| Part I Clinical Retrospective Study of Geriatric Trauma PatientsObjective:The goal of this study was to summarized the clinical features of geriatric trauma, to investigate the factors influencing mortality and morbidity.Method:A retrospective study of clinical data.Clinical data of geriatric trauma patients(AGE≥60years) admitted to Guangzhou General Hospital of Guangzhou Commandfrom January 2011 to December 2015 were collected.For each patient,demographic data, systolic blood pressure,heart rate,respiratory rate,time of injury,mechanism of injury,site of injury,Glasgow Coma Score(GCS),Revised Trauma Scores(RTS),Injury Severity Scores(ISS),length of stay,Mortality,outcome were collected. Summarizes the features of the indicators,analyze the difference between survival and nonsurvival.Results:There were 2715 patients,1326 males(48.8%),1389 females(51.2%),me an agewas 73.61±9.23 years.There were 2117 patients 65 years and older.The incidence of geriatric trauma showed an increasing trend,from 2011 to 2015 h ad an increase of 23.4%.Seasonal presence differences incidence in geriatric tr auma,winter high incidence(28.0%),followed by spring(24.3%).In the age of 65 year-olds,the four mostcommon mechanisms of injury were falls(71.4%),overe xertion(10.9%),road traffic collisions(10.7%)and falls from height(3.6%).In the 60-65-year-olds, the four most common mechanisms of injury were falls(41. 0%),road traffic collisions(24.6%),falls from height(12.0%) and overexertion(11. 5%)(P=0.000).The three most common site of injury were limbs and pelvis(49. 4%),head and neck(16.4%),abdomen and pelvis(12.4%)(P=0.000).There were 17 9 multiple injuries patients,mainly trauma mechanism were road traffic collisio ns(52.3%),falls from height(17.3%) and falls(14.5%).There were significant diff erences between mechanisms of injury in age,RTS,GCS,ISS, length of stay(P< 0.05).Falls,overexertion and other had the highest mean age (75.78±8.93 vs.73.24±8.83 vs.70.65±10.39,P=0.00).Road traffic collisions,securit y incidents,falls from height had the lowest RT)S(7.34±1.20 vs.7.52±1.35 vs.7. 61±0.82,P=0.00),GCS(13.11±3.58 vs.13.90±2.86 vs.14.19±2.37,P=0.00).Road traf fic collisions,falls fromheight,security incidents had the highest ISS(16.58±12.5 2 vs.14.54±11.02 vs.9.82±10.66,P=0.00).Road traffic collisions,animal bites and falls had the longest length of stay(24.97±25.27 vs.20.00±7.07 vs.19.81±21.90, P=0.00).There were significant differences between site of injury in age,RTS,G CS,ISS,length of stay(P< 0.05).Surface,limbs and pelvis,chest trauma patients maximum age,(76.80±9.37 vs.74.99±9.90 vs.74.84±8.55,P=0.00).Multiple injury, head and neck,limbs and pelvic patients had the lowest RTS(7.15±1.56 vs.7.33 ±1.05 vs.7.81±0.32,P=0.00),the longest lengthof stay (25.93±29.22 vs.22.81±28. 69 vs.20.68±19.95,P=0.00).Falls from high(5.3%) had the highest mortality,followed by security incidents(5.0%)and road traffic collisions (4.3%).There was significant difference between survival and nonsurvival in site of injury(P=0.00).Multiple injuries(8.9%) had the highest mortality,followed by the headand neck(5.6%) and pelvis and extremities(2.7%).There was no significant difference between survivors and nonsurvivors in length of stay(19.65±21.54 vs.19.65±21.54)(P>0.05).Male(4.3%) had higher mortality than females(1.9%) (p=0.000).There were significant differences between survivors and nonsurvivors in age(73.50±9.20vs.77.54±9.64,P< 0.05),GCS(14.55±1.77 vs.10.89±5.12,P<0.05), RTS(7.94±0.49 vs.6.30±2.27,P=0.000),ISS(9.49±7.10 vs.17.92±12.91,P=0.00).Conclusion:Winter is the high-risk season for geriatric trauma.Falls were the most common mechanisms of injury in geriatric.The most common injured site were limbs and pelvis. Increasing age,gender,site of injury,mechanism of injury,injury severity were the predictors of mortality.Part