Systemic Inflammatory Response Syndrome (SIRS) Score Independently Predicts Poor Outcome in Isolated Traumatic Brain Injury

Systemic inflammation following traumatic injury and its impact on neuroinflammatory gene expression in the rodent brain

BACKGROUND

Trauma can result in systemic inflammation that leads to organ dysfunction, but the impact on the brain, particularly following extracranial insults, has been largely overlooked.

METHODS

Building upon our prior findings, we aimed to understand the impact of systemic inflammation on neuroinflammatory gene transcripts in eight brain regions in rats exposed to (1) blast overpressure exposure [BOP], (2) cutaneous thermal injury [BU], (3) complex extremity injury, 3 hours (h) of tourniquet-induced ischemia, and hind limb amputation [CEI+tI+HLA], (4) BOP+BU or (5) BOP+CEI and delayed HLA [BOP+CEI+dHLA] at 6, 24, and 168 h post-injury (hpi).

RESULTS

Globally, the number and magnitude of differentially expressed genes (DEGs) correlated with injury severity, systemic inflammation markers, and end-organ damage, driven by several chemokines/cytokines (Csf3, Cxcr2, Il16, and Tgfb2), neurosteroids/prostaglandins (Cyp19a1, Ptger2, and Ptger3), and markers of neurodegeneration (Gfap, Grin2b, and Homer1). Regional neuroinflammatory activity was least impacted following BOP. Non-blast trauma (in the BU and CEI+tI+HLA groups) contributed to an earlier, robust and diverse neuroinflammatory response across brain regions (up to 2-50-fold greater than that in the BOP group), while combined trauma (in the BOP+CEI+dHLA group) significantly advanced neuroinflammation in all regions except for the cerebellum. In contrast, BOP+BU resulted in differential activity of several critical neuroinflammatory-neurodegenerative markers compared to BU. t-SNE plots of DEGs demonstrated that the onset, extent, and duration of the inflammatory response are brain region dependent. Regardless of injury type, the thalamus and hypothalamus, which are critical for maintaining homeostasis, had the most DEGs. Our results indicate that neuroinflammation in all groups progressively increased or remained at peak levels over the study duration, while markers of end-organ dysfunction decreased or otherwise resolved.

CONCLUSIONS

Collectively, these findings emphasize the brain's sensitivity to mediators of systemic inflammation and provide an example of immune-brain crosstalk. Follow-on molecular and behavioral investigations are warranted to understand the short- to long-term pathophysiological consequences on the brain, particularly the mechanism of blood-brain barrier breakdown, immune cell penetration-activation, and microglial activation.

Development of a Nomogram Model Based on Lactate-To-Albumin Ratio for Prognostic Prediction in Hospitalized Patients with Intracerebral Hemorrhage

OBJECTIVE

This study aims to develop a nomogram model incorporating lactate-to-albumin ratio (LAR) to predict the prognosis of hospitalized patients with intracerebral hemorrhage (ICH) and demonstrate its excellent predictive performance.

METHODS

A total of 226 patients with ICH from the Medical information mart for intensive care III (MIMIC Ⅲ) database were randomly split into 8:2 ratio training and experimental groups, and 38 patients from the eICU-CRD for external validation. Univariate and multivariate Cox proportional hazards regression analysis was performed to identify independent factors associated with ICH, and multivariate Cox regression was used to construct nomograms for 7-day and 14-day overall survival (OS). The performance of nomogram was verified by the calibration curves, decision curves, and receiver operating characteristic (ROC) curves.

RESULTS

Our study identified LAR, glucose, mean blood pressure, sodium, and ethnicity as independent factors influencing in-hospital prognosis. The predictive performance of our nomogram model for predicting 7-day and 14 -day OS (AUCs: 0.845 and 0.830 respectively) are both superior to Oxford Acute Severity of Illness Score, Simplified acute physiology score II, and SIRS (AUCs: 0.617, 0.620 and 0.591 and AUCs: 0.709, 0.715 and 0.640, respectively) in internal validation, and also demonstrate favorable predictive performance in external validation (AUCs: 0.778 and 0.778 respectively).

CONCLUSIONS

LAR as a novel biomarker is closely associated with an increased risk of in-hospital mortality of patients with ICH. The nomogram model incorporating LAR along with glucose, mean blood pressure, sodium, and ethnicity demonstrate excellent predictive performance for predicting the prognosis of 7- and 14-day OS of hospitalized patients with ICH.

Effects of poloxamer 188 on traumatic brain injury

Traumatic Brain Injury (TBI) is a major cause of severe disability and death, resulting in significant health care and economic burden. Poloxamer 188, a synthetic tri-block copolymer approved by the FDA, has been studied for its potential effects on traumatic brain injury (TBI). The neuroprotective abilities of P188 have attracted significant attention. This systematic review aims to compile evidence of P188's effect on the treatment of TBI. A comprehensive literature search was conducted using PubMed, SCOPUS, and Google Scholar databases, which yielded 20 articles that satisfied the inclusion criteria. These articles have shown direct protective effects of P188 on brain tissue following TBI, including restitution of the increase cell membrane permeability, attenuation of neuronal necrosis and apoptosis, improvement of mitochondrial viability, reduction in axonal disruption, and restoration of the blood brain barrier. In animals, P188 has been shown to improve sensorimotor functions, as well as spatial learning and memory.

Importance of AIM2 as a serum marker for reflecting severity and predicting a poor outcome of human severe traumatic brain injury: A prospective longitudinal cohort study

BACKGROUND

Absent in melanoma 2 (AIM2) participates in neuroinflammation. Here, the prognostic significance of serum AIM2 was explored in severe traumatic brain injury (sTBI).

METHODS

A total of 135 sTBI patients and 80 healthy controls were recruited in this prospective cohort study. Serum C-reactive protein (CRP) and AIM2 levels were measured. Glasgow Coma Scale (GCS) and Rotterdam computed tomography (CT) classification were recorded as the severity indicators. Prognostic parameters were posttraumatic six-month extended Glasgow outcome scale (GOSE) scores and poor outcome (GOSE scores of 1-4).

RESULTS

As opposed to controls, there were significantly elevated serum AIM2 levels after sTBI. Serum AIM2 levels were independently correlated with serum CRP levels, GCS scores, Rotterdam CT scores, GOSE scores and poor outcome. Also, serum AIM2 levels were efficiently predictive of poor outcome under the receiver operating characteristic (ROC) curve. Under the restricted cubic spline, serum AIM2 levels were linearly correlated with risk of poor outcome. Using subgroup analysis, serum AIM2 levels did not significantly interact with other indices, such as age, gender, alcohol drinking, cigarette smoking, etc. Also, combination model, in which serum AIM2, GCS scores and Rotterdam CT scores were merged, was outlined using nomogram and performed well under calibration curve, ROC curve and decision curve.

