Medline ® Abstracts for References 10-18

Twenty-six per cent of adults in the Unites States are obese and trauma remains a major cause of death. We assessed the impact of morbid obesity on mortality in patients with blunt trauma. We reviewed the records of patients with a body mass index 40 kg/m2 or greater injured by blunt trauma from 1993 to 2003 and compared them with a 4:1 control population with a normal body mass index and matched for sex and constellation of injuries. For comparison, patients were categorized by Injury Severity Score 9 or less or Injury Severity Score 10 or greater. Student t test and chi2 were used for statistical analysis. P<0.05 was considered significant. One hundred seven morbidly obese patients were identified and compared with 458 control subjects with a normal body mass index and matched for sex and constellation of injuries. Although the morbidly obese patients were found to be significantly younger, those who incurred multiorgan injury experienced a significantly longer hospital length of stay and displayed a greater than fourfold increase in mortality when compared with the control subjects. Furthermore, the number of morbidly obese patients admitted over the 10-year period significantly increased by fourfold (0.4% to 1.5%). Over the last decade, there has been a significant increase in morbidly obese patients cared for in our trauma center. Although these patients were significantly younger with a similar Glasgow Coma Score as that of the control population, morbid obesity significantly increased mortality when the injury from blunt trauma transitioned from a single to a multiorgan injury.

BACKGROUND: Increasing age and significant pre-existing medical conditions (PMCs) are independent risk factors associated with increased mortality after trauma. Our aim was to review all trauma deaths, identifying the cause and the relation to time from injury, ISS, age and PMCs.

METHODS: A retrospective analysis of trauma deaths over a 6-year period at the study centre was conducted. Information was obtained from the Trauma Audit and Research Network (TARN) dataset, hospital records, death certificates and post-mortem reports. The time and cause of death, ISS, PMCs were analysed for two age groups (<65 years and>or= 65 years).

RESULTS: Patients>or= 65 years old were at an increased risk of death (OR 6.4, 95% CI 5.2-7.8, p<0.001). Thirty-two patients with an ISS of>15 and died within the first 24 hours of admission, irrespective of age, from causes directly related to their injuries. Twelve patients with an ISS of<16, died after 13 days of medical conditions not directly related to their injuries (p = 0.01). Thirty four patients had significant PMCs, of which 11 were<65 years (34.4% of that age group) and 23 were>or= 65 years (95.8% of that age group) (p = 0.02). The risk of dying late after sustaining minor trauma (ISS<16) is increased if a PMC exists (OR 5.5, p = 0.004).

CONCLUSION: Elderly patients with minor injuries and PMCs have an increased risk of death relative to their younger counterparts and are more likely to die of medical complications late in their hospital admission.

BACKGROUND: Elderly patients suffer higher mortality rates after trauma than younger patients. This increased mortality is attributable to age, preexisting disease, and complications as well as injury severity.

METHODS: Records from 5,139 adult patients from a Level I trauma center were retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score (RTS), early mortality (<24 hours), and late mortality (>24 hours) were determined for elderly (>or =65 years) and younger (16-64 years) patients. Preexisting diseases and complications were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis coding.

RESULTS: Mortality in elderly patients was twice that in younger patients despite equivalent injury severity (p<0.001), and elderly patients were more likely to suffer later death than younger patients (p<0.005). The prevalence of preexisting disease was greater in the elderly, as was the incidence of complications. Using logistic regression, ISS, RTS, preexisting cardiovascular or liver disease, the development of cardiac, renal, or infectious complications, and geriatric statuswere all independently predictive of late mortality (p<0.05).

CONCLUSION: Elderly trauma patients more frequently suffer late mortality than younger patients because of the combination of injury and increased preexisting disease and complications after injury. Aggressive treatment of the elderly trauma patient is warranted; however, in the face of significant preexisting disease or complications, survival is less likely. Predictive models of survival can be developed, taking into account preexisting disease and complications as well as admission parameters such as age, ISS, and RTS, and specific risk of mortality quantitated.

BACKGROUND: This study was designed to show the importance of age, presence of premorbid conditions, and the type of injury on time and location of adult inhospital trauma mortality.

METHODS: All acute blunt trauma deaths at a Level I urban trauma center between April 1, 1993 and March 31, 2003 were individually reviewed to collect data on the following variables: age, gender, presence and number of premorbid conditions, mechanisms of trauma, location of death, acute transfer from another hospital, delay to death, initial Glasgow Coma Score (GCS), Abbreviated Injury Score (AIS), Injury Severity Score (ISS), and revised trauma score (RTS). Bivariate analysis using simple logistic regression was used to show the association between each variable and delay to death. Variables significantly associated with death underwent multivariate analysis to yield adjusted odds ratios (aORs) with 95% confidence interval (CI).

