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author:("hourly, Debra")
1.  Early Intervention May Prevent the Development of PTSD: A Randomized Pilot Civilian Study with Modified Prolonged Exposure 
Biological psychiatry  2012;72(11):957-963.
Background
Posttraumatic stress disorder is a major public health concern with long term sequelae. There are no accepted interventions delivered in the immediate aftermath of trauma. This study tested an early intervention aimed at modifying the memory to prevent the development of PTSD prior to memory consolidation.
Methods
Patients (N=137) were randomly assigned to receive 3 sessions of an early intervention beginning in the emergency department (ED) compared to an assessment only control group. Posttraumatic stress reactions (PTSR) were assessed at 4 and 12 weeks post-injury and depression at baseline and week 4. The intervention consisted of modified prolonged exposure including imaginal exposure to the trauma memory, processing of traumatic material, and in vivo and imaginal exposure homework.
Results
Patients were assessed an average of 11.79 hours post-trauma. Intervention participants reported significantly lower PTSR than the assessment group at 4 weeks post-injury, p < 0.01, and at 12 weeks post-injury, p < 0.05, and significantly lower depressive symptoms at Week 4 than the assessment group, p < 0.05. In a subgroup analysis the intervention was the most effective at reducing PTSD in rape victims at Week 4 (p=.004) and Week 12 (p=.05).
Conclusions
These findings suggest that the modified prolonged exposure intervention initiated within hours of the trauma in the ED is successful at reducing PTSR and depression symptoms one and three months after trauma exposure and is safe and feasible. This is the first behavioral intervention delivered immediately post-trauma that has been shown to be effective at reducing PTSR.
doi:10.1016/j.biopsych.2012.06.002
PMCID: PMC3467345  PMID: 22766415
early intervention; secondary prevention; PTSD; Acute Stress Disorder; prolonged exposure; memory consolidation
2.  Unrecognized suicidal ideation in ED patients: are we missing an opportunity? 
Objective
To determine if patients who disclosed suicidal ideation during a health risk survey had their mental health symptoms documented by physicians and were given mental health referrals and to evaluate how many of these patients subsequently attempted suicide.
Methods
As part of a larger survey, patients responded to questions on a computer kiosk about general health risk behaviors and mental health symptoms. Fifteen months after initiating the survey, we reviewed medical records on those patients who had disclosed suicidal ideation. A standardized abstraction sheet was used to collect data regarding the ED diagnosis at the time of enrollment, physician documentation of suicidal ideation, and referral to psychiatric services, as well as subsequent ED and clinic visits and suicide attempts.
Results
Of the 165 patients who disclosed suicidal ideation on the computer survey, 118 charts (72%) were available. During the index ED visit, only 25% of patients had suicidal ideation or other mental health issues noted on the chart. The majority of patients (76%) were discharged home, 10% were transferred to psychiatric services, and 3% were admitted for medical reasons. Although 72 patients had no future visits to the ED or other hospital-affiliated clinics, 39% of patients had at least one subsequent visit to the ED, and 17% had at least one visit to the psychiatric services. Four patients attempted suicide following their initial index visit to the ED.
Conclusion
Suicidal ideation was self disclosed frequently by waiting room patients in our urban ED and patients who disclosed suicidal ideation did not always receive referrals for mental health services.
doi:10.1016/j.ajem.2007.09.006
PMCID: PMC3746995  PMID: 18606326
suicidal ideation; screening; emergency department; kiosk
4.  Prevalence of Exposure to Risk Factors for Violence among Young Adults Seen in an Inner-City Emergency Department 
Introduction: To assess the prevalence of risk factors for violent injury among young adults treated at an urban emergency department (ED).
Methods: This study is a cross-sectional analysis of data collected as part of a longitudinal study. Enrollment took place in an urban ED in a Level 1 trauma center, June through December 2010. All patients aged 18–24 years were eligible. Patients were excluded if they were incarcerated, critically ill, or unable to read English. Study participants completed a 10-minute multiple-choice questionnaire using previously validated scales: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, and e) community exposure to violence.
