The Low Fall as a Surrogate Marker of Frailty Predicts Long-Term Mortality in Older Trauma Patients

Mapping sex and gender differences in falls among older adults: A scoping review

BACKGROUND

There is growing recognition of the importance of sex and gender differences within falls literature, but the characterization of such literature is uncertain. The aim of this scoping review was to (1) map the nature and extent of falls literature examining sex or gender differences among older adults, and (2) identify gaps and opportunities for further research and practice.

METHODS

We used a scoping review methodology. Eligible studies included participants with a mean age of ≥ 60 years and study aims specifying falls and either sex or gender concepts. MEDLINE, Embase, CINAHL, Ageline, and Psychinfo databases were searched from inception to March 2, 2022. Records were screened and charted by six independent reviewers. Descriptive and narrative reports were generated.

RESULTS

A total of 15,266 records were screened and 74 studies were included. Most studies reported on sex and gender differences in fall risk factors (n = 52, 70%), incidence/prevalence (n = 26, 35%), fall consequences (n = 22, 30%), and fall characteristics (n = 15, 20%). The majority of studies (n = 70, 95%) found significant sex or gender differences in relation to falls, with 39 (53%) identifying significant sex differences and 31 (42%) identifying significant gender differences. However, only three (4%) studies defined sex or gender concepts and only nine (12%) studies used sex or gender terms appropriately. Fifty-six (76%) studies had more female participants than males. Four (5%) were intervention studies. Studies did not report falls in line with guidelines nor use common fall definitions.

CONCLUSION

Sex and gender differences are commonly reported in falls literature. It is critical for future research to use sex and gender terms appropriately and include similar sample sizes across all genders and sexes. In addition, there is a need to examine more gender-diverse populations and to develop interventions to prevent falls that address sex and gender differences among older adults.

Association Between Falls, Head Impacts, and Mortality Among Older Adults in Long-Term Care

OBJECTIVES

Residents in long-term care (LTC) are at high risk for falls, and falls in LTC often result in impact to the head, with clinical consequences that may be challenging to detect. We examined whether the survival of LTC residents associates with falls and fall-related head impacts.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

This study was conducted in 2 Vancouver-area LTC homes where falls were captured on video from surveillance cameras. A total of 232 participants (133 females, 99 males) experienced at least 1 fall captured on video, among whom 84% (n = 194) died between January 2011 and January 2020. The mean age at death was 86.5 (SD = 8.5) years, and the mean survival time after enrollment to this study was 3.8 (SD = 2.1) years.

METHODS

Univariable and multivariable models were used to determine how survival time depended on the rate of falls (falls per 365 days), the percentage of falls on video involving head impact, sex, age at death, and baseline physical and cognitive status.

RESULTS

On average, participants experienced 6.2 (SD = 7.0) falls per 365 days, and 36.9% (SD = 36.3) of video-captured falls resulted in head impact. In multivariable analyses, an increase of 1 fall per 365 days resulted in a 4.2% higher risk of death [hazard ratio (HR) = 1.042, 95% CI 1.023-1.062, P < .001]. A 1% increase in falls involving head impact resulted in an 0.5% higher risk of death (HR 1.005, 95% CI 1.001-1.010, P = .015). Participants who experienced head impact in all video-captured falls had a 50% higher risk for death than those who always avoided head impact.

CONCLUSIONS AND IMPLICATIONS

Survival in LTC is associated with the rate of falls and percentage of falls involving head impact. Improved efforts are required to prevent falls in LTC, and reduce the frequency and consequences of head impacts during falls (eg, through compliant flooring).

Pragmatic multicentre stepped-wedge cluster randomised trial to investigate the effectiveness of community-based falls prevention programme for older adults with falls risk in Singapore: a protocol paper

INTRODUCTION

Falls are an important public health issue with consequences that include injuries, quality of life reduction and high healthcare costs. Studies show that falls prevention strategies are effective in reducing falls rate among community-dwelling older adults. However, the evaluation for effectiveness was usually done in a controlled setting with homogeneous population, and thus may not be generalisable to a wider population. This study aims to evaluate the impact of community falls prevention programmes with group-based strength and balance exercises, on falls risk and health outcomes for older adults with falls risk in Singapore.

METHODS AND ANALYSIS

This is a pragmatic closed cohort stepped-wedge cluster randomised trial design study, which involves sequential crossover of clusters from the waitlist control condition to the intervention condition, with the sequence of crossover randomly determined. The intervention will be sequentially rolled out to 12 clusters (a minimum of 5 participants/cluster), over 6 time periods with 8-week intervals in Central and North regions of Singapore. The primary analysis will be conducted under the intention-to-treat principle. A general linear mixed model or generalised estimating equation analysis appropriate for a multilevel longitudinal study incorporating an appropriate error distribution and link function will be used. Markov model will be developed to estimate the incremental cost per quality-adjusted life years and incremental cost per fall prevented from the implementation of falls prevention strategies from a societal perspective. Conditional on there being clinically relevant differences in short-term outcomes, we will implement simulation modelling to project the long-term divergence in trajectories for outcomes and costs using the Markov model.

ETHICS AND DISSEMINATION

Ethics approval has been obtained. Results will be disseminated in publications and other relevant platforms.

TRIAL REGISTRATION NUMBER

NCT04788251.

Care and support networks of community-dwelling frail individuals in North West London: a comparison of patient and healthcare workers' perceptions

BACKGROUND

Evidence suggests that successful assessment and care for frail individuals requires integrated and collaborative care and support across and within settings. Understanding the care and support networks of a frail individual could therefore prove useful in understanding need and designing support. This study explored the care and support networks of community-dwelling older people accessing a falls prevention service as a marker of likely frailty, by describing and comparing the individuals' networks as perceived by themselves and as perceived by healthcare providers involved in their care.

METHODS

A convenience sample of 16 patients and 16 associated healthcare professionals were recruited from a community-based NHS 'Falls Group' programme within North-West London. Individual (i.e., one on one) semi-structured interviews were conducted to establish an individual's perceived network. Principles of quantitative social network analysis (SNA) helped identify the structural characteristics of the networks; qualitative SNA and a thematic analysis aided data interpretation.

RESULTS

All reported care and support networks showed a high contribution level from family and friends and healthcare professionals. In patient-reported networks, 'contribution level' was often related to the 'frequency' and 'helpfulness' of interaction. In healthcare professional reported networks, the reported frequency of interaction as detailed in patient records was used to ascertain 'contribution level'.

CONCLUSION

This study emphasises the importance of the role of informal carers and friends along with healthcare professionals in the care of individuals living with frailty. There was congruence in the makeup of 'patient' and 'provider' reported networks, but more prominence of helper/carers in patients' reports. These findings also highlight the multidisciplinary makeup of a care and support network, which could be targeted by healthcare professionals to support the care of frail individuals.

Negative and positive experiences of caregiving among family caregivers of older blunt trauma patients

OBJECTIVES

Family caregivers play a fundamental role in the care of the older blunt trauma patient. We aim to identify risk factors for negative and positive experiences of caregiving among family caregivers.

DESIGN

Prospective, nationwide, multi-center cohort study.

SETTING AND PARTICIPANTS

110 family caregivers of Singaporeans aged≥55 admitted for unintentional blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS)≥10 were assessed for caregiving-related negative (disturbed schedule and poor health, lack of family support, lack of finances) and positive (esteem) experiences using the modified-Caregiver Reaction Assessment (m-CRA) three months post-injury.

METHODS

The association between caregiver and patient factors, and the four m-CRA domains were evaluated via linear regression.

