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��ࡱ�>��	������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	����bjbj���	4�����9�-�������X	X	������������8��,�c3
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�-330c3�(R:6!�:&)&)n:��)\��>$������2�2�#F���c3������������������������������������������������������������������������:���������X		a:	Title:  Studying the lasting effects of trauma on the everyday function of young assault patients

Authors:  Virginia Shalkey BS1, Michael L. Nance MD2, C. William Schwab MD FACS4, Judd E. Hollander MD3, Therese S. Richmond PhD CRNP FAAN5, Charles Branas PhD6, Douglas J. Wiebe PhD6
Affiliations: 
1. School of Medicine, University of Pennsylvania, Philadelphia, PA
2. Department of Surgery, Children�s Hospital of Philadelphia, Philadelphia, PA
3. Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
4. Division of Trauma, Department of Surgery, University of Pennsylvania, Philadelphia, PA
5.  School of Nursing, University of Pennsylvania, Philadelphia, PA
6.  Department of Biostatistics and Epidemiology, School of Medicine, University of   
   Pennsylvania, Philadelphia, PA
Correspondence:
Douglas J. Wiebe, PhD
Department of Biostatistics and Epidemiology, School of Medicine, University of  Pennsylvania, Philadelphia, PA 19104-6021. Tel 215-746-0149. Fax 215-573-2265.Email dwiebe@exchange.upenn.edu

Disclosures: Completed with support from the National Institute on Alcohol Abuse and Alcoholism (grant number R01AA014944) and the Summer Research Fellowship, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. The authors have no conflicts of interest to disclose.  The work described here was presented at the Annual Meeting of the American Public Health Association in Philadelphia, PA on November 10, 2009.  

Acknowledgements:  We are grateful to Beth Ellis Ohr and Luke Basta for their assistance in protocol development and data management.
Abstract
Background: Assault patients are underrepresented in trauma recovery research. We assessed whether follow-up phone calls initiated post-discharge could enable recruiting assault patients for research and assessed lasting emotional and physical wounds.  

Methods:  56 patients 18-24 years old treated for assault-related gunshot wound (GSW) or non-GSW injuries at an urban Level 1 trauma center were recruited by telephone 1-18 months after discharge for a 15-minute telephone interview about quality of life and symptoms since discharge.  Analyses included tests of proportions and regression.

Results:  509 calls were placed to determine final dispositions for the 56 patients. Doing so revealed 3 GSW patients had been killed since discharge and 3 were incarcerated. Of 50 eligible patients, 10 of 17 GSW and 11 of 33 non-GSW patients (42.0%) were successfully enrolled (mean=10 calls/enrollment). The number of calls required for a final disposition decreased with age (rate ratio, RR=0.91, p=0.040) and increased with months since discharge (RR=1.05, p=0.014). The odds of successful enrollment decreased with age (OR=0.73, p=0.050) and months since discharge (OR=0.87, p=0.043) and were higher for non-GSW versus GSW patients (OR=6.04, p=0.009). GSW patients reported more difficulty performing moderate activities (7 vs. 1, p=0.007) and climbing stairs (8 vs. 0, p=0.001), pain during normal activities (8 vs. 5, p=0.049), and higher median PTSD symptom scores (3.0 vs. 1.0, p=0.001).  

Conclusion: Physical and emotional wounds of assault patients are frequent, can last long after discharge, and are more common among GSW than non-GSW patients.  Tertiary prevention activities and larger cohort studies with recruitment initiated before discharge are warranted.

Keywords: Wounds; injuries; violence; stress disorders, post-traumatic.


