Outcome from injury: general health, work status, and satisfaction 12 months after trauma

Early predictors of health-related quality of life outcomes at 12 months post-burn: ABLE study

There remains a paucity of evidence on the early predictors of long-term Health-Related Quality of Life (HRQoL) outcomes post-burn in hospitalised adults. The overall aim of this study was to identify the factors (personal, environmental, burn injury and burn treatment factors) that may predict long-term HRQoL outcomes among adult survivors of hospitalised burn injuries at 12 months post-burn. A total of 274 participants, aged 18 years or over, admitted to a single state-wide burn centre with a burn injury were recruited. Injury and burn treatment information were collected from medical records or the hospital database and surveys collected demographic and social data. HRQoL outcome data were collected at 3-, 6- and 12-months using the 12-Item Short Form Survey (SF-12 v1) and Burns Specific Health Scale-Brief (BSHS-B). Personal, environmental, burn injury and burn treatment factors were also recorded at baseline. Analyses were performed using linear and logistic regression. Among 274 participants, 71.5 % (N=196) remained enrolled in the study at 12 months post-burn. The majority of participants reported HRQoL outcomes comparable with population norms and statistically significant improvements in generic (SF-12 v1) and condition-specific (BSHS-B) outcomes over time. However, for participants with poor HRQoL outcomes at 12-months post-burn, Univariable predictors included longer hospital length of stay, unemployment at the time of injury, a diagnosed pre-injury mental health condition, inadequate pre-burn social support, intentional injury, recreational drug use pre-injury and female gender. The early multivariable predictors of insufficient HRQoL outcomes were female gender, a previously diagnosed mental health condition, unemployment, inadequate social support, intentional injury, and prolonged hospital length of stay. These results suggest potential factors that could be used to screen and burns patients for psychosocial intervention and long-term follow up.

History of Racial Discrimination by Police Contributes to Worse Physical and Emotional Quality of Life in Black Americans After Traumatic Injury

BACKGROUND

Black Americans are more likely than their White counterparts to experience traumatic injury and worse functional outcomes. Unfair police treatment has been identified as one specific form of racial discrimination potentially driving these deleterious outcomes. The aim of the investigation was to better understand the relationship between experiences of discrimination by police and trauma-specific quality of life outcomes, including PTSD symptom severity, in Black Americans following traumatic injury.

METHOD

Traumatically injured Black American adults (N = 53) presenting to a level 1 trauma center completed a measure of police and law enforcement discrimination at baseline, and quality of life and PTSD were assessed 6 months later.

RESULTS

Stepwise regressions results showed more frequent discrimination by police and law enforcement significantly predicted lower emotional and physical well-being 6 months after injury. Further, more frequent police discrimination resulted in more severe PTSD symptoms by 6 months after injury.

CONCLUSIONS

Findings underscore that following an injury not specifically related to discrimination by police, patients' historical, negative police experiences contributed to worse physical and emotional recovery in the present. These findings, in unison with prior investigations, reveal the need to consider patients' history of negative police experiences as a social determinant of health in their recovery.

Time to recovery and its predictors following traumatic injuries among injured victims in Dessie Comprehensive Specialized Hospital, North East of Ethiopia, 2022: a retrospective follow-up study

BACKGROUND

Injuries are an extremely important public health problem worldwide. Despite being largely preventable and despite government efforts, injuries continue to be a major public health issue. Thus, the study tends to evaluate the time to recovery and its predictors for traumatic injuries.

METHODS

A hospital-based retrospective follow-up study was used. A total of 329 medical charts were actually reviewed. Traumatic injury victims from January 1, 2018-December 31, 2022 were included, and a simple random sampling technique was utilized. The data was gathered by reviewing medical charts. Data was coded and entered into Epi-Data Manager version 4.6.0.4 statistical software and further analyzed using STATA version 17. Descriptive statistics were performed to see the frequency distribution of variables. A Kaplan-Meier survival estimate and log rank test were performed to plot the overall survival curve and compare the difference in recovery among predictor categories, respectively. A model fitness test was done by using the Cox-Snell residual test and Harrell's C concordance statistic. Finally, a Cox proportional hazard model was fitted to determine the effect of predictors on recovery time from traumatic injuries.

RESULTS

The median time to recovery of traumatic injuries was 5 days (IQR: 3-10 days), with an overall incidence density of 8.77 per 100 person-days of observation. In the multivariable cox proportional regression model, variables such as being male (AHR: 0.384, 95%CI: 0.190-0.776, P-value: 0.008), the Glasgow coma scale of 13-15 (AHR: 2.563, 95%CI: 1.070-6.139, P-value: 0.035), intentional injury (AHR: 1.934, 95%CI: 1.03-3.632, P-value: 0.040), mild traumatic brain injury (AHR: 2.708, 95%CI: 1.095-6.698, P-value: 0.031), and moderate traumatic brain injury (AHR: 2.253, 95%CI: (1.033-4.911, P-value: 0.041) were statistically significant variables.

CONCLUSIONS

The median recovery time for traumatically injured respondents was 5 days. Independent predictors such as the Glasgow coma scale, time taken for surgical management, intent of injury, and traumatic brain injury were statistically significant with time to recovery from trauma.

Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial

INTRODUCTION

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

METHODS

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

RESULTS

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

CONCLUSIONS

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

Utility of the Healthy Aging Brain Care Monitor as a Patient-Reported Symptom Monitoring Tool in Older Injury Survivors

INTRODUCTION

The objective of this study was to evaluate the performance of the Healthy Aging Brain Care Monitor (HABC-M) as a patient-reported outcome tool to measure cognitive, functional, and psychological symptoms among older adults who sustained non-neurologic injuries requiring hospital admission.

METHODS

We used data from a multicenter randomized controlled trial to evaluate the utility of the HABC-M Self-Report version in older patients recovering from traumatic injuries. A total of 143 patients without cognitive impairment were included in the analysis. Cronbach's alpha was used to measure the internal consistency, and Spearman's rank correlation test was used to evaluate the relationship of the HABC-M with standard measures of cognitive, functional, and psychological outcomes.

RESULTS

The HABC-M subscales and the total scale showed satisfactory internal consistency (Cronbach's alpha = 0.64 to 0.77). The HABC-M cognitive subscale did not correlate with the Mini-Mental State Examination. The HABC-M functional and psychological subscales correlated with corresponding standard reference measures (|rs| = 0.24-0.59).

CONCLUSIONS

The HABC-M Self-Report version is a practical alternative to administering multiple surveys to monitor functional and psychological sequelae in older patients recovering from recent non-neurologic injuries. Its clinical application may facilitate personalized, multidisciplinary care coordination among older trauma survivors without cognitive impairment.

Prevalence of Psychiatric Morbidity and Stress Burden among Patients with Limb Fracture

Background

To assess the prevalence of psychiatric morbidity and stress burden among the patients with limb fractures and compare them with age and gender matched control group.

Materials and Methods

The cross-sectional study was conducted on 25 patients each of lower and upper limb fractures, presenting 2 weeks or more after the fracture to orthopedics OPD of Dayanand Medical College and Hospital. Psychiatric manifestations and stress burden were assessed using Mini International Neuropsychiatric Interview (M.I.N.I.), perceived stress scale (PSS), and impact of event scale-revised (IES-R) on the patients. It was compared to an equal number of age and gender matched normal control group.

Results

Majority of the patients with limb fractures were male (70%). The upper limb fracture was in age group of 18-30 years (52%), and those with lower limb fracture were >50 years of age (48%). Most common psychiatric morbidity seen in patients was major depressive disorder (52%) which was statistically significant in comparison with control group. The impact of trauma on patients resulted in avoidance and hyperarousal symptoms significantly in lower limb fracture patients than upper limb ones (P < 0.05).

Conclusions

The long bone injuries in patient cause significant psychiatric morbidity which increases the stress burden in such patients due to immobility and pain.

