Health-related quality of life after pediatric trauma

Beyond Physical Injury: Routine Screening for Acute Stress Disorder and Posttraumatic Stress Disorder in Pediatric Trauma Patients - A Longitudinal Cohort Pilot Study

INTRODUCTION

Early identification of children at risk for PTSD is critical for improving mental health outcomes after traumatic injury. Currently, there is no standard PTSD screen for pediatric trauma patients and limited data on long-term quality of life for those who screen positive.

METHODS

In 2022, we piloted a comprehensive routine screening program for ASD and PTSD at our Level I PTC. All admitted trauma patients ≥8 years old were eligible for screening. Inpatients were administered the ASC3. Those who screened positive were referred for follow-up and repeat mental health evaluation. PTSD screening (CTSQ, CPSS) and quality-of-life screening (PedsQL™) surveys were administered to eligible discharged trauma patients at 1-month post-injury. Children who screened positive on the CTSQ or CPSS were referred for behavioral health services.

RESULTS

205 children were screened for ASD using the ASC3. 49/205 children (23.9 %) had a positive screen (score ≥3). 56 children completed PTSD screening at 1-month post-discharge. 14/54 children (25.9 %) screened positive on CTSQ, and 8/50 children (16 %) screened positive on CPSS. There was a significant positive correlation between CTSQ and CPSS scores (r 0.76, ∗P<0.0001). When stratified by screening results, patients who screened positive on CTSQ and CPSS were found to have the most significant correlations with poor School and Emotional Functioning on their quality-of-life inventory.

CONCLUSION

Early screening for ASD may be predictive of later development of PTSD in children. Screening using previously validated tools (ASC3, CTSQ, CPSS) were effective in identifying children with negative emotional functioning lasting beyond the acute phase of physical recovery following injury. CTSQ and CPSS both performed well for screening at one-month post-discharge. Early identification can facilitate timely referral to mental health services to potentially minimize long-term socioemotional impact of PTSD.

Burden of unintentional pediatric firearm injury: An examination of the Nationwide Readmission Database

BACKGROUND

Significant increases in firearm-related mortality in the US pediatric population drive an urgent need to study these injuries to drive prevention policies. The purpose of this study was (1) to characterize those with and without readmissions, (2) to identify risk factors for 90-day unplanned readmission, and (3) to examine reasons for hospital readmission.

METHODS

The 2016-2019 Nationwide Readmission Database of the Healthcare Cost and Utilization Project was used to identify hospital admissions with unintentional firearm injury in patients younger than 18 years. Ninety-day unplanned readmission characteristics were assessed and detailed. Multivariable regression analysis was used to assess factors associated with unplanned 90-day readmission.

RESULTS

Over 4 years, 1,264 unintentional firearm injury admissions resulted in 113 subsequent readmissions (8.9%). There were no significant differences in age or payor, but more women (14.7% vs. 23%) and older children (13-17 years [80.5%]) had readmissions. The mortality rate during primary hospitalization was 5.1%. Survivors of initial firearm injury were more frequently readmitted if they had a mental health diagnosis (22.1% vs. 13.8%; p = 0.017). Readmission diagnosis included complications (15%), mental health or drug/alcohol (9.7%), trauma (33.6%), a combination of the prior three (28.3%), and chronic disease (13.3%). More than a third (38.9%) of the trauma readmissions were for new traumatic injury. Female children, those with longer lengths of stay, and those with more severe injuries were more likely to have unplanned 90-day readmissions. Mental health and drug/alcohol abuse diagnoses were not an independent predictor for readmission.

CONCLUSION

This study provides insight into the characteristics of and risk factors for unplanned readmission in the pediatric unintentional firearm injury population. In addition to using prevention strategies, the utilization of trauma-informed care must be integrated into all aspects of care for this population to help minimize the long-term psychological impact of surviving firearm injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Psychometric Properties of the German Version of the Quality of Life after Brain Injury Scale for Kids and Adolescents (QOLIBRI-KID/ADO) Using Item Response Theory Framework: Results from the Pilot Study

Health-related quality of life (HRQOL) is an important indicator for recovery after pediatric TBI. To date, there are a few questionnaires available for assessing generic HRQOL in children and adolescents, but there are not yet any TBI-specific measures of HRQOL that are applicable to pediatric populations. The aim of the present study was to examine psychometric characteristics of the newly developed Quality of Life After Brain Injury Scale for Kids and Adolescents (QOLIBRI-KID/ADO) questionnaire capturing TBI-specific HRQOL in children and adolescents using an item response theory (IRT) framework. Children (8-12 years; n = 152) and adolescents (13-17 years; n = 148) participated in the study. The final version of the QOLIBRI-KID/ADO, comprising 35 items forming 6 scales, was investigated using the partial credit model (PCM). A scale-wise examination for unidimensionality, monotonicity, item infit and outfit, person homogeneity, and local independency was conducted. The questionnaire widely fulfilled the predefined assumptions, with a few restrictions. The newly developed QOLIBRI-KID/ADO instrument shows at least satisfactory psychometric properties according to the results of both classical test theoretical and IRT analyses. Further evidence of its applicability should be explored in the ongoing validation study by performing multidimensional IRT analyses.

