ISS Score Research Articles

The Role of Leu-Enkephalin Synthetic Analogue in Regulation of Systemic Inflammatory Response and Prevention of ARDS in Severe Combined Injury

The aim of the study. To study the effect of ley-enkephalin synthetic analogue on the dynamics of inflammatory response markers and organ dysfunction in patients with severe combined trauma.Materials and methods. A prospective clinical study with historical control from two clinical centers — N. I. Pirogov State Clinical Hospital No. 1 and N.V. Sklifosovsky Clinical and Research Institute for Emergency Medicine — included men and women with severe combined trauma and the ISS scores values of 18–44, aged 18 to 70 years. Diagnostic and therapeutic approaches in all patients followed current international, national& local protocols and 2022 clinical recommendations of the Russian Society of Surgeons «Combined and multiple trauma in combination with shock (Polytrauma)». In the study group, treatment was supplemented with extended (72 hours from the admission) infusion of the test drug through a syringe dispenser following the study protocol. Effects of the test drug prolonged infusion were evaluated for the following laboratory parameters: levels of cortisol, procalcitonin, interleukin 6, NTproBNP and leukocyte count. Laboratory tests were performed at 4 time points: prior to test drug infusion, 24 hours and 72 hours after initiation of infusion, and on Day 7. The study evaluated patient’s dynamics using APACHE II, SOFA and SAPS II scales and percentage of patients developing organ dysfunction (renal, respiratory, cardiovascular), rates of sepsis complications and mortality.Results. Patients who received the test drug had significantly lower concentrations of systemic inflammatory response markers, i. e. PCT (P=0.001) and IL-6 (P=0.010) after 24 hours of follow-up vs the control group patients. The incidence of ARDS has also decreased in the study group (P=0.011 vs control). Acute kidney injury (AKI) rate was insignificantly higher in the control group (P=0.349). The duration of hospital stay in the control group was 35 (17; 51) days vs 18 (14; 30) days in the study group (P=0.140)Conclusion. The use of ley-enkephalin synthetic analogue inhibits production of such key systemic inflammatory response markers as PCT and IL-6, and reduces PCT concentrations within 24 hours in patients with severe combined trauma. ARDS developed less frequently in the study group, but there was no significant difference in the incidence of AKI, AHF and infectious complications between the groups.

Overview of Pelvic Ring Fracture Patients: Observational Study in the Emergency Department at Dr. Kariadi General Hospital, Semarang, Indonesia

Background: Although the incidence of pelvic fractures is only 7% of all trauma, the mortality reaches 21.5%. Management of pelvic fractures remains a challenge because it is often a polytrauma that requires multidisciplinary management and large resources. Knowledge of the characteristics of patients with pelvic fractures is expected to help in management and reduce mortality. Methods: This observational study was conducted retrospectively with a population and sample of all pelvic fracture patients in the emergency room at Dr. Kariadi Hospital Semarang for the period January 2021 to December 2023. The characteristics observed included gender, age, fracture classification, etiology, trauma score, fracture pattern, and management. and output. The data obtained is then presented descriptively. Results: A total of 34 patients with pelvic fractures were recorded in this study. There were 16 male patients and 18 female patients. A total of 3 patients were less than 17 years old, 19 patients were 17-34 years old, 7 patients were 35-52 years old and 3 patients were more than 52 years old. The most common cause of pelvic fractures was traffic accidents (KLL) with 28 patients, followed by work accidents (4 patients) and other trauma (2 patients). Based on the Young-Burgess classification, the most common pelvic fracture pattern was LC1 (11 patients), followed by APC1 (3 patients), APC2 (4 patients), APC3 (3 patients), LC2 (2 patients), LC3 (6 patients), VS (4 patients), and CM (1 patient). A total of 4 patients had an ISS score of 1-8, 8 patients had an ISS score of 9-15, 9 patients had an ISS score of 16-25, and 13 patients had an ISS score of more than 25. The most common accompanying injury was long bone fracture (15 patients), head injury in 10 patients, abdominal trauma in 9 patients, and thorax trauma in 4 patients. Operative treatment was carried out in 21 patients, while 13 other patients were treated non-operatively. Of the 34 patients, 8 patients died and 26 others were discharged in good condition. Conclusion: Most pelvic fractures occur at the age of 17-34 years and the most common cause is KLL. All pelvic fracture patients had concomitant injuries and the majority of patients had unstable fractures that required operative treatment. Mortality due to pelvic fracture and/or accompanying injuries is 23.5%.

Scapular fractures: A regional and rural perspective.

