Prior differences in previous trauma exposure primarily drive the observed racial/ethnic differences in posttrauma depression and anxiety following a recent trauma.

BACKGROUND: Racial and ethnic groups in the USA differ in the prevalence of posttraumatic stress disorder (PTSD). Recent research however has not observed consistent racial/ethnic differences in posttraumatic stress in the early aftermath of trauma, suggesting that such differences in chronic PTSD rates may be related to differences in recovery over time. METHODS: As part of the multisite, longitudinal AURORA study, we investigated racial/ethnic differences in PTSD and related outcomes within 3 months after trauma. Participants (n = 930) were recruited from emergency departments across the USA and provided periodic (2 weeks, 8 weeks, and 3 months after trauma) self-report assessments of PTSD, depression, dissociation, anxiety, and resilience. Linear models were completed to investigate racial/ethnic differences in posttraumatic dysfunction with subsequent follow-up models assessing potential effects of prior life stressors. RESULTS: Racial/ethnic groups did not differ in symptoms over time; however, Black participants showed reduced posttraumatic depression and anxiety symptoms overall compared to Hispanic participants and White participants. Racial/ethnic differences were not attenuated after accounting for differences in sociodemographic factors. However, racial/ethnic differences in depression and anxiety were no longer significant after accounting for greater prior trauma exposure and childhood emotional abuse in White participants. CONCLUSIONS: The present findings suggest prior differences in previous trauma exposure partially mediate the observed racial/ethnic differences in posttraumatic depression and anxiety symptoms following a recent trauma. Our findings further demonstrate that racial/ethnic groups show similar rates of symptom recovery over time. Future work utilizing longer time-scale data is needed to elucidate potential racial/ethnic differences in long-term symptom trajectories.

The effect of written informed consent on detection of violence in the home.

UNLABELLED: Studies of programmatic interventions for victims of violence in the home may require the use of informed consent. The use of informed consent may result in ascertainment bias, with victims of violence being less likely to participate. OBJECTIVE: To investigate the effect of written informed consent on the detection of violence in the home during emergency department (ED) screening. METHODS: The authors performed a nonrandomized, controlled trial of 3,466 patients at an urban university ED. On odd days, patients (n = 1,857) were read a brief scripted statement and screened using standardized questions. On even days, patients (n = 1,609) received standard written informed consent prior to the same screening questions (writ-IC). The main outcome was the number of cases of violence in the home detected using each screening protocol. RESULTS: Fewer writ-IC patients participated in screening (82% vs 92%; p < 0.001). Despite a higher refusal rate in the writ-IC group, there was no difference in the number of victims detected by each screening method: choked/kicked/bit/punched? (writ-IC, 7.3 vs routine screen, 6.5%; p = 0.3); slapped/grabbed/shoved? (7.3 vs 6.7%; p = 0.4); threatened/actually used knife/gun to scare/hurt you? (8.3 vs 9.4%; p = 0.3); thrown object to harm you? (5.2 vs 4.6%; p = 0.4); forced sex? (5.8 vs 4.7%; p = 0.15); or afraid current/former intimate partner would hurt you physically? (13.9 vs 11.9%; p = 0.9). CONCLUSIONS: A written informed consent process in screening for violence in the home is associated with a higher refusal rate than routine screening, but use of written informed consent does not result in a lower rate of detection for multiple forms of violence. The authors did not find any support for the hypothesis that the use of written informed consent would decrease detection of violence in the home.

Emergency department evaluation of acute stress disorder symptoms in violently injured youths.

STUDY OBJECTIVE: We assess the feasibility of evaluating acute stress disorder (ASD) symptoms in the emergency department and provide an initial estimate of the prevalence, severity, and variability of these symptoms in violently injured urban children and young adults. METHODS: The Immediate Stress Response Checklist (ISRC) was administered to violently injured patients between the ages of 8 and 24 years who presented to 2 urban, academic medical center EDs during a 10-week period. The ISRC is designed to assess ASD symptoms in children and youths immediately after a traumatic event. Responses are described using summed symptom severity scores and counts of symptoms. RESULTS: Out of 109 identified youths, 81 participated. Fear, helplessness, or horror during the injury event was reported by 59 (73%) of study participants. Each of the following categories of ASD symptoms was reported by a significant number of youths: peritrauma dissociation, 63 (78%); posttrauma dissociation, 33 (41%); re-experiencing intrusive thoughts or images, 66 (82%); avoidance, 53 (65%); and hyperarousal, 32 (39%). The ISRC demonstrated high internal consistency (Cronbach alpha=.88) in this cohort. CONCLUSION: The ISRC can be used to assess acute stress reactions in violently injured youths in the immediate period after injury. Although these reactions appear to be common, there is substantial variability among distinct symptom categories. These results support the need for further investigation of the relationship between immediate stress responses and longer-term emotional impact of violent injury. Clinicians should consider assessing the emotional responses of children and adolescents who are injured by interpersonal violence, even when these injuries seem minor.

Violence between women in an urban emergency department patient population.

OBJECTIVE: To determine what percentage of women presenting to an urban emergency department (ED) for any reason had been the victims of violence committed by another woman in the previous year. METHODS: This was a prospective study of a consecutive sample of female patients of legal age presenting to the ED between 8 AM and 12 midnight over an 11-week period. Patients were asked a series of questions adapted from the George Washington University Universal Violence Prevention Screening Protocol. Non-English-speaking patients, those unable to give informed consent, and those meeting regional criteria for major trauma were excluded. RESULTS: One thousand six hundred seventy-six women participated; 426 (25%) refused. Of the 1,250 women interviewed, 118 (9.4%; 95% CI = 7.8% to 11.1%) reported being assaulted by another woman in the previous 12 months. Compared with the nonvictims, the victims were more frequently younger and single. The most common forms of assault were slapping, grabbing, and shoving (54.7% of victims). These were followed by being choked, kicked, bitten, or punched (46.2%). Eighteen percent of the assaults involved a weapon or an object. Five percent of the victims described being forced to have sex. Thirty-seven percent of the victims contacted the police, 13% required medical attention, 17% pursued legal action, and 10% sought follow-up counseling. CONCLUSIONS: Nine percent of the women in the study sample had been assaulted by another woman in the previous year. Further attention to the recognition and management of violence committed by women against other women may be warranted to ensure that patients receive appropriate treatment and referral.

Violence prevention in the emergency department: clinician attitudes and limitations.

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.

A sighting of orbital pseudotumor.

A 39-year-old woman developed bilateral proptosis, photophobia, and pain with extraocular movements over the course of 5 days. Her findings initially were ocular pain and photophobia which progressed to periorbital edema and nasal discharge ultimately resulting in proptosis with vertical globe displacement and decreased visual acuity. She was diagnosed with corneal abrasion and sinusitis respectively during two initial emergency department visits. On her third visit to the emergency department within 4 days, she developed acute visual deficits. The patient was subsequently diagnosed with orbital pseudotumor after computed tomography scan revealed inflammation of orbital structures bilaterally.

Violence during pregnancy.

This article discusses intimate partner abuse during pregnancy. The population at risk is defined, including risk behaviors, possible identifying factors during presentation to the emergency department, and available outcome data on violence to the fetus and the pregnant mother. Legal and ethical issues are also discussed. Intervention techniques are presented, emphasizing the role of the emergency physician in coordinating referrals to social service agencies and helping victims develop safety plans.

Utilization of the 911 system as an identifier of domestic violence.

This cross-sectional study was performed to determine (1) whether female victims of domestic violence (DV) are more likely to use the 911 system than nonvictims (NVs) and (2) whether DV and NVs call 911 for different reasons so that 911 may be used as a screening tool for abuse. The study was performed in an academic adult urban emergency department (ED). Ambulatory female patients presenting to the ED were studied. Eligible patients were administered a brief survey by trained research assistants. Questions included (1) history of DV, (2) relationship of assailant to victim, (3) chief complaint, and (4) use of the 911 system. Records of 911 calls were obtained by patient's address. Four hundred sixty-one women were enrolled in the study. One hundred seven (23%) reported a history of DV. Intimate partners accounted for 67.2% of assailants. DV victims were more likely to be single and younger (P < .05). Of DV victims, 77% reported calling 911 for any reason in the past 2 years compared with 47% of nonvictims (difference = 30%; 95% CI, 19%, 40%). DV victims were more likely to call 911 than nonvictims for definite and possible cases of domestic dispute (1.4 v0.5 calls, P = .007; 11.7 v6.1 calls, P = .0003). Victims and nonvictims did not differ in the number of nondomestic dispute calls (8.4 v6.2 calls; P = .15). DV victims were more likely to access the 911 system and call for domestic disturbances compared with nonvictims. 911 calls may serve as an indicator of ongoing abuse and may identify women at risk, providing a potential opportunity for intervention.