RESULTS

Caregivers of retired patients and caregivers of functionally dependent patients (post-injury Barthel score <80) reported a worse experience in terms of disturbed schedule and poor health (β-coefficient 0.42 [95% Confidence Interval 0.10, 0.75], p = .01; 0.77 [0.33, 1.21], p = .001), while male caregivers and caregivers who had more people in the household reported a better experience (-0.39 [-0.73, -0.06], p = .02; -0.16 [-0.25, -0.07], p = .001). Caregivers of male patients, retired patients, and patients living in lower socioeconomic housing were more likely to experience lack of family support (0.28, [0.03, -0.53], p = .03; 0.26, [0.01, 0.52], p = .05; 0.34, [0.05, -0.66], p = .02). In the context of lack of finances, caregivers of male patients and caregivers of functionally dependent patients reported higher financial strain (0.74 [0.31, 1.17], p = .001; 0.84 [0.26, 1.43], p = .01). Finally, caregivers of male patients reported higher caregiver esteem (0.36 [0.15, 0.57], p = .001).

CONCLUSIONS AND IMPLICATIONS

Negative and positive experiences of caregiving among caregivers of older blunt trauma patients are associated with pre-injury disability and certain patient and caregiver demographics. These factors should be considered when planning the post-discharge support of older blunt trauma patients.

Epidemiology and outcomes of older trauma patients in Singapore: A multicentre study

BACKGROUND

An ageing population has caused rising trauma cases amongst older patients. Multiple comorbidities, polypharmacy and limited reserves predispose them to poorer outcomes following a traumatic event. The Comorbidity Polypharmacy Score (CPS) has been found to predict outcomes and mortality in older trauma patients, but has not been studied in Asians.

AIM

We aim to describe the epidemiological characteristics of older trauma patients and explore the association of CPS on clinical outcomes.

METHODS

We conducted a retrospective observational study using data from the trauma registries of 2 tertiary trauma centres. Patients aged 45 years and above attending the emergency departments (EDs) from January 2011 to December 2015 with traumatic injuries (Injury Severity Score [ISS] of 9 and above) were included. Demographics, clinical data including number of comorbidities and medications used were collected to calculate the CPS. Outcomes of mortality, ED disposition and hospital discharge venue were examined.

RESULTS

There were 4,522 patients (median age 70 years; males 53.8%), with majority sustaining Tier 2 injuries (ISS 9 to 15; 68.9%). Falls were the predominant mechanism for those aged above 60 years and above (76%). Median CPS was 6 (interquartile range [IQR] 1 to 11). Amongst patients 75 years and older, 56% comprised the moderate to morbid CPS groups (CPS ≥ 8). Overall mortality was 8.4%; patients above 75 years had longer median length of stay (10 versus 7.1-8.9 days in other ages). Male gender (adjusted odds ratio [aOR] 1.51; 95% confidence interval [CI] 1.12-2.02), increasing age (aOR 1.04; 95% CI 1.03-1.05), injury to abdomen (aOR 3.24; 95% CI 1.93-5.45) and severe CPS category (aOR 1.88; 95% CI 1.23-2.89) were associated with increased odds of death. Increasing age and moderate CPS category increased odds of discharge to a rehabilitation (aOR for age 1.03, 95% CI 1.02-1.04; aOR for moderate CPS 1.72, 95% CI 1.43-2.07) or long-term care facility (aOR for age 1.05, 95% CI 1.03-1.06; aOR for CPS 1.60, 95% CI 1.10-2.32).

CONCLUSION

CPS predicted mortality and discharge to a rehabilitation or care facility in this urban, ageing Asian population. Its use may aid future trauma research and needs assessments in such patients.

Clinical Outcomes at 1 Year Following Transcatheter Left Atrial Appendage Occlusion in the United States

OBJECTIVES

The aim of this study was to report 1-year clinical outcomes following commercial transcatheter left atrial appendage occlusion (LAAO) in the United States.

BACKGROUND

The National Cardiovascular Data Registry LAAO Registry was initiated to meet a condition of Medicare coverage and allow the assessment of clinical outcomes. The 1-year rates of thromboembolic events after transcatheter LAAO in such a large cohort of "real-world" patients have not been previously reported.

METHODS

Patients entered into the National Cardiovascular Data Registry LAAO Registry for a Watchman procedure between January 1, 2016, and December 31, 2018, were included. The primary endpoint was ischemic stroke. Key secondary endpoints included the rate of ischemic stroke or systemic embolism, mortality, and major bleeding. Major bleeding was defined as any bleeding requiring hospitalization, and/or causing a decrease in hemoglobin level > 2g/dL, and/or requiring blood transfusion that was not hemorrhagic stroke. The Kaplan-Meier method was used for 1-year estimates of cumulative event rates.

RESULTS

The study population consisted of 36,681 patients. The mean age was 76.0 ± 8.1 years, the mean CHA₂DS₂-VASc score was 4.8 ± 1.5, and the mean HAS-BLED score was 3.0 ± 1.1. Prior stroke was present in 25.5%, clinically relevant bleeding in 69.5%, and intracranial bleeding in 11.9%. Median follow-up was 374 days (IQR: 212-425 days). The Kaplan-Meier-estimated 1-year rate of ischemic stroke was 1.53% (95% CI: 1.39%-1.69%), the rate of ischemic stroke or systemic embolism was 2.19% (95% CI: 2.01%-2.38%), and the rate of mortality was 8.52% (95% CI: 8.19%-8.87%). The 1-year estimated rate of major bleeding was 6.93% (95% CI: 6.65%-7.21%). Most bleeding events occurred between discharge and 45 days following the procedure.

CONCLUSIONS

This study characterizes important outcomes in a national cohort of patients undergoing transcatheter LAAO in the United States. Clinicians and patients can integrate these data in shared decision making when considering this therapy.

Health Services Use and Functional Recovery Following Blunt Trauma in Older Persons - A National Multicentre Prospective Cohort Study

OBJECTIVE

Frailty is associated with morbidity and mortality in older injured patients. However, for older blunt-trauma patients, increased frailty may not manifest in longer length of stay at index admission. We hypothesized that owing to time spent in hospital from readmissions, frailty would be associated with less total time at home in the 1-year postinjury period.

DESIGN

Prospective, nationwide, multicenter cohort study.

SETTING AND PARTICIPANTS

All Singaporean residents aged ≥55 years admitted for blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS) ≥10 from March 2016 to July 2018.

METHODS

Frailty (by modified Fried criteria) was assessed at index admission, based on questions on preinjury weight loss, slowness, exhaustion, physical activity, and grip strength at the time of recruitment. Low time at home was defined as >14 hospitalized days within 1 year postinjury. The contribution of planned and unplanned readmission to time at home postinjury was explored. Functional trajectory (by Barthel Index) over 1 year was compared by frailty.

RESULTS

Of the 218 patients recruited, 125 (57.3%) were male, median age was 72 years, and 48 (22.0%) were frail. On univariate analysis, frailty [relative to nonfrail: odds ratio (OR) 3.45, 95% confidence interval (CI) 1.33-8.97, P = .01] was associated with low time at home. On multivariable analysis, after inclusion of age, gender, ISS, intensive care unit admission, and surgery at index admission, frailty (OR 5.21, 95% CI 1.77-15.34, P < .01) remained significantly associated with low time at home in the 1-year postinjury period. Unplanned readmissions were the main reason for frail participants having low time at home. Frail participants had poorer function in the 1-year postinjury period.

CONCLUSIONS AND IMPLICATIONS

In the year following blunt trauma, frail older patients experience lower time at home compared to patients who were not frail at baseline. Screening for frailty should be considered in all older blunt-trauma patients, with a view to being prioritized for postdischarge support.

CHA2DS2-VASc and has-BLED scores do not accurately stratify risk for stroke or bleed in fall victims with atrial fibrillation

BACKGROUND

Falls are the leading cause of morbidity and mortality in the elderly. Non-valvular Atrial fibrillation (AF) is present in up to 9% of this group and often requires oral anticoagulation (OAC). The CHA₂DS₂-VASc and HAS-BLED scores are validated tools assessing risk of ischemic stroke from AF and major bleeding (MB) from OAC. It is unclear if these predictions remain accurate in post-fall patients. This study seeks to determine the stroke and major bleeding rate in atrial fibrillation patients after a ground level fall and identify if validated risk scoring systems accurately stratify risk in this cohort.

METHODS

Retrospective review of patients with AF presented to the emergency department after a fall. CHA₂DS₂-VASc and HAS-BLED scores were calculated. Follow up information was reviewed to 1 year. Patients were grouped according to discharge thromboprophylaxis plan (DTP): no treatment, Anti-platelet (AP), OAC, and AP + OAC. Outcomes were ischemic stroke, MB, or death at 1 year. Ischemic stroke and MB rates were calculated. Kruskal-Wallis, Χ², Fisher's exact, and multivariable logistic regression were used to evaluate for clinical associations.

RESULTS

192 patients were included. MB rate was 14.5 bleeds/100 person-years, and ischemic stroke rate was 10.9/100 person-years. There were no observed differences between DTPs. Overall, one-year mortality was 22.1%. On unadjusted analysis, CHA₂DS₂-VASc did associate with ischemic stroke (p = 0.03); HAS-BLED did not associate with MB (p = 0.17). After logistic regression accounting for known risk factors, neither system associated with ischemic stroke or MB.

CONCLUSIONS

Fall patients are at higher risk for both ischemic stroke and MB compared to previously published reports. Current risk assessment tools should be used with caution. Further study of risk factors is warranted to guide medication decisions in these patients.

Changing Demographic Trends in spine trauma: The presentation and outcome of Major Spine Trauma in the elderly

INTRODUCTION

Major trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in the near future. However, whether a similar trend exists in those undergoing operative intervention for spinal trauma remains to be elucidated.

AIMS

To compare the presentation and outcomes of patients ≥65 years of age sustaining spine trauma to those <65 years at a national tertiary referral spine centre.

METHODS

The local Trauma Audit Research Network (TARN) database was analysed to identify spinal patients referred to our institution, a national tertiary referral centre, between 01/2016 and 05/2019. Patients were divided into a young cohort (16-64 years old) and an elderly cohort (> 64 years old). No explicit distinction was made between major and minor spine trauma cases. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay.

RESULTS

A total of 669 patients were admitted of which 480 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 75.3% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%), while low falls (<2 m) (57.4%) were the most common mechanism among the older population. Patients ≥65 years old had significantly longer length of stay (21 days [1-194] v 14 days [1-183]) and suffered higher 30-day mortality rates (4.6% [0-12] v 0.97% [0-4]).

CONCLUSION

Orthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.

Frailty and length of stay in older adults with blunt injury in a national multicentre prospective cohort study

Background

Patients suffering moderate or severe injury after low falls have higher readmission and long-term mortality rates compared to patients injured by high-velocity mechanisms such as motor vehicle accidents. We hypothesize that this is due to higher pre-injury frailty in low-fall patients, and present baseline patient and frailty demographics of a prospective cohort of moderate and severely injured older patients. Our second hypothesis was that frailty was associated with longer length of stay (LOS) at index admission.

Methods

This is a prospective, nation-wide, multi-center cohort study of Singaporean residents aged ≥55 years admitted for ≥48 hours after blunt injury with an injury severity score or new injury severity score ≥10, or an Organ Injury Scale ≥3, in public hospitals from 2016–2018. Demographics, mechanism of injury and frailty were recorded and analysed by Chi-square, or Kruskal-Wallis as appropriate.

Results

218 participants met criteria and survived the index admission. Low fall patients had the highest proportion of frailty (44, 27.3%), followed by higher level fallers (3, 21.4%) and motor vehicle accidents (1, 2.3%) (p < .01). Injury severity, extreme age, and surgery were independently associated with longer LOS. Frail patients were paradoxically noted to have shorter LOS (p < .05).

Conclusion

Patients sustaining moderate or severe injury after low falls are more likely to be frail compared to patients injured after higher-velocity mechanisms. However, this did not translate into longer adjusted LOS in hospital at index admission.

RISC II is superior to TRISS in predicting 30-day mortality in blunt major trauma patients in Hong Kong

PURPOSE

Hong Kong (HK) trauma registries have been using the Trauma and Injury Severity Score (TRISS) for audit and benchmarking since their introduction in 2000. We compare the mortality prediction model using TRISS and Revised Injury Severity Classification, version II (RISC II) for trauma centre patients in HK.

METHODS

This was a retrospective cohort study with all five trauma centres in HK. Adult trauma patients with Injury Severity Score (ISS) > 15 suffering from blunt injuries from January 2013 to December 2015 were included. TRISS models using the US and local coefficients were compared with the RISC II model. The primary outcome was 30-day mortality and the area under the receiver operating characteristic curve (AUC) for tested models.

RESULTS

1840 patients were included, of whom 1236/1840 (67%) were male. Median age was 59 years and median ISS was 25. Low falls were the most common mechanism of injury. The 30-day mortality was 23%. RISC II yielded a superior AUC of 0.896, compared with the TRISS models (MTOS: 0.848; PATOS: 0.839; HK: 0.858). Prespecified subgroup analyses showed that all the models performed worse for age ≥ 70, ASA ≥ III, and low falls. RISC II had a higher AUC compared with the TRISS models in all subgroups, although not statistically significant.

CONCLUSION

RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult blunt major trauma patients. RISC II may be useful when performing future audit or benchmarking exercises for trauma in Hong Kong.

CYP2D6-inhibiting drugs and risk of fall injuries after newly initiated antidepressant and antipsychotic therapy in a Swedish, register-based case-crossover study

Drug-drug interactions have been shown to affect the risk of fall injuries when opioids are used concomitantly with drugs inhibiting the cytochrome P450 2D6 (CYP2D6) enzyme in a previous pharmacoepidemiological study. The aim of this study was to determine whether CYP2D6-inhibiting drugs reinforce the risk of fall injuries when used concomitantly with antidepressants or antipsychotics. We identified all 252,704 adults with a first fall injury leading to hospitalisation from the National Patient Register in Sweden 2006–2013. Data on dispensed drugs was linked from the Swedish Prescribed Drug Register. We applied a case-crossover design to analyse newly dispensed (28 days preceding the fall injury, preceded by a 12-week washout period) antidepressants and antipsychotics, respectively, in relation to risk of a fall injury and according to concomitant use of CYP2D6-inhibiting drugs. Newly dispensed drugs were assessed correspondingly in a control period of equal length, 28 days prior to the 12-week washout period. Overall, the risk of fall injury was increased after newly initiated antidepressant and antipsychotic treatment. For antidepressants, concomitant CYP2D6 inhibitor use further elevated the risk estimates compared to non-use, most pronounced for the groups selective serotonin reuptake inhibitors (sertraline excluded) [OR = 1.47 (95% CI 1.19–1.80) vs. OR = 1.19 (95% CI 1.13–1.26)], and tricyclic antidepressants [OR = 1.71 (95% CI 1.17–2.51) vs. 1.27 (95% CI 1.11–1.47)] as well as for sertraline [OR = 1.61 (95% CI 1.05–2.38) vs. 1.12 (95% CI 1.00–1.26)]. For antipsychotics, the risk of fall injury was not altered by concomitant use of CYP2D6-inhibiting drugs. In conclusion, concomitant use of CYP2D6 inhibiting drugs tends to further increase the risk of fall injury in newly initiated antidepressant treatment, but not in antipsychotic treatment.