Scapular fractures (SFs) have historically been associated with severe trauma and multiple injuries. Recent studies have demonstrated improved outcomes. However, SFs have never been studied from a strictly rural or Australian perspective. The study's objective was to assess whether associations still exist between a fractured scapula and trauma scores, mortality rates, and other commonly associated injuries in a regional Australian trauma centre. The study design examined prospectively collected data from a regional hospital between the years 2012 to 2021 presenting to the emergency department with traumatic SFs. Primary outcomes of interest were mortality rate, method of injury, ISS scores, and associated injuries. One hundred and five patients had a SF. The median age was 49 with 93 (89%) being male. Most fractures were located in the body of the scapula (80%). The primary mechanism of injury was motorbike accidents (36%), falls (24%), and motor vehicle accidents (22%). Two patients died from their injuries (1.9%). Thirty-four percent demonstrated mild trauma scores, with 36% moderate, 28% severe, and 1.9% critical. Commonly observed associated injuries included chest wall fractures, vertebral fractures, thoracic injuries, brain injury, and abdominal trauma. A minority of SFs were associated with severe or critical trauma, and overall, patients who sustained a SF had a low mortality rate. These findings suggest that patients from regional areas have similar outcomes to those from more urban centres in other parts of the world. Given these results, a re-examination of whether SFs are a reliable marker of severe trauma should be considered.

The paediatric polytrauma CT-indication (PePCI)-score–Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients

BackgroundWhole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients. MethodsA retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients’ symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model. ResultsMultiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores. ConclusionWith the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.

Predicting outcomes in trauma patients by using reverse shock index multiplied by Glasgow coma scores (rSIG): A retrospective cross-sectional study

Introduction: This study aimed to determine the predictive value of the reverse shock index (rSI) using the Glasgow Coma Score (GCS) to predict the outcome of traumatic patients. Methods: This study included all patients with a traumatic injury aged≥18 years with ISS score≥16 and head Abbreviated Injury Scale (AIS)≥2 admitted to the Imam Reza hospital of Tabriz, Iran from 1 March, 2021 to 1 July, 2021. After excluding the patients with incomplete data, 216 patients were enrolled. In this study, the rSIG is the product of rSI multiplied by the GCS score. The patients’ symptoms were recorded routinely in the summary section of all patients’ records using the studied indexes. Data collection was performed using the researcher-made forms. The SPSS software v.21 was used to analyze the data. A P-value<0.05 was considered as statistically significant. Results: The results of data analysis demonstrated that the regression model by two predicting variables of rSI and rSIG was statistically significant. Also, the model can distinguish between the patients who died and those who were discharged. In addition, the Hosmer-Lemeshow test confirmed the model’s advantage and its accuracy (χ2=14.12, df=8, P>0.05). Conclusion: So, the predictive value of rSI with GCS in predicting the outcome of traumatic patients was high.

Характеристика множественной и сочетанной офтальмотравмы у детей на современном этапе

Aim: to identify the medical and epidemiological hallmarks of eye damage in children with complex and multiple injuries in a specialized surgical department. Patients and Methods: this study included 403 children aged 1 month to 18 years with eye injuries associated with multiple or complex injuries of varying severity on the day before hospital admission. All children were admitted between 2014 and 2020. The following data were evaluated: patient's age, gender, severity of complex trauma based on the ISS score, cause of trauma, combination of anatomical areas involved. Results: among children with mechanical complex eye injuries, 255 (63%) were boys and 148 (37%) were girls. The mean age of boys was 10.2±0.34 years, and the mean age of girls was 8.5±0.42 years. Furthermore, more than half (67.5%) of those included in the study were school-aged children and adolescents. The most common types of injuries were those resulting from falls from height, school, sports, gunshot/mine blast, and street incidents. In more than half of the children (n=227, 56.4%), orbital traumas affecting the walls and/or content were reported. The most common type of eye damage was a complex damage to the orbit and ocular adnexa (most often as a periorbital hematoma). The percentage of children with multiple fractures of the orbital walls increases with an increase in the severity of polytrauma. Conclusions: children most often received mechanical complex eye injuries as a result of road traffic accidents. The percentage of children with minor, moderate, and severe complex injuries (assessed by the ISS) was 47.1%, 18.4%, and 33.5%, respectively. Orbital fractures are the most common surgical entities in children with complex mechanical eye injuries. Unilateral orbital fractures were diagnosed in 56.4% of cases, while bilateral orbital fractures were diagnosed in 17.9%. In the majority of instances, mechanical complex eye injuries are associated with traumatic brain injury (99%). KEYWORDS: complex eye injuries, multiple injury, combined injury, mechanical complex eye injury, orbital fracture, orbital injury, morbidity pattern, damage to eye. FOR CITATION: Arzhimatova G.Sh., Karaseva O.V., Koroleva E.A., Chernakova G.M. Multiple and complex eye injuries in children. Russian Journal of Clinical Ophthalmology. 2024;24(2):78–82 (in Russ.). DOI: 10.32364/2311-7729-2024-24-2-6.

