Gender-specific issues in traumatic injury and resuscitation: consensus-based recommendations for future research

Epidemiology of Shoulder Injuries Presenting to US Emergency Departments

BACKGROUND

Shoulder injuries are a significant cause of musculoskeletal complaints in emergency departments (EDs), but data on these injuries in the United States are limited. This study analyzed shoulder injuries reported to US EDs from 2006 to 2016, focusing on trends in injury mechanisms, diagnoses, and demographics.

MATERIALS AND METHODS

Data from the National Electronic Injury Surveillance System (NEISS) database were used to analyze 6,689,422 shoulder injuries reported to US EDs during 11 years, examining injury rates, causes, diagnoses, and demographics.

RESULTS

An estimated 6,689,422 shoulder injuries were reported during the study period, accounting for 4.35% of all injuries reported to US EDs. The highest injury rate was observed in individuals 15 to 24 years (3.15 per 1000 US population), while children younger than 5 years had the lowest rate (0.97 per 1000). The most common causes of injury were sports and recreation (45.84%), home structure (20.79%), and home furniture (18.91%). The most frequent diagnoses included fractures (20.30%), contusions (18.23%), and dislocations (12.92%). More than one-third of the injuries (39.2%) occurred at home. Injury rates decreased for individuals younger than 25 years but increased for those 45 to 64 years during the study period. Younger individuals and males showed greater sport-related injuries, while older populations and females more commonly presented with home-related injuries.

CONCLUSION

This study revealed unique demographic patterns in the causes and mechanisms of shoulder injuries. These findings suggest that tailored prevention strategies could be particularly effective, helping to improve both injury prevention efforts and the clinical care of patients with shoulder injuries. [Orthopedics. 2025;48(2):e81-e87.].

Trauma outcomes differences in females: a prospective analysis of 76 000 trauma patients in the Asia-Pacific region and the contributing factors

BACKGROUND

Trauma is a leading cause of mortality, particularly in low and middle-income countries. While extensively studied in North America and Europe, data from the Asia-Pacific are limited. An important area of research is the difference in trauma outcomes, which are theoretically noted to be better among females. However, the clinical findings are inconclusive among Asians. This study examines sex-based differences in trauma outcomes in Asia Pacific, focusing on in-hospital mortality and functional recovery at discharge.

METHODS

This observational study, from the Pan-Asia Trauma Outcomes Study (PATOS), included 76,645 trauma patients from 12 Asian Pacific countries. We analysed in-hospital mortality and functionality at discharge using the Glasgow Outcome Scale (GOS) and the modified Rankin Scale (mRS). Logistic regression models were built to test the association of sex on the outcomes.

RESULTS

Males exhibited higher in-hospital mortality (1.6%) compared to females (1.06%) ( p < 0.001). Adjusted logistic regression models showed that the female sex is not independently associated with in-hospital mortality. Females have a better functional outcome at discharge for patients younger than 50 years with ISS < 16. However, no significant differences existed between those > 50 years and ISS > 15.

CONCLUSION

This study indicates no difference in the general trauma outcomes in the Asia Pacific between females and males. Although younger females with less severe injuries had better functional outcomes, this advantage disappeared in severe injuries and those over 50 years. These results align with some previous studies, and understanding the nuances may lead to more tailored trauma care, potentially improving patient outcomes.

Societal Burden of Trauma and Disparities in Trauma Care

Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.

CT Utilization in a Level One Trauma Center in South Africa

Introduction

Computed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging.

Methods

This was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department’s picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate.

Results

There were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan.

Conclusions

South Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting. 

Cerebral Regional Tissue Oxygenation as Surrogate for Blood Loss in Nonhuman Primate Models of Shock

INTRODUCTION

Hemorrhage is the leading cause of preventable death, with a majority of mortalities in the prehospital setting. Current hemorrhage resuscitation guidelines cannot predict the critical point of intervention to activate massive transfusion (MT) and prevent cardiovascular decompensation. We hypothesized that cerebral regional tissue oxygenation (CrSO₂) would indicate MT need in nonhuman primate models of hemorrhagic shock.

