[The place of the psychologist in the orthopedics department]. / La place du psychologue dans le service d'orthopédie.

The essential place of the psychologist in the orthopedics department of Pitié-Salpêtrière is to relieve the suffering of polytraumatized patients, to work in a multidisciplinary manner, to participate in the staff of the department to have complete information of the patients, to give an informed opinion on the psychological state of the patient, so as to help in the discussion for making decisions on their trajectory. The role of the psychologist is part of the overall care of patients, care which sometimes extends to the family, the patient's loved ones and the teams who care for them.

What can we learn about polytrauma typologies by comparing population-representative to trauma-exposed samples: A Nepali example.

BACKGROUND: Potentially traumatic events (PTEs) are common and associated with detrimental outcomes over the life-course. Previous studies exploring the causes and consequences of PTE-exposure profiles are often from high-income settings and fail to explore the implications of sample selection (i.e., population-representative versus PTE-restricted). METHODS: Among individuals in the Nepal Chitwan Valley Family Study, latent class analyses (LCA) were performed on 11 self-reported PTEs collected by the Nepali version of the World Mental Health Consortium's Composite International Diagnostic Interview 3.0 from 2016 to 2018, in a population-representative sample (N = 10,714), including a PTE-restricted subsample (N = 9183). Multinomial logistic regressions explored relationships between sociodemographic factors and class membership. Logistic regressions assessed relationships between class membership and psychiatric outcomes. RESULTS: On average, individuals were exposed to 2 PTEs in their lifetime. A five-class solution showed optimal fit for both samples; however, specific classes were distinct. No single sociodemographic factor was universally associated with PTE class membership in the population-representative sample; while several factors (e.g., age, age at incident PTE, education, marital status, and migration) were consistently associated with class membership in the PTE-subsample. PTE class membership differentiated psychiatric outcomes in the population-representative sample more than the PTE-subsample. LIMITATIONS: Primary limitations are related to the generalizability to high-income settings, debate on LCA model fit statistic usage for final class selection, and cross-sectional nature of data collection. CONCLUSIONS: Although population-representative samples provide information applicable to large-scale, population-based programming and policy, PTE-subsample analyses may provide additional nuance in PTE profiles and their consequences, important for specialized prevention efforts.

Biological Connection of Psychological Stress and Polytrauma under Intensive Care: The Role of Oxytocin and Hydrogen Sulfide.

This paper explored the potential mediating role of hydrogen sulfide (H2S) and the oxytocin (OT) systems in hemorrhagic shock (HS) and/or traumatic brain injury (TBI). Morbidity and mortality after trauma mainly depend on the presence of HS and/or TBI. Rapid "repayment of the O2 debt" and prevention of brain tissue hypoxia are cornerstones of the management of both HS and TBI. Restoring tissue perfusion, however, generates an ischemia/reperfusion (I/R) injury due to the formation of reactive oxygen (ROS) and nitrogen (RNS) species. Moreover, pre-existing-medical-conditions (PEMC's) can aggravate the occurrence and severity of complications after trauma. In addition to the "classic" chronic diseases (of cardiovascular or metabolic origin), there is growing awareness of psychological PEMC's, e.g., early life stress (ELS) increases the predisposition to develop post-traumatic-stress-disorder (PTSD) and trauma patients with TBI show a significantly higher incidence of PTSD than patients without TBI. In fact, ELS is known to contribute to the developmental origins of cardiovascular disease. The neurotransmitter H2S is not only essential for the neuroendocrine stress response, but is also a promising therapeutic target in the prevention of chronic diseases induced by ELS. The neuroendocrine hormone OT has fundamental importance for brain development and social behavior, and, thus, is implicated in resilience or vulnerability to traumatic events. OT and H2S have been shown to interact in physical and psychological trauma and could, thus, be therapeutic targets to mitigate the acute post-traumatic effects of chronic PEMC's. OT and H2S both share anti-inflammatory, anti-oxidant, and vasoactive properties; through the reperfusion injury salvage kinase (RISK) pathway, where their signaling mechanisms converge, they act via the regulation of nitric oxide (NO).

