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Yap SE, Wong HC, Chong SL, Ganapathy S, Ong GYK. Validation of motor component of Glasgow coma scale in lieu of total Glasgow coma scale as a pediatric trauma field triage tool. Am J Emerg Med 2024; 81:105-110. [PMID: 38733662 DOI: 10.1016/j.ajem.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Prehospital trauma triage and disability assessment of pediatric patients can be challenging on the field, especially in the pre-verbal age group. It would be useful if the same triage tool and criteria can be used for both adults and children to risk-stratify the need of higher acuity of trauma care. STUDY OBJECTIVE We aimed to investigate if using only the motor component of Glasgow Coma Scale (mGCS), as a quick field trauma triage tool, was non-inferior to total GCS (tGCS), and if mGCS <6 was non-inferior to tGCS <14, in predicting the need for intensive care or mortality in the pediatric population. METHODS We performed a retrospective review of patients <18-years-old, who presented to our emergency department (ED) with moderate (Injury Severity Score (ISS) 9-15) to severe (ISS > 15) traumatic injuries from January 2012 to December 2021. Using ED triage data, mortality and the need for intensive care unit (ICU) admission were used as surrogate outcomes to investigate if mGCS <6 was non-inferior to tGCS <14, and the area-under-the-receiver-operating-characteristic curve (AUROC) was used as a measure of comparability. RESULTS Among 582 included for analysis, the median age was 7-years-old (2-12), and most were male (63.4%). 22.4% patients demised or required ICU care. mGCS <6 had an AUROC of 0.75 (95% CI 0.70 to 0.79), which was non-inferior to tGCS <14; AUROC 0.76, (95% CI 0.72 to 0.81), for identifying children requiring ICU management or demised. The results shown here were based on the AUROCs that were used to evaluate the discriminatory ability of tGCS <14 and mGCS <6 in prediction of mortality and the need for ICU care. CONCLUSION Our study showed that mGCS was significantly associated with tGCS, and was non- inferior to the latter as a triage tool in pediatric trauma. It validated the use of mGCS <6 in lieu of tGCS <14 in the pre-hospital field triage of pediatric patients, in identification of children at risk of death or requiring ICU care. Larger prospective, observational studies using on-scene data would be required for more robust validation and determine optimal cut-offs.
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Affiliation(s)
- Shiyi Eileen Yap
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
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Melo JRT, de Brito Tischer CM, Rodrigues FPA, Giordano JC, de Oliveira LFG, Bodra SM, de Oliveira JG, Veiga JCE. Accuracy of acute hyperglycemia as a biomarker of severe brain damage in children with traumatic brain injury. Childs Nerv Syst 2024:10.1007/s00381-024-06488-4. [PMID: 38862794 DOI: 10.1007/s00381-024-06488-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Biomarkers are substances measured at the systemic level to evaluate organic responses in certain situations, establishing diagnoses, disease staging, and prognosis. Blood glucose is a biomarker recognized as a predictor of prognosis in children victims of traumatic brain injury (TBI). The scope of this study was to identify the accuracy of blood glucose as a biomarker of severe brain injury. METHODS A retrospective analytical study was conducted through the consecutive review of medical records of children and teenage victims of TBI who underwent neurological surgery between 2016 and 2023 in a level 1 trauma center. Two groups were compared: children with Glasgow Coma Scale (GCS) score ≤ 8 and children with GCS > 8. We calculated the predictive values to define the accuracy of blood glucose as a biomarker of brain injury. RESULTS Ninety-two medical records were included for analysis. Hyperglycemia predominated in cases with GCS ≤ 8 (48% vs 3%; p < 0.0001; OR, 30; 95% CI, 5.9902-150.2448). The glycemic measurement considering the cutoff point of 200 mg/dL or 11.1 mmol/L showed a specificity of 97%, a positive predictive value of 86%, an accuracy of 84%, and a likelihood ratio for a positive test of 16. CONCLUSION Victims with GCS ≤ 8 are 16 times more likely to develop acute hyperglycemia after TBI when compared to those with GCS > 8. Blood glucose is a biomarker with an accuracy of 84% to predict severe brain injury, considering the cutoff point of 200 mg/dL or 11.1 mmol/L.
