Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study

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Various factors influence patient outcome and predefining these could allow prognostication. The aim of this study was to identify predictors of mortality from major trauma in intensive care. Methods This was a retrospective study of adult trauma patients admitted to general intensive care between January 2018 and December 2019. We assessed the impact on mortality of patient demographics, patterns of injury, injury scores (Glasgow Coma Score (GCS), Charlson’s comorbidity index (CCI), Acute Physiology and Health Evaluation II (APACHE II), Injury Severity Score (ISS) and Probability of Survival Score (Ps19)), number of surgeries and mechanism of injury using logistic regression. Results A total of 414 patients were included with a median age of 54 years (IQR 34–72). Overall mortality was 18.6%. The most common mechanism of injury was traffic collision (46%). Non-survivors were older, had higher ISS scores with lower GCS on admission and lower probability of survival scores. Factors independently predictive of mortality were age 70-80 (OR 3.267, p = 0.029), age >80 (OR 27.043, p < 0.001) and GCS < 15 (OR 8.728, p < 0.001). Ps19 was the best score for predicting mortality (p < 0.001 for each score category), with an AUROC of 0.90. Conclusions The significant mortality predictors were age, GCS < 15 and Ps19. Contrary to previous studies, CCI and APACHE II did not significantly predict mortality. Although Ps19 was found to be the best current prognostic score, trauma prognostication would benefit from a single validated scoring system incorporating both physiological variables and injury patterns. 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F1000Research 2024, 12 :974 ( https://doi.org/10.12688/f1000research.138364.5 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] Previously titled: Predictors of mortality for major trauma patients in intensive care: A retrospective cohort study Michael Jennings https://orcid.org/0000-0001-7588-2827 1,2 , James Booker 3 , Amy Addison 4 , Rebecca Egglestone 1 , Ahilanandan Dushianthan https://orcid.org/0000-0002-0165-3359 1,4,5 Michael Jennings https://orcid.org/0000-0001-7588-2827 1,2 , James Booker 3 , [...] Amy Addison 4 , Rebecca Egglestone 1 , Ahilanandan Dushianthan https://orcid.org/0000-0002-0165-3359 1,4,5 PUBLISHED 06 Dec 2024 Author details Author details 1 General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK 2 Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 3 Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK 4 Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK 5 NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Tremona Road, Southampton, SO16 6YD, UK Michael Jennings Roles: Data Curation, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing James Booker Roles: Data Curation, Formal Analysis, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Amy Addison Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rebecca Egglestone Roles: Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Ahilanandan Dushianthan Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Major trauma places substantial demand on critical care services, is a leading cause of death in under 40-year-olds and causes significant morbidity and mortality across all age groups. Various factors influence patient outcome and predefining these could allow prognostication. The aim of this study was to identify predictors of mortality from major trauma in intensive care. Methods This was a retrospective study of adult trauma patients admitted to general intensive care between January 2018 and December 2019. We assessed the impact on mortality of patient demographics, patterns of injury, injury scores (Glasgow Coma Score (GCS), Charlson’s comorbidity index (CCI), Acute Physiology and Health Evaluation II (APACHE II), Injury Severity Score (ISS) and Probability of Survival Score (Ps19)), number of surgeries and mechanism of injury using logistic regression. Results A total of 414 patients were included with a median age of 54 years (IQR 34–72). Overall mortality was 18.6%. The most common mechanism of injury was traffic collision (46%). Non-survivors were older, had higher ISS scores with lower GCS on admission and lower probability of survival scores. Factors independently predictive of mortality were age 70-80 (OR 3.267, p = 0.029), age >80 (OR 27.043, p < 0.001) and GCS < 15 (OR 8.728, p < 0.001). Ps19 was the best score for predicting mortality (p < 0.001 for each score category), with an AUROC of 0.90. Conclusions The significant mortality predictors were age, GCS < 15 and Ps19. Contrary to previous studies, CCI and APACHE II did not significantly predict mortality. Although Ps19 was found to be the best current prognostic score, trauma prognostication would benefit from a single validated scoring system incorporating both physiological variables and injury patterns. READ ALL READ LESS Keywords intensive care, critical care, trauma, mortality, scoring systems Corresponding Author(s) Michael Jennings ( [email protected] ) Close Corresponding author: Michael Jennings Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Jennings M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Jennings M, Booker J, Addison A et al. Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.12688/f1000research.138364.5 ) First published: 14 Aug 2023, 12 :974 ( https://doi.org/10.12688/f1000research.138364.1 ) Latest published: 06 Dec 2024, 12 :974 ( https://doi.org/10.12688/f1000research.138364.5 ) Revised Amendments from Version 4 The primary change for this version included recalculation of CCI values for the univariate analysis and calculation of a modified CCI variable removing the age component for the multivariate analysis. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract has been updated to include the newly calculated odds ratios. Methods section has been updated to include explanation of our calculation of a modified CCI score which removes the age component of CCI for the multivariate analysis. CCI medians were recalculated and updated in table 1. CCI values were recalculated and updated in the univariate analysis section of the results and in table 2. Modified CCI was added to the multivariate analysis section of the results and updated in table 3. Section added to discussion containing explanation for significance of CCI in univariate analysis but not multivariate analysis. New data has been uploaded to online repository and references updated accordingly. The primary change for this version included recalculation of CCI values for the univariate analysis and calculation of a modified CCI variable removing the age component for the multivariate analysis. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract has been updated to include the newly calculated odds ratios. Methods section has been updated to include explanation of our calculation of a modified CCI score which removes the age component of CCI for the multivariate analysis. CCI medians were recalculated and updated in table 1. CCI values were recalculated and updated in the univariate analysis section of the results and in table 2. Modified CCI was added to the multivariate analysis section of the results and updated in table 3. Section added to discussion containing explanation for significance of CCI in univariate analysis but not multivariate analysis. New data has been uploaded to online repository and references updated accordingly. See the authors' detailed response to the review by Adnan Özpek See the authors' detailed response to the review by Neta Cohen READ REVIEWER RESPONSES Introduction Major trauma accounts for almost 10% of all deaths worldwide. 1 The National Audit Office estimates that there are more than 20,000 major trauma cases each year in England, resulting in 5,400 deaths. 2 Furthermore, the demographics and injury patterns of the major trauma population in the UK are changing. Data from the Trauma Audit and Research Network (TARN) show that there has been an increase in the mean age of trauma patients between 1990 and 2013 (36.1 years to 53.8 years), along with a change in the most common mechanism of injury from road traffic collision (RTC) (59.1%) in 1990, to low fall (39.1%) in 2013. Critically unwell trauma patients typically require admission to the Intensive Care Unit (ICU), frequently making up the most resource-intensive critical care patient group (46.9% of ICU patients in a multicentre US study), 3 with significant morbidity and mortality. The burden caused by trauma patients on healthcare systems and the shifts in trauma patient populations has increased the need for evaluating existing scoring systems for their prognostication potential in the ICU trauma population. 4 Predicting mortality in the critically unwell trauma patient poses a significant challenge due to the heterogeneity of the patient group and the multitude of patient specific factors that affect ICU outcomes, such as age, comorbidities, and injury patterns. 5 – 10 Many of these factors have been examined by several previous studies, but there is no consensus on the most useful prognostication scores. Both physiological and anatomical scoring systems have been purported to correlate best with mortality, 11 , 12 thus there is a current requirement for development of a new scoring tool for early mortality prediction in trauma ICU patients that incorporates a combination of physiological and anatomical scoring components. 13 , 14 The aim of this investigation was to determine which patient specific factors (present at the point of admission) and which injury severity scoring systems are the most accurate predictors of poor outcome in trauma patients admitted to ICU. Methods Study design This is a retrospective study of all critically ill trauma patients aged ≥18 years admitted to the General Intensive Care Unit (GICU) at Southampton General Hospital, between January 2018 and December 2019. 