Alcohol consumption and all-cause and cause-specific mortality among US adults: prospective cohort study

BACKGROUND

Previous studies have shown inconsistent findings regarding the association of light to moderate alcohol consumption with cause-specific mortality. Therefore, this study sought to examine the prospective association of alcohol consumption with all-cause and cause-specific mortality in the US population.

METHODS

This was a population-based cohort study of adults aged 18 years or older in the National Health Interview Survey (1997 to 2014) with linkage to the National Death Index records through December 31, 2019. Self-reported alcohol consumption was categorized into seven groups (lifetime abstainers; former infrequent or regular drinkers; and current infrequent, light, moderate, or heavy drinkers). The main outcome was all-cause and cause-specific mortality.

RESULTS

During an average follow-up of 12.65 years, among the 918,529 participants (mean age 46.1 years; 48.0% male), 141,512 adults died from all causes, 43,979 from cardiovascular disease (CVD), 33,222 from cancer, 8246 from chronic lower respiratory tract diseases, 5572 from accidents (unintentional injuries), 4776 from Alzheimer's disease, 4845 from diabetes mellitus, 2815 from influenza and pneumonia, and 2692 from nephritis, nephrotic syndrome, or nephrosis. Compared with lifetime abstainers, current infrequent, light, or moderate drinkers were at a lower risk of mortality from all causes [infrequent-hazard ratio: 0.87; 95% confidence interval: 0.84 to 0.90; light: 0.77; 0.75 to 0.79; moderate 0.82; 0.80 to 0.85], CVD, chronic lower respiratory tract diseases, Alzheimer's disease, and influenza and pneumonia. Also, light or moderate drinkers were associated with lower risk of mortality from diabetes mellitus and nephritis, nephrotic syndrome, or nephrosis. In contrast, heavy drinkers had a significantly higher risk of mortality from all causes, cancer, and accidents (unintentional injuries). Furthermore, binge drinking ≥ 1 day/week was associated with a higher risk of mortality from all causes (1.15; 1.09 to 1.22), cancer (1.22; 1.10 to 1.35), and accidents (unintentional injuries) (1.39; 1.11 to 1.74).

CONCLUSIONS

Infrequent, light, and moderate alcohol consumption were inversely associated with mortality from all causes, CVD, chronic lower respiratory tract diseases, Alzheimer's disease, and influenza and pneumonia. Light or moderate alcohol consumption might also have a beneficial effect on mortality from diabetes mellitus and nephritis, nephrotic syndrome, or nephrosis. However, heavy or binge had a higher risk of all-cause, cancer, and accidents (unintentional injuries) mortality.

Risk factors of deterioration in patients of head injury with non-operative management on first neurosurgical consultation

Objectives

In most of the emergency trauma intensive care units (ICUs) of India, neurosurgical opinion is sought for patients presenting with head trauma after earliest possible resuscitation to determine the further line of management. This study aimed to identify common risk factors, leading to neurological deterioration in conservatively managed patients of traumatic brain injury (TBI).

Materials and Methods

This retrospective study analyzed patients admitted with acute TBI and traumatic intracranial hematoma under emergency trauma care ICU who did not require neurosurgical operation within 48 h of trauma. The recorded data were analyzed to determine the predictors of neurological deterioration using univariate and binary logistic regression analysis in SPSS-16 software.

Results

Medical records of consecutive 275 patients of acute TBI presenting to the emergency department were studied. One hundred and ninety-three patients were afflicted with mild TBI (70.18%), 49 patients had moderate TBI (17.81%), and 33 had severe TBI (12%). In the outcome, 74.54% of patients were discharged, and operative decision was made on 6.18% of patients and 19.27% died. Severe TBI is the independent predictor of neurological deterioration during their stay in ICU. Progressive hemorrhagic injury (PHI) showed neurological deterioration in 86.5% of patients. Systemic inflammatory response syndrome (SIRS) was present in 93.5% of patients who had deteriorated neurologically. Dyselectrolytemia was the biochemical derangements seen in 24.36% of cases.

Conclusion

This study revealed severe TBI, PHI, and SIRS to be strong and independent risk factors of neurological deterioration.

Vices-paradox in trauma: Positive alcohol and drug screens associated with decreased mortality

BACKGROUND

Improved survival in trauma patients with acute alcohol intoxication has been previously reported. The effect of illegal and controlled substances on mortality is less clear. We hypothesized that alcohol, illegal and controlled substances are each independently associated with lower odds of mortality in adult trauma patients.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients screening positive for alcohol, illegal or controlled substances on admission. A multivariate logistic regression analysis was used to determine odds of mortality. A similar analysis was used after stratification by injury severity scale (ISS).

RESULTS

From 1,299,705 adult patients, 660,135 were screened for substance use. Of these patients, 497,872 were male, 227,995 (34.5 %) screened positive for alcohol, 155,437 (23.5 %) for illegal substances and 90,259 (13.7 %) for controlled substances. Mortality rate was 6.2 % with alcohol, 5.1 % with illegal substances, and 5.7 % with controlled substances compared to 8.0 % with no substance use (p < 0.001). After controlling for covariates, all groups had lower odds of mortality: alcohol (OR = 0.88, CI = 0.84-0.92, p < 0.001), illegal substances (OR = 0.83, CI = 0.77-0.90, p < 0.001), controlled substances (OR = 0.72, CI = 0.67-0.79, p < 0.001). When stratified by ISS, alcohol and illegal substances continued to be associated with decreased mortality until ISS 50. Controlled substances were associated with decreased mortality when ISS > 16.

CONCLUSION

Patients positive for alcohol, illegal or controlled substances have 12 %, 17 %, and 28 % decreased odds of mortality, respectively. This paradoxical association should be confirmed with future clinical studies and merits basic science research to identify biochemical or physiological components conferring a protective effect on survival in trauma patients.

