Predictors of mortality after craniotomy for geriatric traumatic brain injury

BACKGROUND

With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy.

METHODS

We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08.

RESULTS

We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all).

CONCLUSIONS

Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome.

LEVEL OF EVIDENCE

Level III retrospective study.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

P–229 Oxidative stress and Metformin; an in-vitro study on serum and primary human granulosa cell cultures

Study question

What is the effect of administration of Metformin on the oxidative stress (OS) levels in serum and primary human granulosa cell cultures of infertile females?

Summary answer

Metformin suppresses oxidative stress in serum and human granulosa cells and increases the expression of SIRT1 in OS induced environment.

What is known already

Oxidative stress (OS) is a resultant of mitochondrial dysfunction when it either fails to fight against the oxidants or the expression of the antioxidants is not sufficient. Cellular damage including DNA damage is a common resultant of oxidative stress. OS effects the oocyte maturation and moreover, the cleavage phase in the early embryonic stage. The raised levels of OS makers are hypothesized to compromise the nuclear maturation and the mitotic spindles of the maturing oocytes. Metformin seemed to decrease oxidative stress and improve insulin resistance, dyslipidaemia and endothelial dysfunction in PCOS patients

Study design, size, duration

This cross-sectional study was conducted from August 2017 – July 2019, at Aga Khan Hospital in collaboration with Australian Concept Infertility Medical Centre (ACIMC) on ten infertile patients undergoing egg retrieval after ethical approval from of Aga Khan Hospital (AKU-ERC–2018–0557–601).

Participants/materials, setting, methods

Serum samples were obtained and analysed. Follicular fluid of these subjects was collected for establishment of primary cell culture model of normal human granulosa cells (hGCs). Serum and hGC cultures were grouped as; a) control: treatment, b) Test1: H2O2 induced OS, and c) Test2: H2O2 induced OS treated with metformin. OS was estimated in all groups by Mishra method. The two Test groups were assessed for SIRT1 levels using quantitative PCR employing SIRT1 specific primers

Main results and the role of chance

With mean age of 32.04 ± 2.29 years the mean BMI was 27.61 ± 2.15 kg/m2. OS was induced and measured by an increase in optical density (OD) in hGC Test samples which showed 0.28 (0.16–0.40) OD when compared with control hGC samples 0.153 (0.09–0.23). There was a significant reduction in ODs after metformin treatment in the stress induced cells 0.182 (0.05–0.30). A similar pattern was observed in the serum samples in ODs; control: 0.105 (0.09–0.15), stress induced samples: 0.199 (0.19–0.20). and stress induced serum sample with metformin treatment: 0.1415 (0.06–0.18).

The Ct values obtained to express the effect of metformin on SIRT1 levels, for OS induced (Test1) and OS induced metformin treated (Test2) cells were found to be 29.12 and 26.42, respectively. We also observed a significant (85%) difference in the fold change of SIRT1 expression between metformin treated and untreated cells.

Limitations, reasons for caution

Small sample size is the limitation of this study. The impact of metformin on cell cultures due to different causes of infertility could not be ascertained

Wider implications of the findings: Metformin suppresses oxidative stress in serum and human granulosa cells and increases the expression of SIRT1 in OS induced environment, therefore, metformin may be considered as a treatment of oxidative stress in infertile patients. Randomized control trial with large sample size is recommended to confirm the cause and effect relationship.

Trial registration number

Not applicable

Predicting the need for tracheostomy in trauma patients without severe head injury

BACKGROUND

Early tracheostomy is recommended in patients with severe traumatic brain injury (TBI); however, predicting the timing of tracheostomy in trauma patients without severe TBI can be challenging.

METHODS

A one year retrospective analysis of all trauma patients who were admitted to intensive Care Unit for > 7 days was performed, using the ACS-TQIP database. Univariate and Multivariate regression analyses were performed to assess the appropriate weight of each factor in determining the eventual need for early tracheostomy.