Quality of life related to both general and oral health two years after treatment for subcondylar fracture

The success of treatment for condylar fractures is usually assessed by functional outcomes, while studies on patient perceptions are scarce. A cross-sectional study was performed to assess the middle-term quality of life, related to both general health and oral health, of patients treated for subcondylar fracture, either by open reduction or by closed fixation, compared to healthy volunteers. In a single trauma centre, among 226 consecutive patients with subcondylar fractures that were treated in years 2018-2019 (two to three years prior to the survey), 148 fulfilled the selection criteria. They were classified as those with other facial fractures that were treated by open reduction (n = 79), and those without other fractures that were treated either by open reduction (n = 34) or by closed fixation (n = 35). An age matched group of healthy volunteers (n = 65) also participated in the study. All participants replied to the Short-Form-Health-Survey (SF-36) and the Oral-Health-Impact-Profile (OHIP-49), using the social messenger platform WhatsApp. The SF-36 showed that patients with closed-fixation reported better mental health than patients with open reduction, but worse than healthy volunteers. Contrariwise, on the OHIP-49, compared to patients with open reduction (with/without other facial fractures) and to healthy volunteers, patients with closed-fixation reported worse quality of life on physical pain, psychological discomfort, and physical disability. The influence of age was evident just on the OHIP-49, on the report of physical limitation and physical pain. Two to three years after the subcondylar fracture, patients treated either by open reduction or closed fixation might report decreased quality of life compared to healthy volunteers; patients treated by open reduction might report lesser mental health related quality of life (SF-36), but superior oral health related quality of life (OHIP-49) than patients treated by closed fixation.

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.

Influence of psychiatric co-morbidity on health-related quality of life among major trauma patients

PURPOSE

The purpose of this study was to compare 1-year post-discharge health-related quality of life (HRQL) between trauma patients with and without psychiatric co-comorbidity.

METHODS

A retrospective single-center cohort study identified all severely injured adult trauma patients admitted to a Level 1 trauma center between 2018 and 2019. Bivariate analysis compared patients with and without psychiatric co-morbidity, which was defined as prior diagnosis by a healthcare provider or acute psychiatric consultation for new or chronic mental illness. HRQL metrics included the EuroQol-5D-5L (EQ-5D) questionnaire, visual analogue scale (EQ-VAS), and overall index score. A multiple linear regression model was utilized to identify predictors of EQ-5D index scores.

RESULTS

Analysis of baseline characteristics revealed significantly greater rates of substance abuse, severe extremity injuries, inpatient morbidity, and hospital length-of-stay among patients with psychiatric illness. At 1-year follow-up, patients with psychiatric co-morbidity had lower median EQ-5D index scores compared to the control group (0.71, interquartile range [IQR] 0.32 vs. 0.79, IQR 0.22, p = 0.03). There were no differences between groups in individual EQ-5D dimensions, nor in EQ-VAS scores. Presence of psychiatric co-morbidity was not found to independently predict EQ-5D index scores in the linear regression model. Instead, Injury Severity Score (standardized regression coefficient [SRC] - 0.15, 95% confidence interval [CI] - 0.010 to - 0.001) and American Society of Anesthesiologists Physical Status score (SRC - 0.13, 95% CI - 0.08 to - 0.004) predicted poor HRQL 1-year after injury.

CONCLUSIONS

Psychiatric co-morbidity does not independently predict low HRQL 1 year after injury. Instead, lower HRQL scores among patients with psychiatric co-morbidity appear to be mediated by baseline health status and injury severity.

Important Issues to Severe Trauma Survivors: A Qualitative Study

OBJECTIVE

Identify issues that are important to severe trauma survivors up to 3 years after the trauma.

BACKGROUND

Severe trauma is the first cause of disability-adjusted life years worldwide, yet most attention has focused on acute care and the impact on long-term health is poorly evaluated.

METHOD

We conducted a large-scale qualitative study based on semi-structured phone interviews. Qualitative research methods involve the systematic collection, organization, and interpretation of conversations or textual data with patients to explore the meaning of a phenomenon experienced by individuals themselves. We randomly selected severe trauma survivors (abbreviated injury score ≥3 in at least 1 body region) who were receiving care in 6 urban academic level-I trauma centers in France between March 2015 and March 2018. We conducted double independent thematic analysis. Issues reported by patients were grouped into overarching domains by a panel of 5 experts in trauma care. Point of data saturation was estimated with a mathematical model.

RESULTS

We included 340 participants from 3 months to 3 years after the trauma [median age: 41 years (Q1-Q3 24-54), median injury severity score: 17 (Q1-Q3 11-22)]. We identified 97 common issues that we grouped into 5 overarching domains: body and neurological issues (29 issues elicited by 277 participants), biographical disruption (23 issues, 210 participants), psychological and personality issues (21 issues, 147 participants), burden of treatment (14 issues, 145 participants), and altered relationships (10 issues, 87 participants). Time elapsed because the trauma, injury location, or in-hospital trauma severity did not affect the distribution of these domains across participants' answers.

CONCLUSIONS

This qualitative study explored trauma survivors' experiences of the long-term effect of their injury and allowed for identifying a set of issues that they consider important, including dimensions that seem overlooked in trauma research. Our findings confirm that trauma is a chronic medical condition that demands new approaches to post-discharge and long-term care.

Factors Associated with the Development of Persistent Pain after mTBI

BACKGROUND

Persistent pain after mild traumatic brain injury (mTBI) is widely experienced, yet little is known about who is at risk for experiencing persistent pain after their injury.

AIMS

The purpose of this study was to 1) determine if there are factors associated with later experiencing persistent pain after mTBI and 2) examine if there are symptom patterns associated with the experience of persistent pain.

DESIGN

Secondary analysis was conducted using de-identified data from an NIH-funded longitudinal study.SettingsParticipants were enrolled in the emergency department.

PARTICIPANTS

Participants were aged 21 to 92 and all had experienced mTBI.

METHODS

We examined baseline characteristics, symptoms, and injury related variables associated with the endorsement of persistent pain among those with mTBI (N = 183) from baseline to 6 months post-injury. In order to identify a persistent pain phenotype, exploratory factor analysis was used to determine which symptoms co-occur with persistent pain.

RESULTS

Persistent pain was found in 78% of those with mTBI. Those with lower overall health status at day 7 and at 1-month following injury had greater odds of developing persistent pain. Those with higher levels of general health status and physical function health status at day 7 and 1 month, and those with higher levels of overall health related status at 1 month had significantly lesser odds of persistent pain at 6 months. Factor analysis revealed that persistent pain and co-occurring symptoms (anxiety, depression, dizziness, nausea and vomiting, sleep disturbance, poor memory, poor concentration, longer to think and light sensitivity) loaded on one factor, indicating that these symptoms are associated.

CONCLUSIONS

Those at increased risk for persistent pain should be screened beginning early in the recovery trajectory to reduce their risk of developing persistent pain. Identification of a phenotype offers potential for recognition of symptoms that cluster with persistent pain, improving the ability to treat patients more holistically, and develop interventions to support recovery from injury.

"Do You Need a Doctor's Note?" Factors Leading to Delayed Return to Work after Blunt Chest Trauma

BACKGROUND

Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma.

MATERIALS AND METHODS

Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups.

RESULTS

Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents' report limitations in daily activities due to physical health after discharge.

CONCLUSIONS

The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.

Patient experiences of rehabilitation following traumatic complex musculoskeletal injury – A mixed methods pilot study

Introduction

The aim of this pilot study was to measure patient reported outcomes and evaluate their rehabilitation experience following traumatic complex musculoskeletal (CMSK) injury.

Methods

A mixed methods prospective observational study was undertaken between December 2015 and March 2018 to explore patient reported outcomes following CMSK injury sustained as a result of major trauma and perception of their rehabilitation and its impact on their recovery. The participants were asked to complete a series of outcome measures at 18-months post-injury. The data was anonymised and analysed by the lead researcher.