Postmortem Analysis of Fall Victims According to Age Groups: A Comparative Study

Fall represents an important cause of death and its relation with the population aging evidences the need of a broad analysis considering different aspects associated with its occurrence. The objective of this study was to compare fatal victims due to unintentional fall among adults, young olds, olds, and oldest olds, according to sociodemographic data, characteristics, and severity of the trauma. This study is a cross-sectional, comparative study analyzing autopsy reports of fatal victims due to fall, admitted to the Medical Legal Institute of Sao Paulo, Sao Paulo, Brazil, in 2015. The following age groups were: adults (≥18 and <60 years), young olds (≥60 and <70 years), olds (≥70 and <80 years), and oldest olds (≥80 years). The Pearson's χ, Fisher's exact, Kruskal-Wallis, and Dunn tests were applied to compare the groups, with a significance level of 5%. Regarding the 469 fatalities analyzed (57.8% males, mean age: 71.3 ± 18.2 years), there was a higher frequency of oldest olds (43.5%), ground-level falls (70.1%), femoral fractures (35.0%), and delayed deaths (79.6%) due to posttraumatic complications (57.2%). Adults, young olds, olds, and oldest olds differed significantly (p ≤ .005) in relation to the total of analyzed variables, with a special remark on the differences between the age extremes. High frequencies of femoral fractures and delayed deaths due to complications of treatment in low-severity fall victims, especially those older than 70 years, make it necessary to improve fall prevention programs in the older adults and to create a line of care for this population.

Mortality in severely injured patients: nearly one of five non-survivors have been already discharged alive from ICU

BACKGROUND

Most trauma patients admitted to the hospital alive and die later on, decease during the initial care in the emergency department or the intensive care unit (ICU). However, a number of patients pass away after having been discharged from the ICU during the initial hospital stay. On first sight these cases could be seen as "failure to rescue" of potentially salvageable patients. A low rate of such patients might be a potential indicator of quality for trauma care on ICUs and surgical wards.

METHODS

Retrospective analysis of the TraumaRegister DGU® with data from 2015 to 2017. Patients that died during the initial ICU stay were compared to those who were discharged from the initial ICU stay for at least 24 h but died later on.

RESULTS

A total of 82,313 trauma patients were included in the TraumaRegister DGU®. In total, 6576 patients (8.0%) died during their hospital stay. Out of those, 5481 were admitted to the ICU alive and 972 patients (17.7%) were discharged from ICU and died later on. Those were older (mean age: 77 vs. 68 years), less severely injured (mean ISS: 23.1 vs. 30.0 points) and had a longer mean ICU length of stay (10 vs. 6 days). A limitation of life-sustaining therapy due to a documented living will was present in 46.1% of all patients who died during their initial ICU stay and in 59.9% of patients who died after discharge from their initial ICU stay.

CONCLUSIONS

17.7% of all non-surviving severely injured trauma patients died within the hospital after discharge from their initial ICU treatment. Their death can partially be explained by a limitation of therapy due to a living will. In conclusion, the rate of such late deaths may partially represent patients that died of potentially avoidable or treatable complications.

The 11-Item Modified Frailty Index as a Tool to Predict Unplanned Events in Traumatic Brain Injury

BACKGROUND

Frailty has been studied extensively in trauma, but there is minimal research detailing its impact on traumatic brain injury (TBI). We hypothesized that the 11-item modified frailty index (mFI-11) would predict complications and discharge outcomes in patients with TBI.

METHODS

A retrospective review of our trauma quality improvement program (TQIP) registry was conducted for all patients with TBI. The mFI-11 score was calculated for each patient. Multivariable logistic regression was used to assess the relationship between mFI-11 and cardiovascular, infectious, pulmonary, renal, thromboembolic, and unplanned complications (ie, unplanned intensive care unit [ICU] admission, intubation, or return to the operating room).

RESULTS

There were 2352 patients with TBI of whom 61.6% (n = 1450) were not frail, 19.3% (n = 454) were mildly frail, and 19.1% (n = 448) were moderately to severely frail. Higher frailty scores were associated with increasing age (P < .0001) and decreasing injury severity score [ISS] (P = 0.001). Higher frailty scores also correlated with increasing rates of a skilled nursing facility/long-term acute care hospital/rehabilitation discharge (P = .0002). On multivariable logistic regression adjusting for age, Glasgow Coma Scale (GCS) score, ISS, mechanism, and sex, moderate to severe frailty increased the odds of acute kidney injury (odds ratio [OR] 2.06, 95% CI 1.07-3.99, P = .03) and any unplanned event (OR 1.6, 95% CI 1.1-2.3, P = .01).

CONCLUSION

Frailty measured by the mFI-11 is associated with greater rates of discharge to unfavorable locations and increased odds of acute kidney injury and unplanned events among patients with TBI. These findings suggest that frail patients with TBIs require greater vigilance to avoid such unanticipated outcomes.

Using Machine Learning to Make Predictions in Patients Who Fall

BACKGROUND

As the population ages, the incidence of traumatic falls has been increasing. We hypothesize that a machine learning algorithm can more accurately predict mortality after a fall compared with a standard logistic regression (LR) model based on immediately available admission data. Secondary objectives were to predict who would be discharged home and determine which variables had the largest effect on prediction.

METHODS

All patients who were admitted for fall between 2012 and 2017 at our level 1 trauma center were reviewed. Fourteen variables describing patient demographics, injury characteristics, and physiology were collected at the time of admission and were used for prediction modeling. Algorithms assessed included LR, decision tree classifier (DTC), and random forest classifier (RFC). Area under the receiver operating characteristic curve (AUC) values were calculated for each algorithm for mortality and discharge to home.

RESULTS

About 4725 patients met inclusion criteria. The mean age was 61 ± 20.5 y, Injury Severity Score 8 ± 7, length of stay 5.8 ± 7.6 d, intensive care unit length of stay 1.8± 5.2 d, and ventilator days 0.7 ± 4.2 d. The mortality rate was 3% and three times greater for elderly (aged 65 y and older) patients (5.0% versus 1.6%, P < 0.001). The AUC for predicting mortality for LR, DTC, and RFC was 0.78, 0.64, and 0.86, respectively. The AUC for predicting discharge to home for LR, DTC, and RFC was 0.72, 0.61, and 0.74, respectively. The top five variables that contribute to the prediction of mortality in descending order of importance are the Glasgow Coma Score (GCS) motor, GCS verbal, respiratory rate, GCS eye, and temperature.

CONCLUSIONS

RFC can accurately predict mortality and discharge home after a fall. This predictive model can be implemented at the time of patient arrival and may help identify candidates for targeted intervention as well as improve prognostication and resource utilization.

Major trauma due to suicide attempt: increased workload but not mortality

INTRODUCTION

Suicide attempt is a common cause for major trauma. Due to the underlying psychiatric disease, patients` compliance or even prognosis may be reduced. Modalities of discharge after surgical acute care might differ.

METHODS

Retrospective study including trauma patients of two urban level 1 trauma centers between 2013 and 2017. Data originally collected for quality management using the German trauma registry were supplemented after review of medical charts with details on psychiatric disease and discharge modalities.

