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

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.

Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients

Background

The lack of a widely-used tool for predicting early cricothyroidotomy in trauma patients prompted us to develop the Cricothyroidotomy After Trauma (CAT) score. We aimed to predict the need for cricothyroidotomy within one hour of trauma patient arrival.

Methods

Derivation and validation datasets were obtained from the Trauma Quality Improvement Program (TQIP) database. Logistic modeling identified predictors, and weighted averages were used to create the CAT score. The score's performance was assessed using AUROC.

Results

Among 1,373,823 derivation patients, <1 % (n = 339) underwent cricothyroidotomy within one hour. The CAT score, comprising nine predictors, achieved an AUROC of 0.88. Severe neck injury and gunshot wound were the strongest predictors. Cricothyroidotomy rates increased from 0.4 % to 9.3 % at scores of 5 and 8, respectively. In the validation set, the CAT tool yielded an AUROC of 0.9.

Conclusion

The CAT score is a validated tool for predicting the need for early cricothyroidotomy in trauma patients. Further research is necessary to enhance its utility and assess its value in trauma care.

What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures?

BACKGROUND

Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF.

QUESTIONS/PURPOSES

(1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure?

METHODS

The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI.

RESULTS

Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI.

CONCLUSION

One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patterns of attendances to the hospital emergency eye care service: a multicentre study in England

BACKGROUND/OBJECTIVES

To characterise the patterns of presentation and diagnostic frequencies in Hospital Emergency Eye Care Services (HEECS) across 13 hospitals in England.

METHODS

Retrospective, cross-sectional, observational multi-centre (n = 13) study to assess HEECS attendances over a 28-day study period. Data derived included: number of consecutive attendances, patient demographics and diagnoses. Age and gender variations, the impact of day of the week on attendance patterns, diagnostic frequencies and estimates of the annual incidence and attendance rates were evaluated.

RESULTS

A total of 17,667 patient (mean ± standard deviation age = 49.6 ± 21.8 years) attendances were identified with an estimated HEECS annual new attendance rate of 31.0 per 1,000 population. Significantly more females (53%) than males (47%) attended HEECS (p < 0.001). Female attendances were 13% higher in those ≥50 years of age. Weekends were associated with a significant reduction in attendances compared to weekdays (χ2 = 6.94, p < 0.001). Among weekdays, Mondays and Fridays were associated with significantly higher attendances compared with midweek (χ2 = 2.20, p = 0.032). Presenting pathologies involving the external eye, cornea and conjunctiva accounted for 28.6% of the caseload.

CONCLUSION

This is the largest multicentre study assessing attendance patterns in HEECS in England. We have, for the first time, observed a "weekend effect" in relation to attendance to HEECS. Differences in health-seeking behaviour and lack of awareness of HEECS weekend services may be partly attributed to the differences observed. Our findings, along with the type of presentations, have the potential to guide commissioners with future planning of HEECS.

Sex Differences in the Massively Transfused Trauma Patient

INTRODUCTION

Recent studies have suggested the female hypercoaguable state may have a protective effect in trauma. However, whether this hypercoagulable profile confers a survival benefit in massively transfused trauma patients has yet to be determined. We hypothesized that females would have better outcomes than males after traumatic injury that required massive transfusion protocol (MTP).

PATIENTS AND METHODS

All trauma patients who underwent MTP at an urban, level 1, academic trauma center were reviewed from November 2007 to October 2018. Female MTP patients were compared to their male counterparts.

RESULTS

There were a total of 643 trauma patients undergoing MTP. Of these, 90 (13.8%) were female and 563 (86.2%) were male. Presenting blood pressure, heart rate, shock index, and injury severity score (ISS) were not significantly different. Overall mortality and incidence of venous thromboembolism were similar. Complication profile and hospital stay were similar. On logistic regression, female sex was not associated with survival (HR: 1.04, 95% CI: 0.56-1.92, P = 0.91). Variables associated with mortality included age (HR: 1.02, 95% CI: 1.05-1.09, P = 0.03) and ISS (HR: 1.07, 95% CI: 1.05-1.09, P < 0.001). Increasing Glascow Coma Scale was associated with survival (HR: 0.85, 95% CI: 0.82-0.89, P < 0.001). On subset analysis, premenopausal women (age < 50) did not have a survival advantage in comparison with similar aged males (HR: 0.68, 95% CI: 0.36-1.28, P = 0.24).

DISCUSSION

Sex differences in coagulation profile do not result in a survival advantage for females when MTP is required.

Trauma Resuscitation Consideration: Sex Matters

BACKGROUND

Sex dimorphisms in coagulation have been recognized, but whole blood assessment of these dimorphisms and their relationship to outcomes in trauma have not been investigated. This study characterizes the viscoelastic hemostatic profile of severely injured patients by sex, and examines how sex-specific coagulation differences affect clinical outcomes, specifically, massive transfusion (MT) and death. We hypothesized that severely injured females are more hypercoagulable and therefore, have lower rates of MT and mortality.

