Clinical presentation, acute care management and discharge information of patients with thoracic trauma in South Africa and Sweden: a prospective multicenter observational study.

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Heleen van Aswegen, Ronel Roos, Anna Svensson-Raskh, Annie Svensson, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5237772/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jan, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: Thoracic trauma causes pain and hospitalisation. Middle- and high-income countries have different trauma contexts and populations. To report patients’ clinical presentation (pain and shortness of breath) and its influence on hospital length of stay (LOS), acute care management, and discharge destinations in South Africa (SA) and Sweden. Methods: Prospective observational multicenter study by means of clinical record review. One thousand nine hundred and eighteen adults with thoracic trauma were screened. Study objectives guided information retrieved from clinical records. Statistical analysis was done with significance at p-value < 0.05. Results: Three-hundred-sixty-four participants were recruited with most being male (n = 170 (95%) SA; n = 125 (68%) Sweden). Type and mechanism of injury differed (SA penetrating (82%) versus Sweden blunt (95%); SA assaults (90%) versus Sweden falls (44%)). Unilateral haemopneumothorax was common (SA 68%, Sweden 35%) and managed with intercostal drainage. Rib cage injuries were common in the Swedish cohort with rib fixation surgery for 17%. Physiotherapy treatment frequency was mostly daily. Swedish participants reported higher pain levels during deep breathing (day 1: p = 0.053; day 2: p < 0.001; day 3: p < 0.001). Shortness of breath during activity was higher for the Swedish cohort (day 1: p = 0.023; day 2: p = 0.001; day 3: p < 0.001). LOS was shorter for SA cohort (5.4 (± 4.3) versus 6.6 (± 5.1) days; p = 0.024). Pulmonary complications (p = 0.013) and moderate-to-severe pain on day 3 (p = 0.005) influenced LOS. Discharge destination was mostly home (99% SA, 56% Sweden). Conclusion: Moderate-to-severe pain on day three suggests priority care for those with thoracic trauma to prevent pulmonary complications and prolonged hospitalisation. Thoracic trauma pain shortness of breath pulmonary complications length of stay Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Traumatic injury continues to be a significant health risk and cause of death and disability on a global level [ 1 ]. Thoracic trauma is observed in approximately two-thirds of patients with traumatic injury and is the third most common cause of morbidity and mortality among such patients [ 2 – 3 ]. The incidence of traumatic injury differs according to region and a country’s economic standing [ 4 – 5 ]. In South Africa (SA), injuries contribute significantly to the quadruple burden of disease with an incidence of 100.3 per 100 000 population [ 6 ]. The incidence of road traffic accidents has decreased by 29% between 2009 and 2017 [ 6 ]; however penetrating injuries to the thorax are rising with 82%-94% due to stab wounds and 6%-18% due to gunshot wounds [ 7 ]. In Sweden, trauma is the sixth leading cause of death in all age groups according to the Swedish Trauma Registry [ 8 ]. Blunt trauma is the dominating injury mechanism, occurring in approximately 90% of cases, although penetrating injuries are on the rise [ 8 ]. Road traffic accidents make up about 50% of all trauma cases in Sweden [ 8 ]. In both countries, males are reported to be more involved in thoracic trauma than their female counterparts [ 6 , 8 – 9 ]. Severity of thoracic injury determines the need for hospitalisation. Most patients can be managed conservatively through multidisciplinary team involvement, with only 10% requiring surgical intervention [ 10 ]. Injury to the thorax causes pain from structural and tissue damage which presents as nociceptive and/or neuropathic in nature [ 11 ]. Implementation of appropriate pain relief strategies is essential during patient management [ 12 – 14 ]. Persistent pain leads to reflex shortness of breath and, if either is not well-managed, increases patients’ risk for pulmonary complications such as atelectasis, pneumonia, respiratory distress, and respiratory failure [ 3 , 12 – 13 ]. In addition, injury severity, age and prior health condition of the patient influences their risk of developing such complications [ 12 ]. Pulmonary complications may necessitate admission to an intensive care unit and result in prolonged hospital length of stay (LOS) [ 15 ]. No prospective data, to mirror actual clinical practice, exists on the levels of pain and shortness of breath that patients with thoracic trauma experience during their hospital stay, acute care management provided to such patients from countries with varying trauma contexts and populations, pulmonary complications developed, and discharge information. This paper reports on these outcomes and identifies factors that influenced patients’ hospital LOS. Methods Study design and population A prospective multicenter observational study by means of a clinical record review of adult patients with thoracic trauma needing hospitalization, was conducted. Thoracic trauma was defined as blunt or penetrating injury resulting in pneumothorax, haemothorax, fractures of the chest wall, diaphragm and/or lung laceration, and/or pulmonary contusion. The STROBE checklist was used in reporting of this study. All six participating sites were public healthcare sector university-affiliated hospitals. In SA, Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic hospitals, situated in Johannesburg, participated. Ethics approval was obtained from University of the Witwatersrand Human Research Ethics (Medical) committee (Date: 27/06/2020, No. M200222) for both study sites. Permissions and consent were obtained from the National Department of Health, and the chief executive officers, trauma unit managers, physiotherapy heads-of-department and patients at these two participating sites. In Sweden, Sahlgrenska University hospital (Gothenburg), Karolinska University hospital (Stockholm), University hospital of Umeå (Umeå), and Skåne University hospital (Lund) participated. Ethics approval was obtained from the Swedish Ethical Review Authority for the region of Västra Götaland and all study-sites were included in the approval (Date: 22/10/2019, No. Dnr2019-04848). Consent was obtained from all head-of-departments and the patients at the four participating sites. The South African patients approached for participation were managed in the trauma ICU and wards of the two participating hospitals. The Swedish patients were managed either in trauma centres (Karolinska and Sahlgrenska University hospitals) or surgical wards with trauma profile (Umeå and Skåne University hospitals). Participants were treated according to standard trauma and physiotherapy practice at all hospitals. Physiotherapy services were always available on weekdays in all hospitals, but the availability of physiotherapists on duty during weekends varied. New patient admissions or patients with acute respiratory symptoms at weekends could receive physiotherapy services at Chris Hani Baragwanath Academic hospital, and Karolinska and Sahlgrenska University hospitals while treatment at the other hospitals were conducted individually or supervised by nursing staff, with standard service delivery resuming the following Monday. Inclusion and exclusion criteria Patients with thoracic trauma who were 18 years or older and of both genders were consecutively screened at the ICUs and trauma or surgical wards of all participating sites for possible inclusion, using the ICU or ward admission registers. Those with dementia, acute or previously diagnosed spinal cord injury, moderate (Glasgow coma scale (GCS) 9–12) and severe (GCS < 9) traumatic brain injury, complex pelvic fractures, lower limb fractures, lower limb amputation that restricted active mobilisation, and extensive abdominal trauma were excluded. Data collected Meetings were held with the clinical physiotherapy staff who worked in the trauma units and wards of the participating study sites to explain the study purposes. The physiotherapists that oversee the trauma ICU, high care units and surgical/trauma wards at the participating sites were responsible for participant recruitment, as they screened the wards and units daily for new admissions. Participants gave their written consent before any of their data were captured. The physiotherapists captured participant details on study specific data forms. Information captured included demographics (age, sex, height, weight, smoking history, presence of chronic pulmonary disease), clinical presentation (type and mechanism of injury, pain, shortness of breath), medical, surgical and physiotherapy management received, pulmonary complications developed during hospitalisation, and discharge information (length of stay, and discharge destination). All participating hospitals in SA and Sweden had the same protocol for data capturing and included the data prospectively. Variables covering days before participant consent were not registered. Recruitment and data collection occurred over a total of 18 months at the SA participating sites (October 2020 to October 2021 (Chris Hani Baragwanath Academic hospital); August 2022 to February 2023 (Charlotte Maxeke Johannesburg Academic hospital)) and over 12 months in Sweden (September 2021 to September 2022). Figure 1 summarises the process of recruitment of participants. Data were captured onto two electronic databases (Research Electronic Data Capture hosted at the University of the Witwatersrand (South Africa) and Google Drive (Sweden)). Statistical analysis Data were cleaned and imported to IBM® SPSS® version 28 for analysis. Descriptive statistics were used to summarise the data. Comparison of findings between cohorts were made using Pearson Chi-squared test (categorical variables e.g. types and mechanisms of injury), Mann Whitney-U test (ordinal variables e.g. Numeric Rating Scale (NRS) for pain and Borg (CR-10) scale for shortness of breath), and independent t-test (continuous variables e.g. age and length of stay). Significance was determined at p < 0.05. Univariate linear regression was done to identify contributing factors to hospital LOS. The dependent variable was logLOS as the LOS data were skewed. The independent variables were sex, age, type of injury (blunt vs penetrating), rib