Trauma-related Outcomes Research Articles

Comparison of planned caesarean delivery and planned vaginal delivery in women with a twin pregnancy: A nation wide cohort study

ObjectiveTo compare, in women with twin pregnancy with the first twin in cephalic position, neonatal morbidity and mortality rates after planned caesarean delivery (CD) versus planned vaginal delivery (VD). Study DesignA nationwide cohort study on women pregnant with twins and the first child in cephalic position, who delivered between 32 + 0–41 + 0 weeks between 2000 and 2012 in the Netherlands, using multivariate logistic regression analysis to compare neonatal morbidity and mortality according to planned delivery mode, and looking at subgroups 32 + 0–36 + 6 and 37 + 0–41 + 0 weeks. ResultsWe included 21,107 women, of whom 1384 (6.6%) had a planned CD. Of the 19,723 women (93.4%) who had a planned VD, 19.7% delivered by intrapartum CD. We found no significant differences in ‘any mortality’ (aOR planned CD vs. planned VD 1.34 (95% CI 0.63–2.60)), the outcome ‘Apgar score (AS) < 4 or death within 28 days’ (aOR 1.28 (95% CI 0.77–2.11) or asphyxia-related morbidity (aOR 0.57 (95% CI 0.32–1.03)). After planned CD more prematurity-related morbidity (aOR 1.55 (95% CI 1.21–1.98)), other morbidity (aOR 1.50 (95% CI 1.26–1.78)) and ‘any morbidity or mortality’ (aOR 1.41 (95% CI 1.20–1.66) was noted. Trauma-associated morbidity was absent after planned CD and occurred 45 times (0.2%) after planned VD.Before 36 + 6 weeks, planned CD resulted in more perinatal mortality (aOR 2.10 (95% CI 0.92–4.76)), while asphyxia-related morbidity did not differ (aOR 0.80 (95% CI 0.41–1.54). Planned CD resulted in more ‘any morbidity or mortality’ (aOR 1.52 (95% CI 1.25–1.84)), ‘AS < 4 or death within 28 days’ (aOR 1.77 (95% CI 1.02–3.09)), prematurity-related morbidity (aOR 1.73 (95% CI 1.34–2.23)), and ‘other morbidity’ (aOR 1.56 (95% CI 1.28–1.90)).After 37 weeks, no significance differences in mortality, ‘any morbidity or mortality <28 days’ (aOR 0.96 (95% CI 1 (0.67–1.38)), or ‘AS < 4 or death within 28 days’ (aOR 0.41 (95% CI (0.10–1.70)) were found. There was less asphyxia-related morbidity after planned CD (aOR 0.24 (95% CI 0.06–1.002)). ConclusionPlanned VD results in comparable neonatal outcomes as planned CD for twin pregnancy with the first twin in cephalic position, even with a low intrapartum CD rate of 19.7%. At term, a planned CD may result in less asphyxia- and trauma-related outcomes.

Pregnant Women Experiencing Violent Trauma Have Higher Death Rates Despite Less Severe Injuries [36G

INTRODUCTION: Trauma is the leading non-obstetric cause of maternal death with 5-8% incidence in the United States. We compared violence-related outcomes between pregnant women and their non-pregnant counterparts. METHODS: We studied 197 pregnant and 4658 non-pregnant women of reproductive age (14-49) who experienced violent trauma between 2005-2015 as captured in the Pennsylvania Trauma Outcomes Study. We used modified Poisson regression to estimate relative rates of trauma-related outcomes. All models were adjusted for injury severity score and age. RESULTS: Compared to non-pregnant women, pregnant women were younger (mean age=24.3 versus 30.6 years, p &lt; 0.001), more likely to be African-American (54.3% versus 40.1%, p&lt; 0.001), and to have Medicaid insurance (63.1% versus 57.6%, p=0.04). They were less likely to have preexisting psychiatric, drug use, and alcohol use disorders (18.8%, 8.6%, and 2.0% for pregnant women versus 30.1%, 14.2%, and 8.8% for non-pregnant women, respectively, p &lt; 0.03 for all). Pregnant women had a mean injury severity score of 8.7 compared to 9.5 for non-pregnant women (p=0.3), and were significantly more likely to suffer trauma secondary to assault (adjusted relative rate-aRR)=1.06, 95%CI: 1.00-1.12, p=0.04). Pregnant women were more likely to require surgery (aRR=1.06, 95%CI1.01-1.12, p=0.03), and were 3.4 times more likely to undergo hospital transfer (aRR=3.41, 95%CI: 2.32-5.00, p &lt; 0.001). Pregnant women had mortality rates twice that of their non-pregnant counterparts despite lower injury severity scores (aRR=1.98, 95%CI: 1.24-3.07, p=0.004). CONCLUSION: After violent trauma, pregnant women have twice the death rate of their non-pregnant counterparts. Screening for violence during pregnancy is paramount for prevention of trauma-related death.

