Cherisse Berry

The effect of gender on patients with moderate to severe head injuries.

BACKGROUND Male and female nervous systems respond differently to traumatic brain injury (TBI) and in vivo research relates this difference to neuroprotection from female sex hormones. Attempts to replicate female sex hormone-related neuroprotection in clinical studies have been unsuccessful. The objective of this study was to determine whether gender or menopausal status affects mortality in patients with moderate to severe TBI. METHODS A retrospective review of all patients with isolated moderate to severe TBI was undertaken using data from the National Trauma Database version 6.2 (2000-2005). Isolated TBI was defined as head Abbreviated Injury Score >/=3 in patients without significant extracranial injuries (Abbreviated Injury Score <3 for other anatomic regions). Demographics, Injury Severity Score, and outcomes (mortality, intensive care unit and hospital length of stay, and complications) were compared. The population was stratified into age subgroups: 14 to 45 years (premenopausal), 46 to 55 years (perimenopausal), and older than 55 years (postmenopausal). Logistic regression analysis was used to determine the relationship among female gender, mortality, and development of complications after moderate to severe TBI. RESULTS A total of 72,294 patients with moderate to severe TBI were evaluated. Females showed a significantly lower risk in both mortality (adjusted odds ratios [AOR], 0.82; 95% confidence intervals [CI], 0.77-0.87; p < 0.0001) and in developing any type of complications (AOR, 0.88; 95% CI, 0.84-0.93; p < 0.0001) than the male population after adjusting for differences in patient characteristics. After age stratification, perimenopausal women (46-55 years) and postmenopausal women (older than 55 years) showed a significantly lower risk in mortality (AOR, 0.76; 95% CI, 0.63-0.92; p < 0.0044 and AOR, 0.79; 95% CI, 0.73-0.86; p < 0.0001, respectively). There was no difference in mortality in premenopausal women compared with their male age-matched counterparts (AOR, 1.09; 95% CI, 0.99-1.21; p = 0.0917). CONCLUSIONS Female gender is independently associated with reduced mortality and decreased complications after TBI. As peri- and postmenopausal women demonstrated improved survival, and premenopausal women did not, estrogen unlikely confers neuroprotection in women after TBI. Future TBI treatment may benefit with further research focused on why peri- and postmenopausal women show decreased mortality after TBI.

Redefining hypotension in traumatic brain injury

BACKGROUND Systemic hypotension is a well documented predictor of increased mortality following traumatic brain injury (TBI). Hypotension is traditionally defined as systolic blood pressure (SBP)<90 mmHg. Recent evidence defines hypotension by a higher SBP in injured (non-TBI) trauma patients. We hypothesize that hypotension threshold requires a higher SBP in isolated moderate to severe TBI. PATIENTS AND METHODS A retrospective database review of all adults (≥ 15 years) with isolated moderate to severe TBI (head abbreviated injury score (AIS)≥ 3, all other AIS ≤ 3), admitted from five Level I and eight Level II trauma centres (Los Angeles County), between 1998 and 2005. Several fit statistic analyses were performed for each admission SBP from 60 to 180 mmHg to identify the model that most accurately defined hypotension for three age groups: 15-49 years, 50-69 years, and ≥ 70 years. The main outcome variable was mortality, and the optimal definition of hypotension for each group was determined from the best fit model. Adjusted odds ratios (AOR) were then calculated to determine increased odds in mortality for the defined optimal SBP within each age group. RESULTS A total of 15,733 patients were analysed. The optimal threshold of hypotension according to the best fit model was SBP of 110 mmHg for patients 15-49 years (AOR 1.98, CI 1.65-2.39, p<0.0001), 100 mmHg for patients 50-69 years (AOR 2.20, CI 1.46-3.31, p=0.0002), and 110 mmHg for patients ≥ 70 years (AOR 1.92, CI 1.35-2.74, p=0.0003). CONCLUSIONS Patients with isolated moderate to severe TBI should be considered hypotensive for SBP<110 mmHg. Further research should confirm this new definition of hypotension by correlation with indices of perfusion.

Severe traumatic brain injury: is there a gender difference in mortality?

BACKGROUND Emerging evidence suggests that male and female nervous systems respond differently to traumatic brain injury (TBI). The objective of this study was to examine outcomes between the sexes after TBI. PATIENTS AND METHODS A retrospective review of all severe TBI patients admitted between January and December 2005 was performed. Isolated severe TBI was defined as a head abbreviated injury score greater than 3 with an abbreviated injury score of 3 or less for other anatomic regions. The population was stratified into age subgroups (<14 y, 14-44 y, 45-54 y, and > or =55 y). Logistic regression was used to identify independent predictors of mortality. RESULTS A total of 1,807 TBI patients were admitted. The mortality was significantly higher for women (43.2% vs 36.2%, P < .01) with an adjusted odds ratio of 1.4 (95% confidence interval, 1.1-1.9, P < .05). After stratification, only women age 55 and older had a significant difference in mortality (odds ratio, 1.71; 95% confidence interval, 1.11-2.62, P = .02). CONCLUSIONS Female sex (particularly those age > or =55 y) is associated independently with higher mortality in isolated severe TBI. This increased mortality of postmenopausal women after isolated TBI may suggest a hormonal influence and warrants further investigation.