RESULTS

A total of 21,663 trauma patients who met inclusion and exclusion criteria were identified. Overall, tracheostomy was performed in 18.3% of patients. On multivariate regression analysis age >70, flail chest, major operative intervention, ventilator days >5 days and underlying COPD were independently associated with need of tracheostomy. Based on these data, we developed a scoring system to predict risk for requiring tracheostomy.

CONCLUSION

Age >70, presence of flail chest, need for major operative intervention, ventilator days >5 and underlying COPD are independent predictors of need for tracheostomy in trauma patients without severe TBI.

Metabolic Syndrome Exponentially Increases the Risk of Adverse Outcomes in Operative Diverticulitis

BACKGROUND

Metabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients.

METHODS

We analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m², hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed.

RESULTS

A total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m². 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (β = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone.

CONCLUSIONS

Adverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality.

LEVEL OF EVIDENCE

Level III Prognostic.

Is There a Need for Platelet Transfusion After Traumatic Brain Injury in Patients on P2Y12 Inhibitors?

BACKGROUND

A significant portion of patients sustaining traumatic brain injury (TBI) are on antiplatelet medications. The reversal of P2Y12 agents after intracranial hemorrhage (ICH) remains unclear. The aim of our study is to evaluate outcomes after TBI in patients who are on preinjury P2Y12 inhibitors and received a platelet transfusion.

METHODS

We analyzed our prospectively maintained TBI database from 2013 to 2016 and included all patients with isolated ICH who were on P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor). Regression analysis was performed adjusting for demographics and injury parameters. Outcome measures included progression of ICH, adverse discharge disposition (skilled nursing facility), and mortality.

RESULTS

A total 243 patients with ICH on preinjury P2Y12 inhibitor met our inclusion criteria and were analyzed. Mean age was 55 ± 18 y, 58% were males and 60% were white and median injury severity score was 13 [9-18]. 73.6% received platelet transfusion after admission. The median packs of platelet transfusion were 1 [1-2] units. After controlling for confounders, patients who received platelet transfusion had a lower rate of progression (OR: 0.68, P = 0.01) and decreased rate of neurosurgical intervention (OR: 0.80, P = 0.03). Overall mortality was 12.3%. Patients on P2Y12 inhibitors who received platelet transfusion had lower odds of discharge to a skilled nursing facility (OR: 0.75, P = 0.02) and mortality (OR: 0.85, P = 0.04).

CONCLUSIONS

Platelet transfusion after isolated traumatic ICH in patients on P2Y12 inhibitors is associated with improved outcomes. Platelet transfusion was associated with decreased risk of progression of ICH, neurosurgical intervention, and mortality. Further randomized studies to validate the use of platelet transfusion and define the optimal dose in patients on P2Y12 inhibitors are warranted.

Massive Transfusion: The Revised Assessment of Bleeding and Transfusion (RABT) Score

BACKGROUND

Massive transfusion (MT) is a lifesaving treatment for trauma patients with hemorrhagic shock, assessed by Assessment of Blood Consumption (ABC) Score based on mechanism of injury, systolic blood pressure (SBP), tachycardia, and FAST exam. The aim of this study was to assess the performance of ABC score by replacing hypotension and tachycardia; with Shock Index (SI) > 1.0 and including pelvic fractures.

METHODS

We performed a 2-year (2014-2015) analysis of all high-level trauma activations and excluded patients dead on arrival. The ABC score was calculated using the 4-point score [blunt (0)/penetrating trauma (1), HR ≥ 120 (1), SBP ≤ 90 mmHg (1), and FAST positive (1)]. The Revised Assessment of Bleeding and Transfusion (RABT) score also included 4 points, calculated by replacing HR and SBP with SI > 1.0 and including pelvic fracture. AUROC compared performances of the two scores.

RESULTS

A total of 380 patients were included. The overall MT was 27%. Patients receiving MT had higher median ABC scores [1.1 (0-2) vs. 1 (0-2), p = 0.15] and RABT scores [2 (1-3) vs. 1 (0-2), p < 0.001]. The RABT score had better discriminative power (AUROC = 0.828) compared to ABC score (AUROC = 0.617) for predicting the need for MT. Cutoff of RABT score ≥ 2 had a sensitivity of 84% and specificity of 77% for predicting need for MT compared to ABC score with 39% sensitivity and 72% specificity.

