Body mass index is not associated with time on veno-venous extracorporeal membrane oxygenation or in-hospital mortality.

Morbid obesity, as characterized by BMI, is often utilized as an exclusion criterion for VV-ECMO because of presumed poor prognosis and technically complex cannulation. However, the "obesity paradox" suggests obesity may be protective during critical illness, and BMI does not capture variations in body type, adiposity, or fluid balance. This study examines relationships between BMI and patient outcomes. Adult VV-ECMO patients with BMI ≥ 35 kg/m2 admitted January 2012 to June 2021 were identified from an institutional registry. BMI and outcomes were analyzed with Mann-Whitney U tests and Pearson correlations with Bayesian post-hoc analyses. 116 of 960 ECMO patients met inclusion criteria. Median (Q1, Q3) BMI was 42.3 (37.3, 50.8) and min, max of 35.0, 87.8 with 9.0 (5.0, 15.5) ECMO days. BMI was not significantly correlated with ECMO days (r = -0.102; p = .279). Bayesian analyses showed moderate evidence against BMI correlating with ECMO days. In-hospital mortality (27%) was significantly associated with ECMO days (p = .014) but not BMI (p = .485). In this cohort of high-BMI patients, BMI was not associated with survival or time on ECMO. BMI itself should not be used as an exclusion criterion for VV-ECMO.

Utilizing psoas muscle cross-sectional area to predict functional outcome.

Background: This study evaluated psoas muscle area (PMA) as a predictor of frailty and functional outcome in trauma patients. Methods: The cohort included 211 trauma patients admitted to an urban level I trauma center from March 2012 to May 2014 who consented to participate in a longitudinal study and underwent abdominal-pelvic computed tomography scans during their initial evaluation. Physical component scores (PCS) of the Veterans RAND 12-Item Health Survey were administered to assess physical functionality at baseline and at 3, 6, and 12 months after injury. PMA in mm2 and Hounsfield units was calculated using the Centricity PACS system. Statistical models were stratified by injury severity score (ISS), <15 or ≥15, and adjusted for age, sex, and baseline PCS. Follow-up PCS were analyzed using general linear regression models. Results: For participants with an ISS <15, increased PMA was significantly associated with higher PCS at 3 (P = 0.008), 6 (P = 0.02), and 12 months (P = 0.002), although this relationship was not statistically significant for ISS ≥15 (P = 0.85, 0.66, 0.61). Conclusion: For mild to moderately injured (but not seriously injured) patients, those with larger psoas muscles experience better functional outcomes after injury.

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84. CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: Prognostic, level IV.

Driver see, driver crash: Associations between televised stock car races' audience size and the incidence of speed-related motor vehicle collisions in the United States.

Several studies have examined road rage, but few studies have examined other psychosocial factors that may contribute to the number of motor vehicle collisions (MVCs). One study found increases in MVCs in West Virginia following televised NASCAR races but did not account for audience size. This study examined associations between NASCAR's television viewership ratings and the incidence of speed-related MVCs in the USA using generalized estimating equations that controlled for seasonal effects, intoxication, road surface conditions, and lighting conditions. A 1% increase in the number of US households watching NASCAR races per month was associated with a 6.3% (95% confidence interval [CI], 3.0% to 9.7%; P < 0.001) increase in the incidence of speed-related MVCs-approximately 4911 (95% CI, 2353 to 7470) speed-related MVCs per month or one speed-related MVC per 595 (95% CI, 382 to 1354) viewers. As expected, similar results were not found for the total number of MVCs. These data suggest that televised NASCAR races may be associated with substantial increases in the incidence of speed-related MVCs. Making drivers aware of psychological factors that may increase risky driving behaviors could prove beneficial because self-monitoring can result in safer driving.

Better with age? A comparison of geriatric and non-geriatric trauma patients' psychological outcomes 6 months post-injury.

