Multi-institutional analysis of neutrophil-to-lymphocyte ratio (NLR) in patients with severe hemorrhage: A new mortality predictor value

Enhancing the Understanding of Abdominal Trauma During the COVID-19 Pandemic Through Co-Occurrence Analysis and Machine Learning

BACKGROUND

This study examines the impact of the COVID-19 pandemic on abdominal trauma management by comparing pre-pandemic (17 February 2018-26 February 2020) and pandemic periods (27 February 2020-7 March 2022).

METHODS

Analyzing data from 118 patients at the Emergency County Clinical Hospital of Craiova, we identified significant shifts in clinical practices affecting patient outcomes.

RESULTS

During the pandemic, a moderate increase in surgical interventions for specific abdominal traumas indicated the effective adaptation of the medical system. Prioritizing critical cases and deferring non-urgent procedures optimized limited resources. Demographic and clinical factors-including age, sex, body mass index (BMI), and red cell distribution width (RDW)-significantly influenced the hospitalization duration and recovery outcomes. Gender disparities in mortality lessened during the pandemic, possibly due to standardized interventions and the physiological effects of SARS-CoV-2. The link between occupation and obesity highlighted how work environments impact trauma severity, especially as lifestyle changes affect BMI. While age remained a major predictor of mortality, its influence slightly decreased, potentially due to improved protocols for elderly patients. RDW emerged as an important prognostic marker for disease severity and mortality risk.

CONCLUSIONS

Employing advanced co-occurrence analysis enhanced with machine learning, we uncovered complex relationships between clinical and demographic variables often overlooked by traditional methods. This innovative approach provided deeper insights into the collective impact of various factors on patient outcomes. Our findings demonstrate the healthcare system's rapid adaptations during the pandemic and offer critical insights for optimizing medical strategies and developing personalized interventions in global crises.

Retrospective evaluation of the neutrophil-to-lymphocyte ratio as a prognostic marker in cats with blunt trauma (2018-2021): 177 cases

OBJECTIVE

To investigate the utility of the neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker in cats with blunt trauma.

DESIGN

Retrospective study from January 2018 to December 2021.

SETTING

University teaching hospital.

ANIMALS

Medical records of 177 cats admitted with blunt trauma were evaluated. History, clinical findings, blood cell count-based ratios, thoracic radiographs on presentation, and outcome were reviewed. The Animal Trauma Triage (ATT) score was assessed in each cat and classified as mild (1-3), moderate (4-7), and severe trauma (≥8). Forty-eight healthy blood donor cats served as the control population. NLR, neutrophil counts, and lymphocyte counts were compared between cats with blunt trauma and controls, and among trauma patients.

INTERVENTIONS

None MEASUREMENTS AND MAIN RESULTS: NLR, neutrophil counts, and lymphocyte counts significantly differ in cats with blunt trauma compared to controls (p < 0.001), and NLR was higher in patients with thoracic trauma (p = 0.044). Nonsurvivors had lower lymphocyte counts (p = 0.041), although those values do not appear to be clinically relevant. A significant increase in NLR was observed with increasing severity of trauma (p < 0.001). The NLR was not associated with the length of hospitalization, intensive care assistance, or mortality.

CONCLUSION

NLR is a widely available diagnostic tool, which can be used in addition to ATT to assess trauma severity, although in our study it was not predictive of the outcome.

Predictive Performance Neutrophil-to-Lymphocyte Ratio of Acute Tonsillitis with Deep Neck Space Infection in Adult Patients

The aim of this study was to examine the neutrophil-to-lymphocyte ratio (NLR) in patients diagnosed with a deep neck infection (DNI) to identify helpful indicators for the initial differential diagnosis. This study was conducted as a single-center, retrospective cohort study that utilized data from the electronic medical records of patients who visited the emergency department in a tertiary university hospital between February 2018 and April 2022. The study enrolled patients aged ≥18 years who were diagnosed with tonsillitis with or without DNI during the study period. The NLR of patients without DNI was 6.1 ± 5.03, and the NLR of patients with acute tonsillitis with DNI was 8.0 ± 5.67, showing significant differences. The rate of admission in the general wards (GWs) and ICUs was significantly higher in patients with DNI, and the length of hospital stay was also significantly longer in patients with DNI. Older age, male, lower body temperature, C-reactive protein, and NLR were significant independent risk factors for DNI in patients with tonsillitis. The cutoff value for predicting DNI in patients with body temperature <37.5 was 3.09. The NLR of patients with tonsillitis, especially those with normal body temperature, can be used to predict their prognosis.