Alcohol and trauma: the influence of blood alcohol levels on the severity of injuries and outcome of trauma patients - a retrospective analysis of 6268 patients of the TraumaRegister DGU®

Background

Blood alcohol level (BAL) has previously been considered as a factor influencing the outcome of injured patients. Despite the well-known positive correlation between alcohol-influenced traffic participation and the risk of accidents, there is still no clear evidence of a positive correlation between blood alcohol levels and severity of injury. The aim of the study was to analyze data of the TraumaRegister DGU^® (TR-DGU), to find out whether the blood alcohol level has an influence on the type and severity of injuries as well as on the outcome of multiple-trauma patients.

Methods

Datasets from 11,842 trauma patients of the TR-DGU from the years 2015 and 2016 were analyzed retrospectively and 6268 patients with a full dataset and an AIS ≥ 3 could be used for evaluation. Two groups were formed for data analysis. A control group with a BAL = 0 ‰ (BAL negative) was compared to an alcohol group with a BAL of ≥0.3‰ to < 4.0‰ (BAL positive). Patients with a BAL >  0‰ and <  0.3‰ were excluded. They were compared with regard to various preclinical, clinical and physiological parameters. Additionally, a subgroup analysis with a focus on patients with a traumatic brain injury (TBI) was performed.

A total of 5271 cases were assigned to the control group and 832 cases to the BAL positive group. 70.3% (3704) of the patients in the control group were male. The collective of the control group was on average 5.7 years older than the patients in the BAL positive group (p < .001). The control group showed a mean ISS of 20.3 and the alcohol group of 18.9 (p = .007). In terms of the injury severity of head, the BAL positive group was significantly higher on average than the control group (p <  0.001), whereas the control group showed a higher AIS to thorax and extremities (p <  0.001). The mean Glasgow Coma Scale (GCS) was 10.8 in the BAL positive group and 12.0 in the control group (p <  0.001). Physiological parameters such as base excess (BE) and International Normalized Ratio (INR) showed reduced values ​​for the BAL positive group. However, neither the 24-h mortality nor the overall mortality showed a significant difference in either group (p = 0.19, p = 0.14). In a subgroup analysis, we found that patients with a relevant head injury (AIS: Abbreviated Injury Scale head ≥3) and positive BAL displayed a higher survival rate compared to patients in the control group with isolated TBI (p < 0.001).

Conclusions

This retrospective study analyzed the influence of the blood alcohol level in severely injured patients in a large national dataset. BAL positive patients showed worse results with regard to head injuries, the GCS and to some other physiological parameters. Finally, neither the 24-h mortality nor the overall mortality showed a significant difference in either group. Only in a subgroup analysis the mortality rate in BAL negative patients with TBI was significantly higher than the mortality rate of BAL positive patients with TBI. This mechanism is not yet fully understood and is discussed controversially in the literature.

Association between alcohol intoxication and mortality in severe traumatic brain injury in the emergency department: a retrospective cohort

BACKGROUND

Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI).

METHODS

This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication.

RESULTS

Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09).

CONCLUSION

In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.

Blood Alcohol Concentration Is Associated With Improved AIS Motor Score After Spinal Cord Injury

Objective

To investigate the relationship between blood alcohol concentration (BAC) and neurologic recovery after traumatic spinal cord injury (TSCI) using standardized outcome measures from the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) examination.

Method

This is a retrospective review of merged, prospectively collected, multicenter data from the Spinal Cord Injury Model Systems Database and institutional trauma databases from five academic medical centers across the United States. Patients with SCI and a documented BAC were analyzed for American Spinal Injury Association Impairment Scale (AIS) motor score, FIM, sensory light touch score, and sensory proprioception score upon admission and discharge from rehabilitation. Linear regression was used for the analysis.

Results

The study identified 210 patients. Mean age at injury was 47 ± 20.5 years, 73% were male, 31% had an AIS grade A injury, 56% had ≥1 comorbidity, mean BAC was 0.42 ± 0.9 g/dL, and the mean Glasgow Coma Score upon arrival was 13.27 ± 4.0. ISNCSCI motor score gain positively correlated with higher BAC (4.80; confidence interval [CI], 2.39-7.22; p < .0001). FIM motor gain showed a trend toward correlation with higher BAC, although it did not reach statistical significance (3.27; CI, -0.07 to 6.61; p = .055). ISNCSCI sensory light touch score gain and sensory proprioception score gain showed no correlation with BAC (p = .44, p = .09, respectively).

Conclusion

The study showed a positive association between higher BAC and neurologic recovery in patients with SCI as measured by ISNCSCI motor score gain during rehabilitation. This finding has not been previously reported in the literature and warrants further study to better understand possible protective physiological mechanisms underlying the relationship between BAC and SCI.

Effect of Chronic Alcoholism on Traumatic Intracranial Hemorrhage

BACKGROUND

Traumatic intracranial hemorrhage (TICH) is one of the commonest indications for neurosurgical consultation after trauma. Worsening neurologic examination results, size of initial TICH, presence of displaced skull fracture, and concomitant anticoagulant use at the time of injury drive the recommendations for repeat computed tomography of head (RCTH), to assess for stability of intracranial hemorrhage. Chronic alcohol use is not generally considered an indication for repeat head computed tomography (CT).

METHODS

A retrospective study of 423 patients with TICH with normal admission platelet (PLT) counts was reviewed for this study, taken as a subset of 1330 patients with TICH admitted to Lahey Hospital and Medical Center over a 3-year period. Of these 423 patients, 330 were classified as nonalcoholics and 93 were classified as alcoholics, based on whether alcohol use disorder was documented in the patient's medical record, present before injury. The normal PLT level was defined as ≥100,000 μ/L. Patients were excluded from review if they had comorbid conditions that could cause PLT dysfunction or coagulopathy. Continuous and categorical variables were compared using independent t test and χ², respectively. Binary logistic regression was used to predict outcome: stable versus worsening of TICH on RCTH. Statistical analysis was conducted using SPSS version 25.

RESULTS

The mean age of the nonalcoholic and alcoholic cohorts were 71.9 years and 54.8 years, respectively. A significantly higher percentage of alcoholics were male. There was a statistically significant difference (χ² = 8.14; P < 0.004) in radiologic progression of TICH between the 2 groups, with the alcoholics having a worsening RCTH 16.1% of the time compared with only 6.7% in nonalcoholics. Chronic alcohol use was an independent predictor of radiologic progression in patients with normal PLT level (odds ratio, 2.69; confidence interval, 1.34-5.43; P < 0.006).