CONCLUSION

Replacement of hypotension and tachycardia with a SI > 1.0 and inclusion of pelvic fracture enhanced discrimination of ABC score for predicting the need for MT. The current ABC score would benefit from revision to more appropriately identify patients requiring MT.

Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program

BACKGROUND

Advancement in trauma care has led to the evolution of emergency resuscitative thoracotomy (ERT) for the revival of trauma patients. We now have more precise understanding of selecting suitable patients for achieving optimal outcomes. The aim of our study was to analyze the utilization and survival trends during the past 5 years, as well as factors that influence survival after ERT.

METHODS

A 5-year (2010-2014) analysis of all trauma patients ≥18 years who underwent ERT in the American College of Surgeons Trauma Quality Improvement Program. Outcome measures were utilization rates and survival trends after ERT during the 5-year period. Regression analysis was performed.

RESULTS

2229 patients underwent ERT, mean age was 37±17 years, 81% were male. Overall 56% patients had penetrating mechanism, location of major injury was thorax in 48, and 71% had signs of life (SOL) on arrival. The overall survival rate was 9.6%. From 2010-2014 ERT utilization has decreased from 331/100 000 to 243/100 000 trauma admissions (p=0.002) and the survival rate has improved from 7.9% to 11.3% (p<0.001). On regression, the independent predictors of survival were penetrating mechanism, age<60 years, SOL on arrival, no prehospital CPR and ISS. No patient aged >60 years with a blunt mechanism of injury (MOI) survived, and there were no survivors above the age of 70 years, regardless of injury mechanism.

DISCUSSION

Utilization of ERT has been decreased during the study period along with improved survival rates. The results of our study demonstrate that performing ERT on patients aged >60 years with a blunt MOI or on any patient aged ≥70 years, regardless of MOI, is futile and should be avoided.

LEVEL OF EVIDENCE

Level III, prognostic studies.

Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis

BACKGROUND

The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis.

METHODS

We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost.

RESULTS

A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality.

CONCLUSIONS

Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

Evaluating the Relevance of the 2013 Tokyo Guidelines for the Diagnosis and Management of Cholecystitis

BACKGROUND

The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13.

STUDY DESIGN

Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13.

RESULTS

Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67% were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4% were febrile on presentation and 51% of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53% for diagnosing AC (definitive 27%, suspected 26%, and undiagnosed 47%) when compared with the final pathology report; 92.5% of patients with grade I, 93% with grade II, and even 64% with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7% vs 4.7%; p = 0.81), return to operating room rates (0.6% vs 0.7%; p = 0.95), or mortality rates (0.3% vs 0%; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy.

CONCLUSIONS

The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.

The burden of firearm violence in the United States: stricter laws result in safer states

BACKGROUND

Increasing firearm violence has resulted in a strong drive for stricter firearm legislations. Aim of this study was to determine the relationship between firearm legislations and firearm-related injuries across states in the United States.

METHODS

We performed a retrospective analysis of all patients with trauma related hospitalization using the 2011 Nationwide Inpatient Sample database. Patients with firearm-related injury were identified using E-codes. States were dichotomized into strict firearm laws [SFL] or non-strict firearm laws [Non-SFL] states based on Brady Center score. Outcome measures were the rate of firearm injury and firearm mortality. Linear Regression and correlation analysis were used to assess outcomes among states.

RESULTS

1,277,250 patients with trauma related hospitalization across 44 states were included of which, 2,583 patients had firearm-related injuries. Ten states were categorized as SFL and 34 states as Non-SFL. Mean rate of firearm related injury per 1000 trauma patients was lower in SFL states (1.3±0.5 vs. 2.1±1.4; p=0.006) and negatively correlated with Brady score (R2 linear=-0.07; p=0.04). SFL states had a 28% lower incidence of firearm related injuries compared to Non-SFL states (Beta coefficient, -0.28; 95% CI, -1.7- -0.06; p=0.04). Firearm related mortalities resulted in overall 9,722 potential life years lost and more so in the non-SFL states (p=0.001).

