A multicenter study of post-traumatic stress disorder after injury: Mechanism matters more than injury severity

The cross-sectional and longitudinal interconnectedness of physical, psychological and role functioning following physical trauma: A network analysis

OBJECTIVE

Surviving physical trauma can have a large impact on one's daily life. Patients are at increased risk for poor physical health, psychological complaints, and problems in role functioning - which is often experienced simultaneously. The present study explores the interconnectedness of physical, psychological, and role functioning during the first two years post-injury, both cross-sectionally and longitudinally from a network perspective.

METHODS

3785 trauma patients (Mage = 64.2 years, SDage = 18.9 years, 50.5% female) completed questionnaires on physical, psychological, and role functioning across six measurement occasions during the first two years post-injury. The Injury Severity Score (ISS) was retrieved from the local trauma registry. Mixed graphical network models and cross-lagged network models were estimated to examine which items of recovery played a central role and were mostly related to other items in cross-sectional and longitudinal networks respectively.

RESULTS

The cross-sectional networks showed especially strong interconnections between impairments of physical and role functioning and also within post-traumatic stress symptoms. The longitudinal networks extended these results by showing that pain, impaired mobility, limitations in self-care, anxiety/depressive symptoms, and several post-traumatic stress symptoms were strong predictors for impairments in functioning at later stages of recovery.

CONCLUSION

Our findings showed that impairments in physical, psychological, and role functioning experienced by trauma patients are largely intertwined across the two years following injury. Monitoring physical impairments and psychological complaints early in recovery might help to more promptly provide the best fitting aftercare for trauma patients, which can improve recovery on the long-term.

Risk factors for posttraumatic stress disorder in trauma patients from bullfighting-related events in Spain

BACKGROUND

Unintentional Trauma injuries are one of the leading causes of posttraumatic stress disorder development. However, screening for this condition is not typically included in routine medical care. Research on posttraumatic stress disorder after unintentional injuries sustained during entertainment activities involving risk, has been scarce. This study aimed to analyze the proportion of posttraumatic stress disorder and its risk factors in patients with trauma injuries sustained during bullfighting-related events in Spain.

METHODS

Two hundred and seventy-four patients were evaluated to determine the presence of posttraumatic stress disorder at least one month after the injury. Data about sociodemographic variables, injury circumstances, characteristics of the injury, and treatments were collected by the surgery team on-site or collected during the follow-up assessment. Diagnosis of posttraumatic stress disorder was made by a trained clinician using a structured clinical interview based on DSM criteria.

RESULTS

The estimated proportion of was 25.18 % (95 % CI: 20.18 %, 30.18 %). Residing in areas with a bullfighting tradition, female gender, referral to a medical center, hospitalization, events involving fighting bulls, and having been injured by the crowd were significant predictors.

LIMITATIONS

The short-term follow-up and the inability to evaluate some predictors of interest, including the body site of the injury, the presence of disfigurement, and comorbid anxiety and depression, were noted.

CONCLUSION

Posttraumatic stress disorder could have a high prevalence in individuals injured in these types of events, especially in women, those who are not familiar with the situation, and those who require medical attention. These results highlight the need for routine screening for posttraumatic stress disorder in individuals with trauma injuries for early symptom management.

Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review

INTRODUCTION

Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality.

METHODS AND ANALYSIS

We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach.

ETHICS AND DISSEMINATION

Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).

Descriptive Analysis of Trauma Admission Trends before and during the COVID-19 Pandemic

INTRODUCTION

Traumatic injuries are a significant global health concern, with profound medical and socioeconomic impacts. This study explores the patterns of trauma-related hospitalizations in the Lublin Province of Poland, with a particular focus on the periods before and during the COVID-19 pandemic.

AIM OF THE STUDY

The primary aim of this research was to assess the trends in trauma admissions, the average length of hospital stays, and mortality rates associated with different types of injuries, comparing urban and rural settings over two distinct time periods: 2018-2019 and 2020-2021.