Evaluation of Midkine levels in pregnant women with preterm premature rupture of membranes: A cohort study from a tertiary hospital

OBJECTIVE

To assess midkine (MK) levels in pregnant women with preterm premature rupture of membranes (PPROM) and compare them to healthy pregnant women. We also assessed the performance of the maternal serum MK level in predicting neonatal intensive care unit (NICU) requirement in the PPROM group.

METHODS

Forty pregnant women who presented to our clinic at 24-37 gestational weeks and were diagnosed with PPROM were included in the study group. During the same period, 40 healthy pregnant women at similar gestational weeks were randomly selected as the control group. Clinical characteristics, inflammatory markers, and serum MK levels were compared between the groups. The same parameters were then compared between the PPROM cases with and without NICU requirement. Finally, the receiver operating characteristic (ROC) analysis was performed to assess the predictive value of MK for NICU requirement.

RESULTS

The PPROM and control groups were similar in terms of demographics. The MK level of the pregnant woman with PPROM was significantly higher than that of the controls. No statistically significant difference was found between the MK levels of the cases with and without NICU requirement in the PPROM group. In the ROC analysis, the optimal cut-off value of was found to be 0.287, at which it had 63 % sensitivity and 65 % specificity (area under the curve(AUC): 0.78, 95 % confidence interval(CI): 0.683-0.881, p < 0.001) for the prediction of NICU requirement in cases with PPROM. In the same analysis performed for the prediction of PPROM, when the optimal cut-off value was taken as 0.298, MK had 56 % sensitivity and 60 % specificity (AUC: 0.65, 95 % CI: 0.522-0.770, p = 0.037).

CONCLUSION

Serum MK seems to be associated with complicated inflammatory processes leading to PPROM, and this novel marker has the potential to predict NICU requirement in PPROM cases.

Effect of intraoperative blood transfusion on inflammatory response in parturients with placenta previa undergoing cesarean section: A prospective observational study

Background

The neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and red cell distribution width (RDW) have been reported as useful biomarkers for evaluating inflammation and a predictor of surgical prognosis. Although there have been recent reports that transfusion may affect inflammatory responses, studies on the post-transfusion inflammatory response in parturients are rare. Therefore, this study aimed to observe changes in inflammatory response after transfusion during cesarean section (C-sec) through NLR, PLR, and RDW.

Methods

Parturients aged 20-50 years who underwent C-sec under general anesthesia due to placenta previa totalis from March 4, 2021, to June 10, 2021 were participated in this prospective observational study. We compared postoperative NLR, PLR, and RDW between the transfusion and non-transfusion groups.

Results

A total of 53 parturients were included in this study, of which 31 parturients received intraoperative transfusions during C-sec. There were no significant difference in preoperative NLR (3.6 vs. 3.4, p = 0.780), PLR (132.8 vs. 111.3, p = 0.108), and RDW (14.2 vs. 13.6, p = 0.062) between the two groups. However, postoperative NLR was significantly higher in the transfusion group than in the non-transfusion group (12.2 vs. 6.8, p < 0.001). Postoperative RDW was significantly higher in the transfusion group than in the non-transfusion group (14.6 vs. 13.9, p = 0.002) whereas postoperative PLR was not significantly different between the two groups (108.0 vs. 117.4, p = 0.885).

Conclusions

Postoperative NLR and RDW, the inflammatory biomarkers, were significantly higher in the transfused C-sec parturients. These results suggest a significant association between postoperative inflammatory response and transfusion in obstetric practice.

Effects of hemodilution on coagulation function during prolonged hypotensive resuscitation in a porcine model of severe hemorrhagic shock

Background

Although hemorrhage remains the leading cause of survivable death in casualties, modern conflicts are becoming more austere limiting available resources to include resuscitation products. With limited resources also comes prolonged evacuation time, leaving suboptimal prehospital field care conditions. When blood products are limited or unavailable, crystalloid becomes the resuscitation fluid of choice. However, there is concern of continuous crystalloid infusion during a prolonged period to achieve hemodynamic stability for a patient. This study evaluates the effect of hemodilution from a 6-hour prehospital hypotensive phase on coagulation in a porcine model of severe hemorrhagic shock.

Methods

Adult male swine (n=5/group) were randomized into three experimental groups. Non-shock (NS)/normotensive did not undergo injury and were controls. NS/permissive hypotensive (PH) was bled to the PH target of systolic blood pressure (SBP) 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by PH resuscitation with crystalloid for 6 hours. Hemorrhaged animals were then resuscitated with whole blood and recovered. Blood samples were collected at certain time points for analysis of complete blood counts, coagulation function, and inflammation.

Results

Throughout the 6-hour PFC, hematocrit, hemoglobin, and platelets showed significant decreases over time in the Decomp/PH group, indicating hemodilution, compared with the other groups. However, this was corrected with whole blood resuscitation. Despite the appearance of hemodilution, coagulation and perfusion parameters were not severely compromised.

Conclusions

Although significant hemodilution occurred, there was minimal impact on coagulation and endothelial function. This suggests that it is possible to maintain the SBP target to preserve perfusion of vital organs at a hemodilution threshold in resource-constrained environments. Future studies should address therapeutics that can mitigate potential hemodilutional effects such as lack of fibrinogen or platelets.

Level of evidence

Not applicable-Basic Animal Research.

The Predictive Role of Systemic Inflammatory Markers in the Development of Acute Kidney Failure and Mortality in Patients with Abdominal Trauma

Background: Abdominal trauma is defined as a variety of injuries to the abdominal wall, solid or hollow intra-abdominal organs, and various intra-abdominal vessels. Recently, there has been a significant amount of interest in the establishment of a reliable biomarker that can predict the outcome in patients with an abdominal injury. The purpose of this study is to confirm the predictive role of inflammatory biomarkers and underlying risk factors and the risk of acute kidney insufficiency (AKI) developing and mortality in abdominal trauma patients; Materials and methods: The current study was intended as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with a diagnosis of abdominal trauma confirmed through a CT scan admitted to the County Emergency Clinical Hospital of Targu-Mureș, Romania between January 2017, and December 2021; Results: Non-survivor patients had a greater age (p = 0.02), as well as a higher prevalence of ischemic heart disease (IHD) (p = 0.007), history of myocardial infarction (MI) (p = 0.002), peripheral arterial disease (PAD) (p = 0.01), chronic kidney disease (CKD) (p = 0.01), and all risk factors (p = 0.0004 and p < 0.0001). In terms of injured organs, we have in the second group a higher incidence of kidney injury (p = 0.003) and hemoperitoneum (p = 0.008). Multivariate analysis showed a high baseline value for all inflammatory biomarkers that are independent predictors of adverse outcomes for all recruited patients. Furthermore, for all hospitalized patients, the history of MI (p = 0.03; p = 0.001; and p = 0.003), PAD (p = 0.01; p = 0.01; and p = 0.002), obesity (for all p < 0.0001), CKD (p < 0.001; p = 0.01; and p = 0.001), and kidney injury (p = 0.02; p = 0.004; and p = 0.01) were independent predictors of all outcomes. Moreover, IHD (p = 0.008 and p = 0.02), tobacco (p < 0.0001 and p = 0.02), and hemoperitoneum (p = 0.009 and p = 0.01) were predictors of mortality and composite endpoint, but not for AKI risk, as well as atrial fibrillation [AF] (p = 0.04) as predictors of the composite endpoint Conclusions: Higher monocyte to lymphocyte ratio (MLR), platelets to lymphocyte ratio (PLR), systemic inflammatory index (SII), neutrophil to lymphocyte ratios (NLR), aggregate inflammatory systemic index (AISI), and systemic inflammatory response index (SIRI) levels at admission, according to our data, highly predict AKI risk and death.

Longitudinal analysis of neutrophil-to-lymphocyte ratio over time after major trauma

Background

The neutrophil-to-lymphocyte ratio has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. However, the initial neutrophil-to-lymphocyte ratio does not appear to be predictive of in-hospital mortality. The aim of this study is to determine the discriminative ability of the neutrophil-to-lymphocyte ratio profile over 48 h as a predictor of in-hospital mortality following major trauma.