METHODS

Nineteen anesthetized male rhesus macaques underwent hemorrhage via a volume-targeted (VT) or pressure-targeted (PT) method. VT animals were monitored for 30 min following 30% blood volume hemorrhage. PT animals were hemorrhaged to mean arterial pressure (MAP) of 20 mmHg and maintained for at least 60 min until decompensation. Statistics for MAP, heart rate (HR), end tidal carbon dioxide (EtCO₂), and CrSO₂ were analyzed via one- or two-way repeated-measures analysis of variance, Pearson's R, and receiver-operator curve. A P < 0.05 is considered significant.

RESULTS

Following initial hemorrhage (S0), there were no significant differences between groups. After cessation of hemorrhage in the VT group, MAP and EtCO₂ returned to baseline while CrSO₂ plateaued. The PT group maintained model-defined low MAP, suppressing EtCO₂, and significantly decreased CrSO₂ compared to the VT group by S25. Linear regression of CrSO₂versus shed blood volume demonstrated R² = 0.7539. CrSO₂ of 47% was able to detect >40% blood loss with an area under the curve of 0.9834 at 92.3% (66.7%-99.6%) sensitivity and 95.5% (84.9%-99.2%) specificity.

CONCLUSIONS

Regardless of hemorrhage modality and compensatory response, CrSO₂ correlated strongly with shed blood volume. Analysis demonstrated that CrSO₂ values below 49% indicate Advanced Trauma Life Support class IV shock (blood loss>40%). CrSO₂ at the point of care may help indicate MT need earlier and more accurately than traditional markers.

Sex discrimination after injury: is inequity in tranexamic acid administration just the tip of the iceberg?

There is emerging evidence of inequalities in healthcare provision between women and men. Trauma care is no exception with a number of studies indicating lower levels of prioritisation for injured female patients. The antifibrinolytic drug tranexamic acid, reduced trauma deaths to a similar extent in females and males in the international Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) randomised controlled trials, but in real-world practice, national registry data shows females are less likely to receive tranexamic acid than males. Inequity in the provision of tranexamic acid may extend beyond sex (and gender), and further study is required to examine the effect of age and mechanism of injury differences between men and women in the decision to treat.

General practitioner gender and use of diagnostic procedures: a French cross-sectional study in training practices

OBJECTIVES

The acceleration in the number of female doctors has led to questions about differences in how men and women practice medicine. The aim of this study was to assess the influence of general practitioner (GP) gender on the use of the three main categories of diagnostic procedures-clinical examinations, laboratory tests and imaging investigations.

DESIGN

Cross-sectional nationwide multicentre study.

SETTING

French training general practices.

PARTICIPANTS

The patient sample included all the voluntary patients over a cumulative period of 5 days per office between November 2011 and April 2012. The GP sample included 85 males and 43 females.

METHODS

54 interns in general practice, observing their GP supervisors, collected data about the characteristics of GPs and consultations, as well as the health problems managed during the visit and the processes of care associated with them. Using hierarchical multilevel mixed-effect logistic regression models, we performed multivariable analyses to assess differences in each of the three main categories of diagnostic procedures, and two specific multivariable analyses for each category, distinguishing screening from diagnostic or follow-up procedures. We searched for interactions between GP gender and patient gender or type of health problem managed.

RESULTS

This analysis of 45 582 health problems managed in 20 613 consultations showed that female GPs performed more clinical examinations than male GPs, both for screening (OR 1.75; 95% CI 1.19 to 2.58) and for diagnostic or follow-up purposes (OR 1.41; 95% CI 1.08 to 1.84). Female GPs also ordered laboratory tests for diagnostic or follow-up purposes more frequently (OR 1.21; 95% CI 1.03 to 1.43). Female GPs performed even more clinical examinations than male GPs to diagnose or follow-up injuries (OR 1.69; 95% CI 1.19 to 2.40).

CONCLUSION

Further research on the appropriateness of diagnostic procedures is required to determine to what extent these differences are related to underuse or overuse.

A scoping review of female drowning: an underexplored issue in five high-income countries

BACKGROUND

Drowning is a significant public health issue, with females accounting for one third of global drowning deaths. The rate of female drowning has not decreased within high-income countries and presentations to hospital have increased. This scoping review aimed to explore adult female unintentional drowning, including risk factors, clinical treatment and outcomes of females hospitalised for drowning.