RESULTS

We included 2118 consecutive patients of which 108 (5%) attempted suicide. Most common psychiatric diagnosis were depression (38%) and schizophrenia (25.9%). Comparing patients after suicide attempt with others, suicide attempt was associated with a younger age (42.3 vs. 49.0 years), a higher injury severity (mean ISS 24.7 vs. 16.8) and consecutively, a higher expected mortality (risk-adjusted prognosis for mortality 18.0 vs. 8.1%), while observed mortality was lower than expected in both groups (16.7 vs. 6.4%). Survivors after suicide attempt had a longer stay on ICU (mean days on ICU 17 vs. 7). 56% were transferred to psychiatric facilities and only 4% could be discharged home after acute surgical care.

CONCLUSION

Incidence of suicide attempts among major trauma patients is high. Mean injury severity is higher than in unintended trauma and associated with a prolonged stay on intensive care unit even after adjustment for injury severity and age. Risk-adjusted mortality is not increased. Proportion of patients discharged home or to out-patient rehabilitation is very low. Specialized institutions who offer both, musculoskeletal rehabilitation and psychiatric care are required for rehabilitative treatment after the acute surgical care.

Effect of Height of Fall on Mortality in Patients with Fall Accidents: A Retrospective Cross-Sectional Study

Background: Accidental falls are a common cause of injury and deaths. Both ground-level falls (GLF) and non-GLF may lead to significant morbidity or mortality. This study aimed to explore the relationship between height of falls and mortality. Method: This is a retrospective study based on the data from a registered trauma database and included 8699 adult patients who were hospitalized between 1 January 2009 and 31 December 2017 for the treatment of fall-related injuries. Study subjects were divided into three groups of two categories based on the height of fall: GLF (group I: < 1 m) and non-GLF (group II: 1–6 m and group III: > 6 m). The primary outcome was in-hospital mortality. The adjusted odds ratio (AOR) of mortality adjusted for age, sex, and comorbidities with or without an injury severity score (ISS) was calculated using multiple logistic regression. Results: Among the 7001 patients in group I, 1588 in group II, and 110 in group III, patients in the GLF group were older, predominantly female, had less intentional injuries, and had more pre-existing comorbidities than those in the non-GLF group. The patients in the non-GLF group had a significantly lower Glasgow Coma Scale (GCS), a higher injury severity score (ISS), worse physiological responses, and required more procedures performed in the emergency department. The mortality rate for the patients in group I, II, and III were 2.5%, 3.5%, and 5.5%, respectively. After adjustment by age, sex, and comorbidities, group II and group III patients had significantly higher adjusted odds of mortality than group I patients (AOR 2.2, 95% CI 1.64–2.89, p < 0.001 and AOR 2.5, 95% CI 1.84–3.38, p < 0.001, respectively). With additional adjustment by ISS, group II did not have significantly higher adjusted odds of mortality than group I patients (AOR 1.4, 95% CI 0.95–2.22, p = 0.082), but group III patients still had significantly higher adjusted odds of mortality than group I patients (AOR 10.0, 95% CI 2.22–33.33, p = 0.002). Conclusion: This study suggested that patients who sustained GLF and non-GLF were distinct groups of patients, and the height of fall did have an impact on mortality in patients of fall accidents. A significantly higher adjusted odds of mortality was found in the GLF group than in the non-GLF group after adjusting for age, sex, and comorbidities.

Falls and long-term survival among older adults residing in care homes

Objectives

To assess the association between having suffered a fall in the month prior to interview and long-term overall survival in nursing-home residents.

Methods

Retrospective cohort study conducting an overall survival follow-up of 689 representative nursing-home residents from Madrid, Spain. Residents lived in three types of facilities: public, subsidized and private and its information was collected by interviewing the residents, caregivers and/or facility physicians. Residents contributed to follow-up time from their baseline interviews until death or being censored at the end of the 5-year follow-up period. The association between suffering a fall during the month prior to interview and long-term overall survival was analyzed using Cox proportional hazards models. To adjust for potential confounders we used progressive adjusted models. We then repeated the analyses with severity of the fall (no fall, non-severe, severe) as the main independent variable.

Results

After a 2408 person-year follow-up (median 4.5 years), 372 participants had died. In fully-adjusted models, residents who had suffered any kind of fall in the previous month showed virtually the same survival rates compared to non-fallers (hazard ratio (HR) = 1.03; 95% CI = 0.75–1.40). There was a weak graded relationship between increased fall severity and survival rates for the non-severe fall group (HR = 0.92; 95% CI = 0.58–1.45) and the severe fall group (HR = 1.36; 95% CI = 0.73–2.53) compared with residents who had not suffered any kind of fall. The hazard ratios for severe falls were higher in men, residents with less comorbidity, fewer medications, and those functionally independent.

Conclusion

We found no associations between having suffered a fall in the month prior to interview and long-term survival; neither did we find a marked association when severity of fall was accounted for in the whole population. In some subgroups, however, the results merit further scrutiny.

Post-stroke patients with moderate function have the greatest risk of falls: a National Cohort Study

BACKGROUND

Stroke patients have increased risks of falls. We examined national registry data to evaluate the association between post-stroke functional level and the risk of low falls among post-stroke patients.

METHODS

This retrospective cohort study analyzed data from national registries to examine the risk factors for post-stroke falls. Data for patients who suffered ischemic strokes and survived the index hospital admission was obtained from the Singapore National Stroke Registry and matched to the National Trauma Registry, from 2011 to 2015. The primary outcome measure was a low fall (fall height ≤ 0.5 m). Competing risk analysis was performed to examine the association between functional level (by modified Rankin score [mRS] at discharge) and the risk of subsequent low falls.

RESULTS

In all, 2255 patients who suffered ischemic strokes had recorded mRS. The mean age was 66.6 years and 58.5% were men. By the end of 2015, 54 (2.39%) had a low fall while 93 (4.12%) died. After adjusting for potential confounders, mRS was associated with fall risk with an inverted U-shaped relationship. Compared to patients with a score of zero, the sub-distribution hazard ratio (SHR) increased to a maximum of 3.42 (95%CI:1.21-9.65, p = 0.020) for patients with a score of 2. The SHR then declined to 2.45 (95%CI:0.85-7.12, p = 0.098), 2.86 (95%CI:0.95-8.61, p = 0.062) and 1.93 (95%CI:0.44-8.52, p = 0.38) for patients with scores of 3, 4 and 5 respectively.

CONCLUSIONS

An inverted U-shaped relationship between functional status and fall risk was observed. This is consistent with the complex interplay between decreasing mobility (hence decreased opportunity to fall) and increasing susceptibility to falls. Fall prevention intervention could be targeted accordingly. (263 words).

Investigating the functional grip strength of elderly fallers in Singapore

Background:

Static grip strength has been a reliable method for assessing the functional capacity of the individual and can be a useful marker for identifying elderly people at risk of functional deterioration leading to a fall. However, static grip strength alone may not represent the true maximum strength that an individual could exert in his/her daily life, especially if the task requires simultaneous forces from gripping and a forearm twisting action, which is termed as functional isometric grip strength. Hence, the objectives of this study were to determine the differences in the fallers’ grip strengths at static-neutral grip position and during isometric forearm pronation/supination, as well as the differences between the maximum and sustained isometric grip strengths.

Methods:

Data were analysed from 31 elderly people (11 males and 20 females) aged 70 and over. Using a custom-made hand strength measurement device, three measurements were taken: (1) grip strength in neutral forearm position; (2) grip strength during isometric forearm pronation; and (3) grip strength during isometric forearm supination.