Results: 403 eligible patients were approached, of whom 365 (90.1%) consented to participate. Average age was 21.1 (95% confidence interval: 20.9, 21.3) years, and participants were 57.2% female, 85.7% African American, and 82.2% were educated at the high school level or beyond. Among study participants, rates of high-risk exposure to individual risk factors ranged from 7.4% (recent violent behavior) to 24.5% (exposure to community violence), with 32.3% of patients showing high exposure to at least one risk factor. When comparing participants by ethnicity, no significant differences were found between White, African-American, and Hispanic participants. Males and females differed significantly only on 1 of the scales – community violence, (20.4% of males vs. 30.3% of females, p= 0.03). Self-reported hostile/aggressive feelings were independently associated with initial presentation for injury-associated complaint after controlling for age, sex, and race (odds ratio 3.48 (1.49–8.13).
Conclusion: Over 30% of young adults presenting to an urban ED reported high exposure to risk factors for violent injury. The high prevalence of these risk factors among ED patients highlights the potential benefit of a survey instrument to identify youth who might benefit from a targeted, ED-based violence prevention program.
doi:10.5811/westjem.2013.2.14810
PMCID: PMC3735376  PMID: 23930142
5.  Diagnosing HIV in Men Who Have Sex with Men: An Emergency Department's Experience 
AIDS Patient Care and STDs  2012;26(4):202-207.
Abstract
In the United States, men who have sex with men (MSM) constitute the risk group in which the prevalence of new HIV infection is increasing. The percentage of undiagnosed HIV infection and HIV risk behaviors in MSM and non-MSM participating in an emergency department-based rapid HIV screening program were compared. Medical records of all male patients participating in the program from May 2008 to October 2010 were reviewed. MSM were identified as male or male-to-female patients reporting oral and/or anal sex with a male. Males eligible for testing were aged 18 or older, English-speaking, not known to be HIV infected, and able to decline testing. A total of 6672 males were approached for testing; 5610 (84.1%) accepted, 366 (6.5%) were MSM, and 5244 (93.5%) were non-MSM. A total of 90.7% were black. Median age was 41. Fifty-nine MSM (16.1%) were diagnosed with HIV compared to 81 (1.5%) non-MSM. MSM were 10 times more likely than non-MSM to have undiagnosed HIV infection (odds ratio [OR] 10.4, 95% confidence interval [CI] 7.3, 14.0). HIV-infected MSM (median age, 26) were younger than non-MSM (median age, 41). HIV-infected non-MSM were 2 times more likely than MSM to have CD4 counts less than 200 cells per microliter. MSM were more likely to report previous HIV testing (OR 1.9, 95% CI 1.4, 2.5) and risk behaviors, including sex without a condom (OR 2.0, 95% CI 1.5, 2.6), sex with an HIV-infected partner (OR 14.6, 95% CI 8.3, 25.6) and sex with a known injection drug user (OR 4.1, 95% CI 2.0, 8.4). Further investigation of emergency department-based HIV testing and risk reduction programs targeting MSM is warranted.
doi:10.1089/apc.2011.0303
PMCID: PMC3317392  PMID: 22356726
6.  Efficacy of an Emergency Department-Based HIV Screening Program in the Deep South 
Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) continue to be a significant public health concern in the United States. It disproportionately affects persons in the Deep South of the United States, specifically African Americans. This is a descriptive report of an Emergency Department (ED)-based HIV screening program in the Deep South using the 2006 Centers for Disease Control and Prevention (CDC) recommendations for rapid testing and opt-out consent. Between May 2008 and March 2010, patients presenting for medical care to the ED Monday through Friday between 10 am and 10 pm were approached for HIV screening. Patients were eligible for screening if they were 18 or older, had no previous history of positive HIV tests, were English-Speaking, and were not incarcerated, medically unstable, or otherwise able to decline testing. All patients were tested using the OraQuick® rapid HIV 1/2 antibody test. Patients with non-reactive results were referred to community anonymous testing sites for further testing. Patients with reactive results had confirmatory Western blot and CD4 counts drawn and were brought back to the ED for disclosure of the results. All patients with confirmed HIV positive via reactive Western blot were referred to the hospital-based infectious disease clinic or county health department. We tested 7,616 patients out of 8,922 approached. The overall test acceptance rate was 85.4%. 91.0% of patients tested were African American. The most common reason for refusal was recent HIV test. 1.7% of patients tested were confirmed HIV positive via Western blot. 95.2% of patients testing HIV positive were African American. The average CD4 count for patients testing positive was 276 cells/μl, with 42.0% of patients having CD4 counts ≤200 μl, consistent with an AIDS diagnosis. 88.4% of patients who had reactive oral swabs returned for Western blot results and 75.0% of patients attended their first clinic visit. We have been able to successfully carry out an ED-based HIV screening program in a resource-poor urban teaching facility in the Deep South. We define our success based on our relatively high test acceptance rate and high rate of attendance at first clinic visit. Our patient population has a relatively high undocumented HIV prevalence and are at advanced stage of disease at the time of diagnosis.
