Sex-based differences in outcomes after severe injury: an analysis of blunt trauma patients in China

Sex-related immunity: could Toll-like receptors be the answer in acute inflammatory response?

An increasing number of studies have highlighted the existence of a sex-specific immune response, wherein men experience a worse prognosis in cases of acute inflammatory diseases. Initially, this sex-dependent inflammatory response was attributed to the influence of sex hormones. However, a growing body of evidence has shifted the focus toward the influence of chromosomes rather than sex hormones in shaping these inflammatory sex disparities. Notably, certain pattern recognition receptors, such as Toll-like receptors (TLRs), and their associated immune pathways have been implicated in driving the sex-specific immune response. These receptors are encoded by genes located on the X chromosome. TLRs are pivotal components of the innate immune system, playing crucial roles in responding to infectious diseases, including bacterial and viral pathogens, as well as trauma-related conditions. Importantly, the TLR-mediated inflammatory responses, as indicated by the production of specific proteins and cytokines, exhibit discernible sex-dependent patterns. In this review, we delve into the subject of sex bias in TLR activation and explore its clinical implications relatively to both the X chromosome and the hormonal environment. The overarching objective is to enhance our understanding of the fundamental mechanisms underlying these sex differences.

Fibrinogen Fragment X Mediates Endothelial Barrier Disruption via Suppression of VE-Cadherin

INTRODUCTION

Major traumatic injury is associated with early hemorrhage-related and late-stage deaths due to multiple organ failure (MOF). While improvements to hemostatic resuscitation have significantly reduced hemorrhage-related deaths, the incidence of MOF among trauma patients remains high. Dysregulation of vascular endothelial cell (EC) barrier function is a central mechanism in the development of MOF; however, the mechanistic triggers remain unknown. Accelerated fibrinolysis occurs in a majority of trauma patients, resulting in high circulating levels of fibrin(ogen) degradation products, such as fragment X. To date, the relationship between fragment X and EC dysregulation and barrier disruption is unknown. The goal of this study was to determine the effects of fragment X on EC barrier integrity and expression of paracellular junctional proteins that regulate barrier function.

METHODS

Human lung microvascular endothelial cells (HLMVECs) were treated with increasing concentrations of fragment X (1, 10, and 100 μg/mL), and barrier function was monitored using the xCELLigence live-cell monitoring system. Quantitative PCR (qPCR) was performed to measure changes in EC expression of 84 genes. Immunofluorescent (IF) cytostaining was performed to validate qPCR findings.

RESULTS

Fragment X treatment significantly increased endothelial permeability over time (P < 0.05). There was also a significant reduction in VE-cadherin mRNA expression in fragment X-treated HLMVECs compared to control (P = 0.01), which was confirmed by IF staining.

CONCLUSIONS

Fragment X may induce EC hyperpermeability by reducing VE-cadherin expression. This suggests that a targeted approach to disrupting EC-fragment X interactions could mitigate EC barrier disruption, organ edema, and MOF associated with major trauma.

Sex differences in frailty among older adults

By definition, aging is a natural, gradual and continuous process. On the other hand, frailty reflects the increase in vulnerability to stressors and shortens the time without disease (health span) while longevity refers to the length of life (lifespan). The average life expectancy has significantly increased during the last few decades. A longer lifespan has been accompanied by an increase in frailty and decreased independence in older adults, with major differences existing between men and women. For example, women tend to live longer than men but also experience higher rates of frailty and disability. Sex differences prevent optimization of lifestyle interventions and therapies to effectively prevent frailty. Sex differences in frailty and aging are rooted in a complex interplay between uncontrollable (genetic, epigenetic, physiological), and controllable factors (psychosocial and lifestyle factors). Thus, understanding the underlying causes of sex differences in frailty and aging is essential for developing personalized interventions to promote healthy aging and improve quality of life in older men and women. In this review, we have discussed the key contributors and knowledge gaps related to sex differences in aging and frailty.

Firearms-related injury and sex: a comparative National Trauma Database (NTDB) Study

Background

Existing study findings on firearms-related injury patterns are largely skewed towards males, who comprise the majority of this injury population. Given the paucity of existing data for females with these injuries, we aimed to elucidate the demographics, injury patterns, and outcomes of firearms-related injury in females compared with males in the USA.

