The Impact of Major Trauma: Quality-of-Life Outcomes Are Worse in Women than in Men, Independent of Mechanism and Injury Severity

[Surviving multiple trauma--what comes next? The rehabilitation of seriously injured patients]

The survival chances of multiple trauma patients have improved continuously over the last decades. Therefore, not only the question of whether the patient survives a serious accident arises, but rather how the patient survives it. The after effects of trauma are seen not only physically, but also psychologically and socially. These affect quality of life and are evident years after the accident. The International Classification of Functioning, Disability and Health (ICF) provides a system to classify the after effects of trauma, which can be measured with the help of assessment instruments. Knowing which parameters can influence trauma after effects is essential for the planning, organization, and implementation of a rehabilitation programme following severe injury. The requirements of an optimal rehabilitation process place high demands on the rehabilitation facility and on the rehabilitation team, which ultimately can only be fulfilled by specialized facilities.

Memories and health-related quality of life after intensive care: a follow-up study

OBJECTIVE

The overall aim of this study was to describe changes in health-related quality of life, anxiety, depression, and return to work from 0.5-1.5 yrs to 4.5-5.5 yrs after injury in patients with and without delusional memories during their intensive care unit stay. A secondary aim was to explore factors that were related to health-related quality of life and to compare trauma patients' health-related quality of life 4.5 to 5.5 yrs after injury with a reference group.

DESIGN

Longitudinal, prospective.

SETTINGS

Multicentre study.

PATIENTS

Trauma patients treated in the intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A follow-up study was conducted with 153 consenting adults. Each patient answered a postal questionnaire twice, 0.5-1.5 yrs to 4.5-5.5 yrs after the injury. Health-related quality of life was assessed by Short Form-36 and anxiety and depression by the Hospital Anxiety and Depression Scale. Delusional memories and other clinical variables were assessed in a previous study and used in this study as possible precipitants of poor health-related quality of life. Seventy-five percent were males and mean Injury Severity Scores were 10.7 +/- 7.1. When comparing health-related quality of life over time, there was significant improvement in five domains of health-related quality of life for patients with delusional memories compared with 4 yrs previously. Significantly more patients with delusions had anxiety and depression (Hospital Anxiety and Depression Scale > or =8). Patients with delusional memories were still significantly separated from the other patients in all health-related quality-of-life domains except for general health. Seventy-five percent of all patients had returned to work. Despite a poorer health-related quality of life, patients with delusions had returned to work to the same degree. Patients with trauma still scored significantly lower in all domains 4.5 to 5.5 yrs after the injury compared with the Swedish population in the reference group (p < .001). Two factors, delusional memories during intensive care unit stay and pre-existing disease prior the trauma, had the most influence on a poorer health-related quality of life.

CONCLUSIONS

From a long-term perspective, health-related quality of life has improved but not reached the reference sample scores in Short Form-36. Seventy-five percent had returned to work. Patients with delusional memories still experienced poorer health-related quality of life and more patients had anxiety and depression compared with patients without those memories.

The effect of gender on patients with moderate to severe head injuries

BACKGROUND

Male and female nervous systems respond differently to traumatic brain injury (TBI) and in vivo research relates this difference to neuroprotection from female sex hormones. Attempts to replicate female sex hormone-related neuroprotection in clinical studies have been unsuccessful. The objective of this study was to determine whether gender or menopausal status affects mortality in patients with moderate to severe TBI.

METHODS

A retrospective review of all patients with isolated moderate to severe TBI was undertaken using data from the National Trauma Database version 6.2 (2000-2005). Isolated TBI was defined as head Abbreviated Injury Score >/=3 in patients without significant extracranial injuries (Abbreviated Injury Score <3 for other anatomic regions). Demographics, Injury Severity Score, and outcomes (mortality, intensive care unit and hospital length of stay, and complications) were compared. The population was stratified into age subgroups: 14 to 45 years (premenopausal), 46 to 55 years (perimenopausal), and older than 55 years (postmenopausal). Logistic regression analysis was used to determine the relationship among female gender, mortality, and development of complications after moderate to severe TBI.

RESULTS

A total of 72,294 patients with moderate to severe TBI were evaluated. Females showed a significantly lower risk in both mortality (adjusted odds ratios [AOR], 0.82; 95% confidence intervals [CI], 0.77-0.87; p < 0.0001) and in developing any type of complications (AOR, 0.88; 95% CI, 0.84-0.93; p < 0.0001) than the male population after adjusting for differences in patient characteristics. After age stratification, perimenopausal women (46-55 years) and postmenopausal women (older than 55 years) showed a significantly lower risk in mortality (AOR, 0.76; 95% CI, 0.63-0.92; p < 0.0044 and AOR, 0.79; 95% CI, 0.73-0.86; p < 0.0001, respectively). There was no difference in mortality in premenopausal women compared with their male age-matched counterparts (AOR, 1.09; 95% CI, 0.99-1.21; p = 0.0917).

CONCLUSIONS

Female gender is independently associated with reduced mortality and decreased complications after TBI. As peri- and postmenopausal women demonstrated improved survival, and premenopausal women did not, estrogen unlikely confers neuroprotection in women after TBI. Future TBI treatment may benefit with further research focused on why peri- and postmenopausal women show decreased mortality after TBI.

Predictors of posttraumatic stress disorder and return to usual major activity in traumatically injured intensive care unit survivors

OBJECTIVE

To assess intensive care unit (ICU)/acute care service-delivery characteristics and pre-ICU factors as predictors of posttraumatic stress disorder (PTSD) and return to usual major activity after ICU admission for trauma.

METHOD

Data from the National Study on the Costs and Outcomes of Trauma were used to evaluate a prospective cohort of 1906 ICU survivors. We assessed PTSD with the PTSD Checklist. Regression analyses ascertained associations between ICU/acute care service-delivery characteristics, pre-ICU factors, early post-ICU distress and 12-month PTSD and return to usual activity, while controlling for clinical and demographic characteristics.

RESULTS

Approximately 25% of ICU survivors had symptoms suggestive of PTSD. Increased early post-ICU distress predicted both PTSD and diminished usual major activity. Pulmonary artery catheter insertion [risk ratio (RR) 1.28, 95% confidence interval (95% CI) 1.05-1.57, P=.01] and pre-ICU depression (RR 1.23, 95% CI 1.02-1.49, P=.03) were associated with PTSD. Longer ICU lengths of stay (RR 1.21, 95% CI 1.03-1.44, P=.02) and tracheostomy (RR 1.29, 95% CI 1.05-1.59, P=.01) were associated with diminished usual activity. Greater preexisting medical comorbidities were associated with PTSD and limited return to usual activity.