A systematic literature review and narrative synthesis on the risk factors for developing affective disorders in open lower-limb fracture patients

Background

Despite the advancements made in the management of the physical complications of open lower-limb fractures, few studies have been performed which investigate the association of such injuries with affective disorders. The complications resulting from this injury may result in significant psychological distress.

Aim

To evaluate the risk factors associated with the development of affective disorders, in patients with open lower-limb fractures.

Methods

A systematic review protocol was registered with PROSPERO and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. A comprehensive literature search was performed to gather relevant papers. Two independent reviewers screened titles and abstracts according to the inclusion and exclusion criteria.

Results

2488 were screened according to the inclusion and exclusion criteria resulting in seven articles eligible for inclusion. Of the seven articles, two assessed for PTSD, one assessed for depression and PTSD concurrently, two assessed for anxiety and depression concurrently, and two assessed for psychological distress. With the exception of two studies, open lower limb fracture patients were included with other lower-limb injuries in their analysis. Furthermore, not all variables were available in all included studies. Risk factors identified included post-operative pain, mechanism and severity of injury, age of patient, social support and social deprivation.

Conclusions

Further studies are required within this area. However, addressing risk factors such as pain management, poor social support and inappropriate coping mechanisms, may reduce the incidence of affective disorders by equipping patients with necessary psychosocial resources.

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Patients with strong social support have, in general, a lower risk of depression and psychological distress.

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Poverty is a risk factor in general for psychological distress.

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Negative affect may play an important role in determining physical function during the recovery period.

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In most patients, symptoms of psychological distress improve over time.

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Not all patients may display symptoms of psychological distress immediately post-injury.

Parent-Reported Health-Related Quality of Life of Pediatric Burn Patients 5 to 7 Years after Burn Injuries: A Multicenter Study

BACKGROUND

 Pediatric burns significantly impact the short-term health-related quality of life (HRQL) of children. Knowledge regarding the long-term impact is scarce. We therefore evaluated the parent-reported HRQL in pediatric burn patients 5 to 7 years after burns.

METHODS

 We invited parents of eligible children admitted to a Dutch Burn Center between August 2011 and September 2012. This sample was enriched with children with severe burns (> 10% of total body surface area [TBSA] burned) admitted between January 2010 and March 2013. The EQ-5D was completed by parents 5 to 7 years postburn. Outcomes and predictive factors were studied and compared between children with minor/moderate and severe burns.

RESULTS

 We included 130 children (mean TBSA burned 7%): 102 children with mild/intermediate burns and 28 with severe burns. Mean EQ-5D summary was 0.96 and EQ visual analogue scale (VAS) 93.1. These outcomes were significantly better in children with minor/moderate burns (0.97; 94.4) compared with children with severe burns (0.93; 88.3) (p < 0.05). Nineteen percent of the children with minor/moderate burns and 43% of those with severe burns reported any problems. The most frequently reported problem was anxiety/depression for both groups. Pain/discomfort (p = 0.012) and cognition (p = 0.035) were statistically significantly worse in children with severe burns compared with those with minor/moderate burns. Full thickness burns and number of surgeries were found to predict long-term HRQL impairment.

CONCLUSION

 Five to seven years postburn, the majority of children in our study (76%) did not experience long-term problems with HRQL. In a minority of the children, burns showed to have a prolonged negative impact, especially in those being severely burned and who had to undergo surgery for their burns. Most experienced problems were related to anxiety/depression. These important insights could be used to inform children and their parents about the expected long-term HRQL after pediatric burns.

Predictors of 12 month functional outcomes and length of stay of severely injured children in NSW, Australia. A longitudinal multi-centre study

BACKGROUND

The majority of paediatric injury outcomes studies focus on mortality rather than the impact on long-term quality of life, health care use and other health-related outcomes. This study sought to determine predictors of 12-month functional and psychosocial outcomes for children sustaining major injury in NSW.

