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Craig HA, Lowe DJ, Khan A, Paton M, Gordon MW. Exploring the impact of traumatic injury on mortality: An analysis of the certified cause of death within one year of serious injury in the Scottish population. Injury 2024; 55:111470. [PMID: 38461710 DOI: 10.1016/j.injury.2024.111470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/01/2024] [Accepted: 02/25/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Few studies effectively quantify the long-term incidence of death following injury. The absence of detailed mortality and underlying cause of death data results in limited understanding and a potential underestimation of the consequences at a population level. This study takes a nationwide approach to identify the one-year mortality following injury in Scotland, evaluating survivorship in relation to pre-existing comorbidities and incidental causes of death. STUDY DESIGN This retrospective cohort study assessed the one-year mortality of adult trauma patients with an Injury Severity Score ≥ 9 during 2020 using the Scottish Trauma Audit Group (STAG) registry linked to inpatient hospital data and death certificate records. Patients were divided into three groups: trauma death, trauma-contributed death, and non-trauma death. Kaplan-Meier curves were used for survival analysis to evaluate mortality, and cox proportional hazards regression analysed risk factors linked to death. RESULTS 4056 patients were analysed with a median age 63 years (58-88) and male predominance (55.2 %). Falls accounted for 73.1 % of injuries followed by motor vehicle accidents (16.3 %) and blunt force (4.9 %). Extremity was the most commonly injured region overall followed by chest and head. However, head injury prevailed in those who died. The registry demonstrated a one-year mortality of 19.3 % with 55 % deaths occurring post-discharge. Of all deaths reported, 35.3 % were trauma deaths, and 47.7 % were trauma-contributed deaths. These groups accounted for over 70 % of mortality within 30 days of hospital admission and continued to represent the majority of deaths up to 6 months post-injury. Patients who died after 6 months were mainly the result of non-traumatic causes, frequently circulatory, neoplastic, and respiratory diseases (37.7 %, 12.3 %, 9.1 %, respectively). Independent risk factors for one-year mortality included a GCS ≤ 8, modified Charlson Comorbidity score >5, Injury Severity Score >25, serious head injury, age and sex. CONCLUSION With a one-year mortality of 19.3 %, and post-discharge deaths higher than previously appreciated, patients can face an extended period of survival uncertainty. As mortality due to index trauma lasted up to 6 months post-admission, short-term outcomes fail to represent trauma burden and so cogent survival predictions should be avoided in clinical and patient settings.
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Affiliation(s)
- Hannah A Craig
- University of Glasgow School of Medicine, G12 8QQ, Glasgow, United Kingdom.
| | - David J Lowe
- Department of Emergency Medicine, Queen Elizabeth University Hospital, Glasgow, G51 4TF, United Kingdom; Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, United Kingdom
| | - Angela Khan
- Scottish National Audit Programme, Area 143c, Clinical & Protecting Health Directorate, Public Health Scotland, 1 South Gyle Crescent, Edinburgh EH12 9EB, United Kingdom
| | - Martin Paton
- Scottish National Audit Programme, Public Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, United Kingdom
| | - Malcolm Wg Gordon
- Department of Emergency Medicine, Queen Elizabeth University Hospital, Glasgow, G51 4TF, United Kingdom
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Kuo LW, Wang YH, Wang CC, Huang YTA, Hsu CP, Tee YS, Chen SA, Liao CA. Long-term survival after major trauma: a retrospective nationwide cohort study from the National Health Insurance Research Database. Int J Surg 2023; 109:4041-4048. [PMID: 37678288 PMCID: PMC10720785 DOI: 10.1097/js9.0000000000000697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Most trauma-related studies are focused on short-term survival and complications within the index admission, and the long-term outcomes beyond discharge are mainly unknown. The purpose of this study was to analyze the data from the National Health Insurance Research Database (NHIRD) and to assess the long-term survival of major trauma patients after being discharged from the index admission. MATERIAL AND METHODS This retrospective, observational study included all patients with major trauma (injury severity score ≥16) in Taiwan from 2003 to 2007, and a 10-year follow-up was conducted on this cohort. Patients aged 18-70 who survived the index admission were enrolled. Patients who survived less than one year after discharge (short survival, SS) and those who survived for more than one year (long survival, LS) were compared. Variables, including preexisting factors, injury types, and short-term outcomes and complications, were analyzed, and the 10-year Kaplan-Meier survival analysis was conducted. RESULTS In our study, 9896 patients were included, with 2736 in the SS group and 7160 in the LS group. Age, sex, comorbidities, low income, cardiopulmonary resuscitation event, prolonged mechanical ventilation, prolonged ICU length of stay (LOS), and prolonged hospital LOS were identified as the independent risk factors of SS. The 10-year cumulative survival for major trauma patients was 63.71%, and the most mortality (27.64%) occurred within the first year after discharge. CONCLUSION 27.64% of patients would die one year after being discharged from major trauma. Major trauma patients who survived the index admission still had significantly worse long-term survival than the general population, but the curve flattened and resembled the general population after one year.
