Association of easy albumin-bilirubin score with increased mortality in adult trauma patients.

Introduction: The easy albumin-bilirubin (EZ-ALBI) score is calculated using the equation: total bilirubin (mg/dl) - 9 × albumin (g/dl), and is used to evaluate liver functional reserve. This study was designed to investigate whether the EZ-ALBI score serves as an independent risk factor for mortality and is useful for stratifying the mortality risk in adult trauma patients. Methods: We retrospectively reviewed data from the registered trauma database of the hospital and included 3,637 adult trauma patients (1,241 deaths and 2,396 survivors) due to all trauma caused between January 1, 2009, and December 31, 2021. The patients were allocated to the two study groups based on the best EZ-ALBI cutoff point (EZ-ALBI = -28.5), which was determined based on the area under the receiver operating characteristic curve. Results: Results revealed that the non-survivors had a significantly higher EZ-ALBI score than the survivors (-26.4 ± 6.5 vs. -31.5 ± 6.2, p < 0.001). Multivariate logistic regression analysis revealed that EZ-ALBI ≥ -28.5was an independent risk factor for mortality (odds ratio, 2.31; 95% confidence interval, 1.63-3.28; p < 0.001). Patients with an EZ-ALBI score ≥ -28.5 presented with 2.47-fold higher adjusted mortality rates than patients with an EZ-ALBI score < -28.5. A propensity score-matched pair cohort of 1,236 patients was developed to reduce baseline disparities in trauma mechanisms. The analysis showed that patients with an EZ-ALBI score ≥ -28.5 had a 4.12 times higher mortality rate compared to patients with an EZ-ALBI score < -28.5. Conclusion: The EZ-ALBI score was a significant independent risk factor for mortality and can serve as a valuable tool for stratifying mortality risk in adult trauma patients by all trauma causes.

The Influence of Hyponatremia and Hypokalemia on the Risk of Fractures in Various Anatomical Regions among Adult Trauma Patients: A Propensity Score-Matched Analysis.

BACKGROUND: Hyponatremia and hypokalemia are common electrolyte imbalances in trauma patients and have been identified to be risk factors for a fall. In addition, hyponatremia was reported to be related to osteoporosis and fragility fractures, while the association between hypokalemia and osteoporosis has only been reported in rare case reports. This study investigated the impact of hyponatremia and hypokalemia on the incidence of fractures in various body regions of adult trauma patients, using the propensity score-matched patient cohort to reduce the influence of patients' baseline characteristics. METHODS: The study analyzed data from 11,173 hospitalized adult trauma patients treated from 1 January 1998, to 31 December 2022. The study included 1968 patients with hyponatremia and 9205 without, and 1986 with hypokalemia and 9187 without. Different 1:1 propensity score-matched cohorts were generated to create the 1903 pairings of patients with or without hyponatremia, 1977 pairings of patients with or without hypokalemia, and 380 pairing of patients with both hyponatremia and hypokalemia vs. normal control patients. Analysis was conducted on the incidence of fracture in various anatomic regions. RESULTS: Hyponatremic patients had increased odds of thoracic vertebral fracture [odds ratio (95% confidence interval) 1.63 (1.10-2.42), p = 0.014], pelvic fracture [2.29 (1.12-4.67), p = 0.019], and femoral fracture [1.28 (1.13-1.45), p < 0.001] but decreased odds of radial and patella fractures. Hypokalemic patients showed no significant differences in fracture risk except for a decreased likelihood of radial fractures. The patients with both hyponatremia and hypokalemia showed a decreased likelihood of radial fractures and patella fractures. CONCLUSION: Hyponatremia may have a greater impact on the occurrence of bone fractures than hypokalemia in trauma patients who have suffered a fall. Electrolyte abnormalities should be taken into account while assessing the risk of fractures in trauma patients.

Evaluation of the Easy Albumin-Bilirubin Score as a Prognostic Tool for Mortality in Adult Trauma Patients in the Intensive Care Unit: A Retrospective Study.

