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will be a key issue in the following years<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a> and constitute an area of uncertainty&#44; especially in trauma patients&#46; In this setting&#44; clinical guidelines from <span class="elsevierStyleItalic">The Eastern Association for the Surgery of Trauma</span> suggest that in the very old trauma patient&#44; the presence of multiple comorbidities is not necessarily an indicator of poor outcome and&#44; with the exception of the moribund geriatric trauma patients&#44; the initial treatment approach must follow the same principles that in younger counterparts&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> The final outcomes of very elderly trauma patients are a matter of debate&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#8211;10</span></a> but recent evidence supports an initial aggressive approach and admission to specialized trauma ICUs&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our objective was to analyze the outcomes and factors related to mortality of very elderly trauma patients admitted to the ICUs participating in the Spanish Trauma ICU Registry &#40;RETRAUCI&#41;&#44; taking into consideration the influence of the limitation of life sustaining therapies &#40;LLST&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">RETRAUCI is an observational&#44; prospective and multicenter nationwide registry initiated on November&#44; 2012&#46; It has the endorsement of the <span class="elsevierStyleItalic">Neurointensive Care and Trauma Working Group</span> of the <span class="elsevierStyleItalic">Spanish Society of Intensive Care Medicine</span> &#40;<span class="elsevierStyleItalic">SEMICYUC</span>&#41;&#46; It currently includes 50 registered ICUs with 124 investigators collecting data from trauma patients on a web-based system &#40;<a href="http://www.retrauci.org/">www&#46;retrauci&#46;org</a>&#41;&#46; Ethics Committee approval for the registry was obtained &#40;Hospital Universitario 12 de Octubre&#44; Madrid&#58; 12&#47;209&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We included in this study all traumatic patients aged &#8805;80 years-old in the participating ICUs from November&#44; 2012 to May&#44; 2017 with complete medical records &#40;death or hospital discharge&#41;&#46; Data on epidemiology&#44; acute management&#44; type and severity of injury&#44; resources utilization&#44; complications and outcomes were recorded&#46; The list of definitions used is shown in the <span class="elsevierStyleItalic">Electronic Supplementary Material</span>&#44; as previously published&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> As per protocol&#44; LLST &#40;withholding or withdrawing therapy&#41; is noted in the registry as a dichotomous variable &#40;yes&#47;no&#41;&#46; Patients were followed-up until hospital discharge&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data used for calculating the <span class="elsevierStyleItalic">Revised Trauma Score</span> &#40;RTS&#41; &#40;respiratory rate&#44; systolic blood pressure and Glasgow coma scale score&#41; were obtained from the first medical attention before initiating resuscitation and&#47;or mechanical ventilation&#46; Data used for calculating the <span class="elsevierStyleItalic">Injury Severity Score</span> &#40;ISS&#41; were prospectively collected by the intensivist at charge of the patient after ICU admission according to the <span class="elsevierStyleItalic">Abbreviated Injury Scale</span> &#40;AIS&#41; updated in 2008&#46; Probability of survival was calculated using the <span class="elsevierStyleItalic">Trauma and Injury Severity Score</span> &#40;<span class="elsevierStyleItalic">TRISS</span>&#41; methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a> The expected mortality for the whole sample was calculated as the sum of the individual probabilities of mortality&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Incomplete data to obtain hospital outcome was the exclusion criteria&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Quantitative data were reported as median<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation and categorical data as number &#40;percentage&#41;&#46; Comparison of groups with quantitative variables was performed using Wilcoxon test and differences between groups with categorical variables were compared using the Chi-squared test or Fisher&#39;s exact test as appropriate&#46; A multiple logistic regression analysis was performed to analyze clinical variables related to mortality&#46; The variables entered in logistic regression analysis were those significantly associated with mortality in the univariate analysis&#46; A <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered significant&#46; We reported all results as stated in the RECORD statement&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a> Statistical analysis was performed with STATA 15 &#40;StataCorp&#46; 2017&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 465 patients &#40;8&#37; of the whole sample&#41; aged &#8805;80 years-old were included&#46; Six patients were excluded from the final analysis because of incomplete data or unknown outcome at hospital discharge &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Mean age was 83&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;3 years&#44; being male 281 &#40;60&#46;4&#37;&#41;&#46; Antiplatelets or anticoagulants were prescribed previously in 271 patients &#40;59&#46;3&#37;&#41;&#46; The main mechanisms of injury were low-energy falls in 256 patients &#40;55&#46;1&#37;&#41; and road traffic accidents in 153 patients &#40;33&#46;3&#37;&#41;&#46; Trauma was blunt in 99&#37; of the cases&#46; Hemodynamic instability was found in 189 patients &#40;41&#46;2&#37;&#41;&#46; Unilateral mydriasis was found in 37 patients &#40;8&#46;1&#37;&#41; and bilateral mydriasis in 36 patients &#40;7&#46;8&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Mean <span class="elsevierStyleItalic">ISS</span> was 20&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;1&#46; According to the <span class="elsevierStyleItalic">AIS</span>&#44; the most severe injuries corresponded to the area of the head &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Up to 125 very elderly patients &#40;27&#46;3&#37;&#41; underwent urgent &#40;&#60;24<span class="elsevierStyleHsp" style=""></span>h&#41; surgical procedures&#44; being the most frequent the neurosurgical interventions &#40;57 out of 125 patients&#44; 45&#46;6&#37; of the urgent surgeries performed&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Very