Real World Evidence- the Proportion of Myeloma Patients' Death Due to Early Progression

Introduction: Real-world (RW) studies provide valuable insights and complimentary data that may not be covered by clinical trials. In general, RW studies customarily collect data retrospectively, but it is important to have prospective RW studies that can contribute in a better way to reduce possible bias and qualify information. Besides that, RW data fully represent patients followed in a routine practice and can better evidence the treatment accessibility impact. Here we analyzed data on patients in the Brazilian Multiple Myeloma Study Group (GBRAM) database platform who have since deceased. Methods: Patients diagnosed with MM after January 1, 2018 have been included prospectively. The eligibility criteria were: intent-to-treat (ITT) MM patients, aged over 18 years and under care in any healthcare system (private and public). The present study describes the decease data of the patients (pts) included to date. Analysis was performed with the JAMOVI project software v2.3. Results: A total of 1,992 pts were included, 1,570 (78.8%) of whom were treated in the public sector (PuS) and 422 (21.2%) in the non-public sector (NPuS). The median age of the total population at diagnosis was 63.6 (25 - 96) and 1,024 (51.4%) patients were male. A total of 452 (22.7%) deaths, of whom 354 (78.3%) and 98 (21.7%) came from the PuS and NPuS, respectively, were registered. Of these obits, 192 (42.4%) occurred in the first year, 122 (27%) during the second year and 138 (29.6%) over two years or more from diagnosis. Death was related to progression in 68 (35.5%), 54 (44%) and 78 (56.5%) pts in the first year, second and over the second year from diagnosis, respectively. The median age of those who died was 66.2 (33 - 96) and 240 (53.1%) pts were male. The ECOG performance was 0 for 56 (12.4%), 1 for 103 (22.8%), 2 for 53 (11.7%) and 3/4 for 122 (27%) patients. When the ECOG was evaluated by pt origin, it was 3/4 for 16% and 30% of NPuS and PuS, respectively. The ISS was 3 for 232 (51.3%) of the pts and it represents 39% and 55% of the NPuS and PuS pts, respectively. The MM IgG isotype represents 221 (48.9%) pts. Regarding the eligibility criteria for the ASCT for the deceased population, 220 (48.7%) and 216 (47.8%) were eligible and ineligible, respectively. Of the 452 deceased pts, two hundred and one patients (44.5%) died because of progression, the majority 174 (86.6%) being from the PuS ( p < 0.01). D iscussion: This prospective study shows RW data regarding deaths which occurred in a multiple myeloma Brazilian group series. The PuS pts had a worse performance than those in the NPuS and represent 75% of the cases. It became evident that the PuS had higher ECOG and ISS scores and the main cause of death was progression in the PuS. Conclusion: This study demonstrates the high discrepancy between PuS and NPuS regarding the risk of death due to progression. The treatment accessibility could impact on that and public health policies need an emergency review to allow for an egalitarian system.

Adolescents and Young Adults with Multiple Myeloma, Kuwait Experience

Background Multiple myeloma MM is an incurable plasma cell malignancy with a median age of 65 years at diagnosis worldwide, a small number of publications were focused on young adult Multiple myeloma MM with special characteristics and clinical outcomes. Objectives To evaluate the incidence of MM among adolescent and young adults (AYA) in Kuwait aged 40 and below. Also, to describe the clinical characteristics, high risk features and treatment outcomes at the Kuwait Cancer Control Centre (KCCC). Materials & Methods We collected data retrospectively from the hematological malignancy registry at KCCC and looked at AYA patients (pts) with a confirmed diagnosis of Multiple myeloma at our center from 2015 till 2022, we looked at age of onset, gender, nationality, year of myeloma diagnosis, presence of extramedullary disease, International Staging System score (ISS score), cytogenetic aberrations, induction therapy, receipts of auto-transplant and maintenance therapy. Results From 2015 till 2022, 340 patients were diagnosed with MM in Kuwait, eleven patients were found 40 years old or younger, only one was female patients, the median age was 35 years old, around a third were Kuwaiti, 73% were non-Kuwaiti of middle eastern background, 4 patients were found to have extramedullary disease at diagnosis, with advanced stage ISS III found in 3/9 pts. One patient was found with 1Q gain and the rest of the 10 patients were with negative del17p, t (4,14), t(14,16), gain1q and t(11,14). Of note, interphase FISH cytogenetic is not done with CD138 selection. Six patients were treated with RVD induction (Lenalidomide, Bortizomib, Dexamethasone), two patients treated by CTD (Cyclophosphamide, Thalidomide, Dexamethasone), one pt treated by VCD (Bortizomib,Cyclophosphamide,Dexamethasone), one patient treated by Daratumumab RVD, and one patient treated by VTD. Overall response rate (ORR) was 90.9%, (10/11) responded patients proceeded to HDCT/ASCT and all these patients went on maintenance post-transplant, two patients were lost to follow up while 9 patients still under follow up, median follow up 33 months, one pt had a relapse after transplant. Conclusion MM is an uncommon disease among AYA in Kuwait (3.2%) of all myeloma patients, with favorable durable responses in this group of patients.

