Vincent J. Perciaccante

Head, neck, and facial injuries as markers of domestic violence in women

PURPOSE The diagnosis of domestic violence (DV) is difficult because of a lack of clearly defined signs and symptoms. The goal of this study was to confirm and refine the role of head, neck, and face (HNF) injuries as markers of DV. PATIENTS AND METHODS A cross-sectional study design and a sample of female trauma patients treated in an inner-city hospital emergency room (Grady Memorial Hospital, Atlanta, GA) were used. The predictor study variable was injury location (HNF or other location). The outcome variable was traumatic origin (DV or other cause). A victim of DV was defined as a patient who gave a history of being injured by her spouse or sexual partner. Other data included age, nature of the injury (blunt or penetrating), and injury severity score (ISS). Descriptive, bivariate, and logistic regression statistical analyses were performed. RESULTS The sample consisted of 100 injured women, with a mean age of 40+/-16.3 years and a mean ISS of 3.3+/-3.0. Thirty-four women were victims of DV. The mean age of the DV victims was 32.5+/-7.3 years, compared with a mean age of 43.9+/-18.2 year in the other-causes group (P = .001). The mean ISS for the DV victims was 3.4+/-3.0, and the mean ISS for the other-causes group was 3.2+/-3.0 (P = .65). DV victims were 7.5 (2.5 < RR < 22.9) times more likely to have HNF injuries than other trauma patients (P < .001). Age was associated with cause and location of injury. After controlling for age, location remained statistically associated with cause (P = .0002). Sensitivity and specificity of HNF injuries and DV were 91% and 59%, respectively. CONCLUSIONS The data suggest that although HNF injuries and age were sensitive predictors of DV, they remain poor in their specificity as markers.

Markers for Intimate Partner Violence in the Emergency Department Setting

PURPOSE Intimate partner violence (IPV) is a serious, under-reported public health problem in the United States. Pilot studies suggested that injury location, that is, head, neck, or face, was a sensitive but nonspecific marker for IPV-related injuries. This studys goal was to determine whether adding a second element to the diagnostic protocol-response to an IPV-screening questionnaire-improved the specificity of the protocol. MATERIALS AND METHODS We used a cross-sectional study design and a sample composed of women presenting to the emergency department for evaluation and management of injuries of non-verifiable etiology. The predictor study variables were injury location (head, neck, or face vs other), responses to a verbal questionnaire (Partner Violence Screen or Woman Abuse Screening Tool), and the combination of both elements. By combining both elements, the probability for IPV-related injury was classified as high or low. The outcome variable was self-report of injury etiology (IPV or other etiology). Appropriate univariate and bivariate statistics were computed, including estimates of sensitivity, specificity, positive and negative predictive values, and relative risk. RESULTS The sample was composed of 300 women with a mean age of 36.5 years. The frequency of self-reported IPV-related injury was 32.3%. The sensitivities and specificities for injury location and the questionnaires combined ranged from 86.5% to 91.8% and 93.1% to 96.1%, respectively. CONCLUSIONS The study findings suggest that combining information regarding injury location and the results of a screening questionnaire was a better predictor of a womans likelihood to report IPV-related injuries than either modality alone.

Bullet Embolus to the Pulmonary Artery After Gunshot Wound to the Face: Case Report and Review of Literature

Gunshot wounds to the face can have devastating effects on local and distant tissues. The amount of local damage is directly proportional to the kinetic energy transmitted by the missile. Distant injuries, not in the path of the bullet, can be incurred by a pressure wave created by the temporary cavity, a secondary projectile, aspiration of the missile or bony fragments, and embolization of the bullet, which is a rare phenomenon. Embolization, aspiration, and ingestion of the missile should be suspected when there is an entry wound but no exit wound and no missile is found on x-ray in the expected area after a gunshot wound to the head and neck. Bullet embolism to the heart after gunshot wound of the mandible has been reported in the literature. There are several case reports of bullet embolization to the pulmonary artery after sustaining gunshot wounds to the chest, abdomen, and/or extremities. The purpose of this article is to present a case of bullet embolization to the pulmonary artery after a gunshot wound to the face, fracturing the mandible along its course, to review the literature, and to offer a strategy for managing such injuries.

Nutritional status of substance abusers with mandible fractures

PURPOSE The purposes of this study were 1) to assess the validity of patient self-report in identifying illegal substance abuse and 2) to identify nutritional deficiencies in substance abusers presenting for treatment of mandible fractures. PATIENTS AND METHODS To address the research purposes, a prospective cohort study was conducted of patients presenting for treatment of mandible fractures. A urine drug screen was used to determine the validity of patient self-report of substance abuse. For purposes of assessing nutritional status, 2 categories of substance abusers were identified: illegal and legal (alcohol). The nutritional status was measured using various laboratory markers. RESULTS The sample was composed of 93 subjects. Urine drug studies were available for 32 patients. Of the 22 patients who denied illegal drug use, 12 (55%) had a positive drug screen. Of the 10 patients reporting a positive history of illicit drug use, 7 (70%) had a positive urine drug screen (P = .47). A positive correlation was found between alcohol exposure and serum aspartate aminotransferase, mean corpuscular volume, and lactate dehydrogenase. Positive drug screens also were associated with increased serum ferritin levels. CONCLUSIONS The results of this study suggest that patient self-report of illicit drug use may be unreliable. The findings also suggest that legal and illegal substance abusers presenting for treatment of mandible fractures have minimal nutritional deficiencies.

Validation of a Diagnostic Protocol Used to Identify Intimate Partner Violence in the Emergency Department Setting

PURPOSE To assess the internal validity of a diagnostic protocol developed to facilitate the identification of women with intimate partner violence (IPV)-related injuries. MATERIALS AND METHODS Using a cross-sectional study design, we enrolled a sample of female subjects presenting to the emergency department for treatment of injuries with non-verifiable etiologies. The study sample was divided randomly into index and validation sets. The index set was used to develop the diagnostic protocol, and the validation set was used to assess the protocols internal validity. The predictor study variable was risk for IPV-related injury (ie, high or low). The outcome variable was self-report of injury etiology (IPV or other etiology). Appropriate univariate, bivariate, and multivariate statistics were computed, including estimates of sensitivity, specificity, and relative risk. Goodness of fit of the diagnostic protocol was estimated with the Hosmer-Lemeshow statistic. For all analyses, P < or = .05 was considered statistically significant. RESULTS The index and validation samples were composed of 200 and 100 women, respectively. In the index sample, subjects categorized at high risk of IPV-related injuries were statistically associated with an increased risk for self-report of IPV-related injury (relative risk, 25.2; 95% confidence interval, 10.6-59.5 [P < .05]; sensitivity, 90.2%; specificity, 96.4%; positive predictive value, 90.1%; negative predictive value, 96.4%). The agreement between the predicted and actual observations showed excellent agreement in the index and validation samples (P = .999, Hosmer-Lemeshow chi(2)). CONCLUSION The proposed diagnostic protocol effectively stratifies risk for IPV-related injuries with good internal validity.