The effect of post-injury depression on return to pre-injury function: a prospective cohort study

Patient Experiences of Acute and Postacute Care After Trauma

INTRODUCTION

Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge.

METHODS

Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis.

RESULTS

Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination.

CONCLUSIONS

Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.

Qualitative Research in Return to Sport: a Current Review of the Literature

PURPOSE OF REVIEW

Return to sport (RTS) is an important metric tied to patient satisfaction after receiving treatment for a sports-related injury. Recently, there has been an explosion of literature on RTS; yet a comprehensive review encompassing multiple injuries does not exist. Furthermore, RTS has historically been defined by quantitative measures that assess strength, function, and pain but little consideration has been given to psychologic factors nor has there been an open-ended forum for athletes to share with health care providers which factors they feel are most influential for RTS. This review also serves to heighten surgeons' awareness of underlying psychologic/psychosocial factors affecting RTS.

RECENT FINDINGS

Qualitative studies which employ open-ended questioning of athletes who have undergone surgical management of superior labral anterior-posterior (SLAP) tears, shoulder instability, ulnar collateral ligament (UCL) rupture, femoral acetabular impingement (FAI), and anterior cruciate ligament (ACL) tear demonstrate that fear of reinjury, lack of social support, and unrealistic expectations are all barriers to RTS. Qualitative studies give health care providers unique insight into the perspectives of their patients so that unmet postoperative needs can be addressed to facilitate RTS. Sports psychologists, coaches, athletic trainers, and physical therapists should create a positive environment to address these needs and provide optimal, holistic care to return athletes to the field safely. Though time consuming, further qualitative research is necessary to understand the unique factors affecting RTS in athletes.

The Contribution of Neighborhood Characteristics to Psychological Symptom Severity in a Cohort of Injured Black Men

BACKGROUND

Traumatic injury is not evenly distributed by race and class in the USA. Black men are marginalized in the society, often reside in disadvantaged neighborhoods, and are at higher risk for injury mortality and ongoing physical and psychological problems following injury. Post-traumatic stress disorder (PTSD) and depressive symptom severity are among several problematic and disabling conditions faced by injury survivors. While much research has examined individual factors that lead to increased post-injury psychological symptom severity, the contribution of the social and physical environment has been relatively understudied.

OBJECTIVE

To examine the contribution of neighborhood characteristics to PTSD and depressive symptom severity in Black men following traumatic injury.

DESIGN

Prospective cohort study. Participant data were linked via GIS to neighborhood characteristics (constructs established by factor analysis) to spatially model factors associated with increased post-injury psychological symptom severity using a GEE regression analysis, adjusting for injury mechanism and severity, age, and insurance.

PARTICIPANTS

Four hundred fifty-one adult Black males hospitalized for traumatic injury.

RESULTS

The 4 constructs were neighborhood disconnectedness, concentrated disadvantage/deprivation, crime/violence/vacancy, and race/ethnicity. High depressive and PTSD symptom severity was reported by 36.8% and 30.4% of participants, respectively. Higher PTSD symptom severity was associated with crime/violence/vacancy, and higher depressive symptom severity was associated with neighborhood disconnectedness. PTSD and depressive symptom severity were associated with intentional injury mechanisms and Medicaid/no insurance. Higher injury severity was associated with depressive symptoms.

CONCLUSION

Neighborhood characteristics are associated with psychological symptom severity after injury.

Psychological distress 12 years following injury in New Zealand: findings from the Prospective Outcomes of Injury Study-10 years on (POIS-10)

BACKGROUND

Injuries can have detrimental impacts on mental health, even after physical recovery. In our Prospective Outcomes of Injury Study (POIS), 25% of participants experienced psychological distress (assessed using the Kessler 6) three months after a sentinel injury event (SIE), declining to 16% at 24 months post-SIE. Internationally, studies of hospitalised patients found distress persisted beyond 24 months post-injury and remained higher than the general population. However, most studies only assessed distress at one timepoint, relied on long-term recall, or were limited to small samples or specific injury types. Therefore, we aim to describe the prevalence of psychological distress 12 years post-SIE and to investigate pre-injury, injury-related and early post-injury characteristics associated with long-term distress.

METHODS

POIS is a longitudinal cohort study of 2856 New Zealanders injured between 2007 and 2009, who were on the national injury insurer, Accident Compensation Corporation entitlement claims' register. Of these, 2068 POIS participants completed an interview at 24 months and agreed to further contact. They were invited to a follow-up interview 12 years post-SIE which included the Kessler-6 (K6), the psychological distress outcome of interest. Data about a range of pre-injury, injury-related and early (3 months) post-injury characteristics were collected via earlier interviews or administrative data sources (e.g. hospital discharge data).

RESULTS

Twelve years post-SIE, 1543 (75%) people were re-interviewed and 1526 completed the K6; n = 177 (12%) reported psychological distress. Multivariable modified Poisson regression models found pre-injury characteristics were associated with an increased risk of clinically relevant distress at 12 years, i.e. having inadequate income, identifying as Māori, Pacific or Asian and having one mental health condition. Early post-injury psychological distress and dissatisfaction with social relationships also increased risk. However, being older was associated with a reduced risk of distress.

CONCLUSION

Clinically relevant distress persists long-term post-injury among adults with varying injury severity, types and causes, and at higher prevalence than in the general population. Early identification of injured people at risk of long-term psychological distress provides opportunities for timely interventions to reduce psychological distress.

Does the Treatment Approach for Mandibular Condyle Fractures Impact Self-Perceived Quality of Life?

PURPOSE

There is no consensus in mandibular condylar fracture/s treatment. In medicine, quality of life (QOL) includes the individual's satisfaction toward their own health condition, disease, or treatment. The purpose of this study was to investigate self-perception QOL outcomes for patients who sustained mandibular condylar fracture/s.

METHODS

This cross-sectional study surveyed patients at Grady Memorial Hospital in Atlanta, Georgia from November 2016 to June 2020. The study included patients who were at least 16 years old at the time of injury, diagnosed with mandibular condylar fracture/s, treated by close reduction or open reduction and internal fixation (ORIF), presented for 6-months post-operative follow-up, and had a valid phone number. The primary predictor variable was treatment approach. The primary outcome variable was mood. Covariates were demographics, injury details, and self-perception QOL questionnaire. Univariate, bivariate, and ordinal regression analysis were performed (P < .05 significance).

