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\"One of the greatest storytellers of his generation, Grant Morrison's arrival onto the Dark Knight was one of the most hyped debuts in industry history. This collection includes time-spanning epic graphic novels featuring the cataclysmic events of FINAL CRISIS and the introduction of Batman's son, Damian Wayne! These blockbuster stories featured a deconstruction of super hero comics like never before, with challenging, thought-provoking takes on the modern, four-color icons.\"-- Provided by publisher.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of trauma patients in shock undergoing REBOA versus no-REBOA. This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000-2019). REBOA (R; 2015-2019) patients were propensity matched 2:1 to historic (H; 2000-2012) and contemporary (C; 2013-2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively. A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups. In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.

Variations in admission patterns have been previously identified in non-elective surgical services, but minimal data on the subject exists with respect to burn admissions. Improved understanding of the temporal pattern of burn admissions could inform resource utilization and clinical staffing. We hypothesize that burn admissions have a predictable temporal distribution with regard to the time of day, day of week, and season of year in which they present. A retrospective, cohort observational study of a single burn center from 7/1/2016 to 3/31/2021 was performed on all admissions to the burn surgery service. Demographics, burn characteristics, and temporal data of burn admissions were collected. Bivariate absolute and relative frequency data was captured and plotted for all patients who met inclusion criteria. Heat-maps were created to visually represent the relative admission frequency by time of day and day of week. Frequency analysis grouped by total body surface area against time of day and relative encounters against day of year was performed. 2213 burn patient encounters were analyzed, averaging 1.28 burns per day. The nadir of burn admissions was from 07:00 and 08:00, with progressive increase in the rate of admissions over the day. Admissions peaked in the 15:00 hour and then plateaued until midnight (p<0.001). There was no association between day of week in the burn admission distribution (p>0.05), though weekend admissions skewed slightly later (p = 0.025). No annual, cyclical trend in burn admissions was identified, suggesting that there is no predictable seasonality to burn admissions, though individual holidays were not assessed. Temporal variations in burn admissions exist, including a peak admission window late in the day. Furthermore, we did not find a predictable annual pattern to use in guiding staffing and resource allocation. This differs from findings in trauma, which identified admission peaks on the weekends and an annual cycle that peaks in spring and summer.

Acute limb ischemia necessitates prompt revascularization to preserve viability and minimize systemic ischemia–reperfusion injury. Delays in care increase morbidity and mortality, underscoring the need for nonsurgical temporizing methods. Lower Extremity Extracorporeal Distal Revascularization (LEEDR) is a percutaneous technique that delivers oxygenated blood from the contralateral femoral artery to the ischemic limb via a retrograde tibial cannula. This study aimed to evaluate LEEDR compared to prolonged untreated warm ischemia. Anesthetized Yorkshire swine (40–60 kg) underwent hindlimb ischemia via endovascular balloon occlusion of the left external iliac and middle sacral arteries and were randomized to control (n = 6; 9 h ischemia) or LEEDR (n = 6; 1-h ischemia plus 8 h extracorporeal support). Revascularization was achieved by balloon deflation, followed by 48 h of observation. The primary outcome was survival; secondary outcomes included gait function, compartment pressure, and biochemical markers of ischemia–reperfusion injury. Survival was significantly higher in the LEEDR group (83% vs. 0%; p  = .001). LEEDR animals demonstrated improved gait function (5.8 ± 0.34 vs. 2.5 ± 0.7; p  < .001), lower compartment pressures (9.9 ± 1.7 vs. 28.5 ± 4.2 mm Hg; p  < .001), and reduced serum potassium (4.57 ± 0.22 vs. 5.14 ± 0.54 mmol/L; p  < .001) and lactate concentrations (1.4 ± 0.55 vs. 2.5 ± 1.6 mmol/L; p  < .001) during reperfusion and recovery. LEEDR effectively mitigated the consequences of 9 h of warm ischemia in a swine model, improving survival, preserving limb function, and preventing compartment syndrome. This percutaneous technique may serve as a viable temporizing strategy in patients with delayed access to definitive revascularization.

Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time. Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution. We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury.

