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Development of a Screening Tool for Pediatric Sexual Assault May Reduce Emergency Department Visits:...
1
10 years. The endovascular group’s survival was 85.7% at 1 and 5 years (where 10-year follow-up was not yet available). There was an obvious trend toward both lower in-hospital mortality and higher long-term survival in the endovascular group when compared to the conservative or surgical group, however, nei- ther proved to be statistically significant. Cumulative survival free from aorta-related complications (defined as complications requiring re-intervention or resulting in death) was recorded only for the conservative group and was as follows: 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. The results, however, were limited by statistically significant differences among the three groups, including age (significantly lower aver- age age in the open surgical group) and type of aortic injury (significantly smaller proportion of major ATAI in the conserva- tive group). Cox regression analysis identified two risk factors for the subsequent development of aorta-related complications: initial type of aortic lesion (hazard ratio [HR] 2.94; p = 0.002) and Trauma Injury Severity Score of > 50 (HR 1.49; p = 0.042). The researchers concluded that although not statisti- cally significant, the highest rate of aorta-related complications and highest overall mortality were found in the conservatively managed group, making conservative medical management safe only in a select number of patients, such as those with multiple severe associated injuries, in patients with high-risk comorbidities, or in minor ATAI. They go on to recommend that early endovascular repair be considered whenever possible in all ATAIs. [Lina Tran, MD Denver Health Medical Center, Denver, CO] Comment: This preliminary study raises the interesting possibility of a new means of managing selected patients with traumatic aortic injury. Clearly, until larger studies can be done, this will remain an experimental procedure for very select patients. Still, based on these early results, endovascular repair may hold promise for the future of the management of these injuries. , DEVELOPMENT OF A SCREENING TOOL FOR PEDIATRIC SEXUAL ASSAULT MAY REDUCE EMER- GENCY DEPARTMENT VISITS. Floyed RL, Hirsh DA, Greenbaum VJ, Simon HK. Pediatrics 2011;128:221–6. This study retrospectively analyzed 163 cases of alleged sexual assault in children < 12 years of age who presented to an Atlanta Emergency Department (ED) over a 2-year period. Investigators sought to define a screening tool that could accu- rately identify children who should receive their initial evalua- tion in a non-emergent setting. The screening tool consisted of the following four questions: 1) Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal con- tact? 2) Was genital or rectal pain, bleeding, discharge, or injury present? 3) Was there concern for the child’s safety? 4) Was an unrelated emergency medical condition present? An affirmative response to any of these questions was considered a positive screen. Of the 163 cases that were evaluated, 90 (55%) had positive screens and 73 (45%) had negative screens. Patients were defined as being high risk if they had positive physical examination findings of anogenital trauma or infection, a change in custody, or an emergency medical condition. Fifty-six of the 163 cases were identified as high risk, and none of these patients had a negative screen. The sensitivity and negative predictive value of this four-question screening tool were both 100%. The specificity was 68% and the positive predictive value was 62%. [Mike Miller Denver Health Medical Center, Denver, CO] Comments: Although limited by its retrospective design, this study successfully evaluated whether a simple four-question screening tool can help physicians identify children who are not high risk after alleged sexual assault and do not require ED evaluation. These individuals may be better served with a non-emergent evaluation at a child advocacy center, where victims of alleged sexual assault tend to receive a more compre- hensive physical examination in a less chaotic environment. A prospective evaluation of the screening tool would help to ensure its validity. , HEART DISEASE MAY BE A RISK FACTOR FOR PULMONARY EMBOLISM WITHOUT PERIPHERAL DEEP VENOUS THROMBOSIS. Sørensen HT, Horvath- Puho E, Lash TL, et al. Circulation 2011;124:1435–41. This study from Denmark sought to evaluate whether com- mon heart diseases that increase the risk of left-sided arterial embolism (such as heart failure, myocardial infarction, atrial fibrillation, atrial flutter) are also associated with an increased incidence of isolated pulmonary embolism (embolism without an apparent peripheral venous source). This was a case-control study with data gathered over 27 years from 1980 to 2007 from the Danish National Patient Registry, totaling 109,752 patients with a first recorded incident of pulmonary embolism (PE) or deep vein thrombosis (DVT), or both, in the lower limb both as primary or secondary discharge diagnosis. For each case, a risk-set sampling was utilized to select five population con- trols matched to index patient’s age, sex, and date of diagnosis, totaling 541,561 population controls. Confounders, such as pre- ceding inpatient cancer, fractures, trauma, surgery, pregnancy, obesity, and psychiatric disease (considering this a marker for antipsychotic drug use, a risk factor for pulmonary embolism), were identified and utilized to classify as provoked vs. unpro- voked thromboembolisms. Statistical analysis comparing the frequency and proportion of venous thromboembolism cases and controls were calculated within categories of demographic variables, heart disease history, and candidate cofounders gener- ating associations using odds ratios (OR) with 95% confidence intervals (CI) to generate a rate ratio. Multiple outcomes com- bining PE and DVT were compared by utilizing estimated OR with adjustment for matching factors and covariants. Among the groups, 59,790 had a diagnosis of DVT only, 45,282 had PE only, and 4680 had a diagnosis of DVT with PE. All three case groups had a higher prevalence of previous hospitalizations for heart disease for all cases with unprovoked presentation, particularly if there was a heart disease hospitalization in the previous 3 months. Isolated PE was associated with acute myo- cardial infarction (MI) (OR 43.5; 95% CI 39.6–47.8) and heart The Journal of Emergency Medicine 123
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Transcript of Development of a Screening Tool for Pediatric Sexual Assault May Reduce Emergency Department Visits:...