doi:10.1007/s11524-011-9588-z
PMCID: PMC3232419  PMID: 21630105
Rapid HIV screening; Emergency Department; Southeastern United States
7.  Does mentoring new peer reviewers improve review quality? A randomized trial 
BMC Medical Education  2012;12:83.
Background
Prior efforts to train medical journal peer reviewers have not improved subsequent review quality, although such interventions were general and brief. We hypothesized that a manuscript-specific and more extended intervention pairing new reviewers with high-quality senior reviewers as mentors would improve subsequent review quality.
Methods
Over a four-year period we randomly assigned all new reviewers for Annals of Emergency Medicine to receive our standard written informational materials alone, or these materials plus a new mentoring intervention. For this program we paired new reviewers with a high-quality senior reviewer for each of their first three manuscript reviews, and asked mentees to discuss their review with their mentor by email or phone. We then compared the quality of subsequent reviews between the control and intervention groups, using linear mixed effects models of the slopes of review quality scores over time.
Results
We studied 490 manuscript reviews, with similar baseline characteristics between the 24 mentees who completed the trial and the 22 control reviewers. Mean quality scores for the first 3 reviews on our 1 to 5 point scale were similar between control and mentee groups (3.4 versus 3.5), as were slopes of change of review scores (-0.229 versus -0.549) and all other secondary measures of reviewer performance.
Conclusions
A structured training intervention of pairing newly recruited medical journal peer reviewers with senior reviewer mentors did not improve the quality of their subsequent reviews.
doi:10.1186/1472-6920-12-83
PMCID: PMC3494517  PMID: 22928960
Mentoring; Peer review; Scientific publication; Critical analysis; Journal peer reviewer
9.  The Contributions of Prior Trauma and Peritraumatic Dissociation to Predicting Post-Traumatic Stress Disorder Outcome in Individuals Assessed in the Immediate Aftermath of a Trauma 
Objective
This study analyzed predictors of post-traumatic stress disorder (PTSD) in civilian trauma victims to assess how peritraumatic dissociation (PD) relates to PTSD symptom development. We examined PD and PTSD symptoms from a prior trauma simultaneously to better understand the extent to which past and current reactions to a trauma can predict the development of PTSD for a current trauma.
Methods
Participants (N=48) were recruited from the emergency department (ED) of a large, southeastern hospital and assessed immediately after a trauma and again at 4 weeks and 12 weeks post-trauma. We used both self-report and interviewer-based questionnaires to assess PD and PTSD symptoms for prior and current trauma.
Results
A hierarchical linear regression revealed that at 4-week follow up, when controlling for several demographic variables and trauma type, a model including both PD and PTSD symptoms from a prior trauma significantly predicted PTSD outcome (F(47)= 3.70, p=0.00), with PD and prior PTSD symptoms significantly contributing 17% and 9% of variance respectively. At 12 weeks, PTSD symptoms from prior trauma (β=0.094, p=0.538) and PD (β=−0.017, p=0.909) did not account for a significant proportion of the variance in PTSD for the enrolling trauma.
Conclusion
Prior and current reactions to trauma are both important factors in predicting the development of PTSD symptoms to a current trauma. The more immediate measurement of PD during presentation to the ED may explain the strength of its relationship to PTSD symptom development. Furthermore, our findings support the use of PTSD symptoms of a past trauma, as opposed to trauma frequency, as a predictor of PTSD from a subsequent trauma. Methodological limitations and future directions are discussed.
doi:10.5811/westjem.2012.3.11777
PMCID: PMC3415825  PMID: 22900118
10.  Benefit of a Tiered-Trauma Activation System to Triage Dead-on-Arrival Patients 
Introduction
Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA).