CONCLUSIONS

Raised serum AIM2 levels after sTBI, in intimate correlation with systemic inflammation and trauma severity, are independently discriminative of posttraumatic six-month neurological outcome, substantializing serum AIM2 as an inflammatory prognostic biomarker of sTBI.

Prediction of in-hospital mortality in patients with exertional heatstroke: a 13-year retrospective study

Hyperactivity of coagulation is common in exertional heatstroke (EHS). Disseminated intravascular coagulation (DIC) is the most severe form of coagulation dysfunction and associated with poor outcome. DIC, temperature and Glasgow coma scale score were identified as independent risk factors for in-hospital mortality by multivariate logistic regression analysis, and we developed a nomogram for predicting in-hospital mortality in a 13-year EHS patient cohort. The nomogram was assessed by calibration curves and bootstrap with 1,000 resamples. The receiver operating characteristic curve was constructed, and the area under the curve (AUC) was compared. Two hundred and ten patients were included. The in-hospital mortality was 9.0%, and the incidence of DIC was 17.6%. The AUC of the nomogram was 0.897 (95% CI 0.848-0.935, p < .0001) and was non-inferior to SOFA and APACHE II scores but superior to SIRS score, which were widely-used score systems of disease severity. The nomogram contributed to the adverse outcome prediction of EHS.

Postoperative systemic inflammatory response syndrome predicts increased mortality in patients after elective craniotomy

Introduction

Patients undergoing craniotomy are at high risk of perioperative morbidity and mortality due to excessive inflammatory responses. The purpose of the present study is to evaluate the prognostic utility of postoperative systemic inflammatory response syndrome (SIRS) in patients undergoing craniotomy.

Methods

We performed a retrospective cohort study of patients who underwent craniotomy between January 2011 and March 2021. SIRS was diagnosed based on two or more criteria (hypo-/hyperthermia, tachypnea, leukopenia/leukocytosis, tachycardia). We used univariate and multivariate analysis for the development of SIRS with postoperative 30-day mortality.

Results

Of 12,887 patients who underwent craniotomy, more than half of the patients (n = 6,725; 52.2%) developed SIRS within the first 7 days after surgery, and 157 (1.22%) patients died within 30 days after surgery. In multivariable analyses, SIRS (OR, 1.57; 95% CI, 1.12-2.21) was associated with 30-day mortality. Early SIRS was not predictive of 30-day mortality, whereas delayed SIRS was predictive of 30-day mortality. Abnormal white blood cell (WBC) counts contributed the most to the SIRS score, followed by abnormal body temperature, respiratory rate, and heart rate.

Conclusion

Postoperative SIRS commonly occurs after craniotomy and is an independent predictor of postoperative 30-day mortality. This association was seen only in delayed SIRS but not early SIRS. Moreover, increased WBC counts contributed the most to the SIRS score.

Systemic inflammation induced from remote extremity trauma is a critical driver of secondary brain injury

Blast exposure, commonly experienced by military personnel, can cause devastating life-threatening polysystem trauma. Despite considerable research efforts, the impact of the systemic inflammatory response after major trauma on secondary brain injury-inflammation is largely unknown. The aim of this study was to identify markers underlying the susceptibility and early onset of neuroinflammation in three rat trauma models: (1) blast overpressure exposure (BOP), (2) complex extremity trauma (CET) involving femur fracture, crush injury, tourniquet-induced ischemia, and transfemoral amputation through the fracture site, and (3) BOP+CET. Six hours post-injury, intact brains were harvested and dissected to obtain biopsies from the prefrontal cortex, striatum, neocortex, hippocampus, amygdala, thalamus, hypothalamus, and cerebellum. Custom low-density microarray datasets were used to identify, interpret and visualize genes significant (p < 0.05 for differential expression [DEGs]; 86 neuroinflammation-associated) using a custom python-based computer program, principal component analysis, heatmaps and volcano plots. Gene set and pathway enrichment analyses of the DEGs was performed using R and STRING for protein-protein interaction (PPI) to identify and explore key genes and signaling networks. Transcript profiles were similar across all regions in naïve brains with similar expression levels involving neurotransmission and transcription functions and undetectable to low-levels of inflammation-related mediators. Trauma-induced neuroinflammation across all anatomical brain regions correlated with injury severity (BOP+CET > CET > BOP). The most pronounced differences in neuroinflammatory-neurodegenerative gene regulation were between blast-associated trauma (BOP, BOP+CET) and CET. Following BOP, there were few DEGs detected amongst all 8 brain regions, most were related to cytokines/chemokines and chemokine receptors, where PPI analysis revealed Il1b as a potential central hub gene. In contrast, CET led to a more excessive and diverse pro-neuroinflammatory reaction in which Il6 was identified as the central hub gene. Analysis of the of the BOP+CET dataset, revealed a more global heightened response (Cxcr2, Il1b, and Il6) as well as the expression of additional functional regulatory networks/hub genes (Ccl2, Ccl3, and Ccl4) which are known to play a critical role in the rapid recruitment and activation of immune cells via chemokine/cytokine signaling. These findings provide a foundation for discerning pathophysiological consequences of acute extremity injury and systemic inflammation following various forms of trauma in the brain.

The effect of low dietary inflammatory index score formula on inflammatory, metabolic, and clinical outcomes in critically ill traumatic brain injury patients: A single-blind randomized controlled pilot study

In traumatic brain injury (TBI) patients, a complex cascade of inflammatory responses are frequently observed following trauma. Numerous dietary agents have long been found to have potential in modulating inflammatory responses. This pilot study, designed an enteral formula with low inflammatory properties based on the dietary inflammatory index (DII®) and evaluated its effect on inflammatory and metabolic factors in critically ill TBI patients. This single-blind randomized controlled pilot study was conducted at the Neurosurgical ICU of Shahid Kamyab Hospital (Mashhad, Iran). A total of 20 TBI patients were randomly assigned to receive either low-DII score or standard formula at the intensive care unit (ICU). The primary outcomes of the study included clinical status, inflammatory biomarkers, APACHE II, SAPS II, SOFA, and NUTRIC scores. The trial groups did not differ significantly in baseline values. Following 14 days of intervention, there was a statistically significant decrease in the APACHE II, SAPS II, and NUTRIC scores and a significant increase in the GCS score in the low-DII score formula group compared to the standard formula group. Over 2 weeks, high sensitivity C-reactive protein (hs-CRP) values of -2.73 (95% CI: -3.67, -1.79) mg/dL in the low-DII score formula group versus 0.65 (95% CI: -0.29, 1.58) mg/dL in controls were obtained. Moreover, the length of hospital stay was longer for the standard formula group than for the low-DII score formula group. The low-DII score formula improves inflammatory factors (serum hs-CRP) and metabolic biomarkers (LDL-c and FBS). Furthermore, clinical outcomes, including the length of hospital stay and disease severity, appear to be enhanced.

