Development of a Human Trafficking Flowsheet for Clinical Forensic Examiners.

ABSTRACT: When trafficked patients are identified in the healthcare setting, clinical forensic examiners, including sexual assault nurse examiners (SANEs), may be consulted to provide medical care and to collect forensic evidence. However, using a standard sexual assault protocol and documentation form may not completely identify or address the unique needs of these patients. Our SANE program sought to improve the healthcare approach to trafficked patients by developing a trafficking-specific documentation flowsheet. The goal of this quality improvement project was to guide a clinical forensic examiner through a comprehensive examination while addressing specific patient needs and optimizing trauma-informed service delivery. We gathered several local multidisciplinary human trafficking specialists together to provide expert recommendations and feedback during the creation process. Both paper and electronic forms of the flowsheet were designed. SANEs completed the flowsheet on 22 patient encounters and filled out a utilization review survey describing their experience. Feedback data collected through the utilization review process guided further modifications to the flowsheet, which were then implemented into clinical practice guidelines. We found that engaging multidisciplinary specialists and community partners both enhanced the effectiveness of the flowsheet and supported the learning needs of our SANEs. We recommend that clinical forensic programs that wish to develop a similar flowsheet collaborate with local professional agencies to meet the unique needs of the populations within their catchment area and use examiner feedback to maximize the usefulness of the flowsheet.

Recent sexual violence exposure is associated with immune biomarkers of HIV susceptibility in women.

PROBLEM: HIV/AIDS and sexual violence act synergistically and compromise women's health. Yet, immuno-biological mechanisms linking sexual violence and increased HIV susceptibility are poorly understood. METHODS: We conducted a cross-sectional pilot study of HIV-uninfected women, comparing 13 women exposed to forced vaginal penetration within the past 12 weeks (Exposed) with 25 Non-Exposed women. ELISA assays were conducted for 49 biomarkers associated with HIV pathogenesis in plasma and cervicovaginal lavage (CVL). Differences between Exposed and Non-Exposed were analyzed by linear and logistic regression, using propensity score weighting to control for age, race, socioeconomic status, menstrual cycle, and contraceptive use. RESULTS: In CVL, Exposed women had significantly reduced chemokines MIP-3α (p < .01), MCP-1 (p < .01), and anti-HIV/wound-healing thrombospondin-1 (p = .03). They also had significantly increased inflammatory cytokine IL-1α (p < 0.01) and were more likely to have detectable wound-healing PDGF (p = .02). In plasma, Exposed women had reduced chemokines MIP-3α (p < .01) and IL-8 (p < .01), anti-inflammatory cytokine TGF-ß (p = .02), anti-HIV/antimicrobial HBD-2 (p = .02), and wound-healing MMP-1 (p = 0.02). They also had increased thrombospondin-1 (p < .01) and Cathepsin B (p = .01). After applying the stringent method of false discovery rate adjustment, differences for IL-1α (p = .05) and MCP-1 (p = .03) in CVL and MIP-3α (p = .03) in plasma remained significant. CONCLUSIONS: We report systemic and mucosal immune dysregulation in women exposed to sexual violence. As these biomarkers have been associated with HIV pathogenesis, dysregulation may increase HIV susceptibility.

Poor test characteristics for the digital rectal examination in trauma patients.

STUDY OBJECTIVE: Current advanced trauma life support guidelines recommend that a digital rectal examination be performed as part of the initial evaluation of all trauma patients. Our goal is to estimate the test characteristics of the digital rectal examination in trauma patients. METHODS: We conducted a retrospective medical record review study of consecutive trauma patients treated in our emergency department from January 2003 to February 2005 for whom the trauma team was activated and who had a documented digital rectal examination. RESULTS: One thousand four hundred one patients met our selection criteria and were included in the analysis. We estimated the composite sensitivity of the digital rectal examination (any abnormal finding) for detecting any of the index injuries to be 22.9% (95% confidence interval [CI] 16% to 30%) and the specificity to be 94.7% (95% CI 93% to 96%). The calculated sensitivity and specificity for the digital rectal examination were 37% (95% CI 23% to 50%) and 96% (95% CI 95% to 97%), respectively, for detection of spinal cord injury, 5.7% (95% CI 0% to 13%) and 98.9% (95% CI 98% to 99%) for detection of bowel injury, 33.3% (95% CI 0% to 87%) and 99.8% (95% CI 99% to 100%) for detection of rectal injury, 0% and 99.8% (95% CI 99% to 100%) for detection of pelvic fracture, and 20% (95% CI 0% to 55%) and 99% (95% CI 98% to 100%) for detection of urethral disruption. CONCLUSION: The digital rectal examination has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the digital rectal examination should not be used as a screening tool for detecting injuries in trauma patients.

Lack of evidence to support routine digital rectal examination in pediatric trauma patients.

BACKGROUND: Current advanced trauma life support guidelines recommend that a digital rectal examination (DRE) should be performed as part of the initial evaluation of all trauma patients. Our primary goal was to estimate the test characteristics of the DRE in pediatric patients for the following injuries: (1) spinal cord injuries, (2) bowel injuries, (3) rectal injuries, (4) pelvic fractures, and (5) urethral disruptions. METHODS: We conducted a nonconcurrent, observational, chart review study of a consecutive series of pediatric trauma patients. We enrolled all patients younger than 18 years seen in our ED from January 2003 to February 2005, for whom the trauma team was activated and who had a documented DRE. For each patient, we reviewed all available clinical documents in a computerized medical record system to identify the DRE findings followed by review of radiological reports, operative reports, and discharge summaries to identify specific injuries. RESULTS: Two hundred thirteen patients met our selection criteria and were included in the analysis. We identified 3 patients with spinal cord injury (1% prevalence), 13 patients with bowel injury (6%), 5 patients with rectal injury (2%), 12 patients with a pelvic fracture (6%), and 1 patient with urethral disruption (0.5%). The DRE failed to diagnose (false-negative rate) 66% of spinal cord injuries, 100% of bowel injuries, 100% of rectal wall injuries, 100% of pelvic fractures, and 100% of urethral disruption injuries. CONCLUSIONS: The DRE has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the DRE should not be routinely used in pediatric trauma patients.

Challenges in conducting research on sexual violence and HIV and approaches to overcome them.

Studies have implicated sexual violence as a strong correlate of HIV acquisition in women. Characterizing how such violence affects the female immune system may provide insight into the biological mechanisms of HIV transmission and ultimately improve global HIV prevention strategies. Little research has been carried out in this domain, and the obstacles to investigation can be daunting. Here, we describe methodological challenges encountered and solutions explored while implementing a study of dysregulation of immune biomarkers potentially indicative of increased HIV susceptibility in women following sexual assault. Challenges included accessing sexual assault survivors and defining sexual assault, promoting study participant well-being during research engagement, reducing selection and information bias, collecting and processing biological samples, and adjusting for confounders such as reproductive tract infections and emotional and physical abuse. We found that many survivors of sexual assault welcomed the attention from study staff and felt empowered by the opportunity to help other women at risk for violence. Well-trained research staff and well-articulated community and medical partnerships were key methods to overcoming challenges while promoting the safety and welfare of vulnerable study participants.

Acute visual changes in the elderly.

Changes in vision are common complaints among the geriatric population. Causes range from cataracts and glaucoma to cerebral strokes or other systemic diseases. Loss of vision may be the turning point from independence to dependence in an elderly person's life. This article focuses on acute vision changes and provides a systematic, symptom-based approach to the evaluation and diagnosis of these processes. It is important that the primary practitioner or geriatrician recognize and evaluate acute vision changes, determine whether a treatable or reversible condition exists, and know when to refer to an ophthalmologist or neurologist for a complete evaluation and management.

Sexual assault.

Sexual assault is a problem that permeates all socioeconomic classes and impacts hundreds of thousands in the United States and millions worldwide. Most victims do not report the assault; those that do often present to an emergency department. Care must encompass the patients' physical and emotional needs. Providers must be cognizant regarding handling of evidence and possible legal ramifications. This article discusses the emergency medicine approach to history taking, physical examination, evidence collection, chain of custody, psychological and medical treatment, and appropriate follow-up. Special circumstances discussed include intimate partner violence, male examinations, pediatric examinations, suspect examinations, and drug-facilitated assaults.

The feasibility of pain assessment in the prehospital setting.

OBJECTIVE: To determine the feasibility of prehospital pain measurement among patients 13 years of age or older using a verbal and numeric rating scale and to assess the severity of pain in a prehospital patient population. METHODS: Retrospective cross-sectional study of emergency medical services (EMS) run sheets after the adoption of a universal prehospital pain assessment protocol. Data were abstracted from a sequential (1:4) sample of run sheets from the first three months after adoption of the protocol. Verbal rating scale (VRS) and numeric rating scale (NRS) pain assessment information was obtained, along with demographic, location, and call information. Run sheets without pain assessment underwent structured review and classification according to predefined protocol. Descriptive statistics and 95% confidence intervals were calculated. RESULTS: A total of 1,227 run sheets were reviewed, 582 (47%) of patients were male, and 452 (36%) were 65 years of age or older. A total of 907 (75%) were nontrauma transports and 27 (2%) were unconscious. Among conscious patients, pain was assessed using the protocol in 1,002 of 1,200 (84% [range, 81%-86%]). Among patients reporting pain, 104 of 518 (20% [range, 17%-24%] completed a VRS but not an NRS. The greatest risk factor for no pain assessment was altered mental status (39% of patients not assessed). Forty-eight percent (23 of 48) of patients with altered mental status reporting pain completed a VRS only. Thirty-one percent (range, 28%-34%) of all patients in the sample reported moderate or severe pain. CONCLUSION: Prehospital pain assessment using a VRS and NRS was feasible in this patient population. Further studies are needed to confirm this finding in other settings. Moderate or severe pain was present in approximately 31% of patients.