RESULTS

A total of 108 patients met inclusion criteria. Response rate was 84.2%. Our data showed that patients who underwent ORIF treatment were statistically more likely to experience no or milder pain when chewing (tau = 0.390, P = .002), to not require pain medications (tau = 0.389, P = .002), to report larger maximum mouth opening (tau = 0.402, P = .0003), and to report better QOL (tau = 0.440, P = 7.407e-05). Ordinal regression analysis showed that patients who had undergone ORIF treatment were positively associated with better mood (estimate: -0.062; OR: 0.54; P = .29) and statistically significant associated with excellent QOL (estimate: -2; OR: 0.13; P = 3.99e-05). Patients who sustained class III Lindahl mandibular condyle fracture were statistically significantly associated with depressed mood (estimate: 1.46; OR: 4.33; P = .002).

CONCLUSION

ORIF treatment was positively associated with better QOL when compared to closed reduction for mandibular condyle fracture.

Comparison of two screeners predicting the future development of depression and posttraumatic stress disorder in Black men after serious injury

Background To assess the predictive performance of two established, short clinical screeners in predicting the future development of post-injury depression and PTSD. Methods This was a prospective, cohort design with a 3-month follow-up. Black adult male trauma patients were enrolled at an urban, Level 1 trauma center. The Penn Richmond Screener and the Posttraumatic Adjustment Scale (PAS) were collected in-hospital. Participants were categorized as depressed using the Quick Inventory of Depressive Symptoms-Self Report and as positive for PTSD using the PTSD Check List - 5 (PCL-5) at 3-months post-discharge. Sensitivity, specificity, PPV and NPV of each screener were calculated. We used receiver operating curve (ROC) analyses to calculate the area under the curve (AUC) with 95% CI to assess predictive performance of each screener. Results A cohort of 623 hospitalized, injured Black men were enrolled during acute hospitalization. 503 participants (80.6%) were retained at 3-months and formed the analytic sample. Mean age was 36.8 years (SD 15.4), 53.1% of injuries were intentional; median injury severity score was 9. At 3 months, 35.3% had moderate to severe depression, 32.7% had significant PTSD symptoms, and 22.4% met criteria for both depression and PTSD. Penn Richmond Screener: sensitivity 0.68, specificity 0.56, and AUC 0.62 for PTSD, and sensitivity 0.64, specificity 0.63, and AUC 0.64 for depression. PAS: sensitivity 0.59, specificity 0.73, and AUC 0.66 for PTSD, and sensitivity 0.75, specificity 0.49, and AUC 0.62 for depression. Conclusions This study validated the performance of both screeners within the same population, allowing a direct comparison. Two predictive screeners, developed through different methods and in different countries, showed comparable predictive ability. These findings indicate that risk markers for adverse psychological consequences of traumatic injury share some core similarities across populations and countries.

Mental health and other factors associated with work productivity after injury in the UK: multicentre cohort study

INTRODUCTION

Mental health conditions are a major contributor to productivity loss and are common after injury. This study quantifies postinjury productivity loss and its association with preinjury and postinjury mental health, injury, demographic, health, social and other factors.

METHODS

Multicentre, longitudinal study recruiting hospitalised employed individuals aged 16-69 years with unintentional injuries, followed up at 1, 2, 4 and 12 months. Participants completed questionnaires on injury, demographic factors, health (including mental health), social factors, other factors and on-the-job productivity upon return to work (RTW). ORs were estimated for above median productivity loss using random effects logistic regression.

RESULTS

217 adults had made an RTW at 2, 4 or 12 months after injury: 29% at 2 months, 66% at 4 months and 83% at 12 months. Productivity loss reduced over time: 3.3% of working time at 2 months, 1.7% at 4 months, 1% at 12 months. Significantly higher productivity loss was associated with preinjury psychiatric conditions (OR 21.40, 95% CI 3.50 to 130.78) and post-traumatic stress avoidance symptoms at 1 month (OR for 1-unit increase in score 1.15, 95% CI 1.07 to 1.22). Significantly lower productivity loss was associated with male gender (OR 0.32, 95% CI 0.14 to 0.74), upper and lower limb injuries (vs other body regions, OR 0.15, 95% CI 0.03 to 0.81) and sports injuries (vs home, OR 0.18, 95% CI 0.04 to 0.78). Preinjury psychiatric conditions and gender remained significant in analysis of multiply imputed data.

CONCLUSIONS

Unintentional injury results in substantial productivity loss. Females, those with preinjury psychiatric conditions and those with post-traumatic stress avoidance symptoms experience greater productivity loss and may require additional support to enable successful RTW.

Prevalence and predictors of psychological distress following injury: findings from a prospective cohort study

BACKGROUND

Research examining psychological distress in people who have experienced an injury has focused on those with serious injuries or specific injury types, and has not involved long-term follow up. The aims of this investigation were to describe the prevalence of, and factors contributing to, psychological distress in a cohort of people with a broad range of injuries.

METHODS

The Prospective Outcomes of Injury Study (POIS) is a longitudinal cohort study of 2856 injured New Zealanders recruited from a national insurance entitlement claims register between 2007 and 2009. Participants were interviewed approximately 3, 12, and 24 months after their injury. The Kessler Psychological Distress Scale (K6) was used to measure psychological distress at each interview.

RESULTS

25% of participants reported clinically relevant distress (K6 ≥ 8) 3 months post-injury, 15% reported distress at 12 months, and 16% reported distress at 24 months. Being 45 years or older, Māori or Pacific ethnicity, experiencing pre-injury mental health conditions, having inadequate pre-injury income, reporting poor pre-injury health or trouble accessing healthcare, having a severe injury or an injury resulting from assault, and reporting clinically relevant distress 3 months post-injury were independently associated with an increased risk of distress 12 months post-injury. The majority of these associations were also evident with respect to distress 24 months post-injury.

CONCLUSIONS

Distress is common after injury among people with a broad range of injury types and severities. Screening for distress early after injury is important to identify individuals in need of targeted support.

The Comparative Mental Health Responses Between Post-Musculoskeletal Injury and Post-Concussive Injury Among Collegiate Athletes: A Systematic Review

BACKGROUND

The average annual national estimate of injuries sustained by collegiate athletes is 210,674, which encompasses both those of a musculoskeletal and a concussive nature. Although athletic injuries are sustained through physical means and produce physical symptoms, sports-related injuries may be a stressor among athletes that is related to mental health.