METHODS

The study included all children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW at a paediatric trauma centre (PTC). Children were identified through the three PTCs and NSW Trauma Registry. The paediatric Quality of Life Inventory (PedsQL) and EuroQol five-dimensional EQ-5D-Y were used to measure HRQoL post-injury, completed via parent/carer proxy recruited through NSW PTCs.

RESULTS

There were 510 children treated at the three NSW PTCs during the 15-month study period. The mean (SD) age was 6.7 (6.0) years, with a median NISS (New Injury Severity Score) of 11 (IQR: 9-18). Regression analysis showed worse psychosocial health at twelve months was associated with hospital length of stay (LoS) and number of body regions injured (F₂,₆₅ = 5.85, p = 0.005). Physical outcome was associated with LoS and intensive care unit (ICU) admission (F_2,66 = 13.48, p < 0.001). Hospital LoS was significantly associated with NISS and head injury (F_2,398 = 51.5, p < 0.001).

CONCLUSION

Hospital length of stay and polytrauma are independent factors that negatively influence psychological and physical outcomes of children with major injuries. Early intervention to enable emotional well-being, discharge home and long-term follow up such as dedicated family support and rehabilitation at home could reduce preventable poor outcomes.

Health-related quality of life after pediatric traumatic brain injury: A qualitative comparison between children's and parents' perspectives

BACKGROUND

Pediatric traumatic brain injury (TBI) may cause a wide range of symptoms, which can negatively affect the quality of life of patients and their entire families. No internationally and simultaneously developed disease-specific instrument exists for assessing pediatric health-related quality of life (HRQoL) after TBI. The aim of the current project is to provide original material from small group interviews with individuals after TBI concerning what they state is relevant for their HRQoL. This material is required for a further study to generate items for age-adapted questionnaires assessing the TBI-specific HRQoL of children and adolescents (C&A): the QOLIBRI-Kiddy/Kid/Ado and proxy versions (Quality of Life after Brain Injury-Kiddy/Kids/Adolescents/Proxy) for individuals aged 6-17 and their parents.

METHODS

The semi-structured interviews were conducted with separate small groups of C&A (n = 19), divided into three age groups (5-7y, 8-12y, 13-17y), after mild, moderate, and severe TBI, and with groups of the corresponding parents (n = 26). All interviews lasted for about 60 minutes, were recorded and transcribed verbatim. The statements were investigated by qualitative analyses and sorted into categories relevant to the HRQoL of C&A after TBI. Only descriptive group comparisons but no pairwise comparisons between children and corresponding parents were performed.

RESULTS

The analyses led to 32 subcategories, which were assigned to six main theoretically based HRQoL categories. Many agreements exist between the C&A's and parents' perspectives within the main categories, however their focus on HRQoL differs, especially concerning age-related contents. Parents of the youngest participant group already focus on topics such as autonomy, whereas this only becomes relevant for C&A from the age of eight years on. Interestingly, even 5-year-old children were able to discuss their HRQoL, which indicates the importance of a self-report instrument.

CONCLUSIONS

Results obtained from this qualitative study identify the content of the HRQoL dimensions important for C&A after TBI and their parents. Both, differences and similarities in the children's and the parents' views were investigated, to get a first insight in valid dimensions for the prospective questionnaires to be developed. In a future study, items for the questionnaires will be deducted from the small group interview material and psychometrically tested in C&A after TBI from Germany. This study will address whether all statements were assigned to the suitable dimensions and whether differences between C&A and parents persist.

Predictors of participation and quality of life following major traumatic injuries in childhood: a systematic review

OBJECTIVE

Review the literature on predictors of participation and quality of life in children and young people who sustained a traumatic brain injury (TBI), spinal cord injury (SCI), and/or multi-trauma in a motor vehicle or other accident or trauma.

DESIGN

This systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered on PROSPERO (registration number CRD42020131698). Electronic databases were searched for studies published between January 2000 and August 2020. Prospective and retrospective cohort studies were considered and risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

The search yielded 5771 articles of which 30 studies met the inclusion criteria. Nineteen studies included patients with TBI and 11 with SCI. No studies of patients with multi-trauma met criteria. Evidence was found for associations with various factors (e.g., injury severity, level of education, mental health problems), although these findings are limited due to the quality of the studies (5 studies moderate and 25 high risk of bias).

