Sex-based differences in transfusion need after severe injury: Findings of the PROPPR study

EFFECT OF GENDER ON 28-DAY SURVIVAL RATES AND TRANSFUSION VOLUME IN SEVERE TRAUMA PATIENTS: A MULTICENTER OBSERVATIONAL STUDY

ABSTRACT

Background: This study clarified the relationship between sex with survival and transfusion volume in severe trauma cases. Methods: A multicenter, collaborative post hoc analysis of patients with trauma in Japan was conducted. Patients aged ≥18 years with severe trauma indicated by an Injury Severity Score (ISS) of 16 or higher were enrolled. Patients were matched and analyzed by gender based on propensity score with factors determined at the time of injury. Subgroup analysis was performed on patients younger than 50 years and older than 50 years. The significance level was defined as P < 0.05. Results: The 1,189 patients included in this registry were divided into adjusted groups of 226 male and female patients each. In the main analysis, 28-day survival rates in females were significantly higher than those in males ( P = 0.046). In the subgroup analyses, there was no statistically significant prognostic effect of gender. Secondary outcomes, including transfusion volume, showed no significant gender-based variations. Logistic regression analyses consistently demonstrated that female sex was a significant favorable prognostic factor in all ages. This was true for the over-50 group on subgroup analysis, but no significant gender-prognosis relationship was identified in the under-50 age group. High ISSs were associated with poorer outcomes across all age groups. Conclusion: In severe trauma, survival at 28 days was significantly lower in males. However, this trend was not observed in patients aged <50 years. Factors other than sex hormones may be responsible for differences in posttraumatic outcomes by gender.

Patient sex and outcomes in children with life-threatening hemorrhage

BACKGROUND

Recent data suggest female sex imparts a survival benefit after trauma in adults. The independent associations between patient sex and age with outcomes have not been examined in children with life-threatening hemorrhage (LTH) from all etiologies.

STUDY DESIGN AND METHODS

In a secondary analysis of a multicenter prospective observational study of children with LTH, Massive Transfusion in Children (MATIC), we analyzed if patient sex and age were associated with differences in severity of illness, therapies, and outcomes. Primary outcomes were 24 hour mortality and weight-adjusted transfusion volume during LTH. Kruskal-Wallis, chi-square testing, and multivariable linear regression were used for adjusted analyses.

RESULTS

Of 449 children, 45% were females and 55% were males. Females were more commonly younger, white, and with less trauma as the etiology of LTH compared to males. Markers of clinical severity were similar between groups, except injury severity score (ISS) was higher in females in the trauma subgroup. In terms of resuscitative practices, females received greater weight-adjusted total transfusion volumes compared to males (76 (40-150) mL/kg vs. 53 (24-100) mL/kg), as well as increased red blood cells (RBCs), plasma, and platelets compared to males. After adjustment for confounders, female sex and age 0-11 years were independently associated with increased transfusion volume during LTH. There were no differences in mortality or adverse outcomes according to patient sex.

CONCLUSION

Patient sex and age may impact factors associated with LTH and therapies received. Studies in developmental hemostasis are needed to determine the optimal transfusion strategy for LTH according to patient sex and age.

Sex dimorphisms in coagulation: Implications in trauma-induced coagulopathy and trauma resuscitation

Trauma-induced coagulopathy (TIC) is one of the leading causes of preventable death in injured patients. Consequently, it is imperative to understand the mechanisms underlying TIC and how to mitigate this mortality. An opportunity for advancement stems from the awareness that coagulation demonstrates a strong sex-dependent effect. Females exhibit a relative hypercoagulability compared to males, which persists after injury and confers improved outcomes. The mechanisms underlying sex dimorphisms in coagulation and its protective effect after injury have yet to be elucidated. This review explores sex dimorphisms in enzymatic hemostasis, fibrinogen, platelets, and fibrinolysis, with implications for resuscitation of patients with TIC.

Gender specific data in patients with acute appendicitis: a single center perspective

BACKGROUND

The influence of sex, socioeconomic status, and other factors on outcomes from acute illness has been found recently with an increasing interest; acute appendicitis is the most frequent urgency in pediatric age. The aim of this study was to show any gender differences.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis. Inclusion and exclusion criteria were created. Patient data, demographics, characteristics, and outcomes were studied and evaluated on a gender perspective.

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 364 patients were studied; focusing on final outcomes, it was possible to add news from a gender perspective of appendicitis: gangrenous appendicitis was associated with younger female and older female were more likely to have false positive appendicitis; female had less postoperative pain respect to age-match male for all appendicitis and males had more symptoms respect to females especially for phlegmonous and gangrenous appendicitis.