15 Major trauma patients were defined as those who had sustained significant injuries due to trauma, resulting in requirement for organ support. Only these patients met the admission requirements for GICU and only GICU patients were included in this study. Patients admitted to other clinical areas including the high dependency unit (HDU) and the neurosciences intensive care unit (NICU) were excluded. These patients did not meet major trauma admission criteria for GICU because they had suffered either minor trauma or isolated neurological trauma, thus they were deemed outside the scope of this study. Penetrating trauma patients were not deliberately excluded, however, our dataset contained only blunt trauma patients as a consequence of the local epidemiology. The sample size was determined by the number patients admitted during the defined time period and was comparable to studies of similar design. Authors did not have access to information that could identify individual participants during or after data collection. Ethical approval was obtained through Ethics and Research Governance Online (ERGO) by the Faculty of Medicine at Southampton University on 4 August 2020, Reference 56519. This study was part of the large CRIT-CO study (Outcomes of Patients Admitted with Critical-Illness to the General Intensive Care Unit – a Retrospective Observational Study) IRAS Reference 232922. This study used retrospective analysis of non-identifiable patient data, thus the need for individual informed consent was waived. Baseline data and outcomes The following variables were collected from all available Southampton General Hospital databases: age, sex, comorbidities, mechanism of injury, and injury distribution. 15 The following scores were recorded based on each patient’s condition on admission: Glasgow Coma Score (GCS) – assessment of impairment of conscious level in response to defined stimuli, initially developed for assessment of traumatic brain injury. It has a minimum score of 3 and a maximum score of 15 and is the most widely-used score we evaluated. 16 Injury Severity Score (ISS) – used to describe severity of injury in trauma patients. Injury severity of each of 6 body systems are scored according the Abbreviated Injury Scale (AIS) 0-6. The three body systems with the highest AIS scores are used to calculate ISS. Each is squared and the sum of these three scores gives the ISS which ranges in value from 3-75. If any system has an 'unsurvivable' injury (AIS = 6), the total score automatically becomes 75. 17 TARN Probability of Survival Score (Ps19) – an updated composite score based on Trauma Score and Injury Severity Score (TRISS). It incorporates age, sex, trauma type (blunt/penetrating), Revised Trauma Score (RTS), Injury Severity Score (ISS), Glasgow Coma Scale (GCS), number of comorbidities and outcomes at 30 days to give a probability of survival. 18 Acute Physiology and Health Evaluation II (APACHE II) score – a physiological scoring system that incorporates age, serum laboratory values (pH, sodium, potassium, creatinine, haematocrit, white blood cell count), patient signs (temperature, mean arterial pressure, heart rate, respiratory rate, FiO2), and both acute and chronic diseases (acute renal failure, history of immunocompromise and organ failure). APACHE II is normally used for predicting mortality in ICU patients. The score ranges from 0-71 with increasing score associated with higher mortality. 19 Charlson’s comorbidity index (CCI) – most widely used comorbidity index. Determines survival rate (1 year and 10 year) in patients with multiple comorbidities. CCI has been adapted multiple times since its inception in 1987 and for the purposes of our study, CCI was determined using an online calculator. 20 0-4 points were assigned for advancing age and between 1 and 6 points are assigned for comorbidities based on their severity including myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, rheumatological disease, peptic ulcer disease, liver disease, diabetes, hemiplegia, paraplegia, renal disease, malignancy, leukaemia, lymphoma and acquired immunodeficiency syndrome (AIDS). Scores were summed to provide a total score to predict mortality. For the multivariate analysis, a modified CCI score was calculated by subtracting the age component of CCI from the total CCI score to avoid confounding between age and CCI. The outcomes evaluated in our study were duration of mechanical ventilation, ICU and hospital length of stay, and 28-day all cause hospital mortality. Statistical analysis Continuous variables are expressed as median and interquartile range (IQR). Mann Whitney U was used as the statistical analysis for continuous variables and chi-square for categorical variables. The distribution of variables was assessed and if they had a non-normal distribution they were dichotomised into categorical variables with equal sized groups. Univariate analysis using logistic regression to investigate if variables that varied significantly between the survival and non-survival group, were also significant predictors of mortality. Prior to a multivariate analysis a correlation matrix was done to assess the collinearity between each of the significant predictors using Spearman’s test. This informed the subsequent multivariate analysis using a logistic regression to identify independent significant predictors of survival. Predictors were deemed significant if p < 0.05. Additionally, receiver operating characteristics (ROC) area under the curve (AUC) graphs were constructed to assess each variables performance in predicting mortality. Data analysis was done in SPSS Version 25 (RRID:SCR_016479) and RStudio Version 1.4.1103 (RRID:SCR_000432) using packages: dplyr, ggplot2, lme4 and pROC. 15 Results Demographics A total of 414 critically injured trauma patients were admitted to the Intensive Care Unit between January 2018 and December 2019. Of these, 69.3% (n = 287) were male and 30.7% (n = 127) were female. The median age was 54 years (IQR 34–72). Of those admitted, 66.2% (n = 274) had at least one co-morbidity and the median CCI was 1 (IQR 0–3). The most common mechanism of injury was vehicle incident (46.1%), followed by fall <2 metres (23.9%). The most common body part injured was chest (29.2%), followed by other (20%), multiple injuries (19.1%), head (12.1%), abdominal (8.7%), spinal (6.3%), limbs (3.6%) and facial injuries (1%) ( Figure 1 ). The median GCS, ISS and APACHE II scores were 15, 22 and 11 respectively. Figure 1. The mechanism of injury and proportion of injuries in different body regions. Overall, the 28-day all cause hospital survival was 81.4% (n = 337), with survivors being on average younger than non-survivors (51 (32–68) vs 74-years-old (55–85). There were no survival differences between male and female patients. Survivors had fewer comorbidities than non survivors (CCI medians of 1 (0–4) and 4, 1 – 4 respectively). Among non-survivors, fall of <2 metres was the most common mechanism of injury (39%) reflecting the older age of this group, followed by an RTC (32.5%). Among survivors, the most common mechanism of injury was RTC (49.3%), followed by fall from <2 metres (20.5%). Non-survivors had lower GCS at presentation than survivors (9 vs 15). They also had higher ISS (25 vs 20) and higher APACHE-II scores (13 vs 11) than survivors at presentation. The Ps19 predictive model was significantly lower for non-survivors (59 vs 98). The type of body region injured also varied between survivors and non-survivors. The non-survivors had increased frequency of head injury and the survivors had more chest injuries. Abdominal injuries were more common in survivors than non-survivors (10.1% vs 2.6%), whereas limb injuries were more common in non-survivors than survivors (10.4% and 2.1% respectively) ( Table 1 ). Table 1. Patient demographics and injury characteristics. Variable All patients (n = 414) Survivors (n = 337) Non-survivors (n = 77) Age, years 54 (34–72) 51 (32–68) 74 (55–85) Gender Female 127 (30.7%) 103 (30.6%) 24 (31.2%) Male 287 (69.3%) 234 (69.4%) 53 (68.8%) Co-morbidity Any 274 (66.2%) 218 (64.7%) 56 (72.72) CCI median 2 (1-4) 2 (1-4) 4 (2-5) Mechanism of injury Vehicle incident (RTC) 191 (46.1%) 166 (49.3%) 25 (32.5%) Fall > 2 m 58 (14.0%) 48 (14.2%) 10 (13.0%) Fall < 2 m 99 (23.9%) 69 (20.5%) 30 (39.0%) Other 66 (15.9%) 54 (16.0%) 12 (15.6%) GCS 15 (14–15) 15 (14–15) 9 (3–15) ISS score 22 (13–29) 20 (12–29) 25 (16–38) Ps19 97 (86–99) 98 (92–99) 59 (25–85) APACHE II 11 (7–14) 11 (7–14) 13 (9–18) Number of surgeries (n) 1 (0–2) 1 (0–2) 0 (0–1) Most severely injured body region : Head 50 (12.1%) 24 (7.1%) 26 (33.8%) Face 4 (1.0%) 4 (1.2%) 0 Chest 121 (29.2%) 112 (33.3%) 9 (11.7%) Spine 26 (6.3%) 22 (6.5%) 4 (5.2%) Abdomen 36 (8.7%) 34 (10.1%) 2 (2.6%) Multiple 79 (19.1%) 64 (19.0%) 15 (19.5%) Limbs 15 (3.6%) 7 (2.1%) 8 (10.4%) Other 83 (20.0%) 70 (20.8%) 13 (16.9%) We performed univariate logistic regression analysis to assess the association between common variables that demonstrated significant difference between survivor and non-survivor groups with 28-day hospital survival ( Table 2 ). In the univariate analysis, the following factors were found to be significant predictors of mortality: age (OR 1.04, CI 1.03-1.06, p < 0.001), CCI (OR 1.51, CI 1.32-1.74, p < 0.001, fall <2 metres (OR 3,17, CI 1.74–5.84, p < 0.001), GCS <15 (OR 3.79, CI 2.21–6.63, p < 0.001), ISS 41–60 (OR 3.10, CI 1.46–6.46, p = 0.00269), Ps19 < 81 (p = 0.001), number of surgeries (OR 0.627, CI 0.467–0.806, p < 0.001) and the most severely injured body region of the head (OR 11.1, CI 4.87–27.1, p < 0.001), multiple injuries (OR 2.60, CI 1.12–6.31, p = 0.0288) and other injuries (OR 12.7, 95% CI (3.84–44.0, p = 0.001) ( Table 2 ). A multivariate analysis was conducted using these variables which demonstrated that age 70-80 (OR 3.267, CI 1.102-9.404, p = 0.029), age >80 (OR 27.043, CI 10.228-78.264, p < 0.001) and GCS < 15 (OR 8.728, CI 4.273-19.504, p < 0.001), were independent predictors of mortality ( Table 3 ). Modified CCI, fall <2 metres, and number of surgeries were not found to independently predict mortality in the multivariate analysis. Table 2. Univariate analysis of variables that significantly differed between survivor and non-survivor groups using logistic regression to predict mortality. Predictor Estimate Standard error Z value P value OR (CI) Age 0.0437 0.00710 6.15 <0.001 *** 1.04 (1.03-1.06) Charlson Comorbidity Index 0.414 0.0.071 5.849 2 m • Fall<2 m • Other 0 a 0.371 1.15 0.436 0 a 0.411 0.308 0.387 0 a 0.905 3.75 1.13 0 a 0.366 <0.001 *** 0.260 0 a 1.45 (0.624-3.17) 3.17 (1.74-5.84) 1.55 (0.705-3.25) Glasgow Coma Score (GCS) • 15 • <15 0 a 1.33 0 a 0.279 0 a 4.77 0 a <0.001 *** 0 a 3.79 (2.21-6.63) Injury Severity Score (ISS) • 1-20 • 21-40 • 41-60 • 61-80 0 a 0.541 1.13 1.89 0 a 0.285 0.378 1.02 0 a 1.90 3.00 1.85 0 a 0.0580 0.00269 ** 0.0645 0 a 1.72 (0.985-3.02) 3.10 (1.46-6.46) 6.62 (0.767-57.1) Probability of Survival (Ps19) • 81-100 • 61-80 • 41-60 • 21-40 • 0-20 0 a 2.18 3.51 2.81 5.33 0 a 0.420 0.569 0.549 1.05 0 a 5.18 6.17 5.12 5.06 0 a <0.001 *** <0.001 *** <0.001 *** <0.001 *** 0 a 8.81 (3.82-20.1) 33.5 (11.6-112) 16.5 (5.68-50.3) 206 (39.4-3800) APACHE II • 0-10 • 11-20 • 21-30 0 a 0.648 0.638 0 a 0.406 0.701 0 a 1.60 0.910 0 a 0.110 0.363 0 a 1.91 (0.874-4.36) 1.89 (0.399-6.83) Number of surgeries -0.466 0.139 -3.35 0.001 *** 0.627(0.467-0.806) Most severely injured body region • Chest • Head • Face • Spine • Abdomen • Multiple • Limbs • Other 0 a 2.41 -13.2 0.702 -0.426 0.956 0.723 2.54 0 a 0.435 728 0.636 0.799 0.437 0.448 0.614 0 a 5.54 -0.018 1.10 0.533 2.19 1.62 4.14 0 a <0.001 *** 0.986 0.270 0.594 0.0288 * 0.106 0.001 *** 0 a 11.1 (4.87-27.1) 0 (0-2x10 30 ) 2.02 (0.517-6.66) 0.653 (0.0973-2.63) 2.60 (1.12-6.31) 2.06 (0.861-5.07) 12.7 (3.84-44.0) * p < 0.05. ** p < 0.01. *** p < 0.001. Table 3. Multivariate analysis of variables that were significant in the univariate analysis that were not prediction variables. Analysis done using logistic regression predicting mortality. Predictor Estimate Standard error Z value P value OR (CI) Age • 80 0 a 1.010 0.663 1.184 3.297 0 a 0.523 0.576 0.541 0.517 0 a 1.929 1.153 2.187 6.382 0 a 0.090 0.284 0.029 * <0.001 *** 0 a 2.744 (0.955-7.590) 1.941 (0.594-5.484) 3.267 (1.102-9.404) 27.043 (10.228-78.264) Modified Charlson’s Comorbidity Index (CCI) -0.002 0.226 -0.007 0.994 0.998 (0.627-1.538) Glasgow Coma Score (GCS) • 15 • <15 0 a 2.167 0 a 0.384 0 a 5.643 0 a 2 m • Fall<2 m • Other 0 a 0.164 0.512 0.840 0 a 0.489 0.419 0.481 0 a 0.337 1.224 1.746 0 a 0.736 0.221 0.081 0 a 1.179 (0.435-3.007) 1.670 (0.733-3.814) 2.316 (0.886-5.922) Number of surgeries -0.123 0.131 -0.940 0.347 0.884 (0.667-1.122) * p < 0.05. ** p < 0.01. *** p < 0.001. We performed a probability of survival analysis based on variables including age and the scoring systems Ps19, ISS, GCS, and APACHE-II ( Figure 2 ). For Ps19 ( Figure 2A ), patients with a low Ps19 0–20 had an almost linear decrease in survival probability up until 14 days, had a lower survival probability and were more likely to die sooner. Patients with Ps19 scores between 21–60 had similar survival probabilities until day seven, at which point they diverge with the 41–60 group having the lowest survival probability at 28 days (28%), and the 21–40 group having a survival probability of 44%. Patients with Ps19 scores of 61 or higher had significantly higher probability of survival than the other groups, with the 61–80 group demonstrating more than 70% chance of survival at 28 days. The Ps19 score >80 group demonstrated a survival probability of over 90%. Figure 2. Survival probability and trauma scoring systems. Probability of survival against total number of days in hospital. Patients are categorised into groups based on their scores in scoring systems. A: Ps19 Survival probability. B: APACHE II Survival probability. APACHE II scores could not be calculated for 139 patients, so this is taken into consideration with a N/A line. One patient was excluded from the APACHE II graph due to being the only one who had a score >30. C: GCS Survival probability. D: ISS Survival probability. APACHE II: Acute physiology and chronic health evaluation; GCS: Glasgow coma scale; ISS: Injury severity score; Ps19: Probability of survival. For APACHE II score, likelihood of survival at 28 days decreased with increasing APACHE II scores ( Figure 2B ). Until the seventh day there was a similar survival curve for all APACHE II scores groups, after which patients with a score of 0–10 clearly show a higher probability of survival compared to patients with an APACHE II score of 11–20 or 21–30, (92%, 89% and 87% at 28 days, respectively). Patients with reduced GCS ( Figure 2C ), had lower likelihood of survival compared to those admitted GCS 15 (73% and 94% at 28 days respectively). For ISS scores ( Figure 2D ), patients in the highest score range (61–80) had only a 50% chance of survival at 28 days. Patients with a score of 41–60 had a 70% survival probability, those scoring 21–40 had an 84% chance of survival whereas the group scoring 1–20 had a 90% probability of survival. Thus, a higher ISS score was associated with a lower probability of survival. The difference between the predicted Ps19 and observed mortality for the cohort is shown in Figure 3 . The Ps19 predicted score was similar to the expected mortality for most ages, except for the groups >80 years of age ( Figure 3 ). Figure 3. Observed vs Ps19 predicted survival in different age groups. The area under the receiver operator curve (AUROC) was statistically significant for all variables ( Figure 4 ). Ps19 was the best predictor of mortality with an AUROC of 0.90 (95% CI 0.85–0.96) followed by GCS AUROC of 0.75 (95% CI 0.64–0.86) and age 0.73 (95% CI 0.62–0.85). ISS, APACHE II and number of surgeries were less predictive of mortality in comparison to these variables with ISS being the worst predictor with an AUROC of 0.66 (95% CI 0.50–0.76). Figure 4. ROC curves comparing predictors of mortality. Calculated for APACHE II Score, ISS, GCS, Ps19 and Number of surgeries in mortality correlation prediction. ROC: receiver operator characteristic, AUROC: area under the receiver operator curve, APACHE II: Acute physiological assessment and chronic health evaluation, ISS: Injury Severity Score, GCS: Glasgow Coma Scale, Ps19: Probability of Survival Score. Overall, 190 patients (45.9%) required invasive mechanical ventilation and the proportion was higher in non-survivors, compared with survivors (68.8% vs 40.7%) and for both groups the duration of mechanical ventilation was three days. Median ICU and hospital length stay were 3 (IQR 1, 7) and 13 (IQR 7, 26) respectively. There was no statistically significant difference between the ICU length of stay (LOS) for survivors and non-survivors; however, survivors had a longer hospital LOS (15 vs 7 days p < 0.01) ( Table 4 ). Table 4. Duration of mechanical ventilation, ICU and hospital length of stay. Data presented as median and interquartile ranges. Outcome All patients Survivors Non-survivors p-value Mechanical ventilation days 3 (2, 6) 3 (2, 6) 3 (2, 6) 0.772 ICU length of stay (days) 3 (1, 7) 3 (1, 7) 3 (1, 6) 0.430 Hospital length of stay (days) 13 (7, 26) 15 (9, 27) 7 (2,18) <0.001 *** * p < 0.05. ** p < 0.01. *** p < 0.001. Discussion This study evaluated different patient specific and injury specific factors that influence hospital mortality in critically ill blunt trauma patients. Patient specific factors we investigated included age, gender, and pre-existing comorbidities. Increased age was unsurprisingly found to be associated with a higher mortality. This association is likely to be multifactorial due to an increased risk of frailty, higher likelihood of under triage, and altered physiological mechanisms in elderly patients. Moreover, older patients may have fallen due to an intracranial neurological reason, and are also more likely to develop complications from a long-lie. Older patients have increased comorbidities with concurrent risk of polypharmacy including anticoagulant medication, which further increases risk of adverse outcome from trauma. Presence of comorbidities in our cohort as determined by CCI was found to be predictive of mortality in the univariate analysis, however modified CCI was not found to be predictive of mortality in the multivariate analysis. This suggests the predictive power of CCI was dominated by the age component. In contrast to our findings, previous studies have found a direct impact of CCI on mortality. 13 Whilst some studies have given conflicting evidence as to the effect of comorbidities on hospital length of stay, 21 , 22 their importance is acknowledged by their inclusion in trauma scoring systems such as the Ps19 model. In our study, only age and GCS were found were associated with increased hospital mortality in critically ill trauma patients in the multivariate model. Injury specific factors such as mechanism of injury, body region injured, and severity of injury were all found to affect mortality in our univariate analyses. In our cohort, most deaths were due to head injuries or polytrauma. Falls and RTC were the most common mechanism of injury, which is consistent with published data from both the UK and the USA. 23 , 24 The overall mortality in our cohort was 18.6%, with an increased mortality in patients with a fall from <2 metres. Of those injured in an RTC, 86.9% survived compared to 69.7% of those who fell 2 metres are considered by NHS England a sufficient mechanism to activate major trauma responses and divert patients to a Major Trauma Centre. 25 It appeared counterintuitive that patient falls <2 metres had worse outcomes. However, this finding was not significant in the multivariate model and can be explained by a higher age in this cohort. Older patients are more likely to have severe injuries from <2 metres and subsequent ICU admission. This is consistent with national data from the TARN database. 26 In our multivariate models, no injury specific factors were found to be an independent predictor for mortality, which is consistent with findings from previous studies. 12 , 27 Two recent single-centre retrospective observational studies found the following factors to be associated with increased mortality in ICU from trauma: age >60 years, comorbidities (CCI), severity of trauma (New Injury Severity Score (NISS) and Revised Injury Severity Classification (RISC)), patient severity (APACHE II), traumatic brain injury, the use of mechanical ventilation, renal dysfunction in the first 24 hours, and the use of vasoactive drugs and circulatory complications. 28 , 29 In contrast to our findings, the scores most highly predictive for mortality were APACHE II and NISS. An Australian meta-analysis of over 5000 patients across 25 centres demonstrated similar findings but also showed the Australian and New Zealand Risk of Death (ANZROD) mortality prediction model and APACHE III to be superior to the anatomical scoring systems for mortality prediction (e.g., ISS and NISS). 13 Although a higher APACHE II score and CCI were more commonly found in the non-survivor group in our study, these associations proved inadequate predictors of mortality in univariate analyses. However, our findings agreed with previous work that an increased ISS and decreased Ps19 both predict increased mortality. 27 , 29 – 31 Ps19 was our best performing mortality predictor with an AUROC of 0.9 (95% Cl 0.85–0.96), outperforming ISS (the most used scoring tool). Our study presents significant limitations. Firstly, the dataset was collected retrospectively from a single centre, notably excluding patients with primary head injury. Secondly, our study did not extensively examine indicators of patient morbidity following trauma; for example, renal dysfunction and ICU interventions such as other organ support measures including renal replacement therapy and the use of vasopressors. We also did not assess other important outcomes such as lasting neurological deficits, rehabilitation required following discharge, which may have provided further context for mortality prediction analyses. We did not include some trauma scores which other authors have found valuable, such as the calculated Revised Trauma Score (cRTS), analysis of which would have produced a more exhaustive study. Finally, the outcome of our study was limited to 28-day mortality and does not report mortality data at longer timepoints. Whilst there are logistical challenges with data collection over extended timeframes in ICU patients following their discharge, the decision to limit the mortality window to 28 days limits the scope of conclusions to prognostication within a short pre-defined window. Nevertheless, our study complements the existing literature with noteworthy analysis of the mortality prediction capability of a range of scoring systems including ICU specific scoring systems and presents comparable sample sizes to similar recent single-centre studies. 28 , 29 It was also noted that neither of these studies included the Ps19 scoring system, which is currently used by the TARN (UK), which we found to be the most highly predictive of mortality from trauma in ICU. Conclusions This study shows that various internal and external factors determine the mortality of ICU patients within a single-centre general ICU. The most significant independent predictors of mortality were age, and GCS. Ps19 and ISS were also found to be useful scores for mortality prediction in our probability of survival analyses. Ps19 was the best performing score overall for mortality prediction. Contrary to previous studies, we did not demonstrate a strong association between mortality and the CCI and APACHE II scoring systems. Our study findings suggest helpful scoring systems, however, currently no scoring system is exhaustive and larger studies exploring multiple component of age, patient characteristics, injury types and frailty may be useful for trauma prognostication. An all-inclusive single validated scoring system incorporating physiological variables, injury patterns and ICU variables could mitigate extended ICU stays by ensuring that interventions patients receive are better tailored to their individual physiological profile and possibly reduce overall mortality in ICU trauma patients. Future studies would benefit from inclusion of morbidity indicators to provide context for the quality of life experienced by survivors of major trauma. Data availability Underlying data Zenodo: Underlying data for ‘Predictors of mortality for major trauma patients in intensive care: A retrospective cohort study’, https://doi.org/10.5281/zenodo.14218022 . 15 This project contains the following underlying data: • Data sheet 2018–2019 29.09.20.xlsx • Trauma analysis.pptx • Ps19 vs survival.tiff • ROCs.tiff • traumadata.csv Reporting guidelines STROBE checklist for ‘Predictors of mortality for major trauma patients in intensive care: A retrospective cohort study’, https://doi.org/10.5281/zenodo.14218022 . 15 Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). 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Comments on this article Comments (0) Version 5 VERSION 5 PUBLISHED 14 Aug 2023 ADD YOUR COMMENT Comment Author details Author details 1 General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK 2 Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 3 Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK 4 Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK 5 NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Tremona Road, Southampton, SO16 6YD, UK Michael Jennings Roles: Data Curation, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing James Booker Roles: Data Curation, Formal Analysis, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Amy Addison Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rebecca Egglestone Roles: Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Ahilanandan Dushianthan Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (5) version 5 Revised Published: 06 Dec 2024, 12:974 https://doi.org/10.12688/f1000research.138364.5 version 4 Revised Published: 01 Oct 2024, 12:974 https://doi.org/10.12688/f1000research.138364.4 version 3 Revised Published: 12 Aug 2024, 12:974 https://doi.org/10.12688/f1000research.138364.3 version 2 Revised Published: 24 Jun 2024, 12:974 https://doi.org/10.12688/f1000research.138364.2 version 1 Published: 14 Aug 2023, 12:974 https://doi.org/10.12688/f1000research.138364.1 Copyright © 2024 Jennings M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Jennings M, Booker J, Addison A et al. Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.12688/f1000research.138364.5 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 5 VERSION 5 PUBLISHED 06 Dec 2024 Revised Views 0 Cite How to cite this report: Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.174997.r346596 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v5#referee-response-346596 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Dec 2024 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel Approved VIEWS 0 https://doi.org/10.5256/f1000research.174997.r346596 The authors much improved their methods ... Continue reading READ ALL The authors much improved their methods and I have no more comments. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.174997.r346596 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v5#referee-response-346596 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 4 VERSION 4 PUBLISHED 01 Oct 2024 Revised Views 0 Cite How to cite this report: Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.172463.r328484 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v4#referee-response-328484 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Oct 2024 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.172463.r328484 CCI reflects both patients age and comorbidities, hence, CCI and age are cofactors. The authors removed CCI from tha analysis, but it was not what I meant. CCI is an important factor as it reflects both age and ... Continue reading READ ALL CCI reflects both patients age and comorbidities, hence, CCI and age are cofactors. The authors removed CCI from tha analysis, but it was not what I meant. CCI is an important factor as it reflects both age and chronic disease. Hence , the authors need to remove points from CCI of each one of the patients, which were given due to advanced age (0-4 points are assigned for advancing age). In this way, the authors will have the ability to explore age and chronic disease separately: they will create 2 separate different parameters: 1. age 2. Comorbidities. Next, they can insert both age and comorbidity to the multivariable model to see if they may be independent predictors for mortality. The other option (more easy, less accurate) is to insert only CCI (and not age) to the multivariable analysis, but then we could not know if the comorbidity or age are responsible for the outcome - it can be discussed in the discussion. In any way: to remove CCI from the analysis is not acceptable as it is a very important parameter for mortality... Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.172463.r328484 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v4#referee-response-328484 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Dec 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 06 Dec 2024 Author Response Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI ... Continue reading Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI variable removing the age component for the multivariate analysis as you have suggested. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract - updated to include the newly calculated odds ratios. Methods - updated to include explanation of a modified CCI score which removes the age component of CCI for the multivariate analysis. Results - Table 1 - CCI medians were recalculated. CCI values were recalculated and updated in the univariate analysis and in Table 2. Modified CCI was added to the multivariate analysis section and added to Table 3. Discussion - Explanation added for significance of CCI in univariate analysis but not multivariate analysis. New dataset added to online repository and references updated. Best wishes, Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI variable removing the age component for the multivariate analysis as you have suggested. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract - updated to include the newly calculated odds ratios. Methods - updated to include explanation of a modified CCI score which removes the age component of CCI for the multivariate analysis. Results - Table 1 - CCI medians were recalculated. CCI values were recalculated and updated in the univariate analysis and in Table 2. Modified CCI was added to the multivariate analysis section and added to Table 3. Discussion - Explanation added for significance of CCI in univariate analysis but not multivariate analysis. New dataset added to online repository and references updated. Best wishes, Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Dec 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 06 Dec 2024 Author Response Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI ... Continue reading Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI variable removing the age component for the multivariate analysis as you have suggested. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract - updated to include the newly calculated odds ratios. Methods - updated to include explanation of a modified CCI score which removes the age component of CCI for the multivariate analysis. Results - Table 1 - CCI medians were recalculated. CCI values were recalculated and updated in the univariate analysis and in Table 2. Modified CCI was added to the multivariate analysis section and added to Table 3. Discussion - Explanation added for significance of CCI in univariate analysis but not multivariate analysis. New dataset added to online repository and references updated. Best wishes, Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI variable removing the age component for the multivariate analysis as you have suggested. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract - updated to include the newly calculated odds ratios. Methods - updated to include explanation of a modified CCI score which removes the age component of CCI for the multivariate analysis. Results - Table 1 - CCI medians were recalculated. CCI values were recalculated and updated in the univariate analysis and in Table 2. Modified CCI was added to the multivariate analysis section and added to Table 3. Discussion - Explanation added for significance of CCI in univariate analysis but not multivariate analysis. New dataset added to online repository and references updated. Best wishes, Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Version 3 VERSION 3 PUBLISHED 12 Aug 2024 Revised Views 0 Cite How to cite this report: Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.169909.r313280 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v3#referee-response-313280 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Aug 2024 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.169909.r313280 I hope this time authors will address the critical issues.: 1. Cci definition 2. Cci and age are co factors and can not be analysed together in this form 3. Major trauma definition to understand the inclusion ... Continue reading READ ALL I hope this time authors will address the critical issues.: 1. Cci definition 2. Cci and age are co factors and can not be analysed together in this form 3. Major trauma definition to understand the inclusion criteria Minor comments are : 1. Fall from 2 meters definition in the methods, 2. Definition of all severity scores 3. Insert ps 19 to the roc curve figure to see its performance compared to other. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.169909.r313280 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v3#referee-response-313280 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 01 Oct 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 01 Oct 2024 Author Response Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and ... Continue reading Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and indexing. We have taken care to address your concerns in turn. The changes we have made are as follows: 1) GCS, ISS, Ps19, APACHE II and CCI have now been defined in the methods section and appropriate references added. 2) Major trauma for the purposes of this study has been defined in the paragraph on study design in the methods section. 3) CCI has been removed from the multivariable analysis (Table 3) because it was a confounder. The results section and the abstract have been updated to reflect this new data in table 3. 4) Ps19 was added to the ROC curves in figure 4 to compare its performance against other scoring systems. 5) Figure legends for figure 3 and 4 were switched - this was a mistake in the previous version and the figure legend for figure 4 has been altered to better reflect the contents of the figure. I hope you are willing to approve the updated manuscript. Best wishes Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and indexing. We have taken care to address your concerns in turn. The changes we have made are as follows: 1) GCS, ISS, Ps19, APACHE II and CCI have now been defined in the methods section and appropriate references added. 2) Major trauma for the purposes of this study has been defined in the paragraph on study design in the methods section. 3) CCI has been removed from the multivariable analysis (Table 3) because it was a confounder. The results section and the abstract have been updated to reflect this new data in table 3. 4) Ps19 was added to the ROC curves in figure 4 to compare its performance against other scoring systems. 5) Figure legends for figure 3 and 4 were switched - this was a mistake in the previous version and the figure legend for figure 4 has been altered to better reflect the contents of the figure. I hope you are willing to approve the updated manuscript. Best wishes Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 01 Oct 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 01 Oct 2024 Author Response Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and ... Continue reading Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and indexing. We have taken care to address your concerns in turn. The changes we have made are as follows: 1) GCS, ISS, Ps19, APACHE II and CCI have now been defined in the methods section and appropriate references added. 2) Major trauma for the purposes of this study has been defined in the paragraph on study design in the methods section. 3) CCI has been removed from the multivariable analysis (Table 3) because it was a confounder. The results section and the abstract have been updated to reflect this new data in table 3. 4) Ps19 was added to the ROC curves in figure 4 to compare its performance against other scoring systems. 5) Figure legends for figure 3 and 4 were switched - this was a mistake in the previous version and the figure legend for figure 4 has been altered to better reflect the contents of the figure. I hope you are willing to approve the updated manuscript. Best wishes Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and indexing. We have taken care to address your concerns in turn. The changes we have made are as follows: 1) GCS, ISS, Ps19, APACHE II and CCI have now been defined in the methods section and appropriate references added. 2) Major trauma for the purposes of this study has been defined in the paragraph on study design in the methods section. 3) CCI has been removed from the multivariable analysis (Table 3) because it was a confounder. The results section and the abstract have been updated to reflect this new data in table 3. 4) Ps19 was added to the ROC curves in figure 4 to compare its performance against other scoring systems. 5) Figure legends for figure 3 and 4 were switched - this was a mistake in the previous version and the figure legend for figure 4 has been altered to better reflect the contents of the figure. I hope you are willing to approve the updated manuscript. Best wishes Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 24 Jun 2024 Revised Views 0 Cite How to cite this report: Özpek A. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.167939.r295150 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v2#referee-response-295150 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 03 Jul 2024 Adnan Özpek , Umraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey Approved VIEWS 0 https://doi.org/10.5256/f1000research.167939.r295150 Dear Editor, I do not have any additional revision suggestions ... Continue reading READ ALL Dear Editor, I do not have any additional revision suggestions regarding the article. It can be indexed in its current form. Best Regards, Dr.Adnan Özpek Competing Interests: No competing interests were disclosed. Reviewer Expertise: General Surgery, Trauma and Emergency Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Özpek A. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.167939.r295150 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v2#referee-response-295150 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.167939.r295151 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v2#referee-response-295151 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 02 Jul 2024 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.167939.r295151 My main additional comments to the authors are: 1. A. Please test in your univariable analysis the parameter " CCI" (either as any or as continuous variable). B. Please explain what is CCI and how did you calculate ... Continue reading READ ALL My main additional comments to the authors are: 1. A. Please test in your univariable analysis the parameter " CCI" (either as any or as continuous variable). B. Please explain what is CCI and how did you calculate it, and if you took age >60 etc as one of the parameters to calculate the CCI. C. Due to its importance, even if it is not significant in the univariable analysis, you can still test it in your multivariable model. To improve the sensitivity of mulktivariable models I reccomend either to insert any clinical important variable (according to the authors decision and based on the literature) OR to rely on the univariable findings but with higher P value (0.1 is acceptable). Personally I prefer the first method. 2. With respect to fall< 2 meters - if it is not significant in the multivariable model - so it is not significant and doesnt merit any further details. you can simply conclude that no mechanism was independent predictor for severity in your analysis , and to cite relevant literature with similar findings. Mechanism is known from previous studies to be poorly associated with injury severity. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.167939.r295151 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v2#referee-response-295151 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 12 Aug 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 12 Aug 2024 Author Response Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within ... Continue reading Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within the univariate and multivariate analyses. (Tables 2 and 3) Your other comments have been addressed within the body of the new manuscript. Many thanks, Dr Mike Jennings Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within the univariate and multivariate analyses. (Tables 2 and 3) Your other comments have been addressed within the body of the new manuscript. Many thanks, Dr Mike Jennings Competing Interests: No competing interests were disclosed. Close Report a concern Author Response 12 Aug 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 12 Aug 2024 Author Response Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section ... Continue reading Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section has been updated to remove fall < 2m and injury to the head and limbs as significant mortality predictors because these were not significant in the new multivariate analysis. Methods: A description of how CCI was calculated has been added Results: Multivariate analysis section has been updated to include CCI as one of the variables Table 2 has been reformatted to fix an issue with alignment. Table 3 has been changed to include CCI as one of the variables tested Discussion: The section on age as a significant mortality indicator has been reworded to include parts of the discussion that originally referred to falls < 2m. This was in line with Dr Cohen’s suggestions that we should not place emphasis on falls <2 predicting mortality, given that this finding was not significant in the multivariate analysis. Further explanation of this has been added when we refer to age as a confounding factor in the falls < 2m paragraph. Conclusion: Fall from a height of <2m and injury of head and limbs have been removed from the conclusion in line with our latest multivariate analysis Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section has been updated to remove fall < 2m and injury to the head and limbs as significant mortality predictors because these were not significant in the new multivariate analysis. Methods: A description of how CCI was calculated has been added Results: Multivariate analysis section has been updated to include CCI as one of the variables Table 2 has been reformatted to fix an issue with alignment. Table 3 has been changed to include CCI as one of the variables tested Discussion: The section on age as a significant mortality indicator has been reworded to include parts of the discussion that originally referred to falls < 2m. This was in line with Dr Cohen’s suggestions that we should not place emphasis on falls <2 predicting mortality, given that this finding was not significant in the multivariate analysis. Further explanation of this has been added when we refer to age as a confounding factor in the falls < 2m paragraph. Conclusion: Fall from a height of <2m and injury of head and limbs have been removed from the conclusion in line with our latest multivariate analysis Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 12 Aug 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 12 Aug 2024 Author Response Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within ... Continue reading Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within the univariate and multivariate analyses. (Tables 2 and 3) Your other comments have been addressed within the body of the new manuscript. Many thanks, Dr Mike Jennings Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within the univariate and multivariate analyses. (Tables 2 and 3) Your other comments have been addressed within the body of the new manuscript. Many thanks, Dr Mike Jennings Competing Interests: No competing interests were disclosed. Close Report a concern Author Response 12 Aug 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 12 Aug 2024 Author Response Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section ... Continue reading Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section has been updated to remove fall < 2m and injury to the head and limbs as significant mortality predictors because these were not significant in the new multivariate analysis. Methods: A description of how CCI was calculated has been added Results: Multivariate analysis section has been updated to include CCI as one of the variables Table 2 has been reformatted to fix an issue with alignment. Table 3 has been changed to include CCI as one of the variables tested Discussion: The section on age as a significant mortality indicator has been reworded to include parts of the discussion that originally referred to falls < 2m. This was in line with Dr Cohen’s suggestions that we should not place emphasis on falls <2 predicting mortality, given that this finding was not significant in the multivariate analysis. Further explanation of this has been added when we refer to age as a confounding factor in the falls < 2m paragraph. Conclusion: Fall from a height of <2m and injury of head and limbs have been removed from the conclusion in line with our latest multivariate analysis Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section has been updated to remove fall < 2m and injury to the head and limbs as significant mortality predictors because these were not significant in the new multivariate analysis. Methods: A description of how CCI was calculated has been added Results: Multivariate analysis section has been updated to include CCI as one of the variables Table 2 has been reformatted to fix an issue with alignment. Table 3 has been changed to include CCI as one of the variables tested Discussion: The section on age as a significant mortality indicator has been reworded to include parts of the discussion that originally referred to falls < 2m. This was in line with Dr Cohen’s suggestions that we should not place emphasis on falls <2 predicting mortality, given that this finding was not significant in the multivariate analysis. Further explanation of this has been added when we refer to age as a confounding factor in the falls < 2m paragraph. Conclusion: Fall from a height of <2m and injury of head and limbs have been removed from the conclusion in line with our latest multivariate analysis Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 14 Aug 2023 Views 0 Cite How to cite this report: Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.151554.r266548 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v1#referee-response-266548 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 May 2024 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.151554.r266548 This is a retrospective study of all critically ill trauma patients aged ≥18 years admitted to the General Intensive Care Unit (GICU), aimed to determine which patient specific factors (present at the point of admission) and which injury severity scoring systems ... Continue reading READ ALL This is a retrospective study of all critically ill trauma patients aged ≥18 years admitted to the General Intensive Care Unit (GICU), aimed to determine which patient specific factors (present at the point of admission) and which injury severity scoring systems are the most accurate predictors of poor outcome in trauma patients admitted to ICU. Such similar studies were performed earlier (Cohen, N., et.al., 2023 (Ref 1) However, considering the importance of the topic, and the appropriate design, I believe it merit publication. Comments: 1. Why did you exclude patients from high dependency units and neuroscience intensive care unit? 2. CCI and AGE are co-factors, as age >60 is one of the factors including in the CCI. Try to examine each one separately in the logistic regression model. Please add it in addition to your limitation. 3, How do you explain falling from height 2 meters? how did you decide about cut-off of 2 meters ( the usual cutoff is 3 meters).? 4. Please explain better what are the implication of your findings? Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly References 1. Cohen N, Mattar R, Feigin E, Mizrahi M, et al.: Refining triage practices by predicting the need for emergent care following major trauma: the experience of a level 1 adult trauma center. Eur J Trauma Emerg Surg . 2023; 49 (4): 1717-1725 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: pediatric emergency medicine, emergency medicine, trauma I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cohen N. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.151554.r266548 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v1#referee-response-266548 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 24 Jun 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 24 Jun 2024 Author Response Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the ... Continue reading Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the high dependency unit and the neuroscience intensive care unit has been further explained within the methods section. 2) To address your comments that CCI and age are cofactors, the univariate and multivariate analyses in tables 2 and 3 have been reanalysed with age as a categorical variable. 3) Falls of less than 2 meters were found to be a significant predictor of mortality in the univariate analysis, but not the multivariate analysis. The explanation of this finding has been added to the discussion section along with an explanation for why the cut-off of two meters was chosen. 4) This discussion and conclusion sections of the manuscript have been improved to explain the implications of our findings in more detail. Many thanks Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the high dependency unit and the neuroscience intensive care unit has been further explained within the methods section. 2) To address your comments that CCI and age are cofactors, the univariate and multivariate analyses in tables 2 and 3 have been reanalysed with age as a categorical variable. 3) Falls of less than 2 meters were found to be a significant predictor of mortality in the univariate analysis, but not the multivariate analysis. The explanation of this finding has been added to the discussion section along with an explanation for why the cut-off of two meters was chosen. 4) This discussion and conclusion sections of the manuscript have been improved to explain the implications of our findings in more detail. Many thanks Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 24 Jun 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 24 Jun 2024 Author Response Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the ... Continue reading Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the high dependency unit and the neuroscience intensive care unit has been further explained within the methods section. 2) To address your comments that CCI and age are cofactors, the univariate and multivariate analyses in tables 2 and 3 have been reanalysed with age as a categorical variable. 3) Falls of less than 2 meters were found to be a significant predictor of mortality in the univariate analysis, but not the multivariate analysis. The explanation of this finding has been added to the discussion section along with an explanation for why the cut-off of two meters was chosen. 4) This discussion and conclusion sections of the manuscript have been improved to explain the implications of our findings in more detail. Many thanks Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the high dependency unit and the neuroscience intensive care unit has been further explained within the methods section. 2) To address your comments that CCI and age are cofactors, the univariate and multivariate analyses in tables 2 and 3 have been reanalysed with age as a categorical variable. 3) Falls of less than 2 meters were found to be a significant predictor of mortality in the univariate analysis, but not the multivariate analysis. The explanation of this finding has been added to the discussion section along with an explanation for why the cut-off of two meters was chosen. 4) This discussion and conclusion sections of the manuscript have been improved to explain the implications of our findings in more detail. Many thanks Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Özpek A. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.151554.r246878 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v1#referee-response-246878 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 01 Mar 2024 Adnan Özpek , Umraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.151554.r246878 I congratulate the authors for their study. My suggestions for the study are as follows: 1- It appears that all the patients in the study were blunt trauma patients, which should be noted in the title of this article. If ... Continue reading READ ALL I congratulate the authors for their study. My suggestions for the study are as follows: 1- It appears that all the patients in the study were blunt trauma patients, which should be noted in the title of this article. If patients with penetrating trauma are included in the study, it should be stated. 2- Calculated Revised Trauma Score (cRTS) also can be used in addition to the trauma scoring systems used in the study. 3- In the study, mortality rates for falls below 2 meters were significantly higher than for falls above 2 meters. This is not an expected result. It should be questioned whether the patients who fell below 2 meters fell due to an intracranial neurological reason. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: General Surgery, Trauma and Emergency Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Özpek A. Reviewer Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.151554.r246878 ) The direct URL for this report is: https://f1000research.com/articles/12-974/v1#referee-response-246878 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 24 Jun 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 24 Jun 2024 Author Response Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma ... Continue reading Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma patients were included. See changes to title, abstract and methods section. 2) Mention of cRTS has been added to the limitations section of the discussion as an example of useful scoring systems that were omitted. 3) Factors contributing to our finding that falls < 2 metres being associated with higher mortality have been discussed in more detail in the discussion section. Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma patients were included. See changes to title, abstract and methods section. 2) Mention of cRTS has been added to the limitations section of the discussion as an example of useful scoring systems that were omitted. 3) Factors contributing to our finding that falls < 2 metres being associated with higher mortality have been discussed in more detail in the discussion section. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 24 Jun 2024 Michael Jennings , Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK 24 Jun 2024 Author Response Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma ... Continue reading Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma patients were included. See changes to title, abstract and methods section. 2) Mention of cRTS has been added to the limitations section of the discussion as an example of useful scoring systems that were omitted. 3) Factors contributing to our finding that falls < 2 metres being associated with higher mortality have been discussed in more detail in the discussion section. Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma patients were included. See changes to title, abstract and methods section. 2) Mention of cRTS has been added to the limitations section of the discussion as an example of useful scoring systems that were omitted. 3) Factors contributing to our finding that falls < 2 metres being associated with higher mortality have been discussed in more detail in the discussion section. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 5 VERSION 5 PUBLISHED 14 Aug 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 5 (revision) 06 Dec 24 read Version 4 (revision) 01 Oct 24 read Version 3 (revision) 12 Aug 24 read Version 2 (revision) 24 Jun 24 read read Version 1 14 Aug 23 read read Adnan Özpek , University of Health Sciences, İstanbul, Turkey Neta Cohen , Tel Aviv University, Tel Aviv, Israel Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Dec 2024 | for Version 5 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors much improved their methods and I have no more comments. Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Cohen N. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.174997.r346596) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-974/v5#referee-response-346596 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Oct 2024 | for Version 4 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions CCI reflects both patients age and comorbidities, hence, CCI and age are cofactors. The authors removed CCI from tha analysis, but it was not what I meant. CCI is an important factor as it reflects both age and chronic disease. Hence , the authors need to remove points from CCI of each one of the patients, which were given due to advanced age (0-4 points are assigned for advancing age). In this way, the authors will have the ability to explore age and chronic disease separately: they will create 2 separate different parameters: 1. age 2. Comorbidities. Next, they can insert both age and comorbidity to the multivariable model to see if they may be independent predictors for mortality. The other option (more easy, less accurate) is to insert only CCI (and not age) to the multivariable analysis, but then we could not know if the comorbidity or age are responsible for the outcome - it can be discussed in the discussion. In any way: to remove CCI from the analysis is not acceptable as it is a very important parameter for mortality... Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 06 Dec 2024 Michael Jennings, Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK Dear Dr Cohen, Thank you for your comments. I hope you will find our changes suitable. We have recalculated CCI values for the univariate analysis and calculated a modified CCI variable removing the age component for the multivariate analysis as you have suggested. This has resulted in new values in tables 1, 2 and 3. We have therefore modified the following sections of the manuscript: Abstract - updated to include the newly calculated odds ratios. Methods - updated to include explanation of a modified CCI score which removes the age component of CCI for the multivariate analysis. Results - Table 1 - CCI medians were recalculated. CCI values were recalculated and updated in the univariate analysis and in Table 2. Modified CCI was added to the multivariate analysis section and added to Table 3. Discussion - Explanation added for significance of CCI in univariate analysis but not multivariate analysis. New dataset added to online repository and references updated. Best wishes, View more View less Competing Interests None reply Respond Report a concern Cohen N. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.172463.r328484) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-974/v4#referee-response-328484 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Aug 2024 | for Version 3 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I hope this time authors will address the critical issues.: 1. Cci definition 2. Cci and age are co factors and can not be analysed together in this form 3. Major trauma definition to understand the inclusion criteria Minor comments are : 1. Fall from 2 meters definition in the methods, 2. Definition of all severity scores 3. Insert ps 19 to the roc curve figure to see its performance compared to other. Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 01 Oct 2024 Michael Jennings, Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK Dear Dr Cohen, I hope you will approve of the changes we have made to the manuscript for V4 and will now be able to approve its publication and indexing. We have taken care to address your concerns in turn. The changes we have made are as follows: 1) GCS, ISS, Ps19, APACHE II and CCI have now been defined in the methods section and appropriate references added. 