fractures (yes/no), pulmonary contusion (yes/no), other injuries (yes/no), moderate-to-severe pain (≥ 4/10) reported during deep breathing on days 1–3 (yes/no), and lastly moderate-to-severe pain (≥ 4/10) reported during deep breathing on day 3 (yes/no). The independent variables that had a significant impact on LOS at univariate analysis were entered into a backward linear regression for multivariate analysis to determine which impacted on LOS. Results Patient characteristics and types and mechanisms of injury A total of 1 918 patients were admitted to the participating sites during the study period (Fig. 1). Three-hundred-sixty-four patients with thoracic trauma participated of which 179 (49.2%) were from South Africa and 185 (50.8%) from Sweden. Characteristics of the participants are summarized in Table 1. Table 1: Characteristics of the patients with thoracic trauma in the study cohorts. Variable Description South African cohort (n=179) Swedish cohort (n=185) p-value between cohorts Sex (n,%) Male 170 (95) 125 (68) <0.001 Female 9 (5) 60 (32) Age (mean, SD) Years 33 (10) 58 (18) <0.001 BMI (mean, SD) kg/m 2 23 (5) 26 (6) <0.001 Current smokers (n,%) 96 (54) 24 (13) <0.001 Pulmonary disease (n,%) 1 (1) 20 (11) <0.001 Abbreviations: BMI body mass index Participants were mostly male. Most were between the ages of 30 to 64 years (n=103 (58%) SA; n=107 (58%) Sweden). The SA cohort was significantly younger than the Swedish cohort. More than half of the SA cohort were current smokers, and 21% (n=37) had a BMI of 25-30 kg/m 2 compared to the Swedish cohort of whom 13% were current smokers and 55% (n=84) had a raised BMI. More Swedish participants had chronic respiratory disease prior to thoracic trauma. Most participants were recruited from a ward setting (SA 92%, Sweden 69%) with few recruited within ICU (SA 6%, Sweden 3%). The types and mechanisms of thoracic injury sustained are summarized in Table 2. Table 2: Types and mechanisms of thoracic injury sustained. Variable (n, %) Description South African cohort (n=179) Swedish cohort (n=185) p-value between cohorts Type of injury Blunt injury 33 (18) 175 (95) <0.001 Penetrating injury 146 (82) 10 (5) Mechanism of injury Assault 161 (90) 18 (10) <0.001 Attempted suicide 1 (1) 4 (2) MVC 9 (5) 31 (17) PVC 5 (3) 30 (16) Cycling accident 0 7 (4) Falls 0 81 (44) Miscellaneous 3 (2) 14 (8) Rib fractures 1-3 ribs fractured unilaterally 15 (8) 61 (33) 0.005 4-6 ribs fractured unilaterally 12 (7) 42 (23) >3 ribs fractured bilaterally 2 (1) 29 (16) Flail rib injury 0 40 (22) Intrapleural abnormality Pneumothorax unilateral 41 (23) 41 (23) 0.023 Pneumothorax bilateral 0 2 (1) Haemo-/haemopneumothorax unilateral 122 (68) 64 (35) Haemo-/haemopneumothorax bilateral 10 (6) 4 (2) Pulmonary contusion Yes 9 (5) 42 (23) <0.001 Lung laceration Yes 6 (3) 8 (4) 0.787 Diaphragm rupture Yes 4 (2) 2 (1) 0.445 Sternal fracture Yes 0 16 (9) <0.001 Abbreviations: MVC motor vehicle crash, PVC pedestrian vehicle crash The type of injury differed as most SA participants had penetrating thoracic injury (82%) and Swedish participants had blunt injury (95%). Mechanism of injury was different between the two cohorts with the SA cohort injured through assault (90%) compared to the Swedish cohort who were injured through falls (44%) (Fig. 2). Rib fractures and flail rib injury were higher in the Swedish cohort with no flail rib injury reported for the SA cohort. Most participants in both cohorts sustained unilateral haemopneumothorax. The Swedish cohort had significantly more other orthopaedic injuries (Supplementary table 1). There was no difference in the types of internal organ injuries sustained by both cohorts. Acute care management Patients with thoracic trauma mostly received conservative management and physiotherapy with some needing surgical interventions. Table 3 summarizes and compares the conservative and surgical interventions used within the two cohorts during acute care management. Table 3: Conservative and surgical management provided to patients with thoracic trauma during their hospitalization. Acute care management (n,%) South African cohort (n=179) Swedish cohort (n=185) p-value between cohorts Analgesia 176 (98) 185 (100) 0.148 Sedation 6 (3) 7 (4) 0.825 Mechanical ventilation 7 (4) 4 (2) 0.339 Non-invasive ventilation 0 3 (2) 0.087 High flow nasal oxygen therapy 3 (2) 3 (2) 0.973 Oxygen therapy 86 (48) 96 (52) 0.023 Intercostal drain insertion 165 (92) 69 (37) <0.001 Rib fixation surgery 0 32 (17) <0.001 Other surgeries 24 (13) 29 (16) 0.484 The management provided to both cohorts was similar as most participants received analgesia (intravenous or oral opioid therapy) and few were sedated, but more SA participants (52%) were breathing at room air than their Swedish counterparts (34%) (p=0.023). More SA participants (92%) were managed with intercostal drainage systems than their Swedish counterparts (37%) (p<0.001) because of a higher incidence of penetrating trauma. Rib fixation surgery was performed for 17% of the Swedish cohort and none of the SA cohort. The types of other surgeries performed in the two cohorts are summarized in Fig. 3. Significantly more participants in the SA cohort (n=160, 93%) received physiotherapy management from Day 1 after admission to the hospital than in the Swedish cohort (n=106, 73%, p<0.001). Most SA participants (99%) received one physiotherapy treatment session per day over the first three days of hospital stay, whereas some participants in the Swedish cohort (7%-9%) received two or more treatment sessions. Details of physiotherapy management approaches used for patient care in the two cohorts are reported elsewhere. Pain and shortness of breath experienced Level of pain experienced at rest and during deep breathing was measured with the NRS (Fig. 4). The Swedish cohort had significantly more pain at rest on day 2 (p=0.047) and during deep breathing on days 1-3 (day 1: p=0.053; day 2: p<0.001; day 3: p<0.001). Subgroup analysis was performed to distinguish between the pain reported during rest and deep breathing by SA and Swedish participants with blunt thoracic trauma and those with penetrating trauma. No significant differences were found in level of pain reported over the first three days of hospitalisation. Shortness of breath at rest and during activity was reported using the Borg CR-10 scale (Fig. 5). The Swedish cohort had significantly more shortness of breath at rest on day 3 (p<0.001) and when performing activity on days 1-3 (day 1: p=0.023; day 2: p=0.001; day 3: p<0.001). The Swedish cohort with blunt thoracic trauma (n=52) experienced more shortness of breath at rest on day 3 (p<0.028) than the SA cohort (n=11) with blunt trauma. No differences in shortness of breath during activity were found between these cohorts with blunt trauma. Subgroup analysis for those with penetrating trauma was not possible due to missing data. Length of stay and pulmonary complications developed The SA cohort had a mean hospital LOS of 5.4 (±4.3) days which was significantly shorter than that of the Swedish cohort (6.6 ±5.1; p=0.024). Pulmonary complications during hospital stay were rare. Atelectasis was reported in four patients in SA and 16 in Sweden (2.2 vs. 8.6%, p=0.007). None of the SA patients developed pneumonia during hospitalisation compared to 8 (4.3%) in Sweden (p=0.005). Among the SA participants, none needed non-invasive ventilation as a result of complications developed, in contrast to two in the Swedish cohort. In both cohorts one participant each required mechanical ventilation. Multivariate analysis showed that the development of pulmonary complications and reporting of moderate-to-severe pain at day 3 of hospitalisation impacted significantly on LOS (Table 4). Table 4: Factors that impact on length of stay – univariate and multivariate analysis results. Variables Univariate analysis Multivariate analysis Adjusted R square B coefficient Standard error p-value B coefficient Standard error p-value Dependent variable LOS Independent variables Age a 0.049 0.004 0.001 <0.001* -1.434 0.001 0.991 Other injuries combined a 0.043 0.134 0.032 <0.001* 0.057 0.040 0.165 Moderate to severe pain D1-D3 -0.003 0.013 0.040 0.738 - - - Moderate to severe pain D3 a 0.054 0.123 0.040 0.003* 0.112 0.039 0.005* Pulmonary complications a 0.057 0.275 0.058 <0.001* 0.179 0.072 0.013* Rib fractures 0.000 0.031 0.033 0.342 - - - Type of injury (Blunt vs Penetrating) -0.001 -0.026 0.033 0.438 - - - Abbreviations: LOS length of stay, D1 day 1, D3 day 3, a entered into multivariate analysis, * p-value <0.05 Discharge information More SA participants were discharged to their homes (99% SA, 56% Sweden, p<0.001). Thirty-five of the remaining Swedish participants were transferred to another ward/hospital and were lost to follow-up for the purposes of this study. Seven were sent to convalescence care and 32 to follow-up rehabilitation after discharge from the acute care settings. Discussion This prospective observational study is the first to report on levels of pain and shortness of breath experienced by adults with thoracic injury in the first three days of admission, its influence on hospital LOS and patient discharge destination. In addition, it describes and compares the cohort of patients with thoracic trauma in two countries with different socioeconomic levels and the acute care management that they received, mirroring actual clinical practice in the six participating sites. Males were predominantly involved in thoracic trauma in SA and Sweden, similar to other studies [6,9]. The SA cohort was younger and were smokers compared to the Swedish cohort that had more participants with chronic respiratory disease. Moreover, the SA participants predominantly had penetrating thoracic injury because of assault, while the Swedish participants had blunt thoracic injury sustained through falls. These findings conform with reports by others [6-9,16-18]. It contrasts the notion that the majority of thoracic trauma cases is caused by blunt injury [10] and confirms that the types of thoracic trauma cases encountered is determined by the region of the world and socio-economic standing of the community under investigation [4-5]. The different mechanisms of injury reported in this study reflect the differences in socio-economic levels between the two countries and affect the human body differently. Assault was more often due to stab- or gunshot wounds that did not involve the bony structure of the thorax, although some internal organs of