CONCLUSIONS

Easily identifiable risk factors including ICU/acute care service-delivery characteristics and early post-ICU distress were associated with increased risk of PTSD and limitations in return to usual major activity. Future investigations could develop early screening interventions in acute care settings targeting these risk factors, facilitating appropriate treatments.

Post-traumatic stress impacts on quality of life in children after road traffic accidents: prospective study

OBJECTIVE

There is little knowledge on health-related quality of life (HRQOL) of injured children and adolescents after road traffic accidents (RTA). Although findings in injured adults suggest that post-traumatic stress symptoms (PTSS) may be important predictors of HRQOL, this issue has never been prospectively examined in children. The aim of the present study was therefore to prospectively assess HRQOL in children after RTA and specifically examine the impact of PTSS on HRQOL.

METHOD

Sixty-eight children (aged 6.5-14.5 years) were interviewed 1 month and 1 year after an RTA using the Child PTSD Reaction Index and the Toegepast Natuurwetenschappelijk Onderzoek-Academisch Ziekenhuis Leiden (TNO-AZL) Questionnaire for Children's Health-Related Quality of Life. Parents and physicians were assessed with questionnaires.

RESULTS

Eleven children (16.2%) showed moderate to severe post-traumatic stress reactions at 1 month, and 12 children (17.6%) at 1 year. At 1 month, patients reported reduced motor functioning and autonomy and impairments in some parts of emotional functioning compared to a community sample. At 1 year all dimensions of HRQOL were within or above normal ranges. Multivariate analysis indicated that PTSS at 1 month significantly predicted HRQOL at 1 year.

CONCLUSIONS

This prospective study provides evidence for a long-term negative influence of early PTSS on HRQOL in injured children. The return of injured children to pre-injury HRQOL may therefore not only depend on optimal medical care but also on awareness and timely interventions regarding PTSS.

Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care

BACKGROUND

To examine the relationship between delusional memories from the Intensive Care Unit (ICU) stay, health related quality of life (HRQoL), anxiety, and symptoms of depression in patients with physical trauma, 6 months to 18 months after their ICU stay.

METHODS

Multicenter study in five combined medical and surgical ICUs (n = 239). A questionnaire comprising the Medical outcome Short Form 36, the Hospital Anxiety and Depression scale, and the Intensive Care Unit Memory tool was sent to the patients with trauma 6 months to 18 months after their discharge from the ICU. Clinical data were drawn from patient records in retrospect. A matched reference sample (n = 159) was randomly drawn from the Swedish Short Form 36 norm database (n = 8,930).

RESULTS

Patients with trauma had significantly lower HRQoL than the reference sample. One or more delusional memories such as hallucinations, nightmares, dreams, or sensations of people trying to hurt them in the ICU were experienced by 26%. These patients were significantly younger, had a longer ICU stay, relied more on mechanical ventilation, and had higher Injury Severity Score and Sequential Organ Failure Assessment scores. They also reported a significantly poorer HRQoL and a higher probability of experiencing anxiety (51% vs. 29%) and symptoms of depression (48% vs. 26%) compared with patients without such memories.

CONCLUSIONS

Our results highlight the importance of treating the delusional memories experienced by ICU patients with a trauma diagnosis as a postinjury factor with a potential to create anxiety and symptoms of depression and which may affect HRQoL after discharge.

PTSD in the combat veteran: using Roy's Adaptation Model to examine the combat veteran as a human adaptive system

Posttraumatic stress disorder (PTSD) is the most prevalent mental disorder arising from combat and is poised to be a considerable health risk for our military veterans. To date, there is a paucity of nursing research that examines PTSD in this vulnerable population. The purpose of this article is to demonstrate how Roy's Adaptation Model can be an effective framework for nurses to understand the phenomenon of posttraumatic stress disorder in the combat veteran population. Current research conducted on PTSD across other disciplines is highlighted within the context of Roy's model to elucidate the idea of the combat veteran as a human adaptive system and to identify gaps for future nursing research.

Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients involving dedicated early rehabilitation intervention programs: design of a prospective, multi-centre, non-randomised clinical trial

Background

In conventional multi-trauma care service (CTCS), patients are admitted to hospital via the accident & emergency room. After surgery they are transferred to the IC-unit followed by the general surgery ward. Ensuing treatment takes place in a hospital's outpatient clinic, a rehabilitation centre, a nursing home or the community. Typically, each of the CTCS partners may have its own more or less autonomous treatment perspective. Clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('Supported Fast-track multi-Trauma Rehabilitation Service': SFTRS), featuring: 1) earlier transfer to a specialised trauma rehabilitation unit; 2) earlier start of 'non-weight-bearing' training and multidisciplinary treatment; 3) well-documented treatment protocols; 4) early individual goal-setting; 5) co-ordination of treatment between trauma surgeon and physiatrist, and 6) shorter lengths-of-stay, may be more (cost-)effective.

This paper describes the design of a prospective cohort study evaluating the (cost-) effectiveness of SFTRS relative to CTCS.

Methods/design

The study population includes multi-trauma patients, admitted to one of the participating hospitals, with an Injury Severity Scale score > = 16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. In a prospective cohort study CTCS and SFTRS will be contrasted. The inclusion period is 19 months. The duration of follow-up is 12 months, with measurements taken at baseline, and at 3,6,9 and 12 months post-injury.

Primary outcome measures are 'quality of life' (SF-36) and 'functional health status' (Functional Independence Measure). Secondary outcome measures are the Hospital Anxiety & Depression Scale, the Mini-Mental State Examination as an indicator of cognitive functioning, and the Canadian Occupational Performance Measure measuring the extent to which individual ADL treatment goals are met. Costs will be assessed using the PROductivity and DISease Questionnaire and a cost questionnaire.

Discussion

The study will yield results on the efficiency of an adapted care service for multi-trauma patients (SFTRS) featuring earlier (and condensed) involvement of specialised rehabilitation treatment. Results will show whether improved SFTRS logistics, combined with shorter stays in hospital and rehabilitation clinic and specialised early rehabilitation training modules are more (cost-) effective, relative to CTCS.

