Perceived threat to life predicts posttraumatic stress disorder after major trauma: risk factors and functional outcome

Differences in intestinal bacteria in traumatic injury survivors with and without probable posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a common consequence of traumatic injury, yet certain biological factors contributing to PTSD are poorly understood. The gut microbiome may influence mental health outcomes, but its role in heterogeneous PTSD presentations requires elucidation.

METHODS

Bacterial composition was examined in adults 2-4 years post-trauma with probable PTSD (n = 24) versus trauma-exposed controls without probable PTSD (n = 24). 16S rRNA sequencing and bioinformatic tools assessed microbial diversity and abundance. Relationships between taxa and PTSD symptom clusters were evaluated.

RESULTS

No differences were found in overall microbial community structure between groups. The probable PTSD group exhibited significantly reduced Actinobacteriota and increased Verrucomicrobiota phylum abundance compared to controls. Specific taxa showed notable inverse associations with negative mood/cognition versus hyperarousal symptoms. Prevotella and Ruminococcaceae were negatively associated with negative mood but positively associated with hyperarousal.

CONCLUSIONS

Results demonstrate microbial signatures of probable PTSD subtypes, highlighting the microbiome as a potential mediator of heterogeneous trauma psychopathology. Definition of PTSD microbial correlates provides a foundation for personalized psychobiotic interventions targeting predominant symptom profiles.

Predictive risk factors of adverse mental health outcomes in the facial trauma patient

Patients with facial trauma often experience a psychological burden from their injuries. This study aimed to identify risk factors for adverse mental health outcomes in patients affected by facial trauma, using the 'Integrating Mental and Physical Healthcare: Research, Training and Services' (IMPARTS) screening tool. All patients >18 years of age who completed more than one IMPARTS screening tool in the Oral and Maxillofacial Trauma Clinic between 2019 and 2021 were included in this study. This tool was used to assess the risk of post-traumatic stress disorder (PTSD), generalized anxiety disorder, and depression. Included patients completed the IMPARTS questionnaire at initial follow-up (mean 18 days post-trauma) and one subsequent time point (mean 82 days). 167 patients were included in the study. On multivariable analysis, a history of psychiatric illness (P = 0.015) and interpersonal violence as the mechanism of injury (P = 0.010) were identified as predictive of risk of PTSD. Risk of PTSD was lower in zygomatic injuries (P = 0.001), while nasal involvement increased at-risk status for depression (P = 0.009). 47.3% of patients screened positive on initial IMPARTS assessment, while 35.3% screened positive on follow-up IMPARTS assessment. This study supports the IMPARTS tool in allowing the prompt identification of mental health adversity in facial trauma.

A comparison of the psychometric properties of a person-administered vs. automated screening tool for posttraumatic stress disorder (PTSD) in traumatically injured patients

BACKGROUND

The American College of Surgeons Committee on Trauma (ACS-CoT) mandated that trauma centers have mental health screening and referral protocols in place by 2023. This study compares the Injured Trauma Survivor Screen (ITSS) and the Automated Electronic Medical Record (EMR) Screen to assess their performance in predicting risk for posttraumatic stress disorder (PTSD) within the same sample of trauma patients to inform trauma centers' decision when selecting a tool to best fit their current clinical practice.

METHODS

This was a secondary analysis of three prospective cohort studies of traumatically injured patients (N = 255). The ITSS and Automated EMR Screen were compared using receiver operating characteristic curves to predict risk of subsequent PTSD development. PTSD diagnosis at 6-month follow-up was assessed using the Clinician Administered PTSD Scale for DSM-5.

RESULTS

Just over half the sample screened positive on the ITSS (57.7%), while 67.8% screened positive on the Automated EMR Screen. The area under the curve (AUC) for the two screens was not significantly different (ITSS AUC = 0.745 versus Automated EMR Screen AUC = 0.694, p = 0.21), similar performance in PTSD risk predication within the same general trauma population. The ITSS and Automated EMR Screen had similar sensitivities (86.5%, 89.2%), and specificities (52.5%, 40.9%) respectively at their recommended cut-off points.

CONCLUSION

Both screens are psychometrically comparable. Therefore, trauma centers considering screening tools for PTSD risk to comply with the ACS-CoT 2023 mandate should consider their local resources and patient population. Regardless of screen selection, screening must be accompanied by a referral process to address the identified risk.

Validation of the Italian version of the Neuroception of Psychological Safety Scale (NPSS)

Research on the neuroscience of fear in both humans and non-humans has suggested that a lack of acquisition of safety cues might be a biological hallmark of posttraumatic stress disorder (PTSD). Danger perception, and in particular, feeling as one's own life is in danger, is thought to represent a major predictor of PTSD. Persistent danger perception is concurrently associated with a persistence of lack of safety. However, despite several research efforts, no validated psychometric tools exist regarding psychological safety as a unique core construct in the domain of a soothing-contentment system. By including social, compassionate, and bodily components, the Neuroception of Psychological Safety Scale (NPSS), neurophysiologically rooted in the polyvagal theory, aims to specifically assess psychological safety. Originally developed in English, we employed a rather large non clinical sample to validate our Italian translation of the NPSS (n = 338) and the scale was found to retain a three-factor structure. In light of its positive moderate correlations with the Unconditional Self-Kindness Scale (ρ = 0.376) and the Self-Compassion Scale-Short-Form (ρ = 0.481), good convergent validity and robust psychometric properties were shown by the NPSS. The Subjective Traumatic Outlook Questionnaire (ρ = -0.283) and the three subscales of the Body Perception Questionnaire-22-Body Awareness (ρ = -0.103), Supradiaphragmatic Reactivity (ρ = -0.234), and Body Awareness/Subdiaphragmatic Reactivity (ρ = -0.146)-were found to have weak negative correlations with the NPSS, which further demonstrated its good discriminant validity. Eventually, the NPSS was found to show good test-retest reliability (intraclass correlation coefficient = 0.922; three-week time interval), and its usage is fostered in clinical and research contexts where the evaluation of psychological safety is of relevance.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early Identification of Post-Traumatic Stress Disorder in Trauma Patients: Development of a Multivariable Risk Prediction Model

BACKGROUND

The purpose of this study was to build a risk prediction model to identify trauma patients at the time of injury who are at high risk for post-traumatic stress disorder (PTSD) 1 year later.

METHODS

Patients 18+ with operative orthopedic trauma injuries were enrolled in prospective social determinants of health cohort. Data were collected through initial surveys, medical records at time of injury, and 1-year follow-up phone screenings. Univariate analysis examined associations between factors and PTSD at 1 year. The best fit multivariable logistic regression model led to a novel PTSD risk prediction tool based on weights assigned similar to the Charlson index methods.

RESULTS

Of 329 enrolled patients, 87 (26%) completed follow-up surveys; 58% screened positive for chronic PTSD. The best fit model predicting PTSD included age, insurance, violent mechanism, and 2 acute stress screening questions (AUC .89). Using these parameters, the maximum possible TIPPS index was 19. Those with PTSD at 1 year had a mean TIPPS index of 12.9 ± 4.0, compared to 5.9 ± 4.2 for those who did not (P < .001).

DISCUSSION

Traumatic injury often leads to PTSD, which can be predicted by a novel risk score incorporating age, insurance status, violent injury mechanism, and acute stress reaction symptoms. Stability in life and relationships with primary care physicians may be protective of PTSD.

LEVEL OF EVIDENCE

Diagnostic level II.

Serially mediated effects of psychological inflexibility on quality of life of refugees in Uganda during coronavirus pandemic

The unexpected outbreak and rapid spread of COVID-19 necessitated radical and stringent control measures, consequently changing how people live globally. To vulnerable populations like refugees, who were already living a disrupted life, the outbreak of COVID-19 and accompanying control measures complicated their living conditions and drastically affected their mental health and, consequently, their quality of life. The current study aimed to test whether psychological inflexibility was a factor in lowering the quality of life of refugees in Uganda during the COVID-19 pandemic. The study further examines whether the effects of psychological inflexibility on quality of life were serially mediated by avoidance coping, perceived threat, adherence to COVID-19 control measures, and general mental health states. The study was conducted among refugees living in Kampala city suburbs and Bidibidi refugee settlement in Uganda. Data was collected using a survey questionnaire during the partial reopening of the economy in mid-2020, after the first lockdown. The analysis assesses a serial mediation model of the effects of psychological inflexibility on the quality of life of refugees through avoidance coping, perceived threat, adherence to COVID-19 control measures, and mental health using PROCESS Macro. The study involved 353 participants. Our analyses revealed that psychological inflexibility was negatively associated with the perceived threat, adherence, and quality of life. Psychological inflexibility was positively associated with avoidance coping and poor mental health. The data supported all hypothesized mediation paths. These findings support literature suggesting that psychological inflexibility is a maladaptive attribute that thwarts positive coping and behavior adjustment in times of crisis. Consequently, psychological inflexibility can worsen mental health problems and quality of life, especially in populations such as refugees in low-income countries who live in precarious conditions. Incorporating interventions that reduce psychological inflexibility in crisis management efforts can help refugees maintain good psychological functioning and quality of life.

