RESUMO
BACKGROUND: Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan veterans. The purpose of this study is to describe long-term functional outcomes in veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. METHODS: Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain; Short Musculoskeletal Function Assessment (SMFA) for self-reported bother and dysfunction; and Veterans RAND 12-Item Health Survey (VR-12) physical and mental component scores (PCS; MCS) for quality of life, depression, post-traumatic stress disorder, and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. RESULTS: Eighty-one patients responded with an average time since injury of 129 months (SD: 31; range 67-180 months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (P = 0.004). Respondents screened positive for probable depression (55%) and post-traumatic stress disorder (51%). Compared with population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse), and PCS was similar. The multivariable models adjusted for age, marital status and pain. The higher SMFA is part of the results of the multivariable models. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA dysfunction was associated with better family functioning. CONCLUSIONS: EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms, and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by veterans with EVI.
Assuntos
Dor Crônica/diagnóstico , Avaliação da Deficiência , Extremidades/irrigação sanguínea , Medição da Dor , Qualidade de Vida , Lesões do Sistema Vascular/diagnóstico , Saúde dos Veteranos , Adaptação Psicológica , Adolescente , Adulto , Fatores Etários , Dor Crônica/epidemiologia , Dor Crônica/fisiopatologia , Dor Crônica/psicologia , Depressão/epidemiologia , Depressão/psicologia , Feminino , Estado Funcional , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Prognóstico , Resiliência Psicológica , Medição de Risco , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Fatores de Tempo , Lesões do Sistema Vascular/epidemiologia , Lesões do Sistema Vascular/fisiopatologia , Lesões do Sistema Vascular/psicologia , Adulto JovemRESUMO
BACKGROUND: Cerebrovascular diseases play an important role in dementia. Air pollution is associated with cardiovascular disease, with growing links to neurodegeneration. Prior studies demonstrate associations between fine particulate matter (PM2.5) and biomarkers of endothelial injury in the blood; however, no studies have evaluated these biomarkers in cerebrospinal fluid (CSF). OBJECTIVE: We evaluate associations between short-term and long-term PM2.5 exposure with CSF vascular cell adhesion molecule-1 (VCAM-1) and e-selectin in cognitively normal and mild cognitive impairment (MCI)/Alzheimer's disease (AD) individuals. METHODS: We collected CSF from 133 community volunteers at VA Puget Sound between 2001-2012. We assigned short-term PM2.5 from central monitors and long-term PM2.5 based on annual average exposure predictions linked to participant addresses. We performed analyses stratified by cognitive status and adjusted for key covariates with tiered models. Our primary exposure windows for the short-term and long-term analyses were 7-day and 1-year averages, respectively. RESULTS: Among cognitively normal individuals, a 5 µg/m3 increase in 7-day and 1-year average PM2.5 was associated with elevated VCAM-1 (7-day: 35.4 (9.7, 61.1) ng/ml; 1-year: 51.8 (6.5, 97.1) ng/ml). A 5 µg/m3 increase in 1-year average PM2.5, but not 7-day average, was associated with elevated e-selectin (53.3 (11.0, 95.5) pg/ml). We found no consistent associations among MCI/AD individuals. CONCLUSIONS: We report associations between short-term and long term PM2.5 and CSF biomarkers of vascular damage in cognitively normal adults. These results are aligned with prior research linking PM2.5 to vascular damage in other biofluids as well as emerging evidence of the role of PM2.5 in neurodegeneration.
Assuntos
Poluentes Atmosféricos/efeitos adversos , Biomarcadores/líquido cefalorraquidiano , Material Particulado/efeitos adversos , Lesões do Sistema Vascular/líquido cefalorraquidiano , Lesões do Sistema Vascular/psicologia , Idoso , Idoso de 80 Anos ou mais , Poluição do Ar/efeitos adversos , Doença de Alzheimer/líquido cefalorraquidiano , Cognição , Estudos de Coortes , Selectina E/análise , Exposição Ambiental , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tamanho da Partícula , Molécula 1 de Adesão de Célula Vascular/líquido cefalorraquidianoRESUMO
OBJECTIVE: Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management. METHOD: The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method. RESULTS: Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives." CONCLUSIONS: Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.
