Age-specific Patterns of Intimate Partner Violence Related Injuries in US Emergency Departments.

PURPOSE: To identify intimate partner violence (IPV)-related injury patterns of U.S. patients of three age groups: <18 years (adolescents), 18-25 years (emerging adults), and >25 years (adults). METHODS: We performed a nationally representative retrospective review of all patients presenting to U.S. Emergency Department for IPV-related injuries from 2005 through 2020. Demographics and injury patterns were calculated using statistical methods accounting for the weighted stratified data. Main outcomes were injury morphology, mechanism, severity, location, and temporal associations of IPV-related injuries among the three age groups. RESULTS: There was a higher proportion of female victims, sexual assault cases, and lower trunk injuries among adolescents compared to emerging adults and adults. There was increasing injury severity, fractures, and hospital admissions with increasing age. Adolescents experienced a greater prevalence of fractures of the head, neck, hands, fingers, and distal lower extremity, while trunk fractures increased with age. The peak prevalence of violence-related Emergency Department visits among adolescents was in June and September, with the peak day as Tuesday. DISCUSSION: Injurious forms of IPV are prevalent across all age groups, with sexual assault cases demonstrably higher among adolescents and increasing severity of injuries as victims age. Identification of age-specific injury patterns will aid health-care professionals and policymakers in developing targeted interventions for adolescents who experience IPV.

National Prevalence of Diabetes and Barriers to Care Among U.S. Farmworkers and Association With Migrant Worker Status.

OBJECTIVE: To quantify the prevalence of diabetes and barriers to care among U.S. migrant farmworkers (i.e., those who travel from their permanent residence for seasonal farmwork). RESEARCH DESIGN AND METHODS: Age-adjusted prevalence of self-reported diabetes and barriers to care were calculated among adult U.S. farmworkers from 2008 to 2017 National Agricultural Workers Surveys. RESULTS: Among 16,913 farmworkers, 30.7% reported one or more barriers to care, most often due to cost. Age-adjusted self-reported prevalence of diabetes was 13.51% (95% CI 10.0-17.1) among migrant farmworkers and 10.8% (95% CI 9.0-12.6) among nonmigrant farmworkers with access to health care. Migrant farmworkers without recent health care had 83% lower odds of reporting known diabetes (adjusted odds ratio 0.17; 95% CI 0.06-0.54) compared with nonmigrant farmworkers, likely because of poor health care access and/or a healthy worker effect. CONCLUSIONS: Many migrant farmworkers face barriers to care, which may lead to significant underdiagnosis of diabetes in this vulnerable population.

Factors that influence interprofessional implementation of trauma-informed care in the emergency department.

Background: To describe factors that influence interprofessional staff decisions and ability to implement trauma-informed care (TIC) in a level-one emergency department (ED) trauma center. Methods: This qualitative research study consisted of semi-structured interviews and quantitative surveys that were conducted between March and December 2020 at an urban trauma center. Eligible participants were staff working in the ED. Interview questions were developed using the Theoretical Domains Framework (TDF), which is designed to identify influences on health professional behavior related to implementation of evidence-based recommendations. Interview responses were transcribed, coded using Atlas software, and analyzed using thematic analysis. Results: Key themes identified included awareness of TIC principles, impact of TIC on staff and patients, and experiences of bias. Participants identified opportunities to improve care for patients with a trauma history, including staff training, more time with patients, and efforts to decrease bias toward patients. Most participants (85.7%) felt that a TIC plan, tiered trauma inquiry, and warm handovers would be easy or very easy to implement. Conclusion: We identified key interprofessional staff beliefs and attitudes that influence implementation of TIC in the ED. These factors represent potential individual, team-based, and organizational targets for behavior change interventions to improve staff response to patient trauma and to address secondary trauma experienced by ED staff.

Cradling Hope.

In this narrative medicine essay, a physician recounts her family's experience with critical illness and death and how she came to appreciate both the health care team's perspective and the family's perspective regarding when to have hope and when to let go.

Assessment of Microfinance Interventions and Intimate Partner Violence: A Systematic Review and Meta-analysis.