CONCLUSION

Research on predictors of participation and quality of life following major traumatic injuries in childhood is lacking. More methodologically sound prospective, longitudinal studies are needed across different injury groups to further elucidate predictors of outcome.IMPLICATIONS FOR REHABILITATIONWhile long-term participation and quality of life is influenced by injury characteristics (i.e., injury severity), a number of potential modifiable factors can be targeted to improve outcomes following traumatic injuries in childhood.Young people should be provided with support to stay in school and pursue further education.Early intervention and prevention of mental health problems may improve long-term outcomes.Better management of ongoing medical problems and greater support for functional independence may improve participation.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre

AIM

We examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.

METHOD

Patients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured.

RESULTS

We identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation.

CONCLUSION

Limb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Quality of life and post-traumatic stress symptoms in paediatric patients with tibial fractures during treatment with cast or Ilizarov frame

PURPOSE

To compare quality of life in children and adolescents with tibial fracture during treatment with either a definitive long-leg cast or Ilizarov frame.

METHODS

A prospective, longitudinal cohort study was undertaken. Patients aged between 5 and 17 years with tibial fractures treated definitively using a long-leg cast or Ilizarov frame were recruited at first follow-up. Health related quality of life was measured at each clinic appointment during treatment using the Pediatric Quality of Life Inventory (PedsQL) [1]; a validated measure of age-adjusted physical and psychosocial functioning. Psychological trauma symptoms were assessed using the Children's Revised Impact of Events Scale (CRIES) [2]. Results were analysed based on time from injury (less than 30 days, 30 to 120 days). Data regarding injury and treatment was recorded from the clinical records. Statistical analysis was undertaken using a Kruksal-Wallis test with a Tukey-Kramer subgroup analysis.

RESULTS

Twenty-five patients from each group were included in the final analysis. Injuries were more severe in the frame patients based on the AO/OTA classification and number of open fractures. No statistically significant differences were detected in any of the outcome scores between treatment groups at either time point. A significant improvement was found in the child reported physical and total domains in both treatment groups based on time from application (<30 days vs. >30 days, frame: p < 0.0001, cast: p = 0.003). There were no differences in the child reported psychosocial domain scores at any time point or between treatment groups. Parent reported scores only showed a significant physical improvement in the frame group (p < 0.0001). CRIES scores for psychological trauma in the intrusion and avoidance domain improved significantly in the cast group between time points (p < 0.05), Multivariate analysis identified polytrauma, mechanism of injury and time from injury but not treatment modality (cast or frame) as significant predictors of quality of life scores (PedsQL) and severity of post-traumatic symptoms (CRIES).

CONCLUSION

We found no difference in health-related quality of life during treatment between our patients treated for tibial fractures using a cast or an Ilizarov frame.

Association between unintentional injuries and self-harm among adolescent emergency department patients

BACKGROUND

Unintentional injury, a leading cause of morbidity among adolescents, may also be a risk factor for deliberate self-harm. To inform clinical and public health prevention efforts in adolescent populations, we examined whether distinct subtypes of unintentional injury were differentially associated with deliberate self-harm.

METHODS

Statewide, all-payer, individually linkable administrative data on adolescent patients presenting to any California emergency department (ED) in 2010 (n = 490,071) were used to investigate longitudinal associations between subtypes of unintentional injury and deliberate self-harm. Adolescents aged 10-19 years presenting with unintentional drug poisoning, other poisoning, fall, suffocation, or cutting/piercing injuries formed the exposure groups; adolescents presenting with unintentional strike injuries formed the primary referent group. Study patients were followed back in time (2006-2009) to compare the groups' odds of a prior ED visit for deliberate self-harm, as well as forwards in time (2010-2015) to compare their risks of subsequent self-harm.

RESULTS

Unintentional drug-poisoning injury was strongly associated with increased likelihood of ED visits for deliberate self-harm, assessed both retrospectively (adjusted OR = 4.52; 95% confidence interval [CI] = 3.08, 6.64) and prospectively (adjusted RR = 3.74; 95% CI = 3.03, 4.60). Positive associations with odds of prior self-harm and/or risk of subsequent self-harm were also observed for patients with unintentional non-drug poisoning, suffocation, and cutting/piercing injuries.

CONCLUSIONS

Certain subtypes of unintentional injury, particularly drug poisoning, are strongly associated with risk for deliberate self-harm among adolescents, a finding with implications for targeting clinical assessment and intervention in emergency department settings. More research is needed to understand the mechanisms underlying these associations.