This is the first study to compare both physical and psychological outcomes in geriatric and non-geriatric patients (n = 268) at baseline and 6 months post-trauma. Demographic, clinical, and psychological data, including screens for alcohol use, depressive symptoms, and post-traumatic stress symptoms (PTSS) were collected from 67 geriatric patients (70.7 ± 8.0 years) and 201 non-geriatric patients (40.2 ± 12.8 years) admitted to a Level I trauma center for ≥ 24 h. Geriatric patients were significantly less likely to screen positive for alcohol use at baseline, and depression, PTSS, and alcohol use at follow-up. When not controlling for discharge to rehabilitation or nursing facility, geriatric patients had significantly lower odds of alcohol use at follow-up. There was no significant difference in injury severity, resilience, or pre-trauma psychological status between the two groups. Results indicate that geriatric trauma patients fare better than their younger counterparts at 6 months post-trauma on measures of alcohol use, depression, and PTSS. Screenings and interventions for both age groups could improve psychological health post-trauma, but younger patients may require additional attention.

Craniofacial Trauma Is Associated With Significant Psychosocial Morbidity 1 Year Post-Injury.

PURPOSE: The face and head play critical roles in one's sense of self and body image; as such, facial, head, and scalp injuries and potential associated disfigurement can lead to particular difficulties in coping. This study examined the psychosocial outcomes of patients with craniofacial (CF) trauma 1 year after injury and compared these outcomes with those of other traumatically injured patients who did not sustain such injuries. It was hypothesized that participants in the CF injury group would have worse outcomes than those without CF trauma. MATERIALS AND METHODS: This prospective longitudinal study included patients at least 18 years of age admitted to the trauma service of a level I trauma center for at least 24 hours. Demographic and injury-related variables were collected. CF injury was determined by International Classification of Diseases, Ninth Revision codes. Outcomes were measured at baseline and at 12 months and included depression, post-traumatic stress disorder (PTSD), alcohol use, and pain severity. Paired t tests and logistic regression were used for analysis. RESULTS: Fifteen percent (n = 35) of the study sample (N = 230) had CF injuries. Those with CF injuries had lower income, higher injury severity, and higher intensive care unit admission rates. The CF and non-CF trauma groups did not differ in rates of depression or PTSD at either time point. However, participants with CF trauma had higher odds of risky alcohol use than those without CF trauma at baseline and lower odds of a higher pain severity score at baseline and 12 months. CONCLUSIONS: The groups did not differ in depression and PTSD. However, rates of depression, PTSD, alcohol use, and physical pain were higher than expected for the 2 groups. Given the high rate of psychological morbidity found after CF trauma, patients with these injuries should be screened for symptoms soon after injury and provided with resources for treatment.

Avoiding Cribari gridlock: The standardized triage assessment tool improves the accuracy of the Cribari matrix method in identifying potential overtriage and undertriage.

BACKGROUND: The Cribari matrix method (CMM) is the standard to identify potential overtriage and undertriage but requires case reviews to correct for the fact that Injury Severity Score does not account for physiology or comorbidities, nor is it well correlated with resource consumption. Further, the secondary reviews introduce undesirable subjectivity. This study assessed if the Standardized Triage Assessment Tool (STAT)-a combination of the CMM and the Need For Trauma Intervention-could more accurately determine overtriage and undertriage than the CMM alone. METHODS: The registry of an American College of Surgeons verified Level I adult trauma center in Texas was queried for all new emergency department traumas 2013 to 2016 (n = 11,110). Binary logistic regressions were used to test the associations between the triage determinations of each metric against indicators of injury severity (risk factors, complications, and mortality) and resource consumption (number of procedures in 3 days and total length of stay). RESULTS: Both metrics were associated with the indicators of injury severity and resource consumption in the expected directions, but STAT had stronger or equivalent associations with all variables tested. Using the CMM, there was 50.4% overtriage and 9.1% undertriage. Using STAT, overtriage was reduced to 30.8% (relative reduction = 38.9%) and undertriage was reduced to 3.3% (relative reduction = 63.7%). CONCLUSION: Using the CMM with secondary case reviews makes valid multi-institutional triage rate comparisons impossible because of the subjective and unstandardized nature of these reviews. STAT's out-of-box triage determinations (i.e., without manual case review) outperformed CMM in almost every tested variable for both over- and undertriage. STAT, an automatic, standardized method offers significant improvements compared to the current subjective system. Further, by accounting for both anatomic injury severity and resource consumption, STAT may allow trauma centers to better allocate resources and predict patient needs with fewer cases requiring manual review. LEVEL OF EVIDENCE: Prognostic, level III.

