Predictors of mortality after craniotomy for geriatric traumatic brain injury.

BACKGROUND: With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy. METHODS: We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08. RESULTS: We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all). CONCLUSIONS: Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome. LEVEL OF EVIDENCE: Level III retrospective study.

Shock Index is a Stronger Predictor of Outcomes in Older Compared to Younger Patients.

INTRODUCTION: The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults. METHODS: We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy). RESULTS: A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both). CONCLUSIONS: These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.

Is there a need for fresh frozen plasma and platelet transfusion in trauma patients receiving submassive transfusion?

Background: Blood transfusions have become a vital intervention in trauma care. There are limited data on the safety and effectiveness of submassive transfusion (SMT), that is defined as receiving less than 10 units packed red blood cells (PRBCs) in the first 24 hours. This study aimed to evaluate the efficacy and safety of fresh frozen plasma (FFP) and platelet transfusions in patients undergoing SMT. Methods: This is a retrospective cohort, reviewing the Trauma Quality Improvement Program database spanning 3 years (2016 to 2018). Adult patients aged 18 years and older who had received at least 1 unit of PRBC within 24 hours were included in the study. We used a multivariate regression model to analyze the cut-off units of combined resuscitation (CR) (which included PRBCs along with at least one unit of FFP and/or platelets) that leads to survival improvement. Patients were then stratified into two groups: those who received PRBC alone and those who received CR. Propensity score matching was performed in a 1:1 ratio. Results: The study included 85 234 patients. Based on the multivariate regression model, transfusion of more than 3 units of PRBC with at least 1 unit of FFP and/or platelets demonstrated improved mortality compared with PRBC alone. Among 66 319 patients requiring SMT and >3 units of PRBCs, 25 978 received PRBC alone, and 40 341 received CR. After propensity matching, 4215 patients were included in each group. Patients administered CR had a lower rate of complications (15% vs 26%), acute respiratory distress syndrome (3% vs 5%) and acute kidney injury (8% vs 11%). Rates of sepsis and venous thromboembolism were similar between the two groups. Multivariate regression analysis indicated that patients receiving 4 to 7 units of PRBC alone had significantly higher ORs for mortality than those receiving CR. Conclusion: Trauma patients requiring more than 3 units of PRBCs who received CR with FFP and platelets experienced improved survival and reduced complications. Level of evidence: Level III retrospective study.

Extracellular vesicles and their therapeutic applications: a review article (part1).

Extracellular vesicles (EVs) have emerged as a captivating field of study in molecular biology with diverse applications in therapeutics. These small membrane-bound structures, released by cells into the extracellular space, play a vital role in intercellular communication and hold immense potential for advancing medical treatments. EVs, including exosomes, microvesicles, and apoptotic bodies, are classified based on size and biogenesis pathways, with exosomes being the most extensively studied. The aim of this study was to examine the molecular secretory pathway of exosomes and to discuss the medical applications of exosomes and the methods for employing them in laboratory models. The therapeutic potential of EVs has garnered significant attention. Their unique properties, such as stability, biocompatibility, and capacity to traverse biological barriers, make them promising vehicles for targeted drug delivery. By engineering EVs to carry specific cargo molecules, such as therapeutic proteins, small interfering Ribonucleic Acid (RNAs) (siRNAs), or anti-cancer drugs, researchers can enhance drug stability and improve their targeted delivery to specific cells or tissues. This approach has the potential to minimize off-target effects and increase therapeutic efficacy, offering a more precise and effective treatment strategy. EVs represent a captivating and rapidly evolving field with significant therapeutic implications. Their role in intercellular communication, targeted drug delivery, and regenerative medicine makes them valuable tools for advancing medical treatments. As our understanding of EV biology and their therapeutic applications continues to expand, we can expect remarkable advancements that will revolutionize the field of medicine and lead to more personalized and effective therapies.

Fragmentation of Care After Geriatric Trauma: A Nationwide Analysis of outcomes and Predictors.

