xa9; 2025 The Author(s). Published by Wolters Kluwer Health, LLC. on behalf of the American Association for the Surgery of Trauma.). Therapeutic/Care Management; Level IV.

Intercostal nerve cryoablation (IC) is commonly performed during surgical stabilization of rib fractures (SSRF) to provide analgesic benefit; however, evidence supporting its efficacy is limited, and long-term outcomes are not well described. We performed a retrospective cohort study of consecutive patients who underwent SSRF for acute indications at a Level I trauma center between 2016 and 2025. During SSRF, IC was performed at surgeon discretion. Patients were excluded if they received any operation besides SSRF during admission. Outcomes were compared based on treatment with IC and further stratified by mechanical ventilation status. The primary outcome was opioid exposure, evaluated in the nonventilated cohort using multivariable linear regression. Long-term follow-up outcomes were reported. One hundred thirty-four patients met the inclusion criteria. In adjusted regression analysis of nonventilated patients (n=104), IC demonstrated no clear reduction in average daily opioid exposure (-10.4 MME/d, 95% CI: -32.7 to 11.9, p=0.357). In ventilated patients (n=30), IC was associated with reductions in duration of mechanical ventilation (median 1.8 vs. 5.3&#xa0;d, p=0.040) and pneumonia (10% vs. 50%, p=0.049). After discharge, IC was associated with more frequent referral to pain management specialty care for intercostal neuralgia (20% vs. 4.5%, p=0.018). These data do not support the routine use of IC during SSRF for nonventilated patients, although selective IC may benefit ventilated patients. When surgeons consider offering IC, the risk of intercostal neuralgia should be weighed against anticipated benefits. Future studies should control for ventilator status, as it may greatly influence the treatment effect. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Therapeutic/Care Management; Level IV.

Detecting right-sided venous congestion (RSVC) is more difficult than left-sided venous congestion (LSVC). Point-of-care ultrasound (POCUS) can assess venous Doppler flow patterns in the hepatic (HV), portal (PV), and renal (RV) veins. RSVC can predict organ injury from volume overload in critically ill patients. The prevalence and feasibility of measuring RSVC are unknown in traumatic hemorrhagic shock (THS). This is a retrospective review of quality improvement data regarding feasibility and utility of assessing RSVC in THS. All trauma patients who were transfused, had at least one systolic blood pressure measurement <90&#xa0;mmHg, and/or a heart rate >108 beats per minute, and/or lactate >2.0&#xa0;mmol/L within one hour of admission were flagged. Sonographic examinations were performed within 48 hours. RSVC included PV >30% pulsatility, HV systolic<diastolic, RV pulsatility. LSVC included B-lines. Statistical significance was assessed with &#x3c7;2 and Fischer exact tests. Of 182 patients screened, 135 met inclusion criteria. Ninety-six examinations were performed. Seventy-eight percent were male with mean age of 48.3 years. Forty-seven percent were African American and 42% Caucasian. Seventy percent sustained blunt injury. Median injury severity score on admission was 24. Venous congestion was assessed in 94.7% of patients; PV in 81.3%, HV in 79.1%, and RV in 51%. Thirty-seven percent had at least one metric of RSVC. Conversely, LSVC was present in only 4.2% of patients, P<0.001. Patients with an abnormal TAPSE (&#x2264;1.7&#xa0;cm) have an OR of RSVC of 4.24 (CI: 1.17-13.73, P=0.046). Evidence of RSVC is prevalent in patients with THS, significantly more than LSVC at 24 hours. This could be an unintended consequence of life-saving massive transfusion and cardiac dysfunction and may identify a cohort of patients that would benefit from a fluid-restricted approach to resuscitation. Further studies are needed for validation and to better understand the etiology and clinical relevance of RSVC in THS. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Level IV.