Method
We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system.
Results
We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries, who sustained pre-hospital TCPA requiring prolonged CPR in the field and were brought to the emergency department (ED). Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55 penetrating), who died after receiving < 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the ED lasting > 45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA).
Conclusion
Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting.
doi:10.5811/westjem.2012.3.11781
PMCID: PMC3415826  PMID: 22900119
11.  Association between Intimate Partner Violence and Health Behaviors of Female Emergency Department Patients 
Introduction
We assessed the correlation between intimate partner violence (IPV) and health behaviors, including seat belt use, smoke alarm in home, handgun access, body mass index, diet, and exercise. We hypothesized that IPV victims would be less likely to have healthy behaviors as compared to women with similar demographics.
Methods
All adult female patients who presented to 3 Atlanta-area emergency department waiting rooms on weekdays from 11AM to 7PM were asked to participate in a computer-based survey by trained research assistants. The Universal Violence Prevention Screen was used for IPV identification. The survey also assessed seatbelt use, smoke alarm presence, handgun access, height, weight, exercise, and diet. We used chi-square tests of association, odds ratios, and independent t-tests to measure associations between variables.
Results
Participants ranged from 18 to 68 years, with a mean of 38 years. Out of 1,452 respondents, 155 patients self-identified as white (10.7%), and 1,218 as black (83.9%); 153 out of 832 women who were in a relationship in the prior year (18.4%) screened positive for IPV. We found significant relationships between IPV and not wearing a seatbelt (p<0.01), handgun access (p<0.01), and eating unhealthy foods (p<0.01).
Conclusion
Women experiencing IPV are more likely to exhibit risky health behaviors than women who are not IPV victims.
doi:10.5811/westjem.2012.3.11747
PMCID: PMC3415833  PMID: 22900126
12.  Effect of a Targeted Women's Health Intervention in an Inner-City Emergency Department 
Objective. To evaluate the effect of an Emergency Department (ED) based, educational intervention for at-risk health behaviors. Methods. A randomized trial over a one-year period. African American women, aged 21–55, presenting to the ED waiting room were eligible. Each participant took a computer-based survey on health risk behaviors. Participants who screened positive on any of four validated scales (for IPV, nicotine, alcohol, or drug dependence) were randomized to standard information about community resources (control) or to targeted educational handouts based upon their screening results (intervention). Participants were surveyed at 3 months regarding contacts with community resources and harm-reduction actions. Results. 610 women were initially surveyed; 326 screened positive (13.7% for IPV, 40.1% for nicotine addiction, 26.6% for alcohol abuse, and 14.4% for drug abuse). 157 women were randomized to intervention and 169 to control. Among women who completed follow-up (n = 71), women in the Intervention Group were significantly more likely to have contacted local resources (37% versus 9%, P = 0.04) and were more likely to have taken risk-reducing action (97% versus 79%, P = 0.04). Conclusion. Targeted, brief educational interventions may be an effective method for targeting risk behaviors among vulnerable ED populations.
doi:10.1155/2011/543493
PMCID: PMC3235772  PMID: 22203904
14.  Injury Secondary to Antiretroviral Agents: Retrospective Analysis of a Regional Poison Center Database 
Introduction:
Poisoning is an increasingly important cause of injury in the United States. In 2009 poison centers received 2,479,355 exposure reports, underscoring the role of poison centers in intentional and unintentional injury prevention. Antiretroviral (ARV) agents are commonly prescribed drugs known to cause toxicity, yet the frequency of these incidents is unknown. The objectives of this study were to quantify the number of reported cases of toxicity secondary to ARV agents at a regional poison center, and to describe the circumstances and clinical manifestations of these poisonings.
Methods:
We conducted a retrospective review of poison center records between December 1, 2001, and January 7, 2010.
Results:
One hundred sixty-two exposures to ARV agents were reported to the poison center, of which 30% were intentional and 70% were unintentional. Three patients developed major toxicity and no deaths occurred. The remaining patients developed moderate and minor effects as defined by poison center guidelines.
