Prevalence and incidence of longer term pain in survivors of polytrauma

Parameters influencing health-related quality of life after severe trauma: a systematic review (part II)

INTRODUCTION

It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma.

METHODS

The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner.

RESULTS

A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability.

CONCLUSION

Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]

BACKGROUND

Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated.

OBJECTIVES

Initial evaluation of frequency of chronic pain after occupational accidents.

METHODS

In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months.

PRIMARY OUTCOME

frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity.

RESULTS

Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002).

CONCLUSION

Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

[Quality of Life and Return to Work Following Rehabilitation - Results of the icfPROreha Study]

BACKGROUND

Not only the severity of an injury, but also bio-psycho-social factors affect health-related quality of life and participation in social life after severe musculoskeletal injuries.

METHODS

Multicentre prospective longitudinal study with follow-up up to 78 weeks after discharge from inpatient trauma rehabilitation. Data were collected using a comprehensive assessment tool. Quality of life was assessed using the EQ-5D-5L, return to work by patients' self-reports and routine data of health insurances. Analyses of the association between quality of life and return to work, change over time in quality of life compared to the general German population and multivariate analyses to predict quality of life were conducted.

RESULT

Of 612 study participants (444 men (72.5%); M=48.5 years; SD 12.0), 502 (82.0%) returned to work 78 weeks after discharge from inpatient rehabilitation. Quality of life improved during rehabilitation treatment from 50.18 to 64.50 (mean of visual analogue scale of EQ-5D-5L) and slightly to 69.38 78 weeks after discharge from inpatient trauma rehabilitation. EQ-5D index was below the values of the general population. In total, 18 factors were selected to predict quality of life 78 weeks after discharge from inpatient trauma rehabilitation. Among others, pain at rest and suspected anxiety disorder at admission had a very strong effect on quality of life. Contextual factors such as therapies after acute care and self-efficacy also had an effect on quality of life 78 weeks after discharge from inpatient rehabilitation.

CONCLUSION

Bio-psycho-social factors affect long-term quality of life of patients with musculoskeletal injuries. Already at the time of discharge from acute treatment and even more at the beginning of inpatient rehabilitation, decisions can be made in order to achieve the best possible quality of life for those affected.

Health-related quality of life after severe trauma and available PROMS: an updated review (part I)

Introduction

Throughout the years, a decreasing trend in mortality rate has been demonstrated in patients suffering severe trauma. This increases the relevance of documentation of other outcomes for this population, including patient-reported outcome measures (PROMs), such as health-related quality of life (HRQoL). The aim of this review was to summarize the results of the studies that have been conducted regarding HRQoL in severely injured patients (as defined by the articles’ authors). Also, we present the instruments that are used most frequently to assess HRQoL in patients suffering severe trauma.

Methods

A literature search was conducted in the Cochrane Library, EMBASE, PubMed, and Web of Science for articles published from inception until the 1st of January 2022. Reference lists of included articles were reviewed as well. Studies were considered eligible when a population of patients with major, multiple or severe injury and/or polytrauma was included, well-defined by means of an ISS-threshold, and the outcome of interest was described in terms of (HR)QoL. A narrative design was chosen for this review.

Results

The search strategy identified 1583 articles, which were reduced to 113 after application of the eligibility criteria. In total, nineteen instruments were used to assess HRQoL. The SF-36 was used most frequently, followed by the EQ-5D and SF-12. HRQoL in patients with severe trauma was often compared to normative population norms or pre-injury status, and was found to be reduced in both cases, regardless of the tool used to assess this outcome. Some studies demonstrated higher scoring of the patients over time, suggesting improved HRQoL after considerable time after severe trauma.

Conclusion

HRQoL in severely injured patients is overall reduced, regardless of the instrument used to assess it. The instruments that were used most frequently to assess HRQoL were the SF-36 and EQ-5D. Future research is needed to shed light on the consequences of the reduced HRQoL in this population. We recommend routine assessment and documentation of HRQoL in severely injured patients.

