In person versus computer screening for intimate partner violence among pregnant patients.

OBJECTIVE: To compare in person versus computerized screening for intimate partner violence (IPV) in a hospital-based prenatal clinic and explore women's assessment of the screening methods. METHODS: We compared patient IPV disclosures on a computerized questionnaire to audio-taped first obstetric visits with an obstetric care provider and performed semi-structured interviews with patient participants who reported experiencing IPV. RESULTS: Two-hundred and fifty patient participants and 52 provider participants were in the study. Ninety-one (36%) patients disclosed IPV either via computer or in person. Of those who disclosed IPV, 60 (66%) disclosed via both methods, but 31 (34%) disclosed IPV via only one of the two methods. Twenty-three women returned for interviews. They recommended using both types together. While computerized screening was felt to be non-judgmental and more anonymous, in person screening allowed for tailored questioning and more emotional connection with the provider. CONCLUSION: Computerized screening allowed disclosure without fear of immediate judgment. In person screening allows more flexibility in wording of questions regarding IPV and opportunity for interpersonal rapport. PRACTICE IMPLICATIONS: Both computerized or self-completed screening and in person screening is recommended. Providers should address IPV using non-judgmental, descriptive language, include assessments for psychological IPV, and repeat screening in person, even if no patient disclosure occurs via computer.

Partner violence screening in mental health.

OBJECTIVE: To study a mental health sample to assess (1) the prevalence of physical, sexual and emotional intimate partner violence (IPV) victimization and perpetration, (2) the extent this sample reported being asked about IPV by mental health clinicians and (3) how prevalence and screening rates varied by gender. METHOD: Women and men receiving services at a large psychiatric facility completed anonymous written questionnaires. RESULTS: A total of 524 adults were approached for study participation, and 428 (158 men, 270 women) completed a survey. Over half (51%) of participants experienced some form of IPV; 63% of women and 32% of men reported IPV victimization. Experience of IPV was more likely if participants were women and had diagnoses of posttraumatic stress disorder, anxiety disorder or bipolar disorder. Both women (33%) and men (16%) reported perpetrating IPV. The reported IPV screening rate by mental health providers was 44% for the whole sample (women: 55%; men: 27%). CONCLUSION: IPV victimization and perpetration is a prevalent problem among women and men receiving mental health services. Clinicians are missing opportunities to screen for IPV as part of mental health evaluation and treatment.

Now is the chance: patient-provider communication about unplanned pregnancy during the first prenatal visit.

OBJECTIVE: Unplanned pregnancy is associated with psychosocial stress, post-partum depression, and future unplanned pregnancies. Our study describes how topics related to unplanned pregnancy were addressed with patients during the first prenatal visit. METHODS: We audio-recorded and transcribed initial prenatal visits between 48 patients and 16 providers from a clinic serving racially diverse, lower-socio-economic patients. We conducted a fine-grained thematic analysis of cases in which the patient's pregnancy was unplanned. RESULTS: Of the 48 patients, 35 (73%) had unplanned pregnancies. Twenty-nine visits for unplanned pregnancies (83%) included discussion of the patient's feelings about the pregnancy. Approximately half (51%) of the visits touched on partner or other types of social support. Six patients (17%) were offered referrals to counseling or social services. Only four visits (11%) touched on future birth control options. CONCLUSION: Most initial prenatal visits for unplanned pregnancies included discussion of patient feelings about the pregnancy. However, opportunities to discuss future birth control and for more in-depth follow-up regarding social support and psychological risks associated with unplanned pregnancy were typically missed. PRACTICE IMPLICATIONS: Obstetrics care providers should be cautious about making assumptions and should consider discussing pregnancy circumstances and psychosocial issues in more depth when treating patients facing unplanned pregnancy.

Understanding turning points in intimate partner violence: factors and circumstances leading women victims toward change.