Results

Thirty patients were recruited into the study (19 males, 11 females) between 23 and 76 years of age (median 52 years). Their injury profile was split between open fractures 30%, pelvic fractures 23%, multiple fractures 27% and polytrauma 20%. The majority (60%) reported moderate disability at 18-months post injury with 50% returning to full time employment. Patients with multiple or open fractures reported the worst outcomes. There was no relationship between frequency, quantity or duration of physiotherapy and outcome. However, 77% reported supplementing their NHS rehabilitation with other interventions such as gym membership, hydrotherapy and psychological therapies. The thematic analysis showed that patients considered intensity, quality and coordinated timely access to rehabilitation as the most important factors.

Conclusion

From a patient perspective, the current NHS rehabilitation provision does not appear to meet their complex needs. In addition to physical and vocational rehabilitation, patients wanted effective pain management and psychological support. Strengthening current therapy services and involving other sectors (e.g. Citizen’s Advice) could help achieve this. Early access to an intensive multidisciplinary rehabilitation programme was perceived to have positive benefits and improve outcomes.

Psychological risk factors that characterize the trajectories of quality of life after a physical trauma: a longitudinal study using latent class analysis

BACKGROUND

The course and corresponding characteristics of quality of life (QOL) domains in trauma population are unclear. Our aim was to identify longitudinal QOL trajectories and determine and predict the sociodemographic, clinical, and psychological characteristics of trajectory membership in physical trauma patients using a biopsychosocial approach.

METHODS

Patients completed a questionnaire set after inclusion, and at 3, 6, 9, and 12 months follow-up. Trajectories were identified using repeated-measures latent class analysis. The trajectory characteristics were ranked using Cohen's d effect size or phi coefficient.

RESULTS

Altogether, 267 patients were included. The mean age was 54.1 (SD = 16.1), 62% were male, and the median injury severity score was 5.0 [2.0-9.0]. Four latent trajectories were found for psychological health and environment, five for physical health and social relationships, and seven trajectories were found for overall QOL and general health. The trajectories seemed to remain stable over time. For each QOL domain, the identified trajectories differed significantly in terms of anxiety, depressive symptoms, acute stress disorder, post-traumatic stress disorder, Neuroticism, trait anxiety, Extraversion, and Conscientiousness.

DISCUSSION

Psychological factors characterized the trajectories during 12 months after trauma. Health care providers can use these findings to identify patients at risk for impaired QOL and offer patient-centered care to improve QOL.

Association of Severe Trauma With Work and Earnings in a National Cohort in Canada

Importance

Traumatic injury disproportionately affects adults of working age. The ability to work and earn income is a key patient-centered outcome. The association of severe injury with work and earnings appears to be unknown.

Objective

To evaluate the association of severe traumatic injury with subsequent employment and earnings in long-term survivors.

Design, Setting, and Participants

This is a retrospective, matched, national, population-based cohort study of adults who had employment and were hospitalized with severe traumatic injury in Canada between January 2008 and December 2010. All acute care hospitalizations for severe injury were included if they involved adults aged 30 to 61 years who were hospitalized with severe traumatic injury, working in the 2 years prior to injury, and alive through the third calendar year after their injury. Patients were matched with unexposed control participants based on age, sex, marital status, province of residence, rurality, baseline health characteristics, baseline earnings, self-employment status, union membership, and year of the index event. Data analysis occurred from March 2019 to December 2019.

Main Outcomes and Measures

Changes in employment status and annual earnings, compared with unexposed control participants, were evaluated in the third calendar year after injury. Weighted multivariable probit regression was used to compare proportions of individuals working between those who survived trauma and control participants. The association of injury with mean yearly earnings was quantified using matched difference-in-difference, ordinary least-squares regression.

Results

A total of 5167 adults (25.6% female; mean [SD] age, 47.3 [8.8] years) with severe injuries were matched with control participants who were unexposed (25.6% female; mean [SD] age, 47.3 [8.8] years). Three years after trauma, 79.3% of those who survived trauma were working, compared with 91.7% of control participants, a difference of -12.4 (95% CI, -13.5 to -11.4) percentage points. Three years after injury, patients with injuries experienced a mean loss of $9745 (95% CI, -$10 739 to -$8752) in earnings compared with control participants, representing a 19.0% difference in annual earnings. Those who remained employed 3 years after injury experienced a 10.8% loss of earnings compared with control participants (-$6043 [95% CI, -$7101 to -$4986]). Loss of work was proportionately higher in those with lower preinjury income (lowest tercile, -18.5% [95% CI, -20.8% to -16.2%]; middle tercile, -11.5% [95% CI, -13.2% to -9.9%]; highest tercile, -6.0% (95% CI, -7.8% to -4.3%]).

Conclusions and Relevance

In this study, severe traumatic injury had a significant association with employment and earnings of adults of working age. Those with lower preinjury earnings experienced the greatest relative loss of employment and earnings.

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.

Relationship between disability and pain to post-traumatic stress disorder, depression, and anxiety in patient with postoperative brachial plexus injury (BPI)

BACKGROUND

Orthopedic trauma patients have the risk to experience mental disorders, including depression, anxiety, post-traumatic stress disorder (PTSD), and other mental disorders. However, studies that analyze the relationship between mental disorders in orthopedic trauma patients, especially post-operative brachial plexus injury (BPI), are still difficult to find. This study aims to evaluate the relationship between disability and pain to post-traumatic stress disorder, depression, and anxiety in patient with postoperative BPI.

MATERIALS AND METHODS

It was an observational analysis with cross-sectional design study. Data were collected from July 2019 to September 2019. All subjects were patients of Orthopedics Clinic Dr. Soetomo General Academic Hospital Surabaya. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was used to determine the disability level in patients. Visual Analog Score (VAS) was an instrument for assessing pain scale and mental disorders used Mini International Psychiatry Interview (MINI).

RESULTS

There were 41 subjects met the research criteria, consisted of 10 men (24.39%) and 31 women (75.61%), aged 12-63 years. Based on the status of education, most subjects were graduated from junior/senior high school with 28 subjects (68.29%). The most common cause of BPI was traffic accidents as many as 37 people (90.24%). Mental disorders diagnosed from MINI found ten people (24.39%) were diagnosed with major depression; two subjects (4.87%) had generalized anxiety disorder. The average VAS score was 5.15 and the average DASH score was 52.02. There was no significant difference in VAS scores in the major depression group and PTSD group. However, there was an association between DASH score and depression (p < 0.05). Surprisingly, this study found the risk of suicide among BPI (7.3%) and one person with psychotic disorders (2.43%).

CONCLUSION

The level of disability and pain in orthopedic trauma patients with depression tend to more severe than without depression.

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.

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validation of Abbreviated Four- and Eight-Item Versions of the PTSD Checklist for DSM-5 in a Traumatically Injured Sample

Rates of posttraumatic stress disorder (PTSD) are three times higher in traumatically injured populations than the general population, yet limited brief, valid measures for assessing PTSD symptom severity exist. The PTSD Checklist for DSM-5 (PCL-5) is a valid, efficient measure of symptom severity, but its completion is time consuming. Subsequently, abbreviated four- and eight-item versions were developed using the Mini-International Neuropsychiatric Interview-7 PTSD module and validated in Veteran samples. This study aimed to validate these abbreviated versions using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the gold standard for PTSD diagnosis, in a traumatically injured civilian population. Participants were 251 traumatically injured adults (M_age = 42.52 years; 69.3% male; 50.2% Caucasian) recruited from a Level 1 trauma center inpatient unit; 32.3% and 17.9% of participants experienced a motor vehicle crash or gunshot wound, respectively. The CAPS-5 and PCL-5 were administered approximately 6.5 months postinjury. We examined whether compared to the full PCL-5, the abbreviated versions would adequately differentiate between participants with and without a CAPS-5 PTSD diagnosis. The abbreviated versions were highly correlated with the total scale and showed good-to-excellent internal consistency. The diagnostic utility of the abbreviated measures was comparable to that of the total scale regarding sensitivity, suggesting they may be useful as abbreviated screening tools; however, the total scale functioned better regarding specificity. The abbreviated versions of the PCL-5 may be useful screening instruments in the long-term care of traumatic injury survivors and may be more likely to be implemented across routine clinical and research contexts.