Violência em crianças, estudo de casos hospitalizados e seguidos nos serviços de Urgência de Pediatria e Medicina Legal no Hospital Central de Maputo em 2019 / Violence in children, a study of cases hospitalized and followed up in the pediatrics and forensic medicine emergency services at maputo central hospital in 2019

Introdução: Em Moçambique, anualmente, milhares de crianças são vítimas de violência, incluindo as suas formas mais extremas, como a violência física e sexual, o que compromete a saúde física e psicológica destas crianças. Objectivo: Analisar a violência nas crianças, em relação às características demográficas (da criança e do perpetrador), bem como descrever os aspectos clínicos da violência. Métodos: É um estudo transversal e retrospectivo, baseado em registos hospitalares dos serviços da Urgência de Pediatria e da Medicina Legal do Hospital Central de Maputo. Para a recolha de dados utilizámos o Formulário de Relatório de Casos Notificados. Foi utilizado o programa Excel® e testes de qui-quadrado para a análise dos resultados. Resultados: Identificámos um total de 329 casos de lesões relacionadas com a violência que afectaram crianças no Hospital Central de Maputo em 2019, dos quais 143 (43,5%) foram registados na Urgência de Pediatria e 186 (56,5%) na Medicina Legal. A violência sexual foi a forma de violência mais frequente (58% no total). Em ambos os serviços, as vítimas foram maioritariamente meninas do que meninos. As crianças mais velhas (11-14 anos) foram mais observadas na Medicina Legal (47,3% em comparação com 30,1% da Urgência de Pediatria) e as mais novas (0-5), na Urgência de Pediatria (37,1% em comparação com 28,6% a Medicina Legal). A violência sexual foi mais frequente entre as meninas em ambos os serviços, por outro lado, os meninos sofreram mais violência física. Os homens foram os principais perpetradores (81,8% no total) e a maioria deles eram conhecidos da família ou da vítima. As meninas sofreram lesões mais graves, exigindo cuidados médicos intensivos (12,0% em comparação a e 4,5% dos meninos). Em contrapartida, os meninos tiveram mais consultas médicas com alta imediata. As meninas tiveram de longe mais lesões genitais (66,4%) enquanto que os meninos tiveram mais lesões em todas as outras partes do corpo (cabeça, membros superiores, tórax e abdómen, membros inferiores e anal). Conclusões: A violência sexual foi a forma mais frequente de violência nos dois serviços. As meninas foram as vítimas de violência mais frequentemente descritas, tanto nos dois serviços como para a violência sexual em todas idades. Por outro lado, a violência física foi mais frequente entre os meninos. Os homens foram os principais perpetradores de violência especialmente da violência sexual, sendo estes, frequentemente conhecidos da família da vítima ou da própria vítima, é em vários casos um familiar. A casa da vítima ou do perpetrador é onde ocorreu a maioria dos eventos violentos. As crianças apresentaram várias lesões em consequência da violência sofrida, mas nem todos casos foram considerados graves. As meninas apresentaram lesões mais graves que exigiram cuidados médicos intensivos ou até cirurgia e os rapazes mais consultas médicas com alta imediata.