Materials and methods

A 7-year (2013-2019) retrospective review of the National Trauma Database was conducted to identify all adult patients who suffered firearms-related injuries. Patients who were males were matched (1:1, caliper 0.2) to patients who were females by demographics, comorbidities, injury patterns and severity, and payment method, to compare differences in mortality and several other post-injury outcomes.

Results

There were 196 696 patients admitted after firearms-related injury during the study period. Of these patients, 23 379 (11.9%) were females, 23 378 of whom were successfully matched to a male counterpart. After matching, females had a lower rate of in-hospital mortality (18.6% vs. 20.0%, p<0.001), deep vein thrombosis (1.2% vs. 1.5%, p=0.014), and had a lower incidence of drug or alcohol withdrawal syndrome (0.2% vs. 0.5%, p<0.001) compared with males.

Conclusion

Female victims of firearms-related injuries experience lower rates of mortality and complications compared with males. Further studies are needed to elucidate the cause of these differences.

Level of evidence

Level III.

Anemia Recovery After Lung Contusion, Hemorrhagic Shock, and Chronic Stress Is Gender-Specific in a Rat Model

Background: Severe trauma and hemorrhagic shock lead to persistent anemia. Although biologic gender is known to modulate inflammatory responses after critical illness, the impact of gender on anemia recovery after injury remains unknown. The aim of this study was to identify gender-specific differences in anemia recovery after critical illness. Materials and Methods: Male and proestrus female Sprague-Dawley rats (n = 8-9 per group) were subjected to lung contusion and hemorrhagic shock (LCHS) or LCHS with daily chronic stress (LCHS/CS) compared with naïve. Hematologic data, bone marrow progenitor growth, and bone marrow and liver gene transcription were analyzed on day seven. Significance was defined as p < 0.05. Results: Males lost substantial weight after LCHS and LCHS/CS compared with naïve males, while female LCHS rats did not compared with naive counterparts. Male LCHS rats had a drastic decrease in hemoglobin from naïve males. Male LCHS/CS rats had reduced colony-forming units-granulocyte, -erythrocyte, -monocyte, -megakaryocyte (CFU-GEMM) and burst-forming unit-erythroid (BFU-E) when compared with female counterparts. Naïve, LCHS, and LCHS/CS males had lower serum iron than their respective female counterparts. Liver transcription of BMP4 and BMP6 was elevated after LCHS and LCHS/CS in males compared with females. The LCHS/CS males had decreased expression of bone marrow pro-erythroid factors compared with LCHS/CS females. Conclusions: After trauma with or without chronic stress, male rats demonstrated increased weight loss, substantial decrease in hemoglobin level, dysregulated iron metabolism, substantial suppression of bone marrow erythroid progenitor growth, and no change in transcription of pro-erythroid factors. These findings confirm that gender is an important variable that impacts anemia recovery and bone marrow dysfunction after traumatic injury and shock in this rat model.

Injury characteristics and predictors of mortality in patients undergoing pancreatic excision after abdominal trauma: A National Trauma Data Bank (NTDB) study

Pancreatic tumors and pancreatitis are the main indications for pancreatic excision (PE). However, little is known about this type of intervention in the context of traumatic injuries. Surgical care for traumatic pancreatic injuries is challenging because of the location of the organ and the lack of information on trauma mechanisms, vital signs, hospital deposition characteristics, and associated injuries. This study examined the demographics, vital signs, associated injuries, clinical outcomes, and predictors of in-hospital mortality in patients with abdominal trauma who had undergone PE. Following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, we analyzed the National Trauma Data Bank and identified patients who underwent PE for penetrating or blunt trauma after an abdominal injury. Patients with significant injuries in other regions (abbreviated injury scale score ≥ 2) were excluded. Of the 403 patients who underwent PE, 232 had penetrating trauma (PT), and 171 had blunt trauma (BT). The concomitant splenic injury was more prevalent in the BT group; however, the frequency of splenectomy was comparable between groups. In particular, concomitant kidney, small intestine, stomach, colon, and liver injuries were more common in the PT group (all P < .05). Most injuries were observed in the pancreatic body and tail regions. The trauma mechanisms also differed between the groups, with motor vehicles accounting for most of the injuries in the BT group and gunshots accounting for most of the injuries in the PT group. In the PT group, major liver lacerations were approximately 3 times more common (P < .001). The in-hospital mortality rate was 12.4%, with no major differences between the PT and BT groups. Furthermore, there was no difference between BT and PT with respect to the location of the injuries in the pancreas, with the pancreatic tail and body accounting for almost 65% of injuries. Systolic blood pressure, Glasgow Coma Scale score, age, and major liver laceration were revealed by logistic regression as independent predictors of mortality, although trauma mechanisms and intent were not linked to mortality risk.