CONCLUSIONS

Chronic alcohol use was an independent predictor of radiologic progression of TICH in the setting of normal PLT level. Modification of this risk of progression with transfusion of fresh PLTs in chronic alcoholic patients with TICH needs to be investigated in a prospective trial.

Cannabis, alcohol and cigarette use during the acute post-concussion period

Objective: To document the prevalence of acute post-concussion cannabis, alcohol and cigarette use and their association with clinical recovery and symptom burden.Methods: A prospective cohort study was conducted. Concussions were physician-diagnosed and presented to the emergency department and concussion clinic within 7 days post-injury. Participants were assessed weekly and followed for a minimum 4 weeks. A survival analysis (using physician-determined recovery to both cognitive and physical activities) in addition to a weekly symptom score analysis was conducted.Results: A total of 307 acute concussions with a mean age of 33.7 years (SD, 13.0) were included. Acute post-concussion cannabis, alcohol and cigarette use were identified in 43 (14.0%), 125 (40.7%) and 61 (19.9%) individuals. Acute cannabis, alcohol and cigarette use were not associated with recovery to cognitive (p > .05) or physical activity (p > .05). Acute cigarette use was associated with a higher unadjusted symptom severity score at week1 (p = .003). Acute cannabis use was associated with lower symptom severity scores at week-3 (p = .061) and week-4 (p = .029).Conclusion: In conclusion, cannabis, alcohol and cigarette use were prevalent in the acute period post-concussion; however, were not observed to impact recovery within the first 4 weeks post-injury. Amongst unrecovered individuals, acute cannabis use was associated with lower symptom burden, while cigarette use was associated with greater initial symptom burden.

Alcohol in Traumatic Brain Injury: Toxic or Therapeutic?

BACKGROUND

Alcohol (EtOH) poses a challenge in traumatic brain injuries (TBIs) given its metabolic and neurologic impact. Studies have had opposing results regarding mortality and complication rates in the intoxicated TBI patient. We hypothesized that trauma mechanism, brain injury severity, and blood alcohol concentration (BAC) would influence the impact of EtOH on mortality in TBI.

METHODS

We performed a single-institution retrospective review of consecutive adult trauma patients tested for EtOH and a diagnosis of TBI. The primary outcome was mortality, and secondary outcomes included infectious complications. The primary analysis included univariate and multivariate regression comparing mortality between intoxicated and sober patients, at different values of BAC, different brain injury severities, and among mechanisms of trauma.

RESULTS

Admission EtOH was assessed in 583 patients with TBI, with 256 testing positive for EtOH and 327 testing negative. Overall, EtOH was associated with lower mortality on univariate analysis (4.7% versus 8.9%, P = 0.05) but not on multivariate analysis (P = 0.21). There was no effect of EtOH on mortality when patients were stratified by brain injury severity or among penetrating trauma victims. However, EtOH was associated with lower overall infectious complications on univariate and multivariate regression. Finally, EtOH was predictive of mortality with an area under the receiver operator characteristic curve of 0.83.

CONCLUSIONS

We found that EtOH is not associated with mortality in the patient with TBI, suggesting no causative effect. However, EtOH showed some predictability of mortality based on a receiver operator characteristic analysis. Interestingly, EtOH was associated with lower infectious complications, suggesting an immunomodulatory effect of EtOH in TBI.

Very High Blood Alcohol Concentration and Fatal Hemorrhage in Acute Subdural Hematoma

INTRODUCTION

Alcohol intoxication is often present concurrently with traumatic brain injury (TBI). Recent studies have looked at the effect alcohol has on TBI and on coagulopathy. Typically, cases reviewed in the current literature report only on the effects of modest alcohol intoxication.

CASE DESCRIPTION

A 43-year-old male presented to the trauma center after a fall, with rapidly deteriorating mental status. Computed tomography of the head demonstrated a 1.9-cm acute subdural hematoma. Of note, classical coagulation studies were normal, but blood ethanol level was high, 436 mg/dL. Postoperatively, the patient suffered an intracerebral hemorrhage requiring emergent return to the operating room, where a large volume of unclotted blood and clinical coagulopathy was encountered.

DISCUSSION

We review the literature pertaining to coagulopathy in the context of TBI and ethanol intoxication. This case is a cautionary tale of a phenomenon of unmeasured coagulopathy in the face of severe alcohol intoxication manifested by intraoperative coagulopathy with new postoperative hemorrhage. Although routine preoperative testing indicated normal clotting function, a thromboelastogram demonstrated delayed clot formation. The protective effects of alcohol are well described; however, we believe that there is a population of patients with severe acute intoxication who have coagulopathy that may go undetected by routine preoperative screening.

CONCLUSIONS

Caution should be exercised when taking care of patients with very high levels of alcohol because physiologic derangements may be unpredictable. Additional research is needed for patients with very high levels of alcohol intoxication and the effect it may have on coagulation.

Association of Alcohol With Mortality After Traumatic Brain Injury

Although alcohol exposure results in reduced mortality after traumatic brain injury (TBI) in animal models, clinical trials based on proposed mechanisms have been disappointing and have reported conflicting results. Methodological issues common to many of these clinical studies may have contributed to the spurious results. Our objective was to evaluate the association between blood alcohol concentration (BAC) and in-hospital mortality after TBI, and overcome methodological problems of prior studies. We conducted a retrospective cohort study on individuals treated for isolated TBI (n = 1,084) at the R Adams Cowley Shock Trauma Center (Baltimore, Maryland) from 1997 to 2012. We excluded individuals with injury to other body regions and examined multiple cutpoints of BAC. Our primary outcome was in-hospital mortality. In adjusted logistic regression models, the upper level of each blood alcohol categorization from 0.10 g/dL (odds ratio = 0.63, 95% confidence interval: 0.40, 0.97) through 0.30 g/dL (odds ratio = 0.25, 95% confidence interval: 0.08, 0.84) was associated with reduced risk of mortality after TBI compared with individuals with undetectable BAC. In sensitivity analyses among individuals without penetrating brain injuries (95% firearm-related) (n = 899), the protective association was eliminated. This study provides evidence that the observed protective association between BAC and in-hospital mortality after TBI resulted from bias introduced by inclusion of penetrating injuries.

