The present study described the epidemiology and outcomes of hospitalized violence-related traumatic injuries in Qatar. Although the number of victims increased over the years, the hospitalization rate decreased by 15 %, throughout the study period. The computed hospitalization rate was 4.6 per 100,000 population per year. A significantly higher rate was found in males and in the 25-34 years age-group. Notably, children (<18y) represented 7% of the victims. Although the South Asians were proportionately affected according to their population distribution in the country, they were the principal victims in our study. As such, any future interventions to prevent violence in Qatar must be culturally and linguistically appropriate for South Asian populations and lessons must be taken from successful programs from their home countries. Multivariate analysis showed that male gender and BAC positivity were predictors for IPV whereas South Asian nationality was a negative predictor of SII. One fifth of cases were refereed for psychiatric consultation; three-quarters of them were self-inflicted violence victims. The admission GCS and ISS were independent predictors of mortality in hospitalized violence related trauma patients in our analysis.
Interpersonal violence was the major contributor in most of victims followed by SII. More than one out of five patients were shown to be under the influence of alcohol and had a mean BAC level corresponding to the central nervous system depression level. Head and chest injuries were the most common severe injuries. The ISS data showed that polytrauma was not frequent in our study population. As per our knowledge, this is the first trauma registry-based study conducted on hospitalized violence-related trauma in Qatar. Such studies are rare in the Arabian Gulf region. A hospital-based retrospective study in Jordan demonstrated that violence (71%) was the most frequent cause of ED visits followed by road traffic injuries (23%) .
Bala et al., studied the prevalence of physical fighting and its associated factors among the adolescent population in Qatar . This study was based on a student health survey in school to determine the prevalence and factors associated with being engaged in a physical fight. On the other hand, authors from Saudi Arabia reported factors of intimate partner violence against Saudi women based on a survey among participants attending primary healthcare clinics . In that study, the author estimated the prevalence of different types of domestic violence and its associated risk factors among Saudi women who attended a primary care center .
Notably, the majority of patients in our study were victims of IPV. The Osman et al., study from the Al-Ain city in the United Arab Emirates (UAE) was a trauma registry- based study on violence that was specific for IPV . Our study and UAE study were based on trauma hospitalization; however, a significant number of admissions were mild cases, which is evident from the overall ISS. Osman et al., estimated that the interpersonal violence-related hospitalization rate in Al-Ain (UAE) was 6.7 per 100,000 population, which was higher than the estimated rate in our study . The mean age of victims in the UAE and our study was 30 and 31 years respectively. Male predominance among the victims was evident in our study (90%), UAE (85%) and Jordan (87%) studies [17, 21]. Our study demonstrated that females were more likely to sustain SII when compared to the IPV group in which males were more prevalent. The population structure in Qatar showed that females make up approximately a quarter of total population, this could explain the gender discrepancy among the injured population.
The present study showed that in-hospital mortality was higher among SII in comparison to IPV, however, this difference was not statistically significant. On the other hand, there were no deaths reported in the UAE study. The overall in-hospital mortality in our study was 6.4% and could be related to the severity of injuries. Nearly 28% of our patients required ICU admission; whereas the UAE based study revealed that less than 3% were admitted to the ICU .
Blunt injuries were common in our study population, especially SII. This contrasts with studies from level 1 trauma centers in Western settings where penetrating injuries especially gunshots were more common . In addition to the differences in geographical, cultural and religious backgrounds in the Middle Eastern settings, factors such as urbanization, crime rates, and legislation concerning firearm use could contribute to these existing variations. Dijkink et al., demonstrated that the proportion of admitted patients with gunshot wounds was almost twice as high in level 1 trauma centers in the United States when compared to level 1 trauma centers in Netherlands, even though the geographical areas in both countries had comparable urbanization and violence crime rates .
Strength and limitation: The major strength of our study is its internal and external validity since the data are obtained from the Qatar national trauma registry and the only referral level 1 trauma center in the country, therefore our findings provide representative information on the hospitalized violence-related injuries in Qatar. In the process of submitting our registry data to TQIP, the submission file goes through validation and will be checked, a submission frequency report will be provided for reference, and the file will be rejected if any major errors are found for correction. The TQIP reports are reviewed to pick up any outliers to review and correct any errors that might have been missed and then resubmit the changes.
The main limitation of the study is the retrospective design. Also, selection bias cannot be ruled out as in some situations the victims may not be willing to report the occurrence of violence and minor injuries may not attend and be admitted to the HTC. Although the frequency of hospital visits following violence-related injuries by nationality data was available, the annual nationality-specific population data were unavailable and therefore the disproportionate burden of injuries was not estimated based on the rate. In addition, several other important socio-economic data were unavailable; however, the available data addressed the main objectives of the study. The present study excluded those who died at the site of injury or on arrival to the ED and therefore data represented those with comparatively less severe injuries. Changes in population growth rates over the years due to the influx of foreign workers, especially males, recruited for the major development projects in Qatar could explain the changes in the rates of violence related injuries across the study period . Testing for non-prescription drugs are not routinely performed at the HTC, as such their role in violence-related injuries cannot yet be established.