the trunk were injured. This is evident from the higher number of participants in the SA cohort who underwent sternotomy. Falls are more likely to affect the stability of the ribcage and involve injury to extrapulmonary structures. The marked need for rib fixation and additional orthopaedic surgery in the Swedish cohort confirm their higher severity of injury. It may reflect a difference in the management of severe thoracic injuries between the two countries. Subsequently there was a different panorama of injury between the cohorts which might explain the reported differences in pain at rest and while deep breathing, the duration of hospitalisation and need for additional care after discharge from the acute care setting. Many participants had intrapleural abnormality and the most common was unilateral haemopneumothorax. Pulmonary contusion, lung laceration and diaphragm rupture were less common. Intra-thoracic injuries are common in both blunt and penetrating trauma [10,13]. Most injuries can be managed with only a chest tube, although not all had an indication for chest tube drainage. Penetrating injuries require intra-thoracic surgery via sternotomy/thoracotomy to a greater extent than blunt trauma. However, blunt trauma with severe injury to the chest wall may require surgery, and the patient is more likely to be operated on if they are managed at a centre where this is provided, such as Sahlgrenska Academy that has a tradition of rib surgery and where 98% of surgeries in this study were performed. Whole-body CT-scan is standard practice in the management of patients with thoracic trauma in both countries. Additional orthopaedic injury was present in one-third of participants where upper limb fractures and spinal fractures were most common. Liver injury affected a small percentage of participants, but other internal organ injuries were rare. In addition, mild neurological injury affected five percent of participants. This reflects the injury panorama of participants included in the study. Patients with more severe traumatic neurological injury were excluded from this study due to predetermined criteria. Acute care management of these cohorts were similar for administration of analgesia, MV and high flow nasal cannula oxygen therapy, and few participants were sedated. Some Swedish participants were managed with non-invasive ventilation which may be due to the greater incidence of unilateral and bilateral rib fractures and flail chest injuries. Non-invasive ventilation administered to appropriately selected patients with blunt chest injury decreases complications and the need for intubation and mechanical ventilation [19] but is known to increase LOS [20]. This may be one of the explanations for the longer hospitalisation observed in the Swedish cohort. Other explanations may be the older Swedish trauma population and socio-economic differences between the two countries where the Swedish state invests more time in planning for home care. In South Africa patients are discharged earlier into the care of their families. Moderate-to-severe pain was reported by both cohorts during deep breathing in the three days after admission, with significantly higher levels of pain observed in the Swedish cohort. This observation occurred despite the administration of analgesia. One explanation is that the elderly experience and tolerate pain differently [21]. One third of the Swedish cohort was older than 65 years. Hyperalgesia, in the elderly, lasts longer, and combined with slower healing results in prolonged periods of physical discomfort and functional limitations [21]. The effectiveness of analgesia in the elderly is blunted by physiological body system changes and their response to analgesia varies widely which complicates pain management [21]. Most SA and Swedish participants had unilateral haemopneumothorax which was managed with intercostal drainage. The presence of drainage tubes and residual blood in the pleura compress and irritate the intercostal nerves and contribute to inflammation and pain [22]. In addition, pain is caused by damage to myofascial structures [23]. The Swedish cohort had significantly more rib fractures, flail injuries, and sternal fractures and more underwent surgery. Some SA participants had sternotomy due to internal organ injury. Surgery is a common cause of damage to myofascial structures and resultant severe pain. Any movement such as deep breathing and coughing causes tension around the incision site and increases the level of pain experienced [10,22-23]. This may relate to the increased pain intensity experienced by both cohorts during such activities. Shortness of breath was reported by both cohorts when performing any form of activity. Trauma causes pain as discussed earlier and leads to reflex dyspnoea. Haemothorax is a recognised cause of shortness of breath [10, 24] and was commonly diagnosed in these cohorts. The SA cohort subsequently experienced less shortness of breath during activity on days two and three than their Swedish counterparts. The Swedish cohort presented with significantly more chronic pulmonary diseases. Dyspnoea is a known symptom in chronic respiratory disease and is associated with reduced physical activity, higher levels of anxiety and depression, and lower levels of quality of life [24-25]. Additionally, dyspnoea and respiratory muscle weakness both influence walking distance in individuals with pulmonary disease [26]. This comorbidity could have influenced the Swedish cohort’s level of shortness of breath at rest and during activity following the acute thoracic trauma sustained. Thoracic trauma is associated with an increased risk for the development of pulmonary complications such as atelectasis, pneumonia and respiratory distress [10,13]. More Swedish participants developed such complications than their SA counterparts. This occurred even though more Swedish participants received twice daily physiotherapy management. The consistently higher levels of pain and shortness of breath experienced from the more complex thoracic injury and non-surgical management may explain the higher observed rates. Following the differences between the cohorts, LOS and need of additional hospital care, significantly more Swedish participants were transferred to rehabilitation facilities or convalescence care prior to returning home. The SA cohort was younger, less severely injured and majority were discharged directly to their homes. Age, pain, type of injury, and rib fractures are associated with longer hospitalisation; however, none of these had a significant impact in the multivariate analysis. Pulmonary complications and moderate-to-severe pain on day three of admission influenced participants’ LOS. The type and complexity of thoracic injury could have influenced participants’ ability to optimally ventilate their lungs and cough effectively. Some participants required surgical procedures to stabilise their injuries. Post-operative pulmonary complications (PPC) increase duration of hospitalisation [27] and thoracic surgery increases the risk of PPC [27]. Early mobilisation as a means of optimising patient ventilation and oxygenation could have been influenced by multiple factors in the current study. The effect of early mobilisation in trauma patients admitted to ICU varies as it may decrease duration of mechanical ventilation but its impact on mortality and LOS remains similar to usual care [28]. There were some limitations to this study. No injury severity score data were accessible for direct capturing from patient files in both countries. Retrospective information may be obtained from the Swedish National Trauma Registry; unfortunately, such data cannot be retrieved for the SA cohort, therefore it is not reported. The COVID-19 pandemic may have impacted on the incidence of trauma and hospital admission rates due to various stages of lockdown experienced in SA. Information on the medication used for sedation, and the use of epidural and intercostal blockade were not included in the data collection forms and limits extrapolations made about pain management. No data was collected for reasons why intercostal drainage or rib fixation surgery were not performed in cases where it may have been indicated. The amount of missing data for pain variables limited the generalisability of the multivariate analysis results on LOS. Data was collected from public healthcare sector university-affiliated hospitals in SA and Sweden which limits the generalisability of results to thoracic trauma management in other settings. A strength of this study is that data capturing was prospective in nature and occurred in parallel to clinical practice. The authors collaborated closely to facilitate an easy and simple data collection process for all involved but there remained some challenges with the amount of data that was captured. In conclusion, this study confirms the contextual differences in clinical presentation, acute care management and discharge destinations of patients with thoracic trauma in SA and Sweden. It highlights that reassessment of care provided should be prioritised for those patients who report moderate-to-severe pain on day three of admission to decrease their risk of developing pulmonary complications and prolonged hospital stay. Declarations Competing interests: The authors declare that they have no relevant financial or non-financial interests to declare. Authors’ contributions HvA contributed substantially to conceptualisation, data cleaning and analysis and interpretation of results, drafting and finalising the manuscript for review. RR, ECC and FP contributed to interpretation of results and to the content of the manuscript. ARS, AS and MS contributed to acquisition of the data, interpretation of results and to the content of the manuscript. MFO contributed substantially to conceptualisation, data cleaning and analysis and interpretation of results, and drafting of the manuscript. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. In South Africa, approval was granted by the University of the Witwatersrand Human Research Ethics (Medical) committee (Date: 27/06/2020; No. M200222). In Sweden, approval was granted by the Regional Ethics Committee for the region of Västra Götaland (Date: 22/10/2019; No. Dnr2019-04848). Permission was obtained from all relevant authorities at the two participating sites in South Africa and the four participating sites in Sweden. Informed consent was obtained from all potential participants before study enrolment. Availability of data and materials Data supporting the results presented in this manuscript are available from the corresponding author on reasonable request. Declarations related to funding and the acknowledgements are captured in the Title Page of this submission. References World Health Organisation. Global status report on road safety 2018: summary [Internet]: Geneva: World Health Organization; 2018 [cited 2024 Sept 27]. https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/ Adal O, Tareke AA, Bogale EK, Anagaw TF, Tiruneh MG, Fenta ET, et al. Mortality of traumatic chest injury and its predictors across sub-Saharan Africa: systematic review and meta-analysis, 2024. 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Abdelwahed HS, Martinez FE. ICU length of stay and factors associated with longer stay of major trauma patients with multiple rib fractures: a retrospective observational study. Crit Care Res Pract. 2022. https://doi.org/10.1155/2022/6547849 . Parkinson F, Kent S, Aldous C, Oosthuizen G, Clarke DL. Patterns of injury seen in road crash victims in a South African trauma centre. S Afr J Surg. 2013;51(4):131–43. 10.7196/SAJS.1627 . Boachie MK, Rossouw L, Ross H. The economic cost of smoking in South Africa, 2016. Nicotine Tob Res. 2021;23(2):286–93. 10.1093/ntr/ntaa162 . Serrano-Alacrón M, Kunst AE, Bosdriesz JR, Perelman J. Tobacco control policies and smoking among older adults: a longitudinal analysis of 10 European countries. Addiction. 2019;114(6):1076–85. 10.1111/add.14577 . Udekwa P, Patel S, Farrell M, Vincent R. Favorable outcomes in blunt chest injury with non-invasive bi-level positive airway pressure ventilation. Am Surg. 2017;83(7):687–95. Duggal A, Perez P, Golan E, Tremblay L, Sinuff T. Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review. Crit Care. 2013;17(4):R142. 10.1186/cc12821 . Mullins S, Hosseini F, Gibson W, Thake M. Physiological changes from ageing regarding pain perception and its impact on pain management for older adults. Clin Med (Lond). 2022;22(4):307–10. 10.7861/clinmed.22.4.phys . Mergner D. Pain Management in Patients with a Chest Drain. In: Kiefer T, editor. Chest Drains in Daily Clinical Practice. Konstanz: Springer; 2017. p.171 – 80. Kolettas A, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I, et al. Postoperative pain management. J Thorac Dis. 2015;7(S1):S62–72. 10.3978/j.issn.2072-1439.2015.01.15 . Coccia CBI, Palkowski GH, Schweitzer B, Motsohi T, Ntusi NAB. Dyspnoea: pathophysiology and a clinical approach. S Afr Med J. 2016;106(1):32–6. 10.7196/SAMJ.2016.v106i1.10324 . Anzueto A, Miravitlles M. Pathophysiology of dyspnea in COPD. Postgrad Med. 2017;129(3):366–74. 10.1080/00325481.2017.1301190 . de Souza Y, Suzana ME, Medeiros S, Macedo J, da Costa CH. Respiratory muscle weakness and its association with exercise capacity in patients with chronic obstructive pulmonary disease. Clin Respir J. 2022;16(2):162–6. 10.1111/crj.13449 . Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317–34. 10.1093/bja/aex002 . Higgins SD, Erdogan M, Coles SJ, Green RS. Early mobilization of trauma patients admitted to intensive care units: A systematic review and meta-analyses. Injury. 2019;50(11):1809–15. https://doi.org/10.1016/j.injury.2019.09.007 . Additional Declarations No competing interests reported. Supplementary Files Supplementarytable1.docx Cite Share Download PDF Status: Published Journal Publication published 16 Jan, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 16 Nov, 2024 Reviews received at journal 10 Nov, 2024 Reviewers agreed at journal 21 Oct, 2024 Reviews received at journal 21 Oct, 2024 Reviewers agreed at journal 21 Oct, 2024 Reviewers invited by journal 21 Oct, 2024 Editor assigned by journal 21 Oct, 2024 Submission checks completed at journal 18 Oct, 2024 First submitted to journal 10 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5237772","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":378859036,"identity":"db61f7fd-24f6-48bf-a510-6bc5ad1f38ba","order_by":0,"name":"Heleen van Aswegen","email":"data:image/png;base64,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","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":true,"prefix":"","firstName":"Heleen","middleName":"van","lastName":"Aswegen","suffix":""},{"id":378859037,"identity":"41cc1e6e-b69e-4ca5-876d-6f673ec53556","order_by":1,"name":"Ronel Roos","email":"","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":false,"prefix":"","firstName":"Ronel","middleName":"","lastName":"Roos","suffix":""},{"id":378859038,"identity":"5539a9af-a127-479c-8bd9-12d7516f52b5","order_by":2,"name":"Anna Svensson-Raskh","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Svensson-Raskh","suffix":""},{"id":378859039,"identity":"ee4a4e86-3119-4cec-bb51-fc6b00ec038a","order_by":3,"name":"Annie Svensson","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Annie","middleName":"","lastName":"Svensson","suffix":""},{"id":378859040,"identity":"2ef68f19-fca9-4399-a150-616d7720d889","order_by":4,"name":"Maria Sehlin","email":"","orcid":"","institution":"Umeå University","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Sehlin","suffix":""},{"id":378859041,"identity":"a68488a9-0858-4a1f-b970-d11e8265c089","order_by":5,"name":"Eva-Corina Caragounis","email":"","orcid":"","institution":"Sahlgrenska University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eva-Corina","middleName":"","lastName":"Caragounis","suffix":""},{"id":378859042,"identity":"e4635ec1-c809-4824-aee1-288ce89d97ea","order_by":6,"name":"Frank Plani","email":"","orcid":"","institution":"Netcare Alberton Hospital","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Plani","suffix":""},{"id":378859043,"identity":"2b90ff51-5306-4d82-add8-a7b6a39826f1","order_by":7,"name":"Monika Fagevik Olsén","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Monika","middleName":"Fagevik","lastName":"Olsén","suffix":""}],"badges":[],"createdAt":"2024-10-10 08:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5237772/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5237772/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-024-02753-y","type":"published","date":"2025-01-16T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70951065,"identity":"984dca07-1be1-4f51-b4fc-e525b0785eda","added_by":"auto","created_at":"2024-12-09 13:39:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":137275,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant recruitment and flow through the study.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/e4c528329930d2fac2d9c91a.png"},{"id":70951068,"identity":"5733643c-6a94-4b89-ae21-f9c55a3d75ff","added_by":"auto","created_at":"2024-12-09 13:39:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":7628,"visible":true,"origin":"","legend":"\u003cp\u003eType and mechanism of thoracic injury per cohort. Abbreviations: \u003cem\u003eSA\u003c/em\u003eSouth Africa, \u003cem\u003eSW\u003c/em\u003e Sweden, \u003cem\u003eMVC \u003c/em\u003emotor vehicle crash, \u003cem\u003ePVC\u003c/em\u003epedestrian vehicle crash\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/6915c74b85d9b55cd74977aa.png"},{"id":70951071,"identity":"894ad61c-9161-4ba4-82a0-61b717371685","added_by":"auto","created_at":"2024-12-09 13:39:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5677,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of patients who received other types of surgery presented per cohort.\u003c/p\u003e","description":"","filename":"Onlinedrawingimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/0edee186d7221ff74cb20530.png"},{"id":70951072,"identity":"a9b819f0-0b58-4589-ac8c-3b940384859e","added_by":"auto","created_at":"2024-12-09 13:39:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":7480,"visible":true,"origin":"","legend":"\u003cp\u003eLevel of pain reported on days 1-3 of admission by participants at rest and during deep breathing. *Significant difference at \u0026lt;0.05. Abbreviations: \u003cem\u003eNRS\u003c/em\u003eNumeric Rating Scale, \u003cem\u003eSA\u003c/em\u003e South Africa.\u003c/p\u003e","description":"","filename":"Onlinedrawingimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/b2d52fbabaa0a06300131cdc.png"},{"id":70951067,"identity":"86f10a32-dae9-4e39-bf60-6e812a60d3d6","added_by":"auto","created_at":"2024-12-09 13:39:08","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":7151,"visible":true,"origin":"","legend":"\u003cp\u003eShortness of breath reported by participants at rest and during activity on the first three days of admission. *Significant difference at \u0026lt;0.05. Abbreviations: \u003cem\u003eSA\u003c/em\u003e South Africa\u003c/p\u003e","description":"","filename":"Onlinedrawingimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/bf364b9e441310f915039078.png"},{"id":74284711,"identity":"085061b2-41eb-400e-8fe9-4d6b07a541e8","added_by":"auto","created_at":"2025-01-20 16:11:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1078911,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/463de342-2ad3-4a8d-9f27-4c0ece7339f8.pdf"},{"id":70951066,"identity":"babfe4de-ea18-4690-8237-c1dd5134066a","added_by":"auto","created_at":"2024-12-09 13:39:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17190,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5237772/v1/d0459f565f08b393668dc558.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical presentation, acute care management and discharge information of patients with thoracic trauma in South Africa and Sweden: a prospective multicenter observational study.