RESULTS: During the study period there were 463 blunt trauma deaths (6.8%). Their mean age was 67.5 years, mean ISS was 22.6, mean GCS was 11.0, and 55.3% were male. Most deaths occurred in either the intensive care unit (45.8%) or the ward (46.4%); there werefew deaths in the emergency department (6.8%) or the operating room (0.4%). The following were significant bivariate predictors for death: presence of premorbid conditions, number of premorbid conditions, age>60, pulmonary diseases, cardiac diseases, diabetes mellitus, neurologic diseases, GCS, AIS>or =4, and ISS. Multivariate analysis demonstrated the following significant findings: patients with severe thoracic injuries were significantly more likely to die in the first 6 hours (aOR = 1.37; CI = 1.12-1.68; p = 0.002); and patients with severe head injuries were more likely to die after 48 hours (aOR = 1.275; CI = 1.158-1.405; p = 0.0001). Older patients and those with neurologic diseases were more likely to die later and in a hospital ward (aOR = 2.18; CI = 1.25-3.81; p = 0.006). Men and women differed as to age, ISS, mechanism of injury, and type of injury, but not as to delay to death.

CONCLUSIONS: Age, body area injured, and presence and type of premorbid conditions are significant predictors of location of and delay to death after blunt trauma. We think that incorporating information on premorbid conditions is essential for mortality analysis in an aging population.

BACKGROUND: The average life expectancy of Japanese individuals is the longest in the world. The mortality rate from injury is increasing among older people. There have been no detailed reports on the relationship between pre-existing medical conditions (PMCs) and mortality from trauma among elderly people in Japan.

STUDY DESIGN: We conducted a retrospective analysis using 20,257 cases recorded in the Japan Trauma Data Bank from 2004 to 2007. The subjects were 11,590 hospital inpatients (57.2%) 16 years of age or older. A logistic regression analysis was conducted for the relation between 23 PMCs and in-hospital mortality.

RESULTS: Overall in-hospital mortality was 10.8%, and for people 75 years of age and older, was 17.7%. The incidence of PMC was 4,752 (41.0%). Patients with PMCs of cirrhosis, active cancer, chronic obstructive pulmonary disease, hematologic disorders, anticoagulation drugs, dementia or mental retardation, or other conditions had higher in-hospital mortality. The existence of a single PMC did not increase mortality, but with 2 or more PMCs, mortality significantly increased. The existence of 2 or more PMCs in the 50- to 74-year-old age group and in the minor injury group strongly affected the odds ratio for mortality.

CONCLUSIONS: The existence of certain PMCs or of 2 or more PMCs increases in-hospital mortality from injury. This effect is particularly conspicuous in middle-aged patients and people with minor injuries, but was not found to be a problem among elderly people. The increased mortality from injury in elderly people in Japan is therefore not affected by the existence of PMCs.

BACKGROUND: One third of US adults are obese. The impact of obesity on outcomes after blunt traumatic injury has been studied with discrepant results. The aim of our study was to evaluate outcomes in morbidly obese patients after blunt trauma. We hypothesized that morbidly obese patients have adverse outcomes as compared with nonobese patients after blunt traumatic injury.

METHODS: We performed a retrospective analysis of all blunt trauma patients (≥18 years) using the National Trauma Data Bank for years 2007 to 2010. Patients with recorded comorbidity of morbid obesity (body mass index≥40) were identified. Patients transferred, dead on arrival, and with isolated traumatic brain injury were excluded. Propensity score matching was used to match morbidly obese patients to non-morbidly obese patients (body mass index<40) in a 1:1 ratio based on age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and systolic blood pressure on presentation. The primary outcome was mortality, and the secondary outcome was hospital complications.

RESULTS: A total of 32,780 patients (morbidly obese, 16,390; nonobese, 16,390) were included in the study. Morbidly obese patients were more likely to have in-hospital complications (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.6-1.9), longer hospital stay (OR, 1.2; 95% CI, 1.1-1.3), and longer intensive care unit stay (OR, 1.15; 95% CI, 1.09-1.2). The overall mortality rate was 2.8% (n = 851). Mortality was higher in morbidly obese patients compared with the nonobese patients (3.0 vs. 2.2; OR, 1.4; 95% CI, 1.1-1.5).

CONCLUSION: In a cohort of matched patients, morbid obesity is a risk factor for the development of in-hospital complications and mortality after blunt traumatic injury. The results of our study call for attention through focused injury prevention efforts. Future studies are needed to help define the consequences of obesity that influence outcomes.

LEVEL OF EVIDENCE: Prognostic study, level III.

BACKGROUND: This study sought to describe variations in the risk of motor vehicle collision (MVC) injury and death by occupant body mass index (BMI) class and vehicle type. We hypothesized that the relationship between BMI and the risk of MVC injury or mortality would be modified by vehicle type.

METHODS: This is a retrospective cohort study of occupants involved in MVCs using data from the Crash Injury Research and Engineering Network and the National Automotive Sampling System Crashworthiness Data System. Occupants were grouped based on vehicle body style (passenger car, sport utility vehicle, or light truck) and vehicle size (compact or normal, corresponding to below- or above-average curb weight). The relationship between occupant BMI class (underweight, normal weight, overweight, or obese) and risk of injury or mortality was examined for each vehicle type. Odds ratios (ORs) adjusted for various occupant and collision characteristics were estimated.

