Global health: injuries and violence

Influence of hypocalcemia on the prognosis of patients with multiple trauma

BACKGROUND

Hypocalcemia is highly common in hospitalized patients, especially in those with trauma, On the other hand, abnormal calcium metabolism is an important metabolic challenge; however, it is often neglected and untreated, and certain factors may induce serious neurological and cardiovascular complications.

AIM

To retrospectively analyze the impact of hypocalcemia on the prognosis of patients with multiple traumas.

METHODS

The study was conducted from January 2020 to December 2021. Ninety-nine patients with multiple injuries were treated at the critical care medicine department of Fuyang People’s Hospital. The selected indicators included sex, age, and blood calcium and hematocrit levels. Many indicators were observed, including within 24 h of hospitalization, and the prognosis was collected after 28 d. Based on the blood calcium levels, the patients were divided into the following two groups: Normocalcemia and hypocalcemia. Of the 99 patients included, 81 had normocalcemia, and 18 had hypocalcemia. Separate experiments were conducted for these two groups.

RESULTS

There was an association between serum calcium levels and the prognosis of patients with polytrauma.

CONCLUSION

Clinically, the prognosis of patients with multiple traumas can be preliminarily evaluated based on serum calcium levels.

Effects of ulinastatin therapy in emergency severe multiple trauma: A single-center randomized controlled trial

BACKGROUND

Severe multiple traumas are one of the most common diseases and carry a significant financial burden with high disability and mortality. There are no effective drugs in the clinical management of severe multiple traumas, and there is an absence of evidence-based medicine concerning the treatment of severe multiple traumas.

METHODS

The present study explored whether ulinastatin (UTI) can improve the outcome of severe multiple traumas. The present research included patients who were hospitalized in intensive care units after being diagnosed with severe multiple trauma. Patients received UTIs (400,000 IU) or placebos utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures were 30-day mortality, multiple organ dysfunction syndrome, inflammatory response, coagulation function, infection, liver function, renal function, and drug-related adverse effects.

RESULTS

A total of 239 individuals were classified into 2 groups, namely, the placebo group (n = 120) and the UTI group (n = 119). There were no statistically significant differences in baseline clinical data between the 2 groups. The 30-day mortality and multiple organ dysfunction syndrome in the UTI group were remarkably improved compared with those in the placebo group. UTI can protect against hyperinflammation and improve coagulation dysfunction, infection, liver function, and renal function. UTI patients had markedly decreased hospitalization expenditures compared with the placebo group.

CONCLUSION

The findings from the present research indicated that UTIs can improve the clinical outcomes of patients with severe multiple traumas and have fewer adverse reactions.

Trauma exposure and posttraumatic stress disorder in a large community sample of Chinese adults

BACKGROUND

This study investigated the prevalence and related factors of trauma exposure and probable posttraumatic stress disorder (PTSD) in adults from a Chinese community sample.

METHODS

Participants were 7218 adults recruited from Jiangxi and Hunan provinces in China. Life Events Checklist and Posttraumatic Stress Disorder Checklist for DSM-5 were used to screen lifetime trauma exposure and PTSD symptoms, respectively. Participants' adverse and positive childhood experiences, behavioral inhibition, depression, insomnia, psychotic-like experiences (PLEs) and ADHD symptoms were also measured. Multiple regressions were performed to examine the correlates of PTSD.

RESULTS

Approximately 67.1% of participants reported one traumatic event; 27.1% experienced four or more. Participants recruited from private school, male, young age, low socioeconomic status, and poor physical health were associated with more trauma-exposure. The prevalence of PTSD was 2.1% in the total sample and 3.1% among the trauma-exposed. Among participants with PTSD, 53.6% were screened as depression, 54.3% had insomnia, 65.6% had one to three PLEs, 12.6% had four to seven PLEs, and 26.5% were screened as likely ADHD, and 5.3% highly likely ADHD. Younger age, being less educated, poor marriage quality and physical health, more adverse childhood experiences, behavioral inhibition and less positive childhood experiences were associated with increased risk of PTSD among the trauma exposed. After adjustment of these related factors, depression, insomnia, PLEs and ADHD were related to PTSD.