Despite the growing awareness of social determinants of health in pediatric trauma care, the influence of fathers and male caregivers on recovery following violent injury remains underexplored. Understanding this potential protective factor is essential to developing wraparound service models and resilience-building strategies for high-risk youth. We conducted a retrospective cohort analysis of a prospectively maintained database of patients aged 0 to 17 enrolled in a hospital-based violence intervention program at an ACS-verified Level I pediatric trauma center. Eligible patients sustained violent injuries, including gunshot wounds, assaults, or stabbings, and received longitudinal case management over 6 to 12 months. Demographic, household, and social data were collected, with specific attention to caregiver composition. Outcomes included school enrollment, violent reinjury, juvenile court involvement, safety assessments, and resilience scores from Coping Orientation to Problems Experienced (COPE). Comparative analyses were performed based on the presence or absence of a father or male caregiver in the home. Among 227 patients enrolled over 3 years, only 31 (14%) had a father present, and 36 (16%) had any male caregiver. Mothers were present in 89% of households. Mean age was 15 years (IQR: 11-16); 67% were male, and 65% were gunshot wound victims. No significant differences were found in baseline social determinants or postdischarge safety concerns. Children with fathers demonstrated higher Coping Orientation to Problems Experienced resilience scores and showed a greater likelihood of accepting emotional support, engaging in prayer or meditation, and finding comfort in spiritual beliefs (all p<0.05). School enrollment postprogram was higher among those with fathers (100% vs. 82%, p=0.016) and was associated with fewer juvenile adjudications (p=0.002). Few violently injured children have a father or male caregiver present. The presence of male caregivers was associated with improved school engagement and psychological resilience following violent trauma, emphasizing the importance of male involvement in recovery and possibly prevention efforts. (J Trauma Acute Care Surg. 2026;101: 233-240. Copyright &#xa9; 2026 Wolters Kluwer Health, Inc. All rights reserved.). Prognostic/Epidemiological; Level III.

Hemorrhage is a leading cause of preventable trauma death, particularly in rural settings where prolonged transport times delay resuscitation. Low-titer O+ whole blood (LTOWB) is increasingly favored for prehospital resuscitation due to its combined oxygen-carrying and hemostatic properties. However, logistical challenges and concerns regarding waste and cost have limited its implementation in rural trauma systems. This study evaluates the feasibility and clinical utility of a prehospital LTOWB pilot program at a rural Level I trauma center. We conducted a prospective, single-center pilot study from April 2023 to March 2024, comparing LTOWB data to historical component therapy from the prior year. One unit of LTOWB was deployed weekly to the Helicopter Emergency Medical Services. To mitigate waste, unutilized LTOWB was converted to packed red blood cells on Day 14 post collection. Data on utilization, waste, cost, and availability were collected and analyzed. During the 55-week period, 55 units of LTOWB were deployed, of which 45.5% were used as LTOWB (27.3% prehospital, 18.2% in-hospital) and 47.3% as processed packed red blood cells. Only four units (7.2%) were lost to waste or expiration. The average monthly waste cost was $1,576.79 during the study versus $1,493.89 historically (p = 0.692). Despite supply limitations, prehospital LTOWB availability was maintained for 84.2% of the study days. Implementing a prehospital LTOWB pilot program in a rural trauma system is feasible and cost-neutral. A structured processing protocol achieves high utilization while minimizing waste. These findings support the expansion of whole blood programs to enhance early resuscitation and potentially improve patient outcomes in resource-limited environments. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright &#xa9; 2026 Wolters Kluwer Health, Inc. All rights reserved.). Economic/Value-based Evaluations, Level III.