C-Reactive Protein/Albumin Ratio Is Associated with Mortality in Patients with Moderate to Severe Traumatic Brain Injury

BACKGROUND

The C-reactive protein/albumin ratio (CAR), Glasgow coma scale score, and blood glucose level serve as reference values to evaluate the prognosis of critically ill patients. However, the prognostic significance of the admission serum CAR for patients with moderate to severe traumatic brain injury (TBI) has remained unclear. We examined the effect of the admission CAR on the outcomes of patients with moderate to severe TBI.

METHODS

The clinical data from 163 patients with moderate to severe TBI were collected. Before analysis, the patients' records were anonymized and de-identified. Multivariate logistic regression analyses were used to investigate the risk factors and construct a prognostic model of in-hospital mortality. The predictive value of different models was compared by evaluating the areas under the receiver operating characteristic curve.

RESULTS

Of the 163 patients, those who had not survived (nonsurvivors, n = 34) had had a higher CAR than that of the survivors (3.8 vs. 2.6; P < 0.001). The results of multivariate logistic regression analysis indicated that the Glasgow coma scale score (odds ratio [OR], 0.430; P = 0.001), blood glucose (OR, 1.290; P = 0.017), and CAR (OR, 1.609; P = 0.036) were independent risk factors for mortality and were used to construct the prognostic model. The area under the receiver operating characteristic curve of the prognostic model was 0.922 (95% confidence interval, 0.875-0.970), higher than that for the CAR (P = 0.0409). We had screened 195 patients for inclusion in the present study and excluded 32 patients.

CONCLUSIONS

The CAR can serve as an independent risk factor of mortality for patients with moderate to severe TBI. Incorporating CAR into a predictive model could contribute to efficiently predicting the prognosis of adults with moderate to severe TBI.

Immune regulation in neurovascular units after traumatic brain injury

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Survivors may experience movement disorders, memory loss, and cognitive deficits. However, there is a lack of understanding of the pathophysiology of TBI-mediated neuroinflammation and neurodegeneration. The immune regulation process of TBI involves changes in the peripheral and central nervous system (CNS) immunity, and intracranial blood vessels are essential communication centers. The neurovascular unit (NVU) is responsible for coupling blood flow with brain activity, and comprises endothelial cells, pericytes, astrocyte end-feet, and vast regulatory nerve terminals. A stable NVU is the basis for normal brain function. The concept of the NVU emphasizes that cell-cell interactions between different types of cells are essential for maintaining brain homeostasis. Previous studies have explored the effects of immune system changes after TBI. The NVU can help us further understand the immune regulation process. Herein, we enumerate the paradoxes of primary immune activation and chronic immunosuppression. We describe the changes in immune cells, cytokines/chemokines, and neuroinflammation after TBI. The post-immunomodulatory changes in NVU components are discussed, and research exploring immune changes in the NVU pattern is also described. Finally, we summarize immune regulation therapies and drugs after TBI. Therapies and drugs that focus on immune regulation have shown great potential for neuroprotection. These findings will help us further understand the pathological processes after TBI.

C-reactive Protein/Albumin Ratio as a Prognostic Indicator in Posttraumatic Shock and Outcome of Multiple Trauma Patients

OBJECTIVE

C-reactive protein (CRP)/albumin ratio (CAR) is a new inflammation-based index for predicting the prognosis of various diseases. The CAR determined on admission may help to predict the prognostic value of multiple trauma patients.

METHODS

A total of 264 adult patients with severe multiple trauma were included for the present retrospective study, together with the collection of relevant clinical and laboratory data. CAR, CRP, albumin, shock index and ISS were incorporated into the prognostic model, and the receiver operating characteristic (ROC) curve was drawn. Then, the shock index for patients with different levels of CAR was analyzed. Finally, univariate and multivariate logistic regression analyses were performed to identify the independent risk factors for the 28-day mortality of multiple trauma patients.

RESULTS

A total of 36 patients had poor survival outcomes, and the mortality rate reached 13.6%. Furthermore, after analyzing the shock index for patients with different levels of CAR, it was revealed that the shock index was significantly higher when CAR was ≥4, when compared to CAR <2 and 2≤ CAR <4, in multiple trauma patients. The multivariate logistic analysis helped to identify the independent association between the variables CAR (P=0.029) and shock index (P=0.019), and the 28-day mortality of multiple trauma patients.

CONCLUSION

CAR is higher in patients with severe multiple trauma. Furthermore, CAR serves as a risk factor for independently predicting the 28-day mortality of multiple trauma patients. The shock index was significantly higher when CAR was ≥4 in multiple trauma patients.

Effect of Red Cell Distribution Width on the Prognosis of Patients with Traumatic Brain Injury: A Retrospective Cohort Study

BACKGROUND

The link between red cell distribution width (RDW) and prognosis of traumatic brain injury (TBI) is controversial. Whether RDW can increase the prognostic value of established predictors remains unknown. This study aimed to provide supportive evidence for the prognostic value of RDW.

METHODS

Clinical data of 1488 patients with TBI were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database and classified into 2 groups: 1) one with RDW <14.5% (n = 1061) and 2) the other with RDW ≥14.5% (n = 427). Multivariable logistic regression models were used to estimate the relationship between RDW and outcomes. Stratified analyses and interactions were also performed. We compared the area under the receiver operating characteristic curve of the International Mission for Prognoses and Clinical Trial Design in TBI (IMPACT) core and extended models with and without RDW.

RESULTS

After adjusting for confounding factors, RDW was an independent risk consideration for TBI prognoses; the odds ratios were 1.62 (95% confidence interval (CI): 1.05, 2.50) and 1.89 (95% CI: 1.35, 2.64) for hospital mortality and 6-month mortality, respectively. This association was crucial for patients with a Glasgow Coma Score of 3-12 (odds ratio, 2.79; 95% CI: 1.33, 5.87). For 6-month mortality, when RDW was added to the core and extended IMPACT models, the area under the receiver operating characteristic curve increased from 0.833 to 0.851 (P = 0.001) and from 0.842 to 0.855 (P = 0.002), respectively.

CONCLUSIONS

Elevated RDW is an independent risk consideration for hospital and 6-month mortality rates. When RDW was added to the IMPACT core and extended models, it improved its predictive ability for 6-month mortality in patients with TBI.

Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score

PURPOSE

To develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments.

METHODS

We analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009-5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration.

RESULTS

The MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161).

CONCLUSIONS

Certain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.

Prognostic Value of Serum Procalcitonin Based Model in Moderate to Severe Traumatic Brain Injury Patients

Objective

Procalcitonin (PCT) is an acknowledged marker of systemic inflammatory response. Previous studies have not reached agreement on the association between serum PCT and outcome of traumatic brain injury (TBI) patients. We designed this study to confirm the prognostic value of PCT in isolated TBI and those with extracranial injury, respectively.

Methods

Patients hospitalized in our hospital for moderate-to-severe TBI between March 2015 and December 2019 were included. Logistic regression analysis was performed to validate the association between PCT and in-hospital mortality in these patients. AUC (area under the receiver operating characteristics curve) of PCT and constructed model were calculated and compared.

