Physical and psychological long-term outcome after traumatic brain injury in children and adult patients.

BACKGROUND: Several studies have indicated that younger age is associated with worse recovery after pediatric traumatic brain injury (TBI) compared to elder children. In order to verify this association between long-term outcome after moderate to severe TBI and patient's age, direct comparison between different pediatric age groups as well as an adult population was performed. METHODS: This investigation represents a retrospective cohort study at a level I trauma center including patients with moderate to severe, isolated TBI with a minimum follow-up of 10 years. According to their age at time of injury, patients were divided in pre-school (0-7 years), school (8-17 years) and adult (18-65 years) patients. Physical examination and standardized questionnaire on physical and psychological aspects (Glasgow Outcome Scale, Barthel Index, Impact of Event Scale, Hospital Anxiety and Depression Scale, short form 12) were performed. RESULTS: 135 traumatized patients were included. Physical and psychological long-term outcome was associated with injury severity but not with patients' age at time of injury. Outcome recovery measured by Glasgow Outcome Scale was demonstrated with best results for pre-school aged children (p = 0.009). According to the Hospital Anxiety and Depression Scale an increased incidence of anxiety (p = 0.010) and depression (p = 0.026) was evaluated in older patients. CONCLUSION: Long-term outcome perceptions after moderate to severe TBI presented in this study question current views of deteriorated recovery for the immature brain. The sustained TBI impact seemed not to reduce the child's ability to overcome the suffered impairment measured by questionnaire based psychological, physical and health related outcome scores. These results distinguish the relevance of rehabilitation and family support in the long term.

Subjective impact of traumatic brain injury on long-term outcome at a minimum of 10 years after trauma- first results of a survey on 368 patients from a single academic trauma center in Germany.

BACKGROUND: Traumatic Brain Injury (TBI) may lead to significant impairments in personal, social and professional life. However, knowledge of the influence on long-term outcome after TBI is sparse. We therefore aimed to investigate the subjective effects of TBI on long-term outcome at a minimum of 10 years after trauma in one of the largest study populations in Germany. METHODS: The current investigation represents a retrospective cohort study at a level I trauma center including physical examination or standardized questionnaires of patients with mild, moderate or severe isolated TBI with a minimum follow-up of 10 years. We investigated the subjective physical, psychological and social outcome evaluating the Glasgow Outcome Scale, short-form 12, and social as well as vocational living circumstances. RESULTS: 368 patients aged 0 to 88 years were included. Patients with severe TBI were younger compared to patients with moderate or mild TBI (p < 0.05). Patients with severe TBI lived more often as single after the trauma impact. A significantly worse outcome was associated with higher severity of TBI resulting in an increased incidence of mental disability. A professional decline was analyzed in case of severe TBI resulting in significant loss of salary. CONCLUSIONS: The severity of TBI significantly influenced the subjective social and living conditions. Subjective mental and physical outcome as well as professional life depended on the severity of TBI 10 years after the injury.

Head injury in polytrauma-Is there an effect on outcome more than 10 years after the injury?

INTRODUCTION: Head injuries are of great relevance for the prognosis of polytrauma patients during acute care. However, knowledge about the impact on the long-term outcome is sparse. Therefore, this study analysed the role of head injuries on the outcome of polytrauma patients more than 10 years after injury in a matched-pair analysis. PATIENTS AND METHODS: Out of 620 polytrauma patients with and without head injury, a matched-pair analysis with comparable age, injury severity and gender distribution and a minimum of 10 years follow-up was performed. The outcome and quality-of-life were measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form 12 (SF-12), Glasgow Outcome Scale (GOS) and other parameters. RESULTS: The matched-pair analysis consisted of 125 pairs (age 27.9 ± 1.2 years, ISS 20.0 ± 0.8 [head injury] vs ISS 19.8 ± 0.8 [no head injury]). A significant difference was shown for the GOS Score only (GOS head injury 4.3 ± 0.3 vs no head injury 4.9 ± 0.2, p = 0.01). The psychological outcome was similar in both groups. Both groups reported comparable subjective rehabilitation satisfaction. CONCLUSIONS: Matching pairs of equally injured polytrauma patients of same gender with and without head injury 10 years following trauma indicated significantly worse results in the GOS due to head injury.

[Permanent disability and death among German workers with depression]. / Invalidität und Tod bei Erwerbsfähigen mit Depressionen.

OBJECTIVE: It was the aim of this study to estimate effects of depression on permanent disability and death in a statutory health insurance population. METHODS: Data from 128,001 clients were used with a mean follow up of 6.4 years. Excess risks were calculated with Cox regression models adjusted for age, gender, education and job classification. RESULTS: Outpatient treatment for depression was associated with an elevated relative risk for permanent disability, but inpatient treatment even more so. Life table analysis suggests higher risks of early retirement for males who get ill early in life. Depression treated solely in an outpatient setting may be associated with lower mortality early in life, but this was only significant for women. CONCLUSIONS: Outpatient treatment should include an emphasis on occupational functioning, but also a gender-specific approach is needed.

Predictors of late clinical outcome following orthopedic injuries after multiple trauma.

