A statewide population-based study of gender differences in trauma: validation of a prior single-institution study

Sex-Specific Factors Affecting Quality of Life After Major Trauma: Results of a Prospective Multicenter Registry-Based Cohort Study

Background: Major trauma is a leading cause of severe disability and mortality. The influence of patient sex on outcome after severe trauma is a topic of ongoing discussion. We present a prospective multicenter study on the effects of trauma severity on health-related quality of life (HRQoL) of female patients. We hypothesized that the impairment of HRQoL after major trauma between the sexes depends not only on sex itself but also on age. Methods: This multicenter prospective registry-based observational study compared sex-based differences in HRQoL of patients who sustained major trauma Injury Severity Score (ISS ≥ 16). The HRQoL was assessed using the EQ-5D-3L (European Quality of Life 5-Dimension 3-Level Version) score over 2 years post-trauma. Results: We included 416 patients (116 female/300 male) with an ISS > 16 (median ISS 22 IQR 18/30). All patients had a lower HRQoL after trauma than the population norm. Increased AIS (Abbreviated Injury Scale) face and extremity scores and ASA (American Society of Anesthesiologists) scores showed a significant decrease in HRQoL. Even though the groups of female and male patients were comparable in injury severity, female patients reported significantly more problems on the anxiety and depression scales than male patients 6 months (p = 0.003) and 24 months (p = 0.044) after trauma (6 months: female 46% vs. male 30%; 24 months: female 44% vs. male 32%). We observed the greatest improvement in the EQ Index over time in patients between 16 and 39 years of age, especially female patients (0.78 to 0.87 in females under 39 years of age, compared to males in the same age group 0.76 to 0.81). Females over 65 years of age initially presented the lowest EQ Index of 0.62. It remained significantly lower over time and was lower compared to male patients of the same age group (female EQ Index after 24 months was 0.68 compared to men over the age of 65 who presented an EQ Index of 0.75). Conclusions: All patients included in this study presented a lower HRQoL after trauma than the population norm. Female patients under 39 years of age reported the most improvement. Females over 65 years of age showed a limited HRQoL, which remained significantly lower over time. Female patients reported significantly more anxiety and depression after major trauma than male patients. Thus, further development and methodologically rigorous testing of ortho-geriatric initiatives, psychosocial support, and prevention measures are required to improve the care after major trauma, particularly for the female elderly.

Predictors of sepsis in trauma patients: a National Trauma Data Bank analysis

Background

Trauma remains a global health issue being one of the leading causes of death worldwide. Sepsis and infections are common complications contributing to mortality, emphasizing the need to understand factors leading to such complications following trauma.

Aim

This study aimed to identify risk factors associated with post-trauma sepsis using data from the National Trauma Data Bank (NTDB).

Methods

Using the 2017 National Trauma Data Bank (NTDB), this is a retrospective case-control study that looked at pre-hospital and in-hospital patient data. Trauma patients aged over 15 years presenting to the emergency department (ED) and admitted to a tertiary care center were included. The primary outcome assessed was the development of sepsis post-trauma. Logistic regression analysis was used to identify risk factors, considering patient demographics, injury characteristics, and clinical variables.

Results

Among 997,970 trauma patients in the 2017 NTDB, 296,974 were excluded, leaving 700,996 patients for analysis, with 2,297 developing sepsis. Patients who developed sepsis were older than those who did not develop sepsis (mean age 57.57 vs. 53.42 years, p-value<0.001) and predominantly white males. Risk factors associated with sepsis development included: respiratory intubation with mechanical ventilation (OR = 11.99; 95% CI = 10.66-13.48), blood transfusion administration (OR = 2.03; 95% CI = 1.83-2.25), Injury Severity Score (ISS) ≥ 16 (OR = 1.69; 95% CI = 1.51-1.89), chronic obstructive pulmonary disease (COPD) (OR = 1.65; 95% CI = 1.44-1.89), diabetes mellitus (DM) (OR = 1.41; 95% CI = 1.26-1.58), male sex (OR = 1.42; 95% CI = 1.28-1.57), hypertension (HTN) (OR = 1.30; 95% CI = 1.16-1.45), anticoagulation therapy (OR = 1.21; 95% CI = 1.05-1.39), older age (OR = 1.02; 95% CI = 1.01-1.02), and current smoking status (OR = 1.18; 95% CI = 1.06-1.32).

Conclusion

This study identified key risk factors for post-trauma sepsis. Recognition of preexisting conditions and injury severity is crucial in trauma patient management to mitigate septic complications. Early identification of at-risk patients could facilitate timely interventions and potentially reduce mortality rates in trauma care settings.

Platinum Hour: Emergency Department Length of Stay and Trauma Patients' Outcomes

INTRODUCTION

Trauma bay and emergency department (ED) length of stay (LOS) are important time measures in patient care. The data on this subject are inconclusive or specific to one condition. Our goal was to determine the relationship between ED LOS and outcomes or mortality of trauma patients. We sought to investigate certain cofactors which influence this relationship. We hypothesized that ED LOS will be correlated with negative patient outcomes and mortality for moderately and severely injured trauma patients.

METHODS

A retrospective study was conducted from June 2018 to June 2022 at our level 1 Trauma center. Patients ≥18 y that arrived as a trauma activation were included. Patients were excluded if they were transfers in or out, expired before arrival, or were discharged from the ED. Univariate and multivariable statistical analysis based on disposition time were performed. The primary outcome was mortality.

RESULTS

Six thousand seven hundred eighty-one patients met the inclusion criteria. Patients were stratified based on time to disposition ≤60 (n = 521) and >60 min (n = 6260). The ≤60-min group was younger than the >60-min group (53 (interquartile range (IQR) 30-73) versus 68 (IQR 48-82), P < 0.001), and was more often male (69.48% (n = 362) versus 50.32% (n = 3150), P < 0.001). The ≤60-min group had a lower Glasgow Coma Scale (14 (IQR 8-15) versus 15 (IQR 15-15), P < 0.001), a longer intensive care unit LOS (2 (IQR 1-5) versus 1 (IQR 1-3), P < 0.001), a longer hospital LOS (4 (IQR 1-10) versus 3 (IQR 2-6), P < 0.001), and a greater Injury Severity Score (13 (IQR 5-22) versus 5 (IQR 4-10), P < 0.001) compared to the >60-min group. The ≤60-min group was also more likely to receive blood products (39.92% (n = 208) versus 13.15% (n = 823), P < 0.001) compared to the >60-min group. A greater risk of mortality was found in the ≤60-min versus >60-min group (17.47% (n = 91) versus 2.75% (172), P < 0.001). The ≤60-min group had a shorter transport time (14 (IQR 8-21) versus 17 (IQR 11-24), P < 0.001). On multivariable analysis, there was an association between a disposition time of 60 min or less and a decreased risk of mortality. However, men had a greater risk of mortality compared to women. Patients that received blood products and patients with more severe injuries had a higher likelihood of mortality.