Co-Expression of GPRC5D, FcRH5 and BCMA Suggests That Targeting More Than One Cell Surface Marker May be a Viable Strategy in Relapsed/Refractory Multiple Myeloma (RRMM): Biomarker Results from the Phase I Study of Forimtamig, a GPRC5DxCD3 Bispecific Antibody

Background: Forimtamig is a GPRC5DxCD3 T-cell engaging bispecific antibody that induces T-cell mediated multiple myeloma (MM) cell killing and has shown promising clinical activity in a Phase I study (NCT04557150) in patients with RRMM (Carlo-Stella et al. ASH 2022). GPRC5D is known to be overexpressed in MM plasma cells (MMPCs), but little is known about its prevalence in relation to risk status and other identified MM targets like FcRH5 and BCMA. We developed a unique exploratory multiparameter flow cytometry panel to characterize GPRC5D, FcRH5 and BCMA expression on MMPCs (Lelios et al. Cyto 2023). We present data on the prevalence and co-expression of these targets, and their association with baseline patient characteristics and response to forimtamig. Methods: Baseline bone marrow aspirate samples were collected from patients who received intravenous or subcutaneous forimtamig during dose-escalation, and were analyzed with flow cytometry. Target expression was depicted as frequency of positive MMPCs and as receptor density (molecules of equivalent soluble fluorochrome). Patients were grouped by number of prior lines of therapy, ISS score, cytogenetic risk (high risk defined as presence of one or more of the following abnormalities: del(17p), t(4;14), t(14;16), and response to forimtamig (responder [≥PR] or non-responder [<PR]). All patients provided informed consent. Results: At data cut-off (June 15, 2023), 48/163 patients were biomarker evaluable (samples passing pre-defined quality standards and containing ≥100 acquired MMPCs). GPRC5D was detected at baseline in 46/48 (96%) patients, with most MMPCs expressing the target (median 95.6%; min-max: 0-100%). GPRC5D expression was more prevalent on MMPCs than FcRH5 (median 78.6%; min-max: 3.7-100%) and BCMA (median 40.3%; min-max: 0-100%; Figure). Interestingly, GPRC5D receptor density (median 20,612; min-max: 6495-208,072) was 47-100-fold higher and more homogenous than FcRH5 (median 436; min-max: 8-3921) and BCMA (median 206; min-max: 14-6657). Clinical response to forimtamig was not correlated with GPRC5D+ MMPC frequency or GPRC5D receptor density measured by flow cytometry ( Table). Percentages of GPRC5D+, FcRH5+ and BCMA+ MMPCs and receptor densities did not significantly differ between patient groups defined by ISS score, cytogenetic risk and number of prior lines of therapy. Patients previously exposed to BCMA-targeted agents (n=7) tended to have lower BCMA expression levels. GPRC5D and FcRH5 were co-expressed on 75.4% of MMPCs (min-max: 0-100%) followed by MMPCs co-expressing GPRC5D and BCMA (median 31.9%; min-max: 0-100%) or BCMA and FcRH5 (median 25.3%; min- max: 0-94.3%). In the majority of patients, double and triple negative MMPCs were rarely observed (0.5-6% of MMPCs expressed only one or none of the three targets across all analyzed patients). Conclusions: GPRC5D, FcRH5 and BCMA are highly prevalent across MM patient subgroups, including high-risk patients who may warrant targeted therapy approaches. Based on our data and previously published work for FcRH5- and BCMA-targeted T-cell bispecifics (Sumiyoshi et al. EHA 2021; Cortes-Selva et al. ASH 2022), target expression on MMPCs, as measured by flow cytometry, has not been associated with clinical response to the corresponding CD3 bispecifics, likely due to the high efficacy of T-cell mediated tumor cell killing. Co-expression of MM targets suggests that targeting more than one MM surface marker may result in double/triple hits on individual tumor cells. Our data support further testing of dual/triple MMPC targeting as a promising concept to promote fast and deep tumor clearance, and to achieve durable responses, while potentially avoiding clonal selection, in patients with RRMM. Further investigation is needed to understand the relevance of target expression differences measured by flow cytometry compared to other methods like immunohistochemistry, as well as to understand T-cell bispecific resistance mechanisms beyond target expression. Updated data will be presented.