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraumatic injury continues to be a significant health risk and cause of death and disability on a global level [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Thoracic trauma is observed in approximately two-thirds of patients with traumatic injury and is the third most common cause of morbidity and mortality among such patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The incidence of traumatic injury differs according to region and a country\u0026rsquo;s economic standing [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In South Africa (SA), injuries contribute significantly to the quadruple burden of disease with an incidence of 100.3 per 100 000 population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The incidence of road traffic accidents has decreased by 29% between 2009 and 2017 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; however penetrating injuries to the thorax are rising with 82%-94% due to stab wounds and 6%-18% due to gunshot wounds [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Sweden, trauma is the sixth leading cause of death in all age groups according to the Swedish Trauma Registry [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Blunt trauma is the dominating injury mechanism, occurring in approximately 90% of cases, although penetrating injuries are on the rise [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Road traffic accidents make up about 50% of all trauma cases in Sweden [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In both countries, males are reported to be more involved in thoracic trauma than their female counterparts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeverity of thoracic injury determines the need for hospitalisation. Most patients can be managed conservatively through multidisciplinary team involvement, with only 10% requiring surgical intervention [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Injury to the thorax causes pain from structural and tissue damage which presents as nociceptive and/or neuropathic in nature [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Implementation of appropriate pain relief strategies is essential during patient management [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Persistent pain leads to reflex shortness of breath and, if either is not well-managed, increases patients\u0026rsquo; risk for pulmonary complications such as atelectasis, pneumonia, respiratory distress, and respiratory failure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, injury severity, age and prior health condition of the patient influences their risk of developing such complications [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Pulmonary complications may necessitate admission to an intensive care unit and result in prolonged hospital length of stay (LOS) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNo prospective data, to mirror actual clinical practice, exists on the levels of pain and shortness of breath that patients with thoracic trauma experience during their hospital stay, acute care management provided to such patients from countries with varying trauma contexts and populations, pulmonary complications developed, and discharge information. This paper reports on these outcomes and identifies factors that influenced patients\u0026rsquo; hospital LOS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eA prospective multicenter observational study by means of a clinical record review of adult patients with thoracic trauma needing hospitalization, was conducted. Thoracic trauma was defined as blunt or penetrating injury resulting in pneumothorax, haemothorax, fractures of the chest wall, diaphragm and/or lung laceration, and/or pulmonary contusion. The STROBE checklist was used in reporting of this study.\u003c/p\u003e \u003cp\u003eAll six participating sites were public healthcare sector university-affiliated hospitals. In SA, Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic hospitals, situated in Johannesburg, participated. Ethics approval was obtained from University of the Witwatersrand Human Research Ethics (Medical) committee (Date: 27/06/2020, No. M200222) for both study sites. Permissions and consent were obtained from the National Department of Health, and the chief executive officers, trauma unit managers, physiotherapy heads-of-department and patients at these two participating sites. In Sweden, Sahlgrenska University hospital (Gothenburg), Karolinska University hospital (Stockholm), University hospital of Ume\u0026aring; (Ume\u0026aring;), and Sk\u0026aring;ne University hospital (Lund) participated. Ethics approval was obtained from the Swedish Ethical Review Authority for the region of V\u0026auml;stra G\u0026ouml;taland and all study-sites were included in the approval (Date: 22/10/2019, No. Dnr2019-04848). Consent was obtained from all head-of-departments and the patients at the four participating sites.\u003c/p\u003e \u003cp\u003eThe South African patients approached for participation were managed in the trauma ICU and wards of the two participating hospitals. The Swedish patients were managed either in trauma centres (Karolinska and Sahlgrenska University hospitals) or surgical wards with trauma profile (Ume\u0026aring; and Sk\u0026aring;ne University hospitals). Participants were treated according to standard trauma and physiotherapy practice at all hospitals. Physiotherapy services were always available on weekdays in all hospitals, but the availability of physiotherapists on duty during weekends varied. New patient admissions or patients with acute respiratory symptoms at weekends could receive physiotherapy services at Chris Hani Baragwanath Academic hospital, and Karolinska and Sahlgrenska University hospitals while treatment at the other hospitals were conducted individually or supervised by nursing staff, with standard service delivery resuming the following Monday.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003ePatients with thoracic trauma who were 18 years or older and of both genders were consecutively screened at the ICUs and trauma or surgical wards of all participating sites for possible inclusion, using the ICU or ward admission registers. Those with dementia, acute or previously diagnosed spinal cord injury, moderate (Glasgow coma scale (GCS) 9\u0026ndash;12) and severe (GCS\u0026thinsp;\u0026lt;\u0026thinsp;9) traumatic brain injury, complex pelvic fractures, lower limb fractures, lower limb amputation that restricted active mobilisation, and extensive abdominal trauma were excluded.\u003c/p\u003e\n\u003ch3\u003eData collected\u003c/h3\u003e\n\u003cp\u003eMeetings were held with the clinical physiotherapy staff who worked in the trauma units and wards of the participating study sites to explain the study purposes. The physiotherapists that oversee the trauma ICU, high care units and surgical/trauma wards at the participating sites were responsible for participant recruitment, as they screened the wards and units daily for new admissions. Participants gave their written consent before any of their data were captured. The physiotherapists captured participant details on study specific data forms. Information captured included demographics (age, sex, height, weight, smoking history, presence of chronic pulmonary disease), clinical presentation (type and mechanism of injury, pain, shortness of breath), medical, surgical and physiotherapy management received, pulmonary complications developed during hospitalisation, and discharge information (length of stay, and discharge destination). All participating hospitals in SA and Sweden had the same protocol for data capturing and included the data prospectively. Variables covering days before participant consent were not registered.\u003c/p\u003e \u003cp\u003eRecruitment and data collection occurred over a total of 18 months at the SA participating sites (October 2020 to October 2021 (Chris Hani Baragwanath Academic hospital); August 2022 to February 2023 (Charlotte Maxeke Johannesburg Academic hospital)) and over 12 months in Sweden (September 2021 to September 2022). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the process of recruitment of participants. Data were captured onto two electronic databases (Research Electronic Data Capture hosted at the University of the Witwatersrand (South Africa) and Google Drive (Sweden)).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were cleaned and imported to IBM\u0026reg; SPSS\u0026reg; version 28 for analysis. Descriptive statistics were used to summarise the data. Comparison of findings between cohorts were made using Pearson Chi-squared test (categorical variables e.g. types and mechanisms of injury), Mann Whitney-U test (ordinal variables e.g. Numeric Rating Scale (NRS) for pain and Borg (CR-10) scale for shortness of breath), and independent t-test (continuous variables e.g. age and length of stay). Significance was determined at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Univariate linear regression was done to identify contributing factors to hospital LOS. The dependent variable was logLOS as the LOS data were skewed. The independent variables were sex, age, type of injury (blunt vs penetrating), rib fractures (yes/no), pulmonary contusion (yes/no), other injuries (yes/no), moderate-to-severe pain (\u0026ge;\u0026thinsp;4/10) reported during deep breathing on days 1\u0026ndash;3 (yes/no), and lastly moderate-to-severe pain (\u0026ge;\u0026thinsp;4/10) reported during deep breathing on day 3 (yes/no). The independent variables that had a significant impact on LOS at univariate analysis were entered into a backward linear regression for multivariate analysis to determine which impacted on LOS.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient characteristics and types and mechanisms of injury\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1 918 patients were admitted to the participating sites during the study period (Fig. 1). Three-hundred-sixty-four patients with thoracic trauma participated of which 179 (49.2%) were from South Africa and 185 (50.8%) from Sweden. Characteristics of the participants are summarized in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1: Characteristics of the patients with thoracic trauma in the study cohorts.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSouth African cohort (n=179)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eSwedish cohort (n=185)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ep-value between cohorts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSex (n,%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e170 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e125 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e60 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eAge (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eYears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e33 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e58 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBMI (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003ekg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e23 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e26 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCurrent smokers (n,%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e96 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e24 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePulmonary disease (n,%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e20 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: \u003cem\u003eBMI\u003c/em\u003e body mass index\u003c/p\u003e\n\u003cp\u003eParticipants were mostly male. Most were between the ages of 30 to 64 years (n=103 (58%) SA; n=107 (58%) Sweden). The SA cohort was significantly younger than the Swedish cohort. More than half of the SA cohort were current smokers, and 21% (n=37) had a BMI of 25-30 kg/m\u003csup\u003e2\u003c/sup\u003e compared to the Swedish cohort of whom 13% were current smokers and 55% (n=84) had a raised BMI. More Swedish participants had chronic respiratory disease prior to thoracic trauma.