Pierrette Charnay

Functional outcome after road-crash injury: Description of the ESPARR victims cohort and 6-month follow-up results

OBJECTIVE It is essential to know about the long-term consequences of road crashes involving corporal injury in order to adopt relevant public health measures. METHODS The ESPARR cohort comprises 1168 road-crash victims, aged 16 or over, managed in hospitals in the Rhône administrative départment (France). It is based on the Registry of Road Traffic Casualties, which has been collecting exhaustive data since 1995. Two groups are monitored: mild to moderate (M-AIS 1 or 2) and severe (M-AIS > or =3). Patients were interviewed at the point of primary care, between 1 October 2004 and 31 July 2006. 6 months later, their state of health and presence of pain were compared. Multivariate analysis (logistic regression) was performed to identify factors related to residual pain. RESULTS Adults of the cohort were compared to the road crash population as a whole recorded over the same period in the same area. At 6 months post-accident, only 31.9% of victims deemed their health status to have entirely returned to normal; 63.8% of mild to moderate and 89.2% of severe cases reported residual pain, but neither pain frequency nor intensity correlated with M-AIS. Residual pain was related to lower limb injuries (OR=1.6; 95% CI=1.1-2.4). After adjustment, pain was essentially related to age, seriousness of the lesions and a stay in a rehabilitation unit. CONCLUSION The ESPARR cohort provides a unique opportunity in France to describe the trajectory of a road crash victim, in terms both of care and rehabilitation and of resumption of work and personal activity.

Predictive factors of chronic post-traumatic stress disorder 6 months after a road traffic accident

BACKGROUND This study sets out to identify risk factors for post-traumatic stress disorder (PTSD) after a road traffic accident with a view to improving prevention. METHODS The study used a prospective cohort of road traffic accident casualties. All subjects over 15 years of age were recruited in the course of an interview conducted while they were receiving care in a hospital of the Rhône area administrative département. Six months after their accident, they answered a self-administered postal questionnaire that included the Post-traumatic Check-List Scale (PCLS) in order to evaluate PTSD. Multivariate logistic regression analysis was conducted to compare those subjects with a PCLS score of 44 or over with those with a lower score, in order to identify factors that might be associated with PTSD. RESULTS 592 subjects (out of 1168) returned the 6-month questionnaire and 541 completed the PCLS test. One hundred subjects had a PCLS score ≥ 44, suggesting PTSD, and 441 subjects did not. The factors associated with PTSD were initial injury severity, post-traumatic amnesia, the feeling of not being responsible for their accident and persistent pain 6 months after it. A lower odds-ratio was associated with users of two-wheel than four-wheel motor vehicles (OR=0.4; 0.2-0.9). CONCLUSION Besides predictive factors for PTSD (injury severity, post-traumatic amnesia and the feeling of not being responsible for their accident), our study suggested a reduced risk of PTSD among two-wheel motor vehicle users.

Return to work following road accidents: Factors associated with late work resumption

OBJECTIVE To analyse factors associated with late return to work in road accident victims. MATERIALS AND METHODS The ESPARR cohort comprises road accident victims monitored over time from initiation of hospital care. A total of 608 ESPARR cohort subjects were working at the time of their accident and answered questionnaires at 6 months and/or 1 year. For each level of overall severity of injury (Maximum - Abbreviated Injury Scale (M-AIS) 1, 2, 3 and 4-5), a time-off-work threshold was defined, beyond which the subject was deemed to be a late returner; 179 subjects were considered to be late in returning to work, while 402 showed a normal pattern of return. Logistic regression identified factors associated with late return. RESULTS Type of journey, overall injury severity and intention to press charges emerged as factors predictive of late return to work on the basis of the data collected at inclusion alone. After adjustment, pain (odds ratio (OR): 2.6; 95% confidence interval (95% CI) 1.0-6.7) and physical sequelae (OR: 3.8; 95% CI 1.7-8.3) at 6 months and the fact of pressing charges (OR: 2.6; 95% CI 1.2-5.5) remained significantly linked with late return to work. CONCLUSION Impaired health status at 6 months after the initial accident (in the form of persistent pain and physical sequelae) is a determining factor delaying return to work following a road traffic accident.