The easy albumin-bilirubin (EZ-ALBI) score is derived using the following equation: total bilirubin (mg/dL) - 9 × albumin (g/dL). This study aimed to determine whether the EZ-ALBI score predicted mortality risk in adult trauma patients in an intensive care unit (ICU). Data from a hospital's trauma database were retrospectively evaluated for 1083 adult trauma ICU patients (139 deaths and 944 survivors) between 1 January 2016 and 31 December 2021. Patients were classified based on the ideal EZ-ALBI cut-off of -26.5, which was determined via receiver operating characteristic curve analysis. The deceased patients' EZ-ALBI scores were higher than those of the surviving patients (-26.8 ± 6.5 vs. -30.3 ± 5.9, p = 0.001). Multivariate logistic analysis revealed that, in addition to age, the presence of end-stage renal disease, Glasgow Coma Scale scores, and injury severity scores, the EZ-ALBI score is an independent risk factor for mortality (odds ratio (OR), 1.10; 95% confidence interval (CI): 1.06-1.14; p = 0.001)). Compared with patients with EZ-ALBI scores < -26.5, those with scores ≥ -26.5 had a 2.1-fold higher adjusted mortality rate (adjusted OR, 2.14; 95% CI: 1.43-3.19, p = 0.001). In conclusion, the EZ-ALBI score is a substantial and independent predictor of mortality and can be screened to stratify mortality risk in adult trauma ICU patients.

Elevation of White Blood Cell Subtypes in Adult Trauma Patients with Stress-Induced Hyperglycemia.

BACKGROUND: Blood immune cell subset alterations following trauma can indicate a patient's immune-inflammatory status. This research explored the influence of stress-induced hyperglycemia (SIH) on platelet counts and white blood cell (WBC) subtypes, including the derived indices of the monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), in trauma patients. METHODS: We studied 15,480 adult trauma patients admitted from 1 January 1998 to 31 December 2022. They were categorized into four groups: nondiabetic normoglycemia (NDN, n = 11,602), diabetic normoglycemia (DN, n = 1750), SIH (n = 716), and diabetic hyperglycemia (DH, n = 1412). A propensity score-matched cohort was formed after adjusting for age, sex, and comorbidities, allowing for comparing the WBC subtypes and platelet counts. RESULTS: Patients with SIH exhibited significantly increased counts of monocytes, neutrophils, and lymphocytes in contrast to NDN patients. However, no significant rise in platelet counts was noted in the SIH group. There were no observed increases in these cell counts in either the DN or DH groups. CONCLUSIONS: Our results demonstrated that trauma patients with SIH showed significantly higher counts of monocytes, neutrophils, and lymphocytes when compared to NDN patients, whereas the DN and DH groups remained unaffected. This underscores the profound association between SIH and elevated levels of specific WBC subtypes.

The Addition of the Geriatric Nutritional Risk Index to the Prognostic Scoring Systems Did Not Improve Mortality Prediction in Trauma Patients in the Intensive Care Unit.

Background: Malnutrition is prevalent among critically ill patients and has been associated with a poor prognosis. This study sought to determine whether the addition of a nutritional indicator to the various variables of prognostic scoring models can improve the prediction of mortality among trauma patients in the intensive care unit (ICU). Methods: This study's cohort included 1,126 trauma patients hospitalized in the ICU between January 1, 2018, and December 31, 2021. Two nutritional indicators, the prognostic nutrition index (PNI), a calculation based on the serum albumin concentration and peripheral blood lymphocyte count, and the geriatric nutritional risk index (GNRI), a calculation based on the serum albumin concentration and the ratio of current body weight to ideal body weight, were examined for their association with the mortality outcome. The significant nutritional indicator was served as an additional variable in prognostic scoring models of the Trauma and Injury Severity Score (TRISS), the Acute Physiology and Chronic Health Evaluation (APACHE II), and the mortality prediction models (MPM II) at admission, 24, 48, and 72 h in the mortality outcome prediction. The predictive performance was determined by the area under the receiver operating characteristic curve. Results: Multivariate logistic regression revealed that GNRI (OR, 0.97; 95% CI, 0.96-0.99; p=0.007), but not PNI (OR, 0.99; 95% CI, 0.97-1.02; p=0.518), was independent risk factor for mortality. However, none of these predictive scoring models showed a significant improvement in prediction when the GNRI variable is incorporated. Conclusions: The addition of GNRI as a variable to the prognostic scoring models did not significantly enhance the performance of the predictors.