2016 Trauma Association of Canada Annual Scientific Meeting Abstracts.

2016 Trauma Association of Canada Annual Scientific Meeting Abstracts.

Impact of Type of Health Insurance on Infection Rates among Young Trauma Patients.

Many studies have described the detrimental effect of lack of health insurance on trauma-related outcomes. It is unclear, though, whether these effects are related to pre-injury health status, access to trauma centers, or differences in quality of care after presentation. The aim of this study was to determine if patient and insurance type affect outcomes after trauma surgery. We conducted a retrospective chart review of prospectively collected data at the American College of Surgeons level 1 trauma registry in Rhode Island. All blunt trauma patients aged 18-45 observed from 2004 to 2014 were included. Patients were divided into one of four groups on the basis of their type of insurance: Private/commercial, Medicare, Medicaid, and uninsured. Co-morbidities and infections were recorded. Analysis of variance or the Mann-Whitney U test, as appropriate, was used to analyze the data. A total of 8,018 patients were included. Uninsured patients were more likely to be male and younger, whereas the Medicare patient group had significantly fewer male patients. Rates of co-morbidities were highest in the Medicare group (28.1%) versus the private insurance (16.7%), Medicaid (19.9%), and uninsured (12.9%) groups (p < 0.05). However, among patients with any co-morbidity, there was no difference in the average number of co-morbidities between insurance groups. The rate of infection was highest in Medicaid patients (7.7%) versus private (5.6%), Medicare (6.3%), and uninsured (4.3%) patients (p < 0.05). Only Medicaid was associated with a significantly greater risk of developing a post-injury infection (odds ratio 1.6; 95% confidence interval 1.1-2.3). The presence of insurance, namely Medicaid, does not equate to diagnosis and management of conditions that affect trauma outcomes. Medicaid is associated with worse pre-trauma health maintenance and a greater risk of infection.

Geriatric Trauma Patients: What is the Difference?

Geriatric population is the fastest growing segment of the total population. They represent about 12 % of the US population. By the year 2030 it has been estimated that 19 % of the population will be older than 65 years. Currently elderly are more active and independent that increases the risk of trauma. Elderly are unique in their responses to trauma injury. The age-related physiological changes affect elderly ability to withstand trauma stress and increase the incidence of complications and deaths. Trauma surgeons and staff awareness of age-related changes and challenges will improve trauma-related outcomes in geriatric trauma patients.

The differential associations of preexisting conditions with trauma-related outcomes in the presence of competing risks

IntroductionPre-existing chronic conditions (PECs) pose a unique problem for the care of aging trauma populations. However, the relationships between specific conditions and outcomes after injury are relatively unknown. Evaluation of trauma patients is further complicated by their discharge to care facilities, where mortality risk remains high. Traditional approaches for evaluating in-hospital mortality do not account for the discharge of at-risk patients, which constitutes a competing risk event to death. The objective of this study was to evaluate associations between 40 PECs and two clinical outcomes in the context of competing risks among older trauma patients. MethodsThis retrospective study evaluated blunt-injured patients aged 55 years and older admitted to a level I trauma centre in 2006–2012. Outcomes were hospital length of stay (HLOS) and in-hospital mortality. Survivors were classified as discharges home or discharges to care facilities. Competing risks regression was used to evaluate each PEC with in-hospital mortality, accounting for discharges to care facilities as competing events. Competing risk estimates were compared to Cox model estimates, for which all survivors to discharge were non-events. Analyses were stratified using injury-based mortality risk at a 50% cutpoint (high versus low). ResultsAmong 4653 patients, 176 died in-hospital, 3059 were discharged home, and 1418 were discharged to a care facility. Most patients (98%) were classified with a low mortality risk. Only haemophilia and coagulopathy were consistently associated with longer HLOS. In the low-risk subgroup, in-hospital mortality was most strongly associated with liver diseases, haemophilia, and coagulopathy. In the high-risk group, Parkinson's disease, depression, and cancers showed the strongest associations. Accounting for the competing event altered estimates for 12 of 19 significant conditions. ConclusionsExcess mortality among patients expected to survive their injuries may be attributable to complications resulting from PECs. Discharges to care facilities constitute a bias in the evaluation of in-hospital mortality and should be considered for the accurate calculation of risk. In conjunction with injury measures, consideration of PECs provides physicians with a foundation to plan clinical decisions in older trauma patients.