Diseases, consumption of medicines and responsibility for a road crash: A case-control study

UNLABELLED The role of medical conditions in crashes is a topic of public debate. Some studies suggest that there has been a reduction in road traffic crashes subsequent to the medical restrictions introduced on drivers with medical deficiencies. As in todays society the car is an important factor for independence and socialization, it seems important to consider whether diseases or consumption of drugs increase the risk of causing a road crash in comparison to well-known major crash risk factors. A case-control study was conducted (733 injured drivers). The cases were subjects who were partly or totally responsible for their crash. The 304 controls were the non-responsible drivers. Diseases and medicine consumption were analyzed using logistic regression models. Cases were characterized by a higher percentage of young men. They were more frequently affected by fatigue, as were subjects who had consumed alcohol. A higher risk in subjects suffering from hypertension is observed (adjusted odds ratio [adjOR]=3.82; 95%CI=[1.42-10.24]). An association between antidepressant consumption and responsibility appeared (adjOR=3.61; 95%CI=[1.30-10.03]). CONCLUSION Medical factors associated with responsibility were arterial hypertension and antidepressant consumption. Other medical conditions do not seem to play a preponderant role comparing to individual behaviours.

Quality of life one year after a road accident: Results from the adult ESPARR cohort

BACKGROUND There are a few studies assessing repercussions in road accident victims, which reported their results in quality of life (QoL), on an epidemiologic point of view. METHODS ESPARR (follow-up of victims of road accident in the Rhône) is a prospective cohort study of 1,168 individuals (age ≥ 16 years) involved in road traffic accidents, having been admitted to one of the hospitals in the Rhône département (France). The World Health Organization Quality of Life Questionnaire–Brief Version (WHOQOL-Bref) was used to assess QoL at the 1-year follow-up. &khgr;2 analysis was performed to test differences between groups, logistic regression was performed to examine predictors of global QoL and health, and linear regression was performed to examine predictors of the four functioning domains of the WHOQOL-Bref. RESULTS Lesion severity (New Injury Severity Index ≥ 16; odds ratio, 2.6; 95% confidence interval, 1.7–3.9) and presence of head lesions (odds ratio, 1.5; 95% confidence interval, 1.1–2.2) were predictive of unsatisfactory QoL. Female sex, educational level lower than school graduation, severe injury, intention to lodge a complaint, early postaccident medical complications were predictive of health dissatisfaction. Several factors seemed to be associated to a poor QoL; notably, posttraumatic stress disorder was associated with low scores in all four WHOQOL-Bref domains. Socioeconomic factors were also significant, notably financial problems. CONCLUSION The strong points of the present study lie in the fact that it is based on a representative cohort of road accident victims in an area in which all those treated within the hospital system after a road accident have been registered. The present study shows the strong correlation between QoL and posttraumatic stress disorder. LEVEL OF EVIDENCE Prognostic study, level II.

A few seconds to have an accident, a long time to recover: Consequences for road accident victims from the ESPARR cohort 2 years after the accident