CONCLUSIONS

PTSD is relatively prevalent among Chinese community population. Childhood experiences, behavioral inhibition, and concurrent mental health account for individual differences in vulnerability to PTSD.

Road safety data collection systems in Iran: A comparison based on relevant organizations

PURPOSE

Various organizations and institutions are involved in road traffic injury (RTI) and crash registration such as police, forensic medicine organization, hospitals and emergency medical services. But there is a substantial uncertainty in interpreting the data, duplicated data collection and missing data in relation to RTI in most systems. This study aims to identify data sources for RTI surveillance in Iran and to explore traffic safety data source domains, data elements and detailed information by each data source.

METHODS

This is a qualitative study which was conducted in 2017 in Iran. Data were collected employing semi-structured interviews with informants in road safety organizations in relation to traffic safety including Police, Ministry of Health and Medical Education as well as Forensic Medicine Organization and other authorities-in-charge. For completing the preliminary extraction information, the minimum data set was used and compared in each system.

RESULTS

Eight different organizations relevant to road traffic safety were identified. The main domain of data provided by each one consists of Emergency Medical System form, Police KAM114 form, Ministry of Transport and Road Administration, Red Crescent Organization/Disaster Management Information System, Ministry of Health and Medical Education, Forensic Medicine Organization, Insurance Company and Ministry of Justice. Each system has its own database, based upon its scope and mainly at crash and post-crash status and little on pre-crash circumstance.

CONCLUSION

All current registry systems are not surveillance systems for RTI prevention. Huge data have been collected in various registry systems in Iran, but most of the collected variables are duplicated in each system. On the other hand, some variables like alcohol and substance abuse, child seat belt, helmet use in relation to RTI prevention are missed in all systems. Accordingly, it is a critical need to integrate and establish a comprehensive surveillance system, with focus on the goal of each system and collection of minimum data in each organization, which currently is underway.

Syndemic effects in complex humanitarian emergencies: A framework for understanding political violence and improving multi-morbidity health outcomes

A hallmark of complex humanitarian emergencies is the collective exposure, often over extended periods of time, to political violence in the forms of war, terrorism, political intimidation, repression, unlawful detention, and forced displacement. Populations in complex humanitarian emergencies have higher risks of multiple co-morbidities: mental disorders, infectious diseases, malnutrition, and chronic non-communicable diseases. However, there is wide variation in the health impacts both across and within humanitarian emergencies. Syndemic theory is an approach to conceptualizing disease and social determinants to understand differential patterns of multi-morbidity, elucidate underlying mechanisms, and better design interventions. Syndemic theory, if applied to complex humanitarian emergencies, has the potential to uncover origins of localized patterns of multi-morbidity resulting from political violence and historical inequities. In this paper, we present two case studies based on mixed-methods research to illustrate how syndemic models can be applied in complex humanitarian emergencies. First, in a Nepal case study, we explore different patterns of posttraumatic stress disorder (PTSD) and depression co-morbidity among female former child soldiers returning home after war. Despite comparable exposure to war-related traumas, girl soldiers in high-caste Hindu communities had 63% co-morbidity of PTSD and depression, whereas girl soldiers in communities with mixed castes and religions, had 8% PTSD prevalence, but no cases of PTSD and depression co-morbidity. In the second case study, we explore the high rates of type 2 diabetes during a spike in political violence and population displacement. Despite low rates of obesity and other common risk factors, Somalis in Ethiopia experienced rising cases of and poor outcomes from type-2 diabetes. Political violence shapes healthcare resources, diets, and potentially, this epidemiological anomaly. Based on these case studies we propose a humanitarian syndemic research agenda for observational and intervention studies, with the central focus being that public health efforts need to target violence prevention at family, community, national, and global levels.

•

Violence is a key feature of syndemic interactions in many contexts.

•

In complex humanitarian emergencies, political violence exacerbates multi-morbidity.

•

A syndemic approach could integrate fragmented and siloed health responses in complex humanitarian emergencies.

•

A syndemic approach demands mitigating the roots of political violence and resulting multi-morbidities.