Introduction: In Mozambique, yearly, thousands of children are victims of violence, including its most extreme forms, such as physical and sexual violence, which hinders their healthy development. Objective: To analyze violence in children, in relation to demographic characteristics (child and perpetrator) as well as to describe the clinical aspects of violence-related injury. Methods: This study is cross-sectional and retrospective. Based on hospital records from the two services of Maputo Central Hospital, namely Pediatric Emergency and Forensic Medicine. For data collection we used a standardized Case Report Form. Excel® program and chi-square tests were used to analyze the results. Results: We identified a total of 329 cases of violence-related injuries affecting children at Maputo Central Hospital in 2019, of which 143 (43.5%) were registered at Pediatric Emergency and 186 (56.5%) at Forensic Medicine. Sexual violence was most common (58% in total). In both services, the victims were more frequently girls than boys. Also, older children (11-14 years) were more often seen at Forensic Medicine (47.3% compared with 30.1% at Pediatric Emergency) and younger ones (0-5), at Pediatric Emergency (37.1% compared with 28.6% at Forensic Medicine). Sexual violence was by far the most frequent among girls in both services, by contrast, boys suffered more physical violence. Males were the most common perpetrators (81.8%) and most of them were known to the family or the victim in both services. Girls also had more severe injuries, requiring intensive medical care than boys (12.0% and 4.5% respectively). By contrast, boys had more medical consultation with immediate discharge. Girls had by far more genital injuries (66.4%) while boys had more injuries in all other body parts (head, upper limbs, thorax and abdomen, lower limbs and anal). Conclusions: Sexual violence was the most common form of violence afflicting the children, most often girls, presenting at the two services. Sexual violence was most common among girls at all ages and physical violence, among boys. Men were identified as the main perpetrator, especially of sexual violence. The perpetrators were also very frequently known to the family of the victim, in several instances a relative. The victim's or perpetrator's home, is where most of the violent events take place. Multiple injuries were sustained but not all were severe. Girls had more severe injuries requiring intensive medical care and surgery, and boys, more medical consultations with immediate discharge.

A test of the fear avoidance model to predict chronic pain outcomes in a polytrauma sample.

BACKGROUND: Chronic musculoskeletal pain is a complex problem, particularly for individuals with head injury and comorbid psychiatric conditions. The Fear Avoidance Model offers one of the strongest opportunities to conceptualize comorbid traumatic injury and pain, but this model is largely untested. OBJECTIVE: This study tests the Fear Avoidance Model of chronic pain using a sample from a study of polytrauma patients in a large Department of Veterans Affairs facility who participated in a federally-funded study of interdisciplinary chronic pain management. METHODS: The present study comprises a secondary analysis of 93 veterans with chronic pain, head injury, posttraumatic stress symptoms and a history of persistent opioid use. Standardized measures of Fear Avoidance Model risk factors (e.g., pain catastrophizing, fear avoidance beliefs, anxiety, depression) were examined as cross-sectional predictors of pain-related disability. RESULTS: Secondary data analysis revealed that Fear Avoidance Model factors accounted for almost 40% of the variance in pain-related disability, with pain catastrophizing and depression demonstrating the strongest relationships with disability. A summary variable combining all four factors revealed a 6% increase in disability for each factor that was clinically significant for the sample patients. CONCLUSIONS: This study represents the first attempt to examine a complex, theoretical model of pain in a comorbid pain and TBI sample. Findings revealed a strong relationship between this model and pain-related disability that outperforms pain intensity ratings. This model could be used to guide better treatment for comorbid pain and TBI.

Dimensionality of DSM-5 PTSD symptoms: Validation of the Chinese version of the posttraumatic diagnostic scale for DSM-5 across multiple trauma samples.

The Posttraumatic Diagnostic Scale for DSM-5 (PDS-5) is an updated DSM-5 version of the PDS, a widely used measure for PTSD. The PDS-5 has recently been shown to possess sound psychometric properties and awaits cross-cultural validation. The present study aimed first, to evaluate the psychometric properties of the Chinese version of the PDS-5; second, to evaluate alternative factor models of DSM-5 PTSD symptoms with multiple trauma samples. Data were collected from five samples of Taiwanese trauma-exposed individuals (total N = 903): 138 burn injury survivors, 403 earthquake survivors, 181 trauma-exposed young adults, 91 trauma-exposed undergraduates, and 90 female domestic violence survivors. The Chinese PDS-5 possessed excellent internal consistency (α s = .94-.95) and satisfactory five-week (r = .80) and one-year temporal stability (r = 0.76). Convergent, concurrent, and discriminant validity were also established. Consistent with recent studies, confirmatory factor analyses demonstrated the best fit of a seven-factor Hybrid model, followed by a six-factor Anhedonia model across multiple trauma samples.

Prevalence, injury-, and non-injury-related factors associated with anxiety and depression in polytrauma patients - A retrospective 20 year follow-up study.