OBJECTIVE The aim of the present study was to describe the consequences of a road accident in adults, taking account of the type of road user, and to determine predictive factors for consequences at 2 years. DESIGN Prospective follow-up study. METHODS The cohort was composed of 1168 victims of road traffic accidents, aged ≥16 years. Two years after the accident, 912 victims completed a self-administered questionnaire. Weighted logistic regression models were implemented to compare casualties still reporting impact related to the accident versus those reporting no residual impact. Five outcomes were analysed: unrecovered health status, impact on occupation or studies, on familial or affective life, on leisure or sport activities and but also the financial difficulties related to the accident. RESULTS 46.1% of respondents were motorised four-wheel users, 29.6% motorised two-wheel (including quad) users, 13.3% pedestrians (including inline skate and push scooter users) and 11.1% cyclists. 53.3% reported unrecovered health status, 32.0% persisting impact on occupation or studies, 25.2% on familial or affective life, 46.9% on leisure or sport activities and 20.2% still had accident-related financial difficulties. Type of user, adjusted on age and gender, was linked to unrecovered health status and to impact on leisure or sport activities. When global severity (as measured by NISS) was integrated in the previous model, type of user was also associated with impact on occupation or studies. Type of user was further associated with impact on occupation or studies and on leisure or sport activities when global severity and the sociodemographic data obtained at inclusion were taken into account. It was not, however, related to any of the outcomes studied here, when the models focused on the injured body region. Finally, type of road user did not seem, on the various predictive models, to be related to financial difficulties due to the accident or to impact on familial or affective life. CONCLUSIONS Overall, victims were affected by their accident even 2 years after it occurred. The severity of lesions induced by the accident was the main predictive factor. However, considering lesion as intermediary factors between the accident and the recovery status at 2 year post-accident, impact on health status was lower for cyclists than M4W users or M2W users.

PReDICTINg SelF-RePORTeD ReCOveRy ONe yeAR AFTeR MAJOR ROAD TRAFFIC ACCIDeNT TRAUMA

OBJECTIVE The aim of this study was to examine the self-reported health status of road traffic accident victims and the predictors of self-assessed recovery 1 year after major trauma in a French population. DESIGN A follow-up study. METHODS The cohort comprised 276 seriously injured victims of road traffic accidents, aged > 16 years from the Rhône administrative department, France. Victim characteristics at the time of the crash and self-reported health status 1 year after trauma were collected. Predictive factors for self--assessed recovery were examined using a Poisson regression approach. RESULTS The majority of victims were male (76%); most had severe injuries (76%), involving mainly the lower limbs and the head (68% and 55%, respectively). At 1-year follow-up, 80% reported being not fully recovered. Self-reported health status was not significantly associated with age, gender, being in employment, type of road user, or health status during the year preceding the accident, but rather with low socio-economic status, high injury severity, and presence of lower limb injury. CONCLUSION Care for subjects who are at high risk of not fully recovering (manual workers, the very seriously injured, and those with lower limb injury) needs to be extended and improved. Longer follow-up studies on the risk factors for not fully recovering are needed in order to reduce harmful consequences for victims.

Cognitive and behavioural post-traumatic impairments: What is the specificity of a brain injury ? A study within the ESPARR cohort

OBJECTIVE The variety and extent of impairments occurring after traumatic brain injury vary according to the nature and severity of the lesions. In order to better understand their interactions and long-term outcome, we have studied and compared the cognitive and neurobehavioral profile one year post onset of patients with and without traumatic brain injury in a cohort of motor vehicle accident victims. METHOD The study population is composed of 207 seriously injured persons from the ESPARR cohort. This cohort, which has been followed up in time, consists in 1168 motor vehicle accident victims (aged 16 years or more) with injuries with all degrees of severity. Inclusion criteria were: living in Rhone county, victim of a traffic accident having involved at least one wheel-conducted vehicle and having occurred in Rhone county, alive at the time of arrival in hospital and having presented in one of the different ER facilities of the county. The cohorts representativeness regarding social and geographic criteria and the specificities of the accidents were ensured by the specific targeting of recruitment. Deficits and impairments were assessed one year after the accident using the Neurobehavioral Rating Scale - Revised and the Trail-Making Test. Within our seriously injured group, based on the Glasgow Score, the presence of neurological deficits, aggravation of neurological condition in the first 72hours and/or abnormal cerebral imaging, we identified three categories: (i) moderate/severe traumatic brain injury (n=48), (ii) mild traumatic brain injury (n=89), and (iii) severely injured but without traumatic brain injury (n=70). RESULTS The most frequently observed symptoms were anxiety, irritability, memory and attention impairments, depressive mood and emotional lability. While depressive mood and irritability were observed with similar frequency in all three groups, memory and attention impairments, anxiety and reduced initiative were more specific to traumatic brain injury whereas executive disorders were associated with moderate/severe traumatic brain injury. DISCUSSION-CONCLUSION The presence and the initial severity of a traumatic brain injury condition the nature and frequency of residual effects after one year. Some impairments such as irritability, which is generally associated with traumatic brain injury, do not appear to be specific to this population, nor does depressive mood. Substantial interactions between cognitive, affective and neurobehavioral disorders have been highlighted.