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Affiliation(s)
| | | | | | - Yu-Tung A. Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City
| | | | - Yu-San Tee
- Department of Trauma and Emergency Surgery
| | | | - Chien-An Liao
- Department of Trauma and Emergency Surgery
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei City, Taiwan
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Eskesen TO, Sillesen M, Pedersen JK, Pedersen DA, Christensen K, Rasmussen LS, Steinmetz J. Association of Trauma With Long-Term Risk of Death and Immune-Mediated or Cancer Disease in Same-Sex Twins. JAMA Surg 2023; 158:738-745. [PMID: 37195677 PMCID: PMC10193261 DOI: 10.1001/jamasurg.2023.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/04/2023] [Indexed: 05/18/2023]
Abstract
Importance Immediate consequences of trauma include a rapid and immense activation of the immune system, whereas long-term outcomes include premature death, physical disability, and reduced workability. Objective To investigate if moderate to severe trauma is associated with long-term increased risk of death or immune-mediated or cancer disease. Design, Setting, and Participants This registry-based, matched, co-twin control cohort study linked the Danish Twin Registry and the Danish National Patient Registry to identify twin pairs in which 1 twin had been exposed to severe trauma and the other twin had not from 1994 to 2018. The co-twin control design allowed for matching on genetic and environmental factors shared within twin pairs. Exposure Twin pairs were included if 1 twin had been exposed to moderate to severe trauma and the other twin had not (ie, co-twin). Only twin pairs where both twins were alive 6 months after the trauma event were included. Main Outcome and Measure Twin pairs were followed up from 6 months after trauma until 1 twin experienced the primary composite outcome of death or 1 of 24 predefined immune-mediated or cancer diseases or end of follow-up. Cox proportional hazards regression was used for intrapair analyses of the association between trauma and the primary outcome. Results A total of 3776 twin pairs were included, and 2290 (61%) were disease free prior to outcome analysis and were eligible for the analysis of the primary outcome. The median (IQR) age was 36.4 (25.7-50.2) years. The median (IQR) follow-up time was 8.6 (3.8-14.5) years. Overall, 1268 twin pairs (55%) reached the primary outcome; the twin exposed to trauma was first to experience the outcome in 724 pairs (32%), whereas the co-twin was first in 544 pairs (24%). The hazard ratio for reaching the composite outcome was 1.33 (95% CI, 1.19-1.49) for twins exposed to trauma. Analyses of death or immune-mediated or cancer disease as separate outcomes provided hazard ratios of 1.91 (95% CI, 1.68-2.18) and 1.28 (95% CI, 1.14-1.44), respectively. Conclusion and Relevance In this study, twins exposed to moderate to severe trauma had significantly increased risk of death or immune-mediated or cancer disease several years after trauma compared with their co-twins.