Violent Injuries Among College Students in China: An Exploration of Gender Mental Stress Model

The purpose of this study was to explore the gender-specific mental stress model of violent injuries among Chinese college students. A cross-sectional, multistage sampling process was employed to recruit a total of 5025 college students from 22 universities in China. Survey respondents reported their exposure to violent injuries and noted individual and environmental factors that could relate to violent injuries. Both unadjusted and adjusted statistical methods were used to examine the relationships between selected individual and environmental variables with violent injuries among male and female college students. The overall prevalence of violent injuries among male and female college students in this study was 4.40% (95% CI [0.10%, 7.80%]) and 5.20% (95% CI [0.05%, 10.35%]). The study found that higher mental stress (OR: 3.32), lower level universities (OR: 5.99), and family location in rural areas (OR: 4.00) were associated with a higher likelihood of violent injuries, and mothers employed as professionals (OR: 0.07) was associated with lower prevalence of violent injuries among male students. Unlike male students, mental stress and mothers’ occupation were not associated with violent injuries among female students. University type was also associated with violent injuries but this association was inverted (OR: 0.06) among female students. This study found gender-specific relationships affecting violent injuries among college students in China. Prevention strategies need to be developed in consideration of gender influences and should be enacted to reduce the negative impact of violent injuries on society and personal health in China.

Trauma induced clotting factor depletion in severely injured children: a single center observational study

Background

Coagulopathy following severe trauma contributes significantly to mortality. Impaired clotting factors have been observed in adult trauma patients, but in pediatric trauma victims their activity has not yet been investigated.

Methods

Sixteen pediatric trauma patients were evaluated according to the ISS and assigned to two cohorts. An additional control group (CO; n = 10) was formed. Routine coagulation parameters and the soluble clotting factors (F) were tested. Nonparametric data was analyzed using the Mann-Whitney U test. Results are reported as median and interquartile range.

Results

The ISS of severely (SI, n = 8) and mildly (MI, n = 8) injured children differed significantly (25 [19–28] vs. 5 [4–6]; p < 0.001). INR was elevated in the SI cohort only when compared to the CO (1.21 [1.04-1.58] vs. 0.96 [0.93-1.00]; p = 0.001). Differences between SI and MI were found for FII (67 [53-90] vs. 82 [76-114] %; p = 0.028), FV (76 [47-88] vs. 92 [82-99] %; p = 0.028), and FXIII (67 [62-87] vs. 90 [77-102] %; p = 0.021). Comparison of the SI with the CO (FII 122 [112-144] %; p < 0.001; FV 123 [100-142] %; p = 0.002; and FXIII 102 [79-115] %; p = 0.006) also revealed a reduction in the activity of these factors. Furthermore, fibrinogen (198 [80-242] vs. 296 [204-324] mg/dl; p = 0.034), FVII (71 [63-97] vs. 114 [100-152] %; p = 0.009), FIX (84 [67-103] vs. 110 [90-114] %; p = 0.043), and FX (70 [61-85] vs. 122 [96-140] %; p = 0.001) were reduced in the SI in comparison with the CO. Finally, FVIII was considerably, yet not significantly, increased in both patient cohorts (235 [91-320] % and 197 [164-238] %, respectively).

Conclusions

This study proves that children suffer a depletion of clotting factors following severe injury which basically reflects the findings for adult trauma patients. Attempts to correct the impaired clotting factor activity could be based on a specific hemostatic therapy involving administration of coagulation factors. Nevertheless, therapeutic implications need to be investigated in future studies.

A functional SNP in MIR124-1, a brain expressed miRNA gene, is associated with aggressiveness in a Colombian sample

Background:

Interpersonal violence and suicide are among the main causes of mortality and morbidity around the world. In several developing countries, such as Colombia, they are among the first five entities of public health concern. Aggressiveness is an important endophenotype for aggression and suicidal behavior, having a heritability of around 50%. Exploration of classical candidate genes, involved in serotoninergic and dopaminergic neurotransmission, has identified few consistent risk factors for aggressiveness. miRNAs are a novel class of molecules with a growing role in normal neural function and neuropsychiatric disorders; of special interest, miR-124 is a brain-specific miRNA that is key for neuronal plasticity. We evaluated the hypothesis that a functional polymorphism in MIR124-1 gene might be associated with aggressiveness in a Colombian sample.

Methods:

The Spanish adaptation of the refined version of the Aggression Questionnaire and the abbreviated Barratt Impulsiveness Scale were applied to 170 young subjects. The functional SNP in MIR124-1 (rs531564) was genotyped by a TaqMan assay.