What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? a qualitative study set within the UK National Health Service

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.

Medical and socio-occupational predictive factors of psychological distress 5 years after a road accident: a prospective study

PURPOSE

Psychosocial consequences of road accidents are a major clinical problem that incurs significant social, occupational, and economic costs. The purpose of our study was to assess medical and socio-occupational factors of psychological distress in the severely injured 5 years after a road accident.

METHODS

A total of 691 of the 1168 subjects enrolled in a prospective cohort of road accident casualties (ESPARR cohort) responded to both standardized follow-up questionnaires at 1 and 5 years, assessing socio-occupational characteristics, physical and psychological sequelae, pain and perceived quality of life.

RESULTS

One quarter of participants exhibited psychological distress 5 years after the road accident; most of whom are women, with low educational level, and suffering from spinal lesions. After adjusting for several factors, psychological distress at 5 years was predicted by female gender and low educational level, and by several other factors observed 1 year after the road accident: poor self-reported quality of life, attention deficit and symptoms of anxiety.

CONCLUSIONS

Early-stage improvement in the screening and care of mental disorders in road accident casualties should help to reduce long-term psychological distress.

Caring for people with serious injuries in urban and regional communities: a qualitative investigation of healthcare providers' perceptions

Purpose: To understand the factors that affect the management of people after serious injury in urban and regional settings, beyond hospital discharge from the perspectives of allied health professionals (AHPs).Materials and methods: An exploratory qualitative study of AHPs caring for people with serious injuries post-hospital discharge in urban and regional areas of Victoria, Australia was completed. Twenty-five semi-structured interviews were undertaken with AHPs and thematically analysed.Results: Allied health professionals in urban and regional settings reported the benefits of a multi-disciplinary team to deliver high-quality care. However, a number of barriers to service delivery were identified that impacted on their ability to meet the needs of patients. These included insufficient psychological services, a shortage of available carers and an unmet need for external clinical support in regional areas. Communication between AHPs and other services, and care co-ordination of post-discharge services, was also highlighted as key areas to improve for optimal patient care.Conclusions: Factors that influenced optimal patient management included the availability of psychological and carer services, communication between health professionals and coordination of post-discharge care. The experiences of AHPs can offer practical suggestions to optimise service delivery and post-discharge care for people with serious injuries.Implications for RehabilitationAllied health professionals (AHPs) face a number of challenges in the provision of optimal care to people with serious injuries.Improving the availability of psychological support and attendant carers is needed in regional areas.A designated care coordinator role may assist people with serious injuries transitioning between hospital and home to engage with necessary services and reduce administrative burden for AHPs.Telehealth may provide facilitate improved communication between health professionals and support regional clinicians caring for people with complex injuries.

Screening and treating hospitalized trauma survivors for posttraumatic stress disorder and depression

Traumatic injury affects over 2.6 million U.S. adults annually and elevates risk for a number of negative health consequences. This includes substantial psychological harm, the most prominent being posttraumatic stress disorder (PTSD), with approximately 21% of traumatic injury survivors developing the disorder within the first year after injury. Posttraumatic stress disorder is associated with deficits in physical recovery, social functioning, and quality of life. Depression is diagnosed in approximately 6% in the year after injury and is also a predictor of poor quality of life. The American College of Surgeons Committee on Trauma suggests screening for and treatment of PTSD and depression, reflecting a growing awareness of the critical need to address patients' mental health needs after trauma. While some trauma centers have implemented screening and treatment or referral for treatment programs, the majority are evaluating how to best address this recommendation, and no standard approach for screening and treatment currently exists. Further, guidelines are not yet available with respect to resources that may be used to effectively screen and treat these disorders in trauma survivors, as well as who is going to bear the costs. The purpose of this review is: (1) to evaluate the current state of the literature regarding evidence-based screens for PTSD and depression in the hospitalized trauma patient and (2) summarize the literature to date regarding the treatments that have empirical support in treating PTSD and depression acutely after injury. This review also includes structural and funding information regarding existing postinjury mental health programs. Screening of injured patients and timely intervention to prevent or treat PTSD and depression could substantially improve health outcomes and improve quality of life for this high-risk population. LEVEL OF EVIDENCE: Review, level IV.

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.

Trauma exposure, mental health, and quality of life among injured service members: Moderating effects of perceived support from friends and family

Poor mental health and quality of life (QOL) are common among service members exposed to trauma and may be more pronounced among those injured on combat deployment. It is vital to identify factors that attenuate these issues. This study examined whether perceived support from friends and family buffer associations between level of trauma exposure, mental health symptoms (i.e., posttraumatic stress disorder [PTSD], depression), and QOL. Military health care records and cross-sectional web-assessment data were collected for 1,643 individuals who were participating in a large-scale surveillance project of patient-reported outcomes of Service members injured on combat deployment. General linear models revealed perceived support from family and friends were independently related to lower depression and PTSD symptoms, and higher QOL. Perceived support from friends buffered associations between trauma exposure and depression symptoms and QOL, but not PTSD symptoms. In contrast, individuals with high family support reported the lowest levels for both PTSD and depression symptoms at low levels of trauma exposure. At high levels of trauma exposure, however, symptoms were similar across levels of family support. A similar trend was observed for QOL. Such evidence reinforces the importance of interpersonal relationships and support for injured service members, and highlights the need to address these topics in existing treatment and rehabilitation programs.

Polytrauma outcome: implementation of health-related quality of life assessment into the German Trauma Registry

INTRODUCTION

As a result of improvement in polytrauma management within the last years, more patients survive a significant trauma. Trauma registers, such as the TraumaRegister DGU^®, played a role in identifying risk factors of poor outcomes which led to an improvement of survival rates. In recent years the health-related quality of life (HRQoL) after trauma got into the focus of trauma studies.

MATERIALS AND METHODS

Under the sponsorship of the German Society of Trauma Surgery (DGU) the members of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) convened intending to identify an assessment tool for implementation into the TraumaRegister DGU^®.

RESULTS

After the conduct of a systematic literature review, the working group decided to choose the 12-item Short-Form Health Survey (SF-12) and five more questions, capturing the satisfaction of treatment, work capacity and trauma-related medical treatment.

CONCLUSION

The data collection of HRQoL and the additional variables started in 2017 in participating clinics as a part of the regular data collection of the TraumaRegister DGU^®.

Psychometric properties of the psychosocial screening instrument for physical trauma patients (PSIT)

Background

Early detection of psychosocial problems post-injury may prevent them from becoming chronic. Currently, there is no psychosocial screening instrument that can be used in patients surviving a physical trauma or injury. Therefore, we recently developed a psychosocial screening instrument for adult physical trauma patients, the PSIT. The aim of this study was to finalize and psychometrically examine the PSIT.

Methods

All adult (≥ 18 years) trauma patients admitted to a Dutch level I trauma center from October 2016 through September 2017 without severe cognitive disorders (n = 1448) received the PSIT, Impact of Events Scale-Revised (IES-R), Patient Health Questionnaire-9 (PHQ-9), Rosenberg Self-Esteem Scale (RSES), State-Trait Anxiety Inventory-State (STAI-S), and the World Health Organization Quality of Life-Abbreviated version (WHOQOL-Bref). After 2 weeks, a subgroup of responding participants received the PSIT a second time. The internal structure (principal components analysis, PCA; and confirmatory factor analysis, CFA), internal consistency (Cronbach’s alpha, α), test-retest reliability (Intraclass Correlation Coefficient, ICC), construct validity (Spearman’s rho correlations), diagnostic accuracy (Area Under the Curve, AUC), and potential cut-off values (sensitivity and specificity) were examined.

