Comparative prevalence of anogenital injury following sexual assault in women who have had recent consensual sexual contact.

OBJECTIVE: The purpose of this study was to compare the frequency and types of anogenital trauma in rape victims as a function of the time interval between the assault and recent (72 h) consensual sexual intercourse. METHODS: This retrospective cohort trial evaluated consecutive female patients, age 13 years or older, presenting to a community-based nurse examiner clinic (NEC) during a 5-year study period. The NEC facility is staffed by forensic nurses trained to perform medical-legal examinations using colposcopy with nuclear staining and digital imaging. Eligible patients were classified into five different groups based on the time interval from the last consensual intercourse to the forensic examination (none, 0-24 h, 25-48 h, 49-72 h, 73-96 h). Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. RESULTS: A total of 947 cases of sexual assault met the inclusion criteria and were divided into five groups. The age range was 13 to 87 years (mean, 23.9 years); 78% were examined within 24 h following sexual assault. The five study groups were comparable in terms of demographics, assault history, and incidence of non-genital injuries. The overall frequency, type, or location of anogenital injury did not vary significantly between groups (p > 0.5). CONCLUSION: This is the first clinical study to systematically compare the prevalence and typology of anogenital injuries in sexual assault victims who have had consensual intercourse within four days before a forensic exam. The frequency, type or location of anogenital trauma did not vary significantly based on the time interval from last consensual intercourse to the forensic examination.

Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers.

INTRODUCTION: Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers. METHODS: We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale. RESULTS: There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198). CONCLUSIONS: Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.

Tension pneumocephalus and bilateral orbital compartment syndrome relieved by lateral canthotomies.

Traumatic tension pneumocephalus and orbital compartment syndrome are rare, tend to be associated with severe craniofacial injuries, and can occur following both blunt and penetrating injury. Early recognition and high index of clinical suspicion are important in both cases. Emergency decompression results in improvement in vast majority of cases.

BET 1: Does inhaled tranexamic acid reduce morbidity in adults with haemoptysis?

A short cut review was carried out to establish whether inhaled tranexamic acid is more effective than placebo at controlling bleeding in patients with haemoptysis. Thirty-four papers were found using the reported searches, of which one presented the best available evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper is tabulated. It is concluded that in patients with non-massive haemoptysis, management with nebulised TXA leads to fast resolution.

BET 2: Is there an association between iodine, shellfish and contrast agent allergies?

A shortcut review was carried out to establish whether having a shellfish or iodine allergy changed the risk of allergic reaction in patients receiving radiocontrast medium more than other concomitant allergies. One relevant paper (a systematic review) was identified for inclusion using the reported search strategy. The author, date and country of publication; group studied; study type; relevant outcomes; results and study weaknesses of this paper are tabulated. It is concluded that there is no evidence that allergy to shellfish or iodine alters the risk of reaction to intravenous contrast more than any other allergies.

Post-Traumatic Stress Disorder among Older Adults Experiencing Motor Vehicle Collision: A Multicenter Prospective Cohort Study.

OBJECTIVE: To characterize risk factors for and consequences of post-traumatic stress disorder (PTSD) among older adults evaluated in the emergency department (ED) following motor vehicle collision (MVC). DESIGN: Prospective multicenter longitudinal study (2011-2015). SETTING: 9 EDs across the United States. PARTICIPANTS: Adults aged 65 years and older who presented to an ED after MVC without severe injuries. MEASUREMENTS: PTSD symptoms were assessed 6 months after the ED visit using the Impact of Event Scale-Revised. RESULTS: Of 223 patients, clinically significant PTSD symptoms at 6 months were observed in 21% (95% CI 16%-26%). PTSD symptoms were more common in patients who did not have a college degree, had depressive symptoms prior to the MVC, perceived the MVC as life-threatening, had severe ED pain, and expected their physical or emotional recovery time to be greater than 30 days. Three factors (ED pain severity [0-10 scale], perceived life-threatening MVC [0-10 scale], and pre-MVC depressive symptoms [yes to either of two questions]), predicted 6-month PTSD symptoms with an area under the curve of 0.76. Compared to patients without PTSD symptoms, those with PTSD symptoms were at higher risk for persistent pain (72% versus 30%), functional decline (67% versus 42%), and new disability (49% versus 18%). CONCLUSIONS: Among older adults treated in the ED following MVC, clinically significant PTSD symptoms at 6 months were present in 21% of patients and were associated with adverse health outcomes. Increased risk for PTSD development can be identified with moderate accuracy using information readily available in the ED.

Association of Epidemiologic Factors and Genetic Variants Influencing Hypothalamic-Pituitary-Adrenocortical Axis Function With Postconcussive Symptoms After Minor Motor Vehicle Collision.

OBJECTIVES: To determine the influence of epidemiologic factors and the influence of genetic variants affecting FKBP5, a protein known to modulate hypothalamic-pituitary-adrenocortical axis function, on the severity of somatic symptoms commonly termed "postconcussive" 6 and 12 months after motor vehicle collision (MVC). METHODS: European Americans 18 to 65 years of age who presented to one of eight emergency departments (EDs) after MVC were enrolled. Exclusion criteria included hospital admission. Blood samples were collected in the ED for genotyping. Participants completed evaluations including an adapted Rivermead Post-Concussive Symptoms Questionnaire in the ED and at 6 weeks, 6 months, and 1 year. Repeated-measures analysis of covariance was used to evaluate the association between epidemiologic factors (sociodemographic, pre-MVC health, collision characteristics, head injury, peritraumatic pain, and stress), FKBP5 genetic variants, and postconcussive symptom severity. RESULTS: Among 943 patients recruited in the ED, follow-up was completed on 835 (88%) at 6 months and 857 (90%) at 1 year. Self-reported head impact during collision was not associated with chronic postconcussive symptom severity. After correction for multiple testing, three FKBP5 single-nucleotide polymorphisms (rs3800373, rs7753746, and rs9380526) predicted chronic postconcussive symptom severity, with an average symptom severity of 1.10 (95% confidence interval = 0.96-1.24), 1.36 (1.21-1.51), and 1.55 (1.23-1.88) for one, two, or three copies of minor allele at rs3800373 (p = .001). Similar effect sizes were observed for the minor alleles of rs7753746 and rs9380526. CONCLUSIONS: Postconcussive symptoms after minor MVC are not generally related to the severity of mild brain injury. This study shows that neurobiologic stress systems may play a role in the pathogenesis of postconcussive symptoms.

Persistent Pain Among Older Adults Discharged Home From the Emergency Department After Motor Vehicle Crash: A Prospective Cohort Study.

STUDY OBJECTIVE: Motor vehicle crashes are the second most common form of trauma among older adults. We seek to describe the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the emergency department (ED) after a motor vehicle crash. METHODS: We conducted a prospective longitudinal study of patients aged 65 years or older who presented to one of 8 EDs after motor vehicle crash between June 2011 and June 2014 and were discharged home after evaluation. ED evaluation was done through in-person interview; follow-up data were obtained through mail-in survey or telephone call. Pain severity (0 to 10 scale) overall and for 15 parts of the body were assessed at each follow-up point. Principal component analysis was used to assess the dimensionality of the locations of pain data. Participants reporting pain severity greater than or equal to 4 attributed to the motor vehicle crash at 6 months were defined as having persistent pain. RESULTS: Of the 161 participants, 72% reported moderate to severe pain at the ED evaluation. At 6 months, 26% of participants reported moderate to severe motor vehicle crash-related pain. ED characteristics associated with persistent pain included acute pain severity; pain located in the head, neck, and jaw or lower back and legs; poor self-rated health; less formal education; pre-motor vehicle crash depressive symptoms; and patient's expected time to physical recovery more than 30 days. Compared with individuals without persistent pain, those with persistent pain were substantially more likely at 6-month follow-up to have also experienced a decline in their capacity for physical function (73% versus 36%; difference=37%; 95% confidence interval [CI] 19% to 52%), a new difficulty with activities of daily living (42% versus 17%; difference=26%; 95% CI 10% to 43%), a 1-point or more reduction in overall self-rated health on a 5-point scale (54% versus 30%; difference=24%; 95% CI 6% to 41%), and a change in their living situation to obtain additional help (23% versus 8%; difference=15%; 95% CI 2% to 31%). CONCLUSION: Among older adults discharged home from the ED post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.

Restricted activity and persistent pain following motor vehicle collision among older adults: a multicenter prospective cohort study.

BACKGROUND: Restricted physical activity commonly occurs following acute musculoskeletal pain in older adults and may influence long-term outcomes. We sought to examine the relationship between restricted physical activity after motor vehicle collision (MVC) and the development of persistent pain. METHODS: We examined data from a prospective study of adults ≥65 years of age presenting to the emergency department (ED) after MVC without life-threatening injuries. Restricted physical activity 6 weeks after MVC was defined in three different ways: 1) by a ≥25 point decrease in Physical Activity Scale in the Elderly (PASE) score, 2) by the answer "yes" to the question, "during the past two weeks, have you stayed in bed for at least half a day?", and 3) by the answer "yes" to the question, "during the past two weeks, have you cut down on your usual activities as compared to before the accident?" We examined relationships between each definition of restricted activity and pain severity, pain interference, and functional capacity at 6 months with adjustment for confounders. RESULTS: Within the study sample (N = 164), adjusted average pain severity scores at 6 months did not differ between patients with and without restricted physical activity based on decreased PASE score (2.54 vs. 2.07, p = 0.32). In contrast, clinically and statistically important differences in adjusted average pain severity at 6 months were observed for patients who reported spending half a day in bed vs. those who did not (3.56 vs. 1.91, p < 0.01). In adjusted analyses, both decreased PASE score and cutting down on activity were associated with functional capacity at 6 months, but only decreased PASE score was associated with increased ADL difficulty at 6 months (0.70 vs. -0.01, p = 0.02). CONCLUSIONS: Among older adults experiencing MVC, those reporting bed rest or reduced activity 6 weeks after the collision reported higher pain and pain interference scores at 6 months. More research is needed to determine if interventions to promote activity can improve outcomes after MVC in older adults.