Disparities in Non-Fatal Health Outcomes in Pediatric General Trauma Studies

When prevention efforts fail, injured children require high-quality health services to support their recovery. Disparities in non-fatal injury outcomes, an indicator of health-care quality, have received minimal attention. We evaluated the extent to which general trauma follow-up studies published in the peer-reviewed scientific literature provide evidence of socially patterned inequities in health, functional or disability outcomes ≥4 weeks after childhood injuries. Using a systematic search, we identified 27 eligible cohort studies from 13 high-income countries. We examined the extent to which the reported health outcomes varied across the PROGRESS criteria: place of residence, race/ethnicity, occupation, gender/sex, religion, socio-economic status, and social capital. The available evidence on differential outcomes is limited as many studies were compromised by selection or retention biases that reduced the participation of children from demographic groups at increased risk of adverse outcomes, or the analyses mainly focused on variations in outcomes by sex. Given the limited research evidence, we recommend greater attention to systematic collection and reporting of non-fatal injury outcomes disaggregated by socio-demographic indicators in order to identify disparities where these exist and inform equity-focused interventions promoting the recovery of injured children.

The Relationship Between Traumatic Injury in Children and Long-Term Use of Health and Social Services by Children and Their Families

To increase understanding of relationships between general traumatic injury in children and long-term use of resources in the health care and social services (HSS) sectors by these children and their families 8-10 years after traumatic injury. This study was a cross-sectional retrospective cohort study of prognosis from 2001 to 2003 that quantified recent expenditures on and use of HSS by children and also by their parents. Forty-eight cases of children were selected from the Hamilton Health Sciences pediatric trauma database in the period from January 2001 to December 2003 after incurring a traumatic injury with Injury Severity Score greater than 12. The average total cost to the HSS system per child's family was $4,326.62 during the preceding 6 months. During the same period, average use of HSS was 7 visits. Total service costs incurred by caregivers of injured children increased with severity of the traumatic injury (p= .009). Caregiver HSS use was higher when the injury was caused by a motor vehicle accident than by other types of accidents (p< .001) and increased with the injury severity (p< .001). HSS use by children was related to gender (p< .001), injury mechanism (p< .001), age at accident (p< .001), and time since accident (p= .012), among other factors. Pediatric trauma appears to have long-term effects on expenditures on and use of HSS by the affected children and their families. The findings emphasize the need for long-term assessment and possible delivery of services to the families of the injured children.

A preliminary examination of child well-being of physically abused and neglected children compared to a normative pediatric population

Federal mandates require state child welfare systems to monitor and improve outcomes for children in three areas: safety, permanency, and well-being. Research across separate domains of child well-being indicates maltreated children may experience lower pediatric health-related quality of life (HRQL). This study assessed well-being in maltreated children using the Pediatric Quality of Life Inventory (PedsQL 4.0), a widely used measure of pediatric HRQL. The PedsQL 4.0 was used to assess well-being in a sample of children (N = 129) receiving child welfare services following reports of alleged physical abuse or neglect. We compared total scores and domain scores for this maltreated sample to those of a published normative sample. Within the maltreated sample, we also compared well-being by child and family demographic characteristics. As compared with a normative pediatric population, maltreated children reported significantly lower total, physical, and psychosocial health. We found no significant differences in total and domain scores based on child and parent demographics within the maltreated sample. This preliminary exploration indicates children receiving child welfare services have significantly lower well-being status than the general child population and have considerable deficits in social and emotional functioning. These findings support continued investment in maltreatment prevention and services to improve the well-being of victims of maltreatment.

Quality-of-life after brain injury in childhood: time, not severity, is the significant factor

OBJECTIVE

Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.

METHODS

The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.

RESULTS

The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.

CONCLUSIONS

QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.

Assessing recovery and disability after physical trauma: the Pediatric Injury Functional Outcome Scale

OBJECTIVE

To establish reliability and validity of the Pediatric Injury Functional Outcome Scale (PIFOS), a brief injury-specific rating scale covering motor, self-care, communication, social-emotional, cognition, physical, and academic areas.

METHODS

In a prospective longitudinal study, the PIFOS structured interview was administered to parents of children 3-15 years of age at 3 and 12 months after hospitalization for traumatic brain injury (TBI) or orthopedic injury (OI).

RESULTS

The total score had good internal consistency (α = .90-.93) and inter-rater reliability (α = .90) and correlated significantly with injury severity and neurodevelopmental outcomes. Generalized linear modeling showed the PIFOS was sensitive to the type and severity of injury, showed specific initial and persisting difficulties following TBI and OI, and was responsive to change during the first year after injury. Both groups had residual difficulties with coordination, emotionality, social participation, and discomfort.

CONCLUSION

The PIFOS is useful in examining recovery in natural history and intervention studies.