Methods

This was a case-control study involving all major trauma patients meeting the criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period. Patients were then divided into two groups, cases being major trauma patients who died at hospital discharge and controls being patients who survived. We extracted data for Day 0, Day 1 and Day 2 neutrophil-to-lymphocyte ratio values for each patient. The primary outcome was mortality at hospital discharge.

Results

Data were extracted for 1689 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) patients presented after a blunt mechanism of injury. There were 165 cases that were compared to 1524 controls. Patients who died were older ( p < 0.001), and had higher injury severity scores ( p < 0.001) and lower revised trauma scores ( p < 0.001). Analysis of response profiles demonstrated a significant difference between the trajectories of the neutrophil-to-lymphocyte ratio over time ( p < 0.001).

Conclusions

The profile of neutrophil-to-lymphocyte ratio over 48 h after injury shows promise as a prognostic tool in trauma and warrants further investigation.

Platelet-Lymphocyte and Neutrophil-Lymphocyte Ratio for Prediction of Hospital Outcomes in Patients with Abdominal Trauma

Background

The platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) reflect the patient inflammatory and immunity status. We investigated the role of on-admission PLR and NLR in predicting massive transfusion protocol (MTP) activation and mortality following abdominal trauma.

Methods

A 4-year retrospective analysis of all adult abdominal trauma patients was conducted. Patients were classified into survivors and nonsurvivors and low vs. high PLR. The discriminatory power for PLR and NLR to predict MTP and mortality was determined. Multivariate logistic regression analysis was performed for predictors of mortality.

Results

A total of 1199 abdominal trauma patients were included (18.7% of all the trauma admissions). Low PLR was associated with more severe injuries and greater rates of hospital complications including mortality in comparison to high PLR. On-admission PLR and NLR were higher in the survivors than in nonsurvivors (149.3 vs. 76.3 (p = 0.001) and 19.1 vs. 13.7 (p = 0.009), respectively). Only PLR significantly correlated with injury severity score, revised trauma score, TRISS, serum lactate, shock index, and FASILA score. Optimal cutoffs of PLR and NLR for predicting mortality were 98.5 and 18.5, respectively. The sensitivity and specificity of PLR were 81.3% and 61.1%, respectively, and 61.3% and 51.3%, respectively, for NLR. The AUROC for predicting MTP was 0.69 (95% CI: 0.655–0.743) for PLR and 0.55 (95% CI: 0.510–0.598) for NLR. To predict hospital mortality, the area under the curve (AUROC) for PLR was 0.77 (95% CI: 0.712–0.825) and 0.59 (95% CI: 0.529–0.650) for the NLR. On multivariate logistic regression analysis, the age, Glasgow Coma Scale, sepsis, injury severity score, and PLR were independent predictors of mortality.

Conclusion

On-admission PLR but not NLR helps early risk stratification and timely management and predicts mortality in abdominal trauma patients. Further prospective studies are required.

Potential Immune Indicators for Predicting the Prognosis of COVID-19 and Trauma: Similarities and Disparities

Although cellular and molecular mediators of the immune system have the potential to be prognostic indicators of disease outcomes, temporal interference between diseases might affect the immune mediators, and make them difficult to predict disease complications. Today one of the most important challenges is predicting the prognosis of COVID-19 in the context of other inflammatory diseases such as traumatic injuries. Many diseases with inflammatory properties are usually polyphasic and the kinetics of inflammatory mediators in various inflammatory diseases might be different. To find the most appropriate evaluation time of immune mediators to accurately predict COVID-19 prognosis in the trauma environment, researchers must investigate and compare cellular and molecular alterations based on their kinetics after the start of COVID-19 symptoms and traumatic injuries. The current review aimed to investigate the similarities and differences of common inflammatory mediators (C-reactive protein, procalcitonin, ferritin, and serum amyloid A), cytokine/chemokine levels (IFNs, IL-1, IL-6, TNF-α, IL-10, and IL-4), and immune cell subtypes (neutrophil, monocyte, Th1, Th2, Th17, Treg and CTL) based on the kinetics between patients with COVID-19 and trauma. The mediators may help us to accurately predict the severity of COVID-19 complications and follow up subsequent clinical interventions. These findings could potentially help in a better understanding of COVID-19 and trauma pathogenesis.

