Intentional Head Injury : Survivor Victim ' s Profile , Gender Differences and Role of Alcohol Use at Manipal Teaching Hospital , Pokhara , Nepal

Results Inten onal head injury accounted to 17.40% of all head injury cases admi ed during the study period. Among them 48 (76.19%) were males and 15 (23.81%) were females. The minimum age of the pa ent was 15 years and maximum was 84 years with a mean age of 33.89±14.67 years. Most of the vic ms of physical assault belonged to the age group of 21 to 30 years. Blunt object was the most commonly used for assault. Loss of consciousness was associated only with 49.21% of cases and 14.29% cases had bleeding from ear and/or nose. More than 75% of the cases had significant radiological finding in the form of fracture and/or intracranial lesion. Majority of the vic ms during the study were treated conserva vely and were discharged with advice. Alcohol use was involved in 36.51% cases of inten onal head injuries.


ORA 15 INTRODUCTION
Any external injury to face, scalp and calvarium in the form of abrasion, contusion, lacera on or fracture is non-specifically 1 designated as head injury.Trauma c brain injury (TBI) is altera on in brain func on as a consequence of penetra ng or blunt trauma to head.Head injury can occur without associated TBI and vice versa.Assaults are inten onal overt behaviour directed towards another person to cause harm.Inten onal head injuries are assaults to the head either to kill or incapacitate a person.Inten onal injuries in the form of interpersonal violence range from minor assaults to homicides.These behaviours can be impulsive or premeditated.There are various studies conducted in Nepalese se ng on the trauma c injuries, yet no study is found in par cular that has in-depth assessment of [2][3][4][5][6] inten onal injuries confined to head.The objec ve of this study was to evaluate the sociodemographic spectrum, severity, radiological findings and outcome of vic ms assaulted to the head.Furthermore, the study aims to correlate such findings to the role of alcohol use in Nepalese context.

METHODOLOGY
With the approval of ethics commi ee of Manipal Teaching Hospital longitudinal study was carried out.Vic ms of trauma c head injury as a result of physical assault who were admi ed in the Neurosurgery Unit of Manipal Teaching Hospital from 1 January 2015 to 31 December 2015 were included in the study.This study did not include cases of head injury due to physical assault who were brought dead i.e. died on the spot or on the way to hospital and discharged from the emergency department a er first aid.
The head injury cases were recorded using a proforma which sought the following informa on: name, gender, age, address, telephone number, date of incident, diagnosis, vitals including Glasgow Coma Score (GCS), radiological findings, treatment offered, and date of discharge.The proforma also included whether the pa ent was intoxicated at the me of assault or not.This proforma was a ached to the pa ent's file in the Neurosurgery unit and was completed by the in-trainee doctor on duty.When the proforma was not completed by the doctor on duty, the academic researcher collected the necessary data directly from the pa ent or a family member.The data were entered, and analyzed using SPSS (Sta s cal Package for Social Sciences) version 21 and presented in appropriate tables.

RESULTS
During the one year study period 374 pa ents were treated for head injury out of which 12 pa ents died (mortality rate 3.2%).Of the surviving 362 pa ents, 63 cases (17.40%) had inten onal head injury of which 48 (76.19%) were males and 15 (23.81%) were females.The minimum age of the pa ent was 15 years and maximum was 84 years with a mean age of 33.89±14.67years.Most of the vic ms of physical assault belonged to the age group of 21 to 30 years comprising of 41.27% (n=26) of total study popula on (Table 1).Glasgow Coma Scale (GCS) on arrival to casualty room was computed to be 5 as the lowest score and 15 being maximum with a mean score of 14.35±1.97.On external examina on, only 9 pa ents (14.29%) had bleeding from ear/nose /throat while 54 pa ents (85.71%) had no such bleeding.History sugges ve of post trauma c seizure was present only in 2 cases.Headache was the presen ng symptom as complained by the pa ent in 18 cases.The dura on of loss of consciousness based upon the history of the pa ent and/or their caregivers is shown in (Table 2).In 15 cases (24.2%) there was no visible external injury and the computerized tomographic (CT) scan also did not reveal any intracranial lesion.The pa ern of injuries sustained by the vic ms is shown in the (Table 3).The weapon of offence used by the assailant was blunt object in 44 cases (69.84%) and sharp cu ng objects in 13 cases (20.63%).In 6 cases (9.52%) the offending weapon was not iden fied (Table 4).Blunt objects included stone and bricks, metal bar, wooden log and s cks, furniture, garden hoes, fists and kicks and intact beer/ whiskey bo les.Khukuri, sickle, knives and axe were the popular sharp weapons in the study.Out of 47 males, 16 were (25.4%) were intoxicated during assault whereas none of the females in the study had consumed alcohol at the me of assault.History suggested that 7 females were beaten up by their husband or other family members under the influence of alcohol.Alcohol use was involved in 36.51% (n=23) cases of inten onal head injuries.The treatment modality was surgical in 14 cases, conserva ve in 41 cases whereas 8 cases were admi ed for observa on (Table 5).The minimal dura on of hospital stay was 2 days and maximum of 120 days with a mean of 11.86±19.84days.In the present study 58 pa ents (92.1%) were discharged with advice and 2 pa ents (3.1%) were discharged on request of pa ent's care givers whereas 3 cases (4.8%) discon nued treatment and le against medical advice (LAMA).

