Steven R. Lowenstein

Predictive validity of a screen for partner violence against women.

BACKGROUND While public health leaders recommend screening for partner violence, the predictive value of this practice is unknown. The purpose of this study was to test the ability of a brief three-question violence screen to predict violence against women in the ensuing months. METHODS We conducted a prospective cohort study of adult women participating in the Colorado Behavioral Risk Factor Surveillance System (BRFSS), a population-based, random-digit-dialing telephone survey. During 8 monthly cohorts, 695 women participated in the BRFSS; 409 women participated in follow-up telephone interviews approximately 4 months later. Violent events during the follow-up period, measured using a modified 28-item Conflict Tactics Scale, were compared between women who initially screened positive and those who screened negative. RESULTS Among BRFSS respondents, 8.4% (95% confidence interval [CI]=6.3%-10.5%) had an initial positive screen. During the follow-up period, women who screened positive were 46.5 times (5.4-405) more likely to experience severe physical violence, 11.7 times (5.0- 27.3) more likely to experience physical violence, 3.6 (2.4-5.2) times more likely to experience verbal aggression, and 2.5 times (1.2-5.1) more likely to experience sexual coercion. In a multivariate model, separation from ones spouse and a positive screen were significant independent predictors of physical violence. CONCLUSIONS A brief violence screen identifies a subset of women at high risk for verbal, physical, and sexual partner abuse over the following 4 months. Women with a positive screen who are separated from their spouse are at highest risk.

Prehospital advanced trauma life support for penetrating cardiac wounds

Prehospital advanced trauma life support (ATLS) is controversial because the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to determine the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcome. Thirty-one patients sustained gunshot wounds, and 39 had stab wounds. The mean Revised Trauma Score was 2.8 +/- 0.5. Paramedics spent an average of 10.7 +/- 0.5 minutes at the scene. Seventy-one percent of the patients underwent endotracheal intubation; 93% had at least one IV line inserted; and 57% had two IV lines inserted. Twenty-one (30%) survived. There was no correlation between on-scene time and either the total number of procedures performed (r = .17, P = .17) or IV lines established (r = .06, P = .6). On-scene times did not differ regardless of whether endotracheal intubation or pneumatic antishock garment applications occurred. We conclude that well-trained urban paramedics can perform multiple life-support procedures with very short on-scene times and a high rate of patient survival and that prehospital trauma systems require a minimum obligatory on-scene time to locate patients and prepare them for transport.

Vertical trauma: injuries to patients who fall and land on their feet.

We reviewed the patterns of injuries sustained by 12 consecutive fallers and jumpers in whom primary impact was onto the feet. The fall heights ranged from 20 to 100 ft. The 12 patients sustained 49 significant injuries. Skeletal injuries were most frequent and included 15 lower extremity fractures, four pelvic fractures, and nine spinal fractures. In two patients, paraplegia resulted. Genitourinary tract injuries included bladder hematoma, renal artery transection, and renal contusion. Thoracic injuries included rib fractures, pneumothorax, and hemothorax. Secondary impact resulted in several craniofacial and upper extremity injuries. Chronic neurologic disability and prolonged morbidity were common. One patient died; the patient who fell 100 ft survived. After initial stabilization, survival is possible after falls or jumps from heights as great as 100 feet It is important to recognize the skeletal and internal organs at risk from high-magnitude vertical forces.

Frequently nebulized β-agonists for asthma: Effects on serum eleetrolytes

Study objective: To determine the magnitude of the changes in serum potassium, magnesium, and phosphate during the treatment of acute bronchospasm with repeated doses of β-adrenergic agonists. Design: Prospective study of a convenience sample of asthmatic patients. Setting: University teaching hospital emergency department. Type of participants: Twenty-three patients met the inclusion criteria of age of more than 16 years; a history of asthma or chronic obstructive pulmonary disease, and an acute exacerbation. Interventions: Baseline peak expiratory flow rate and serum potassium, magnesium, and phosphate levels were measured

A Positive Domestic Violence Screen Predicts Future Domestic Violence

The objective of this study was to determine if a brief screen for domestic violence (DV) predicts future violence. We conducted a cohort study of adult women who presented to an inner-city emergency department during an 8-week study period. Participants were screened for DV using the Partner Violence Screen (PVS). At 4 months, follow-up telephone interviews were conducted: rates of verbal and physical violence were measured using the modified Conflict Tactics Scale. Relative risks of violent events (physical and verbal) were calculated.Of the 215 women who enrolled,36 (16%) had an initial screen positive for DV. Ninety-six women participated in the follow-up phase; of these women, 9% had screened positive for DV. At 4 months, women with DV were 11.3 times more likely to experience physical violence and 7.3 times more likely to experience verbal aggression. The study’s screen identified women at high risk for subsequent physical violence and verbal aggression.