Conclusion:
ARV drug toxicity appears to be infrequently reported to the poison center. Fatal and major toxicities are uncommon, and intentional overdoses are associated with a more serious toxicity. Educational efforts should encourage clinicians to report toxicities related to the use of ARV agents to poison centers in order to better study this problem.
PMCID: PMC3117603  PMID: 21731784
15.  Treatment, Services and Follow-up for Victims of Family Violence in Health Clinics in Maputo, Mozambique 
Background:
Family violence (FV) is a global health problem that not only impacts the victim, but the family unit, local community and society at large.
Objective:
To quantitatively and qualitatively evaluate the treatment and follow up provided to victims of violence amongst immediate and extended family units who presented to three health centers in Mozambique for care following violence.
Methods:
We conducted a verbally-administered survey to self-disclosed victims of FV who presented to one of three health units, each at a different level of service, in Mozambique for treatment of their injuries. Data were entered into SPSS (SPSS, version 13.0) and analyzed for frequencies. Qualitative short answer data were transcribed during the interview, coded and analyzed prior to translation by the principal investigator.
Results:
One thousand two hundred and six assault victims presented for care during the eight-week study period, of which 216 disclosed the relationship of the assailant, including 92 who were victims of FV. Almost all patients (90%) waited less than one hour to be seen, with most patients (67%) waiting less than 30 minutes. Most patients did not require laboratory or radiographic diagnostics at the primary (70%) and secondary (93%) health facilities, while 44% of patients received a radiograph at the tertiary care center. Among all three hospitals, only 10% were transferred to a higher level of care, 14% were not given any form of follow up or referral information, while 13% required a specialist evaluation. No victims were referred for psychological follow-up or support. Qualitative data revealed that some patients did not disclose violence as the etiology, because they believed the physician was unable to address or treat the violence-related issues and/or had limited time to discuss.
Conclusion:
Healthcare services for treating the physical injuries of victims of FV were timely and rarely required advanced levels of medical care, but there were no psychological services or follow-up referrals for violence victims. The healthcare environment at all three surveyed health centers in Mozambique does not encourage disclosure or self-report of FV. Policies and strategies need to be implemented to encourage patient disclosure of FV and provide more health system-initiated victim resources.
PMCID: PMC3117612  PMID: 21731793
16.  Characteristic of victims of family violence seeking care at health centers in Maputo, Mozambique 
Background:
Family violence (FV) is a common, yet often invisible, cause of violence. To date, most literature on risk factors for family, interpersonal and sexual violence is from high-income countries and might not apply to Mozambique.
Aims:
To determine the individual risk factors for FV in a cohort of patients seeking care for injuries at three health centers in Maputo, Mozambique.
Setting and Design:
A prospective multi-center study of patients presenting to the emergency department for injuries from violence inflicted by a direct family member in Maputo, Mozambique, was carried out.
Materials and Methods:
Patients who agreed to participate and signed the informed consent were verbally administered a pilot-tested blank-item questionnaire to ascertain demographic information, perpetrator of the violence, historical information regarding prior abuse, and information on who accompanied the victim and where they received their initial evaluation. De-identified data were entered into SPSS 13.0 (SPSS, version 13.0) and analyzed for frequencies.
Results:
During the 8-week study period, 1206 assault victims presented for care, of whom 216 disclosed the relationship of the assailant, including 92 being victims of FV (42.6%). The majority of FV victims were women (63.0%) of age group 15-34 years (76.1%) and were less educated (84%) compared to national averages. Of the patients who reported assault on a single occasion, most were single (58.8%), while patients with multiple assaults were mostly married (63.2%). Most commonly, the spouse was the aggressor (50%) and a relative accompanied the victim seeking care (54.3%). Women most commonly sought police intervention prior to care (63.2%) in comparison to men (35.3%).
Conclusion:
In Mozambique, FV affects all ages, sexes and cultures, but victims seeking care for FV were more commonly women who were less educated and poorer.
doi:10.4103/0974-2700.83866
PMCID: PMC3162707  PMID: 21887028
Emergency care; family violence; injuries; Mozambique
17.  Standardized Patients to Teach Medical Students about Intimate Partner Violence 
Objective
To use 360-degree evaluations within an Observed Structured Clinical Examination (OSCE) to assess medical student comfort level and communication skills with intimate partner violence (IPV) patients.