Lateral implosion injuries (LIIs) result from lateral trauma to the thoracic cage and shoulder, causing concomitant rib and shoulder girdle fractures. While individual combinations of rib and shoulder girdle fractures have been described, the clinical significance of LIIs is poorly understood. Current classification of LIIs relies on radiographic scores such as RibScore, which assess rib or shoulder fractures in isolation. The Ch-Sh (Chest-Shoulder) Classification was proposed to predict risk in LIIs, but its clinical validity has not been evaluated. A retrospective cohort study of patients admitted to a Major Trauma Centre in the UK with multiple rib fractures between 2010 and 2024. Patients were classified as LIIs or isolated rib fractures (IRFs) without additional shoulder injury. A validation cohort was established with patients stratified according to the original and a modified Ch-Sh Classification. Multivariable regression was used to assess associations of injury type (LII vs. IRF) and modified Ch-Sh score with outcomes. Discriminatory performance of a modified Ch-Sh Classification, RibScore, and a combined model was compared. A total of 4145 patients met the inclusion criteria. Seven hundred eighty-two (18.9%) suffered LIIs, and 3363 (81.1%) suffered IRFs. LIIs were associated with increased hospital length of stay (p < 0.001), resource utilisation (p < 0.001), and adverse outcomes (p < 0.001). In the validation cohort (n = 539), higher Ch-Sh scores were associated with increased length of stay, resource utilisation, and adverse outcomes. The modified Ch-Sh Classification mostly demonstrated discriminatory ability comparable to RibScore, but Ch-Sh was superior for shoulder open reduction and internal fixation while RibScore was superior for SSRF. Discrimination significantly improved in the combined model. LIIs represent a distinct injury pattern associated with increased morbidity and resource utilisation compared with IRFs. The Ch-Sh Classification demonstrated associations with outcomes and resource utilisation, suggesting that its use may improve risk stratification in LIIs. (J Trauma Acute Care Surg 2026;00:000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Prognostic/Epidemiological; Level III.

The growing usage of direct oral anticoagulants (DOACs) has brought into question the need for pharmacologic reversal in patients who develop traumatic brain injuries (TBIs). While there are specific benefits in reversal for TBI patients on warfarin, the impact has not been clearly shown in DOAC populations. This study evaluated radiographic and clinical outcomes among patients with isolated mild TBIs to determine whether DOAC usage or its reversal confers measurable differences in early outcomes. We conducted a retrospective review of adults (18 to 99&#xa0;y) with isolated mild TBI (Glasgow Coma Scale: 13 to 15) after ground-level falls at a Level I trauma center from 2016 to 2024. The primary outcome was radiographic hemorrhage progression, defined as >2-mm increase in hemorrhage or need for >2 head computed tomographies within 24 hours. Secondary outcomes included Glasgow Coma Scale decline, intensive care unit length of stay, neurosurgical intervention, thromboembolic events, disposition, and inpatient mortality. Multivariable logistic regression and propensity score matching were used to evaluate associations between DOAC usage, reversal therapy, and outcomes. Among 273 patients, 96 (35%) were taking a DOAC, and of these, 41 received four-factor prothrombin complex concentrate and 18 received andexanet alfa. DOAC patients demonstrated similar rates of radiographic progression, intensive care unit length of stay, and discharge disposition compared with non-DOAC patients. In multivariate analysis, DOAC usage was not associated with increased radiographic progression, measured by subdural hemorrhage growth (47.5% vs. 44.8%; p = 0.70) or increased need for >2 computed tomography scans (49.1% vs. 48.9%, p = 1.00). Among DOAC users, reversal was also not associated with improved radiographic progression or secondary outcomes. No significant outcome differences were observed between reversal with four-factor prothrombin complex concentrate and andexanet alfa. In isolated mild TBI after ground-level falls, DOAC usage was not associated with worsened clinical outcomes or increased radiographic progression. Pharmacologic reversal offered no measurable benefit. These findings support selective reversal in stable mild TBI. (J Trauma Acute Care Surg. 2026;00: 000-000 Copyright &#xa9; 2026 Wolters Kluwer Health, LLC. All rights reserved.). Therapeutic/Care Management; Level III.

Loss-of-function (LOF) alterations in PTCH1 are a hallmark of basal cell carcinoma (BCC) and drive activation of the Hedgehog (Hh) signaling pathway. Hh inhibitors are approved to treat advanced BCC, but little is known about the frequency, biology, and treatment of PTCH1 alterations in other cancers. We analyzed PTCH1 LOF alterations across diverse solid tumors and evaluated outcomes of patients with non-BCC tumors who received Hh inhibitors. Among 121,490 tumor samples, 2064 (1.7%) harbored PTCH1 LOF alterations. Among 13 patients with non-BCC tumors treated with an Hh inhibitor, the response rate was 31%, with responses seen in sebaceous adenocarcinoma, squamous cell lung cancer (SCC), cutaneous SCC and glioblastoma. Median progression-free survival was 4.1 months, and median overall survival was 9.8 months. PTCH1 LOF alterations may identify a tumor-agnostic subset of patients who could derive benefit from Hh inhibitors beyond BCC, supporting further prospective evaluation.