The Association of Albumin-Bilirubin (ALBI) Grade with Mortality Risk in Trauma Patients with Liver Injuries.

Introduction: The albumin-bilirubin (ALBI) grade objectively assesses liver function with better performance than the Child-Pugh and end-stage liver disease scores. However, the evidence is lacking on the ALBI grade in trauma cases. This study aimed to identify the association between the ALBI grade and mortality outcomes in trauma patients with liver injury. Methods: Data from 259 patients with traumatic liver injury at a level I trauma center between January 1, 2009, and December 31, 2021 were retrospectively analyzed. Independent risk factors for predicting mortality were identified using multiple logistic regression analysis. Participants were characterized by ALBI score into grade 1 (≤ -2.60, n = 50), grade 2 (-2.60 < and ≤ -1.39, n = 180), and grade 3 (> -1.39, n = 29). Results: Compared to survival (n = 239), death (n = 20) was associated with a significantly lower ALBI score (2.8±0.4 vs 3.4±0.7, p < 0.001). The ALBI score was a significant independent risk factor for mortality (OR, 2.79; 95% CI, 1.27-8.05; p = 0.038). Compared with grade 1 patients, grade 3 patients had a significantly higher mortality rate (24.1% vs 0.0%, p < 0.001) and a longer hospital stay (37.5 days vs 13.5 days, p < 0.001). Discussion: This study showed that ALBI grade is a significant independent risk factor and an useful clinical tool to discover liver injury patients who are more susceptible to death.

Using Second Measurement of De Ritis Ratio to Improve Mortality Prediction in Adult Trauma Patients in Intensive Care Unit.

The De Ritis ratio (DRR), the ratio of serum levels of aspartate aminotransferase/alanine aminotransferase, has been reported to be a valuable biomarker in risk stratification for many liver and non-liver diseases. This study aimed to explore whether the inclusion of DRR at the date of intensive care unit (ICU) admission or days after ICU admission improves the predictive performance of various prognosis prediction models. This study reviewed 888 adult trauma patients (74 deaths and 814 survivors) in the trauma registered database between 1 January 2009, and 31 December 2020. Medical information with AST and ALT levels and derived DRR at the date of ICU admission (1st DRR) and 3-7 day after ICU admission (2nd DRR) was retrieved. Logistic regression was used to build new probability models for mortality prediction using additional DRR variables in various mortality prediction models. There was no significant difference in the 1st DRR between the death and survival patients; however, there was a significantly higher 2nd DRR in the death patients than the survival patients. This study showed that the inclusion of the additional DRR variable, measured 3-7 days after ICU admission, significantly increased the prediction performance in all studied prognosis prediction models.

Delta De Ritis Ratio Is Associated with Worse Mortality Outcomes in Adult Trauma Patients with Moderate-to-Severe Traumatic Brain Injuries.

This study aimed to investigate whether changes in the De Ritis ratio (DRR) can be used to stratify the mortality risk of patients with moderate-to-severe traumatic brain injury (TBI). This retrospective study reviewed data for 1347 adult trauma patients (134 deaths and 1213 survival) with moderate-to-severe TBI between 1 January 2009, and 31 December 2020, from the registered trauma database. The outcomes of the patients allocated into the two study groups were compared based on the best Delta DRR (ΔDRR) cutoff point. The first and second DRR of patients who died were significantly higher than those of patients who survived. Elevation of DRR 72-96 h later was found for patients who died, but not for those who survived; the ΔDRR of the patients who died was significantly higher than that of those who survived (1.4 ± 5.8 vs. -0.1 ± 3.3, p = 0.004). Multivariate logistic regression analysis revealed that ΔDRR was a significant independent risk factor for mortality in these patients. Additionally, a ΔDRR of 0.7 was identified as the cutoff value for mortality stratification of adult trauma patients at high risk of mortality with moderate-to-severe TBI.

From Death Triad to Death Tetrad-The Addition of a Hypotension Component to the Death Triad Improves Mortality Risk Stratification in Trauma Patients: A Retrospective Cohort Study.