Results

A total of 364 (25.1%) patients participated, of whom 128 completed the PSIT again after 19.5 ± 6.8 days. Test-retest reliability was good (ICC = 0.86). Based on PCA, five items were removed because of cross-loadings ≥ 0.3. Three subscales were identified: (1) Negative affect (7 items; α = 0.91; AUC = 0.92); (2) Anxiety and Post-Traumatic Stress Symptoms (4 items; α = 0.77; AUC = 0.88); and (3) Social and self-image (4 items; α = 0.79; AUC = 0.92). CFA supported this structure (comparative fit index = 0.96; root mean square error of approximation = 0.06; standardized rood mean square residual = 0.04). Four of the five a priori formulated hypotheses regarding construct validity were confirmed. The following cut-off values represent maximum sensitivity and specificity: 7 on subscale 1 (89.6% and 83.4%), 3 on subscale 2 (94.4% and 90.3%), and 4 on subscale 3 (85.7% and 90.7%).

Conclusion

The final PSIT has good psychometric properties in adult trauma patients.

Examining satisfaction of older adult patients and their caregivers following traumatic injury: a cross-sectional study of three level I trauma centres

OBJECTIVE

To explore satisfaction of care received by older adult patients and their primary caregivers following traumatic injury.

DESIGN

Prospective, cross-sectional study using the FAMCARE (Family Satisfaction with Advanced Cancer Care Scale) satisfaction surveys prior to discharge.

SETTING

Three level I trauma centres in Colorado from November 2016 to December 2017.

PARTICIPANTS

Trauma patients ≥55 years old and their primary caregivers.

OUTCOME MEASURES

Overall mean (SD) satisfaction, satisfaction <80% vs ≥80%, and mean satisfaction by survey conceptual structures.

RESULTS

Of the 319 patients and 336 caregivers included, the overall mean (SD) patient satisfaction was 81.7% (15.0%) and for caregivers was 83.6% (13.4%). The area with the highest mean for patient and caregiver satisfaction was psychosocial care (85.4% and 86.9%, respectively). Information giving was the lowest for patients (80.4%) and caregivers (80.9%). When individual items were examined, patients were significantly more satisfied with 'availability of nurses to answer questions' (84.5 (15.3) vs 87.4 (14.8), p=0.02) and significantly less satisfied with 'speed with which symptoms were treated' (80.6 (17.9) vs 84.0 (17.0), p=0.03) compared with caregivers. Patients with a history of smoking (least squares mean difference: -0.096 (-0.18 to -0.07), p<0.001) and hospital discharge destination to an outside facility of care (adjusted OR: 1.6 (1.0 to 2.4), p=0.048) were identified as independent predictors of lower overall satisfaction in generalised linear and logistic models, respectively.

CONCLUSIONS

Our data suggest that patients' medical history was driving both patient and caregiver satisfaction. Patient characteristics and expectations need to be considered when tailoring healthcare interventions.

MPPED2 Polymorphism Is Associated With Altered Systemic Inflammation and Adverse Trauma Outcomes

Trauma is a leading cause of morbidity and mortality. It is unclear why some trauma victims follow a complicated clinical course and die, while others, with apparently similar injury characteristics, do not. Interpatient genomic differences, in the form of single nucleotide polymorphisms (SNPs), have been associated previously with adverse outcomes after trauma. Recently, we identified seven novel SNPs associated with mortality following trauma. The aim of the present study was to determine if one or more of these SNPs was also associated with worse clinical outcomes and altered inflammatory trajectories in trauma survivors. Accordingly, of 413 trauma survivors, DNA samples, full blood samples, and clinical data were collected at multiple time points in the first 24 h and then daily over 7 days following hospital admission. Subsequently, single-SNP groups were created and outcomes, such as hospital length of stay (LOS), ICU LOS, and requirement for mechanical ventilation, were compared. Across a broad range of Injury Severity Scores (ISS), patients carrying the rs2065418 TT SNP in the metallophosphoesterase domain-containing 2 (MPPED2) gene exhibited higher Marshall MODScores vs. the control group of rs2065418 TG/GG patients. In patients with high-severity trauma (ISS ≥ 25, n = 94), those carrying the rs2065418 TT SNP in MPPED2 exhibited higher Marshall MODScores, longer hospital LOS (21.8 ± 2 days), a greater requirement for mechanical ventilation (9.2 ± 1.4 days on ventilator, DOV), and higher creatinine plasma levels over 7 days vs. the control group of rs2065418 TG/GG high-severity trauma patients (LOS: 15.9 ± 1.2 days, p = 0.03; DOV: 5.7 ± 1 days, p = 0.04; plasma creatinine; p < 0.0001 MODScore: p = 0.0003). Furthermore, rs2065418 TT patients with ISS ≥ 25 had significantly different plasma levels of nine circulating inflammatory mediators and elevated dynamic network complexity. These studies suggest that the rs2065418 TT genotype in the MPPED2 gene is associated with altered systemic inflammation, increased organ dysfunction, and greater hospital resource utilization. A screening for this specific SNP at admission might stratify severely injured patients regarding their lung and kidney function and clinical complications.

Patient-Reported Outcome Measures and Patient Activation: What Are Their Roles in Orthopedic Trauma?

The rise of patient-reported outcome (PRO) measurement across medicine has been swift and now extends to the world of orthopedic trauma. However, PRO measures (PROMs) applied to trauma patients pose special considerations; measuring "episodes of care" is less straightforward, injuries are heterogeneous in their severity, and the patient's initial visit is "postinjury." Obtaining baseline scores and assessing the impact of a traumatic event on mental health are key considerations. Currently, few, if any, trauma registries include PROs; though general and condition-specific PROMs plus the patient empowerment measure of Patient Activation represent meaningful inputs for the clinical decision-making process. To be useful in trauma care, PROMs should be psychometrically sound and validated, be used for capturing function, screen for mental state and substance use, and give the clinician a sense of the patient's "activation" (engagement in their own health). Although the implementation of routine PRO collection can seem daunting, clinicians can use a multitude of electronic resources to access validated measures and simplify the implementation process. Computer-adaptive testing has evolved to help minimize patient burden, and PROM collection must maximize efficiency. Once established as part of your practice, PROs become an important tool to track recovery, identify mental health issues, engage in the prevention of future injury, and enable care of the whole patient.

Creating Value by Prioritizing Mental and Social Health After Injury

Given the strong influence of mental and social health on symptom intensity and magnitude of limitations, attempts to increase value in orthopedic trauma must attend to emotional and social recovery. Low value and potentially harmful interventions after trauma such as excessive reliance on medication, low value surgeries for "delayed healing" or "symptomatic implants," repeated visits with a physical therapist, and other biomedical interventions often reflect misdiagnosis and mismanagement of social and mental health. A better approach is to anticipate emotional and social recovery; to get social and mental health specialists involved immediately after injury; and to develop strategies that set firm limits on biomedical tests and treatments that are unlikely to contribute to health and risk reinforcing stress, distress, and less effective coping strategies.

Mental health outcomes after major trauma in Ontario: a population-based analysis

BACKGROUND

Major injury continues to be a common source of morbidity and mortality; improving the functional recovery of survivors of major trauma requires a better understanding of the mental health outcomes that may occur in this population. We assessed the association between major trauma and the development of a new mental health diagnosis or death by suicide.

METHODS

We completed a population-based, self-controlled, longitudinal cohort analysis using linked administrative data on patients treated for major trauma in Ontario between 2005 and 2010. All survivors were included and composite rates of mental health diagnoses during inpatient admissions were compared between the 5 years after injury and the 5 years before injury, using Poisson regression with generalized estimating equations. The incidence of suicide was calculated for the 5 years after injury. Risk factors for suicide were calculated using Cox proportional hazard regression analyses.