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Affiliation(s)
- Trine O. Eskesen
- Department of Anesthesia and Trauma Centre, Section 6011, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
| | - Martin Sillesen
- Department of Organ Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
- Center for Surgical Translational and Artificial Intelligence Research, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Krabbe Pedersen
- The Danish Twin Registry, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Dorthe Almind Pedersen
- The Danish Twin Registry, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kaare Christensen
- The Danish Twin Registry, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Lars S. Rasmussen
- Department of Anesthesia and Trauma Centre, Section 6011, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia and Trauma Centre, Section 6011, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
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4
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Nieto K, Ang D, Liu H. Dysphagia among geriatric trauma patients: A population-based study. PLoS One 2022; 17:e0262623. [PMID: 35134076 PMCID: PMC8824344 DOI: 10.1371/journal.pone.0262623] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/29/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To determine the significance of dysphagia on clinical outcomes of geriatric trauma patients. Methods This is a retrospective population-based study of geriatric trauma patients 65 years and older utilizing the Florida Agency for Health Care Administration dataset from 2010 to 2019. Patients with pre-admission dysphagia were excluded. Multivariable regression was used to create statistical adjustments. Primary outcomes included mortality and the development of dysphagia. Secondary outcomes included length of stay and complications. Subgroup analyses included patients with dementia, patients who received transgastric feeding tubes (GFTs) or tracheostomies, and speech language therapy consultation. Results A total of 52,946 geriatric patients developed dysphagia after admission during a 9-year period out of 1,150,438 geriatric trauma admissions. In general, patients who developed dysphagia had increased mortality, length of stay, and complications. When adjusted for traumatic brain and cervical spine injuries, the addition of mechanical ventilation decreased the mortality odds. This was also observed in the subset of patients with dysphagia who had GFTs placed. Of the three primary risk factors for dysphagia investigated, mechanical ventilation was the most strongly associated with later development of dysphagia and mortality. Conclusion The geriatric trauma population is vulnerable to dysphagia with a large number associated with traumatic brain injury, cervical spine injury, and polytraumatic injuries that lead to mechanical ventilation. Earlier intubation/mechanical ventilation in association with GFTs was found to be associated with decreased inpatient hospital mortality. Tracheostomy placement was shown to be an independent risk factor for the development of dysphagia. The utilization of speech language therapy was found to be inconsistently utilized.
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Affiliation(s)
- Kenny Nieto
- Department of Surgery, University of Central Florida/HCA Healthcare-GME Consortium, Ocala, Florida, United States of America
- * E-mail: , (KN); (DA)
| | - Darwin Ang
- Department of Surgery, University of Central Florida/HCA Healthcare-GME Consortium, Ocala, Florida, United States of America
- Department of Surgery, University of South Florida, Tampa, Florida, United States of America
- Department of Surgery, Division of Trauma, Ocala Regional Medical Center, Ocala, Florida, United States of America
- * E-mail: , (KN); (DA)
| | - Huazhi Liu
- Department of Surgery, Division of Trauma, Ocala Regional Medical Center, Ocala, Florida, United States of America
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Hickey MC, Gray R, van Galen G, Ward MP. Distribution of mortality patterns in cats with naturally occurring trauma: A Veterinary Committee on Trauma registry study. Vet J 2021; 278:105765. [PMID: 34715365 DOI: 10.1016/j.tvjl.2021.105765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 10/20/2022]
Abstract
A greater understanding of the prognostic variables that affect the timing of death for cats with trauma may help clinicians select treatments and monitoring plans. This study investigated the mortality rate and its distribution pattern in a large population of cats to identify variables associated with the timing of trauma-related deaths. Clinical data was retrieved from the Veterinary Committee on Trauma database to determine mortality rates and timing of deaths, defined as early death (ED; <1 day post-presentation) or delayed death (DD; ≥1 day post-presentation). Multivariable logistic regression analyses were performed to identify characteristics and interventions that best predicted timing of death. Overall mortality rate for 6703 feline trauma patients with complete records was 17.2%, with 7.6% due to natural death and 92.3% due to euthanasia. Among the subset of 543 cats with trauma that died after presentation or required euthanasia due to a grave prognosis (representing an 8.1% mortality rate), EDs were more common (71.7%) than DD and the cause of death was not significantly associated with the timing of death. Clinical pathology parameters were unable to identify animals more likely to die or to require euthanasia due to a poor prognosis during hospitalisation. Factors that were significantly different for cats with ED vs. DD included the median cumulative results for the Modified Glasgow Coma Scale (MGCS) score and the Animal Trauma Triage (ATT) score, the presence of spinal trauma, administration of blood products and undertaking surgical procedures. An increased likelihood of DD rather than ED was associated with the administration of blood products (odds ratio [OR], 3.959; P = 0.019) vs. not, performing a surgical procedure (OR, 6.055; P < 0.001) vs. not, and a cumulative MGCS of 15-17 or 18 (OR, 1.947 and 3.115; P = 0.031 and P = 0.01, respectively) vs. a cumulative MGCS ≤ 11.