Health status recovery at one year in children injured in a road accident: A cohort study

Despite the frequency of traumatic injuries due to road accidents and potential importance of identifying children at risk of impaired recovery one year after a road accident, there is a lack of data on long-term recovery of health status, except in children with severe traumatic brain injury. The aim of the present study was to evaluate predictive factors of recovery in children one year after road traffic injuries. The prospective cohort study was composed of children aged <16 years, admitted to public or private sector hospitals in the Rhône administrative area of France following a road accident. Recovery of health status one year after the accident and information concerning quality of life and the consequences of the accident for the child or family 1 year after the accident were collected by questionnaire, usually completed by the parents. Victims were in majority male (64.6%) and had mild or moderate injuries (81.9% with Maximum Abbreviated Injury Scale (M-AIS) <3). One year after the accident, 75.0% of the mild-to-moderate and 34.8% of the severe cases estimated health status as fully recovered. After adjustment, severity score (M-AIS≥3) and lower limb injury (AIS>1) were associated with incomplete recovery of health status: weighted odds ratio (ORw), 4.3 [95% confidence interval (95% CI), 1.3-14.6] and ORw, 6.5 [95% CI, 1.9-21.7], respectively. Recovery status correlated significantly with quality of life physical scores (r=0.46), especially body pain (r=0.48) and role/social-physical (r=0.50) and, to a lesser extent, quality of life psychosocial scores (r=0.21). In a cohort of children injured in a road accident, those with high injury severity score and those with lower limb injuries are less likely to recover full health status by 1 year. Impaired health status was associated with a lower physical quality of life score at 1 year.

Evaluation of the Injury Impairment Scale, a tool to predict road crash sequelae, in a French cohort of road crash survivors

Objective: The objective of the present study was to validate sequelae prediction by the Maximal Injury Impairment Score (M-IIS) in comparison with the Functional Independence Measure (FIM) assessed at 1-year follow-up of severe road crash victims. Methods: The study population came from “the Etude et Suivi d’une Population d’Accidentés de la Route dans le Rhône” (ESPARR; Rhône Area Road Crash Victim Follow-up Study) cohort: 178 victims (with Maximal Abbreviated Injury Scale ≥ 3) of road crashes in the Rhône administrative department of France, aged ≥ 16 years and with medical examination including FIM scoring 1 year postaccident. Two thresholds were tested for both scores. Firstly, the relation between FIM and M-IIS was assessed on logistic regression models adjusted on age and presence of complications at 1 year postaccident. The predictive capacity of M-IIS was expressed as its negative and positive predictive values and was considered good when 80 percent or better. Results: Sixty-three of the 178 adult subjects (mean age = 37.7 years; range = 16.1–82.9 years) showed postaccident complications. One-year sequelae prediction on M-IIS was greater in head, spine, and limb lesions but limited to slight impairments (M-IIS = 1). There was a significant correlation between FIM and M-IIS, although age and medical complications were confounding factors on certain multivariate models. The predictive capacity of M-IIS was low for all types of sequelae. Conclusions: M-IIS, in this severely injured population, failed to predict sequelae at 1 year as measured by the FIM, despite a good correlation between the two. Complications are to be taken into account in assessing the M-IISs capacity to predict sequelae. Further evaluation will be needed on larger series or assessment of other indicators and measures of sequelae at 1 year to obtain a robust tool to predict road crash sequelae.