Importance: An estimated 27% of ever-partnered women aged 15 to 49 years have experienced intimate partner violence (IPV) in their lifetimes, which has been associated with a wide range of both acute and chronic illness. Poverty is thought to be a major driver of IPV, and economic empowerment programs may reduce violence. Objective: To evaluate whether microfinance interventions are associated with reductions in various forms of IPV. Data Sources: On August 3, 2022, PubMed, CINAHL, Embase, Web of Science, EconLit, and 5 global health databases were searched from inception. Study Selection: Included studies were randomized clinical trials evaluating the effect of microfinance interventions vs control on exposure to IPV. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data Extraction and Synthesis: Authors independently assessed study eligibility, extracted prespecified data, and evaluated risk of bias using the Cochrane Risk of Bias tool. Main Outcomes and Measures: Outcome measures of interest were exposure to overall IPV and 4 World Health Organization-designated IPV domains: physical, psychological and emotional, sexual, and controlling behaviors. Univariate meta-analyses using a random effects model were used to calculate the standardized mean differences (SMDs) and 95% CIs for each IPV outcome. The Grading of Recommendations Assessment, Development, and Evaluation method was used to rate the certainty of findings. Results: Overall, 10 randomized clinical trials met inclusion criteria, with a total of 16 136 participants, of whom 98% identified as women, with a mean age of 28.9 years. Compared with no intervention, participation in microfinance was associated with lower rates of psychological and emotional violence (SMD, 0.87; 95% CI, 0.80-0.95; I2 = 46%; high certainty), sexual violence (SMD, 0.76; 95% CI, 0.63-0.90; I2 = 44%; low certainty), and controlling behaviors (SMD, 0.82; 95% CI, 0.74-0.92; I2 = 54%; high certainty). There was no significant association with physical violence (SMD, 0.89; 95% CI, 0.76-1.04; very-low certainty). Conclusions and Relevance: This systematic review and meta-analysis of microfinance interventions found a reduction in exposure to psychological and emotional IPV as well as controlling behaviors among participants receiving microfinance interventions, with high certainty evidence. Further work is needed to evaluate which types of microfinance interventions are most effective at reducing the various forms of IPV.

Multiyear, Multisectoral Training Program in Kenya to Enhance Medical-Legal Processes in Response to Sexual and Gender-Based Violence.

Sexual and gender-based violence (SGBV) leads to severe sequelae for individuals and communities. Lack of cross-sector coordination inhibits effective medical-legal support and justice for survivors. Multisectoral trainings for health, legal, and law enforcement professionals on survivor-centered SGBV care were conducted in Kenya during 2012-2018. Evaluation utilized objective structured clinical examinations, standardized patients, knowledge assessments, and interviews. A total of 446 professionals participated in 18 trainings. Mean knowledge scores increased from 75.6% to 84.7% (p < .001). Thirty interviews revealed improved survivor confidentiality, increased specialized hospital care, more comprehensive forensic care, and greater cross-sector collaboration. Participants reported survivors feeling more comfortable pursuing legal action and increased perpetrator convictions.

Assessing Knowledge and Acceptability of a Trauma-Informed Training Model to Strengthen Response to Conflict and Gender-Based Violence in the Democratic Republic of Congo.

BACKGROUND: Conflict-related sexual and gender-based violence is common in the eastern Democratic Republic of Congo, but there are few evaluations of multisectoral training interventions in conflict settings. We conducted high-quality, trauma-informed medicolegal trainings amongst multisectoral professionals, and sought to describe changes in knowledge after training and perceived training acceptability. METHODS: Participants were health, law enforcement, and legal professionals who completed training at one of four sites from January 2012 to December 2018. Twelve trainings were randomly selected for evaluation. We conducted pre- and post-training assessments and semi-structured interviews of participants within 12 months of index training. FINDINGS: Forty-six trainings of 1,060 individuals were conducted during the study period. Of the randomly selected trainings, 368 questionnaires were included in the analysis (36% health, 31% legal, 12% law enforcement, 21% other). The mean knowledge scores (standard deviation) significantly improved after training: 77.9 (22.9) vs. 70.4 (20.8) (p <0.001). Four key benefits were identified: 1) improved cross-sector coordination; 2) enhanced survivor-centered care; 3) increased standardization of forensic practices; and 4) higher quality evidence collection. CONCLUSION: Participants completing the training had improved knowledge scores and perceived several key benefits, suggesting the multisectoral training was acceptable in this under-resourced, conflict region.

Development and validation of a data quality index for forensic documentation of sexual and gender-based violence in Kenya.

