***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    Input: Introduction Nonoperative management ( NOM ) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury . Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States . This study was design ed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center . Methods An analysis of a prospect i ve trauma registry was performed for a 6-year period before ( period 1 ) and after the introduction and implementation of splenic artery embolization ( SAE ) ( period 2 ) . Primary outcome was the failure rate of initial treatment . Results A total of 151 patients were review ed . An increased use of  SAE  and a reduction of splenic operations during the second period was observed . Compared with period 1 , the failure rate after observation in period 2 decreased from 25 % to 10 % . The failure rate after SAE in period 2 was 18 % . The splenic salvage rate ( SSR ) after observation increased from 79 % in the first period to 100 % in the second period . During the second period , all patients with failure after observation were successfully treated with SAE . The SSR after SAE in periods 1 and 2 was respectively 100 % and 86 % . Conclusions SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations . The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers . Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States BACKGROUND Nonoperative management ( NOM ) of patients with severe splenic injuries carries a significant risk of failure . We hypothesized that adding angiographic embolization ( AE ) to the NOM protocol would decrease the laparotomy rate , and increase the success rate of NOM and splenic salvage rate . METHODS A protocol introducing AE in the treatment of splenic injuries was implemented . AE was performed in OIS splenic injury grade s 3 to 5 and in all cases where signs of ongoing bleeding were encountered regardless of injury grade . Patients included in a prospect i ve study during a 24-month period were compared with a historic control group . RESULTS Group 1 ( before AE ) consisted of 69 patients with a mean Injury Severity Score ( ISS ) of 31 , and group 2 ( after introducing AE ) included 64 patients with a mean ISS of 30 . In group 1 , 30 patients underwent immediate laparotomy  ( 43 % ) , and the NOM success rate was 79 % . After introducing AE , 17 patients underwent immediate laparotomy  ( 27 % ; p = 0.04 ) , with a NOM success rate of 96 % ( p = 0.02 ) . Overall splenic salvage rate increased from 57 % to 75 % ( p = 0.02 ) . Angiography was performed in 31 patients in group 2 . Embolization was performed in 27 of these patients . AE failure rate was 4 % . NOM was successful in 14 of 15 patients with OIS injury grade s 4 and 5 after the introduction of AE ( 93 % ) . CONCLUSION A formal protocol adding m and atory AE to NOM for severe splenic injuries increased the percentage of patients in whom NOM was attempted , the NOM success rate , and the splenic salvage rate OBJECTIVE Conflicting data exist regarding pseudoaneurysm screening ( PSA-S ) , initial angioembolization ( IE ) , deep venous thrombosis prophylaxis ( DVT-P ) , and activity limitation after hemodynamically stable blunt splenic injury ( BSI ) . To determine whether there was consensus regarding BSI management , the multi-institutional trial committee of the American Association for the Surgery of Trauma ( AAST ) approved a survey of member practice patterns regarding BSI management . METHODS Over 2 months , AAST members were invited to participate in an online survey .  Practice patterns and attitudes surrounding PSA-S , IE , DVT-P , and activity limitation after BSI  were determined . RESULTS The response rate was 37.5 % . Practice patterns varied by injury grade . Observation only was thought appropriate for grade s I ( 94.4 % ) and II ( 84.6 % ) injuries . For grade s III to V injuries , fewer and fewer respondents felt observation only was appropriate .  PSA-S  was the most commonly used strategy for grade s IV and V injuries ( 32.7 % and 28.2 % ) , and IE was thought to be appropriate by 23.5 % of respondents for grade IV injuries and 25.5 % of respondents with grade V injuries . Thirty percent of respondents felt that no DVT-P was indicated for adult patients with BSI . Recommendations regarding return to full activity varied by perceived risk to the patient and by injury grade . CONCLUSIONS There is considerable variation in the opinions of AAST members regarding BSI management , particularly for high- grade injuries . These results will aid in the design of prospect i ve observational and r and om trials to determine optimal BSI management Nonoperative management of blunt splenic trauma is widely accepted ; however , reported failure rates have ranged as high as 40 % . There are few factors available to identify failures reliably . To characterize failures of nonoperative management better , we retrospectively review ed 309 blunt splenic injuries treated at our level I trauma center over a 5-year period . Eighty-nine patients were initially managed nonoperatively ( 29 % ) , and 12 patients failed this approach ( 13 % ) . Upon review of the initial computed tomography scans , a hyperdense collection of contrast media in the splenic parenchyma , or " contrast blush , " was noted in 8 of 12 ( 67 % ) patients who failed and in 5 of 77 ( 6 % ) of those who were successfully managed nonoperatively ( p < 0.0001 ) . These data suggest that the presence of a contrast blush is an important consideration when deciding the method for management of the splenic injury . If these results are confirmed in a prospect i ve fashion , the failure rate of nonoperative management of blunt splenic trauma could be reduced by identification of the contrast blush Background : The purpose of this study was to evaluate the effect of the method of splenic injury management on early infectious complications . Methods : Prospect i ve observational , multicenter study which included all patients with blunt splenic injury surviving at least 72 hours . Epidemiologic and clinical data , grade of splenic injury , method of splenic management , and infectious complications during the initial hospitalization were collected according to a st and ardized collecting data sheet . Logistic regression analysis was used to