PURPOSE

The purpose of this systematic review is to summarize existing literature describing mental health responses in collegiate athletes with a concussion compared to those with a musculoskeletal injury.

STUDY DESIGN

Systematic Review.

METHODS

Systematic searches of PubMed, CINAHL, Scopus, ProQuest, and SportDiscus were completed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tool. Data extracted from the included articles included the study design, number of participants, type of injury, sex, age, sport participation, outcome measures, and time to return to play.

RESULTS

A total of six articles were included. Peak depressive symptoms in athletes who sustain a concussion or musculoskeletal injury occur within one-week post-injury. No significant differences between the concussive and musculoskeletal groups anxiety scores were found at baseline or at each follow-up session. Athletes from both groups were found to be returning to their respective sports with anxiety scores representative of clinical anxiety.

CONCLUSION

Similar trends in depressive and anxiety symptoms at various time points post-injury were observed in athletes with both musculoskeletal and concussive injuries. This study identified that athletes were returning to play before their psychological symptoms had returned to their baseline.

LEVEL OF EVIDENCE

2a.

Beyond morbidity and mortality: The practicality of measuring patient-reported outcomes in trauma

BACKGROUND

The 2016 Zero Preventable Deaths report highlighted the need for comprehensive injury data to include long term outcomes such as societal and workforce re-entry. Currently, postinjury quality of life is poorly understood. We hypothesized that routine measurement of patient-reported outcomes is feasible as a part of post-discharge follow-up, and that trauma patients would report that their injury had a detrimental impact on health-related quality of life (HRQoL) after discharge.

METHODS

After instruction, patients self-administered the PROMIS-29 instrument in our outpatient office (11/2019-4/2020). We surveyed 7 domains: Participation in Social Roles/Activities, Anxiety, Depression, Fatigue, Pain Interference, Physical Function, and Sleep Disturbance. Results are reported as means (SD) and compared to the U.S population by t-score (mean score=50). Higher scores in negatively-worded domains (e.g. "Depression") are worse; vice versa for positively-worded domains (e.g. "Physical Function"). Repeated scores among patients returning for a second visit were analyzed using paired t-tests.

RESULTS

103 patients completed the PROMIS-29. Mean (SD) age was 42.3 (17.3) years, 75% were male, and 42% suffered a penetrating injury. Median length of stay was 3 days and median time from injury to clinic visit was 18 days. Mean scores were worse than population means in every domain. Pain Interference (mean 63.5, 95%CI [61.8-65.3]) and Physical Function (38.0 [36.2-39.8]) were particularly affected. Among patients returning for a second visit (n=10; median time between clinic visits: 17.5 days), there were no significant differences in domain scores over time.

CONCLUSION

Trauma patients are at high risk for poor quality of life outcomes in the short term following injury. Our results highlight the need for early recognition and multidisciplinary treatment following injury.

'Sharing things with people that I don't even know': help-seeking for psychological symptoms in injured Black men in Philadelphia

Objectives: Psychological distress is common in survivors of traumatic injury, yet across United States' trauma systems, it is rare that standard injury care integrates psychological evaluation and professional mental healthcare. The purpose of this study was to explore help-seeking for psychological symptoms in injured Black men living in Philadelphia. Design: A subset of a cohort of 551 injured Black men admitted to a Trauma Center in Philadelphia participated in qualitative interviews that explored their perceptions of psychological symptoms after injury and the factors that guided their decision to seek professional mental health help. Data from 32 participants were analyzed for narrative and thematic content. Results: Three overarching themes emerged: (1) facilitators of help-seeking, (2) barriers to help-seeking, and (3) factors underlying the decision not to consider professional help. Five participants felt that their injury-related psychological distress was severe enough to merit professional help despite any perceived barriers. Seventeen participants identified systemic and interpersonal obstacles to professional help that prevented them from seeking this kind of care. These included: financial constraints, limited access to mental healthcare services, and fear of the judgments of mental healthcare professionals. Ten participants would not consider professional help; these men perceived a lack of need and sufficiency in their existing social support networks. Conclusions: Research is needed to inform or identify interventions that diminish the impact of barriers to care, and identify from whom, where, and how professional mental health help might be more effectively offered to injured Black men in recovery environments like Philadelphia.

Pathways to Help-Seeking Among Black Male Trauma Survivors: A Fuzzy Set Qualitative Comparative Analysis

Many Black men suffer symptoms of traumatic stress in the aftermath of traumatic injury, and they also often carry social concerns, including experiences of discrimination and stigma, and a lack of financial resources. The objective of the present study was to understand how traumatic symptoms and social factors combine in complex ways toward the outcome of psychological help-seeking. We analyzed qualitative and quantitative data from 32 injured Black men admitted to a Level 1 trauma center. Qualitative interviews explored their attitudes toward seeking professional psychological help. We analyzed quantitative data, collected using validated instruments, on posttraumatic stress and depression symptoms, financial worry, and discrimination/stigma. Fuzzy set qualitative comparative analysis (fsQCA) was conducted by calibrating each condition to fuzzy set membership scores based on our knowledge of the causal conditions and the cases. We then constructed truth tables for QCA analysis using fsQCA software. Three causal pathways for psychological help-seeking were identified: Two pathways showed that severe trauma symptoms in the absence of financial worry were sufficient for seeking help, whereas the third showed that financial worry and discrimination in the absence of trauma symptoms were sufficient for help-seeking. We identified two causal pathways for negated help-seeking, in which low posttraumatic symptom severity and low levels of discrimination or financial worry were sufficient for not seeking psychological help. The QCA analysis revealed multiple pathways for psychological help-seeking among Black men who suffer trauma. These findings highlight the need for further research to understand complex pathways toward psychological help-seeking in this population.

Contributors to Postinjury Mental Health in Urban Black Men With Serious Injuries

Importance

Physical injury is associated with postinjury mental health problems, which typically increase disability, cost, recidivism, and self-medication for symptoms.

Objective

To determine risk and protective factors across the life span that contribute to depression and posttraumatic stress symptom severity at 3 months after hospital discharge.