History of domestic violence among male patients presenting to an urban emergency department.

OBJECTIVE: To establish the prevalence of domestic violence committed by women against male patients presenting to an urban ED for any reason. METHODS: This was a prospective survey in which male patients of legal age presenting to the ED over a 13-week period were interviewed. Patients answered a series of six questions adapted from the George Washington University Universal Violence Prevention Screening Protocol. Patients who could not speak English, those refusing to participate, those unable to give informed consent, and those meeting regional criteria for major trauma were excluded. RESULTS: Of 866 male patients interviewed, 109 (12.6%) had been the victims of domestic violence committed by a female intimate partner within the preceding year. Victims were more likely to be younger, single, African American, and uninsured. The most common forms of assault were slapping, grabbing, and shoving (60.6% of victims). These were followed by choking, kicking, biting, and punching (48.6%), or throwing an object at the victim (46.8%). Thirty-seven percent of cases involved a weapon. Seven percent of victims described being forced to have sex. Nineteen percent of victims contacted the police; 14% required medical attention; 11% pressed charges or sought a restraining order; and 6% pursued follow-up counseling. CONCLUSIONS: Almost 13% of men in this sample population had been victims of domestic violence committed by a female intimate partner within the previous year. Further attention to the recognition and management of domestic violence committed by women against men may be warranted.

Abdominal pain in a patient with melanoma.

BACKGROUND: Malignant melanoma is the most common metastatic tumor of the gastrointestinal tract and can present with abdominal pain, small bowel obstruction, or occult gastrointestinal bleeding. Diagnosing abdominal pain due to metastatic melanoma is best accomplished by intraluminal studies and computed tomography. Surgical resection of the tumor burden limited to the gastrointestinal tract has been shown to extend periods of palliation in this poor long-term survival group. OBJECTIVES: We will review a case of abdominal pain in a melanoma patient and review the literature.

A case presentation of Sweet's syndrome and discussion of life-threatening dermatoses.

Sweet first described acute febrile neutrophilic dermatosis in 1964. Since then, more than 425 cases of this typically benign, steroid-responsive disease have been recorded. Although often associated with myelodysplasic syndromes or hematologic malignancies, Sweet's syndrome has also been related to pregnancy, autoimmune disorders, and many drug therapies. Although it is not typically an acutely life-threatening illness, there is a potential for significant pulmonary involvement and respiratory compromise. Additionally, emergency physicians should be aware of this unusual disease and its frequent association with systemic illnesses. We report the first case of Sweet's syndrome in the emergency medicine literature and present a review and discussion of several common life-threatening dermatoses.

Pediatric ophthalmology.

A wide variety of pediatric ophthalmologic diseases may present to the emergency physician. It is important for emergency physicians to know which diseases can be treated and which require urgent ophthalmologic intervention. Any asymmetry in a patient's ophthalmologic examination must be referred to a specialist for continuing care and definitive treatment. When identified early, strabismus, esotropia, or exotropia can be treated with significant benefit to the child's vision in the future. Abnormalities in size, shape, or color of the anterior portions of the eye are easily detected with inspection and may be indications of more serious illnesses such as conjunctivitis, glaucoma, cataracts, or tumors. These entities can be recognized by their distinguishing characteristics, and treatment can be initiated. Chlamydial and herpetic conjunctivitis, orbital cellulitis, posterior uveitis, and glaucoma are a few of the more urgent problems that may present to the emergency physician and should not be missed. A good history and careful examination will prevent the devastating effects of these diseases.