INTRODUCTION: Survival rate after polytrauma increased over the past decades resulting in an increase of long-term complaints. These include physical and psychological impairments. The aim of this study was to describe the prevalence and risk factors for developing depression and anxiety more than twenty years after polytrauma. METHODS: We contacted patients who were treated due to a polytrauma between 1973 and 1990 at one level 1 trauma center after more than 20 years. These patients received a self-administered questionnaire, to assess symptoms of depression and anxiety. Analysis based on multivariable logistic regression models include injury severity and non-injury related factors to determine risk factors associated with the development of depression and anxiety. RESULTS: Patients included in this study (n = 337) had a mean ISS of 20.3 (4 to 50) points. In total, 173 (51.3%) showed psychiatric sequelae (depression n = 163, 48.2%; anxiety n = 14, 4.1%). Injury severity was not associated with the development of depression or anxiety. However, the patients, who required psychiatric therapy prior to the injury had higher risk of developing psychiatric symptoms (OR 1.3, 95%CI 1.1 to 1.8, p = 0.018) as did patients who suffered from additional psychiatric insults after the injury (OR 1.4, 95%CI 1.2 to 2.0, p = 0.049). CONCLUSION: More than half of polytrauma patients developed psychiatric sequelae. Risk factors include mainly non-injury related factors such as psychiatric comorbidities and additional psychiatric insults after the injury.

Respuesta emocional a una simulación de alta fidelidad en trauma: un estudio observacional / Emotional response to a high-fidelity trauma simulation: an observational study

INTRODUCCIÓN: El entorno emocional que se crea en una sesión de simulación puede afectar al proceso de aprendizaje. Las emociones positivas mejoran el proceso de percepción y facilitan el aprendizaje. Sin embargo, las emociones negativas pueden disminuir la memoria de trabajo, lo que da lugar a menor adquisición de aprendizaje. OBJETIVOS: El objetivo del estudio fue investigar el impacto que la simulación tiene sobre las emociones durante todas las fases de una simulación de alta fidelidad, usando un prebriefing estandarizado y el debriefing «con buen juicio». MÉTODOS: Es un estudio observacional que incluyó a 74 anestesiólogos que participaron en una sesión de simulación. Se utilizó un prebriefing estandarizado y el debriefing «con buen juicio». Para evaluar las emociones, usamos el modelo circumplejo de las emociones aplicando la escala Affect Grid, que se utilizó antes del prebriefing (estadio 1), antes del caso (estadio 2), antes del debriefing (estadio 3) y después de él (estadio 4). RESULTADOS: La muestra final fueron los resultados de la escala Affect Grid obtenidos de 67 participantes. Tras el debriefing, esta simulación sobre un caso de paciente politraumatizado fue experimentada de manera significativamente más placentera que en estadios previos (p <0,01). Además, se percibió como una actividad cada vez más activa según iba avanzando (p <0,01). CONCLUSIONES: El entrenamiento en atención al trauma grave mediante simulación en un entorno seguro con un prebriefing estandarizado y el debriefing «con buen juicio» fue experimentado como una actividad placentera y activa durante todas las fases de la simulación. Se necesitan nuevas investigaciones para evaluar el impacto de estos resultados en el aprendizaje

INTRODUCTION: The emotional environment created during a simulation session can influence learning. Positive emotions improve perceptual processing and facilitate learning, while negative emotions can reduce working memory, resulting in poorer learning outcomes. OBJECTIVES: The aim of this study was to investigate the impact of simulation training on emotions during all phases of a high-fidelity simulation using standard prebriefing and «good judgement debriefing » techniques. METHODS: This was an observational study that included 74 anesthesiologists participating in a simulation-based training. A standardized prebriefing was followed by «good judgement debriefing». In order to assess emotions, we used the circumplex model of emotion, and asked participants to complete the affect grid scale before prebriefing (Stage 1), before starting the simulation (Stage 2), before debriefing (Stage 3) and following debriefing (Stage 4). RESULTS: The affect grid scores obtained from 67 participants were analyzed. Following debriefing, the experience of the polytrauma patient simulation was significantly more pleasant compared to previous stages (P<0.01). In addition, participants perceived the activity as becoming increasingly active as it progressed (P<0.01). CONCLUSIONS: High-fidelity trauma simulation creating a safe environment using a standardized prebriefing and «good judgement debriefing» is experienced as a pleasant and active activity at all stages of the simulation. Further investigation is needed to assess the impact of these results on learning

Emotional response to a high-fidelity trauma simulation: An observational study. / Respuesta emocional a una simulación de alta fidelidad en trauma: Un estudio observacional.