Glomerular hyperfiltration in patients with severe trauma

Background and objectiveAugmented renal clearance or glomerular hyperfiltration (GHF) can significantly affect the clinical outcomes of renally eliminated drugs by promoting subtherapeutic drug exposure. The aggression suffered in patients who suffer severe trauma is a predisposition to manifest GHF and the identification of these patients remains a clinical challenge. The main objective of this study was to describe the prevalence of GHF in a cohort of critically ill trauma patients. Materials and methodsProspective observational study of a cohort of adult patients admitted after suffering severe trauma or polytrauma in the Anesthesiology ICU of the University Hospital of Albacete (Spain). Creatinine clearance (ClCr) was calculated in a 4-h urine collection sample at 24, 72 and 168 h after admission applying the formula; CrCl: [Diuresis in ml (urine/4 h) × Creatinine in urine (mg/dl)] ÷ [240 (minutes) × Creatinine in plasma (mg/dl)]. A CrCl above 130 mL/min was considered GHF. The analyses were performed with the statistical software R version 4.0.4. Results85 patients were included. The median age of the patients was 51 years (IQR 26), 78.82% male. 68 patients were male (78.82%). 75.29% of the patients were polytraumatized. 61 patients (71.76%) presented GHF at some point in the CrCl determination. At 24 h of admission, 56.34% of the patients presented GHF with a mean CrCl of 195.8 ml/min, 61.11% of the patients presented it at 72 h with a mean CrCl of /min and 56.52% presented GHF at 168 h of admission with a mean CrCl of 207 ml/min. A significant positive relationship (p = 0.07) was found between GHF manifested at 72 h and at 168 h. We observed a statistically significant relationship between this phenomenon with younger ages, lower ISS scores and lower plasma creatinines. ConclusionsGHF are a common condition in critically ill patients admitted for severe trauma. We recommend the use of CrCl to assess renal function and make dosage adjustments. Studies are required to understand the clinical impact of these phenomena on drug elimination and to be able to establish the ideal dosage in those cases.

Internalized social stigma and its determinants among drug-sensitive tuberculosis patients in Armenia

Abstract Background Internalized social stigma (ISS) is still an issue among tuberculosis (TB) patients, exacerbating their suffering and affecting their treatment compliance. Quantitative studies of TB-related ISS are scarce. This study sought to measure ISS and identify its predictors among primary drug-sensitive TB patients in Armenia. Methods All patients throughout Armenia diagnosed with drug-sensitive TB from Apr, 2019 through Feb, 2021 were targeted for baseline and follow-up interviews at the start of their TB treatment and shortly after completing it, respectively. The instrument included domains on patient's social support, TB knowledge, health, and stigma. ISS was measured via a 10-item scale previously used in Armenia, with the total score ranging from 10 to 50. Fitted linear regression models identified predictors of ISS at each assessment. Results Overall, 401 patients were interviewed at the baseline and 285 at the follow-up. Between the assessments, patient's ISS score decreased from 27.4 to 23.8 (p < 0.01). Factors related to higher stigma at the baseline included age (B = 0.13, p < 0.01), rural residence (B = 1.56, p < 0.05), depression (B = 2.46, p < 0.01), frequent alcohol use (B = 2.67, p < 0.01), and higher stigma in the family (B = 0.55, p < 0.01), while socioeconomic status score was protective against ISS (B = (-0.74), p < 0.01). The fitted model explained 33.4% of the ISS score variance. Age and depression were related to higher ISS score at the follow-up as well, while quality of life score (B = (-5.27), p < 0.01), family support score (B = (-0.53), p < 0.01), and receiving psychological counseling/education (B = (-2.04), p < 0.05) were protective against ISS. Conclusions This study found rather high levels of ISS both at the time of TB diagnosis and after the treatment course. It also pointed out several factors that could be targeted to reduce ISS, including educating TB patients and their family members, providing them timely psychological counseling and financial support. Key messages • During TB treatment, ISS decreased significantly. Modifiable factors protective against ISS included more support in the family and family's satisfactory financial status. • After the treatment, ISS score was significantly lower among those patients who received psychological counseling and education on TB at the treatment start compared to those who did not receive it.

Impact of premorbid oral anticoagulant use on survival in patients with traumatic intracranial hemorrhage.