Trauma-Informed Medical Care: Patient Response to a Primary Care Provider Communication Training

ABSTRACTTrauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma’s effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs.

Fruits of trauma? Posttraumatic growth among suicide-bereaved parents.

While there is evidence that suicide-bereaved individuals may be at higher risk for trauma-related outcomes, such as posttraumatic stress disorder or prolonged grief, positive psychology suggests that suicide bereavement may also promote personal growth within the confines of distress characterized as posttraumatic growth (PTG). The aim of this study was to investigate PTG and what variables, such as reflective rumination, resilience, personality variables, and mood states, contribute to PTG among suicide-bereaved parents. Online survey methods were employed using a convenience sample of 154 parents bereaved by the suicide death of their child within 2 years. Multiple regression analyses revealed that resilience inversely predicted PTG scores, but reflective rumination did not predict PTG. PTG scores were in the low-moderate range and were lower than those of parents bereaved by other causes of death. Items endorsed most strongly corresponded to the PTG factors Relating to Others, Spiritual Change, and Appreciation of Life. In this study, PTG manifests among suicide-bereaved parents, but may be complicated by the proximity to the death and by concurrent brooding and reflective rumination unique to answering the question of "why" in this population.

Examining cultural, social, and self-related aspects of stigma in relation to sexual assault and trauma symptoms.

The current study investigated a model explaining sexual assault victims' severity of trauma symptoms that incorporated multiple stigma constructs. Integrating the sexual assault literature with the stigma literature, this study sought to better understand trauma-related outcomes of sexual assault by examining three levels of stigma-cultural, social, and self. Results showed self-stigma was significantly and positively related to trauma symptom severity. Thus, results revealed that the internalized aspect of stigma served as a mechanism in the relation between sexual assault severity and increased levels of trauma symptom severity, highlighting the importance of assessing self-stigma in women reporting sexual assault experiences.

The Combined Treatment of PTSD with Borderline Personality Disorder

Psychotherapies are currently the front-line approach to treating individuals with comorbid post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD). Of the available psychotherapeutic treatment options, those that have been evaluated in randomized controlled trials (RCTs) and shown to be efficacious in reducing PTSD among individuals with BPD include: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Dialectical Behavior Therapy (DBT), DBT for PTSD (DBT-PTSD), and DBT with the DBT Prolonged Exposure protocol (DBT + DBT PE). In addition, Narrative Exposure Therapy (NET) has shown preliminary evidence of effectiveness in an open trial. The available research indicates that individuals with a primary diagnosis of PTSD and mild or sub-threshold BPD (e.g., without suicidal or serious self-injurious behavior or other severe comorbidities) can be effectively treated via brief (9–14 session), single-diagnosis treatments such as PE and CPT that focus solely on treating PTSD. PE and CPT appear to be comparably efficacious for individuals with PTSD and mild BPD. Individuals with PTSD and a moderate level of BPD (e.g., active non-suicidal self-injury [NSSI] without recent life-threatening behavior, some significant comorbidities) have shown good outcomes in DBT-PTSD, a 12-week, residential, phase-based treatment that targets comorbid problems (e.g., emotion dysregulation, psychosocial impairment) before and after addressing PTSD. Finally, individuals with PTSD and a severe level of BPD (e.g., with recent and/or acute suicidal behavior, serious NSSI and multiple severe comorbidities) have been effectively treated in longer-term (one year), integrated treatments such as DBT and DBT + DBT PE that concurrently target BPD, PTSD, and other related problems. Of these integrated treatments, DBT + DBT PE appears to be more efficacious than DBT alone in improving PTSD, suicidal and self-injurious behavior, and other trauma-related outcomes among severe BPD patients.