Results:

We found a significant association between the MIR124-1 and aggressiveness in our sample, with G/G carriers having lower scores (P = 0.01). This association seemed to be specific for aggressiveness, as it was not significant for impulsiveness.

Conclusions:

We showed for the first time the association of a functional polymorphism in MIR124-1 and aggressiveness. Known targets of miR-124 (such as BDNF and DRD4 genes) could explain the effect of this miRNA on behavior. A future analysis of additional novel functional polymorphisms in other brain expressed miRNAs could be useful for a deeper understanding of aggression in humans.

Nonunited Lower Extremity Fractures Initially Repaired Outside the Developed Western World Develop a High Rate of Postoperative Complications After Nonunion Repair

OBJECTIVES

To evaluate the clinical and functional outcomes after operative repair of nonunited lower extremity fractures initially repaired outside the developed Western world.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

From September 2004 through February 2017, 227 patients who underwent operative repair of a lower extremity fracture nonunion were prospectively enrolled in a research registry. All patients underwent previous fracture surgery and had at least 12 months of postoperative follow-up.

INTERVENTION

Repair of lower extremity fracture nonunion.

MAIN OUTCOME MEASUREMENTS

Postoperative complications, reoperation rate, time to union, and functional outcomes were assessed using the Short Musculoskeletal Function Assessment and Visual Analog Scale pain scores. Univariate and multivariate analyses were performed to evaluate the differences in patients who underwent initial fracture repair outside the developed Western world as opposed to within the United States.

RESULTS

Twenty-one patients (9.3%) underwent initial fracture repair outside the developed Western world. These patients had a greater incidence of infected nonunions (47.6% vs. 23.3%; P = 0.015) and failure of a previous implant at the time of presentation (52.4% vs. 22.8%; P = 0.003) than those initially managed within the United States. This cohort also experienced a greater rate of postoperative complications after nonunion repair (23.8% vs. 6.3%; P = 0.016). The geographic location of initial fracture repair was not associated with postoperative Short Musculoskeletal Function Assessment scores or Visual Analog Scale pain scores after controlling for possible confounding variables.

CONCLUSIONS

Patients who present with a nonunited lower extremity fracture initially repaired outside the developed Western world experience a high rate of postoperative complications after fracture nonunion repair but can expect good short- and long-term functional outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Longitudinal depressive and anxiety symptoms of adult injury patients in Kenya and their risk factors

Background: Injuries account for a significant proportion of the health and economic burden for populations in low- and middle-income countries. However, little is known about psychological distress trajectories amongst injury survivors in low- and middle-income countries.Methods: Adult injury patients (n = 644) admitted to Kenyatta National Hospital in Nairobi, Kenya, were enrolled and interviewed in the hospital, and at 1, 2-3, and 4-7 months after hospital discharge through phone to assess depressive and anxiety symptoms and level of disability. Growth mixture modeling was applied to identify latent trajectories of depressive and anxiety symptoms.Results: Elevated depressive and moderate-level anxiety symptoms (13%) and low depressive and anxiety symptoms (87%) trajectories were found between hospitalization and up to seven months after hospital discharge. Being female, prior trauma experience, longer hospitalization, worse self-rated health status while in the hospital, and lack of monetary assistance during hospitalization were associated with the elevated symptoms trajectory. The higher symptoms trajectory associated with higher disability levels after hospital discharge and significantly lower proportion of resuming daily activities and work.Conclusion: The persistence of elevated depressive symptoms and associated reduced functioning several months after physical injury underscores the importance of identifying populations at risk for preventive and early interventions.Implications for RehabilitationHealth providers following up with injury survivors should screen for depressive and anxiety symptomsSpecial attention to women and people with a potential traumatic exposure historyIncorporation of evidence-based culturally adapted psychosocial interventions in rehabilitation and outpatient clinics.

