Reviewer's report
Title:Patterns, aetiology and risk factors of intimate partner violence-related
injuries to head, neck and face in Chinese women: A retrospective study
Version: 1Date:29 August 2013
Reviewer: Sheila Sprague
Reviewer's report:
I would like to thank the editor and the authors for the opportunity to review this
interesting study. The current study is a retrospective analysis of medical charts
of patients who reported that they had experienced injuries due to intimate
partner violence in Hong Kong.
General Comments:
The current study is a well-designed retrospective study of medical charts. The
paper needs more detail and description, especially in the introduction and
methods sections. The statistical analysis plan is unclear and should be
significantly revised. The overall study will be of modest impact in the IPV field.
Specific Comments:
Major Compulsory Revisions
Abstract
1. In the findings section of the abstract, it is unclear what the comparator is. For
example, “punching with a fist was exerted significantly more on the upper third
of the maxillofacial region”. What is this compared to?
Introduction
2. The first paragraph of the introduction nicely introduces the concept of IPV and
the consequences of HNF injuries. The remainder of the introduction could be
reorganized to include a discussion of why HNF injuries specifically are important
in IPV. A bit more background on the work done in the HNF injury field would be
helpful along with a description of current guidelines (or lack thereof). Dentistry
has a large amount of literature on HNF injuries and IPV.
3. The introduction does not make a case for why it is important to determine
patterns of injury and etiology. Some information on this would really let the
reader know why this particular study will make an impact.
4. Paragraph 1 line 4-5 states that “Of IPV-related physical injuries, over 90%
have been found to involve the head, neck or face...” The first reference listed
(Monahan & O’Leary, 199) reports that 35% of physical IPV injuries involve the
head. Another study by my research group (Bhandari M, Dosanjh S, Tornetta P
3rd, Matthews D. Musculoskeletal manifestations of physical abuse after intimate
partner violence. J Trauma. 2006 Dec;61(6):1473-9) reports that 40% of physical
IPV injuries are HNF related. This is not an exhaustive search so I suggest that
the authors complete a more thorough search of the literature on the topic and
this sentence should be revised to reflect current literature.
Methods
5. Overall, the study is a well-designed retrospective study but the manuscript
lacks important details. In the eligibility criteria section, the authors should state
how many charts they reviewed and how many were excluded and the reasons
for exclusion to give the reader an idea of how much bias could have been
introduced into the screening and eligibility process. The use of two reviewers for
eligibility, however, is excellent.
6. Paragraph 3 of the data abstraction section states that the ISS was used for
determining severity. It is unclear how the authors applied the ISS to determine
the severity. Did the ISS include all of a patient’s injuries or just the HNF injury?
This should be clarified within the manuscript.
7. I have many questions about the data analysis, which overall requires more
description. The data analysis paragraph states that a logistic regression was
conducted for each region of injury. More information is needed on the nature of
the analysis. For example, how many factors went into the model, which factors,
and how did the authors decide which factors were used? Was a stepwise
method used or another method? It is unclear what the comparator was in the
regression analysis. Did the analysis compare patients with HNF injuries and
those without? The authors should state this explicitly.
8. There is no mention of a sample size calculation or power analysis. The
authors should state their rationale for including 223 charts.
9. Was the data analysis plan determined a priori or after the data was collected?
I am concerned that there are a large number of analyses and no mention of any
corrections for multiple testing. The authors did not provide a rationale for why so
many analyses were carried out.
Results
10. Table 2 could have been done with a chi-square analysis instead of a
regression. What is the rationale for a regression? It is unclear what this table
adds to the paper.
11. Table 3 should include an indication of how many patients were included in
the analysis (N).
12. It is also unclear what table 4 adds to the paper. Why not just add “multiple
injuries” as a factor in the original regression. The authors may have issues with
being underpowered for the analysis in table 4.
Discussion
13. The discussion states that “Based on the natural selection theory, cohabiting
couples with lower levels of violence tend to move from cohabitation to marriage,
whereas couples with higher levels of violence tend to stay in cohabiting
relationships.” I don’t believe that this is true. Often, violence men are not violent
while they are dating then become violence once married as she is now “under
his control”. This certainly doesn’t apply to many Eastern cultures such as India,
where dating and cohabiting are less popular. One could also argue that
cohabiting relationships are easier to leave than marriages, therefore there
should be less violence in cohabiting relationships. Regardless, this sentence
needs to be rewritten or requires a reference.
14. Paragraph 4, line 1 states that “IPV-related injuries tended to occur
repeatedly among abused women.” This sentence is unclear and imprecise. The
sentence should be rewritten to note that this is for physically injured IPV victims
who present to AEDs, not the general population of abused women.
15. The conclusion states that the findings are “essential to help clinicians to
improve diagnosis” for IPV victims. It is unclear how knowing about these factors
will help diagnose victims. Many attempts have been made to create a predictive
model of determining who is at risk for IPV, but none have been sensitive or
specific enough. How does this study add to that body of literature? Some
discussion of these past attempts would be beneficial.
Minor Essential Revisions
16. Introduction Paragraph 2, line 1: incorrect use of the word “despite”. The
wording should be revised to make the author’s point clearer.
Discretionary Revisions
17. The first paragraph of the results section states that only three quarters of the
participants were Chinese. Was being Chinese not an eligibility criterion? If not,
then can this really be called a study of Chinese women? Perhaps the authors
should rephrase the title.
18. In the Pattern of HNF Injuries section, it may be helpful for the authors to
report actual numbers as well as percentages in this paragraph.
19. Figure 1 is very difficult to read in greyscale. Will this be published in colour?
If not, the authors should consider making the figure into a table for the reader’s
convenience.
20. Discussion Paragraph 4, line 4-5: The sentence can be reworded to include
the next part as follows, “It is likely that the women will return to their abusive
partners due to a variety of reasons such as, financial dependence, emotional
dependence, and protection of their children.”
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests