Identifying subgroups of refugees from Syria resettled in Sweden based on multiple trauma exposures: A latent class analysis of trauma history and mental health outcomes.

OBJECTIVE: Many refugees have been subjected to pre-migratory trauma. Evidence is needed to address the heterogeneity within refugee populations in regard to patterns of multiple trauma exposures. This study identified subgroups within a refugee population displaying different profiles of multiple trauma exposures and assessed sociodemographic predictors and differences in mental health symptom severity across these classes. METHODS: Study population consisted of 1215 refugees from Syria resettled in Sweden. Latent class analysis 3-step method for modelling predictors and outcomes and a class-specific weighted multigroup approach were used to identify classes of refugees using self-reported data on violent and non-violent trauma exposures, sociodemographic variables and symptom severity scores for depression, anxiety and PTSD. RESULTS: Three classes were identified: class 1 'multiple violent and non-violent trauma' (39.3%, n = 546); class 2 'witnessing violence and multiple non-violent trauma' (40.8%, n = 569); and class 3 'low multiple non-violent trauma' (20.1%, n = 281). Trauma exposure and gender significantly predicted class membership. Male gender and highest severity of mental ill health defined class 1. Female gender predicted higher mental ill health within classes 1 and 2. Across all three classes living with a partner was associated with lower severity of mental ill health regardless of trauma exposure classes. CONCLUSIONS: There are distinct patterns within refugee populations concerning exposure to multiple trauma. Violence is a primary marker for higher likelihood of multiple trauma exposures and severity of mental health. Gender predisposes individuals to trauma exposure and its outcomes differentially.

Incidence and Characteristics of Low-Speed Vehicle Run-Over Events in Australian Aboriginal and/or Torres Strait Islander Children and Other Australian Children Aged 0 to 14 Years in Queensland: An 11-Year (1999-2009) Retrospective Analysis.

The main objective of this study is to describe incidence rates (IRs) of low-speed vehicle run-over events among children aged 0 to 14 years in Queensland, Australia, from 1999 to 2009, by Indigenous Australian status. Data on low-speed vehicle run-over events among children aged 0 to 14 years in Queensland were obtained for 11 calendar years (1999-2009) from all relevant data sources using International Classification of Diseases (ICD) codes, text description, word searches, and medical notes and were manually linked. Crude fatal and nonfatal IRs were calculated for Indigenous and non-Indigenous children; trends over time were analyzed by chi-square test for trend. Relative risks (RRs) were also calculated. Data on demographics, health service usage/outcomes, incident characteristics, and injury characteristics were obtained. Descriptive and multivariate analyses were performed in order to investigate whether these characteristics varied with Indigenous status. IRs were higher among Indigenous Australian children aged 0 to 14 years (21.76/100,000/annum) than other Australian children (14.09), for every year of the 11-year study. The age group most at risk for low-speed vehicle run-over events were young children aged 0 to 4 years, where incidence was 2.13 times greater among Indigenous Australian children (95% confidence interval [CI] = 1.67-2.71). There were no significant changes in incidence of low-speed vehicle run-overs among Indigenous Australian children for 0 to 4, 5 to 9, and 10 to 14 years or overall (0-14 years), during the 11-year study period. Over three quarters (n = 107) of low-speed vehicle run-over events involving Indigenous Australian children occurred outside of major cities (43.7% in other Australian children). These data indicate that Indigenous Australian children are at increased risk of low-speed vehicle run-over events and that characteristics of these events may vary as a function of Indigenous status. These results highlight that culturally specific interventions to reduce low-speed vehicle run-over events are required.

CAVH in the Combat Environment: A Case Report and Lessons Learned in Southern Afghanistan.

Background: Acute kidney injury is a common complication of both civilian and military trauma. The lack of dedicated resources restrict dialysis in the forward setting. We report a case of a combat polytrauma and renal failure, using continuous arteriovenous hemofiltration to clear uremia and remove volume, allowing for ventilator liberation and safe disposition. Materials and Methods: The patient presented with traumatic lower extremity injuries and abdominal wounds and developed acute post-traumatic renal failure. Using available supplies, the patient was cannulated for continuous arteriovenous hemofiltration. Aggressive fluid and electrolyte management accomplished specific goals of ventilator liberation and clearance of uremia. Results: Over 48 h, blood urea nitrogen was reduced from 101 mg/dL to 63 mg/dL. Creatinine was reduced from 8.2 mg/dL to 4.7 mg/dL. Acute respiratory distress syndrome was improved reducing P:F (PaO2:FiO2) ratio from 142 to 210. The patient was extubated and transferred safely. Conclusions: The ability to perform acute dialysis can be lifesaving. Although resource constrained, we created a dialysis system in the forward environment with a filter and universally available equipment. This represents the first described use of continuous arteriovenous hemofiltration at the NATO Role 3 hospital in Afghanistan. This technique represents another potential tool for deployed trauma teams to improve care.