The death triad, including coagulopathy, hypothermia, and acidosis, is shown to be a strong predictor of mortality in trauma patients. We aimed to investigate whether the inclusion of hypotension, defined as systolic blood pressure (SBP) < 60 mmHg, as a fourth factor in the death triad would comprise a death tetrad to help stratify mortality risk in trauma patients. A total of 3361 adult trauma patients between 1 January 2009 and 31 December 2019 were allocated into groups to investigate whether hypotension matters in determining the mortality outcome of trauma patients who possess 1−3 death triad components compared to those without any component. Hypotension was added to the death tetrad, and the adjusted mortality outcome was compared among groups with 0−4 death tetrad components. Herein, we showed that SBP < 60 mmHg could be used to identify patients at risk of mortality among patients with one or two death triad components. Patients with one, two, and three death tetrad components had respective adjusted mortality rates of 3.69-, 10.10-, and 40.18-fold, determined by sex, age, and comorbidities. The mortality rate of trauma patients with all the four death tetrad components was 100%. The study suggested that hypotension, defined as an SBP < 60 mmHg, may act as a proper death tetrad component to stratify the mortality risk of trauma patients.

Association between Elevated De Ritis Ratio and Mortality Outcome in Adult Patients with Thoracoabdominal Trauma.

The De Ritis ratio is widely used to differentiate various causes of liver disease and serves as an independent prognostic predictor for different malignancies and non-malignant illnesses. This retrospective study aimed to identify the association between the De Ritis ratio on admission and mortality outcomes in adult thoracoabdominal trauma patients. A total of 2248 hospitalized adult trauma patients with thoracoabdominal injury, defined as an abbreviated injury scale (AIS) score ≥ 1 in the thoracic and abdominal regions, between 1 January 2009, and 31 December 2019, were included. They were categorized into three tertile groups according to the De Ritis ratio. A 1:1 propensity score-matched study group was established to attenuate the confounding effect of patient characteristics on the mortality outcome assessment. The AST levels of the tertile 1, 2, and 3 groups were 115.8 ± 174.9, 115.7 ± 262.0, and 140.5 ± 209.7 U/L, respectively. Patients in the tertile 3 group had a significantly higher level of AST than those in the tertile 1 group (p = 0.032). In addition, patients in the tertile 1 group had a significantly higher level of ALT than those in the tertile 2 and 3 groups (115.9 ± 158.1 U/L vs. 74.5 ± 107.0 U/L and 61.9 ± 86.0 U/L, p < 0.001). The increased De Ritis ratio in trauma patients with thoracoabdominal injuries was mainly attributed to elevated AST levels. The propensity score-matched patient cohorts revealed that the patients in the tertile 3 group presented a 3.89-fold higher risk of mortality than the patients in the tertile 2 group. In contrast, the patients in the tertile 1 group did not have a significantly different mortality rate than those in the tertile 2 group. This study suggests that a De Ritis ratio > 1.64 may be a useful biomarker to identify patients with a higher risk for mortality.

Comparing Outcomes between Major Trauma Patients Transferred from a Different Hospital and Patients Transported Directly to Trauma Centers: A Retrospective Analysis with Propensity Score Matching Analysis.

This study aimed to explore differences in outcomes between these major trauma patients who were transferred and those directly transported to trauma centers. The medical information and outcome of 5,341 major trauma patients with an injury severity score (ISS) ≥ 16 who were hospitalized for treatment between January 1, 2009, and December 31, 2019, were collected from the Trauma Registry System of the hospital. There were 2,386 patients who were transferred (transfer group) and 2,955 patients transported directly to trauma centers first (direct group). Regarding the outcomes, there was no significant difference in the mortality rate between patients in the transfer group and the direct group (11.1% vs. 10.5%, respectively, p=0.527). However, the patients in the transfer group had a longer hospital stay (16.8 days vs. 14.3 days, respectively, p < 0.001) and higher incidence of intensive care unit (ICU) admission (74.9% vs. 70.5%, respectively, p < 0.001) than those patients in the direct group. Similar results were observed in the selected 2,139 pairs of propensity score-matched patient populations, who did not present with significant differences in sex, age, comorbidities, trauma mechanisms, and ISS. This study revealed no significant difference in the mortality rate between the two groups of major trauma patients. However, the transferred patients had significantly longer hospital stays and higher rates of ICU admission than patients directly transported to trauma centers.