A comparison of quality improvement practices at adult and pediatric trauma centers*

OBJECTIVES

Quality assurance practices are structured performance improvement and patient safety processes designed to continuously monitor, evaluate, and improve the performance of a trauma program. These practices are integral in the provision of quality injury care, and yet no comprehensive description of existing quality improvement practices used by pediatric trauma centers is available. Therefore, we compared the quality improvement programs used in adult and pediatric trauma centers by performing a reanalysis of our recent survey of trauma quality improvement practices in Canada, United States, Australia, and New Zealand.

DESIGN

Prospective observational study.

SETTING

Pediatric and adult trauma centers in United States, Canada, and Australasia.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS

We surveyed 184 trauma centers verified by professional trauma organizations in the United States, Canada, and Australasia regarding their quality improvement programs. Centers were classified according to population served (adult, adult and pediatric, or pediatric patients), and quality improvement programs were compared using descriptive statistics.

RESULTS

Most of the trauma centers reported engagement in quality improvement activities. Adult centers devoted a larger percentage of their quality indicators to the measurement of safety (adult 50% vs adult and pediatric 53% vs pediatric 38%, p < 0.001), whereas pediatric centers placed a greater emphasis on the timeliness of care (20% vs 24% vs 30%, p < 0.001). Few centers used quality indicators to measure the patient-centered nature of care, long-term outcomes, or secondary injury prevention.

CONCLUSIONS

Opportunities for the improvement of pediatric quality improvement programs exist including a need to determine the optimal structure for trauma quality improvement, develop patient-centered quality indicators of injury care, measure long-term outcomes, and create measures of secondary injury prevention.

Physical disability after injury-related inpatient rehabilitation in children

OBJECTIVE

To determine the residual physical disability after inpatient rehabilitation for children 7 to 18 years old with traumatic injuries.

METHODS

This was a retrospective cohort study of patients aged 7 to 18 years who underwent inpatient rehabilitation for traumatic injuries from 2002 to 2011. Patients were identified from the Uniform Data System for Medical Rehabilitation. Injuries were captured by using standardized Medicare Inpatient Rehabilitation Facility Patient Assessment Instrument codes. Functional outcome was measured with the Functional Independence Measure (FIM) instrument. A validated, categorical grading system of the FIM motor items was used, consisting of clinically relevant levels of physical achievement from grade 1 (need for total assistance) to grade 7 (completely independent for self-care and mobility).

RESULTS

A total of 13,798 injured children underwent inpatient rehabilitation across 523 facilities during the 10-year period. After a mean 3-week length of stay, functional limitations were reduced, but children still tended to have residual physical disabilities (median admission grade: 1; median discharge grade: 4). Children with spinal cord injuries, either alone or in combination with other injuries, had lower functional grade at discharge, longer lengths of stay, and more comorbidities at discharge than those with traumatic brain injuries, burns, and multiple injuries (P < .0001 for all comparisons).

CONCLUSIONS

Children had very severe physical disability on admission to inpatient rehabilitation for traumatic injuries, and those with spinal cord injuries had persistent disability at discharge. These traumatic events during critical stages of development may result in a substantial care burden over the child's lifespan.

Health-related quality of life in children and adolescents following traumatic injury: a review

This paper comprehensively reviews the published literature investigating health-related quality of life (HRQOL) following general traumatic injury in individuals between birth and 18 years. Studies were not considered if they primarily compared medical treatment options, evaluated physical function but not other aspects of HRQOL, or focused on non-traumatic wounds. Specific injury types (e.g., burn injury) were also not included. A total of 16 studies met criteria. Participants were age 1-18 years, with 12 studies considering children 5 years of age or older. Males were overrepresented. Injury severity averaged mostly in the moderate range. HRQOL deficits were noted in injured samples in all studies except the two with the longest time to follow-up (6-11 years). Some improvement was seen 6 months to 2 years after injury. Factors associated with HRQOL deficits were investigated, with acute and posttraumatic stress disorder symptoms showing the strongest relationship. Research to date in this area is impressive, particularly the number of studies using prospective longitudinal investigations and validated measures. Challenges remain regarding methodologic differences, assessment of preinjury status, retention of participants, and management of missing data. Suggested future directions include extension of follow-up duration, utilization of pediatric self-report when possible, inclusion of younger children, and development of intervention programs.

Health-related quality of life in the aftermath of child maltreatment: follow-up study of a hospital sample

OBJECTIVE

In the aftermath of child maltreatment or neglect, the health-related quality of life (HRQoL) in children is likely to be affected. However, research on quality of life in maltreated children is lacking. The aim of this study is to compare the HRQoL in a follow-up sample of children referred to an interdisciplinary hospital child protection team (CPT) to match controls and to explore correlates of HRQoL.