METHODS

This descriptive study analyzed trauma admission data from 35 hospitals in the Lublin Province, as recorded in the National General Hospital Morbidity Study (NGHMS). Patients were classified based on the International Classification of Diseases Revision 10 (ICD-10) codes. The data were compared for two periods: an 11-week span during the initial COVID-19 lockdown in 2020 and the equivalent period in 2019.

RESULTS

The study found a decrease in overall trauma admissions during the pandemic years (11,394 in 2020-2021 compared to 17,773 in 2018-2019). Notably, the average length of hospitalization increased during the pandemic, especially in rural areas (from 3.5 days in 2018-2019 to 5.5 days in 2020-2021 for head injuries). Male patients predominantly suffered from trauma, with a notable rise in female admissions for abdominal injuries during the pandemic. The maximal hospitalization days were higher in rural areas for head and neck injuries during the pandemic.

CONCLUSIONS

The study highlights significant disparities in trauma care between urban and rural areas and between the pre-pandemic and pandemic periods. It underscores the need for healthcare systems to adapt to changing circumstances, particularly in rural settings, and calls for targeted strategies to address the specific challenges faced in trauma care during public health crises.

Implementation of a Stepped Care Program to Address Emotional Recovery among Traumatic Injury Patients

BACKGROUND

Annually, over 600,000 adults served in US trauma centers (≥20%) develop posttraumatic stress disorder (PTSD) and/or depression in the first year after injury. American College of Surgeons guidelines include screening and addressing mental health recovery in trauma centers. Yet, many trauma centers do not monitor and address mental health recovery, and it is a priority to learn how to implement evidence-informed mental health programs in trauma centers.

STUDY DESIGN

This report describes our application of the Exploration, Preparation, Implementation, Sustainment model to implement the Trauma Resilience and Recovery Program (TRRP) in 3 Level I and II trauma centers to address patients' mental health needs. TRRP is a scalable and sustainable stepped model of care-one of the few in the US-that provides early intervention and direct services after traumatic injury.

RESULTS

Trauma centers are well positioned to accelerate patients' mental health recovery via early identification, education, screening, and referrals to mental health agencies that provide best-practice care. We found that TRRP was acceptable to the 3 partnering trauma centers we studied. Early engagement of patient, provider, and hospital administration stakeholders enhanced buy-in during the early stages of the implementation process and promoted sustainability. Active processes to support monitoring, evaluation, and adaptation were critical.

CONCLUSIONS

Our work demonstrates the feasibility of implementing and adapting TRRP, a cost-efficient and sustainable stepped care intervention, in Level I and II trauma centers. Several factors should be carefully considered by trauma centers seeking to integrate behavioral health interventions into their trauma program.

Implementation of a stepped care program to address posttraumatic stress disorder and depression in a Level II trauma center

BACKGROUND

The Trauma Resilience and Recovery Program (TRRP) is a technology enhanced model of care that includes education, screening, and service referrals to address posttraumatic stress disorder and depression following traumatic injury. TRRP has shown high rates of engagement at a Level I trauma center, but Level II centers have fewer resources and face more challenges to addressing patients' mental health needs.

METHODS

We utilized clinical administrative data to examine engagement in TRRP in a Level II trauma center with 816 adult trauma activation patients.

RESULTS

Most patients (86%) enrolled in TRRP, but only 30% completed screens during a 30-day follow-up call. Three-quarters of patients who endorsed clinically significant symptoms accepted treatment recommendations/referrals.

CONCLUSIONS

Engagement at each step of the model was lower than previously reported in a Level I center. Differences likely correspond to lower rates of mental health symptoms in the trauma patients at this setting. We discuss program adaptations that may be needed to improve patient engagement.

Long-term Mental Health Trajectories of Injured Military Servicemembers: Comparing Combat to Noncombat Related Injuries

OBJECTIVE

We sought to quantify the impact of injury characteristics and setting on the development of mental health conditions, comparing combat to noncombat injury mechanisms.

BACKGROUND

Due to advances in combat casualty care, military service-members are surviving traumatic injuries at substantial rates. The nature and setting of traumatic injury may influence the development of subsequent mental health disorders more than clinical injury characteristics.