Association of White Blood Cell Subtypes and Derived Ratios with a Mortality Outcome in Adult Patients with Polytrauma.

Background. After trauma, the subtypes of white blood cells (WBCs) in circulation and the derived neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) may undergo relative changes and reflect the patients' immune-inflammatory status and outcome. This retrospective study was designed to investigate the relationship between these variables and the mortality outcomes in adult patients with polytrauma, which is defined as an abbreviated injury scale (AIS) score ≥ 3 in two or more different body regions. Methods. A comparison of the expression of subtypes of WBCs, NLR, MLR, and PLR upon arrival to the emergency department was performed in selected propensity score-matched patient cohorts created from 479 adult patients with polytrauma between 1 January 2015 and 31 December 2019. A multivariate logistic regression analysis was used to identify the independent risk factors for mortality. Results. There were no significant differences in monocyte, neutrophil, and platelet counts, as well as in MLR, NLR, and PLR, between deceased (n = 118) and surviving (n = 361) patients. In the propensity score-matched patient cohorts, which showed no significant differences in sex, age, comorbidities, and injury severity, deceased patients had significantly higher lymphocyte counts than survivors (2214 ± 1372 vs. 1807 ± 1162 [106/L], respectively, p = 0.036). In addition, the multivariate logistic regression analysis revealed that the lymphocyte count (OR, 1.0; 95% confidence interval [CI], 1.00-1.06; p = 0.043) was a significant independent risk factor for mortality in these patients. Conclusions. This study revealed that there was no significant difference in the counts of monocytes, neutrophils, and platelets, as well as in MLR, NLR, and PLR, between deceased and surviving patients with polytrauma. However, a significantly higher lymphocyte count may be associated with a worse mortality.

The Association between Skull Bone Fractures and the Mortality Outcomes of Patients with Traumatic Brain Injury.

Introduction: Skull fractures are often found in patients with traumatic brain injury (TBI). Although skull fractures may indicate greater force impact and are associated with local or diffuse brain injuries, the prognostic value of skull fractures remains unclear. This retrospective study aimed to assess the association between skull fractures and mortality in patients with TBI. Methods: This study included 5,430 TBI patients registered in the trauma registry system from January 2009 to December 2018. Clinical and demographic data including age, sex, trauma mechanisms, comorbidities, Glasgow Coma Scale (GCS) score, abbreviated injury score (AIS)-head, injury severity score (ISS), and in-hospital mortality were acquired. Multiple logistic regression and propensity score matching were used to elucidate the effect of skull fractures on mortality outcomes of TBI patients. Results: Compared to TBI patients without skull fracture, patients with skull fractures were predominantly male, younger, had lower GCS upon arrival at the emergency room, and had higher AIS-head, ISS, and in-hospital mortality. The patients with skull fracture had 1.7-fold adjusted odds of mortality (95% confidence interval (CI): 1.27-2.25; p < 0.001) than those without skull fracture, controlling for age, sex, comorbidities, and AIS-head. Additionally, the propensity score-matched analysis of 1,023 selected paired patients revealed that skull fracture was significantly associated with increased 1.4-fold odds of risk for mortality (95% CI: 1.02-1.88; p=0.036). Conclusions: Using a propensity score-matched cohort to attenuate the confounding effect of age, comorbidities, and injury severity, skull fracture was identified as a significant independent risk factor for mortality in patients with TBI.

Association of Platelets and White Blood Cells Subtypes with Trauma Patients' Mortality Outcome in the Intensive Care Unit.