Results:

Elderly fallers could only achieve approximately 60%–80% of the maximum normative strength. Additionally, it was found that their functional isometric grip strengths were generally weaker than their static maximal grip strength, especially during isometric supination as either maximum or sustained isometric supination grip strengths (Dominant hand: 10.6 kg and 8.5 kg, respectively (males); 6.0 kg and 4.4 kg, respectively (females)).

Conclusion:

Elderly fallers are weaker when their grip is subjected to additional torque, endurance or both. Hence, these findings have potential implications for designing better screening tools for the geriatric population.

Timing and methods of frailty assessments in geriatric trauma patients: A systematic review

INTRODUCTION

The trauma population is aging and better prognostic measures for geriatric trauma patients are required. Frailty rather than age appears to be associated with poor outcomes. This systematic review aimed to identify the optimum frailty assessment instrument and timing of assessment in patients aged over 65 years admitted to hospital after traumatic injury. The secondary aim was to evaluate outcomes associated with frailty in elderly trauma populations.

METHODS

This systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018090620). A MEDLINE and EMBASE literature search was conducted from inception to June 2019 combining the concepts of injury, geriatric, frailty, assessment and prognosis. Included studies were in patients 65 years or older hospitalised after injury and exposed to an instrument meeting consensus definition for frailty assessment. Study quality was assessed using criteria for review of prognostic studies combined with a GRADE approach.

RESULTS

Twenty-eight papers met inclusion criteria. Twenty-eight frailty or component instruments were reported, and assessments of pre-injury frailty were made up to 1-year post injury. Pre-injury frailty prevalence varied from 13% (13/100) to 94% (17/18), with in-hospital mortality rates from 2% (5/250) to 33% (6/18). Eleven studies found an association between frailty and mortality. Eleven studies reported an association between frailty and a composite outcome of mortality and adverse discharge destination. Generalisability and assessment of strength of associations was limited by single centre studies with inconsistent findings and overlapping cohorts.

CONCLUSIONS

Associations between frailty and adverse outcomes including mortality in geriatric trauma patients were demonstrated despite a range of frailty instruments, administering clinicians, time of assessment and data sources. Although evidence gaps remain, incorporating frailty assessment into trauma systems is likely to identify geriatric patients at risk of adverse outcomes. Consistency in frailty instruments and long-term geriatric specific outcome measures will improve research relevance.

LEVEL OF EVIDENCE

Level III prognostic.

Influence of fall environment and fall direction on risk of injury among pre-frail and frail adults

In this prospective study, half of all falls resulted in injury. Pre-frail adults sustained more injuries, while more frail adults had injuries requiring hospitalization or fractures. Pre-frail adults fell more often when in movement compared with frail adults who fell more often when standing and in indoor public spaces.

PURPOSE

To assess prospectively how fall environment and direction are related to injury among pre-frail and frail adults.

METHODS

We included 200 community-dwelling adults with a prior fall (pre-frail, mean age 77 years) and 173 adults with acute hip fracture (frail, mean age 84 years; 77% community-dwelling). Falls were prospectively recorded using standardized protocols in monthly intervals, including date, time, fall direction and environment, and injury. We used logistic regression to assess the odds of injury adjusting for age, body mass index (BMI), and gender.

RESULTS

We recorded 513 falls and 331 fall-related injuries (64.5%) among the 373 participants. While the fall rate was similar between groups, pre-frail adults had more injuries (71% among pre-frail vs. 56% among frail, p = 0.0004) but a lower incidence of major injuries (9% among pre-frail vs. 27% among frail, p = 0.003). Pre-frail adults fell more often while in movement (84% among pre-frail vs. 55% among frail, p < 0.0001), and frail adults fell more often while standing (26% vs. 15% respectively, p = 0.01). The odds of injury among frail adults was increased 3.3-fold when falling sideways (OR = 3.29, 95% CI = 1.68-6.45) and 2.4-fold when falling in an indoor public space (OR = 2.35, 95% CI = 1.00-5.53), and was reduced when falling at home (OR = 0.55, 95% CI = 0.31-0.98). The odds of injury among pre-frail adults was not influenced by environment and was 53% lower when falling backwards (OR = 0.47, 95% CI = 0.26-0.82).

CONCLUSION

While pre-frail adults sustain more fall-related injuries, frail adults were more likely to sustain major injuries, especially when falling sideways or outside their home.

The price of personal mobility: burden of injury and mortality from personal mobility devices in Singapore - a nationwide cohort study

BACKGROUND

Personal mobility devices (PMDs) like skate-scooters, electric bicycles (e-bikes) or motorised scooters (e-scooters) have become widely available globally. There are several studies describing the rising incidence of injury from such devices. The aim of our study was to examine PMD user factors between motorised (MotPMDs) vs non-motorised PMDs (NonPMDs) as risk factors for severe injury and the need for hospital admission.

METHODS

We analysed de-identified National Trauma Registry data (2015 to 2017) from all public sector hospitals in Singapore for patients aged 12 and above presenting to emergency departments with PMD-related injuries. Multivariable logistic regression was used to identify risk factors for the primary outcome of interest (higher injury severity, defined as Injury Severity Score / ISS > =9), and the secondary outcome of interest (need for hospital admission). Additional subgroup analysis was conducted comparing only scooters (manual vs electric), the most common sub-type of PMD in our study.

RESULTS

Of the 614 patients in our study, majority were male (74%), median age 33 years, with 136 (22%) sustaining injuries with ISS > =9; 185 (30%) admitted [median stay length 3 days (IQR: 1-6)] and 93 (15%) required surgery. MotPMDs were more common (480, 78%), with e-scooters being the most common motorised device (393, 64%). There were 6 deaths, all in MotPMD users. On both univariate and multivariable regression, MotPMD users [OR 3.82, 95% CI 1.51-12.9, p = 0.01] and older users (> = 60 years) [OR 9.47, 95% CI 2.45-62.9, p = 0.004] were more likely to sustain injuries with ISS > =9, and more likely to need admission (MotPMD users [OR 1.8, 95% CI 1.04-3.29, p = 0.045], age > =60 years [OR 4.72, 95% CI 1.86-13.0, p = 0.002]).

CONCLUSION

MotPMDs tripled the risk of severe injury and doubled the risk of requiring hospitalisation, compared to NonPMDs, likely due to higher travelling speeds. Increased age was also associated with severe injury and requiring hospitalisation.

Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment

Background

Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate.

Methods

Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d’Aubigne and the EQ. 5D-3 L scores.

Results

Over an 11-year period (2004–14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d’Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts.

Conclusion

Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients.

Trial registration

DRKS, no. 00000488. Registered 14th July 2010 - Retrospectively registered

Spinal fractures incurred by a fall from standing height

OBJECTIVE

Falls from standing are common, particularly amongst the aging population, due to declining mobility, proprioception and vision. They are often complicated by fragility fractures, including vertebral fractures, that are associated with significant morbidity and may represent a pre-terminal condition with high one-year mortality rates.

PATIENTS AND METHODS

A retrospective review of the Trauma Audit and Research Network database for a major trauma centre was conducted for all patients admitted between January 2011 and December 2016. Patients with a spinal fracture and a confirmed fall from standing height were eligible for inclusion. Case notes were reviewed for demographics, Injury Severity Score, Charlson co-morbidity score, treatment, complications and outcomes.

RESULTS

Of 1408 patients with a spine fracture admitted during the study period, 229 (16.3%) were confirmed to be secondary to a fall from standing height. The average age of this cohort was 76.6 ± 14.5 years and 134 (58.5%) cases were female. The average ISS score was 9.7 ± 5.4. The 229 patients sustained 283 fractures with a distribution of: cervical (n = 140), thoracic (n = 65) and lumbar (n = 78) spine. Fifty-six (24.5%) patients underwent surgical intervention. Forty-three patients (18.7%) died within 6 months of admission and all-cause mortality was significantly higher in patients with increasing age and Charlson co-morbidity score.