Prospective Evaluation of Posttraumatic Stress Disorder and Depression in Orthopaedic Injury Patients With and Without Concomitant Traumatic Brain Injury.

OBJECTIVES: Psychological morbidities after injury [eg, posttraumatic stress disorder (PTSD) and depression] are increasingly recognized as a significant determinant of overall outcome. Traumatic brain injury (TBI) negatively impacts outcomes of patients with orthopaedic injury, but the association of concurrent TBI, orthopaedic injury, and symptoms of PTSD and depression has not been examined. This study's objective was to examine symptoms of PTSD and depression in patients with orthopaedic trauma with and without TBI. DESIGN: Longitudinal prospective cohort study. SETTING: Urban Level I Trauma Center in the Southwest United States. PATIENTS/PARTICIPANTS: Orthopaedic trauma patients older than 18 years admitted for ≥24 hours. MAIN OUTCOME MEASUREMENTS: Questionnaires examining demographics, injury-related variables, PTSD, and depression were administered during hospitalization and 3, 6, and 12 months later. Orthopaedic injury and TBI were determined based on ICD-9 codes. Generalized linear models determined whether PTSD and depression at follow-up were associated with TBI. RESULTS: Of the total sample (N = 214), 44 (21%) sustained a TBI. Those with TBI had higher rates of PTSD symptoms, 12 months postinjury (P = 0.04). The TBI group also had higher rates of depressive symptoms, 6 months postinjury (P = 0.038). CONCLUSIONS: Having a TBI in addition to orthopaedic injury was associated with significantly higher rates of PTSD at 12 months and depression at 6 months postinjury. This suggests that sustaining a TBI in addition to orthopaedic injury places patients at a higher risk for negative psychological outcomes. The findings of this study may help clinicians to identify patients who are in need for psychological screening and could potentially benefit from intervention. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Alcohol Use, History of Homelessness, and Intent of Injury Among a Sample of Adult Emergency Department Patients.

BACKGROUND: The literature is clear that adults who are currently homeless also have higher rates of intentional injuries, such as assault and suicide attempts. No study has assessed whether intentional injuries are exacerbated because of substance use among adults with a history of homelessness. METHODS: Data were obtained from a cohort of adults admitted to 3 urban emergency departments (EDs) in Texas from 2007 to 2010 (N = 596). Logistic regression analyses were used to determine whether a history of homelessness was associated with alcohol use at time of injury in intentional violent injuries (gunshot, stabbing, or injury consistent with assault). RESULTS: 39% adults with a history of homelessness who were treated at trauma centers for a violent injury. Bivariate analyses indicated that adults who had ever experienced homelessness have 1.67 increased odds, 95% confidence interval (CI) [1.11, 2.50], of any intentional violent injury and 1.95 increased odds (95% CI [1.12, 3.40]) of a stabbing injury than adults with no history of homelessness. CONCLUSIONS: Adults who experienced homelessness in their lifetime were more likely to visit EDs for violencerelated injuries. Given our limited knowledge of the injuries that prompt ED use by currently homeless populations, future studies are needed to understand the etiology of injuries, and substance-related injuries specifically, among adults with a history of homelessness.

Discrepancy in caregiving expectations predicts problematic alcohol use among caregivers of trauma injury patients six months after ICU admission.