Although oral anticoagulant use has been implicated in worse outcomes for patients with a traumatic brain injury (TBI), prior studies have mostly examined the use of vitamin K antagonists (VKAs). In an era of increasing use of direct oral anticoagulants (DOACs) in lieu of VKAs, the authors compared the survival outcomes of TBI patients on different types of premorbid anticoagulation medications with those of patients not on anticoagulation. The authors retrospectively reviewed the records of 1186 adult patients who presented at a level I trauma center with an intracranial hemorrhage after blunt trauma between 2016 and 2022. Patient demographics; comorbidities; and pre-, peri-, and postinjury characteristics were compared based on premorbid anticoagulation use. Multivariable Cox proportional hazards regression modeling of mortality was performed to adjust for risk factors that met a significance threshold of p < 0.1 on bivariate analysis. Of 1186 patients with a traumatic intracranial hemorrhage, 49 (4.1%) were taking DOACs and 53 (4.5%) used VKAs at the time of injury. Patients using oral anticoagulants were more likely to be older (p < 0.001), to have a higher Charlson Comorbidity Index (p < 0.001), and to present with a higher Glasgow Coma Scale (GCS) score (p < 0.001) and lower Injury Severity Score (ISS; p < 0.001) than those on no anticoagulation. Patients using VKAs were more likely to undergo reversal than patients using DOACs (53% vs 31%, p < 0.001). Cox proportional hazards regression demonstrated significantly increased hazard ratios (HRs) for VKA use (HR 2.204, p = 0.003) and DOAC use (HR 1.973, p = 0.007). Increasing age (HR 1.040, p < 0.001), ISS (HR 1.017, p = 0.01), and Marshall score (HR 1.186, p < 0.001) were associated with an increased risk of death. A higher GCS score on admission was associated with a decreased risk of death (HR 0.912, p < 0.001). Patients with a traumatic intracranial injury who were on oral anticoagulant therapy before injury demonstrated higher mortality rates than patients who were not on oral anticoagulation after adjusting for age, comorbid conditions, and injury presentation.

Psychiatric Consults Associated With Longer Length of Stay in Trauma Patients—A Retrospective Study

IntroductionMental illness is a risk factor for intentional and unintentional injury and is associated with readmission. The impact of psychiatric consults on length of stay (LOS) of trauma patients is still undergoing study. MethodsTrauma registry at Ascension St. Mary's of Saginaw, a community level 2 trauma center, was queried. Further chart review was performed to demographically characterize the control and intervention groups. Univariate and multivariate regression was performed to identify the association between psychiatric consultation and LOS while considering demographic variables and Injury Severity Score. ResultsA total of 661 patients were identified with trauma and a documented mental health disorder. 612 did not receive a psychiatric consultation and 49 did. The group without a psychiatric consultation had a mean and median LOS of 6 d and 4 d, respectively, compared to 12 d and 10 d for those with a psychiatric consult (P < 0.0001). Mean ISS scores comparable across all groups. Delirium was associated with the highest LOS with a mean of 17.25 d and a median of 14.5 d. All 11 patients transferred to a psychiatric facility at discharge received a consult for self-harm. ConclusionsPsychiatric consultations were associated with lengthened stay of trauma patients independent of initial injury severity and documented mental health disorders, and more transfers to inpatient psych facilities. This represents an important prognostic factor for a patient's course of care and suggests that trauma physicians should be well-versed at identifying mental health issues which may require early intervention, as well as managing delirium.

Outcomes of Injured Patients Before and After the Institution of a Third-Tier Activation at a Level 1 Trauma Center.

We hypothesized that the addition of a third-level trauma activation would improve outcomes by formalizing an evaluation process for patients in need of urgent evaluation who did not meet the criteria for full or partial trauma alert activation. Admission records for all trauma patients admitted between 2000 and 2021 were obtained. The gamma alert trauma activation was implemented in 2011. A washout period of 6 months was used to account for adjustment to the new protocol. Propensity score matching was performed based on ISS scores, age, injury mechanism, and best-validated comorbidities to create a balanced patient distribution. Patients with missing data were excluded from this study. The association between era and outcomes was determined using logistic and linear regression analyses. The matched cohort was well balanced (SMD <.1, all balanced covariates) and included 18,572 patients. Patients in the gamma alert era had decreased ED dwell time, hospital length of stay, and intensive care unit (ICU) length of stay. Readmission rates and rates of upgrade to ICU status were reduced in the gamma alert era. This era was also associated with lower rates of renal failure, UTI, and pneumonia. There was no significant difference in mortality following implementation of the gamma alert. Implementation of the gamma alert was associated with an improvement in ED dwell times, fewer unplanned admissions to the ICU, decreased readmissions, and a reduction in other in-hospital events. We believe that this reflects improved triage of patients to the ICU and more effective care of trauma patients.