Trauma Exposure, Posttraumatic Stress Disorder Symptoms Trajectory, and Disability Level Among Hospitalized Injury Survivors in Kenya

Potentially traumatic events (PTEs) have been consistently associated with posttraumatic stress disorder (PTSD). However, the extent of association and attribution to subsequent disability has varied, with limited studies conducted in urban low-income contexts. This longitudinal study estimated the trajectory of PTSD symptoms up to 7 months after hospitalization and the associated disability level among adult patients who had been hospitalized due to injury. Adult injury patients (N = 476) admitted to Kenyatta National Hospital in Nairobi, Kenya, were interviewed in person in the hospital, and via phone at 1, 2-3, and 4-7 months after hospital discharge. Using latent growth curve modeling, two trajectories of PTSD symptoms emerged: (a) persistently elevated PTSD symptoms (9.2%), and (b) low PTSD symptoms (90.8%). Number of PTEs experienced remained moderately associated with the elevated trajectory after controlling for in-hospital depressive symptoms. Having previously witnessed killings or serious injuries, AOR = 2.32, 95% CI [1.07, 5.05]; being female, AOR = 4.74, 95% CI [4.53, 4.96]; elevated depressive symptoms during hospitalization, AOR = 2.96, 95% CI [1.28, 6.83]; and having no household savings/assets, AOR = 1.28, 95% CI [1.13, 1.44], were associated with the elevated PTSD symptoms trajectory class after controlling for other risk factors. Latent membership in the elevated PTSD trajectory was associated with a significantly higher level of disability several months after hospital discharge, p < .001, after controlling for injury and demographic characteristics. These results underline the associations among in-hospital depressive symptoms, witnessing atrocities, and poverty, and an elevated PTSD symptoms trajectory.

Slow as Compared to Rapid Rewarming After Mild Hypothermia Improves Survival in Experimental Shock

BACKGROUND

Accidental hypothermia following trauma is an independent risk factor for mortality. However, in most experimental studies, hypothermia clearly improves outcome. We hypothesized that slow rewarming is beneficial over rapid rewarming following mild hypothermia in a rodent model of hemorrhagic shock.

MATERIALS AND METHODS

We subjected 32 male Wistar rats to severe hemorrhagic shock (25-30 mmHg for 30 min). Rats were assigned to four experimental groups (normothermia, hypothermia, rapid rewarming [RW], and slow RW). During induction of severe shock, all but the normothermia group were cooled to 34°C. After 60 min of shock, rats were resuscitated with Ringer's solution. The two RW groups were rewarmed at differing rates (6°C/h versus 2°C/h).

RESULTS

Slow RW animals exhibit a significantly prolonged survival compared with the rapid RW animals (P < 0.05). Nevertheless, hypothermic animals show a significant survival benefit as compared to all other experimental groups. Whereas seven animals of the hypothermia group survived to the end of the experiment, none of the other animals did (P < 0.001). No significant differences were found regarding acid base status, metabolism, parameters of organ injury, and coagulation.

CONCLUSIONS

The results indicate that even slow RW with 2°C/h may be still too fast in the setting of experimental hemorrhage. Too rapid rewarming may result in a loss of the protective effects of hypothermia. As rewarming is ultimately inevitable in patients with trauma, potential effects of rewarming on patient outcome should be further investigated in clinical studies.

Exploring injury severity measures and in-hospital mortality: A multi-hospital study in Kenya

INTRODUCTION

Low- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya.

METHODS

This study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations.

RESULTS

A total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866-0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852-0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736-0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures.

CONCLUSIONS

This multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya.

Returning from the acidotic abyss: Mortality in trauma patients with a pH < 7.0

INTRODUCTION

We hypothesized that a pH of <7.0 on presentation would correlate with almost universal mortality in trauma patients.

METHODS

A retrospective cohort study was performed on a Level I trauma center registry from 2013 to 2014. Hospital mortality was the primary outcome, which was compared by pH cohort (<7.0 or ≥7.0) using standard univariate statistics and multivariate logistic regression.

RESULTS

There were 593 patients included in the analysis: 66 in <7.0, 527 in ≥7.0. Mortality was 3× higher in the <7.0 pH cohort (62.1 vs. 20.3%; p < 0.0001), however there was no threshold for a pH below which there was 100% mortality. After controlling for these confounding variables, initial pH was found to be an independent predictor of inpatient mortality: pH < 7.0 (OR 6.33, 3.29-12.19; p < 0.0001).