Overdiagnosis of heparin-induced thrombocytopenia in surgical ICU patients.

BACKGROUND Heparin use in surgical patients places them at increased risk for developing heparin-induced thrombocytopenia (HIT). The false positive rate of HIT using the current standard criteria is unknown in surgical ICU patients, who often have confounding factors that cause thrombocytopenia. STUDY DESIGN Surgical ICU patients, admitted over a 2-year period with a positive screening test for HIT (platelet factor [PF] 4 ≥ 0.4 optical density [OD]), were reviewed retrospectively at a single institution. Correlation of the Warkentin 4-T score and commercial heparin PF4 ELISA with serotonin releasing assay (SRA) was performed. Logistic regression was used to determine independent risk factors associated with the development of HIT. RESULTS PF4 tests were requested in 643 patients based on a clinical suspicion of HIT. Of these, 104 patients had a PF4 result, an SRA value (%), and a 4-T score available. Twenty patients (19%) had true positive HIT, defined as a positive PF4 and positive SRA (SRA ≥ 20%). Eighty-four patients (81%) were false positive, defined as a positive PF4 and negative SRA. Five of 58 patients with Warkentin score of 0 to 3, and 6 of 14 patients with Warkentin score of 6 to 8 were HIT positive by SRA. CONCLUSIONS In surgical ICU patients, clinical suspicion for HIT necessitates PF4 and SRA analysis. Testing for HIT or treatment with a direct thrombin inhibitor should not depend on the Warkentin 4-T score alone. Although a PF4 ≥ 0.4 OD is considered a positive screening test for HIT, a PF4 ≥ 2.0 OD is preferable in surgical ICU patients.

In-house coordinator programs improve conversion rates for organ donation.

BACKGROUND The organ supply shortage continues to be a public health care crisis, with nearly 20 people dying each day awaiting transplantation. Inability to obtain consent remains one of the major obstacles to converting potential donors into organ donors. We hypothesize that the presence of in-house coordinators (IHCs) from organ procurement organizations (OPOs) will improve organ donor conversion rates. METHODS This retrospective review analyzed the effect of an IHC program on organ donation outcome. Referrals for possible organ donation from three IHC programs to regional organ procurement organizations were included. Data regarding organ donation demographics and outcomes were compared before (Pre-IHC) and after (Post-IHC) the establishment of an IHC program. The main outcome measures were conversion and family decline rates. The conversion rate was calculated as the number of actual donors divided by the number of eligible deaths and is represented as a percentage. The IHC functioned to assess for potential donors, ensure timely referrals, provide hospital staff education, assist with family consent and donor management, and provide family support. RESULTS Post-IHC was associated with a significantly lower family decline rate (6% vs. 18%, p < 0.001), a significantly higher consent for research rate (8% vs. 0.4%, p < 0.001), and a significantly higher conversion rate (77% vs. 63%, p = 0.007) compared with Pre-IHC. In addition, a significant increase in referrals per day (0.35 vs. 0.27, p < 0.05) and organs transplanted per eligible death were noted Post-IHC. CONCLUSION The presence of an IHC program significantly improves conversion rates for organ donation as well as organ yield. An IHC program should be considered as a viable option to bridge the gap between organ supply and organ demand.

Pre-hospital intubation is associated with increased mortality after traumatic brain injury.

BACKGROUND Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI. METHODS The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality. RESULTS A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7-13.7, P = 0.004). CONCLUSIONS Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.

Race Affects Mortality After Moderate to Severe Traumatic Brain Injury

BACKGROUND Traumatic brain injury (TBI) is the most common cause of death and disability in trauma patients, affecting over 1 million Americans per year. Minorities are at disproportionate risk for TBI, and they account for nearly half of all brain injury hospitalizations. Little is known regarding racial disparities in TBI patients. The objective of this study was to investigate the association of race on mortality in patients with moderate to severe isolated TBI. METHODS The Los Angeles County Trauma System database, consisting of admissions from five Level I and eight Level II trauma centers, was queried for all patients with isolated moderate to severe TBI admitted between 1998 and 2005. Demographics and mortality were compared between races: Asian, African American, Hispanic, White, and Other. Multivariate logistic regression was used to determine the relationship between race and mortality. RESULTS A total of 17,977 (23.8% female, 76.2% male) severe TBI patients were evaluated. Of this study population, 7.1% were Asian, 13.5% were African American, 42.3% were Hispanic, 32.5% were White, and 4.7% where classified as Other. Overall, Asians (adjusted Odds Ratio [AOR] 1.4; 95% CI: 1.14-1.71, P = 0.001) had a significantly higher risk in mortality when compared with Whites. Surprisingly, neither African Americans (AOR 1.02; 95% CI: 0.87-1.2, P = 0.82), nor Hispanics (AOR 1.00; 95% CI: 0.89-1.13, P > 0.9) were at increased risk of death compared to their White counterparts. CONCLUSION This data supports the hypothesis that race may play a role in mortality in moderate to severe TBI. However, only Asians were at higher risk for death.