METHODS

TRICARE claims data was used to identify servicemembers injured in combat between 2007 and 2011. Controls were servicemembers injured in a noncombat setting matched by age, sex, and injury severity. The rate of development, and time to diagnosis [in days (d)], of 3 common mental health conditions (post-traumatic stress disorder, depression, and anxiety) among combat-injured servicemembers were compared to controls. Risk factors for developing a new mental health condition after traumatic injury were evaluated using multivariable logistic regression that controlled for confounders.

RESULTS

There were 3979 combat-injured servicemember and 3979 matched controls. The majority of combat injured servicemembers (n = 2524, 63%) were diagnosed with a new mental health condition during the course of follow-up, compared to 36% (n = 1415) of controls ( P < 0.001). In the adjusted model, those with combat-related injury were significantly more likely to be diagnosed with a new mental health condition [odds ratio (OR): 3.18, [95% confidence interval (CI): 2.88-3.50]]. Junior (OR: 3.33, 95%CI: 2.66-4.17) and senior enlisted (OR: 2.56, 95%CI: 2.07-3.17) servicemem-bers were also at significantly greater risk.

CONCLUSIONS

We found significantly higher rates of new mental health conditions among servicemembers injured in combat compared to service-members sustaining injuries in noncombat settings. This indicates that injury mechanism and environment are important drivers of mental health sequelae after trauma.

Impact of COVID-19 on outcomes after trauma the impact of the COVID-19 pandemic on functional and mental health outcomes after trauma

Background

The COVID-19 pandemic has led to decreased access to care and social isolation, which have the potential for negative psychophysical effects. We examine the impact of the pandemic on physical and mental health outcomes after trauma.

Methods

Patients in a prospective study were included. The cohort injured during the pandemic was compared to a cohort injured before the pandemic. We performed regression analyses to evaluate the association between the COVID-19 pandemic and physical and mental health outcomes.

Results

1,398 patients were included. In adjusted analysis, patients injured during the pandemic scored significantly worse on the SF-12 physical composite score (OR 2.21; [95% CI 0.69–3.72]; P = 0.004) and were more likely to screen positive for depression (OR 1.46; [1.02–2.09]; P = 0.03) and anxiety (OR 1.56; [1.08–2.26]; P = 0.02). There was no significant difference in functional outcomes.

Conclusions

Patients injured during the COVID-19 pandemic had worse mental health outcomes but not physical health outcomes.

Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern

BACKGROUND

Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described.

METHODS

The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors.

RESULTS

We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures.

CONCLUSION

Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury.

LEVEL OF EVIDENCE

Prognostic/epidemiologic, level III.

Somatic Symptom Severity, Not Injury Severity, Predicts Probable Posttraumatic Stress Disorder and Major Depressive Disorder in Wounded Service Members

Although previous studies have reported an association between patient-reported somatic symptom severity and the development of posttraumatic stress disorder (PTSD) or major depressive disorder (MDD) in injured military service members (SMs), conclusions from other studies regarding the association between clinician-determined injury severity and PTSD or MDD remain unclear. The present study investigated whether somatic symptoms or injury severity predict the development of probable PTSD or MDD in wounded SMs medically evacuated from combat areas. Data including SM demographic characteristics, clinician-determined injury severity (i.e., Injury Severity Score [ISS] and Abbreviated Injury Scale [AIS] values), and self-report assessments of PTSD (PTSD Checklist-Civilian Version), MDD (Patient Health Questionnaire [PHQ]-9), and somatic symptoms (PHQ-15) were analyzed. A total of 2,217 SMs completed at least one self-assessment between 2003 and 2014, with 425 having completed assessments at each assessment period (AP), conducted 1-75 (AP1), 76-165 (AP2), and 166-255 (AP3) days postinjury. Between AP1 and AP3, the rates of probable PTSD and MDD increased from 3.0% to 11.7% and from 2.8% to 9.2%, respectively. Somatic symptom severity at AP1 predicted probable PTSD and MDD at all three APs, odds ratios (ORs) = 3.5-11.5; however, ISS values did not predict probable PTSD or MDD at any AP, ORs = 0.6-0.9. This suggests that the initial severity of self-reported somatic symptoms rather than clinician-determined injury severity predicts the development of probable PTSD and MDD in wounded SMs.