RESULTS

The analysis included 19 338 patients, predominantly men (70.7%) from urban areas (82.6%), with unintentional (89%), blunt injuries (93.4%). Overall, trauma was associated with a 40% increase in the postinjury rate of mental health diagnoses (incidence rate ratio [IRR] 1.4, 95% [confidence interval] CI 1.1 to 1.8). The suicide rate was 70 per 100 000 patients per year, substantially higher than the population average. Risk factors for completing suicide were prior inpatient diagnosis of mood disorder (hazard ratio [HR] 4.3, 95% CI 2.1 to 8.8) and self-inflicted injury (HR 7.8, 95% CI 3.9 to 15.4).

INTERPRETATION

Survivors of major trauma are at a heightened risk of developing mental health conditions or death by suicide in the years after their injury. Patients with pre-existing mental health disorders or who are recovering from a self-inflicted injury are at particularly high risk.

Predictors of psychological distress following major trauma

AIM

The aim of this study was to identify variables that may predict later psychological distress in patients following admission to a Major Trauma Centre (MTC) and to determine whether a psychological screening tool, the Posttraumatic Adjustment Screen (PAS), administered on admission was able to contribute to this.

METHODS

Patients referred to the MTC clinical psychology service completed the PAS during their inpatient stay over an eight-month period. Following discharge from hospital, patients were telephoned (1 month, 3 months and 6 months post injury) by a member of the clinical psychology team and asked two validated questionnaires; the Impact of Events Scale revised (IES-R) (measure of posttraumatic stress symptoms) and the CORE-10 (measure of global psychological distress). In addition, patients' data from the local Trauma Audit & Research Network (TARN) database was reviewed to identify information related to injury and other demographic data. Patients were divided into groups for comparison based upon their PAS scores using previously described severity cut offs for posttraumatic stress symptoms and depression. Receiver Operator Characteristic and Multiple Linear Regression analysis was used to examine for significant baseline predictors of psychological distress during follow up according to the IES and CORE-10 scores.

RESULTS

One hundred and fourteen patients completed the PAS over the study period. Follow-up psychological data was available for 63 (56%) of patients. Except for the patient's home address, no baseline parameter examined in this study regarding patient demographics, injury or treatment was associated with reported psychological symptoms in the first six months post injury as measured by the IES-R or CORE-10 scores. Multiple linear regression analysis revealed that both PAS-P and PAS-D were significant predictor variables for patients reporting significant symptoms of posttraumatic stress and global psychological distress (according to IES-R and CORE-10 scores) in the first six months post injury.

CONCLUSIONS

Psychological screening on admission may be helpful in identifying patients admitted to MTCs who are at risk at developing posttraumatic stress symptoms and psychological distress following major trauma.

Association of pain after trauma with long-term functional and mental health outcomes

BACKGROUND

Chronic pain after trauma is associated with serious clinical, social, and economic burden. Due to limitations in trauma registry data and previous studies, the current prevalence of chronic pain after trauma is unknown, and little is known about the association of pain with other long-term outcomes. We sought to describe the long-term burden of self-reported pain after injury and to determine its association with positive screen for posttraumatic stress disorder (PTSD), functional status, and return to work.

METHODS

Trauma survivors with moderate or severe injuries and one completed follow-up interview at either 6 months or 12 months after injury were identified from the Functional Outcomes and Recovery after Trauma Emergencies project. Multivariable logistic regression models clustered by facility and adjusting for confounders were used to obtain the odds of positive PTSD screening, not returning to work, and functional limitation at 6 months and 12 months after injury, in trauma patients who reported to have pain on a daily basis compared to those who did not.

RESULTS

We completed interviews on 650 patients (43% of eligible patients). Half of patients (50%) reported experiencing pain daily, and 23% reported taking pain medications daily between 6 months and 12 months after injury. Compared to patients without pain, patients with pain were more likely to screen positive for PTSD (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.97-8.85), have functional limitations for at least one daily activity (OR, 2.42; 95% CI, 1.38-4.26]), and not return to work (OR, 1.86; 95% CI, 1.02-3.39).

CONCLUSIONS

There is a significant amount of self-reported chronic pain after trauma, which is in turn associated with positive screen for PTSD, functional limitations, and delayed return to work. New metrics for measuring successful care of the trauma patient are needed that span beyond mortality, and it is important we shift our focus beyond the trauma center and toward improving the long-term morbidity of trauma survivors.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Psychiatric outcome at least 20 years after trauma: A survey on the status of subjective general health and psychiatric symptoms with a focus on posttraumatic stress disorder

BACKGROUND

Information on long-term psychiatric sequelae after severe trauma is sparse. We therefore performed a survey addressing several symptoms related to posttraumatic stress disorder (PTSD) in patients who sustained multiple injuries more than 20 years after trauma.

METHODS

Patients injured between January 1, 1973, and December 31, 1990, were contacted at least 20 years later. We included multiply injured patients aged between 3 and 60 years from a single level 1 trauma center. A questionnaire based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for PTSD, including individual symptoms related to intrusion, avoidance, and hyperarousal was sent to all patients.

RESULTS

A total of 359 patients (56.35%) received a questionnaire. Of these, 337 patients (93.87%) returned the questionnaire and were included in the study (223 males [66.17%] and 114 females [33.82%]). Mean ± SD follow-up was 29.5 ± 8.5 years. Nearly half the study population (47.18%) experienced lasting psychiatric sequelae, such as intrusive recollection (n = 65, 19.28%), avoidance (n = 92, 27.29%), or hyperarousal (n = 95, 28.18%) at least monthly. Ten patients (2.96%) fulfilled all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for PTSD. A total of 131 patients (38.87%) reported fair or poor general health status. There was no difference in injury severity in patients with or without PTSD (injury severity score, 8.33 vs. 20.36, respectively; p = 0.52) or PTSD-related symptoms including intrusion (19.88 vs. 20.32, p = 0.74), avoidance (19.99 vs. 20.3, p = 0.79), and hyperarousal (19.36 vs. 20.68, p = 0.26).

CONCLUSION

At least 20 years after injury, no correlation was found between the development of psychiatric complications and the severity of injury. While the rate of full-blown PTSD was low, nearly half the study population regularly suffered from at least one psychiatric symptom attributable to the initial trauma. Awareness for the development of psychiatric complications and early initiation of psychiatric counseling are advisable.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, level II.

Detecting PTSD in a traumatically injured population: The diagnostic utility of the PTSD Checklist for DSM-5

BACKGROUND

The posttraumatic stress disorder (PTSD) Checklist for DSM-5 (PCL-5) is among few validated measures of PTSD severity in line with the DSM-5. Validation efforts among veteran samples have recommended cut scores of 33 and 38 to indicate PTSD; cut scores vary across populations depending on factors such as trauma type. The purpose of this study was to evaluate the diagnostic utility of and identify optimal cut scores for the PCL-5 in relation to the gold standard Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) among traumatically injured individuals 6 months after discharge from a level I trauma center.

METHODS

A total of 251 participants completed the PCL-5 and CAPS-5 6 months after discharge from a level I trauma center following traumatic injury. Receiver operating characteristic curve analyses detailed diagnostic accuracy of the PCL-5 and identified the optimal cut score via Youden's J index. Cut scores were also broken down by intentional versus nonintentional injury.

RESULTS

The PCL-5 produces satisfactory diagnostic accuracy, with adequate sensitivity and specificity, in a traumatically injured population. Estimates indicate the optimal cut score as >30; the optimal cut score for intentional injuries was >34 and >22 for nonintentional injuries.

CONCLUSIONS

This investigation provides support for the PCL-5 in detection of PTSD among injured individuals 6 months after discharge from a level I trauma center. PCL-5 specificity and sensitivity suggest clinicians working with this population can feel confident in using this measure over more onerous structured interviews (e.g., CAPS-5). This study signifies a move toward ensuring those experiencing mental health difficulties after traumatic injury are identified and connected to resources.