CONCLUSIONS

Trauma patients with a decreased ED LOS had a higher rate of mortality, contrary to our hypothesis. The patients with a decreased ED LOS were also more severely injured. It may be reasonable that trauma patients can receive the same level of care regardless of location in the hospital.

The beneficial roles and mechanisms of estrogens in immune health and infection disease

Multiple epidemiologic studies have revealed that gender is considered one of the important factors in the frequency and severity of certain infectious diseases, in which estrogens may play a vital role. There is growing evidence that estrogens as female sex hormone can modulate multiple biological functions outside of the reproductive system, such as in brain and cardiovascular system. However, it is largely unknown about the roles and mechanisms of estrogens/estrogen receptors in immune health and infection disease. Thence, by reading a lot of literature, we summarized the regulatory mechanisms of estrogens/estrogen receptors in immune cells and their roles in certain infectious diseases with gender differences. Therefore, estrogens may have therapeutic potentials to prevent and treat these infectious diseases, which needs further clinical investigation.

Traumatic injuries to the renal blood vessels and in-hospital renal complications in patients with penetrating or blunt trauma

Background

Traumatic injuries to renal blood vessels (IRBV) can have significant consequences for patients, impacting their mortality, morbidity, and quality of life.

Objective

This study aimed to compare trauma types and injury characteristics, vital signs, and outcomes in patients with and without IRBV (nIRBV) and examine whether IRBV and pre-existing renal dysfunction affected the likelihood of in-hospital renal complications (iHRC).

Materials and Methods

After identifying penetrating and blunt trauma victims with IRBV in the National Trauma Data Bank, patient demographics, injury-related variables, treatment outcomes, and deaths under care were analyzed and compared.

Results

Of the 994,184 trauma victims, 610 (0.6%) experienced IRBV. Victims in the IRBV group (IRBVG) had a significantly higher frequency of penetrating injuries (19.5% vs. 9.2%, P < 0.001) and higher injury severity score (ISS ≥25, 61.5% vs. 6.7%). Most injuries in both groups were unintentional, although a higher frequency of assault was noted in the IRBVG. The incidence of iHRC was higher in the IRBVG (6.6%) than in the nIRBVG (0.4%; P < 0.001). The IRBV {OR = 3.5 [95% CI = (2.4-5.0)]}, preexisting renal disorders {OR = 2.5 [95% CI = (2.1-2.9)]}, and in-hospital cardiac arrest {OR = 8.6 [95% CI = (7.7-9.5)]} were found to be among the factors associated with a higher risk of iHRC.

Conclusions

IRBV and pre-existing renal disorders considerably increased the risk of developing iHRC. Due to the long- and short-term consequences of associated cardiovascular, renal, and hemodynamic complications, victims of IRBV require specialized renal management and close monitoring.

The impact of gender on clinical outcomes after sustaining a pelvic fracture

INTRODUCTION

In trauma care, pelvic fractures contribute to morbidity and mortality. Since men and women have different pelvic structures and hormonal milieu, we studied if these gender differences affect clinical outcomes after pelvic fractures.

METHODS

Using the 2016 American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) database, we stratified 24,425 patients with pelvic fractures by gender. Male and female patients were analyzed for differences in comorbidities,  mechanism of injury, complications, and other clinical parameters.

RESULTS

Female patients were older (p < 0.001) and had more comorbidities (p < 0.001), such as bleeding disorder, congestive heart failure, chronic obstructive pulmonary disorder, dementia, chronic renal failure, diabetes mellitus, and hypertension. Although female patients were sicker before sustaining pelvic fractures, male patients had higher rates of post-trauma complications (p < 0.001), such as acute kidney injury, deep vein thrombosis, unplanned admission to the intensive care unit (ICU), and unplanned return to the operating room (OR). Multivariate logistic regression further supports this as male gender was independently associated with a 26.1% higher risk of developing at least one complication (p < 0.001), despite having a higher average Injury Severity Score (ISS) (21.91 ± 0.09 versus 20.71 ± 0.11, p < 0.001). Interestingly, male patients also had a longer hospital length of stay than female patients (13.36 ± 0.12 days versus 11.8 ²± 0.14 days, p < 0.001).

CONCLUSION

Even though female patients were older and had more pre-existing comorbidities, male patients developed more complications and had longer hospital stays. Trial registration number Not a clinical trial.

State-of-the-Art Review: Sex Hormone Therapy in Trauma-Hemorrhage

ABSTRACT

Trauma-hemorrhage is the leading cause of prehospital and early in-hospital deaths, while also significantly contributing to the later development of multisystem organ dysfunction/failure and sepsis. Common and advanced resuscitative methods would potentially demonstrate benefits in the prehospital setting; however, they face a variety of barriers to application and implementation. Thus, a dialogue around a novel adjunct has arisen, sex hormone therapy. Proposed candidates include estradiol and its derivatives, metoclopramide hydrochloride/prolactin, dehydroepiandrosterone, and flutamide; with each having demonstrated a range of salutary effects in several animal model studies. Several retrospective analyses have observed a gender-based dimorphism in mortality following trauma-hemorrhage, thus suggesting that estrogens contribute to this pattern. Trauma-hemorrhage animal models have shown estrogens offer protective effects to the cardiovascular, pulmonary, hepatic, gastrointestinal, and immune systems. Additionally, a series of survival studies utilizing 17α-ethinylestradiol-3-sulfate, a potent, water-soluble synthetic estrogen, have demonstrated a significant survival benefit and beneficial effects on cardiovascular function. This review presents the findings of retrospective clinical studies, preclinical animal studies, and discusses how and why 17α-ethinylestradiol-3-sulfate should be considered for investigation within a prospective clinical trial.

An estrogen (17α-ethinyl estradiol-3-sulfate) reduces mortality in a swine model of multiple injuries and hemorrhagic shock

BACKGROUND

Although 17α-ethinyl estradiol-3-sulfate (EES) reduces mortality in animal models of controlled hemorrhage, its role in a clinically relevant injury model is unknown. We assessed the impact of EES in a swine model of multiple injuries and hemorrhage.

METHODS

The study was performed under Good Laboratory Practice, with 30 male uncastrated swine (25-50 kg) subjected to tibial fracture, pulmonary contusion, and 30% controlled hemorrhage for an hour. Animals were randomized to one of five EES doses: 0 (control), 0.3, 1, 3, and 5 mg/kg, administered postinjury. Subjects received no resuscitation and were observed for 6 hours or until death. Survival data were analyzed using Cox-proportional hazard regression. Left ventricular pressure-volume loops were used to derive preload recruitable stroke work as a measure of cardiac inotropy. Immediate postinjury preload recruitable stroke work values were compared with values at 1 hour post-drug administration.