CONCLUSION

This data indicates that while patients with severe acidosis are at increased risk for mortality, a pH < 7.0 is still recoverable in select cases.

Exploring data sources for road traffic injury in Cameroon: Collection and completeness of police records, newspaper reports, and a hospital trauma registry

BACKGROUND

Road traffic injury surveillance systems are a cornerstone of organized efforts at injury control. Although high-income countries rely on established trauma registries and police databases, in low- and middle-income countries, the data source that provides the best collection of road traffic injury events in specific low- and middle-income country contexts without mature surveillance systems is unclear. The objective of this study was to compare the information available on road traffic injuries in 3 data sources used for surveillance in the sub-Saharan African country of Cameroon, providing potential insight on data sources for road traffic injury surveillance in low- and middle-income countries. We assessed the number of events captured and the information available in Yaoundé, Cameroon, from 3 separate sources of data on road traffic injuries: trauma registry, police records, and newspapers.

METHODS

Data were collected from a single-hospital trauma registry, police records, and the 6 most widely circulated newspapers in Yaoundé during a 6-month period in 2009. The number of road traffic injury events, mortality, and other variables included commonly in injury surveillance systems were recorded. We compared these sources using descriptive analysis.

RESULTS

Hospital, police, and newspaper sources recorded 1,686, 273, and 480 road traffic injuries, respectively. The trauma registry provided the most complete data for the majority of variables explored; however, the newspaper data source captured 2, mass casualty, train crash events unrecorded in the other sources. Police data provided the most complete information on first responders to the scene, missing in only 7%.

CONCLUSION

Investing in the hospital-based trauma registry may yield the best surveillance for road traffic injuries in some low- and middle-income countries, such as Yaoundé, Cameroon; however, police and newspaper reports may serve as alternative data sources when specific information is needed.

Evaluation of Potential Clinical Surrogate Markers of a Trauma Induced Alteration of Clotting Factor Activities

Objective. The aim of this study was to identify routinely available clinical surrogate markers for potential clotting factor alterations following multiple trauma. Methods. In 68 patients admitted directly from the scene of the accident, all soluble clotting factors were analyzed and clinical data was collected prospectively. Ten healthy subjects served as control group. Results. Patients showed reduced activities of clotting factors II, V, VII, and X and calcium levels (all P < 0.0001 to 0.01). Levels of hemoglobin and base deficit correlated moderately to highly with the activities of a number of clotting factors. Nonsurvivors and patients who needed preclinical intubation or hemostatic therapy showed significantly reduced factor activities at admission. In contrast, factor VIII activity was markedly elevated after injury in general (P < 0.0001), but reduced in nonsurvivors (P < 0.05). Conclusions. Multiple trauma causes an early reduction of the activities of nearly all soluble clotting factors in general. Initial hemoglobin and, with certain qualifications, base deficit levels demonstrated a potential value in detecting those underlying clotting factor deficiencies. Nevertheless, their role as triggers of a hemostatic therapy as well as the observed response of factor VIII to multiple trauma and also its potential prognostic value needs further evaluation.

Nonfatal injury incidence and risk factors among middle school students from four Polynesian countries: The Cook Islands, Niue, Samoa, and Tonga

INTRODUCTION

The burden of injuries in Pacific Island countries is understudied despite the known challenges associated with many residents having limited access to advanced medical and surgical care when they sustain a serious injury. This paper examines nonfatal injuries among early adolescent schoolchildren (those primarily ages 13-15 years) from four Polynesian countries.

METHODS

Self-reported data from the 5507 middle school students who were randomly sampled for participation in the nationwide Global School-based Student Health Surveys (GSHS) in the Cook Islands (in the year 2009), Niue (2010), Samoa (2011), and Tonga (2010) were analysed with various statistical methods including regression models. Injuries were defined by the GSHS questionnaire as serious if they resulted in a full day of missed school or other usual activities or required medical treatment.

RESULTS

The proportion of students reporting a serious injury in the past year was 43.1% in the Cook Islands, 40.8% in Niue, 73.8% in Samoa, and 49.1% in Tonga. In the Cook Islands and Samoa, boys reported more injuries than girls (p<0.01). The most common types of serious injuries reported were cuts and other skin trauma; broken bones and dislocated joints; and concussions, other head injuries, or difficulty breathing. The most common causes of serious injuries reported were falls; motor vehicle accidents; and attacks, fights, or abuse. For both boys and girls, being bullied in the past month, being physically attacked or in a physical fight in the past year, using alcohol and tobacco, skipping school, and having anxiety or loneliness were associated with a higher likelihood of injuries.