68 The Diurnal and Seasonal Relationships of Young Pedestrian Injuries Secondary to Motor Vehicles

Abstract Aim There remains a significant morbidity and mortality in young pedestrians hit by motor vehicles. The of this study was to compare the incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. Method Data was retrieved from the National Trauma Audit and Research Network (TARN) database for patients between 10-25 years old who had been involved as pedestrians in motor vehicle accidents between 2013 -2020. The incidence of injuries, their severity (using the Injury Severity Score [ISS]), and mortality were analysed according to the hours of daylight, darkness, and season. Results The study identified a seasonal pattern, highlighting that injuries were most prevalent during autumn (34.9% of injuries). Prevalence decreased throughout the year from winter (25.4%) to summer (18.3%). The greatest incident rate (number of incidents/hour) occurred between 1500-1630hrs, correlating to school pick up times. A significant relationship between ISS and daylight hours was demonstrated (p-value = 0.0124), whereby moderate injuries (ISS score: 9-15) were more likely during the day (72.7%), while severe injuries (ISS Score &amp;gt; 15) were more likely at night (55.8%). Conclusions We identified a relationship between the time of day and the frequency and severity of pedestrian trauma in young people. In addition, particular time groupings correspond to the greatest incidents rate, suggesting that reduced visibility coupled with school pick up times play a significant role. We recommend targeted public health measures to improve road safety that focus on these high-risk times of the day.

1264 The Impact of ‘Rib Block’ Administration on Patients with Multiple Rib Fractures at a Major Trauma Centre: A Retrospective Observational Study

Abstract Aim Rib fractures carry a mortality rate of 10% which is doubled in the elderly population. They are common following blunt thoracic trauma and are a marker of injury severity. The timely delivery of regional analgesia is crucial to prevent pain induced hypoxia, atelectasis, pneumonia and respiratory failure. We compare the trauma-related injuries and outcomes between patients with &amp;gt;2 rib fractures who received regional analgesic blocks with those who didn’t receive blocks. Method Retrospective data was collected from 187 patients presenting as a trauma call with &amp;gt;2 rib fractures over a period of 18 months. Patient demographics, ISS, length of stay and respiratory complications were collected from electronic patient records (EPR). Results 69 patients received a regional rib block compared with 118 who did not. Patients who had a rib block were older compared to those who did not have a block (62.1±17.6 vs 55.4±18.2, p = 0.007). There was no significant difference in number of rib fractures (6.8±3.2, p&amp;lt;0.2), post-admission chest infection rate (23.1±42.5 vs 20.8±40.8, p&amp;lt;0.4), or length of hospital stay (18.7±13.3 vs 21.7±19.1, p&amp;lt;0.2). ISS score was significantly higher in non-blocked patients compared to blocked patients (27.4±14.3 vs 19.5±9.5, p&amp;lt;0.05). Conclusions Patients with significantly higher ISS scores did not receive a regional rib block, however this did not appear to impact on post-admission chest infection rate or length of stay. Further work is needed to identify the reasons behind this trend.

Predictors of Facial Fractures in Trauma Patients: Retrospective Review at a Level I Trauma Center.

The incidence and causes of facial fractures differ between patients, but patterns arise within populations. These patterns vary by gender, age, and between countries. This study aims to determine variables to identify patients at risk for facial fractures in a United States trauma population. This is a single-center study of Trauma Registry data, inclusive of years July 1, 2016, to January 31, 2022. Inclusion criteria were based upon all trauma patients. Confirmation of a non-isolated facial fracture (dependent variable) was verified using ICD10 diagnosis codes. A logistic regression was performed in SPSS to ascertain the effects of predictor variables on the likelihood that a trauma patient will experience a facial fracture. 20377 patients were included in the analysis based upon the requirements specified in the methods section; 1575 (7%) had a positive facial fracture. The logistic regression model was statistically significant (N = 18507, P < .01). Significant risk factors for facial fracture identified included helicopter transport (OR = 1.35, P < .01) and increasing injury severity scores (OR = 1.07, P < .01). Modes of injury most likely to predict facial fracture included assault (OR = 6.62, P < .01), moped (OR = 2.02, P < .01), and motorcycle trauma (OR = 1.55, P < .01). The discharge disposition most likely among facial fracture patients included short-term general hospital (OR = 1.71, P < .01) and intermediate care facility (OR = 4.47, P < .01). Patients with traumatic injuries from assault, moped, and motorcycle accidents were more likely to present with facial fractures. These patients had more severe injuries, seen as increased ISS scores, higher likelihood of transport by helicopter, and the need for additional care after discharge.