RESULTS

Six-hour survival for the 0, 0.3, 1, 3, and 5 mg/kg groups was 0%, 50%, 33.3%, 16.7%, and 0%, respectively. Following Cox regression, the hazard (95% confidence interval) of death was significantly reduced in the 0.3 (0.22 [0.05-0.93]) and 1 (0.24 [0.06-0.89]) mg/kg groups but not the 3 (0.49 [0.15-1.64]) and 5 (0.46 [0.14-1.47]) mg/kg groups. Mean survival time was significantly extended in the 1 mg/kg group (246 minutes) versus the 0 mg/kg group (96 minutes) (p = 0.04, t test). At 1 hour post-drug administration, inotropy was significantly higher than postinjury values in the 0.3 and 1 mg/kg groups (p = 0.003 and p < 0.001, respectively). Inotropy was unchanged in the 3 and 5 mg/kg groups but significantly depressed in the control (p = 0.022).

CONCLUSION

Administration of EES even in the absence of fluid resuscitation reduces mortality and improves cardiac inotropy in a clinically relevant swine model of multiple injuries and hemorrhage. These findings support the need for a clinical trial in human trauma patients.

Staffing in a Level 1 Trauma Center: Quantifying Capacity for Preparedness

OBJECTIVE

We sought to determine who is involved in the care of a trauma patient.

METHODS

We recorded hospital personnel involved in 24 adult Priority 1 trauma patient admissions for 12 h or until patient demise. Hospital personnel were delineated by professional background and role.

RESULTS

We cataloged 19 males and 5 females with a median age of 50-y-old (interquartile range [IQR], 35.5-67.5). The average number of hospital personnel involved was 79.71 (standard deviation, 17.62; standard error 3.6). A median of 51.2% (IQR, 43.4%-59.8%) of personnel were first involved within hour 1. More personnel were involved in direct versus indirect care (median 54.5 [IQR, 47.5-67.0] vs 25.0 [IQR, 22.0-30.5]; P < 0.0001). Median number of health-care professionals and auxiliary staff were 74.5 (IQR, 63.5-90.5) and 6.0 (IQR, 5.0-7.0), respectively. More personnel were first involved in hospital locations external to the emergency department (median, 53.0 [IQR, 41.5-63.0] vs 27.5 [IQR, 24.0-30.0]; P < 0.0001). No differences existed in total personnel by Injury Severity Score (P = 0.1266), day (P = 0.7270), or time of admission (P = 0.2098).

CONCLUSIONS

A large number of hospital personnel with varying job responsibilities respond to severe trauma. These data may guide hospital staffing and disaster preparedness policies.

Sex differences in long-term outcomes after traumatic injury: A mediation analysis

BACKGROUND

We sought to examine the association and potential mediators between sex and long-term trauma outcomes.

METHODS

Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis.

RESULTS

2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes.

CONCLUSIONS

There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.

Neuroendocrine Modulation of the Immune Response after Trauma and Sepsis: Does It Influence Outcome?

Although the treatment of multiple-injured patients has been improved during the last decades, sepsis and multiple organ failure (MOF) still remain the major cause of death. Following trauma, profound alterations of a large number of physiological systems can be observed that may potentially contribute to the development of sepsis and MOF. This includes alterations of the neuroendocrine and the immune system. A large number of studies focused on posttraumatic changes of the immune system, but the cause of posttraumatic immune disturbance remains to be established. However, an increasing number of data indicate that the bidirectional interaction between the neuroendocrine and the immune system may be an important mechanism involved in the development of sepsis and MOF. The aim of this article is to highlight the current knowledge of the neuroendocrine modulation of the immune system during trauma and sepsis.

The Importance of Sex Differences on Outcome after Major Trauma: Clinical Outcome in Women Versus Men

Purpose: The purpose of this study was to evaluate epidemiological and clinically relevant sex-related differences in polytraumatized patients at a Level 1 Trauma Center. Methods: 646 adult patients (210 females and 436 males) who were classified as polytraumatized (at the point of admission) and treated at our Level I Trauma Center were reviewed and included in this study. Demographic data as well as mechanism of injury, injury severity, injury pattern, frequency of preclinical intubation, hemodynamic variables on admission, time of mechanical ventilation and of intensive care unit (ICU) treatment, as well as the incidence of acute respiratory distress syndrome (ARDS), multi organ failure (MOF), and mortality were extracted and analyzed. Results: A total of 210 female and 436 male patients formed the basis of this report. Females showed a higher mean age (44.6 vs. 38.3 years; p < 0.0001) than their male counterparts. Women were more likely to be injured as passengers or by suicidal falls whereas men were more likely to suffer trauma as motorcyclists. Following ICU treatment, female patients resided significantly longer at the casualty ward than men (27.1 days vs. 20.4 days, p = 0.013) although there was no significant difference regarding injury severity, hemodynamic variables on admission, and incidence of MOF, ARDS, and mortality. Conclusion: The positive correlation of higher age and longer in-hospital stay in female trauma victims seems to show women at risk for a prolonged in-hospital rehabilitation time. A better understanding of the impact of major trauma in women (but also men) will be an important component of efforts to improve trauma care and long-term outcome.

The role of sociodemographics in the occurrence of orthopaedic trauma

INTRODUCTION

We sought to determine the effects of sociodemographic factors on the occurrence of orthopaedic injuries in an adult population presenting to a level 1 trauma center.

MATERIALS AND METHODS

We conducted a retrospective chart review of patients who received orthopaedic trauma care at a level 1 academic trauma center.

RESULTS

20,919 orthopaedic trauma injury cases were treated at an academic level 1 trauma center between 01 January 1993 and 27 August 2017. Following application of inclusion/exclusion criteria, a total of 14,654 patients were retrieved for analysis. Out of 14,654 patients, 4602 (31.4%) belonged to low socioeconomic status (SES), 4961 (32.0%) to middle SES and 5361 (36.6%) to high SES. Following adjustment for age, sex, race, insurance status and injury severity score (ISS), patients belonging to middle SES vs. low SES (OR 0.77 [95% CI 0.63-0.94]; p = 0.009) or high SES vs. low SES (OR 0.77 [95% CI 0.62-0.95]; p = 0.016) had lower odds of receiving a penetrating injury as compared to a blunt injury.

CONCLUSION

The results from this study indicate that a link exists between sociodemographic factors and the occurrence of orthopaedic injuries presenting to a level 1 trauma center. The most common cause of injury varied within age groups, by sex, and within the different socioeconomic groups.

Among Trauma Patients, Younger Men with Ventilator-Associated Pneumonia Have Worse Outcomes Compared to Older Men-An Exploratory Study

Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP). Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival. Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, (p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days (p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09). Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.