Methods
We assessed a cohort of fourth year medical students’ performance using an IPV standardized patient (SP) encounter in an OSCE. Blinded pre- and post-tests determined the students’ knowledge and comfort level with core IPV assessment. Students, SPs and investigators completed a 360-degree evaluation that focused on each student’s communication and competency skills. We computed frequencies, means and correlations.
Results
Forty-one students participated in the SP exercise during three separate evaluation periods. Results noted insignificant increase in students’ comfort level pre-test (2.7) and post-test (2.9). Although 88% of students screened for IPV and 98% asked about the injury, only 39% asked about verbal abuse, 17% asked if the patient had a safety plan, and 13% communicated to the patient that IPV is illegal. Using Likert scoring on the competency and overall evaluation (1, very poor and 5, very good), the mean score for each evaluator was 4.1 (competency) and 3.7 (overall). The correlations between trainee comfort level and the specific competencies of patient care, communication skill and professionalism were positive and significant (p<0.05).
Conclusion
Students felt somewhat comfortable caring for patients with IPV. OSCEs with SPs can be used to assess student competencies in caring for patients with IPV.
PMCID: PMC3027446  PMID: 21293773
19.  Correlation Between Intimate Partner Violence Victimization and Risk of Substance Abuse and Depression among African-American Women in an Urban Emergency Department 
Objective:
To assess rates of substance abuse (including tobacco, alcohol, and drug abuse) as well as rates of intimate partner violence (IPV) among African-American women seen in an urban emergency department (ED).
Methods:
Eligible participants included all African-American women between the ages of 21–55 years old who were seen in an urban ED for any complaint and triaged to the waiting room. Eligible women who consented to participate completed a computer-based survey that focused on demographic information and general health questions, as well as standardized instruments to screen for alcohol abuse, tobacco abuse, and illicit drug use. This analysis uses results from a larger study evaluating the effects of providing patients with targeted educational literature based on the results of their screening.
Results:
Six-hundred ten women were surveyed; 430 women reported being in a relationship in the past year and among these, 85 women (20%) screened positive for IPV. Women who screened positive for IPV were significantly more likely to also screen positive for tobacco abuse (56% vs. 37.5%, p< 0.001), alcohol abuse (47.1% vs. 23.2%, p < 0.001), and drug abuse (44.7% vs. 9.5%, p<0.001). Women who screened positive for IPV were also more likely to screen positive for depression and report social isolation.
Conclusions:
African-American women seen in the ED, who screen positive for IPV, are at significantly higher risk of drug, alcohol, tobacco abuse, depression and social isolation than women who do not screen positive for IPV. These findings have important implications for ED-based and community-based social services for women who are victims of intimate partner violence.
PMCID: PMC2941362  PMID: 20882145
20.  Feasibility of Identifying Eligible Trauma Patients for Posttraumatic Stress Disorder Intervention 
Objective:
This research report examines the feasibility of identifying eligible trauma patients for a study providing an early therapeutic intervention for the prevention of posttraumatic stress disorder (PTSD), and identifies reasons around participation.
Methods:
This prospective observational study used a convenience sample of acute trauma victims presenting to a university-affiliated Level One trauma center in a large southeastern city. Patients eligible to participate in the early intervention study were adults (18– 65) who experienced a traumatic event within 72 hours of presentation, feared that they might be killed or seriously injured during the event, and were able to return for follow-up appointments. Patients were excluded if they were non-English speaking; experienced a loss of consciousness greater than five minutes; had a history of a serious mental illness or were currently suicidal; or endorsed current substance dependence. Descriptive statistics were conducted to determine differences in ineligible, eligible, and consenting trauma patients who enrolled in the intervention study.
Results:
Over a six-month period, n =1961 patients presented for treatment of a traumatic injury during study hours. Results showed that eligible patients were significantly younger than ineligible patients. Survivors of assaults (physical and sexual), younger patients, and women were generally more likely to participate in a study offering a psychological intervention in the immediate aftermath of a traumatic event.