CONCLUSIONS

School-based health education programs targeting prevention of intentional and unintentional injuries may benefit from emphasising Polynesian values and promoting personal mental and physical health, healthy behaviours, and healthy family and community relationships.

The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium

BACKGROUND

Considerable research has documented that exposure to traumatic events has negative effects on physical and mental health. Much less research has examined the predictors of traumatic event exposure. Increased understanding of risk factors for exposure to traumatic events could be of considerable value in targeting preventive interventions and anticipating service needs.

METHOD

General population surveys in 24 countries with a combined sample of 68 894 adult respondents across six continents assessed exposure to 29 traumatic event types. Differences in prevalence were examined with cross-tabulations. Exploratory factor analysis was conducted to determine whether traumatic event types clustered into interpretable factors. Survival analysis was carried out to examine associations of sociodemographic characteristics and prior traumatic events with subsequent exposure.

RESULTS

Over 70% of respondents reported a traumatic event; 30.5% were exposed to four or more. Five types - witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury - accounted for over half of all exposures. Exposure varied by country, sociodemographics and history of prior traumatic events. Being married was the most consistent protective factor. Exposure to interpersonal violence had the strongest associations with subsequent traumatic events.

CONCLUSIONS

Given the near ubiquity of exposure, limited resources may best be dedicated to those that are more likely to be further exposed such as victims of interpersonal violence. Identifying mechanisms that account for the associations of prior interpersonal violence with subsequent trauma is critical to develop interventions to prevent revictimization.

Evaluation of clotting factor activities early after severe multiple trauma and their correlation with coagulation tests and clinical data

INTRODUCTION

Traumatic injuries are amongst the leading causes of death worldwide, frequently as a result of uncontrolled hemorrhage. Critical deficiencies in clotting factors have been noted in trauma-induced coagulopathy. However, the exact underlying conditions that result in devastating coagulopathies remain unclear. The purpose of this study was to elucidate these underlying deficiencies.

METHODS

Blood samples were drawn from 45 severely injured trauma patients on their arrival at the resuscitation room, and the activities of all soluble clotting factors and routine coagulation tests were assessed. The Mann-Whitney-U-test was used to assess differences in coagulation activity between the patients and healthy controls. Furthermore, Spearman's rank correlation was used to analyze the blood work.

RESULTS

After severe trauma the levels of serum fibrinogen and calcium were significantly reduced. Furthermore, traumatized patients had a significantly increased International Normalized Ratio (INR) compared to healthy controls. The median activities of all clotting factors were reduced after severe multiple trauma, with the exception of factor VIII, which was increased. Statistically significant differences were observed for factors II (80 vs. 122 %, P < 0.0001), V (76 vs. 123 %, P < 0.0001), VII (90 vs. 114 %, P = 0.002), VIII (200 vs. 108 %, P < 0.0001), and X (86 vs. 122 %, P < 0.0001). Spearman's correlation indicated a significant negative correlation between INR on arrival with fibrinogen and levels of factors II, V, and VII, whereas Partial Thromboplastin Time was significantly negatively correlated with factor VIII (all P < 0.0001).

CONCLUSIONS

These findings suggest a general but rather moderate impairment of clotting factor activities following severe multiple trauma. In the concept of a calculated coagulation therapy, this could demand for the use of factor concentrates with higher ratios of clotting factors. Finally, the physiological importance of strongly elevated factor VIII activity remains unclear, but a possible interference with ex vivo measurements of Partial Thromboplastin Time has to be considered.

Intentional injury and violence in Cape Town, South Africa: an epidemiological analysis of trauma admissions data

Background

Injury is a truly global health issue that has enormous societal and economic consequences in all countries. Interpersonal violence is now widely recognized as important global public health issues that can be addressed through evidence-based interventions. In South Africa, as in many low- and middle-income countries (LMIC), a lack of ongoing, systematic injury surveillance has limited the ability to characterize the burden of violence-related injury and to develop prevention programmes.

