Ovarian torsion: a fifteen-year review.

STUDY OBJECTIVE: Our purpose was to describe the history, physical, and laboratory findings in women with ovarian torsion (OT). METHODS: A retrospective chart review was conducted at 2 urban teaching hospitals. All women admitted from 1984 to 1999 with surgically proven OT were included in the study. RESULTS: The 87 women ranged in age from 14 to 82 years (mean 32 years). Twelve were pregnant, 15 were postmenopausal, and 7 were posthysterectomy. Thirty-five (40%) had prior pelvic surgery; 18 of these (21% of the total) had undergone tubal ligation. Twenty-two (25%) women had a history of an ovarian cyst. Sixty-five (75%) patients were seen in the emergency department. Pain characteristics were variable: the onset was sudden in 51 (59%); "sharp" or stabbing in 61 (70%); and radiated to the flank, back, or groin in 44 (51%) patients. Only 3 had peritoneal signs at presentation. The majority of patients (70%) had nausea or vomiting. Fever was rare (2 patients). OT was considered in the admitting differential diagnosis in 41 (47%) patients. An enlarged ovary (>5 cm) was found in 77 (89%) patients at surgery. Only 26 patients had surgery within 24 hours. In 8 (9%) patients, detorsion was possible; of these, 3 had surgery within 24 hours. CONCLUSION: The diagnosis of OT is often missed and ovarian salvage is rare. Pain characteristics are variable and objective findings are uncommon in OT.

Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department.

The determination of decision-making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision-making capacity should be determined on some level during each patient encounter. Decision-making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.

Accuracy of 3 brief screening questions for detecting partner violence in the emergency department.

OBJECTIVE: To devise a brief screening instrument to detect partner violence and to partially validate this screen against established instruments. DESIGN: Prospective survey. SETTING: Two urban, hospital-based emergency departments. PARTICIPANTS: Of 491 women presenting during 48 randomly selected 4-hour time blocks, 322 (76% of eligible patients) participated. Respondents had a median age of 36 years; 19% were black, 45% white, and 30% Hispanic, while 6% were of other racial or ethnic groups; 54% were insured. INTERVENTIONS: We developed a partner violence screen (PVS), consisting of 3 questions about past physical violence and perceived personal safety. We administered the PVS and 2 standardized measures of partner violence, the Index of Spouse Abuse (ISA) and the Conflict Tactics Scale (CTS). MAIN OUTCOME MEASURES: Sensitivity, specificity, and predictive values of the PVS were compared with the ISA and the CTS as criterion standards. RESULTS: The prevalence rate of partner violence using the PVS was 29.5% (95% confidence interval [CI], 24.6%-34.8%). For the ISA and CTS, the prevalence rates were 24.3% (95% CI, 19.2%-30.1 %) and 27.4% (95% CI, 21.7%-33.6%), respectively. Compared with the ISA, the sensitivity of the PVS in detecting partner abuse was 64.5%; the specificity was 80.3%. When compared with the CTS, sensitivity of the PVS was 71.4%; the specificity was 84.4%. Positive predictive values ranged from 51.3% to 63.4%, and negative predictive values ranged from 87.6% to 88.7%. Overall, 13.7% of visits were the result of acute episodes of partner violence. CONCLUSION: Three brief directed questions can detect a large number of women who have a history of partner violence.

Unusual cause of abdominal pain: pelvic vein thrombosis in a nonpregnant woman.

We present a case of isolated pelvic vein thrombosis in which clinical diagnosis was difficult and the results of routine diagnostic tests were normal. We eventually used ventilation-perfusion scanning and abdominal computed tomography to make the correct diagnosis.

The use of bone morphogenetic protein in the treatment of non-union in a canine model.

A non-union model was established in the mid-part of the radial diaphysis in dogs. The non-union was treated with operative implantation of a carrier (guanidine-extracted, demineralized bovine bone or a polylactic acid polymer), alone or in combination with fractions that had been enriched in bone morphogenetic protein. All sites of treatment were examined radiographically and histomorphometrically at twelve weeks after implantation. Guanidine-extracted, demineralized bovine bone, alone or combined with fifteen milligrams of canine bone morphogenetic protein, failed to induce any healing of the non-union. When polylactic acid alone had been implanted, a small amount of reparative new bone was found in the defect at three months. When polylactic acid combined with fifteen milligrams of canine bone morphogenetic protein had been implanted, a significant increase in new bone formation was seen (p less than 0.03), compared with that seen in control animals. Trabecular bone bridged the gap between the proximal and distal fragments in all four specimens from the dogs that had received that treatment. In contrast, when polylactic acid combined with bovine bone morphogenetic protein had been implanted, significant reparative new bone was not found in the defect at three months.