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Affiliation(s)
- M C Hickey
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown 2006, Australia.
| | - R Gray
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown 2006, Australia
| | - G van Galen
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown 2006, Australia
| | - M P Ward
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, Camperdown 2006, Australia
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Miranda D, Maine R, Cook M, Brakenridge S, Moldawer L, Arbabi S, O'Keefe G, Robinson B, Bulger EM, Maier R, Cuschieri J. Chronic critical illness after hypothermia in trauma patients. Trauma Surg Acute Care Open 2021; 6:e000747. [PMID: 34423134 PMCID: PMC8323397 DOI: 10.1136/tsaco-2021-000747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives Chronic critical illness (CCI) is a phenotype that occurs frequently in patients with severe injury. Previous work has suggested that inflammatory changes leading to CCI occur early following injury. However, the modifiable factors associated with CCI are unknown. We hypothesized that hypothermia, an early modifiable factor, is associated with CCI. Methods To determine the association of hypothermia and CCI, a secondary analysis of the Inflammation and Host Response to Injury database was performed, and subsequently validated on a similar cohort of patients from a single level 1 trauma center from January 2015 to December 2019. Hypothermia was defined as initial body temperature ≤34.5°C. CCI was defined as death or sustained multiorgan failure ≥14 days after injury. Data were analyzed using univariable analyses with Student’s t-test and Pearson’s χ2 test, and logistic regression. An arrayed genomic analysis of the transcriptome of circulating immune cells was performed in these patients. Results Of the initial 1675 patients, 254 had hypothermia and 1421 did not. On univariable analysis, 120/254 (47.2%) of patients with hypothermia had CCI, compared with 520/1421 (36.6%) without hypothermia who had CCI, p<0.001. On multivariable logistic regression, hypothermia was independently associated with CCI, OR 1.61 (95% CI 1.17 to 2.21) but not mortality. Subsequent validation in 1264 patients of which 172 (13.6%) were hypothermic, verified that hypothermia was independently associated with CCI on multivariable logistic regression, OR 1.84 (95% CI 1.21 to 2.41). Transcriptomic analysis in hypothermic and non-hypothermic patients revealed unique cellular-specific genomic changes to only circulating monocytes, without any distinct effect on neutrophils or lymphocytes. Conclusions Hypothermia is associated with the development of CCI in severely injured patients. There are transcriptomic changes which indicate that the changes induced by hypothermia may be associated with persistent CCI. Thus, early reversal of hypothermia following injury may prevent the CCI. Level of evidence III.
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Affiliation(s)
- David Miranda
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Rebecca Maine
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Scott Brakenridge
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Lyle Moldawer
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Saman Arbabi
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Grant O'Keefe
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bryce Robinson
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ronald Maier
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph Cuschieri
- Surgery at ZSFG, University of California San Francisco, San Francisco, California, USA
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7
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Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma. Am J Surg 2021; 223:998-1003. [PMID: 34384589 PMCID: PMC8818056 DOI: 10.1016/j.amjsurg.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about potential disparities in end-of-life care in trauma. We examined racial/ethnic differences in withdrawal of life-sustaining treatment (WLST) in non-head injury trauma. METHODS We retrospectively analyzed the National Trauma Databank (2017-2018), including patients ≥ 18 years without head injury. We performed a bivariate analysis by WLST status and used logistic regression to estimate adjusted odds of WLST by racial/ethnic group. RESULTS Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41-0.57) and Hispanics (OR 0.71, 95% CI 0.57-0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days. CONCLUSIONS Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.
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Upadhyaya GK, Iyengar KP, Jain VK, Garg R. Evolving concepts and strategies in the management of polytrauma patients. J Clin Orthop Trauma 2021; 12:58-65. [PMID: 33716429 PMCID: PMC7920163 DOI: 10.1016/j.jcot.2020.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.
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Affiliation(s)
- Gaurav K. Upadhyaya
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, 229405, India
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
- Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India.