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost participants were recruited from a ward setting (SA 92%, Sweden 69%) with few recruited within ICU (SA 6%, Sweden 3%). The types and mechanisms of thoracic injury sustained are summarized in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Types and mechanisms of thoracic injury sustained.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"888\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eVariable (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSouth African cohort (n=179)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSwedish cohort (n=185)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ep-value between cohorts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eType of injury\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eBlunt injury\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e33 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e175 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003ePenetrating injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e146 (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e10 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eMechanism of injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eAssault\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e161 (90)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e18 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eAttempted suicide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eMVC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e31 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003ePVC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e30 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eCycling accident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eFalls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e81 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eMiscellaneous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e14 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eRib fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e1-3 ribs fractured unilaterally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e15 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e61 (33)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e4-6 ribs fractured unilaterally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e42 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u0026gt;3 ribs fractured bilaterally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e29 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eFlail rib injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e40 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eIntrapleural abnormality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003ePneumothorax unilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e41 (23)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e41 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003ePneumothorax bilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHaemo-/haemopneumothorax unilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e122 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e64 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHaemo-/haemopneumothorax bilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003ePulmonary contusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e42 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eLung laceration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e8 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eDiaphragm rupture\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.445\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eSternal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e16 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: \u003cem\u003eMVC\u003c/em\u003e motor vehicle crash, \u003cem\u003ePVC\u0026nbsp;\u003c/em\u003epedestrian vehicle crash\u003c/p\u003e\n\u003cp\u003eThe type of injury differed as most SA participants had penetrating thoracic injury (82%) and Swedish participants had blunt injury (95%). Mechanism of injury was different between the two cohorts with the SA cohort injured through assault (90%) compared to the Swedish cohort who were injured through falls (44%) (Fig. 2).\u003c/p\u003e\n\u003cp\u003eRib fractures and flail rib injury were higher in the Swedish cohort with no flail rib injury reported for the SA cohort. Most participants in both cohorts sustained unilateral haemopneumothorax. The Swedish cohort had significantly more other orthopaedic injuries (Supplementary table 1). There was no difference in the types of internal organ injuries sustained by both cohorts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcute care management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with thoracic trauma mostly received conservative management and physiotherapy with some needing surgical interventions. Table 3 summarizes and compares the conservative and surgical interventions used within the two cohorts during acute care management. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3: Conservative and surgical management provided to patients with thoracic trauma during their hospitalization.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAcute care management (n,%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSouth African cohort (n=179)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eSwedish cohort (n=185)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ep-value between cohorts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAnalgesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e176 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e185 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSedation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eMechanical ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eNon-invasive ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eHigh flow nasal oxygen therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.973\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eOxygen therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e86 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e96 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eIntercostal drain insertion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e165 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e69 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eRib fixation surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e32 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eOther surgeries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e24 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e29 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe management provided to both cohorts was similar as most participants received analgesia (intravenous or oral opioid therapy) and few were sedated, but more SA participants (52%) were breathing at room air than their Swedish counterparts (34%) (p=0.023). More SA participants (92%) were managed with intercostal drainage systems than their Swedish counterparts (37%) (p\u0026lt;0.001) because of a higher incidence of penetrating trauma. Rib fixation surgery was performed for 17% of the Swedish cohort and none of the SA cohort. The types of other surgeries performed in the two cohorts are summarized in Fig. 3.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Significantly more participants in the SA cohort (n=160, 93%) received physiotherapy management from Day 1 after admission to the hospital than in the Swedish cohort (n=106, 73%, p\u0026lt;0.001). Most SA participants (99%) received one physiotherapy treatment session per day over the first three days of hospital stay, whereas some participants in the Swedish cohort (7%-9%) received two or more treatment sessions. Details of physiotherapy management approaches used for patient care in the two cohorts are reported elsewhere. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePain and shortness of breath experienced\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLevel of pain experienced at rest and during deep breathing was measured with the NRS (Fig. 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Swedish cohort had significantly more pain at rest on day 2 (p=0.047) and during deep breathing on days 1-3 (day 1: p=0.053; day 2: p\u0026lt;0.001; day 3: p\u0026lt;0.001). Subgroup analysis was performed to distinguish between the pain reported during rest and deep breathing by SA and Swedish participants with blunt thoracic trauma and those with penetrating trauma. No significant differences were found in level of pain reported over the first three days of hospitalisation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eShortness of breath at rest and during activity was reported using the Borg CR-10 scale (Fig. 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Swedish cohort had significantly more shortness of breath at rest on day 3 (p\u0026lt;0.001) and when performing activity on days 1-3 (day 1: p=0.023; day 2: p=0.001; day 3: p\u0026lt;0.001). The Swedish cohort with blunt thoracic trauma (n=52) experienced more shortness of breath at rest on day 3 (p\u0026lt;0.028) than the SA cohort (n=11) with blunt trauma. No differences in shortness of breath during activity were found between these cohorts with blunt trauma. Subgroup analysis for those with penetrating trauma was not possible due to missing data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLength of stay and pulmonary complications developed\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SA cohort had a mean hospital LOS of 5.4 (\u0026plusmn;4.3) days which was significantly shorter than that of the Swedish cohort (6.6 \u0026plusmn;5.1; p=0.024). Pulmonary complications during hospital stay were rare. Atelectasis was reported in four patients in SA and 16 in Sweden (2.2 vs. 8.6%, p=0.007). None of the SA patients developed pneumonia during hospitalisation compared to 8 (4.3%) in Sweden (p=0.005). Among the SA participants, none needed non-invasive ventilation as a result of complications developed, in contrast to two in the Swedish cohort. In both cohorts one participant each required mechanical ventilation. Multivariate analysis showed that the development of pulmonary complications and reporting of moderate-to-severe pain at day 3 of hospitalisation impacted significantly on LOS (Table 4).