METHOD

Of the 319 in- and outpatient children referred to the CPT at the University Children's Hospital Zurich between 2005 and 2006, an eligible sample of 180 children was contacted for a follow-up. HRQoL was assessed for 42 former patients using the self- and proxy-rated KIDSCREEN-27 for children above the age of 6 years and the TAPQOL parent report for children younger than 6 years. HRQoL-scores in the maltreatment group were compared with HRQoL in 39 matched controls.

RESULTS

Self-reported HRQoL in maltreated children above the age of 6 years was significantly impaired compared to matched controls. The caregiver-rated HRQoL of maltreated children, however, was not affected. Low socioeconomic status and number of life events were associated with impaired self-reported HRQoL. Analyzed together with these factors, maltreatment lost its predictive power on HRQoL.

CONCLUSION

Maltreated children and adolescents suffer from impaired HRQoL even after the maltreatment has been disclosed and targeted by interventions. The impact of socioeconomic environment reinforces the importance of a multidisciplinary and systemic approach to maltreatment as applied by the CPT. Although the nature of discordance between child and caregiver report is not known, researchers and clinicians are strongly encouraged to assess the victim's self-reported HRQoL independently of their proxies' view.

Neurologic long term outcome after drowning in children

Drowning is a major source of mortality and morbidity in children worldwide. Neurocognitive outcome of children after drowning incidents cannot be accurately predicted in the early course of treatment. Therefore, aggressive out-of-hospital and in-hospital treatment is emphasized. There are "miracle" cases after long submersion times that have been reported in the medical literature, which mostly concern small children. However, many of the survivors will remain severely neurologically compromised after remarkably shorter submersion times and will consequently be a great burden to their family and society for the rest of their lives. The duration of submersion, the need of advanced life support at the site of the accident, the duration of cardiopulmonary resuscitation, whether spontaneous breathing and circulation are present on arrival at the emergency room are important factors related to survival with mild neurological deficits or intact function in drowned children. Data on long-term outcome are scarce. The used outcome measurement methods and the duration of follow-up have not been optimal in most of the existing studies. Proper neurological and neurophysiological examinations for drowned children are superior to outcome scales based chart reviews. There is evidence that gross neurological examination at the time of discharge from the hospital in young children does not reveal all the possible sequelae related to hypoxic brain injury and thus long-term follow-up of drowned resuscitated children is strongly recommended.

Pediatric trauma due to motor vehicle accidents on high traffic roadway

OBJECTIVE: To outline a profile of pediatric trauma victims and verify the likelihood of trauma in children on a high traffic roadway. METHODS: A descriptive cohort study of the records of emergency medical service activations on the Rio-Niterói Bridge, a high traffic roadway in Rio de Janeiro, Brazil. Descriptive statistics were expressed as absolute and relative frequencies. The estimated risk of trauma in children aged < 12 years was calculated by means of odds ratios, with a 95% confidence interval. RESULTS: Trauma accounted for 514 of 1,244 activations (41.31%) of the Rio-Niterói Bridge emergency medical service between March 2002 and March 2003. Response to incidents involving children aged < 12 years accounted for 52 of these (4.18%). Half of victims were between the ages of 6 and 12 years (n = 26), and 55.76% were male (n = 29). Of the 52 victims, 37 (71.15%) were involved in motor vehicle accidents (OR: 3.70; 95%CI: 1.94-7.13; p < 0.0001). Of these, 28 were vehicle-vehicle collisions (75.67%). The most common sites of injury were the extremities (n = 12; 32.43%), face (n = 10; 27.02%), and head (n = 9; 24.32%). Pre-hospital procedures were performed on 23 of the 37 patients (62.16%), and 44.23% (n = 23/52) required hospital transportation. There were no deaths during the study period. CONCLUSIONS: In this study, children were at significantly higher odds of being treated for trauma while on a highway with heavy traffic flow. The most common sites of injury in this sample were the lower extremities and the head, face, and neck complex.