Traumatic Life Events and Association With Depression, Anxiety, and Somatization Symptoms in Female Refugees

Importance

Different types of traumatic life events have varying impacts on symptoms of depression, anxiety, and somatization. For women from areas of the world experiencing war and humanitarian crises, who have experienced cumulative trauma exposure during war and forced migration, it is not known whether cumulative trauma or particular events have the greatest impact on symptoms.

Objective

To examine which traumatic life events are associated with depression, anxiety, and somatization symptoms, compared with the cumulative amount, in a sample of female refugees.

Design, Setting, and Participants

For this cross-sectional study, data were collected in 2016 as a part of The Study on Female Refugees. The current analysis was conducted in 2022 to 2023. This multicenter study covered 5 provinces in Germany. Participants were recruited at reception centers for refugees. Women volunteered to participate and to be interviewed after information seminars at the different centers.

Exposure

Traumatic life events experienced by refugees from areas of the world experiencing war and humanitarian crises.

Main Outcomes and Measures

Demographic variables (age, country of origin, religion, education, relationship status, and children), traumatic and adverse life events, and self-reported depression, anxiety, and somatization symptoms were measured. Random forest regressions simultaneously examined the importance of these variables on symptom scores. Follow-up exploratory mediation models tested potential associative pathways between the identified variables of importance.

Results

For the final sample of 620 refugee women (mean [SD] age, 32.34 [10.35] years), family violence was most associated with depression (mean [SD] variable of importance [VIM], 2.93 [0.09]), anxiety (mean [SD] VIM, 4.15 [0.11]), and somatization (mean [SD] VIM, 3.99 [0.15]), even though it was less common than other traumatic experiences, including war, accidents, hunger, or lack of housing. Other factors, such as childhood sexual abuse, injury, near-death experiences, and lack of access to health care, were also important. Follow-up analyses showed partial mediation effects between these factors in their association with symptoms, supporting the unique importance of family violence in understanding mental health.

Conclusions and Relevance

The findings of this cross-sectional study of refugee women who experienced multiple severe traumas related to war in their home countries and danger encountered during their migration suggest that family violence was key to their current mental health problems. Culturally sensitive assessment and treatment need to place special emphasis on these family dynamics.

A 16-month longitudinal investigation of risk and protective factors for mental health outcomes throughout three national lockdowns and a mass vaccination campaign: Evidence from a weighted Israeli sample during COVID-19

BACKGROUND

COVID-19 is an ongoing global crisis, with a multitude of factors that affect mental health worldwide. We explored potential predictors for the emergence and maintenance of depression, anxiety, and posttraumatic stress symptoms (PTSS) in the general population in Israel.

METHODS

Across the span of 16 months, 2478 people completed a repeated self-report survey which inquired psychiatric symptoms and pandemic related stress factors (PRSF). We applied mixed-effects models to assess how each stressor contributes to depression, anxiety and PTSS at each time point, and longitudinally assessed participants who completed at least two consecutive surveys (n = 400). We weighted our sample to increase representativeness of the population.

RESULTS

Fatigue was the strongest predictor for depression, anxiety and PTSS at all time points, and predicted deterioration overtime. Financial concerns associated with depression and anxiety at all time points, and with their deterioration overtime. Health related concerns were uniquely associated with anxiety and PTSS at all time points and their deterioration, but not with depression. Improvement in sense of protection overtime associated with decrease in depression and anxiety. Hesitancy towards vaccination was associated to higher financial concerns and lower sense of protection by the authorities.

CONCLUSIONS

Our findings accentuate the multitude of risk factors for psychiatric morbidity during COVID-19, and the centrality of fatigue in determining mental health outcomes.

Examining sex differences in responses to footshock stress and the role of the metabotropic glutamate receptor 5: an [18F]FPEB and positron emission tomography study in rats

Clinical investigations suggest involvement of the metabotropic glutamate receptor 5 (mGluR5) in the pathophysiology of fear learning that underlies trauma-related disorders. Here, we utilized a 4-day fear learning paradigm combined with positron emission tomography (PET) to examine the relationship between mGluR5 availability and differences in the response of rats to repeated footshock exposure (FE). Specifically, on day 1, male (n = 16) and female (n = 12) rats received 15 footshocks and were compared with control rats who did not receive footshocks (n = 7 male; n = 4 female). FE rats were classified as low responders (LR) or high responders (HR) based on freezing to the context the following day (day 2). PET with [18F]FPEB was used to calculate regional mGluR5 binding potential (BPND) at two timepoints: prior to FE (i.e., baseline), and post-behavioral testing. Additionally, we used an unbiased proteomics approach to assess group and sex differences in prefrontal cortex (PFC) protein expression. Post-behavioral testing we observed decreased BPND in LR females, but increased BPND in HR males relative to baseline. Further, individuals displaying the greatest freezing during the FE context memory test had the largest increases in PFC BPND. Males and females displayed unique post-test molecular profiles: in males, the greatest differences were between FE and CON, including upregulation of mGluR5 and related molecular networks in FE, whereas the greatest differences among females were between the LR and HR groups. These findings suggest greater mGluR5 availability increases following footshock exposure may be related to greater contextual fear memory. Results additionally reveal sex differences in the molecular response to footshock, including differential involvement of mGluR5-related molecular networks.

[Assessment of the Individual Experience of Sexual Violence in War and Forced Displacement and its Consequences Among Male Victims: A Narrative Literature Review]

From a psychological perspective, male survivors of sexual violence in the context of war and forced displacement represent a highly burdened population. An adequate assessment of traumatic events and trauma related disorders is often hampered by both disclosure barriers from the patient side as well as by lack of awareness on the part of healthcare professionals regarding male victimization. Based on a narrative literature review, relevant characteristics of violence and their relation to the diagnostic process are elaborated on eight dimensions of individual experience of violence (form of violence, frequency and severity, perpetrator-victim context, societal discrimination, subjective evaluation, concept of masculinity, culture-specific norms, and trauma sequelae). The dimensions are delineated in a case study. In order to thoroughly assess sexualized experiences of violence, there is a need for sensitivity on the part of practitioners to the signs of male victimization and regular assessment of sexualized violence in male patients. In this context, certainty about the confidentiality of the information disclosed and recognition of the injustice are of central importance for those affected. In the long term, the development of specialized support services for male victims is needed.

Systematic Review and Meta-Analysis of Stepped Care Psychological Prevention and Treatment Approaches for Posttraumatic Stress Disorder

Stepped care approaches have been developed to increase treatment accessibility for individuals with posttraumatic stress disorder (PTSD). However, despite guidelines recommending stepped care, it is currently unclear how the approach compares to other treatments for PTSD in terms of symptom reduction, cost, and client-rated acceptability. We conducted a systematic review and meta-analysis of randomized controlled and open trials evaluating stepped care prevention (i.e., targeting those with recent trauma exposure at risk of developing PTSD) and treatment approaches for adults and adolescents/children with PTSD. Eight prevention and four treatment studies were included. There was considerable variation in the sample types, stepped approaches, and control conditions. Most studies found no significant differences between stepped care (both prevention and treatment) and control (active and usual care) in terms of PTSD severity, loss of PTSD diagnosis, depression severity, and quality of life at the final follow-up. There was some evidence to suggest that stepped care was more cost-effective, and as acceptable or more acceptable compared to controls. Interpretations were tempered by high statistical heterogeneity, risk of bias, and lack of recommended evidence-based treatments. Stepped care can make PTSD treatment more accessible; however, more high-quality research is needed comparing stepped care to active controls.

Posttraumatic growth in palliative care patients and its associations with psychological distress and quality of life

OBJECTIVES

Posttraumatic growth (PTG) refers to positive psychological changes resulting from individuals' inner struggles with traumatic events such as life-threatening illness. Although palliative care patients are confronted with their own mortality, little is known about their PTG experience. This study investigates whether PTG is an empirically relevant concept for palliative patients by assessing the prevalence and areas of growth, and examining associations with psychological distress and quality of life.

METHODS

Participants were recruited in Switzerland. Using validated questionnaires, we assessed PTG (Posttraumatic Growth Inventory, PTGI), psychological distress (Hospital Anxiety and Depression Scale), and quality of life (McGill-Quality of Life Questionnaire - Revised). We performed descriptive analyses, Spearman correlations, and linear regressions.