Introduction
Homicide is the second leading cause of death among adolescents and young adults in the United States, ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2009. Date accessed: October 30</Year><RecNum>3649</RecNum><IDText>2009.  Available at http://www.cdc.gov/nciplc/wisqars.</IDText><record><rec-number>3649</rec-number><ref-type name="Electronic Source">12</ref-type><contributors><authors><author>CDC</author></authors></contributors><auth-address>CDC (Centers for Disease Control and Prevention)</auth-address><titles><title>WISQARS Leading cause of death reports, 2008</title></titles><dates><year>2009. Date accessed: October 30, 2009.  Available at http://www.cdc.gov/nciplc/wisqars.</year></dates><publisher>Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC</publisher><urls><related-urls><url>http://www.cdc.gov/ncipc/wisqars/ </url></related-urls></urls><research-notes>There were about 17,400 firearm related deaths, second only to cancer, for 0-44 year olds, in 2004.</research-notes></record></Cite></EndNote>1 however the majority of assault victims presenting to trauma centers survive. ADDIN EN.CITE <EndNote><Cite ExcludeYear="1"><Author>CDC</Author><RecNum>3647</RecNum><record><rec-number>3647</rec-number><ref-type name="Electronic Source">12</ref-type><contributors><authors><author>CDC</author></authors></contributors><auth-address>Centers for Disease Control and Prevention</auth-address><titles><title>WISQARS Nonfatal Injury Reports, 2008. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.  Data accessed: July 22, 2010. Available at: http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html</title></titles><dates></dates><publisher>Office of Statistics and Programming, </publisher><urls></urls></record></Cite></EndNote>2 Many of these survivors have residual physical and emotional wounds that warrant extended care. Studies have found that traumatic injuries negatively impact quality of life and lead to persisting symptoms of depression and post-traumatic stress disorder (PTSD). ADDIN EN.CITE <EndNote><Cite><Author>Richmond</Author><Year>2000</Year><RecNum>2210</RecNum><record><rec-number>2210</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Richmond, T. S.</author><author>Thompson, H. J.</author><author>Deatrick, J. A.</author><author>Kauder, D. 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L.</author><author>Hoyt, D. B.</author><author>Coimbra, R.</author><author>Potenza, B.</author><author>Sise, M. J.</author><author>Sack, D. I.</author><author>Anderson, J. P.</author></authors></contributors><auth-address>Division of Trauma, Department of Surgery, University of California, CA, USA. tholbrook@ucsd.edu</auth-address><titles><title>Trauma in adolescents causes long-term marked deficits in quality of life: adolescent children do not recover preinjury quality of life or function up to two years postinjury compared to national norms</title><secondary-title>J Trauma</secondary-title></titles><periodical><full-title>J Trauma</full-title></periodical><pages>577-83; discussion 583</pages><volume>62</volume><number>3</number><keywords><keyword>Adolescent</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Injury Severity Score</keyword><keyword>Male</keyword><keyword>*Quality of Life</keyword><keyword>*Recovery of Function</keyword><keyword>*Sickness Impact Profile</keyword><keyword>*Wounds and Injuries/etiology/pathology/psychology</keyword></keywords><dates><year>2007</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>17414331</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=17414331 </url></related-urls></urls></record></Cite><Cite><Author>Sluys</Author><Year>2005</Year><RecNum>3844</RecNum><record><rec-number>3844</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sluys, K.</author><author>Haggmark, T.</author><author>Iselius, L.</author></authors></contributors><auth-address>Department of Surgical Science, Karolinska Institute, Stockholm, Sweden. kerstin.sluys@telia.com</auth-address><titles><title>Outcome and quality of life 5 years after major trauma</title><secondary-title>J Trauma</secondary-title></titles><periodical><full-title>J Trauma</full-title></periodical><pages>223-32</pages><volume>59</volume><number>1</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Injury Severity Score</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Outcome Assessment (Health Care)</keyword><keyword>*Quality of Life</keyword><keyword>Risk Factors</keyword><keyword>Statistics, Nonparametric</keyword><keyword>Wounds and Injuries/complications/*therapy</keyword></keywords><dates><year>2005</year><pub-dates><date>Jul</date></pub-dates></dates><accession-num>16096568</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16096568 </url></related-urls></urls></record></Cite><Cite><Author>Winthrop</Author><Year>2005</Year><RecNum>3845</RecNum><record><rec-number>3845</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winthrop, A. L.</author><author>Brasel, K. J.</author><author>Stahovic, L.</author><author>Paulson, J.</author><author>Schneeberger, B.</author><author>Kuhn, E. M.</author></authors></contributors><auth-address>Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. winthrop@mcw.edu</auth-address><titles><title>Quality of life and functional outcome after pediatric trauma</title><secondary-title>J Trauma</secondary-title></titles><periodical><full-title>J Trauma</full-title></periodical><pages>468-73; discussion 473-4</pages><volume>58</volume><number>3</number><keywords><keyword>*Activities of Daily Living</keyword><keyword>Adaptation, Psychological</keyword><keyword>Adolescent</keyword><keyword>Attitude to Health</keyword><keyword>Causality</keyword><keyword>Child</keyword><keyword>Child Psychology</keyword><keyword>Child, Preschool</keyword><keyword>Cost of Illness</keyword><keyword>Family/psychology</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Hospitals, Pediatric</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Injury Severity Score</keyword><keyword>Male</keyword><keyword>Prospective Studies</keyword><keyword>*Quality of Life</keyword><keyword>Questionnaires</keyword><keyword>*Recovery of Function</keyword><keyword>Sickness Impact Profile</keyword><keyword>Statistics, Nonparametric</keyword><keyword>Time Factors</keyword><keyword>Treatment Outcome</keyword><keyword>Wisconsin</keyword><keyword>Wounds, Nonpenetrating/physiopathology/psychology/*rehabilitation</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>15761338</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=15761338 </url></related-urls></urls></record></Cite></EndNote>3-6 However, victims of violent assault have comprised only a small percentage of the patients enrolled as subjects in past research. Compared to prior studies assessing outcomes after trauma in general, studies focused on assault-related trauma may show an even higher prevalence of poor outcomes.  Relatively little is known about the lasting effects that assault-related trauma can have on young patients� lives, and few studies have assessed the mental health consequences of assault. This gap in our knowledge is potentially substantial and may limit clinicians� ability to provide optimal injury care and preventive follow-up. Family practitioners in particular have an opportunity to coordinate and provide this care for this unique patient population.