CONCLUSIONS

States without SFL have higher firearm related injury rates, higher firearm related mortality rate, and significant potential years of life lost compared to SFL states. Further analysis of differences in the legislation between SFL and non-SFL states may help reduce firearm related injury rate.

Geriatric rescue after surgery (GRAS) score to predict failure-to-rescue in geriatric emergency general surgery patients

BACKGROUND

Geriatric-patients(GP) undergoing emergency-general-surgery(EGS) are vulnerable to develop adverse-outcomes. Impact of patient-level-factors on Failure-to-Rescue(FTR) in EGS-GP remains unclear. Aim of our study was to determine factors associated with FTR(death from major-complication) and devise simple-bedside-score that predicts FTR in EGS-GP.

METHODS

3-year(2013-15) analysis of patients, age≥65y on acute-care-surgery-service and underwent EGS. Regression analysis used to analyze factors associated with FTR and natural-logarithm of significant odds-ratio used to calculate estimated-weights for each factor. Geriatric-Rescue-After-Surgery(GRAS)-score calculated for each-patient. AUROC used to assess model discrimination.

RESULTS

725 EGS-patients analyzed. 44.6%(n = 324) had major-complications. The FTR-rate was 11.5%. Overall-mortality rate was 15.3%. On regression, significant-factors with their estimated-weights were:Age≥80y(2), Chronic-Obstructive-Pulmonary-Disease(COPD)(1), Chronic-renal-failure(CRF)(2), Congestive-heart-failure(CHF)(1), Albumin<3.5(1) and ASA score>3(2). AUROC of score was 0.787.

CONCLUSION

GRAS-score is first score based on preoperative assessment that can reliably predict FTR in EGS-GP. Preoperative identification of patients at increased-risk of FTR can help in risk-stratification and timely-mobilization of resources for successful rescue of these patients.

Primary repair for pediatric colonic injury: Are there differences among adult and pediatric trauma centers?

BACKGROUND

Management of colonic injuries (colostomy [CO] versus primary anastomosis [PA]) among pediatric patients remains controversial. The aim of this study was to assess outcomes in pediatric trauma patient with colonic injury undergoing operative intervention.

METHODS

The National Trauma Data Bank (2011-2012) was queried including patients with isolated colonic injury undergoing exploratory laparotomy with PA or CO with age ≤18 y. Missing value analysis was performed. Patients were stratified into two groups: PA and CO. Outcome measures were mortality, in-hospital complications, and hospital length of stay. Multivariate regression analysis was performed.

RESULTS

A total of 1151 patients included. Mean ± standard deviation age was 11.61 ± 2.8 y, and median [IQR] Injury Severity Score was 12 [8-16]; 39% (n = 449) of the patients had CO, and 35.6% (n = 410) were managed in pediatric trauma centers (PC). Patients with CO had a higher Injury Severity Score (P < 0.001), a trend toward lower blood pressure (P = 0.40), and an older age (P < 0.001). There was no difference in mortality between the PA and CO groups. However, patients who underwent PA had a shorter length of stay (P < 0.001) and lower in-hospital complications (P < 0.001). A subanalysis shows that, after controlling for all confounding factors, patients managed in PC were 1.2 times (1.2 [1.1-2.1], P = 0.04) more likely to receive a CO than those patients managed in adult trauma centers (AC). Moreover, there was no difference in mortality between the AC and the PC (P = 0.79).

CONCLUSIONS

Our data demonstrate no difference in mortality in pediatric trauma patients with colonic injury who undergo primary repair or CO. However, adult trauma centers had lower rates of CO performed as compared to a similar cohort of patients managed in pediatric trauma centers. Further assessment of the reasons underlying such differences will help improve patient outcomes.