The health care system for the elderly is fragmented, that is worsened when readmission occurs to different hospitals. There is limited investigation into the impact of fragmentation on geriatric trauma patient outcomes. The aim of this study was to compare the outcomes following readmissions after geriatric trauma. The Nationwide Readmissions Database (2016-2017) was queried for elderly trauma patients (aged ≥65 years) readmitted due to any cause. Patients were divided into 2 groups according to readmission: index vs non-index hospital. Outcomes were 30 and 180-day complications, mortality, and the number of subsequent readmissions. Multivariable logistic regression was performed to analyze the independent predictors of fragmentation of care. A total of 36,176 trauma patients were readmitted, of which 3856 elderly patients (aged ≥65 years) were readmitted: index hospital (3420; 89%) vs non-index hospital (436; 11%). Following 1:2 propensity matching, elderly with non-index hospital readmission had higher rates of death and MI within 180 days (P = .01 and .02, respectively). They had statistically higher 30 and 180-day pneumonia (P < .01), CHF (P < .01), arrhythmias (P < .01), MI (P < .01), sepsis (P < .01), and UTI (P < .01). On multivariable binary logistic regression analysis, pneumonia (OR 1.70, P = .03), congestive heart failure (CHF) (OR 1.80, P = .03), female gender (OR .72, P = .04), and severe Head and Neck trauma (AIS≥3) (OR 1.50, P < .01) on index admission were independent predictors of fragmentation of care. While the increase in time to readmission (OR 1.01, P < .01) was also associated independently with non-index hospital admission. Fragmented care after geriatric trauma could be associated with higher mortality and complications.

Comparison of High Uterosacral and Sacrospinous Ligament Suspension Surgeries for the Treatment of Pelvic Organ Prolapse in Women.

Background: Pelvic floor disorders include urinary incontinence, fecal incontinence, and pelvic floor prolapse, which are common complaints in women. Patients that suffer from uterine prolapse could benefit from surgical procedures that stabilize pelvic ligaments. Here, we aimed to compare the high uterosacral and sacrospinous ligament suspension surgeries. Materials and Methods: This clinical trial was performed in 2019-2021 on 64 women with uterine prolapse. Demographic data of the patients, including age, body mass index (BMI), past medical diseases, history of delivery, type of delivery, and duration of hospitalization, were collected. We assessed their urinary symptoms, prolapse degree, and sexual symptoms using the Female Sexual Function Index (FSFI) and Pelvic Floor Disability Index (PFDI-20) questionnaires before surgical interventions. Patients were divided into two groups undergoing high uterosacral and sacrospinous ligament suspension. They were followed up 6 and 12 months after surgeries. Results: Patients treated with sacrospinous ligament suspension had higher frequencies of surgical complications (P = 0.039), and the most common complication was low back pain (15.6%). The uterine prolapse andC point degree improved significantly in all cases after 6 and 12 months (P < 0.001). The Pelvic Organ Prolapse Quantifications System (POP-Q) scores improved significantly in both groups 6 and 12 months after surgery (P < 0.001), and patients who underwent sacrospinous ligament suspension had significantly lower pain intensity compared to the other group (P = 0.003). FSFI scores improved significantly in patients treated in both groups (P < 0.001). Conclusion: Both high uterosacral and sacrospinous ligament suspension techniques significantly improved pain, uterine prolapse, and C point degree.

Comparative study of the consequences of abdominal aortic aneurysm repair surgery using open and endovascular surgical methods.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a life-threatening condition. Open surgery and endovascular repair are the options for treating AAA. This study aimed to compare the frequencies of in-hospital complications and outcomes in two groups of patients who underwent AAA repair surgery using either an open or an endovascular repair method. METHODS: This retrospective study was conducted on the records of 60 patients with AAA undergoing elective surgery repair using endovascular approaches or open surgery at Razi Hospital from 2010 to 2019. Patients' related information, including age, sex, changes in blood pressure, respiratory complications, renal complications, myocardial infarction, paraplegia, cloneischemia, lower limb ischemia, duration of hospital stay in intensive care unit and hospital, the dose of packed RBC, the dose of injectable narcotic analgesics, the need for vasopressor medication, duration of surgery, duration of postoperative oral feeding, and death during hospitalization were assessed. RESULTS: A total of 60 patients in two groups were studied. The mean age of patients was 72.4 ± 6.28 years, and most were male (86.7%). The incidence of renal complications (3.3%) and respiratory complications (0%), rate of decrease in arterial blood oxygen saturation, length of stay in ICU (median 2 vs. 4) and hospital (median 4.5 vs. 7), the need for vasopressor injection and the dose of packed RBC (median 0.4 vs. 3.33), the dose of narcotic analgesic injection (53.3%), duration of surgery (median 2.5 vs. 3), duration of postoperative oral feeding (median 23 vs. 54), and the incidence of death were significantly lower in the endoscopic surgery group. CONCLUSION: Endovascular surgery repairing the rupture of an AAA is associated with fewer postoperative complications and in-hospital death than open surgery.