Long-Term Effects of Psychological Symptoms after Occupational Injury on Return to Work: A 6-Year Follow-Up

Psychological factors may compromise return to work among workers with occupational injuries, and little is known about the long-term consequences of psychological symptoms relating to return to work. The study examined the impact of psychological symptoms on return to work as well as exploring factors associated with return to work among injured workers. A total of 572 workers who experienced occupational injuries were recruited in this prospective cohort study. Surveys of the psychological symptoms using the 5-item Brief Symptom Rating Scale (BSRS-5) were conducted at 3 and 12 months after the injury. All of the workers were invited to join the study at year 6 after the injury. Sociodemographic factors, psychological symptoms, injury severity, and return-to-work status were collected. Approximately 10% of injured workers could not return to work even 6 years after the injury. Severe psychological symptoms within 1 year after the injury presented a significant risk factor for not returning to work 6 years after the injury (adjusted OR = 0.7, 95% CI: 0.5⁻0.8). Furthermore, age, education level, length of hospitalization, and injury-induced changes in appearance had significant independent influence on return to work as well. These findings highlight the importance of the effects of mental health within 1 year post injury on return to work, and support the concept of early screening, detection, and intervention in at-risk occupational injured workers with severe psychological symptoms.

Physical injury, health, and well-being: Role of stress perception

OBJECTIVE

Physical injuries are common occurrences that can have substantial implications for mental health and well-being. Ample studies indicated that increased levels of perceived stress is associated with increased prevalence of general health problems, as well as reduced health-related quality of life. Thus, the goal of the present study was to examine the long-lasting association between bodily injuries and general health. In addition, the role of stress perception in moderating the association between injury and general health was assessed.

METHODS

Two-hundred and forty victims of past injury and 251 non-injured participants completed a self-report health inventory questionnaire assessing illness prevalence during the six-month period prior to the study. In addition, they completed the short-form Medical Outcomes Survey (MOS SF-36) questionnaire and the Perceived Stress Scale.

RESULTS

Victims of past injuries reported higher incidences of illness, mainly upper respiratory infections and fever, compared to non-injured participants. In addition, injured participants reported poorer perceived health status, including reduced general health, physical functioning, and health beliefs. Perceived stress levels were similar in injured and non-injured participants, however, correlations between perceived stress and self-reported medical outcomes were stronger in injured participants compared to non-injured controls.

CONCLUSIONS

Past physical injuries are associated with increased incidence of general health concerns and poorer health-related well-being. Moreover, injured individuals do not report increased stress perception; however, when stressed, injured individuals are more affected and health-related quality of life is reduced. Promoting well-being in individuals who have suffered a significant injury is, thus, a clinical necessity and a pressing social priority. This study highlights the role of stress perception in the association between physical injury and health, and may assist in providing better multi-disciplinary care for the injured.

Comparison of the performance of mental health, drug and alcohol comorbidities based on ICD-10-AM and medical records for predicting 12-month outcomes in trauma patients

Background

Many outcome studies capture the presence of mental health, drug and alcohol comorbidities from administrative datasets and medical records. How these sources compare as predictors of patient outcomes has not been determined. The purpose of the present study was to compare mental health, drug and alcohol comorbidities based on ICD-10-AM coding and medical record documentation for predicting longer-term outcomes in injured patients.

Methods

A random sample of patients (n = 500) captured by the Victorian State Trauma Registry was selected for the study. Retrospective medical record reviews were conducted to collect data about documented mental health, drug and alcohol comorbidities while ICD-10-AM codes were obtained from routinely collected hospital data. Outcomes at 12-months post-injury were the Glasgow Outcome Scale – Extended (GOS-E), European Quality of Life Five Dimensions (EQ-5D-3L), and return to work. Linear and logistic regression models, adjusted for age and gender, using medical record derived comorbidity and ICD-10-AM were compared using measures of calibration (Hosmer-Lemeshow statistic) and discrimination (C-statistic and R²).

Results

There was no demonstrable difference in predictive performance between the medical record and ICD-10-AM models for predicting the GOS-E, EQ-5D-3L utility sore and EQ-5D-3L mobility, self-care, usual activities and pain/discomfort items. The area under the receiver operating characteristic (AUC) for models using medical record derived comorbidity (AUC 0.68, 95% CI: 0.63, 0.73) was higher than the model using ICD-10-AM data (AUC 0.62, 95% CI: 0.57, 0.67) for predicting the EQ-5D-3L anxiety/depression item. The discrimination of the model for predicting return to work was higher with inclusion of the medical record data (AUC 0.69, 95% CI: 0.63, 0.76) than the ICD-10-AM data (AUC 0.59, 95% CL: 0.52, 0.65).

Conclusions

Mental health, drug and alcohol comorbidity information derived from medical record review was not clearly superior for predicting the majority of the outcomes assessed when compared to ICD-10-AM. While information available in medical records may be more comprehensive than in the ICD-10-AM, there appears to be little difference in the discriminative capacity of comorbidities coded in the two sources.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3248-x) contains supplementary material, which is available to authorized users.

Quality of life and level of post-traumatic stress disorder among trauma patients: A comparative study between a regional and a university hospital

BACKGROUND

The aim of this study was to assess outcome in long-term quality of life (QoL) and post-traumatic stress disorder (PTSD) among adult survivors of trauma. Secondary aim was to compare levels of the outcome with injury severity and specialization level of two trauma centres.

METHODS

A retrospective study included patients received by the trauma response teams at two hospitals in 2013 aged 18 or more at follow-up. We assessed QoL and PTSD with one mailed questionnaire to each patient at either 12 or 24 months of follow-up. Health status was measured by EuroQol EQ-5D and the Glasgow Outcome Scale. PTSD symptoms were classified according to the Post-Traumatic Stress Disorder Checklist (PCL) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).

RESULTS

A questionnaire was mailed to 774 patients at end of 2014 or early 2015, 455 were included for analysis; median age 44 (IQR 25-57; 68% male); median NISS 9 (IQR 2-17); At follow-up 24% (95% CI 20-28) reported a EQ index score value equivalent to the lowest 2.3% in the Danish population norm. Probable PTSD was present in 19% (95% CI 13-27) of patients with severe injuries (NISS> 15), and 23% (95% CI 19-28) of those with NISS < 15.

CONCLUSION

Severe trauma has substantial impact on QoL and PTSD assessed at 12-24 months after the trauma. The QoL was well below the Danish population norm. The presence of PTSD was independent of injury severity. Trauma Centres should consider to include this as part of the treatment principles.

"That's what you do for people you love": A qualitative study of social support and recovery from a musculoskeletal injury

Background

Social support has been identified as a significant factor in facilitating better health outcomes following injury. However, research has primarily focused on the role of social support from the perspective of the person experiencing an injury. Limited research has examined the experiences of the family members and friends of a person with injury. This study aims to explore the perceptions and experiences of social support and recovery following a transport-related musculoskeletal injury (MSI) in a population of injured persons and their family members and friends.

Methods

This study was conducted using a phenomenological qualitative research design. In-depth semi-structured interviews were conducted with ten persons with MSI, recruited via the Transport Accident Commission (TAC) in Victoria, Australia. Seven family members and friends were also interviewed. The data was analysed using constant comparative method and thematic analysis.

Results

Several themes were identified including: (1) key sources and types of support received, (2) relationship development and (3) challenges of providing and receiving support. Participants with MSI reported stories about how the social network provided emotional and tangible support. Family members and friends confirmed the supportive acts provided to the participants with MSI. Positive iterative changes in relationships were reported by the participants with MSI. Participants with MSI, their family members and friends described several difficulties including loss of independence, feeling like a burden, and the impact of caring on health and well-being.

Conclusions

The role of social support is complex given the multitude of people involved in the recovery process. The findings of this study suggest that persons with MSI may benefit from support groups and maintenance of existing support networks. Furthermore, family members and friends engaged in the recovery process may benefit from support in this role.