Assessment of patient-reported outcomes after polytrauma - instruments and methods: a systematic review

OBJECTIVES

We (1) collected instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL) and social participation during follow-up after polytrauma, (2) described their use and (3) investigated other relevant patient-reported outcomes (PROs) assessed in the studies.

DESIGN

Systematic Review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, as well as the trials registers ClinicalTrials.gov and WHO ICTRP were searched from January 2005 to April 2018.

ELIGIBILITY CRITERIA

All original empirical research published in English or German including PROs of patients aged 18-75 years with an Injury Severity Score≥16 and/or an Abbreviated Injury Scale≥3. Studies with defined injuries or diseases (e.g. low-energy injuries) and some text types (e.g. grey literature and books) were excluded. Systematic reviews and meta-analyses were excluded, but references screened for appropriate studies.

DATA EXTRACTION AND SYNTHESIS

Data extraction, narrative content analysis and a critical appraisal (e.g. UK National Institute for Health and Care Excellence) were performed by two reviewers independently.

RESULTS

The search yielded 3496 hits; 54 publications were included. Predominantly, HRQoL was assessed, with Short Form-36 Health Survey applied most frequently. ADL and (social) participation were rarely assessed. The methods most used were postal surveys and single assessments of PROs, with a follow-up period of one to one and a half years. Other relevant PRO areas reported were function, mental disorders and pain.

CONCLUSIONS

There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but require further harmonisation between central players. Additional knowledge on rarely reported PRO areas (e.g. (social) participation, social networks) may lead to their consideration in health services provision.

PROSPERO REGISTRATION NUMBER

CRD42017060825.

Chronic Pain Following Fracture-Related Surgery: Posttraumatic Rather Than Postsurgical Origin Promotes Chronification-A Prospective Observational Study With 1-Year Follow-up

BACKGROUND

Chronic posttraumatic/postsurgical pain (CPSP) is common after traumatic or surgical damage. Exposure to both trauma and surgery, with the potential for repeated bone and nerve damage, may increase the risk of CPSP after fracture-related surgery. But the (long-term) incidences of CPSP and neuropathic CPSP and the ensuing burdens are unknown. Therefore, the patients were prospectively assessed within 1 year, and the patient-specific characteristics were explored.

METHODS

Between 2017 and 2018, 127 patients (age: 52.9 ± 17.1 years, male: 55.1%) with traumatic fractures needing osteosynthesis (extremities: 91.3%) were assessed posttrauma (before surgery), postsurgery at days 1 to 5, 6 weeks, 3 and 12 months. The primary outcomes are as follows: incidence at 3 and 12 months of CPSP (defined as pain intensity on a numerical rating scale [NRS: 0-10] ≥3), secondary exploration: neuropathic CPSP (NRS ≥3 and Douleur Neuropathique 4 interview [DN4i] score ≥3 [Douleur Neuropathique interview: 0-7]); burden: quality of life (QoL, the EuroQOL five dimensions questionnaire [EQ-5D-3L] descriptive system); and inter alia, the number of analgesics (trial registration: DRKS00011601).

RESULTS

The incidence of CPSP was 57.1% (52/91, n/N) at 3 and 42.7% (35/82) at 12 months postsurgery, including neuropathic CPSP 7.7% (4/52) and 17.1% (6/35), respectively. Descriptively, posttraumatic higher pain intensity at rest (difference of 0.9 ± 1.8 NRS) and the need for more frequent analgesics (by 34.3%) were associated with CPSP a year after surgery compared to those without. As soon as week 6, these patients had developed descriptively a 15% more impaired QoL, with 25% more impairment after 1 year. The patients with CPSP presented with at least 1 neuropathic symptom 12 months later in 68.6% (24/35) of cases, mainly with an early posttraumatic occurrence (without fulfilling the definition of neuropathic CPSP).