RESULTS

Fifty-five patients completed the PTGI, 44% of whom experienced no/low growth, 47% moderate growth, and 9% high/very high growth. Participants experienced the greatest positive changes in terms of appreciating life and relating to others. We found significant negative bivariate correlations between PTG and psychological distress (r = -0.33) and between PTG and depression (r = -0.47). Linear regressions showed that PTG is associated with depression (β = -0.468; p = 0.000), but not with anxiety or quality of life (adjusted R² = 0.219).

SIGNIFICANCE OF RESULTS

Over half of our patients experienced moderate to very high growth, indicating that PTG is an empirically relevant psychological process in palliative care. PTG is associated with lower levels of depression, possibly as those experiencing growth are more able to process past traumas and build a more positive outlook on one's life and self. By contrast, the relative independence of anxiety and PTG points to the likely coexistence of positive and negative psychological responses to trauma. The lack of association between PTG and quality of life points to the uniqueness of the PTG concept in capturing how people access deeper meaning and greater appreciation of life along the path toward posttraumatic self-reconstruction.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study

OBJECTIVES

In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.

DESIGN

An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

SETTING

The ED of three academic medical centers.

PATIENTS

Mechanically ventilated adult patients that received neuromuscular blockers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

CONCLUSIONS

AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Epidemiology and factors associated with acute stress disorder in burned patients: a case-control study

INTRODUCTION

A burn injury is a very painful experience, with subsequent emotional problems, which have been gaining relevance to the extent that survival from burns has improved. Among the alterations of the mental sphere in this population is Acute Stress Disorder (ASD) that has been described in up to one-third of patients with major burns.

METHODOLOGY

A nested case-control study was carried out in a cohort of hospitalized patients in a burn referral unit, in patients over 16 years of age. A total of 135 patients, 41 cases, and 94 controls were included. All of them underwent a psychiatric interview, a standardized form was filled out on sociodemographic and clinical information, and the PID-5-BF scale was applied to evaluate associated personality elements. The diagnosis of acute stress was made with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.

RESULTS

The incidence of acute stress was 23.4%. When the clinical and sociodemographic characteristics of both the cases and the controls were compared, the risk factors were subsidized insurance, flame burn, burn in a special area, third-degree burn, high pain, stay in the Intensive Care Unit (ICU), peritraumatic amnesia and life threat. Patients also had a higher percentage of burned body surface, higher average pulse, longer hospital length of stay, higher average in the negative affect variable and in the psychoticism variable of the PID-5-BF scale. But for the multivariate analysis using logistic regression, the model that best explains the presence of acute stress only includes the variables life threat (Odds Ratio adjusted (ORa): 117.0; Confidence Interval (CI): 10.9-1258.5), severe pain (ORa: 9.9; CI: 1.8-52.8), electrical burn (ORa: 20.8; CI: 17.2-250), burn in a special area (ORa: 8.9; CI: 1, 0-76.8), third-degree burn (ORa: 10.4; CI: 0.7-166.7).

CONCLUSION

Acute stress disorder is frequent in the hospitalised burn population, and is more frequent than in other types of trauma. Associated factors with the presentation of Acute Stress Disorder are the feeling of life threat at the time of the burn, having pain classified as strong (Visual Analog Scale (VAS) 5-10), electrical burn, and burns in special areas.

Screening tools for predicting posttraumatic stress disorder in acutely injured adult trauma patients: A systematic review

BACKGROUND

Adult trauma patients are at risk of developing posttraumatic stress disorder (PTSD). Early intervention reduces the development of PTSD, but few trauma patients seek and obtain care. Valid and reliable screening tools are needed to identify patients at risk of developing PTSD. The objective of this review is to identify existing screening tools and evaluate their accuracy for predicting PTSD outcomes.

METHODS

PubMed, PsychInfo, and ClinicalTrials.gov were searched for studies evaluating the predictive accuracy of PTSD screening tools among traumatically injured adult civilians. Eligible studies assessed patients during acute hospitalization and at least 1 month following injury to measure PTSD outcome. Eligible outcomes included measures of predictive accuracy, such as sensitivity and specificity. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias of each study, and the strength of evidence was assessed following the Agency for Healthcare Research and Quality guidelines.

RESULTS

Forty-nine studies were included evaluating the predictive accuracy of 38 screening tools. Most tools were assessed in a single study. Questionnaire-style tools had more favorable predictive ability than diagnostic interview assessments. The Injured Trauma Survivor Screen, Posttraumatic Adjustment Screen, the PTSD Checklist for DSM-5, and the Richmond et al. tool demonstrated the most favorable predictive accuracy, with high sensitivity (75-100%) and specificity (67-94%). Common sources of bias were selection bias due to high attrition rate and using nondiagnostic tools to assess PTSD symptoms at follow-up.

CONCLUSION

Although sensitivity and specificity of PTSD predictive tools varied widely, several emerged with favorable predictive accuracy. Further research is needed to define the ability of screening and intervention to prevent PTSD in injured trauma survivors. The results of this review can inform screening tool options for screening programs and future intervention studies.

LEVEL OF EVIDENCE

Systematic review, level III.

Life threat during assaultive trauma: Critical posttraumatic stress disorder risk factors for injured patients

BACKGROUND

Rates of posttraumatic stress disorder (PTSD) among injury survivors are higher relative to the general population, supporting the need to identify those most at risk for PTSD following injury given negative impact of PTSD on recovery. Perceived life threat and assaultive trauma are consistent risk factors for subsequent PTSD development, although less work has explored them in combination. The current study evaluated whether trauma type (assaultive vs. nonassaultive) and perceived life threat, together, led to greater PTSD symptoms 1 month and 6 months postinjury.

METHODS

Participants included adult injured trauma survivors admitted to a level 1 trauma center. While hospitalized, perceived life threat during trauma was assessed and mechanism of injury was collected via record review and was collapsed into two categories: assaultive and nonassaultive. The Clinician-Administered PTSD Scale (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) was administered at 1 month (N = 137) and 6 months (N = 220) after injury.

RESULTS

The four symptoms clusters of PTSD (intrusions, avoidance, hyperarousal, and negative mood/cognitions) were examined using four 2 (time) × 2 (life threat) × 2 (trauma type) mixed methods analyses of variance to assess differences based on risk factors and time. Results showed significant interaction effects of life threat, trauma type, and time for intrusive symptoms and avoidance symptoms. Individuals with life threat during assaultive traumas maintained heightened intrusive symptoms across time and increased avoidance at 6 months. On the other hand, participants with either life threat or assaultive traumas had decreased symptoms at 6 months.

CONCLUSION

Experiencing assaultive trauma and life threat led to greater symptoms of PTSD. Individuals with assaultive traumas who experienced life threat may represent a specific at-risk group following injury. Avoidance can protract functional impairment and impede access to care, negatively impacting recovery. This study highlights a need to assess for these peritrauma factors during hospitalization and supports early intervention targeting avoidance and intrusive symptoms in this group.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level IV.

The Relationship Between Perceived Social Support and PTSD Symptoms After Exposure to Physical Assault: An 8 Years Longitudinal Study

Consequences of nondomestic violence are known to be multifaceted with high rates of emotional and psychological problems in addition to physical injuries, and victims report many trauma related symptoms. This study explore if perceived social support (PSS) (Social Provisions Scale [SPS]) and post-traumatic stress disorder (PTSD) symptoms (Impact of Event Scale [IES-22]) are interrelated among adult victims at four assessment points up until eight years after the exposure to physical assault; soon after the event (T1), three months after T1 (T2), one year after T1 (T3), and eight years after T1 (T4). One hundred and forty-three subjects participated at T1, 94 at T2, 73 at T3, and 47 accepted a follow-up at T4. At T1, 138 of 143 completed the questionnaires within 16 weeks after the incident. PTSD symptoms were highly correlated across time (p < .001); PSS were significantly correlated only between T1 and T2 (p < .001), T1 and T3 (p < .05), and between T2 and T3 (p < .05). Cross-lagged analyses showed an inverse relationship between prior PSS and later PTSD symptoms across all time points (ps < .05); not proved between prior PTSD symptoms and later PSS (ps > .1). PSS at T1 was an independent predictor of PSS one year and eight years after the incident. We conclude that higher perception of social support protects against the development of PTSD symptoms; diminished perception of social support increases the risk of developing PTSD symptoms. These findings suggest that PSS after experiencing a violent assault should be considered as an important factor in natural recovery in the long run, as well as essential alongside psychiatric treatment. Establishing psychosocial interventions for victims of physical violence in the acute phase may prevent prolonged trauma reactions.

PTSD is not the emblematic disorder of the COVID-19 pandemic; adjustment disorder is

BACKGROUND

Posttraumatic stress disorder (PTSD) has been hailed by some as the emblematic mental disorder of the COVID-19 pandemic, assuming that PTSD's life-threat criterion was met de facto. More plausible outcomes like adjustment disorder (AD) have been overlooked.