A major barrier to better understanding the residual physical and emotional wounds of patients treated for violence assault is the challenge of recruiting assault patients as subjects in clinical research. ADDIN EN.CITE <EndNote><Cite><Author>Furimsky</Author><Year>2008</Year><RecNum>3655</RecNum><record><rec-number>3655</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Furimsky, I.</author><author>Cheung, A. H.</author><author>Dewa, C. S.</author><author>Zipursky, R. B.</author></authors></contributors><auth-address>Mental Health and Addictions Program, St Joseph&apos;s Healthcare Hamilton, Hamilton, ON, Canada. ivanafurimsky@hotmail.com</auth-address><titles><title>Strategies to enhance patient recruitment and retention in research involving patients with a first episode of mental illness</title><secondary-title>Contemp Clin Trials</secondary-title></titles><pages>862-6; PMID: 18721902 [PubMed - indexed for MEDLINE]</pages><volume>29</volume><number>6</number><keywords><keyword>*Clinical Trials as Topic</keyword><keyword>*Depression</keyword><keyword>Health Knowledge, Attitudes, Practice</keyword><keyword>Health Services Accessibility</keyword><keyword>Humans</keyword><keyword>*Mental Health</keyword><keyword>*Patient Selection</keyword><keyword>*Psychotic Disorders</keyword></keywords><dates><year>2008</year><pub-dates><date>Nov</date></pub-dates></dates><accession-num>18721902</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18721902 </url></related-urls></urls></record></Cite></EndNote>7  Recruiting patients in the emergency medicine environment requires special considerations given the rapid time from presentation to discharge for many patients. ADDIN EN.CITE <EndNote><Cite><Author>Cofield</Author><Year>2010</Year><RecNum>3945</RecNum><record><rec-number>3945</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cofield, S. S.</author><author>Conwit, R.</author><author>Barsan, W.</author><author>Quinn, J.</author></authors></contributors><auth-address>Department of Biostatistics, The University of Alabama at Birmingham, USA.</auth-address><titles><title>Recruitment and retention of patients into emergency medicine clinical trials</title><secondary-title>Acad Emerg Med</secondary-title></titles><pages>1104-12</pages><volume>17</volume><number>10</number><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><accession-num>21040112</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=21040112 </url></related-urls></urls></record></Cite></EndNote>8  We expect that recruitment may be even more difficult if an investigator�s first attempt to contact a patient for recruitment is initiated after the patient has been discharged from the hospital. For example, contact telephone numbers may be incorrect or may change, and the opportunity to develop rapport with the patient in person has been lost. We conducted a pilot study to assess the feasibility of using phone calls placed to assault patients after as hospital discharge as a way to contact and enroll assault patients in research about lasting health consequences of trauma. Our second aim was to assess the prevalence of lasting physical and emotional wound among this young urban patient population. 