Results

Among the included 211 patients, 81 patients suffered a poor outcome, with a mortality rate of 38.4%. Non-survivors had a higher level of serum PCT (2.73 vs 0.72, p<0.001) and lower GCS (5 vs 7, p<0.001) on admission than survivors. AUC of single PCT for predicting mortality in isolated TBI and those with extracranial injury were 0.767 and 0.553, respectively. Multivariate logistic regression showed that GCS (OR=0.744, p=0.008), glucose (OR=1.236, p<0.001), cholesterol (OR=0.526, p=0.002), and PCT (OR=1.107, p=0.022) were independently associated with mortality of isolated TBI. The AUC of the prognostic model composed of GCS, glucose, cholesterol, and PCT was 0.868 in isolated TBI.

Conclusion

PCT is an efficient marker of outcome in isolated moderate-to-severe TBI but not those with extracranial injury. A prognostic model incorporating PCT is useful for clinicians to make early risk stratification for isolated TBI.

Mortality and Risk Factors in Isolated Traumatic Brain Injury Patients: A Prospective Cohort Study

INTRODUCTION

Outcomes in patients with isolated traumatic brain injury (iTBI) have not been evaluated comprehensively in low-income and middle-income countries. We aimed to study the in-hospital iTBI mortality and its associated risk factors in a prospective multicenter Indian trauma registry.

METHODS

Patients with iTBI (head and neck Abbreviated Injury Score ≥2 and other region Abbreviated Injury Score ≤2) were included. Study variables comprised age, gender, mechanism of injury, systolic blood pressure (SBP) at arrival, Glasgow Coma Scale (GCS) score - classified as mild (13-15), moderate (9-12), and severe (3-8), transfer status, and time to presentation at any participating hospital. A multivariable logistic regression was performed to assess the impact of these factors on 24-h and 30-d mortality following iTBI.

RESULTS

Among 5042 included patients, 24-h and 30-d in-hospital mortalities were 5.9% and 22.4%. On a regression analysis, 30-d mortality was associated with age ≥45 y (odds ratio [OR] = 2.1 [1.6-2.7]), railway injury mechanisms (OR = 2.1 [1.3-3.5]), SBP <90 mmHg (OR = 2.6 [1.6-4.1]), and moderate (OR = 3.8 [3.0-5.0]) to severe (OR = 21.1 [16.8-26.7]) iTBI based on GCS scores. 24-h mortality showed similar trends. Patients transferred to the participating hospitals from other centers had higher odds of 30-d mortality (OR = 1.4 [1.2-1.8]) compared to those arriving directly. Those who received neurosurgical intervention had lower odds of 24-h mortality (0.3 [0.2-0.4]).

CONCLUSIONS

Age ≥45 y, GCS score ≤12, and SBP <90 mmHg at arrival increased the risk of in-hospital mortality from iTBI.

Incidence, Risk Factors and Outcomes of Sepsis in Critically Ill Post-craniotomy Patients: A Single-Center Prospective Cohort Study

Background

Data concerning the epidemiology of sepsis in critically ill post-craniotomy patients are scarce. This study aimed to assess the incidence, risk factors, and outcomes of sepsis in this population.

Methods

This was a single-center prospective cohort study. Post-craniotomy patients admitted to the intensive care unit (ICU) were screened daily for the presence of infection and sepsis.

Results

Of the 900 included patients, 300 developed sepsis. The cumulative incidence of sepsis was 33.3% [95% confidence interval (CI), 30.2–36.4%]. Advanced age, male, hypertension, trauma, postoperative intracranial complications, and lower Glasgow Coma Scale (GCS) on the first postoperative day were independent risk factors of sepsis. Septic patients had higher hospital mortality (13.7 vs. 8.3%, P = 0.012), longer ICU length of stay (LOS) (14 vs. 4 days, P < 0.001), longer hospital LOS (31 vs. 19 days, P < 0.001), and higher total medical cost (CNY 138,394 vs. 75,918, P < 0.001) than patients without sepsis.

Conclusion

Sepsis is a frequent complication in critically ill post-craniotomy patients. Advanced age, male, hypertension, trauma, postoperative intracranial complications, and lower GCS on the first postoperative day were independent risk factors of sepsis.

Lactate Albumin Ratio Is Associated With Mortality in Patients With Moderate to Severe Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is a serious public health issue all over the world. This study was designed to evaluate the prognostic value of lactate to albumin ratio (LAR) on patients with moderate to severe TBI.

Methods

Clinical data of 273 moderate to severe TBI patients hospitalized in West China Hospital between May 2015 and January 2018 were collected. Multivariate logistic regression analyses were used to explore risk factors and construct a prognostic model of in-hospital mortality in this cohort. A receiver operating characteristic (ROC) curve was drawn to evaluate the discriminative ability of this model.

Results

Non-survivors had higher LAR than survivors (1.09 vs. 0.53, p < 0.001). Results of multivariate logistic regression analysis showed that Glasgow Coma Scale (GCS; odds ratio [OR] = 0.743, p = 0.001), blood glucose (OR = 1.132, p = 0.005), LAR (OR = 1.698, p = 0.022), subdural hematoma (SDH; OR = 2.889, p = 0.006), intraparenchymal hemorrhage (IPH; OR = 2.395, p = 0.014), and diffuse axonal injury (DAI; OR = 2.183, p = 0.041) were independent risk factors of in-hospital mortality in included patients. These six factors were utilized to construct the prognostic model. The area under the ROC curve (AUC) values of single lactate, albumin, and LAR were 0.733 (95% Cl; 0.673–0.794), 0.740 (95% Cl; 0.683–0.797), and 0.780 (95% Cl; 0.725–0.835), respectively. The AUC value of the prognostic model was 0.857 (95%Cl; 0.812–0.901), which was higher than that of LAR (Z = 2.1250, p < 0.05).

Conclusions

Lactate to albumin ratio is a readily available prognostic marker of moderate to severe TBI patients. A prognostic model incorporating LAR is beneficial for clinicians to evaluate possible progression and make treatment decisions in TBI patients.

A Prognostic Model Incorporating Red Cell Distribution Width to Platelet Ratio for Patients with Traumatic Brain Injury

BACKGROUND

As an inflammation-based marker, red cell distribution width to platelet ratio (RPR) has been verified to be associated with disease severity and outcome in many clinical settings. We designed this study to evaluate the prognostic value of RPR in patients with traumatic brain injury (TBI).

METHODS

A total of 420 patients admitted with TBI were included in this study. Laboratory and clinical data were collected from an electronic medical record system. Univariate and multivariate logistic regression analyses were sequentially performed to discover risk factors of in-hospital mortality. Receiver operating characteristic (ROC) curves were drawn to confirm the predictive value of different markers including RPR in training set and testing set.