CONCLUSIONS

There is a gender difference in appendicitis; as for adult girls appear to be affected less, have fewer symptoms, and have better postoperative results.

Sex Dimorphism in Outcome of Trauma Patients Presenting with Severe Shock: A Multicenter Cohort Study

Background: The objective of this study was to determine the association between sex and outcome among severely injured patients who were admitted in severe shock. Methods: A retrospective multicenter study was performed in trauma patients (Injury Severity Score (ISS) ≥ 16) aged ≥ 16 presenting with severe shock (Shock Index > 1.3) over a 4-year period. To determine if sex was associated with mortality, Intensive Care Unit (ICU) admission, mechanical ventilation, blood transfusion and in-hospital complications, multivariable logistic regressions were performed. Results: In total, 189 patients were admitted to the Emergency Department in severe shock. Multivariable logistic regression analysis showed that female sex was independently associated with a decreased likelihood of acute kidney injury (OR 0.184; 95% CI 0.041-0.823; p = 0.041) compared to the male sex. A significant association between female sex and mortality, ICU admission, mechanical ventilation, other complications and packed red blood cells transfusion after admission could not be confirmed. Conclusion: Female trauma patients in severe shock were significantly less likely to develop AKI during hospital stay. These results could suggest that female trauma patients may manifest a better-preserved physiologic response to severe shock when compared to their male counterparts. Prospective studies with a larger study population are warranted.

Characterization of Combined Blast- and Fragment-Induced Pelvic Injuries and Hemostatic Resuscitation in Rabbits

INTRODUCTION

To establish a blast- and fragment-induced pelvic injury animal model in rabbits, observe its injury characteristics, and explore the effects of hemostatic resuscitation combined with damage control surgery (DCS) with respect to this injury model.

METHODS

Forty-eight rabbits were randomly allocated to four groups: group A rabbits were subjected to pelvic injury, group B rabbits to pelvic injury + DCS, group C rabbits to pelvic injury + DCS + resuscitation with Hextend, and group D rabbits to pelvic injury + DCS + Hextend + hemostatic resuscitation with tranexamic acid, fibrinogen concentrate, and prothrombin complex concentrate. Simulated blast and fragment-induced pelvic injury was produced by a custom-made machine. We implemented CT scanning and necropsy to assess the injury state and calculated the coefficient of variation (CV) of the cumulative abbreviated injury scale (AIS) to assess the reproducibility of the animal model. Immediately after instrumentation (0 h), and 1 h, 2 h, 4 h, and 8 h after injury, blood samples were taken for laboratory tests.

RESULTS

We found that severe pelvic injury was produced with an AIS CV value of 10.32%, and the rabbits demonstrated severe physiologic impairment and coagulo-fibrinolytic derangements with high mortality. In rabbits of group D, however, physiologic and coagulo-fibrinolytic parameters were significantly enhanced with improved organ function and lowered mortality when compared with the other three groups.

CONCLUSIONS

We herein established in rabbits a blast- and fragment-induced pelvic injury animal model that exhibited high reproducibility, and we demonstrated that hemostatic resuscitation plus DCS was effective in improving the outcome.

Sex discrimination after injury: is inequity in tranexamic acid administration just the tip of the iceberg?

There is emerging evidence of inequalities in healthcare provision between women and men. Trauma care is no exception with a number of studies indicating lower levels of prioritisation for injured female patients. The antifibrinolytic drug tranexamic acid, reduced trauma deaths to a similar extent in females and males in the international Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) randomised controlled trials, but in real-world practice, national registry data shows females are less likely to receive tranexamic acid than males. Inequity in the provision of tranexamic acid may extend beyond sex (and gender), and further study is required to examine the effect of age and mechanism of injury differences between men and women in the decision to treat.

Thromboelastography-Based Evaluation of Gender-Associated Hypercoagulability

BACKGROUND

Age, race, and gender differences in coagulation status of healthy volunteers have been reported in previous case series; however, rigorous multivariate analysis adjusting for these factors is lacking. We aimed to investigate the effects of age, race, and gender on baseline coagulation status in healthy volunteers.

METHODS

Thirty healthy volunteer controls with no history of bleeding or thrombotic events and no previous anticoagulant or antiplatelet use were recruited. Citrated and heparinized blood samples were drawn, and kaolin and platelet-mapping thromboelastography (TEG) assays performed.