RESULTS: Of an estimated 44 million occupants of MVCs sampled from 2000 to 2009, 37.1% sustained an injury. We limited our analysis to injuries achieving an Abbreviated Injury Scale (AIS) score of 2 or more severe, totaling 17 million injuries. Occupants differed substantially in terms of demographic and collision characteristics. After adjustment for confounding factors, we found that obesity was a risk factor for mortality caused by MVC (OR, 1.6; 95% confidence interval [CI], 1.2-2.0). When stratified by vehicle type, we found that obesity was a risk factor for mortality in larger vehicles, including any-sized light trucks (OR, 2.1; 95% CI, 1.3-3.5), normal-sized passenger cars (OR, 1.6; 95% CI, 1.1-2.3), and normal-sized sports utility vehicles or vans (OR, 2.0; 95% CI, 1.0-3.8). Being overweight was a risk factor in any-sized light trucks (OR, 1.5; 95% CI, 1.1-2.1).

CONCLUSION: We identified a significant interaction between occupant BMI class and vehicle type in terms of MVC-related mortality risk. Both factors should be taken into account when considering occupant safety, and additional study is needed to determine underlying causes of the observed relationships.

LEVEL OF EVIDENCE: Epidemiologic study, level III.

IMPORTANCE: With the dramatic growth in the very old population and their concomitant heightened exposure to traumatic injury, the trauma burden among this patient population is estimated to be exponentially increasing.

OBJECTIVE: To determine the clinical outcomes and predictors of in-hospital and 1-year mortality in nonagenarian and centenarian trauma patients (NCTPs).

DESIGN, SETTING, AND PARTICIPANTS: All patients 90 years or older admitted to a level 1 academic trauma center between January 1, 2006, and December 31, 2010, with a primary diagnosis of trauma were included. Standard trauma registry data variables were supplemented by systematic medical record review. Cumulative mortality rates at 1, 3, 6, and 12 months after discharge were investigated using the Social Security Death Index. Univariate and multivariable analyses were performed to identify the predictors of in-hospital and 1-year postdischarge cumulative mortalities.

MAIN OUTCOMES AND MEASURES: Length of hospital stay, in-hospital mortality, and cumulative mortalities at 1, 3, 6, and 12 months after discharge.

RESULTS: Four hundred seventy-four NCTPs were included; 71.7% were female, and a fall was the predominant mechanism of injury (96.4%). The mean patient age was 93 years, the mean Injury Severity Score was 12, and the mean number of comorbidities per patient was 4.4. The in-hospital mortality was 9.5% but cumulatively escalated at 1, 3, 6, and 12 months after discharge to 18.5%, 26.4%, 31.3%, and 40.5%, respectively. Independent predictors of in-hospital mortality were the Injury Severity Score (odds ratio [OR], 1.09; 95% CI, 1.02-1.16; P = .01), mechanical ventilation (OR, 6.23; 95% CI, 1.42-27.27; P = .02), and cervical spine injury (OR, 4.37; 95% CI, 1.41-13.50; P = .01). Independent predictors of cumulative 1-year mortality were head injury (OR, 2.65; 95% CI, 1.24-5.67; P = .03) and length of hospital stay (OR, 1.06; 95% CI, 1.02-1.11; P = .005). Cumulative 1-year mortality in NCTPs with a head injury was 51.1% and increased to 73.2% if the Injury Severity Score was 25 or higher and to 78.7% if mechanical ventilation was required. Most NCTPs required rehabilitation; only 8.9% were discharged to home.

CONCLUSIONS AND RELEVANCE: Despite low in-hospital mortality, the cumulative mortality rate among NCTPs at 1 year after discharge is significant, particularly in the presence of head injury, spine injury, mechanical ventilation, high injury severity, or prolonged length of hospital stay. These considerations can help guide clinical decisions and family discussions.

OBJECTIVE: This study aims to assess the effect of obesity on injury severity score (ISS), mortality and course of hospital stay among trauma patients.

METHOD: A systematic review of the literature was conducted by Internet search. Data were extracted from included studies and analysed using a random-effects model to compare outcomes in the obese (body mass index (BMI)≥30kgm(-2)) with the non-obese (BMI<30kgm(-2)) group.

RESULT: Eventually, 18 studies met our inclusion criteria with 7751 obese patients representing 17% of the pooled study population. The data revealed that obesity was associated with increased risk of mortality, longer stay in the intensive care unit and higher rates of complication. Additionally, obese patients seemed to have longer duration of mechanical ventilation and hospital length of stay but it did not reach statistical significance. No difference was observed in ISS between the two groups.

CONCLUSION: Evidence strongly supports thecorrelation of obesity with worse prognosis in trauma patients and further studies should target this kind of population for therapy and prevention.