Patient reported outcomes 6 to 12 months after interpersonal violence: A multicenter cohort study

PURPOSE

Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes.

METHODS

We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes.

RESULTS

A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59-4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes.

CONCLUSION

The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Impact of the COVID-19 Pandemic on Long-Term Recovery from Traumatic Injury

OBJECTIVE

Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort.

BACKGROUND

The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients.

METHODS

Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6-14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes.

RESULTS

Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status (SES), extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the SF-12 and to screen positive for PTSD and depression.

CONCLUSIONS

The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population.

Long-Term Functional Outcomes of Trauma Patients With Facial Injuries

BACKGROUND

Facial trauma can have long-lasting consequences on an individual's physical, mental, and social well-being. The authors sought to assess the long-term outcomes of patients with facial injuries.

METHODS

This is a prospective multicenter cohort study of patients with face abbreviated injury scores ≥1 within the Functional Outcomes and Recovery after Trauma Emergencies registry. The Functional Outcomes and Recovery after Trauma Emergencies registry collects patient-reported outcomes data for patients with moderate-severe trauma 6 to 12 months after injury. Outcomes variables included general and trauma-specific quality of life, functional limitations, screening for post-traumatic stress disorder, and postdischarge healthcare utilization.

RESULTS

A total of 188 patients with facial trauma were included: 69.1% had an isolated face and/or head injury and 30.9% had a face and/or head injuries as a part of polytrauma injury. After discharge, 11.7% of patients visited the emergency room, and 13.3% were re-admitted to the hospital. Additionally, 36% of patients suffered from functional limitations and 17% of patients developed post-traumatic stress disorder. A total of 34.3% patients reported that their injury scars bothered them, and 49.4% reported that their injuries were hard to deal with emotionally.

CONCLUSIONS

Patients who sustain facial trauma suffer significant long-term health-related quality of life consequences stemming from their injuries.

Intranasal temperature-sensitive hydrogels of cannabidiol inclusion complex for the treatment of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a psychiatric disease that seriously affects brain function. Currently, selective serotonin reuptake inhibitors (SSRIs) are used to treat PTSD clinically but have decreased efficiency and increased side effects. In this study, nasal cannabidiol inclusion complex temperature-sensitive hydrogels (CBD TSGs) were prepared and evaluated to treat PTSD. Mice model of PTSD was established with conditional fear box. CBD TSGs could significantly improve the spontaneous behavior, exploratory spirit and alleviate tension in open field box, relieve anxiety and tension in elevated plus maze, and reduce the freezing time. Hematoxylin and eosin and c-FOS immunohistochemistry slides showed that the main injured brain areas in PTSD were the prefrontal cortex, amygdala, and hippocampus CA1. CBD TSGs could reduce the level of tumor necrosis factor-α caused by PTSD. Western blot analysis showed that CBD TSGs increased the expression of the 5-HT1A receptor. Intranasal administration of CBD TSGs was more efficient and had more obvious brain targeting effects than oral administration, as evidenced by the pharmacokinetics and brain tissue distribution of CBD TSGs. Overall, nasal CBD TSGs are safe and effective and have controlled release. There are a novel promising option for the clinical treatment of PTSD.

Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review

BACKGROUND

The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries.

METHODS

Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results.

RESULTS

Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33).

CONCLUSION

We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care.

LEVEL OF EVIDENCE

Systematic Reviews & Meta-analyses, Level IV.

Sex differences in long-term outcomes after traumatic injury: A mediation analysis

BACKGROUND

We sought to examine the association and potential mediators between sex and long-term trauma outcomes.

METHODS

Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis.

RESULTS

2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes.

CONCLUSIONS

There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.