INTRODUCTION: The emotional environment created during a simulation session can influence learning. Positive emotions improve perceptual processing and facilitate learning, while negative emotions can reduce working memory, resulting in poorer learning outcomes. OBJECTIVES: The aim of this study was to investigate the impact of simulation training on emotions during all phases of a high-fidelity simulation using standard prebriefing and «good judgement debriefing ¼ techniques. METHODS: This was an observational study that included 74 anesthesiologists participating in a simulation-based training. A standardized prebriefing was followed by «good judgement debriefing¼. In order to assess emotions, we used the circumplex model of emotion, and asked participants to complete the affect grid scale before prebriefing (Stage 1), before starting the simulation (Stage 2), before debriefing (Stage 3) and following debriefing (Stage 4). RESULTS: The affect grid scores obtained from 67 participants were analyzed. Following debriefing, the experience of the polytrauma patient simulation was significantly more pleasant compared to previous stages (P<0.01). In addition, participants perceived the activity as becoming increasingly active as it progressed (P<0.01). CONCLUSIONS: High-fidelity trauma simulation creating a safe environment using a standardized prebriefing and «good judgement debriefing¼ is experienced as a pleasant and active activity at all stages of the simulation. Further investigation is needed to assess the impact of these results on learning.

Factors Affecting Interprofessional Teamwork in Emergency Department Care of Polytrauma Patients: Results of an Exploratory Study.

Considering that traumatic injuries are the leading cause of death among young adults across the globe, emergency department care of polytrauma patients is a crucial aspect of optimized care and premature death prevention. Unfortunately, many studies have highlighted important gaps in collaboration among different trauma team professionals, posing a major quality-of-care challenge. Using the conceptual framework for interprofessional teamwork (IPT) of , the aim of this qualitative descriptive exploratory study was to better understand IPT from the perspective of health professionals in emergency department care of polytrauma patients, specifically by identifying factors that facilitate and impede IPT. Data were collected from a sample of 7 health professionals involved in the care of polytrauma patients through individual interviews and a focus group. In the second phase, 2 structured observations of polytrauma patient care were conducted. Following a thematic analysis, results revealed multiple factors affecting IPT, which can be divided into 5 broad categories: individual, relational, processual, organizational, and contextual. Individual factors, a category that is not part of the conceptual framework of , also emerged as playing a major part in IPT.

Experiences of suffering multiple trauma: A qualitative study.

OBJECTIVES: In an effort to strengthen health care professionals' ability to anticipate and address multiple trauma patients' needs, this study aims to explore the experience of suffering from multiple trauma. DESIGN: This is a qualitative descriptive study. Nine interviews were analysed using content analysis. SETTING: The study included patients who had been registered in the Swedish Intensive Care registry [SIR] due to suffering multiple trauma. FINDINGS: The analysis revealed one theme, A detour in life, based on three sub-themes: (a) Feeling lost and not knowing what to expect, (b) Striving to get life back on track and (c) Dealing with 'dead ends' during rehabilitation. The theme showed that those who suffered multiple trauma did not know what to expect of their recovery and they expressed experiencing a lack of understanding and guidance from healthcare professionals. As it was important to focus on the present and find ways to move on in life, they sought for other ways to find direction in matters of rehabilitation and care. CONCLUSIONS: A shared understanding is essential in order to define a person's needs. By setting short-term goals and improving documentation, healthcare professionals across the trauma recovery continuum could more easily gain insight of their patients' needs and address them with supportive guidance.

Providing Care for Comorbid Mental Health Conditions in the Polytrauma System of Care.