METHODS

An online cross-sectional survey was launched in the initial stage of the pandemic using a convenience sample of 5 913 adults to compare the prevalence of COVID-related probable PTSD versus probable AD. The abridged Impact of Event Scale - Revised (IES-6) assessed the severity of trauma- and stressor-related symptoms over the previous week. Demographic and pandemic-related data (e.g., receiving a formal diagnosis of COVID-19, job loss, loss of loved one, confinement, material hardship) were collected. A Classification and Regression Tree analysis was conducted to uncover the pandemic experiences leading to clinical 'caseness'. Caseness was defined by a score > 9 on the IES-6 symptom measure and further characterized as PTSD or AD depending on whether the Peritraumatic Distress Inventory's life-threat item was endorsed or not.

RESULTS

The participants were predominantly Caucasian (72.8%), women (79.2%), with a university degree (85%), and a mean age of 42.22 (SD = 15.24) years; 3 647 participants (61.7%; 95%CI [60.4, 63.0]) met the threshold for caseness. However, when perceived life-threat was accounted for, only 6.7% (95%CI [6.1, 7.4]) were classified as PTSD cases, and 55% (95%CI [53.7, 56.2]) as AD cases. Among the AD cases, three distinct profiles emerged marked by the following: (i) a worst personal pandemic experience eliciting intense fear, helplessness or horror (in the absence, however, of any life-threat), (ii) a pandemic experience eliciting sadness/grief, and (iii) worrying intensely about the safety of significant others.

CONCLUSIONS

Studies considering the life-threat criterion as met de facto during the pandemic are confusing PTSD for AD on most counts. This misconception is obscuring the various AD-related idioms of distress that have emerged during the pandemic and the actual treatment needs.

Psychological risk factors that characterize acute stress disorder and trajectories of posttraumatic stress disorder after injury: a study using latent class analysis

Background

The course and different characteristics of acute and posttraumatic stress disorder (ASD, PTSD) in trauma populations are unclear.

Objective

The aims were to identify longitudinal trajectories of PTSD, to establish a risk profile for ASD and PTSD based on patients' sociodemographic, clinical, and psychological characteristics, and to study the effect of ASD and dissociation on PTSD during 12 months after trauma.

Method

Patients completed questionnaires after inclusion and at 3, 6, 9, and 12 months afterwards. Trajectories were identified using repeated measures latent class analysis (RMLCA). The risk profile was based on a ranking of importance of each characteristic using Cohen's d effect sizes and odds ratios. The impact of ASD and dissociation on PTSD was examined using logistic regression analyses.

Results

Altogether, 267 patients were included. The mean age was 54.0 (SD = 16.1) and 62% were men. The prevalence rate of ASD was approximately 21.7% at baseline, and 36.1% of trauma patients exhibited PTSD at 12 months after injury. Five trajectories were identified: (1) no PTSD symptoms, (2) mild, (3) moderate, (4) subclinical, and (5) severe PTSD symptoms. These trajectories seemed to remain stable over time. Compared with patients in other trajectories, patients with ASD and (subclinical) PTSD were younger and scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety. Regarding dissociation symptoms, inability to recall memories about the event was significantly more present than an altered sense of reality, (105 (40.7%) versus 56 (21.7%), p = .031), although that symptom had the strongest likelihood for PTSD. Patients with dissociation were significantly at risk for PTSD than patients without dissociation (OR = 4.82; 95%CI: 1.91-12.25).

Conclusions

Psychological factors characterized ASD and trajectories of PTSD during 12 months post-trauma. Healthcare providers who are aware of these findings could early identify patients at risk for ASD and PTSD and refer them for patient-centred interventions.

"Did You Think You Would Die?": Fear of Death and Its Relationship to the Development of Posttraumatic Stress Disorder After Traumatic Injury

INTRODUCTION

Patient-specific factors may influence posttraumatic stress disorder (PTSD) development and warrant further examination. This study investigates potential association between patient-reported fear of death at the time of injury and development of PTSD.

METHODS

Over 35 months, 250 patients were screened for PTSD at their first posthospitalization clinic visit and were asked "Did you think you were going to die from this injury?" (yes or no). PTSD screening was conducted using the PTSD checklist for DSM-5 questionnaire. A score ≥33 was considered positive for PTSD, and patients were offered ancillary psychiatric services. Retrospectively, medical records were reviewed for baseline demographics and injury information.

RESULTS

Forty-three patients (17%) indicated a fear of death. The mean age was 46 years, with patients who feared death being younger (36 versus 48, P < 0.001), and 62% were male. The most common mechanisms of injury were motor vehicle or motorcycle collisions (30%) and ground-level falls (21%). Gunshot wounds were more common among patients who feared death from trauma (44% versus 7%, P < 0.001). PTSD questionnaires were completed a median of 26 days after injury, with an average score of 12.6. PTSD scores were higher for patients with fear of death (32.7 versus 8.5), and these patients required more acute interventions (47% versus 7%), both P < 0.001. After multivariable logistic regression, patients who thought that they would die from their trauma had >13 times higher odds of developing PTSD (odds ratios: 13.42, P < 0.0001). Apart from positive psychiatric history (OR: 5.46, P = 0.001), no factors (ie, age, sex, mechanism, or any injury or treatment characteristic) were predictive of positive PTSD scores on regression.

DICUSSION

Patients who reported fear of death at the time of injury were 13 times more likely to develop PTSD. Simply asking patients whether they thought that they would die at the time of injury may prospectively identify PTSD risk.

LEVEL OF EVIDENCE

Prognostic Level II.

Recognizing risk and presence of posttraumatic stress disorder in women

ABSTRACT

US women who report having experienced significant trauma at some point in their lives range from 50% to 90%. Yet posttraumatic stress disorder (PTSD) goes largely unrecognized in women. This article discusses ways to monitor, screen, and intervene for PTSD in women.

Psychological distress and alcohol use disorder during the COVID-19 era among middle- and low-income U.S. adults

PURPOSE

This study examined how exposure to events during the Coronavirus Disease-19 (COVID-19) era is linked to symptoms of major depressive disorder (MDD), generalized anxiety disorder (GAD), COVID-19 era-related stress (CS), alcohol use disorder (AUD), and suicidal ideation (SI) in low and middle-income U.S adults.

METHODS

A national sample of 6,607 adults (4.4% who reported testing positive for COVID-19, 25.3% testing negative, and 70.3% untested) were recruited an online platform andcompleted the Patient Health Questionnaire-2, Generalized Anxiety Disorder-2, PTSD-Checklist for DSM-5, the Alcohol Use Disorder Identification-Consumption scale, and an item assessing SI in May-June 2020. A series of multivariable analyses were conducted.

RESULTS

In the total sample, 35.3% screened positive for current AUD, 33.6% for MDD, 33.6% for GAD, 24.6% for SI, and 20.2% for CS. Past 2-week SI (adjusted odds ratios [AORs]= 1.49-12.06), number of close friends (AORs= 1.40-2.72), history of AUD (AORs= 1.15-1.92), history of anxiety disorder (AORs= 1.07-2.63), and younger age (AORs= 0.97-0.98) were significantly associated with screening positive for MDD, GAD, CS, and AUD. COVID-19 status was not independently associated with these conditions, but the combination of testing positive for COVID-19, meeting criteria for AUD, and screening positive for MDD, GAD, or CS predicted a 96% probability for SI.

CONCLUSION

Predisposing factors are stronger predictors of psychological distress than personal COVID-19 infection or exposure. The additive effects of COVID-19 infection, alcohol use, and psychiatric problems in predicting SI suggest screening, monitoring, and treating these conditions in population-based prevention and treatment efforts may be important.

Health status after penetrating major trauma in Victoria, Australia: a registry-based cohort study

PURPOSE

As few studies have examined long-term health after penetrating injury, this population-based registry study sought to assess health outcomes up to 24 months post-injury.

METHODS

Major trauma patients with penetrating trauma (2009-2017) were included from the Victorian State Trauma Registry (N = 1,067; 102 died, 208 were lost to follow-up). The EQ-5D-3L was used to measure health status at 6, 12 and 24-months. Mixed linear and logistic regressions were used to examine predictors of summary scores, and problems versus no problems on each health dimension.

RESULTS

Average health status summary scores were 0.70 (sd = 0.26) at 6 and 12 months, and 0.72 (sd = 0.26) at 24 months post-injury. Prevalence of problems was consistent over time: mobility (24-26%), self-care (17-20%), usual activities (47-50%), pain/discomfort (44-49%), and anxiety/depression (54-56%). Lower health status and reporting problems was associated with middle-older age, female sex, unemployment; pre-injury disability, comorbid conditions; and assault and firearm injury versus cutting/piercing.

CONCLUSION

Problems with usual activities, pain/discomfort and anxiety or depression are common after penetrating major trauma. Risk factor screening in hospital could be used to identify people at risk of poor health outcomes, and to link people at risk with services in hospital or early post-discharge to improve their longer-term health outcomes.