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Affiliation(s)
- José Roberto Tude Melo
- Division of Neurosurgery, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil.
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil.
| | - Chiara Maria de Brito Tischer
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Fernanda Paiva Augusto Rodrigues
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Júlia Calviello Giordano
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Larissa Ferreira Gomes de Oliveira
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Stephannie Monaco Bodra
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Jean Gonçalves de Oliveira
- Division of Neurosurgery, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - José Carlos Esteves Veiga
- Division of Neurosurgery, Department of Surgery, Santa Casa of São Paulo, Hospital and School of Medical Sciences, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
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Zhang KY, Li PL, Yan P, Qin CJ, He H, Liao CP. The significance of admission blood lactate and fibrinogen in pediatric traumatic brain injury: a single-center clinical study. Childs Nerv Syst 2024; 40:1207-1212. [PMID: 38147105 DOI: 10.1007/s00381-023-06257-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/15/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in pediatric patients, leading to long-term physical, cognitive, and psychological impairments. Blood lactate and fibrinogen levels have emerged as potential biomarkers associated with tissue hypoperfusion and coagulation dysfunction, respectively. However, limited research has specifically focused on the significance of these biomarkers in pediatric TBI. This study aimed to investigate the clinical significance of blood lactate and fibrinogen levels upon admission in pediatric patients with traumatic brain injury. METHODS The medical records of 80 children with a traumatic brain injury who were admitted from January 2017 to January 2021 were retrospectively analyzed. The two groups were compared according to whether the blood lactate in the admission arterial blood gas increased and the fibrinogen content in the coagulation function decreased. The clinical data of the children in the two groups were different, and then they were divided into a good prognosis group and a poor prognosis group according to the GOS prognostic score, and the differences in the clinical indicators of the two groups were compared. RESULTS Among the 80 patients, 33 had elevated blood lactate levels, 34 had decreased fibrinogen levels, and 29 had an unfavorable outcome (GOS < 4). Compared to the normal blood lactate group, there were no statistically significant differences in age, sex ratio, or platelet count in the elevated blood lactate group (P > 0.05). However, the elevated blood lactate group had lower Glasgow Coma Scale (GCS) scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stay, lower GOS scores, and a higher proportion of GOS < 4 (P < 0.05). Compared to the normal fibrinogen group, there were no statistically significant differences in age, sex ratio, or platelet count in the decreased fibrinogen group (P > 0.05). However, the decreased fibrinogen group had lower GCS scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stays, lower GOS scores, and a higher proportion of GOS < 4 (P < 0.05). Compared to the favorable outcome group, there were no statistically significant differences in age, sex ratio, or platelet count in the unfavorable outcome group (P > 0.05). However, the unfavorable outcome group had lower GCS scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stays, a higher incidence of pulmonary infection, a higher incidence of stress ulcers, and lower GOS scores (P < 0.05). CONCLUSION The levels of blood lactate and fibrinogen may represent the severity of children with traumatic brain injury and may be risk factors for poor prognosis of children with traumatic brain injury.
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Affiliation(s)
- Kun-Yuan Zhang
- Department of Neurosurgery, Second People's Hospital of Pingchang, Pingchang, Sichuan, P.R. China
| | - Pei-Long Li
- Kunming Children's Hospital, Children's Hospital Affiliated to Kunming Medical University, Kunming Medical University, Kunming, P.R. China
| | - Peng Yan
- Department of Neurosurgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, P.R. China
| | - Cheng-Jian Qin
- Department of Neurosurgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, P.R. China
| | - Hao He
- Department of Neurosurgery, Second People's Hospital of Pingchang, Pingchang, Sichuan, P.R. China
| | - Chang-Pin Liao
- Department of Neurosurgery, People's Hospital of Baise, No. 8, Chengxiang Street, Youjiang District, Baise, Guangxi, P.R. China.