Conclusion:
Fourteen percent of trauma patients were eligible and entered a study offering an early psychological intervention for the prevention of PTSD. Trauma type, age and gender may play a role in determining preference for receiving psychological services immediately after experiencing a traumatic event.
PMCID: PMC2941366  PMID: 20882149
21.  Intimate Partner Violence and Functional Health Status: Associations with Severity, Danger, and Self-Advocacy Behaviors 
Journal of Women's Health  2009;18(5):625-631.
Abstract
Objective
To assess physical and mental functional health status as associated with the severity of intimate partner violence (IPV) and perceived danger.
Methods
Prospective cross-sectional survey of all patients aged 18–55 in an urban emergency department during a convenience sample of shifts. Instruments included the George Washington Universal Violence Prevention Screening protocol, administered by computer during the initial visit, the Short-Form 12 Health Survey (SF-12), the Conflict Tactics Scale (CTS2), and the Revised Danger Assessment (DA), administered by interview at 1 week follow-up.
Results
In total, 548 (20%) participants screened disclosed IPV victimization. Of those, 216 (40%) completed the follow-up assessment 1 week later. This cohort was 91% African American, 70% single, and 63% female, with a mean age of 35 (SD 10.41). Both physical and mental health functioning scores were lower than normative levels (50) compared with national averages: Physical Component Summary (PCS) scale 43.64 (SD 10.86) and Mental Component Summary (MCS) scale 37.46 (SD 12.29). As physical assault, psychological aggression, and reported injury increased on the CTS2, mental health functioning diminished (p < 0.01). Increased physical assault and psychological aggression were also associated with diminished physical health functioning (p < 0.05). As victim-perceived danger increased on the DA, both physical and mental health functioning decreased (p < 0.01, p < 0.001, respectively). Greater self-advocacy activities were associated with lower mental (but not physical) health functioning as well. Females experienced worsening mental health functioning as both physical assault and psychological aggression increased, whereas male victims experienced worsening mental health functioning only as psychological aggression increased.
Conclusions
These findings suggest that IPV takes a greater mental than physical toll (for both sexes) and that as IPV severity increases, mental health functioning diminishes and self-advocacy behaviors increase. Additionally, as perceived danger increases, both physical and mental health status worsens. This has important implications for clinicians to assess and consider IPV victims' perceptions of their situations relative to danger, not just the levels of abuse they are experiencing.
doi:10.1089/jwh.2007.0521
PMCID: PMC2872257  PMID: 19445614
22.  Differences in Female and Male Victims and Perpetrators of Partner Violence With Respect to WEB Scores 
Journal of interpersonal violence  2008;23(8):1041-1055.
Measurements of intimate partner violence (IPV) based on acts of violence have repeatedly found substantial bilateral violence between intimates. However, the context of this violence is not well defined by acts alone. The objective of this research was to compare differences in women and men within each IPV status category (victim, perpetrator, and both) with respect to levels of battering as defined by their scores on the Women’s Experience With Battering Scale (WEB), which asks gender-neutral questions about the abuse of power and control and fear in an intimate relationship. In our study, women disclosed higher levels of battering on the WEB, despite IPV status (victimization or both victimization and perpetration). In addition, female IPV victims were 5 times more likely than their male counterparts to disclose high rates of battering on the WEB. Depressive symptoms, symptoms of posttraumatic stress disorder, African American race, and IPV victimization were independently associated with higher WEB scores.
doi:10.1177/0886260507313969
PMCID: PMC2562919  PMID: 18272721
intimate partner violence; victim; perpetrator; battering; mental health; Women’s Experience With Battering Scale
23.  Does Screening in the Emergency Department Hurt or Help Victims of Intimate Partner Violence? 
Annals of emergency medicine  2008;51(4):433-442.e7.
Study objective
Recent systematic reviews have noted a lack of evidence that screening for intimate partner violence does more good than harm. We assess whether patients screened for intimate partner violence on a computer kiosk in the emergency department (ED) experienced any adverse events during or subsequent to the ED visit and whether computer kiosk identification and referral of intimate partner violence in the ED setting resulted in safety behaviors or contact with referrals.