METHODS

A systematic search of the literature following the PRISMA-ScR framework was undertaken. The databases OVID MEDLINE, Embase, CINAHL, OVID Emcare, Web of Science, Informit and Scopus were accessed. Study locations of focus were Australia, Canada, New Zealand, the United Kingdom, and the United States. Studies from January 2003 to April 2019 were included. The quality of evidence of included studies was assessed using GRADE guidelines.

RESULTS

The final search results included 14 studies from Australia (n = 4), Canada (n = 1), New Zealand (n = 1), United States (n = 6), United Kingdom (n = 1), and one study reporting data from both Australia and United States. Nine studies reported risk factors for female drowning including age, with the proportion of female drowning incidence increasing with age. Although females are now engaging in risk-taking behaviours associated with drowning that are similar to males, such as consuming alcohol and swimming in unsafe locations, their exposure to risky situations and ways they assess risk, differ. Females are more likely to drown from accidental entry into water, such as in a vehicle during a flood or fall into water. This review found no evidence on the clinical treatment provided to females in hospital after a drowning incident, and only a small number of studies reported the clinical outcomes of females, with inconsistent results (some studies reported better and some no difference in clinical outcomes among females).

CONCLUSION

Adult females are a group vulnerable to drowning, that have lacked attention. There was no single study found which focused solely on female drowning. There is a need for further research to explore female risk factors, the clinical treatment and outcomes of females hospitalised for drowning. This will not only save the lives of females, but also contribute to an overall reduction in drowning.

Altered Processing of Complex Visual Stimuli in Patients with Postconcussive Visual Motion Sensitivity

BACKGROUND AND PURPOSE

Vestibular symptoms are common after concussion. Vestibular Ocular Motor Screening identifies vestibular impairment, including postconcussive visual motion sensitivity, though the underlying functional brain alterations are not defined. We hypothesized that alterations in multisensory processing are responsible for postconcussive visual motion sensitivity, are detectable on fMRI, and correlate with symptom severity.

MATERIALS AND METHODS

Twelve patients with subacute postconcussive visual motion sensitivity and 10 healthy control subjects underwent vestibular testing and a novel fMRI visual-vestibular paradigm including 30-second "neutral" or "provocative" videos. The presence of symptoms/intensity was rated immediately after each video. fMRI group-level analysis was performed for a "provocative-neutral" condition. Z-statistic images were nonparametrically thresholded using clusters determined by Z > 2.3 and a corrected cluster significance threshold of P = .05. Symptoms assessed on Vestibular Ocular Motor Screening were correlated with fMRI mean parameter estimates using Pearson correlation coefficients.

RESULTS

Subjects with postconcussive visual motion sensitivity had significantly more Vestibular Ocular Motor Screening abnormalities and increased symptoms while viewing provocative videos. While robust mean activation in the primary and secondary visual areas, the parietal lobe, parietoinsular vestibular cortex, and cingulate gyrus was seen in both groups, selective increased activation was seen in subjects with postconcussive visual motion sensitivity in the primary vestibular/adjacent cortex and inferior frontal gyrus, which are putative multisensory visual-vestibular processing centers. Moderate-to-strong correlations were found between Vestibular Ocular Motor Screening scores and fMRI activation in the left frontal eye field, left middle temporal visual area, and right posterior hippocampus.

CONCLUSIONS

Increased fMRI brain activation in visual-vestibular multisensory processing regions is selectively seen in patients with postconcussive visual motion sensitivity and is correlated with Vestibular Ocular Motor Screening symptom severity, suggesting that increased visual input weighting into the vestibular network may underlie postconcussive visual motion sensitivity.