Functional impairment in Posttraumatic Stress Disorder: A systematic review and meta-analysis

Posttraumatic Stress Disorder (PTSD) is a serious and debilitating condition often associated with significant impairments in daily functioning. To date, research on the complexity of functional impairment in individuals with PTSD is scarce and only limited. Yet, a quantitative synthesis and comprehensive review of existing evidence is needed to better characterize the magnitude of functional impairment in PTSD in distinct domains. We conducted a systematic literature search including observational studies comparing functioning of individuals with and without PTSD. Random effects meta-analyses were performed for the different functional domains according to the WHO International Classification of Functioning, Disability and Health (ICF). The protocol followed the MOOSE guidelines for systematic reviews. A total of thirty-four studies comprising 14 206 participants were included in the study. Compared to healthy individuals, subjects with PTSD showed significant (ps < 0.001) impairments with large to very large effect sizes (ds > 1) in all domains. Subjects with, compared to without, PTSD showed significant (ps < 0.001) impairments with medium to large effect sizes (ds > 0.5) in the domains General Tasks and Demands, Mobility, Self Care, Domestic Life, Interpersonal Interactions and Relationships, Major Life Areas and Community, Social and Civic Life. Significant impairments with small to medium effect sizes in the same domains were observed comparing PTSD to other mental disorders. In conclusion, PTSD has a significant impact on most areas of daily functioning as conceptualized in the International Classification of Functioning, Disability and Health (ICF) of the WHO. Early detection and targeted treatment of functional deficits is warranted in this patient population.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Forecasting individual risk for long-term Posttraumatic Stress Disorder in emergency medical settings using biomedical data: A machine learning multicenter cohort study

The necessary requirement of a traumatic event preceding the development of Posttraumatic Stress Disorder, theoretically allows for administering preventive and early interventions in the early aftermath of such events. Machine learning models including biomedical data to forecast PTSD outcome after trauma are highly promising for detection of individuals most in need of such interventions. In the current study, machine learning was applied on biomedical data collected within 48 h post-trauma to forecast individual risk for long-term PTSD, using a multinominal approach including the full spectrum of common PTSD symptom courses within one prognostic model for the first time. N = 417 patients (37.2% females; mean age 46.09 ± 15.88) admitted with (suspected) serious injury to two urban Academic Level-1 Trauma Centers were included. Routinely collected biomedical information (endocrine measures, vital signs, pharmacotherapy, demographics, injury and trauma characteristics) upon ED admission and subsequent 48 h was used. Cross-validated multi-nominal classification of longitudinal self-reported symptom severity (IES-R) over 12 months and bimodal classification of clinician-rated PTSD diagnosis (CAPS-IV) at 12 months post-trauma was performed using extreme Gradient Boosting and evaluated on hold-out sets. SHapley Additive exPlanations (SHAP) values were used to explain the derived models in human-interpretable form. Good prediction of longitudinal PTSD symptom trajectories (multiclass AUC = 0.89) and clinician-rated PTSD at 12 months (AUC = 0.89) was achieved. Most relevant prognostic variables to forecast both multinominal and dichotomous PTSD outcomes included acute endocrine and psychophysiological measures and hospital-prescribed pharmacotherapy. Thus, individual risk for long-term PTSD was accurately forecasted from biomedical information routinely collected within 48 h post-trauma. These results facilitate future targeted preventive interventions by enabling future early risk detection and provide further insights into the complex etiology of PTSD.

Risk Perception and PTSD Symptoms of Medical Staff Combating Against COVID-19: A PLS Structural Equation Model

Medical staff were battling against coronavirus disease 2019 (COVID-19) at the expense of their physical and mental health, particularly at risk for posttraumatic stress disorder (PTSD). In this case, intervening PTSD of medical staff and preparing them for future outbreaks are important. Previous studies showed that perceived stress was related to the development of PTSD. Hence, in this study, the association between risk perception of medical staff and PTSD symptoms in COVID-19 and the potential links were explored. Three hundred four medical staff's exposure to COVID-19 patients, risk perception for working during COVID-19, PTSD symptoms, anxiety, and sleep quality were measured. Mediation analysis tested the indirect effects of anxiety and sleep quality on the relationship between risk perceptions and PTSD symptoms; 27.6% of participants were deemed as having probable PTSD diagnosis. Mediation analysis showed a significant chain-mediating effect of anxiety and sleep quality on the relationships between risk perceptions and PTSD symptoms; higher risk perceptions were related to increased anxiety, worsened sleep quality, and severe PTSD symptoms. Conclusively, medical staff have a high prevalence of PTSD symptoms after 3 months of COVID-19. Their PTSD symptoms were associated with the perceived risk level through the potential links with anxiety and sleep quality. Therefore, risk perception could be critical for our medical staff's responses to public health emergencies. It could be plausible to intervene in the perceived stress to alleviate aroused anxiety and improve sleep quality and thereby deter the development of PTSD.

Psychological predictors of functional outcomes in service members with traumatic brain injury

PRIMARY OBJECTIVE

Research is increasingly demonstrating the significant impact that non-medical factors can have on outcomes of service members (SMs) with mild traumatic brain injury (mTBI). Thus, the current study examined which demographic, TBI-related factors, and psychological variables are most predictive of functional outcomes.

RESEARCH DESIGN

Retrospective database analysis from medical chart review.

METHODS AND PROCEDURES

One hundred forty-one patients who received rehabilitation services at an outpatient TBI military treatment facility between 2013 and 2018. Data collected included demographic variables, time since injury, neuropsychological measures, psychological diagnoses, Personality Assessment Inventory (PAI) scores, and Walter Reed Functional Impairment Scale (FIS). Hierarchical linear regression models were used to predict functional outcomes (measured by FIS total, work, social functioning scales).

MAIN OUTCOMES AND RESULTS

Results indicated that comorbid PTSD diagnosis and PAI Negative Impression Management (NIM) score were predictive of total functional, work, and social outcomes, over and above demographic and TBI-related factors.

CONCLUSIONS

Current findings confirmed the importance of evaluating and treating psychological factors, as well as exploring one's responding style (NIM), when managing chronic mTBI in SMs. Given ongoing findings of psychological underpinnings to mTBI outcome, there is further need to focus on early interventions to optimize psychological and functional outcomes for SMs.

A trauma medical home, evaluating collaborative care for the older injured patient: study protocol for a randomized controlled trial

Background

It is estimated that 55 million adults will be 65 years and older in the USA by 2020. These older adults are at increased risk for injury and their recovery is multi-faceted. A collaborative care model may improve psychological and functional outcomes of the non-neurologically impaired older trauma patient and reduce health care costs.

Methods

This is a randomized controlled trial of 430 patients aged 50 and older who have suffered a non-neurologic injury and are admitted to a level one trauma center in Indianapolis, IN, or Madison, WI. Participants will be assigned to either the Trauma Medical Home (TMH) intervention or usual care. The TMH intervention is a collaborative care model that includes validated protocols addressing the multi-faceted needs of this population, with the help of care coordination software and a mobile office concept. The primary outcome is self-reported physical recovery at 6- and 12-month follow-up. Secondary outcomes include self-reported psychological recovery, acute health care utilization, and cost-effectiveness of the intervention at 6 and 12 months. The TMH collaborative care model will be delivered by a registered nurse care coordinator. The assessments will be completed by trained blinded research assistants.

Discussion

The proposed study will evaluate a collaborative care model to help maximize psychological and functional recovery for non-neurologically injured older patients at four level one trauma centers in the Midwest.

Trial registration

Clinical Trials. NCT03108820. Registered on 11 April 2017.

Protocol Version 6: Study # 1612690852. April 12, 2019.

Sponsor: Indiana University. Human subjects and IRB contact information: irb@iu.edu

Prospectively registered in the WHO ICTRP on 4 June 2017.

Psychological Prophylaxis: An Integrated Psychological Services Program in Trauma Care

The primary medical goals of acute care are restoration of physical health and return to physical function. However, in response to traumatic events and injuries, psychological factors are critical to one's overall recovery. Both pre-morbid psychiatric comorbidities and post-injury psychological compromise affect physical and psychological recovery in inpatient trauma populations. The Psychological Services Program (PSP), a model trauma/acute care program, addresses these critical factors in a Level 1 Trauma Center. The program routinely treats over one-quarter of the trauma patients at any given time. The incorporation of the PSP into treatment team care ensures that patients in need of mental health support can be identified and treated during their recovery. This unique model is recommended as a potential injury prevention and recovery intervention strategy for the myriad mental health comorbidities that may function as risk factors for poor post-injury adaptation and also as risk factors for possible future traumatic injury.

Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data

Background

Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL).

Methods

A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward’s minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan’s multiple range test was used to group clusters into domains by QOL.

Results

Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain.

Conclusions

The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.