The efficacy and safety of Bruton tyrosine kinase inhibitors as monotherapy in the treatment of newly diagnosed patients with Waldenström macroglobulinemia

Objective: To investigate the efficacy and safety of Bruton tyrosine kinase inhibitors (BTKi) ibrutinib or zanubrutinib monotherapy in newly diagnosed patients with Waldenström macroglobulinemia (WM) . Methods: The efficacy and adverse effects of 58 patients with newly diagnosed WM receiving BTKi monotherapy in Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were analyzed retrospectively from January 2018 to August 2022. Results: The response of 55 patients may be examined. Forty patients received ibrutinib monotherapy for a median of 15 months, with an overall response rate (ORR) of 85%, a main remission rate (MRR) of 70%, and a very good partial remission (VGPR) rate of 10%. Fifteen patients received zanubrutinib monotherapy for a median of 13 months, with an ORR of 93%, an MRR of 73%, and a VGPR rate of 0%. For various reasons, 10 patients were converted from ibrutinib to zanubrutinib. Ibrutinib treatment lasted an average of 7.5 months before conversion. The median duration of zanubrutinib therapy after conversion was 3.5 months. The ORRs before and after conversion were 90% and 100%, MRRs were 80% and 80%, and VGPR rates were 10% and 50%, respectively. After a median of 16 months, the 24-month progression-free survival (PFS) rate of patients who received both BTKi was 86%. PFS did not differ statistically across individuals with low, medium, and high-risk ISS scores (P=0.998). All of the patients survived. The most common side effects of BTKi were neutropenia and thrombocytopenia, which occurred in 12% and 10% of all patients, respectively. Ibrutinib accounts for 5% of atrial fibrillation, and zanubrutinib has a 7% risk of bleeding. Conclusions: In treating WM, ibrutinib or zanubrutinib provides good efficacy and tolerable adverse effects.

ASSOCIATION OF MULTIPLE TRAUMA REFERRAL DISTANCE WITH MORTALITY IN H. ADAM MALIK GENERAL HOSPITAL MEDAN

Abstract. Introduction: The increasing distance from the location of the trauma to the trauma center can cause an increase in mortality. The farther the distance from the trauma center, the higher the mortality of trauma patients due to motor vehicle accidents. Geographical variations in care may contribute to the effect of the relationship between distance and mortality in trauma patients. This study wanted to determine the relationship between multiple trauma referral distances and mortality based on ISS at Haji Adam Malik General Hospital Medan. Methods: The study design was an analytic study with the independent variable being the patient's referral distance and the dependent variable being the predictor of mortality in multiple trauma. The approach used in this research design is a retrospective approach where the data taken are data that have existed before. Results: The mean age of the patients was 31.08 ± 17.820 years. Most of the patients were male, most died, and the average referral distance was 79.67 ± 63,244 km. The majority of the ISS scores were 16. The relationship between referral distance and death in the hospital has a P value of &lt; 0.05 Conclusion: There is a significant relationship between multiple trauma patients' referral distance and hospital mortality.

High Versus Low Energy Intertrochanteric Hip Fractures in Young Patients: Injury Characteristics and Factors Associated with Complications.

To compare fracture patterns and associated injuries for young patients with high-versus low-energy intertrochanteric hip fractures and to report on factors associated with complications after surgical fixation of high-energy fractures. Retrospective comparative study. Academic Level 1 Trauma Center. A total of 103 patients < 50 years old were included: 80 high-energy fractures and 23 low-energy fractures. Cephalomedullary nailing (CMN) (N=92) or a sliding hip screw (SHS) (N=11). Radiographic characteristics of fracture morphology, implant position, and reduction quality as well as post-operative complications. Compared to young patients with low-energy fractures, those with high-energy fractures had more fracture comminution (p=0.013) and higher ISS scores (p<0.003), and were more likely to require open reduction (p<0.001). Patients with low-energy fractures from a ground level fall had higher rates of alcohol abuse (0.032), cirrhosis (0.010), and chronic steroid use (0.048). Overall reoperation rate for high-energy fractures was 7% including 2 IT fracture nonunions (5%) and 1 deep infection (2%). For high-energy fractures, ASA class (p=0.026), anterior lag screw position (p=0.001), and varus malreduction (p<0.001) were associated with malunion. Four-part fracture (OTA/AO 31A2.3/Jensen 5) (p=0.028) and residual calcar gap >3mm (p=0.03) were associated with reoperation. Surgical treatment of high-energy IT fractures in young patients is technically demanding with potential untoward outcomes. Injury characteristics and severity are significantly different for young patients with high-energy IT fractures compared to low-energy fractures. For young patients with a high-energy IT fracture, surgeons can anticipate a high rate of associated injuries and complex fracture patterns requiring open reduction. For young patients with a low-energy IT fracture, co-management with a hospitalist or geriatrician should be considered since they may be physiologically older.