Early thromboprophylaxis with low-molecular-weight heparin is safe in patients with pelvic fracture managed nonoperatively

INTRODUCTION

Early initiation of thromboprophylaxis is highly desired in pelvic fracture patients, but it is often delayed due to the fear of hemorrhage. Aim of our study was to assess the safety of early initiation of venous thromboprophylaxis in patients with pelvic trauma managed nonoperatively.

METHODS

Three-year (2010-2012) retrospective study of trauma patients with pelvic fractures who were managed nonoperatively and received thromboprophylaxis with low-molecular-weight heparin (LMWH). Patients were stratified in two groups based on the timing of initiation of prophylaxis; early (initiation within first 24 h) and late (after 24 h). Primary outcome measures included decrease in hemoglobin (Hb) levels, number of packed red blood cell (pRBC) units transfused, and the need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Regression analysis was performed.

RESULTS

255 patients were included (158 in early and 97 in late group). Mean ± standard deviation age was 48.2 ± 23.3 y, and 50.6% were male. After adjusting for confounders, there was no difference between the two groups in the decrease in Hb levels (b = 0.087, 95% confidence interval [CI] = -0.253 to 1.025; P = 0.23) or pRBC units transfused (b = -0.005, 95% CI = -0.366 to 0.364; P = 0.75).One patient required hemorrhage control postprophylaxis and belonged to the late group. Subanalysis of patients with signs of bleeding (n = 52) showed no difference between the two groups in the decrease in Hb levels or pRBC units transfused. Patients who received LMWH after 24 h had a higher incidence of symptomatic deep venous thrombosis and a longer hospital length of stay.

CONCLUSIONS

Early initiation of thromboprophylaxis with LMWH in patients with pelvic fractures managed nonoperatively is safe and decreases the risk of symptomatic deep venous thrombosis.

The impact of Glasgow Coma Scale-age prognosis score on geriatric traumatic brain injury outcomes

BACKGROUND

As the population ages, increasing number of geriatric patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information is crucial for making informed decisions on behalf of such patients. Therefore, the aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients.

METHODS

We performed a 1-y (2011) retrospective analysis of isolated geriatric TBI patients (age ≥65 y, head abbreviated injury score [AIS] ≥ 3, and other body AIS < 3) in the National Trauma Data Bank. We calculated a Glasgow Coma Scale (GCS)-age prognosis (GAP) score (age/GCS score) for all patients. Outcome measures were in-hospital adverse outcomes (mortality and Rehab/skilled nursing facility discharge disposition). Regression analysis and receiver operator characteristic curve analysis were performed to determine the discriminatory power of GAP score.

RESULTS

A total of 8750 geriatric patients with TBI were included. Mean age was 77.8 ± 7.1 y, the median (interquartile range) GCS was 15 (13-15), and the median (interquartile range) head AIS was 4 (3-4). The overall in-hospital mortality rate was 12.7%, and 34.2% of the patients were discharged home. As the GAP score increased, the mortality rate increased and discharge to-home decreased. Receiver operator characteristic curve analysis revealed excellent discriminatory power for mortality (area under the curve: 0.826). Above a GAP score of 12, the mortality rate was >50% and more than 45% of the patients were discharged to Rehab/skilled nursing facility.

CONCLUSIONS

For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in a drastic increase in mortality and an adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patients' families.

High prevalence of genu varum/valgum in European children with low vitamin D status and insufficient dairy products/calcium intakes

OBJECTIVE

The prevalence of lower limb deformities physiologically decreases after 5 years of age. It remains high in some tropical and subtropical regions where it has been associated with severe vitamin D deficiency, low calcium/milk intakes, malnutrition, and/or fluoride overexposure. Very little data is available in apparently healthy Caucasian children and adolescents.

DESIGN

We evaluated the prevalence of genu varum/valgum and other clinical symptoms, and assessed vitamin D status and markers of calcium metabolism in 226 apparently healthy European full-time boarders (7-16 years) seen during winter-spring and fed a cereal-based diet with little access to meat, milk, and dairy products. A cohort of 71 white children and adolescents hospitalized for acute illness served as age-matched controls.