An Increasing Neutrophil-to-Lymphocyte Ratio Trajectory Predicts Organ Failure in Critically-Ill Male Trauma Patients. An Exploratory Study

Background: Although the association of neutrophil proportions with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. We sought to investigate the association of neutrophil proportions with organ failure in critically-ill trauma patients. Methods: We reviewed a randomly-selected group of trauma patients admitted to our level-1 trauma intensive care unit between July 2007 and December 2016. Data collected included demographics, injury mechanism and severity (ISS), neutrophil-to-lymphocyte ratio (NLR) at admission and at 24 and 48 hours and organ failure data. NLR patterns during the first 48 hours were divided into two trajectories identified by applying factor and cluster analysis to longitudinal measures. Logistic regression was performed for the association between NLR trajectories and any organ failure; negative binomial regression was used to model the number of organ failures and stage of kidney failure measured by KDIGO classification. Results: 207 patients had NLR data at all three time points. The average age was 44.9 years with mean ISS of 20.6. Patients were 72% male and 23% had penetrating trauma. The 74 patients (36%) with Trajectory 1 had a mean NLR at admission of 3.6, which increased to 14.7 at 48 hours. The 133 (64%) patients in Trajectory 2 had a mean NLR at admission of 8.5 which decreased to 6.6 at 48 hours. Mean NLR was different between the two groups at all three time points (all p < 0.01). There was no significant difference in ISS, age or gender between the two trajectory groups. Models adjusted for age, gender and ISS showed that relative to those with trajectory 2, patients with the trajectory 1 were more likely to have organ failure OR 2.96 (1.42⁻6.18; p < 0.01), higher number of organ failures IRR 1.50 (1.13⁻2.00, p < 0.01), and degree of AKI IRR 2.06 (1.04⁻4.06, p = 0.04). In all cases, the estimated associations were higher among men vs. women, and all were significant among men, but not women. Conclusions: Trauma patients with an increasing NLR trajectory over the first 48 hours had increased risk, number and severity of organ failures. Further research should focus on the mechanisms behind this difference in outcome.

Gender Disparities in Trauma Care: How Sex Determines Treatment, Behavior, and Outcome

Trauma data bank and other research reveal sex disparities in trauma care. Risk-taking behaviors leading to traumatic injury have been associated with sex, menstrual cycle timing, and cortisol levels. Trauma patient treatment stratified by sex reveals differences in access to services at trauma centers as well as specific treatments, such as venous thromboembolism prophylaxis and massive transfusion component ratios. Trauma patient outcomes, such as in-hospital mortality, multiple organ failure, pneumonia, and sepsis are associated with sex disparities in the general trauma patient. Outcome after general trauma and specifically traumatic brain injury show mixed results with respect to sex disparity.

Sexual dimorphism in bacterial infections

Background

Sex differences are important epidemiological factors that impact in the frequency and severity of infectious diseases. A clear sexual dimorphism in bacterial infections has been reported in both humans and animal models. Nevertheless, the molecular mechanisms involved in this gender bias are just starting to be elucidated. In the present article, we aim to review the available data in the literature that report bacterial infections presenting a clear sexual dimorphism, without considering behavioral and social factors.

Main body

The sexual dimorphism in bacterial infections has been mainly attributed to the differential levels of sex hormones between males and females, as well as to genetic factors. In general, males are more susceptible to gastrointestinal and respiratory bacterial diseases and sepsis, while females are more susceptible to genitourinary tract bacterial infections. However, these incidences depend on the population evaluated, animal model and the bacterial species. Female protection against bacterial infections and the associated complications is assumed to be due to the pro-inflammatory effect of estradiol, while male susceptibility to those infections is associated with the testosterone-mediated immune suppression, probably via their specific receptors. Recent studies indicate that the protective effect of estradiol depends on the estrogen receptor subtype and the specific tissue compartment involved in the bacterial insult, suggesting that tissue-specific expression of particular sex steroid receptors contributes to the susceptibility to bacterial infections. Furthermore, this gender bias also depends on the effects of sex hormones on specific bacterial species. Finally, since a large number of genes related to immune functions are located on the X chromosome, X-linked mosaicism confers a highly polymorphic gene expression program that allows women to respond with a more expanded immune repertoire as compared with men.

Conclusion

Notwithstanding there is increasing evidence that confirms the sexual dimorphism in certain bacterial infections and the molecular mechanisms associated, further studies are required to clarify conflicting data and to determine the role of specific hormone receptors involved in the gender bias of bacterial infections, as well as their potential as therapeutic targets.

Effects of Estrogen on Bacterial Clearance and Neutrophil Response After Combined Burn Injury and Wound Infection

Females have a higher rate of mortality following burn injury, largely due to differences in sepsis-related mortality. The present study seeks to understand the underpinnings of the estrogen's immunomodulatory effects in a murine model of burn injury and infection. Gonad-intact and ovariectomized female mice were subjected to a 15% total BSA scald injury and then inoculated with 3000 CFU of Pseudomonas aeruginosa by topical application to the wound. Animals were killed at 1, 2, or 7 days after injury. Tissue and whole blood were collected. Cultures were performed of all tissues to assess for bacteria content. Lungs were examined for histologic appearance and homogenates were analyzed for chemokines and myeloperoxidase activity. Mortality reached 95% by 3 days after injury for gonad intact mice, whereas in ovariectomized mice it was 76% at 7 days. Blood and tissue samples from gonad intact mice had significantly higher levels of P. aeruginosa compared with ovariectomized mice. Histologic assessment of lungs demonstrated a similar overall cellularity in ovariectomized mice relative to gonad intact mice 1 day after injury, but increased neutrophil count in gonad intact mice. This correlated with chemotactic signaling as lung homogenates had lower levels of KC in ovariectomized mice (128.0 ± 19.8 vs 48.3 ± 5.7 pg/mg protein). Also, myeloperoxidase was significantly lower in lung homogenates of ovariectomized mice (1.12 ± 0.34 vs 0.56 ± 0.08 units/mg protein). Ovariectomy confers an early, but brief survival advantage in female mice after burn injury and wound infection. This appears to be secondary to enhanced bacterial clearance.

Impact of Sexual Dimorphism on Trauma Patterns and Clinical Outcomes of Patients with a High-Risk Score of the Osteoporosis Self-Assessment Tool for Asians: A Propensity Score-Matched Analysis

The Osteoporosis Self-assessment Tool for Asians (OSTA) is a validated index based on age and weight to predict the risk of osteoporosis in women. This cross-sectional study was designed to evaluate the impact of sexual dimorphism on the trauma patterns and the clinical outcomes of patients with high-risk OSTA scores. Trauma data of patients with high-risk OSTA scores between 1 January 2009 and 31 December 2015 were retrieved from the trauma registry system of a level I trauma center. A total of 2248 patients including 1585 women and 663 men were included in this study. In-hospital mortality was assessed as the primary outcome in the propensity score-matched analyses of the female and male patients, which were created in a 1:1 ratio under the adjustment of potential confounders, including age, co-morbidity, mechanism and injury-severity score (ISS). Female patients with a high-risk OSTA score had significantly lower mortality rates than their male counterparts. Among the propensity score-matched population, female patients had lower odds of having cerebral contusion and pneumothorax, but higher odds of presenting with radial, ulnar and femoral fractures than male patients. In addition, the female patients still had significantly lower odds of mortality (odds ratio (OR), 0.5; 95% confidence interval (CI), 0.29-0.90; p = 0.019) than the male patients. However, no significant differences were noted in the length of stay (LOS) in hospital, intensive-care unit (ICU) admission, and LOS in the ICU between the sexes. Female patients with high-risk OSTA scores showed different injury patterns and significantly lower mortality rates than their male counterparts, even after controlling for potential confounding factors.

