1
|
Craig HA, Lowe DJ, Khan A, Paton M, Gordon MW. Exploring the impact of traumatic injury on mortality: An analysis of the certified cause of death within one year of serious injury in the Scottish population. Injury 2024; 55:111470. [PMID: 38461710 DOI: 10.1016/j.injury.2024.111470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/01/2024] [Accepted: 02/25/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Few studies effectively quantify the long-term incidence of death following injury. The absence of detailed mortality and underlying cause of death data results in limited understanding and a potential underestimation of the consequences at a population level. This study takes a nationwide approach to identify the one-year mortality following injury in Scotland, evaluating survivorship in relation to pre-existing comorbidities and incidental causes of death. STUDY DESIGN This retrospective cohort study assessed the one-year mortality of adult trauma patients with an Injury Severity Score ≥ 9 during 2020 using the Scottish Trauma Audit Group (STAG) registry linked to inpatient hospital data and death certificate records. Patients were divided into three groups: trauma death, trauma-contributed death, and non-trauma death. Kaplan-Meier curves were used for survival analysis to evaluate mortality, and cox proportional hazards regression analysed risk factors linked to death. RESULTS 4056 patients were analysed with a median age 63 years (58-88) and male predominance (55.2 %). Falls accounted for 73.1 % of injuries followed by motor vehicle accidents (16.3 %) and blunt force (4.9 %). Extremity was the most commonly injured region overall followed by chest and head. However, head injury prevailed in those who died. The registry demonstrated a one-year mortality of 19.3 % with 55 % deaths occurring post-discharge. Of all deaths reported, 35.3 % were trauma deaths, and 47.7 % were trauma-contributed deaths. These groups accounted for over 70 % of mortality within 30 days of hospital admission and continued to represent the majority of deaths up to 6 months post-injury. Patients who died after 6 months were mainly the result of non-traumatic causes, frequently circulatory, neoplastic, and respiratory diseases (37.7 %, 12.3 %, 9.1 %, respectively). Independent risk factors for one-year mortality included a GCS ≤ 8, modified Charlson Comorbidity score >5, Injury Severity Score >25, serious head injury, age and sex. CONCLUSION With a one-year mortality of 19.3 %, and post-discharge deaths higher than previously appreciated, patients can face an extended period of survival uncertainty. As mortality due to index trauma lasted up to 6 months post-admission, short-term outcomes fail to represent trauma burden and so cogent survival predictions should be avoided in clinical and patient settings.
Collapse
Affiliation(s)
- Hannah A Craig
- University of Glasgow School of Medicine, G12 8QQ, Glasgow, United Kingdom.
| | - David J Lowe
- Department of Emergency Medicine, Queen Elizabeth University Hospital, Glasgow, G51 4TF, United Kingdom; Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, United Kingdom
| | - Angela Khan
- Scottish National Audit Programme, Area 143c, Clinical & Protecting Health Directorate, Public Health Scotland, 1 South Gyle Crescent, Edinburgh EH12 9EB, United Kingdom
| | - Martin Paton
- Scottish National Audit Programme, Public Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, United Kingdom
| | - Malcolm Wg Gordon
- Department of Emergency Medicine, Queen Elizabeth University Hospital, Glasgow, G51 4TF, United Kingdom
| |
Collapse
|
2
|
Agoubi LL, Reimel BA, Maine RG, O’Connell KM, Maier RV, McIntyre LK. Intensive care unit readmission in injured older adults: Modifiable risk factors and implications. J Trauma Acute Care Surg 2024; 96:813-819. [PMID: 37926991 PMCID: PMC11043003 DOI: 10.1097/ta.0000000000004203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Prior evaluations of intensive care unit (ICU) readmission among injured older adults have inconsistently identified risk factors, with findings limited by use of subanalyses and small sample sizes. This study aimed to identify risk factors for and implications of ICU readmission in injured older adults. METHODS This retrospective, single-center cohort study was conducted at a high-volume Level 1 trauma center and included injured older adult patients (65 years or older) requiring at least one ICU admission during hospitalization between 2013 and 2018. Patients who died <48 hours of admission were excluded. Exposures included patient demographics and clinical factors. The primary outcome was ICU readmission. Multivariable regression was used to identify risk factors for ICU readmission. RESULTS A total of 6,691 injured adult trauma patients were admitted from 2013 to 2018, 55.4% (n = 3,709) of whom were admitted to the ICU after excluding early deaths. Of this cohort, 9.1% (n = 339) were readmitted to the ICU during hospitalization. Readmitted ICU patients had a higher median Injury Severity Score (21 [interquartile range, 14-26] vs. 16 [interquartile range, 10-24]), with similar mechanisms of injury between the two groups. Readmitted ICU patients had a significantly higher mortality (19.5%) compared with single ICU admission patients (9.9%) ( p < 0.001) and higher rates of developing any complication, including delirium (61% vs. 30%, p < 0.001). On multivariable analysis, the factors associated with the highest risk of readmission were delirium (Relative Risk, 2.6; 95% confidence interval, 2.07-3.26) and aspiration (Relative Risk, 3.04; 95% confidence interval, 1.67-5.54). More patients in the single ICU admission cohort received comfort-focused care at the time of their death as compared with the ICU readmission cohort (93% vs. 85%, p = 0.035). CONCLUSION Readmission to the ICU is strongly associated with higher mortality for injured older adults. Efforts targeted at preventing respiratory complications and delirium in the geriatric trauma population may decrease the rates of ICU readmission and related mortality risk. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Collapse
Affiliation(s)
- Lauren L. Agoubi
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Beth Ann Reimel
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Rebecca G. Maine
- Department of Surgery, University of Washington, Seattle, WA, USA
| | | | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Lisa K. McIntyre
- Department of Surgery, University of Washington, Seattle, WA, USA
| |
Collapse
|
3
|
Smith SM, Zhao X, Kenzik K, Michael C, Jenkins K, Sanchez SE. Risk factors for loss to follow-up after traumatic injury: An updated view of a chronic problem. Surgery 2024; 175:1445-1453. [PMID: 38448279 DOI: 10.1016/j.surg.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 01/24/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Loss to follow-up after traumatic injury occurs at rates of up to 47%. However, the most recent data are over a decade old, and recent changes in traumatic injury patterns necessitate an updated assessment of risk factors for loss to follow-up after trauma. METHODS We conducted a retrospective chart review of trauma admissions from January 1, 2018 to December 31, 2021. Categorical variables were compared using χ2 analyses, and continuous variables were analyzed using Mann-Whitney Wilcoxon tests. Multivariable logistic regression was used to adjust for relevant factors identified on unadjusted analysis. RESULTS Among 3,034 patients, overall loss to follow-up was 36.9%. Non-White patients, patients who underwent operations or non-surgical procedures, and patients discharged to rehabilitation facilities were more likely to have follow-up appointments within 30 days. Patients with substance use disorder and, among White patients, those with public insurance had higher loss to follow-up rates. Having a follow-up appointment scheduled with a primary care provider was the single most significant factor associated with attending a follow-up appointment. CONCLUSION Social determinants of health, such as insurance status and substance use disorder, are associated with loss of follow-up after trauma. Primary care appointments are associated with the highest attendance rates, supporting that all patients should be offered primary care appointments after traumatic injury.
Collapse
Affiliation(s)
- Sophia M Smith
- Department of Surgery, Boston Medical Center, Boston, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
| | - Xuewei Zhao
- Department of Surgery, Boston Medical Center, Boston, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Cara Michael
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Kendall Jenkins
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA. https://twitter.com/SESanchezMD
| |
Collapse
|
4
|
Tilahun L, Zeleke M, Desu B, Dagnew K, Nega A, Birrie E, Estifanos N, Tegegne A, Feleke A. Time to recovery and its predictors following traumatic injuries among injured victims in Dessie Comprehensive Specialized Hospital, North East of Ethiopia, 2022: a retrospective follow-up study. BMC Emerg Med 2024; 24:44. [PMID: 38500020 PMCID: PMC10949805 DOI: 10.1186/s12873-024-00960-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/03/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Injuries are an extremely important public health problem worldwide. Despite being largely preventable and despite government efforts, injuries continue to be a major public health issue. Thus, the study tends to evaluate the time to recovery and its predictors for traumatic injuries. METHODS A hospital-based retrospective follow-up study was used. A total of 329 medical charts were actually reviewed. Traumatic injury victims from January 1, 2018-December 31, 2022 were included, and a simple random sampling technique was utilized. The data was gathered by reviewing medical charts. Data was coded and entered into Epi-Data Manager version 4.6.0.4 statistical software and further analyzed using STATA version 17. Descriptive statistics were performed to see the frequency distribution of variables. A Kaplan-Meier survival estimate and log rank test were performed to plot the overall survival curve and compare the difference in recovery among predictor categories, respectively. A model fitness test was done by using the Cox-Snell residual test and Harrell's C concordance statistic. Finally, a Cox proportional hazard model was fitted to determine the effect of predictors on recovery time from traumatic injuries. RESULTS The median time to recovery of traumatic injuries was 5 days (IQR: 3-10 days), with an overall incidence density of 8.77 per 100 person-days of observation. In the multivariable cox proportional regression model, variables such as being male (AHR: 0.384, 95%CI: 0.190-0.776, P-value: 0.008), the Glasgow coma scale of 13-15 (AHR: 2.563, 95%CI: 1.070-6.139, P-value: 0.035), intentional injury (AHR: 1.934, 95%CI: 1.03-3.632, P-value: 0.040), mild traumatic brain injury (AHR: 2.708, 95%CI: 1.095-6.698, P-value: 0.031), and moderate traumatic brain injury (AHR: 2.253, 95%CI: (1.033-4.911, P-value: 0.041) were statistically significant variables. CONCLUSIONS The median recovery time for traumatically injured respondents was 5 days. Independent predictors such as the Glasgow coma scale, time taken for surgical management, intent of injury, and traumatic brain injury were statistically significant with time to recovery from trauma.
Collapse
Affiliation(s)
- Lehulu Tilahun
- College of Medicine and Health Sciences, Department of Emergency and Ophthalmic Nursing, Wollo University, PO Box 1145, Dessie, Ethiopia.
| | - Mulusew Zeleke
- College of Medicine and Health Sciences, Department of Adult Health Nursing, Wollo University, Dessie, Ethiopia
| | - Birhanu Desu
- College of Medicine and Health Sciences, Department of Emergency and Ophthalmic Nursing, Wollo University, PO Box 1145, Dessie, Ethiopia
| | - Kirubel Dagnew
- College of Medicine and Health Sciences, Department of Comprehensive Nursing, Wollo University, Dessie, Ethiopia
| | - Aytenew Nega
- College of Medicine and Health Sciences, Department of Emergency and Ophthalmic Nursing, Wollo University, PO Box 1145, Dessie, Ethiopia
| | - Endalk Birrie
- College of Medicine and Health Sciences, Department of Pediatrics and Child Health, Wollo University, Dessie, Ethiopia
| | - Nathan Estifanos
- College of Medicine and Health Sciences, Department of Comprehensive Nursing, Wollo University, Dessie, Ethiopia
| | - Akele Tegegne
- College of Medicine and Health Sciences, Department of Emergency and Ophthalmic Nursing, Wollo University, PO Box 1145, Dessie, Ethiopia
| | - Asresu Feleke
- College of Medicine and Health Sciences, Department of Emergency and Critical Care Nursing, Dilla University, Dilla, Ethiopia
| |
Collapse
|
5
|
Harris KA, Zhou Y, Jou S, Greenwald BD. Disorders of Consciousness Programs: Components, Organization, and Implementation. Phys Med Rehabil Clin N Am 2024; 35:65-77. [PMID: 37993194 DOI: 10.1016/j.pmr.2023.06.014] [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] [Indexed: 11/24/2023]
Abstract
Rehabilitation of patients with disorders of consciousness (DoC) presents unique challenges requiring comprehensive and specialized care. This article reviews the components, organization, and implementation of an inpatient DoC program under the framework of recent evidence-based practice guidelines and minimum competency recommendations. The evidence and clinical applications of these recommendations are elaborated upon with the goal of offering providers a reference to translate guidelines into clinical practice.