RESULTS

Non-survivors had higher level of RPR than survivors (P<0.001). Logistic regression analysis showed that RPR was significantly associated with mortality even after adjusting for confounding factors (P<0.001). The area under the ROC curve (AUC) value of Glasgow Coma Scale (GCS) for predicting mortality was 0.761 and 0775 in training set and testing set, respectively. And the constructed predictive model incorporating RPR had the highest AUC value of 0.858 and 0.884 in training set and testing set.

CONCLUSION

RPR is significantly associated with mortality in TBI patients. Utilizing RPR to construct a predictive model is valuable to evaluate prognosis of TBI patients.

Relationship Between Red Blood Cell Distribution Width and All-Cause Mortality in Disseminated Intravascular Coagulation Patients: A Retrospective Analysis

Purpose

Studies regarding death risk factors of disseminated intravascular coagulation (DIC) patients were limited. We conducted this study to investigate whether red blood cell distribution width (RDW) was independently related to all-cause mortality of DIC patients.

Methods

We used data from the Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III v1.4). A total of 2098 patients with DIC were included. The main outcome was in-hospital all-cause mortality.

Results

After adjusting for potential covariates, the in-hospital all-cause mortality was positively correlated with RDW. The hazard ratio (HR), 95% confidence intervals (CI), and P-value were 1.08, (1.05, 1.12), and P<0.0001, respectively. The Kaplan-Meier curve found DIC patients with elevated RDW had a lower survival rate than patients with normal RDW (P<0.0001). A nonlinear relationship between RDW and mortality was found with the inflection point 19.2%. When RDW <19.2%, RDW was positively correlated with in-hospital all-cause mortality of DIC patients (HR (95% CI): 1.17 (1.11, 1.24), P<0.0001). An elevation in RDW greater than 19.2% did not result in an additional increased risk of mortality (HR=0.97, 95% CI: 0.91-1.04, P=0.4617).

Conclusion

RDW is an independent predictor of all-cause mortality in DIC patients. Furthermore, there is a nonlinear association between RDW and all-cause mortality of DIC patients.

The Association Between Serum Anion Gap and All-Cause Mortality in Disseminated Intravascular Coagulation Patients: A Retrospective Analysis

Purpose

Studies regarding death risk factors of disseminated intravascular coagulation (DIC) patients were limited. Therefore, we conducted this study to investigate whether the serum anion gap (AG) was independently related to all-cause mortality of DIC patients.

Methods

We used the data from Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III v1.4). A total of 2,654 DIC patients were included. The main outcomes were in-hospital, 30-day, and 90-day all-cause mortality. The AG was measured upon ICU admission and its association with mortality was evaluated using the Cox proportional-hazards regression model. The generalized additive model and the smooth curve fitting were introduced to examine the non-linear association.

Results

After adjusting for potential covariates, the in-hospital, 30-day, and 90-day all-cause mortality were positively correlated with AG. The hazard ratio (HR), confidence intervals (CI), and P were 1.05 (1.04–1.07) <0.0001, 1.06 (1.04–1.07) <0.0001, and 1.05 (1.03–1.07) <0.0001, respectively. We did not find an obvious non-linear relationship between AG and in-hospital, 30-day, and 90-day mortality, which indicated that the association between AG and all-cause mortality of DIC patients was nearly linear.

Conclusion

Serum AG is positively related with all-cause mortality in DIC patients.

Neuroinflammation and Hypothalamo-Pituitary Dysfunction: Focus of Traumatic Brain Injury

The incidence of traumatic brain injury (TBI) has increased over the last years with an important impact on public health. Many preclinical and clinical studies identified multiple and heterogeneous TBI-related pathophysiological mechanisms that are responsible for functional, cognitive, and behavioral alterations. Recent evidence has suggested that post-TBI neuroinflammation is responsible for several long-term clinical consequences, including hypopituitarism. This review aims to summarize current evidence on TBI-induced neuroinflammation and its potential role in determining hypothalamic-pituitary dysfunctions.

Distant Organ Damage in Acute Brain Injury

Acute brain injuries pose a great threat to global health, having significant impact on mortality and disability. Patients with acute brain injury may develop distant organ failure, even if no systemic diseases or infection is present. The severity of non-neurologic organs' dysfunction depends on the extremity of the insult to the brain. In this comprehensive review we sought to describe the organ-related consequences of acute brain injuries. The clinician should always be aware of the interplay between central nervous system and non-neurological organs, that is constantly present. Cerebral injury is not only a brain disease, but also affects the body as whole, and thus requires holistic therapeutical approach.

Epidemiology and Outcomes of Acute Respiratory Distress Syndrome Following Isolated Severe Traumatic Brain Injury

Patients with traumatic brain injury (TBI) are at risk for extra-cranial complications, such as the acute respiratory distress syndrome (ARDS). We conducted an analysis of risk factors, mortality, and healthcare utilization associated with ARDS following isolated severe TBI. The National Trauma Data Bank (NTDB) dataset files from 2007-2014 were used to identify adult patients who suffered isolated [other body region-specific Abbreviated Injury Scale (AIS) < 3] severe TBI [admission total Glasgow Coma Scale (GCS) from 3 to 8 and head region-specific AIS >3]. In-hospital mortality was compared between patients who developed ARDS and those who did not. Utilization of healthcare resources (ICU length of stay, hospital length of stay, duration of mechanical ventilation, and frequency of tracheostomy and gastrostomy tube placement) was also examined. This retrospective cohort study included 38,213 patients with an overall ARDS occurrence of 7.5%. Younger age, admission tachycardia, pre-existing vascular and respiratory diseases, and pneumonia were associated with the development of ARDS. Compared to patients without ARDS, patients that developed ARDS experienced increased in-hospital mortality (OR 1.13, 95% CI 1.01-1.26), length of stay (p = <0.001), duration of mechanical ventilation (p = < 0.001), and placement of tracheostomy (OR 2.70, 95% CI 2.34-3.13) and gastrostomy (OR 2.42, 95% CI 2.06-2.84). After isolated severe TBI, ARDS is associated with increased mortality and healthcare utilization. Future studies should focus on both prevention and management strategies specific to TBI-associated ARDS.

Polygenic Risk Score for Early Prediction of Sepsis Risk in the Polytrauma Screening Cohort

BACKGROUND

Increasing genetic variants associated with sepsis have been identified by candidate-gene and genome-wide association studies, but single variants conferred minimal alterations in risk prediction. Our aim is to evaluate whether a weighted genetic risk score (wGRS) that aggregates information from multiple variants could improve risk discrimination of traumatic sepsis.

METHODS

Sixty-four genetic variants potential relating to sepsis were genotyped in Chinese trauma cohort. Genetic variants with mean decrease accuracy (MDA) > 1.0 by random forest algorithms were selected to construct the multilocus wGRS. The area under the curve (AUC) and net reclassification improvement (NRI) were adopted to evaluate the discriminatory and reclassification ability of weighted genetic risk score (wGRS).