Cannabis Use Has Negligible Effects Following Severe Traumatic Injury

Nearly half of all states have legalized medical marijuana or recreational-use marijuana. As more states move toward legalization, the effects on injured patients must be evaluated. This study sought to determine effects of cannabis positivity at the time of severe injury on hospital outcomes compared with individuals negative for illicit substances and those who were users of other illicit substances. A Level I trauma center performed a retrospective chart review covering subjects over a 2-year period with toxicology performed and an Injury Severity Score (ISS) of more than 16. These individuals were divided into the negative and positive toxicology groups, further divided into the marijuana-only, other drugs-only, and mixed-use groups. Differences in presenting characteristics, hospital length of stay, intensive care unit (ICU) stays, ventilator days, and death were compared. A total of 8,441 subjects presented during the study period; 2,134 (25%) of these had toxicology performed; 843 (40%) had an ISS of more than 16, with 347 having negative tests (NEG); 70 (8.3%) substance users tested positive only for marijuana (MO), 323 (38.3%) for other drugs-only, excluding marijuana (OD), and 103 (12.2%) subjects showed positivity for mixed-use (MU). The ISS was similar for all groups. No differences were identified in Glasgow Coma Scale (GCS), ventilator days, blood administration, or ICU/hospital length of stay when comparing the MO group with the NEG group. Significant differences occurred between the OD group and the NEG/MO/MU groups for GCS, ICU length of stay, and hospital charges. Cannabis users suffering from severe injury demonstrated no detrimental outcomes in this study compared with nondrug users.

Acute Alcohol Exposure and Risk of Mortality of Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

After traumatic brain injury (TBI), patients usually live with significant disability and socioeconomic burdens. Acute exposure to alcohol is considered a major risk factor for TBI. Numerous studies have examined whether alcohol exposure is related to the risk of mortality in patients with TBI, yet the results remain inconsistent. We performed a meta-analysis to assess whether acute alcohol exposure affects the mortality rate of TBI patients. We searched PubMed, EMBASE, and the Cochrane Library up to November 2015 for relevant studies. We screened studies based on their inclusion criteria and selected the studies that reported mortality rate, which included 18 observational studies. We used R to analyze the included data. An initial result showed that the presence of a positive blood alcohol concentration (BAC) had no significant relation with mortality rate (OR = 0.92, 95% CI = 0.83 to 1.01), but there was notable heterogeneity along with variable results according to sensitivity analysis. For the BAC-positive population, low BAC (1 to 100 mg/dl) carried a higher risk of mortality than moderate BAC (100 to 230 mg/dl) (OR = 1.40, 95% CI = 1.09 to 1.81), moderate and high BAC as a single category (>100 mg/dl) (OR = 1.57, 95% CI = 1.28 to 1.94), or high BAC (>230 mg/dl) (OR = 1.76, 95% CI = 1.34 to 2.30). However, moderate BAC did not increase the mortality risk when compared with high BAC (OR = 1.20, 95% CI = 0.89 to 1.63). Whether positive BAC at the time of admission after TBI reduces mortality rate compared with the rate under negative BAC remains unknown. In addition, low BAC (1 to 100 mg/dl) poses a risk of mortality compared with higher BAC. Further studies assessing the effect of alcohol between the BAC-positive group and the BAC-negative group are still needed.

Total shoulder arthroplasty: risk factors for intraoperative and postoperative complications in patients with primary arthritis

BACKGROUND

This study evaluated and identified risk factors for the development of intraoperative and postoperative surgical complications in total shoulder arthroplasty in patients with primary osteoarthritis.

METHODS

We evaluated patient-specific factors, including age, sex, body mass index, prior nonarthroplasty surgery, smoking, alcohol consumption, and the American Society of Anesthesiologists (ASA) Physical Status Classification System in 275 patients (76 men, 199 women) with an average age of 68 years (range, 51-85 years). We categorized the number and severity of all complications and correlated these results with the patient-specific factors RESULTS: Twenty-seven complications (9.8%) in 275 shoulder arthroplasties were recorded. We identified 22 patients (8%) with category I complications and 5 (2.8%) with category II complications. Patients with an ASA score of 3 showed an increased likelihood of having a surgical complication compared with the control group with ASA scores of 1 and 2 (odds ratio, 4.28; 95% confidence interval, 1.79-10.20; P < .01). Smokers were more prone to surgical complications than nonsmokers (odds ratio, 5.08; 95% confidence interval, 1.96-13.11; P = .02).

CONCLUSION

Surgical complication rates after anatomic total shoulder arthroplasty in patients with primary osteoarthritis correlate with the patient's overall health status and nicotine consumption. This may be useful for predicting the likelihood of surgical complications and may thus prove important for clinicians to better assess and explain possible risks before surgery.

Association between the Osteoporosis Self-Assessment Tool for Asians Score and Mortality in Patients with Isolated Moderate and Severe Traumatic Brain Injury: A Propensity Score-Matched Analysis