RESULTS

Association studies showed a high prevalence of lower limb deformities (36%) and higher alkaline phosphate activities in the 21% of children and adolescent full-time boarders with serum 25-(OH)D levels ≤ 30 nmol/l, and low serum calcium in the 74% of boarders with 25-(OH)D levels ≤ 50 nmol/l, compared with boarders with higher vitamin D status. No such anomalies were found in the control cohort despite lower serum 25-(OH)D levels.

CONCLUSIONS

Low 25-(OH)D levels, at least during winter-spring, combined with additional risk factors such as very low calcium/milk intakes and possibly digestive disorders, are associated with an increased risk of genu varum/valgum in European children and adolescents. Thus, dietary fortification, or supplementation with vitamin D, may be recommended, at least during the winter, to European children and adolescents with either none or insufficient calcium/dairy product intakes.

High prevalence of genu varum/valgum in European children with low vitamin D status and insufficient dairy products/calcium intakes

OBJECTIVE

The prevalence of lower limb deformities physiologically decreases after 5 years of age. It remains high in some tropical and subtropical regions where it has been associated with severe vitamin D deficiency, low calcium/milk intakes, malnutrition, and/or fluoride overexposure. Very little data is available in apparently healthy Caucasian children and adolescents.

DESIGN

We evaluated the prevalence of genu varum/valgum and other clinical symptoms, and assessed vitamin D status and markers of calcium metabolism in 226 apparently healthy European full-time boarders (7-16 years) seen during winter-spring and fed a cereal-based diet with little access to meat, milk, and dairy products. A cohort of 71 white children and adolescents hospitalized for acute illness served as age-matched controls.

RESULTS

Association studies showed a high prevalence of lower limb deformities (36%) and higher alkaline phosphate activities in the 21% of children and adolescent full-time boarders with serum 25-(OH)D levels ≤ 30 nmol/l, and low serum calcium in the 74% of boarders with 25-(OH)D levels ≤ 50 nmol/l, compared with boarders with higher vitamin D status. No such anomalies were found in the control cohort despite lower serum 25-(OH)D levels.

CONCLUSIONS

Low 25-(OH)D levels, at least during winter-spring, combined with additional risk factors such as very low calcium/milk intakes and possibly digestive disorders, are associated with an increased risk of genu varum/valgum in European children and adolescents. Thus, dietary fortification, or supplementation with vitamin D, may be recommended, at least during the winter, to European children and adolescents with either none or insufficient calcium/dairy product intakes.

Season of birth and not vitamin D receptor promoter polymorphisms is a risk factor for multiple sclerosis

Both genetic and environmental factors contribute to multiple sclerosis, the most common neurodegenerative disorder with onset in young adults. The objective of the current study is, based on the hypothesis that environmentally predisposed individuals are at risk for multiple sclerosis, to investigate whether they also carry genetic variants within the vitamin D machinery. Using medical files and DNA samples from 583 trios (a patient and both parents) of the French Multiple Sclerosis Genetics Group as well as data from the French Statistics Bureau, we aimed to assess whether: (1) a seasonality of birth was observed in French multiple sclerosis patients; (2) three single nucleotide polymorphisms within the promoter region of the vitamin D receptor were associated with multiple sclerosis susceptibility; and (3) the combination of a high risk month of birth and vitamin D receptor polymorphisms were correlated to multiple sclerosis incidence. We observed a significantly reduced number of individuals born in November who were later diagnosed as multiple sclerosis patients. However, we found no association between the three studied vitamin D receptor polymorphisms and multiple sclerosis. In conclusion, our data suggest that high levels of vitamin D during the third trimester of pregnancy could be a protective factor for multiple sclerosis.

Milk, rather than other foods, is associated with vertebral bone mass and circulating IGF-1 in female adolescents

SUMMARY

Low calcium intake hampers bone mineral acquisition in adolescent girls. This study explores dietary calcium sources and nutrients possibly associated with vertebral mass. Milk intake is not influenced by genetic variants of the lactase gene and is positively associated with serum IGF-1 and with lumbar vertebrae mineral content and density.