OBJECTIVE: To summarize challenges and best practices relevant to providing care for mental health comorbidities in veterans and service members (V/SM) treated in the Polytrauma System of Care (PSC) and to review themes that emerged during a May 2017 meeting of rehabilitation professionals on this topic. Management of comorbid mental health conditions remains a critical issue within the PSC, given the high rate of these comorbidities and the impact of mental health conditions on treatment planning and outcomes. DESIGN: To identify the challenges of concomitantly treating TBI-related symptoms and mental health comorbidities in V/SM treated within the PSC, describe specialty programs within the Veterans Health Administration designed to treat these comorbid conditions, and report on the themes and recommendations identified by rehabilitation professionals at the 2017 meeting. CONCLUSION: To further develop mental health treatment within the PSC, the following recommendations were made: (1) continued support for family members as critical members of the rehabilitation team; (2) adding measures and mechanisms to monitor mental health within the PSC; and (3) exploration of modern technologies to enhance care of existing polytrauma clients and to better prepare to serve clients with all types of acquired brain injury.

Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions.

OBJECTIVE/PURPOSE: Veterans and service members (V/SMs) with traumatic brain injury (TBI) and comorbid conditions are treated in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC). These V/SMs comprise a unique population with distinct needs for restoring community reintegration, including participation in meaningful employment. Low employment rates after TBI vary and are influenced by many factors. Employment is a central aspect of the VHA priority of facilitating adjustment, and addressing vocational needs alongside healthcare is critical to community reintegration. The purpose of this article is to outline current practices of addressing vocational rehabilitation in the PSC, discuss the unique challenges in serving Veterans with polytrauma, and outline future directions to improve vocational services and outcomes. METHODS: Briefly review literature on V/SM with TBI and employment, describe the PSC and VHA vocational programs for V/SM with polytrauma, and synthesize proceedings on vocational rehabilitation from the 2017 VHA "Community Reintegration in the Polytrauma System of Care" meeting. CONCLUSIONS: To advance and expand vocational services the following guidelines were recommended: (1) designing flexible services based on individualized needs, (2) increasing access to vocational services through communication and collaboration, (3) promoting cross-disciplinary education and engagement in vocational care, and (4) systematically tracking employment outcomes.

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

BACKGROUND: Information on long-term psychiatric sequelae after severe trauma is sparse. We therefore performed a survey addressing several symptoms related to posttraumatic stress disorder (PTSD) in patients who sustained multiple injuries more than 20 years after trauma. METHODS: Patients injured between January 1, 1973, and December 31, 1990, were contacted at least 20 years later. We included multiply injured patients aged between 3 and 60 years from a single level 1 trauma center. A questionnaire based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for PTSD, including individual symptoms related to intrusion, avoidance, and hyperarousal was sent to all patients. RESULTS: A total of 359 patients (56.35%) received a questionnaire. Of these, 337 patients (93.87%) returned the questionnaire and were included in the study (223 males [66.17%] and 114 females [33.82%]). Mean ± SD follow-up was 29.5 ± 8.5 years. Nearly half the study population (47.18%) experienced lasting psychiatric sequelae, such as intrusive recollection (n = 65, 19.28%), avoidance (n = 92, 27.29%), or hyperarousal (n = 95, 28.18%) at least monthly. Ten patients (2.96%) fulfilled all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for PTSD. A total of 131 patients (38.87%) reported fair or poor general health status. There was no difference in injury severity in patients with or without PTSD (injury severity score, 8.33 vs. 20.36, respectively; p = 0.52) or PTSD-related symptoms including intrusion (19.88 vs. 20.32, p = 0.74), avoidance (19.99 vs. 20.3, p = 0.79), and hyperarousal (19.36 vs. 20.68, p = 0.26). CONCLUSION: At least 20 years after injury, no correlation was found between the development of psychiatric complications and the severity of injury. While the rate of full-blown PTSD was low, nearly half the study population regularly suffered from at least one psychiatric symptom attributable to the initial trauma. Awareness for the development of psychiatric complications and early initiation of psychiatric counseling are advisable. LEVEL OF EVIDENCE: Prognostic and epidemiologic, level II.