Physical injury and psychotic experiences in 48 low- and middle-income countries

BACKGROUND

Psychotic experiences (PEs) may be associated with injuries, but studies focusing specifically on low- and middle-income countries (LAMICs) are scarce. Thus, the current study examined the link between injuries and PEs in a large number of LAMICs.

METHOD

Cross-sectional data were used from 242 952 individuals in 48 LAMICs that were collected during the World Health Survey in 2002-2004 to examine the association between traffic-related and other (non-traffic-related) forms of injury and PEs. Multivariable logistic regression analysis and meta-analysis were used to examine associations while controlling for a variety of covariates including depression.

RESULTS

In fully adjusted analyses, any injury [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.85-2.31], traffic injury (OR 1.84, 95% CI 1.53-2.21) and other injury (OR 2.09, 95% CI 1.84-2.37) were associated with higher odds for PEs. Results from a country-wise analysis showed that any injury was associated with significantly increased odds for PEs in 39 countries with the overall pooled OR estimated by meta-analysis being 2.46 (95% CI 2.22-2.74) with a moderate level of between-country heterogeneity (I2 = 56.3%). Similar results were observed across all country income levels (low, lower-middle and upper-middle).

CONCLUSIONS

Different types of injury are associated with PEs in LAMICs. Improving mental health systems and trauma capacity in LAMICs may be important for preventing injury-related negative mental health outcomes.

Factors Associated With Long-term Outcomes After Injury: Results of the Functional Outcomes and Recovery After Trauma Emergencies (FORTE) Multicenter Cohort Study

OBJECTIVE

The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury.

SUMMARY OF BACKGROUND DATA

Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma.

METHODS

Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes.

RESULTS

We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were.

CONCLUSION

The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.

Reduced chronic pain: Another benefit of recovery at an inpatient rehabilitation facility over a skilled nursing facility?

BACKGROUND

We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF).

METHODS

Trauma patients admitted to 3 Level-I trauma centers were interviewed to evaluate the presence of daily pain requiring medication, functional outcomes, and physical and mental health-related quality-of-life at 6-12 months post-injury. Inverse-probability-of-treatment-weighting (IPTW)-adjusted analyses were performed to compare outcomes between patients who were discharged to IRF vs SNF.

RESULTS

A total of 519 patients were included: 389 discharged to IRFs and 130 to SNFs. In adjusted analyses, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (28.3% vs. 44.7%; OR:0.49; 95% CI, 0.26-0.91; P = .02). However, there were no significant differences in functional outcome or SF-12 composite scores between groups.

CONCLUSION

Our findings suggest that injured patients discharged to an IRF as compared to a SNF had less chronic pain and analgesic use.

Predictors of Posttraumatic Growth: Insights From a Comparison Between Assault Victims and Nonassault Victims

Posttraumatic growth (PTG) has been investigated in many different areas of trauma, including cancer, occupation-related injuries, and crimes. In the current study, we aimed to examine the effects of traumatic events on the victims' PTG. The current study was a survey study with group comparison. We recruited 143 victims of trauma (74 nonassault victims and 69 assault victims) and compared victims' PTG and its related factors according to the trauma type. Nonassault victims showed better outcomes in terms of adverse childhood experience, depression, anxiety, and acceptance than assault victims. Only for assault victims, PTG was predicted significantly by the individuals' resilience. For nonassault victims, anxiety showed significance in predicting PTG. Assault victims seemed to be at significantly higher risk for psychological issues in adaptation afterward than nonassault victims. The implications of the results, including more tailored support for assault victims, as well as future study suggestions, are discussed.

Lower education and income predict worse long-term outcomes after injury

BACKGROUND

Lower socioeconomic status (SES) is known to be associated with higher morbidity and mortality following injury. However, the impact of individual SES on long-term outcomes after trauma is unknown. The objective of this study was to determine the impact of educational level and income on long-term outcomes after injury.