Methods
We conducted a prospective, observational study in which a convenience sample of male and female ED patients triaged to the waiting room who screened positive (on a computer kiosk-based questionnaire) for intimate partner violence in the past year were provided with resources and information and invited to participate in a series of follow-up interviews. At 1-week and 3-month follow-up visits, we assessed intimate partner violence, safety issues, and use of resources. In addition, to obtain an objective measure of safety, we assessed the number of violence-related 911 calls to participant addresses within a call district 6 months before and 6 months after the index ED visit.
Results
Of the 2,134 participants in a relationship in the last year, 548 (25.7%) screened positive for intimate partner violence. No safety issues, such as calling security or a partner’s interference with the screening, occurred during the ED visit for any patient who disclosed intimate partner violence. Of the 216 intimate partner violence victims interviewed in person and 65 contacted by telephone 1 week later, no intimate partner violence victims reported any injuries or increased intimate partner violence resulting from participating in the study. For the sample in the local police district, there was no increase in the number of intimate partner violence victims who called 911 in the 6 months after the ED visit. Finally, 35% (n=131) reported they had contacted community resources during the 3-month follow-up period.
Conclusion
Among patients screening positive for intimate partner violence, there were no identified adverse events related to screening, and many had contacted community resources.
doi:10.1016/j.annemergmed.2007.11.019
PMCID: PMC2276575  PMID: 18313800
24.  Development of a Brief Mental Health Screen for Intimate Partner Violence Victims in the Emergency Department 
Background
Emergency physicians routinely treat victims of intimate partner violence (IPV) and patients with mental health symptoms, although these issues may be missed without routine screening. In addition, research has demonstrated a strong association between IPV victimization and mental health symptoms.
Objectives
To develop a brief mental health screen that could be used feasibly in an emergency department to screen IPV victims for depressive symptoms, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation.
Methods
The authors conducted a pretest/posttest validation study of female IPV victims to determine what questions from the Beck Depression Inventory II, Posttraumatic Stress Diagnostic Scale, and Beck Scale for Suicide Ideation would predict moderate to severe levels of depressive symptoms, PTSD symptoms, and suicidal ideation. A principal components factor analysis was conducted to determine which questions would be used in the brief mental health screen. Scatter plots were then created to determine a cut point.
Results
Scores on the brief mental health screen ranged from 0 to 8. A cutoff score of 4 was used, which resulted in positive predictive values of 96% for the brief mental health screen for depression, 84% for PTSD symptoms, and 54% for suicidal ideation. In particular, four questions about sadness, experiencing a traumatic event, the desire to live, and the desire to commit suicide were associated with moderate to severe mental health symptoms in IPV victims.
Conclusions
The brief mental health screen provides a tool that could be used in an emergency department setting and predicted those IPV victims with moderate to severe mental health symptoms. Using this tool can assist emergency physicians in recognizing at-risk patients and referring these IPV victims to mental health services.
doi:10.1197/j.aem.2006.09.056
PMCID: PMC2258422  PMID: 17242384
intimate partner violence; depression; PTSD; suicide; emergency department
25.  Stages of Change as a Correlate of Mental Health Symptoms in Abused, Low-Income African American Women 
Journal of clinical psychology  2006;62(12):1531-1543.
The current study aims to further our understanding of the applicability of the transtheoretical model (TM) to intimate partner violence (IPV), with particular focus on mental health symptoms (depression, posttraumatic stress disorder symptomatology, suicidal ideation) in a sample of low-income African American women seeking medical services at an inner city emergency department. Results revealed that of the 121 abused African American women, the majority (95%) were in the precontempla-tion and contemplation stages of the change process. Further, contrary to predictions, bivariate analyses revealed those at further stages of change endorsed more severe mental health symptoms. However, a multivariate analysis of variance examining differences in level of mental health symptoms between women high and low on stages of change was inconclusive due to the small number of women at the higher stages of the TM model. These findings contribute to the growing body of literature supporting the TM as applied to IPV. Results are discussed in terms of applicability to intervention design.
doi:10.1002/jclp.20310
PMCID: PMC1635429  PMID: 16897735
intimate partner violence; African American women; transtheoretical model

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