Metabolic Profiling of a Porcine Combat Trauma-Injury Model Using NMR and Multi-Mode LC-MS Metabolomics-A Preliminary Study

Profiles of combat injuries worldwide have shown that penetrating trauma is one of the most common injuries sustained during battle. This is usually accompanied by severe bleeding or hemorrhage. If the soldier does not bleed to death, he may eventually succumb to complications arising from trauma hemorrhagic shock (THS). THS occurs when there is a deficiency of oxygen reaching the organs due to excessive blood loss. It can trigger massive metabolic derangements and an overwhelming inflammatory response, which can subsequently lead to the failure of organs and possibly death. A better understanding of the acute metabolic changes occurring after THS can help in the development of interventional strategies, as well as lead to the identification of potential biomarkers for rapid diagnosis of hemorrhagic shock and organ failure. In this preliminary study, a metabolomic approach using the complementary platforms of nuclear magnetic resonance (NMR) spectroscopy and liquid chromatography coupled with mass spectrometry (LC-MS) was used to determine the metabolic changes occurring in a porcine model of combat trauma injury comprising of penetrating trauma to a limb with hemorrhagic shock. Several metabolites associated with the acute-phase reaction, inflammation, energy depletion, oxidative stress, and possible renal dysfunction were identified to be significantly changed after a thirty-minute shock period.

Sex-based differences in transfusion need after severe injury: Findings of the PROPPR study

BACKGROUND

Women are underrepresented in trauma research, and aggregated results of clinical trials may mask effects that differ by sex. It is unclear whether women respond differently to severe hemorrhage compared with men. We sought to evaluate sex-based differences in outcomes after severe trauma with hemorrhage.

METHODS

We performed a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Trauma patients predicted to require massive transfusion were randomized to a 1:1:1 vs 1:1:2 plasma to platelet to red blood cell transfusion ratio. Analysis was performed according to sex, controlling for clinical characteristics and transfusion arm.

RESULTS

A total of 134 women and 546 men were analyzed. In multivariable analysis, there was no difference in mortality at 24 hours (hazard ratio for women 0.64, 95% confidence interval 0.34-1.23, P = .18) or in time to hemostasis (hazard ratio 1.10, 95% confidence interval 0.84-1.42, P = .49) by sex. We observed no difference between sexes in volume of blood products transfused during active hemorrhage. However, after anatomic hemostasis, women received lower volumes of all products, with a 38% reduction in fresh frozen plasma (mean ratio 0.62 (95% confidence interval 0.43-0.89, P = .01), 49% reduction in platelets (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01) and 49% reduction in volume of red blood cells (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01).

CONCLUSION

Mortality and time to hemostasis of trauma patients with hemorrhage did not differ by sex. Although there was no difference in transfusion requirement during active hemorrhage, once hemostasis was achieved, women received fewer units of all blood products than men. Further research is required to determine whether women exhibit differences in coagulation during and after severe traumatic hemorrhage.

Sex hormones modulate pathogenic processes in experimental traumatic brain injury

Clinical and animal studies have revealed sex-specific differences in histopathological and neurological outcome after traumatic brain injury (TBI). The impact of perioperative administration of sex steroid inhibitors on TBI is still elusive. Here, we subjected male and female C57Bl/6N mice to the controlled cortical impact (CCI) model of TBI and applied pharmacological inhibitors of steroid hormone synthesis, that is, letrozole (LET, inhibiting estradiol synthesis by aromatase) and finasteride (FIN, inhibiting dihydrotestosterone synthesis by 5α-reductase), respectively, starting 72 h prior CCI, and continuing for a further 48 h after CCI. Initial gene expression analyses showed that androgen (Ar) and estrogen receptors (Esr1) were sex-specifically altered 72 h after CCI. When examining brain lesion size, we found larger lesions in male than in female mice, but did not observe effects of FIN or LET treatment. However, LET treatment exacerbated neurological deficits 24 and 72 h after CCI. On the molecular level, FIN administration reduced calpain-dependent spectrin breakdown products, a proxy of excitotoxicity and disturbed Ca²⁺ homeostasis, specifically in males, whereas LET increased the reactive astrocyte marker glial fibrillary acid protein specifically in females. Examination of neurotrophins (brain-derived neurotrophic factor, neuronal growth factor, NT-3) and their receptors (p75^NTR , TrkA, TrkB, TrkC) revealed CCI-induced down-regulation of TrkB and TrkC protein expression, which was reduced by LET in both sexes. Interestingly, FIN decreased neuronal growth factor mRNA expression and protein levels of its receptor TrkA only in males. Taken together, our data suggest a sex-specific impact on pathogenic processes in the injured brain after TBI. Sex hormones may thus modulate pathogenic processes in experimental TBI.