II A comparison of the APACHE II score and the TRISS for outcome assessment in intensive care unit Geriatric Trauma PatientsObjective:To assess the ability of the APACHE II system and TRISS system in predicting group outcome in intensive care unit (ICU) Geriatric Trauma.Method:A retrospective study of clinical data.Clinical data of geriatric trauma patients(Age≥60years) admitted to intensive care unit of Guangzhou General Hospital of Guangzhou Command from January 2011 to December 2015 were collected.For each patient,demographic data,mechanism of injury,site of injury,Glasgow Coma Score(GCS),Revised Trauma Scores(RTS),Injury Severity Scores(ISS),Trauma-Injury Severity Scoring(TRISS),Acute Physiology and Chronic Health Evaluation (APACHE II),ICU length of stay,length of stay,Mortality,outcome were collected. The probability of death was calculated for each patient based on the APACHE II and TRISS equations.The ability to predict group mortality for APACHE II and TRISS was assessed by receiver operating characteristic curve analysis, calibration curve analysis,and two by two decision matrices.Results:There were 2715 geriatric trauma patients.129(4.7%) were admitted to the ICU.91 males(70.5%) and 38 females(29.5%).Mean age was 74.15±10.19 years.44(34.1%) patients died while 85(65.9%) survived. There were no significant difference in age,gender,ICU length of stay between two groups (P=0.877,0.278,0.578,respectively).The length of stay of the nonsurvivors was(19.98 ±21.24)day,while it was(42.07±46.74)day in the survival,with a significant difference between the two groups(P<0.01).The three most common mechanisms of injury were falls(48.8%),road traffic collisions(37.2%)and falls from height(11.6%).There was no significant difference between the two groups in mechanism of injury(P=0.887).The there most common site of injury were limbs and pelvis(40.3%), followed by multiple injuries (37.5%) and head and neck (26.0%).There was no significant difference between the two groups between site of injury (P=0.616).There were significant differences between survivors and nonsurvivors in GCS(11.55±3.93 vs.6.64±4.20,P=0.01),RTS(6.84± 1.19 vs.3.78±1.98,P<0.05)and APACHE Ⅱ score(15.52±6.47vs.28.22±7.57,P< 0.05).There was no significant differences between survivors and nonsurvivors in ISS(23.14±15.17 vs.25.32±17.73,P>0.05).By receiver operating characteristic curve analysis,the areas under the curves(AU-ROC) (±SE) of APACHE II and TRISS were 0.901±0.028 and 0.825±0.038,respectively.The best cut-off for APACHE II was 21.5, with the sensitivity of 74.1% and specificity of 81.2%.The best cut-off for TRISS was 0.49, with the sensitivity of 75.0% and specificity of 77.6%.There was no significant difference between the APACHE II and TRISS in AU-ROC (APACH-EⅡ vs. TRISS,0.856 vs.0.759, p=0.946).The two by two decision matrices at a decision criterion of 50%, the sensitivities, specificities and percentages correctly classified were 50.0%,96.5% and 80.6%, respectively, for APACHE II, and 70.5%,81.2% and 77.5%, respectively, for TRISS. At a decision criterion of 70%, the sensitivities, specificities and percentages correctly classified were 20.5%,98.8% and 72.1%, respectively, for APACHE II, and 61.4%,85.9% and 77.5%, respectively,for TRISS. From the calibration curves,both APACHE II and TRISS predicted death rates were significantly correlated to observed death rates (p=0.000 and 0.002, respectively).The R2 (0.81) from APACHE II was higher than the R2 (0.71) from TRISS.However,neither regression line lies on the 45 degrees line.The slopes of regression lines were 1.07and 0.73,respectively.Conclusions:Both APACHE II and TRISS scores were shown to accurately predict group mortality in ICU geriatric trauma patients.Part Ⅲ The Value of HLA-DR+/CD14+ in Sepsis and Prognostic in Geriatric Trauma PatientsObjection:To