Social support among releasing men prisoners with lifetime trauma experiences

High rates of lifetime trauma experiences exist among men incarcerated in US state and federal prisons. Because lifetime trauma experiences have been linked to problematic behavioral and psychiatric outcomes for incarcerated populations, trauma-informed interventions could improve post-release well-being of releasing men prisoners with trauma histories. Social support has consistently been found to have a positive impact on trauma-related outcomes in non-incarcerated populations. Therefore, it is reasonable to hypothesize that social support may be an important intervention component for releasing men prisoners with trauma experiences; yet, the relationship between trauma experiences, psychiatric and behavioral factors, and social support has received almost no attention in research with men prisoners. Using a probability sample of 165 soon-to-be-released men, the present study examined differences in certain demographic, criminal justice history, mental health, substance abuse, and social support (type, quality, amount, and source) variables between releasing men prisoners with and without lifetime trauma experiences. Results indicate that men with trauma histories had more negative social support experiences and fewer positive social support resources before prison than their counterparts. Men with trauma histories also had more lifetime experiences with mental health and substance use problems. On further investigation of the subsample of men with trauma histories, those who were older, had substance use disorders, and histories of mental health problems anticipated fewer post-release social support resources. Study findings underscore the nuances of social support for men prisoners with trauma experiences and point to implications for future directions in targeted trauma-informed intervention development for releasing men prisoners.

Longitudinal Predictors of Women’s Experiences of Social Reactions Following Intimate Partner Abuse

Researchers using the Social Reactions Questionnaire (SRQ; Ullman, 2000) have documented links between women's perceptions of social reactions following sexual assault and trauma-related distress (e.g., self-blame, problem drinking, and posttraumatic stress disorder [PTSD] symptoms). The SRQ has been used primarily with female sexual assault victims with instructions to think about reactions from other people told about the assault. Research has generally relied on cross-sectional methods and assumed that social reactions lead to trauma-related outcomes. Reliance on cross-sectional methods has impeded testing assumptions about directionality (e.g., trauma-related distress might increase negative social reactions from others). Furthermore, links between victims' reports of negative social reactions and distress might reflect an overall negative reporting bias. The current study examined women's perceptions of social reactions for an incident of intimate partner abuse (IPA) reported to law enforcement. At a baseline interview (within approximately 28 days of the IPA incident), we assessed demographic factors, characteristics of the IPA, and social support as well as depression and PTSD symptom severity. One year later, PTSD symptom severity consistently predicted women's reports of negative social reactions from others, though not positive social reactions. This research advances understanding of social reactions and points to the role that PTSD symptom severity may have in contributing to social reactions, not only being a consequence of social reactions.

Trauma-Related Symptoms in Sri Lankan Adult Survivors After the Tsunami

Limited research has addressed factors associated with psychological distress following disasters among non-Western populations. The 2004 tsunami affected 1.7 million people across South Asia and Africa, with considerable variations in trauma-related outcomes. Pretraumatic and peritraumatic conditions associated with trauma-related symptoms in 305 Sri Lankan adult survivors (28% male, aged 18-83 years; mean = 39.9 years; standard deviation = 15.3), clinically assessed 1 month posttsunami, were evaluated retrospectively. Outcome measures were total scores on 11 trauma-related symptoms. Multivariate linear regression analyses tested for associations between pretraumatic and peritraumatic conditions and symptom scores, with peritraumatic conditions adjusted for pretraumatic variables. Pretraumatic conditions of female gender, employment, prior health and social issues, and substance use and peritraumatic conditions of loss of family, witnessing the tsunami, or suffering an injury were associated with trauma-related symptoms. The findings facilitate understanding cultural contexts that define risk factors associated with trauma-related symptoms in Sri Lankans, which are critical for developing culturally appropriate interventions.

Experiential avoidance as a moderator of the relationship between behavioral inhibition system sensitivity and posttraumatic stress symptoms