Background: White blood cell (WBC) subtypes have been suggested to reflect patients' immune-inflammatory status. Furthermore, the derived ratio of platelets and WBC subtypes, including monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), is proposed to be associated with patient outcome. Therefore, this study aimed to identify the association of platelets and white blood cells subtypes with the mortality outcome of trauma patients in the intensive care unit (ICU). Method: The medical information from 2854 adult trauma patients admitted to the ICU between 1 January 2009 and 31 December 2019 were retrospectively retrieved from the Trauma Registry System and classified into two groups: the survivors group (n = 2524) and the death group (n = 330). The levels of monocytes, neutrophils, lymphocytes, platelets, and blood-drawn laboratory data detected upon patient arrival to the emergency room and the derived MLR, NLR, and PLR were calculated. Multivariate logistic regression analysis was used to determine the independent effects of univariate predictive variables on mortality occurrence. Result: The results revealed the patients who died had significantly lower platelet counts (175,842 ± 61,713 vs. 206,890 ± 69,006/µL, p < 0.001) but higher levels of lymphocytes (2458 ± 1940 vs. 1971 ± 1453/µL, p < 0.001) than the surviving patients. However, monocyte and neutrophil levels were not significantly different between the death and survivor groups. Moreover, dead patients had a significantly lower PLR than survivors (124.3 ± 110.3 vs. 150.6 ± 106.5, p < 0.001). However, there was no significant difference in MLR or NLR between the dead patients and the survivors. Multivariate logistic regression revealed that male gender, old age, pre-existing hypertension, coronary artery disease and end-stage renal disease, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), higher level of lymphocytes and lower level of red blood cells and platelets, longer activated partial thromboplastin time (aPTT), and lower level of PLR were independent risk factors associated with higher odds of trauma patient mortality outcome in the ICU. Conclusion: This study revealed that a higher lymphocyte count, lower platelet count, and a lower PLR were associated with higher risk of death in ICU trauma patients.

Geriatric Nutritional Risk Index as a Prognostic Factor for Mortality in Elderly Patients with Moderate to Severe Traumatic Brain Injuries.

BACKGROUND: The Geriatric Nutritional Risk Index (GNRI) is a simple and objective screening tool for clinicians to screen patients' nutritional status based on serum albumin level and their weight and height. The original study had divided patients based on GNRI into quartiles of nutritional risk for death: a no-risk group (GNRI >98), a low-risk group (GNRI 92-98), a moderate-risk group (GNRI 82 to <92), and a major-risk group (GNRI <82). Given that the patients generally sustained traumatic brain injury (TBI) in an acute condition, the study aimed to explore whether GNRI presents a prognostic value for the mortality outcome of these patients. METHODS: From January 1, 2009, to December 31, 2019, 581 elderly patients with moderate to severe TBI, which was defined as sustaining a head Abbreviated Injury Scale ≥3, was included in the study population. The collected data included age, sex, body mass index, serum albumin levels at admission, preexisting comorbidities, Glasgow Coma Scale, and Injury Severity Score. The primary outcome in the comparison was in-hospital mortality. RESULTS: Multivariate logistic regression analysis revealed that GNRI, ESRD, and ISS were significant independent risk factors for mortality in patients with moderate to severe TBI. When subgrouping the study population into four nutritional risk categories according to the quartile deviation as Q1 (GNRI <85, n = 145), Q2 (GNRI 85 to <93.8 n = 145), Q3 (GNRI 93.8 to 103, n = 145), and Q4 (GNRI >103, n = 146), Q1 patients had a significantly longer LOS in hospital (25.2 days vs 18.6 days, respectively; p = 0.004) and higher mortality rate (28.3% vs 11.7%, respectively; p < 0.001) than Q4 patients. The mortality rate was significantly higher in Q1 patients than in Q4 patients (OR, 2.8; 95% CI, 1.14-6.78; p = 0.021). CONCLUSION: This study revealed that the GNRI is a significant independent risk factor and a promising simple assessment tool for mortality in elderly patients with moderate to severe TBI.

Reply to Comment on Tsai, Y.-C., et al. Association of Stress-Induced Hyperglycemia and Diabetic Hyperglycemia with Mortality in Patients with Traumatic Brain Injury: Analysis of a Propensity Score-Matched Population. Int. J. Environ. Res. Public Health 2020, 17, 4266.

Thank you for Eduardo Mekitarian Filho's appreciation of our work on the study of stress-induced hyperglycemia (SIH) and diabetic hyperglycemia (DH) in patients with traumatic brain injuries [...].

Association between Geriatric Nutritional Risk Index and Mortality in Older Trauma Patients in the Intensive Care Unit.