OBJECTIVE: When counseling women experiencing intimate partner violence (IPV), healthcare providers can benefit from understanding the factors contributing to a women's motivation to change her situation. We wished to examine the various factors and situations associated with turning points and change seeking in the IPV situation. METHODS: We performed qualitative analysis on data from 7 focus groups and 20 individual interviews with women (61 participants) with past and/or current histories of IPV. RESULTS: The turning points women identified fell into 5 major themes: (1) protecting others from the abuse/abuser; (2) increased severity/humiliation with abuse; (3) increased awareness of options/access to support and resources; (4) fatigue/recognition that the abuser was not going to change; and (5) partner betrayal/infidelity. CONCLUSIONS: Women experiencing IPV can identify specific factors and events constituting turning points or catalyst to change in their IPV situation. These turning points are dramatic shifts in beliefs and perceptions of themselves, their partners, and/or their situation that alter the women's willingness to tolerate the situation and motivate them to consider change. When counseling women experiencing IPV, health providers can incorporate understanding of turning points to motivate women to move forward in their process of changing their IPV situation.

Helping women victims of intimate partner violence: comparing the approaches of two health care settings.

Health professionals from two different clinical settings were asked about their comfort level in dealing with intimate partner violence (IPV). Focus groups and semistructured interviews were used to gather information. Staff in an obstetrics and gynecology setting relatively rich in IPV resources described feeling capable dealing with IPV. The staff in a general medicine setting dedicated to women's health but without a focus on IPV and with fewer supports described discomfort and difficulty dealing with IPV. Presence of systemic prioritization of and resources for IPV were described as contributing to the confidence in addressing the issue. Other necessary elements identified included (a) on-site resources, (b) adequate time, (c) focused IPV training, and (d) a team or systemic approach.

When pregnant patients disclose substance use: missed opportunities for behavioral change counseling.

OBJECTIVE: The first obstetric visit is an opportunity to provide counseling to women with substance abuse risks, including smoking, drug use, and alcohol use. Little is known about how obstetric care providers and patients discuss these issues. Our objective was to examine patient-provider communication about substance use behaviors during these visits. METHODS: We audio-taped and transcribed verbatim first prenatal visits in an outpatient hospital clinic, then qualitatively analyzed them for content and process of communication using modified grounded theory methods. RESULTS: Twenty-nine providers (21 residents, 5 midwives, 3 nurse practitioners) and 51 patients participated. Twenty-five patients were smokers, 4 used alcohol, and 11 used drugs. Provider responses to smoking disclosures included discussions of risks, encouragement to quit-cut down, affirmation of attempts to quit-cut down, and referral to smoking cessation programs. Responses to alcohol or drug disclosures included only a general statement regarding risks and referral to genetics. CONCLUSION: Providers were less attentive to alcohol and drugs than smoking where they had pre-established patterns of response. PRACTICE IMPLICATIONS: Providers should discuss behavioral change strategies and motivations with pregnant patients who use drugs and/or alcohol as well as those who smoke.

The process of change for victims of intimate partner violence: support for a psychosocial readiness model.

Intimate partner violence (IPV) victimization is a women's health problem that imposes a significant health and health care cost burden. Although IPV victims cannot change the perpetrator's behavior, they can take actions to reduce exposure to the partner's abuse. The process of change for IPV victims has been described using the transtheoretical model (TTM), among others. We report results of a qualitative study with current and past IPV victims to 1) explicate the process of safety-seeking behavior change for female victims of IPV and 2) explore the fit of the TTM for explaining this process. Based on the results, we propose the psychosocial readiness model to describe the process of change for female victims of IPV. This model considers readiness as a continuum that ranges from robustly defending the status quo on 1 end to being ready to take action toward change on the other. Movement toward and away from change along the continuum results from a dynamic interplay of both internal factors and external interpersonal and situational factors.

Understanding behavior change for women experiencing intimate partner violence: mapping the ups and downs using the stages of change.