The influence of sex steroid hormones on the response to trauma and burn injury

Trauma and related sequelae result in disturbance of homeostatic mechanisms frequently leading to cellular dysfunction and ultimately organ and system failure. Regardless of the type and severity of injury, gender dimorphism in outcomes following trauma have been reported, with females having lower mortality than males, suggesting that sex steroid hormones (SSH) play an important role in the response of body systems to trauma. In addition, several clinical and experimental studies have demonstrated the effects of SSH on the clinical course and outcomes following injury. Animal studies have reported the ability of SSH to modulate immune, inflammatory, metabolic and organ responses following traumatic injury. This indicates that homeostatic mechanisms, via direct and indirect pathways, can be maintained by SSH at local and systemic levels and hence result in more favourable prognosis. Here, we discuss the role and mechanisms by which SSH modulates the response of the body to injury by maintaining various processes and organ functions. Such properties of sex hormones represent potential novel therapeutic strategies and further our understanding of current therapies used following injury such as oxandrolone in burn-injured patients.

Comparative analysis of gender differences in outcomes after trauma in India and the USA: case for standardised coding of injury mechanisms in trauma registries

Introduction

While females generally have better outcomes than males after traumatic injury, higher mortality has been shown to occur in females after intentional trauma in lower-income countries. However, gender differences in trauma outcomes in different countries have not been previously compared. We conducted a two-country comparative analysis to characterise gender differences in mortality for different mechanisms of injury.

Methods

Two urban trauma databases were analysed from India and the USA for fall, motor vehicle collision (MVC) and assault patients between 2013 and 2015. Coarsened exact matching was used to match the two groups based on gender, age, injury severity score, Glasgow Coma Score and type of injury (blunt vs penetrating). The primary outcome of mortality was studied by using logistic regression to calculate the odds of death in the four country/gender subgroups.

Results

A total of 10 089 and 14 144 patients were included from the Indian and US databases, respectively. After matching on covariates, 7505 and 9448 patients were included in the logistic regression. Indian males had the highest odds of death compared with US males, US females and Indian females for falls, MVC and assaults. Indian females had over 7 times the odds of dying after falls, 5 times the odds of dying for MVC and 40 times the odds of dying after assaults when compared with US females.

Conclusion

The high odds of death for Indian females compared with US females suggests that there are other injury and systemic factors that contribute to this discrepancy in mortality odds. This same mortality pattern and implication is seen for Indian males compared with all subgroups. Standardised coding of injury mechanism in trauma registries, in addition to intentionality of injury, can help further characterise discrepancies in outcomes by gender and country, to guide targeted injury prevention and care.

Do male and female trauma patients receive the same prehospital care?: an observational follow-up study

BACKGROUND

Trauma-related mortality can be lowered by efficient prehospital care. Less is known about whether gender influences the prehospital trauma care provided. The aim of this study was to explore gender-related differences in prehospital trauma care of severely injured trauma patients, with a special focus on triage, transportation, and interventions.

METHODS

We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County, Sweden. A total of 383 trauma patients (279 males and 104 females) > 15 years of age with an Injury Severity Score (ISS) of > 15 transported to emergency care hospitals in the Stockholm area were included.

RESULTS

Male patients had a 2.75 higher odds ratio (95 % CI, 1.2-6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. No significant difference between genders was detected regarding other aspects of the prehospital care provided.

CONCLUSIONS

This study indicated that prehospital prioritization among severely injured late adolescent and adult trauma patients differs between genders. Knowledge of a more diffuse presentation of symptoms in female trauma patients despite severe injury may help to adapt and improve prehospital trauma care for this group.

Gender-Specific Effects on Immune Response and Cardiac Function after Trauma Hemorrhage and Sepsis

Background

Studies in human as well as animal models indicate a gender-specific responsiveness of the immune and organ systems with regard to shock, trauma, and sepsis.

Methods

A literature review was performed.

Results

Cell-mediated immune responses and cardiovascular functions are suppressed in males following trauma hemorrhage, whereas they are maintained or even enhanced in females in the proestrus state of the estrus cycle. Experimental studies have demonstrated that divergent immune responses in males and females following adverse circulatory conditions are mediated by the gender-specific hormones testosterone and estrogen. Several clinical trials, however, failed to demonstrate a significant association of gender and inflammatory response. This may be explained by the heterogeneity of the population in terms of their hormonal status at the time of injury.

Conclusions

With regard to the underlying mechanisms, receptors for sex hormones have been identified on various immune cells, suggesting direct effects of these hormones on immune function. Alternatively, indirect effects of sex steroids such as changes in cardiovascular responses or androgen- and estrogen-synthesizing enzymes might contribute to gender-specific immune responses. Clinical studies suggest that sex hormones, such as dehydroepiandrosterone, modulate the function of peripheral blood mononuclear cells also following abdominal surgery. Thus, sex hormones, receptor antagonists, and sex steroid-synthesizing enzymes might be useful in the future for modulating the complex immune responses after trauma hemorrhage and sepsis.

Association between male sex and increased mortality after falls

OBJECTIVES

Whether sex affects the mortality of trauma patients remains unknown. The hypothesis of this study was that sex was associated with altered mortality rates in trauma.

METHODS

A retrospective review of trauma patients' records in the Japan Trauma Data Bank was conducted (n = 80,813) from 185 major emergency hospitals across Japan. The primary outcome variable was in-hospital mortality within 28 days. Secondary outcome variables included serious injuries to different body regions with an Abbreviated Injury Scale of ≥3.

RESULTS

In the analysis of 80,813 trauma patients, males had significantly greater 28-day mortality compared to females (adjusted p = 0.0072, odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.06 to 1.23) via logistic regression analysis adjusted for age, mechanism, Injury Severity Score, Revised Trauma Score, and potential preexisting risk factors. Of 10 injury categories examined, sex significantly affected in-hospital 28-day mortality rate in falls (adjusted p < 0.0001, OR = 1.34, 95% CI = 1.19 to 1.52). Further analysis of three fall subcategories by falling distance revealed that male patients who fell from ground level had significantly higher 28-day mortality (adjusted p < 0.0001, OR = 1.75, 95% CI = 1.43 to 2.14) and a significantly greater frequency of serious injury to the head, thorax, abdomen, and spine, but a lower frequency of serious injury to the extremities, compared to female patients.