Initial neutrophil and lymphocyte ratio as a predictor of mortality and ICU admission after major trauma

Introduction

The neutrophil-to-lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. We aimed to determine the discriminative ability of initial NLR as a predictor of outcomes following major trauma.

Methods

This was a registry-based cohort study involving all major trauma patients meeting criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period (January 2018 to December 2019). The initial NLR was calculated for each patient and was compared against the Shock Index (SI), lactate and Revised Trauma Score (RTS). Outcomes observed were mortality at hospital discharge and intensive care unit (ICU) admission. We assessed the predictive capacity of each test using the receiver operating characteristic (ROC) curve and performed area under the ROC curve (AUROC) analysis to compare their performance.

Results

Data were extracted for 1687 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) of patients presented after a blunt mechanism of injury. In-hospital mortality occurred in 165 (9.77%) patients, and 725 (42.92%) patients required ICU admission. The median NLR was 6.84 (IQR 3.89–11.52). Initial NLR performed poorly with an AUROC of 0.46 (95% confidence interval (CI): 0.40–0.52) for prediction of mortality and AUROC of 0.53 (95% CI: 0.50–0.56) for prediction of ICU admission. The AUROCs of initial NLR for both mortality at hospital discharge and ICU admission were significantly lower than SI, lactate and RTS.

Conclusion

Initial NLR was not predictive of outcomes in major trauma. NLR at other time-points may provide better predictive capacity for outcomes.

Association of the neutrophil–lymphocyte ratio to patient outcomes after trauma: A systematic review

Introduction

Early identification of trauma injury severity is important for prognostication. The neutrophil–lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. The aim of this systematic review is to compile all the best evidence available to determine the prognostic capabilities of the NLR in trauma and to assess the NLR as a predictor of mortality in adult major trauma patients. Additionally, comparing NLR and hospital length of stay (LOS), ICU LOS, mechanical ventilation and transfusion requirements.

Methods

We conducted a search of online information sources to identify manuscripts observing the NLR in adult major trauma patients. Outcomes of interest include mortality as defined by the author, hospital LOS, ICU LOS, mechanical ventilation and transfusion requirements. Quality was assessed using the Newcastle–Ottawa Scale. We aimed to conduct a meta-analysis if there were sufficient manuscripts included.

Results

Eight studies fulfilled our inclusion criteria. Trials were of good methodological quality. Substantial heterogeneity present between the studies prevented a meta-analysis from being conducted. Overall, five studies demonstrated the NLR as a significantly predictive marker of mortality. NLR was observed to be significantly associated with increased ICU LOS and longer duration of mechanical ventilation. Mixed results were observed between NLR and hospital LOS and transfusion requirements.

Conclusions

A potential association between NLR and mortality, ICU LOS and duration of mechanical ventilation has been reported. However, clinical utility of this measure during trauma resuscitation remains unknown.

Late Mortality Prediction of Neutrophil-to-lymphocyte and Platelet Ratio in Patients With Trauma Who Underwent Emergency Surgery: A Retrospective Study

BACKGROUND

We aimed to evaluate the usefulness of neutrophil-to-lymphocyte (N/L) and neutrophil-to-lymphocyte platelet (N/LP) ratios in predicting late mortality of patients with trauma who underwent emergency surgery.

MATERIALS AND METHODS

We retrospectively evaluated patients with trauma older than 19 y who underwent emergency surgery at our level I trauma center. Blood count-based ratios (N/L and N/LP at days 1, 3, and 7 of hospitalization) and trauma scores were analyzed. Statistical analysis was performed using univariable logistic regression and receiver operating curves.

RESULTS

A total of 209 patients were evaluated. N/LP at day 7, N/L at day 7, Trauma Injury Severity Score, Revised Trauma Score, and Injury Severity Score were significantly associated with late mortality. Area under the receiver operating characteristic curves for predicting mortality was highest for N/LP at day 7 (0.867 [95% confidence interval 0.798-0.936], P < 0.001). The group with N/LP greater than the cutoff value (9.3, sensitivity 77.3%, specificity 83.1%) at day 7 showed higher mortality than the group with N/LP less than the cutoff value (35.4% versus 3.2%, P < 0.001, respectively) at day 7.

CONCLUSIONS

N/LP at day 7 may be a superior predictor of late mortality compared with preexisting trauma scores in patients with major trauma undergoing emergency surgery, by better reflecting the systemic inflammation status.