MANAGEMENT OF ACUTE PYELONEPHRITIS IN AN EMERGENCY DEPARTMENT OBSERVATION UNIT

STUDY OBJECTIVES To determine whether moderately to severely ill patients with acute pyelonephritis can be treated successfully on an outpatient basis, and whether any aspect of history, physical examination, or initial laboratory data predicts failure of outpatient therapy and the need for hospitalization. DESIGN Retrospective chart review of all patients with a diagnosis of acute pyelonephritis seen during a three-year period. SETTING Emergency department observation unit of an urban teaching hospital serving residents of the city and county of Denver. TYPE OF PARTICIPANTS Women between the ages of 15 and 50 with symptoms, physical examination, and initial laboratory data consistent with a diagnosis of pyelonephritis. INTERVENTIONS Patients received IV antibiotics, rehydration, analgesics, and antiemetics in an observation unit for up to 12 hours, when they were either admitted to the hospital or discharged home on oral antibiotics. MEASUREMENTS AND MAIN RESULTS Sixty-three of 87 patients (72%) with acute pyelonephritis were managed successfully as outpatients, nine (22%) were hospitalized directly from the observation unit because they were considered to be too ill to go home, and five (6%) returned with persistent symptoms after ED therapy and were hospitalized. No clinical or laboratory variable predicted success or failure of ED observation unit therapy at the time of initial presentation. CONCLUSION In selected patients, the observation unit may be used to initiate therapy for acute pyelonephritis. Those with an adequate clinical response to initial treatment may be discharged on oral antibiotic therapy with appropriate follow-up.

Measuring the accuracy of the infrared tympanic thermometer: Correlation does not signify agreement

This prospective study assessed the accuracy of the infrared tympanic thermometer (ITT) compared to the rectal thermometer (RT) using statistical measures of agreement. In a convenience sample of 100 adult emergency department patients, ear examinations to assess for cerumen or otitis were followed by temperature measurements using the First Temp 2000A thermometer in both ears and the IVAC 2000 rectally. Left and right ITT temperatures showed high correlation and agreement; therefore, only right ITT results are reported. Both the ITT and RT recorded similar mean temperatures, standard deviations, and ranges. The correlation of the ITT and RT and agreement were below the 0.8 level, indicating excellent agreement. The mean temperature difference (RT-ITT) between the two devices was 0.1 +/- 0.7 degrees C; in 10% of patients, the temperature difference was > or = 1 degree C. Among 10 patients identified as febrile by RT (RT > or = 38.5 degrees C), 6 were febrile by ITT. Significant differences occurred between the temperature measurements using the ITT and RT; these devices do not demonstrate excellent agreement.

Granulomatous tenosynovitis and carpal tunnel syndrome caused by sporothrix schenckii

Although the usual form of sporotrichosis is a lymphocutaneous lesion, Sporothrix schenckii can cause articular disease that is difficult to diagnose. We describe two patients with sporotrichosis who presented with tenosynovitis and the carpal tunnel syndrome. A tissue specimen is required for a precise diagnosis; granulomatous tenosynovitis suggests an infectious cause. Unless appropriate cultures for bacteria, mycobacteria and fungi are obtained, the diagnosis may be missed or delayed. Mouse inoculations may be required to isolate S. schenckii from tissue, which rarely shows the delicate fungus in histologic sections. Our patients were cured by a combination of synovectomy and the intravenous administration of amphotericin B. Sporotrichosis should be considered in the differential diagnosis of the carpal tunnel syndrome, particularly when surgical exploration discloses a granulomatous tenosynovitis.

Safety Belt Nonuse by Internal Medicine Patients: A Missed Opportunity in Clinical Preventive Medicine

BACKGROUND The United States Preventive Services Task Force recommends that physicians routinely counsel all patients to wear safety belts. We undertook this study to determine the prevalence of the nonuse of safety belts among internal medicine patients, to measure the association of nonuse with other health risk factors, and to ascertain the safety belt counseling practices of physicians. PATIENTS AND METHODS A total of 492 consecutive patients attending a university-based general medicine clinic were given a validated, self-administered questionnaire, and 94% responded. A medical chart review was performed in a blinded fashion on 94% of the eligible charts. RESULTS Of the 454 patients who provided safety belt information, 243 (54%) did not wear safety belts. Nonusers were more likely to be problem drinkers, inactive, obese, and to have a low income (adjusted odds ratios 1.8 to 2.0). Of patients with all four of these characteristics, 91% did not use safety belts. The leading reasons for safety belt nonuse were discomfort (35%), short driving distances (24%), and forgetfulness (13%). Obese patients were more likely to report discomfort as their reason for nonuse (odds ratio 2.4; 95% confidence limit 1.4 to 4.3). Eighteen patients (3.9%) reported that a physician had ever counseled them about safety belt use. Only two of 314 medical records (0.6%) noted physician questioning or counseling about safety belt use. CONCLUSIONS The majority of patients attending an internal medicine clinic do not wear safety belts. Nonusers are more likely to be problem drinkers, inactive, obese, and to have a low income. Patients with multiple health risk factors are at significant risk of nonuse. The most common reason for nonuse is physical discomfort, especially among obese patients. Finally, physicians rarely counsel patients to use safety belts.

The electrocardiogram in chronic obstructive pulmonary disease

The electrocardiogram is often abnormal in patients who have chronic obstructive pulmonary disease. The most frequent abnormalities are a rightward P-wave axis (greater than or equal to 70 degrees) and a rightward QRS axis (greater than or equal to 90 degrees). In addition, low voltage in the limb leads, an S1S2S3 pattern, poor R-wave progression, a posterior-superior terminal QRS vector or other changes may be present. Transient atrial and ventricular dysrhythmias are common. Knowledge of the usual electrocardiographic manifestations of chronic obstructive pulmonary disease enables the clinician to recognize uncharacteristic abnormalities, which often represent the effects of superimposed illnesses or drug toxicity.