CONCLUSIONS

Compared to female trauma patients, male trauma patients had greater 28-day mortality. In particular, ground-level falls had a significant sex difference in mortality, with serious injury to different body regions. Sex differences appeared to be important for fatalities from ground-level falls.

The influence of sex on outcomes in trauma patients: a meta-analysis

BACKGROUND

This study aims to assess the influence of sex on outcomes among trauma patients, including injury severity, medical resource utility, complications, and mortality.

METHODS

A systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes between male and female injured patients.

RESULTS

Eventually, 19 studies met our inclusion criteria with 100,566 men and 39,762 women. Pooled data revealed that male sex was associated with increased risk of mortality, hospital length of stay, and higher incidence of complications. No difference was detected in injury severity between male and female patients.

CONCLUSION

Evidence of this meta-analysis strongly supports the sex dimorphism in the prognosis of trauma patients and further work should be done to decipher potential mechanism.

Gender-specific issues in traumatic injury and resuscitation: consensus-based recommendations for future research

Traumatic injury remains an unacceptably high contributor to morbidity and mortality rates across the United States. Gender-specific research in trauma and emergency resuscitation has become a rising priority. In concert with the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a consensus-building group consisting of experts in emergency medicine, critical care, traumatology, anesthesiology, and public health convened to generate research recommendations and priority questions to be answered and thus move the field forward. Nominal group technique was used for the consensus-building process and a combination of face-to-face meetings, monthly conference calls, e-mail discussions, and preconference surveys were used to refine the research questions. The resulting research agenda focuses on opportunities to improve patient outcomes by expanding research in sex- and gender-specific emergency care in the field of traumatic injury and resuscitation.

Mortality in cancer patients after a fall-related injury: The impact of cancer spread and type

BACKGROUND

Cancer patients are at an increased risk of dying following an injury, of which among the elderly is predominately caused by falling. In addition, patients with certain types of cancer are more prone to bone injury. However, studies are needed that examine the role of cancer site and metastasis on the relationship between cancer and death following traumatic injury.

METHODS

A total of 4201 cancer patients from 2000 to 2009 in the Illinois Hospital Discharge and Illinois Trauma Registry, and 4201 patients without cancer met eligibility criteria (e.g., fell and were injured; 50-96 years old). A multivariable logistic regression analysis was conducted to assess the relationship between cancer and death following traumatic injury, including models stratified by cancer site and metastasis.

RESULTS

The demographic characteristics, prevalence of comorbid conditions, and injury severity and type did not differ substantially between patients with and without diagnoses for cancer. In the main adjusted model, patients with cancer were more likely to die during the course of hospitalization after a fall than those without cancer (OR=2.58; CI 95%: 1.91-3.49). Patients with metastatic malignancies had a higher risk of in-hospital death than patients without metastasis (adjusted OR=3.59 and OR=2.18, respectively). Patients with diagnoses for all specific cancer sites, except prostate and breast, were also significantly more likely to die.

DISCUSSION

Cancer patients with and without spread over the age of 50 years are more likely to die in-hospital after a fall than elderly patients without cancer. However, this relationship may exist only for patients with specific cancer types.

Efficacy of 17α-ethynylestradiol-3-sulfate for severe hemorrhage in minipigs in the absence of fluid resuscitation

BACKGROUND

Of the potentially survivable US battlefield deaths from 2001 to 2011, 80% to 91% were caused by severe hemorrhage. We subjected minipigs to acute severe blood loss, administered a single dose of 17α-ethynylestradiol-3-sulfate (EE-3-SO4) without resuscitative fluids, and determined survival as well as cardiovascular, biochemical, and physiologic response parameters.

METHODS

Following controlled removal of 60% circulating blood volume over 1 hour, minipigs received EE-3-SO4 at 0, 1, 3, or 5-mg/mL saline per kilogram of body weight in Experiment 1 (n = 25) and 0-, 0.1-, 0.3-, or 1-mg/mL saline per kilogram in Experiment 2 (n = 23). Survival times and response parameters were recorded for the next 6 hours.

RESULTS

Median survival times of the minipigs receiving 1 mg/kg (257 minutes and 360 minutes) were 1.8 times and 5 times those of the control group (140 minutes and 65 minutes) in Experiments 1 and 2, respectively. For both experiments combined, the log-rank p value was 0.0002, and the number of animals alive at 6 hours was 6 (50%) of 12 in the 1-mg/kg groups versus 0 (0%) of 12 in the control groups. Early increases in glucose, lactate, potassium, and phosphate as well as decreases in bicarbonate and mean arterial pressure correlated with shorter survival times.

CONCLUSION

Administration of a single dose of 1-mg/kg EE-3-SO4 in 1-mL/kg of saline following severe hemorrhage increased survival in 60% acutely bled minipigs by 3.5-fold. Slightly elevated blood pressure values, more physiologic values of oxidative phosphorylation parameters, and lower elevations of possible tissue necrosis parameters correlated with longer survival time. These results support the further product development of EE-3-SO4 for the indication of severe hemorrhage when standard resuscitative fluids are not available.

Gender-specific differences in severely injured patients between 2002 and 2011: data analysis with matched-pair analysis

INTRODUCTION

Previous studies reported divergent results concerning the effect of gender on patient outcome after severe injury. Results suggest that women have better outcomes because they have lower rates of sepsis and multi-organ failure. The objective of this analysis was to study gender differences in a Level 1 trauma center in Germany.

METHODS

Patients who were admitted to hospital between 2002 and 2011 with an Injury Severity Score (ISS) ≥16 were included. Data were collected from the Trauma Registry of the German Society for Trauma Surgery and from hospital records. The effects of gender on a variety of parameters were investigated. To eliminate the influence of differences in ISS, an analysis of groups with similar ISS was performed. Also, a matched-pair analysis of 422 patients was performed.

RESULTS

A total of 962 patients met the inclusion criteria. The mortality rate was lower in male patients (25.4% versus 36.59%). Female patients had more severe head injuries, received less fluid volume and had a lower rate of sepsis. Men were more frequently involved in motorcycle accidents and sustained more penetrating trauma. Women were more frequently involved in pedestrian accidents and sustained more falls from under 3 m. The effects of gender were reduced when the data were analyzed by matching ISS. The mortality rate was significantly different in the ISS 26 to 35 group but in mostly all groups, the mortality rate was higher in women. In the matched-pair analysis, the rate of sepsis and the length of the ICU stay were significantly lower in women and the mortality rate showed no significant difference (28.1% for male patients versus 33.01% for female patients). Women died after an average of 5.22 days, and men died after an average of 9.02 days.

CONCLUSIONS

Gender-based differences in patient outcome after severe trauma were observed in this study. Women are more likely to die in the first days after trauma. Upon extended hospital stay, women had a better survival rate because they had a lower rate of sepsis. No significant differences in mortality rate could be found, but there was a trend towards a higher rate in female patients.