The Trajectory of Alterations in Immune-Cell Counts in Severe-Trauma Patients Is Related to the Later Occurrence of Sepsis and Mortality: Retrospective Study of 917 Cases

Background

Severe trauma is believed to disrupt the homeostasis of the immune system, and lead to dramatic changes in the circulating immune-cell count (ICC). The latter fluctuates widely over time. Knowledge about the relationship between these dramatic changes and dynamic fluctuations and the late prognosis of trauma patients is sparse. We investigated the relationship between the trajectory of alterations in the circulating ICC within 7 days in severe-trauma patients and subsequent sepsis and mortality.

Methods

A retrospective analysis of 917 patients with an Injury Severity Score ≥16 was undertaken. The absolute neutrophil, lymphocyte, and monocyte counts (ANC, ALC, and AMC, respectively) on days 1, 3, and 7 (D1, D3, and D7, respectively) after trauma, and whether sepsis or death occurred within 60 days, were recorded. As the disordered circulating ICCs fluctuated widely, their time-varying slopes (D3/D1 and D7/D3) were calculated. Patients were divided into “sepsis” and “non-sepsis” groups, as well as “alive” and “death” groups. Comparative studies were conducted between every two groups. Univariate and multivariate logistic regression analyses were used to identify variables related to the risk of sepsis and mortality. Receiver operating characteristic curves were plotted to assess the predictive value of various risk factors.

Results

More severe trauma caused more pronounced increases in the ANC and slower recovery of the ALC within 7 days. The ALC (D3), ANC (D7), ALC (D3/D1), and ANC (D7/D3) were independent risk factors for sepsis. The ALC (D3), ALC (D7), AMC (D7), and ALC (D3/D1) were independent risk factors for mortality. A combination of the ALC (D3) and ALC (D3/D1) exerted a good predictive value for sepsis and death.

Conclusions

The trajectory of alterations in the circulating ICC in the early stage after trauma is related to subsequent sepsis and mortality.

Cohort retrospective study: the neutrophil to lymphocyte ratio as an independent predictor of outcomes at the presentation of the multi-trauma patient

BACKGROUND

Although the association of neutrophil to lymphocyte ratio (NLR) with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. Recent studies suggest that the NLR has a predictive value of mortality in trauma patients during various times of admission. This study aimed to determine the prognostic impact of NLR at the presentation in critically ill trauma patients.

METHODS

A retrospective cohort study of adult trauma patients between July 2017 and November 2017 in Tishreen Hospital. All patients who had arrived at the emergency department with multi-trauma injury within the age category (14-80 years) were included in this analysis. The prophetical capability of NLR on mortality was assessed by the receiver operative characteristics (ROC) curve. To identify the impact of the NLR on survival, a separate log-rank test was used. Multivariable Cox proportional hazard modeling was used to identify independent predictors of mortality.

RESULTS

Throughout the time of the study, 566 patients met the inclusion criteria. Of these, 98.8% were male, 75.8% sustained penetrating trauma, and median age [IQR25-IQR75] was 26 [23-32]. Ninety-seven patients (17.1%) had major trauma, with an Injury Severity Score (ISS) ≥ 15. Using the ROC curve analyses hospitalization day 1, optimal NLR cutoff values of 4.00 were calculated by maximizing the Youden index. Kaplan-Meier curves revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality (p = 0.020, log-rank test). The Cox regression model demonstrated significant collinearity among the predictive variables (all VIF results < 2). Only ISS > 15 has a significant statistical relation with elevated NLR on day 1 (p = 0.010).

CONCLUSIONS

Elevated NLR on day 1 has high predictive power for overall survival during the first 30 days after trauma, but it was not independent of other factors.

Among Trauma Patients, Younger Men with Ventilator-Associated Pneumonia Have Worse Outcomes Compared to Older Men-An Exploratory Study

Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP). Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival. Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, (p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days (p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09). Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.