Clinical Implication of Altered Inhibitory Response in Patients with Post-traumatic Stress Disorder: Electrophysiological Evidence from a Go/Nogo Task

Inhibitory dysfunction is closely associated to post-traumatic stress disorder (PTSD). The present study investigated the neurophysiological evidence for and the brain regions related to inhibitory dysfunction in PTSD. Fifty patients with PTSD and 63 healthy controls (HCs) participated in a Go/Nogo task combined with electroencephalographic recordings. The N2-P3 complexes of event-related potentials (ERPs) elicited during the Nogo condition were compared between groups. Participants underwent structural magnetic resonance imaging to examine cortical volumes and completed questionnaires. Correlations between altered ERPs and cortical volumes of regions of interest as well as psychological symptoms were analysed. Nogo-N2 latencies at five electrode sites (Fz, FCz, Cz, CPz, and Pz) were significantly delayed in patients with PTSD compared to HCs. Nogo-N2 latency had a significant negative correlation with the volume of gyrus in the inferior frontal cortex, orbitofrontal cortex, amygdala, and medial prefrontal cortex. Nogo-N2 latency was significantly and positively correlated with catastrophizing, anxiety, and perceived threat. These findings show inhibitory dysfunction in patients with PTSD, reflected by the delay in Nogo-N2 latencies. They also indicate that Nogo-N2 latencies are associated with smaller cortical volumes responsible for inhibition as well as with major symptoms of PTSD.

Association Between Perceived Threat and the Development of Posttraumatic Stress Disorder Symptoms in Patients With Life-threatening Medical Emergencies

BACKGROUND

Our objectives were to test whether during a potentially life-threatening medical emergency, perceived threat (a patient's sense of life endangerment) in the emergency department (ED) is common and associated with the subsequent development of posttraumatic stress disorder (PTSD) symptoms.

METHODS

This study was an ED-based prospective cohort study in an academic hospital. We included adult patients requiring acute intervention in the ED for resuscitation of a potentially life-threatening medical emergency, defined as respiratory or cardiovascular instability. We measured patient-perceived threat in the ED using a validated patient self-assessment measure (score range = 0 to 21, with higher scores indicating greater perceived threat). We performed blinded assessment of PTSD symptoms 30 days after discharge using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5).

RESULTS

Ninety-nine of 113 (88%) patients completed follow-up, with 98% reporting some degree of perceived threat, median (interquartile range [IQR]) perceived threat score 12 (6 to 17), and 72% reported PTSD symptoms in relation to their ED visit (median [IQR] PCL-5 score = 7 [0 to 30]). Patients with respiratory instability had higher median (IQR) perceived threat scores (16 [9 to 18] vs. 9 [6 to 14)] and PCL-5 scores (10 [2 to 40] vs. 3 [0 to 17]) compared to patients without respiratory instability. In a multivariable linear regression model adjusting for potential confounders, greater perceived threat in the ED was independently associated with higher PCL-5 scores (β = 0.79, 95% confidence interval [CI] = 0.15 to 1.42). Among the individual perceived threat items, the feeling of helplessness during resuscitation had the strongest association with PCL-5 score (β = 5.24, 95% CI = 2.29 to 8.18).

CONCLUSIONS

Perceived threat during potentially life-threatening emergencies is common and independently associated with development of PTSD symptoms. Additional research to test whether reduction of perceived threat in the ED attenuates the development of PTSD symptoms following potentially life-threatening emergencies is warranted.

Perceived loss of social support after non-neurologic injury negatively impacts recovery

BACKGROUND

Traumatic injury is not only physically devastating, but also psychologically isolating, potentially leading to poor quality of life, depression and posttraumatic stress disorder (PTSD). Perceived social support (PSS) is associated with better outcomes in some populations. What is not known is if changes in PSS influence long-term outcomes following nonneurologic injury. We hypothesized that a single drop in PSS during recovery would be associated with worse quality of life.

METHODS

This is a post hoc analysis of a prospectively collected database that included patients 18 years or older admitted to a Level I trauma center with Injury Severity Score (ISS) of 10 or higher, and no traumatic brain or spinal cord injury. Demographic and injury data were collected at the initial hospital admission. Screening for depression, PTSD, and Medical Outcomes Study Short Form 36 Mental Composite Score (MCS) were obtained at the initial hospitalization, 1, 2, 4, and 12 months postinjury. The Multidimensional Scale of Perceived Social Support (MSPSS) was obtained at similar time points. Patients with high MSPSS (>5) at baseline were included and grouped by those that ever reported a score ≤5 (DROP), and those that remained high (STABLE). Outcomes were determined at 4 and 12 months.

RESULTS

Four hundred eleven patients were included with 96 meeting DROP criteria at 4 months, and 97 at 1 years. There were no differences in sex, race, or injury mechanism. The DROP patients were more likely to be single (p = 0.012 at 4 months, p = 0.0006 at 1 year) and unemployed (p = 0.016 at 4 months, and p = 0.026 at 1 year) compared with STABLE patients. At 4 months and 1 year, DROP patients were more likely to have PTSD, depression, and a lower MCS (p = 0.0006, p < 0.0001).

CONCLUSION

Patients who have a drop in PSS during the first year of recovery have significantly higher odds of poor psychological outcomes. Identifying these socially frail patients provides an opportunity for intervention to positively influence an otherwise poor quality of life.

LEVEL OF EVIDENCE

Therapeutic, Prognostic and Epidemiological, Level III.

Trajectories of posttraumatic stress in patients with confirmed and rule-out acute coronary syndrome

Many patients evaluated in the emergency department (ED) for acute coronary syndrome (ACS) develop posttraumatic stress symptoms (PTSS), but little is known about symptom trajectories over time. We estimated longitudinal trajectories of PTSS from ED to 1 year after evaluation for suspected ACS (N = 1000), and the effect of threat perceptions and discharge diagnosis. Participants reported on threat perceptions in the ED, ongoing cardiac threat at 1 month, and PTSS at 1, 6, and 12 months. Latent growth mixture modeling identified 3 PTSS trajectories over 1 year: Resilient (81.75%), Chronic-Worsening (13.69%), and Acute-Recovering (4.56%). Chronic-Worsening and Acute-Recovering classes reported significantly higher ED and cardiac threat perceptions than Resilient class. Discharge diagnosis did not differ (χ²(2) = 2.93, p = .231). PTSS are common following evaluation for suspected ACS, and trajectories vary, but targeting threat perceptions may reduce PTSS and improve clinical course, whether or not patients are ultimately diagnosed with ACS.

Long-term Functional, Psychological, Emotional, and Social Outcomes in Survivors of Firearm Injuries

Importance

The outcomes of firearm injuries in the United States are devastating. Although firearm mortality and costs have been investigated, the long-term outcomes after surviving a gunshot wound (GSW) remain unstudied.

Objective

To determine the long-term functional, psychological, emotional, and social outcomes among survivors of firearm injuries.

Design, Setting, and Participants

This prospective cohort study assessed patient-reported outcomes among GSW survivors from January 1, 2008, through December 31, 2017, at a single urban level I trauma center. Attempts were made to contact all adult patients (aged ≥18 years) discharged alive during the study period. A total of 3088 patients were identified; 516 (16.7%) who died during hospitalization and 45 (1.5%) who died after discharge were excluded. Telephone contact was made with 263 (10.4%) of the remaining patients, and 80 (30.4%) declined study participation. The final study sample consisted of 183 participants. Data were analyzed from June 1, 2018, through June 20, 2019.

Exposures

A GSW sustained from January 1, 2008, through December 31, 2017.

Main Outcomes and Measures

Scores on 8 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (Global Physical Health, Global Mental Health, Physical Function, Emotional Support, Ability to Participate in Social Roles and Activities, Pain Intensity, Alcohol Use, and Severity of Substance Use) and the Primary Care PTSD (posttraumatic stress disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Results

Of the 263 patients who survived a GSW and were contacted, 183 (69.6%) participated. Participants were more likely to be admitted to the hospital compared with those who declined (150 [82.0%] vs 54 [67.5%]; P = .01). Participants had a median time from GSW of 5.9 years (range, 4.7-8.1 years) and were primarily young (median age, 27 years [range, 21-36 years]), black (168 [91.8%]), male (169 [92.3%]), and employed before GSW (pre-GSW, 139 [76.0%]; post-GSW, 113 [62.1%]; decrease, 14.3%; P = .004). Combined alcohol and substance use increased by 13.2% (pre-GSW use, 56 [30.8%]; post-GSW use, 80 [44.0%]). Participants had mean (SD) scores below population norms (50 [10]) for Global Physical Health (45 [11]; P < .001), Global Mental Health (48 [11]; P = .03), and Physical Function (45 [12]; P < .001) PROMIS metrics. Eighty-nine participants (48.6%) had a positive screen for probable PTSD. Patients who required intensive care unit admission (n = 64) had worse mean (SD) Physical Function scores (42 [13] vs 46 [11]; P = .045) than those not requiring the intensive care unit. Survivors no more than 5 years after injury had greater PTSD risk (38 of 63 [60.3%] vs 51 of 119 [42.9%]; P = .03) but better mean (SD) Global Physical Health scores (47 [11] vs 43 [11]; P = .04) than those more than 5 years after injury.