Background: The purpose of this study was to use a propensity score-matched analysis to investigate the association between the Osteoporosis Self-Assessment Tool for Asians (OSTA) scores and clinical outcomes of patients with isolated moderate and severe traumatic brain injury (TBI). Methods: The study population comprised 7855 patients aged ≥40 years who were hospitalized for treatment of isolated moderate and severe TBI (an Abbreviated Injury Scale (AIS) ≥3 points only in the head and not in other regions of the body) between 1 January 2009 and 31 December 2014. Patients were categorized as high-risk (OSTA score < -4; n = 849), medium-risk (-4 ≤ OSTA score ≤ -1; n = 1647), or low-risk (OSTA score > -1; n = 5359). Two-sided Pearson's chi-squared, or Fisher's exact tests were used to compare categorical data. Unpaired Student's t-test and Mann-Whitney U test were performed to analyze normally and non-normally distributed continuous data, respectively. Propensity score-matching in a 1:1 ratio was performed using NCSS software, with adjustment for covariates. Results: Compared to low-risk patients, high- and medium-risk patients were significantly older and injured more severely. The high- and medium-risk patients had significantly higher mortality rates, longer hospital length of stay, and a higher proportion of admission to the intensive care unit than low-risk patients. Analysis of propensity score-matched patients with adjusted covariates, including gender, co-morbidity, blood alcohol concentration level, Glasgow Coma Scale score, and Injury Severity Score revealed that high- and medium-risk patients still had a 2.4-fold (odds ratio (OR), 2.4; 95% confidence interval (CI), 1.39-4.15; p = 0.001) and 1.8-fold (OR, 1.8; 95% CI, 1.19-2.86; p = 0.005) higher mortality, respectively, than low-risk patients. However, further addition of age as a covariate for the propensity score-matching demonstrated that there was no significant difference between high-risk and low-risk patients or between medium-risk and low-risk patients, implying that older age may contribute to the significantly higher mortality associated with a lower OSTA score. Conclusions: Older age may be able to explain the association of lower OSTA score and higher mortality rates in patients with isolated moderate and severe TBI.

Impact of day-of-injury alcohol consumption on outcomes after traumatic brain injury: A meta-analysis

Although a known risk factor for traumatic brain injury (TBI), alcohol has been found to both promote and protect against secondary brain damage. However, it is presently unclear whether the cognitive, psychological and medical/functional outcomes of adults who have consumed alcohol prior to sustaining a TBI differ from those who have not. This meta-analysis examined the outcomes of groups that differed in terms of their day-of-injury (DOI) blood alcohol levels (BALs) by comparing positive with zero BAL (BAL⁺/BAL^-) and high with low BAL (BAL^high/BAL^low) samples. The PubMed, PsycINFO, EMBASE, and Scopus databases were searched from inception until the end of March 2015. Hedge's g effects (continuous data) and odds ratios (categorical data) were calculated for 27 studies that compared either the outcomes of BAL⁺ and BAL^- groups or BAL^high and BAL^low groups. BAL⁺ was associated with significantly poorer cognitive outcomes (overall and on general tests) and higher levels of disability, and BAL^high was associated with shorter stays in intensive care. More generally, however, most effect sizes were small to low-moderate in size, non-significant and inconsistent in their direction. Although DOI alcohol consumption increases the risk of sustaining a TBI, it is not consistently associated with better or worse outcomes, other than subtle cognitive deficits; the source of which remains to be determined.

Alcohol and mortality after moderate to severe traumatic brain injury: a meta-analysis of observational studies

OBJECT

Experimental studies have shown numerous neuroprotective properties of alcohol (“ethanol”) after TBI, but clinical studies have provided conflicting results. The authors aimed to assess the relationship between positive blood alcohol concentration (BAC) on hospital admission and mortality after moderate to severe traumatic brain injury (TBI).

METHODS

The authors searched 8 databases for observational studies reported between January 1, 1990, and October 7, 2013, and investigated the effect of BAC on mortality after moderate to severe TBI. Reviews of each study were conducted, and data were extracted according to the MOOSE and PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa scale. The Mantel-Haenszel fixed effect methodology was used to generate pooled estimates. Heterogeneity was dealt with by multiple sensitivity analyses.

RESULTS

Eleven studies with a total of 95,941 patients (42% BAC positive and 58% BAC negative) were identified for the primary analysis (overall mortality 12%). Primary analysis showed a significantly lower risk of death for BAC-positive patients compared with BAC-negative patients (crude mortality 11.0% vs 12.3%, pooled OR 0.84 [95% CI 0.81–0.88]), although flawed by heterogeneity (I2 = 68%). Multiple sensitivity analyses, including 55,949 and 51,772 patients, yielded similar results to the primary analysis (crude mortality 12.2% vs 14.0%, pooled OR 0.87 [95% CI 0.83–0.92] and crude mortality 8.7% vs 10.7%, pooled OR 0.78 [95% CI 0.74–0.83]) but with good study homogeneity (I2 = 36% and 14%).

CONCLUSIONS

Positive BAC was significantly associated with lower mortality rates in moderate to severe TBI. Whether this observation is due to selection bias or neuroprotective effects of alcohol remains unknown. Future prospective studies adjusting for TBI heterogeneity is advocated to establish the potential favorable effects of alcohol on outcome after TBI.

Alcohol Intake and Reduced Mortality in Patients with Traumatic Brain Injury

BACKGROUND

The purpose of our study was to determine whether alcohol intake influences short-term mortality in patients with traumatic brain injury (TBI), using a comprehensive trauma database.

METHODS

We collected data from 7 emergency departments (EDs) between June 1, 2008 and May 31, 2010, using the same data form. Cases were included if they met the following criteria: (i) older than 15 and (ii) injuries including TBI. Demographics and outcomes were compared between patients with and without alcohol intake. We present the risk of mortality using hazard ratios and 95% confidence intervals.

RESULTS

A total of 76,596 trauma patients visited the EDs during the study period; 12,980 patients were older than 15 and had TBI. There were 4,009 (30.9%) patients in the alcohol-intake group, of whom 3,306 (82.5%) patients were male, 1,450 (36.2%) patients were moved by ambulance, and 1,218 (30.4%) patients' injuries were intentional. The most frequent injury mechanism was falling down with alcohol intake and blunt injury without alcohol intake. Mortality rate was 1.0% with alcohol intake and 2.0% without alcohol intake. After adjusting for all factors related to mortality, the hazard ratio of mortality was 0.72 in the alcohol-intake group.

CONCLUSIONS

Mortality rate due to TBI in the alcohol-intake group appears to be lower compared to that in the no-alcohol-intake group after adjusting for main confounding variables.