RESULTS

Seventeen variants were extracted to construct the wGRS in 883 trauma patients. The wGRS was significantly associated with sepsis after trauma (OR = 2.19, 95% CI = 1.53-3.15, P = 2.01 × 10-5) after being adjusted by age, sex, and ISS. Patients with higher wGRS have an increasing incidence of traumatic sepsis (P trend = 6.81 × 10-8), higher SOFA (P trend = 5.00 × 10-3), and APACHE II score (P trend = 1.00 × 10-3). The AUC of the risk prediction model incorporating wGRS into the clinical variables was 0.768 (95% CI = 0.739-0.796), with an increase of 3.40% (P = 8.00 × 10-4) vs. clinical factor-only model. Furthermore, the NRI increased 25.18% (95% CI = 17.84-32.51%) (P = 6.00 × 10-5).

CONCLUSION

Our finding indicated that genetic variants could enhance the predictive power of the risk model for sepsis and highlighted the application among trauma patients, suggesting that the sepsis risk assessment model will be a promising screening and prediction tool for the high-risk population.

The predictive value of RDW in AKI and mortality in patients with traumatic brain injury

Background

Red blood cell distribution width (RDW) has been validated valuable in predicting outcome and acute kidney injury (AKI) in several clinical settings. The aim of this study was to explore whether RDW is associated with outcome and AKI in patients with traumatic brain injury (TBI).

Methods

Patients admitted to our hospital for TBI from January 2015 to August 2018 were included in this study. Multivariate logistic regression analysis was performed to identify risk factors of AKI and outcome in patients with TBI. The value of RDW in predicting AKI and outcome was evaluated by receiver operating characteristic (ROC) curve.

Results

Three hundred and eighteen patients were included in this study. The median of RDW was 14.25%. We divided subjects into two groups based on the median and compared difference of variables between two groups. The incidence of AKI and mortality was higher in high RDW (RDW > 14.25) group (31.45% vs 9.43%, P < .001; 69.81% vs 29.56%, P < .001). Spearman's method showed RDW was moderately associated with 90‐day Glasgow Outcome Scale (GOS) (P < .001). In multivariate logistic regression analysis, RDW, lymphocyte, chlorine, and serum creatinine were risk factors of AKI. And Glasgow Coma Scale (GCS), glucose, chlorine, AKI, and RDW were risk factors of mortality. The area under the ROC curve (AUC) of RDW for predicting AKI and mortality was 0.724 (0.662‐0.786) and 0.754 (0.701‐0.807), respectively. Patients with higher RDW were likely to have shorter median survival time (58 vs 70, P < .001).

Conclusions

Red blood cell distribution width is an independent risk factor of AKI and mortality in patients with TBI.

Preinjury Use of Marijuana and Outcomes in Trauma Patients

BACKGROUND

Recent studies have examined the effects of marijuana in various populations; however, there has been limited research on the effect of marijuana use in severely injured trauma patients. We hypothesized that preinjury use of marijuana would be associated with improved outcomes in severely injured trauma patients.

METHODS

All adult (18+ y) level I and level II trauma activations who presented to two large regional trauma centers between 2014 and 2018 were reviewed. Delta-9-tetrahydrocannabinol (THC)- indicated absence of drugs confirmed by testing and as THC + confirmed THC without another drug present.

RESULTS

Of the 4849 patients included, 1373 (28.3%) were THC+. The THC + cohort was younger, had more males, and was more likely to be injured by penetrating mechanism (P < 0.001 for all) than THC-. THC + patients had shorter median length of stay (LOS) (P < 0.001) and intensive care unit LOS (P < 0.001). Mortality rate was lower in the THC + group (4.3% versus 7.6%, P < 0.001), but not in multivariate analysis. THC + patients with traumatic brain injury had shorter hospital LOS (P = 0.025) and shorter ventilator days (P = 0.033) than THC- patients. In patients with Injury Severity Score ≥16, THC + patients had significantly lower intensive care unit LOS (P = 0.009) and mortality (19.3% versus 25.0% P = 0.038) than drug-negative patients.

CONCLUSIONS

Although preinjury use of marijuana does not improve survival in trauma patients, it may provide some improvement in outcomes in patients with traumatic brain injury and those that are more severely injured (Injury Severity Score ≥16). The mechanism behind this finding needs further evaluation.

Non-neurologic organ dysfunction plays a major role in predicting outcomes in pediatric traumatic brain injury

BACKGROUND

Nonneurological organ dysfunction (NNOD) occurs after traumatic brain injury (TBI) and is associated with mortality. The aim of our study was to evaluate the prevalence of NNOD and its association with outcomes in pediatric patients with TBI. We hypothesized that NNOD is associated with worse outcomes in pediatric patients with severe TBI.

METHODS

We performed a 4-year (2013-16) analysis of our prospectively maintained TBI database. All patients (age < 18) with an isolated-severe TBI (head-abbreviated injury scale: AIS ≥ 3 & extracranial-AIS < 3) were included. NNOD was measured using the pediatric multiple organ dysfunction (P-MOD) score. Outcomes were in-hospital mortality, Glasgow Outcome Scale-Extended (GOS-E), and adverse discharge disposition: rehabilitation or skilled nursing facility (SNF). Regression analysis was performed.

RESULTS

We analyzed 292 patients. Mean age was 11 ± 6 years, 57% were male and the mortality rate was 18.1%. The incidence of NNOD was 35%. The most common dysfunctional organ system was the respiratory (25%) followed by the cardiovascular (12%). On regression analysis, the presence of at least one NNOD was independently associated with in-hospital mortality (OR 2.1 [1.7-2.9]; p < 0.01), low GOS-E (OR 1.8 [1.5-2.3]; p < 0.01), and SNF disposition (OR 1.7 [1.2-2.1]; p < 0.01).

CONCLUSION

NNOD develops in one of every three severe TBI pediatric patients and is independently associated with adverse outcomes. Identification of NNOD in pediatric TBI and focusing on management of NNOD could improve outcomes.

LEVEL OF EVIDENCE

III Prognostic.

CRP Albumin ratio is positively associated with poor outcome in patients with traumatic brain injury

OBJECTIVES

The C-reactive protein/albumin ratio (CAR), a novel inflammation-based index, has been proved useful in predicting outcome of various diseases. We designed this study to explore the prognostic value of CAR in patients with traumatic brain injury (TBI).

PATIENTS AND METHODS

We retrospectively included 151 patients diagnosed with TBI and collected related clinical and laboratory data. Univariate and multivariate logistic regression were conducted to find independent risk factors of mortality. Then, we incorporated CAR into prognostic model and drew receiver operating characteristic (ROC) curve of models. Finally, we compared the predictive value of different models by evaluating the area under the receiver operating characteristic curves (AUC).