Gender differences in sepsis: cardiovascular and immunological aspects

During sepsis, a complex network of cytokine, immune, and endothelial cell interactions occur and disturbances in the microcirculation cause organ dysfunction or even failure leading to high mortality in those patients. In this respect, numerous experimental and clinical studies indicate sex-specific differences in infectious diseases and sepsis.

Female gender has been demonstrated to be protective under such conditions, whereas male gender may be deleterious due to a diminished cell-mediated immune response and cardiovascular functions. Male sex hormones, i.e., androgens, have been shown to be suppressive on cell-mediated immune responses. In contrast, female sex hormones exhibit protective effects which may contribute to the natural advantages of females under septic conditions. Thus, the hormonal status has to be considered when treating septic patients.

Therefore, potential therapies could be derived from this knowledge. In this respect, administration of female sex hormones (estrogens and their precursors) may exert beneficial effects. Alternatively, blockade of male sex hormone receptors could result in maintained immune responses under adverse circulatory conditions. Finally, administration of agents that influence enzymes synthesizing female sex hormones which attenuate the levels of pro-inflammatory agents might exert salutary effects in septic patients. Prospective patient studies are required for transferring those important experimental findings into the clinical arena.

Factors affecting mortality of critical care trauma patients

BACKGROUND

Critically-ill trauma patients have a high mortality.

OBJECTIVE

To study the factors affecting the mortality of ICU trauma patients treated at Al-Ain Hospital, United Arab Emirates (UAE).

METHODS

All trauma patients who were admitted to the ICU were prospectively collected over three years (2003-2006). Univariate and multivariate analysis were used to compare patients who died and who did not. Gender, age, nationality, mechanism of injury, systolic blood pressure and GCS on arrival, the need for ventilation, presence of head or chest injuries, AIS for the chest and head injuries and the ISS were studied.

RESULTS

There were 202 patients (181 males). The most common mechanism of injury was road traffic collisions (72.3 %). The overall mortality was 13.9%. A direct logistic regression model has shown that factors that affected mortality were decreased GCS (p < 0.0001), mechanism of injury (p = 0.004) with burns having the highest mortality, increased age (p = 0.004), and increased ISS (p = 0.02). The best GCS that predicted mortality was 5.5 while the best ISS that predicted mortality was 13.5.

CONCLUSION

Road traffic collision is the most common cause of serious trauma in UAE followed by falls. Decreased GCS was the most significant factor that predicted mortality in the ICU trauma patients.

Penetrating trauma in urban women: patterns of injury and violence

BACKGROUND

Penetrating trauma is known to occur with less frequency in women than in men, and this difference has resulted in a lack of characterization of penetrating injury patterns involving women. We hypothesized that the nature of penetrating injury differs significantly by gender and that these injuries in women are associated with important psychosocial and environmental factors.

MATERIALS AND METHODS

A level 1 urban trauma center registry was queried for all patients with penetrating injuries from 2002-2010. Patient and injury variables (demographics and mechanism of injury) were abstracted and compared between genders; additional social and psychiatric histories and perpetrator information were collected from the records of admitted female patients.

RESULTS

Injured women were more likely to be Caucasian, suffer stab wounds instead of gunshot wounds, and present with a higher blood alcohol level than men. Compared with women with gunshot wounds, those with stab wounds were three times more likely to report a psychiatric or intimate partner violence history. Women with self-inflicted injuries had a significantly greater incidence of prior penetrating injury and psychiatric and criminal history. Male perpetrators outnumbered female perpetrators; patients frequently not only knew their perpetrator but also were their intimate partners. Intimate partner violence and random cross-fire incidents each accounted for about a quarter of injuries observed.

CONCLUSIONS

Penetrating injuries in women represent a nonnegligible subset of injuries seen in urban trauma centers. Psychiatric and social risk factors for violence play important roles in these cases, particularly when self-infliction is suspected. Resources allocated for urban violence prevention should proportionately reflect the particular patterns of violence observed in injured women.

Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis

BACKGROUND

Sexual dimorphism in critical diseases has been documented. Severe acute pancreatitis is a disease with high mortality. We hypothesized that admission sex hormone levels may be used as an early predictor of outcome in these patients.

METHODS

A prospective cohort of patients with severe acute pancreatitis admitted to the intensive care unit for at least 48 h were enrolled (n = 62). Serum levels of estradiol, progesterone, and testosterone were determined on admission. The association of sex hormone levels and various disease severity scoring systems with patient outcome was analyzed.

RESULTS

There was no difference in overall mortality between the sexes. However, estradiol was significantly elevated in nonsurvivors (39 vs. 206 pg/mL, p < 0.001). The estradiol level was the best single-variable predictor of mortality (area under the curve 0.97), followed by the sequential organ failure assessment score, the multiple organ dysfunction score, and the acute physiology and chronic health care evaluation II (APACHE II) score. A serum estradiol level of 102 pg/mL was both sensitive and specific to predict mortality. There were no differences between survivors and non-survivors in terms of age, body mass index, or progesterone and testosterone levels.

CONCLUSIONS

Admission serum estradiol level is a good marker of disease severity and predictor of death in patients with severe acute pancreatitis.

Understanding trauma as a men's health issue: sex differences in traumatic injury presentations at a level 1 trauma center in Australia

Predominantly, males have a higher risk of injury mortality and morbidity than females. However, less is known about gender differences for injury and trauma outcome at a regional level. The aim of this study was to examine the epidemiologic profile and trauma outcomes of males and females at a level 1 trauma center to inform local injury prevention efforts. A retrospective review was conducted of injuries identified from the trauma registry of the New South Wales St George Public Hospital during January 1, 2004, to December 31, 2008. There were 6763 major trauma presentations, and 65.1% of these were of males. Males had a higher proportion of trauma presentations in each age group, except for those younger than 15 years, 45 to 54 years, and older than 65 years. Almost all presentations were as a result of unintentional injuries. However, 8% of males were victims of assault compared with 2% of females. Males were more likely to be injured while working and during leisure or sports activities and at sporting, farming, home, trade, and industrial locations than females. Males were more likely to be more severely injured than females and generally had a longer hospital length of stay. There was no significant difference in the rate of mortality between the genders. There are distinct differences between the sexes regarding the mechanism and severity of injury and trauma outcomes. Local injury prevention initiatives should be targeted to address gender differences. Future social research should examine the interplay of the construction of masculinities with male injury.

Does gender influence outcomes in critically ill patients?

Investigators continue to debate whether gender plays any role in patient outcome following injury/critical illness. We submit that age and hormonal milieu at the time of injury, rather than gender, are the critical factors influencing patient outcome under those conditions.

Testosterone depletion or blockade in male rats protects against trauma hemorrhagic shock-induced distant organ injury by limiting gut injury and subsequent production of biologically active mesenteric lymph

BACKGROUND

We tested the hypothesis that testosterone depletion or blockade in male rats protects against trauma hemorrhagic shock-induced distant organ injury by limiting gut injury and subsequent production of biologically active mesenteric lymph.