Design, Setting, and Participants

This prospective cohort study used a 3-month postdischarge follow-up of patients who had been treated at an urban, level 1 trauma center in the Northeastern United States. Men with injuries who were hospitalized, self-identified as black, were 18 years or older, and resided in the Philadelphia, Pennsylvania, region were eligible and consecutively enrolled. Those who were experiencing a cognitive dysfunction or psychotic disorder, hospitalized because of attempted suicide, or receiving current treatment for depression or posttraumatic stress disorder (PTSD) were excluded. Data were collected from January 2013 to October 2017. Data analysis took place from January 2018 to August 2018.

Exposures

A serious injury requiring hospitalization; adverse childhood experiences, childhood neighborhood disadvantage, and preinjury physical and mental health; and emotional resources, injury intent, and acute stress responses.

Main Outcomes and Measures

Depression and PTSD symptom severity were assessed with the Quick Inventory of Depressive Symptoms-Self-report and the PTSD Check List-5. The a priori hypothesis was that risk and protective factors are associated with depression and PTSD symptom severity. The analytic approach was structural equation modeling.

Results

A total of 623 black men were enrolled. Of these, 502 participants (80.6%) were retained at 3-month follow-up. Their mean (SD) age was 35.6 (14.9) years; 346 (55.5%) had experienced intentional injuries, and the median (range) Injury Severity Score was 9 (1-45). Of the 500 participants with complete primary outcome data, 225 (45.0%) met the cut point criteria for mental health diagnoses at 3 months. For both mental health outcomes, the models fit the data well (depression: root mean square error of approximation [RMSEA], 0.044; comparative fit index [CFI], 0.93; PTSD: RMSEA = 0.045; CFI = 0.93), and all hypothesized paths were significant and in the hypothesized direction. Outcomes were associated with poor preinjury health (standardized weights: depression, 0.28; P < .001; PTSD, 0.17; P = .02), acute psychological reactions (depression, 0.34; PTSD, 0.38; both P < .001), and intentional injury (depression, 0.16; PTSD, 0.24; both P < .001). Acute psychological reactions were associated with childhood adversity (depression, 0.33; PTSD, 0.36; both P < .001). A history of prior mental health challenges (depression, 0.70; PTSD, 0.70; both P < .001) and psychological or emotional health resources (depression, -0.22; PTSD, -0.23; both P = .003) affected poor preinjury health, which was in turn associated with acute psychological reaction (depression, 0.44; PTSD, 0.42; both P < .001).

Conclusions and Relevance

The intersection of prior trauma and adversity, prior exposure to neighborhood disadvantage, and poorer preinjury health and functioning are important, even in the midst of acute medical care for traumatic injury. These results support the importance of trauma-informed health care and focused assessment to identified patients with injuries who are at highest risk for poor postinjury mental health outcomes.

Do Exercisers With Musculoskeletal Injuries Report Symptoms of Depression and Stress?

CONTEXT

Sports injuries in athletes can lead to negative emotional responses in terms of anger, anxiety, confusion, and sadness. Severe injuries can be understood as a stressful life event with increased levels of psychological distress, but injury assessment and rehabilitation typically focus on somatic symptoms.

OBJECTIVE

The primary aim of this study was to estimate the prevalence of depression and emotional stress and to measure self-rated health in regular exercisers presenting to a sports medicine clinic with musculoskeletal injury. The secondary aim was to identify psychosocial factors associated with depression in injured exercisers and the potential need for psychological counseling.

DESIGN

A cross-sectional survey study.

SETTING

A sports medicine clinic for injuries of the foot, knee, or shoulder.

PARTICIPANTS

Regular exercisers with present injuries (N = 694) and exercisers without injuries (N = 494). Regular exercisers were defined as those undertaking moderate exercise at least once a week.

INTERVENTION

A questionnaire survey completed on paper by patients in a sports medicine clinic and a web-based version completed by online sports communities.

MAIN OUTCOME MEASURES

Participants completed the Major Depression Inventory, Perceived Stress Scale, health-related quality of life, and questions on sociodemographics, exercise habits, and injury history.

RESULTS

Symptoms of depression were reported by 12% of injured exercisers and 5% of noninjured controls (P < .001). Clinical stress was found in 30% of injured exercisers and 22% of controls (P = .002), and the EQ-5D-5L Visual Analog Scale score was lower for injured (69 [SD = 19]) than noninjured exercisers (87 [SD = 13], P < .001). Injured exercisers with symptoms of depression reported high stress levels and impaired daily functioning, were younger, and were more likely to have over 10 days injury-related work absence.

CONCLUSIONS

The authors recommend psychological assessment of exercisers attending a sports medicine clinic for musculoskeletal injury and a supplemental clinical psychological interview for suspected depression or stress-related psychopathology.

Trauma Providers' Knowledge, Views, and Practice of Trauma-Informed Care

Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care, and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting the use of TIC in practice. Of 147 participants, the majority were nurses (65%), followed by therapists (18%) and physicians (17%), with a median 3 years of experience; 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. Nineteen percent rated themselves as less than "somewhat competent." All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about retraumatizing patients. Self-rated competence was the most consistent predictor of providers' reported use of specific TIC practices. Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed and should aim to build providers' perceived competence in providing TIC.

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.

Concussions in NCAA Varsity Football Athletes: A Qualitative Investigation of Player Perception and Return to Sport

Background

The objective of this study was to understand the experiences and perspectives of varsity football athletes on return to play following a concussion injury.

Methods

Two experienced interviewers conducted qualitative, semistructured interviews of college-level football players who had sustained at least one concussion during their varsity careers.

Results

Twenty varsity football players who averaged 2.3 concussions each (range, 1-5) were interviewed regarding peer pressure, the culture of football, and player awareness as factors affecting return to sport following a concussion. Less common secondary factors included risk management, severity and timing of the injury, and team support.

Conclusions

Psychological stressors, the culture of football, and increased awareness were the most influential factors affecting collegiate football players' deciding to return to sport following a concussion.

Level of Evidence

Level III.

Psychological morbidity and return to work after injury: multicentre cohort study

BACKGROUND

The benefits of work for physical, psychological, and financial wellbeing are well documented. Return to work (RTW) after unintentional injury is often delayed, and psychological morbidity may contribute to this delay. The impact of psychological morbidity on RTW after a wide range of unintentional injuries in the UK has not been adequately quantified.

AIM

To quantify the role of psychological factors, including anxiety, depression, and post-traumatic distress, on RTW following unintentional injuries.