Non-compressible torso hemorrhage (NCTH), leading to exsanguination cardiac arrest, remains the primary cause of preventable death in combat trauma. As the future operational environment shifts toward large-scale combat operations (LSCO) with delayed evacuations and increased casualty volumes, existing damage control strategies may prove inadequate due to limited resources and delayed evacuation. In 1984, US Army Colonel Ronald Bellamy challenged military medicine to develop new interventions for hemorrhagic shock, emphasizing the need for technologies that could ‘buy time’ for evacuation and surgical intervention. Decades later, Emergency Preservation and Resuscitation (EPR), which induces a hypometabolic state through profound hypothermia, offers a potential solution to this problem. This review summarizes the historical evolution of the EPR concept, from early military observations to modern preclinical and clinical advancements in EPR. We explore emerging technologies, such as portable extracorporeal life support systems (eg, MobyBox and CARL), organ perfusion platforms (BrainEx and OrganEx) and adjunctive pharmacologic agents (eg, Frunexian, PEG-20K, TAT-PHLPP9c and mitochondrial transplantation), that can enhance the efficacy of EPR, leading to optimized organ recovery. These innovations provide a foundation for developing resource-expedient EPR capabilities tailored for future battlefields. By synthesizing current evidence and examining the military context of prolonged casualty care, this paper outlines how EPR could meet Bellamy’s challenge and serve as a next-generation tool for combat casualty care. As military medicine prepares for future conflicts, EPR may provide a critical capability to reduce mortality from NCTH and revolutionize combat trauma management in LSCO scenarios.

New low-cost technologies are needed to salvage lost blood in low-resource settings and large animal laboratories. The Hemafuse device is a simple mechanical device that can recover lost blood during surgery. The aim of this study is to assess the feasibility of this device for resuscitating large animals with controlled and unintended hemorrhage and to provide device considerations for use in this context. This study had two experimental components: (1) the Hemafuse device was kept on-shelf and used as needed to assess real-world use for unintended hemorrhage during experiments, and (2) animals underwent a controlled hemorrhage protocol, where four anesthetized swine underwent aortic and external jugular vein catheterization for pressure monitoring. Animals were hemorrhaged into the pelvis, and the Hemafuse device was used to suction the blood through a filter and pushed into a heparinized bag for subsequent retransfusion. Blood samples were collected at baseline, hemorrhage, within the device, and post-retransfusion and laboratory tests were performed. Animals that underwent controlled hemorrhage had a baseline mean arterial pressure of 83.6 ± 7.8 mmHg, and central venous pressure of 12.8 ± 1.9 mmHg, with expected changes throughout hemorrhage and resuscitation. Following resuscitation, pH was similar to baseline (7.39 ± 0.05 vs. 7.31 ± 0.03, = 0.24). Lactate increased throughout the experiment with no significant differences after autotransfusion compared to baseline (2.7 ± 0.7 vs. 4.1 ± 1.4 mmol/L, = 0.37). There were no significant changes in metabolic physiology. Compared to baseline, the hemoglobin (7.8 ± 2.4 vs. 7.3 ± 1.8 g/dL, = 0.74), hematocrit (23% ± 6.9 vs. 21.3% ± 5.6, = 0.71), and activated clotting time (268.5 ± 44.5 vs. 193 ± 24.6 s, = 0.35) were similar after retransfusion. When used for unintended hemorrhage, the animals were resuscitated using the device with a mean time to retransfusion time of 128.7 ± 13.3 s and 100% survival throughout the experiment. The Hemafuse device is feasible and efficacious for supporting large animal resuscitation. This is preliminary evidence that the device is a low-risk and low-cost off-the-shelf option for resuscitation using autologous blood with no significant effect on physiology post-retransfusion. We recommend that research laboratories consider the Hemafuse device for emergency use, particularly for highly invasive surgical laboratories where banked blood is not readily available.