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Qadri SK, Lee JH, Zhu Y, Caporal P, Roa G JD, González-Dambrauskas S, Yock-Corrales A, Abbas Q, Kazzaz Y, Shi L, Sri Dewi D, Chong SL. A multicenter observational study on outcomes of moderate and severe pediatric traumatic brain injuries-time to reappraise thresholds for treatment. Acta Neurochir (Wien) 2023; 165:3197-3206. [PMID: 37728830 DOI: 10.1007/s00701-023-05741-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/22/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Children with moderate traumatic brain injury (modTBI) (Glasgow Coma Scale (GCS) 9-13) may benefit from better stratification. We aimed to compare neurocritical care utilization and functional outcomes between children with high GCS modTBI (hmodTBI, GCS 11-13), low GCS modTBI (lmodTBI, GCS 9-10), and severe TBI (sTBI, GCS ≤ 8). We hypothesized that patients with lmodTBI have higher neurocritical care needs and worse outcomes than patients with hmodTBI and are similar to patients with sTBI. METHODS Prospective observational study from June 2018 to October 2022 in 28 pediatric intensive care units (PICU) in Asia, South America, and Europe. We included children (age < 18 years) with modTBI and sTBI admitted to PICU and measured functional outcomes at 3 months using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds, scale 1-8, 1 = upper good recovery, 8 = death). RESULTS We analyzed 409 patients: 98 (24%) and 311 (76%) with modTBI and sTBI, respectively. Patients with lmodTBI (vs. hmodTBI) were more likely to have invasive ICP monitoring (32.3% vs. 4.5%, p < 0.001), longer PICU stay (days, median [IQR]; 5.00 [4.00, 9.75] vs 4.00 [2.00, 5.00], p = 0.007), and longer hospital stay (days, median [IQR]: 13.00 [8.00, 17.00] vs. 8.00 [5.00, 12, 25], p = 0.015). Median GOS-E Peds scores were significantly different (hmodTBI (1.00 [1.00, 3.00]), lmodTBI (3.00 [IQR 2.00, 5.75]), and sTBI (5.00 [IQR 1.00, 6.00]) (p < 0.001)). After adjusting for age, sex, presence of polytrauma and cerebral edema, lmodTBI, and sTBI remained significantly associated with higher GOS-E scores (adjusted coefficient (standard error): 1.24 (0.52), p = 0.018, and 1.27 (0.33), p < 0.001, respectively) compared with hmodTBI. CONCLUSIONS Children with lmodTBI have higher rates of neurocritical care utilization and worse functional outcomes than those with hmodTBI but better than those with sTBI. Children with lmodTBI may benefit from guideline-based management similar to what is implemented in children with sTBI. This work was performed in hospitals within the PACCMAN and LARed networks. No reprints will be ordered.
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Affiliation(s)
- Syeda Kashfi Qadri
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Duke-NUS Medical School, SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Singapore, Singapore.
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke-NUS Medical School, SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Singapore, Singapore
| | - Yanan Zhu
- Department of Epidemiology, Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
| | - Paula Caporal
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Buenos Aires, Argentina
- Pediatric Critical Care Unit - HIAEP Sor María Ludovica, La Plata, Buenos Aires, Argentina
| | - Juan D Roa G
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Bogotá, Colombia
- Pediatric Critical Care Unit - Fundacion Homi, Bogotá, Colombia
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatría Y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de La República, Montevideo, Uruguay
| | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", CCSS, San José, Costa Rica
| | | | - Yasser Kazzaz
- Department of Pediatrics, College of Medicine, Ministry of National Guards Health AffairsKing Saud Bin Abdulaziz University for Health SciencesKing Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Luming Shi
- Department of Epidemiology, Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Dianna Sri Dewi
- Department of Epidemiology, Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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Chao M, Wang CC, Chen CPC, Chung CY, Ouyang CH, Chen CC. The Influence of Serious Extracranial Injury on In-Hospital Mortality in Children with Severe Traumatic Brain Injury. J Pers Med 2022; 12:jpm12071075. [PMID: 35887572 PMCID: PMC9323906 DOI: 10.3390/jpm12071075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Serious extracranial injury (SEI) commonly coexists with sTBI after the high impact of trauma. Limited studies evaluate the influence of SEI on the prognosis of pediatric sTBI. We aimed to analyze SEI’s clinical characteristics and initial presentations and evaluate if SEI is predictive of higher in-hospital mortality in these sTBI children. (2) Methods: In this 11-year-observational cohort study, a total of 148 severe sTBI children were enrolled. We collected patients’ initial data in the emergency department, including gender, age, mechanism of injury, coexisting SEI, motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and intracranial Rotterdam computed tomography (CT) score of the first brain CT scan, as potential mortality predictors. (3) Results: Compared to sTBI children without SEI, children with SEI were older and more presented with initial hypotension and hypothermia; the initial lab showed more prolonged prothrombin time and a higher in-hospital mortality rate. Multivariate analysis showed that motor components of mGCS, fixed pupil reaction, prolonged prothrombin time, and higher Rotterdam CT score were independent predictors of in-hospital mortality in sTBI children. SEI was not an independent predictor of mortality. (4) Conclusions: sTBI children with SEI had significantly higher in-hospital mortality than those without. SEI was not an independent predictor of mortality in our study. Brain injury intensity and its presentations, including lower mGCS, fixed pupil reaction, higher Rotterdam CT score, and severe injury-induced systemic response, presented as initial prolonged prothrombin time, were independent predictors of in-hospital mortality in these sTBI children.