The Moderation of Blood Alcohol Levels on Higher Odds of Survival among American Indians with Violent, Blunt-Force Traumatic Brain Injuries

This study assessed the moderation of blood alcohol level (BAL) and American Indian race on survival of patients with violent traumatic brain injury (TBI). An initial logistic regression model indicated that those who were American Indian and insured had higher odds of survival and those with higher injury severity scores and low-medium BAL were less likely to survive. A second logistic regression model including a relationship between American Indians and BAL found that American Indians had a higher odds of survival which tripled when they have no BAL. Low-medium and high BAL were associated with less likelihood of survival among White patients.

Ethanol and isolated traumatic brain injury

The aim of this systematic review was to determine whether ethanol is neuroprotective or associated with adverse effects in the context of traumatic brain injury (TBI). Approximately 30-60% of TBI patients are intoxicated with ethanol at the time of injury. We performed a systematic review of the literature using a combination of keywords for ethanol and TBI. Manuscripts were included if the population studied was human subjects with isolated moderate to severe TBI, acute ethanol intoxication was studied as an exposure variable and mortality reported as an outcome. The included studies were assessed for heterogeneity. A meta-analysis was performed and the pooled odds ratio (OR) for the association between ethanol and in-hospital mortality reported. There were seven studies eligible for analysis. A statistically significant association favouring reduced mortality with ethanol intoxication was found (OR 0.78; 95% confidence interval 0.73-0.83). Heterogeneity among selected studies was not statistically significant (p=0.25). Following isolated moderate-severe TBI, ethanol intoxication was associated with reduced in-hospital mortality. The retrospective nature of the studies, varying definitions of brain injury, degree of intoxication and presence of potential confounders limits our confidence in this conclusion. Further research is recommended to explore the potential use of ethanol as a therapeutic strategy following TBI.

Acute alcohol intoxication and long-term outcome in patients with traumatic brain injury

The effect of blood alcohol concentration (BAC) on outcome after traumatic brain injury (TBI) is controversial. We sought to assess the independent effect of positive BAC on long-term outcome in patients with TBI treated in the intensive care unit (ICU). We performed a retrospective analysis of 405 patients with TBI, admitted to the ICU of a large urban Level 1 trauma center between January 2009 and December 2012. Outcome was six-month mortality and unfavorable neurological outcome (defined as a Glasgow Outcome Scale score of 1 [death], 2, [vegetative state], or 3 [severe disability]). Patients were categorized by admission BAC into: no BAC (0.0‰; n=99), low BAC (<2.3‰; n=140) and high BAC (≥2.3‰; n=166). Logistic regression analysis, adjusting for baseline risk and severity of illness, was used to assess the independent effect of BAC on outcome (using the no BAC group as the reference). Overall six-month mortality was 25% and unfavorable outcome was 46%. Multivariate analysis showed low BAC to independently reduce risk of six-month mortality compared with no BAC (low BAC adjusted odds ratio [AOR] 0.41, 95% confidence interval [CI] 0.19-0.88, p=0.021) and high BAC (AOR 0.58, 95% CI 0.29-1.15, p=0.120). Furthermore, a trend towards reduced risk of six-month unfavorable neurological outcome for patients with positive BAC, compared to patients with negative BAC, was noted, although this did not reach statistical significance (low BAC AOR 0.65, 95% CI 0.34-1.22, p=0.178, and high BAC AOR 0.59, 95% CI 0.32-1.09, p=0.089). In conclusion, low admission BAC (<2.3‰) was found to independently reduce risk of six-month mortality for patients with TBI, and a trend towards improved long-term neurological outcome was found for BAC-positive patients. The role of alcohol as a neuroprotective agent warrants further studies.

Positive blood alcohol is associated with reduced DVT in trauma

INTRODUCTION

Trauma patients exhibit a complex coagulopathy which is not fully understood and deep venous thrombosis (DVT) rates remain high. The effects of alcohol (EtOH) consumption on coagulopathy in trauma patients have not been studied. We hypothesized that acute EtOH intoxication would produce a relative hypocoagulable state as measured by thrombelastography (TEG) and would be associated with reduced DVT rates.

METHODS

Data were prospectively collected on 213 trauma patients at a level 1 trauma centre and analyzed in a retrospective secondary analysis. Thrombelastography (TEG), standard laboratory tests and ETOH levels were performed. If the level was positive, patients were grouped as EtOH+ and all patients were screened for DVT using a standard protocol. Statistical significance was p<0.05.

RESULTS

The EtOH+ group was predominantly male (76%), was younger (p<0.05), had a lower BMI (p<0.05), demonstrated a lower AIS extremity score (p<0.01) and was less likely to have a blunt injury (p<0.01) than the EtOH- group. Gender, ISS and other AIS scores were not significantly different. TEG values in the alcohol group demonstrated a relative hypocoagulable state that was associated with a reduced DVT incidence, 1.4% versus 16.2%, (p<0.01). This difference was not detected with conventional assays. A multivariate logistic regression was performed, controlling for common risk factors for DVT and a positive EtOH level on admission was independently associated with reduced DVT incidence.

CONCLUSIONS

Alcohol consumption is associated with a relative hypocoagulable state on TEG that is associated with a decreased DVT incidence. This difference is not detected by conventional assays.

Alcohol intoxication and its effects on traumatic spinal cord injury outcomes

There are sparse data regarding the impact of alcohol on in-hospital complications associated with traumatic spinal cord injuries (TSCIs). We set out to quantify the impact of alcohol on TSCI outcomes and its influence on health care cost and utilization. The National Trauma Data Bank (NTDB) Research Data Set version 7.2 (2000-2006) was utilized to gather data between 2007 and 2009. We extracted cases of TSCI (International Classification of Diseases, Ninth Revision, Clinical Modification codes 806.xx) without concurrent traumatic brain injury. Outcomes of interest were mortality, length of stay (LOS), intensive care unit (ICU) days, ventilator days, and complications. Continuous outcomes such as LOS, ICU days, and ventilator days were analyzed using linear regression. Risk-adjusted analysis of risk factors for mortality and complication rates were performed using multiple logistic regression. Of the 10,611 persons identified in the NTDB, alcohol was present in approximately one fifth of all cases (20.76%). A majority of TSCI patients were young (mean age, 39 years) Caucasian (65.07%) males (75.93%). Blunt injury was the most common mechanism of injury. The presence of alcohol did not significantly affect mortality or neurological complications. Alcohol in the blood was associated with extended LOS, longer ICU stays, more days spent ventilated, and increased risk of all-type complications. Further, there was a statistically significant association with the presence alcohol and increased risk for pulmonary, pneumonia, deep vein thrombosis and pulmonary embolism, urinary tract infection, and ulcer/skin complications. Alcohol intoxication is associated with increased in-hospital morbidity. The significant association with in-hospital complications increases health resource utilization after spinal cord injury.