Conclusions and Relevance

This study's results suggest that the lasting effects of firearm injury reach far beyond mortality and economic burden. Survivors of GSWs may have negative outcomes for years after injury. These findings suggest that early identification and initiation of long-term longitudinal care is paramount.

Pharmacological rewriting of fear memories: A beacon for post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a psychopathological response that develops after exposure to an extreme life-threatening traumatic event. Its prevalence ranges from 0.5% to 14.5% worldwide. Due to the complex pathophysiology of PTSD, currently available treatment approaches are associated with high chances of failure, thus further research to identify better pharmacotherapeutic approaches is needed. The traumatic event associated with fear memories plays an important role in the development of PTSD and could be considered as the main culprit. PTSD patient feels frightened in a safe environment as the memories of the traumatic event are revisited. Neurocircuit involving normal processing of fear memories get disturbed in PTSD hence making a fear memory to remain to dominate even after years of trauma. Persistence of fear memories could be explained by acquisition, re-(consolidation) and extinction triad as all of these processes have been widely explored in preclinical as well as clinical studies and set a therapeutic platform for fear memory associated disorders. This review focuses on neurocircuit and pathophysiology of PTSD in context to fear memories and pharmacological targeting of fear memory for the management of PTSD.

Long-term follow-up of patients treated for traumatic injury regarding physical and psychological function and health-related quality of life

PURPOSE

Trauma patients often suffer for long time after their injury with physical and psychological problems. Patient-reported outcome measurements (PROM) help us to understand outcomes beyond mortality. The aim of the study was to describe a sample of Swedish trauma patients, regarding their physical function, psychological morbidity, and quality of life after trauma.

METHODS

The study population was sourced from the Swedish Trauma Register: taking 1 month of data from five hospitals, over three consecutive years. 218 patients met the inclusion criteria, 147 data sets were used. Inclusion criteria included: age ≥ 18; New Injury Severity Scale (NISS) ≥ 9; and discharged alive. Data were collected at 3, 6, and 12 months after the trauma. EuroQol-5D (EQ-5D), Posttraumatic Symptom Scale-10 (PTSS-10) questionnaires and Glasgow Outcome Score (GOS) instrument were used with additional questions about pain and return to work.

RESULTS

12 months after the trauma: full functional recovery (GOS 5) was seen in 68% of the patients; 59% reported difficult or moderate pain or discomfort; and 44.5% of the patients had returned to work. In EQ-5D mobility dimension, no recovery was evident between 6 and 12 months. Twenty percent of the patients had significant symptoms for PTSD after 6 months and 16% after 3 months and 12 months.

CONCLUSION

Trauma patients had decreased physical function and psychological morbidity up to 1 year after the initial injury. Incorporating PROM in the follow-up after trauma is important to understand the patient's perspective of care and treatment.

Individual variability in behavior and functional networks predicts vulnerability using an animal model of PTSD

Only a minority of individuals experiencing trauma subsequently develop post-traumatic stress disorder (PTSD). However, whether differences in vulnerability to PTSD result from a predisposition or trauma exposure remains unclear. A major challenge in differentiating these possibilities is that clinical studies focus on individuals already exposed to trauma without pre-trauma conditions. Here, using the predator scent model of PTSD in rats and a longitudinal design, we measure pre-trauma brain-wide neural circuit functional connectivity, behavioral and corticosterone responses to trauma exposure, and post-trauma anxiety. Freezing during predator scent exposure correlates with functional connectivity in a set of neural circuits, indicating pre-existing circuit function can predispose animals to differential fearful responses to threats. Counterintuitively, rats with lower freezing show more avoidance of the predator scent, a prolonged corticosterone response, and higher anxiety long after exposure. This study provides a framework of pre-existing circuit function that determines threat responses, which might directly relate to PTSD-like behaviors.

Health-Related Quality of Life Profiles among Patients with Different Road Traffic Injuries in an Urban Setting of Vietnam

Road traffic injuries (RTIs) cause a substantial disease burden in Vietnam. Evaluating health-related quality of life (HRQOL) among patients having a diversity of RTIs informs an integral part of treatment effectiveness. This study aims to examine HRQOL of patients suffering different RTIs in Vietnam’s urban areas. A cross-sectional study was conducted on 408 patients from October to December 2018 in six hospitals in Thai Binh. The EuroQol-5 dimensions-5 levels (EQ-5D-5L) and visual analog scale (VAS) were used to assess the HRQOL of patients. Multivariable Tobit regression was applied to measure the difference of HRQOL among different kinds of injuries. The mean EQ-5D-5L and VAS score was 0.40–0.66, respectively. Mean EQ-5D-5L index was lowest in patients with oral and facial injuries (0.22) and fracture injuries (0.23), while patients having hand injuries had the highest EQ-5D-5L index (0.54). EQ-5D-5L index had a negative association with oral, facial, and fracture injuries. Meanwhile, patients with brain, fracture, and multiple injuries tended to have lower VAS score. Poor HRQOL among patients injured in road traffic were observed. Pain management, early rehabilitation, and mental health counseling services should be considered during treatment time, especially among those having the brain, oral and facial trauma, fracture, and multiple injuries.

Risk factors for complications and adverse outcomes in polytrauma patients with associated upper extremity injuries

BACKGROUND

In terms of upper extremity fractures by patients with multiple injuires, a lot of studies have assessed the functional outcome following trauma to have less favorable outcomes in regards to functional recovery. We tested the hypothesis that differences in clinical outcome occur between shaft and articular injuries of the upper extremity, when patients that sustained neurologic deficits (e.g. brachial plexus lesions) are excluded.

METHODS

We involved Patients with isolated or combined upper extremity fracture, ISS > 16 in a level one trauma center. The follow up was at least 10 years after the initial injury. Both clinical examination (range of motion, instability, contractures, peripheral nerve damage) and radiographic analysis were carried out. We evaluated also the development of heterotopic ossifications. To analyse patients were subdivided into 3 different subgroups (articular [IA], shaft [IS], and combined [C]).

RESULTS

A statistically significant difference was found when ROM was compared between Group IS and C (p = 0.012), for contractures between Groups IA and C (p = 0.009) and full muscle elbow forces between Groups IS and C (p = 0.005) and Group IA and IS (p = 0.021). There was a significantly increased incidence in heterotopic ossifications when articular involvement was present. This applied for the isolated (p < 0.02) and the combined group (Group C vs Group IS, p = 0.003).When Brooker type I/II in group IA and Brooker types III/IV were combined, there was a significant difference (p < 0.001). In group IA (n = 1) and in group C (n = 6), HO developed or worsened after revision surgery, all of which were performed for malunion or nonunion.

CONCLUSIONS

In this study, patients with isolated shaft fractures of the upper extremity tend to have a more favorable outcome in comparison with combined to isolated articular fractures in terms of range of motion, pain and the ability to use the arm for everyday activities.In the clinical practice of the treatment of polytraumatized patients with upper extremity injuries, we feel that the relevance of these injuries should not be underestimated. They are especially prone to development of heterotopic ossifications, thus requiring prophylactic measures, if necessary. As their incidence increases with the rate of reoperations, we feel that even during initial care, meticulous surgery is required to avoiding the necessity of revision surgeries. Similar to injuries below the knee, upper extremity injuries, should be treated to avoid any functional disability.

Patterns of peritraumatic threat perceptions in patients evaluated for suspected acute coronary syndrome according to prior and current posttraumatic stress symptoms

OBJECTIVE

Prior posttraumatic stress disorder (PTSD) and elevated threat perceptions predict posttraumatic psychopathology after evaluation for acute coronary syndrome (ACS), but most research has measured threat retrospectively. We investigated how threat perceptions during ACS evaluation in the emergency department (ED) and upon recall were associated with posttraumatic psychopathology burden due to prior trauma and the suspected ACS.

METHODS

Perceived threat was assessed in the ED, and ED threat recall was assessed upon inpatient transfer/discharge, along with acute stress disorder (ASD) symptoms due to suspected ACS and PTSD symptoms due to prior trauma. The sample comprised 894 participants (mean age = 60.7 ± 13.1 years; 46.8% female; 56.3% Hispanic; 20.5% Black). One-way ANOVAs examined how those with consistent posttraumatic psychopathology (prior PTSD/ASD; 14.8%), prior posttraumatic psychopathology (prior PTSD/no ASD; 6.8%), new-onset posttraumatic psychopathology (no PTSD/ASD; 15.7%), or no posttraumatic psychopathology (no PTSD/no ASD; 62.8%) differed in threat perception, threat recall, and their discrepancy.