Collapse
Affiliation(s)
- Kristen A Harris
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA.
| | - Yi Zhou
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA
| | - Stacey Jou
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA
| | - Brian D Greenwald
- JFK Johnson Rehabilitation Institute/Hackensack Meridian School of Medicine, Rutgers Robert Wood Johnson Medical School, 65 James Street, Edison, NJ 08820, USA
| |
Collapse
|
6
|
Cuschieri J, Kornblith L, Pati S, Piliponsky A. The injured monocyte: The link to chronic critical illness and mortality following injury. J Trauma Acute Care Surg 2024; 96:195-202. [PMID: 37880827 PMCID: PMC10986485 DOI: 10.1097/ta.0000000000004173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND This study aimed to understand the altered innate immune response in severely injured patients leading to chronic critical illness (CCI). Specifically, it focused on characterizing the monocyte populations and their correlation with CCI development and long-term complications. METHODS Over a 3-year period, we monitored patients with severe injuries for up to 1-year postinjury. Chronic critical illness was defined as an ICU stay exceeding 14 days with persistent organ failure. Blood samples were collected on Days 1 and 5 for monocyte phenotypic expression analysis using cytometry by time flight. The monocyte subpopulations studied were classical (CL), intermediate (INT), and nonclassical (NC), along with cell surface receptor expression and activation. RESULTS Out of 80 enrolled patients, 26 (32.5%) developed CCI. Patients with CCI had more severe injuries (Injury Severity Score, 32.4 + 5.2 vs. 29.6 + 4.1, p = 0.01) and received a higher number of red blood cells (8.9 + 4.1 vs. 4.7 + 3.8 units, p < 0.01) compared with those without CCI. In patients with CCI, the NC monocytes were significantly reduced by over twofold early, and significantly increased later, compared with those without CCI. Moreover, significant changes in intracellular cytokine expression and cell receptors were observed within each monocyte subpopulation in patients with CCI, indicating an increased proinflammatory phenotype but decreased phagocytic capacity and antigen presentation. The development of CCI and the presence of this unique monocyte phenotype were associated with a significantly increased risk of infection, discharge to a long-term care facility, and 1-year mortality of 27%. CONCLUSION Development of CCI following severe injury is associated with significant long-term morbidity and unacceptably high mortality. The altered NC phenotype with reduced phagocytic capacity and antigen presentation in patients developing CCI after severe injury is appears partially responsible. Early identification of this unique phenotype may help predict and treat patients at risk for CCI, leading to improved outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Collapse
Affiliation(s)
- Joseph Cuschieri
- From the Department of Surgery (J.C.), Department of Surgery (L.K.), Department of Laboratory Medicine (S.P.), University of California San Francisco, San Francisco, California; and Department of Pediatrics (A.P.), University of Washington, Seattle, Washington
| | | | | | | |
Collapse
|
7
|
Gebran A, El Moheb M, Herrera-Escobar JP, Proaño-Zamudio JA, Maurer LR, Lamarre TE, Bou Zein Eddine S, Sanchez SE, Nehra D, Salim A, Velmahos GC, Kaafarani HMA. Insurance Not Socioeconomic Status is Associated With Access to Postacute Care After Injury: A Multicenter Cohort Study. J Surg Res 2024; 293:307-315. [PMID: 37806216 DOI: 10.1016/j.jss.2023.08.036] [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: 12/13/2022] [Revised: 07/19/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Access to postacute care services in rehabilitation or skilled nursing facilities is essential to return trauma patients to their preinjury functional level but is often hindered by systemic barriers. We sought to study the association between the type of insurance, socioeconomic status (SES) measures, and postacute care utilization after injury. METHODS Adult trauma patients with an Injury Severity Score (ISS) ≥9 admitted to one of three Level I trauma centers were contacted 6-12 mo after injury to gather long-term functional and patient-centered outcome measures. In addition to SES inquiry specifically focused on education and income levels, patients were asked to subjectively categorize their perceived SES (p-SES) as high, mid-high, mid-low, or low. Insurance and income data were retrieved from trauma registries. Multivariable regression models were built to determine the association between type of insurance, SES, and discharge disposition after adjusting for patient and injury characteristics and hospitalization events. RESULTS A total of 1373 patients were included, of which 44% were discharged to postacute care facilities. The median age (IQR) was 65 (46, 76) years, 56% of patients were male, 11% were on Medicaid, 68% had attained education higher than high school, 27% had low income, and 29% reported a low/mid-low p-SES. Medicaid patients were less likely to be discharged to postacute care compared to privately insured (OR [95% CI]: 0.41 [0.29-0.58]) and Medicare patients (OR [95% CI]: 0.29 [0.16-0.50]). The latter relationship was true across p-SES categories. P-SES, income and educational level were not associated with discharge destination. CONCLUSIONS Insurance status, specifically having Medicaid, can pose a barrier to access to postacute care services in the trauma patient population across patients of all SES. Initiatives and policies that aim at reducing these access disparities are warranted.
Collapse
Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Taylor E Lamarre
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Savo Bou Zein Eddine
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sabrina E Sanchez
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, Massachusetts
| | - Deepika Nehra
- Division of Trauma, Burn & Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
8
|
El-Qawaqzeh K, Anand T, Alizai Q, Colosimo C, Hosseinpour H, Spencer A, Ditillo M, Magnotti LJ, Stewart C, Joseph B. Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same? J Surg Res 2024; 293:316-326. [PMID: 37806217 DOI: 10.1016/j.jss.2023.09.015] [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: 03/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale. METHODS This is a retrospective analysis of 2017-2019 American College of Surgeons Trauma Quality Improvement Program. We included moderate to severely injured (Injury Severity Score >8) older adult (≥65 y) trauma patients. Patients were stratified into geriatric (65 y ≤ Age <80 y) and super-geriatric (Age ≥80 y). Outcomes included interventions, complications, failure-to-rescue, withdrawal of support treatment, and mortality. RESULTS We identified 269,208 patients (geriatric = 57%; super-geriatric = 43%). Both groups had similar vital signs and Injury Severity Score (geriatric = 9[9-12] versus super-geriatric = 9[9-11]). The super-geriatric were more likely to have falls (71% versus 89%, P < 0.001), while the geriatric were more likely to have Motor vehicle collision (17% versus. 7%, P < 0.001). On multivariate analyses, geriatric patients were more likely to be treated at a Level I Trauma Center (adjusted Odds Ratio [aOR] = 1.1, P < 0.001), undergo hemorrhage control surgery (aOR = 1.5, P < 0.001), be admitted to the intensive care unit (aOR = 1.15, P < 0.001), or intubated (aOR = 1.4, P < 0.001). However, they were less likely to have withdrawal of support treatment (aOR = 0.37, P < 0.001) compared to the super-geriatric. Furthermore, geriatric patients were more likely to develop major complications (aOR = 1.08, P < 0.01). However, they had lower odds of failure-to-rescue (aOR = 0.69, P < 0.001) and in-hospital mortality (aOR = 0.56, P < 0.001) compared to the super-geriatric. CONCLUSIONS Significant differences exist in injury patterns, interventions, and outcomes between the geriatric and super-geriatric. Future studies and guidelines may need to classify older adults into geriatric and super-geriatric categories to facilitate tailored care and overall improvement of management strategies for older populations.
Collapse
Affiliation(s)
- Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Audrey Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Collin Stewart
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
| |
Collapse
|
9
|
Kuo LW, Wang YH, Wang CC, Huang YTA, Hsu CP, Tee YS, Chen SA, Liao CA. Long-term survival after major trauma: a retrospective nationwide cohort study from the National Health Insurance Research Database. Int J Surg 2023; 109:4041-4048. [PMID: 37678288 PMCID: PMC10720785 DOI: 10.1097/js9.0000000000000697] [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: 06/01/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Most trauma-related studies are focused on short-term survival and complications within the index admission, and the long-term outcomes beyond discharge are mainly unknown. The purpose of this study was to analyze the data from the National Health Insurance Research Database (NHIRD) and to assess the long-term survival of major trauma patients after being discharged from the index admission. MATERIAL AND METHODS This retrospective, observational study included all patients with major trauma (injury severity score ≥16) in Taiwan from 2003 to 2007, and a 10-year follow-up was conducted on this cohort. Patients aged 18-70 who survived the index admission were enrolled. Patients who survived less than one year after discharge (short survival, SS) and those who survived for more than one year (long survival, LS) were compared. Variables, including preexisting factors, injury types, and short-term outcomes and complications, were analyzed, and the 10-year Kaplan-Meier survival analysis was conducted. RESULTS In our study, 9896 patients were included, with 2736 in the SS group and 7160 in the LS group. Age, sex, comorbidities, low income, cardiopulmonary resuscitation event, prolonged mechanical ventilation, prolonged ICU length of stay (LOS), and prolonged hospital LOS were identified as the independent risk factors of SS. The 10-year cumulative survival for major trauma patients was 63.71%, and the most mortality (27.64%) occurred within the first year after discharge. CONCLUSION 27.64% of patients would die one year after being discharged from major trauma. Major trauma patients who survived the index admission still had significantly worse long-term survival than the general population, but the curve flattened and resembled the general population after one year.
Collapse
Affiliation(s)
| | | | | | - Yu-Tung A. Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City
| | | | - Yu-San Tee
- Department of Trauma and Emergency Surgery
| | | | - Chien-An Liao
- Department of Trauma and Emergency Surgery
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei City, Taiwan
| |
Collapse
|
10
|
Sánchez-Arguiano MJ, Miñambres E, Cuenca-Fito E, Suberviola B, Burón-Mediavilla FJ, Ballesteros MA. Chronic critical illness after trauma injury: outcomes and experience in a trauma center. Acta Chir Belg 2023; 123:618-624. [PMID: 35881765 DOI: 10.1080/00015458.2022.2106626] [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: 11/04/2021] [Accepted: 07/23/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To determine the prevalence, risk factors and functional results of chronic critical illness (CCI) in polytrauma patients. DESIGN Single-center observational retrospective study. SETTING ICU at a tertiary hospital in Santander, Spain, between 2015 and 2019. PATIENTS Adult trauma patients who survived beyond 48 h after injury. CCI was defined as the need for mechanical ventilation for at least 14 days or tracheostomy for difficult weaning. MEASUREMENTS AND MAIN RESULTS About 62/575 developed CCI. These patients were characterized by higher ISS score [17 (SD 10) vs. 13.8 (SD 8.2); p < 0.001] and higher NISS (26 (SD 11) vs. 19.2 (SD 10.5); p = 0.001). CCI group had greater proportion of hospital-acquired infections (100% vs. 18.1%; p < 0.001), and acute kidney failure (33.9% vs. 22.8% p < 0.001). During the first 24 h of admission, CCI group required in a greater proportion surgical intervention (50% vs. 29%; p = 0.001), and blood products (31.3% vs. 20.5%; p < 0.047). Hospital ward stay was longer in CCI patients [9.5 days (IQR 5-16.9) vs. 43.9 (IQR 30.3-53) p < 0.001]. The CCI mortality was higher (19.5% vs. 8.1%; p = 0.004). Surgical intervention in the first 24 h (OR 2.5 95% CI 1.1-4.1), age (> 55 years) (OR 2.1 95%CI 1.1-4.2), ISS score (OR 1.1 95%CI 1.02-1.3), GCS score (OR 0.8 95%CI 0.4-23.2) and multiple organ failure (OR 9.5 95%CI 3.9-23.2) were predictors of CCI in the multivariate analysis. CONCLUSIONS CCI after severe trauma appears in a considerable proportion of patients. Early identification and implementation of specific interventions could change the evolution of this process.
Collapse
Affiliation(s)
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Elena Cuenca-Fito
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | - María A Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| |
Collapse
|
11
|
Stern K, Aaltonen HL, Weykamp M, Gaskins D, Qui Q, O'Keefe G, Littman A, Linnau K, Rowhani-Rahbar A. Associations of Fatty Liver Disease With Recovery After Traumatic Injury. J Surg Res 2023; 291:270-281. [PMID: 37480755 DOI: 10.1016/j.jss.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/25/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
INTRODUCTION Fatty liver disease (FLD) is associated with systemic inflammation, metabolic disease, and socioeconomic risk factors for poor health outcomes. Little is known on how adults with FLD recover from traumatic injury. METHODS We studied adults admitted to the intensive care unit of a level 1 trauma center (2016-2020), excluding severe head injury/cirrhosis (N = 510). We measured the liver-spleen attenuation difference in Hounsfield units (HUL-S) using virtual noncontrast computerized tomography scans: none (HUL-S>1), mild (-10≤HUL-S<1), moderate/severe (HUL-S < -10). We used Cox models to examine the "hazard" of recovery from systemic inflammatory response (SIRS score 2 or higher) organ dysfunction, defined as sequential organ failure assessment score 2 or higher, and lactate clearance (<2 mmol/L) in relation to FLD. RESULTS Fifty-one participants had mild and 29 had moderate/severe FLD. The association of FLD with recovery from SIRS differed according to whether an individual had shock on admission (hazard ratio [HR] = 0.76; 95% confidence interval [CI] 0.55-1.05 with shock; HR = 1.81; 95% CI 1.43-2.28 without shock). Compared to patients with no FLD, the hazard of lactate clearance was similar for mild FLD (HR = 1.04; 95% CI 0.63-1.70) and lower for moderate/severe FLD (HR = 0.40; 95% CI 0.18-0.89). CONCLUSIONS FLD is common among injured adults. Associations of FLD with outcomes after shock and critical illness warrant further study.