An Increasing Neutrophil-to-Lymphocyte Ratio Trajectory Predicts Organ Failure in Critically-Ill Male Trauma Patients. An Exploratory Study

Background: Although the association of neutrophil proportions with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. We sought to investigate the association of neutrophil proportions with organ failure in critically-ill trauma patients. Methods: We reviewed a randomly-selected group of trauma patients admitted to our level-1 trauma intensive care unit between July 2007 and December 2016. Data collected included demographics, injury mechanism and severity (ISS), neutrophil-to-lymphocyte ratio (NLR) at admission and at 24 and 48 hours and organ failure data. NLR patterns during the first 48 hours were divided into two trajectories identified by applying factor and cluster analysis to longitudinal measures. Logistic regression was performed for the association between NLR trajectories and any organ failure; negative binomial regression was used to model the number of organ failures and stage of kidney failure measured by KDIGO classification. Results: 207 patients had NLR data at all three time points. The average age was 44.9 years with mean ISS of 20.6. Patients were 72% male and 23% had penetrating trauma. The 74 patients (36%) with Trajectory 1 had a mean NLR at admission of 3.6, which increased to 14.7 at 48 hours. The 133 (64%) patients in Trajectory 2 had a mean NLR at admission of 8.5 which decreased to 6.6 at 48 hours. Mean NLR was different between the two groups at all three time points (all p < 0.01). There was no significant difference in ISS, age or gender between the two trajectory groups. Models adjusted for age, gender and ISS showed that relative to those with trajectory 2, patients with the trajectory 1 were more likely to have organ failure OR 2.96 (1.42⁻6.18; p < 0.01), higher number of organ failures IRR 1.50 (1.13⁻2.00, p < 0.01), and degree of AKI IRR 2.06 (1.04⁻4.06, p = 0.04). In all cases, the estimated associations were higher among men vs. women, and all were significant among men, but not women. Conclusions: Trauma patients with an increasing NLR trajectory over the first 48 hours had increased risk, number and severity of organ failures. Further research should focus on the mechanisms behind this difference in outcome.

Determining the optimal cutoff point for lymph node density and its impact on overall survival in children with Wilms' tumor

Objective

Previous studies showed that the lymph node density (LND) was a predictor of survival in Wilms’ tumor (WT). However, the optimal LND cutoff point is controversial due to methodological shortcomings of previous studies, and no studies have shown the effect of LND on survival in children with WT. The purpose of this study was to remedy this situation.

Methods

We identified 376 children with WT. LND cutoff point was determined using the median value, the X-tile program, the survival-tree algorithm, and the time-dependent ROC curve analysis. Survival functions were estimated by the Kaplan–Meier method. We used Cox regression analysis to determine the impact of LND on survival. Smooth curve fitting between relative mortality risk and LND was performed.

Results

The LND cutoff point was 0.44, 0.65, 0.65, and 0.64 according to the median value, the X-tile program, the survival-tree algorithm, and the time-dependent ROC curve analysis, respectively. The 5-, 10-, and 20-year overall survival rates were 86.9%, 86.9%, and 84.7%, respectively, in the <0.44 group and 81.3%, 80.3%, and 80.3%, respectively, in the ≥0.44 group. Survival did not differ significantly between the two groups (P=0.185). The 5-, 10-, and 20-year overall survival rates were 87.8%, 87.8%, and 86.0%, respectively, in the < 0.65 or < 0.64 group and 76.5%, 75.1%, and 75.1%, respectively, in the ≥ 0.65 or ≥ 0.64 group. Children with the high LND had a significantly worse survival (P=0.011) if 0.64 or 0.65 was used for the stratification. LND was a significant predictor for overall survival in the multivariate Cox regression analysis (HR =1.797; 95% CI, 1.043–3.097; P=0.035). Smooth curve fitting suggested that the risk of mortality tended to be ascending with the increase in LND in general.

Conclusion

The three methods including the X-tile program, the survival-tree algorithm, and the time-dependent receiver operating characteristic (ROC) curve analysis are equivalent in their ability to stratify patients and clearly better than the median method. The results showed that the optimal LND cutoff point was around 0.65 and the LND was a reliable predictor of overall survival in children with WT.

The impact of septic stimuli on the systemic inflammatory response and physiologic insult in a preclinical non-human primate model of polytraumatic injury

BACKGROUND

Established animal trauma models are limited in recapitulating the pathophysiology of human traumatic injury. Herein, we characterize the physiologic insult and inflammatory response in two clinically relevant non-human primate (NHP) trauma models.