CONCLUSIONS

After early fracture-related surgery, high incidences of CPSP (43%) were prospectively observed 1 year postsurgery, up to approximately 1 in 5 patients who had neuropathic CPSP. At the same time, CPSP was accompanied with an impacted QoL and analgesic dependence, both indicating clinical relevance. Moreover, the high incidence and the early posttraumatic occurrence of more intense pain suggest that the initial fracture-related trauma, rather than the surgical trauma, may predominantly trigger CPSP at Y1 (1 year). Therefore, these exploratory results set the direction of required future research. A future clinical hypothesis might be: treat first what hurts first.

Main factors predicting somatic, psychological, and cognitive patient outcomes after significant injury: a pilot study of a simple prognostic tool

Background

There are still insufficient data on the complexity and predictability of patient-related outcomes following trauma. The aim of this study was to assess longer-term outcomes in patients with significant injury and to develop a simple scoring method to identify patients at high risk of subsequent deficits 1–2 years after injury.

Methods

We conducted a prospective cohort study of survivors of significant injury (New Injury Severity Score, NISS greater than or equal to 8), with analysis of patients’ 1- to 2-year health-related quality of life (HRQoL) and their functional outcomes based on Short Form-36 (SF-36), Trauma Outcome Profile (TOP), and Quality Of Life after Brain Injury (QOLIBRI). Documented variables suspected or known from the literature to be possible factors associated with outcome were first analysed by univariate analysis, and significant variables were entered into a stepwise logistic regression analysis. Scores predicting longer-term impaired outcome were constructed from risk factors resulting from multivariate analysis.

Results

Depending on the patient-reported outcome measure (PROM) used, up to 30 per cent of 1052 study patients (mean NISS 18.6) indicated somatic, 27 per cent psychological, and 54 per cent cognitive deficits. The investigated sociodemographic, injury-related, treatment, and early hospital outcome variables demonstrated only low associations with longer-term outcome in univariate analysis that were highest for preinjury pain or function (R = 0.4) and outcome at hospital discharge (R = 0.3). After logistic regression, the study variables explained a maximum variance of 23 per cent for somatic, 11 per cent for psychological, and 14 per cent for cognitive longer-term outcomes. The resulting Aarau trauma prognostic longer-term outcome scoring (ATPLOS) system, developed by checking eight risk factors, had a specificity of up to 80 per cent, and importantly may facilitate early detection of patients at risk of a poorer longer-term outcome.

Conclusion

Despite the high rate of deficits recorded for survivors of significant injury, particularly in loss of cognitive function, the multiple variables analysed only led to a limited characterization of patient-related longer-term outcomes. Until more is known about additional individual influencing factors, the proposed scoring system may serve well for clinical evaluation.

Registration number

NCT 02165137 (http://www.clinicaltrials.gov)

A systematic review of studies measuring health-related quality of life of general injury populations: update 2010-2018

Background

Studies examining the impact of injury on health-related quality of life (HRQL) over time are necessary to understand the short- and long-term consequences of injury for population health. The aim of this systematic review was to provide an evidence update on studies that have measured HRQL over time in general injury populations using a generic (general) health state measure.

Methods

Studies conducted between 2010 and 2018 that assessed HRQL at more than one time point among general injury populations were eligible for inclusion. Two reviewers independently extracted information from each study on design, HRQL measure used, method of HRQL measure administration, timing of assessment(s), predictive variables, ability to detect change, and findings. Quality appraisals of each study were also completed by two reviewers using items from the RTI Item Bank on Risk of Bias and Precision of Observational Studies and the Guidelines for the Conduction of Follow-up Studies Measuring Injury-Related Disability.