Collapse
Affiliation(s)
- Katherine Stern
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; University of California San Francisco East Bay General Surgery Residency Program, Oakland, California; University of Washington School of Public Health, Seattle, Washington.
| | - H Laura Aaltonen
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Mike Weykamp
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; University of Washington School of Public Health, Seattle, Washington
| | - Devin Gaskins
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Qian Qui
- Harborview Injury Prevention & Research Center, Seattle, Washington
| | - Grant O'Keefe
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Harborview Injury Prevention & Research Center, Seattle, Washington
| | - Alyson Littman
- University of Washington School of Public Health, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Ken Linnau
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | | |
Collapse
|
12
|
Carlson JM, Lin DJ. Prognostication in Prolonged and Chronic Disorders of Consciousness. Semin Neurol 2023; 43:744-757. [PMID: 37758177 DOI: 10.1055/s-0043-1775792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.
Collapse
Affiliation(s)
- Julia M Carlson
- Division of Neurocritical Care, Department of Neurology, University of North Carolina Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Division of Neurocritical Care and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Neurorestoration and Neurotechnology, Rehabilitation Research and Development Service, Department of Veterans Affairs, Providence, Rhode Island
| |
Collapse
|
13
|
Zebley JA, Wanersdorfer K, Chang P, Schwartz R, Forssten MP, Cao Y, Mohseni S, Sarani B, Kartiko S. Early Tracheostomy in Older Trauma Patient Is Associated With Comparable Outcomes to Younger Cohort. J Surg Res 2023; 290:178-187. [PMID: 37269801 DOI: 10.1016/j.jss.2023.03.051] [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: 11/28/2022] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Early tracheostomy (ET) is associated with a lower incidence of pneumonia (PNA) and mechanical ventilation duration (MVD) in hospitalized patients with trauma. The purpose of this study is to determine if ET also benefits older adults compared to the younger cohort. METHODS Adult hospitalized trauma patients who received a tracheostomy as registered in The American College of Surgeons Trauma Quality Improvement Program from 2013 to 2019 were analyzed. Patients with tracheostomy prior to admission were excluded. Patients were stratified into 2 cohorts consisting of those aged ≥65 and those aged <65. These cohorts were analyzed separately to compare the outcomes of ET (<5 d; ET) versus late tracheostomy (LT) (≥5 d; LT). The primary outcome was MVD. Secondary outcomes were in-hospital mortality, hospital length of stay (HLOS), and PNA. Univariate and multivariate analyses were performed with significance defined as P value < 0.05. RESULTS In patients aged <65, ET was performed within a median of 2.3 d (interquartile range, 0.47-3.8) after intubation and a median of 9.9 d (interquartile range, 7.5-13) in the LT group. The ET group's Injury Severity Score was significantly lower with fewer comorbidities. There were no differences in injury severity or comorbidities when comparing the groups. ET was associated with lower MVD (d), PNA, and HLOS on univariate and multivariate analyses in both age cohorts, although the degree of benefit was higher in the less than 65 y cohort [ET versus LT MVD: 5.08 (4.78-5.37), P < 0.001; PNA: 1.45 (1.36-1.54), P < 0.001; HLOS: 5.48 (4.93-6.04), P < 0.001]. Mortality did not differ based on time to tracheostomy. CONCLUSIONS ET is associated with lower MVD, PNA, and HLOS in hospitalized patients with trauma regardless of age. Age should not factor into timing for tracheostomy placement.
Collapse
Affiliation(s)
- James A Zebley
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Karen Wanersdorfer
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Parker Chang
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Rachel Schwartz
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Susan Kartiko
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia.
| |
Collapse
|
14
|
Okada K, Ohde S, Yagi T, Hara Y, Yokobori S. Development and validation of prediction scores for the outcome associated with persistent inflammation, immunosuppression, and catabolism syndrome among patients with trauma. Trauma Surg Acute Care Open 2023; 8:e001134. [PMID: 37484838 PMCID: PMC10357651 DOI: 10.1136/tsaco-2023-001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/02/2023] [Indexed: 07/25/2023] Open
Abstract
Background Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has impacted on long-term prognosis of patients with trauma. We aimed to identify patients with trauma at risk of PICS-related complications early in the intensive care unit (ICU) course. Methods A single-center retrospective cohort study was conducted. All consecutive patients with trauma who had stayed in the ICU for >7 days were included in the study. We developed the prediction score for the incidence of PICS-related outcomes in the derivation cohort for the initial period and then evaluated in the validation cohort for the subsequent period. Other outcomes were also assessed using the score. Results In total, 170 and 133 patients were included in the derivation and validation cohorts, respectively. The prediction score comprised the variables indicating PICS presence, including a maximum value of C-reactive protein >15 mg/dL, minimum value of albumin <2.5 g/dL, and an episode of nosocomial infection for the first 7 days after admission. A score of 1 was assigned to each variable. The area under the receiver operating characteristic curve of the score to predict PICS incidence was 0.74 (95% CI 0.66 to 0.81) and 0.72 (95% CI 0.64 to 0.81) in the derivation and validation cohorts, respectively. The higher score was also significantly associated with a higher Sequential Organ Failure Assessment score at day 14, a longer duration of mechanical ventilation, a longer length of stay in ICU, and experienced multiple episodes of infection. Similar results were obtained in the validation cohort. Conclusions Our scoring system could predict the outcomes associated with PICS among patients with trauma. Because the score comprised the parameters measured for the first 7 days during the ICU course, it could contribute to identifying patients at a high risk of unfavorable outcome earlier. Level of evidence Multivariate prediction models; level IV.
Collapse
Affiliation(s)
- Kazuhiro Okada
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Sachiko Ohde
- St Luke’s International University School of Public Health, Tokyo, Japan
| | - Takanori Yagi
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshiaki Hara
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
15
|
Liu T, Li Y, Li J, Fan H, Cao C. Temporal Trend and Research Focus of Injury Burden from 1998 to 2022: A Bibliometric Analysis. J Multidiscip Healthc 2023; 16:1869-1882. [PMID: 37425247 PMCID: PMC10327907 DOI: 10.2147/jmdh.s414859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Background Injury is one of the leading causes of mortality and disability worldwide. It is a major contributor to the overall burden of disease. This study aimed to analyze the temporal trend, research focus and future direction of research related to injury burden. Methods Publications on injury burden published between January 1998 and September 2022 were extracted from the Web of Science Core Collection (WoSCC) through topic advanced search strategy. Microsoft Excel, RStudio, VOSviewer, and CiteSpace were used to extract, integrate, and visualize bibliometric information. Results A total of 2916 articles and 783 reviews were identified. The number of publications on injury burden showed a steady upward trend. The United States of America (USA) (n=1628) and the University of Washington (n=1036) were the most productive country and institution. High-income countries started research in this domain earlier, while research in low- and middle-income countries began in recent years. Lancet was the most influential journal. Public, environmental occupational health, general medicine and neurology were the predominant research domains. Based on keyword co-occurrence analysis, the research focus was divided into five clusters: injury epidemiology and prevention, studies related to the global burden of disease (GBD), risk factors for injury, clinical management of injury, and injury outcome assessment and economic burden. Conclusion The burden of injury has drawn increasing attention from various perspectives over the years. The research field on injury burden is also becoming more and more extensive. However, there are some gaps among different countries or regions, and more attention needs to be paid to low and middle-income countries.
Collapse
Affiliation(s)
- Tao Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, People’s Republic of China
| | - Yue Li
- College of Management and Economics, Tianjin University, Tianjin, People’s Republic of China
| | - Ji Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, People’s Republic of China
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, People’s Republic of China
| | - Chunxia Cao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, People’s Republic of China
| |
Collapse
|
16
|
Cameron PA, Gabbe B. Is the current model of trauma care fit for purpose? Injury 2023; 54:110786. [PMID: 37295845 DOI: 10.1016/j.injury.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Peter A Cameron
- School Public Health and Preventive Medicine, Monash University, Australia.
| | - Belinda Gabbe
- School Public Health and Preventive Medicine, Monash University, Australia
| |
Collapse
|
17
|
Eskesen TO, Sillesen M, Pedersen JK, Pedersen DA, Christensen K, Rasmussen LS, Steinmetz J. Association of Trauma With Long-Term Risk of Death and Immune-Mediated or Cancer Disease in Same-Sex Twins. JAMA Surg 2023; 158:738-745. [PMID: 37195677 PMCID: PMC10193261 DOI: 10.1001/jamasurg.2023.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/04/2023] [Indexed: 05/18/2023]
Abstract
Importance Immediate consequences of trauma include a rapid and immense activation of the immune system, whereas long-term outcomes include premature death, physical disability, and reduced workability. Objective To investigate if moderate to severe trauma is associated with long-term increased risk of death or immune-mediated or cancer disease. Design, Setting, and Participants This registry-based, matched, co-twin control cohort study linked the Danish Twin Registry and the Danish National Patient Registry to identify twin pairs in which 1 twin had been exposed to severe trauma and the other twin had not from 1994 to 2018. The co-twin control design allowed for matching on genetic and environmental factors shared within twin pairs. Exposure Twin pairs were included if 1 twin had been exposed to moderate to severe trauma and the other twin had not (ie, co-twin). Only twin pairs where both twins were alive 6 months after the trauma event were included. Main Outcome and Measure Twin pairs were followed up from 6 months after trauma until 1 twin experienced the primary composite outcome of death or 1 of 24 predefined immune-mediated or cancer diseases or end of follow-up. Cox proportional hazards regression was used for intrapair analyses of the association between trauma and the primary outcome. Results A total of 3776 twin pairs were included, and 2290 (61%) were disease free prior to outcome analysis and were eligible for the analysis of the primary outcome. The median (IQR) age was 36.4 (25.7-50.2) years. The median (IQR) follow-up time was 8.6 (3.8-14.5) years. Overall, 1268 twin pairs (55%) reached the primary outcome; the twin exposed to trauma was first to experience the outcome in 724 pairs (32%), whereas the co-twin was first in 544 pairs (24%). The hazard ratio for reaching the composite outcome was 1.33 (95% CI, 1.19-1.49) for twins exposed to trauma. Analyses of death or immune-mediated or cancer disease as separate outcomes provided hazard ratios of 1.91 (95% CI, 1.68-2.18) and 1.28 (95% CI, 1.14-1.44), respectively. Conclusion and Relevance In this study, twins exposed to moderate to severe trauma had significantly increased risk of death or immune-mediated or cancer disease several years after trauma compared with their co-twins.
Collapse
Affiliation(s)
- Trine O. Eskesen
- Department of Anesthesia and Trauma Centre, Section 6011, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
| | - Martin Sillesen
- Department of Organ Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
- Center for Surgical Translational and Artificial Intelligence Research, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Krabbe Pedersen
- The Danish Twin Registry, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Dorthe Almind Pedersen
- The Danish Twin Registry, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kaare Christensen
- The Danish Twin Registry, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Lars S. Rasmussen
- Department of Anesthesia and Trauma Centre, Section 6011, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia and Trauma Centre, Section 6011, Center of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
| |
Collapse
|
18
|
Totman AA, Lamm AG, Goldstein R, Giacino JT, Bodien YG, Ryan CM, Schneider JC, Zafonte R. Longitudinal Trends in Severe Traumatic Brain Injury Inpatient Rehabilitation. J Head Trauma Rehabil 2023; 38:E186-E194. [PMID: 36730991 PMCID: PMC10102246 DOI: 10.1097/htr.0000000000000814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The goal of this study is to describe national trends in inpatient rehabilitation facility (IRF) discharges for the most severely disabled cohort of patients with traumatic brain injury (TBI). METHODS Data from the Uniform Data System for Medical Rehabilitation for patients discharged from an IRF between January 1, 2002, and December 31, 2017, with a diagnosis of TBI and an admission Functional Independence Measure of 18, the lowest possible score, were obtained and analyzed. RESULTS Of the 252 112 patients with TBI discharged during the study period, 10 098 met the study criteria. From 2002 to 2017, the number of patients with an IRF admission Functional Independence Measure of 18 following TBI discharged from IRFs annually decreased from 649 to 488, modeled by a negative regression (coefficient = -2.97; P = .001), and the mean age (SD) increased from 43.0 (21.0) to 53.7 (21.3) years (coefficient = 0.70; P < .001). During the study period, the number of patients with the most severe disability on admission to IRF who were discharged annually as a proportion of total patients with TBI decreased from 5.5% to 2.5% (odds ratio = 0.95; P < .001) and their mean length of stay decreased from 41.5 (36.2) to 29.3 (24.9) days (coefficient = -0.83; P < .001]. CONCLUSION The number and proportion of patients with the most severe disability on IRF admission following TBI who are discharged from IRFs is decreasing over time. This may represent a combination of primary prevention, early mortality due to withdrawal of life-sustaining treatment, alternative discharge dispositions, or changes in admitting and reimbursement practices. Furthermore, there has been a decrease in the duration of IRF level care for these individuals, which could ultimately lead to poorer functional outcomes, particularly given the importance of specialized rehabilitative care in this population.