The geriatric nutritional risk index (GNRI) is a simple and efficient tool to assess the nutritional status of patients with malignancies or after surgery. Because trauma patients constitute a specific population that generally acquires accidental and acute injury, this study aimed to identify the association between the GNRI at admission and mortality outcomes of older trauma patients in the intensive care unit (ICU). METHODS: The study population included 700 older trauma patients admitted to the ICU between 1 January 2009 and 31 December 2019. The collected data included age, sex, body mass index (BMI), albumin level at admission, preexisting comorbidities, injury severity score (ISS), and in-hospital mortality. Multivariate logistic regression analysis was conducted to identify the independent effects of univariate predictive variables resulting in mortality in our study population. The study population was categorized into four nutritional risk groups: a major-risk group (GNRI < 82; n = 128), moderate-risk group (GNRI 82 to <92; n = 191), low-risk group (GNRI 92-98; n = 136), and no-risk group (GNRI > 98; n = 245). RESULTS: There was no significant difference in sex predominance, age, and BMI between the mortality (n = 125) and survival (n = 575) groups. The GNRI was significantly lower in the mortality group than in the survival group (89.8 ± 12.9 vs. 94.2 ± 12.0, p < 0.001). Multivariate logistic regression analysis showed that the GNRI (odds ratio-OR, 0.97; 95% confidence interval (CI) 0.95-0.99; p = 0.001), preexisting end-stage renal disease (OR, 3.6; 95% CI, 1.70-7.67; p = 0.001), and ISS (OR, 1.1; 95% CI, 1.05-1.10; p < 0.001) were significant independent risk factors for mortality. Compared to the patients in group of GNRI > 98, those patients in group of GNRI < 82 presented a significantly higher mortality rate (26.6% vs. 13.1%; p < 0.001) and length of stay in hospital (26.5 days vs. 20.9 days; p = 0.016). CONCLUSIONS: This study demonstrated that GNRI is a significant independent risk factor and a promising simple screening tool to identify the subjects with malnutrition associated with higher risk for mortality in those ICU elderly trauma patients.

Geriatric Nutritional Risk Index as a Tool to Evaluate Impact of Malnutrition Risk on Mortality in Adult Patients with Polytrauma.

BACKGROUND: Identification of malnutrition is especially important in severely injured patients, in whom hypermetabolism and protein catabolism following traumatic injury worsen their nutritional condition. The geriatric nutritional risk index (GNRI), based on serum albumin level and the current body weight/ideal body weight ratio, is useful for identifying patients with malnutrition in many clinical conditions. This study aimed to explore the association between admission GNRI and mortality outcomes of adult patients with polytrauma. METHODS: From 1 January 2009 to 31 December 2019, a total of 348 adult patients with polytrauma, registered in the trauma database of a level I trauma center, were recognized and categorized into groups of death (n = 71) or survival (n = 277) and into four nutritional risk groups: a high-risk group (GNRI < 82, n = 87), a moderate-risk group (GNRI 82 to <92, n = 144), a low-risk group (GNRI 92-98, n = 59), and a no-risk group (GNRI > 98, n = 58). Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for mortality. The mortality outcomes of patients at various nutritional risks were compared to those of patients in the no-risk group. RESULTS: The comparison between the death group (n = 71) and the survival group (n = 277) revealed that there was no significant difference in gender predominance, age, pre-existing comorbidities, injury mechanism, systolic blood pressure, and respiratory rate upon arrival at the emergency room. A significantly lower GNRI and Glasgow Coma Scale score but higher injury severity score (ISS) was observed in the death group than in the survival group. Multivariate logistic regression analysis revealed that Glasgow Coma Scale (GCS), odds ratio (OR), 0.88; 95% confidence interval (CI), 0.83-0.95; p < 0.001), ISS (OR, 1.07; 95% CI, 1.04-1.11; p < 0.001), and GNRI (OR, 0.94; 95% CI, 0.91-0.97; p < 0.001) were significant independent risk factors for mortality in these patients. The mortality rates for the high-risk, moderate-risk, low-risk, and no-risk groups were 34.5%, 20.1%, 8.5%, and 12.1%, respectively. Unlike patients in the moderate-risk and low-risk groups, patients in the high-risk group had a significantly higher death rate than that of those in the no-risk group. CONCLUSIONS: This study revealed that the GNRI may serve as a simple, promising screening tool to identify the high risk of malnutrition for mortality in adult patients with polytrauma.