Female sex is independently associated with reduced inpatient mortality after endovascular repair of blunt thoracic aortic injury

BACKGROUND

Female sex has been associated with decreased mortality after blunt trauma, but whether sex influences the outcomes of thoracic endovascular aortic repair (TEVAR) for traumatic blunt thoracic aortic injury (BTAI) is unknown.

METHODS

In this retrospective study of a prospectively maintained database, the Vascular Quality Initiative registry was queried from 2013 to 2020 for patients undergoing TEVAR for BTAI. Univariate Student's t-tests and χ² tests were performed, followed by multivariate logistic regression for variables associated with inpatient mortality.

RESULTS

Of 806 eligible patients, 211 (26.2%) were female. Female patients were older (47.9 vs 41.8 years, P < .0001) and less likely to smoke (38.3% vs 48.2%, P = .044). Most patients presented with grade III BTAI (54.5% female, 53.6% male), followed by grade IV (19.0% female, 19.5% male). Mean Injury Severity Scores (30.9 + 20.3 female, 30.5 + 18.8 male) and regional Abbreviated Injury Score did not vary by sex. Postoperatively, female patients were less likely to die as inpatients (3.8% vs 7.9%, P = .042) and to be discharged home (41.4% vs 52.2%, P = .008). On multivariate logistic regression, female sex (odds ratio [OR]: 0.05, P = .002) was associated with reduced inpatient mortality. Advanced age (OR: 1.06, P < .001), postoperative transfusion (OR: 1.05, P = .043), increased Injury Severity Score (OR: 1.03, P = .039), postoperative stroke (OR: 9.09, P = .016), postoperative myocardial infarction (OR: 9.9, P = .017), and left subclavian coverage (OR: 2.7, P = .029) were associated with inpatient death.

CONCLUSIONS

Female sex is associated with lower odds of inpatient mortality after TEVAR for BTAI, independent of age, injury severity, BTAI grade, and postoperative complications. Further study of the influence of sex on postdischarge outcomes is needed.

The effects of sex and neuter status on trauma survival in dogs: A Veterinary Committee on Trauma registry study

OBJECTIVE

To determine the effect of sex and neuter status on trauma survival in dogs.

DESIGN

Multi-institutional prospective case series, September 2013 to March 2019, retrospectively analyzed.

SETTING

Level I and II Veterinary Trauma Centers.

ANIMALS

Consecutive sample of 2649 dogs in the American College of Veterinary Emergency and Critical Care Veterinary Committee on Trauma patient registry meeting inclusion criteria. For inclusion, dogs had to have complete data entries, be postpubertal (≥7 months age in females and ≥10 months age in males), and have sustained moderate to severe trauma (animal trauma triage [ATT] score ≥5/18). Dogs that were dead upon arrival, euthanized for financial or unknown reasons alone, or that were presented by a Good Samaritan but subsequently humanely euthanized were excluded.

MEASUREMENTS AND MAIN RESULTS

Data collected included age, sex, neuter status (intact, neutered), trauma type (blunt, penetrating, both), outcome (survived to hospital discharge, died, euthanized), and reason for euthanasia (grave prognosis, financial reasons, or both). Of 2649 eligible dogs, 56% survived to hospital discharge (n = 1469). Neutered females had a significantly higher survival rate (58.3% vs 51.3%; P = 0.03) compared to intact females, and neutered males had a significantly higher survival rate (56.6% vs 50.7%; P = 0.04) compared to intact males. There was no significant difference in survival between intact females and intact males (P = 0.87) or between neutered females and neutered males (P = 0.46). Mean cumulative ATT score was higher in intact groups and was found to be a significant predictor of survival (P < 0.01). Based on logistic models, overall odds of survival were 20.7% greater in neutered dogs.