Objective

To describe the profile of trauma presenting to the trauma centre of Groote Schuur Hospital in Cape Town, South Africa – relating to interpersonal violence, using data collected from a newly implemented surveillance system. Particular emphasis was placed on temporal aspects of injury epidemiology, as well as age and sex differentiation.

Design

Data were collected prospectively using a standardized trauma admissions form for all patients presenting to the trauma centre. An epidemiological analysis was conducted on 16 months of data collected from June 2010 to October 2011.

Results

A total of 8445 patients were included in the analysis, in which the majority were violence-related. Specifically, 35% of records included violent trauma and, of those, 75% of victims were male. There was a clear temporal pattern: a greater proportion of intentional injuries occur during the night, while unintentional injury peaks late in the afternoon. In total, two-third of all intentional trauma is inflicted on the weekends, as is 60% of unintentional trauma. Where alcohol was recorded in the record, 72% of cases involved intentional injury. Sex was again a key factor as over 80% of all records involving alcohol or substance abuse were associated with males. The findings highlighted the association between violence, young males, substance use, and weekends.

Conclusions

This study provides the basis for evidence-based interventions to reduce the burden of intentional injury. Furthermore, it demonstrates the value of locally appropriate, ongoing, systematic public health surveillance in LMIC.

The effect of injuries on health measured by short form 8 among a large cohort of Thai adults

INTRODUCTION

We investigate the links between health and injury in Thailand. This is important because of the high burden of injury in transitional countries and limited information for public health.

METHODS

We analyse 2005 baseline and 2009, 4-year follow-up data from distance learning students of Sukhothai Thammathirat Open University residing nationwide (n = 60569). Injury was reported for the past year in both periods. Medical Outcome Study Short-Form (SF-8™) health status was reported and Physical and Mental Component Summary Scores (PCS and MCS) were calculated. Analyses used covariate-adjusted multivariate linear regression.

RESULTS

In 2009, increasing numbers of traffic injuries (0, 1, 2, 3, 4+) associated with declining PCS scores (49.8, 48.4, 46.9, 46.2, 44.0), along with a similar monotonic decline for MCS scores (47.6, 46.0, 44.2, 42.7, 40.6). A similar (but smaller) dose-response gradient was found between non-traffic injuries and SF-8 scores. Longitudinal analyses showed those with incident injury (no injury 2005, injury 2009) had lower PCS and MCS scores compared to those with no injury in both periods. Individuals with reverting injury status (injury 2005, no injury 2009) reported improvement in PCS and MCS scores over the four-year period.

CONCLUSION

We found significant and epidemiologically important associations between increasing injury frequency and worse health in the past year, especially traffic injuries. Longitudinal 2005-2009 results were supportive and revealed statistically significant adverse 4-year effects of incident injury on health. If injury reverted over four years, low initial scores improved greatly. Findings highlight the importance of injury prevention as a public health priority.

Study on the trend and disease burden of injury deaths in Chinese population, 2004-2010

Injuries are a growing public health concern in China, accounting for more than 30% of all Person Years of Life Lost (PYLL) due to premature mortality. This study analyzes the trend and disease burden of injury deaths in Chinese population from 2004 to 2010, using data from the National Disease Surveillance Points (DSPs) system, as injury deaths are classified based on the International Classification of Disease-10(th) Revision (ICD-10). We observed that injury death accounted for nearly 10% of all deaths in China throughout the period 2004-2010, and the injury mortality rates were higher in males than those in females, and higher in rural areas than in urban areas. Traffic crashes (33.79-38.47% of all injury deaths) and suicides (16.20-22.01%) were the two leading causes of injury deaths. Alarmingly, suicide surpassed traffic crashes as the leading cause of injury mortality in rural females, yet adults aged 65 and older suffered the greatest number of fatal falls (20,701 deaths, 2004-2010). The burden of injury among men (72.11%) was about three times more than that of women's (28.89%). This study provides indispensible evidence that China Authority needs to improve the surveillance and deterrence of three major types of injuries: Traffic-related injury deaths should be targeted for injury prevention activities in all population, people aged 65+ should be encouraged to take individual fall precautions, and prevention of suicidal behavior in rural females should be another key priority for the government of China.