Physical Trauma Patients with Symptoms of an Acute and Posttraumatic Stress Disorder: Protocol for an Observational Prospective Cohort Study

Background

Injury, medical treatment, and rehabilitation can have major impacts on patients’ wellbeing. About 25-33% of the patients experience an acute stress disorder (ASD) or a posttraumatic stress disorder (PTSD) after injury. ASD is a relatively new diagnosis. Therefore, knowledge about patients’ experiences, the course of ASD and PTSD, and who is at risk for developing ASD or PTSD is lacking.

Objective

The aims of this multi-method study are to explore patients’ experiences with injury (and their care) using a focus group study. Then, in the observational study, different courses of ASD, PTSD, and quality of life will be examined. In addition, this study will examine if these courses could be characterized by socio-demographic, clinical, and psychological variables. Consequently, a risk profile will be developed to determine which patients are at risk for developing ASD or PTSD during the 12 months after injury.

Methods

Trauma patients treated in the shock room (in 2015) of the Elisabeth-TweeSteden Hospital will share their experiences with injury in the focus group study. Open, axial, and selective coding will be used to analyze the data. Concerning the observational study, patients treated in the shock room (during 2016 and 2017, Elisabeth-TweeSteden Hospital and Erasmus Medical Centre) will be asked to participate. The inclusion period is 12 months. Participants will complete the Impact of Event Scale-Revised, MINI-plus, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF after inclusion and at 3, 6, 9, and 12 months after injury. The NEO-Five Factor Inventory and the State-Trait Anxiety Inventory-Trait are completed after inclusion only. Repeated measures of latent class analysis and linear mixed models will be used to examine the research aims.

Results

This project was funded in August 2015 by ZonMw. The results of the focus group study are expected in the first trimester of 2018. With regard to the observational study, recruitment is currently underway. Data collection will be completed in November 2018. The first results will be expected in the first trimester of 2019.

Conclusions

This is the first multi-method study in trauma patients that examines patients’ experiences (qualitative design) as well as psychological disorders (observational prospective). This study will contribute to necessary information on psychological consequences after injury. Moreover, it provides knowledge about which patients to include in future psychological intervention research. Finally, awareness in clinicians about the psychological consequences can be created, so they are able to act more effectively to provide patient-oriented care.

Trial Registration

Netherlands Trial Registry NTR6258; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6258 (Archived by WebCite at http://www.webcitation.org/6xSCiO1bS)

Survival and health related quality of life after severe trauma - a 15 years follow up study

INTRODUCTION

As the primary treatment of patients with severe trauma continues to improve, increasing interest has been directed towards long-term survival and Health Related Quality of Life (HRQoL). In trauma patients, there are few studies describing long-term outcome using tools specifically directed at HRQoL.

HYPOTHESIS

HRQoL measured with EQ-5D is significantly reduced compared to the Danish norm score 15 years after severe injury.

MATERIALS AND METHODS

All patients more than 18 years of age, admitted to a level 1 trauma center from March 1996 to September 1997 were prospectively included and scored with Injury Severity Score (ISS). Survival status was recorded in May 2012 and EQ-5D questionnaires were sent out.

RESULTS

95 of the original 154 trauma patients were eligible for participation. The response rate was 66%. The average EQ-5D index score in the trauma population was significantly reduced compared to the index score in the Danish norm population (P=0.00, one-sample t-test). In addition, ISS is associated with HRQoL and ISS≥16 predicts poorer HRQoL.

CONCLUSION

EQ-5D is significantly reduced 15years after severe trauma High ISS was associated with low HRQoL. Knowledge of the distribution and predictors of long-term disability can be used to develop more efficient prevention policies and to improve trauma care in general.

The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect

OBJECTIVE

To examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external fixator.

MATERIALS AND METHODS

The SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov).

RESULTS

The patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4).

CONCLUSIONS

Although both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients' mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients' mental, the impact of the Orthofix LRS was less severe.

Impact of Work-Related Burn Injury on Social Reintegration Outcomes: A Life Impact Burn Recovery Evaluation (LIBRE) Study

OBJECTIVE

To examine differences in long-term social reintegration outcomes for burn survivors with and without work-related injuries.

DESIGN

Cross-sectional survey.

SETTING

Community-dwelling burn survivors.

PARTICIPANTS

Burn survivors (N=601) aged ≥18 years with injuries to ≥5% total body surface area or burns to critical areas (hands, feet, face, or genitals).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Life Impact Burn Recovery Evaluation Profile was used to examine the following previously validated 6 scale scores of social participation: Family and Friends, Social Interactions, Social Activities, Work and Employment, Romantic Relationships, and Sexual Relationships.

RESULTS

Older participants, those who were married, and men were more likely to be burned at work (P<.01). Burn survivors who were injured at work scored significantly lower on the Work and Employment scale score after adjusting for demographic and clinical characteristics (P=.01). All other domain scale scores demonstrated no significant differences between groups. Individuals with work-related injuries scored significantly worse on 6 of the 19 items within the Work and Employment scale (P<.05). These individuals were more likely to report that they were afraid to go to work and felt limited in their ability to perform at work.

CONCLUSIONS

Burn survivors with work-related injuries report worse work reintegration outcomes than those without work-related injuries. Identification of those at higher risk for work reintegration challenges after burn injury may enable survivors, providers, employers, and insurers to better use appropriate resources to promote and target optimal employment outcomes.

Continuing Trauma: The Unmet Needs of Trauma Patients in the Postacute Care Setting

Trauma care has traditionally focused on prehospital and hospital settings, yet many injured patients report emotional distress in the postacute care setting, which is known to impair recovery. The objective of this study was to assess postdischarge emotional recovery and communication preferences. An observational cohort of 100 adult patients from our Level 1 Trauma Center was surveyed one to two months postdischarge. Among those employed preinjury, 44 per cent had not returned to work. Nearly half screened positive for emotional issues (posttraumatic stress disorder, depression, and/or psychological distress); of these, only 35 per cent considered getting professional help and only 10 per cent received help. The barrier most cited (58%) was cost; 42 per cent did not know how or where to get help. Most participants responded “no” or “I don't know” when asked if they had received information about coping with negative emotions after injury and how to seek help from a doctor to address these emotions. Two-thirds preferred to receive such information via phone call from a health care provider or by text. Eighty-nine per cent owned a cellphone. Our trauma systems are failing to provide comprehensive care or look at the ultimate outcomes of our patients, yet modern technology could provide needed resources to patients in novel ways.

Factors associated with non-return to work in the severely injured victims 3 years after a road accident: A prospective study

Road accidents may impact victims' physical and/or mental health and socio-occupational life, particularly the capacity to return to work. The purpose of our study is to assess modifiable medical and socio-occupational factors of non-return to work in the severely injured 3 years after a road accident. Among1,168 road accidents casualties in the Rhône administrative Département of France followed for five years, 141 of the 222 severely injured (Maximal Abbreviated Injury Scale ≥ 3) aged more than 16 years who were in work at the time of the accident, reported whether they had returned to work in the 3 years following the accident. The subgroups of those who had (n=113) and had not returned to work (n=28) were compared for socio-occupational (gender, age, educational level, marital status, socio-occupational group) accident-related medical factors (type of road user, type of journey, responsibility in the accident, initial care) and post-accident medical factors (pain intensity, post-traumatic stress disorder, physical sequelae, quality of life) by using standardized tools. Severity of initial head, face and lower-limb injury, intense persistent pain, post-traumatic stress disorder, poor self-assessed quality of life and health status at 3 years were associated with non-return to work on univariate analysis. On multivariate analysis, severity of initial head and lower-limb injury, intense persistent pain at 3 years and post-traumatic stress disorder were significantly associated with non-return to work 3 years following severe road-accident injury. Post-traumatic stress disorder and chronic pain were essential modifiable medical determinants of non-return to work in the severely injured after a road accident: early adapted management could promote return to work in the severely injured. Improve early adapted treatment of pain and PTSD in the rehabilitation team should help the severely injured return to work following a road accident.