The effect of alcohol intoxication on mortality of blunt head injury

Alcohol is found to have neuroprotection in recent studies in head injuries. We investigated the association of blood alcohol concentration (BAC) with mortality of patients with blunt head injury after traffic accident. All patients sustaining blunt head injury caused by traffic accident brought to our emergency department who had obtained a brain computed tomography scans and BAC were analyzed. Patients with unknown mechanisms, transfers from outside hospitals, and incomplete data were excluded. Logistic regression was used to identify independent predictors of mortality. During the study period, 3,628 patients with brain computed tomography (CT) were included. Of these, BAC was measured in 556 patients. Patients with the lowest BAC (less than 8 mg/dl) had lower mortality; intoxicated patients with BAC between 8 and less than 100 mg/dl were associated with significantly higher mortality than those patients in other intoxicated groups. Adjusted logistic regression demonstrated higher BAC group and Glasgow coma scale (GCS) scores, and lower ISS and age were identified as independent predictors of reduced mortality. In our study, we found that patients who had moderate alcohol intoxication had higher risk of mortality. However, higher GCS scores, lower ISS, and younger age were identified as independent predictors of reduced mortality in the study patients.

Ethanol, Trauma, and the Brain

Alcohol intoxication plays a significant and causal role in various fatal injuries. In comparison to sober individuals, intoxicated people have a greater generic risk for being involved in hazardous activities that may result in fatal injuries. However, it is not clear whether the biological effects of acute alcohol intoxication result in worse injuries than those sustained by sober individuals who are injured by identical mechanisms. Alcohol intoxication has a neuroprotective effect in experimental animal models of traumatic brain injury (TBI) but the evidence for a similar effect in humans is controversial. Earlier studies found such a protective effect, but more recent large epidemiological studies have not confirmed this finding; some studies also suggest a dose-related protective or exacerbating effect of alcohol intoxication on TBI. There are two apparent alcohol-associated syndromes in which an otherwise survivable blunt force impact to the head of an intoxicated individual is fatal at the scene. The first is a fatal cardiorespiratory arrest (the so-called alcohol concussion syndrome or “commotio medullaris”); the second is “traumatic basilar subarachnoid hemorrhage” (secondary to tears in the cerebral arteries, particularly the intracranial and extracranial vertebral arteries).

Effects of time of hospital admission on outcomes after severe traumatic brain injury in Austria

BACKGROUND

The goal of this study was to compare outcomes of patients with severe traumatic brain injury (TBI) who had been admitted either during workdays from 7 a.m. to 7 p.m. ("regular service") or during any other time ("on-call service").

MATERIAL AND METHODS

Between March 2002 and April 2012, 17 Austrian centers enrolled TBI patients into two observational studies that focused on effects of guideline compliance (n = 400) and on prehospital and early hospital management (n = 777), respectively. Data on trauma severity, clinical status, treatment, and outcomes were collected prospectively. All patients with severe TBI (Glasgow Coma Scale score < 9) were selected for this analysis. Secondary transfers and patients with unsurvivable injuries were excluded. The International Mission for Prognosis and Analysis of Clinical Trials in TBI core model was used to estimate probabilities of hospital death and unfavorable long-term outcome (Glasgow Outcome Scale score < 4). Based on time of arrival, patients were assigned to groups "regular service" or "on-call service."

RESULTS

Data from 852 patients were analyzed (413 "regular," 439 "on-call service"). "On-call" patients were younger (45 vs. 51 years, P < 0.001) and had a higher rate of alcohol intoxication (41 vs. 11 %, P < 0.001). Trauma severity was comparable; the probabilities of death and unfavorable outcome were identical. There were no differences regarding computed tomography findings or treatment. Hospital mortality (24 vs. 28 %, P = 0.191) and rate of patients with unfavorable outcome at 6 months (43 vs. 48 %, P = 0.143) were comparable.

CONCLUSIONS

In Austria, the time of hospital admission has no influence on outcomes after severe TBI.

Effects of extracellular pressure and alcohol on the microglial response to inflammatory stimulation

BACKGROUND

Traumatic brain injury induces a neuroinflammatory response frequently associated with increased intracranial pressure. The aim of this study was to investigate the effects of alcohol and increased extracellular pressure on murine BV-2 microglial proliferation and cytokine responses to lipopolysaccharide (LPS) stimulation.

METHODS

BV-2 cells were cultured under 0 or 30 mm Hg increased extracellular pressure without or with ethanol (100 mmol/L) or LPS (10 ng/mL) for 24 hours. Cell proliferation was assessed using MTS assay and secretion of the proinflammatory cytokines tumor necrosis factor (TNF)-α, interleukin (IL)-6, and monocyte chemotactic protein (MCP)-1 by enzyme-linked immunosorbent assay.

RESULTS

Increased pressure and LPS stimulation each promoted proliferation. Ethanol pretreatment blocked these effects. Basal TNF-α and IL-6 secretion was at the limits of delectability. Basal MCP-1 production was stimulated by pressure, which was blocked by ethanol. Even this low LPS dose stimulated microglial secretion of TNF-α, IL-6, and MCP-1. Pressure inhibited LPS-stimulated production of these proinflammatory cytokines, while ethanol pretreatment blocked LPS-stimulated cytokine production. The combination of pressure and ethanol further reduced TNF-α, IL-6, and MCP-1 secretion by LPS-stimulated microglial cells.