Results

Twenty-nine studies (44 articles) that met the inclusion criteria were identified. HRQL was measured using 14 different generic measures; the SF-36, SF-12, and EQ-5D were used most frequently. A varying number of follow-up assessments were undertaken, ranging from one to five. Follow-up often occurred 12 months post-injury. Fewer studies (n = 11) examined outcomes two or more years post-injury, and only one to 10 years post-injury. While most studies documented improvements in HRQL over time since the injury event, study populations had not returned to pre-injury status or reached general population norm HRQL values at post-injury follow-ups.

Conclusions

Since 2010 there has been a substantial increase in the number of studies evaluating the HRQL of general injury populations. However, significant variability in study design continues to impede quantification of the impact of injury on population health over time. Variation between studies is particularly evident with respect to timing and number of follow-up assessments, and selection of instruments to evaluate HRQL.

The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain

Chronic pain after tissue trauma is frequent and may have a lasting impact on the functioning and quality of life of the affected person. Despite this, chronic postsurgical and posttraumatic pain is underrecognised and, consequently, undertreated. It is not represented in the current International Classification of Diseases (ICD-10). This article describes the new classification of chronic postsurgical and posttraumatic pain for ICD-11. Chronic postsurgical or posttraumatic pain is defined as chronic pain that develops or increases in intensity after a surgical procedure or a tissue injury and persists beyond the healing process, ie, at least 3 months after the surgery or tissue trauma. In the classification, it is distinguished between tissue trauma arising from a controlled procedure in the delivery of health care (surgery) and forms of uncontrolled accidental damage (other traumas). In both sections, the most frequent conditions are included. This provides diagnostic codes for chronic pain conditions that persist after the initial tissue trauma has healed and that require specific treatment and management. It is expected that the representation of chronic postsurgical and posttraumatic pain in ICD-11 furthers identification, diagnosis, and treatment of these pain states. Even more importantly, it will make the diagnosis of chronic posttraumatic or postsurgical pain statistically visible and, it is hoped, stimulate research into these pain syndromes.

Firearm Violence: A Global Priority for Nursing Science

PURPOSE

This purpose of this article is to frame firearm violence as a health and public health problem, to illustrate the magnitude of the problem, to examine factors that increase the risk to be injured by a firearm, or conversely, that confer protection, and to identify relevant priority areas for nursing science.

ORGANIZING CONSTRUCT

Firearm violence results in physical and psychological injuries and is a global health priority. Firearm violence is categorized as intentional (interpersonal and self-inflicted) and unintentional (interpersonal and self-inflicted) and accounts for an estimated 196,000 to 220,000 nonconflict deaths annually.

METHODS

We reviewed the theoretical and scientific literature to analyze the magnitude and geographic distribution of firearm violence, the factors associated with firearm injury, the consequences of firearm violence, and areas where nursing science can make an impact on prevention, outcomes, and recovery.

FINDINGS

Firearm violence is a significant public health problem that affects the health of individuals, families, and communities. The burdens and contributors to firearm violence vary worldwide, making it important to understand the local context of this global phenomenon. Relevant areas of inquiry span primary prevention focusing on individual and environmental risk factors; and focus on managing the physical and psychological consequences postinjury; and mitigating long-term consequences of firearm violence.

CONCLUSIONS

Reducing the global burden of firearm violence and improving the health and safety of individuals, families, and communities provide compelling reasons to integrate this area into nursing science.

CLINICAL RELEVANCE

The goals of nursing are to keep people healthy and safe and to help return those injured to their optimal levels of health and well-being. Understanding the factors that come together to injure people with a firearm in various physical, social, economic, and cultural environments positions nurses to both extend the dialogue beyond pro-gun versus anti-gun and to design and carry out rigorous studies to reduce firearm violence.

Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.

The effect of socio-economic status on non-fatal outcome after injury: A systematic review

BACKGROUND

Over the past decades, the number of survivors of injuries has rapidly grown. It has become important to focus more on the determinants of non-fatal outcome. Although socio-economic status (SES) is considered to be a fundamental determinant of health in general, the role of SES as a determinant of non-fatal outcome after injury is largely unknown.