INTRODUCTION

Low calcium intake hampers bone mineral acquisition during adolescence. We identified calcium sources and nutrients possibly associated with lumbar bone mineralization and calcium metabolism in adolescent girls and evaluated the possible influence of a genetic polymorphic trait associated with adult-type hypolactasia.

METHODS

Lumbar bone mineral content (BMC), bone mineral density (BMD), and area, circulating IGF-1, markers of bone metabolism, and -13910 LCT (lactase gene) polymorphism; and intakes of milk, dairy products, calcium, phosphorus, magnesium, proteins, and energy were evaluated in 192 healthy adolescent girls.

RESULTS

After menarche, BMC, BMD, serum IGF-1, and serum PTH were tightly associated with milk consumption, but not with other calcium sources. All four parameters were also associated with phosphorus, magnesium, protein, and energy from milk, but not from other sources. Girls with milk intakes below 55 mL/day have significantly lower BMD, BMC, and IGF-1 and higher PTH compared to girls consuming over 260 mL/day. Neither BMC, BMD, calcium intakes, nor milk consumption were associated with -13910 LCT polymorphism.

CONCLUSIONS

Milk consumption, preferably to other calcium sources, is associated with lumbar BMC and BMD in postmenarcheal girls. Aside from being a major source of calcium, milk provides phosphates, magnesium, proteins, and as yet unidentified nutrients likely to favor bone health.

The Wilms' tumor gene product (WT1) modulates the response to 1,25-dihydroxyvitamin D3 by induction of the vitamin D receptor

The Wilms' tumor gene (wt1) encodes a transcription factor involved in urogenital development, in particular in renal differentiation, and in hematopoietic differentiation. Differentiation of a number of solid tumor and leukemic cells lines can be mediated by 1,25-dihydroxyvitamin D(3). This is predominantly mediated by the nuclear receptor for 1,25-dihydroxyvitamin D(3), the vitamin D receptor (VDR). In initial experiments addressing a possible link between WT1 and VDR, we observed a correlated expression of WT1 and VDR mRNA in samples from renal tissues. HT29 colon carcinoma cells, stably transfected to express WT1, exhibited elevated endogenous VDR levels compared with control cells transfected with a control construct. Elevated VDR expression was found in wt1-transfected human embryonic kidney 293 cells, as well. In transient cotransfection experiments, we observed an activation of a vdr promoter reporter by WT1 through a WT1 recognition element, indicating transcriptional regulation of the vdr gene expression by WT1. The responsive sequence element was specifically bound by wild-type, but not by mutated WT1, in electrophoretic mobility shift assays. HT29 colon carcinoma cells, which respond to 1,25-dihydroxyvitamin D(3) with slow induction of growth arrest, were investigated for the influence of WT1 on 1,25-dihydroxyvitamin D(3)-mediated growth suppression. Although HT29 cells transfected with a control construct responded moderately to 1,25-dihydroxyvitamin D(3), the response of HT29 cells expressing WT1 was strikingly enhanced. Stimulation with dihydroxyvitamin D(3) caused an up to 3-fold reduction in the growth rate of different HT29 clones expressing WT1 as compared with control cells lacking WT1 expression. Thus, induction of VDR by WT1 leads to an enhanced response to 1,25-dihydroxyvitamin D(3). We conclude that the vitamin D receptor gene is a target for transcriptional activation by WT1, suggesting a possible physiological role of this regulatory pathway.