METHODS

Trauma patients with moderate to severe injuries admitted to three Level-I trauma centers were contacted 6 months to 12 months after injury to evaluate functional status, return to work/school, chronic pain, and posttraumatic stress disorder (PTSD). Lower SES status was determined by educational level and income. Adjusted logistic regression models were built to determine the association between educational level and income (lowest vs. highest quartile determined by census-tract area) on each of the long-term outcomes. A sensitivity analysis was performed using the national median household income ($57,617) as threshold for defining low versus high income.

RESULTS

A total of 1,516 patients were followed during a 36-month period. Forty-nine percent had a low educational level, and 26% were categorized in the low-income group. Mean (SD) age and injury severity score were 60 (21.5) and 14.3 (7.3), respectively, with most patients (94%) having blunt injuries. After adjusting for confounders, low educational level was associated with poor long-term outcomes: functional limitation [odds ratio (OR), 1.78 (95% confidence interval (CI), 1.41-2.26)], has not yet returned to work/school [OR, 2.48 (95% CI, 1.70-3.62)], chronic pain [OR, 1.63 (95% CI, 1.27-2.10)], and PTSD [OR, 2.23 (95% CI, 1.60-3.11)]. Similarly, low-income level was associated with not yet return to work/school [OR, 1.97 (95% CI, 1.09-3.56)], chronic pain [OR,1.70 (95% CI, 1.14-2.53)], and PTSD [OR, 2.20 (95% CI, 1.21-3.98)]. In sensitivity analyses, there were no significant differences in long-term outcomes between income levels.

CONCLUSION

Low educational level is strongly associated with worse long-term outcomes after injury. However, although household income is associated with long-term outcomes, it matters where the threshold is. The impact of different socioeconomic measures on long-term outcomes after trauma cannot be assumed to be interchangeable.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Posttraumatic stress disorder after minor trauma - A prospective cohort study

BACKGROUND

Posttraumatic stress disorder (PTSD) can arise as a reaction to a traumatic experience. While many data concerning PTSD in severely injured patients are available, little is known about this disease in slightly injured patients after road traffic accidents. It is rather assumed that PTSD does not exist after objectively slight injuries.

METHODS

In total, 36 patients (Injury Severity Score < 16) after road traffic accidents were included in this prospective cohort study. Next to demographic and accident-specific data, the PDI (Peritraumatic Distress Inventory: individual experienced distress directly during or immediately after the traumatic event), THQ (Trauma History Questionnaire) and the BDI-II (Beck Depression Inventory-II: self-report measurement tool to examine the severity of depression) were assessed immediately after trauma (t0). Six weeks (t1) and 3 months (t2) after trauma the Impact of Event Scale - Revised (IES-R), a screening instrument for PTSD, and the BDI-II were collected.

RESULTS

Overall 2 patients showed critical measurement values in IES-R after 6 weeks. A strong correlation between PDI and IES-R at t1 and t2 could be detected (p < 0.05). Furthermore, a significant correlation of BDI-II and IES-R after 6 weeks and 3 months was found (p < 0.05). Neither age or sex showed a significant correlation to IES-R (p ≥ 0.05).

CONCLUSION

The present study showed that symptoms of PTSD can also occur after minor trauma. Especially high peritraumatic distress is associated with developing a PTSD. The occurrence of PTSD should be considered not only in severely injured patients, but also in slightly injured patients after road traffic accidents.

Long-term social dysfunction after trauma: What is the prevalence, risk factors, and associated outcomes?

BACKGROUND

Social functioning-the ability to participate in organized or informal family, friend, or peer groups and communal activities-is intertwined with physical and emotional health. Although trauma can have a lasting effect on both the physical and emotional well-being of patients, little is known about the long-term impact of injury on social functioning. We sought to determine the prevalence of, risk factors for, and outcomes associated with long-term social dysfunction after trauma.

METHODS

Adults with moderate-to-severe injuries managed at three Level I trauma centers were contacted at 6 to 12 months after injury to inquire about social dysfunction. Demographics, socioeconomic parameters, and injury-related and hospital course information were also obtained. A stepwise backward logistic regression model was fitted to determine independent risk factors of social dysfunction, and multiple logistic regression models were used to determine associations between social dysfunction and post-traumatic stress disorder, functional limitations, and return to work.

