Pediatric Adjusted Shock Index as a Predictor of Mortality by Sex Disparity in Pediatric Trauma: A Pan-Asian Trauma Outcome Study (PATOS)

doi:10.21203/rs.3.rs-1755325/v1

Background

There are no reports of sex-specific, pediatric age-adjusted shock index (PASI) for pediatric trauma patients in previous studies. We aimed to determine the association between PASI and in-hospital mortality of pediatric trauma patients and whether this association differs depending on sex.

Methods

This is a prospective, multinational, and multicenter cohort study using the Pan-Asian Trauma Outcome Study (PATOS) registry in the Asia-Pacific region, conducted in pediatric patients who visited the participating hospitals. The main exposure of our study was abnormal (elevated) PASI measured in an emergency department (ED). The main outcome was in-hospital mortality. We performed a multivariable logistic regression analysis to estimate the association between abnormal PASI and study outcomes after adjusting for potential confounders. An interaction analysis between PASI and sex was also conducted.

Results

Of 6,280 pediatric trauma patients, 10.9% (686/6,280) of the patients had abnormal PASI. In multivariable logistic regression analysis, abnormal PASI was significantly associated with increased in-hospital mortality (aOR, 1.71; 95% confidence interval [CI], 1.16—2.53). Abnormal PASI had interaction effects with sex for in-hospital mortality (aOR, 1.86; 95% CI, 1.18—2.92 and aOR, 1.38; 95% CI, 0.64—2.95 for male and female, respectively) (p < 0.01).

Conclusions

Abnormal PASI is associated with increased in-hospital mortality in pediatric trauma patients. The prediction power of PASI for in-hospital mortality was maintained only in male patients. Further studies with sex- and age-specific shock index and age-specific are warranted.

Traumatic injury is the leading cause of mortality in pediatric patients (1). Rapid and accurate identification of severe trauma patients and appropriate triage are important in reducing mortality (2). In recent years, research studies have focused on evidence-based criteria for determining trauma team activation or treatment direction of trauma patients; these criteria help optimize the classification of such patients and efficiently distribute trauma-related resources (3).

The shock index (SI), defined as the heart rate (HR) divided by systolic blood pressure (SBP), has been used to identify mortality, the need for massive transfusions, and as a marker, even in the presence of severe trauma (4–6). However, because limitations have been reported in applying the SI equally to all age groups, pediatric age-adjusted shock index (PASI) values have subsequently been defined to account for variations in physiologically normal ranges displayed in pediatric populations (2). PASI has been validated in pediatric trauma patients by demonstrating its utility in predicting the severity of injury, need for blood transfusion, surgical procedures, and mortality (2, 7, 8).

Although there are no reports of sex-specific SI or PASI, a previous report on the sex-specific normal value of SI stated that the SI of females patients tended to be higher than those of male patients of all ages (9). Therefore, changing patterns of physiological indicators, including SBP and HR after trauma, may differ according to age and sex at the same age (10).

Studies on the prediction utility of PASI are limited in pediatric trauma patients, and no study has considered physiological differences according to sex. Therefore, we hypothesized that the PASI can predict the mortality of pediatric trauma patients and that these prediction utilities would differ according to sex.

Our study aimed to determine the association between PASI and mortality in pediatric trauma patients and whether this association differs depending on sex.

Study design and setting

This study was a cross-sectional study using a prospective multicenter trauma registry from the Pan-Asian Trauma Outcomes Study (PATOS) database in the Asia-Pacific region from January 2015 to December 2020 (11).

PATOS, a unique, self-funded, low-cost model of the collaborative clinical research network, was first launched in 2013 to build a multicenter registry for injured patients in Asia-Pacific countries. The 85 centers voluntarily participate in this network and are from China, India, Japan, Korea, Laos, Malaysia, Philippines, Singapore, Taiwan, Thailand, the UAE, and Vietnam. The age-standardized mortality rate per 100,000 injured population in the participating countries varies from 25.8 in Japan to 91.4 in India (11). There are many differences in trauma systems in Asia-Pacific countries, including emergency medical service (EMS) systems (12). The operation of the EMS system is varied: fire-based in four countries, volunteer-based in two countries, and public health-based in one country. The highest level of EMS providers is doctors in five countries, intermediate emergency medical technician (EMT) in four countries, EMT paramedic in one country, EMT basic in one country, and multiple levels in one country. Regarding the national trauma registry, a registry system has not been established in most low- and middle-income countries, and even if such a registry system exists, the registry is often rudimentary and incomplete (13).

Data sources

The PATOS database is a multicenter trauma registry compiled by the Asia-Pacific clinical research network. This study reports on injured patients transferred to the emergency departments (ED) of participating hospitals by EMS in developed countries and various other vehicles in developing countries. Information on patients who visit the ED is entered into the registry system within 1 week. Only patients related to a traffic accident, falls, poisoning, burns, and violence (self-inflicted violence, assault, or acts of war) (14), which are the case definition of the World Health Organization, were included. Prehospital information was collected from the ambulance run sheet and EMS dispatch records, and hospital information was obtained from the in-hospital discharge record. Information on long-term outcomes was collected at 6 and 12 months after hospital discharge through a telephone survey by investigators. All variable definitions and coding instructions are contained in the data dictionary and distributed to participating hospitals. The data are then collected using an electronic data capture system (see http://epatos,org), and the collected data are managed and cleaned by the PATOS Data Quality Management Committee (QMC) to address incomplete and/or invalid entries. All sites respond to the PATOS data QMC within 2 weeks of receiving data verification requests.

Study population

The population of our study was pediatric patients with traumatic injury aged < 18 years who visited the participating hospitals between January 2015 and December 2020. Patients aged < 3 years (36 months after birth) were excluded because the normal range of vital signs varies drastically by month, and the normal range of PASI values in this population is not clearly categorized in previous studies. Cases with unknown information on SBP, HR, and clinical outcomes at hospital discharge were excluded.

Variables and measurements

The main exposure of our study was elevated PASI, defined as SI greater than the maximum age-adjusted SI. Cut-offs included SI > 1.22 (age, 4—6), > 1.0 (7—12), and > 0.9 (13—18). Maximum age-adjusted SI was based on published normal ranges compiled from two pediatric textbooks and the US Department of Health and Human Services Pediatric Basic and Advanced Life Support Guidelines (15, 16). We collected data on patients’ demographics (country of residence, age, and sex), injury characteristics (intentionality, place of injury, activity at the time of injury, and mechanism of injury), prehospital care (EMS use, fluid resuscitation, and immobilization), ED and hospital care (injury area and vital signs at ED arrival including SBP, HR, and Glasgow coma scale [GCS]), and clinical outcomes at the time of hospital discharge (11).

Main outcomes

The primary outcome measure was mortality at hospital discharge, and the secondary outcome measure was poor functional recovery at hospital discharge measured by the modified Rankin Scale (mRS); poor functional recovery was defined by mRS scores of 4 (moderately severe disability), 5 (severe disability), and 6 (death).

Statistical analysis

We compared the characteristics of patients according to the PASI measure in the ED just after hospital arrival using the chi-square test for categorical variables and the Wilcoxon rank-sum test for nonparametrically distributed continuous variables.

Multivariable logistic regression analyses were performed to estimate the effect size of PASI for in-hospital mortality and poor functional recovery after excluding potential confounders. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Finally, the effect of the interaction between PASI and sex on the study outcomes was analyzed to investigate whether the prediction power of PASI in ED was modified according to sex.

All statistical analyses were performed using SAS version 9.4 (SAS institute Inc., Cary, NC, USA). All p-values were two-tailed and p < 0.05 was considered statistically significant.

Ethics statements

This study complies with the Declaration of Helsinki. This study was approved by the Institutional Review Board (IRB) of Seoul National University Hospital (IRB No. H-1509-045-702) and the requirement for informed consent was waived due to the retrospective nature of this study by Seoul National University Hospital IRB center. All methods were performed in accordance with relevant guidelines and regulations.

Demographic findings

A total of 6,280 pediatric trauma patients were finally enrolled. We excluded patients aged > 18 years and < 3 years and patients with unknown data on SBP and HR (Fig. 1).

The characteristics of the study population according to PASI are shown in Table 1. Of the 6,280 pediatric patients, 10.9% (686/6280) had abnormal PASI. For the total study population, the proportion of in-hospital mortality was 3.2% (198/6280): 2.9% (164/5,594) in the normal PASI group and 5.0% (34/686) in the abnormal (elevated) PASI group (p < 0.01). The rate of poor functional outcome was 5.3% (334/6280): 4.4% (247/5,594) in the normal PASI group and 12.7% (87/686) in the abnormal (elevated) PASI group (p < 0.01).

Table 1

Characteristics of the study population according to the Pediatric age-adjusted SI
Variables	All	Pediatric age-adjusted SI
Variables	All	Normal	Abnormal	p value
All	6,280 (100.0)	5,594 (100.0)	686 (100.0)
Country				< 0.01
Korea	3,419 (54.4)	3,107 (55.5)	312 (45.5)
Vietnam	710 (11.3)	636 (11.4)	74 (10.8)
Malaysia	1,834 (29.2)	1,582 (28.3)	252 (36.7)
Other	317 (5.0)	269 (4.8)	48 (7.0)
Age (median, IQR)	13 (7–16)	13 (8–16)	10 (5–15)	< 0.01
Sex, female	1,787 (28.5)	1,536 (27.5)	251 (36.6)	< 0.01
Intentionality, yes	257 (4.1)	214 (3.8)	43 (6.3)	< 0.01
Place of injury				< 0.01
Home	1,505 (24.0)	1,321 (23.6)	184 (26.8)
Street	3,197 (50.9)	2,844 (50.8)	353 (51.5)
School	572 (9.1)	522 (9.3)	50 (7.3)
Sports and athletics area	264 (4.2)	242 (4.3)	22 (3.2)
Other	742 (11.8)	665 (11.9)	77 (11.2)
Activity				0.16
Travel	1,357 (21.6)	1,209 (21.6)	148 (21.6)
Sports and leisure	1,484 (23.6)	1,334 (23.8)	150 (21.9)
Education or work	578 (9.2)	520 (9.3)	58 (8.5)
Other	2,861 (45.6)	2,531 (45.2)	330 (48.1)
Mechanism				0.06
Traffic accident	2,933 (46.7)	2,612 (46.7)	321 (46.8)
Fall-down	1,649 (26.3)	1,468 (26.2)	181 (26.4)
Other	1,698 (27.0)	1,514 (27.1)	184 (26.8)
Mode of arrival, EMS	4,918 (78.3)	4,435 (79.3)	483 (70.4)	0.03
Prehospital treatment
Fluid resuscitation	261 (4.2)	217 (3.9)	44 (6.4)	< 0.01
Immobilization	1,780 (28.3)	1,613 (28.8)	167 (24.3)	0.95
Injury area
Head	1,893 (30.1)	1,664 (29.7)	229 (33.4)	0.14
Neck and face	1,905 (30.3)	1,716 (30.7)	189 (27.6)	< 0.01
Chest	374 (6.0)	308 (5.5)	66 (9.6)	< 0.01
Abdomen	349 (5.6)	281 (5.0)	68 (9.9)	< 0.01
Spine	134 (2.1)	114 (2.0)	20 (2.9)	< 0.01
Extremity	3,364 (53.6)	3,015 (53.9)	349 (50.9)	< 0.01
Other	590 (9.4)	496 (8.9)	94 (13.7)	< 0.01
SBP (median, IQR)	123 (111–142)	124 (113–143)	116 (100–139)	< 0.01
HR (median, IQR)	94 (81–111)	92 (80–106)	110 (92–125)	< 0.01
GCS				< 0.01
15	5,442 (86.7)	4,896 (87.5)	546 (79.6)
13–14	133 (2.1)	111 (2.0)	22 (3.2)
9–12	72 (1.1)	51 (0.9)	21 (3.1)
3–8	633 (10.1)	536 (9.6)	97 (14.1)
Severity of trauma (NISS)				< 0.01
1–8	4,642 (73.9)	4,224 (75.5)	418 (60.9)
9–15	526 (8.4)	434 (7.8)	92 (13.4)
16–24	172 (2.7)	137 (2.4)	35 (5.1)
25–75	940 (15.0)	799 (14.3)	141 (20.6)
Clinical outcomes
Poor functional outcome	334 (5.3)	247 (4.4)	87 (12.7)	< 0.01
In-hospital mortality	198 (3.2)	164 (2.9)	34 (5.0)	< 0.01
SI, shock index; IQR, interquartile range; EMS, emergency medical service; SBP, systolic blood pressure; HR, heart rate; GCS, Glasgow coma scale; NISS, new injury severity score;

The characteristics of the study population according to sex are shown in Table 2. Of the 6,280 patients, 71.5% (4,493/6280) were male and 28.5% (1,787/6,280) were female. In-hospital mortality and poor functional outcomes in the two groups did not differ significantly.

Table 2

Characteristics of the study population according to sex.
Variables		Sex
Variables	All	Male	Female	p-value
All	6,280 (100.0)	4,493 (100.0)	1,787 (100.0)
Country				< 0.01
Korea	3,419 (54.4)	2,374 (52.8)	1,045 (58.5)
Vietnam	710 (11.3)	472 (10.5)	238 (13.3)
Malaysia	1,834 (29.2)	1,428 (31.8)	406 (22.7)
Other	317 (5.0)	219 (4.9)	98 (5.5)
Age (median, IQR)	13 (7–16)	13 (8–16)	11 (6–16)	< 0.01
Intentionality, yes	257 (4.1)	164 (3.7)	93 (5.2)	< 0.01
Place of injury				< 0.01
Home	1,505 (24.0)	941 (20.9)	564 (31.6)
Street	3,197 (50.9)	2,391 (53.2)	806 (45.1)
School	572 (9.1)	424 (9.4)	148 (8.3)
Sports and athletics area	264 (4.2)	210 (4.7)	54 (3.0)
Other	742 (11.8)	527 (11.7)	215 (12.0)
Activity				< 0.01
Travel	1,357 (21.6)	1,010 (22.5)	347 (19.4)
Sports and leisure	1,484 (23.6)	1,175 (26.2)	309 (17.3)
Education or work	578 (9.2)	414 (9.2)	164 (9.2)
Other	2,861 (45.6)	1,894 (42.2)	967 (54.1)
Mechanism				< 0.01
Traffic accident	2,933 (46.7)	2,192 (48.8)	741 (41.5)
Fall-down	1,649 (26.3)	1,138 (25.3)	511 (28.6)
Other	1,698 (27.0)	1,163 (25.9)	535 (29.9)
Mode of arrival, EMS	4,918 (78.3)	3,542 (78.8)	1,376 (77.0)	0.11
Prehospital treatment
Fluid resuscitation	261 (4.2)	218 (4.9)	43 (2.4)	< 0.01
Immobilization	1,780 (28.3)	1,373 (30.6)	407 (22.8)	< 0.01
Injury area
Head	1,893 (30.1)	1,411 (31.4)	482 (27.0)	0.67
Neck and face	1,905 (30.3)	1,370 (30.5)	535 (29.9)	< 0.01
Chest	374 (6.0)	300 (6.7)	74 (4.1)	0.05
Abdomen	349 (5.6)	266 (5.9)	83 (4.6)	0.45
Spine	134 (2.1)	92 (2.0)	42 (2.4)	< 0.01
Extremity	3,364 (53.6)	2,458 (54.7)	906 (50.7)	0.44
Other	590 (9.4)	414 (9.2)	176 (9.8)
SBP (median, IQR)	123 (111–142)	124 (112–142)	120 (110–141)	< 0.01
HR (median, IQR)	94 (81–111)	93 (80–108)	98 (85–118)	< 0.01
GCS				0.45
15	5,442 (86.7)	3,877 (86.3)	1,565 (87.6)
13–14	133 (2.1)	94 (2.1)	39 (2.2)
9–12	72 (1.1)	55 (1.2)	17 (1.0)
3–8	633 (10.1)	467 (10.4)	166 (9.3)
Shock index, abnormal
SI	1,400 (22.3)	896 (19.9)	504 (28.2)	< 0.01
Pediatric age-adjusted SI	686 (10.9)	435 (9.7)	251 (14.0)	< 0.01
reverse SI	721 (11.5)	437 (9.7)	284 (15.9)	< 0.01
reverse SI x GCS	1,072 (17.1)	731 (16.3)	341 (19.1)	< 0.01
Severity of trauma (NISS)				< 0.01
1–8	4,642 (73.9)	3,292 (73.3)	1,350 (75.5)
9–15	526 (8.4)	409 (9.1)	117 (6.5)
16–24	172 (2.7)	142 (3.2)	30 (1.7)
25–75	940 (15.0)	650 (14.5)	290 (16.2)
Clinical outcomes
Poor functional outcome	334 (5.3)	255 (5.7)	79 (4.4)	0.05
In-hospital mortality	198 (3.2)	153 (3.4)	45 (2.5)	0.07
SI, shock index; IQR, interquartile range; EMS, emergency medical service; SBP, systolic blood pressure; HR, heart rate; GCS, Glasgow coma scale; NISS, new injury severity score;

Main outcomes

In multivariable logistic regression analysis, abnormal PASI was significantly associated with increased in-hospital mortality (aOR, 1.71; 95% CI, 1.16—2.53) and poor functional outcome (aOR, 3.41; 95% CI, 2.60—4.46) after adjusting for potential confounders (Table 3).

Table 3

Multivariable logistic regression analysis on study outcomes by the PASI and SI
	Total	Outcome		Model 1	Model 2
	N	N	%	aOR (95% CI)	aOR (95% CI)
In hospital mortality
Total population	6280	198	3.2
Normal SI	4880	147	3.0	ref.	ref.
abnormal SI	1400	51	3.6	1.61 (1.13–2.30)	1.49 (1.04–2.13)
Normal PASI	5594	164	2.9	ref.	ref.
abnormal PASI	686	34	5.0	1.90 (1.29–2.79)	1.71 (1.16–2.53)
Poor functional outcome
Total population	6280	334	5.3
Normal SI	4880	229	4.7	ref.	ref.
abnormal SI	1400	105	7.5	2.71 (2.08–3.54)	2.66 (2.03–3.49)
Normal PASI	5594	247	4.4	ref.	ref.
abnormal PASI	686	87	12.7	3.47 (2.66–4.53)	3.41 (2.60–4.46)
SI, shock index; PASI, pediatric age-adjusted shock index; aOR, adjusted odds ratio; CI, confidence interval;
Model 1 adjusted for age, sex, comorbidities (hypertension and diabetes mellitus)
Model 2 adjusted for variables in Model 1 and intentionality, place of injury, activity, and mechanism of injury

Interaction analysis

The interaction analysis was used to assess whether study outcomes of PASI varied according to sex. The ORs for in-hospital mortality differed according to the sex of the injured patients (p < 0.01). The association of PASI with in-hospital mortality was maintained only in males (aOR, 1.86; 95% CI, 1.18—2.92) but not in females (aOR, 1.38; 95% CI, 0.64—.2.95) (Table 4).

Table 4

Interaction analysis between the PASI/SI and sex on study outcome
	Normal SI	Abnormal SI
	aOR (95% CI)	aOR (95% CI)	p for interaction
In hospital mortality			0.76
Male	ref.	1.36 (0.89–2.07)
Female	ref.	1.57 (0.82–2.99)
Poor functional outcome			0.44
Male	ref.	2.33 (1.69–3.20)
Female	ref.	2.54 (1.56–4.13)
	Normal PASI	Abnormal PASI
	aOR (95% CI)	aOR (95% CI)
In hospital mortality			< 0.01
Male	ref.	1.86 (1.18–2.92)
Female	ref.	1.38 (0.64–2.95)
Poor functional outcome			0.14
Male	ref.	3.74 (2.35–6.01)
Female	ref.	2.74 (1.89–3.33)

Using a prospective international multicenter registry of injury in the Asia-Pacific region, the results of this study showed that elevated PASI was associated with a higher probability of in-hospital mortality and poor functional recovery in pediatric trauma patients. In the interaction analysis, elevated PASI was associated with increased in-hospital mortality only in males but not in females. This research contributes to a better understanding of the usefulness of PASI in predicting the clinical outcome of pediatric trauma patients who visit the ED. Furthermore, it shows a limit to applying the previously suggested cut-off value of PASI to predict mortality regardless of sex.

SI predicts hemodynamic instability more sensitively than traditional vital signs such as SBP and HR. In a prospective study evaluating hypovolemia detection, SI was a more accurate predictor of acute changes in the blood volume than was SBP or HR alone (17). Furthermore, in studies of geriatric patients, SI predicted the overall mortality better than did traditional vital signs (18). A study of pediatric patients with sepsis reported a higher mortality risk with increasing SI, although there was no clear cut-off value (19). Studies to predict mortality in adult trauma patients have used abnormal SI, defined as SI > 0.9 to 1, as a cut-off value for mortality prediction (20). However, it is not ideal to apply the cut-off value of adult physiological indicators to pediatric patients due to their unique anatomy and physiological differences compared to adults. Furthermore, the pattern and degree of changes in vital signs, such as SBP and HR, when bleeding from trauma occurs in pediatric patients are different from those in adults (21).

To increase the ability of SI to predict clinical outcomes in pediatric trauma patients, age-specific SI was applied to pediatric trauma patients in several studies (22–24). PASI was found to be a good predictor of mechanical ventilation or blood transfusion needs, increased intensive care unit hospitalization, and longer in-hospital stays (22–24). However, previous studies on PASI mainly focused on blunt injured pediatric patients; hence, studies on the generalizability of PASI to indicate negative clinical outcomes and the need for increased resources for pediatric patients who sustain injuries other than blunt injury are limited.

Our study targeted all pediatric trauma patients, and to our knowledge, is the first study to suggest the association between SI and functional outcome of pediatric trauma patients. In our study, although elevated SI and elevated PASI were associated with worse clinical outcomes, the associations with PASI in predicting worse clinical outcomes were stronger, similar to that in previous studies.

In the interaction analysis of our study, elevated PASI was associated with in-hospital mortality in males but not in females. However, regardless of sex, the SI of nonsurvivors was higher than that of survivors, suggesting that setting of the cut-off point requires sex-specific adjustment, and is not a functional limitation of the SI itself.

In previous studies, the SI of females was higher than that of males in all age groups, and in the study of SI components, although SBP did not show a clear difference according to sex, HR showed a significantly higher tendency in females than in males (9, 25). Although no sex-specific studies have reported changes in vital signs, including SBP and HR, after trauma, it can be expected that the male group with a low baseline SI would show a generally decreasing trend even after trauma. Hence, elevated PASI in males indicates a poorer physiological state compared to females, and this eventually leads to worse clinical results.

In our study, as in previous studies, the normal cut-off values for SI were 1.22, 1.0, and 0.9 for ages 4—6, 7—12, and 13—18 years, respectively. However, based on the results of our study, it would be more appropriate for the female cut-off value to be higher than the current value.

Although PASI is an important predictor of in-hospital mortality and poor functional recovery in pediatric trauma patients, the results of our study, which have different predictive powers according to sex, provide a theoretical basis that sex-specific and age-specific normal values of SI may be more effective in screening for trauma severity than a single-value threshold.

This study has several limitations that need to be addressed. First, although intentionality, activity at the time of the injury, location, and mechanism of injury were adjusted in the multivariable logistic regression analysis; hence, the effect of the characteristics of trauma itself on the study outcomes could not be completely excluded. Second, pediatric patients may have inaccurate measurements of vital signs at ED compared to adults, possibly affecting the study results. Third, although several age-specific cut-off values for SI have been suggested in previous studies, one of the values was taken and used in our study, which may have resulted in a bias. Fourth, investigators in the PATOS registry were not blinded to the study hypothesis, which could have led to biased data collection. Finally, since this was not a randomized controlled trial, there could have been some potential biases that were not controlled.

Abnormal PASI is associated with increased in-hospital mortality and poor functional recovery in pediatric trauma patients; however, the prediction power of mortality is significant only in male patients. More studies on sex- and age-specific cut-off value of SI are warranted to predict clinical outcomes in pediatric trauma patients.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request (Email: em.ryu.hyunho @gmail.com)

Author Contributions

Conceptualization: EJ, YSR

Data curation: EJ and SDS

Formal analysis: EJ

Funding acquisition: SDS

Investigation: EJ and HHR

Methodology: HHR

Software: EJ

Supervision: EJ and HHR

Validation: EJ and YSR

Visualization: EJ and YSR

Writing - original draft: EJ

Writing - review & editing: HHR

Approval of the final manuscript: all authors

Declaration of Interest

The authors have no potential conflict of interest to declare.

Funding

There was no funding for this study.

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No competing interests reported.

Pediatric Adjusted Shock Index as a Predictor of Mortality by Sex Disparity in Pediatric Trauma: A Pan-Asian Trauma Outcome Study (PATOS)

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Study design and setting

Data sources

Study population

Variables and measurements

Main outcomes

Statistical analysis

Ethics statements

Results

Demographic findings

Main outcomes

Interaction analysis

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1