Methods
Study Design 
A retrospective cohort study was conducted by recruiting, enrolling, and comparing two groups of patient-subjects who had experienced different exposures, gunshot wound (GSW) or non-GSW. The outcomes included results of the recruitment and enrollment efforts and subjects� quality of life scores and PTSD symptoms. The study was approved by the Institutional Review Board (IRB) of the University of Pennsylvania. Written consent was waived by the IRB and verbal consent was obtained from all participants.

Study Setting and Population
Patients between 18 to 24 years old who had been treated for assault-related GSW or non-GSW injuries at an urban Level 1 trauma center during 2007-2008 were recruited by telephone within 18 months of hospital discharge. The recruited patients were patients who had participated in an earlier interview in the hospital that investigated the effect of patients� daily activities on their risk of being assaulted. For that parent study, patients were recruited by trained research assistants while still in the Emergency Department. At that time they were asked to provide a personal telephone number (home or cell), a work telephone number, and the contact number of someone who could reach them if the previous numbers did not work. They also provided consent to be contacted again at sometime in the future.

Study Protocol 
The present study was conducted by placing calls to patients based on the contact telephone numbers provided during the parent study. Patients were called between 1-18 months after presentation to the hospital. Calls were made between 8am-9pm on weekdays and between 9am-9pm on weekends over a 4-month period. A given phone number was called until a final disposition was determined: the phone had been disconnected; the patient was not associated with the phone number; the caller was told not to call back; 5 messages had been unreturned; the patient was unable to participate (e.g., incarcerated); the patient was contacted and refused. Eligible subjects were consented verbally and were administered a 15-minute telephone interview consisting of questions from standardized instruments. Participants were given a $20 gift card as remuneration. The study was approved by the Institutional Review Board IRB of the University of Pennsylvania. 

Measurements 
Symptoms of PTSD were assessed using the Primary Care PTSD Screen (scored on a scale from 0-4). ADDIN EN.CITE <EndNote><Cite><Author>Prins</Author><Year>2004</Year><RecNum>3848</RecNum><record><rec-number>3848</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Prins, A.</author><author>Ouimette, P.</author><author>Kimerling, R.</author><author>Cameron, R. P.</author><author>Hugelshofer, D. S.</author><author>Shaw-Hegwer, J.</author><author>Thraikill, A.</author><author>Gusman, F. D.</author><author>Sheikh, J. I.</author></authors></contributors><titles><title>The primary care PTSD screen (PC-PTSD): development and operating characteristics</title><secondary-title>Primary Care Psychiatry</secondary-title></titles><periodical><full-title>Primary Care Psychiatry</full-title></periodical><pages>9-14</pages><volume>9</volume><dates><year>2004</year></dates><urls><related-urls><url>http://ncptsd.va.gov/ncmain/ncdocs/assmnts/the_primary_care_ptsd_screen_pcptsd.html</url></related-urls></urls></record></Cite></EndNote>9  The SF-12 v2 Health Survey was used to assess quality of life. ADDIN EN.CITE <EndNote><Cite><Author>Ware</Author><Year>1996</Year><RecNum>3003</RecNum><record><rec-number>3003</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ware, J., Jr.</author><author>Kosinski, M.</author><author>Keller, S. D.</author></authors></contributors><auth-address>Health Institute, New England Medical Center, Boston, Massachusetts, USA.</auth-address><titles><title>A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity</title><secondary-title>Med Care</secondary-title></titles><pages>220-33</pages><volume>34</volume><number>3</number><keywords><keyword>Cross-Sectional Studies</keyword><keyword>*Health Status</keyword><keyword>*Health Surveys</keyword><keyword>Humans</keyword><keyword>Longitudinal Studies</keyword><keyword>*Mental Health</keyword><keyword>Outcome Assessment (Health Care)</keyword><keyword>Regression Analysis</keyword><keyword>Reproducibility of Results</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>1996</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>8628042</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=8628042 </url></related-urls></urls></record></Cite></EndNote>10 Patients were also asked about attendance of their 30-day trauma follow-up visits and about the injury event itself via questions used in previous research. ADDIN EN.CITE <EndNote><Cite><Author>Holbrook</Author><Year>2007</Year><RecNum>3843</RecNum><record><rec-number>3843</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Holbrook, T. L.</author><author>Hoyt, D. B.</author><author>Coimbra, R.</author><author>Potenza, B.</author><author>Sise, M. J.</author><author>Sack, D. I.</author><author>Anderson, J. P.</author></authors></contributors><auth-address>Division of Trauma, Department of Surgery, University of California, CA, USA. tholbrook@ucsd.edu</auth-address><titles><title>Trauma in adolescents causes long-term marked deficits in quality of life: adolescent children do not recover preinjury quality of life or function up to two years postinjury compared to national norms</title><secondary-title>J Trauma</secondary-title></titles><periodical><full-title>J Trauma</full-title></periodical><pages>577-83; discussion 583</pages><volume>62</volume><number>3</number><keywords><keyword>Adolescent</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Injury Severity Score</keyword><keyword>Male</keyword><keyword>*Quality of Life</keyword><keyword>*Recovery of Function</keyword><keyword>*Sickness Impact Profile</keyword><keyword>*Wounds and Injuries/etiology/pathology/psychology</keyword></keywords><dates><year>2007</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>17414331</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=17414331 </url></related-urls></urls></record></Cite></EndNote>4 