METHODS

Male, castrated male, or flutamide-treated rats (25 mg/kg subcutaneously after resuscitation) were subjected to a laparotomy (trauma), mesenteric lymph duct cannulation, and 90 minutes of shock (35 mm Hg) or trauma sham-shock. Mesenteric lymph was collected preshock, during shock, and postshock. Gut injury was determined at 6 hours postshock using ex vivo ileal permeability with fluorescein dextran. Postshock mesenteric lymph was assayed for biological activity in vivo by injection into mice and measuring lung permeability, neutrophil activation, and red blood cell deformability. In vitro neutrophil priming capacity of the lymph was also tested.

RESULTS

Castrated and flutamide-treated male rats were significantly protected against trauma hemorrhagic shock (T/HS)-induced gut injury when compared with hormonally intact males. Postshock mesenteric lymph from male rats had a higher capacity to induce lung injury, Neutrophil (PMN) activation, and loss of red blood cell deformability when injected into naïve mice when compared with castrated and flutamide-treated males. The increase in gut injury after T/HS in males directly correlated with the in vitro biological activity of mesenteric lymph to prime neutrophils for an increased respiratory burst.

CONCLUSIONS

After T/HS, gut protective effects can be observed in males after testosterone blockade or depletion. This reduced gut injury contributes to decreased biological activity of mesenteric lymph leading to attenuated systemic inflammation and distant organ injury.

Mortality after thermal injury: no sex-related difference

BACKGROUND

Young women have been reported to be more likely to survive than men after severe trauma. Girls also have less inflammation and hypermetabolism after major burns. Yet burned women have been found to have a twofold greater risk of death than men. Our aim was to find out if there is a sex-related difference in mortality after thermal injury, particularly in the age group between 16 years and 49 years, when hormonal differences would be most influential.

METHODS

All patients admitted to the Linköping University Hospital Burn Unit with thermal injuries during the years 1993-2008 were included and the variables percentage burned total body surface area (TBSA%), age, type of burn, mechanical ventilation, and year were included in a multiple regression (Poisson log) model.

RESULTS

Of 1,119 patients with thermal injury, 792 (71%) were men. Crude mortality was 5% among men, and 8% among women (p = 0.04). After adjustment for age and TBSA%, there was no correlation between mortality and sex, in any age group. Eight men and four women died in the group of young adults (16-49 years) in which TBSA% correlated with mortality (p < 0.01) but age did not. Mortality was 14% (32 of 221) among the men and 23% (23 of 102) of women in the group of older adults (50 years and older), and both age and TBSA% correlated with mortality (p < 0.001).

CONCLUSIONS

There is no relevant sex-related difference in survival after thermal injury. The conclusion is, however, tempered by the few deaths, particularly among younger adults.

Patients with pelvic fractures due to falls: A paradigm that contributed to autopsy-based audit of trauma in Greece

BACKGROUND

Evaluation of the pelvic fractures (PFx) population in auditing effective components of trauma care is the subject of this study.

METHODS

A retrospective, case-control, autopsy-based study compared a population with PFx to a control-group using a template with trauma outcome variables, which included demographics, ICD-9, intention, mechanisms, toxicology, Abbreviated Injury Scale (AIS-90), Injury Severity Score (ISS), causes of haemorrhage, comorbidity, survival time, pre-hospital response, in hospital data, location of death, and preventable deaths.

RESULTS

Of 970 consecutive patients with fatal falls, 209 (21.5%) had PFx and constituted the PFx-group while 761 (78.5%) formed the control-group.Multivariate analysis showed that gender, age, intention, and height of fall were risk factors for PFx. A 300% higher odds of a psychiatric history was found in the PFx-group compared to the control-group (p < 0.001).The median ISS was 50 (17-75) for the PFx-group and 26 (1-75) for the control-group (p < 0.0001). There were no patients with an ISS less than 16 in the PFx group.Associated injuries were significantly more common in the PFx-group than in the control-group. Potentially preventable deaths (ISS < 75) constituted 78% (n = 163) of the PFx-group. The most common AIS3-5 injuries in the potentially preventable subset of patients were the lower extremities in 133 (81.6%), thorax in 130 (79.7%), abdomen/pelvic contents in 99 (60.7%), head in 95 (58.3%) and the spine in 26 (15.9%) patients.A subset of 126 (60.3%) potentially preventable deaths in the PFx-group had at least one AIS-90 code other than the PFx, denoting major haemorrhage. Deaths directly attributed to PFx were limited to 6 (2.9%).The median survival time was 30 minutes for the PFx-group and 20 hours for the control-group (p < 0.001). For a one-group increment in the ISS-groups, the survival rates over the post-traumatic time intervals were reduced by 57% (p < 0.0001).Pre-hospital mortality was significantly higher in the PFx-group i.e. 70.3% of the PFx-group versus 42.7% of the control-group (p < 0.001).

CONCLUSIONS

The PFx-group shared common causative risk factors, high severity and multiplicity of injuries that define the PFx-group as a paradigm of injury for audit. This reduced sample of autopsies substantially contributed to the audit of functional, infrastructural, management and prevention issues requiring transformation to reduce mortality.

Evidence of hormonal basis for improved survival among females with trauma-associated shock: an analysis of the National Trauma Data Bank

BACKGROUND

Basic science research suggests that sex hormones affect survival after traumatic shock. This study sought to determine the independent effect of gender on mortality among trauma patients in different hormone-related age groups.

METHODS

Review of severely injured trauma patients with shock included in the National Trauma Databank. Patients were stratified into three groups on the basis of likely hormonal status: prehormonal (age, 0-12 years), hormonal (age,13-64 years), and posthormonal (age, ≥ 65 years). Multiple logistic regression was used to analyze the independent effect of gender on mortality in each group, adjusting for anatomic and physiologic injury severity.

RESULTS

A total of 48,394 patients met our inclusion criteria (Injury Severity Score ≥ 16 and systolic blood pressure <90 mm Hg). Crude mortality was higher (p < 0.05) for males in all categories: prehormonal = 29% for males (n = 3,553) versus 24% for females (n = 1,831); hormonal = 34% for males (n = 26,778) versus 30% for females (n = 8,677) and posthormonal = 36% for males (n = 4,280) versus 31% for females (n = 3,275). After adjusting for covariates, women in the hormonally active group had a 14% decreased odds of death (0.86 [95% CI, 0.76-0.93]) compared with men. Females did not exhibit this survival advantage in the prehormonal (odds of death = 0.92 [0.74-1.14]) or posthormonal (odds of death = 0.90 [0.76-1.05]) groups.

CONCLUSIONS

Females aged between 13 and 64 years exhibit significantly lower mortality than males after trauma-associated shock. This outcome difference is lost at the extremes of age (preadolescent children and individuals aged ≥ 65 years) where the effects of sex hormones are absent or diminished. These findings suggest that hormonal differences play a role in the gender-based outcome disparities after traumatic shock.