Trial registration

Current Controlled Trials register (ISRCTN68246661) and Netherlands Trial Register (NTR139).

Factors influencing outcome after orthopedic trauma

BACKGROUND

Some recent studies have suggested that certain types of orthopedic trauma result in ongoing disability and that factors other than injury severity or location may influence outcome. This study aimed to evaluate outcome 12 months and 2 years after severe orthopedic trauma, as measured on the Short Form (SF)-36 Health Survey, relative to a control group, to examine change over time and to examine which demographic, injury-related and psychological factors are associated with persisting disability.

METHODS

One hundred thirteen orthopedic trauma patients, recruited during rehabilitation, and 61 demographically similar uninjured controls were followed up at 1 and 2 years postinjury. Measures included the SF-36 Health Survey, Symptom Checklist-90-R, Brief Pain Inventory, Hospital Anxiety and Depression Scales, and Posttraumatic Stress Disorder Checklist-Specific.

RESULTS

Results indicated presence of significant ongoing disability in all SF-36 physical and mental health domains, significant ongoing psychologic adjustment problems, including posttraumatic stress disorder (PTSD) symptoms, and pain, with little or no improvement between 1 and 2 years postinjury. The presence of ongoing pain, anxiety, depression or PTSD symptoms were the strongest predictors of outcome on most variables, with older age also contributing to negative outcomes. Injury severity and type did not predict outcome, although those with lower limb fractures had greater pain and poorer physical outcomes that those with fractures in other locations.

CONCLUSIONS

This study has highlighted pain and PTSD symptoms as frequent and disabling factors after othropedic trauma. There is clearly a need to focus on alleviating these problems as part of the rehabilitation process.

Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise

STUDY DESIGN

A center parallel cohort study with blinded inclusion based on clinical equipoise.

OBJECTIVE

To compare outcomes of nonoperative and operative treatment strategies in terms of quality of life and neurologic and functional status.

SUMMARY OF BACKGROUND DATA

Despite a considerable body of literature, sound evidence regarding the optimal treatment for traumatic thoracic and lumbar spine fractures is lacking.

METHODS

Medical records of patients hospitalized for traumatic spinal fractures between 1991 and 2002 were identified in 2 trauma centers in the same country with established and different treatment strategies. Eligibility was retrospectively assessed for each case by a panel of orthopaedic surgeons who were representative of the 2 medical centers, and who were blinded to the treatment actually administered. Patients were included in the study when there was disagreement on the suggested treatment method. Thus, 2 comparable groups were identified undergoing nonoperative or operative treatment. Outcome assessment and comparison across groups focused on quality of life, residual pain, neurologic recovery, and employment in the middle-long-term follow-up.

RESULTS

Discordance in regards to choice of treatment was identified in 190 (95 treated nonoperative, 95 operative) of 636 potentially eligible patients. Patients were comparable regarding baseline characteristics, except for a somewhat higher proportion of males and neurologic impairment in the operative group. Seventeen percent of the nonoperative and 21% of the operative group developed complications and 3 patients displayed neurologic deterioration for which a treatment change was considered necessary. Follow-up was complete in 79%; mean follow-up time was 6.2 years with a minimum of 2 years. Pain scores, disability indexes, and general health outcome were comparable at follow-up. Compared with matched population norms, outcomes were poorer regardless of treatment method. Neurologic recovery was better in the operative group, but this difference did not reach statistical significance. Multivariate regression analyses revealed that female gender and neurologic impairment were independent predictors of poor functional outcome. Eighty-eight and 83% of the nonoperatively and operatively treated patients were employed at some point after a rehabilitation period.

CONCLUSION

Overall outcome of nonoperative and operative treatment in middle-long-term follow up is comparable, although there seems to be a difference in neurologic recovery patterns. Studies on the cost-effectiveness of treatment options and the patterns of recovery within 2 years after injury would assist in guideline development and stimulate interest for future research.

Health-related quality of life in Nigerian patients with facial trauma and controls: a preliminary survey

We examined the health-related quality of life (HR QoL) of patients with facial trauma and compared it with that of healthy controls; temporal changes in HR QoL of patients over 12 weeks compared with baseline values; and whether the risk of depression could be identified by baseline HR QoL. For 26 months we recruited 126 consecutive patients with facial injuries and 126 age and sex-matched healthy controls for the study. Enrollment criteria included age 18 years and over, Glasgow coma scale score on admission of 12 and over, and duration of stay of more than 24 hours. HR QoL was measured using the 26-item World Health Organization Quality of Life Questionnaire (WHO QoL-Bref), and depression was measured with the Hospital Anxiety and Depression Scale (HADS). Scores in all domains of the WHO QoL-Bref (physical, psychological, social relations, and environment) were considerably reduced in injured patients compared with controls. During follow up there were improvements only in the domains of physical health and environment, but not in psychological health. There was a significant reduction in the HR QoL domain of social relationships with time. The regression equation for all four QoL domains as predictors was significantly related to depression scores throughout the study period. Patients with facial injuries are at risk of poor QoL after trauma. There was a high incidence of depression throughout the follow-up period, and poor QoL at baseline predicted depression during follow-up.

Quality of life 2-7 years after major trauma

BACKGROUND

The aim of the present study was to assess potential long-term reduction in health-related quality of life (HRQOL) in adult trauma patients 2-7 years after discharge from an intensive care unit (ICU), and to study possible determinants of the HRQOL reduction.

METHODS

Follow-up study of a cohort of 341 trauma patients admitted to the ICU of a university hospital during 1998-2003. Of the 228 eligible patients, 210 (92%) completed the study. A telephone interview using the EuroQol 5-D (EQ-5D) was conducted. Patients reported their HRQOL both at present and before trauma.

RESULTS

Before trauma 88% reported in retrospect no problem in any EQ-5D dimension, compared with 20% at follow-up. After trauma (median 4.0 years) 58% suffered pain/discomfort, 44% reported alterations in usual activities, 40% reduced mobility, 35% anxiety/depression, and 15% limited autonomy. A total of 74% experienced reduction in HRQOL. Severe problems were reported by 16%. Women experienced more anxiety/depression than men. Simplified Acute Physiology Score (SAPS) II and Injury Severity Score (ISS) were significantly associated with impaired HRQOL, while age was not. Patients with severe head injury reported better HRQOL than those without severe head injury.

CONCLUSION

More than 2 years post-injury, 74% reported impaired HRQOL but only 16% had severe problems. The majority still suffered pain/discomfort, indicating that pain management is a key factor in improving long-term outcome after severe trauma.

Employment after traumatic brain injury: differences between men and women

OBJECTIVE

To determine whether there are sex differences in employment 1 year after traumatic brain injury.

DESIGN

Prospective cohort.

SETTING

Acute care hospitals in South Carolina and Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.

PARTICIPANTS

Subjects in the TBIMS national dataset and the South Carolina Traumatic Brain Injury Follow-up Registry who were expected to be working before injury and followed at 1 year postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in employment from preinjury to 1 year postinjury.

RESULTS

When other measured influences on change in hours worked were held constant, there were significant interactions for sex by age and sex by marital status. Compared with men, women were more likely to decrease hours or stop working, except in the oldest age group (55-64y) in which men were more likely to stop working. For women, there was a pattern showing better employment outcomes as age increased. Decreased employment for women was most evident for married women, who were much more likely to reduce hours or stop working. There was also a tendency for divorced women to be more likely to stop working when compared with divorced men.

CONCLUSIONS

These findings run counter to the current literature. Although definitive explanations must await future studies, causal factors arising from differential societal behavior toward women as well as discriminatory attitudes about women and employment deserve further study.

General health status and functional disability following injury in traffic crashes

OBJECTIVE

With increasing rates of survival associated with traffic crashes, a shift to understand the consequences of injury has risen to prominence. This prospective cohort study set out to examine general health status and functional disability at 2 months and 6-8 months post-crash.

METHODS

Participants were otherwise healthy adults aged 18-59 years admitted to hospitals, excluding those with moderate-severe head injury and spinal cord injury. Sixty-two adults completed interviews prior to discharge and at 2 months and 8 months post-discharge.

RESULTS

By 8 months post-crash, 89 percent had resumed employment and or study, two thirds rated the resolution of their medical problems to be excellent (14.5 percent) or good (53 percent), and 82 percent were considered to be fully self-sufficient with respect to activities of daily living. Despite this, results from the SF-36 indicated significant reductions in health status at 2 and 8 months post-crash relative to pre-crash health, with domain scores up to 26 percent lower than pre-crash scores, while assessment of activities of daily living indicated residual functional disability at both follow-up times. Self-reported pain was higher for both males and females at both follow-up times compared with pre-crash self-reported pain.

CONCLUSION

This study demonstrated significant, ongoing loss of health-related quality of life and impairment associated with injuries sustained in road crashes, highlighting the need for continuing care post-discharge to facilitate a rapid return to optimal health.

Determinants of long-term functional consequences after major trauma

OBJECTIVE

The purpose of this study was to describe the long-term functional consequences from major trauma and to quantify the effect of sociodemographic, injury-related, and physical determinants of its outcome.

METHODS

A prospective cohort study was performed at the University Medical Center Utrecht (Level I trauma center) in the Netherlands during 1999 and 2000. All severely (injury severity score [ISS] >or=16) injured adult (age >or=16) trauma survivors (n = 359) were selected for follow-up. Between 12 and 18 months after trauma, outcome was assessed by means of Glasgow Outcome Scale (GOS), EuroQol (EQ-5D), and cognitive complaints.

RESULTS

Follow-up assessments (overall response rate 93%) were obtained of 335 patients (249 men, 86 women) with a mean age of 38 years (SD = 17) and a mean ISS of 25 (SD = 10.6). The mean visual analog scale score on the EuroQol (EQvas) was 73.5 (SD = 17.8) and the mean utility score (EQus) was 69.1 (SD = 29.9), both below the norm. Patients reported limitations of mobility (48%); self-care (18%); daily activities (55%); pain and discomfort (63%); anxiety or depression (28%); and cognitive complaints (65%). In multivariate analyses, injury localization (spinal cord injury, lower extremity injury, or brain injury) was significantly associated with EQvas, EQus, and other outcome measures. Educational level was significantly associated with EQvas, anxiety/depression, and cognitive complaints. Comorbidity was significantly associated with EQvas, EQus, all dimensions of the EQ-5D (except anxiety/depression), and cognitive complaints.

CONCLUSION

In addition to the injury localization, educational level and comorbidity were identified as important independent predictors of long-term functional consequences after major trauma. These determinants need further attention in outcome research and clinical practice.

[Quality of life in patients with oropharyngeal carcinoma. Gender influences the subjective evaluation]

BACKGROUND

The purpose of this study was to evaluate the impact of patient characteristics and surgical interventions on quality of life (QoL) after primary surgery and postoperative irradiation in patients with oropharyngeal carcinoma.

PATIENTS AND METHODS

Between January 1997 and February 2002, 169 patients with carcinoma of the oropharynx were treated with curative intent. In September 2002, a total of 88 disease-free survivors were identified and included in this study. A retrospective chart review was performed and patient responses to the SF-36 Health Survey, EORTC QLQ-C30 and EORTC QLQ-H&N35 questionnaires were evaluated. The questionnaires were completed by 34 patients (39% response rate).

RESULTS

All patients were treated with primary surgery followed by postoperative irradiation. The median follow-up was 2.3 years (range 0.5-4.9 years). Using Bonferroni-Holm adjustment for alpha, gender was found to be an important factor in QoL. Females scored significantly worse than males in all three questionnaires. We could not identify other factors influencing QoL.

CONCLUSION

The impact of gender on QoL must be considered as very significant.

Trauma in Adolescents Causes Long-Term Marked Deficits in Quality of Life: Adolescent Children do not Recover Preinjury Quality of Life or Function up to Two Years Postinjury Compared to National Norms

BACKGROUND

Injury is a leading cause of death and preventable morbidity in adolescents. Little is known about long-term quality of life (QoL) outcomes in injured adolescents. The objectives of the present report are to describe long-term QoL outcomes and compare posttrauma QoL to national norms for QoL in uninjured adolescents from the National Health Interview Survey (NHIS).

METHODS

In all, 401 trauma patients aged 12 to 19 years were enrolled in the study. Enrollment criteria excluded spinal cord injury. QoL after trauma was measured using the Quality of Well-being (QWB) scale, a sensitive and well-validated functional index (range: 0 = death to 1.000 = optimum functioning). Patient outcomes were assessed at discharge, and 3, 6, 12, 18, and 24 months after discharge. NHIS data were based on 3 survey years and represent a population-based U.S. national random sample of uninjured adolescents.

RESULTS

Major trauma in adolescents was associated with significant and marked deficits in QoL throughout the 24-month follow-up period, compared with NHIS norms for this age group. Compared with NHIS norms for QoL in uninjured adolescents aged 12 to 19 years (N = 81,216,835; QWB mean = 0.876), injured adolescents after major trauma had striking and significant QoL deficits beginning at 3-month follow-up (QWB mean = 0.694, p < 0.0001), that continued throughout the long-term follow-up 24 months after discharge (6-month follow-up QWB mean = 0.726, p < 0.0001; 12-month follow-up QWB mean = 0.747, p < 0.0001; 18-month follow-up QWB mean = 0.758, p < 0.0001; 24-month follow-up QWB mean = 0.766, p < 0.0001). QoL deficits were also strongly associated with age (>or=15 years) and female sex. Other significant risk factors for poor QoL outcomes were perceived threat to life, pedestrian struck mechanism, and Injury Severity Scores >16.

CONCLUSIONS

Major trauma in adolescents is associated with significant and marked deficits in long-term QoL outcomes, compared with U.S. norms for healthy adolescents. Early identification and treatment of risk factors for poor long-term QoL outcomes must become an integral component of trauma care in mature trauma care systems.

Functional outcome at 2.5, 5, 9, and 24 months after injury in the Netherlands

BACKGROUND

The collection of empirical data on the frequency, severity, and duration of functioning is a prerequisite to identify patient groups with long term or permanent disability.

METHODS

We fielded postal questionnaires in a stratified sample of 8,564 injury patients aged 15 years and older, who had visited an emergency department in the Netherlands. Measurements were at 2.5, 5, 9, and 24 months after the injury and included a generic health status classification (EQ-5D), socio-demographic, and medical information. We analyzed determinants of long-term functional outcome by multivariate regression analysis.

RESULTS

Five months after the injury health status of nonhospitalized injury patients was comparable to the general population's health (EQ-5D summary measure 0.87). Health status of patients admitted for 3 days or less improved until 9 months (0.82). For those admitted more than 3 days health status improved until 24 months (0.48 toward 0.67), but remained below population norms. Hospitalization, age and sex (females), type of injury (spinal cord injury, hip fracture, and lower extremity injury), and comorbidity were significant predictors of poor functioning in the long term.

CONCLUSIONS

Recovery patterns vary widely between nonhospitalized, shortly, and long hospitalized injury patients. Nonhospitalized injury patients recover within 5 months from an injury whereas a considerable group of hospitalized injury patients suffer from persistent health problems. Our study indicates the importance of health monitoring with an adapted longitudinal design for injury patients. The time intervals used should match the various stages of the recovery process, which depends on the severity of the injury studied.

Long-Term Multidimensional Functional Consequences of Severe Multiple Injuries Two Years After Trauma: A Prospective Longitudinal Cohort Study

BACKGROUND

The assessment of outcome after multiple injuries in a rehabilitation perspective is increasingly important in trauma research. The purpose of this study was to assess functioning and quality of life after severe injuries using a prospective cohort design.

METHODS

One hundred and five patients with a New Injury Severity Score >15, aged 18 to 67 years, and admitted to a Level I trauma center were included consecutively starting January 2002 through June 2003. Outcomes were assessed 6 weeks after discharge and 1 and 2 years after injury. Self-reported functioning and quality of life was measured by Short Form (SF)-36, World Health Organization Disability Assessment Schedule II (WHODAS II) and a cognitive function scale (COG).

RESULTS

Mean age was 35.3 years (standard deviation [SD], 14.0), 83% were male. Mean New Injury Severity Score was 34.6 (SD, 12.6). Disease burden measured by SF-36 showed scores below the general population. Effect sizes showed that the largest difference was for physical functioning, social functioning, and physical and emotional role functioning. The WHODAS II disability score showed substantially worse functioning compared with general population data. Profession, injury severity, pain, and physical, cognitive, and social functioning made independent contributions to WHODAS II 2 years after injury and explained 69% of the variance of the model.

CONCLUSIONS

Long-lasting functional problems after multiple injuries affect most life domains. Knowledge about the reduced physical, mental, cognitive, social, and role functioning should impact the rehabilitation services provided for severely injured patients, from primary care to community rehabilitation.

Trauma patients in the intensive care unit: short- and long-term survival and predictors of 30-day mortality

BACKGROUND

The aims of this cohort study were to assess the survival of trauma patients treated in a general intensive care unit (ICU) and to evaluate the simplified acute physiology score (SAPS) II, maximum sequential organ failure assessment (SOFA) score, injury severity score (ISS), age, sex and severe head injury as predictors of 30-day mortality.

METHODS

Three hundred and twenty-five adult patients admitted during 1998-2003 were evaluated retrospectively with update of survival data in January 2005. Kaplan-Meier statistics and Cox proportional hazards regression were used to study survival and to assess predictors of mortality, respectively.

RESULTS

The 30-day mortality was 16.9%, ICU mortality 13.8% and hospital mortality 17.8%. Long-term survival (observation time, 1-7 years) was 77.8%. After 3.5 years, mortality was the same as for the background population. Severe head injury was the main cause of death and increased the risk of 30-day mortality 2.4-fold. In addition, SAPS II and an age above 50 years proved to be significant predictors of mortality in a multivariate analysis. Sex was not associated with mortality, and ISS and the maximum SOFA score were significant predictors in univariate analyses only.

CONCLUSION

Reduced long-term survival was observed up to 3.5 years after acute injury. The 30-day mortality was strongly related to severe head injury, SAPS II and an age above 50 years. These variables may be useful as predictors of mortality, and may contribute to risk adjustment of this subset of trauma patients when treatment results from different centres are compared.

The mind does matter: Psychological and physical recovery after musculoskeletal trauma

BACKGROUND

Posttraumatic psychopathology (PTP) is important to the orthopedic surgeon because it appears to be much more common than might have been suspected and may complicate the recovery from musculoskeletal injury. We have investigated the relationship between physical and psychological recovery in victims of musculoskeletal trauma.

METHODS

A prospective cohort of 200 patients with musculoskeletal injuries were studied, correlating development of psychopathology (measured by the General Health Questionnaire) and functional outcome (measured by Short Form-36, Sickness Impact Profile, and Musculoskeletal Function Assessment) 2 and 6 months after their injuries.

RESULTS

Pre-existing psychological disturbance was found in 11% of our patients; this figure rose to 46% of patients at 2 months but fell to 22% at 6 months. The posttraumatic disturbance correlated strongly with impaired functional outcome as measured by all three outcomes measures (total and category scores) (p < 0.05).

CONCLUSIONS

The strong correlation of PTP with impaired functional outcome after musculoskeletal trauma stresses that it is a significant problem. Further research is required to determine whether an approach that combines physical and psychological treatment can improve patient outcomes.

Demographic, social and economic variables that affect lower extremity injury outcomes

While behavioral, demographic and vocational factors are commonly know as risk factors for sustaining a traumatic injury, less is known about the social, demographic and economic determinants of outcome following injury. The Lower Extremity Assessment Project (LEAP) identified a prospective cohort of 601 patients who were admitted to eight level I trauma centers in the United States for treatment of severe lower extremity trauma. Prospective data was accumulated on these individuals throughout their initial hospitalization and at regular follow-up intervals including a cohort at seven years post-injury. The results of the LEAP investigations showed that even at five to seven years following injury, reconstruction for the treatment of injuries to the lower extremity typically result in functional outcomes equivalent to those of the amputation. Clearly, factors other than the traditional variables such as fracture healing, joint function, and ability to ambulate have a profound effect on the patient's estimation of improvement. The purpose of this report is to summarize the data from the LEAP study and other investigations related to demographic, social and behavioral factors which impact outcome following lower extremity injury.

Routine Follow Up of Major Trauma Patients From Trauma Registries: What are the Outcomes?

BACKGROUND

Routine measurement of outcomes other than mortality in trauma is needed to monitor trauma care, benchmark trauma hospitals and systems, and to guide resource provision. Trauma registries are ideally placed to capture morbidity outcomes such as functional loss, disability, and handicap. This study aimed to provide a broad description of the 6-month outcomes of major trauma patients captured by a population-based trauma registry, establish the follow-up rate of registry patients, and determine any biases associated with loss to follow up.

METHODS

The Victorian State Trauma Registry (VSTR) is a population-based registry in Victoria, Australia. Major trauma patients captured by the VSTR with a date of injury from October 1, 2003 to September 30, 2004 were followed up at 6 months postinjury by telephone to collect information about their living status, functional levels, and return to work.

RESULTS

Of the 1,102 eligible patients, 67% were successfully followed up at 6 months postinjury. Eighteen patients had died since discharge. Patients lost to follow up were less severely injured (p = 0.004) and younger (p = 0.010) at baseline than those followed up. The vast majority of major trauma patients are independent with respect to locomotion (78%), feeding (93%), and expression (93%) by 6 months postinjury. Of those working before injury, 60% had returned to work.

CONCLUSIONS

The findings show that follow up of registry patients is feasible, results in few biases in the follow-up population, and reports similar findings to individual studies of trauma populations.

Racial disparities in acute outcomes of life-threatening injury

PURPOSE

To critically analyze racial and ethnic disparities in acute outcomes of life-threatening injury in the United States (US).

DESIGN

Integrative review of literature.

METHODS

A search of Medline (1966-2005) and CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1982-2002) scientific literature databases was undertaken to identify research aimed at correlating minority race and ethnicity to acute outcomes of life-threatening injury in the US.

RESULTS

Although injury is the leading cause of death for adults 15 to 44 years of age, racial and ethnic health disparities in acute outcomes of life-threatening injury have been relatively unexplored: only seven of 352 (2%) studies. The findings from these studies were mixed. Four studies indicated significant relationships between race or ethnicity to acute outcomes in injury morbidity and mortality, but three studies showed no significant relationships between these variables. Other variables associated with health disparities, such as income and education, were rarely (income) or not (education) addressed.

CONCLUSIONS

These inconclusive results indicate the need for more research aimed at investigating racial and ethnic disparities in acute outcomes of life-threatening injury.

Predicting quality of life six months after traumatic injury

BACKGROUND

Many factors are known to impact quality of life (QoL) after injury, but predictors of diminished QoL and the time course of recovery remain incompletely understood. This study examines predictors and correlates of QoL measured by the Short Form-36 (SF-36) one and six months postinjury.

METHODS

Adults with nonneurologic blunt injury were prospectively enrolled. Demographic, injury, and socioeconomic data were collected. Patients were assessed with functional and psychologic measures. In all, 196 patients had 1-month data and 123 had 6-month data available. Scores were compared at each time point and also to population norms using t-tests. Multiple regression techniques were used to identify associations between the physical and mental component scores (PCS & MCS) of the SF-36 and patient characteristics.

RESULTS

PCS scores improved significantly (32.8 +/- 0.9 versus 41.3 +/- 1.0, p < 0.05) whereas MCS scores (47.5 +/- 1.1 versus 47.2 +/- 1.1, p = NS) did not. Both remained significantly below population norms. Functional Independence Measure (FIM) at one month was predictive of PCS at 6 months. Posttraumatic stress disorder (PTSD) was predictive of lower MCS, and depression was associated with poor MCS. Injury Severity Score was not associated with PCS or MCS.

CONCLUSIONS

Overall physical and mental QoL measured by the SF-36 remains significantly below population norms 6 months after traumatic injury. It is possible to identify patients at risk for diminished QoL early during recovery by screening for functional status, PTSD, social support, and depression. Interventions to address these areas should be further studied with respect to their impact on long-term QoL.

Traumatic brain injury outcomes in pre- and post- menopausal females versus age-matched males

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.

Outcome From Serious Injury in Older Adults

PURPOSE

To analyze the research published in peer-reviewed journals between 1996 and 2005 about factors affecting the physical outcomes of older adults after serious traumatic injury.

ORGANIZING CONSTRUCT

Twenty-seven primary research studies published in the last 10 years pertained to in-hospital and long-term outcomes of serious injury among older adults. Research specific to isolated hip injury, traumatic brain injury, and burn trauma was excluded.

METHODS

An integrative review of research published between January 1996 and January 2005 was carried out to examine the relationship between older age and outcome from severe injury. MEDLINE, BIOSIS previews, CINAHL, and PsycINFO databases were searched using the MeSH terms: injury, serious injury, trauma and multiple trauma, and crossed with type, severity, medical/surgical management, complication, outcome, mortality, morbidity, survival, disability, quality of life, functional status, functional recovery, function, and placement.