OBJECTIVE: For women who are experiencing intimate partner violence (IPV), making changes toward safety is often a gradual process. When providing counseling and support, health care providers may benefit from better understanding of where women are in their readiness to change. Our objective was to apply the transtheoretical model's stages of change to the experiences of women who experienced IPV and map their experiences of change as they moved toward increased safety. METHODS: A multi-disciplinary team designed a qualitative interview process with 20 women who had current or past histories of IPV in order to explore their experiences. RESULTS: The women in our study (1) moved through stages of readiness generally in a nonlinear fashion, with varying rates of progression between safe and nonsafe situations, (2) were able to identify a "turning-point" in their situations, (3) attempted multiple "action" steps and (4) were influenced by internal and external factors. CONCLUSIONS: Our study suggests that focusing on the transtheoretical model to develop stage-based interventions for IPV may not be the most appropriate given the nonsequential movement between stages and influence of external factors. PRACTICE IMPLICATIONS: The "change mapping" technique can be used as an educational and counseling tool with patients, as well as a training tool for health care providers.

Preventable wheelchair-related thermal injury.

BACKGROUND/OBJECTIVE: Wheelchair-related injuries are common, and with proper reporting of injuries, advanced technologic support may offer new ways to prevent those injuries. METHOD: Case REPORT AND FINDINGS: A man with tetraplegia who retains only minimal use of his right hand experienced a right-sided armrest malfunction of his wheelchair resulting in his wheelchair controls being out of reach. This left him stranded in the sun for almost 2 hours in 86 degrees F weather. During that time, he developed full thickness sunburns of his left forearm and deep partial thickness burns of the left fingertips where they were in contact with the left armrest. CONCLUSION: This patient's full thickness burns could have been prevented if his motorized wheelchair had back-up communication in the event of a malfunction. Technology developers must realize the need for such systems. Health care professionals must advocate for a higher standard of safety and report injuries related to wheelchair malfunction.

Prediction of postoperative seroma after latissimus dorsi breast reconstruction.

BACKGROUND: The latissimus dorsi flap has become a first-line option in reconstruction of the breast cancer patient. Donor-site seroma is a commonly described postoperative complication of the latissimus dorsi flap. METHODS: A retrospective chart review from 1998 to 2003 of all patients undergoing latissimus dorsi breast reconstruction was performed (n = 50). Age of the patients, timing of breast reconstruction, type of nodal dissection (axillary versus sentinel versus none), and chemotherapy status of the patients were examined. RESULTS: The overall incidence of seroma formation was 47 percent. Those patients who had undergone prior or concurrent nodal dissection at the time of breast reconstruction were found to have a higher incidence of seroma formation than patients who had no nodal dissection (52 percent versus 25 percent) (p = 0.15). Age also was a risk factor for seroma formation, as 63 percent of patients older than 50 had formed seroma as compared with 39 percent of those younger than age 50 (p = 0.08). CONCLUSION: The authors conclude that advanced age and the presence of nodal disruption before or concurrent with latissimus dorsi breast reconstruction are predictors of donor-site seroma formation.

Health care interventions for intimate partner violence: what women want.

OBJECTIVE: We sought to determine what women want from health care interventions for intimate partner violence (IPV) and understand why they found certain interventions useful or not useful. METHODS: We conducted interviews with 21 women who have a past or current history of intimate partner violence. Participants were given cards describing various IPV interventions and asked to perform a pile sort by placing cards into three categories ("definitely yes," "maybe," and "definitely no") indicating whether they would want that resource available. They were then asked to explain their categorizations. RESULTS: The pile sort identified that the majority of participants supported informational interventions and individual counseling. Only 9 of 17, however, felt couple's counseling was a good idea with seven reporting it was definitely not useful. Half wanted help with substance use and treatment for depression. Interventions not well regarded included "Receiving a follow-up telephone call from the doctor's office/clinic" and "Go stay at shelter" with only 7 and 5 of the 21 women placing these cards in the "definitely yes" pile. "Health provider reporting to police" was the intervention most often placed in the "definitely no" pile, with 9 of 19 women doing so. The women described several elements that affected their likelihood of using particular IPV interventions. One theme related stages of "readiness" for change. Another theme dealt with the complexity of many women's lives. Interventions that could accommodate various stages of "readiness" and helped address concomitant issues were deemed more useful. Characteristics of such interventions included: 1) not requiring disclosure or identification as IPV victims, 2) presenting multiple options, and 3) preserving respect for autonomy. CONCLUSIONS: Women who had experienced IPV described not only what they wanted from IPV interventions but how they wished to receive these services and why they would chose to use certain resources. They advised providing a variety of options to allow individualizing according to different needs and readiness to seek help. They emphasized interventions that protected safety, privacy, and autonomy.

A long-term retrospective outcome assessment of facial growth, secondary surgical need, and maxillary lateral incisor status in a surgical-orthodontic protocol for complete clefts.

In 1965, the cleft palate team at Children's Memorial Hospital embarked on a new surgical-orthodontic protocol in the habilitation of newborn complete cleft lip and palate cases. It brought the orthodontic effort into focus at birth and in planned sequence to correspond with the surgical procedures of lip closure, maxillary alveolar stabilization by means of an autogenous graft of the authors' design, and complete palate closure, all within the first year of life. The purpose of this investigation is threefold: first, to review the authors' previous publications and assess growth, secondary surgical need, and lateral incisor status of teeth adjacent to the cleft in a series of patients who have all followed a precise, early surgical/orthodontic protocol; second, to compare these cases with other collaborative studies wherein this protocol was not used; and third, to report on an additional 82 cases with regard to secondary surgical need and the status of teeth adjacent to the cleft. Methods of assessment have included cephalometric radiography, periapical and occlusal dental radiography, computer-assisted tomography, plaster cast analysis, and intraoral and extraoral photography. The authors have demonstrated, along with other collaborative studies, that there is growth as good as other similar samples wherein there was no primary osteoplasty. In addition, the authors found their incidence of orthognathic surgery to be 18.29 percent; pharyngoplasty, 3.65 percent; and oronasal fistulas requiring surgical closure, 29.27 percent. In the case of unilateral complete clefts, 53.13 percent of those lateral incisors present adjacent to the cleft area were usable, and in bilateral cases, 57.77 percent were usable. The authors remain convinced after more than 35 years of following this successful protocol that early maxillary orthopedics and their technique of primary osteoplasty in planned sequence with lip and palate closure can produce a more favorable alignment of maxillary growth potential and, with comprehensive orthodontic treatment, can lead to teeth in a better overall occlusion than if these procedures had not been undertaken.

Incidence of intercostobrachial nerve injury after transaxillary breast augmentation.

BACKGROUND: Although many studies on transaxillary breast augmentation (TBA) have been published, none has examined the incidence of intercostobrachial nerve (ICBN) injury after aesthetic surgery. OBJECTIVE: This study was designed to measure the incidence of ICBN injury after endoscopic and non-endoscopic TBA, and to determine anatomic guidelines for the avoidance of iatrogenic injury to the ICBN. METHODS: A questionnaire was distributed nationally to 1000 plastic surgeons selected randomly from the roster of the American Society of Plastic Surgeons. The questionnaire sought information on the surgeons' experience, technique, and complication rate with regard to TBA. Anatomic dissections of 6 unpreserved axillae were also performed. RESULTS: Our survey response rate was 50%; of those responding, 26.8% of surgeons (134) performed TBA. Of the 134 surgeons performing TBA, 72 (53.7%) used an endoscope. The overall complication rate was 62.7%, which included upper-arm and shoulder pain, numbness, sensory loss, and tingling, and upper-arm fibrous banding. No significant differences were seen between the complication rates for the endoscopic (66.7%) and open (58.1%) TBA groups. With few exceptions, all symptoms resolved in 3 to 6 months. The dissection study confirmed the location of the ICBN as being immediately subcutaneous in the axilla. CONCLUSIONS: TBA is associated with a high incidence of injury to the ICBN. Our findings indicate that the use of an endoscope with the transaxillary approach does not significantly affect the rate of injury to the ICBN. The dissection study performed helped to confirm that an immediately subcutaneous plane of dissection in the axilla is safest with regard to avoiding injury to the ICBN. (Aesthetic Surg J 2002;22:26-32.).