Collapse
Affiliation(s)
- Alissa A Totman
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts (Drs Totman, Goldstein, Giacino, Bodien, Ryan, Schneider, and Zafonte); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts (Drs Totman, Goldstein, Giacino, Bodien, Ryan, Schneider, and Zafonte); Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan (Dr Lamm); Massachusetts General Hospital, Boston, Massachusetts (Drs Giacino, Ryan, and Zafonte); Shriners Hospitals for Children, Boston, Massachusetts (Dr Ryan); and Brigham and Women's Hospital, Boston, Massachusetts (Dr Zafonte)
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Pollack LR, Liao J, Powelson EB, Gause E, Robinson BRH, Vavilala MS, Engelberg RA, Reed MJ, Arbabi S, O'Connell KM. Long-term health-related quality of life and independence among older survivors of serious injury. J Trauma Acute Care Surg 2023; 94:624-631. [PMID: 36623274 PMCID: PMC10038848 DOI: 10.1097/ta.0000000000003864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Little is known about the recovery experiences of older trauma intensive care unit (TICU) survivors and the relationship between geriatric trauma care and long-term functional ability and health-related quality of life (HRQOL). METHODS We conducted a prospective cohort study of 218 patients (age, ≥65 years) admitted to a Level 1 regional trauma center TICU before versus after implementation of a geriatric care bundle with protocolized geriatrics consultations (Geri-T). Survivors or their proxies were interviewed approximately 1 year after hospitalization. Outcomes included the Katz Index of Independence in Activities of Daily Living (ADLs), Lawton Instrumental Activities of Daily Living (IADLs), and EQ-5D-5L HRQOL survey. Two investigator-developed questions regarding recovery experiences were included. Differences in outcomes among survivors admitted before versus after Geri-T were analyzed using multivariable linear regression. Responses to questions about recovery experiences were qualitatively assessed using content analysis. RESULTS We reached 67% (146/218) of hospital survivors or their proxies across both groups; 126 patients were still alive and completed the survey. Mean age was 76 (SD, 8), 36% were female, and 90% were independent with ADLs preinjury. At follow-up, independence with ADLs was 76% and IADLs was 63%. The mean EQ-5D-5L index score was 0.78 (SD, 0.18). Most patients (65%) reported having not returned to preinjury functional status. Neither functional ability or HRQOL differed significantly among patients admitted before versus after Geri-T. Content analysis of open-ended questions revealed themes of activity limitations, persistent pain, and cognitive dysfunction. CONCLUSION Nearly one-fifth of TICU survivors experienced loss of ADL function 1 year after injury, and most reported having not returned to preinjury functional status. Nonetheless, patient-reported HRQOL was comparable to age-adjusted norms. Geri-T was not associated with differences in HRQOL or functional ability. Survivors reported persistent difficulty with activities beyond those of daily living, pain, and cognition. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level III.
Collapse
|
20
|
Naraiah Mukkala A, Petrut R, Goldfarb R, Leigh Beroncal E, Ho Leung C, Khan Z, Ailenberg M, Jerkic M, Andreazza AC, Rhind SG, Jeschke MG, Kapus A, Rotstein OD. Augmented Parkin-dependent mitophagy underlies the hepatoprotective effect of remote ischemic conditioning used prior to hemorrhagic shock. Mitochondrion 2023; 70:20-30. [PMID: 36906251 DOI: 10.1016/j.mito.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/04/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND AIMS Hemorrhagic shock-resuscitation (HSR) following trauma contributes to organ dysfunction by causing ischemia-reperfusion injury (IRI). We previously showed that 'remote ischemic preconditioning' (RIPC) exerted multi-organ protection from IRI. Maintenance of mitochondrial quality by clearance of dysfunctional mitochondria via mitophagy is vital in restoring organ integrity. We hypothesized that parkin-dependent mitophagy played a role in RIPC-induced hepatoprotection following HSR. METHODS The hepatoprotective effect of RIPC in a murine model of HSR-IRI was investigated in wild type and parkin-/- animals. Mice were subjected to HSR ± RIPC and blood and organs were collected, followed by cytokine ELISAs, histology, qPCR, Western blots, and transmission electron microscopy. RESULTS HSR increased hepatocellular injury, as measured by plasma ALT and liver necrosis, while antecedent RIPC prevented this injury; in parkin-/- mice, RIPC failed to exert hepatoprotection. The ability of RIPC to lessen HSR-induced rises in plasma IL-6 and TNFα, was lost in parkin-/- mice. While RIPC alone did not induce mitophagy, the application of RIPC prior to HSR caused a synergistic increase in mitophagy, this increase was not observed in parkin-/- mice. RIPC induced shifts in mitochondrial morphology favoring mitophagy in WT but not in parkin-/- animals. CONCLUSIONS RIPC was hepatoprotective in WT mice following HSR but not in parkin-/- mice. Loss of protection in parkin-/- mice corresponded with the failure of RIPC plus HSR to upregulate the mitophagic process. Improving mitochondrial quality by modulating mitophagy, may prove to be an attractive therapeutic target in disease processes caused by IRI.
Collapse
Affiliation(s)
- Avinash Naraiah Mukkala
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Raluca Petrut
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Rachel Goldfarb
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | | | - Chung Ho Leung
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Zahra Khan
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Menachem Ailenberg
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Mirjana Jerkic
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Ana C Andreazza
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Department of National Defense, Government of Canada, Toronto, Canada
| | - Marc G Jeschke
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Canada
| | - Andras Kapus
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada; Department of Biochemistry, University of Toronto, Toronto, Canada
| | - Ori D Rotstein
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada.
| |
Collapse
|
21
|
Social admissions in older trauma patients, not just a one night stay. Eur J Trauma Emerg Surg 2023; 49:1271-1277. [PMID: 36786875 DOI: 10.1007/s00068-023-02229-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/13/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Older trauma patients (65 years or older), who suffer minor or moderate injury for which immediate hospitalization is not strictly indicated, are often admitted to the hospital due to a self-sufficiency problem. Although hospitalization is expensive and associated with risks, little is known about the course of such a social admission. Therefore, the aim of this study was to clarify the course and outcome of social admissions. METHODS A single centre retrospective cohort study was performed in a level II trauma centre. All hospitalized trauma patients aged 65 or older between 2015 and 2021 with an Abbreviated Injury Scale (AIS) code of 1 or 2 were included. The primary outcome was defined as the number of complications during admission (e.g. pneumonia, urinary tract infection, delirium, decubitus and, in-hospital mortality). Secondary outcomes were missed injury, length of stay, discharge location (home, with homecare or a skilled nursing facility), 30-day hospital return and 1-year mortality. RESULTS Out of 2900 older hospitalized trauma patients, 563 (19.4%) were included. Complications occurred in 99 patients (17.6%), eight patients (1.4%) died during admission, and in 17 patients (3.0%) a previously missed injury was found during the admission. The median length of stay was 5 days [IQR 2.00-9.00] and of all independent living patients, 49.1% could be discharged to their homes. After discharge, 4.4% of the patients returned within 30 days and, a total of 17.6% of all patients died within one year after discharge. CONCLUSIONS One out of five older trauma patients presenting at the emergency department were admitted because of social reasons. Social admissions are lengthy and are accompanied by a considerable amount of complications.
Collapse
|
22
|
Wu A, Zhou J, Quinlan N, Dirlikov B, Singh H. Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center. J Clin Neurosci 2023; 108:1-5. [PMID: 36542995 DOI: 10.1016/j.jocn.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4 % out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR = 5.030, 95 % CI 1.096-23.082, p =.038) and pre-existing dementia (OR = 6.577, 95 % CI 1.726-25.073, p =.006). Average consultation timing was 8.6 (standard deviation ± 7.0) days. Patients with PC consults had longer overall (p =.0031) and intensive care unit (ICU) length of stays (LOS) (p <.0001), more days intubated (p <.0001) and higher costs (p =.0006), although those with earlier-than-average PC consultation had shorter overall (p =.0062) and ICU (p =.011) LOS as well as fewer ventilator days (p =.030) and lower costs (p =.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.
Collapse
Affiliation(s)
- Adela Wu
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States.
| | - James Zhou
- California Northstate University College of Medicine, Elk Grove, CA 95757, United States.
| | - Nicky Quinlan
- Division of Palliative Care, Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, United States.
| | - Benjamin Dirlikov
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA 95128, United States.
| | - Harminder Singh
- Department of Neurosurgery, Santa Clara Valley Medical Center, San Jose, CA 95128, United States.
| |
Collapse
|
23
|
Pierce JG, Ricon R, Rukmangadhan S, Kim M, Rajasekar G, Nuño M, Curtis E, Humphries M. Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US. JAMA Surg 2022; 157:1125-1132. [PMID: 36260298 PMCID: PMC9582969 DOI: 10.1001/jamasurg.2022.4718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/17/2022] [Indexed: 01/11/2023]
Abstract
Importance The American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encourage trauma service clinicians to deliver palliative care in parallel with life-sustaining treatment and recommend goals of care (GOC) discussions within 72 hours of admission for patients with serious illness. Objective To measure adherence to TQIP guidelines-recommended GOC discussions for trauma patients with serious illness, treated at a level I trauma center in the US. Design, Setting, and Participants This retrospective cohort study included 674 adults admitted to a trauma service center for 3 or more days between December 2019 and June 2020. The medical records of 486 patients who met the criteria for serious illness using a consensus definition adapted to the National Trauma Data Bank were reviewed for the presence of a GOC discussion. Patients were divided into 2 cohorts based on admission before or after the guidelines were incorporated into the institutional practice guidelines on March 1, 2020. Main Outcomes and Measures The primary outcomes were GOC completion within 72 hours of admission and during the overall hospitalization. Patient and clinical factors associated with GOC completion were assessed. Other palliative care processes measured included palliative care consultation, prior advance care planning document, and do-not-resuscitate code status. Additional end-of-life processes (ie, comfort care and inpatient hospice) were measured in a subset with inpatient mortality. Results Of 674 patients meeting the review criteria, 486 (72.1%) met at least 1 definition of serious illness (mean [SD] age, 60.9 [21.3] years; mean [SD] Injury Severity Score, 16.9 [12.3]). Of these patients, 328 (67.5%) were male and 266 (54.7%) were White. Among the seriously ill patients, 92 (18.9%) had evidence of GOC completion within 72 hours of admission and 124 (25.5%) during the overall hospitalization. No differences were observed between patients admitted before and after institutional guideline publication in GOC completion within 72 hours (19.0% [47 of 248 patients] vs 18.9% [45 of 238]; P = .99) or during the overall hospitalization (26.2% [65 of 248 patients] vs 24.8% [59 of 238]; P = .72). After adjusting for age, GOC completion was found to be associated with the presence of mechanical ventilation (odds ratio [OR], 6.42; 95% CI, 3.49-11.81) and meeting multiple serious illness criteria (OR, 4.07; 95% CI, 2.25-7.38). Conclusions and Relevance The findings of this cohort study suggest that, despite the presence of national guidelines, GOC discussions for patients with serious illness were documented infrequently. This study suggests a need for system-level interventions to ensure best practices and may inform strategies to measure and improve trauma service quality in palliative care.
Collapse
Affiliation(s)
| | | | | | | | - Ganesh Rajasekar
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| | - Miriam Nuño
- Department of Public Health Sciences, University of California, Davis
| | - Eleanor Curtis
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| | - Misty Humphries
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| |
Collapse
|
24
|
James A, Ravaud P, Riveros C, Raux M, Tran VT. Completeness and Mismatch of Patient-Important Outcomes After Trauma. ANNALS OF SURGERY OPEN 2022; 3:e211. [PMID: 37600291 PMCID: PMC10406046 DOI: 10.1097/as9.0000000000000211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/25/2022] [Indexed: 11/09/2022] Open
Abstract
To assess the completeness of the collection of patient-important outcomes and the mismatch between outcomes measured in research and patients' important issues after trauma. Summary Background Data To date, severe trauma has mainly been assessed using in-hospital mortality. Yet, with 80 to 90% survivors discharged from hospital, it is critical to assess the collection of patient important long-term outcomes of trauma. Methods Mixed methods study combining a systematic review of outcomes and their comparison with domains elicited by patients during a qualitative study. We searched Medline, EMBASE and clinicaltrials.gov from January 1, 2014 to September 30, 2019 and extracted all outcomes from reports including severe trauma. We compared these outcomes with 97 domains that matter to trauma survivors identified in a previous qualitative study. We defined as patient-important outcome as the 10 most frequently elicited domains in the qualitative study. We assessed the number of domains captured in each report to illustrate the completeness of the collection of patient-important outcomes. We also assessed the mismatch between outcomes collected and what matters to patients. Findings Among the 116 reports included in the systematic review, we identified 403 outcomes collected with 154 unique measurements tools. Beside mortality, measurement tools most frequently used were the Glasgow Outcome Scale (31.0%, n=36), questions on patients' return to work (20,7%, n=24) and the EQ-5D (19.0%, n=22). The comparison between the outcomes identified in the systematic review and the domains from the qualitative study found that 10.3% (n=12) reports did not collect any patient-important domains and one collected all 10 patient-important domains. By examining each of the 10 patient-important domains, none was collected in more than 72% of reports and only five were among the ten most frequently measured domains in studies. Conclusion The completeness of the collection of the long-term patient-important outcomes after trauma can be improved. There was a mismatch between the domains used in the literature and those considered important by patients during a qualitative study.
