University of Colorado Health

BackgroundPost-pull chest X-rays (ppCXR) are routinely performed after chest tube (CT) removal despite questionable utility. Prior studies suggest that ppCXR rarely alter management, but the impact of timing remains unknown. This study compares early vs delayed ppCXR on radiographic changes and clinical management in asymptomatic trauma patients. We hypothesized ppCXR timing may influence radiographic findings, but not reintervention rates.MethodsA retrospective study of trauma patients undergoing CT placement and removal at a level 1 trauma center from 2019 to 2022. Each ppCXR was classified as early (≤4h) or delayed (>4h). Primary outcome was reintervention after CT removal (CT replacement, VATS, or thoracotomy). Secondary outcomes included radiographic changes, unplanned ICU transfer, hospital and ICU LOS, and total CXRs.Results318 patients were included with a mean age of 47.2years, 25.2% female, and 77.4% with blunt mechanism. Most had delayed ppCXR (78.3%) with mean delay of 7.2h (2.3 vs 9.5h, P < .001). No differences were found in radiographic changes (26.1 vs 29.3%, P = .708) or reintervention (4.3 vs 5.6%, P = .999) between groups. Radiographic changes occurred in 28.6% of ppCXR, but these findings display poor sensitivity (65.0%) and specificity (73.4%) for reintervention. Delayed ppCXR had more ICU transfers (0 vs 5.6%, P = .046), but no differences in hospital LOS, ICU LOS, or total CXRs.DiscussionThe timing of ppCXR did not affect detection of radiographic changes or reintervention rates. Our findings support growing evidence questioning routine ppCXR in asymptomatic trauma patients. Future multicenter studies are warranted to establish standardized protocols and reduce unnecessary imaging in trauma care.

Background: The Vision, Aphasia, Neglect (VAN) screening tool is a rapid, prehospital assessment to identify large vessel occlusions (LVOs) in acute ischemic stroke patients. Other studies that looked at prehospital utilization of the VAN assessment reported sensitivity and specificity of 81%/38% and 84%/68%, respectively. In particular, one study compared other scales: Rapid Arterial Occlusion Evaluation (84%/60%), Cincinnati Stroke Triage Assessment Tool (71%/67%), and Los Angeles Motor Scale (76%/65%). While prior studies have evaluated its utility, further validation in real-world prehospital settings is warranted. In 2020, our Mobile Stroke Unit (MSU) implemented the VAN to rapidly and efficiently identify a potential LVO. Purpose: The purpose was to assess the sensitivity and specificity of the VAN assessment through a chart review of patients transported from May 2020 - June 2025 on a MSU. Methods: We analyzed VAN assessment results and confirmed LVO diagnoses based on imaging. Due to limitations in obtaining final stroke diagnosis from hospitals outside our network, 190 out of the 334 total cases were included. Patients were categorized based on VAN positive/negative assessment and the presence/absence of LVO. We also examined VAN outcomes in hemorrhagic stroke cases and noted specific areas where the VAN may have reduced accuracy. Results: Of the 190 patients: 111 were VAN negative/LVO negative, 46 VAN positive/LVO negative, 5 VAN negative/LVO positive, and 28 VAN positive/LVO positive. This yielded a sensitivity of 85% and specificity of 71%, with a PPV of 38% and NPV of 96%. Additionally, 12 patients with hemorrhagic strokes were evaluated, 6 were VAN positive and 6 were VAN negative. This indicates a potential overlap in findings with some limitations noted in the carotid terminus and distal middle cerebral artery M2 segment occlusions. Conclusions: To our knowledge, this is the first analysis looking at utilization of VAN assessments on Mobile Stroke Units. In conclusion, our data suggests that the VAN tool is a valuable and effective method for prehospital LVO detection on a MSU, performing with greater accuracy than previously reported in similar EMS-based studies. While not without limitations, the VAN remains a strong candidate for rapid field screening, supporting its continued use and further prospective evaluation.