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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9
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Lee KC, Walling AM, Senglaub SS, Kelley AS, Cooper Z. Defining Serious Illness Among Adult Surgical Patients. J Pain Symptom Manage 2019; 58:844-850.e2. [PMID: 31404642 PMCID: PMC7155422 DOI: 10.1016/j.jpainsymman.2019.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context. OBJECTIVES The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts. METHODS We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement. RESULTS All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V. CONCLUSION We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Affiliated Adjunct Staff, RAND Health, Los Angeles, California, USA
| | - Steven S Senglaub
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Hebrew SeniorLife Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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10
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Adams L, Tucker A, Dennis JA, Dissanaike S. Impact of time spent in the trauma bay on mortality outcomes among level 1 trauma patients. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618789964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The majority of trauma-related deaths occur within the first 24 h of injury, and time elapsed until intervention for an injury is one of the greatest causes of preventable death in mature trauma centers. This study seeks to determine if there is a correlation between time spent in the trauma bay and mortality outcomes. Methods A retrospective analysis of Level 1 trauma patients from 1 January 2010 to 1 January 2016 in a single center. Results Charts from 1678 Level 1 trauma patients with 1290 (76.9%) blunt and 388 (23.1%) penetrating injuries were analyzed. Of these, 345 patients died and 237 (68.7%) died within the first 24 h. Multivariate analysis yields an inverse correlation between increased times spent in the trauma bay and mortality, with controls for injury severity, age, and race/ethnicity and with deaths in the trauma bay excluded ( p < 0.001). Each additional minute spent in the trauma bay increases odds of surviving by 1%. However, increase in ISS and decrease in TRISS were directly correlated with reduced time in the trauma bay for both blunt and penetrating traumas. Results did not differ based on mechanism of injury or destination after the trauma bay. Conclusion Reduced time spent in trauma bay was not correlated with improved mortality outcomes in Level 1 trauma patients. Findings do not necessarily suggest that increased trauma bay time would reduce mortality, but rather current evaluation procedures may prioritize trauma patients appropriately. Instinctive adjustment by emergency care providers to move more severely injured patients out of the trauma bay quicker and other additional variables could account for the measured phenomena. This is the first study to examine trauma bay times and mortality outcomes.
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Affiliation(s)
- Logan Adams
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Amber Tucker
- Trauma and Burn Service Department, University Medical Center, Lubbock, TX, USA
| | - Jeff A. Dennis
- Department of Public Health, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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11
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Duration of Respiratory Failure After Trauma Is Not Associated With Increased Long-Term Mortality. Crit Care Med 2019; 46:1263-1268. [PMID: 29742591 DOI: 10.1097/ccm.0000000000003202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival. DESIGN Retrospective cohort of trauma patients. SETTING Single center, level 1 trauma center. PATIENTS Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (> 14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33-65 yr) and Injury Severity Score was 19 (11-29). Median respiratory failure duration was 3 days (2-6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9-9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality. CONCLUSIONS Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.
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Bridges LC, Christie AB, Awad HH, Sigman EJ, Christie DB, Ackermann RJ. Geriatric Trauma Screening Tool: Preinjury Functional Status Dictates Intensive Care Unit Discharge Disposition. Am Surg 2019. [DOI: 10.1177/000313481908500828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Older adults account for an increasing percentage of trauma patients and have worse outcomes when compared with younger populations. Simple prediction tools are needed to designate risk categories among these patients. The Geriatric Trauma Screening Tool (GTST) was developed to risk stratify older adults admitted to the ICU at a Level 1 trauma center. One hundred fifty patients aged ≥ 65 years were prospectively screened for high-risk (HR) injuries, comorbidities, and pre-hospital function using the GTST. Patients who screened for HR were more likely to have an unfavorable disposition than non-HR patients. HR patients had significantly longer ICU and hospital length of stays when compared with non-HR patients. In addition, patients with prior functional impairment were at higher risk for an unfavorable discharge disposition than their counterparts. Implementation of the GTST predicted discharge disposition in geriatric trauma patients admitted to the ICU. Pre-injury functional status was a better predictor of discharge disposition than either the types of HR injuries or the presence of comorbidities. Risk stratification of geriatric trauma patients allows for early engagement of patients and caregivers regarding transitions of care as well as more efficient utilization of hospital resources.
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Affiliation(s)
| | - Amy B. Christie
- Department of Critical Care, Medical Center Navicent Health, Macon, Georgia
| | - Hamza H. Awad
- Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Erika J. Sigman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | | | - Richard J. Ackermann
- Division of Geriatrics, Department of Family Medicine, Medical Center Navicent Health, Macon, Georgia
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Kizhakke Veetil D, Kumar V, Khajanchi MU, Warnberg MG. A multicenter observational cohort study of 24 h and 30 day in-hospital mortality of pediatric and adult trauma patients - An Indian urban tertiary care perspective. J Pediatr Surg 2019; 54:1421-1426. [PMID: 30594307 DOI: 10.1016/j.jpedsurg.2018.10.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 09/19/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE India with its evolving trauma system needs multicenter studies on trauma outcomes to help determine the need for planning and structuring care better and to bridge the gap between the burden of disease and research. Therefore here we studied 24 h and 30 day mortality in adult and pediatric trauma population presenting to urban tertiary care hospitals. METHODOLOGY Data from multicenter observational cohort study conducted from July 2013 to December 2015, Towards improved trauma care outcomes in India (TITCO) were used. MAIN FINDINGS 3381 pediatric and 12,666 adult trauma patients. Unadjusted analyses of mortality were significantly less in pediatric compared to adult group within 24 h (OR 0.513, 99% CI 0.4-0.658, p < 0.001) and 30 days (OR 0.442, 99% CI 0.383-0.511, p < 0.001). In adjusted analyses pediatric group did not have significantly lower odds of 24-h mortality (OR 0.778, 99% CI 0.106-5.717, P = 0.746). At 30 days, pediatric group had 89% lower odds of death compared to adults (OR 0.11, 99% CI 0.017-0.0714, p = 0.002). CONCLUSION Children had mechanisms of injury different from adults leading to less severe injuries than adults. Children are more likely than adults to survive until 30 days after admission for trauma in urban India. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Monty Uttam Khajanchi
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India.