CONCLUSION

Spinal fractures due to a fall from standing height represent one sixth of the fracture workload of the emergency spinal service at a major trauma centre. Whilst the majority of patients can be managed conservatively there are still considerable implications for hospital bed usage and patient mortality.

Predictors of Change in Functional Outcome at six months and twelve months after Severe Injury: A Retrospective Cohort Study

Background

There is increasing focus on long-term survival, function and quality-of-life for trauma patients. There are few studies tracking longitudinal changes in functional outcome over time. The goal of our study was to compare the Glasgow Outcome Scale-Extended (GOSE) at 6 months and 12 months in blunt trauma survivors with an Injury Severity Score (ISS) of more than 15.

Methods

Using the Singapore National Trauma Registry 2011–2013, patients with 6-month GOSE and 12-month GOSE scores were analysed. Patients were grouped into three categories—those with the same score at 6 months and 12 months, an improvement in score, and a worse score at 12 months. Ordinal regression was used to identify risk factors for improved score. Patients with missing scores at either 6 months or 12 months were excluded.

Results

We identified 478 patients: 174 had an improvement in score, 233 stayed the same, and 71 had worse scores at 12 months compared to 6 months. On univariate ordinal regression, the following variables were associated with same or better function at 12-months compared to 6-months: male gender, being employed pre-injury, thoracic Abbreviated Injury Scale (AIS) of 3 or more, anatomical polytrauma (AIS of 3 or more in 2 or more body regions), and road traffic injury mechanism. Older age, low fall, increasing Charlson comorbidity scores, new injury severity score, and head and neck AIS of 3 or more were associated with worse function at 12 months compared to 6 months. ISS and revised trauma score were not significant predictors on univariate or multivariable analysis.

On multivariable ordinal regression, motor vehicle mechanism (OR 2.78, 1.51–5.12, p = 0.001) was associated with improved function, while male gender (OR 1.36, 95% CI 1.02–1.82, p = 0.039) predicted improved function at 12 months.

Conclusions

Females experience worse functional outcomes at 12 months, potentially due to majority of female injuries being low falls in the elderly. In contrast, motor vehicle injury patients had better functional outcomes at 12 months. Additional interventional strategies for high-risk groups should be explored.

Long-term Posttraumatic Survival of Spinal Fracture Patients in Northern Finland

STUDY DESIGN

A retrospective epidemiological study.

OBJECTIVE

To reveal the long-term survival and causes of death after traumatic spinal fracture (TSF) and to determine the possible factors predicting death.

SUMMARY OF BACKGROUND DATA

Increased mortality following osteoporotic spinal fracture has been represented in several studies. Earlier studies concerning mortality after TSF have focused on specific types of fractures, or else only the mortality of the acute phases has been documented. In-hospital mortality has varied between 0.1% and 4.1%.

METHODS

The study sample of 947 patients including all patients with TSF admitted to Oulu University Hospital, Finland, between January 1, 2007 and December 31, 2011. TSFs were identified using International Classification of Diseases 10th revision or Nordic Classification of Surgical Procedures codes and all patient records were manually reviewed. Times and causes of death, obtained from Statistics Finland's Archive of Death Certificates, were available until the end 2016 and 2015, respectively.

RESULTS

At the end of the follow-up 227 (24.0%) had died. Mortality was 6.8% after the first year and 19.1% after 5 years. Mortality was increased in all age groups compared with the general population, 1-year standardized mortality ratios ranging from 3.1 in over 65-year-olds to 19.8 in under 30-year-olds. In age groups of 50 to 64 years and over 65 years, the most important risk factors for death were males with hazard ratios of 3.0 and 1.6, respectively, and low fall as trauma mechanism with hazard ratios of 9.4 and 10.2, respectively.

CONCLUSION

Traumatic spinal fractures are associated with increased mortality compared with the general population, high mortality focusing especially on older people and men. The increase seems to be comparable to the increase following hip fracture. Patients who sustain spinal fracture due to falling need special attention in care, due to the observation that low fall as trauma mechanism increased the risk of death significantly.

LEVEL OF EVIDENCE

3.

Wearables for gait and balance assessment in the neurological ward - study design and first results of a prospective cross-sectional feasibility study with 384 inpatients

BACKGROUND

Deficits in gait and balance are common among neurological inpatients. Currently, assessment of these patients is mainly subjective. New assessment options using wearables may provide complementary and more objective information.

METHODS

In this prospective cross-sectional feasibility study performed over a four-month period, all patients referred to a normal neurology ward of a university hospital and aged between 40 and 89 years were asked to participate. Gait and balance deficits were assessed with wearables at the ankles and the lower back. Frailty, sarcopenia, Parkinsonism, depression, quality of life, fall history, fear of falling, physical activity, and cognition were evaluated with questionnaires and surveys.

RESULTS

Eighty-two percent (n = 384) of all eligible patients participated. Of those, 39% (n = 151) had no gait and balance deficit, 21% (n = 79) had gait deficits, 11% (n = 44) had balance deficits and 29% (n = 110) had gait and balance deficits. Parkinson's disease, stroke, epilepsy, pain syndromes, and multiple sclerosis were the most common diseases. The assessment was well accepted.

CONCLUSIONS

Our study suggests that the use of wearables for the assessment of gait and balance features in a clinical setting is feasible. Moreover, preliminary results confirm previous epidemiological data about gait and balance deficits among neurological inpatients. Evaluation of neurological inpatients with novel wearable technology opens new opportunities for the assessment of predictive, progression and treatment response markers.

Validation of a Lower Back "Wearable"-Based Sit-to-Stand and Stand-to-Sit Algorithm for Patients With Parkinson's Disease and Older Adults in a Home-Like Environment

Introduction: Impaired sit-to-stand and stand-to-sit movements (postural transitions, PTs) in patients with Parkinson's disease (PD) and older adults (OA) are associated with risk of falling and reduced quality of life. Inertial measurement units (IMUs, also called "wearables") are powerful tools to monitor PT kinematics. The purpose of this study was to develop and validate an algorithm, based on a single IMU positioned at the lower back, for PT detection and description in the above-mentioned groups in a home-like environment. Methods: Four PD patients (two with dyskinesia) and one OA served as algorithm training group, and 21 PD patients (16 without and 5 with dyskinesia) and 11 OA served as test group. All wore an IMU on the lower back and were videotaped while performing everyday activities for 90-180 min in a non-standardized home-like environment. Accelerometer and gyroscope signals were analyzed using discrete wavelet transformation (DWT), a six degrees-of-freedom (DOF) fusion algorithm and vertical displacement estimation. Results: From the test group, 1,001 PTs, defined by video reference, were analyzed. The accuracy of the algorithm for the detection of PTs against video observation was 82% for PD patients without dyskinesia, 47% for PD patients with dyskinesia and 85% for OA. The overall accuracy of the PT direction detection was comparable across groups and yielded 98%. Mean PT duration values were 1.96 s for PD patients and 1.74 s for OA based on the algorithm (p < 0.001) and 1.77 s for PD patients and 1.51 s for OA based on clinical observation (p < 0.001). Conclusion: Validation of the PT detection algorithm in a home-like environment shows acceptable accuracy against the video reference in PD patients without dyskinesia and controls. Current limitations are the PT detection in PD patients with dyskinesia and the use of video observation as the video reference. Potential reasons are discussed.