METHODS

Mauritian Cynomolgus Macaques underwent either a laparoscopic closed abdomen liver injury (laparoscopic 60% left-lobe hepatectomy) in an established uncontrolled severe hemorrhage model (THM), or a polytrauma hemorrhage model (PHM) involving combined liver and bowel injury, uncontrolled severe hemorrhage as well as an open full-thickness cutaneous flank wound. Fixed volume resuscitation strategies were employed in the THM and goal directed resuscitation was used in the PHM. Complete peripheral blood and critical clinical chemistry parameters, serum biomarkers of systemic inflammation, tissue perfusion parameters, as well as survival, were compared between the models throughout the 2-week study period.

RESULTS

NHPs in both the THM (n = 7) and the PHM (n = 21) demonstrated tissue hypoperfusion (peak lactate 6.3 ± 0.71 mmol/L) with end organ injury (peak creatinine 3.08 ± 0.69 mg/dL) from a similar liver injury (60% left hemi-hepatectomy), though the PHM NHPs had a significantly higher blood loss (68.1% ± 12.7% vs. 34.3% ± 2.3%, p = 0.02), lower platelet counts (59 ± 25 vs. 205 ± 46 K/uL, p = 0.03) and a trend towards higher mortality (90.5% vs. 33.3%, p = 0.09). The inflammatory response was robust in both models with peak cytokine (IL-6 > 6000-fold above baseline) and peak leukocyte values (WBC 27 K/uL) typically occurring around t = 240 min from the time of hepatic injury. A more robust systemic inflammatory response was appreciated in the PHM resulting in marked elevations in peak serum IL-6 (7887 ± 2521 pg/mL vs.1076 ± 4833 pg/mL, p = 0.02), IL-1ra (34,499 ± 5987 pg/mL vs. 2511 ± 1228 pg/mL, p < 0.00), and IL-10 (13,411 pg/mL ± 5598 pg/mL vs. 617 pg/mL ± 252 pg/mL, p = 0.03).

CONCLUSION

This comparative analysis provides a unique longitudinal perspective on the post-injury inflammatory response in two clinically relevant models, and demonstrates that the addition of septic stimuli to solid organ injury increases both the hemorrhagic insult and inflammatory response.

Neutrophils to lymphocytes ratio and platelets to lymphocytes ratio in pregnancy: A population study

BACKGROUND

Neutrophils to lymphocytes ratio (NLR) and platelets to lymphocytes ratio (PLR) are both inflammatory ratios that can be easily calculated from a simple blood count. They are frequently reported and tested as prognostic factors in several medical disciplines. Pregnancy involves special reference values for laboratory assays.

OBJECTIVE

The aim of this study was to define pregnancy-related reference values for NLR and PLR according to trimester, background morbidity and according to the patient's age.

STUDY DESIGN

A retrospective analysis of a large cohort undergoing community-based pregnancy surveillance between the years 2011-2016. Data were analyzed according to high-risk patient versus normal-risk patient.

RESULTS

A total of 11,415 patients were included. Mean PLR and NLR values were 136.3±44.3, 2.6±1, respectively during the first trimester, 144.6±47.1, 4.0±1.4 respectively during the second trimester and 118.1±42.0, 3.5±1.2 respectively during the third trimester. No difference was detected between the high-risk and the normal population (P-values 0.3, 0.5 and 0.4 for PLR in each trimester respectively and 0.3, 0.4, 0.6 for NLR in each trimester, respectively). No differences were detected among parity categories. The correlation between patient's age and either PLR and NLR was a weak positive correlation (though statistically significant). Both PLR and NLR reached a maximum value during the second trimester. The differences between mean NLR and PLR between trimesters were significant (P <0.01 for all differences tested). PLR rises in the presence of anemia, reaching statistical significance (P-value for PLR in each trimester was <0.01). NLR showed an opposite trend (P-values for NLR were 0.4, 0.005 and 0.06 in each trimester, respectively).

CONCLUSIONS

In our cohort, there were generally no differences between the high-risk and the normal population, excluding patients with a fibroid uterus or inflammatory bowel disease who presented a significantly elevated PLR through all trimesters. Both PLR and NLR reached a maximum value during the second trimester and were positively correlated with age. We anticipate that the population-based data will assist in providing accurate reference values for future research testing NLR and PLR measures during pregnancy.