Background: Pulmonary hypertension (PH) and heart failure with preserved or reduced ejection fraction (HFpEF/HFrEF) are characterized by elevated filling pressures, limited therapeutic options, and high morbidity. The Occlutech Atrial Flow Regulator (AFR) is a percutaneously implanted, double-disc nitinol device that creates a controlled interatrial shunt. By facilitating left-to-right or right-to-left flow depending on the hemodynamic substrate, the AFR offers a mechanistically attractive approach to decompress atrial chambers and improve symptoms. Methods: A systematic review was performed in accordance with PRISMA guidelines. Literature from PubMed, Scopus, and Google Scholar (2000–2024) were screened to identify clinical studies, registries, and case reports evaluating AFR implantation in patients with HF or PH. Data were synthesized regarding device design, procedural success, clinical efficacy, safety, and long-term outcomes, with emphasis on adverse events and hemodynamic thresholds. Results: Across prospective studies in Group 2 PH/HF populations, AFR implantation demonstrated high procedural success, durable patency, and improvements in NYHA class, six-minute walk distance, pulmonary capillary wedge pressure, and quality of life. Safety outcomes were favorable, although right ventricular dilation and adverse remodeling were observed with larger shunt sizes or in patients with elevated pulmonary vascular resistance. In Group 1 PAH, compassionate-use series reported reductions in right atrial pressure, improvements in cardiac index and functional class, and resolution of syncope, though at the expense of systemic desaturation. Mortality in these cohorts was primarily determined by baseline disease severity rather than device complications. Evidence from comparator devices (IASD, V-Wave) and the REDUCE LAP-HF II trial underscores the critical importance of patient selection, with benefit concentrated in patients demonstrating preserved pulmonary vascular reserve. Conclusions: The AFR represents a promising device-based therapy for patients with advanced HF or PAH by providing controlled interatrial shunting tailored to the underlying physiology. Current data establish its feasibility, safety, and symptomatic benefit in well-selected patients, but highlight risks of worsening PH and right-sided loading if applied outside defined hemodynamic thresholds. Ongoing pivotal trials, including FROST-HF and RESPONDER-HF, are essential to determine the role of AFR in routine clinical practice and to refine phenotypically guided patient selection. Keywords: intra-atrial shunt, pulmonary hypertension, LV failure

Cytotoxic chemotherapies and immunotherapies cause harmful side effects in over half of patients with cancer. Early intervention is critical for improving outcomes, but in outpatient settings, patient self-assessment and patient-initiated pursuit of follow-up care often cause delays. Digital health technologies for remote patient monitoring (RPM) can minimize these delays. This study assessed the feasibility and perceived user experience of RPM technology for early detection of febrile neutropenia and infection in allogeneic bone marrow transplant (BMT) patients. Ten BMT patients between the ages of 18 and 89 years wore biometric monitoring devices for up to 90 days post-transplant. Devices sent real-time alerts to clinicians in response to elevated temperature, heart rate, or respiratory rate. Patients and caregivers completed surveys about their experience at 30 and 90 days post-transplant; patients were asked to participate in interviews at these time points. Providers completed surveys at the end of the study. Biometric and health utilization outcomes and responses to survey items were analyzed through descriptive statistics. Rapid content analysis of survey data and interview data was conducted to explore emergent themes. Seven patients wore RPM devices until study completion. 369 alerts were generated, with 101 requiring follow-up. Two patients had infections during the study. One had infection detected through alert data and received outpatient treatment; the second stopped wearing their device prior to symptom onset and required hospitalization. Overall, RPM technology was perceived as generally acceptable, comfortable, and easy to use. Refinements to alerting practices and technology performance are recommended to improve adoption and use as intended in the outpatient setting.

Ketamine is a dissociative anesthetic often used for airway management in trauma. While perceived to preserve hemodynamic stability, concerns exist regarding its effects on intracranial pressure and cardiac output in critically ill patients. There is a lack of studies evaluating outcomes after ketamine administration in the setting of traumatic brain injury (TBI). This study aimed to investigate the effects of ketamine on outcomes and physiological responses in a large cohort of TBI patients. We hypothesized that ketamine administration would not be associated with differences in survival, vital signs, or disposition outcomes compared with other induction medications when administered following TBI. This was a retrospective, observational study utilizing data from the Linking Investigations in Trauma and Emergency Services registry (2017–2021). Subjects were divided into two groups: those who received only ketamine ( n = 429) and those who received other induction medications (etomidate and/or propofol; n = 993). We compared 24-h mortality, initial in-hospital vital signs (systolic blood pressure [SBP], respiratory rate, heart rate, and Glasgow Coma Scale [GCS]), and hospital discharge disposition; a propensity score analysis adjusted for potential confounders including race, injury type, pre-hospital GCS, initial pre-hospital SBP and site location. Ketamine-exposed subjects were younger and presented with a worse clinical profile, including lower pre-hospital GCS (5 vs. 6, p &lt; 0.01) and lower SBP (126.5 vs. 144.0 mmHg, p &lt; 0.01) compared with the ketamine-unexposed group. Unadjusted analysis showed a significantly higher 24-h mortality rate in the ketamine-exposed group (3.5% vs. 1.4%, p = 0.02), as well as lower initial in-hospital vital signs. After propensity score adjustment, the odds of 24-h mortality remained significantly higher for the ketamine-exposed group (OR 2.358, p = 0.042). Hospital discharge disposition was not different between groups in any analysis. In this retrospective analysis, ketamine administration for pre-hospital airway management in TBI patients was associated with an increased 24-h mortality and lower in-hospital SBP, even after adjusting for baseline differences. However, injury severity and the length of time examined for mortality may explain the significant mortality association for ketamine in this study. Prospective studies are needed to examine the relationship between ketamine administration and mortality following TBI.