One-year and three-year mortality prediction in adult major blunt trauma survivors: a National Retrospective Cohort Analysis

Background

Survivors of trauma are at increased risk of dying after discharge. Studies have found that age, head injury, injury severity, falls and co-morbidities predict long-term mortality. The objective of our study was to build a nomogram predictor of 1-year and 3-year mortality for major blunt trauma adult survivors of the index hospitalization.

Methods

Using data from the Singapore National Trauma Registry, 2011–2013, we analyzed adults aged 18 and over, admitted after blunt injury, with an injury severity score (ISS) of 12 or more, who survived the index hospitalization, linked to death registry data. The study population was randomly divided 60/40 into separate construction and validation datasets, with the model built in the construction dataset, then tested in the validation dataset. Multivariable logistic regression was used to analyze 1-year and 3-year mortality.

Results

Of the 3414 blunt trauma survivors, 247 (7.2%) died within 1 year, and 551 (16.1%) died within 3 years of injury. Age (OR 1.06, 95% CI 1.05–1.07, p < 0.001), male gender (OR 1.53, 95% CI 1.12–2.10, p < 0.01), low fall from 0.5 m or less (OR 3.48, 95% CI 2.06–5.87, p < 0.001), Charlson comorbidity index of 2 or more (OR 2.26, 95% CI 1.38–3.70, p < 0.01), diabetes (OR 1.31, 95% CI 1.68–2.52, p = 0.04), cancer (OR 1.76, 95% CI 0.94–3.32, p = 0.08), head and neck AIS 3 or more (OR 1.79, 95% CI 1.13–2.84, p = 0.01), length of hospitalization of 30 days or more (OR 1.99, 95% CI 1.02–3.86, p = 0.04) were predictors of 1-year mortality. This model had a c-statistic of 0.85. Similar factors were found significant for the model predictor of 3-year mortality, which had a c-statistic of 0.83. Both models were validated on the second dataset, with an overall accuracy of 0.94 and 0.84 for 1-year and 3-year mortality respectively.

Conclusions

Adult survivors of major blunt trauma can be risk-stratified at discharge for long-term support.

Falls, Cognitive Function, and Balance Profiles of Singapore Community-Dwelling Elderly Individuals: Key Risk Factors

Objective:

This study compared occurrence of falls, cognitive function, and balance profiles across participants in elderly age categories, investigating associations between the 3 aspects in a sample of Singapore’s elderly population.

Method:

Community-dwelling elderly individuals (N = 385) were randomly recruited and grouped into “young-old (65-74 years),” “medium-old (75-84 years),” and “oldest-old (above 85 years)” groups. The Fallproof Health and Activity questionnaire, adapted Mini-Mental State Examination (MMSE), and Berg Balance Scale (BBS) tests were used to survey information related to falls, cognition, and balance profiles.

Results:

Findings revealed significant differences in MMSE and BBS scores across the age groups. Participants with mild cognitive impairment (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.08-3.25) and BBS score ≤40 (OR = 0.25, 95% CI = 0.14-0.46) were at the highest risk of falling.

Conclusion:

Community-dwelling elderly individuals with subtle cognitive impairment and BBS scores ≤40 displayed an increased risk of falling.

Buckling up in Singapore: residency and other risk factors for seatbelt non-compliance - a cross-sectional study based on trauma registry data

BACKGROUND

Seatbelt non-compliance is a problem in middle income countries, and little is known about seatbelt compliance in populations with a high proportion of non-residents. This study analyses the profile of seatbelt non-compliance in Singapore based on trauma registry data from five of the six public hospitals.

METHODS

This is a cross-sectional study of seatbelt compliance of patients aged over 18 years, attending the emergency departments of five public hospitals in Singapore after road collisions from 2011-2014. Seatbelt data was obtained from paramedic and patient history.

RESULTS

There were 4,576 patients studied. Most were Singapore citizens (83.4 %) or permanent residents (2.4 %), with the largest non-resident groups from Malaysia, India, and China. Overall seatbelt compliance was 82.1 %. On univariate analysis, seatbelt compliance was higher in older patients (OR 1.02, 95 % CI 1.001-1.021, p < 0.0001); drivers, followed by front passengers (OR 0.65, 95 % CI 0.51-0.83, p < 0.0001), were more compliant than rear passengers (OR 0.08, 0.06-0.09, p < 0.0001); occupants of larger vehicle types (buses, heavy transport vehicles, minibuses and vans) were more non-compliant compared to occupants of private cars and taxis. Morning peak travel (0700 h-0900 h) and being a non-resident were other risk factors for non-compliance. On multivariable analysis, older age (OR 1.01, 95 % CI 1.001-1.014, p = 0.03) was associated with compliance, while non-residents from China (OR 0.43, 95 % CI 0.18-0.99, p = 0.05), seat position (front passenger compared to driver, OR 0.64, 95 % CI 0.48-0.85, p = 0.002; rear passenger compared to driver, OR 0.067, 95 % CI 0.05-0.09, p < 0.0001), vehicle type (bus compared to car, OR 0.04, 95 % CI 0.017-0.11, p < 0.0001, van compared to car, OR 0.55, 95 % CI 0.36-0.83, p = 0.004), and travel at morning peak periods were independent predictors of seatbelt non-compliance. When the sub-group of drivers was analysed, only vehicle type was a significant predictor of seatbelt compliance, with bus drivers least likely to be compliant to seatbelts (multivariable analysis, OR 0.057 compared to cars, 95 % CI 0.019-0.18, p < 0.0001).

CONCLUSIONS

While overall seatbelt compliance in our study is high, efforts can be made to increase compliance for morning rush hour passengers, rear seat passengers, and occupants of buses, heavy transport vehicles, and vans or pickups.

Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study

Background

Anatomy-based injury severity scores are commonly used with physiological scores for reporting severity of injury in a standardized manner. However, there is lack of consensus on choice of scoring system, with the commonly used injury severity score (ISS) performing poorly for certain sub-groups, eg head-injured patients. We hypothesized that adding a dichotomous variable for polytrauma (yes/no for Abbreviated Injury Scale (AIS) scores of 3 or more in at least two body regions) to the New Injury Severity Score (NISS) would improve the prediction of in-hospital mortality in injured patients, including head-injured patients—a subgroup that has a disproportionately high mortality. Our secondary hypothesis was that the ISS over-estimates the risk of death in polytrauma patients, while the NISS under-estimates it.

Methods

Univariate and multivariable analysis was performed on retrospective cohort data of blunt injured patients aged 18 and over with an ISS over 9 from the Singapore National Trauma Registry from 2011–2013. Model diagnostics were tested using discrimination (c-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit statistic). All models included age, gender, and comorbidities.

Results

Our results showed that the polytrauma and NISS model outperformed the other models (polytrauma and ISS, NISS alone or ISS alone) in predicting 30-day and in-hospital mortality. The NISS underestimated the risk of death for patients with polytrauma, while the ISS overestimated the risk of death for these patients.

When used together with the NISS and polytrauma, categorical variables for deranged physiology (systolic blood pressure of 90 mmHg or less, GCS of 8 or less) outperformed the traditional ‘ISS and RTS (Revised Trauma Score)’ model, with a c-statistic of greater than 0.90. This could be useful in cases when the RTS cannot be scored due to missing respiratory rate.

Discussion

The NISS and polytrauma model is superior to current scores for prediction of 30-day and in-hospital mortality. We propose that this score replace the ISS or NISS in institutions using AIS-based scores.

Conclusions

Adding polytrauma to the NISS or ISS improves prediction of 30-day mortality. The superiority of the NISS or ISS depends on the proportion of polytrauma and head-injured patients in the study population.