STUDY DESIGN

Hemostatic profiles and clinical outcomes from all trauma activation patients from 2 level I trauma centers were examined, with sex as an experimental variable. As part of a prospective study, whole blood was collected and thrombelastography (TEG) was performed. Coagulation profiles were compared between sexes, and association with MT and mortality were examined. Poisson regression with robust standard errors was performed.

RESULTS

Overall, 464 patients (23% female) were included. By TEG, females had a more hypercoagulable profile, with a higher angle (clot propagation) and maximum amplitude (MA, clot strength). Females were less likely to present with hyperfibrinolysis or prolonged activating clotting time than males. In the setting of depressed clot strength (abnormal MA), female sex conferred a survival benefit, and hyperfibrinolysis was associated with higher case-fatality rate in males.

CONCLUSIONS

Severely injured females have a more hypercoagulable profile than males. This hypercoagulable status conferred a protective effect against mortality in the setting of diminished clot strength. The mechanism behind these dimorphisms needs to be elucidated and may have treatment implications for sex-specific trauma resuscitation.

Characteristics of patients with neuropathic pain syndromes screened by the painDETECT questionnaire and diagnosed by physician exam

Background

The aim of this study was to identify the clinical characteristics, treatment usage, and health outcomes of US adults diagnosed with neuropathic pain (NeP) by experienced physicians.

Methods

Adults with scores exceeding the threshold for probable NeP (painDETECT ≥19) and diagnosed with NeP by a qualified physician completed a questionnaire that included comorbid conditions, pain symptoms and experiences, medication use, health status (3-level EuroQol 5 Dimensions (EQ-5D-3L]: health utilities index and visual analog scale), pain severity and interference with functioning (Brief Pain Inventory), and work and activity impairment (Work Productivity and Activity Impairment questionnaire). Descriptive analyses were performed for each NeP subtype.

Results

Participants (n=295) were predominantly female (64.4%), middle-aged (53.9%), and white (51.5%). Chronic low back pain was the most frequently diagnosed major NeP syndrome (n=166), followed by diabetic peripheral neuropathy (n=58), post-trauma neuropathy (n=47), post-surgical neuropathy (n=28), and central NeP (n=23). An additional 45 participants were diagnosed, but did not meet the criteria for the aforementioned subtypes. Participants could be diagnosed with multiple subtypes. Across each NeP subtype, patients reported high rates of comorbid disease, including arthritis (range: 39.1%–64.3%) and high blood pressure (range: 26.1%–69.0%), as well as symptomology that included numbness (range: 68.1%–91.4%) and changes in muscular strength (range: 24.1%–65.2%). The majority of patients reported back pain (range: 77.8%–95.7%) and arthritis/joint pain (range: 68.1%–78.6%). The most commonly reported types of NeP pain medication were non-steroidal anti-inflammatory drugs (range: 43.1%–70.2%), weak opioids (range: 22.2%–39.3%), and strong opioids (range: 8.7%–28.6%). All six NeP groups generally reported similar levels of dysfunction on all self-report measures. The most notable finding was that the EuroQol-5D-3L health utilities index scores for each of the six groups were lower than the US norms by a clinically important amount.

Conclusion

These exploratory findings indicate that patients with NeP across different etiologies are medically complex and experience impaired function across multiple domains.

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 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.

Nursing workload in intensive care unit trauma patients: analysis of associated factors

BACKGROUND

From the perspective of nurses, trauma patients in the Intensive Care Unit (ICU) demand a high degree of nursing workload due to hemodynamic instability and the severity of trauma injuries. This study aims to identify the factors related to the high nursing workload required for trauma victims admitted to the ICU.

METHODS

This is a prospective, cross-sectional study using descriptive and correlation analyses, conducted with 200 trauma patients admitted to an ICU in the city of São Paulo, Brazil. The nursing workload was measured using the Nursing Activities Score (NAS). The distribution of the NAS values into tertiles led to the identification of two research groups: medium/low workload and high workload. The Chi-square, Fisher's exact, Mann-Whitney and multiple logistic regression tests were utilized for the analyses.

FINDINGS

The majority of patients were male (82.0%) and suffered blunt trauma (94.5%), with traffic accidents (57.5%) and falls (31.0%) being prevalent. The mean age was 40.7 years (± 18.6) and the mean NAS was 71.3% (± 16.9). Patient gender, the presence of pulmonary failure, the number of injured body regions and the risk of death according to the Simplified Acute Physiology Score II were factors associated with a high degree of nursing workload in the first 24 hours following admission to the ICU.

CONCLUSION

Workload demand was higher in male patients with physiological instability and multiple severe trauma injuries who developed pulmonary failure.