Validation of trauma scales: ISS, NISS, RTS and TRISS for predicting mortality in a Colombian population.

BACKGROUND: Our purpose was to validate the performance of the ISS, NISS, RTS and TRISS scales as predictors of mortality in a population of trauma patients in a Latin American setting. MATERIALS AND METHODS: Subjects older than 15 years with diagnosis of trauma, lesions in two or more body areas according to the AIS and whose initial attention was at the hospital in the first 24 h were included. The main outcome was inpatient mortality. Secondary outcomes were admission to the intensive care unit, requirement of mechanical ventilation and length of stay. A logistic regression model for hospital mortality was fitted with each of the scales as an independent variable, and its predictive accuracy was evaluated through discrimination and calibration statistics. RESULTS: Between January 2007 and July 2015, 4085 subjects were enrolled in the study. 84.2% (n = 3442) were male, the mean age was 36 years (SD = 16), and the most common trauma mechanism was blunt type (80.1%; n = 3273). The medians of ISS, NISS, TRISS and RTS were: 14 (IQR = 10-21), 17 (IQR = 11-27), 4.21 (IQR = 2.95-5.05) and 7.84 (IQR = 6.90-7.84), respectively. Mortality was 9.3%, and the discrimination for ISS, NISS, TRISS and RTS was: AUC 0.85, 0.89, 0.86 and 0.92, respectively. No one scale had appropriate calibration. CONCLUSION: Determining the severity of trauma is an essential tool to guide treatment and establish the necessary resources for attention. In a Colombian population from a capital city, trauma scales have adequate performance for the prediction of mortality in patients with trauma.

Predicting non return to work after orthopaedic trauma: the Wallis Occupational Rehabilitation RisK (WORRK) model.

BACKGROUND: Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. METHODS: Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. RESULTS: At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. CONCLUSIONS: Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.

Surviving multi-trauma in the past.

BACKGROUND: Surviving multi-trauma is strongly associated with emergent resuscitation and treatment in modern medical facilities. Multi-trauma survival before the advent of modern medicine is likely to have been extremely uncommon, particularly in primitive societies. The aim of this study was to investigate the case of an ancient Australian Aboriginal who appeared to have survived multi-trauma. METHODS: We investigated the skeletal remains of an adult Australian Aboriginal with healed fractures of the right femur and humerus. The time of death was assessed by carbon dating. The sex and approximate age of the subject were assessed from the skeleton's morphometry. The fractured bones were assessed by visual inspection, plain radiographs and computer tomography (CT) scanning. RESULTS: The remains were of a male aged approximately 50 years at the time of his death, approximately 1000 years ago, preceding European settlement. Analysis of the malunions indicated that all fractures occurred in one traumatic event, normally a life-threatening injury combination, and that the subject survived for years after this incident, despite no or failed active treatment of his fractures. CONCLUSIONS: The survival of a man living in a primitive society after multi-trauma reflects an impressive depth of nursing and social support in a community of hunter gatherers.

Individualised care from the orthopaedic and trauma patients' perspective: an international comparative survey.

BACKGROUND: Although individualised nursing care is considered a core value in nursing in different countries, international comparative studies in this area are rare. In Western countries, common hospitalised patients, e.g. orthopaedic patients, often perceive health care as impersonal rather than individualised; a term which may also have different connotations in different cultures. OBJECTIVES: To describe and compare orthopaedic and trauma patients' perceptions of individuality in their care in four European countries. DESIGN: A cross-sectional comparative study. SETTINGS: 24 orthopaedic and trauma wards in 13 acute care hospitals. PARTICIPANTS: Data were collected from orthopaedic and trauma patients in Finland (n=425, response rate 85%), Greece (n=315, 86%), Sweden (n=218, 73%) and UK (n=135, 58%) between March 2005 and December 2006. METHODS: Questionnaire survey data using the Individualised Care Scale (ICS) were obtained and analysed using descriptive and inferential statistics including frequencies, percentages, means, standard deviations, 95% confidence intervals (CI), one-way analysis of variance (ANOVA), chi2 statistics and univariate analysis of covariance (ANCOVA). RESULTS: Patients perceived that nurses generally supported their individuality during specific nursing interventions and perceived individuality in their care. There were some between-country differences in the results. Patients' individuality in the clinical situation and in decisional control over their care were also generally well supported and taken into account. However, patients' personal life situation was not supported well through nursing interventions and these patients perceived lower levels of individualised care. CONCLUSIONS: North-South axis differences in patients' perceptions of individualised care may be attributed to the way nursing care is defined and organised in different European countries. Differences may be due to the differences in regional samples, and so no firm conclusions can be made. Further research will be needed to examine the effect of patient characteristics' and health care organisation variables in association with patients' perceptions of individualised care.