BackgroundThoracic endovascular aortic repair (TEVAR) has become the standard of care for thoracic aortic aneurysms and increasingly for blunt thoracic aortic injury (BTAI). Postoperative complications, including spinal cord ischemia and paraplegia, have been shown to be less common with elective TEVAR than with open thoracic or thoracoabdominal repair. Although small cohort studies exist, the postoperative complications of endovascular repair of traumatic aortic injury have not been described through large data set analysis.MethodsA retrospective cohort analysis was performed of the American College of Surgeons Trauma Quality Improvement Program registry spanning from 2007 to 2017. All patients with BTAI who underwent TEVAR, as indicated by the Abbreviated Injury Scale or the International Classification of Diseases (ICD-9 or ICD-10), were included. Categorical data were presented as proportions and continuous data as mean and SD. OR was calculated for each postoperative complication.Results2990 patients were identified as having undergone TEVAR for BTAI. The postoperative incidence of stroke was 2.8% (83), and 4.7% (140) of patients suffered acute kidney injury or renal failure. The incidence of spinal cord ischemia was 1.9% (58), whereas 0.2% (7) of patients suffered complete paraplegia. Renal events and stroke were found to occur significantly more frequently in those undergoing TEVAR (OR 1.758, 1.449–2.134 and OR 2.489, 1.917–3.232, respectively). Notably, there was no difference between TEVAR and non-operative BTAI incidences of spinal cord ischemia or paraplegia (OR 1.061, 0.799–1.409 and OR 1.698, 0.728–3.961, respectively).DiscussionPostoperative intensive care unit care of patients after BTAI has historically focused on awareness of spinal cord ischemia. Our analysis suggests that after endovascular repair of blunt aortic trauma, care should involve vigilance primarily against postoperative cerebrovascular and renal events. Further study is warranted to develop guidelines for the intensivist managing patients after TEVAR for BTAI.Level of evidenceLevel III.

Introduction: Peripheral artery disease (PAD) affects over 200 million people globally and remains a therapeutic challenge, particularly in patients who are not candidates for standard revascularization. While shear stress-induced angiogenesis holds promise as a novel therapeutic strategy, translational platforms to evaluate its efficacy are lacking. Methods: We developed a large-animal model of PAD using familial hypercholesterolemic miniature swine fed an atherogenic diet to induce metabolic syndrome. Hindlimb ischemia was surgically induced by excising the right external iliac artery with collateral ligation. After a 3–4 week ischemic phase, targeted retrograde perfusion was delivered via a miniaturized extracorporeal centrifugal pump to generate sustained flow-mediated shear stress. Functional, imaging, and molecular endpoints were assessed throughout the protocol. Conclusion: This reproducible swine model offers a metabolically relevant platform for investigating perfusion-driven angiogenesis and evaluating novel flow-based revascularization therapies for PAD. It addresses a critical translational gap in preclinical vascular research.

BackgroundResuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) increases cardiac-afterload and is used for patients in hemorrhagic shock. The cardiac tolerance of prolonged afterload augmentation in this context is unknown. The aim of this study is to quantify cardiac injury, if any, following 2, 3 and 4 hours of REBOA.MethodsAnesthetized swine (70–90 kg) underwent a 40% controlled hemorrhage, followed by supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA) for 2 (n=5), 3 (n=5), and 4 hours (n=5). High-fidelity arterial wave form data were collected, and signal processing techniques were used to extract key inflection points. The adjusted augmentation index (AIx@75; augmentation pressure/pulse pressure, normalized for heart rate) was derived for use as a measure of aortic compliance (higher ratio = less compliance). Endpoints consisted of electrocardiographic, biochemical, and histologic markers of myocardial injury/ischemia. Regression modeling was used to assess the trend against time.ResultsAll animals tolerated instrumentation, hemorrhage, and REBOA. The mean (±SD) systolic blood pressure (mm Hg) increased from 65±11 to 212±39 (p<0.001) during REBOA. The AIx@75 was significantly higher during REBOA than baseline, hemorrhage, and resuscitation phases (p<0.05). A time-dependent rise in troponin (R2=0.95; p<0.001) and T-wave deflection (R2=0.64; p<0.001) was observed. The maximum mean troponin (ng/mL) occurred at 4 hours (14.6±15.4) and maximum T-wave deflection (mm) at 65 minutes (3.0±1.8). All animals demonstrated histologic evidence of acute injury with increasing degrees of cellular myocardial injury.DiscussionProlonged REBOA may result in type 2 myocardial ischemia, which is time-dependent. This has important implications for patients where prolonged REBOA may be considered beneficial, and strategies to mitigate this effect require further investigation.Level of evidenceII.