| | - Martin Gerdin Warnberg
- Global Health: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Sweden.
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Atrial Natriuretic Peptide: A Potential Early Therapy for the Prevention of Multiple Organ Dysfunction Syndrome Following Severe Trauma. Shock 2019; 49:126-130. [PMID: 28727609 DOI: 10.1097/shk.0000000000000947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Trauma remains a tremendous medical burden partly because of increased expenditure for the management of multiple organ dysfunction syndrome (MODS) developed during hospital stay. The intestinal barrier injury continues to be a second insult resulting in MODS which currently lacks efficient strategies for prevention. Recent studies have uncovered multi-organ protective benefits of atrial natriuretic peptide (ANP) in cardiovascular disease. However, the role of ANP in the prevention of MODS following severe trauma has not been understood. In our laboratory study, 1-h infusion of exogenous ANP during hemorrhagic shock following severe trauma induced high-level expression of endogenous serum ANP after 24 h, this effect was related to the improved level of functional biomarkers in multiple organs. Such phenomenon has not been found in other laboratories. A thorough literature review consequently was performed to uncover the potential mechanisms, to appraise therapy safety, and to propose uncertainties. In severe trauma, short-term exogenous ANP therapy during hemorrhagic shock may promote sustained endogenous expression of ANP from intestinal epithelium through activating a positive feedback loop mechanism involving phospholipase C-γ1 and reactive oxygen species crosstalk. This feedback loop may prevent MODS through multiple signaling pathways. Administration of ANP during hemorrhagic shock is thought to be safe. Further studies are required to confirm our proposed mechanisms and to investigate the dose, duration, and timing of ANP therapy in severe trauma.
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Wong TH, Nadkarni NV, Nguyen HV, Lim GH, Matchar DB, Seow DCC, King NKK, Ong MEH. One-year and three-year mortality prediction in adult major blunt trauma survivors: a National Retrospective Cohort Analysis. Scand J Trauma Resusc Emerg Med 2018; 26:28. [PMID: 29669572 PMCID: PMC5907285 DOI: 10.1186/s13049-018-0497-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 04/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Survivors of trauma are at increased risk of dying after discharge. Studies have found that age, head injury, injury severity, falls and co-morbidities predict long-term mortality. The objective of our study was to build a nomogram predictor of 1-year and 3-year mortality for major blunt trauma adult survivors of the index hospitalization. Methods Using data from the Singapore National Trauma Registry, 2011–2013, we analyzed adults aged 18 and over, admitted after blunt injury, with an injury severity score (ISS) of 12 or more, who survived the index hospitalization, linked to death registry data. The study population was randomly divided 60/40 into separate construction and validation datasets, with the model built in the construction dataset, then tested in the validation dataset. Multivariable logistic regression was used to analyze 1-year and 3-year mortality. Results Of the 3414 blunt trauma survivors, 247 (7.2%) died within 1 year, and 551 (16.1%) died within 3 years of injury. Age (OR 1.06, 95% CI 1.05–1.07, p < 0.001), male gender (OR 1.53, 95% CI 1.12–2.10, p < 0.01), low fall from 0.5 m or less (OR 3.48, 95% CI 2.06–5.87, p < 0.001), Charlson comorbidity index of 2 or more (OR 2.26, 95% CI 1.38–3.70, p < 0.01), diabetes (OR 1.31, 95% CI 1.68–2.52, p = 0.04), cancer (OR 1.76, 95% CI 0.94–3.32, p = 0.08), head and neck AIS 3 or more (OR 1.79, 95% CI 1.13–2.84, p = 0.01), length of hospitalization of 30 days or more (OR 1.99, 95% CI 1.02–3.86, p = 0.04) were predictors of 1-year mortality. This model had a c-statistic of 0.85. Similar factors were found significant for the model predictor of 3-year mortality, which had a c-statistic of 0.83. Both models were validated on the second dataset, with an overall accuracy of 0.94 and 0.84 for 1-year and 3-year mortality respectively. Conclusions Adult survivors of major blunt trauma can be risk-stratified at discharge for long-term support.