RESULTS

In this study, a total of 54 patients had poor survival outcome with mortality rate of 35.8 %. Results of multivariate analysis showed that GCS score in admission (OR 0.700, 95 %Cl 0.570-0.860, p=0.001), acute kidney injury (AKI) (OR 3.952, 95Cl 1.631-9.577, p=0.002) and CAR (OR 1.202, 95Cl 1.039-1.390, p=0.013) were independently associated with in-hospital mortality. The AUC value of predictive model composed of the above three factors was higher than GCS or CAR alone.

CONCLUSION

CAR is an independent risk factor of mortality in patients with TBI. Incorporating CAR into predictive model could increase the value in predicting outcome of TBI patients.

Controlling nutritional status (CONUT) score is a predictive marker for patients with traumatic brain injury

OBJECT

We designed this study to evaluate whether controlling nutritional status (CONUT) score was valuable in predicting outcome of patients with traumatic brain injury (TBI).

METHODS

Clinical and laboratory data of patients admitted with TBI in our hospital between January 2015 and January 2018 was retrospectively collected. We divided patients into two groups according to in-hospital and 90-day outcome respectively and compared baseline characteristics of two groups. Multivariate analyses were conducted to evaluate whether CONUT score was associated with outcome of included patients. Receiver operating characteristics (ROC) curves were drawn to compare the predictive value of CONUT score and constructed models.

RESULTS

A total of 365 patients were included in our study. Multivariate logistic regression analyses showed that CONUT score was independently associated with in-hospital mortality (OR = 1.244, 95% CI: 1.099-1.408, p = 0.001) and 90-day outcome (OR = 1.441, 95% CI: 1.193-1.741, p < 0.001). ROC curve showed that area under the ROC curve (AUC) of CONUT score for predicting in-hospital mortality and 90-day outcome were 0.790 (95% CI: 0.745-0.836, p < 0.001) and 0.839 (95% CI: 0.792-0.886, p < 0.001), respectively.

CONCLUSION

CONUT score is independently associated with in-hospital mortality and 90-day outcome of patients with TBI.

Serum Procalcitonin Level Predicts Acute Kidney Injury After Traumatic Brain Injury

BACKGROUND

A common non-neurologic complication after traumatic brain injury (TBI), acute kidney injury (AKI) is a risk factor of mortality. Some studies confirmed the predictive value of procalcitonin (PCT) on AKI in several clinical settings. We designed this study to explore the predictive value of PCT on AKI after TBI.

METHODS

We retrospectively enrolled patients with TBI admitted to our hospital from February 2015 to June 2019. Multivariate logistic regression analysis was performed to find the risk factors of AKI and construct a predictive model for AKI. Receiver operating characteristics curves were drawn to compare the predictive value of PCT and the constructed model.

RESULTS

A total of 214 patients were included in this study. The incidence of AKI after TBI was 25.70% in this study. Compared with the non-AKI group, the AKI group had higher age (P = 0.031), lower Glasgow Coma Scale (P < 0.001), and higher incidence of coagulopathy (P < 0.001) and shock (P < 0.001). Moreover, patients complicated with AKI had higher in-hospital mortality (P < 0.001) and worse 90-day outcome (P < 0.001). Multivariate logistic regression analysis indicated that age (P = 0.033), PCT (P = 0.002), serum chlorine (P = 0.011), and creatinine (P < 0.001) were independent risk factors of AKI. We constructed a predictive model using these 4 risk factors. The area under receiver operating characteristics curves of the predictive model was 0.928, which was significantly higher than that of a single PCT value (area under receiver operating characteristics curves = 0.833) (Z = 2.395, P < 0.05).

CONCLUSIONS

PCT is valuable in predicting AKI after TBI. To avoid AKI after TBI, physicians can adjust treatment strategies according to the level of PCT.

Early Systemic Inflammatory Response Syndrome Duration Predicts Infected Pancreatic Necrosis

BACKGROUND AND PURPOSE

Systemic inflammatory response syndrome (SIRS) was considered to play an important role in the progress of acute pancreatitis, but its specific relation with infected pancreatic necrosis remains largely unclear. We aimed to investigate the correlation between SIRS duration and infected pancreatic necrosis, and its application in prediction of infected pancreatic necrosis.

METHODS

A prospective observational cohort study of 2130 patients with acute pancreatitis from 2012 to 2017. The SIRS duration at the first week was registered daily, and demographic, radiology, and all clinical laboratory data were prospectively collected and retrospectively reviewed.

RESULTS

A significant upward tendency of infected pancreatic necrosis incidence was observed with increased SIRS duration. In multivariate logistic regression, SIRS duration (odds ratio, 1.305; 95% CI, 1.161-1.468) was independently associated with infected pancreatic necrosis. ROC analysis demonstrated that the areas under curves of SIRS duration for predicting persistent multi-organ failure, pancreatic infection, and mortality were 0.97 (95% CI, 0.96-0.98), 0.92 (95% CI, 0.91-0.94), and 0.86 (95% CI, 0.83-0.90), respectively, which were comparable to, or even greater than, the area under curves of APACHE II and CT severity index scores.

CONCLUSIONS

Early SIRS duration was strongly associated with infected pancreatic necrosis and could serve as an easy bedside indicator to predict pancreatic infection.

Systemic Immune Response to Traumatic CNS Injuries-Are Extracellular Vesicles the Missing Link?

Inflammation following traumatic injury to the central nervous system (CNS) persists long after the primary insult and is known to exacerbate cell death and worsen functional outcomes. Therapeutic interventions targeting this inflammation have been unsuccessful, which has been attributed to poor bioavailability owing to the presence of blood-CNS barrier. Recent studies have shown that the magnitude of the CNS inflammatory response is dependent on systemic inflammatory events. The acute phase response (APR) to CNS injury presents an alternative strategy to modulating the secondary phase of injury. However, the communication pathways between the CNS and the periphery remain poorly understood. Extracellular vesicles (EVs) are membrane bound nanoparticles that are regulators of intercellular communication. They are shed from cells of the CNS including microglia, astrocytes, neurons and endothelial cells, and are able to cross the blood-CNS barrier, thus providing an attractive candidate for initiating the APR after acute CNS injury. The purpose of this review is to summarize the current evidence that EVs play a critical role in the APR following CNS injuries.

Are Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Associated with Mortality in Pediatric Trauma Patients? A Retrospective Study

BACKGROUND

There are very limited data on the prognostic capacity of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) for the systemic inflammatory response in pediatric trauma (PT) patients. The purpose of this study was to evaluate the prognostic ability of NLR and PLR on mortality in pediatric trauma patients.

METHODS

This study looked at 358 PT patients who were admitted to the Cumhuriyet University Hospital's Emergency Department between January 2010 and June 2018. The NLR and PLR were calculated by dividing the blood neutrophil count and blood platelet count, respectively, by the lymphocyte count, at the time of admission. After performing a stepwise logistic regression analysis to determine the predictive factors on the mortality risk of post-traumatic systemic inflammatory response syndrome (SIRS), receiver operating characteristic (ROC) curve analysis was used to define the optimum cut-off values of the NLR and the PLR parameters for survival.