Geriatric Nutritional Risk Index as a Screening Tool to Identify Patients with Malnutrition at a High Risk of In-Hospital Mortality among Elderly Patients with Femoral Fractures-A Retrospective Study in a Level I Trauma Center.

BACKGROUND: Malnutrition is frequently underdiagnosed in geriatric patients and is considered to be a contributing factor for worse outcomes during hospitalization. In addition, elderly patients who undergo trauma are often malnourished at the time of incurring fractures. The geriatric nutritional risk index (GNRI), calculated based on the serum albumin level and the ratio of present body weight to ideal body weight, was proposed for the assessment of the nutritional status of elderly patients with various illnesses. This study aimed to investigate whether the GNRI has a prognostic value that links the nutritional status and mortality outcomes of elderly patients who have previously undergone trauma with femoral fractures. METHODS: From January 1, 2009 to December 31, 2019, a total of 678 elderly patients with femoral fractures were categorized into four nutritional risk groups: a major-risk group (GNRI <82; group 1, n = 127), moderate-risk group (GNRI 82- <92; group 2, n = 179), low-risk group (GNRI 92-98; group 3, n = 123), and no-risk group (GNRI >98; group 4, n = 249). To minimize the confounding effects of sex, age, preexisting comorbidities, and injury severity of patients on outcome measurements, propensity score-matched patient cohorts were created to assess the impact of patients being in different nutritional risk groups on the in-hospital mortality outcomes against the no-risk group. RESULTS: The patients in groups 1-3 were significantly older and presented a significantly lower body mass index and lower serum albumin levels than those in group 4. Compared with patients in group 4 (3.6%), a significantly higher mortality rate was found in the patients in group 1 (17.3%, p < 0.001), but not in those in group 2 (6.7%) or group 3 (2.4%). The study of propensity score-matched patient cohorts provided similar results; group 1 patients had significantly higher odds of mortality than group 4 patients (odds ratio, 6.3; 95% confidence interval, 1.34-29.37; p = 0.009), but there were no significant differences in mortality risks among patients in groups 2 and 3 compared with those in group 4. CONCLUSIONS: This preliminary study suggested that the GNRI may be used as a screening tool to identify patients with malnutrition at a high risk of mortality among elderly patients with femoral fractures. A prospective study is needed to validate the suggestion.

Performance of Prognostic Scoring Systems in Trauma Patients in the Intensive Care Unit of a Trauma Center.

BACKGROUND: Prediction of mortality outcomes in trauma patients in the intensive care unit (ICU) is important for patient care and quality improvement. We aimed to measure the performance of 11 prognostic scoring systems for predicting mortality outcomes in trauma patients in the ICU. METHODS: Prospectively registered data in the Trauma Registry System from 1 January 2016 to 31 December 2018 were used to extract scores from prognostic scoring systems for 1554 trauma patients in the ICU. The following systems were used: the Trauma and Injury Severity Score (TRISS); the Acute Physiology and Chronic Health Evaluation (APACHE II); the Simplified Acute Physiology Score (SAPS II); mortality prediction models (MPM II) at admission, 24, 48, and 72 h; the Multiple Organ Dysfunction Score (MODS); the Sequential Organ Failure Assessment (SOFA); the Logistic Organ Dysfunction Score (LODS); and the Three Days Recalibrated ICU Outcome Score (TRIOS). Predictive performance was determined according to the area under the receiver operator characteristic curve (AUC). RESULTS: MPM II at 24 h had the highest AUC (0.9213), followed by MPM II at 48 h (AUC: 0.9105). MPM II at 24, 48, and 72 h (0.8956) had a significantly higher AUC than the TRISS (AUC: 0.8814), APACHE II (AUC: 0.8923), SAPS II (AUC: 0.9044), MPM II at admission (AUC: 0.9063), MODS (AUC: 0.8179), SOFA (AUC: 0.7073), LODS (AUC: 0.9013), and TRIOS (AUC: 0.8701). There was no significant difference in the predictive performance of MPM II at 24 and 48 h (p = 0.37) or at 72 h (p = 0.10). CONCLUSIONS: We compared 11 prognostic scoring systems and demonstrated that MPM II at 24 h had the best predictive performance for 1554 trauma patients in the ICU.