INTRODUCTION: High-quality forensic documentation can improve justice outcomes for survivors of sexual and gender-based violence, but there are limited tools to assess documentation data quality. This study aimed to develop and validate a data quality assessment index to objectively assess clinician documentation across the 26 key elements of the standardized forensic evidence forms used in Kenya. METHODS: Informed by prior quality assessment tools, an initial draft of the index was developed. Feedback from Kenya- and U.S.-based clinicians and human rights experts was solicited and incorporated into the draft index in an iterative fashion. Two raters independently employed the finalized Physicians for Human Rights Data Quality Index to assess and score the quality of documentation across 31 clinician-completed forms. Inter-rater reliability was determined using Cohen kappa (к) coefficients. RESULTS: The Index was found to have substantial overall reliability. Of the 26 documentation items, the Index had a perfect (к = 1.0) and almost perfect (к = 0.81-0.99) level of inter-rater agreement across 17 (65.4%) and 5 (19.2%) items, respectively. On a low-to-high documentation quality scale of 0 to 2, the majority of items (n = 19, 73.1%) had a mean documentation quality score >1.5-2. CONCLUSION: Quality assurance of forensic documentation is an essential component of post-sexual assault care. To our knowledge, this is the first validated quality-assessment tool in the peer-reviewed literature for sexual assault documentation and may be a promising strategy to enhance the quality of sexual assault documentation in other settings, locally, regionally, and internationally.

A Critical Look at Race-Based Practices in Rheumatology Guidelines.

OBJECTIVE: To assess how race has been incorporated into rheumatology practice guidelines, including how race is defined and used in diagnostic and treatment recommendations. METHODS: We searched race and ethnicity terms in all clinical practice guidelines from the American College of Rheumatology (ACR) and European Alliance of Associations for Rheumatology (EULAR) that were published between 2010 and 2020 and publicly available on professional society websites. Findings were summarized and assessed through standardized data abstraction forms. Key themes were identified through a thematic analysis approach. RESULTS: A total of 23 ACR clinical practice guidelines and 42 EULAR recommendations were reviewed. In total, 16 of 65 (25%) of the guidelines used race terms in their text. No guideline clearly defined race, and race was often conflated with ethnicity and/or genetic ancestry. Reported racial categories varied substantially by guideline and often used classifications that oversimplified and excluded non-White races. Research with insufficient racial diversity was used to make race-based recommendations for Black patients that may not be generalizable. Additionally, recommendations using research on predominantly White populations reinforced data of White populations as normative and perpetuated race-based stereotypes, especially for rare diseases. Structural causes of identified racial disparities were not discussed in clinical guidelines. CONCLUSION: There is an urgent need for standardized race reporting in rheumatology. Recommendations are provided to enhance consistency and accuracy of race and ethnicity terms, mitigate conflation of race with ethnicity or genetic ancestry, encourage a critical reanalysis of race-based diagnostic tools and treatment options, and better address the structural causes of racial disparities.

How an outbreak became a pandemic: a chronological analysis of crucial junctures and international obligations in the early months of the COVID-19 pandemic.

Understanding the spread of SARS-CoV-2, how and when evidence emerged, and the timing of local, national, regional, and global responses is essential to establish how an outbreak became a pandemic and to prepare for future health threats. With that aim, the Independent Panel for Pandemic Preparedness and Response has developed a chronology of events, actions, and recommendations, from December, 2019, when the first cases of COVID-19 were identified in China, to the end of March, 2020, by which time the outbreak had spread extensively worldwide and had been characterised as a pandemic. Datapoints are based on two literature reviews, WHO documents and correspondence, submissions to the Panel, and an expert verification process. The retrospective analysis of the chronology shows a dedicated initial response by WHO and some national governments, but also aspects of the response that could have been quicker, including outbreak notifications under the International Health Regulations (IHR), presumption and confirmation of human-to-human transmission of SARS-CoV-2, declaration of a Public Health Emergency of International Concern, and, most importantly, the public health response of many national governments. The chronology also shows that some countries, largely those with previous experience with similar outbreaks, reacted quickly, even ahead of WHO alerts, and were more successful in initially containing the virus. Mapping actions against IHR obligations, the chronology shows where efficiency and accountability could be improved at local, national, and international levels to more quickly alert and contain health threats in the future. In particular, these improvements include necessary reforms to international law and governance for pandemic preparedness and response, including the IHR and a potential framework convention on pandemic preparedness and response.

Rallying Against Racism: Hospitals Join the Fight for Racial Justice.

This article highlights the timely situation that resident physicians, faculty, and staff are facing after the recent highly publicized murders of Black Americans and its impact on our healthcare communities. We discuss our experiences of how the hospital can serve as a meeting place for anti-racism, as well as how anti-racist events at the hospital can raise public consciousness and be catalysts for creating a more inclusive, diverse, and welcoming environment for all members of hospital communities.

High Prevalence of Iron Deficiency Despite Standardized High-Dose Iron Supplementation During Recombinant Erythropoietin Therapy in Extremely Low Gestational Age Newborns.

OBJECTIVE: To assess the effects of protocolized recombinant human erythropoietin (r-HuEPO) therapy and standardized high dose iron supplementation on hematologic and iron status measures in a cohort of extremely low gestational age newborns (ELGANs). STUDY DESIGN: Charts of extremely low gestational age newborns admitted from 2006 to 2016 and who had received r-HuEPO per neonatal intensive care unit protocol were reviewed. The r-HuEPO was started at a dose of 900 IU/kg per week after 7 days of age and continued until 35 weeks postmenstrual age. Oral iron supplementation at 6-12 mg/kg per day was used to maintain a transferrin saturation of >20% during r-HuEPO treatment. Data on demographic features, hematologic and iron panel indices, red blood cell transfusions, and clinical outcomes were collected. Quartile groups were created based on serum ferritin levels at the conclusion of the r-HuEPO treatment and the quartiles were compared. RESULTS: The cohort included 116 infants with mean gestational age 25.8 ± 1.5 weeks and birth weight 793 ± 174.1 g. The r-HuEPO promoted erythropoiesis as indicated by increasing hemoglobin, hematocrit, and reticulocyte count. Serum ferritin decreased over time and was ≤75 ng/mL in 60.2% of infants at the conclusion of r-HuEPO therapy; 87% received packed red blood cell transfusions. Transfusion volume, total iron intake, total iron binding capacity, and transferrin concentration differed among infants in the different serum ferritin quartiles (P < .05). CONCLUSIONS: In extremely low gestational age newborns, r-HuEPO therapy promoted erythropoiesis. Despite a biomarker-based standardized high-dose iron supplementation, the majority of infants had evidence of iron deficiency to a degree that is associated with reduced brain function.

The implementation and effectiveness of the one stop centre model for intimate partner and sexual violence in low- and middle-income countries: a systematic review of barriers and enablers.

Introduction: Many low- and middle-income countries have implemented health-system based one stop centres to respond to intimate partner violence (IPV) and sexual violence. Despite its growing popularity in low- and middle-income countries and among donors, no studies have systematically reviewed the one stop centre. Using a thematic synthesis approach, this systematic review aims to identify enablers and barriers to implementation of the one stop centre (OSC) model and to achieving its intended results for women survivors of violence in low- and middle-income countries. Methods: We searched PubMed, CINAHL and Embase databases and grey literature using a predetermined search strategy to identify all relevant qualitative, quantitative and mixed methods studies. Overall, 42 studies were included from 24 low- and middle-income countries. We used a three-stage thematic synthesis methodology to synthesise the qualitative evidence, and we used the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess confidence in the qualitative research. Meta-analysis could not be performed due heterogeneity in results and outcome measures. Quantitative data are presented by individual study characteristics and outcomes, and key findings are incorporated into the qualitative thematic framework. Results: The review found 15 barriers with high-confidence evidence and identified seven enablers with moderate-confidence evidence. These include barriers to implementation such as lack of multisectoral staff and private consultation space as well as barriers to achieving the intended result of multisectoral coordination due to fragmented services and unclear responsibilities of implementing partners. There were also differences between enablers and barriers of various OSC models such as the hospital-based OSC, the stand-alone OSC and the NGO-run OSC. Conclusion: This review demonstrates that there are several barriers that have often prevented the OSC model from being implemented as designed and achieving the intended result of providing high quality, accessible, acceptable, multisectoral care. Existing OSCs will likely require strategic investment to address these specific barriers before they can achieve their ultimate goal of reducing survivor retraumatisation when seeking care. More rigorous and systematic evaluation of the OSC model is needed to better understand whether the OSC model of care is improving support for survivors of IPV and sexual violence.The systematic review protocol was registered and is available online (PROSPERO: CRD42018083988).

Effects of Repeated Eyelid Injections with Botulinum Toxin A on Innervation of Treated Muscles in Patients with Blepharospasm.