identify independent risk factors for infectious complications . Results : During a 22-month period , 269 eligible patients were enrolled in the study . Overall , 105 ( 39.0 % ) patients were observed ; 48 ( 17.8 % ) underwent successful angioembolization , 19 ( 7.1 % ) underwent splenorrhaphy , and 97 ( 36.1 % ) underwent splenectomy . Multivariate analysis adjusting for age , hypotension on admission , Glasgow Coma Scale , Injury Severity Score , Abbreviated Injury Scale , laparotomy , grade of splenic injury , and associated solid and hollow viscus injuries , showed that splenectomy had a significantly higher incidence of infectious complications than splenic preservation ( adjusted odds ratio [ 95 % confidence interval ] , 9.62 [ 3.04–30.30 ] ; p < 0.001 ) . A regression model analysis identified splenectomy , hypotension on admission , associated hollow viscus injury , and high Injury Severity Score as independent risk factors for infectious complications . Forward logistic regression analysis , which included only the 176 patients with grade s III to V splenic injuries , identified splenectomy as the most significant independent risk factors for infection ( adjusted odds ratio [ 95 % confidence interval ] , 16.67 [ 3.76–71.43 ] ; p < 0.001 ) . Conclusions : Splenectomy is an independent risk factor for early infectious complications . Splenic-preserving techniques should be considered more liberally . Level of Evidence : II , therapeutic study BACKGROUND Nonoperative management ( NOM ) of blunt splenic injury is well accepted . Substantial failure rates in higher injury grade s remain common , with one large study reporting rates of 19.6 % , 33.3 % , and 75 % for grade s III , IV , and V , respectively . Retrospective data show angiography and embolization can increase salvage rates in these severe injuries . We developed a protocol requiring referral of all blunt splenic injuries , grade s III to V , without indication for immediate operation for angiography and embolization . We hypothesized that angiography and embolization of high- grade blunt splenic injury would reduce NOM failure rates in this population . STUDY DESIGN This was a prospect i ve study at our Level I trauma center as part of a performance-improvement project . Demographics , injury characteristics , and outcomes were compared with historic controls . The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization . In historic controls , referral was based on surgeon preference . RESULTS From January 1 , 2010 to December 31 , 2012 , there were 168 patients with grade s III to V spleen injuries admitted ; NOM was undertaken in 113 ( 67 % ) patients . The protocol was followed in 97 patients , with a failure rate of 5 % . Failure rate in the 16 protocol deviations was 25 % ( p = 0.02 ) . Historic controls from January 1 , 2007 to December 31 , 2009 were compared with the protocol group . One hundred and fifty-three patients with grade III to V injuries were admitted during this period , 80 ( 52 % ) patients underwent attempted NOM . Failure rate was significantly higher than for the protocol group ( 15 % , p = 0.04 ) . CONCLUSIONS Use of a protocol requiring angiography and embolization for all high- grade spleen injuries slated for NOM leads to a significantly decreased failure rate . We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury . We have prospect ively applied criteria developed from our previous 15-year experience for the nonoperative management ( NOM ) of blunt splenic injury . These criteria consist of 1 ) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion , 2 ) no physical findings or any associated injuries necessitating laparotomy , and 3 ) a transfusion requirement attributable to the splenic injury of 2 units or less . From 1994 through 2000 a total of 99 patients presented with blunt splenic injury . Thirty-one patients ( 31 % ) underwent splenectomy secondary to hemodynamic instability . During the observation period eight of the 68 patients ( 12 % ) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy . All NOM failures occurred within 72 hours of admission . There was no mortality associated with splenic injury in the NOM ( Group I ) or in the group failing NOM ( Group II ) , and no associated morbidities from the splenic injury were seen in either group . No significant differences were seen between Groups I and II in terms of age , gender , mechanism of injury , Injury Severity Score , admitting systolic blood pressure , admitting hemoglobin , transfusion requirements , intensive care unit length of stay , or total hospital length of stay ( all P > 0.200 ) . We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults This is an up date d position article from members of the Western Trauma Association ( WTA ) . It includes recommendations for the management of blunt splenic injury in adult trauma patients based on literature available since the last WTA position article in 2008.1 There remain no prospect i ve r and PURPOSE OF THE STUDY The management of the severe blunt splenic injuries remains debated . The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management ( surgery , embolization , non-operative management [ NOM ] ) . METHODS A prospect i ve multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury . We evaluated severity according to the AAST classification , the presence of hemoperitoneum or a contrast blush on initial CT scan . The initial hemodynamic status , patients co-morbidities , the ISS ( injury severity score ) , management and morbidity were also noted . RESULTS Between May 2010 and May 2012 , 91 patients were included . Thirty-seven patients ( 41 % ) had mild splenic injury ( AAST I or II and a small hemoperitoneum ) while 54 patients ( 59 % ) had severe splenic injury ( AAST III or greater ) . The management included 18 splenectomies ( 20 % ) , 15 embolizations ( 16 % ) . Among 67 patients undergoing NOM without initial embolization , five ( 7 % ) developed secondary bleeding , five required surgery and nine underwent secondary embolization . No patient died and morbidity was 44 % ( n=40 ) , 13 % for mild injuries vs. 65 % for severe injuries ( P<0.01 ) . For severe injuries , total morbidity was 58 % after NOM , 7 
    Output:
    
Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries .