Trevor J. Mills

Indications for computed tomography in patients with minor head injury

BACKGROUND Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT. METHODS In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients. RESULTS Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings. CONCLUSIONS For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.

Frequency and relationship of reported symptomology in victims of intimate partner violence: the effect of multiple strangulation attacks

The objective of this study is to examine the correlation between the number of times a victim of intimate partner violence (IPV) has been strangled and symptom development subsequent to the attacks. One hundred and one female subjects responded to a series of questions regarding the history and characteristics of the strangulation and the development of specific medical symptoms. Multiple strangulation victims, individuals who had experienced more than one strangulation attack, on separate occasions, by the same abuser, reported neck and throat injuries, neurologic disorders, and psychological disorders with increased frequency. Despite the increased frequency of symptoms, only 39% of the multiple strangulation victims sought medical care. These observations strongly support the need for health care professionals to inquire about the incidence of strangulation, examine the victim closely for evidence of injuries caused by the attacks, and recommend immediate care in anticipation of the potentially long term medical needs.

The prevalence of female-to-male intimate partner violence in an urban emergency department

Female-to-male intimate partner violence (IPV) recently has become a recognized health care issue. We screened a heterosexual male Emergency Department population for IPV using the HITS scale, a four-question survey. Two hundred eighty-two men were enrolled in the study. Basic demographics, along with the answers to the HITS scale, were analyzed. Of the men screened, 29.3% had a positive history of IPV. Men who were positive for IPV were more likely to score higher on questions regarding the frequency of verbal aggression than actual or threatened physical violence. This study reinforces the need to screen both genders for IPV in the Emergency Department.

Association of clinical and laboratory variables with ultrasound findings in right upper quadrant abdominal pain

Background: The purpose of this study was to determine how laboratory values and physical examination findings correlate with ultrasound findings in the setting of right upper quadrant pain. Methods: Patients undergoing emergent ultrasound for the evaluation of biliary disease between November 1999 and April 2000 were included. Physical examination findings, laboratory data, and ultrasound results were variables. Logistic regression was performed. Ultrasound diagnosis of acute cholecystitis, cholelithiasis, and normal biliary tract were end points. One hundred seventy-seven patients were enrolled. Results: Forty-two percent were diagnosed with acute cholecystitis, 30.5% with cholelithiasis, and 27.1% with normal biliary tract. Alkaline phosphatase, Murphy sign, white blood cell count, and total bilirubin were statistically significant predictors of acute cholecystitis. A Murphy sign was defined as arrest of inspiration with pressure over the right upper quadrant. Conclusions: The findings from this study allow clinicians to apply objective significance to laboratory data and physical examination findings in patients with suspected gallstone disease. The data can be applied to create a predictive model.

Walking and talking victims of strangulation. Is there a new epidemic? A commentary

This issue of JEM presents five articles addressing the issue of manual strangulation in surviving victims of intimate partner violence (IPV). These landmark articles reveal to the medical community what the social services and advocate community has known for a long time: strangulation, or throttling, is a common means of domestic violence inflicted upon victims by their perpetrators.

Three brief tools for identification of male intimate partner violence in the emergency department

Study objectives: Intimate partner violence (IPV) is a significant health concern. National surveys and law enforcement statistics have shown that women and men are victims of IPV. Most of the survey tools used to identify IPV in the emergency department (ED) have been constructed for, and validated with, female victims. The objective of this study was to compare screening tools for identification of IPV in men with a population-based, validated standard. Methods: Data were collected prospectively in randomized 4-hour blocks over a 6-week period. Consecutive male ED patients were approached for eligibility and consent. Questions were asked in a randomized fashion. The standard for comparison was the Conflict Tactics Scale (CTS), previously validated in men, by using a 95% population norm cutoff for physical IPV (physIPV) and psychologic IPV (psyIPV). Three screening tools, previously validated in women, the Hurt, Insult, Threaten, and Scream (HITS) Brief Domestic Violence Screening Tool, Partner Violence Screen (PVS), and Index of Spousal Abuse (ISA), along with a new, previously unvalidated scale, the Charity Hospital Intimate Partner Abuse Scale (CHIPAS) were compared to the CTS using sensitivity, specificity, and Chronbachs α. Results: Seventy-one (53%) of the eligible men approached agreed to participate in the study. Using the CTS, 15.5% of men reported a history of physIPV (Chronbachs α 0.92) and 8.5% reported a history of psyIPV (Chronbachs α 0.79). Comparing the HITS with CTS physIPV showed a sensitivity of 63.6% and specificity of 95%; comparing HITS to CTS psyIPV showed a sensitivity of 66.7% and specificity of 91% (Chronbachs α 0.84). Comparing the PVS to CTS physIPV showed a sensitivity of 66.7% and specificity of 91%; comparing PVS to CTS psyIPV showed a sensitivity of 83.3% and specificity of 76.9%. Comparing the ISA to CTS physIPV showed a sensitivity of 81.8% and specificity of 93.3% (Chronbachs α 0.89); comparing ISA to CTS psyIPV showed a sensitivity of 81.8% and specificity of 93.3% (Chronbachs α 0.94). Comparing the CHIPAS to the CTS physIPV showed a sensitivity of 100% and specificity of 23.1% (Chronbachs α 0.8); comparing CTS to psyIPV showed a sensitivity of 91.2% and specificity of 71.4% (Chronbachs α 0.74). Conclusion: Survey tools validated for screening for IPV in women showed promise for use in men in the ED setting.