Collapse
Affiliation(s)
- Arthur James
- Centre d’Epidémiologie Clinique, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Paris, France
- Département d’Anesthésie Réanimation, Sorbonne Université, GRC 29, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), INSERM U1153, Paris, France
| | - Philippe Ravaud
- Centre d’Epidémiologie Clinique, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Paris, France
- Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), INSERM U1153, Paris, France
| | - Carolina Riveros
- Centre d’Epidémiologie Clinique, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Paris, France
| | - Mathieu Raux
- Département d’Anesthésie Réanimation, Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Viet-Thi Tran
- Centre d’Epidémiologie Clinique, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Paris, France
- Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), INSERM U1153, Paris, France
| |
Collapse
|
25
|
Wu J, Cyr A, Gruen DS, Lovelace TC, Benos PV, Das J, Kar UK, Chen T, Guyette FX, Yazer MH, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Zuckerbraun BS, Neal MD, Johansson PI, Stensballe J, Namas RA, Vodovotz Y, Sperry JL, Billiar TR. Lipidomic signatures align with inflammatory patterns and outcomes in critical illness. Nat Commun 2022; 13:6789. [PMID: 36357394 PMCID: PMC9647252 DOI: 10.1038/s41467-022-34420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Alterations in lipid metabolism have the potential to be markers as well as drivers of pathobiology of acute critical illness. Here, we took advantage of the temporal precision offered by trauma as a common cause of critical illness to identify the dynamic patterns in the circulating lipidome in critically ill humans. The major findings include an early loss of all classes of circulating lipids followed by a delayed and selective lipogenesis in patients destined to remain critically ill. The previously reported survival benefit of early thawed plasma administration was associated with preserved lipid levels that related to favorable changes in coagulation and inflammation biomarkers in causal modelling. Phosphatidylethanolamines (PE) were elevated in patients with persistent critical illness and PE levels were prognostic for worse outcomes not only in trauma but also severe COVID-19 patients. Here we show selective rise in systemic PE as a common prognostic feature of critical illness.
Collapse
Affiliation(s)
- Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
- Department of Cardiology, The 3rd Xiangya Hospital, Central South University, Changsha, China
- Eight-year program of medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Anthony Cyr
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Tyler C Lovelace
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
- Joint CMU-Pitt PhD Program in Computational Biology, Pittsburgh, PA, USA
| | - Panayiotis V Benos
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jishnu Das
- Center for Systems Immunology, Departments of Immunology and Computational & Systems Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Upendra K Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Tianmeng Chen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Cellular and Molecular Pathology Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H Yazer
- The Institute for Transfusion Medicine, Pittsburgh, PA, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jeffrey A Claridge
- Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Emergency Medical Services, The Capital Region of Denmark, Hillerød, Denmark
| | - Rami A Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA.
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA.
| |
Collapse
|
26
|
Lei M, Han Z, Wang S, Guo C, Zhang X, Song Y, Lin F, Huang T. Biological signatures and prediction of an immunosuppressive status-persistent critical illness-among orthopedic trauma patients using machine learning techniques. Front Immunol 2022; 13:979877. [PMID: 36325351 PMCID: PMC9620964 DOI: 10.3389/fimmu.2022.979877] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/03/2022] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Persistent critical illness (PerCI) is an immunosuppressive status. The underlying pathophysiology driving PerCI remains incompletely understood. The objectives of the study were to identify the biological signature of PerCI development, and to construct a reliable prediction model for patients who had suffered orthopedic trauma using machine learning techniques. METHODS This study enrolled 1257 patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Lymphocytes were tracked from ICU admission to more than 20 days following admission to examine the dynamic changes over time. Over 40 possible variables were gathered for investigation. Patients were split 80:20 at random into a training cohort (n=1035) and an internal validation cohort (n=222). Four machine learning algorithms, including random forest, gradient boosting machine, decision tree, and support vector machine, and a logistic regression technique were utilized to train and optimize models using data from the training cohort. Patients in the internal validation cohort were used to validate models, and the optimal one was chosen. Patients from two large teaching hospitals were used for external validation (n=113). The key metrics that used to assess the prediction performance of models mainly included discrimination, calibration, and clinical usefulness. To encourage clinical application based on the optimal machine learning-based model, a web-based calculator was developed. RESULTS 16.0% (201/1257) of all patients had PerCI in the MIMIC-III database. The means of lymphocytes (%) were consistently below the normal reference range across the time among PerCI patients (around 10.0%), whereas in patients without PerCI, the number of lymphocytes continued to increase and began to be in normal range on day 10 following ICU admission. Subgroup analysis demonstrated that patients with PerCI were in a more serious health condition at admission since those patients had worse nutritional status, more electrolyte imbalance and infection-related comorbidities, and more severe illness scores. Eight variables, including albumin, serum calcium, red cell volume distributing width (RDW), blood pH, heart rate, respiratory failure, pneumonia, and the Sepsis-related Organ Failure Assessment (SOFA) score, were significantly associated with PerCI, according to the least absolute shrinkage and selection operator (LASSO) logistic regression model combined with the 10-fold cross-validation. These variables were all included in the modelling. In comparison to other algorithms, the random forest had the optimal prediction ability with the highest area under receiver operating characteristic (AUROC) (0.823, 95% CI: 0.757-0.889), highest Youden index (1.571), and lowest Brier score (0.107). The AUROC in the external validation cohort was also up to 0.800 (95% CI: 0.688-0.912). Based on the risk stratification system, patients in the high-risk group had a 10.0-time greater chance of developing PerCI than those in the low-risk group. A web-based calculator was available at https://starxueshu-perci-prediction-main-9k8eof.streamlitapp.com/. CONCLUSIONS Patients with PerCI typically remain in an immunosuppressive status, but those without PerCI gradually regain normal immunity. The dynamic changes of lymphocytes can be a reliable biomarker for PerCI. This work developed a reliable model that may be helpful in improving early diagnosis and targeted intervention of PerCI. Beneficial interventions, such as improving nutritional status and immunity, maintaining electrolyte and acid-base balance, curbing infection, and promoting respiratory recovery, are early warranted to prevent the onset of PerCI, especially among patients in the high-risk group and those with a continuously low level of lymphocytes.
Collapse
Affiliation(s)
- Mingxing Lei
- Department of Orthopedic Surgery, Hainan Hospital of Chinese People's Liberation Army (PLA) General Hospital, Sanya, China
- Chinese People's Liberation Army (PLA) Medical School, Beijing, China
- Department of Orthopedic Surgery National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhencan Han
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Shengjie Wang
- Department of Orthopedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Chunxue Guo
- Department of Biostatistics, Hengpu Yinuo (Beijing) Technology Co., Ltd, Beijing, China
| | - Xianlong Zhang
- Department of Orthopedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Ya Song
- Department of Orthopedic, Xiangya Hospital of Central South University, Changsha, China
| | - Feng Lin
- Department of Orthopedic Surgery, Hainan Hospital of Chinese People's Liberation Army (PLA) General Hospital, Sanya, China
- Department of Orthopedic Surgery National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Tianlong Huang
- Department of Orthopedic Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
27
|
Differences in clinical characteristics of cervical spine injuries in older adults by external causes: a multicenter study of 1512 cases. Sci Rep 2022; 12:15867. [PMID: 36151125 PMCID: PMC9508126 DOI: 10.1038/s41598-022-19789-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 09/05/2022] [Indexed: 11/08/2022] Open
Abstract
Although traumatic cervical spine injuries in older adults are commonly caused by minor traumas, such as ground-level falls, their prognosis is often unfavorable. Studies examining the clinical characteristics of cervical spine injuries in older adults according to the external cause of injury are lacking. This study included 1512 patients of ≥ 65 years of age with traumatic cervical spine injuries registered in a Japanese nationwide multicenter database. The relationship between the external causes and clinical characteristics, as well as factors causing unfavorable outcomes at the ground-level falls, were retrospectively reviewed and examined. When fall-induced cervical spine injuries were categorized and compared based on fall height, the patients’ backgrounds and injury statuses differed significantly. Of note, patients injured from ground-level falls tended to have poorer pre-injury health conditions, such as medical comorbidities and frailty, compared with those who fell from higher heights. For ground-level falls, the mortality, walking independence, and home-discharge rates at 6 months post-injury were 9%, 67%, and 80%, respectively, with preexisting medical comorbidities and frailty associated with unfavorable outcomes, independent of age or severity of neurological impairment at the time of injury.
Collapse
|
28
|
Cobert J, Sheckter C, Pham TN. A National Analysis of Discharge Disposition in Older Adults with Burns—Estimating the Likelihood of Independence at Discharge. J Burn Care Res 2022; 43:1221-1226. [DOI: 10.1093/jbcr/irac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Whereas older age predicts higher burn mortality, the impact of age on discharge disposition is less well defined in older adults with burns. This investigation assesses the relationship between older age and discharge disposition after burns in a nationally representative sample. We queried the 2007-2015 National Trauma Data Bank for non-fatal burn hospitalizations in older adults. Pre-defined age categories were 55-64 years (working-age comparison group), 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Covariables included inhalation injury, comorbidities, burn total body surface area, injury mechanism, and race/ethnicity. Discharge to non-independent living (nursing home, rehabilitation, and other facilities) was the primary outcome. Logistic regression assessed the association between older age and discharge to non-independent living. There were 25,840 non-fatal burn hospitalizations in older adults during the study period. Working-age encounters comprised 53% of admissions, young-old accounted for 28%, middle-old comprised 15% and old-old comprised 4%. Discharge to non-independent living increased with burn TBSA and older age in survivors. Starting in young-old, the majority (65 %) of patients with burns ≥20% TBSA were discharged to non-independent living. Adjusted odd ratios for discharge to non-independent living were 2.0 for young-old, 3.3 for middle-old and 5.6 for old-old patients, when compared to working-age patients (all p<0.001). Older age strongly predicts non-independent discharge after acute burn hospitalization. Matrix analysis of discharge disposition indicates a stepwise rise in discharge to non-independent living with higher age and TBSA, providing a realistic discharge framework for treatment decisions and expectations about achieving independent living after burn hospitalization.
Collapse
Affiliation(s)
- Jason Cobert
- University of Rochester, 500 Joseph C. Wilson Blvd, Rochester , New York 14627, USA
| | - Clifford Sheckter
- Department of Surgery; Stanford University, 770 Welch Road, Suite 400 , Palo Alto, California 94304, USA
| | - Tam N Pham
- Department of Surgery; University of Washington-Harborview Medical Center, 325 Ninth Ave, Box 359796 , Seattle, Washington 98104, USA
- Harborview Injury Prevention and Research Center, 325 Ninth Ave, Box 359960 , Seattle, Washington 98104, USA
| |
Collapse
|
29
|
Costantini TW, Galante JM, Braverman MA, Phuong J, Price MA, Cuschieri J, Godat LN, Holcomb JB, Coimbra R, Bulger EM. Developing a National Trauma Research Action Plan: Results from the acute resuscitation, initial patient evaluation, imaging, and management research gap Delphi survey. J Trauma Acute Care Surg 2022; 93:200-208. [PMID: 35444148 DOI: 10.1097/ta.0000000000003648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury is the leading cause of death in patients aged 1 to 45 years and contributes to a significant public health burden for individuals of all ages. To achieve zero preventable deaths and disability after injury, the National Academies of Science, Engineering and Medicine called for the development of a National Trauma Research Action Plan to improve outcomes for military and civilian trauma patients. Because rapid resuscitation and prompt identification and treatment of injuries are critical in achieving optimal outcomes, a panel of experts was convened to generate high-priority research questions in the areas of acute resuscitation, initial evaluation, imaging, and definitive management on injury. METHODS Forty-three subject matter experts in trauma care and injury research were recruited to perform a gap analysis of current literature and prioritize unanswered research questions using a consensus-driven Delphi survey approach. Four Delphi rounds were conducted to generate research questions and prioritize them using a 9-point Likert scale. Research questions were stratified as low, medium, or high priority, with consensus defined as ≥60% of panelists agreeing on the priority category. Research questions were coded using a taxonomy of 118 research concepts that were standard across all National Trauma Research Action Plan panels. RESULTS There were 1,422 questions generated, of which 992 (69.8%) reached consensus. Of the questions reaching consensus, 327 (33.0%) were given high priority, 621 (62.6%) medium priority, and 44 (4.4%) low priority. Pharmaceutical intervention and fluid/blood product resuscitation were most frequently scored as high-priority intervention concepts. Research questions related to traumatic brain injury, vascular injury, pelvic fracture, and venous thromboembolism prophylaxis were highly prioritized. CONCLUSION This research gap analysis identified more than 300 high-priority research questions within the broad category of Acute Resuscitation, Initial Evaluation, Imaging, and Definitive Management. Research funding should be prioritized to address these high-priority topics in the future.