Data Analysis 
The analyses were conducted using Stata version 11 (StataCorp, College Station, TX) with Fisher�s exact tests, nonparametric tests of medians, and logistic regression and negative binomial regression. The incident rate ratios (RR) generated through the latter method represent differences in the mean number of phone calls made among the groups being compared.

Results
During telephone calls made to recruit the 56 potential subjects, we learned that 3 GSW patients had been killed (i.e., homicide) since discharge and 3 GWS patients were incarcerated and thus ineligible. Among eligible patients (n=50), 10 GSW (7 male, 3 female; median 19 years old) and 11 non-GSW patients (10 male, 1 female; median 20 years old) were successfully enrolled (42.0%).  Most (17) subjects were African-American (90.0%), 2 were Caucasian (9.5%), 1 was African (4.8%) and 1 was Asian-American (4.8%). The patients who were enrolled did not differ in median age from those who were not enrolled (19 vs. 19, p=0.201), but were less likely to be GSW patients (47.6% vs. 75.7%, p=0.031).

The recruitment and enrollment process required placing 509 calls to the 56 patients, corresponding to a mean of 10 calls and a median of 6 calls to enroll one patient. The median duration between discharge and first call was 7.2 months, with approximately equal proportions of calls (i.e., 25%) made to patients d"4 months after discharge, 4-8 months after discharge, 9-13 months after discharge, and 14-18 months after discharge. The median duration between discharge and first call was approximately one month shorter (p<0.05) for non-GSW patients (8.7 months; 25th - 75th percentile=5.2-11.2) than for GSW patients (9.8 months; 25th - 75th percentile=3.2-15.0).

The number of calls required to enroll patients increased as a function of duration since discharge. Fitting a least squares regression line through the data revealed a slope of 0.77 (p<0.001), indicating that to complete a final disposition required making an average of one additional telephone call for each additional 0.77 months (approximately 3 weeks) that had elapsed since the patient had been discharged.  

Controlling for age, injury type, and months since discharge, the mean number of calls required to determine a final disposition was inversely associated with age in years (RR=0.91, p=0.040) and positively associated with months since discharge (RR=1.05, p=0.014), but did not vary significantly between non-GSW and GSW patients (0.76, p=0.201) (Table 1). Also, the odds of enrollment decreased as a function of patient age in years (odds ratio, OR=0.73, p=0.050) and months since discharge (OR=0.87, p=0.043) and were increased for non-GSW versus GSW patients (OR=6.04, p=0.009). 
  
Of the 21 enrolled subjects, 8 GSW and 9 non-GSW patients were scheduled for an outpatient follow-up visit with the trauma service 30 days after hospital discharge, and most (7 GSW, 8 non-GSW) attended that visit. Six of the GSW and 1 non-GSW patient reported difficulties in attending the clinical visit because of pain and difficulty walking, lack of money for public transportation, and fear of being assaulted en route to the hospital.

In questions pertaining to the injury event itself, 42.9% of all patients reported that other family members or friends were injured during the assault. Six (6) non-GSW patients versus 1 GSW patient (p=0.043) reported that they had felt some degree of control in preventing the assault event from occurring. All 10 GSW patients and most non-GSW patients (8 of 11) reported being concerned their life was in danger during the assault. However, 7 GSW patients versus only 3 non-GSW patients reported feeling it was likely they would be assaulted again (p=0.089). In the time since discharge, 14 patients (5 GSW, 9 non-GSW reported that their school or work plans had changed and 9 patients (6 GSW and 3 non-GSW) reported that their plans for the future had changed as a result of their injury. Also, 3 patients (2 GSW, 1 non-GSW) had carried a weapon and 2 patients (non-GSW) had been shot in an assault and since discharge.