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Affiliation(s)
- Ting Hway Wong
- Department of General Surgery, Singapore General Hospital / Duke-National University of Singapore Medical School, Outram Road, Singapore, 169608, Republic of Singapore.
| | | | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Canada
| | - Gek Hsiang Lim
- National Registry of Diseases Office, Health Promotion Board, Singapore, Singapore
| | | | - Dennis Chuen Chai Seow
- Department of Geriatric Medicine, Singapore General Hospital / Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Nicolas K K King
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital / Duke-National University of Singapore Medical School, Singapore, Singapore
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Lilley EJ, Scott JW, Weissman JS, Krasnova A, Salim A, Haider AH, Cooper Z. End-of-Life Care in Older Patients After Serious or Severe Traumatic Brain Injury in Low-Mortality Hospitals Compared With All Other Hospitals. JAMA Surg 2018; 153:44-50. [PMID: 28975244 PMCID: PMC5833626 DOI: 10.1001/jamasurg.2017.3148] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/21/2017] [Indexed: 01/19/2023]
Abstract
Importance More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die. Objective To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality. Design, Setting, and Participants A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017. Main Outcomes and Measures End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice. Results Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96). Conclusions and Relevance For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.
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Affiliation(s)
- Elizabeth J. Lilley
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - John W. Scott
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Anna Krasnova
- The Center for Surgery and Public Health, Boston, Massachusetts
| | - Ali Salim
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Adil H. Haider
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Deputy Editor, JAMA Surgery
| | - Zara Cooper
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Eriksson J, Gidlöf A, Eriksson M, Larsson E, Brattström O, Oldner A. Thioredoxin a novel biomarker of post-injury sepsis. Free Radic Biol Med 2017; 104:138-143. [PMID: 28087409 DOI: 10.1016/j.freeradbiomed.2017.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/23/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thioredoxin (TRX), an endogenous anti-oxidant protein induced in inflammatory conditions, has been shown to increase in plasma and to be associated with outcome in septic patients. This biomarker has never been studied in a trauma setting. We hypothesized that TRX would be increased after trauma and associated with post-injury sepsis. METHODS Single-centre prospective observational study conducted at the intensive care unit (ICU) at the Karolinska University Hospital, Stockholm, Sweden, a level-1 trauma centre. Eighty-three severely injured trauma patients, 18 years or older, with an ICU stay of three days or more were included. Plasma samples were obtained on day 1 and 3 after informed consent. Clinical, physiological and outcome data were retrieved from the trauma and ICU research registries. Plasma samples were also obtained from 15 healthy subjects. In addition, a standardized porcine trauma model was conducted where a femur fracture followed by a controlled hemorrhage period were inflicted in four pigs. RESULTS In pigs, however not significant, there was a continuing increase in plasma-TRX after femur fracture and sequential hemorrhage despite near normalisation of cardiac index and lactate levels. In patients, median injury severity score was 29 and 48 patients developed sepsis during their ICU stay. A three-fold increase in initial TRX was seen in trauma patients when compared to healthy volunteers. Thioredoxin was significantly higher in patients in shock on admission, those subject to massive transfusion and in the most severely injured patients. No difference was seen between survivors and non-survivors. Plasma-TRX on day 1 was significantly increased in patients who later developed post-injury sepsis. In a logistic regression analysis including TRX, C-reactive protein, injury severity, massive transfusion, and admission blood pressure, TRX was the only variable independently associated with post-injury sepsis. CONCLUSIONS This study demonstrates that TRX is released into plasma in response to severe trauma and independently associated with post-injury sepsis. The use of TRX as a biomarker in trauma patients needs further evaluation in larger studies. LEVEL OF EVIDENCE Retrospective cohort study, level III.