DESIGN AND SETTING

A longitudinal multicentre prospective study was undertaken in Nottingham, Bristol, Leicester, and Guildford, UK.

METHOD

Participants (n = 273) were 16-69-year-olds admitted to hospital following unintentional injury, who were in paid employment prior to injury. They were surveyed at baseline, then at 1, 2, 4, and 12 months following injury; demographic data were collected along with injury characteristics, psychological morbidity, and RTW status. Associations between demographic, injury and psychological factors, and RTW between 2 and 12 months after injury were quantified using random effects logistic regression.

RESULTS

The odds of RTW between 2 and 12 months after injury reduced as depression scores early in the recovery period (1 month after injury) increased (odds ratio [OR] 0.87, 95% confidence interval [CI] = 0.79 to 0.95) and as length of hospital stay increased (OR 0.91, 95% CI] = 0.86 to 0.96). For those experiencing threatening life events following injury (OR 0.27, 95% CI = 0.10 to 0.72) and with higher scores on the Crisis Support Scale (OR 0.93, 95% CI] = 0.88 to 0.99), the odds of RTW between 2 and 12 months after injury were lower. Multiple imputation analysis found similar results, but those relating to crisis support did not remain statistically significant.

CONCLUSION

Primary care professionals can identify patients at risk of delayed RTW who may benefit from management of psychological morbidity and support to RTW.

Two years after injury: prevalence and early post-injury predictors of ongoing injury-related problems

PURPOSE

To determine, in a cohort with injuries classified anatomically as mainly minor or moderate and for which only 25% were hospitalised acutely, the prevalence of ongoing problems attributed by participants to their injury 2 years prior, and to examine whether three-month post-injury experiences and expectations predict such problems.

METHODS

Participants (N = 2231; 18-64 years at injury) were those in the Prospective Outcomes of Injury Study who completed the initial three-month and final two-year interviews. The outcome measure was whether participants reported ongoing injury-related problems at 2 years. Possible early post-injury predictors were identified from the first interview; pre-injury and injury-related potential confounders from the first interview, insurer records and hospital discharge records. Multivariable models estimated relative risks.

RESULTS

Almost half the participants reported injury-related problems at 2 years. Participants reporting non-recovery at 3 months were more likely than those reporting recovery to have ongoing problems at 2 years, ranging from participants expecting to get better soon [adjusted RR 2.2, 95% CI (1.7,2.8)) to those expecting to never get better (aRR 3.1, 95% CI (2.4,4.0)]. Several three-month post-injury experiences also predicted ongoing problems at 2 years. Participants at highest risk included those with extreme pain [aRR 2.1, 95% CI (1.7,2.5)], and less involvement in usual activities [aRR 1.7, 95% CI (1.5,1.9)].

CONCLUSIONS

Findings indicate that early post-injury characteristics predict longer-term recovery among this cohort, most of who were not classified as seriously injured, and provide guidance for future studies on interventions to reduce poor outcome prevalence, particularly focussing on pain management and enabling return to independence and social participation.

Indicators of injury recovery identified by patients, family members and clinicians

INTRODUCTION

A focus on what is important to patients has been recognized as an essential pillar in care to ensure safe patient care that focuses on outcomes identified as important by patients. Despite this, asking trauma patients and their families what they consider should be the priorities of care and recovery has been neglected.

METHODS

Adult trauma patients admitted to two centers in Australia for ≥24h for the treatment of physical injury, and family members of injured patients and clinicians caring for injured patients were invited to participate. Individual interviews were conducted with the patient and family members prior to hospital discharge, and again one and three months post discharge. Individual interviews or focus groups were conducted with clinicians at one point in time. Content analysis of all transcripts was undertaken to determine the indicators of successful recovery over time.

RESULTS

Participants in the three stakeholder groups were enrolled (patients - 33; family members-22; clinicians-40). Indicators of recovery focused on five main categories including returning to work, resuming family roles, achieving independence, recapturing normality and achieving comfort. Other categories that were less frequently identified included maintaining one's household, restoring emotional stability, cosmetic considerations and appearance, realignment of life goals, psychological recovery and development of self. Indicators of recovery after physical injury were similar across the three stakeholder groups, although with greater detail identified by patients. In addition, indicators evolved over time with increasing recognition of the importance of the overall impact of the injury in general and on activities of daily living and an unfolding appreciation that life could not be taken for granted.

CONCLUSIONS

Description of the indicators of recovery after traumatic injury that matter to patients, family members and clinicians enable an understanding of similarities and differences. Further testing in a broader cohort of participants is essential to identify patient reported outcome measures that might be used in trauma care and associated research.

The effect of early psychological symptom severity on long-term functional recovery: A secondary analysis of data from a cohort study of minor injury patients

BACKGROUND

The mental health consequences of injuries can interfere with recovery to pre-injury levels of function and long term wellbeing.

OBJECTIVES

The purpose of this study was to explore the relationship between psychological symptoms after minor injury and long-term functional recovery and disability.

DESIGN

This exploratory study uses secondary data derived from a longitudinal cohort study of psychological outcomes after minor injury.

SETTING

Participants were recruited from the Emergency Department of an urban hospital in the United States.

PARTICIPANTS

A cohort of 275 patients was randomly selected from 1100 consecutive emergency department admissions for minor injury. Potential participants were identified as having sustained minor injury by the combination of three standard criteria including: presentation to the emergency department for medical care within 24h of a physical injury, evidence of anatomical injury defined as minor by an injury severity score between 2 and 8 and normal physiology as defined by a triage-Revised Trauma Score of 12. Patients with central nervous system injuries, injury requiring medical care in the past 2 years and/or resulting from domestic violence, and those diagnosed with major depression or psychotic disorders were excluded.

METHODS

Psychological symptom severity was assessed within 2 weeks of injury, and outcome measures for functional limitations and disability were collected at 3, 6 and 12 months. A quasi-least squares approach was used to examine the relationship between psychological symptom scores at intake and work performance and requirement for bed rest in the year after injury.

RESULTS

Adjusting for demographic and injury covariates, depression symptoms at the time of injury predicted (p≤0.05) both poorer work performance and increased number of days in bed due to health in the year after injury. Anxiety symptoms predicted (p≤0.05) bed days at 3, 6, and 12 months and work performance at 3 months.