Collapse
Affiliation(s)
- Todd W Costantini
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine (T.W.C.), San Diego, CA; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, University of California Davis School of Medicine (J.M.G.), Sacramento, CA; Coalition for National Trauma Research, (M.A.B.), San Antonio, TX; Harborview Injury Prevention and Research Center, University of Washington (J.P.), Seattle, WA; Coalition for National Trauma Research, (M.A.P.), San Antonio, TX; Division of General Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco School of Medicine (J.C.), San Francisco, CA; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine (L.N.G.); San Diego, CA; Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham School of Medicine (J.B.H.); Birmingham, AL; Riverside University Health System Medical Center, Loma Linda University School of Medicine (R.C.); Riverside, CA; and Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington School of Medicine (E.M.B.); Seattle, WA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Kustermann M, Dasari P, Knape I, Keltsch E, Liu J, Pflüger S, Osen W, Holzmann K, Huber-Lang M, Debatin KM, Strauss G. Adoptively Transferred in vitro-Generated Myeloid-Derived Suppressor Cells Improve T-Cell Function and Antigen-Specific Immunity after Traumatic Lung Injury. J Innate Immun 2022; 15:78-95. [PMID: 35691281 PMCID: PMC10643914 DOI: 10.1159/000525088] [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: 12/20/2021] [Accepted: 05/07/2022] [Indexed: 11/19/2022] Open
Abstract
Immune reactions after trauma are characterized by immediate activation of innate immunity and simultaneously downregulation of adaptive immunity leading to a misbalanced immunohomeostasis and immunosuppression of the injured host. Therefore, the susceptibility to secondary infections is strongly increased after trauma. Immune responses are regulated by a network of immune cells influencing each other and at the same time modifying their functions dependent on the inflammatory environment. Although myeloid-derived suppressor cells (MDSCs) are initially described as T-cell suppressors, their immunomodulatory capacity after trauma is mostly undefined. Therefore, in vitro-generated MDSCs were adoptively transferred into mice after blunt chest trauma (TxT). A single MDSC treatment-induced splenic T-cell expansion decreased apoptosis sensitivity and improved proliferation in the absence of T-cell exhaustion until 2 weeks after trauma. MDSC treatment had a long-lasting effect on the genomic landscape of CD4+ T cells by upregulating primarily Th2-associated genes. Remarkably, immune-activating functions of MDSCs supported the ability of TxT mice to respond to post-traumatic secondary antigen challenge. Secondary insults were mimicked by immunizing MDSC-treated TxT mice with ovalbumin (OVA), followed by OVA restimulation in vitro. MDSC treatment significantly increased the frequency of OVA-specific T cells, enhanced their Th1/Th2 cytokine expression, and induced upregulation of cytolytic molecules finally improving OVA-specific cytotoxicity. Overall, we could show that therapeutic MDSC treatment after TxT improves post-traumatic T-cell functions, which might enable the traumatic host to counterbalance trauma-induced immunoparalysis.
Collapse
Affiliation(s)
- Monika Kustermann
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Prasad Dasari
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Ingrid Knape
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Emma Keltsch
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Jianing Liu
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Silvia Pflüger
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Wolfram Osen
- GMP & T Cell Therapy, German Cancer Research Center, Heidelberg, Germany
| | | | - Markus Huber-Lang
- Institute of Experimental Trauma-Immunology, University Medical Center Ulm, Ulm, Germany
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Gudrun Strauss
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| |
Collapse
|
31
|
Abstract
OBJECTIVE To evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury. BACKGROUND The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors. METHODS Moderate-severely injured adult patients treated at one of three level-1 trauma centers were prospectively followed six to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle two quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury. RESULTS A total of 3,153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). Compared to low SVI patients, high SVI patients were more likely to have new functional limitations (OR, 1.51; 95% CI, 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for PTSD (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes. CONCLUSIONS The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts.
Collapse
|
32
|
Herrera-Escobar JP, Price MA, Reidy E, Bixby PJ, Hau K, Bulger EM, Haider AH. Core outcome measures for research in traumatic injury survivors: The National Trauma Research Action Plan modified Delphi consensus study. J Trauma Acute Care Surg 2022; 92:916-923. [PMID: 35081596 DOI: 10.1097/ta.0000000000003546] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Until recently, survival has been the main outcome measure for injury research. Given the impact of injury on quality of life, the National Academies of Science, Engineering, and Medicine has called for advancing the science of research evaluating the long-term outcomes of trauma survivors. This is necessary so that treatments and interventions can be assessed for their impact on a trauma patients' long-term functional and psychosocial outcomes. We sought to propose a set of core domains and measurement instruments that are best suited to evaluate long-term outcomes after traumatic injury with a goal for these measures to be adopted as a national standard. METHODS As part of the development of a National Trauma Research Action Plan, we conducted a two-stage, five-round modified online Delphi consensus process with a diverse panel of 50 key stakeholders including clinicians, researchers, and trauma survivors from more than 9 professional areas across the United States. Before voting, panelists reviewed the results of a scoping review on patient-reported outcomes after injury and standardized information on measurement instruments following the Consensus-based Standards for the Selection of Health Measurement Instruments guidelines. RESULTS The panel considered a preliminary list of 74 outcome domains (patient-reported outcomes) and ultimately reached the a priori consensus criteria for 29 core domains that encompass aspects of physical, mental, social, and cognitive health. Among these 29 core domains, the panel considered a preliminary list of 199 patient-reported outcome measures and reached the a priori consensus criteria for 14 measures across 13 core domains. Participation of panelists ranged from 65% to 98% across the five Delphi rounds. CONCLUSION We developed a core outcome measurement set that will facilitate the synthesis, comparison, and interpretation of long-term trauma outcomes research. These measures should be prioritized in all future studies in which researchers elect to evaluate long-term outcomes of traumatic injury survivors. LEVEL OF EVIDENCE Diagnostic Test or Criteria, Level IV.
Collapse
Affiliation(s)
- Juan Pablo Herrera-Escobar
- From the Center for Surgery and Public Health (J.P.H.-E., E.R., K.H., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Coalition for National Trauma Research (M.A.P., P.J.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Aga Khan University Medical College (A.H.H.), Karachi, Pakistan
| | | | | | | | | | | | | |
Collapse
|
33
|
Lee JS, Khan AD, Dorlac WC, Dunn J, McIntyre RC, Wright FL, Platnick KB, Brockman V, Vega SA, Cofran JM, Duero C, Schroeppel TJ. The patient's voice matters: The impact of advance directives on elderly trauma patients. J Trauma Acute Care Surg 2022; 92:339-346. [PMID: 34538829 DOI: 10.1097/ta.0000000000003400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (ADs) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of preinjury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality. METHODS A multicenter retrospective review was conducted on patients older than 65 years with traumatic injury between 2017 and 2019. Three Level I trauma centers and one Level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted. RESULTS There were 6,135 patients identified; 751 (12.2%) had a preinjury AD. Patients in the AD+ group were older (86 vs. 77 years, p < 0.0001), more likely to be women (67.0% vs. 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients, and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs. 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs. 39.6%, p = 0.251). A preinjury AD was identified as an independent predictor of mortality, but not a predictor of WOC. CONCLUSION Despite a high WOC rate in patients older than 65 years, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care. LEVEL OF EVIDENCE Prognostic and epidemiological, level IV.
Collapse
Affiliation(s)
- Janet S Lee
- From the Department of Trauma and Acute Care Surgery (J.S.L., A.D.K., V.B., T.J.S.), University of Colorado Health Memorial Hospital, Colorado Springs; Department of Surgery (J.S.L., R.C.M., F.L.W., S.A.V.), University of Colorado Anschutz Medical Campus, Aurora; Department of Trauma and Acute Care Surgery (W.C.D., J.D., J.M.C.), University of Colorado Health Medical Center of the Rockies, Loveland; and Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health (B.P., C.D.), Denver, Colorado
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Bryant MK, Aubry S, Schiro S, Raff L, Perez AJ, Reid T, Maine RG. Causes of death following discharge after trauma in North Carolina. J Trauma Acute Care Surg 2022; 92:371-379. [PMID: 34789699 DOI: 10.1097/ta.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission. METHODS This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis. RESULTS Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days). CONCLUSION After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level IV.
Collapse
Affiliation(s)
- Mary K Bryant
- From the Department of Surgery (M.K.B., S.A., S.S., L.R., A.J.P., T.R.), University of North Carolina, Chapel Hill; Department of General Surgery/Trauma (M.K.B.), WakeMed Health & Hospitals, Raleigh, North Carolina; and Department of Surgery (R.G.M.), University of Washington, Seattle, Washington
| | | | | | | | | | | | | |
Collapse
|
35
|
Wang H, Ou Y, Fan T, Zhao J, Kang M, Dong R, Qu Y. Development and Internal Validation of a Nomogram to Predict Mortality During the ICU Stay of Thoracic Fracture Patients Without Neurological Compromise: An Analysis of the MIMIC-III Clinical Database. Front Public Health 2022; 9:818439. [PMID: 35004604 PMCID: PMC8727460 DOI: 10.3389/fpubh.2021.818439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study aimed to develop and validate a nomogram for predicting mortality in patients with thoracic fractures without neurological compromise and hospitalized in the intensive care unit. Methods: A total of 298 patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database were included in the study, and 35 clinical indicators were collected within 24 h of patient admission. Risk factors were identified using the least absolute shrinkage and selection operator (LASSO) regression. A multivariate logistic regression model was established, and a nomogram was constructed. Internal validation was performed by the 1,000 bootstrap samples; a receiver operating curve (ROC) was plotted, and the area under the curve (AUC), sensitivity, and specificity were calculated. In addition, the calibration of our model was evaluated by the calibration curve and Hosmer-Lemeshow goodness-of-fit test (HL test). A decision curve analysis (DCA) was performed, and the nomogram was compared with scoring systems commonly used during clinical practice to assess the net clinical benefit. Results: Indicators included in the nomogram were age, OASIS score, SAPS II score, respiratory rate, partial thromboplastin time (PTT), cardiac arrhythmias, and fluid-electrolyte disorders. The results showed that our model yielded satisfied diagnostic performance with an AUC value of 0.902 and 0.883 using the training set and on internal validation. The calibration curve and the Hosmer-Lemeshow goodness-of-fit (HL). The HL tests exhibited satisfactory concordance between predicted and actual outcomes (P = 0.648). The DCA showed a superior net clinical benefit of our model over previously reported scoring systems. Conclusion: In summary, we explored the incidence of mortality during the ICU stay of thoracic fracture patients without neurological compromise and developed a prediction model that facilitates clinical decision making. However, external validation will be needed in the future.
Collapse
Affiliation(s)
- Haosheng Wang
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, China
| | - Yangyang Ou
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, China
| | - Tingting Fan
- Department of Endocrinology, Baoji City Hospital of Traditional Chinese Medicine, Baoji, China
| | - Jianwu Zhao
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, China
| | - Mingyang Kang
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, China
| | - Rongpeng Dong
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, China
| | - Yang Qu
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, China
| |
Collapse
|
36
|
Ying M, Temkin-Greener H, Thirukumaran CP, Maddox KEJ, Holloway RG, Li Y. Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance. Med Care 2022; 60:83-92. [PMID: 34812788 PMCID: PMC8665005 DOI: 10.1097/mlr.0000000000001659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.
Collapse
Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY
| | - Karen E. Joynt Maddox
- Cardiovascular Division, School of Medicine, Washington University in St. Louis, St. Louis, MO
- Center for Health Economics and Policy, Washington University Institute for Public Health, St. Louis, MO
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
37
|
James A, Tran VT, Gauss T, Hamada S, Roquet F, Bitot V, Boutonnet M, Raux M, Ravaud P. Important Issues to Severe Trauma Survivors: A Qualitative Study. Ann Surg 2022; 275:189-195. [PMID: 32209913 DOI: 10.1097/sla.0000000000003879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Identify issues that are important to severe trauma survivors up to 3 years after the trauma. BACKGROUND Severe trauma is the first cause of disability-adjusted life years worldwide, yet most attention has focused on acute care and the impact on long-term health is poorly evaluated. METHOD We conducted a large-scale qualitative study based on semi-structured phone interviews. Qualitative research methods involve the systematic collection, organization, and interpretation of conversations or textual data with patients to explore the meaning of a phenomenon experienced by individuals themselves. We randomly selected severe trauma survivors (abbreviated injury score ≥3 in at least 1 body region) who were receiving care in 6 urban academic level-I trauma centers in France between March 2015 and March 2018. We conducted double independent thematic analysis. Issues reported by patients were grouped into overarching domains by a panel of 5 experts in trauma care. Point of data saturation was estimated with a mathematical model. RESULTS We included 340 participants from 3 months to 3 years after the trauma [median age: 41 years (Q1-Q3 24-54), median injury severity score: 17 (Q1-Q3 11-22)]. We identified 97 common issues that we grouped into 5 overarching domains: body and neurological issues (29 issues elicited by 277 participants), biographical disruption (23 issues, 210 participants), psychological and personality issues (21 issues, 147 participants), burden of treatment (14 issues, 145 participants), and altered relationships (10 issues, 87 participants). Time elapsed because the trauma, injury location, or in-hospital trauma severity did not affect the distribution of these domains across participants' answers. CONCLUSIONS This qualitative study explored trauma survivors' experiences of the long-term effect of their injury and allowed for identifying a set of issues that they consider important, including dimensions that seem overlooked in trauma research. Our findings confirm that trauma is a chronic medical condition that demands new approaches to post-discharge and long-term care.