\u003c/p\u003e\n\u003cp\u003eTable 4: Factors that impact on length of stay \u0026ndash; univariate and multivariate analysis results.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"926\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003eUnivariate analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eMultivariate analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAdjusted R square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eB coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eStandard error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eB coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eStandard error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003eDependent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eLOS\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003eIndependent variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-1.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eOther injuries combined\u003csup\u003ea\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eModerate to severe pain D1-D3\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eModerate to severe pain D3\u003csup\u003ea\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003ePulmonary complications\u003csup\u003ea\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eRib fractures\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eType of injury (Blunt vs Penetrating)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: \u003cem\u003eLOS\u003c/em\u003e length of stay, \u003cem\u003eD1\u003c/em\u003e day 1, \u003cem\u003eD3\u003c/em\u003e day 3, \u003cem\u003ea\u003c/em\u003e entered into multivariate analysis, \u003cem\u003e*\u003c/em\u003e p-value \u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDischarge information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore SA participants were discharged to their homes (99% SA, 56% Sweden, p\u0026lt;0.001). Thirty-five of the remaining Swedish participants were transferred to another ward/hospital and were lost to follow-up for the purposes of this study. Seven were sent to convalescence care and 32 to follow-up rehabilitation after discharge from the acute care settings.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective observational study is the first to report on levels of pain and shortness of breath experienced by adults with thoracic injury in the first three days of admission, its influence on hospital LOS and patient discharge destination. In addition, it describes and compares the cohort of patients with thoracic trauma in two countries with different socioeconomic levels and the acute care management that they received, mirroring actual clinical practice in the six participating sites.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMales were predominantly involved in thoracic trauma in SA and Sweden, similar to other studies [6,9].\u0026nbsp;The SA cohort was younger and were smokers compared to the Swedish cohort that had more participants with chronic respiratory disease. Moreover, the SA participants predominantly had penetrating thoracic injury because of assault, while the Swedish participants had blunt thoracic injury sustained through falls. These findings conform with reports by others [6-9,16-18]. It contrasts the notion that the majority of thoracic trauma cases is caused by blunt injury [10] and confirms that the types of thoracic trauma cases encountered is determined by the region of the world and socio-economic standing of the community under investigation [4-5]. The different mechanisms of injury reported in this study reflect the differences in socio-economic levels between the two countries and affect the human body differently. Assault was more often due to stab- or gunshot wounds that did not involve the bony structure of the thorax, although some internal organs of the trunk were injured. This is evident from the higher number of participants in the SA cohort who underwent sternotomy. Falls are more likely to affect the stability of the ribcage and involve injury to extrapulmonary structures. The marked need for rib fixation and additional orthopaedic surgery in the Swedish cohort confirm their higher severity of injury. It may reflect a difference in the management of severe thoracic injuries between the two countries. Subsequently there was a different panorama of injury between the cohorts which might explain the reported differences in pain at rest and while deep breathing, the duration of hospitalisation and need for additional care after discharge from the acute care setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany participants had intrapleural abnormality and the most common was unilateral haemopneumothorax. Pulmonary contusion, lung laceration and diaphragm rupture were less common. Intra-thoracic injuries are common in both blunt and penetrating trauma [10,13]. Most injuries can be managed with only a chest tube, although not all had an indication for chest tube drainage. Penetrating injuries require intra-thoracic surgery via sternotomy/thoracotomy to a greater extent than blunt trauma. However, blunt trauma with severe injury to the chest wall may require surgery, and the patient is more likely to be operated on if they are managed at a centre where this is provided, such as Sahlgrenska Academy that has a tradition of rib surgery and where 98% of surgeries in this study were performed.\u003c/p\u003e\n\u003cp\u003eWhole-body CT-scan is standard practice in the management of patients with thoracic trauma in both countries. Additional orthopaedic injury was present in one-third of participants where upper limb fractures and spinal fractures were most common. Liver injury affected a small percentage of participants, but other internal organ injuries were rare. In addition, mild neurological injury affected five percent of participants. This reflects the injury panorama of participants included in the study. Patients with more severe traumatic neurological injury were excluded from this study due to predetermined criteria.\u003c/p\u003e\n\u003cp\u003eAcute care management of these cohorts were similar for administration of analgesia, MV and high flow nasal cannula oxygen therapy, and few participants were sedated. Some Swedish participants were managed with non-invasive ventilation which may be due to the greater incidence of unilateral and bilateral rib fractures and flail chest injuries. Non-invasive ventilation administered to appropriately selected patients with blunt chest injury decreases complications and the need for intubation and mechanical ventilation [19] but is known to increase LOS [20]. This may be one of the explanations for the longer hospitalisation observed in the Swedish cohort. Other explanations may be the older Swedish trauma population and socio-economic differences between the two countries where the Swedish state invests more time in planning for home care. In South Africa patients are discharged earlier into the care of their families. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eModerate-to-severe pain was reported by both cohorts during deep breathing in the three days after admission, with significantly higher levels of pain observed in the Swedish cohort. This observation occurred despite the administration of analgesia. One explanation is that the elderly experience and tolerate pain differently [21]. One third of the Swedish cohort was older than 65 years. Hyperalgesia, in the elderly, lasts longer, and combined with slower healing results in prolonged periods of physical discomfort and functional limitations [21]. The effectiveness of analgesia in the elderly is blunted by physiological body system changes and their response to analgesia varies widely which complicates pain management [21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost SA and Swedish participants had unilateral haemopneumothorax which was managed with intercostal drainage. The presence of drainage tubes and residual blood in the pleura compress and irritate the intercostal nerves and contribute to inflammation and pain [22]. In addition, pain is caused by damage to myofascial structures [23]. The Swedish cohort had significantly more rib fractures, flail injuries, and sternal fractures and more underwent surgery. Some SA participants had sternotomy due to internal organ injury. Surgery is a common cause of damage to myofascial structures and resultant severe pain. Any movement such as deep breathing and coughing causes tension around the incision site and increases the level of pain experienced [10,22-23]. This may relate to the increased pain intensity experienced by both cohorts during such activities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eShortness of breath was reported by both cohorts when performing any form of activity. Trauma causes pain as discussed earlier and leads to reflex dyspnoea. Haemothorax is a recognised cause of shortness of breath [10, 24] and was commonly diagnosed in these cohorts. The SA cohort subsequently experienced less shortness of breath during activity on days two and three than their Swedish counterparts. The Swedish cohort presented with significantly more chronic pulmonary diseases. Dyspnoea is a known symptom in chronic respiratory disease and is associated with reduced physical activity, higher levels of anxiety and depression, and lower levels of quality of life [24-25]. Additionally, dyspnoea and respiratory muscle weakness both influence walking distance in individuals with pulmonary disease [26]. This comorbidity could have influenced the Swedish cohort\u0026rsquo;s level of shortness of breath at rest and during activity following the acute thoracic trauma sustained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThoracic trauma is associated with an increased risk for the development of pulmonary complications such as atelectasis, pneumonia and respiratory distress [10,13]. More Swedish participants developed such complications than their SA counterparts. This occurred even though more Swedish participants received twice daily physiotherapy management. The consistently higher levels of pain and shortness of breath experienced from the more complex thoracic injury and non-surgical management may explain the higher observed rates.