CONCLUSIONS

Depression and anxiety soon after minor injury may help predict important markers of long-term recovery. With further research, simple assessment tools for psychological symptoms may be useful to screen for patients who are at higher risk for poor long-term recoveries and who may benefit from targeted interventions.

Gender Differences in the Longitudinal Association between Work-Related Injury and Depression

Little is known about gender differences in the association between occupational injury and depression. We investigated the bidirectional association and gender differences between work-related injury and depression using the same cohort in the US Medical Expenditure Panel Survey (MEPS). In Analysis 1, the association of occupational injury and subsequent depression was investigated from 35,155 employees without depression. Analysis 2 included 32,355 participants without previous injury and examined the association of depression and work-related injury. The multivariable-adjusted odds ratio was estimated using a discrete time-proportional odds model. Male workers who had experienced workplace injury were more vulnerable to post-injury depression than non-injured male workers (OR = 2.35, 95% CI: 1.52, 3.65). Female workers with depression were more prone to get injured at the workplace than the non-depressed female workers (OR = 1.44, 95% CI: 1.07, 1.96). These results did not hold in the reverse direction for both genders. Workers compensation benefit was positively associated with the risk of post-injury depression among males, whereas anti-depressant medication and duration of depression were related to workplace injury among females. Gender differences in the direction and associated factors of the relationship between occupational injury and depression highlight the need for gender-specific intervention to the vicious cycle of workplace injury and depression.

Mental disorder in limb reconstruction: Prevalence, associations and impact on work disability

OBJECTIVE

This cross-sectional survey aimed to assess the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), and drug and alcohol dependence in a limb reconstruction population and examine associations with demographic and functional variables.

METHODS

As part of routine clinical care, data were collected from 566 patients attending a tertiary referral centre for limb reconstruction between April 2012 and February 2016. Depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol and drug dependence were measured using standardised self-report screening tools.

RESULTS

173 patients (30.6% CI 26.7-34.4) screened positive for at least one of the mental disorders assessed. 110 (19.4% CI 16.2-22.7) met criteria for probable major depression; 112 (19.9% CI 16.6-23.2) patients met criteria for probable generalised anxiety disorder; and 41 (7.6% CI 5.3-9.8) patients met criteria for probable PTSD. The prevalence of probable alcohol dependence and probable drug dependence was 1.6% (CI 0.6-2.7) and 4.5% (CI 2.7-6.3), respectively. Patients who screened positive for depression, anxiety and PTSD reported significantly higher levels of pain, fatigue, and functional impairment. Depression and anxiety were independently associated with work disability after adjustment for covariates (OR 1.98 (CI 1.08-3.62) and OR 1.83 (CI 1.04-3.23), respectively).

CONCLUSION

The high prevalence and adverse associations of probable mental disorder in limb reconstruction attest to the need for routine psychological assessment and support. Integrated screening and management of mental disorder in this population may have a positive impact on patients' emotional, physical and occupational rehabilitation. A randomised controlled trial is needed to test this hypothesis.

Validation of a brief, two-question depression screen in trauma patients

BACKGROUND

Increasingly, depression following traumatic injury is recognized as a complication of injury. Unlike mandated screening for risky alcohol use in trauma centers, screening for psychological risks is not required by the American College of Surgeons' Committee on Trauma. Limited resources and time constraints are commonly given reasons against routine screening. The purpose of this study was to determine if a two-item screen was as valid as an eight-question screen for depression.

METHODS

A total of 421 patients were given the Patient Health Questionnaire 8 (PHQ-8) during initial hospitalization to assess depression in a prospective study at a Level I trauma center. A cutoff score of 10 or higher (possible range, 0-24) on the PHQ-8 is used as diagnostic for depression. The PHQ-2 (possible range, 0-6) is derived from the first two questions of the PHQ-8 and contains items assessing sad mood and loss of interest/pleasure during the previous 2 weeks. A cutoff score of 3 or higher was considered to be a positive screen result. Discriminatory ability of the PHQ-2 was calculated.

RESULTS

The sample was predominantly male (65%) and white (67%). The majority (85%) sustained a blunt trauma, and the primary cause of injury was motor vehicle collision (37%), with a mean Injury Severity Score (ISS) of 11.6. A total of 142 patients (34%) were positive for depression on the PHQ-8. When comparing the PHQ-2 with the PHQ-8, a sensitivity of 76.1 and a specificity of 92.8 were found, as well as a positive predictive value of 84.4.

CONCLUSION

The result of our study confirms that depression is a frequent condition (34%) among individuals who sustain physical injury. The PHQ-2 seems to have acceptable sensitivity and specificity to identify depression in this population. The use of a two-item screening questionnaire is a minimal addition to the evaluation of patients after injury, allowing for earlier intervention and better outcomes.

LEVEL OF EVIDENCE

Diagnostic study, level IV; prognostic/epidemiologic study, level III.

A longitudinal pilot study of depressive symptoms in concussed and injured/nonconcussed National Collegiate Athletic Association Division I student-athletes

CONTEXT

Depression, which affects millions of Americans each year, among them collegiate student-athletes, can be caused by a wide range of circumstances, including sport-related injuries.

OBJECTIVE

To longitudinally examine the extent to which National Collegiate Athletic Association Division I student-athletes demonstrated postinjury depressive symptoms.

DESIGN

Descriptive epidemiologic study.

SETTING

National Collegiate Athletic Association Division I collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

Concussed, injured/nonconcussed, and healthy Division I collegiate student-athletes (aged 18-22 years) competing in men's basketball, football, and wrestling and women's basketball, soccer, and volleyball.

MAIN OUTCOME MEASURE(S)

Participants completed the Center for Epidemiologic Studies Depression Scale at baseline and at 1 week, 1 month, and 3 months postinjury. We measured differences in depressive scores among concussed, injured/nonconcussed, and healthy participants. Longitudinal changes in postconcussion depressive symptoms were also examined.

RESULTS

No differences in baseline depressive symptoms among subgroups were noted. After an increase between baseline and 1 week (4.3, 95% confidence interval [CI] = 0.41, 8.16, P = .02), depressive symptoms in the concussion group decreased between 1 week and 1 month (-2.7, 95% CI = -4.96, -0.47, P = .01) and between 1 week and 3 months (-4.0, 95% CI = -6.50, -1.49, P = .004). The injured/nonconcussed group showed differences between baseline and 1 week (4.6, 95% CI = 1.08, 8.17, P = .009) and between baseline and 1 month (3.2, 95% CI = -0.05, 6.30, P = .03). No significant differences were present in depressive symptoms between concussed participants and injured/nonconcussed participants at any of the postinjury time points.