Abstract Background The procedural synergy of PVI and LAAC in a single session is increasingly adopted in clinical workflows. However, the acute tissue response to PFA may influence LAAC device sizing and LAA complete seal. This preclinical study investigated healing dynamics, residual flow mechanisms, and structural device integrity using serial contrast CT and post-mortem micro-CT following combined PFA or RFA with WATCHMAN FLX Pro implantation. Methods Nine healthy canines underwent PVI using either PFA (n=6) or RFA (n=3), followed by LAAC in the same setting. Serial TEE and contrast-enhanced CT scans were acquired at baseline, post-procedure, and on days 7, 14, 28, and 45. All animals received DAPT for the duration of follow-up. Hypoattenuated Thickening (HAT) was evaluated to characterize healing and potential thrombus formation. Residual contrast patency was classified by source (e.g., uncovered trabeculations vs. trans-fabric flow). At terminal sacrifice, micro-CT imaging was performed with 35μm resolution and 1120×1120 pixel image size. CTvox software enabled 3D rendering of the devices, which were evaluated for grossly visible structural abnormalities, including fractures, disconnections, tangles, or other surface defects. Results All animals achieved successful LAAC with no acute complications. No device dislodgement was observed on imaging. At day 45, 5 animals (3 PFA, 2 RF) exhibited residual contrast patency. In 3 of these (1 PFA, 2 RF), the source was trans-fabric flow, suggesting incomplete endothelialization of the device fabric. The remaining 2 cases (both PFA) showed contrast patency due to small PDLs (&amp;lt;5mm) (Tables 1a and 1b). HAT was frequently observed early, with HAT noted in 5 animals by day 7 (4 PFA, 1 RFA) 2 of which were protruding – 1 in the PFA and one in the RFA group. Pedunculated HAT was not observed in any of the animals. All HATs evolved toward either a flat sessile phenotype or sub-fabric by day 45, with no evidence of protruding phenotype on final imaging. There were no major differences noted between the treatment groups. Micro-CT confirmed intact structural integrity in all devices despite extreme "deformation" to fit different LAAs 3D geometries, with no evidence of strut fractures, tangling, disconnection or device surface integrity breach (Figure 1). Conclusion In this preclinical model, concomitant PFA or RF ablation followed by WATCHMAN FLX Pro LAAC was procedurally feasible and safe, with no device dislodgment or thrombus formation. Residual contrast patency at day 45 occurred in 5 animals, with trans-fabric flow identified as the source in 3 and minor PDLs in 2 in the PFA group, pointing to a probable localized delay in endothelialization. Micro-CT imaging demonstrated structural device integrity despite deformation across various LAA morphologies.Figure 1 Tables 1a and 1b

The utility of chemotherapy for childhood ependymoma is uncertain without a prior randomized trial. ACNS0831, a multicenter phase 3 randomized study conducted through the Children's Oncology Group (COG), included patients 1-21 years with newly diagnosed intracranial ependymoma. Patients with complete/near-total resections (GTR/NTR) or complete response (CR) to induction therapy were randomized to radiation (RT) alone or RT followed by chemotherapy (RT-CHEMO). Primary outcomes were event-free survival (EFS) and overall survival (OS). Due to anticipated noncompliance with chemotherapy, an "as treated" analysis was planned. Patients with subtotal resection (STR) were non-randomly assigned to RT-CHEMO. Grade 2 supratentorial tumors with GTR or CR to induction therapy were observed. Of 449 eligible patients, 325 with GTR/NTR or CR were randomized. Five-year EFS was 63.7% (95% CI: 55.1%-71.1%) for RT only (n = 161) versus 69.2% (60.8%-76.3%) for RT-CHEMO (n = 164) (1-sided log-rank P = .299, HR = 0.866). Five-year OS was 86.9% (79.8%-91.6%) for RT only versus 88.3% (81.8%-92.6%) for RT-CHEMO (1-sided log-rank P-value = .172, HR = 0.757). The "as treated" and "as randomized" analysis results were similar. Sixty-three subjects with STR were assigned to RT-CHEMO; 5-year EFS was 33.6% (22.1%-45.5%) and OS 74.0% (60.5%-83.5%). Supratentorial grade 2 tumors with GTR or CR were observed with a 5-year EFS of 66.9% (49.0%-79.7%) and OS of 100%. Molecular classification was provided for 94% (n = 422) of all subjects. Primary analysis showed no benefit for maintenance chemotherapy. Further follow-up is important to assess its effect on late relapses. This is the largest cohort of molecularly classified ependymomas treated on a Phase 3 randomized trial.