FINDINGS

Older adults in these studies had higher short- and long-term mortality than did younger adults. The relationship between older age and poorer outcome persisted when adjusting for injury severity, number of injuries, comorbidities, and complications. At the same time, injury severity, number of injuries, complications, and gender each independently correlated with increased mortality among older adults. The body of research is limited by overreliance on retrospective data and heterogeneity in definitional criteria for the older adult population.

CONCLUSIONS

Additional research is needed to clarify the contributory effect of variables such as psychosocial sequelae and physiologic resilience on injury outcome. The field of geriatric trauma would benefit from further population-based prospective investigation of the determinants of injury outcome in older adults in order to guide interventions and acute care treatment.

Prevalence and prognostic factors of disability after childhood injury

OBJECTIVE

To assess the prevalence and the prognostic factors of disabilities after minor and major childhood injuries and to analyze which sociodemographic and injury-related factors are predictive for suboptimal functioning in the long term.

METHOD

We conducted a patient follow-up study in a stratified sample of 1221 injured children who were aged 5 to 14 years and had visited an emergency department in The Netherlands. Our study sample was stratified so that severe, less common injuries were overrepresented. Postal questionnaires were sent 2.5, 5, and 9 months after the injury. We gathered injury and external cause data, sociodemographic information, and data on functional outcome with a generic health status measure EuroQol (EQ-5D) with an additional cognitive dimension. A nonresponse analysis was performed by multivariate logistic regression, and the data were adjusted for nonresponse and the sample stratification. We performed bootstrap analysis to estimate the prevalence of disability in terms of the EQ-5D summary score and the occurrence of limitations in separate health domains: mobility, self-care, usual activities, pain/discomfort, anxiety/depression, and cognition. Respondents also rated their own health state on a visual analog scale, between 0 (worst imaginable health state) and 100 (best imaginable health state). We analyzed the relationship between functional outcome and sociodemographic (age and gender) and injury-related determinants (type of injury, external cause, multiple injury, admission to hospital, and length of stay) by logistic regression analysis.

RESULTS

Response rates with respect to the original sample were 43%, 31%, and 30%, respectively. A total of 37% of the children were admitted to the hospital. The mean age of the children was 9.6 years. In two thirds (65%) of the cases, the injury was attributed to a home and/or leisure injury. The health status of injured children improved from 0.92 (EQ-5D summary score) at 2.5 months to 0.96 at 5 months and 0.98 at 9 months. Of all injured children, 26% had at least 1 functional limitation after 2.5 months, 18% after 5 months, and 8% still experienced functional limitations after 9 months. After 2.5 months, lower extremity fractures and other injuries (eg, spinal cord injury, injury of the nerves) demonstrated the worst functional outcome. Independent of the type of injury, our sample of injured children generally showed good recovery between 2.5 and 9 months. The highest prevalence of dysfunction after 9 months existed for pain/discomfort (7%) and usual activities (5%). Hospital admission (odds ratio: 3.6-5.8) and female gender (odds ratio: 3.0) were predictive for long-term disability. Girls reported more problems for all health domains (except self-care) compared with boys after 9 months, which was also confirmed by the visual analog scale score for self-related health (89 for girls vs 95 for boys). Almost one fifth of injured children with a hospital stay of >3 days still had pain and problems with usual activities 9 months after the injury. Three quarters of all residual problems were caused by nonhospitalized injuries.

CONCLUSION

Most children show quick and full recovery after injury, but a small subgroup of patients (8%) have residual disabilities after 9 months. Girls have a 3-fold risk compared with boys for long-term disability after childhood injury. Prognosis in the long-term is also negatively influenced by hospitalization, but in absolute terms, residual disabilities are frequently caused by injuries that are treated fully in the emergency department. The group of injured children with persistent health problems as identified in this study indicates the importance of health monitoring over a longer period in trauma care, whereas trauma care should be targeted at early identification and management of the particular needs of these patients.

High Rates of Acute Stress Disorder Impact Quality-of-Life Outcomes in Injured Adolescents: Mechanism and Gender Predict Acute Stress Disorder Risk

BACKGROUND

Injury is the leading cause of death and functional disability in adolescent children. Little is known about quality of life and psychological outcomes after trauma in adolescents. The Trauma Recovery Project in Adolescents is a prospective epidemiologic study designed to examine multiple outcomes after major trauma in adolescents aged 12 to 19 years, including quality of life (QoL) and psychological sequelae such as acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). The specific objectives of the present report are to examine ASD rates and the association of ASD with QoL outcomes in injured adolescents.

METHODS

Between April 26, 1999, and November 13, 2002, 401 eligible trauma patients aged 12 to 19 years triaged to five participating trauma center hospitals in a regionalized trauma system were enrolled in the study. The admission criteria for patients were as follows: (1) age 12 to 19 years and (2) injury diagnoses excluding severe traumatic brain injury (TBI) or spinal cord injury. QoL after trauma was measured using the Quality of Well-being (QWB) scale, a sensitive and well-validated functional index (range, 0 = death to 1.000 = optimum functioning). ASD (before discharge) was diagnosed with the Impact of Events Scale-Revised. Scores of 24+ were used to diagnose ASD. Patient outcomes were assessed at discharge and at 3, 6, 12, 18, and 24 months after discharge.

RESULTS

ASD before discharge was diagnosed in 40% of adolescent trauma survivors. ASD status was associated with large QoL deficits during follow-up, as follows: 3-month, ASD-positive QWB score = 0.667 vs. ASD-negative QWB score = 0.710, p < 0.01; 6-month, ASD-positive QWB score = 0.704 vs. ASD-negative QWB score = 0.742, p < 0.001; 12-month: ASD-positive QWB score = 0.718 vs. ASD-negative QWB score = 0.757, p < 0.01; 24-month, ASD-positive QWB score = 0.725 vs. ASD-negative QWB score = 0.769, p < 0.01. Female sex and violent mechanism predicted ASD risk (47% female vs. 36% male; odds ratio, 1.6; p < 0.05; violence 54% vs. 38%; odds ratio, 1.9; p < 0.01).

CONCLUSIONS

Adolescent trauma survivors have high rates of ASD. ASD severely impacts QoL outcomes and is associated with female sex and mechanism of injury in adolescents. Early recognition and treatment of ASD in seriously injured adolescents will improve QoL outcomes.