This prospective study examined the influence of caregiving variables on the development of problematic alcohol use among family members of patients admitted to an urban Level I trauma center. Data were collected from 124 caregivers 48 hrs after initial hospitalization of their family member. The final sample included 81 participants (24.6% male; Mage = 47.8) who completed their follow-up assessment at 6 months. Hierarchical linear and logistic regression analyses assessed increases in consumption and odds of a positive screen for problematic alcohol use in association with caregiver burden, actual time spent in the caregiving role, and caregiving differential (i.e., anticipated time spent caregiving at baseline in relation to actual time caregiving at 6 months). At 6 months, 24.7% of caregivers screened positive for problematic alcohol use. Results uniquely highlighted caregiving differential as a significant predictor of both increases in general alcohol consumption (ΔR2 = .06, p < .01) and odds of screening positive for problematic alcohol use at 6 months (Odds Ratio = 1.05, 95% CI [1.02-1.09]). More specifically, our adjusted model found that providing 10% more time caregiving, relative to expectations at baseline, was associated with an increase in the probability of problematic alcohol use by 22% (95% CI: 8-37%) at 6 months. These results suggest that a discrepancy in expectations regarding anticipated time caregiving and actual time caregiving, rather than solely the amount of caregiving or perceived caregiver burden, may be an important predictor of caregiver alcohol use 6 months after a family member's ICU hospitalization. (PsycINFO Database Record

Severity of traumatic injuries predicting psychological outcomes: A surprising lack of empirical evidence.

Despite widespread beliefs that trauma severity is related to levels of posttraumatic stress symptoms (PTSS), the empirical evidence to support such beliefs is lacking. In the current study we examined Injury Severity Score (ISS), a medical measure of event severity for physical injuries, in a sample of 460 patients admitted to a Level 1 Trauma Center. Results revealed no significant relationship between ISS and PTSS, depression, pain, and general physical and mental health at baseline, three months, and six months post-injury. However, at 12 months post-injury, ISS significantly predicted depression, pain, and physical health, but was unrelated to PTSS. The effect sizes of these relationships were small and would not remain significant if any adjustments for multiple comparisons were employed. We conclude that the relationship between ISS and PTSS is, at best, weak and inconsistent. The results are discussed in the broader picture of event severity and psychological outcomes.

Asking a Better Question: Development and Evaluation of the Need For Trauma Intervention (NFTI) Metric as a Novel Indicator of Major Trauma.

Many existing metrics, such as Injury Severity Score (ISS), cannot fully describe many trauma patients because of comorbidities. This study developed and evaluated the Need For Trauma Intervention (NFTI) metric as a novel indicator of major trauma. The NFTI metric was developed from an analysis of 2,396 trauma patients at a Level I trauma center. Six commonly recorded registry variables were found to be indicative of major trauma and comprised the NFTI criteria: receiving packed red blood cells within 4 hr; discharge from the emergency department (ED) to the operating room within 90 min; discharge from the ED to interventional radiology; discharge from the ED to the intensive care unit (ICU) with an ICU length of stay (LOS) of 3 or more days; mechanical ventilation outside of procedural anesthesia within 3 days; or death within 60 hr. Patients meeting any NFTI criteria are classified as having major traumas and, therefore, needing trauma activations (NFTI+). Need For Trauma Intervention was tested in an overlapping sample of 9,737 patients. Being NFTI+ was associated with higher trauma activation levels, older age, higher ISS, worse ED vitals, longer hospital LOS, and mortality. Only 13 of 561 deaths were not NFTI+ and all were in patients with do not resuscitate (DNR) orders; using ISS greater than 15 missed 73 mortalities, 46 with DNR orders. Results suggest that NFTI provides a comprehensive view of both anatomy and physiology in a manner that self-adjusts for age, frailty, and comorbidities as long as care teams adjust their treatments. Need For Trauma Intervention appears to be a unique, simple, and effective tool to retrospectively identify major trauma, regardless of ISS.

Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury.

OBJECTIVES: The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type. DESIGN: Prospective, longitudinal observational study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifty-nine participants admitted for at least 24 hours. MAIN OUTCOME MEASUREMENTS: The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist-Civilian Version (PCL-C) measured PTS symptoms at 6 months. RESULTS: In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012]. CONCLUSIONS: PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The intensive care unit experience: Psychological impact on family members of patients with and without traumatic brain injury.