Collapse
Affiliation(s)
- Arthur James
- Université de Paris, CRESS, INSERM, INRA, Paris, France
- Center d'épidémiologie clinique, Hôpital Hôtel Dieu, AP-HP, Paris, France AP-HP
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, Paris, France
- Sorbonne Université, Paris, France
| | - Viet-Thi Tran
- Université de Paris, CRESS, INSERM, INRA, Paris, France
- Center d'épidémiologie clinique, Hôpital Hôtel Dieu, AP-HP, Paris, France AP-HP
| | - Tobias Gauss
- Department of Anaesthesia and Critical Care, Hôpital Beaujon, HUPNVS, AP-HP, Clichy, France
| | - Sophie Hamada
- Department of Anesthesiology and Critical Care, AP-HP, Bicêtre Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre, France
- CESP, INSERM, Université paris Sud, UVSQ, Université Paris-Saclay, Paris
| | - Florian Roquet
- Service d'Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
| | - Valérie Bitot
- AP-HP, Hôpitaux Universitaires Henri Mondor, Service d'anesthésie et des réanimations chirurgicales, Créteil Cedex, France
| | - Mathieu Boutonnet
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart Cedex, France
| | - Mathieu Raux
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Philippe Ravaud
- Université de Paris, CRESS, INSERM, INRA, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, Paris, France
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| |
Collapse
|
38
|
Verma S, Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Dhingra NK, Ketchum SB, Juliano RA, Jiao L, Doyle RT, Granowitz C, Gibson CM, Pinto D, Giugliano RP, Budoff MJ, Mason RP, Tardif JC, Ballantyne CM. Icosapent Ethyl Reduces Ischemic Events in Patients With a History of Previous Coronary Artery Bypass Grafting: REDUCE-IT CABG. Circulation 2021; 144:1845-1855. [PMID: 34710343 DOI: 10.1161/circulationaha.121.056290] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. METHODS In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. RESULTS Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63-0.92]; P=0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56-0.87]; P=0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50-0.81]; P=0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%-10.2%) in first events, with a number needed to treat of 16 (95% CI, 10-44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P=0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. CONCLUSIONS In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01492361.
Collapse
Affiliation(s)
- Subodh Verma
- Montreal Heart Institute, Université de Montréal, Quebec, Canada (J-C.T.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B., R.P.G.)
| | - Ph Gabriel Steg
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, French Alliance for Cardiovascular Trials, and Institut National de la Santé et de la Recherche Médicale U-1148, Paris, France (P.G.S.)
| | - Michael Miller
- Department of Medicine, University of Maryland School of Medicine, Baltimore (M.M.)
| | | | - Terry A Jacobson
- Office of Health Promotion and Disease Prevention, Department of Medicine, Emory University School of Medicine, Atlanta, GA (T.A.J.)
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, ON, Canada (S.V., N.K.D.)
| | - Steven B Ketchum
- Amarin Pharma Inc, Bridgewater, NJ (S.B.K., R.A.J., L.J., R.T.D., C.G.)
| | - Rebecca A Juliano
- Amarin Pharma Inc, Bridgewater, NJ (S.B.K., R.A.J., L.J., R.T.D., C.G.)
| | - Lixia Jiao
- Amarin Pharma Inc, Bridgewater, NJ (S.B.K., R.A.J., L.J., R.T.D., C.G.)
| | - Ralph T Doyle
- Amarin Pharma Inc, Bridgewater, NJ (S.B.K., R.A.J., L.J., R.T.D., C.G.)
| | - Craig Granowitz
- Amarin Pharma Inc, Bridgewater, NJ (S.B.K., R.A.J., L.J., R.T.D., C.G.)
| | | | - Duane Pinto
- Baim Clinical Research Institute, Boston, MA (C.M.G., D.P.)
| | - Robert P Giugliano
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B., R.P.G.)
| | - Matthew J Budoff
- David Geffen School of Medicine, Lundquist Institute, Torrance, CA (M.J.B.)
| | | | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montréal, Quebec, Canada (J-C.T.)
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, and Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX (C.M.B.)
| | | |
Collapse
|
39
|
Zhou J, Lv Y, Zhao F, Wei Y, Gao X, Chen C, Lu F, Liu Y, Li C, Wang J, Zhang X, Gu H, Yin Z, Cao Z, Kraus VB, Mao C, Shi X. Albumin-corrected fructosamine predicts all-cause and non-CVD mortality among the very elderly aged ≥ 80 years without diabetes. J Gerontol A Biol Sci Med Sci 2021; 77:1673-1682. [PMID: 34758092 DOI: 10.1093/gerona/glab339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Several guidelines have suggested alternative glycemic markers for hemoglobin A1c among older adults with limited life expectancy or multiple coexisting chronic illnesses. We evaluated associations between fructosamine, albumin-corrected fructosamine (AlbF) and fasting plasma glucose (FPG) and mortality in the diabetic and non-diabetic subpopulations, compared which marker better predicts mortality among participants aged 80 and above. METHODS Included were 2,238 subjects from the Healthy Ageing and Biomarkers Cohort Study (2012-2018) and 207 participants had diabetes at baseline. Multivariable Cox proportional hazards regression models investigated the associations of fructosamine, AlbF, FPG and all-cause, cardiovascular disease (CVD), and non-CVD mortality in the diabetic and non-diabetic subpopulations. Restricted cubic splines (RCS) explored potential non-linear relations. C-statistic, integrated discrimination improvement (IDI) and net reclassification improvement (NRI) evaluated the additive value of different glycemic markers to predict mortality. RESULTS Overall, 1,191 deaths were documented during 6,793 person-years of follow-up. In the linear model, per unit increases of fructosamine, AlbF and FPG were associated with higher risk of mortality in non-diabetic participants, with hazard ratios of 1.02 (1.00, 1.05), 1.27 (1.14, 1.42) and 1.04 (0.98, 1.11) for all-cause mortality, and 1.04 (1.00, 1.07), 1.38 (1.19, 1.59) and 1.10 (1.01, 1.19) for non-CVD mortality, respectively. Comparisons indicated AlbF better predicts all-cause and non-CVD mortality in non-diabetic participants with significant improvement in IDI and NRI. CONCLUSIONS Higher concentrations of fructosamine, AlbF, and FPG were associated with higher risk of all-cause or non-CVD mortality among very elderly where AlbF may constitute an alternative prospective glycemic predictor of mortality.
Collapse
Affiliation(s)
- Jinhui Zhou
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yuebin Lv
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Feng Zhao
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yuan Wei
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China.,Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Xiang Gao
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Chen Chen
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Feng Lu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yingchun Liu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Chengcheng Li
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jiaonan Wang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xiaochang Zhang
- Division of Non-communicable Disease and Healthy Ageing Management, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Heng Gu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhaoxue Yin
- Division of Non-communicable Disease and Healthy Ageing Management, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhaojin Cao
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chen Mao
- Division of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Xiaoming Shi
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| |
Collapse
|
40
|
Haug VF, Tapking C, Panayi AC, Thiele P, Wang AT, Obed D, Hirche C, Most P, Kneser U, Hundeshagen G. Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:736-747. [PMID: 34252062 DOI: 10.1097/ta.0000000000003349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sepsis, major trauma, and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aims of this study were to assess the current state of long-term outcome research and to identify key outcome parameters between the three forms of critical illness. METHODS This systematic review and meta-analysis (MA) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed was searched from January 1, 1975, to December 31, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life and organ-specific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma. RESULTS In total, 125 articles could be included in the systematic review and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared with sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall health-related quality of life, as assessed by Short Form 36 and European Quality-of-Life Index, the three different etiologies were comparable with one another. CONCLUSION The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians and to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts. LEVEL OF EVIDENCE Systematic review and MA, level III.
Collapse
Affiliation(s)
- Valentin F Haug
- From the Department of Hand, Plastic and Reconstructive Surgery (V.F.H., C.T., P.T., C.H., U.K., G.H.), Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Plastic, Hand and Reconstructive Microsurgery (C.H.), Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany; German Center for Cardiovascular Research (DZHK) (P.M.), Partner site Heidelberg/Mannheim, Heidelberg; Division of Plastic Surgery, Department of Surgery (V.F.H., A.C.P., A.T.W., D.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Molecular and Translational Cardiology (P.T.), and Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany; and Division of Molecular and Translational Cardiology, Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Miranda D, Maine R, Cook M, Brakenridge S, Moldawer L, Arbabi S, O'Keefe G, Robinson B, Bulger EM, Maier R, Cuschieri J. Chronic critical illness after hypothermia in trauma patients. Trauma Surg Acute Care Open 2021; 6:e000747. [PMID: 34423134 PMCID: PMC8323397 DOI: 10.1136/tsaco-2021-000747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives Chronic critical illness (CCI) is a phenotype that occurs frequently in patients with severe injury. Previous work has suggested that inflammatory changes leading to CCI occur early following injury. However, the modifiable factors associated with CCI are unknown. We hypothesized that hypothermia, an early modifiable factor, is associated with CCI. Methods To determine the association of hypothermia and CCI, a secondary analysis of the Inflammation and Host Response to Injury database was performed, and subsequently validated on a similar cohort of patients from a single level 1 trauma center from January 2015 to December 2019. Hypothermia was defined as initial body temperature ≤34.5°C. CCI was defined as death or sustained multiorgan failure ≥14 days after injury. Data were analyzed using univariable analyses with Student’s t-test and Pearson’s χ2 test, and logistic regression. An arrayed genomic analysis of the transcriptome of circulating immune cells was performed in these patients. Results Of the initial 1675 patients, 254 had hypothermia and 1421 did not. On univariable analysis, 120/254 (47.2%) of patients with hypothermia had CCI, compared with 520/1421 (36.6%) without hypothermia who had CCI, p<0.001. On multivariable logistic regression, hypothermia was independently associated with CCI, OR 1.61 (95% CI 1.17 to 2.21) but not mortality. Subsequent validation in 1264 patients of which 172 (13.6%) were hypothermic, verified that hypothermia was independently associated with CCI on multivariable logistic regression, OR 1.84 (95% CI 1.21 to 2.41). Transcriptomic analysis in hypothermic and non-hypothermic patients revealed unique cellular-specific genomic changes to only circulating monocytes, without any distinct effect on neutrophils or lymphocytes. Conclusions Hypothermia is associated with the development of CCI in severely injured patients. There are transcriptomic changes which indicate that the changes induced by hypothermia may be associated with persistent CCI. Thus, early reversal of hypothermia following injury may prevent the CCI. Level of evidence III.
Collapse
Affiliation(s)
- David Miranda
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Rebecca Maine
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Scott Brakenridge
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Lyle Moldawer
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Saman Arbabi
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Grant O'Keefe
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bryce Robinson
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ronald Maier
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph Cuschieri
- Surgery at ZSFG, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
42
|
Lussiez A, Montgomery JR, Sangji NF, Fan Z, Oliphant BW, Hemmila MR, Dimick JB, Scott JW. Hospital effects drive variation in access to inpatient rehabilitation after trauma. J Trauma Acute Care Surg 2021; 91:413-421. [PMID: 34108424 PMCID: PMC8375412 DOI: 10.1097/ta.0000000000003215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postacute care rehabilitation is critically important to recover after trauma, but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher-quality and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient vs. injury vs. hospital level) contribute the most. METHODS We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 levels I to IV trauma centers between 2011 and 2015 using the National Trauma Data Bank. Participants were included if they met the following criteria: age >18 years, Injury Severity Score of ≥9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services preferred diagnoses for inpatient rehabilitation under the "60% rule." RESULTS The overall risk- and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the nonelderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient-, injury-, and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9% to 30% in the nonelderly adult cohort and from 7% to 46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the nonelderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort. CONCLUSION Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes. LEVEL OF EVIDENCE Care management, level IV.