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Affiliation(s)
- Min Chao
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-C.W.); (C.-H.O.)
| | - Carl P. C. Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chia-Ying Chung
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-C.W.); (C.-H.O.)
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
- Correspondence:
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Chen CH, Hsieh YW, Huang JF, Hsu CP, Chung CY, Chen CC. Predictors of In-Hospital Mortality for Road Traffic Accident-Related Severe Traumatic Brain Injury. J Pers Med 2021; 11:1339. [PMID: 34945809 PMCID: PMC8706954 DOI: 10.3390/jpm11121339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/02/2021] [Accepted: 12/07/2021] [Indexed: 11/21/2022] Open
Abstract
(1) Background: Road traffic accidents (RTAs) are the leading cause of pediatric traumatic brain injury (TBI) and are associated with high mortality. Few studies have focused on RTA-related pediatric TBI. We conducted this study to analyze the clinical characteristics of RTA-related TBI in children and to identify early predictors of in-hospital mortality in children with severe TBI. (2) Methods: In this 15-year observational cohort study, a total of 618 children with RTA-related TBI were enrolled. We collected the patients' clinical characteristics at the initial presentations in the emergency department (ED), including gender, age, types of road user, the motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and the intracranial computed tomography (CT) Rotterdam score, as potential mortality predictors. (3) Results: Compared with children exhibiting mild/moderate RTA-related TBI, those with severe RTA-related TBI were older and had a higher mortality rate (p < 0.001). The in-hospital mortality rate for severe RTA-related TBI children was 15.6%. Compared to children who survived, those who died in hospital had a higher incidence of presenting with hypothermia (p = 0.011), a lower mGCS score (p < 0.001), a longer initial prothrombin time (p < 0.013), hyperglycemia (p = 0.017), and a higher Rotterdam CT score (p < 0.001). Multivariate analyses showed that the mGCS score (adjusted odds ratio (OR): 2.00, 95% CI: 1.28-3.14, p = 0.002) and the Rotterdam CT score (adjusted OR: 2.58, 95% CI: 1.31-5.06, p = 0.006) were independent predictors of in-hospital mortality. (4) Conclusions: Children with RTA-related severe TBI had a high mortality rate. Patients who initially presented with hypothermia, a lower mGCS score, a prolonged prothrombin time, hyperglycemia, and a higher Rotterdam CT score in brain CT analyses were associated with in-hospital mortality. The mGCS and the Rotterdam CT scores were predictive of in-hospital mortality independently.
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Affiliation(s)
- Chien-Hung Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-H.C.); (C.-Y.C.)
| | - Yu-Wei Hsieh
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Healthy Aging Research Center, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jen-Fu Huang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (J.-F.H.); (C.-P.H.)
| | - Chih-Po Hsu
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (J.-F.H.); (C.-P.H.)
| | - Chia-Ying Chung
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-H.C.); (C.-Y.C.)
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-H.C.); (C.-Y.C.)
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