CONCLUSIONS

Depression may present as a postinjury sequela in Division I collegiate athletes. Athletes who sustain a concussion or other injury resulting in time lost from practice or competition need to be observed carefully for signs and symptoms that may indicate depression. Tools such as the Center for Epidemiologic Studies Depression Scale can be valuable in helping clinicians to recognize and manage depressive symptoms in these individuals.

Reasons for and reservations about research participation in acutely injured adults

PURPOSE

The purpose of this study was to explore the reasons adult patients seeking emergency department care for minor injuries agree to participate in clinical research and to identify their reservations about participating in a research study.

DESIGN AND METHODS

This is a secondary analysis of data from a longitudinal cohort study of 275 adults who sought emergency department care for physical injury and were followed over 12 months. At the final interview, participants were asked open-ended short-answer questions about their perception of participating in the study. Free text responses were analyzed using conventional content analysis.

FINDINGS

The final sample of 214 participants was composed equally of males and females, predominantly Black (54%) and White (42%), with a mean age of 41 years. Six themes about reasons for participation emerged from free text responses: being asked, altruism, potential for personal benefit, financial gain, curiosity, and valuing or knowledge of research. Most did not report reservations. Those reservations identified included time constraints, confidentiality, and whether patients felt well suited to fulfill the study requirements.

CONCLUSIONS

Although injured patients are identified by the research community as vulnerable, they are willing to participate in research studies for diverse reasons, and their participation is commonly associated with positive experiences.

CLINICAL RELEVANCE

Understanding perceptions of participants' experiences of being in a research study after acute injury can guide researchers to improve future study protocols and recruitment strategies in order to optimize participants' experiences. Recruitment and retention into clinical research studies is essential to build nursing science to enhance the recovery of injured individuals.

How well do we report on compensation systems in studies of return to work: a systematic review

PURPOSE

Occupational injury and work-related disability is a significant public health problem. For published research to provide a collective knowledge base for return to work (RTW) policy and practice, features of the compensation system relevant to the research must be described clearly. The level of the reporting on compensation system features is yet to be established. The aim of the present study was to synthesize the evidence for the reporting on compensation systems in prognostic studies of RTW following work-related injuries.

METHODS

A systematic review of the literature was conducted. Ovid Medline and EMBASE were searched for studies published 1996-2011. Included studies were prognostic studies of RTW or work disability following work-related acute traumatic injuries.

RESULTS

The initial search yielded 952 articles; 37 articles fulfilled the inclusion criteria. The majority of studies were based on clinical practice; eight studies were based on administrative data. Only two studies reported seven or more compensation features and two studies reported four to six. The majority of studies (19/37) did not report on any aspect of the compensation system that study participants were interacting with. The most common information reported was the extent of coverage at the population level (7/37) and the availability of wage replacement entitlements (7/37). The name of the compensation system was provided in 5 studies.

CONCLUSIONS

Overall reporting on compensation systems in prognostic studies of RTW needs to be improved if research evidence is to inform policy and practice. Compensation system features that could be reported are provided.

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.

Prevalence and predictors of return to work in hospitalised trauma patients during the first year after discharge: a prospective cohort study

OBJECTIVE

The aim of the study was to investigate the proportion of patients who return to work and predictors of return to pre-injury level of work participation the first year after trauma.

METHODS

A prospective single-centre study of 188 patients aged 18-65 years with different degrees of injury severity was carried out in a trauma referral centre. All patients were working or studying full or part time before the injury. The first assessments were performed a median time of 27 days after discharge. Participation in work/education was measured 3 and 12 months after the first assessment with self-report questionnaires. The Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES) were independent measures of anxiety, depression and post-traumatic stress symptoms (PTS) at baseline and 3 months. The Life Orientation Test Revised (LOT-R) measured optimism and pessimism at baseline. Predictors of return to work were identified by multiple logistic regression analysis.

RESULTS

After one year, 131 patients (70%) had returned to the same level of participation in work or education; 95 (50%) had returned at 3 months. Independent predictors of return to work after 3 months were low age, low Injury Severity Score (ISS) score, not needing ventilator treatment and low score for depression symptoms, adjusted for gender (Nagelkerke R square 0.38). Low ISS, absence of serious head injury, low HADS depression score and an optimistic life orientation remained significant predictors of return to work at the same level after 12 months (Nagelkerke R square 0.38). In addition, good physical function (SF-36 PF score>65) at 3 months was an independent predictor of return to work at 12 months in the 93 patients who had not returned to work at 3 months.

CONCLUSION

Independent predictors of return to work at 3 months were low age, low ISS and absence of depression symptoms. At 12 months, independent predictors of return to work were low ISS, low depression score and an optimistic life orientation. To promote early return to work, trauma patients might be screened for depression symptoms and pessimism, and intervention or treatment provided for those in need.

A model to advance nursing science in trauma practice and injury outcomes research

AIMS

This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion.

BACKGROUND

The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum.

DATA SOURCES

Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990-2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken.

DISCUSSION

Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long-term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long-term outcomes. Implications for policy and practice.  This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long-term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice.

CONCLUSION

Planning and integrating care across the trauma continuum and recognition of the role of the injured person's background, family and resources will lead to improved long-term outcomes.

Health related quality of life in trauma patients. Data from a one-year follow up study compared with the general population

Background

Trauma patients have impaired health-related quality of life (HRQOL) after trauma. The aim of the study was to assess HRQOL during the first year after trauma and hospital stay in trauma patients admitted to an intensive-care unit (ICU) for >24 hours compared with non-ICU trauma patients and the general population, and to identify predictors of HRQOL.

Methods

A prospective one-year follow-up study of 242 trauma patients received by the trauma team of a trauma referral centre in Norway was performed. HRQOL was measured using the Medical Outcomes Study Short Form 36 (SF-36) at 3 and 12 months.