RESULTS

Thirty participants had a mean age of 37, mean body mass index of 29 kg/m², and were 47% African-American and 70% female. Women were significantly older than men (40 ± 11 y vs 28 ± 7 y, P = .002); there were no significant differences in demographics by race. Multivariate analysis of variance for the effect of age, race, and gender across TEG parameters yielded evidence for gender differences in hypercoagulability (Pillai's trace P = .02), which appear to be driven by differences in K-time, alpha angle, maximal amplitude, and G parameter. Women were hypercoagulable compared to men, as manifested by shorter K-time, steeper alpha angle, higher maximal amplitude, and larger G parameter.

DISCUSSION

Women at baseline have relatively hypercoagulable fibrin deposition kinetics, platelet contributions to clot formation, and overall clot strength compared to men, even when adjusted for age and race. Additional research is needed to specifically detail the key patient-level factors, clinical implications, and opportunities for tailored therapy related to gender-associated hypercoagulability.

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage

BACKGROUND

Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage.

METHODS

A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses.

RESULTS

A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, P = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, P = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, P < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, P < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, P = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, P < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group (P > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, P = .48).

CONCLUSIONS

Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.

Quarantine and Appendicitis: A Macro-Area Experience

PURPOSE

Appendicitis is the most frequent urgency in pediatric age; the aim of this study was to investigate the association of quarantine for severe acute respiratory syndrome coronavirus 2 pandemic and the incidence of pediatric appendicitis in a specific macro area.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis in the period March-April since 2014. This specific quarantine period was divided into two phases as indicated by National government. Patient data, demographics, characteristics and outcomes were studied and evaluated comparing patients treated during quarantine especially phase 1 vs. phase 2 (March-April 2020).

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 155 patients were studied; focusing on the final outcome, it is possible to show a decreased amount of appendicitis during phase 1 and a progressive increase during phase 2; respect to previous years, there was a statistical increase in severity of appendicitis during quarantine (gangrenous vs. phlegmonous appendicitis).

CONCLUSION

During this specific quarantine there was a reduction in appendicitis and a progressive increase during phase 2. These results offer new perspective among disease incidences during lockdown.

The protective role of estrogen on endothelial and glycocalyx barriers after shock conditions: A microfluidic study

BACKGROUND

Sexual dimorphism has been demonstrated after major trauma and hemorrhage shock with protective effects related to female sex or estrogen. Traumatic endotheliopathy is an important component of trauma-induced coagulopathy. Components of endothelial barrier dysfunction include degradation of the endothelial glycocalyx and endothelial cellular injury. Estrogen modulates endothelial function via its membrane and cellular receptors. The effects of estrogen on the vascular endothelial barrier after trauma and hemorrhage shock are, however, unknown. This topic was studied in an in vitro model under flow conditions.

METHODS

Monolayers of human umbilical vein endothelial cells were established in microfluidic flow devices. After overnight perfusion, cell monolayers were subjected to normoxic or hypoxic perfusion and then treated with either estrogen (as estradiol), testosterone (as dihydrotestosterone), or media alone. Endothelial activation/injury was indexed by soluble thrombomodulin and glycocalyx degradation by syndecan-1 and hyaluronic acid shedding as well as measurement of the thickness of the glycocalyx layer. The coagulation phenotype of the human umbilical vein endothelial cells was indexed by the relative values of the activities of tissue plasminogen activator and plasminogen activator inhibitor-1. Vascular endothelial growth factor was measured in cell culture supernatants using a solid-phase enzyme-linked immunosorbent assay.

RESULTS

Treatment with estrogen but not testosterone mitigated the adverse effect of shock on endothelial and glycocalyx barrier properties. Our biomimetic model suggests a beneficial effect of estrogen administration after trauma and hemorrhage shock on the glycocalyx and endothelial barriers.

CONCLUSION

Early estrogen treatment after trauma and hemorrhage shock may be a useful adjunct to mitigating the development of traumatic endotheliopathy.

Sex- and Gender-Related Factors in Blood Product Transfusions

Blood products are indicated for a plethora of conditions in several settings, with a variety of products available for transfusion, from highly processed specific components to whole blood. Matching the donor product to the recipient is crucial in avoiding serious transfusion reactions, with the extent of matching depending on the physiological need, setting, and product. There are important factors related to sex and gender differences in donated blood products, adverse reactions to those products, interplay with underlying pathology, as well as sociocultural differences in the collection. This article will review key sex- and gender-specific research related to the use of blood products with an emphasis on the acute care setting.