Preliminary evidence suggests that high emotional reactivity, in conjunction with maladaptive self-regulatory processes, increases one's vulnerability to develop psychopathology. In the present study, associations between behavioral inhibition system (BIS) and behavioral activation system (BAS) sensitivity, experiential avoidance (EA) and trauma-related outcomes (i.e., posttraumatic stress symptoms [PTSS]) were examined in a sample (N=851) of female college students who had experienced at least one traumatic event. Positive associations were observed between BIS sensitivity, EA, and PTSS. In addition, EA moderated the relationship between BIS sensitivity and PTSS, with participants high in BIS sensitivity and high in EA reporting significantly more PTSS than participants high in BIS sensitivity and low in EA. No association was observed between BIS sensitivity and PTSS for participants low in EA. These findings suggest that an unwillingness to experience unwanted private events, in conjunction with increased BIS sensitivity, contributes to PTSS severity. Further, there was a positive association and a negative association found between PTSS and BAS-Drive and BAS-Reward Responsiveness, respectively. A marginally significant EA×BAS-Fun Seeking interaction was also observed. Present findings suggests the importance of pursuing an etiological model of posttraumatic stress disorder in which neurobiological factors (i.e., BIS/BAS sensitivity) and self-regulatory processes (i.e., EA) interact to produce psychopathology.

A novel fuzzy-logic inference system for predicting trauma-related mortality: emphasis on the impact of response to resuscitation.

Trauma scoring aims for quantification and uniform reporting of trauma-related outcomes. Despite significant advances in trauma scoring, the exact time period at which relevant calculations should be made is not clear. Considering the importance of response to resuscitation, calculation of trauma scores after a period of resuscitation can allow better discrimination of patients who will survive. A fuzzy-logic inference system, which is completely based on expert opinion and uses Glasgow Coma Scale (GCS) and systolic blood pressure at arrival to emergency room (ER) and their response to resuscitation as inputs, was developed. Records of the last 150 trauma patients admitted to our surgical intensive care unit (ICU) were used for calculations related to Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma and Injury Severity Score, and A Severity Characterization of Trauma (ASCOT) systems. Calculation of trauma severity and predicted mortality was performed at different time intervals during resuscitation [at arrival to emergency room (ER), after 1h of resuscitation, and at ICU admission]. The performance of conventional systems and fuzzy-logic system was compared. Mean ISS was 32.31±14.01. All systems included showed acceptable discriminative power. Among the conventional systems calculated at emergency room admission, ISS was the best performing [receiver operating characteristics (ROC), 0.9033] and RTS was the worst (ROC, 0.8106). Their performances were improved by up to 13% by use of post-resuscitation physiologic variables. Fuzzy-logic inference system performed slightly better (ROC, 0.9247) then the conventional systems calculated at arrival to ER. Response to resuscitation has significant impact on trauma mortality and must be considered in trauma scoring and mortality prediction. Fuzzy logic provides important opportunities for design of better predictive systems.

Outcomes of mandated treatment for women with histories of abuse and co-occurring disorders

Although there is much momentum for behavioral health policies supporting mandated treatment, there is little evidence supporting its safety and effectiveness for individuals with complex issues. The authors used a national study of women with co-occurring psychiatric, substance use disorders and histories of trauma to compare mandated and voluntary treatment by examining psychiatric, substance use, and trauma-related outcomes following treatment. This quasi-experimental study included 2,726 women, with measures completed at baseline, 6-month, and 12-month follow-up. Two-way analyses of covariance examined the main and interactive effects of coercive status (mandated vs. voluntary) and condition (integrated treatment vs. services as usual) on psychiatric distress, trauma-related symptoms, and substance use outcomes. Women did better with integrated treatment and with mandated treatment regardless of treatment condition for psychiatric, trauma, and substance use outcomes at both follow-ups. Further research clarifying unintended side effects and change mechanisms of mandated treatment is needed to inform policy decisions.

(Mis) Representations of the Long-Term Effects of Childhood Sexual Abuse in the Courts

SUMMARY This study addresses the (mis) representations made by pro-false memory attorneys and expert witnesses in court regarding the long-term effects of childhood sexual abuse (CSA). Five pro-false memory positions were identified: (1) there is no causal connection between CSA and adult psychopathology; (2) the evidence is insufficient; (3) CSA does not cause specific trauma-related outcomes like borderline and dissociative identity disorder; (4) other variables than CSA explain the variance of adult psychopathology; and (5) the long-term effects of CSA are general and non-specific. Examining the testimony revealed that such pro-false memory testimony was based solely on a partial understanding of retrospective data and that pro-false memory experts do not cite the more recent prospective data. Reviewing the totality of the scientific evidence demonstrates that such pro-false memory testimony is inaccurate and has the potential of misleading the jury. Prospective studies provide sufficient evidence to causally link CSA to a number of areas of adult psychopathology including multiple, co-morbid psychiatric conditions, and possibly to link early parent-infant attachment pathology to the development of borderline and dissociative identity disorder.