Results

The mean age of the cohort was 42.3 years (95% CI, 40.4-44.3 years). The median Injury Severity Score (ISS) was 10, interquartile range 16. The HRQOL improved significantly from the 3 to the 12 months follow up in the trauma patients. However their scores were significantly lower for most subscales of SF-36 compared to the general population. Significant differences between ICU and non-ICU patients at 12 months were observed only for physical functioning and role physical subscales. Optimism was an independent predictor of good HRQOL at 12 months, in all dimensions (beta, 0.95-2.45). A higher depression score at baseline predicted lower HRQOL in four of eight dimensions (beta -1.1 to -1.70). In addition, better physical functioning was predicted by lower age (beta, -0.20), and having head injury (reference) as the most severe injury vs. spine or extremity injuries (beta, -9.49 and -10.85), and better mental health by higher age (beta, 0.21) and being employed or studying before the trauma (beta, 12.27). In addition to optimism good general health was predicted by lower score for post-traumatic stress (PTS) symptoms at baseline (beta, -0.27) and lower ISS score (beta -10.59).

Conclusions

The HRQOL improved significantly from the 3 to the 12 months follow up in our sample. However their scores were significantly lower for most subscales of SF-36 compared to the general population. Significant differences between ICU and non-ICU patients were observed for only two subscales. Better HRQOL at 12 months was predicted mainly by optimism, low score for depression and PTS symptoms at baseline. High ISS predicted low general health exclusively.

Predicting the future development of depression or PTSD after injury

OBJECTIVE

The objective was to develop a predictive screener that when given soon after injury will accurately differentiate those who will later develop depression or posttraumatic stress disorder (PTSD) from those who will not.

METHOD

This study used a prospective, longitudinal cohort design. Subjects were randomly selected from all injured patients in the emergency department; the majority was assessed within 1 week postinjury with a short predictive screener, followed with in-person interviews after 3 and 6 months to determine the emergence of depression or PTSD within 6 months after injury.

RESULTS

A total of 192 completed a risk factor survey at baseline; 165 were assessed over 6 months. Twenty-six subjects [15.8%, 95% confidence interval (CI) 10.2-21.3] were diagnosed with depression, four (2.4%, 95% CI 0.7-5.9) with PTSD and one with both. The final eight-item predictive screener was derived; optimal cutoff scores were ≥2 (of 4) depression risk items and ≥3 (of 5) PTSD risk items. The final screener demonstrated excellent sensitivity and moderate specificity both for clinically significant symptoms and for the diagnoses of depression and PTSD.

CONCLUSIONS

A simple screener that can help identify those patients at highest risk for future development of PTSD and depression postinjury allows the judicious allocation of costly mental health resources.

Development and validation of the mortality risk for trauma comorbidity index

OBJECTIVE

The aim of this study was to develop and validate a comorbidity index to predict the risk of mortality associated with chronic health conditions following a traumatic injury.

SUMMARY BACKGROUND DATA

Currently available comorbidity adjustment tools do not account for certain chronic conditions, which may influence outcome following traumatic injury or they have not been fully validated for trauma. Controlling for comorbidity in trauma patients is becoming increasingly important as the population ages and elderly patients are more active, as well as to adjust for bias in trauma mortality studies.

METHODS

Cohort study using data from the National Study on the Costs and Outcome of Trauma. Subject pool (N = 4644/Weighted Number = 14,069) was randomly divided in half; the first half of subjects was used to derive the risk scale, the second to validate the instrument. To construct the Mortality Risk Score for Trauma (MoRT), univariate analysis and odds ratios were performed to determine relative risk of mortality at hospital discharge comparing those persons with a comorbid condition to those without. Conditions significantly associated with mortality (P < 0.05) were included in the multivariate model. The variables in the final model were used to build the MoRT. The predictive ability of the MoRT and the Charlson Comorbidity Index (CCI) for discharge and 1-year mortality were estimated using the c-statistic in the validation sample.

RESULTS

Six comorbidity factors were independently associated with the risk of mortality and formed the basis for the MoRT: severe liver disease, myocardial infarction, cerebrovascular disease, cardiac arrhythmias, dementia, and depression. The MoRT had a similar overall discrimination as the CCI for mortality at hospital discharge in injured adults (c-statistic: 0.56 vs. 0.56) although neither by itself performed well. The addition of age and gender improved the predictive ability of the MoRT (0.59; 95% CI: 0.56, 0.62) and the CCI (0.59; 0.56, 0.62). Similar results were seen at 1-year postinjury. The further addition of Injury Severity Score significantly improved the predictive ability of the MoRT (0.77, 95% CI: 0.74, 0.79) and the CCI (0.77, 95% CI: 0.75, 0.80).

CONCLUSIONS

The MoRTs primary advantage over current instruments is its parsimony, containing only 6 items. In the present study, the comorbid conditions found to be predictive of mortality had some overlap with the CCI, but this study identified 2 novel predictors: cardiac arrhythmias and depression. Inclusion and reporting of these items within trauma registries would therefore be an important step to allow further validation and use of the MoRT.

A systematic review of early prognostic factors for return to work following acute orthopaedic trauma

INTRODUCTION

Acute orthopaedic trauma is a major contributor to the global burden of disease. This study aims to synthesise and summarise current knowledge concerning prognostic factors for return to work and duration of work disability following acute orthopaedic trauma.

METHODS

A systematic review of prognostic studies was performed. The Medline, Embase, PsychINFO, CINAHL and AMED electronic databases were searched for studies between 1985 and May 2009. Included studies were longitudinal, reported results with multivariate statistical analyses appropriate to prognostic studies, comprised persons employed at the time of the injury, included prognostic factors measured proximal to the injury and focused on upper and lower extremity injuries.

RESULTS

Searches yielded 980 studies of which 15 met the inclusion criteria and were rated for methodological quality. Analysis focused on the 14 factors considered in more than one study. There was limited evidence for the role of any factor as a predictor of return to work. There is strong evidence for level of education and blue collar work and moderate evidence for self-efficacy, injury severity and compensation as prognostic factors for the duration of work disability. Significant methodological issues were encountered in the course of the review that limited interpretation of the evidence and the conclusions that could be drawn from the findings.

CONCLUSION

People who have sustained acute orthopaedic trauma regardless of severity experience difficulties in returning to work. Due to the lack of factors considered in more than one cohort, the results of this review are inconclusive. The review highlights the need for more prospective studies that are methodologically rigorous, have larger sample sizes and considers a comprehensive range of factors.