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing the differences between the cohorts, LOS and need of additional hospital care, significantly more Swedish participants were transferred to rehabilitation facilities or convalescence care prior to returning home. The SA cohort was younger, less severely injured and majority were discharged directly to their homes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAge, pain, type of injury, and rib fractures are associated with longer hospitalisation; however, none of these had a significant impact in the multivariate analysis. Pulmonary complications and moderate-to-severe pain on day three of admission influenced participants\u0026rsquo; LOS. The type and complexity of thoracic injury could have influenced participants\u0026rsquo; ability to optimally ventilate their lungs and cough effectively. Some participants required surgical procedures to stabilise their injuries. Post-operative pulmonary complications (PPC) increase duration of hospitalisation [27] and thoracic surgery increases the risk of PPC [27]. Early mobilisation as a means of optimising patient ventilation and oxygenation could have been influenced by multiple factors in the current study. The effect of early mobilisation in trauma patients admitted to ICU varies as it may decrease duration of mechanical ventilation but its impact on mortality and LOS remains similar to usual care [28].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were some limitations to this study. No injury severity score data were accessible for direct capturing from patient files in both countries. Retrospective information may be obtained from the Swedish National Trauma Registry; unfortunately, such data cannot be retrieved for the SA cohort, therefore it is not reported. The COVID-19 pandemic may have impacted on the incidence of trauma and hospital admission rates due to various stages of lockdown experienced in SA. Information on the medication used for sedation, and the use of epidural and intercostal blockade were not included in the data collection forms and limits extrapolations made about pain management. No data was collected for reasons why intercostal drainage or rib fixation surgery were not performed in cases where it may have been indicated. The amount of missing data for pain variables limited the generalisability of the multivariate analysis results on LOS. Data was collected from public healthcare sector university-affiliated hospitals in SA and Sweden which limits the generalisability of results to thoracic trauma management in other settings. A strength of this study is that data capturing was prospective in nature and occurred in parallel to clinical practice. The authors collaborated closely to facilitate an easy and simple data collection process for all involved but there remained some challenges with the amount of data that was captured.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, this study confirms the contextual differences in clinical presentation, acute care management and discharge destinations of patients with thoracic trauma in SA and Sweden. It highlights that reassessment of care provided should be prioritised for those patients who report moderate-to-severe pain on day three of admission to decrease their risk of developing pulmonary complications and prolonged hospital stay. \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no relevant financial or non-financial interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHvA contributed substantially to conceptualisation, data cleaning and analysis and interpretation of results, drafting and finalising the manuscript for review.\u003c/p\u003e\n\u003cp\u003eRR, ECC and FP contributed to interpretation of results and to the content of the manuscript.\u003c/p\u003e\n\u003cp\u003eARS, AS and MS contributed to acquisition of the data, interpretation of results and to the content of the manuscript.\u003c/p\u003e\n\u003cp\u003eMFO contributed substantially to conceptualisation, data cleaning and analysis and interpretation of results, and drafting of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. In South Africa, approval was granted by the University of the Witwatersrand Human Research Ethics (Medical) committee (Date: 27/06/2020; No. M200222). In Sweden, approval was granted by the Regional Ethics Committee for the region of V\u0026auml;stra G\u0026ouml;taland (Date: 22/10/2019; No. Dnr2019-04848). Permission was obtained from all relevant authorities at the two participating sites in South Africa and the four participating sites in Sweden. Informed consent was obtained from all potential participants before study enrolment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the results presented in this manuscript are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eDeclarations related to funding and the acknowledgements are captured in the Title Page of this submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. Global status report on road safety 2018: summary [Internet]: Geneva: World Health Organization; 2018 [cited 2024 Sept 27]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/violence_injury_prevention/road_safety_status/2018/en/\u003c/span\u003e\u003cspan address=\"https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdal O, Tareke AA, Bogale EK, Anagaw TF, Tiruneh MG, Fenta ET, et al. Mortality of traumatic chest injury and its predictors across sub-Saharan Africa: systematic review and meta-analysis, 2024. 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Injury. 2019;50(11):1809\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2019.09.007\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2019.09.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Thoracic trauma, pain, shortness of breath, pulmonary complications, length of stay","lastPublishedDoi":"10.21203/rs.3.rs-5237772/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5237772/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eThoracic trauma causes pain and hospitalisation. Middle- and high-income countries have different trauma contexts and populations. To report patients\u0026rsquo; clinical presentation (pain and shortness of breath) and its influence on hospital length of stay (LOS), acute care management, and discharge destinations in South Africa (SA) and Sweden.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eProspective observational multicenter study by means of clinical record review. One thousand nine hundred and eighteen adults with thoracic trauma were screened. Study objectives guided information retrieved from clinical records. Statistical analysis was done with significance at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThree-hundred-sixty-four participants were recruited with most being male (n\u0026thinsp;=\u0026thinsp;170 (95%) SA; n\u0026thinsp;=\u0026thinsp;125 (68%) Sweden). Type and mechanism of injury differed (SA penetrating (82%) versus Sweden blunt (95%); SA assaults (90%) versus Sweden falls (44%)). Unilateral haemopneumothorax was common (SA 68%, Sweden 35%) and managed with intercostal drainage. Rib cage injuries were common in the Swedish cohort with rib fixation surgery for 17%. Physiotherapy treatment frequency was mostly daily. Swedish participants reported higher pain levels during deep breathing (day 1: p\u0026thinsp;=\u0026thinsp;0.053; day 2: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; day 3: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Shortness of breath during activity was higher for the Swedish cohort (day 1: p\u0026thinsp;=\u0026thinsp;0.023; day 2: p\u0026thinsp;=\u0026thinsp;0.001; day 3: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). LOS was shorter for SA cohort (5.4 (\u0026plusmn;\u0026thinsp;4.3) versus 6.6 (\u0026plusmn;\u0026thinsp;5.1) days; p\u0026thinsp;=\u0026thinsp;0.024). Pulmonary complications (p\u0026thinsp;=\u0026thinsp;0.013) and moderate-to-severe pain on day 3 (p\u0026thinsp;=\u0026thinsp;0.005) influenced LOS. Discharge destination was mostly home (99% SA, 56% Sweden).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eModerate-to-severe pain on day three suggests priority care for those with thoracic trauma to prevent pulmonary complications and prolonged hospitalisation.\u003c/p\u003e","manuscriptTitle":"Clinical presentation, acute care management and discharge information of patients with thoracic trauma in South Africa and Sweden: a prospective multicenter observational study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 13:38:52","doi":"10.21203/rs.3.rs-5237772/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-16T10:42:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T21:22:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35913525716823488356998516869907386239","date":"2024-10-21T14:11:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-21T10:39:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136826211932387927780464668230211244279","date":"2024-10-21T09:45:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-21T09:20:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-21T09:18:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-18T05:56:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-10-10T08:11:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7f3d3215-9b90-4699-a850-25a462b12fd2","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:04:52+00:00","versionOfRecord":{"articleIdentity":"rs-5237772","link":"https://doi.org/10.1007/s00068-024-02753-y","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2025-01-16 15:58:00","publishedOnDateReadable":"January 16th, 2025"},"versionCreatedAt":"2024-12-09 13:38:52","video":"","vorDoi":"10.1007/s00068-024-02753-y","vorDoiUrl":"https://doi.org/10.1007/s00068-024-02753-y","workflowStages":[]},"version":"v1","identity":"rs-5237772","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5237772","identity":"rs-5237772","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}