A number of physical and emotion problems associated with having been assaulted were more prevalent among GSW patients than non-GSW patients (Table 2). Compared to non-GSW patients, GSW patients reported significantly more difficulty performing moderate activities (7 vs. 1, p=0.007), difficulty climbing stairs (8 vs. 0, p=0.001), pain during normal activities (8 vs. 5, p=0.049), and had higher median PTSD symptom scores (3.0 vs. 1.0 on 0-4 scale, p=0.011), with nightmares being most the prevalent symptom (10 vs. 3, p=0.001). 

Discussion
The method of using phone calls to engage assault patients after hospital discharge proved to be a labor-intensive method of recruitment, despite very comprehensive acquisition of telephone numbers during the initial ED visit. This low participation rate of 42% would pose a considerable threat of participation bias in larger follow-up studies aiming to better understand assault patients� health during the months following treatment. Beyond this, it was informative to find that the challenges of recruitment varied according to patient characteristics, with the odds of enrolling discharged patients successfully being lower for older than younger patients, decreasing as function of time since discharge, and being lower among non-GSW than GSW patients.  Among the patients who were enrolled, we found a considerable prevalence of lasting physical and emotional health problems that were disproportionately higher in GSW versus non-GSW patients. Our two sets of findings suggest that continued care is warranted to counteract the impact of assault-related trauma, and that additional studies of assault patients specifically are warranted. However, telephone contact initiated after discharge would be an inefficient and potentially unsound method to attempt recruitment of this patient population, given the effort required and low participation rate.

Subsequent efforts to conduct follow-up research on young assault patient populations would be well served by using the initial hospital visit as the key opportunity to recruit patients for follow-up studies, as opposed to initiating recruitment by telephone at some point after patients have been discharged. Many patients were scheduled for a 30 day follow-up visit to the trauma service outpatient clinic and most attended that visit despite facing obstacles to doing so. This represents another opportunity for intervention and monitoring of outcomes. A clinical trial involving adolescents with mental illness showed the importance of introducing patients to research staff at the time of initial care in order to ensure retention during follow-up. ADDIN EN.CITE <EndNote><Cite><Author>Furimsky</Author><Year>2008</Year><RecNum>3655</RecNum><record><rec-number>3655</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Furimsky, I.</author><author>Cheung, A. H.</author><author>Dewa, C. S.</author><author>Zipursky, R. B.</author></authors></contributors><auth-address>Mental Health and Addictions Program, St Joseph&apos;s Healthcare Hamilton, Hamilton, ON, Canada. ivanafurimsky@hotmail.com</auth-address><titles><title>Strategies to enhance patient recruitment and retention in research involving patients with a first episode of mental illness</title><secondary-title>Contemp Clin Trials</secondary-title></titles><pages>862-6; PMID: 18721902 [PubMed - indexed for MEDLINE]</pages><volume>29</volume><number>6</number><keywords><keyword>*Clinical Trials as Topic</keyword><keyword>*Depression</keyword><keyword>Health Knowledge, Attitudes, Practice</keyword><keyword>Health Services Accessibility</keyword><keyword>Humans</keyword><keyword>*Mental Health</keyword><keyword>*Patient Selection</keyword><keyword>*Psychotic Disorders</keyword></keywords><dates><year>2008</year><pub-dates><date>Nov</date></pub-dates></dates><accession-num>18721902</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18721902 </url></related-urls></urls></record></Cite></EndNote>7 Our findings suggest that assault patients should also be engaged while in the hospital without delay. Other studies have shown that interactive voice response (IVR) telephone surveys provide a successful method to maintain participation in research that requires prolonged follow-up assessments after in-hospital enrollment in the Emergency Department. ADDIN EN.CITE <EndNote><Cite><Author>Wiebe</Author><Year>2008</Year><RecNum>3389</RecNum><record><rec-number>3389</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wiebe, D. J.</author><author>Carr, B. G.</author><author>Datner, E. M.</author><author>Elliott, M. R.</author><author>Richmond, T. S.</author></authors></contributors><auth-address>Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. dwiebe@mail.med.upenn.edu.</auth-address><titles><title>Feasibility of an automated telephone survey to enable prospective monitoring of subjects whose confidentiality is paramount: a four-week cohort study of partner violence recurrence after Emergency Department discharge</title><secondary-title>Epidemiol Perspect Innov</secondary-title></titles><pages>1; PMCID: PMC2262893</pages><volume>5</volume><dates><year>2008</year></dates><accession-num>18179709</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18179709 </url></related-urls></urls></record></Cite><Cite><Author>Blackstone</Author><Year>2009</Year><RecNum>3822</RecNum><record><rec-number>3822</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Blackstone, M. M.</author><author>Wiebe, D. J.</author><author>Mollen, C. J.</author><author>Kalra, A.</author><author>Fein, J. A.</author></authors></contributors><auth-address>Division of Emergency Medicine, Department of Pediatrics, The Children&apos;s Hospital of Philadelphia, Philadelphia, PA, USA. blackstone@email.chop.edu</auth-address><titles><title>Feasibility of an interactive voice response tool for adolescent assault victims</title><secondary-title>Acad Emerg Med</secondary-title></titles><pages>Data Supplement S1. IVR follow-up questions</pages><volume>16</volume><number>10</number><dates><year>2009</year><pub-dates><date>Oct</date></pub-dates></dates><accession-num>19799571</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=19799571 </url></related-urls></urls></record></Cite></EndNote>11,12 However, the data collected through this method fail to reveal reasons for loss to follow-up including homicide and incarceration. We found these outcomes to be important findings in assault-related trauma as several eligible patients � 3 of 56 � had been killed since discharge. This evidence that assault patients face a high homicide risk after discharge stresses the need for follow-up studies to guide the enactment of interventions to decrease this risk. As noted previously, patients treated for assault-related injuries have been underrepresented in trauma follow-up studies and our findings reveal that special considerations for assault patients are needed.  