Assuntos
Adaptação Psicológica , Amputação Cirúrgica , Amputados/psicologia , Artérias/cirurgia , Traumatismos da Perna/cirurgia , Extremidade Inferior/irrigação sanguínea , Qualidade de Vida , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Atividades Cotidianas , Adolescente , Adulto , Amputação Cirúrgica/efeitos adversos , Amputação Cirúrgica/psicologia , Artérias/lesões , Efeitos Psicossociais da Doença , Feminino , Nível de Saúde , Humanos , Relações Interpessoais , Entrevistas como Assunto , Traumatismos da Perna/diagnóstico , Traumatismos da Perna/etiologia , Traumatismos da Perna/psicologia , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Pesquisa Qualitativa , Recuperação de Função Fisiológica , Sistema de Registros , Apoio Social , Suécia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/psicologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/psicologiaRESUMO
OBJECTIVE: Vascular extremity injuries can be a significant burden on a patient's long-term quality of life. Currently, no limb-specific surveys have been used to quantify the relation between injury pattern and the resultant physical or psychological impact. The objective of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) in the setting of extremity vascular injury. METHODS: The Joint Theater Trauma Registry was queried and filtered for U.S. troops with an extremity vascular injury isolated to a single limb. Injury and management data were obtained, and the SMFA was administered after patient contact and consent. Validity was analyzed by characterization of SMFA score distribution, correlation with 36-Item Short Form Health Survey (SF-36) scores, and assessment of its discriminative capability to external measures of injury severity (ie, Injury Severity Score [ISS], Mangled Extremity Severity Score [MESS], and Medicare Part A disability qualification). RESULTS: At mean follow-up of 5 years, 164 patients (median age, 25 years; interquartile range, 22-31 years) completed both surveys. The overall SMFA Dysfunction Index was 24.8 ± 15.2 (range, 0-78; skewness, 0.60; floor/ceiling effect, 0%-1.2%; and nonresponse, 0%), and the overall Bother Index was 29.4 ± 20.2 (range, 0-96; skewness, 0.58; floor/ceiling effect, 0%-4.3%; and nonresponse, 0.6%). SF-36 physical component summary scores correlated inversely with the Dysfunction Index (r = -0.64; P < .01), whereas mental component summary scores correlated inversely with the Bother Index (r = -0.59; P < .01). No difference was found in reported scores between those considered severely injured (ISS > 15) and those not severely injured (ISS ≤ 15). However, those with mangled extremities (MESS ≥ 7) reported higher Dysfunction and Bother indices than those with lower scores (P < .05). In addition, patients considered disabled (per Medicare Part A qualifications) reported higher Dysfunction and Bother indices compared with those not considered disabled (P < .05). CONCLUSIONS: Use of the SMFA is validated in those with extremity vascular injuries, and it should be considered an adjunctive tool in evaluating long-term patient outcomes.
Assuntos
Campanha Afegã de 2001- , Guerra do Iraque 2003-2011 , Extremidade Inferior/irrigação sanguínea , Medicina Militar , Sistema Musculoesquelético/fisiopatologia , Inquéritos e Questionários , Lesões do Sistema Vascular/diagnóstico , Adulto , Avaliação da Deficiência , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Saúde Mental , Valor Preditivo dos Testes , Prognóstico , Qualidade de Vida , Sistema de Registros , Reprodutibilidade dos Testes , Estados Unidos , Lesões do Sistema Vascular/fisiopatologia , Lesões do Sistema Vascular/psicologia , Adulto JovemRESUMO
OBJECTIVE: To date, contemporary studies on wartime vascular trauma have focused on acute management strategies and early results, with no characterization of enduring functional limb salvage or its relation to quality of life. The objective of this study was to describe long-term, patient-based quality of life and function after extremity vascular injury (EVI). METHODS: The Joint Theater Trauma Registry was queried for U.S. troops with EVI. Injury and management data was obtained and the Medical Outcomes Study Short Form 36 (SF-36) Health Survey administered after patient contact and consent. Demographic, injury, and management variables were analyzed and examined for correlation with the primary end points of favorable or unfavorable outcome defined by SF-36 Mental (MCS) or Physical Component Summary (PCS) scores of >42 or <42 (effect size ≥ 0.8). RESULTS: Surveys were completed by 214 patients, who were a median age of 25 years (range, 19-52 years). The Injury Severity Score was 15.3 ± 8.6 and the Mangled Extremity Severity Score was 5.65 ± 1.4. Amputation-free survival was 84% at mean follow-up of 61 ± 24 months. Overall SF-36 PCS and MCS scores were 43.0 ± 9.2 and 46.6 ± 12.4, respectively, with 92 respondents (43%) reporting favorable outcomes on both MCS and PCS. On multivariate analysis, older age, severe extremity injury (Mangled Extremity Severity Scores ≥ 7), and chronic pain were predictive of unfavorable physical outcomes (P < .05). Presence of pain, nerve injury, and junior rank (Assuntos
Campanha Afegã de 2001-
, Extremidades/irrigação sanguínea
, Guerra do Iraque 2003-2011
, Salvamento de Membro
, Medicina Militar
, Avaliação de Resultados da Assistência ao Paciente
, Qualidade de Vida
, Procedimentos Cirúrgicos Vasculares
, Lesões do Sistema Vascular/cirurgia
, Adulto
, Fatores Etários
, Distribuição de Qui-Quadrado
, Dor Crônica/etiologia
, Dor Crônica/psicologia
, Feminino
, Humanos
, Escala de Gravidade do Ferimento
, Estimativa de Kaplan-Meier
, Masculino
, Pessoa de Meia-Idade
, Análise Multivariada
, Sistema de Registros
, Fatores de Risco
, Inquéritos e Questionários
, Fatores de Tempo
, Traumatismos do Sistema Nervoso/etiologia
, Traumatismos do Sistema Nervoso/psicologia
, Resultado do Tratamento
, Estados Unidos
, Procedimentos Cirúrgicos Vasculares/efeitos adversos
, Lesões do Sistema Vascular/complicações
, Lesões do Sistema Vascular/diagnóstico
, Lesões do Sistema Vascular/fisiopatologia
, Lesões do Sistema Vascular/psicologia
, Adulto Jovem