Treatment of early-onset scoliosis (EOS) with the Shilla growth guidance ("Shilla") procedure typically concludes by "graduating" to: (1) posterior spinal fusion (PSF) immediately or later, (2) Shilla construct removal, or (3) Shilla construct retention after skeletal maturity. The optimal final outcome of the Shilla procedure has not been determined. An international, multicenter database of EOS patients was queried for Shilla patients with a minimum 2-year follow-up after the initial Shilla procedure who reached skeletal maturity or had implant removal with PSF with segmental spine instrumentation (SSI) concurrent with Shilla construct removal; implant removal with PSF+SSI during a later, unplanned surgery; or implant removal only. Radiographs were evaluated for major coronal deformity and skeletal maturity (Risser score &#x2265;4). Conclusion of Shilla treatment was confirmed from clinical summaries provided by patients' board-certified orthopaedic surgeons. Subsequent surgeries and complications were tracked. We retrospectively reviewed 74 patients [mean age at implantation was 6.8&#xb1;2.1&#xa0;y (range 2 to 10&#xa0;y), 48 (65%) female]. At the most recent follow-up [mean 8.9&#xb1;3.2&#xa0;y (range: 0.3 to 15&#xa0;y)], 10 patients retained their Shilla construct, of whom 2 (20%) experienced instrumentation-related complications. The remaining 64 underwent construct removal: 49 (77%) underwent immediate PSF + SSI, 3 (6%) of whom experienced deep wound infection (DWI); of 15 (23%) who had construct removal, late PSF+SSI was required in 9 (60%), 2 (22%) of whom experienced DWIs, and the Shilla construct remained removed at latest available follow-up in 6 (40%). Mean progression of major curve angles of those who underwent PSF+SSI with late construct removal was 27&#xb1;31 degrees/year. Many patients who have their Shilla construct removed eventually undergo PSF+SSI because of substantial deformity progression. Patients who underwent late PSF+SSI after construct removal had larger curves and a 22% infection rate, compared with 6% in those who underwent immediate PSF. Retaining a construct still risks instrumentation-related complications, even after reaching skeletal maturity; to minimize later complications, immediate PSF+SSI concurrent with construct removal may be the preferred endpoint of Shilla treatment. Level III.

To determine how cardiovascular disease (CVD) risk factor burden and vascular bed involvement relate to the risk of dementia in individuals with established CVD. Participants were from the prospective, single-center UCC-SMART cohort study, recruited between 1996-2024. CVD risk factor burden was defined as the number of CVD risk factors present. The number of affected vascular beds was the count of coronary artery disease, cerebrovascular disease, and peripheral artery disease. Relations with all-cause dementia were estimated with Cox regression adjusted for confounders. Among 10,321 participants (mean age 61&#xb1;10 years; 27% female), 296 developed dementia during a median follow-up of 10.1 years (IQR 5.0-15.7). Dementia risk increased with higher CVD risk factor burden: compared with 0-1 risk factors, hazard ratios were 1.35 (95% CI 0.95-1.92) for 2 risk factors, 1.58 (95% CI 1.10-2.26) for 3 risk factors, and 1.87 (95% CI 1.31-2.67) for 4-9 risk factors. Compared with 1 affected vascular bed, the hazard ratios were 1.32 (95% CI 1.02-1.71) for 2 affected vascular beds and 1.90 (95% CI 1.05-3.43) for 3 affected vascular beds. Dementia risk was higher in participants with peripheral artery disease (HR 1.68; 95% CI 1.24-2.28) and cerebrovascular disease (HR 2.09; 95% CI 1.61-2.71) than in those with coronary artery disease. Higher CVD risk factor burden and involvement of multiple vascular beds are related to increased dementia risk in individuals with established CVD. These findings underscore the importance of stringent cardiovascular risk management as a potential strategy to lower dementia risk in this population.