CONCLUSIONS

Gonadectomy is associated with lower ATT scores and improved survival after moderate to severe trauma in both female and male dogs.

Patient age affects sex-based differences in post-traumatic mortality: a national trauma registry study in Japan

PURPOSE

Sex-based differences in post-traumatic mortality have been widely discussed for quite some time. We hypothesized that age-related pathophysiologic changes would affect sex-based differences in post-traumatic mortality and aimed to verify the hypothesis using a nationwide trauma registry in Japan.

METHODS

This was a retrospective analysis of trauma patients registered in The Japanese Trauma Data Bank. We stratified the study population into the following three subsets based on age: (1) pediatric subset (age ≤ 14), (2) adult subset (age 15-50) and (3) senior adult subset (age ≥ 51). We evaluated both sex-based differences in mortality in each subset separately using multivariate logistic regression analysis and the two-way interaction effect for predicted survival between the continuous increase of age and the sexes using a nonlinear multivariate regression model.

RESULTS

We included 122,819 trauma patients who fulfilled the inclusion criteria and classified them into the 3 subsets according to age. Male patients were more likely to die compared to female patients only in the senior adult subset (adjusted odds ratio: 1.26; 95% confidence interval: 1.18-1.36), whereas there were no statistically significant differences in the other two subsets. Furthermore, non-linear logistic regression analysis revealed that predicted survival probability in male patients decreased more sharply in accordance with the increase of age compared to that in female patients (p for interaction: 0.051).

CONCLUSION

Age-related change in post-traumatic mortality was significantly different between males and females, and male patients had a relatively higher risk of death in the older population.

Which criteria is a better predictor of ICU admission in trauma patients? An artificial neural network approach

PURPOSE

One of the most critical concerns in the intensive care unit (ICU) section is identifying the best criteria for entering patients to this part. This study aimed to predict the best compatible criteria for entering trauma patients in the ICU section.

METHOD

The present study was a historical cohort study. The data were collected from 2448 trauma patients referring to Shahid Rajaee Hospital between January 2015 and January 2017 in Shiraz, Iran. The artificial neural network (ANN) models with cross-validation and logistic regression (LR) with a backward method was used for data analysis. The final analysis was performed on a total of 958 patients who were transferred to the ICU section.

RESULTS

Based on the present results, the motor component of the GCS score at each cutoff point had the highest importance. The results also showed better performance for the AUC and accuracy rate for ANN compared with LR.

CONCLUSION

The most critical indicators in predicting the optimal use of ICU services in this study were the Motor component of the GCS. Results revealed that the ANN had a better performance than the LR in predicting the main outcomes of the traumatic patients in both the accuracy and AUC index. Trauma section surgeons and ICU specialists will benefit from this study's results and can assist them in making decisions to predict the patient outcomes before entering the ICU.

Impact of patients' gender on microvascular lower extremity reconstruction

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.

Estrogen As A Safe Therapeutic Adjunct in Reducing The Inflammatory Storm in Trauma Hemorrhagic Shock Patients

ABSTRACT

Trauma is a major cause of death and disability throughout the world. It is a leading cause of death with or without sepsis in about 50% of patients. Limited therapeutic options are available besides definitive care with a mortality benefit. Pre-clinical studies have demonstrated the mortality benefit of estrogen in trauma hemorrhagic shock(THS). Based on encouraging results from pre-clinical studies, we hypothesised that early administration of estrogen in male THS patients may reduce the inflammatory storm, prevent sepsis associated problems, and subsequently reduce mortality. The authors studied the safety of early administration of estrogen as a therapeutic adjunct in the emergency department (ED) and its effects on the inflammatory storm, prevention of sepsis, and mortality during the intensive care unit (ICU) stay. 40, THS patients were recruited. THS patients were divided into experimental and placebo control groups based on the estrogen administration in the ED. Serum levels of cytokines and immune cells were measured at different time points on days 0, 3, 7, and 14 in both groups of THS patients. The experimental group received intravenous estrogen (25 mg) at a single time point in the ED beside standard of care as per advanced trauma life support (ATLS) guidelines. Patients did not develop any major or minor adverse events and showed favorable clinical outcomes in the experimental group. The levels of T regulatory cells, monocytes, and systemic cytokines significantly reduced and showed a balanced inflammatory response in THS patients who received estrogen.In conclusion, this preliminary study showed that intravenous estrogen therapy is safe and reduced the inflammatory insult due to trauma hemorrhagic shock. It may protect THS patients from sepsis-associated complications. Future clinical trials are required to study the efficacy and mechanistic pathway.

Role of gender in the survival outcome of acute phase of major trauma: A nationwide, population-based study

BACKGROUND

Animal models of trauma have shown that females have better posttraumatic survival; however, results of previous studies on the influence of gender on major trauma patients have been controversial. This study aimed to evaluate the association between gender and survival in major trauma patients.

METHODS

We retrospectively analyzed patients registered in Taiwan's National Health Insurance Research Database between 2008 and 2012 with the diagnosis codes 800-939 and 950-957 (International Classification of Diseases, ninth revision, clinical modification). Data on gender, age, catastrophic illness, and new injury severity score (NISS) ≥16 were collected for comparing patients' mortality after trauma. Propensity score matching (PSM) was performed to eliminate dissimilarities in age, comorbidities, NISS, and primary traumatic regions between the genders.

RESULTS

Among 10 012 major trauma patients included in the study cohort, 28.8% (n = 2880) were women. The PSM patient group consisted of 50% (2876 of 5752) women. Women had a higher 30-day (15.4% of women vs 13.8% of men; p < 0.05) and hospital (16.1% of women vs 14.5% of men; p < 0.05) mortality and lower incidence rates of acute respiratory dysfunction (62.5% of women vs 65.9% of men; p < 0.005) and acute hepatic dysfunction (0.8% of women vs 2.1% of men; p < 0.001). However, the analysis of PSM patient groups showed lower mortality rates in women with moderate trauma (NISS 16-24) in the acute phase within three days (1.4% of women vs 2.7% of men, p = 0.03). Analysis of patients with an NISS of 16-24 who died within three days showed a higher NISS in women than in men (19.7 ± 2.3 vs 18.0 ±1.9, respectively, p <0.05).

CONCLUSION

There is no gender difference in 30-day or hospital mortality among major trauma patients. However, women admitted for moderate major trauma had higher survival within three days of major trauma.

Reduced Recovery Capacity After Major Trauma in the Elderly: Results of a Prospective Multicenter Registry-Based Cohort Study

AIMS

Considering the worldwide trend of an increased lifetime, geriatric trauma is moving into focus. Trauma is a leading cause of hospitalization, leading to disability and mortality. The purpose of this study was to compare the global health-related quality of life (HRQoL) of geriatric patients with adult patients after major trauma.

METHODS

This multicenter prospective registry-based observational study compares HRQoL of patients aged ≥65 years who sustained major trauma (Injury Severity Score (ISS) ≥ 16) with patients <65 years of age within the trauma registry of the German Trauma Society (DGU). The global HRQoL was measured at 6, 12, and 24 months post trauma using the EQ-5D-3L score.

RESULTS

We identified 405 patients meeting the inclusion criteria with a mean ISS of 25.6. Even though the geriatric patients group (≥65 years, n = 77) had a lower ISS (m = 24, SD = 8) than patients aged <65 years (n = 328), they reported more difficulties in each EQ dimension compared to patients <65 years. Contrary to patients < 65, the EQ-5D Index of the geriatric patients did not improve at 12 and 24 months after trauma.

CONCLUSIONS

We found a limited HRQoL in both groups after major trauma. The group of patients ≥65 showed no improvement in HRQoL from 6 to 24 months after trauma.

Influence of gender difference on outcomes of adult burn patients in a developing country

The aim of this study was to investigate the impact of gender on outcomes among adult burn patients. A retrospective study was conducted on 5061 adult burn patients (16 - 64 years old) admitted to the Vietnam National Burn Hospital over a three-year period (2016 - 2018). Demographic data, burn features and outcome including complications, length of hospital stay and mortality of male and female groups were compared. Results indicated that male patients were predominant (72.8%), younger (35.5 vs. 37.2 years old; p < .001) and admitted sooner to hospital. A greater number of males suffered electrical and flame/heat direct contact injuries, whereas more females suffered scald injury (34.7% vs. 12.2%; p < .001). Burn extent was larger among males (14.9% vs. 12.1%; p < .001). In addition, a higher proportion of deep burn injuries (44.8% vs. 41.2%; p < .05) and number of surgeries (1.2 vs. 1; p < .05), and longer hospital stay (17.8 vs. 15.8 days; p < .001) was recorded among the male group. Post burn complication and overall mortality rate did not differ between the two groups. However, death rate was remarkably higher in the female group when burn extent was ≥ 50% TBSA (72.4% vs. 57.3%; p < .05). In conclusion, burn features and outcomes were not similar between the male and female group. Male patients appear to suffer more severe injury requiring more surgeries and longer hospital stay. However, more attention should be paid to the significantly higher mortality rate among females with extensive burn.

Impact of the academic calendar cycle on survival outcome of injured patients: a retrospective cohort study at a community emergency department in Japan

Background

Commencement of a new academic cycle is presumed to be associated with poor patient outcomes. However, supportive evidence is limited for trauma patients treated in under-resourced hospitals, especially those who require specialized interventions and with little physiological reserve. We examined whether a new academic cycle affects the survival outcomes of injured patients in a typical Japanese teaching hospital.

Methods

This historical cohort study was conducted at a Japanese community emergency department (ED). All injured patients brought to the ED from April 2002 to March 2018 were included in the analysis. The primary exposure was presentation to the ED during the first quartile of the academic cycle (April-June). The primary outcome measure was the hospital mortality rate.

Results

Of the 20,945 eligible patients, 5282 (25.2%) were admitted during the first quartile. In the univariable analysis, the hospital mortality rate was similar between patients admitted during the first quartile of the academic year and those admitted during the remaining quartiles (4.1% vs. 4.4%, respectively; odds ratio [OR], 0.931; 95% confidence interval [CI] 0.796-1.088). After adjusting for the potential confounding factors of the injury severity score, age, sex, Glasgow coma scale score, systolic blood pressure, trauma etiology (blunt or penetrating), and admission phase (2002-2005, 2006-2009, 2010-2013, and 2014-2018), no statistically significant association was present between first-quartile admission and trauma death (adjusted OR 0.980; 95% CI 0.748-1.284). Likewise, when patients were subgrouped according to age of > 55 years, injury severity score of > 15, Glasgow coma scale score of < 9, systolic blood pressure of < 90 mmHg, requirement for doctor car system dispatches, emergency operation, emergency endotracheal intubation, and weekend and night presentation, no significant associations were present between first-quartile admission and hospital mortality in both the univariable and multivariable analysis.

Conclusions

At a community hospital in Japan, admission at the beginning of the academic year was not associated with an increased risk of hospital mortality among trauma patients, even those requiring specialized interventions and with little physiological reserve. Our results support the uniformity of trauma care provision throughout the academic cycle in a typical Japanese trauma system.

Female risk-adjusted survival advantage after injuries caused by falls, traffic or assault: a nationwide 11-year study

BACKGROUND

A female survival advantage after injury has been observed, and animal models of trauma have suggested either hormonal or genetic mechanisms as component causes. Our aim was to compare age and risk-adjusted sex-related mortality in hospital for the three most common mechanisms of injury in relation to hormonal effects as seen by age.

METHODS

All hospital admissions for injury in Sweden during the period 2001-2011 were retrieved from the National Patient Registry and linked to the Cause of Death Registry. The International Classification of Diseases Injury Severity Score (ICISS) was used to adjust for injury severity, and the Charlson Comorbidity Index to adjust for comorbidity. Age categories (0-14, 15-50, and ≥ 51 years) were used to represent pre-menarche, reproductive and post- menopausal women.

RESULTS

Women had overall a survival benefit (OR 0.51; 95% CI 0.50 to 0.53) after adjustment for injury severity and comorbidity. A similar pattern was seen across the age categories (0-14 years OR 0.56 (95% CI 0.25 to 1.25), 15-50 years OR 0.70 (95% CI 0.57 to 0.87), and ≥ 51 years OR 0.49 (95% CI 0.48 to 0.51)).

CONCLUSION

In this 11-year population-based study we found no support for an oestrogen-related mechanism to explain the survival advantage for females compared to males following hospitalisation for injury.

Does County-Level Medical Centre Policy Influence the Health Outcomes of Patients with Trauma Transported by the Emergency Medical Service System? An Integrated Emergency Model in Rural China

This study aimed to assess the effect of the county-level medical centre policy on the health outcomes of trauma patients transported by emergency medical service (EMS) system in rural China. The methodology involved the use of electronic health records (EHRs, after 2016) of patients with trauma conditions such as head injury (n = 1931), chest (back) injury (n = 466), abdominal (waist) injury (n = 536), and limb injury (n = 857) who were transported by EMS to the county-level trauma centres of Huining County and Huan County in Gansu, China. Each patient was matched with a counterpart to a county-level trauma centre hospital by propensity score matching. Cox proportional hazard models were used to estimate the hazard ratios (HRs) of such patients in different hospitals. The HRs of all patients with the abovementioned traumatic conditions transported by EMS to county-level trauma centre hospitals were consistently higher than those transported by EMS to traditional hospitals after adjusting for numerous potential confounders. Higher HRs were associated with all patients with trauma (HR = 1.249, p < 0.001), head injury (HR = 1.416, p < 0.001), chest (back) injury (HR = 1.112, p = 0.560), abdominal (waist) injury (HR = 1.273, p = 0.016), and limb injury (HR = 1.078, p = 0.561) transported by EMS to the county-level trauma centre hospitals. Our study suggests that the construction of county-level medical centre provides an effective strategy to improve the health outcomes of EMS-transported trauma patients in Gansu, China. Policy makers can learn from the experience and improve the health outcomes of such patients through a personalised trauma treatment system and by categorizing the regional trauma centre.

Gender differences in trauma, shock and sepsis

Despite efforts in prevention and intensive care, trauma and subsequent sepsis are still associated with a high mortality rate. Traumatic injury remains the main cause of death in people younger than 45 years and is thus a source of immense social and economic burden. In recent years, the knowledge concerning gender medicine has continuously increased. A number of studies have reported gender dimorphism in terms of response to trauma, shock and sepsis. However, the advantageous outcome following trauma-hemorrhage in females is not due only to sex. Rather, it is due to the prevailing hormonal milieu of the victim. In this respect, various experimental and clinical studies have demonstrated beneficial effects of estrogen for the central nervous system, the cardiopulmonary system, the liver, the kidneys, the immune system, and for the overall survival of the host. Nonetheless, there remains a gap between the bench and the bedside. This is most likely because clinical studies have not accounted for the estrus cycle. This review attempts to provide an overview of the current level of knowledge and highlights the most important organ systems responding to trauma, shock and sepsis. There continues to be a need for clinical studies on the prevailing hormonal milieu following trauma, shock and sepsis.

Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department

The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.

Prehospital Index provides prognosis for hospitalized patients with acute trauma

OBJECTIVE

To evaluate the prognostic value of the Prehospital Index (PHI) for hospitalized patients with acute trauma.

MATERIALS AND METHODS

PHI score and the Injury Severity Score (ISS) were determined in 1,802 hospitalized patients with acute trauma. Receiver-operator characteristic (ROC) curves were used to compare the PHI and ISS in subgroups, and corresponding prediction indicators were calculated.

RESULTS

There were significant differences in PHI score and ISS between the survival group and the death group (Z=2.674, P=0.007). The area under the ROC curve was 0.871 (95% CI 0.855-0.886) for PHI score and 0.792 (95% CI 0.773-0.811) for ISS. Optimal cutoff points to determine the risk of critical illness were PHI ≥4 and ISS ≥22. The sensitivity of the PHI was superior to the ISS (χ²=6.975, P=0.008), but the specificity and the accuracy of the PHI and ISS showed no significant difference (P>0.05).

CONCLUSION

The PHI is valuable in prognostic prediction of hospitalized patients with acute trauma, and it is superior to the ISS. The PHI has such advantages as being simple in operation, easy to learn, capable of reflecting conditions timely and reliably, and suitable for dynamic evaluation and screening for critical patients with trauma.