The mouse vitamin D receptor is mainly expressed through an Sp1-driven promoter in vivo

The availability of the mouse vitamin D receptor (mVDR) gene has allowed a characterization of a TATA-less promoter containing a cluster of four Sp1 sites named Sp1-1, Sp1-2, Sp1-3, and Sp1-4 (F. Jehan and H. F. DeLuca, 1997, Proc. Natl. Acad. Sci. USA 94, 10138-10143). By means of primer extension analysis, S1 nuclease mapping and ribonuclease protection assay, the start site has been deduced, as has the existence of other minor transcription start sites. Initiation of transcription at the major site is located 4 bp upstream of the 5' end of the mVDR cDNA sequence and very close to the putative Sp1 sites. A second minor promoter might exist between exon 1 and exon 2 of the mVDR gene. The nucleotide sequence of the Sp1 region is well conserved between the mouse, the human, and the chicken VDR genes, suggesting an important role for these Sp1 sites. Gel shift analysis of the four Sp1 sites of the mVDR promoter has confirmed specific binding complexes to Sp1-1, Sp1-2, and Sp1-4 (Sp1-3 rather binds an unknown complex that is unable to bind the canonical Sp1 GGGGCGGGGC). Deletion or mutation of all the Sp1 sites eliminates promoter activity. However, mutation or deletion of individual Sp1 sites did not dramatically change the promoter activity, except for mutation of Sp1-3 that increases promoter activity. We, therefore, conclude that the mVDR promoter is controlled by the Sp1 sites and is the main VDR promoter in intestine and kidney.

Isolation and characterization of the chicken vitamin D receptor gene and its promoter

The sequences from several independent cDNA clones encoding the chicken vitamin D receptor as well as primer extension assay have clearly delineated the 5' terminus and the transcriptional start site. Screening a chicken genomic library produced genomic clones containing vitamin D receptor (VDR) gene fragments. Restriction map of clone 8 showed that the 18.6-kb chicken VDR fragment has exons 1 and 2, intron 1, part of intron 2, and 7-kb 5' flanking region. Exons 1, 2, and 3 found in the chicken VDR gene shares low homology with its mammalian counterparts (i.e., E1A, E1B, and E1C in human). By contrast, the fourth exon and following exons for the coding region of VDR gene are highly conserved between avian and mammalian species. While the fourth exon bears the ATG sites for translation initiation in mammals, the third exon in birds has two extra ATG sites for leaky translation as determined previously. Thus, the avian VDR has more N-terminal sequence than the mammalian VDR and is found in two distinct forms. The 5' flanking region from genomic clone 8 shares considerable homology in several regions with the human and mouse VDR promoters. Moreover, the 5' flanking region of chicken VDR gene possesses promoter activity, as shown by its ability to drive the luciferase reporter gene in cell transfection assays. Like other steroid receptor promoters, the chicken VDR promoter contains no TATA box but possesses several GC boxes or SP1 sites. A series of deletional promoter constructs established that the proximal GC boxes are the major drivers of gene transcription, while the more upstream sequences have repressive elements.

DNA bending is induced by binding of vitamin D receptor-retinoid X receptor heterodimers to vitamin D response elements

The ability of vitamin D receptor-retinoid X receptor (VDR-RXR) heterodimers to induce a DNA bend upon binding to various vitamin D response elements (VDRE) has been investigated by circular permutation and phasing analysis. Recombinant rat VDR expressed in the baculovirus system and purified recombinant human RXR beta have been used. The VDREs were from 1,25-dihydroxyvitamin D3 (1,25-[OH]2D3) enhanced genes (rat osteocalcin, rOC; mouse osteopontin, mOP, and rat 1,25-dihydroxyvitamin D3-24-hydroxylase, r24-OHase), and a 1,25-(OH)2D3 repressed gene (human parathyroid hormone, hPTH). As shown by circular permutation analysis, VDR-RXR induced a distortion in DNA fragments containing various VDREs. Calculated distortion angles were similar in magnitude (57 degrees, 56 degrees, 61 degrees, and 59 degrees, respectively for rOC, mOP, r24-Ohase, and hPTH). The distortions took place with or without a 1,25-(OH)2D3 ligand. The centers of the apparent bend were found in the vicinity of the midpoint of all VDREs, except for rOC VDRE which was found 4 bp upstream. Phasing analysis was performed with DNA fragments containing mOP VDRE and revealed that VDR-RXR heterodimers induced a directed bend of 26 degrees, not influenced by the presence of hormone. In this study we report that similar to other members of the steroid and thyroid nuclear receptor superfamily, VDR-RXR heterodimers induce DNA bending.