PURPOSE: To assess changes in innervation and muscle morphology after repeated botulinum toxin A injections in subjects with benign essential blepharospasm. METHODS: Surgical waste specimens were processed for histologic examination of nerve fibers, neuromuscular junctions, fiber size, and central nucleation and compared to age matched controls and to two subjects with blepharospasm that had not received botulinum toxin A injections. RESULTS: There was a significant increase in amount of nerve fibers and numbers of neuromuscular junctions in the orbicularis oculi muscles from subjects with blepharospasm treated repetitively with botulinum toxin A. In addition there was a significant decrease in mean muscle fiber cross-sectional area and an increase in central nucleation. The specimens from the subjects with only blepharospasm had the same density of nerves but had intermediate levels of neuromuscular junctions. CONCLUSIONS: These data suggest that repeated injections of botulinum toxin A has an effect on nerve and neuromuscular junction numbers, which are partly mirrored in orbicularis oculi muscle from subjects with blepharospasm only. These studies suggest the potential for modulating these changes in order to extend the duration of effectiveness of botulinum toxin.

Periorbital Necrobiotic Xanthogranuloma Successfully Treated with Intravenous Immunoglobulin.

BACKGROUND: Necrobiotic xanthogranuloma (NXG) is a rare non-Langerhans histiocytosis with cutaneous manifestations, most commonly of the periorbital skin, and is often associated with hematologic disorders such as monoclonal gammopathy. Treatment of NXG is notoriously difficult, and fraught with recurrence and progression. CASE PRESENTATION: The authors describe a case of NXG with periorbital involvement in a patient with a complex autoimmune and hematologic medical history. The biopsy of this rare lesion prompted subsequent evaluation for an underlying disorder, which led to the diagnosis of multiple myeloma. Her NXG lesions demonstrated remarkable clinical improvement after treatment with intravenous immunoglobulin (IVIG). CONCLUSIONS: This case demonstrates the ophthalmologist's critical role in the diagnosis and management of NXG, as early detection cannot only prevent ophthalmic consequences such as ocular perforation and blindness, but also prompt further investigation that may reveal an underlying disorder or systemic involvement, including hematologic malignancy as in this case. NXG has been effectively treated with IVIG in a handful of reported cases. To the author's knowledge, this is the third case of periorbital NXG successfully treated with IVIG, and the first in the ophthalmic literature.

Barriers to safe abortion access: uterine rupture as complication of unsafe abortion in a Ugandan girl.

A 15-year-old girl at 18 weeks gestation by the last menstrual period presented to a rural Ugandan healthcare facility for termination of her pregnancy as a result of rape by her uncle. Skilled healthcare workers at the facility refused to provide the abortion due to fear of legal repercussions. The patient subsequently obtained an unsafe abortion by vaginal insertion of local herbs and sharp objects. She developed profuse vaginal bleeding and haemorrhagic shock. She was found to have uterine rupture and emergent hysterectomy was performed. Young and poor women are at high risk of unplanned pregnancy and subsequent mortality during pregnancy and childbirth. Unsafe abortion is a leading and entirely preventable cause of maternal mortality worldwide. Multiple barriers restrict access to safe abortions including social and moral stigma, gender-based power imbalances, inadequate contraceptive use and sexual education, high cost and poor availability, and restrictive abortion laws.

Virginity testing: a systematic review.

BACKGROUND: So-called virginity testing, also referred to as hymen, two-finger, or per vaginal examination, is the inspection of the female genitalia to assess if the examinee has had or has been habituated to sexual intercourse. This paper is the first systematic review of available evidence on the medical utility of virginity testing by hymen examination and its potential impacts on the examinee. METHODS: Ten electronic databases and other sources for articles published in English were systematically searched from database inception until January 2017. Studies reporting on the medical utility or impact on the examinee of virginity testing were included. Evidence was summarized and assessed via a predesigned data abstraction form. Meta-analysis was not possible. MAIN RESULTS: Seventeen of 1269 identified studies were included. Summary measures could not be computed due to study heterogeneity. Included studies found that hymen examination does not accurately or reliably predict virginity status. In addition, included studies reported that virginity testing could cause physical, psychological, and social harms to the examinee. CONCLUSIONS: Despite the lack of evidence of medical utility and the potential harms, health professionals in multiple settings continue to practice virginity testing, including when assessing for sexual assault. health professionals must be better informed and medical and other textbooks updated to reflect current medical knowledge. Countries should review their policies and move towards a banning of virginity testing.