Collapse
Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - John R Montgomery
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - Naveen F Sangji
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Bryant W Oliphant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| |
Collapse
|
43
|
Brakenridge SC, Wilfret DA, Maislin G, Andrade KE, Walker V, May AK, Dankner WM, Bulger EM. Resolution of organ dysfunction as a predictor of long-term survival in necrotizing soft tissue infections: Analysis of the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections trial and a retrospective claims database-linked chart study. J Trauma Acute Care Surg 2021; 91:384-392. [PMID: 33797490 DOI: 10.1097/ta.0000000000003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are an acute surgical condition with high morbidity and mortality. Timely identification, resuscitation, and aggressive surgical management have significantly decreased inpatient mortality. However, reduced inpatient mortality has shifted the burden of disease to long-term mortality associated with persistent organ dysfunction. METHODS We performed a combined analysis of NSTI patients from the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections randomized-controlled interventional trial (ATB-202) and comprehensive administrative database (ATB-204) to determine the association of persistent organ dysfunction on inpatient and long-term outcomes. Persistent organ dysfunction was defined as a modified Sequential Organ Failure Assessment (mSOFA) score of 2 or greater at Day 14 (D14) after NSTI diagnosis, and resolution of organ dysfunction defined as mSOFA score of 1 or less. RESULTS The analysis included 506 hospitalized NSTI patients requiring surgical debridement, including 247 from ATB-202, and 259 from ATB-204. In both study cohorts, age and comorbidity burden were higher in the D14 mSOFA ≥2 group. Patients with D14 mSOFA score of 1 or less had significantly lower 90-day mortality than those with mSOFA score of 2 or higher in both ATB-202 (2.4% vs. 21.5%; p < 0.001) and ATB-204 (6% vs. 16%: p = 0.008) studies. In addition, in an adjusted covariate analysis of the combined study data sets D14 mSOFA score of 1 or lesss was an independent predictor of lower 90-day mortality (odds ratio, 0.26; 95% confidence interval, 0.13-0.53; p = 0.001). In both studies, D14 mSOFA score of 1 or less was associated with more favorable discharge status and decreased resource utilization. CONCLUSION For patients with NSTI undergoing surgical management, persistent organ dysfunction at 14 days, strongly predicts higher resource utilization, poor discharge disposition, and higher long-term mortality. Promoting the resolution of acute organ dysfunction after NSTI should be considered as a target for investigational therapies to improve long-term outcomes after NSTI. LEVEL OF EVIDENCE Prognostic/epidemiology study, level III.
Collapse
Affiliation(s)
- Scott C Brakenridge
- From the Department of Surgery (S.C.B.), University of Florida College of Medicine, Gainesville, Florida; Atox Bio, Ltd (D.A.W., W.M.D.), Durham, North Carolina; Biomedical Statistical Consulting (G.M.), Wynnewood, Pennsylvania; Health Economics and Outcomes Research, Optum (K.E.A., V.W.), Eden Prairie, Minnesota; Division of Acute Care Surgery (A.K.M.), Atrium Health, Charlotte, North Carolina; Department of Surgery (E.M.B.) University of Washington, Harborview Medical Center, Seattle, Washington
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
OBJECTIVE Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort. BACKGROUND The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients. METHODS Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6-14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes. RESULTS Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status (SES), extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the SF-12 and to screen positive for PTSD and depression. CONCLUSIONS The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population.
Collapse
|
45
|
McLaughlin CJ, Hess J, Armen SB, Allen SR. Established primary care provider improves odds of survival to discharge for injured patients. J Surg Res 2021; 267:619-626. [PMID: 34271269 DOI: 10.1016/j.jss.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/07/2021] [Accepted: 06/07/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. METHODS Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. RESULTS Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. CONCLUSION Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.
Collapse
Affiliation(s)
| | - Joseph Hess
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA
| | - Scott B Armen
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Penn State Health, Hershey, PA.
| | - Steven R Allen
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Penn State Health, Hershey, PA
| |
Collapse
|
46
|
Hung KKC, Rainer TH, Yeung JHH, Cheung C, Leung Y, Leung LY, Chong M, Ho HF, Tsui KL, Cheung NK, Graham C. Seven-year excess mortality, functional outcome and health status after trauma in Hong Kong. Eur J Trauma Emerg Surg 2021; 48:1417-1426. [PMID: 34086062 DOI: 10.1007/s00068-021-01714-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose was to investigate long-term health impacts of trauma and the aim was to describe the functional outcome and health status up to 7 years after trauma. METHODS We conducted a prospective, multi-centre cohort study of adult trauma patients admitted to three regional trauma centres with moderate or major trauma (ISS ≥ 9) in Hong Kong (HK). Patients were followed up at regular time points (1, 6 months and 1, 2, 3, 4, 5, 6, and 7 years) by telephone using extended Glasgow Outcome Scale (GOSE) and the Short-Form 36 (SF36). Observed annual mortality rate was compared with the expected mortality rate estimated using the HK population cohort. Linear mixed model (LMM) analyses examined the changes in SF36 with subgroups of age ≥ 65 years, ISS > 15, and GOSE ≥ 5 over time. RESULTS At 7 years, 115 patients had died and 48% (138/285) of the survivors responded. The annual mortality rate (AMR) of the trauma cohort was consistently higher than the expected mortality rate from the general population. Forty-one percent of respondents had upper good recovery (GOSE = 8) at 7 years. Seven-year mean PCS and MCS were 45.06 and 52.06, respectively. LMM showed PCS improved over time in patients aged < 65 years and with baseline GOSE ≥ 5, and the MCS improved over time with baseline GOSE ≥ 5. Higher mortality rate, limited functional recovery and worse physical health status persisted up to 7 years post-injury. CONCLUSION Long-term mortality and morbidity should be monitored for Asian trauma centre patients to understand the impact of trauma beyond hospital discharge.
Collapse
Affiliation(s)
- Kevin Kei Ching Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.,Trauma & Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.,School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Timothy H Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.,Emergency Medicine Unit, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Janice Hiu Hung Yeung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.,Trauma & Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Catherine Cheung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Yuki Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Marc Chong
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hiu Fai Ho
- Accident and Emergency Department, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - Kwok Leung Tsui
- Trauma Committee, New Territory West Cluster, Hospital Authority, Kowloon, Hong Kong
| | - Nai Kwong Cheung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.,Trauma & Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Colin Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. .,Trauma & Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. .,School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong.
| |
Collapse
|
47
|
Firchal EW, Sjoberg F, Fredrikson M, Pompermaier L, Elmasry M, Steinvall I. Long-term survival among elderly after burns compared with national mean remaining life expectancy. Burns 2021; 47:1252-1258. [PMID: 34103200 DOI: 10.1016/j.burns.2021.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/10/2021] [Accepted: 05/24/2021] [Indexed: 01/12/2023]
Abstract
INTRODUCTION As compared to younger adults, older people have a greater risk of domestic accidents, such as burns, and their prognosis is worsened by a diminished physiological ability to face a thermal trauma. The in-hospital mortality is adversely affected by old age and burn size, whereas less is known about the long-term-survival in elderly patients who survive a burn injury. The aim of this study was to investigate if elderly burn patients after discharge from a Swedish National Burn Centre have a shorter remaining life compared to the national population, by using calculated remaining Life Expectancy (rLE). METHODS In this retrospective study we included all patients who were admitted for burns to the Linköping Burn Centre during 1993-2016 and who were 60 years or older and alive, at the time of discharge. The control group was extracted from Statistics Sweden, the national statistics database, and consisted of all individuals from the Swedish population matched for each patient in the study group, by sex and age at the year of discharge. The proportion who died before reaching the rLE was compared between the study population and the control group by calculating risk ratio. RESULTS The study group consisted of 111 former patients and 77 of them (69%) died before reaching the rLE, with mean 4.7 years of life lost (YLL), which was 33% more than that (52%) of the control group (RR 1.33, 95% CI 1.18-1.51). Burn related factors, such as TBSA % or FTB % were not found to account for this effect. CONCLUSION We found that the long-time survival of elderly patients after burns is shorter than that of a national control, the magnitude of which is quantitatively important. The current study does not support that burn related factors account for this effect and the reason should therefore be sought in other factors, such as e.g., co-morbidity or psychosocial issues.
Collapse
Affiliation(s)
- Emmelie Westlund Firchal
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping University, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Folke Sjoberg
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping University, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden.
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Laura Pompermaier
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping University, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping University, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping University, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
48
|
Alpert M, Grigorian A, Joe V, Chin TL, Bernal N, Lekawa M, Satahoo S, Nahmias J. No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients. Am Surg 2021; 88:2907-2912. [PMID: 33861652 DOI: 10.1177/00031348211011122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used. RESULTS From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned (P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = .04) and decreased hypertension (52.2% vs. 65.8%, P = .04) in the younger cohort. Octogenarians had similar complications, including acute respiratory distress syndrome, pulmonary embolism, deep vein thrombosis (P > .05), and mortality (15.1% vs. 10.5%, P = .30), compared to the younger cohort. Octogenarians were not associated with an increased mortality risk (odds ratio 1.51, confidence interval 0.24-9.56, P = .67). DISCUSSION Among burn trauma patients ≥65 years, age should not be a sole predictor for mortality risk. Continued research is necessary in order to determine more accurate approaches to prognosticate mortality in geriatric burn trauma patients, such as the validation and refinement of a burn-trauma-related frailty index.
Collapse
Affiliation(s)
- Miriam Alpert
- 6645Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| | - Victor Joe
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| | - Theresa L Chin
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| | - Nicole Bernal
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| | - Shevonne Satahoo
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA
| |
Collapse
|
49
|
Wycech J, Fokin AA, Katz JK, Viitaniemi S, Menzione N, Puente I. Comparison of Geriatric Versus Non-geriatric Trauma Patients With Palliative Care Consultations. J Surg Res 2021; 264:149-157. [PMID: 33831601 DOI: 10.1016/j.jss.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/22/2021] [Accepted: 02/27/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Palliative care in trauma patients is still evolving. The goal was to compare characteristics, outcomes, triggers and timing for palliative care consultations (PCC) in geriatric (≥65 y.o.) and non-geriatric trauma patients. MATERIALS AND METHODS Retrospective study included 432 patients from two level 1 trauma centers who received PCC between December 2012 and January 2019. Non-geriatric (n = 61) and geriatric (n = 371) groups were compared for: mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Score (GCS), Do-Not-Resuscitate (DNR) orders, futile interventions (FI), duration of mechanical ventilation (DMV), ICU admissions, ICU and hospital lengths of stay (ICULOS; HLOS), timing to PCC, and mortality. Further propensity matching (PM) analysis compared 59 non-geriatric to 59 Geriatric patients matched by ISS, GCS, and DNR. RESULTS Geriatric patients were older (85.2 versus 49.7), with falls as predominant MOI. Non-geriatric patients comprised 14.1% of all patients with PCC and were more severely injured than Geriatrics: with statistically higher ISS (24.1 versus 18.5), lower RTS (5.4 versus 7.0), GCS (7.1 versus 11.5), with predominant MOI being traffic accidents, all P < 0.01. Non-Geriatrics had more ICU admissions (96.7% versus 88.1%), longer ICULOS (10.2 versus 4.7 days), DMV (11.1 versus 4.1 days), less DNR (57.4% versus 73.9%), higher in-hospital mortality (12.5% versus 2.6%), but double the time admission-PCC (11.3 versus 4.3 days) compared to Geriatrics, all P < 0.04. In PM comparison, despite same injury severity, Non-geriatrics had triple the time to PCC, five times the HLOS of geriatrics, and more FI (25.4% versus 3.4%), all P < 0.001. CONCLUSIONS PCC remains underutilized in non-geriatric trauma patients. Despite higher injury severity, non-geriatrics received more aggressive treatment, and had three times longer time to PCC, resulting in higher rate of FI than in Geriatrics.
Collapse
Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida.
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Sari Viitaniemi
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Nicholas Menzione
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
| |
Collapse
|
50
|
LaGrone LN, McIntyre L, Riggle A, Robinson BRH, Maier RV, Bulger E, Cuschieri J. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg 2021; 89:1046-1053. [PMID: 32773673 DOI: 10.1097/ta.0000000000002902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A fundamental goal of continuous process improvement programs is to evaluate and improve the ratio of actual to expected mortality. To study this, we examined contributors to error-associated deaths during two consecutive periods from 1996 to 2004 (period 1) and 2005 to 2014 (period 2). METHODS All deaths at a level I trauma center with an anticipated probability of death less than 50% and/or identified through process improvement committees were examined. Demographics were assessed for trend only because period 1 data were only available in median and interquartile range. Each death was critically appraised to identify potential error, with subsequent classification of error type, phase, cause, and contributing cognitive processes, with comparison of outcomes made using χ test of independence. RESULTS During period 1, there were a total of 44,401 admissions with 2,594 deaths and 64 deaths (2.5%) associated with an error, compared with 60,881 admissions during period 2 with 2,659 deaths and 77 (2.9%) associated with an error. Deaths associated with an error occurred in younger and less severely injured patients in period 1 and were likely to occur during the early phase of care, primarily from failed resuscitation and hemorrhage control. In period 2, deaths occurred in older more severely injured patients and were likely to occur in the later phase of care primarily because of respiratory failure from aspiration. CONCLUSION Despite injured patients being older and more severely injured, error-associated deaths during the early phase of care that was associated with hemorrhage improved over time. Successful implementation of system improvements resolved issues in the early phase of care but shifted deaths to later events during the recovery phase including respiratory failure from aspiration. This study demonstrates that ongoing evaluation is essential for continuous process improvement and realignment of efforts, even in a mature trauma system. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
Collapse
Affiliation(s)
- Lacey N LaGrone
- From the Medical Center of the Rockies (L.N.L., L.M., B.R.H.R., R.V.M., E.B., J.C., A.R.), UCHealth, University of Colorado, Trauma & Acute Care Surgery, Loveland, CO
| | | | | | | | | | | | | |
Collapse
|