elderly patients developed respiratory failure &#40;paO2&#47;FiO2<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>300&#41; in 130 cases &#40;28&#46;3&#37;&#41; and required mechanical ventilation in 259 cases &#40;56&#46;4&#37;&#41;&#46; Tracheostomy was performed in 38 patients &#40;8&#46;3&#37;&#41;&#46; Different degrees of renal failure were found in 130 patients &#40;28&#46;3&#37;&#41; and only 11 patients &#40;2&#46;4&#37;&#41; were treated with continuous renal replacement therapy&#46; Rhabdomyolysis was found in 52 patients &#40;11&#46;3&#37;&#41; and massive hemorrhage in 19 patients &#40;4&#46;1&#37;&#41;&#46; A total of 84 patients &#40;18&#46;1&#37;&#41; developed nosocomial infections and 70 patients &#40;14&#37;&#41; developed multiorgan failure&#46; Intracranial hypertension was found in 102 patients &#40;22&#46;2&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mean ICU length of stay was 7&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;9 days and mean length of hospital stay after ICU was 8&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;2 days&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Probability of survival using the <span class="elsevierStyleItalic">TRISS</span> methodology was 69&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;7&#37;&#46; ICU mortality was 15&#46;5&#37; &#40;71 patients&#41;&#46; Hospital mortality after ICU was 3&#46;7&#37; &#40;17 patients&#41;&#46; Overall&#44; in-hospital mortality was 19&#46;2&#37; &#40;88 patients&#41;&#46; The main reason was intracranial hypertension &#40;42&#46;7&#37; of the cases&#41;&#46; Multiple logistic regression analysis showed that the <span class="elsevierStyleItalic">ISS</span> &#40;OR 1&#46;02 95&#37; CI 1&#46;002&#8211;1&#46;051&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#44; the need of first-tier measures to control intracranial pressure &#40;OR 2&#46;85 95&#37; CI 1&#46;143&#8211;7&#46;142&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; the need of second-tier measures to control intracranial pressure &#40;OR 4&#46;56 95&#37; CI 1&#46;740&#8211;11&#46;957&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41; and being admitted to the ICU for intensive care oriented t organ donation &#40;OR 6&#46;61 95&#37; CI 3&#46;121&#8211;14&#46;035&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were independent predictors of death&#46; Predicted and observed mortality distributed by severity of TBI is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Interestingly&#44; 41 patients &#40;9&#37;&#41; were admitted to the ICU for intensive care oriented to donation&#46; Among them&#44; 10 patients &#40;24&#46;4&#37;&#41; actually became organ donors&#46; Additionally&#44; 8 patients who received active ICU treatment also developed brain death and became effective organ donors&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Limitation of life sustaining therapies occurred in 128 patients &#40;27&#46;9&#37;&#41;&#46; When distributing very elderly patients with or without LLST orders we found that patients with LLST were older&#44; with higher severity of injury and with more severe brain injury&#44; as stated by the number of patients with pupillary abnormalities and the AIS head score &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main result of our study was that very elderly trauma patients presented mortality rates were lower than predicted&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The observed mortality found in our series of very elderly trauma patients admitted to the ICU supports the initial aggressive acute care of these patients&#44; as outlined in <span class="elsevierStyleItalic">the Eastern Association for the Surgery of Trauma</span> practice management guideline&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> Mock et al&#46; recently published a single center study of 192 trauma ICU patients with a mean age of 86 years-old and mean <span class="elsevierStyleItalic">ISS</span> 17&#46; Their patients had a 22&#37; mortality rate&#44; similar to that predicted by the <span class="elsevierStyleItalic">Geriatric Trauma Outcome Score</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> The results are comparable to ours&#44; in a less aged population &#40;83&#46;4 years-old&#41; but with most severe trauma&#44; as stated by the mean ISS 20&#46;5&#46; Mock et al&#46; performed a multivariate analysis analyzing factors related to mortality and found that the need of mechanical ventilation&#44; days on mechanical ventilation and admission lactate were independent predictors of outcome&#46; In our series&#44; the severity of injury evaluated by the <span class="elsevierStyleItalic">ISS</span> and specially&#44; the burden of brain injury as demonstrated by the need of first- and second-tier measures to control ICP and being admitted to the ICU oriented to organ donation were independent predictors of death&#46; Consequently&#44; intracranial hypertension was the main cause of death&#46; In the study by Hwabejire et al&#46; including nonagenarian and centenarian patients with an ISS 12&#44; independent predictors of cumulative 1-year mortality were head injury and length of hospital stay&#46; Cumulative 1-year mortality in patients with head injury was 51&#46;1&#37; and increased to 73&#46;2&#37; if the <span class="elsevierStyleItalic">ISS</span> was 25 or higher and to 78&#46;7&#37; if mechanical ventilation was required&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> Our results are in consonance with previous studies in very elderly patients admitted in mixed ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> A recent prediction tool has been developed for medical ICU very elderly patents&#46; Factors related with mortality were age&#44; serum creatinine&#44; Glasgow Coma Scale and serum pH&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> However&#44; this prediction tool has not been validated in very elderly patients with severe trauma yet&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Controversy surrounding the ICU admission of very elderly patients exists&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">17&#44;18</span></a> Our data support admitting these patients and perform an ICU trial&#46; Thereafter&#44; in non-responding trauma patients&#44; LLST should be considered&#46; In our sample&#44; up to 27&#46;9&#37; of trauma patients over 80 years-old received LLST&#44; a percentage very close to that found in a recent multicenter study in general ICU patients including trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> In our study&#44; LLST were more likely to occur in older patients&#44; with higher severity of injury and with more severe brain injury&#44; as stated by the number of patients with pupillary abnormalities and the AIS head score&#44; similarly to the results found by Pe&#241;asco et al&#46; in trauma patients &#8805;65 years-old&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">As known&#44; TBI is a major concern in this population<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a> and plays a major role in outcomes&#44; as seen in our series&#46; However&#44; neurosurgical interventions and modern neurointensive care have improved outcomes of geriatric TBI&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> In the series by Merzo et al&#46;&#44; up to 55&#37; of patients from 70 to 79 years-old and up to 30&#37; of octogenarians with TBI had a favorable neurological outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> Our results also point in this direction since mortality was markedly lower than predicted even in the group who received LLST&#46; This can help to overcome past nihilism when approaching geriatric TBI&#44; which was supported by the 60&#37; mortality and more than 80&#37; of severe neurological disability in patients aged &#62;70 years-old reported by Hukkelhoven et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> and the ominous 6-month outcomes in moderate to severe geriatric TBI patients &#40;none of them was living independently&#41; shown by Utomo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Additionally&#44; we must keep in mind the possibility that this group of patients might increase the pool of organ donors following the intensive care oriented to organ donation strategy&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#44;26</span></a> Up 9&#37; of octogenarians were admitted to the ICU following this policy&#44; but only 1 out of 4 among them finally developed brain death and became organ donors&#46; Eight additional patients developed brain death after active ICU treatment&#46; Overall&#44; 3&#46;9&#37; of octogenarian trauma ICU patients were ultimately organ donors&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study has some limitations that must be acknowledged&#58; the most important one is that our retrospective study is focused in survival rather than in quality of life and this is of special relevance in very elderly patients&#46; In addition we did not take into consideration comorbidities or frailty&#44; which are major determinants of different outcomes in this population&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> and we must acknowledge a selection bias&#44; since we only studied octogenarians ICU patients and this may not represent the whole trauma octogenarian population&#46; We did not evaluate predicted mortality using the specific <span class="elsevierStyleItalic">Geriatric Trauma Outcome Score</span><a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> as did Mock et al&#46; We used the conventional <span class="elsevierStyleItalic">TRISS</span> methodology since we previously compared the performance of the TRISS methodology and the <span class="elsevierStyleItalic">Geriatric Trauma Outcome Score</span> in our geriatric trauma ICU population and we found that the prediction ability of <span class="elsevierStyleItalic">TRISS</span> was higher&#44; most likely due to severity of injury and the high percentage of patients with TBI&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> However&#44; it must be considered that TRISS was created for a different population &#40;younger patients with predominant high-energy mechanisms of injury&#41;&#44; can be difficult to calculate and requires specific skills in the codification of injuries and continuous coefficient updates&#46; Anyway&#44; the mortality of our patients was markedly lower than predicted highlighting the need of newly geriatric-specific scores&#46; Finally&#44; when referred to the analysis of LLST&#44; we did not differentiate between withholding or withdrawing therapies&#44; and unfortunately&#44; our registry cannot provide this information&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; in Spanish ICUs&#44; very elderly trauma ICU patients presented mortality rates lower than predicted by their severity of injury&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Author&#39;s contribution</span><p id="par0125" class="elsevierStylePara elsevierViewall">Mario Chico-Fern&#225;ndez&#58; Design of the study&#44; collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Marcelino S&#225;nchez-Casado&#58; Statistical analysis&#44; critical review&#44; approved the final version&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Jes&#250;s Abelardo Barea-Mendoza&#58; Collected data&#44; statistical analysis&#44; critical review&#44; approved the final version&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Iker Garc&#237;a-S&#225;ez&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Mar&#237;a &#193;ngeles Ballesteros-Sanz&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Francisco Guerrero-L&#243;pez&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Manuel Quintana-D&#237;az&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Ismael Molina-D&#237;az&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Lorena Mart&#237;n-Iglesias&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Jos&#233; Mar&#237;a Toboso-Casado&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Jon P&#233;rez-B&#225;rcena&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Juan Antonio Llompart-Pou&#58; Design of the study&#44; collected data&#44; wrote the first and final draft&#44; approved the final version&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0185" class="elsevierStylePara elsevierViewall">RETRAUCI was supported by a grant for the development of an electronic web-based system awarded to Dr&#46; Chico-Fern&#225;ndez &#40;<span class="elsevierStyleGrantSponsor" id="gs1">Fundaci&#243;n Mutua Madrile&#241;a</span>&#44; reference number <span class="elsevierStyleGrantNumber" refid="gs1">AP117892013</span>&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Presentation</span><p id="par0190" class="elsevierStylePara elsevierViewall">A preliminary version of this manuscript was presented at the LIII CONGRESO NACIONAL SEMICYUC held in Granada&#44; June 2018&#44; obtaining the second prize in the &#8220;PREMIO DR&#46; HELIODORO SANCHO RUIZ&#8221; to the best poster presentation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units &#40;ICUs&#41; participating in the Spanish trauma ICU registry&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A multicenter nationwide registry&#46; Retrospective analysis&#46; November 2012&#8211;May 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Participating ICUs&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Trauma patients aged &#8805;80 years&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The outcomes and influence of limitation of life sustaining therapy &#40;LLST&#41; were analyzed&#46; Comparisons were established using the Wilcoxon test&#44; Chi-squared test or Fisher&#39;s exact test as appropriate&#46; Multiple logistic regression analysis was performed to analyze variables related to mortality&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05 was considered statistically significant&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The mean patient age was 83&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;3 years&#59; 281 males &#40;60&#46;4&#37;&#41;&#46; Low-energy falls were the mechanisms of injury in 256 patients &#40;55&#46;1&#37;&#41;&#46; The mean ISS was 20&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;1&#44; with a mean ICU stay of 7&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;9 days&#46; The probability of survival based on the TRISS methodology was 69&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;7&#37;&#46; The ICU mortality rate was 15&#46;5&#37;&#44; with an in-hospital mortality rate of 19&#46;2&#37;&#46; The main cause of mortality was intracranial hypertension &#40;42&#46;7&#37;&#41;&#46; The ISS&#44; the need for first- and second-tier measures to control intracranial pressure&#44; and being admitted to the ICU for organ donation were independent mortality predictors&#46; LLST was applied in 128 patients &#40;27&#46;9&#37;&#41;&#46; Patients who received LLST were older&#44; with more severe trauma&#44; and with more severe brain injury&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury&#46;</p></span>"
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            "titulo" => "Objective"
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          1 => array:2 [
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            "titulo" => "Design"
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            "titulo" => "Patients"
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            "titulo" => "Main variables of interest"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analizar el desenlace y los factores relacionados con la mortalidad de los pacientes traum&#225;ticos muy ancianos ingresados en las Unidades de Cuidados Intensivos &#40;UCI&#41; participantes en el Registro Espa&#241;ol de Trauma en las UCI &#40;RETRAUCI&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Registro multic&#233;ntrico nacional&#46; An&#225;lisis retrospectivo&#46; Noviembre de 2012-mayo de 2017&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Las UCI participantes&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes o participantes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pacientes traum&#225;ticos con edad &#8805;80 a&#241;os&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s principales</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Analizamos el desenlace y la influencia de la limitaci&#243;n de los tratamientos de soporte vital &#40;LLST&#41;&#46; Las comparaciones entre grupos se realizaron mediante la prueba de Wilcoxon&#44; la prueba de Chi-cuadrado y la prueba exacta de Fisher seg&#250;n estuviera indicado&#46; Se realiz&#243; un an&#225;lisis multivariante mediante regresi&#243;n log&#237;stica para analizar las variables asociadas a la mortalidad&#46; Un valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 se consider&#243; el l&#237;mite de la significaci&#243;n estad&#237;stica&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 83&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;3 a&#241;os&#46; Varones 281 &#40;60&#44;4&#37;&#41;&#46; La causa principal del traumatismo fueron las ca&#237;das de baja energ&#237;a en 256 pacientes &#40;55&#44;1&#37;&#41;&#46; El Injury Severity Score &#40;ISS&#41; medio fue de 20&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;1&#46; La estancia media en las UCI fue de 7&#44;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;9 d&#237;as&#46; La probabilidad de supervivencia&#44; de acuerdo con la metodolog&#237;a TRISS fue de 69&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#44;7&#37;&#46; La mortalidad en las UCI fue del 15&#44;5&#37;&#46; La mortalidad hospitalaria fue del 19&#44;2&#37;&#46; La causa principal fue la hipertensi&#243;n intracraneal &#40;42&#44;7&#37;&#41;&#46; El <span class="elsevierStyleItalic">ISS</span>&#44; la necesidad de medidas de primer o segundo nivel para controlar la presi&#243;n intracraneal y el ingreso en las UCI orientado a la donaci&#243;n de &#243;rganos fueron predictores independientes de mortalidad&#46; Se document&#243; la LLST en 128 pacientes &#40;27&#44;9&#37;&#41;&#46; Los pacientes con LLST fueron mayores&#44; con una mayor gravedad lesional y un traumatismo craneoencef&#225;lico m&#225;s grave&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los pacientes traum&#225;ticos muy ancianos en las UCI presentaron menor mortalidad de la predicha por la gravedad del traumatismo&#46;</p></span>"
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            "identificador" => "abst0060"
            "titulo" => "Pacientes o participantes"
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            "titulo" => "Intervenciones"
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          5 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Variables de inter&#233;s principales"
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            "titulo" => "Resultados"
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                  \t\t\t\t">AIS head&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AIS face&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AIS thorax&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Original article
Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry
Desenlace de los pacientes traumáticos muy ancianos en la unidad de cuidados intensivos. Resultados del Registro Español de Trauma en las UCI
M. Chico-Fernándeza, M. Sánchez-Casadob, J.A. Barea-Mendozaa, I. García-Sáezc, M.Á. Ballesteros-Sanzd, F. Guerrero-Lópeze, M. Quintana-Díazf, I. Molina-Díazg, L. Martín-Iglesiash, J.M. Toboso-Casadoi, J. Pérez-Bárcenaj, J.A. Llompart-Pouj,
Corresponding author
juanantonio.llompart@ssib.es

Corresponding author.
, On behalf of the Neurointensive Care and Trauma Working Group of the Spanish Society of Intensive Care Medicine (SEMICYUC)
a UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
b Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
c Servicio de Medicina Intensiva, Hospital Universitario Donostia, Donostia, Spain
d Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
e Servicio de Medicina Intensiva, UCI Neurotraumatológica, Hospital Virgen de las Nieves, Granada, Spain
f Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain
g Servicio de Medicina Intensiva, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
h Servicio de Medicina Intensiva, Hospital Universitario Central De Asturias, Asturias, Spain
i Servei de Medicina Intensiva, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
j Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Predicted and observed mortality distributed by severity of traumatic brain injury according to the <span class="elsevierStyleItalic">Abbreviated Injury Scale</span> &#40;<span class="elsevierStyleItalic">AIS</span>&#41;&#46;</p>"
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will be a key issue in the following years<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a> and constitute an area of uncertainty&#44; especially in trauma patients&#46; In this setting&#44; clinical guidelines from <span class="elsevierStyleItalic">The Eastern Association for the Surgery of Trauma</span> suggest that in the very old trauma patient&#44; the presence of multiple comorbidities is not necessarily an indicator of poor outcome and&#44; with the exception of the moribund geriatric trauma patients&#44; the initial treatment approach must follow the same principles that in younger counterparts&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> The final outcomes of very elderly trauma patients are a matter of debate&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#8211;10</span></a> but recent evidence supports an initial aggressive approach and admission to specialized trauma ICUs&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our objective was to analyze the outcomes and factors related to mortality of very elderly trauma patients admitted to the ICUs participating in the Spanish Trauma ICU Registry &#40;RETRAUCI&#41;&#44; taking into consideration the influence of the limitation of life sustaining therapies &#40;LLST&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">RETRAUCI is an observational&#44; prospective and multicenter nationwide registry initiated on November&#44; 2012&#46; It has the endorsement of the <span class="elsevierStyleItalic">Neurointensive Care and Trauma Working Group</span> of the <span class="elsevierStyleItalic">Spanish Society of Intensive Care Medicine</span> &#40;<span class="elsevierStyleItalic">SEMICYUC</span>&#41;&#46; It currently includes 50 registered ICUs with 124 investigators collecting data from trauma patients on a web-based system &#40;<a href="http://www.retrauci.org/">www&#46;retrauci&#46;org</a>&#41;&#46; Ethics Committee approval for the registry was obtained &#40;Hospital Universitario 12 de Octubre&#44; Madrid&#58; 12&#47;209&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We included in this study all traumatic patients aged &#8805;80 years-old in the participating ICUs from November&#44; 2012 to May&#44; 2017 with complete medical records &#40;death or hospital discharge&#41;&#46; Data on epidemiology&#44; acute management&#44; type and severity of injury&#44; resources utilization&#44; complications and outcomes were recorded&#46; The list of definitions used is shown in the <span class="elsevierStyleItalic">Electronic Supplementary Material</span>&#44; as previously published&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> As per protocol&#44; LLST &#40;withholding or withdrawing therapy&#41; is noted in the registry as a dichotomous variable &#40;yes&#47;no&#41;&#46; Patients were followed-up until hospital discharge&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data used for calculating the <span class="elsevierStyleItalic">Revised Trauma Score</span> &#40;RTS&#41; &#40;respiratory rate&#44; systolic blood pressure and Glasgow coma scale score&#41; were obtained from the first medical attention before initiating resuscitation and&#47;or mechanical ventilation&#46; Data used for calculating the <span class="elsevierStyleItalic">Injury Severity Score</span> &#40;ISS&#41; were prospectively collected by the intensivist at charge of the patient after ICU admission according to the <span class="elsevierStyleItalic">Abbreviated Injury Scale</span> &#40;AIS&#41; updated in 2008&#46; Probability of survival was calculated using the <span class="elsevierStyleItalic">Trauma and Injury Severity Score</span> &#40;<span class="elsevierStyleItalic">TRISS</span>&#41; methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a> The expected mortality for the whole sample was calculated as the sum of the individual probabilities of mortality&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Incomplete data to obtain hospital outcome was the exclusion criteria&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Quantitative data were reported as median<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation and categorical data as number &#40;percentage&#41;&#46; Comparison of groups with quantitative variables was performed using Wilcoxon test and differences between groups with categorical variables were compared using the Chi-squared test or Fisher&#39;s exact test as appropriate&#46; A multiple logistic regression analysis was performed to analyze clinical variables related to mortality&#46; The variables entered in logistic regression analysis were those significantly associated with mortality in the univariate analysis&#46; A <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered significant&#46; We reported all results as stated in the RECORD statement&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a> Statistical analysis was performed with STATA 15 &#40;StataCorp&#46; 2017&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 465 patients &#40;8&#37; of the whole sample&#41; aged &#8805;80 years-old were included&#46; Six patients were excluded from the final analysis because of incomplete data or unknown outcome at hospital discharge &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Mean age was 83&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;3 years&#44; being male 281 &#40;60&#46;4&#37;&#41;&#46; Antiplatelets or anticoagulants were prescribed previously in 271 patients &#40;59&#46;3&#37;&#41;&#46; The main mechanisms of injury were low-energy falls in 256 patients &#40;55&#46;1&#37;&#41; and road traffic accidents in 153 patients &#40;33&#46;3&#37;&#41;&#46; Trauma was blunt in 99&#37; of the cases&#46; Hemodynamic instability was found in 189 patients &#40;41&#46;2&#37;&#41;&#46; Unilateral mydriasis was found in 37 patients &#40;8&#46;1&#37;&#41; and bilateral mydriasis in 36 patients &#40;7&#46;8&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Mean <span class="elsevierStyleItalic">ISS</span> was 20&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;1&#46; According to the <span class="elsevierStyleItalic">AIS</span>&#44; the most severe injuries corresponded to the area of the head &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Up to 125 very elderly patients &#40;27&#46;3&#37;&#41; underwent urgent &#40;&#60;24<span class="elsevierStyleHsp" style=""></span>h&#41; surgical procedures&#44; being the most frequent the neurosurgical interventions &#40;57 out of 125 patients&#44; 45&#46;6&#37; of the urgent surgeries performed&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Very elderly patients developed respiratory failure &#40;paO2&#47;FiO2<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>300&#41; in 130 cases &#40;28&#46;3&#37;&#41; and required mechanical ventilation in 259 cases &#40;56&#46;4&#37;&#41;&#46; Tracheostomy was performed in 38 patients &#40;8&#46;3&#37;&#41;&#46; Different degrees of renal failure were found in 130 patients &#40;28&#46;3&#37;&#41; and only 11 patients &#40;2&#46;4&#37;&#41; were treated with continuous renal replacement therapy&#46; Rhabdomyolysis was found in 52 patients &#40;11&#46;3&#37;&#41; and massive hemorrhage in 19 patients &#40;4&#46;1&#37;&#41;&#46; A total of 84 patients &#40;18&#46;1&#37;&#41; developed nosocomial infections and 70 patients &#40;14&#37;&#41; developed multiorgan failure&#46; Intracranial hypertension was found in 102 patients &#40;22&#46;2&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mean ICU length of stay was 7&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;9 days and mean length of hospital stay after ICU was 8&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;2 days&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Probability of survival using the <span class="elsevierStyleItalic">TRISS</span> methodology was 69&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;7&#37;&#46; ICU mortality was 15&#46;5&#37; &#40;71 patients&#41;&#46; Hospital mortality after ICU was 3&#46;7&#37; &#40;17 patients&#41;&#46; Overall&#44; in-hospital mortality was 19&#46;2&#37; &#40;88 patients&#41;&#46; The main reason was intracranial hypertension &#40;42&#46;7&#37; of the cases&#41;&#46; Multiple logistic regression analysis showed that the <span class="elsevierStyleItalic">ISS</span> &#40;OR 1&#46;02 95&#37; CI 1&#46;002&#8211;1&#46;051&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#44; the need of first-tier measures to control intracranial pressure &#40;OR 2&#46;85 95&#37; CI 1&#46;143&#8211;7&#46;142&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; the need of second-tier measures to control intracranial pressure &#40;OR 4&#46;56 95&#37; CI 1&#46;740&#8211;11&#46;957&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41; and being admitted to the ICU for intensive care oriented t organ donation &#40;OR 6&#46;61 95&#37; CI 3&#46;121&#8211;14&#46;035&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were independent predictors of death&#46; Predicted and observed mortality distributed by severity of TBI is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Interestingly&#44; 41 patients &#40;9&#37;&#41; were admitted to the ICU for intensive care oriented to donation&#46; Among them&#44; 10 patients &#40;24&#46;4&#37;&#41; actually became organ donors&#46; Additionally&#44; 8 patients who received active ICU treatment also developed brain death and became effective organ donors&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Limitation of life sustaining therapies occurred in 128 patients &#40;27&#46;9&#37;&#41;&#46; When distributing very elderly patients with or without LLST orders we found that patients with LLST were older&#44; with higher severity of injury and with more severe brain injury&#44; as stated by the number of patients with pupillary abnormalities and the AIS head score &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main result of our study was that very elderly trauma patients presented mortality rates were lower than predicted&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The observed mortality found in our series of very elderly trauma patients admitted to the ICU supports the initial aggressive acute care of these patients&#44; as outlined in <span class="elsevierStyleItalic">the Eastern Association for the Surgery of Trauma</span> practice management guideline&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> Mock et al&#46; recently published a single center study of 192 trauma ICU patients with a mean age of 86 years-old and mean <span class="elsevierStyleItalic">ISS</span> 17&#46; Their patients had a 22&#37; mortality rate&#44; similar to that predicted by the <span class="elsevierStyleItalic">Geriatric Trauma Outcome Score</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> The results are comparable to ours&#44; in a less aged population &#40;83&#46;4 years-old&#41; but with most severe trauma&#44; as stated by the mean ISS 20&#46;5&#46; Mock et al&#46; performed a multivariate analysis analyzing factors related to mortality and found that the need of mechanical ventilation&#44; days on mechanical ventilation and admission lactate were independent predictors of outcome&#46; In our series&#44; the severity of injury evaluated by the <span class="elsevierStyleItalic">ISS</span> and specially&#44; the burden of brain injury as demonstrated by the need of first- and second-tier measures to control ICP and being admitted to the ICU oriented to organ donation were independent predictors of death&#46; Consequently&#44; intracranial hypertension was the main cause of death&#46; In the study by Hwabejire et al&#46; including nonagenarian and centenarian patients with an ISS 12&#44; independent predictors of cumulative 1-year mortality were head injury and length of hospital stay&#46; Cumulative 1-year mortality in patients with head injury was 51&#46;1&#37; and increased to 73&#46;2&#37; if the <span class="elsevierStyleItalic">ISS</span> was 25 or higher and to 78&#46;7&#37; if mechanical ventilation was required&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> Our results are in consonance with previous studies in very elderly patients admitted in mixed ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> A recent prediction tool has been developed for medical ICU very elderly patents&#46; Factors related with mortality were age&#44; serum creatinine&#44; Glasgow Coma Scale and serum pH&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> However&#44; this prediction tool has not been validated in very elderly patients with severe trauma yet&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Controversy surrounding the ICU admission of very elderly patients exists&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">17&#44;18</span></a> Our data support admitting these patients and perform an ICU trial&#46; Thereafter&#44; in non-responding trauma patients&#44; LLST should be considered&#46; In our sample&#44; up to 27&#46;9&#37; of trauma patients over 80 years-old received LLST&#44; a percentage very close to that found in a recent multicenter study in general ICU patients including trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> In our study&#44; LLST were more likely to occur in older patients&#44; with higher severity of injury and with more severe brain injury&#44; as stated by the number of patients with pupillary abnormalities and the AIS head score&#44; similarly to the results found by Pe&#241;asco et al&#46; in trauma patients &#8805;65 years-old&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">As known&#44; TBI is a major concern in this population<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a> and plays a major role in outcomes&#44; as seen in our series&#46; However&#44; neurosurgical interventions and modern neurointensive care have improved outcomes of geriatric TBI&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> In the series by Merzo et al&#46;&#44; up to 55&#37; of patients from 70 to 79 years-old and up to 30&#37; of octogenarians with TBI had a favorable neurological outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> Our results also point in this direction since mortality was markedly lower than predicted even in the group who received LLST&#46; This can help to overcome past nihilism when approaching geriatric TBI&#44; which was supported by the 60&#37; mortality and more than 80&#37; of severe neurological disability in patients aged &#62;70 years-old reported by Hukkelhoven et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> and the ominous 6-month outcomes in moderate to severe geriatric TBI patients &#40;none of them was living independently&#41; shown by Utomo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Additionally&#44; we must keep in mind the possibility that this group of patients might increase the pool of organ donors following the intensive care oriented to organ donation strategy&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#44;26</span></a> Up 9&#37; of octogenarians were admitted to the ICU following this policy&#44; but only 1 out of 4 among them finally developed brain death and became organ donors&#46; Eight additional patients developed brain death after active ICU treatment&#46; Overall&#44; 3&#46;9&#37; of octogenarian trauma ICU patients were ultimately organ donors&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study has some limitations that must be acknowledged&#58; the most important one is that our retrospective study is focused in survival rather than in quality of life and this is of special relevance in very elderly patients&#46; In addition we did not take into consideration comorbidities or frailty&#44; which are major determinants of different outcomes in this population&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> and we must acknowledge a selection bias&#44; since we only studied octogenarians ICU patients and this may not represent the whole trauma octogenarian population&#46; We did not evaluate predicted mortality using the specific <span class="elsevierStyleItalic">Geriatric Trauma Outcome Score</span><a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> as did Mock et al&#46; We used the conventional <span class="elsevierStyleItalic">TRISS</span> methodology since we previously compared the performance of the TRISS methodology and the <span class="elsevierStyleItalic">Geriatric Trauma Outcome Score</span> in our geriatric trauma ICU population and we found that the prediction ability of <span class="elsevierStyleItalic">TRISS</span> was higher&#44; most likely due to severity of injury and the high percentage of patients with TBI&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> However&#44; it must be considered that TRISS was created for a different population &#40;younger patients with predominant high-energy mechanisms of injury&#41;&#44; can be difficult to calculate and requires specific skills in the codification of injuries and continuous coefficient updates&#46; Anyway&#44; the mortality of our patients was markedly lower than predicted highlighting the need of newly geriatric-specific scores&#46; Finally&#44; when referred to the analysis of LLST&#44; we did not differentiate between withholding or withdrawing therapies&#44; and unfortunately&#44; our registry cannot provide this information&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; in Spanish ICUs&#44; very elderly trauma ICU patients presented mortality rates lower than predicted by their severity of injury&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Author&#39;s contribution</span><p id="par0125" class="elsevierStylePara elsevierViewall">Mario Chico-Fern&#225;ndez&#58; Design of the study&#44; collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Marcelino S&#225;nchez-Casado&#58; Statistical analysis&#44; critical review&#44; approved the final version&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Jes&#250;s Abelardo Barea-Mendoza&#58; Collected data&#44; statistical analysis&#44; critical review&#44; approved the final version&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Iker Garc&#237;a-S&#225;ez&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Mar&#237;a &#193;ngeles Ballesteros-Sanz&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Francisco Guerrero-L&#243;pez&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Manuel Quintana-D&#237;az&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Ismael Molina-D&#237;az&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Lorena Mart&#237;n-Iglesias&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Jos&#233; Mar&#237;a Toboso-Casado&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Jon P&#233;rez-B&#225;rcena&#58; Collected data&#44; critical review&#44; approved the final version&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Juan Antonio Llompart-Pou&#58; Design of the study&#44; collected data&#44; wrote the first and final draft&#44; approved the final version&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0185" class="elsevierStylePara elsevierViewall">RETRAUCI was supported by a grant for the development of an electronic web-based system awarded to Dr&#46; Chico-Fern&#225;ndez &#40;<span class="elsevierStyleGrantSponsor" id="gs1">Fundaci&#243;n Mutua Madrile&#241;a</span>&#44; reference number <span class="elsevierStyleGrantNumber" refid="gs1">AP117892013</span>&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Presentation</span><p id="par0190" class="elsevierStylePara elsevierViewall">A preliminary version of this manuscript was presented at the LIII CONGRESO NACIONAL SEMICYUC held in Granada&#44; June 2018&#44; obtaining the second prize in the &#8220;PREMIO DR&#46; HELIODORO SANCHO RUIZ&#8221; to the best poster presentation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units &#40;ICUs&#41; participating in the Spanish trauma ICU registry&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A multicenter nationwide registry&#46; Retrospective analysis&#46; November 2012&#8211;May 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Participating ICUs&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Trauma patients aged &#8805;80 years&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The outcomes and influence of limitation of life sustaining therapy &#40;LLST&#41; were analyzed&#46; Comparisons were established using the Wilcoxon test&#44; Chi-squared test or Fisher&#39;s exact test as appropriate&#46; Multiple logistic regression analysis was performed to analyze variables related to mortality&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05 was considered statistically significant&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The mean patient age was 83&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;3 years&#59; 281 males &#40;60&#46;4&#37;&#41;&#46; Low-energy falls were the mechanisms of injury in 256 patients &#40;55&#46;1&#37;&#41;&#46; The mean ISS was 20&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;1&#44; with a mean ICU stay of 7&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;9 days&#46; The probability of survival based on the TRISS methodology was 69&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;7&#37;&#46; The ICU mortality rate was 15&#46;5&#37;&#44; with an in-hospital mortality rate of 19&#46;2&#37;&#46; The main cause of mortality was intracranial hypertension &#40;42&#46;7&#37;&#41;&#46; The ISS&#44; the need for first- and second-tier measures to control intracranial pressure&#44; and being admitted to the ICU for organ donation were independent mortality predictors&#46; LLST was applied in 128 patients &#40;27&#46;9&#37;&#41;&#46; Patients who received LLST were older&#44; with more severe trauma&#44; and with more severe brain injury&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury&#46;</p></span>"
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            "titulo" => "Objective"
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          1 => array:2 [
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            "titulo" => "Design"
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            "titulo" => "Patients"
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            "titulo" => "Main variables of interest"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analizar el desenlace y los factores relacionados con la mortalidad de los pacientes traum&#225;ticos muy ancianos ingresados en las Unidades de Cuidados Intensivos &#40;UCI&#41; participantes en el Registro Espa&#241;ol de Trauma en las UCI &#40;RETRAUCI&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Registro multic&#233;ntrico nacional&#46; An&#225;lisis retrospectivo&#46; Noviembre de 2012-mayo de 2017&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Las UCI participantes&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes o participantes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pacientes traum&#225;ticos con edad &#8805;80 a&#241;os&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s principales</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Analizamos el desenlace y la influencia de la limitaci&#243;n de los tratamientos de soporte vital &#40;LLST&#41;&#46; Las comparaciones entre grupos se realizaron mediante la prueba de Wilcoxon&#44; la prueba de Chi-cuadrado y la prueba exacta de Fisher seg&#250;n estuviera indicado&#46; Se realiz&#243; un an&#225;lisis multivariante mediante regresi&#243;n log&#237;stica para analizar las variables asociadas a la mortalidad&#46; Un valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 se consider&#243; el l&#237;mite de la significaci&#243;n estad&#237;stica&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 83&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;3 a&#241;os&#46; Varones 281 &#40;60&#44;4&#37;&#41;&#46; La causa principal del traumatismo fueron las ca&#237;das de baja energ&#237;a en 256 pacientes &#40;55&#44;1&#37;&#41;&#46; El Injury Severity Score &#40;ISS&#41; medio fue de 20&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;1&#46; La estancia media en las UCI fue de 7&#44;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;9 d&#237;as&#46; La probabilidad de supervivencia&#44; de acuerdo con la metodolog&#237;a TRISS fue de 69&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#44;7&#37;&#46; La mortalidad en las UCI fue del 15&#44;5&#37;&#46; La mortalidad hospitalaria fue del 19&#44;2&#37;&#46; La causa principal fue la hipertensi&#243;n intracraneal &#40;42&#44;7&#37;&#41;&#46; El <span class="elsevierStyleItalic">ISS</span>&#44; la necesidad de medidas de primer o segundo nivel para controlar la presi&#243;n intracraneal y el ingreso en las UCI orientado a la donaci&#243;n de &#243;rganos fueron predictores independientes de mortalidad&#46; Se document&#243; la LLST en 128 pacientes &#40;27&#44;9&#37;&#41;&#46; Los pacientes con LLST fueron mayores&#44; con una mayor gravedad lesional y un traumatismo craneoencef&#225;lico m&#225;s grave&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los pacientes traum&#225;ticos muy ancianos en las UCI presentaron menor mortalidad de la predicha por la gravedad del traumatismo&#46;</p></span>"
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            "identificador" => "abst0060"
            "titulo" => "Pacientes o participantes"
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            "titulo" => "Intervenciones"
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          5 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Variables de inter&#233;s principales"
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            "titulo" => "Resultados"
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                  \t\t\t\t">AIS head&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AIS face&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AIS thorax&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Article information
ISSN: 21735727
Original language: English
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Idiomas
Medicina Intensiva (English Edition)
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