METHODS

An online search was conducted in November 2015 using Embase, Medline, Web of Science, Cinahl, Cochrane, Google scholar and PubMed. Studies examining the relation between SES and a physical or psychological outcome measure, or using SES as a confounder in a general trauma population were included. There were no restrictions regarding study design. The 'Quality in Prognostic Studies tool' was used to assess the methodological quality of the included studies.

RESULTS

The 24 included studies showed large variations in methodological quality. The number of participants ranged from 56 to 4639, and assessments of the measures ranged from immediately to 6year post-injury. Studies used a large number of variables as indicators of SES. Participant's educational level was used most frequently. The majority of the studies used a multivariable technique to analyse the relation between SES and non-fatal outcome after injury. All studies found a positive association (80% of studies significant, n=19) between increased SES and better non-fatal outcome after injury.

CONCLUSION

Although an adequate and valid measure of SES is lacking, the results of this review showed that SES is an important determinant of non-fatal outcome after injury. Future research should focus on the definition and measurement of SES and should further underpin the effect of SES on non-fatal outcome after injury.

[Rehabilitation in the German statutory accident insurance. Guide to the new outpatient and inpatient structures]

BACKGROUND

The German statutory accident insurance (DGUV) has the statutory mandate to eliminate or to prevent an aggravation of the consequences of accidents by all appropriate means and is based on the principle of rehabilitation before pension. For this, special methods have been developed in recent decades, such as employer's mutual insurance inpatient further treatment (BGSW, Berufsgenossenschaftliche Stationäre Weiterbehandlung) and extended outpatient physiotherapy (EAP, Erweiterte Ambulante Physiotherapie). In 2012 the workplace-related musculoskeletal rehabilitation (ABMR, Arbeitsplatz-bezogene muskuloskelettale Rehabilitation) was added to these complex treatments.

SPECIAL REHABILITATION MEASURES

For complex injuries and delayed healing these methods approach their limits. The accident clinics of the Association of Clinics in Statutory Accident Insurance (KUV, Klinikverbund der gesetzlichen Unfallversicherung) provide a number of specialized rehabilitation measures in order to ensure an optimal seamless rehabilitation of the severely injured. In addition to complex inpatient rehabilitation (KSR, Komplexe Stationäre Rehabilitation) integrated special rehabilitation procedures, such as neurorehabilitation for severely traumatic brain injured patients and rehabilitation after spinal cord injury and other special rehabilitation methods, such as occupation-oriented rehabilitation (TOR, Tätigkeitsorientierte Rehabilitation) and pain rehabilitation, ensure that the German Society for Trauma Surgery (DGU) phase model of trauma rehabilitation is implemented. This provides an early start in the context of acute treatment as so-called early rehabilitation. After a specialized post-acute rehabilitation, additional therapeutic options are often required.

CONCLUSION

An appropriate treatment of severely injured patients is important, for example through rehabilitation managers, which must not end with discharge from the rehabilitation hospital. The aim of all efforts is the reintegration into the working and social environment in addition to the best possible quality of life.

Long-term outcomes of individuals injured in motor vehicle crashes: A population-based study

BACKGROUND

Despite decline in U.S. traffic fatalities, non-fatal injuries remain a main cause of reduced self-reported health. The authors used a nationally representative survey to examine the long-term (≥1 year) implications of traffic injuries on self-care, depression, mobility, pain and activity domains of a widely used measure assessing Health-Related Quality of Life (HRQOL).

METHODS

30,576 participants from panels (2000-2002) of the Medical Expenditure Panel Survey (MEPS) were followed for about two years. The associations between reporting a traffic injury in the first follow-up year and the five domains of the Euroqol Health index (EQ-5D) were assessed using mixed logistic models with outcome severe/moderate problem in each domain. Models adjustment variables included age, gender, education, income, diabetes, asthma, smoking and insurance status.