DISCUSSION
Inten onal assault to head comprised of 17.40% of all head injury cases which is similar to a study conducted in 2 university hospital in eastern Nepal.The present study observed high number of interpersonal violence during adolescence and young adulthood with a male/female ra o of 3.2.Contras ngly during old age number of females being admi ed for inten onal assault was higher than males.
It is suggested that females develop internalizing (depressive) symptoms rather than externalizing (angry) symptoms as in males.Lesser number of female vic ms in inten onal assault may be a ributed to the fact that violence 7 upon female posses a greater risk for suicide.Joshi (2009) points out some reasons for under repor ng of violence against women to save family pres ge and privacy, fear of husband and mother-in-law, love and affec on with husband and family members, fear of breaking family rela on, fear of social, tradi onal and socio-cultural values, fear of further bea ng, physical assault, marginaliza on, uncertainty of 8 jus ce, lack of faith in jus ce and support of other.
Inten onal head injuries in females due to in mate partner brutality are likely either not to seek medical care at all or to shun medical care and depart from hospital in advance than 9 scheduled.
Head are the target regions in most assaults as it is easily accessible by assailant's raised arms.Males suffer more serious injuries when compared to females as violence in 10 males usually involves dangerous weapons and objects.
Males in their testosterone years are involved into violence and assault within their peer group (friends or strangers).Physical aggression by males who consumed alcohol usually involve four or more men while incidents and females with no alcohol consump on was with known male most o en a 11 family member in domes c se ng.Tendency of substance abuse and alcohol use was higher among assaulted males while none of the females had a history of alcohol consump on prior to the assault.The known risk factor for violence in males include low self-esteem, apathy to personal safety and the inability regula ng emo onal In Nepal, the liquor law is not strict.Let aside the tea-shops, almost all the grocery shops in the country sale alcoholic beverages.The environment in which alcohol is sold and consumed if changed reducing the access, we could see the drama c decline in alcohol-associated violence.
Physical assault and violence possess a threat not only to the well-being of individuals but also to the families and communi es.There are devasta ng consequences of violence in the form of psychological and emo onal problems which may affect the communica on between pa ents and 13 health professionals.
Pa ents with inten onal head injuries are more likely to be discharged home than rehabilita on when compared to the 14 pa ents with uninten onal head injuries.They also had [15][16] higher caregiver burden and less community reintegra on.
In the present study it was seen that 4.8% of popula on le against medical advice and 3.1% requested for discharge.
Studies have suggested that pa ents with history of alcohol/drug abuse mistrust medical care givers, and also their addic ve behaviour -the desire to get more drug and 17-18 alcohol once discharged is high.
There is a need of wider and more comprehensive awareness programs of these overwhelming consequences of assault from public health perspec ves.

CONCLUSION
The connec on between alcohol and inten onal injuries signifies a stern public health and safety which is totally preventable.The law and policy makers should recognize how crimes are linked to alcohol consump on and therefore plan and implement alcohol law in the country with top priority.Inadequate a en on to alcohol law enforcement as in the current scenario increases alcohol-related violence and its associated human, social, and economic costs.Liquor laws also have a posi ve impact on alcohol-related traffic accidents.The present study demonstrates the urgency in enforcing alcohol law and innova ve strategies for preven on of staggering violence and highlights the need for further research to measure enforcement's impact and op mal design.