Racial disparities in acute outcomes of life-threatening injury.

PURPOSE: To critically analyze racial and ethnic disparities in acute outcomes of life-threatening injury in the United States (US). DESIGN: Integrative review of literature. METHODS: A search of Medline (1966-2005) and CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1982-2002) scientific literature databases was undertaken to identify research aimed at correlating minority race and ethnicity to acute outcomes of life-threatening injury in the US. RESULTS: Although injury is the leading cause of death for adults 15 to 44 years of age, racial and ethnic health disparities in acute outcomes of life-threatening injury have been relatively unexplored: only seven of 352 (2%) studies. The findings from these studies were mixed. Four studies indicated significant relationships between race or ethnicity to acute outcomes in injury morbidity and mortality, but three studies showed no significant relationships between these variables. Other variables associated with health disparities, such as income and education, were rarely (income) or not (education) addressed. CONCLUSIONS: These inconclusive results indicate the need for more research aimed at investigating racial and ethnic disparities in acute outcomes of life-threatening injury.

Methamphetamine use in trauma patients: a population-based study.

BACKGROUND: There are indications that methamphetamine production and illicit use are increasing. We investigated the epidemiology of methamphetamine use in trauma patients in an area of heavy methamphetamine prevalence. STUDY DESIGN: This was a retrospective population-based review. We reviewed toxicology and alcohol test results in trauma patients admitted to the University of California, Davis, between 1989 and 1994 to the only trauma center serving a population of 1.1 million. RESULTS: Positive methamphetamine rates nearly doubled between 1989 (7.4%) and 1994 (13.4%), compared with a minimal increase in cocaine rates (5.8% to 6.2%) and a decrease in blood alcohol rates (43% to 35%). Methamphetamine-positive patients were most likely to be Caucasian or Hispanic; cocaine-positive patients were most likely to be African American. Methamphetamine-positive patients were most commonly injured in motor vehicle collisions or motorcycle collisions; cocaine-positive patients were most commonly injured by assaults, gunshot wounds, or stab wounds. Cocaine positivity and alcohol positivity predicted a decreased need for emergency surgery and cocaine positivity predicted a decreased need for admission to the ICU. CONCLUSIONS: Methamphetamine use in trauma patients increased markedly in our region between 1989 and 1994, alcohol rates decreased, and cocaine rates remained unchanged. Methamphetamine-positive patients had mechanisms of injury similar to those of alcohol-positive patients, so injury prevention strategies for methamphetamine should be patterned after strategies designed for alcohol.

Trauma among American Indians in an urban county.

OBJECTIVE: To describe severe injury among American Indians in a large metropolitan county given that most previous studies of the high Indian injury morbidity and mortality rates have been conducted primarily in rural areas. METHODS: A retrospective analysis of a hospital trauma registry was conducted for the years 1986-92 at the Harborview Medical Center, the only Level I trauma center in King County, Washington, metropolitan county with the seventh largest number of urban American Indians in the United States. RESULTS: Of 14,851 King County residents included in the registry, 593 (4%) were classified as American Indian. With King County whites as the reference, the age-standardized incidence ratio for inclusion of American Indians in the registry was 4.4 (95% confidence interval 4.1, 4.8). The standardized incidence ratios and proportional incidence ratios showed significant differences in mechanism and whether it was intentional or unintentional among Indians compared with whites. Hospitalizations for stab wounds, bites, and other blunt trauma were all significantly more frequent among Indians. Trauma admissions among Indians were disproportionately associated with assaults. A high proportion (72.3%) of American Indians tested had blood alcohol levels exceeding 0.1%. CONCLUSION: Urban American Indians experience high rates of trauma, differing from those among whites. Efforts to reduce injury in urban areas should include collaboration with representative urban American Indian organizations.