Effects of Age and Sex on Hospital Readmission in Traumatic Brain Injury

OBJECTIVE

To investigate the effects of age and sex on 30-, 60-, and 90-day hospital readmission after acute hospital discharge for individuals with traumatic brain injury (TBI).

DESIGN

Retrospective cohort study.

SETTING

Acute hospitals and postacute discharge settings.

PARTICIPANTS

Individuals (N=52,877) with Diagnosis Related Group codes of TBI, who were divided into 4 age groups: 18 to 40, 41 to 65, 66 to 75, and ≥76 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

All-cause hospital readmission.

RESULTS

Sex differences in 30-, 60-, and 90-day hospital readmission were found among all age groups (P<.05 for all). The largest sex differences in hospital readmission were in the 2 oldest groups (66-75 and ≥76y). For both sexes, the oldest group (≥76y) had the highest adjusted 90-day readmission risk (eg, 90-d readmission: odds ratio, 2.32 [95% confidence interval, 2.01-2.69] for men; odds ratio, 1.96 [95% confidence interval, 1.59-2.43] for women). Among those readmitted within 90 days, the youngest group (18-40y) had the highest cumulative readmission percentage (35% for both sexes) within the first week of hospital discharge.

CONCLUSIONS

Age and sex were significantly associated with hospital readmission during the first 90 days postdischarge in our TBI sample. Specifically, those aged 66 to 75 or ≥76 years had the highest readmission risk over 90 days for both sexes. The findings suggest that clinicians should consider age and sex in discharge planning and for the entire episode of care for the population with TBI.

Association of Blood Component Ratio With Clinical Outcomes in Patients After Trauma and Massive Transfusion: A Systematic Review

Component ratios that mimic whole blood may produce survival benefit in patients massively transfused after trauma; other outcomes have not been reviewed. The purpose of this review was to systematically analyze studies where clinical outcomes were compared on the basis of the component ratios administered during massive transfusion in adult patients after trauma. PubMed, CINAHL, and MEDLINE (Ovid) were searched for studies published in English between 2007 and 2015, performed at Level I or major trauma centers. Twenty-one studies were included in the analysis. We used an adapted 9-item instrument to assess bias risk. The average bias score for the studies was 2.86 ± 1.39 out of 16, indicating a low bias risk. The most common bias sources were lack of data about primary outcomes and adverse events. Those who received high ratios experienced not only greater survival benefit but also higher rates of multiple-organ failure; all other clinical outcomes findings were equivocal.

The relevance of gender in the care of hip fracture patients

As in many conditions, gender interplays with other social structures of inequality to impact upon women's and men's health and healthcare. This narrative review examines knowledge about sex, gender and hip fracture and suggests ways of highlighting the influence of gender in hip fracture healthcare. These will be considered in relation to two areas. Firstly the multifactorial dimension of hip fractures which identifies ethnicity, marital status, lifestyle, co-morbidities, environment in relation to falls and osteoporosis as important factors influencing the experience of hip fracture. Secondly the importance of acknowledging gender as a key element within research and management of care. Implications for practice are that we need a raised awareness of gender when we assess and care for patients, to ask critical questions about the gender bias in the evidence we use and reflect on how services and care practices may be biased towards gendered assumptions.

Future directions in sex- and Gender-specific Emergency Medicine

The 2014 Academic Emergency Medicine (AEM) consensus conference "Gender-Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes" convened a diverse group of stakeholders to target gaps in emergency medicine (EM) sex- and gender-specific research and identify research priorities. At the close of the conference, the executive committee sought feedback from group leaders and conference attendees about the next critical steps in EM sex- and gender-specific research, goals for their own future research, and anticipated barriers in pursuing this research. This article summarizes this feedback on the future directions in sex- and gender-specific research in emergency care and strategies to overcome barriers.

Gender-specific research on mental illness in the emergency department: current knowledge and future directions

Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness' epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.