Re-orientation of clinical research in traumatic brain injury: report of an international workshop on comparative effectiveness research

During the National Neurotrauma Symposium 2010, the DG Research of the European Commission and the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS) organized a workshop on comparative effectiveness research (CER) in traumatic brain injury (TBI). This workshop reviewed existing approaches to improve outcomes of TBI patients. It had two main outcomes: First, it initiated a process of re-orientation of clinical research in TBI. Second, it provided ideas for a potential collaboration between the European Commission and the NIH/NINDS to stimulate research in TBI. Advances in provision of care for TBI patients have resulted from observational studies, guideline development, and meta-analyses of individual patient data. In contrast, randomized controlled trials have not led to any identifiable major advances. Rigorous protocols and tightly selected populations constrain generalizability. The workshop addressed additional research approaches, summarized the greatest unmet needs, and highlighted priorities for future research. The collection of high-quality clinical databases, associated with systems biology and CER, offers substantial opportunities. Systems biology aims to identify multiple factors contributing to a disease and addresses complex interactions. Effectiveness research aims to measure benefits and risks of systems of care and interventions in ordinary settings and broader populations. These approaches have great potential for TBI research. Although not new, they still need to be introduced to and accepted by TBI researchers as instruments for clinical research. As with therapeutic targets in individual patient management, so it is with research tools: one size does not fit all.

Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms

OBJECTIVES

Mild traumatic brain injury (TBI) and injury-related outcomes such as postconcussive symptoms (PCS) may influence health-related quality of life (HRQOL) in children.

METHODS

We evaluated HRQOL in 186 8- to 15-year-old children with mild TBI and 99 children with orthopedic injuries (OI). Parents rated the frequency and severity of PCS at an initial assessment within 2-weeks postinjury and rated HRQOL at 3- and 12-months postinjury.

RESULTS

The mild TBI and OI groups did not differ in psychosocial HRQOL, but the mild TBI group showed lower physical HRQOL at the 12-month follow-up. Somatic PCS were a significant predictor of physical HRQOL over time, and both cognitive and somatic PCS were significant predictors of psychosocial HRQOL over time. Children with higher PCS at the initial assessment had lower HRQOL scores at later time points.

CONCLUSIONS

Effective management of PCS may be associated with improvements in HRQOL following pediatric mild TBI.

Community integration following severe childhood traumatic brain injury

PURPOSE OF REVIEW

Severe childhood traumatic brain injury (TBI) is the leading cause of death and acquired disability in children, causing impairments in children's sensory-motor, cognitive and behavioural functioning, with devastating consequences on community integration. Community integration is the ultimate goal of rehabilitation; it is a complex outcome, with many variables contributing to it.

RECENT FINDINGS

Community integration and quality of life (QOL) are lower in children who sustained severe TBI at a younger age. Further, a wide range of injury-related, demographic and postinjury factors influence outcomes, and should serve as targets for specific interventions. An increasing number of interventions targeting cognitive, behavioural or family-related issues have been developed, with promising results.

SUMMARY

Children should benefit from early integrated patient and family-centred specific care, and receive long-term follow-up until early adulthood, with regular assessments, enabling detection and treatment of any emerging problem, and to ensure the acquisition of independent living skills and stable vocational outcome when this is possible. So far, few well conducted intervention studies are available, but their number is increasing with positive results on the trained skills. Well designed studies using large samples and looking at generalization of the skills in everyday life are needed.

Health-related quality of life after a drowning incident as a child

AIM OF THE STUDY

To describe health-related quality of life (HRQoL), quality-adjusted life years (QALYs) gained and school performance in subjects having received either bystander or emergency medical service personnel initiated cardiopulmonary resuscitation (CPR) after a drowning incident in childhood.

MATERIALS AND METHODS

64 children admitted to pediatric intensive care (PICU) after successful CPR between 1985 and 2007. Eleven died in the PICU, 9 other within 6 months. In 2009 all long-term survivors, except for two, lived at home. Of the 40 patients eligible for the study, 29 (73%) responded to a questionnaire. HRQoL was assessed with the generic 15D, or its versions for adolescents (16D) or children (17D), and compared to that of general population. These HRQoL scores, age-specific survival probabilities, and HRQoL scores of the general population were used in a Markov model to estimate the number of QALYs gained.

RESULTS

Median age of the respondents was 17.3 (range: 3.0-28.4) years and 62% were male. At the time of drowning their median age had been 3.0 (range: 1.2-15.7) years. The drowning incident was associated with a significant loss in HRQoL in the oldest age group (total HRQoL total score 0.881 compared to 0.971 in the general population, P<0.01) but not in children (HRQoL score 0.944 vs. 0.938). When submersion time exceeded 10min mean HRQoL score was significantly lower than in patients with a shorter submersion (0.844 vs. 0.938, P=0.032). The mean undiscounted and discounted (at 3%) number of QALYs gained by treatment were 40.8 and 17.0, respectively.

CONCLUSIONS

A good HRQoL will be achieved in the majority of patients surviving long-term after a drowning incident in childhood, although HRQoL is affected by the submersion time.