A multidisciplinary approach in overkill: Analysis of 13 cases and review of the literature.

The term overkill usually indicates the infliction of massive injuries by far exceeding the extent necessary to kill the victim. Only few articles or textbooks report this term that is mostly associated with sex-motivated homicides where injuries, generally stabbing, are directed to significant sexual parts of the body. The aim of this study is to shed light on the phenomenon of overkill by reviewing some cases personally analyzed by the authors from both a forensic pathology rather than forensic psychiatry views. The reported results coupled with the literature revision confirmed the importance of a complete analysis of all criminological elements for better defining overkill cases.

Effects of Poly-Victimization Before Age 18 on Health Outcomes in Young Kenyan Adults: Violence Against Children Survey.

Children's exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

Impact of Fire Arms Training in a Virtual Reality Environment on Occupational Performance (Marksmanship) in a Polytrauma Population.

INTRODUCTION: Polytrauma, to include major limb amputation, in a military population presents unique rehabilitation challenges with the overarching goal of restoring function leading to the primary question, "Is this Service Member (SM) capable of returning to duty following rehabilitation?" The US military has a vested interest in maximizing injured SMs occupational performance to allow for return to duty. The purpose of this report is to describe marksmanship (shot grouping and weapon qualification) and return to duty outcomes following a course of VRE-based firearm training in a polytrauma patient population. METHODS: The medical records, stored in the Armed Forces Health Longitudinal Technology Application (AHLTA), of all patients who received rehabilitative care at the Center for the Intrepid (CFI) to include VRE-based firearms training between 01OCT2015 and 01AUG2016 were manually reviewed for inclusion. Subjects included all adult (18 years and older) SMs (active duty at time of admission) with a diagnosis of polytrauma who had been referred to and treated (received additional services such as physical and or occupational therapy) at the CFI. Approval for this research was received from the Brooke Army Medical Center Department of Clinical Investigation Office of the Institutional Review Board. RESULTS: Medical records of 30 SMs with a polytrauma diagnosis met the inclusion criteria. Mean shot group sizes for the M9 and M4 weapon decreased between initial and post training time points for the M9 zero (p = 0.009) and M4 zero (p = 0.020). There was no significant difference between initial and post training time points at the other shooting distances with either weapon. There was an 89% qualification rate for both the M9 (n = 18) and M4 (n = 19) weapons for those who attempted qualification; 43% of the population (n = 13) did not attempt qualification with either weapon. CONCLUSION: SMs with polytrauma demonstrated a high rate of weapon qualification (accuracy) following VRE-based firearm training. Shot group size (precision) at short distances with a M9 pistol and M4 rifle also improved with training. While overall marksmanship appeared to improve, high return to duty rates were not directly related to firearm training or marksmanship. Future efforts need to focus on consistent clinical documentation of firearm training procedure and the establishment of psychometric properties for marksmanship outcome measures.

Neurobehavioral Management of the Polytrauma Veteran.

Since the inception of the Afghanistan and Iraq wars, an increasing number of veterans have sought treatment from the Department of Veterans Affairs for combat-related injuries. Many veterans experience postconcussive symptoms, traumatic stress, chronic pain, sensory deficits, and/or headaches. The goal of this article was to highlight some of the challenges treatment providers may face, while providing rehabilitation specialists with important evaluation and treatment considerations in working with this population to maximize outcomes for these veterans.

A Model of Care for Community Reintegration: The Polytrauma Transitional Rehabilitation Program.

The Department of Veterans Affairs Polytrauma Transitional Rehabilitation Program was established to extend the rehabilitation of veterans and active duty service members past the acute phase and reintegrate them into the community. Effective community reintegration is best achieved with a diverse interdisciplinary team that treats patients' physical, cognitive, and psychological deficits in a collaborative approach. Barriers, such as lack of accurate awareness of functional limitations and premorbid psychosocial stressors, can limit the recovery process. Recovery from polytrauma injuries is often a lifelong process, with the goal of maximizing functional independence and quality of life.