2) Major trauma for the purposes of this study has been defined in the paragraph on study design in the methods section. 3) CCI has been removed from the multivariable analysis (Table 3) because it was a confounder. The results section and the abstract have been updated to reflect this new data in table 3. 4) Ps19 was added to the ROC curves in figure 4 to compare its performance against other scoring systems. 5) Figure legends for figure 3 and 4 were switched - this was a mistake in the previous version and the figure legend for figure 4 has been altered to better reflect the contents of the figure. I hope you are willing to approve the updated manuscript. Best wishes View more View less Competing Interests None reply Respond Report a concern Cohen N. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.169909.r313280) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-974/v3#referee-response-313280 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Özpek A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 03 Jul 2024 | for Version 2 Adnan Özpek , Umraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey 0 Views copyright © 2024 Özpek A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear Editor, I do not have any additional revision suggestions regarding the article. It can be indexed in its current form. Best Regards, Dr.Adnan Özpek Competing Interests No competing interests were disclosed. Reviewer Expertise General Surgery, Trauma and Emergency Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Özpek A. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.167939.r295150) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-974/v2#referee-response-295150 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 02 Jul 2024 | for Version 2 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (2) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions My main additional comments to the authors are: 1. A. Please test in your univariable analysis the parameter " CCI" (either as any or as continuous variable). B. Please explain what is CCI and how did you calculate it, and if you took age >60 etc as one of the parameters to calculate the CCI. C. Due to its importance, even if it is not significant in the univariable analysis, you can still test it in your multivariable model. To improve the sensitivity of mulktivariable models I reccomend either to insert any clinical important variable (according to the authors decision and based on the literature) OR to rely on the univariable findings but with higher P value (0.1 is acceptable). Personally I prefer the first method. 2. With respect to fall< 2 meters - if it is not significant in the multivariable model - so it is not significant and doesnt merit any further details. you can simply conclude that no mechanism was independent predictor for severity in your analysis , and to cite relevant literature with similar findings. Mechanism is known from previous studies to be poorly associated with injury severity. Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (2) Author Response 12 Aug 2024 Michael Jennings, Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK Dear Dr Cohen, Thank you for your comments on the latest version of the manuscript. In line with your suggestions, for the new version CCI is now included within the univariate and multivariate analyses. (Tables 2 and 3) Your other comments have been addressed within the body of the new manuscript. Many thanks, Dr Mike Jennings View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Author Response 12 Aug 2024 Michael Jennings, Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK Updates from version 2 (v2) to version 3 (v3) are detailed as follows: Abstract: Results section has been updated to include new values from the multivariate regression. Conclusion section has been updated to remove fall < 2m and injury to the head and limbs as significant mortality predictors because these were not significant in the new multivariate analysis. Methods: A description of how CCI was calculated has been added Results: Multivariate analysis section has been updated to include CCI as one of the variables Table 2 has been reformatted to fix an issue with alignment. Table 3 has been changed to include CCI as one of the variables tested Discussion: The section on age as a significant mortality indicator has been reworded to include parts of the discussion that originally referred to falls < 2m. This was in line with Dr Cohen’s suggestions that we should not place emphasis on falls <2 predicting mortality, given that this finding was not significant in the multivariate analysis. Further explanation of this has been added when we refer to age as a confounding factor in the falls < 2m paragraph. Conclusion: Fall from a height of <2m and injury of head and limbs have been removed from the conclusion in line with our latest multivariate analysis View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Cohen N. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.167939.r295151) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-974/v2#referee-response-295151 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 May 2024 | for Version 1 Neta Cohen , Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel 0 Views copyright © 2024 Cohen N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a retrospective study of all critically ill trauma patients aged ≥18 years admitted to the General Intensive Care Unit (GICU), aimed to determine which patient specific factors (present at the point of admission) and which injury severity scoring systems are the most accurate predictors of poor outcome in trauma patients admitted to ICU. Such similar studies were performed earlier (Cohen, N., et.al., 2023 (Ref 1) However, considering the importance of the topic, and the appropriate design, I believe it merit publication. Comments: 1. Why did you exclude patients from high dependency units and neuroscience intensive care unit? 2. CCI and AGE are co-factors, as age >60 is one of the factors including in the CCI. Try to examine each one separately in the logistic regression model. Please add it in addition to your limitation. 3, How do you explain falling from height 2 meters? how did you decide about cut-off of 2 meters ( the usual cutoff is 3 meters).? 4. Please explain better what are the implication of your findings? Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly References 1. Cohen N, Mattar R, Feigin E, Mizrahi M, et al.: Refining triage practices by predicting the need for emergent care following major trauma: the experience of a level 1 adult trauma center. Eur J Trauma Emerg Surg . 2023; 49 (4): 1717-1725 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise pediatric emergency medicine, emergency medicine, trauma I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 24 Jun 2024 Michael Jennings, Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK Thank you very much for your comments. The manuscript has been amended to address them and we have now submitted an updated version. 1) Exclusion of patients from the high dependency unit and the neuroscience intensive care unit has been further explained within the methods section. 2) To address your comments that CCI and age are cofactors, the univariate and multivariate analyses in tables 2 and 3 have been reanalysed with age as a categorical variable. 3) Falls of less than 2 meters were found to be a significant predictor of mortality in the univariate analysis, but not the multivariate analysis. The explanation of this finding has been added to the discussion section along with an explanation for why the cut-off of two meters was chosen. 4) This discussion and conclusion sections of the manuscript have been improved to explain the implications of our findings in more detail. Many thanks View more View less Competing Interests None reply Respond Report a concern Cohen N. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.151554.r266548) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-974/v1#referee-response-266548 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Özpek A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 01 Mar 2024 | for Version 1 Adnan Özpek , Umraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey 0 Views copyright © 2024 Özpek A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I congratulate the authors for their study. My suggestions for the study are as follows: 1- It appears that all the patients in the study were blunt trauma patients, which should be noted in the title of this article. If patients with penetrating trauma are included in the study, it should be stated. 2- Calculated Revised Trauma Score (cRTS) also can be used in addition to the trauma scoring systems used in the study. 3- In the study, mortality rates for falls below 2 meters were significantly higher than for falls above 2 meters. This is not an expected result. It should be questioned whether the patients who fell below 2 meters fell due to an intracranial neurological reason. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise General Surgery, Trauma and Emergency Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 24 Jun 2024 Michael Jennings, Department of Anaesthetics and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK Thank you very much for your comments. They have been addressed in the new updated manuscript. 1) The article has been amended to include stipulation that only blunt trauma patients were included. See changes to title, abstract and methods section. 2) Mention of cRTS has been added to the limitations section of the discussion as an example of useful scoring systems that were omitted. 3) Factors contributing to our finding that falls < 2 metres being associated with higher mortality have been discussed in more detail in the discussion section. View more View less Competing Interests None reply Respond Report a concern Özpek A. Peer Review Report For: Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study [version 5; peer review: 2 approved] . F1000Research 2024, 12 :974 ( https://doi.org/10.5256/f1000research.151554.r246878) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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