PURPOSE/OBJECTIVE: The intensive care unit (ICU) has been identified as a possible contributor to emotional distress. This study seeks to identify whether families of traumatic brain injury (TBI) patients in the ICU experience psychological differences as compared with non-TBI patients' family members. METHOD: Eighty-two family members in a trauma/critical care ICU were assessed at baseline and again at 3 months. The Patient Health Questionnaire 8-Item measured depression, the Primary Care PTSD Screen measured symptoms of posttraumatic stress (PTS). RESULTS: Forty of these individuals were the family members of ICU patients who had sustained a TBI; 42 of the individuals were the family members of non-TBI patients in the ICU. At baseline, 39% (33% non-TBI, 45% TBI, p = .28) of the total sample screened positive for depressive symptoms and 24.3% (26% non-TBI, 23% TBI, p = .69) screened positive for PTS symptoms. However, differences emerged between the groups at 3 months, with family members in the non-TBI group showing a significant decrease in both baseline depression and PTS symptoms. CONCLUSIONS/IMPLICATIONS: This study, to our knowledge, is the first of its kind to examine psychological differences in the ICU in those whose family members either have or do not have a TBI. Results suggest the TBI group endorsed more symptoms of depression and PTS symptoms at 3 months. Although it is unclear whether symptoms were directly related to the ICU experience or the injury itself, future research should explore the possible additive effect of postintensive care syndrome-family symptoms. (PsycINFO Database Record

Improving National Trauma Data Bank® coding data reliability for traumatic injury using a prospective systems approach.

Trauma centers manage an active Trauma Registry from which research, quality improvement, and epidemiologic information are extracted to ensure optimal care of the trauma patient. We evaluated coding procedures using the Relational Trauma Scoring System™ to determine the relative accuracy of the Relational Trauma Scoring System for coding diagnoses in comparison to the standard retrospective chart-based format. Charts from 150 patients admitted to a level I trauma service were abstracted using standard methods. These charts were then randomized and abstracted by trauma nurse clinicians with coding software aide. For charts scored pre-training, percent correct for the trauma nurse clinicians ranged from 52 to 64 percent, while the registrars scored 51 percent correct. After training, percentage correct for the trauma nurse clinicians increased to a range of 80-86 percent. Our research has demonstrated implementable changes that can significantly increase the accuracy of data from trauma centers.

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

BACKGROUND: Increasingly, depression following traumatic injury is recognized as a complication of injury. Unlike mandated screening for risky alcohol use in trauma centers, screening for psychological risks is not required by the American College of Surgeons' Committee on Trauma. Limited resources and time constraints are commonly given reasons against routine screening. The purpose of this study was to determine if a two-item screen was as valid as an eight-question screen for depression. METHODS: A total of 421 patients were given the Patient Health Questionnaire 8 (PHQ-8) during initial hospitalization to assess depression in a prospective study at a Level I trauma center. A cutoff score of 10 or higher (possible range, 0-24) on the PHQ-8 is used as diagnostic for depression. The PHQ-2 (possible range, 0-6) is derived from the first two questions of the PHQ-8 and contains items assessing sad mood and loss of interest/pleasure during the previous 2 weeks. A cutoff score of 3 or higher was considered to be a positive screen result. Discriminatory ability of the PHQ-2 was calculated. RESULTS: The sample was predominantly male (65%) and white (67%). The majority (85%) sustained a blunt trauma, and the primary cause of injury was motor vehicle collision (37%), with a mean Injury Severity Score (ISS) of 11.6. A total of 142 patients (34%) were positive for depression on the PHQ-8. When comparing the PHQ-2 with the PHQ-8, a sensitivity of 76.1 and a specificity of 92.8 were found, as well as a positive predictive value of 84.4. CONCLUSION: The result of our study confirms that depression is a frequent condition (34%) among individuals who sustain physical injury. The PHQ-2 seems to have acceptable sensitivity and specificity to identify depression in this population. The use of a two-item screening questionnaire is a minimal addition to the evaluation of patients after injury, allowing for earlier intervention and better outcomes. LEVEL OF EVIDENCE: Diagnostic study, level IV; prognostic/epidemiologic study, level III.

Mild traumatic brain injury increases risk for the development of posttraumatic stress disorder.