BACKGROUND: The long-term clinical status of surviving patients with multiple injuries has not been well described. The aim of this study was to evaluate whether certain injury patterns predispose a patient to a poor clinical outcome 10 or more years after multiple injuries. METHODS: Patients who were treated at a level I trauma center at least 10 years before participation in this study were reinvited for a follow-up physical examination. Clinical outcome included the assessment of pain, gait, and various outcome scores (Short-Form [SF]-12, Lysholm, Merle D'Aubigne) were also used to measure outcome. STATISTICS: Binary logistic regression was used to test predictors of physical and psychosocial outcomes 10 years or longer after trauma. Differences between the types of injury and outcomes were assessed using Mann-Whitney and Kruskal Wallis tests. RESULTS: Of 1,034, 637 patients (62%) participated in this study. Predictors of poor physical and psychosocial functioning using a clinical outcome score at 10 or more years follow-up included lower extremity amputation (odds ratio = 15.08; 95% confidence interval = 1.87-121.61) and a higher Abbreviated Injury Scale (AIS) spine score (SF-12 Mental subscale [odds ratio = 0.78; 95% confidence interval = 0.64-0.96]). Other factors associated with worse outcome scores were presence of two or more articular injuries, lower extremity injuries, and a combination of shaft and articular injuries. CONCLUSION: If patients survived, traumatic lower extremity amputation and a high initial maximum AIS (MAIS) spine score was the only predictive parameter for an increased odds of adverse clinical outcomes late after trauma. Injuries associated with these outcomes should be the focus of attention regarding injury prevention and priority in care.

Clinical re-examination 10 or more years after polytrauma: is there a gender related difference?

BACKGROUND: : Previous studies documented that premenopausal women better tolerate severe injuries than men in regards to mortality and intensive care complications. We test the hypothesis whether surviving women have a better long-term outcome than surviving men. METHODS: : We reassessed 637 polytrauma patients 10 or more years (mean 17 +/- 5 years) after trauma. Mental health was assessed by the posttraumatic stress diagnostic scale and the Hospital Anxiety and Depression Scale. The clinical outcome was assessed by standardized scores (Hannover Score for Polytrauma Outcome and short form-12). A physical examination was performed by an orthopedic surgeon. RESULTS: : We studied 479 men (M; 75.4%) and 158 women (F; 24.6%) aged M = 26.7 +/- 12.2 versus F = 25.9 +/- 13.0 years (p = 0.47). Injury Severity Score showed M = 20.4 +/- 9.9 versus F = 21.7 +/- 9.7 (p = 0.13). Women showed a higher rate of posttraumatic stress disorder (F = 14.5% vs. M = 6.2%; p = 0.035) and psychologic support (F = 28.0% vs. M = 15.0%; p < 0.001), longer duration of rehabilitation, and longer sick leave time. Quality-of-life was significantly lower in women (Short form-12 psychologic F = 48.6 +/- 10.8 vs. M = 50.8 +/- 9.4; p = 0.02), but the same rate of women (75.3%) and men (75.4%; p = 0.995) felt well rehabilitated. CONCLUSION: : Late after polytrauma, women suffer more severe psychologic impairment than men who had similar injuries. This finding is independent of physical impairment and the subjective feeling of a good rehabilitation outcome. Clinically, women require special support even years after injury to improve their psychologic status. In the future, they might benefit from early concomitant psychologic treatment if mental problems are suspected.

Late death after multiple severe trauma: when does it occur and what are the causes?

INTRODUCTION: The information about the long-term mortality and causes of death after multiple injuries is sparse. In general, most follow-up studies report on 1 year to 3 years maximum follow up. The current literature focuses on causes of death immediately after trauma or during the initial in-hospital stay. We report on long-term mortality and causes of death in patients with multiple injures up to 30 years after the initial injury. METHODS AND MATERIAL: We analyzed the causes of death using patient files, inquiries of patients' relatives, and death certificates. Inclusion criteria are (1) polytrauma (PT) (Injury Severity Score > or = 16) between 1973 and 1990; (2) age 3 years to 60 years at injury; (3) admission to the hospital alive; and (4) death during the study period. Patients were separated into two groups: patients deceased during the initial hospital stay (in-hospital deaths, n = 408) and patients deceased after discharge (postdischarge deaths, n = 103). The survival of the PT victims was compared descriptively with age- and gender-matched data from the general population (GP). RESULTS: Causes of death in in-hospital deaths are head injury (37%), adult respiratory distress syndrome (14%), sepsis (11%), hemorrhagic shock (10%), pneumonia (9%), multiple organ failure (9%), and others (10%). Causes of death after discharge included cardiovascular diseases (23%), second major trauma (19%), neurologic diseases (16%), suicide (10%), malignancies (6%), and others (26%). The analysis of survival showed a higher mortality for PT compared with the GP group during the first year after the event (p < 0.05). Between 2 years and 10 years after the event, the annual mortality of the PT-group approximates the GP group. CONCLUSION: PT patients who die after discharge from the initial hospitalization show other causes of death than age-matched controls of the general population. Among these are second major trauma and suicide. Future studies should investigate whether certain social or psychologic factors might play a role.