CONCLUSION

Alcohol's anti-inflammatory effects may contribute to the reduced mortality from traumatic brain injury that some have described in acutely intoxicated patients, while pressure down-regulation of inflammatory cytokine release could create a negative feedback that ameliorates inflammation in traumatic brain injury.

Arthroplasty knee surgery and alcohol use: risk factor or benefit?

BACKGROUND

Excessive alcohol consumption has been associated with adverse measures of health after elective surgery. However, associations of low/moderate consumption remain uncertain.

QUESTION/PURPOSES

We determined differences among patients with three different self-reported consumption levels in (1) preoperative/postoperative patient-perceived outcomes and knee scores, (2) preoperative/postoperative changes in these scores, (3) preoperative demographics and comorbidities, and (4) length of stay (LOS) and inpatient charges.

METHODS

We retrospectively studied 430 patients (545 TKAs). Based on a self-administered consumption questionnaire, patients were stratified into groups: (1) nondrinkers, (2) occasional drinkers, and (3) moderate drinkers. We compared the following variables between groups: demographics, BMI, American Society of Anesthesiologists score, Charlson Comorbidity Index, preoperative and postoperative Quality of Well-being Index (QWB-7), SF-36 score, WOMAC score, Knee Society (KS) Score, Hospital for Special Surgery (HSS) knee score, LOS, and hospital charges. QWB-7, SF-36, WOMAC, KS, and HSS scores were compared adjusting for patient characteristics. Minimum followup was 1 year (average, 3.4 years; range, 1-6 years).

RESULTS

Preoperatively, compared to self-reported nondrinkers, moderate drinkers had better QWB-7, SF-36, and WOMAC scores. At followup, occasional and moderate drinkers had better KS function and HSS scores. However, nondrinkers had greater SF-36 general health improvement. Most nondrinkers were older, female, and Hispanic and had more comorbidities. Nondrinkers had a longer LOS.

CONCLUSIONS

Self-reported alcohol consumption was more common among men and non-Hispanics. Moderate drinkers had better preoperative QWB-7, SF-36, and WOMAC scores and shorter LOS than nondrinkers. However, after surgery, self-reported abstainers achieved greater improvements in the SF-36 general health score.

Redefining hypotension in traumatic brain injury

BACKGROUND

Systemic hypotension is a well documented predictor of increased mortality following traumatic brain injury (TBI). Hypotension is traditionally defined as systolic blood pressure (SBP)<90 mmHg. Recent evidence defines hypotension by a higher SBP in injured (non-TBI) trauma patients. We hypothesize that hypotension threshold requires a higher SBP in isolated moderate to severe TBI.

PATIENTS AND METHODS

A retrospective database review of all adults (≥ 15 years) with isolated moderate to severe TBI (head abbreviated injury score (AIS)≥ 3, all other AIS ≤ 3), admitted from five Level I and eight Level II trauma centres (Los Angeles County), between 1998 and 2005. Several fit statistic analyses were performed for each admission SBP from 60 to 180 mmHg to identify the model that most accurately defined hypotension for three age groups: 15-49 years, 50-69 years, and ≥ 70 years. The main outcome variable was mortality, and the optimal definition of hypotension for each group was determined from the best fit model. Adjusted odds ratios (AOR) were then calculated to determine increased odds in mortality for the defined optimal SBP within each age group.

RESULTS

A total of 15,733 patients were analysed. The optimal threshold of hypotension according to the best fit model was SBP of 110 mmHg for patients 15-49 years (AOR 1.98, CI 1.65-2.39, p<0.0001), 100 mmHg for patients 50-69 years (AOR 2.20, CI 1.46-3.31, p=0.0002), and 110 mmHg for patients ≥ 70 years (AOR 1.92, CI 1.35-2.74, p=0.0003).

CONCLUSIONS

Patients with isolated moderate to severe TBI should be considered hypotensive for SBP<110 mmHg. Further research should confirm this new definition of hypotension by correlation with indices of perfusion.

Elevated admission systolic blood pressure after blunt trauma predicts delayed pneumonia and mortality

BACKGROUND

Although avoiding hypotension is a primary focus after trauma, elevated systolic blood pressure (SBP) is frequently disregarded. The purpose of this study was to determine the association between elevated admission SBP and delayed outcomes after trauma.

METHODS

The Los Angeles County Trauma System Database was queried for all patients between 2003 and 2008 with blunt injuries who survived for at least 2 days after admission. Demographics and outcomes (pneumonia and mortality) were compared at various admission SBP subgroups (≥160 mm Hg, ≥170 mm Hg, ≥180 mm Hg, ≥190 mm Hg, ≥200 mm Hg, ≥210 mm Hg, and ≥220 mm Hg). Patients with moderate-to-severe traumatic brain injury (TBI), defined as head Abbreviated Injury Score ≥3, were then identified and compared with those without using multivariable logistic regression.

RESULTS

Data accessed from 14,382 blunt trauma admissions identified 2,601 patients with moderate-to-severe TBI (TBI group) and 11,781 without moderate-to-severe TBI (non-TBI group) who were hospitalized ≥2 days. Overall mortality was 2.9%, 7.1% for TBI patients, and 1.9% for non-TBI patients. Overall pneumonia was 4.6%, 9.5% for TBI patients, and 3.6% for non-TBI patients. Regression modeling determined SBP ≥160 mm Hg was a significant predictor of mortality in TBI patients (adjusted odds ratio [AOR], 1.59; confidence interval [CI], 1.10-2.29; p = 0.03) and non-TBI patients (AOR, 1.47; CI, 1.14-1.90; p = 0.003). Similarly, SBP ≥160 mm Hg was a significant predictor for increased pneumonia in TBI patients (AOR, 1.79; CI, 1.30-2.46; p = 0.0004), compared with non-TBI patients (AOR, 1.28; CI, 0.97-1.69; p = 0.08).

CONCLUSIONS

In blunt trauma patients with or without TBI, elevated admission SBP was associated with worse delayed outcomes. Prospective research is necessary to determine whether algorithms that manage elevated blood pressure after trauma, especially after TBI, affect mortality or pneumonia.