BACKGROUND: Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) occur in individuals who sustain physical injury and share a significant overlap in symptoms. PTSD rates in the civilian injury population range from 20% to 40%. The current study examined the presence of PTSD symptoms at multiple time points (3 months and 6 months after injury) among individuals with and without TBI after admission to a Level I trauma center. METHODS: This prospective cohort study included patients 18 years and older admitted to a Level I trauma center for 24 hours or greater. Demographic and injury-related data were gathered in addition to assessments of PTSD during initial hospitalization after injury, as well as 3 months and 6 months later. The Primary Care PTSD Screen and PTSD Checklist-Civilian version were used to determine probable PTSD. International Classification of Diseases, 9th Rev. codes were used to determine mild TBI (MTBI). RESULTS: A total of 494 patients were enrolled at baseline, 311 (63%) completed 3-month follow-up, and 231 (47%) completed 6-month follow-up at the time of analysis. Preinjury PTSD was reported by 7% of the participants. At 3 months, patients with MTBI evidenced a probable PTSD rate of 18%, compared with a rate of 9% for patients with no MTBI (p = 0.04), although this relationship became a nonsignificant trend (p = 0.06) when demographics were included. At 6 months, patients with MTBI evidenced a probable PTSD rate of 26%, compared with a rate of 15% for patients with no MTBI (p = 0.04), and this relationship remained significant when demographics were included. Preinjury history of TBI did not predict PTSD, but incidence of TBI for the injury in which they were hospitalized did predict PTSD. CONCLUSION: TBI at time of injury demonstrated a nonsignificant trend toward higher rates of PTSD at 3 months and significantly predicted PTSD at 6 months after injury. This important finding may help clinicians identify patients at high risk for PTSD after injury and target these patients for screening, intervention, and referral for treatment. LEVEL OF EVIDENCE: Prognostic study, level III.

Perceived injustice after traumatic injury: Associations with pain, psychological distress, and quality of life outcomes 12 months after injury.

OBJECTIVE: There is growing recognition that individuals who experience traumatic injuries perceive themselves as victims of injustice and that elevated levels of perceived injustice are associated with problematic physical and psychological outcomes. To date, research regarding injustice perception and injury outcomes has been restricted to a small number of musculoskeletal pain conditions. No research to date has examined the potential impact of perceived injustice among individuals admitted for trauma care. METHOD: As part of this cross-sectional study, individuals (n = 155) admitted to a Level-1 trauma center completed measures of perceived injustice, pain, depression, posttraumatic stress, and health related (physical and mental/emotional) quality of life (HRQoL) outcomes 12 months after trauma admission. RESULTS: Bivariate analyses revealed significant associations between perceived injustice and demographic variables (education, income, race, and age) as well as injury-related variables (type of injury and length of hospital stay). Perceived injustice was correlated with greater pain intensity, depression, and PTSD symptoms, as well as poorer physical and mental HRQoL. Controlling for relevant demographic and injury-related variables, perceived injustice accounted for unique variance in pain intensity, depression severity, the presence and intensity of PTSD symptoms, mental HRQoL, and was marginally significant for physical HRQoL. CONCLUSIONS: This is the first study to examine perceived injustice in a trauma sample. Results support the presence of injustice perception in this group and its associations with pain and quality of life outcomes. Additional research is suggested to explore the impact of perceived injustice on recovery outcomes among individuals who have sustained traumatic injury.

Recurrent hospitalization for self-injuries and suicide attempts: case study of a super-utilizer.

Super-utilizers, patients who amass disproportionately large occurrences of emergency department visits and hospital admissions, are increasingly recognized as a significant and potentially preventable resource consumer. A comprehensive understanding of these individuals and their situations may prove useful in preventing unnecessary admissions and improving patient care and outcomes. While most super-utilizers suffer from chronic medical issues, this patient is an unusual variant, as his super-utilization stemmed from mental health problems leading to serial self-injury. Between January 2010 and October 2014, the patient performed 49 acts of self-harm resulting in 27 acute hospital admissions and 17 additional admissions secondary to complications. In addition to documented injuries, he and his family reported up to 50 additional self-injuries since his first episode 34 years earlier. It was concluded that the patient's pattern of self-injury resulted from a combination of factors, including underlying psychiatric conditions, chronic noncompliance with medications, and potentially unavoidable behavioral reinforcement from health care professionals.