Incidence of and Risk Factors for Acute Stress Disorder in Children with Injuries

BACKGROUND

To assess the incidence of and risk factors for Acute Stress Disorder (ASD) in children with injuries. Numerous studies have documented the increased incidence of PTSD in those initially diagnosed with ASD. PTSD symptoms cause tremendous morbidity and may persist for many years in some children.

METHODS

Children hospitalized with one or more injuries were interviewed and assessed with the following: Child Stress Disorders Checklist (CSDC), Family Strains Scale, Brief Symptom Inventory (BSI) and Facial Pain Scale.

RESULTS

Participants included sixty-five children (ages 7-18 years). The mechanisms of injury varied (e.g. MVC, penetrating). The mean injury severity score was 8.9 +/- 7. The mean length of hospital stay was 4.6 +/- 4.6 days. Altogether, 18 (27.7%) of participants met DSM IV criteria for ASD during their acute hospital stay. Risk factors such as level of family stress, caregiver stress, child's experience of pain, and child's age were predictive of acute stress symptoms.

CONCLUSION

We have identified four risk factors of ASD that have implications for the treatment, and possibly, preventative intervention for PTSD. Further investigation and greater understanding of risk factors for ASD in children with injuries may facilitate the design of acute interventions to prevent the long-term negative outcomes of traumatic events.

Recovery after musculoskeletal trauma in men and women

BACKGROUND

Recent work has suggested that women are more at risk of impaired outcome after traumatic injuries. This would suggest that resources should be targeted at female trauma patients to optimize their outcomes. We wished to explore the physical and psychological outcomes of women treated in our trauma unit.

METHODS

The Grampian Trauma Outcomes Study recruited patients aged 16 to 70 years with musculoskeletal injuries. Patients with significant head injuries, alcohol intoxication, or low-energy osteoporotic fractures were excluded. Of 227 patients approached, 200 were recruited to the study. Patients were asked to complete physical and psychosocial (Short Form-36 and Musculoskeletal Function Assessment) and psychological (General Health Questionnaire) outcomes measures at initial assessment and at 2- and 6-month follow-up.

RESULTS

Of the 200 patients, 79% completed 2-month follow-up and 75% completed 6-month follow-up. There were no significant differences in the outcomes scores between male and female patients at either of the follow-up points.

CONCLUSION

From our study, women do not appear to have impaired recovery after trauma as compared with men. Larger scale studies are required to assess the need to target specific resources toward the treatment of female trauma victims.

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients

The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non-trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N = 1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries.

Long-Term Posttraumatic Stress Disorder Persists after Major Trauma in Adolescents: New Data on Risk Factors and Functional Outcome

BACKGROUND

Little is known about long-term psychological outcomes after major trauma in adolescents, a leading cause of death and preventable morbidity in this age group. A prospective epidemiologic study was conducted to examine quality of life (QoL) and posttraumatic stress disorder (PTSD) outcomes in injured adolescents. The specific objectives of the present report are to describe long-term PTSD and to identify risk factors for long-term PTSD and the impact of PTSD on QoL.

METHODS

Between April 26, 1999, and November 13, 2002, 401 eligible trauma patients aged 12 to 19 years triaged to five participating trauma center hospitals in a regionalized trauma system were enrolled in the study. The admission criteria for patients were as follows: age 12 to 19 years and injury diagnoses excluding severe traumatic brain injury or spinal cord injury. PTSD was diagnosed with the Impact of Events Scale-Revised; scores of 24+ were used to diagnose PTSD. QoL after trauma was measured using the Quality of Well-Being scale, a sensitive and well-validated functional index (range: 0 = death to 1.000 = optimum functioning). Patient outcomes were assessed at discharge and at 3, 6, 12, 18, and 24 months after discharge.

RESULTS

The rate of long-term PTSD was 27%, with high rates over the follow-up period. Risk factors for long-term PTSD were perceived threat to life (odds ratio [OR], 2.2; p < 0.001.); death of a family member at the scene (OR, 4.7; p < 0.001); no control over injury event (OR, 1.7; p < 0.05), and violence-related injury (OR, 2.2; p < 0.05). PTSD in adolescents was significantly and strongly associated with female gender, older age, low socioeconomic status, drug and alcohol abuse, and other adolescent behavioral problems. Long-term PTSD was also associated with marked and significant QoL deficits throughout the 24-month follow-up interval.

CONCLUSION

High rates of long-term PTSD persist after major trauma in adolescents. Injury events such as perceived threat to life and control over the event are strongly associated with PTSD risk. Prolonged PTSD severely impacts QoL outcomes. Early identification and treatment of risk factors for long-term PTSD will be important to improve outcomes in injured adolescents.

Quality of Life and Functional Outcome after Pediatric Trauma

BACKGROUND

Injury is the leading cause of preventable morbidity and functional limitation in children. Long-term sequelae are measured best by the degree of impairment after recovery from the acute traumatic event. The specific aim of this study was to determine the quality of life and functional status of moderately to severely injured pediatric trauma patients at hospital discharge and at 1, 6, and 12 months postinjury.

METHODS

We conducted a prospective longitudinal study of children aged 1 to 18 years with blunt injury and Injury Severity Score >/= 9, excluding head and spinal cord injury. Children were evaluated at hospital discharge and at 1, 6, and 12 months postinjury, using the Child Health Questionnaire (CHQ), the Functional Independence Measure, and the Impact on Family Scale. Baseline and 1- and 6-month data analyses are reported.

RESULTS

One hundred sixty-two children were enrolled in the study, and 156 had completed 6-month data entry. The mean age was 9.3 +/- 5.3 years, and the mean Injury Severity Score was 14 +/- 7.4. The most common cause of injury was motor vehicular-related (43%). Fifty-eight (37%) had multisystem injuries. Femur fracture represented the most common injury (54.8%). Families experienced economic, social, and personal strain, as measured by the Impact on Family scale. There was a significant improvement in CHQ and Functional Independence Measure scores between baseline and 1 month and between 1 month and 6 months postinjury. However, at 6 months, physical scores remained lower than age-matched norms.

CONCLUSION

Injury in children results in a significant burden on families. Although children demonstrate a rapid recovery of function and quality of life after blunt injury, physical function remains lower than age-matched norms at 6 months postinjury. It is unclear whether this represents a plateau in recovery or whether further improvements can be expected over longer time intervals.