The visits that assault patients make to family physicians and nurse practitioners during the months following hospital treatment for assault represent a key opportunity to identify physical and mental health deficits that may have developed as a result of the assault injury. Our findings highlight the importance of the opportunity that family practitioners have to ask their patients specifically about physical and mental health changes that they have experienced since the time they were assaulted. Assessing these aspects of patients� health for many months following the assault appears to be warranted as an important tertiary prevention strategy.  

Strengths and weakness of the study
Because the patients being recruited were patients who had already participated in a separate study during their initial hospital visit, the participation rate observed here may be higher than could be expected to occur in other studies that may attempt to recruit young assault patients by telephone during the months following their treatment.  At the same time, this adds strength to our conclusion that the use of telephone recruitment should be expected to be an inefficient way to pursue follow-up studies of assault patients to better understand their health following discharge. Given that our primary focus was to assess the feasibility of this recruitment method, the substantive findings from the small sample of patients who were enrolled and interviewed are not expected to be generalizable. Although the substantive findings suggest that there are compelling differences in the physical and mental health prognoses between patients treated for gunshot versus non-gunshot assault, these results were generated by grouping patients who were at a range of durations since being assaulted. The small sample size prevented controlling for time since discharge in these analyses. However, the duration between discharge and first telephone calls was in general shorter among non-GSW than among GSW patients, suggesting that GSW trauma may indeed be associated with prolonged negative health consequences. Strengths of this study include having initiated recruitment with a sample of seriously injured patients treated at a Level 1 trauma center, conducting telephone recruitment comprehensively until a final disposition was reached for each patient, and assessing health conditions using standardized interview items.  

Conclusions
The physical and emotional wounds of young gunshot would patients are frequent, may last long after discharge, and appear more common patients treated for gunshot wound versus non-gunshot assault. Clinical and research efforts are warranted to better understand, treat, and prevent the lasting negative effects of assault-related trauma. Attempts to recruit assault patients for research efforts should be initiated in the hospital given the challenges of contacting patients by telephone after discharge. Family practitioners have an important opportunity to identify patients experiencing lasting medical problems and provide treatment. Doing so represents an important tertiary prevention strategy for a major public health problem.   


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12.Blackstone MM, Wiebe DJ, Mollen CJ, Kalra A, Fein JA. Feasibility of an interactive voice response tool for adolescent assault victims. Acad Emerg Med. Oct 2009;16(10):Data Supplement S1. IVR follow-up questions.











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