RESULTS

Of the 805 screened patients, 45.2% reported social dysfunction. Patients with social dysfunction were more likely to be African American, be Medicaid beneficiaries, be of lower education, require mechanical ventilation, be discharged less often to home, have a lower mean age and had longer hospital stays. In multivariable analysis, low education, longer hospital stay, past psychiatric illness, and African-American race independently increased the risk for social dysfunction. Furthermore, patients with social dysfunction were more likely to screen positive for post-traumatic stress disorder (odds ratio: 16.25 [95% confidence interval: 9.49-27.85]), be experiencing functional limitations (odds ratio: 2.80 [95% confidence interval: 1.76-4.44]), and to not have returned to work (odds ratio: 5.65 [95% confidence interval: 3.92-8.14]).

CONCLUSION

Lower educational attainment, long hospital stay, past pyschiatric illness, and African-American race appear to predispose to social dysfunction after trauma, which in turn is associated with a positive post-traumatic stress disorder screen, functional limitations, and delayed return to work.

It still hurts! Persistent pain and use of pain medication one year after injury

BACKGROUND

Given the scarce literature data on chronic post-traumatic pain, we aim to identify early predictors of long-term pain and pain medication use after major trauma.

METHODS

Major trauma patients (Injury Severity Score ≥ 9) from three Level I Trauma Centers at 12 months after injury were interviewed for daily pain using the Trauma Quality of Life questionnaire. Multivariate logistic regression models identified patient- and injury-related independent predictors of pain and use of pain medication.

RESULTS

Of 1238 patients, 612 patients (49%) felt daily pain and 300 patients (24%) used pain medication 1 year after injury. Of a total of 8 independent predictors for chronic pain and 9 independent predictors for daily pain medication, 4 were common (pre-injury alcohol use, pre-injury drug use, hospital stay ≥ 5 days, and education limited to high school). Combinations of independent predictors yielded weak predictability for both outcomes, ranging from 20% to 72%.

CONCLUSIONS

One year after injury, approximately half of trauma patients report daily pain and one-fourth use daily pain medication. These outcomes are hard to predict.

Posttraumatic Stress Disorder and Associated Factors Among Drivers Surviving Road Traffic Crashes in Southwest Ethiopia

BACKGROUND

Road traffic crashes (RTCs) can cause serious and long-lasting consequences for drivers, both in terms of physical and mental health outcomes. Posttraumatic stress disorder (PTSD) is the most frequent mental disorder occurring after traumatic exposure. Ethiopian drivers experience RTCs more frequently than other sub-Saharan countries. Despite this prevailing phenomenon, limited attention has been given to PTSD among drivers.

OBJECTIVE

To determine the prevalence of PTSD and associated factors among drivers surviving RTCs in southwest Ethiopia.

METHODS

A cross-sectional quantitative study was conducted among 402 male drivers who had survived RTCs. The study was conducted in Jimma zone, southwest Ethiopia from March to June, 2019. All drivers who had survived RTCs in the last year were included in the study. The Trauma Screening Questionnaire was used to determine the prevalence of PTSD. Data were entered in EpiData 3.1 and exported to SPSS 24 for analysis.

RESULTS

The response rate of the study was 398(99%). Fifty of 398 (12.6%, 95% CI 9.5%-16.1%) met PTSD criteria based on the questionnaire. A history of near-miss RTCs (AOR 3.49, 95% CI 1.89-6.43), depression (AOR 3.32, 95% CI 1.36-5.12), and severe-risk cannabis use (AOR 2.51, 95% CI 1.96-7.52) were significantly associated with PTSD.

CONCLUSION AND RECOMMENDATION

The prevalence of PTSD among drivers surviving RTCs was high compared to the general population. A record of near-miss RTCs, depression, and severe-risk cannabis use shown significant associations with PTSD. Strategies and guidelines must be developed to screen and treat PTSD among drivers surviving RTCs. Drivers with experience of near-miss RTCs, depression, and severe-risk cannabis use should be given priority when screening for PTSD.