Contributing Factors for the Willingness to Donate Organs in the Hispanic American Population

OBJECTIVE To identify factors that contribute to intent to donate organs in Hispanic American individuals. DESIGN Cross-sectional telephone surveys. SETTING Four southern California neighborhoods with a high percentage of Hispanic American individuals. PATIENTS Respondents 18 years or older were drawn randomly from lists of Hispanic surnames. MAIN OUTCOME MEASURES Telephone surveys were conducted that measured demographic and socioeconomic factors, cultural factors, awareness and knowledge, and perception and belief regarding organ donation, as well as the intent to become an organ donor. Logistic regression was performed to identify independent contributing factors to intent to register for organ donation. RESULTS Five hundred twenty-four telephone surveys were conducted over a 3-week period. Seventy-three percent of those surveyed were between the ages of 18 and 44 years and the sample was equally divided between men and women. The following independent risk factors contributed to intent to register: low acculturation (adjusted odds ratio [AOR], 0.39; 95% confidence interval [CI], 0.24-0.62; P < .001), religion (AOR, 0.33; 95% CI, 0.17-0.60; P < .001), perception that the wealthy are more likely to receive organs (AOR, 0.41; 95% CI, 0.25-0.65; P = .001), belief that donation disfigures the body and impacts the funeral (AOR, 0.45; 95% CI, 0.22-0.89; P = .02), and family influence (AOR, 2.02; 95% CI, 1.28-3.22; P = .004). CONCLUSIONS Among Hispanic American individuals, low acculturation, religion, belief, and family influence affect the intent to register for organ donation. To improve organ donation, these risk factors should be considered using specific, effective educational programs.

Alcohol is associated with a lower pneumonia rate after traumatic brain injury.

BACKGROUND Recent evidence supports the beneficial effect of alcohol on patients with traumatic brain injury (TBI). Pneumonia is a known complication following TBI; thus, the purpose of this study was to evaluate the effects of alcohol on pneumonia rates following moderate to severe TBI. METHODS From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥ 14 y of age with isolated moderate to severe TBI and admission serum alcohol levels. The incidence of pneumonia was compared between TBI patients with and without a positive blood alcohol concentration (BAC) level. The study population was then stratified into four BAC levels: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥ 230 mg/dL). Pneumonia rates were compared across these levels. RESULTS A total of 3547 patients with isolated, moderate to severe TBI were evaluated. Nearly 66% tested positive for alcohol. The pneumonia rate was significantly lower in the TBI patients who tested positive for alcohol (2.5%) compared with those who tested negative (4.0%, P = 0.017). The pneumonia rate also decreased across increasing BAC levels (linear trend P = 0.03). After logistic regression analysis, a positive ethanol (ETOH) level was associated with a reduced incidence of pneumonia (AOR = 0.62; 95%CI: 0.41-0.93; P = 0.020). CONCLUSION A positive serum alcohol level was associated with a significantly lower pneumonia rate in isolated, moderate to severe TBI patients. This may explain the observed mortality reduction in TBI patients who test positive for alcohol. Additional research is warranted to investigate the potential therapeutic implications of this association.

The Impact of Race on Organ Donation Rates in Southern California

BACKGROUND The Organ Donation Breakthrough Collaborative began in 2003 to address and alleviate the shortage of organs available for transplantation. This study investigated the patterns of organ donation by race to determine if the Collaborative had an impact on donation rates among ethnic minorities. STUDY DESIGN The following data from the Southern California regional organ procurement organization were reviewed between 2004 and 2008: age, race (Caucasian, African-American, Asian, Hispanic, and other), the numbers of eligible referrals for organ donation and actual donors, types of donors, consent rates, conversion rates, organs procured per donor (OPPD), and organs transplanted per donor (OTPD). Logistic regression was used to determine independent predictors of ≥4 OTPD. RESULTS There were 1,776 actual donors out of 2,760 eligible deaths (conversion rate 64%). Hispanics demonstrated a significantly lower conversion rate than Caucasians (64% vs 77%, p < 0.001), but a considerably higher rate than African Americans (50%) and Asians (51%, p < 0.05 for both). There were no significant changes in conversion rates over time in any race. Age was a negative predictor (odds ratio [OR] 0.95), and trauma mechanism (OR 2.1) and standard criteria donor status (OR 2.5) were positive independent predictors of ≥4 OTPD. Race did not affect OTPD (all groups, p > 0.05). CONCLUSIONS Conversion rates among all ethnic minorities were significantly lower than the rates observed in Caucasians. However, when controlling for other factors, race was not a significant risk factor for the number of organs transplanted per donor. The Collaborative has not had an identifiable effect on race conversion rates during the 5 years since its implementation. Further intervention is necessary to improve the conversion rate in ethnic minorities in Southern California.