RESULTS

590 participants reported traffic injuries. In the first follow-up analysis, having an injury was associated with deficits in all domains of the EQ-5D. With the exception of self-care, similar findings were reported in the second follow-up (≥1 year) after injuries with strongest associations between traffic injuries and both mobility and activity (both OR=2.9, P<0.01).

CONCLUSIONS

Traffic injuries are significantly associated with long-term reduced HRQOL. Injured individuals may benefit from early intervention programs to prevent the development of secondary complications and reduced HRQOL.

[Sequelae of severe injuries : consequences for trauma rehabilitation]

Consequences of accidents are found not only in physical but also in psychological and social areas. The quality of life of severely injured patients is significantly reduced compared with the normal population even years after the trauma. Subjective experiences of severely injured patients during and after hospitalization have a major impact on the subsequent quality of life. Knowledge of these factors is essential for the planning, organization and implementation of rehabilitation after severe injury. The phase model of rehabilitation after trauma requires early initiation of therapy even during acute treatment as so-called early rehabilitation. After a specialized post-acute rehabilitation additional therapeutic options are often required. Besides pain management the focus lies especially in work-related rehabilitation and psychological support which is also decisive for the success of rehabilitation of accident victims. For severely injured patients it is important to provide sufficient support, e.g. through a case manager which does not end with discharge from the rehabilitation facility. The aim of all efforts is reintegration into the working and social environment and the best possible quality of life.

[Long-term results after multiple trauma with ISS ≥ 25. Outcome and predictors of quality of life]

BACKGROUND

The survival chances of multiple trauma patients have continually improved over the last decades; therefore, it is often not a question of whether a patient survives a severe accident but rather how the patient survives.

METHODS

In a retrospective study 127 patients were questioned regarding quality of life and health and possible influencing factors using the POLO chart an average of 70 months after suffering severe trauma (ISS Ø 35.6).

RESULTS

The quality of life of severely injured patients is significantly reduced compared with the normal population even years after the trauma. In addition to four pretraumatic factors (older age, female gender, low education and previous illnesses) four posttraumatic variables (difficulties with authorities/institutions and unemployment as a consequence of the accident, long duration and subjectively inadequate treatment in hospital) were identified that have a negative impact on long-term quality of life.

CONCLUSIONS

The self-reported quality of life after multiple trauma no longer permanently achieves the original level despite extensive rehabilitation measures. Post-traumatic factors have a greater impact on the long-term quality of life than the injury severity. A long-term care and specialized rehabilitation services are needed to improve outcome further.

The effect of postinjury depression on quality of life following minor injury

PURPOSE

To describe quality of life (QoL) in the year following minor injury and to test the hypothesis that individuals with depression in the postinjury year experience lower QoL than do individuals with no depression.

DESIGN

Prospective, longitudinal, cohort design. A total of 275 adults were randomly selected from injured patients presenting to an urban emergency department.

METHODS

All participants underwent structured psychiatric diagnostic interviews immediately after injury and at 3, 6, and 12 months. The primary outcome, QoL, was measured using the Quality of Life Index. Covariates included demographics, injury status, preinjury functional status, preinjury social support, and anticipation of problems postdischarge. The General Estimating Equation was used to compare changes in QoL between participants with and without depression over 3, 6, and 12 months, adjusting for covariates.

RESULTS

An 18.1% proportion (95% confidence interval [CI] 13.3, 22.9%) of the sample met criteria for a mood disorder in the postinjury year. The depressed group reported a QoL that was 4.2 points (95% CI 2.8-5.6) lower in the year postinjury compared with that of the nondepressed group.

CONCLUSIONS

Depression after minor injury negatively affects QoL even a full year postinjury.

CLINICAL RELEVANCE

The findings of this study show that patients who have injuries that are treated and discharged from an emergency department can have significantly lower QoL in the year after that injury that is attributed, in part, to postinjury depression. Nurses should provide anticipatory guidance to patients that they may experience feelings of sadness or being "blue," and that if they do, they should seek care.