RESULTS

Threat perception scores ranged from 6 to 24. Participants with consistent posttraumatic psychopathology had higher threat perceptions (M = 14.01) than those with prior posttraumatic psychopathology (M = 12.02) and new-onset posttraumatic psychopathology (M = 12.21) (ps ≤ 0.001); the latter two did not differ significantly but had higher threat perceptions than those with no posttraumatic psychopathology (M = 9.84) (p < .001). Similar results were observed for threat recall (p < .001). The new-onset posttraumatic psychopathology group also had a greater increase in perceived threat versus the no posttraumatic psychopathology group (p = .06). Results were similar adjusting for potential confounders.

CONCLUSIONS

Assessing threat perceptions during ACS evaluation and hospitalization may help identify those at risk for emotional difficulties post-ACS.

Posttraumatic Stress Disorder, Functional Impairment, and Subjective Distress in World Trade Center Disaster Workers

Posttraumatic stress disorder (PTSD) is associated with functional deficits, poor physical health, and diminished quality of life. Limited research has examined PTSD symptom clusters and their associations with functioning and distress among disaster recovery workers, a population at high risk for PTSD due to potential for repeated trauma. The purpose of this study was to investigate associations between overall PTSD severity, as well as PTSD symptom clusters, and social and occupational functioning and subjective distress in World Trade Center (WTC) disaster workers after the terrorist attacks on September 11, 2001 (9/11). Disaster workers deployed to the site of the attacks completed assessments at three time points over approximately 5 years post-9/11. Our sample consisted of participants who met criteria for PTSD or subthreshold PTSD at baseline (n = 514), 1-year (n = 289), and 2-year follow-up (n = 179). Adjusted linear regression indicated that Clinician Administered PTSD Scale (CAPS)-rated PTSD severity was positively associated with subjective distress, and deficits in social and occupational functioning, over time, CAPS Criterion F items; βs = .20 to .62, ps < .001. The reexperiencing and avoidance/numbing symptom clusters were associated with increased subjective distress, the avoidance/numbing and hyperarousal clusters were associated with deficits in social functioning, and the reexperiencing and hyperarousal clusters were associated with worse occupational functioning. These associations were consistent across the study period. Findings point to the importance of targeting PTSD symptom clusters associated with specific areas of functional impairment, with the goal of improving global outcomes.

Quality of life following road traffic injury: A systematic literature review

PURPOSE

To assess and provide a systematic overview of current knowledge about the relationship between quality of life (QoL) and road traffic injury, and to appraise how QoL is affected by road traffic injury.

METHODS

A systematic review of the literature published since 1990 on QoL after a road traffic injury, including adult and paediatric populations, from three databases (Pubmed, PsychInfo and SafetyLit) was undertaken. The methodological quality was assessed according to the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Thirty articles were included and assessed for quality. The QoL scores of those injured were similar to population norms at the first assessment, followed by a drop at the second assessment. An increase of QoL from the second to third assessment was reported, but participants never reached the population norms at the last follow-up (range six weeks to two years), with an exception of those claiming compensation and those with lower extremity fractures. Age, gender, socioeconomic status, injury severity, injury type and post-traumatic stress disorder were associated with reduced QoL.

CONCLUSIONS

Available literature regarding QoL among injured in road traffic crashes is heterogeneous with regard to aims and tools used for assessment. Our review confirmed that independent of measure, the overall QoL was significantly reduced after a road traffic injury compared to the general population norms. Persons who are older, of female gender, lower socioeconomic status, diagnosed with post-traumatic stress disorder, with more severe injuries or injuries to the lower limbs are more vulnerable to loss of QoL following road traffic injury compared to other patient groups injured in road traffic crashes.

Deployment-Related Traumatic Events and Suicidal Behaviours in a Nationally Representative Sample of Canadian Armed Forces Personnel

OBJECTIVE

Worldwide, there has been substantial controversy with respect to whether military deployment is a risk factor for suicidal behaviour. The present study examined the relationship between lifetime exposure to deployment and deployment-related traumatic events (DRTEs) and past-year suicidal ideation (SI), suicidal plans (SP), and suicidal attempts (SA).

METHOD

Data were analysed from the 2013 Canadian Forces Mental Health Survey (8161 respondents; response rate, 79.8%; aged 18-60 years). A total of 12 individual items assessed exposure to DRTEs (e.g., combat, witnessing human atrocities, feeling responsible for the death of Canadian or ally personnel, knowing someone who was injured or killed). We examined each individual DRTE type as well as the number of types of DRTEs in relation to suicidal behaviour.

RESULTS

Lifetime deployment was not significantly associated with suicidal behaviour. In models adjusted for sociodemographic variables, most of the individual DRTE items and the DRTE count variable were significantly associated with suicidal behaviours (adjusted odds ratio ranged between 1.10 and 5.32). When further adjusting for child abuse exposure, these associations were minimally attenuated, and some became nonsignificant. In models adjusting for mental disorders and child abuse, most DRTEs and number of types of DRTEs became nonsignificant in relation to SI, SP, and SA.

CONCLUSIONS

Active military personnel exposed to increasing number of DRTEs are at increased risk for SI, SP, and SA. However, most of the association between DRTEs and suicidal behaviour is accounted for by child abuse exposure and mental disorders.

Insomnia and PTSD one month after wildfires: evidence for an independent role of the "fear of imminent death"

OBJECTIVE

The relationship of insomnia with Post-Traumatic Stress Disorder (PTSD) one month after wildfires and more specifically with the experience of 'fear of imminent death' were investigated.

METHODS

Ninety-two randomly chosen victims of wildfires in the Greek province of Ilia, were assessed through a specifically designed semi-structured psychiatric interview comprising of questionnaires and scales to measure psychopathology, as well as psychosocial and environmental parameters. PTSD was set according to ICD-10 research diagnostic criteria, while insomnia was assessed with the Athens Insomnia Scale (AIS).

RESULTS

The presence of insomnia was identified in 63.0% of the victims. 46.7% of the participants were diagnosed with PTSD in the first post-disaster month, while 51.1% of the total sample experienced 'fear of imminent death'. The majority of sleep complaints were significantly more frequent in subjects with PTSD. Female gender, PTSD, older age, and 'fear of imminent death' were independently associated with insomnia.

CONCLUSIONS

The findings of the present study indicate that the diagnosis of insomnia, as well as, certain specific insomnia complaints were more frequent in female victims of wildfires who have experienced 'fear of imminent death' and have developed PTSD.

Predictors of seeking financial compensation following motor vehicle trauma: inception cohort with moderate to severe musculoskeletal injuries

BACKGROUND

Compensation related factors have been repeatedly associated with poor recovery following orthopaedic trauma. There is limited research into the factors associated with seeking financial compensation. Further understanding of these factors could facilitate injury recovery by purposeful compensation scheme design. The aim of this study was to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation, following motor vehicle related orthopaedic trauma. The study was conducted in New South Wales (NSW), Australia, in motor vehicle crash and workers' compensation schemes.

METHODS

Participants were patients admitted with upper or lower extremity factures following a motor vehicle crash to two trauma hospitals. Data were collected at baseline within two weeks of injury. Participants were followed up at six months. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; and logistic regression for predictor models.

RESULTS

The cohort consisted of 452 participants with a mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries with an Injury Severity Score (ISS) 9-15; 61% had a low-middle range household income; and 35% self-reported at fault in the crash. There was no significant difference in pre-injury/baseline health between compensable and non-compensable participants. Follow up data was available for 301 (67%) participants. The significant predictor of claiming compensation in the adjusted analysis was higher body mass index (BMI) (overweight Odds Ratio [OR] 3.05, 95% Confidence Interval [CI] 1.63-5.68; obese OR 1.63, 95% CI 0.83-3.20). Participants less likely to claim were: involved in a motorcycle crash (OR 0.47, 95% CI 0.28-0.82); socioeconomically less disadvantaged (OR 0.37, 95% CI 0.17-0.82) or least disadvantaged (OR 0.39, 95% CI 0.17-0.90); at risk for short term harm (injury) due to alcohol consumption (OR 0.56, 95% CI 0.32-0.97); and with fair-poor pre-injury health (OR 0.30, 95% CI 0.09-0.94). The predictors for seeking legal representation were speaking a language other than English at home (OR 2.80, 95% CI 1.2-6.52) and lower household income (OR 3.63, 95% CI 1.22-10.72). Participants less likely to seek legal representation were least socioeconomically disadvantaged (OR 0.15, 95% CI 0.04-0.50).

CONCLUSIONS

Seeking financial compensation was associated with a higher pre-injury BMI rather than injury-related factors. Seeking legal representation was solely related to socio-economic factors.