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Affiliation(s)
- Jesper Eriksson
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Andreas Gidlöf
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Mikael Eriksson
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Emma Larsson
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Olof Brattström
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Anders Oldner
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
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Computed tomography abbreviated assessment of sarcopenia following trauma: The CAAST measurement predicts 6-month mortality in older adult trauma patients. J Trauma Acute Care Surg 2016; 80:805-11. [PMID: 26885997 DOI: 10.1097/ta.0000000000000989] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Older adult trauma patients are at increased risk of poor outcome, both immediately after injury and beyond hospital discharge. Identifying patients early in the hospital stay who are at increased risk of death after discharge can be challenging. METHODS Retrospective analysis was performed using our trauma registry linked with the social security death index from 2010 to 2014. Age was categorized as 18 to 64 and 65 years or older. We calculated mortality rates by age category then selected elderly patients with mechanism of injury being a fall for further analysis. Computed Tomography Abbreviated Assessment of Sarcopenia for Trauma (CAAST) was obtained by measuring psoas muscle cross-sectional area adjusted for height and weight. Kaplan-Meier survival analysis was performed, and proportional hazards regression modeling was used to determine independent risk factors for in-hospital and out-of-hospital mortality. RESULTS A total of 23,622 patients were analyzed (16,748, aged 18-64 years; and 6,874, aged 65 or older). In-hospital mortality was 1.96% for ages 18 to 64 and 7.19% for age 65 or older (p < 0.001); postdischarge 6-month mortality was 1.1% for ages 18 to 64 and 12.86% for age 65 or older (p < 0.001). Predictors of in-hospital and postdischarge mortality for ages 18 to 64 and in-hospital mortality for ages 65 or older group included injury characteristics such as ISS, admission vitals, and head injury. Predictors of postdischarge mortality for age 65or older included skilled nursing before admission, disposition, and mechanism of injury being a fall. A total of 57.5% (n = 256) of older patients who sustained a fall met criteria for sarcopenia. Sarcopenia was the strongest predictor of out-of-hospital mortality in this cohort with a hazard ratio of 4.77 (95% confidence interval, 2.71-8.40; p < 0.001). CONCLUSION Out of hospital does not assure out of danger for the elderly. Sarcopenia is a strong predictor of 6-month postdischarge mortality for older adults. The CAAST measurement is an efficient and inexpensive measure that can allow clinicians to target older trauma patients at risk of poor outcome for early intervention and/or palliative care services. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Callcut RA, Wakam G, Conroy AS, Kornblith LZ, Howard BM, Campion EM, Nelson MF, Mell MW, Cohen MJ. Discovering the truth about life after discharge: Long-term trauma-related mortality. J Trauma Acute Care Surg 2016; 80:210-7. [PMID: 26606176 PMCID: PMC4731245 DOI: 10.1097/ta.0000000000000930] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Outcome after traumatic injury has typically been limited to the determination at time of discharge or brief follow-up. This study investigates the natural history of long-term survival after trauma. METHODS All highest-level activation patients prospectively enrolled in an ongoing cohort study from 2005 to 2012 were selected. To allow for long-term follow-up, patients had to be enrolled at least 1 year before the latest available data from the National Death Index (NDI, 2013). Time and cause of mortality was determined based on death certificates. Survival status was determined by the latest date of either care in our institution or NDI query. Kaplan-Meier curves were created stratified for Injury Severity Score (ISS). Survival was compared with estimated actuarial survival based on age, sex, and race. RESULTS A total of 908 highest-level activation patients (median ISS, 18) were followed up for a median 1.7 years (interquartile range 1.0-2.9; maximum, 9.8 years). Survival data were available on 99.8%. Overall survival was 73% (663 of 908). For those with at least 2-year follow-up, survival was only 62% (317 of 509). Severity of injury predicted long-term survival (p < 0.0001) with those having ISS of 25 or greater with the poorest outcome (57% survival at 5 years). For all ISS groups, survival was worse than predicted actuarial survival (p < 0.001). When excluding early deaths (≤30 days), observed survival was still significantly lower than estimated actuarial survival (p < 0.002). Eighteen percent (44 of 245 deaths) of all deaths occurred after 30 days. Among late deaths, 53% occurred between 31 days and 1 year after trauma. Trauma-related mortality was the leading cause of postdischarge death, accounting for 43% of the late deaths. CONCLUSION Postdischarge deaths represent a significant percentage of total trauma-related mortality. Despite having "survived" to leave the hospital, long-term survival was worse than predicted actuarial survival, suggesting that the mortality from injury does not end at "successful" hospital discharge. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Rachael A. Callcut
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Glenn Wakam
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Amanda S. Conroy
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Benjamin M. Howard
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Eric M. Campion
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Mary F. Nelson
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Matthew W. Mell
- Department of Surgery, Stanford University, Stanford, California
| | - Mitchell J. Cohen
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
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