Investigation of clinical findings and CT scan in children with minor head trauma.

BACKGROUND: The most common cause of death or severe impairment in children older than one-year-old is traumatic brain injury (TBI). Assessing TBI in children with minor head trauma (MHT) using clinical findings from history-taking and a physical exam is crucial to minimizing unnecessary brain CTs and more accurately predicting TBI. We aimed to evaluate the findings of brain CT scans in children with mild head trauma and their relationship with clinical signs and symptoms to avoid unnecessary interventions in many children with MHT. METHODS: This cross-sectional-analytical study was performed to evaluate the findings of brain CT scans in children with MHT and their relationship with clinical signs and symptoms that were referred to Poursina Hospital in Rasht in the first half of 2021. Children were divided into two age groups: under two years and 2-12 years, and analyzed separately. Initially, a list containing all demographic information, patients' clinical signs, and symptoms were prepared. The collected data were then analyzed using SPSS software version 26. RESULTS: According to the results, the mean age of patients was 66.01 months and 88 were boys (56.4%). The most common mechanism of injury was falling from a height. Most patients had isolated head injuries. Among the accompanying injuries, facial injuries were the most common. Among the clinical factors studied, cranial fracture on CT scan and GCS less than 15 were significantly associated with the occurrence of traumatic brain injury on CT scan. In addition, cranial fracture on CT scan, injury severity, and history of vomiting had the highest positive predictive value, respectively. CONCLUSION: Standard history and clinical examination are sufficient to identify high-risk cases of pediatric head injuries. GCS is the most important risk factor for pediatric MHT. Requesting a CT scan is not recommended without these risk factors.

Evaluating the preventive effect of metoclopramide and aminophylline on pain after deep vitrectomy.

BACKGROUND: Deep vitrectomy is one of the most frequently performed ophthalmic procedures. Postoperative pain is a common complaint among patients. Consequently, we investigated whether metoclopramide and aminophylline could decrease pain intensity following deep vitrectomy. METHODS: This double-blinded clinical trial study that was approved by the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.3.217) (Thesis Reg. number: 396217) and registered at the Iranian Registry of Clinical Trials (IRCT) (Reg. number: IRCT20170716035104N5, available at https://www.irct.ir/trial/59146) aimed to evaluate 105 patients who were candidates for deep vitrectomy. They were randomly assigned into three groups: metoclopramide (received 0.1 mg/kg diluted in 10 ml of normal saline), aminophylline (received 4 mg/kg diluted in 10 ml of normal saline), and placebo (received 10 ml of normal saline). Postoperative pain was evaluated in all groups. RESULTS: The postoperative pain levels of the three groups differed significantly from the start of the recovery to 30 minutes, 60 minutes, 2 hours, and 4 hours postoperatively, with metoclopramide and aminophylline groups experiencing less postoperative pain than the placebo group. Moreover, there was a significant difference between the groups regarding patient satisfaction (P<0.05). CONCLUSION: Both metoclopramide and aminophylline significantly reduce postoperative pain after deep vitrectomy, although metoclopramide has a greater effect.

Effects of Levothyroxine on Visual Evoked Potential Impairment Following Local Injections of Lysolecithin into the Rat Optic Chiasm.

BACKGROUND: Multiple sclerosis (MS) is a demyelinating disease of the central nervous system which has no any known definitive treatment. Studies have shown that thyroid hormones (THs) in addition to their roles in the development of the nervous system and the production of myelin have important roles in the adult's brain function. Since the only way to treat MS is the restoration of myelin, the aim of this study was to evaluate the effects of levothyroxine on visual evoked potential (VEP) impairment following local injections of lysolecithin into the rat optic chiasm. METHODS: To induce demyelination, lysolecithin was injected into the optic chiasm of male Wistar rats. VEP recording was used to evaluate demyelination and remyelination before and 10, 17, and 24 days after the lysolecithin injection. The rats received an intraperitoneal injection of levothyroxine with doses 20, 50, and 100 µg/kg in different experimental groups. RESULTS: VEP latency and amplitude showed demyelination at 10 and 17 days after an induced lesion in MS group which was reversed at day 24. Levothyroxine prevented these impairments, especially in high doses. CONCLUSIONS: According to the results, lysolecithin-induced demyelination at optic chiasm and VEP impairments can be restored by administration of levothyroxine. Therefore, THs probably have positive effects in demyelinating diseases.