RESULTS

The NLR, and PLR values were significantly higher in survivors than in non-survivors (NLR, 6.2±5.7 versus 2.6±2.5, P<0.001; PLR, 145.3±85.0 versus 46.2±25.2, P<0.001 ). The NLR (odds ratio [OR], 3.21; P=0.048), PLR (OR, 0.90; P=0.032), blood glucose (OR, 1.02; P=0.024), and Injury Severity Score (ISS) (OR, 1.28; P=0.011) were independent predictors of the mortality risk in PT patients. The area under the curve in the ROC curve analysis was 0.764 with a cut-off of 2.77 (sensitivity 70%, specificity 77%) for the NLR; and 0.928 with a cut-off of 61.83 (sensitivity 90%, specificity 85%) for the PLR.

CONCLUSION

Acquiring the NLR and PLR at the time of admission could be a useful predictor for mortality in PT patients.

A Preliminary Report of the Relationship Between Gene Polymorphism of IL-8 and Its Receptors and Systemic Inflammatory Response Syndrome Caused by Wasp Stings

The plasma levels of interleukin-8 (IL-8) and its receptors (CXCR1 and CXCR2) play a significant role in the development of systemic inflammatory response syndrome (SIRS), but it is not clear how these proteins are involved in wasp sting patients developing SIRS. To study potential genetic factors predisposing to the risk of SIRS caused by wasp sting injury, we determined the plasma levels of IL-8 and its receptors among SIRS patients with wasp sting injury and investigated the association of single-nucleotide polymorphisms of these genes with SIRS. A total of 225 patients were divided into the SIRS group (n = 62) and non-SIRS group (control, n = 163), and we associated polymorphisms in IL-8 [rs4073 (-251T>A), rs2227532 (-845C>T), rs2227307 (+396G>T), rs2227306 (+781T>C), CXCR1 rs2234671 (+860C>G), CXCR2 [rs2230054 (+811T>C), rs57929613 (+1235C>T), and rs60626131 (+1440A>G)] with SIRS with a linear additive model. In terms of protein expression, the IL-8, CXCR1, and CXCR2 plasma levels were significantly higher in the SIRS group than in the control group (p < 0.001). Significantly higher frequencies were observed for the IL-8 - 251T allele (AT+TT), CXCR2 + 811T allele (CT+TT), and +1235C allele (TC+CC) in the SIRS group, when compared with the control group, with odds ratio (OR) = 3.971 (95% confidence interval [CI], 1.618-9.734), p = 0.003; OR = 4.223 (95% CI, 1.863-9.571), p = 0.001; and OR = 4.012 (95% CI, 1.773-9.079), p = 0.001; respectively. In addition, SIRS is more likely to occur in males, patients with number of wasp stings ≥10 stings, and stings in the limbs. The current study suggests that the IL-8 - 251T allele (AT+TT) and IL-8 receptor CXCR2 + 811C allele (CT+TT) and +1235T allele (TC+CC) could be risk factors among SIRS patients with wasp sting injury.

Blood Glucose Levels May Aid the Decision for CT Scan in Minor Head Trauma

Traumatic brain injury has been associated with increased blood glucose levels. In the present study, we set out to investigate if blood glucose level in mild head trauma could predict the need for CT. One hundred fifty-nine patients with minor TBI (GCS 13-15) and a mean age of 44.8 ± 23.8 years were included in the study. The most common mechanism of trauma was falls. Patients with positive CT findings had significantly higher glucose levels than patients with negative CT findings. Using ROC curve analysis, serum glucose levels higher than 120 mg dl⁻¹ were the optimal cutoff value for the detection of patients with positive CT findings with a sensitivity of 74.4% and a specificity of 90.7%. Serum glucose level evaluation at presentation in the emergency department may aid CT decision-making in mild TBI.

Interleukin-6 Gene Polymorphism and the Risk of Systemic Inflammatory Response Syndrome Caused by Wasp Sting Injury

Previous studies have shown that serum levels of interleukin-6 (IL-6), which plays an important role in the development of systemic inflammatory response syndrome (SIRS), is significantly increased in wasp sting patients. However, the association between IL-6 gene variants and the risk of SIRS development in these patients is not clearly understood. In this study, we investigated the association between IL-6 gene polymorphism in the promoter region and the risk of SIRS in wasp sting patients. A total of 160 patients were divided into SIRS group and non-SIRS group (control), and evaluated for polymorphisms in IL-6 (-174G/C, -572G/C, -597G/A, and -634C/G), using DNA sequencing. The IL-6 serum levels were assessed using an enzyme-linked immunosorbent assay. Risk factors were analyzed by logistic regression analysis. We found that the IL-6 serum level was significantly higher in the SIRS group than in the control group (p < 0.001). A significant association was observed in the genotypic distribution of the IL-6 - 572G allele in the SIRS group, when compared with the control group [OR = 3.909 (1.906-8.019), p < 0.001], and SIRS is more likely to occur in wasp sting patients with more than 10 stings. Thus, the IL-6 - 572G allele and more than 10 stings can be used as predictors of risk of SIRS development in wasp sting patients.

Is Procalcitonin Useful in Pediatric Critical Care Patients?

This review examines the use of procalcitonin in different clinical situations in the pediatric patient, with special emphasis on those requiring intensive care. We review the latest articles on its potency as a biomarker in both infectious processes at diagnosis and on the response to treatment.

Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies

OBJECTIVE

To identify sensitivity, specificity and predictive accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to predict in-hospital mortality in hospitalized patients with suspected infection.

METHODS

This meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group consensus statement for conducting and reporting the results of systematic review. PubMed and EMBASE were searched for the observational studies which reported predictive utility of qSOFA score for predicting mortality in patients with suspected or proven infection with the following search words: 'qSOFA', 'q-SOFA', 'quick-SOFA', 'Quick Sequential Organ Failure Assessment', 'quick SOFA'. Sensitivity, specificity, area under receiver operating characteristic (ROC) curves with 95% confidence interval (CI) of qSOFA and SIRS criteria for predicting in-hospital mortality was collected for each study and a 2 × 2 table was created for each study.

RESULTS

Data of 406 802 patients from 45 observational studies were included in this meta-analysis. Pooled sensitivity (95% CI) and specificity (95% CI) of qSOFA ≥2 for predicting mortality in patients who were not in an intensive care unit (ICU) was 0.48 (0.41-0.55) and 0.83 (0.78-0.87), respectively. Pooled sensitivity (95% CI) of qSOFA ≥2 for predicting mortality in patients (both ICU and non-ICU settings) with suspected infection was 0.56 (0.47-0.65) and pooled specificity (95% CI) was 0.78 (0.71-0.83).

CONCLUSION

qSOFA has been found to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection. It is reasonable to recommend developing another scoring system with higher sensitivity to identify high-risk patients with infection.