evaluate the value HLA-DR+/CD14+ expression in peripheral blood monocytes in sepsis and prognostic in geriatric trauma patients.Method:A retrospective study of clinical data.Clinical data of geriatric trauma patients(Age≥60years)admitted to intensive care unit(ICU) of Guangzhou General Hospital of Guangzhou Command from January 2011 to December 2015 were collected.For each patient,demographic data,Acute Physiology and Chronic Health Evaluation(APACHE II),Injury Severity Scores(ISS),the expression of HLA-DR+/ CD14+,procalcitonin (PCT),C-reactive protein(CRP),are sepsis,ICU length of stay,length of stay,Mortality,outcome were collected.The expression of HLA-DR+/ CD 14+, PCT,CRP was detected within 24 hours after admission.Using Spearman correlation analysis the correlation between the HLA-DR+/CD14+ and Length of ICU stay,Length of stay,APACHE II.Receiver Operating Characteristic (ROC) curve was used to evaluate the prognostic roles of HLA-DR+/CD14+ expression, PCT,CRP,APACHE II.Results:There were 2715 geriatric trauma patients.129(4.7%) were admitted to the ICU.According to inclusion and exclusion criteria,75 patients were included. Mean age was 73.75±9.71years,48 males(65.4%) and 27 females(34.6%).24 (32.0%) patients died and 51 (68.0%) survived. There were no significant difference in age,gender, ISS, PCT, CRP, ICU length of stay,length of stay between survival and nonsurvivors.There were significant differences between survivors and nonsurvivors in APACHEⅡ (17.49±6.25 vs.27.38±8.68, P< 0.05),HLA-DR+/CD14+(59.80± 18.02 vs.37.70±13.96,P<0.01) and the incidence of sepsis(17.6% vs.66.7%,P< 0.01).There were no significant difference in age,gender,ISS, length of stay between sepsis and non-sepsis(P>0.05).There were significant differences between sepsis and non-sepsis in APACHE II (26.16±8.44 vs.17.90±7.04,P< 0.01),HLA-DR+/CD14+ (38.61±14.48 vs.59.79±18.17,P<0.01),PCT (34.45±68.29vs.4.25±8.26,P<0.01), CRP(129.88±103.25 vs.76.04±73.48,P< 0.05),Mortality(66.7%vs.15.7%,P< 0.01),ICU length of stay(21.88±20.65 vs.10.00±12.54,P< 0.01).It existed a negative relationship between the HLA-DR+/CD14+ and length of ICU stay(r=-0.304,P=0.008),APACHEⅡ(r=-0.559,P=0.000).There was no significant relationship between the HLA-DR+/CD14+ and length of stay(r=0.188, P=0.106).By ROC for sepsis prognostic, the areas under the curves (±SE) of HLA-DR+/CD14+ was were 0.807±0.051(95% CI:0.706,0.907)(P=0.000),the AU-ROC(± SE) of PCT and CRP were 0.714± 0.063(95% CI:0.591,0.837) (P=0.003) and 0.672±0.066 (95% CI:0.542,0.803)(P=0.015),respectivly.There was no difference between the HLA-DR+/CD14+ and PCT in AU-ROC(HLA-DR+/ CD14+vs.PCT,0.807 vs.0.714, P=0.946).The best cut-off for HLA-DR+/CD14+ was 40%, with the sensitivity of 88.0% and specificity of 60.0%.The best cut-off for PCT was 1.01, with the sensitivity of 84.0% and specificity of 65.0%.The best cut-off for CRP was 40, with the sensitivity of 80.0% and specificity of 50.0%.By ROC curve analysis for prognostic, the AU-ROC(±SE) of HLA-DR+/CD14+ and APACHE II were 0.813± 0.049(95% CI:0.716,0.910)(P=0.00) and 0.825±0.052(95% CI:0.724,0.926) (P=0.00),respectively.The best cut-off for HLA-DR+/CD14+ was 36.0%, with the sensitivity of 94.1% and specificity of 50.0%.The best cut-off for APACHE II was 20, with the sensitivity of 80.1% and specificity of 65.0%.There was no difference between the HLA-DR+/CD14+ and APACHE II in AU-ROC (HLA-DR+/CD14+:APACHE II,0.813:0.825,P=0.567).The AU-ROC(±SE) of PCT and CRP were 0.553±0.072(95% CI:0.412,694)(P=0.464)and 0.514 ±0.077(95% CI:0.363,0.666) (P=0.842), respectively.Conclusion:The low expression level of HLA-DR+/CD14+ indicated the hypoimmunity of geriatric trauma patients,and it can play an significant role in predicting the incidence of sepsis and the death. |
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