The Journal of Emergency Medicine 123
10 years. The endovascular group’s survival was 85.7% at 1 and5 years (where 10-year follow-up was not yet available). Therewas an obvious trend toward both lower in-hospital mortalityand higher long-term survival in the endovascular group whencompared to the conservative or surgical group, however, nei-ther proved to be statistically significant. Cumulative survivalfree from aorta-related complications (defined as complicationsrequiring re-intervention or resulting in death) was recordedonly for the conservative group and was as follows: 93% at1 year, 88.5% at 5 years, and 51.2% at 10 years. The results,however, were limited by statistically significant differencesamong the three groups, including age (significantly lower aver-age age in the open surgical group) and type of aortic injury(significantly smaller proportion of major ATAI in the conserva-tive group). Cox regression analysis identified two risk factorsfor the subsequent development of aorta-related complications:initial type of aortic lesion (hazard ratio [HR] 2.94; p = 0.002)and Trauma Injury Severity Score of > 50 (HR 1.49;p = 0.042). The researchers concluded that although not statisti-cally significant, the highest rate of aorta-related complicationsand highest overall mortality were found in the conservativelymanaged group, making conservative medical managementsafe only in a select number of patients, such as those withmultiple severe associated injuries, in patients with high-riskcomorbidities, or in minor ATAI. They go on to recommendthat early endovascular repair be considered whenever possiblein all ATAIs.
[Lina Tran, MD
Denver Health Medical Center, Denver, CO]
Comment: This preliminary study raises the interestingpossibility of a new means of managing selected patients withtraumatic aortic injury. Clearly, until larger studies can bedone, this will remain an experimental procedure for very selectpatients. Still, based on these early results, endovascular repairmay hold promise for the future of the management of theseinjuries.
, DEVELOPMENT OF A SCREENING TOOL FORPEDIATRIC SEXUAL ASSAULT MAY REDUCE EMER-GENCY DEPARTMENT VISITS. Floyed RL, Hirsh DA,Greenbaum VJ, Simon HK. Pediatrics 2011;128:221–6.
This study retrospectively analyzed 163 cases of allegedsexual assault in children < 12 years of age who presented toan Atlanta Emergency Department (ED) over a 2-year period.Investigators sought to define a screening tool that could accu-rately identify children who should receive their initial evalua-tion in a non-emergent setting. The screening tool consisted ofthe following four questions: 1) Did the incident occur in thepast 72 hours, and was there oral or genital to genital/anal con-tact? 2) Was genital or rectal pain, bleeding, discharge, or injurypresent? 3) Was there concern for the child’s safety? 4) Was anunrelated emergency medical condition present? An affirmativeresponse to any of these questions was considered a positivescreen. Of the 163 cases that were evaluated, 90 (55%) hadpositive screens and 73 (45%) had negative screens. Patientswere defined as being high risk if they had positive physical
examination findings of anogenital trauma or infection, a changein custody, or an emergency medical condition. Fifty-six ofthe 163 cases were identified as high risk, and none of thesepatients had a negative screen. The sensitivity and negativepredictive value of this four-question screening tool were both100%. The specificity was 68% and the positive predictive valuewas 62%.
[Mike MillerDenver Health Medical Center, Denver, CO]
Comments:Although limited by its retrospective design, thisstudy successfully evaluated whether a simple four-questionscreening tool can help physicians identify children who arenot high risk after alleged sexual assault and do not requireED evaluation. These individuals may be better served witha non-emergent evaluation at a child advocacy center, wherevictims of alleged sexual assault tend to receive a more compre-hensive physical examination in a less chaotic environment.A prospective evaluation of the screening tool would help toensure its validity.
, HEART DISEASE MAY BE A RISK FACTOR FORPULMONARY EMBOLISM WITHOUT PERIPHERALDEEP VENOUS THROMBOSIS. Sørensen HT, Horvath-Puho E, Lash TL, et al. Circulation 2011;124:1435–41.
This study from Denmark sought to evaluate whether com-mon heart diseases that increase the risk of left-sided arterialembolism (such as heart failure, myocardial infarction, atrialfibrillation, atrial flutter) are also associated with an increasedincidence of isolated pulmonary embolism (embolism withoutan apparent peripheral venous source). This was a case-controlstudy with data gathered over 27 years from 1980 to 2007 fromthe Danish National Patient Registry, totaling 109,752 patientswith a first recorded incident of pulmonary embolism (PE) ordeep vein thrombosis (DVT), or both, in the lower limb bothas primary or secondary discharge diagnosis. For each case,a risk-set sampling was utilized to select five population con-trols matched to index patient’s age, sex, and date of diagnosis,totaling 541,561 population controls. Confounders, such as pre-ceding inpatient cancer, fractures, trauma, surgery, pregnancy,obesity, and psychiatric disease (considering this a marker forantipsychotic drug use, a risk factor for pulmonary embolism),were identified and utilized to classify as provoked vs. unpro-voked thromboembolisms. Statistical analysis comparing thefrequency and proportion of venous thromboembolism casesand controls were calculated within categories of demographicvariables, heart disease history, and candidate cofounders gener-ating associations using odds ratios (OR) with 95% confidenceintervals (CI) to generate a rate ratio. Multiple outcomes com-bining PE and DVT were compared by utilizing estimated ORwith adjustment for matching factors and covariants. Amongthe groups, 59,790 had a diagnosis of DVT only, 45,282 hadPE only, and 4680 had a diagnosis of DVT with PE. All threecase groups had a higher prevalence of previous hospitalizationsfor heart disease for all cases with unprovoked presentation,particularly if there was a heart disease hospitalization in theprevious 3 months. Isolated PE was associated with acute myo-cardial infarction (MI) (OR 43.5; 95% CI 39.6–47.8) and heart
